Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

NSW Cannabis Medicines Advisory Service preliminary survey results - Enquirer perceptions and patient outcomes

Background

In 2018, an innovative, State government‐funded cannabis medicines drug information service was established for health professionals in New South Wales (NSW). The NSW Cannabis Medicines Advisory Service (CMAS) provides expert clinical guidance and support to medical practitioners considering prescribing a cannabis medicine to their patient(s).

Aims

This research examines quality assurance and patient outcomes related to enquirers' experience with NSW CMAS.

Methods

Data collection involved an online, anonymous survey with two components. Following a health professional enquiry, quality assurance data were collected about the enquirers' experience with NSW CMAS. The second survey focussed on patient outcomes and provides real‐world observational data about cannabis medicines safety and effectiveness across a wide range of indications.

Results

Data collection occurred between January 2020 and June 2021. Preliminary analyses were based on 68 quality assurance and 50 patient outcomes survey responses. General practitioners represented the highest proportion of survey responses (n = 33; 49%). The most common enquiry involved ‘patient‐specific advice’ (n = 50; 74%). Patient‐specific information provided by the service was mainly used for prescribing decision support (n = 45; 90%).

Conclusions

Preliminary findings highlight the impact of an innovative cannabis medicines drug information service in supporting health professional clinical practice in an area of rapid knowledge translation. Quality assurance data indicate that the service is perceived well by the majority of enquirers. Patient outcomes data across a wide range of indications suggest some effectiveness and a reasonable safety profile for prescribed cannabis medicines for most patients.

Chlorophyll-a, dissolved organic carbon, turbidity and other variables of ecological importance in river basins in southern Ontario and British Columbia, Canada

Optical sensing of chlorophyll-a (chl-a), turbidity, and fluorescent dissolved organic matter (fDOM) is often used to characterize the quality of water. There are many site-specific factors and environmental conditions that can affect optically sensed readings; notwithstanding the comparative implication of different procedures used to measure these properties in the laboratory. In this study, we measured these water quality properties using standard laboratory methods, and in the field using optical sensors (sonde-based) at water quality monitoring sites located in four watersheds in Canada. The overall objective of this work was to explore the relationships among sonde-based and standard laboratory measurements of the aforementioned water properties, and evaluate associations among these eco-hydrological properties and land use, environmental, and ancillary water quality variables such as dissolved organic carbon (DOC) and total suspended solids (TSS). Differences among sonde versus laboratory relationships for chl-a suggest such relationships are impacted by laboratory methods and/or site specific conditions. Data mining analysis indicated that interactive site-specific factors predominately impacting chl-a values across sites were specific conductivity and turbidity (variables with positive global associations with chl-a). The overall linear regression predicting DOC from fDOM was relatively strong (R² = 0.77). However, slope differences in the watershed-specific models suggest laboratory DOC versus fDOM relationships could be impacted by unknown localized water quality properties affecting fDOM readings, and/or the different standard laboratory methods used to estimate DOC. Artificial neural network analyses (ANN) indicated that higher relative chl-a concentrations were associated with low to no tree cover around sample sites and higher daily rainfall in the watersheds examined. Response surfaces derived from ANN indicated that chl-a concentrations were higher where combined agricultural and urban land uses were relatively higher.

Phylogeny and expression analysis of C-reactive protein (CRP) and serum amyloid-P (SAP) like genes reveal two distinct groups in fish

The acute phase response (APR) is an early innate immune function that is initiated by inflammatory signals, leading to the release of acute phase proteins to the bloodstream to re-establish homeostasis following microbial infection. In this study we analysed the Atlantic salmon (Salmo salar) whole-genome database and identified five C-reactive protein (CRP)/serum amyloid P component (SAP) like molecules namely CRP/SAP-1a, CRP/SAP-1b, CRP/SAP-1c, CRP/SAP-2 and CRP/SAP-3. These CRP/SAP genes formed two distinct sub-families, a universal group (group I) present in all vertebrates and a fish/amphibian specific group (group II). Salmon CRP/SAP-1a, CRP/SAP-1b and CRP/SAP-1c and CRP/SAP-2 belong to the group I family whilst salmon CRP/SAP-3 is a member of group II. Gene expression analysis showed that the salmon CRP/SAP-1a as well as serum amyloid A-5 (SAA-5), one of the major acute phase proteins, were significantly up-regulated by recombinant cytokines (rIL-1β and rIFNγ) in primary head kidney cells whilst the other four CRP/SAPs remained refractory. Furthermore, SAA-5 was produced as the main acute phase protein (APP) in Atlantic salmon challenged with Aeromonas salmonicida (aroA(-) strain) whilst salmon CRP/SAPs remained unaltered. Overall, these data illustrate the potential different functions of expanded salmon CRP/SAPs to their mammalian homologues.

