195 THE IMPACT OF COVID-19 RESTRICTIONS ON PATIENTS ATTENDING A FALLS ASSESSMENT SERVICE

Background

Covid-19 impacted older peoples’ confidence and mobility. Restrictions from March 2020 on our cohort of patients (> 65 years) reduced movement and social interactions leading to deconditioning and brain health implications. In our falls assessment service the clinical nurse specialist conducts a multifactorial assessment. We aimed to see if a difference existed in assessments of similar cohorts of patients’ pre and post restrictions.

Methods

A retrospective review of assessment measures for patients attending the falls service between October – December 2019 and 2021. Measures compared included gender, age, Fear-of-Falling (FOF), Timed Up and Go (TUG), Fracture Risk Assessment tool (FRAX), Vitamin D levels, grip strength and Body Mass Index (BMI).

Results

Twenty-two patient charts were reviewed from 2019 and 2021. Both years had similar female and male patient data reviewed (14/22 female 2019, 15/22 female 2021). FOF was noted in 38% (8/21) of patients in 2019, versus 45% (10/22) in 2021. In 2021 the average age of our patient cohort had decreased by three years. The TUG average time increased by 2 seconds in 2021 (median time decreased by 2.5 seconds). The major osteoporotic average percentage decreased in 2021 by 1.1%, (median drop 9%), the hip fracture percentage decreased by 2.5% in 2021 (median drop 10.5%). The average vitamin D level decreased by 1mmol in 2021 (median decreased 54mmol), while BMI average increased by 2kg/m² (median increased by 6kg/m²). The average grip strength results in 2021 dropped by 11.5kg (median decreased by 10.5kg).

Conclusion

Potential trends are observed in this data. We intend to examine a larger timeline/number of patients to be able to validate these findings, particularly FOF.

356 OLDER PERSONS LIVING ALONE IN INTEGRATED CARE: DEPRESSION, LOW EDUCATION AND FUEL POVERTY

Background

An important consequence of population ageing has been the increasing number of older adults who live alone. According to TILDA data, older adults with the lowest levels of education tend to experience most social isolation and there is a strong association between living alone and loneliness. We sought to compare the cohort of patients open to the Integrated Care for Older Persons (ICPOP) team in a University Teaching Hospital serving a community area of approx. 300,000 population, to this national dataset.

Methods

A convenience sample of 174 patients who underwent comprehensive geriatric assessment via domiciliary visit between July 2021-May 2022 by was analysed. Data was anonymised and analysis was performed using SPSS v.27.

Results

The average age was 81.5 (±8.1) with 63% women in the sample. Eighty-five older adults i.e. 49% of the sample either lived alone or spent more than 21 hours alone per 24-hour period. Compared to those who live with someone, those who lived alone had higher rates of likely depression as determined by Geriatric Depression Score (6.6 vs 4.8 p=0.007). They were also likely to have less educational attainment, as determined by years spent in full time education (11.81 vs 10.42 42 p= 0.0016) and those living alone had overall less central heating in their homes than those not living alone (64/85 vs 81/89 p=0.0109). There were no significant differences in the rates of polypharmacy, falls, dementia and home ownership between groups. There were higher levels of frailty in the group living with someone than those living alone as determined by Clinical Frailty Scale (6.14 vs 5.23 p<0.001).

Conclusion

A high proportion of patients seen by our ICPOP team live alone and have complex care needs that require an innovative, multidisciplinary approach. Financial vulnerability in this group is likely to compound isolation and loneliness.

Morphometric analysis of the human common hepatic artery reveals a rich and accessible target for sympathetic liver denervation

This study quantified the distribution of nerves and adjacent anatomies surrounding human common hepatic artery (CHA) as guidance for catheter based denervation. CHA collected from cadaveric human donors (n = 20) were histologically evaluated and periarterial dimensions and distributions of nerves, lymph nodes, pancreas and blood vessels quantified by digital morphometry. Nerve abundance decreased significantly with distance from the aortic ostium (P < 0.0001) and was higher in the Superior/Inferior compared to the Anterior/Posterior quadrants (P = 0.014). In each locational group, nerves were absent from the artery wall, and starting 0.5–1.0 mm from the lumen exhibited a first order dependence on radial distance, fully defined by the median distance. Median subject-averaged nerve distance to the lumen was 2.75 mm, ranging from 2.1–3.1 mm in different arterial segments and quadrants and 2.0–3.5 mm in individuals. Inter-individual variance was high, with certain individuals exhibiting 50th and 75th nerve distances of, respectively, 3.5 and 6.5 mm The pancreas rarely approached within 4 mm of the lumen proximally and 2.5 mm more distally. The data indicate that the CHA is a rich and accessible target for sympathetic denervation regardless of sex and diabetes, with efficacy and safety most optimally balanced proximally.