A randomized phase 2 study of MK-2206 versus everolimus in refractory renal cell carcinoma

Background

Activation of the phosphoinisitide-3 kinase (PI3K) pathway through mutation and constitutive upregulation has been described in renal cell carcinoma (RCC), making it an attractive target for therapeutic intervention. We performed a randomized phase II study in vascular endothelial growth factor (VEGF) therapy refractory patients to determine whether MK-2206, an allosteric inhibitor of AKT, was more efficacious than the mammalian target of rapamycin inhibitor everolimus.

Patients and methods

A total of 43 patients were randomized in a 2:1 distribution, with 29 patients assigned to the MK-2206 arm and 14 to the everolimus arm. Progression-free survival (PFS) was the primary endpoint.

Results

The trial was closed at the first futility analysis with an observed PFS of 3.68 months in the MK-2206 arm and 5.98 months in the everolimus arm. Dichotomous response rate profiles were seen in the MK-2206 arm with one complete response and three partial responses in the MK-2206 arm versus none in the everolimus arm. On the other hand, progressive disease was best response in 44.8% of MK2206 versus 14.3% of everolimus-treated patients. MK-2206 induced significantly more rash and pruritis than everolimus, and dose reduction occurred in 37.9% of MK-2206 versus 21.4% of everolimus-treated patients. Genomic analysis revealed that 57.1% of the patients in the PD group had either deleterious TP53 mutations or ATM mutations or deletions. In contrast, none of the patients in the non-PD group had TP53 or ATM defects. No predictive marker for response was observed in this small dataset.

Conclusions

Dichotomous outcomes are observed when VEGF therapy refractory patients are treated with MK-2206, and MK-2206 does not demonstrate superiority to everolimus. Additionally, mutations in DNA repair genes are associated with early disease progression, indicating that dysregulation of DNA repair is associated with a more aggressive tumor phenotype in RCC.

The reliability of the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) among dermatologists, rheumatologists and neurologists

BACKGROUND

Previous studies have shown that skin disease in dermatomyositis (DM) is best assessed using the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI). Although the CDASI has been validated for use by dermatologists, it has not been validated for use by other physicians such as rheumatologists and neurologists, who also manage patients with DM and assess skin activity in clinical trials.

OBJECTIVES

To assess the reliability of the CDASI among dermatologists, rheumatologists and neurologists.

METHODS

Fifteen patients with cutaneous DM were assessed using the CDASI and the Physician Global Assessment (PGA) by five dermatologists, five rheumatologists and five neurologists.

RESULTS

The mean CDASI activity scores for dermatologists, rheumatologists and neurologists were 21·0, 21·8 and 20·8, respectively. These mean scores were not different among the specialists. The CDASI damage score means for dermatologists, rheumatologists and neurologists were 5·3, 7·0 and 4·8, respectively. The mean scores between dermatologists and rheumatologists were significantly different, but the means between dermatologists and neurologists were not. The intraclass correlation coefficients (ICCs) for interrater reliability for CDASI activity and damage were good to excellent for dermatologists and rheumatologists, and moderate to excellent for neurologists. The ICCs for intrarater reliability for CDASI activity and damage were excellent for dermatologists and rheumatologists and moderate to excellent for neurologists. The PGA displayed lower interrater and intrarater reliability relative to the CDASI.

CONCLUSIONS

Our results confirm the reliability of the CDASI when used by dermatologists and rheumatologists. The data for its use by neurologists were not as robust.

The pitfalls of prescribing for family and friends

In most of Australia there is no legislation prohibiting medical practitioners from prescribing for family and friends. In South Australia it is prohibited to prescribe Schedule 8 drugs for family members unless it is a verifiable emergency. The Medical Board of Australia states medical practitioners should avoid providing medical care to anyone with whom they have a close personal relationship. Medical defence organisations may exclude treatment of family members from doctors' insurance cover. Think very carefully before you prescribe for family and friends. It is only considered ethically and professionally appropriate to prescribe in exceptional circumstances, and there are potential risks to you and your family member or friend if you do.

Patients' use of social media: e-rating of doctors

BACKGROUND

Patients are increasingly posting online reviews about their medical care, including rating their doctors.

OBJECTIVE

This article discusses patients' use of social media to comment on and 'rate' their medical care, with a particular focus on what a general practitioner (GP) can do about a negative online review.

DISCUSSION

The vast majority of online reviews about doctors are positive. However, the small proportion of negative online reviews can be a source of great distress to those doctors who are the subject of these reviews. GPs should seek advice before considering whether or not to respond to a negative online review.

How to write a medico-legal report

BACKGROUND

The preparation and provision of medico-legal reports by the treating doctor is an inevitable but sometimes unwelcome part of general practice.

OBJECTIVE

This article outlines the steps involved in preparing a 'good' medico-legal report, including some of the common pitfalls to avoid.

DISCUSSION

General practitioners play an important role in providing medico-legal reports about their patients for a wide variety of purposes. A medico-legal report may be seen by a diverse, non-medical audience. Once prepared, the report may be used as evidence in court proceedings and subjected to close scrutiny. A structured and comprehensive medico-legal report may minimise the chances of having to give evidence in court.

First- and second-trimester tests to predict stillbirth in unselected pregnant women: a systematic review and meta-analysis

BACKGROUND

Several biophysical and biochemical tests have been proposed to predict stillbirth but their predictive ability remains unclear.

OBJECTIVE

To assess the accuracy of tests performed during the first and/or second trimester of pregnancy to predict stillbirth in unselected women with singleton, structurally and chromosomally normal fetuses through use of formal methods for systematic reviews and meta-analytic techniques.

SEARCH STRATEGY

Electronic databases, bibliographies and conference proceedings.

SELECTION CRITERIA

Observational studies that evaluated the predictive accuracy for stillbirth of tests performed during the first two trimesters of pregnancy.

DATA COLLECTION AND ANALYSIS

Two reviewers selected studies, assessed risk of bias and extracted data. Summary receiver operating characteristic curves, pooled sensitivities, specificities and likelihood ratios (LRs) were generated. Data were synthesised separately for stillbirth as a sole category and for specific stillbirth categories.

MAIN RESULTS

Seventy-one studies, evaluating 16 single and five combined tests, met the inclusion criteria. A uterine artery pulsatility index >90th centile during the second trimester and low levels of pregnancy-associated plasma protein A (PAPP-A) during the first trimester had a moderate to high predictive accuracy for stillbirth related to placental abruption, small-for-gestational-age or pre-eclampsia (positive and negative LRs from 6.3 to 14.1, and from 0.1 to 0.4, respectively). All biophysical and biochemical tests assessed had a low predictive accuracy for stillbirth as a sole category.

CONCLUSIONS

Currently, there is no clinically useful first-trimester or second-trimester test to predict stillbirth as a sole category. Uterine artery pulsatility index and maternal serum PAPP-A levels appeared to be good predictors of stillbirth related to placental dysfunction disorders.

Advance care planning

BACKGROUND

Good Medical Practice: A Code of Conduct for Doctors in Australia states that in caring for patients towards the end of their life, good medical practice involves facilitating advance care planning.

OBJECTIVE

This article discusses the role of advance care planning in end-of-life care, with an emphasis on the ethical and legal framework for advance care directives.

DISCUSSION

There has been an increased focus on advanced care planning and advance care directives in Australia, partly driven by the ageing population and technological advances, as well as the principle of patient-centred care. General practitioners have an important role in initiating and facilitating advance care planning.

Genetic testing: medico-legal issues

BACKGROUND

The availability and frequency of genetic testing is increasing. Genetic testing poses some unique ethical and legal issues for medical practitioners because of the potential to identify genetic variants that carry implications for the risk of disease in the future for the patient and their relatives. The regulatory framework within which genetic testing is provided in Australia is also changing.

OBJECTIVE

This article examines some medico-legal issues associated with genetic testing that general practitioners (GPs) are likely encounter in their practices.

DISCUSSION

There is inevitable involvement of the GP in the long term care of a patient (and possibly their family) following genetic testing, regardless of whether or not the GP has ordered the testing. Cases are presented to illustrate some of the medico-legal issues that may arise from direct-to-consumer genetic testing, information disclosure to genetic relatives and requests for parentage testing.

Movement patterns and genetic diversity of wild and reintroduced common dormice, Muscardinus avellanarius

Movement is an important life history trait that can have an impact on local adaptation, and other evolutionary phenomena. We used a combination of nestbox survey data and genetic techniques (genotyping at 10 microsatellite loci) to quantify patterns of movement in common dormice Muscardinus avellanarius at two distinct sites in the UK: 1) Bontuchel (a natural population) and 2) Wych (captive-bred individuals that were reintroduced to this site), over three consecutive years (2006-2008). Both methods revealed a consistent pattern of sex-biased movement (movements by adult males and females) in both populations that allowed isolation-by-distance genetic structure to develop within 1 km. The similarity of data from captive-bred and natural individuals indicated that ex situ programing has not significantly altered the natural movement behavior of common dormice; consequently, the two populations could be managed with the same conservation strategies. We also found that the reintroduced dormice in Wych maintained relatively high levels of genetic diversity. This first report of movement patterns in reintroduced and natural populations of M. avellanarius combining genetic and field-survey data highlights the role of genetic studies in the investigation of ecological behaviour and for conservation management.