An Exploration of Sleep and Family Factors in Young Children at Familial Risk for ADHD

Objective: The aim of the current study was to examine relations between sleep problems and family factors and early markers of ADHD in young children with and without a familial risk for ADHD.Methods: Differences in sleep behavior and family functioning in children under 6 years with (n = 72) and without (n = 139) a familial risk for ADHD were investigated. The influence of family and sleep factors on the development of early temperament markers of ADHD (effortful control and negative affect) was explored. Parents/caregivers completed questionnaires on family functioning, child sleep behavior, and general regulatory behaviors.Results: A significant difference was observed between high-risk and low-risk groups for family functioning in the infant/toddler (<3 years) and preschool (>3 years) cohorts. Parents of infants/toddlers in the high-risk group reported poorer infant sleep. However, there were no sleep differences reported for the preschool cohort. Family functioning was found to predict effortful control, while sleep quality predicted negative affect.Conclusion: The results of this study highlight potential family and sleep issues for young children with a familial history of ADHD and the potential influence of these factors on early temperament markers of ADHD. Future research should explore these relations further in order to better establish whether early sleep and family interventions could mitigate later ADHD symptomatology.

726 Return to Sport, Patient Reported Outcomes and Satisfaction Following Anterior Cruciate Ligament Reconstruction

Introduction

Anterior Cruciate Ligament(ACL) rupture is a common sporting injury. Return to sport is a key objective for patients.

The aim of this study was to investigate return to pre-injury level sport at 12- and 24-months post reconstruction and to relate this to types of sport and to patient satisfaction.

Method

A questionnaire was developed, piloted, and then completed by 77 patients that had undergone ACL reconstruction between 2013-2016.

Results

30% of patients returned to pre-injury level of sport at 12 months and 43% by 24 months’ post ACL reconstruction. There was a significant(P = 0.037) relationship between the type of sports that participants played prior to injury and the return to pre-injury level. Sports that involved jumping, hard pivoting and cutting were associated with a lower rate of return to sport. General health profile of the patients was found to be significantly higher in patients that returned to sport(P = 0.024). There was a significant association with return to sport and higher satisfaction and healthcare experience score(P = 0.001).

Conclusions

Patient satisfaction correlated with return to sport. This was inversely related to sports involving jumping, hard pivoting and cutting. Which further illustrates how patient satisfaction post ACL reconstruction was linked to type of sport.

Sensory modulation and negative affect in children at familial risk of ADHD

BACKGROUND/AIMS

Sensory modulation difficulties are commonly reported in patients with ADHD, however there has been little focus on the development of these difficulties in young children at a higher risk of later ADHD diagnosis. This study investigated whether children with a familial history of ADHD show greater sensory modulation difficulties. We also explored whether sensory modulation was linked to negative affectivity, which has been highlighted as a potential early marker of ADHD.

METHODS

Parents of children under 6 years with a family history of ADHD (n = 65) and no family history (n = 122) completed questionnaires on sensory modulation and temperament.

RESULTS

Children from families with ADHD were reported to display extreme patterns of hyperresponsiveness and hyporesponsiveness, relative to controls. No differences emerged for the sensory seeking domain. Some children within the high-risk group reported high scores across all three sensory modulation patterns. Regression analysis revealed that hyperresponsiveness predicted higher levels of negative affect.

CONCLUSIONS/IMPLICATIONS

This study is the first to report greater sensory modulation difficulties in children at familial risk of ADHD. Future research should establish whether children with sensory modulation and temperament difficulties in early childhood are more vulnerable to developing ADHD.

Brief report: Lymph node morphology in stage II colorectal cancer

BACKGROUND

Colorectal cancer is one of the leading causes of cancer-associated morbidity and mortality worldwide. The local anti-tumour immune response is particularly important for patients with stage II where the tumour-draining lymph nodes have not yet succumbed to tumour spread. The lymph nodes allow for the expansion and release of B cell compartments such as primary follicles and germinal centres. A variation in this anti-tumour immune response may influence the observed clinical heterogeneity in stage II patients.

AIM

The aim of this study was to explore tumour-draining lymph node histomorphological changes and tumour pathological risk factors including the immunomodulatory microRNA-21 (miR-21) in a small cohort of stage II CRC.