Managing professional boundaries

The maintenance of boundaries in the doctor-patient relationship is central to good medical practice and the appropriate care of patients. This article examines the nature of boundaries in medical practice and outlines some strategies to minimise the risk of a boundary violation.

The duty of GPs to follow up patients

A recent Supreme Court of Victoria judgement examined the legal obligations of a general practitioner to recall a patient who does not undergo a test that has been recommended by the GP or to return for a consultation, despite being asked to do so.

Isolation of RAG-1 and IgM transcripts from the striped trumpeter (Latris lineata), and their expression as markers for development of the adaptive immune response

A partial sequence of the recombination activating gene-1 (RAG-1) and several full length sequences of the immunoglobulin M (IgM) heavy chain mRNA were obtained from the striped trumpeter (Latris lineata). The RAG-1 fragment consisted of 205 aa and fell within the core region of the open reading frame. The complete IgM heavy chain sequences translated into peptides ranging between 581 and 591 aa. Both genes showed good homology to other vertebrate sequences. The expression of the two genes was assessed throughout the early developmental stages of striped trumpeter larvae (5-100 dph) and used as markers to follow the ontogeny of the adaptive immune response. Using RT-PCR, RAG-1 mRNA expression was detectable at 5 dph and remained so until 80 dph, before becoming undetectable at 100 dph. IgM expression was also detectable at 5 dph, and remained so throughout. These patterns of expression may suggest that the striped trumpeter possess mature B cells with surface IgM at 100 dph. However, complete immunological competence is likely not reached until some time later. The early detection of IgM mRNA at 5 dph led to the investigation of its presence in oocytes. Both RAG-1 and IgM mRNA transcripts were detected in unfertilized oocytes, suggesting that they are maternally transferred. The biological significance of such a phenomenon remains to be investigated.

Identification, cloning and characterisation of interleukin-1F5 (IL-36RN) in the chicken

The human IL-1 family contains eleven genes encoded at three separate loci. Nine, including IL-36 receptor antagonist (IL-36RN), also known as IL-1F5, are present at a single locus on chromosome 2, whereas IL-18 and IL-33 lie on chromosomes 11 and 9 respectively. There are currently only three known orthologues in the chicken - IL-1β, IL-18 and IL-1RN - which are encoded on chromosomes 22, 24 and unplaced, respectively. A novel chicken IL-1 family sequence representing IL-36RN (IL-1F5) was initially identified from an expressed sequence tag (EST) library by its similarity to both chicken IL-1RN and chicken IL-1β. Following isolation of the cDNA from the liver of an uninfected bird, a number of unique sequence features were identified. The predicted protein has a longer NH(2)-terminus than the human protein; however, as in mammals, this region contains neither a prodomain nor a signal peptide. A putative nuclear export sequence is also apparent, yet a similar motif is absent in mammalian IL-36RN. Although chIL-36RN exhibits low homology with its mammalian orthologues, it encodes a predicted β-trefoil structure whose β-strands are conserved with those of the mouse sequence. Unlike in mammals, chIL-36RN expression was constitutive in all tissues and cell subsets examined. In response to viral infection, expression was significantly downregulated in a line of birds which are susceptible to the virus. Chicken IL-36RN, like chIL-1RN, is not encoded at the chIL-1β locus, further emphasising the genomic fragmentation of the large IL-1 gene cluster found in mammals. This suggests differential evolution of this cytokine family since the divergence of birds and mammals from a common ancestor, and underlines the difficulty of determining the full repertoire of chIL-1 family members.

An intellectual property sharing initiative in agricultural biotechnology: development of broadly accessible technologies for plant transformation

The Public Intellectual Property Resource for Agriculture (PIPRA) was founded in 2004 by the Rockefeller Foundation in response to concerns that public investments in agricultural biotechnology benefiting developing countries were facing delays, high transaction costs and lack of access to important technologies due to intellectual property right (IPR) issues. From its inception, PIPRA has worked broadly to support a wide range of research in the public sector, in specialty and minor acreage crops as well as crops important to food security in developing countries. In this paper, we review PIPRA's work, discussing the failures, successes, and lessons learned during its years of operation. To address public sector's limited freedom-to-operate, or legal access to third-party rights, in the area of plant transformation, we describe PIPRA's patent 'pool' approach to develop open-access technologies for plant transformation which consolidate patent and tangible property rights in marker-free vector systems. The plant transformation system has been licensed and deployed for both commercial and humanitarian applications in the United States (US) and Africa, respectively.