METHODS

A total of 23 stage II colorectal cancer patients were included. Tumour and normal mucosa samples were analysed for miR-21 expression levels and B-cell compartments were quantified from Haematoxylin and Eosin slides of lymph nodes. These measures were compared to clinicopathological risk factors such as perforation, bowel obstruction, T4 stage and high-grade.

RESULTS

We observed greater Follicle density in patients with a lower tumour T stage and higher germinal centre density in patients with higher pre-operative carcinoembryonic antigen levels. Trends were also detected between tumours with deficiency in mismatch repair proteins, lymphatic invasion and both the density and size of B-cell compartments. Lastly, elevated tumour miR-21 was associated with decreased Follicle and germinal centre size.

CONCLUSION

Variation in B-cell compartments of tumour-draining lymph nodes is associated with clinicopathological risk factors in stage II CRC patients.

Combined renal and common hepatic artery denervation as a novel approach to reduce cardiometabolic risk: technical approach, feasibility and safety in a pre-clinical model

Background

Cardiovascular and metabolic regulation is governed by neurohumoral signalling in relevant organs such as kidney, liver, pancreas, duodenum, adipose tissue, and skeletal muscle. Combined targeting of relevant neural outflows may provide a unique therapeutic opportunity for cardiometabolic disease.

Objectives

We aimed to investigate the feasibility, safety, and performance of a novel device-based approach for multi-organ denervation in a swine model over 30 and 90 days of follow-up.

Methods

Five Yorkshire cross pigs underwent combined percutaneous denervation in the renal arteries and the common hepatic artery (CHA) with the iRF Denervation System. Control animals (n = 3) were also studied. Specific energy doses were administered in the renal arteries and CHA. Blood was collected at 30 and 90 days. All animals had a pre-terminal procedure angiography. Tissue samples were collected for norepinephrine (NEPI) bioanalysis. Histopathological evaluation of collateral structures and tissues near the treatment sites was performed to assess treatment safety.

Results

All animals entered and exited the study in good health. No stenosis or vessel abnormalities were present. No significant changes in serum chemistry occurred. NEPI concentrations were significantly reduced in the liver (− 88%, p = 0.005), kidneys (− 78%, p < 0.001), pancreas (− 78%, p = 0.018) and duodenum (− 95%, p = 0.028) following multi-organ denervation treatment compared to control animals. Histologic findings were consistent with favourable tissue responses at 90 days follow-up.

Conclusions

Significant and sustained denervation of the treated organs was achieved at 90 days without major safety events. Our findings demonstrate the feasibility of multi-organ denervation using a novel iRF Denervation System in a single procedure.

Associations Between Mutations in MSH6 and PMS2 and Risk of Surveillance-detected Colorectal Cancer

BACKGROUND & AIMS

Lynch syndrome is the most common inherited cause of colorectal cancer (CRC). Contemporary and mutation-specific estimates of CRC-risk in patients undergoing colonoscopy would optimize surveillance strategies. We performed a prospective national cohort study, using data from New Zealand, to assess overall and mutation-specific risk of CRC in patients with Lynch syndrome undergoing surveillance.

METHODS

We performed a prospective study of 381 persons with Lynch syndrome in New Zealand (98 with Lynch-syndrome associated variants in MLH1, 159 in MSH2, 103 in MSH6, and 21 in PMS2). Participants were offered annual colonoscopy starting at age 25 y, and those who underwent 2 or more colonoscopies before December 31, 2017 were included in the final analysis. Patients with previous colonic resection, history of CRC or diagnosis of CRC at index colonoscopy were excluded.

RESULTS

Study participants underwent 2061 colonoscopies during 2296 person-y; the median observation-period was 4.43 y and mean-age at enrollment was 43 y. Eighteen patients developed CRC (8 with variants in MLH1, 8 in MSH2, and 2 in MSH6) after a median follow-up period of 6.5 y (range 1-16 y). Eighty-three percent of patients had a surveillance colonoscopy in preceding 24 months before diagnosis of CRC; 94% were diagnosed with stage 0-II CRC and there was no CRC-related mortality. The overall-risk of developing CRC in the 5 y after first surveillance colonoscopy was 2.49% (95% CI, 1.18-5.23); cumulative risks for CRC in patients with Lynch syndrome-associated variants in MLH1, MSH2, or MSH6 by age 70 y were 17.7%, 17.8%, and 8.5%, respectively. Age-adjusted CRC-risk in patients with variants in MSH6 was lower than in MLH1 (hazard ratio, 0.2; 95% CI, 0.04-0.94; P = .02). Of patients with CRC, 33% had an adenomatous polyp resected from same segment in which a colorectal tumor later developed.

CONCLUSIONS

The risk of CRC in patients with Lynch syndrome-associated mutations in MSH6 or PMS2 was significantly lower than in patients with mutations in MLH1. Incomplete adenomatous polyp resection might be responsible for one third of surveillance-detected CRCs.

Avoiding, diagnosing and treating well leg compartment syndrome after pelvic surgery

Background

Patients undergoing prolonged pelvic surgery may develop compartment syndrome of one or both lower limbs in the absence of direct trauma or pre‐existing vascular disease (well leg compartment syndrome). This condition may have devastating consequences for postoperative recovery, including loss of life or limb, and irreversible disability.

Methods

These guidelines represent the collaboration of a multidisciplinary group of colorectal, vascular and orthopaedic surgeons, acting on behalf of their specialty associations in the UK and Ireland. A systematic analysis of the available peer‐reviewed literature was undertaken to provide an evidence base from which these guidelines were developed.

Results

These guidelines encompass the risk factors (both patient‐ and procedure‐related), diagnosis and management of the condition. Key recommendations for the adoption of perioperative strategies to facilitate prevention and effective treatment of well leg compartment syndrome are presented.

Conclusion

All surgeons who carry out abdominopelvic surgical procedures should be aware of well leg compartment syndrome, and instigate policies within their own institution to reduce the risk of this potentially life‐changing complication.

Forage fish and polycyclic aromatic compounds in the Fort McMurray oil sands area: Body burden comparisons with environmental distributions and consumption guidelines

The Fort McMurray region in northeastern Alberta (Canada) is rich in natural sources of polycyclic aromatic compounds (PACs) from exposed bitumen beds; anthropogenic sources are being released with increased oil sands industry expansion. Here we report on investigations of PACs (47 compounds) in three species of forage fish collected during the 2012-2013 Joint Oil Sands Monitoring Program (JOSMP) fish health investigations and compare results with PAC data for sediment and water collected under JOSMP and earlier programs. PAC concentrations in sediments varied three orders in magnitude and were highest at downstream tributary mouths, which flowed through the exposed McMurray Formation, and along reaches of the Athabasca River where the formation was exposed. PAC concentrations in water were less variable but with higher concentrations near exposed bitumen beds. Forage fish exhibited the weakest spatial gradients in ΣPACs concentration, which averaged 102 ± 32 ng/g in trout-perch from the Athabasca River, 125 ± 22 ng/g in lake chub from the Ells River, and 278 ± 267 ng/g in slimy sculpin from the Steepbank, Firebag, and Dunkirk Rivers. Low-molecular weight compounds, particularly naphthalenes and fluorenes, dominated fish PACs. Phenanthrenes occurred in greater percent composition in fish caught in areas where PAC concentrations in sediments were higher due to the proximity of bitumen sources than in other areas. Dibenzothiophene, a major component of bitumen PAC, was a minor component of fish ΣPACs. Forage fish PAC concentrations were below fish consumption guidelines established by the European Commission (2011) and for the reopening of the commercial fisheries closed by the Deepwater Horizon oil spill. PAC concentrations in forage fish were similar to concentrations observed in many other studies (fish market surveys, estuaries, and marine waters) and lower than in fish sampled from highly impacted areas (near refineries, harbors, and other industrialized areas).

Defining drug and target protein distributions after stent-based drug release: Durable versus deployable coatings

BACKGROUND

Innovations in drug eluting stent designs make it increasingly important to develop models for differentiating performance through spatial definition of drug, receptor binding and cell state.

METHODS

Two designs of sirolimus analog eluting stents were implanted into porcine coronary arteries for 28, 60 or 90 days (n = 9/time point), durable coating (Xience) and deployable absorbable coating (MiStent). Explanted arteries were evaluated for drug content (n = 3/time point) by LC-MS/MS and for drug and target protein (mTOR) distributions by immunofluorescence (IF, n = 6/time point). A computational model was developed to predict drug release and arterial distribution maps.