The interleukins of fish

Interleukins are a subgroup of cytokines, molecules involved in the intercellular regulation of the immune system. The term interleukin was first coined in 1979 to refer to molecules that signal between different leucocyte types, although not exclusively restricted to leucocyte communication. Whilst it is now known that interleukins are produced by a wide variety of cell types, nevertheless many are synthesised by CD4(+) T helper cells, macrophages/monocytes and endothelial cells. The nomenclature is relatively straightforward, with interleukin 1 the first discovered and interleukin 2 the second, etc. However, whilst 35 interleukins are currently described in mammals, several are in fact terms referring to subfamilies of more molecules, as with the IL-1 family where 11 members (IL-1F1-IL-1F11) are present, and the IL-17 family where 6 members (IL-17A-IL-17F) are present. So the total is much higher and splice variants and allelic variation increase this diversity further. This review will focus on what is known about interleukins in fish, and will refer to the major subfamilies rather than try to work through 35 descriptions in a row. It is clear that many direct homologues of molecules known in mammals are present in fish, but that not all are present and some novel interleukins exist that may have arisen from fish specific gene duplication events.

Child abuse - mandatory reporting requirements

All Australian states and territories have legislation that requires medical practitioners to report cases of child abuse to the appropriate child protection service. This article outlines the obligations of medical practitioners to report child abuse and highlights the differences that exist in the legislative requirements in each state and territory.

How to complete a death certificate - a guide for GPs

This article discusses some questions that frequently arise in general practice with regard to the completion of death certificates.

Capacity to consent to treatment

A competent adult patient has an ethical and legal right to give, or withhold, consent to an examination, investigation or treatment. Depending on the nature and complexity of an intervention, a patient with an intellectual disability may be capable of consenting to their own medical treatment. In circumstances in which an adult patient does not have the capacity to consent, there is specific guardianship legislation enacted in each state and territory which provides for valid consent by a substitute decision maker.

Consent to medical treatment: the mature minor

Can children and young people consent to their own medical treatment? Consent issues involving children and young people are complex. This article examines the legal obligations of general practitioners when obtaining consent to medical treatment from patients who are less than 18 years of age.

Sickness certification

This article forms part of our 'Paperwork' series for 2011, providing information about a range of paperwork that general practitioners complete regularly. The aim of the series is to provide information on the purpose of the paperwork, and hints on how to complete it accurately. This will allow the GP to be more efficient and the patient to have an accurately completed piece of paperwork for the purpose required. Sickness certificates are legal documents. Medical boards receive numerous complaints each year from patients, employers, insurers and other parties about the quality and accuracy of sickness certificates. General practitioners who deliberately issue a false, misleading or inaccurate certificate could face disciplinary action, or even a charge of fraud. This article provides some guidance for GPs about writing certificates certifying illness, and discusses common medicolegal issues associated with sickness certificates.

Failure to diagnose: diabetic ketoacidosis

A recent coronial inquest examined the death of a patient, 17 years of age, from fulminant diabetic ketoacidosis.1 The patient's presentation with diabetic ketoacidosis was the first manifestation of the onset of type 1 diabetes. This article examines the Coroner's findings and recommendations.

Lost: loss of chance

Loss of chance claims involve an allegation that a patient has lost the chance of a better medical outcome, in terms of treatment and/or prognosis, as a result of the negligence of the medical practitioner. A recent High Court of Australia judgment confirmed that monetary damages are not available for the loss of a chance of a better medical outcome. This article discusses the judgment and its implications for medical practitioners in Australia.

Mandatory reporting of health practitioners - notifiable conduct

Case histories are based on actual medical negligence claims or medicolegal referrals; however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved. On 26 March 2008, the Council of Australian Governments signed an Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions. The new scheme is scheduled to be introduced on 1 July 2010. As part of the scheme all registered health practitioners will be legally required to report any other registered health practitioner who has behaved in a manner that constitutes 'notifiable conduct'. The threshold to be met to trigger the requirement to report notifiable conduct in relation to a practitioner is high, and the practitioner or employer must have first formed a 'reasonable belief' that the behaviour constitutes notifiable conduct. This article discusses this new legislation, the circumstances in which a colleague's conduct must be reported and how a notification should be made.