RESULTS

Both stents released the majority of drug load by 28 days, with different tissue retention efficiencies (91.4 ± 4.9% MiStent versus 21.5 ± 1.9% Xience, P < 0.001). Computational modeling of MiStent coating deployment and microcrystal dissolution recapitulated in vivo drug release and net tissue content and predicted that >98.5% of deployed drug remains crystalline through 90 days. Immunofluorescence and computational modeling showed peristrut drug localization for both stents, with similar peaks, but high interstrut levels only at sites of coating deployment from the absorbable coating. Co-localization of mTOR-IF with drug-IF for both devices showed persistent drug effects, though with differential drug-receptor pharmacokinetics.

CONCLUSIONS

Immunofluorescence and computational modeling provide insights into drug distribution and binding status that can help differentiate drug delivery technologies. Herein we found that tissue deployment of slow dissolving crystalline drug particles results in temporally and spatially more uniform drug delivery to interstrut zones that might otherwise be under-dosed without excess peristrut drug.

Evaluation of Current Screening and Treatment Patterns for Pediatric Obstructive Sleep Apnea Among Practicing Pediatric Dentists in the United States: A Pilot Study

PURPOSE

The purpose of this study was to provide an evaluation of educational experience, screening, referral, and treatment patterns by pediatric dentists in the United States with regards to obstructive sleep apnea (OSA) and sleep-disordered breathing (SDB).

METHODS

A twenty-six question, multiple choice, electronic survey was developed using SurveyMonkey software. It was distributed to the 6,017 active American Academy of Pediatric Dentistry (AAPD) members, garnering a response rate of 7.0 percent.

RESULTS

A total of 41.2 percent of respondents were uncomfortable or very uncomfortable screening for OSA/SDB; 61.4 percent indicated no formal training in OSA/SDB during residency; 40.7 percent stated they routinely screened for OSA/SDB; and 93.9 percent referred to a physician in suspected cases of OSA/SDB.

CONCLUSIONS

While awareness of OSA and SDB is high among pediatric dental specialists, educational opportunities are limited, routine screening is not standard, and treatment is not commonly provided.

A Rare Variant of Pancreatic Sarcoidosis: Diagnostic Challenge

Pancreatic sarcoidosis is one of the variant of systemic sarcoidosis which is extremely rare in literature and opined as an enigma. Hence, its diagnosis is very challenging as its presentation mimics pancreatic carcinoma. In view of a better understanding, we are presenting a case of pancreatic sarcoidosis to emphasize the above. To clearly distinguish sarcoidosis from malignancy, repeated computed tomography scans, Positron emission tomography scans, fine needle aspiration cytology, endoscopic retrograde cholangio-pancreatography supplemented with histology and relevant blood tests proved it to be a pancreatic sarcoidosis then a malignancy. Over the course, concrete evidence was divulged from lymph node biopsy and histology in clinching the diagnosis which later transformed into a malignancy. Therefore, we concluded it is a rare variant of pancreatic sarcoidosis and careful serial investigations include repeated imaging, histology and blood tests are essential to establish and most importantly differentiate the diagnosis.

How to cite this article

Khangura T, Uddin G, Davies A, Keating J. A Rare Variant of Pancreatic Sarcoidosis: Diagnostic Challenge. Euroasian J Hepato-Gastroenterol 2015;5(2):118-121.

Comparison of outcomes of operatively treated bicondylar tibial plateau fractures by external fixation and internal fixation

ABSTRACT

The outcome of bicondylar tibial plateau fractures treated with either external fixation (35 patients) or internal fixation (24 patients) was reviewed. Outcome measures included the Rasmussen score, clinical complications, development of osteoarthritis and the requirement for total knee replacement (TKR). Twenty-two (92%) anatomical reductions were achieved in the internal fixation group compared to 27 (77%) in the external fixation group. Infective complications were more common in the external fixation group (9 patients, 26%) due to pin tract infection. There were no deep infections in the internal fixation group. The mean Rasmussen score was not significantly different (mean score 32 in external fixation and 29 in internal fixation) between the two groups and the incidence of osteoarthritis was the same in both groups. Four patients in the external fixation group underwent a TKR compared to 5 patients in the internal fixation group. Bicondylar tibial plateau fractures have similar outcomes following external or internal fixation.

KEY WORDS

bicondylar, tibial, plateau, external, internal, fixation, outcome.

GM1-gangliosidosis in American black bears: clinical, pathological, biochemical and molecular genetic characterization

G(M1)-gangliosidosis is a rare progressive neurodegenerative disorder due to an autosomal recessively inherited deficiency of lysosomal β-galactosidase. We have identified seven American black bears (Ursus americanus) found in the Northeast United States suffering from G(M1)-gangliosidosis. This report describes the clinical features, brain MRI, and morphologic, biochemical and molecular genetic findings in the affected bears. Brain lipids were compared with those in the brain of a G(M1)-mouse. The bears presented at ages 10-14 months in poor clinical condition, lethargic, tremulous and ataxic. They continued to decline and were humanely euthanized. The T(2)-weighted MR images of the brain of one bear disclosed white matter hyperintensity. Morphological studies of the brain from five of the bears revealed enlarged neurons with foamy cytoplasm containing granules. Axonal spheroids were present in white matter. Electron microscopic examination revealed lamellated membrane structures within neurons. Cytoplasmic vacuoles were found in the liver, kidneys and chondrocytes and foamy macrophages within the lungs. Acid β-galactosidase activity in cultured skin fibroblasts was only 1-2% of control values. In the brain, ganglioside-bound sialic acid was increased more than 2-fold with G(M1)-ganglioside predominating. G(A1) content was also increased whereas cerebrosides and sulfatides were markedly decreased. The distribution of gangliosides was similar to that in the G(M1)-mouse brain, but the loss of myelin lipids was greater in the brain of the affected bear than in the brain of the G(M1) mouse. Isolated full-length cDNA of the black bear GLB1 gene revealed 86% homology to its human counterpart in nucleotide sequence and 82% in amino acid sequence. GLB1 cDNA from liver tissue of an affected bear contained a homozygous recessive T(1042) to C transition inducing a Tyr348 to His mutation (Y348H) within a highly conserved region of the GLB1 gene. The coincidence of several black bears with G(M1)-gangliosidosis in the same geographic area suggests increased frequency of a founder mutation in this animal population.

Potentiation of azole antifungals by 2-adamantanamine

Azoles are among the most successful classes of antifungals. They act by inhibiting α-14 lanosterol demethylase in the ergosterol biosynthesis pathway. Oropharyngeal candidiasis (OPC) occurs in about 90% of HIV-infected individuals, and 4 to 5% are refractory to current therapies, including azoles, due to the formation of resistant biofilms produced in the course of OPC. We reasoned that compounds affecting a different target may potentiate azoles to produce increased killing and an antibiofilm therapeutic. 2-Adamantanamine (AC17) was identified in a screen for compounds potentiating the action of miconazole against biofilms of Candida albicans. AC17, a close structural analog to the antiviral amantadine, did not affect the viability of C. albicans but caused the normally fungistatic azoles to become fungicidal. Transcriptome analysis of cells treated with AC17 revealed that the ergosterol and filamentation pathways were affected. Indeed, cells exposed to AC17 had decreased ergosterol contents and were unable to invade agar. In vivo, the combination of AC17 and fluconazole produced a significant reduction in fungal tissue burden in a guinea pig model of cutaneous candidiasis, while each treatment alone did not have a significant effect. The combination of fluconazole and AC17 also showed improved efficacy (P value of 0.018) compared to fluconazole alone when fungal lesions were evaluated. AC17 is a promising lead in the search for more effective antifungal therapeutics.

The 'Dr Google' phenomenon--missed appendicitis

Self-diagnosis has been around for many years. In today's society with free access to information, particularly through the Internet, it is more prominent than ever. With new information sources available to patients, doctors may have their diagnostic process influenced. This is the case of a gentleman who self-diagnosed, and subsequently influenced his doctor's diagnostic process, with results detrimental to his outcome. It illustrates the importance of awareness of the risks of self diagnosis, and management of patients who present with information and preconceived ideas regarding their condition.

Ultrasonographic and clinicopathological features of feline gastrointestinal eosinophilic sclerosing fibroplasia in four cats

Four cats with feline gastrointestinal eosinophilic sclerosing fibroplasia (FGESF) are described. Clinical signs included decreased appetite, weight loss, vomiting and diarrhea. Bloodwork abnormalities included mild neutrophilia (n = 2) and hyperglobulinemia with concurrent hyperproteinemia (n = 2). Ultrasonographically, a total of five solitary masses with mural thickening and loss of layering were identified in the stomach, duodenum, jejunum and colon. In one cat a second, separate lesion was diagnosed 3 weeks following surgical resection of one mass. Histopathologically, lesions were characterized by collagen trabeculae and mixed inflammatory cell infiltrates, predominantly eosinophils. Multiple areas of necrosis were also noted, which contained bacteria in 2/4 cats. In two cats, changes consistent with FGESF were also noted in the liver. All cats had surgical resection of their lesions. Two cats are still living at time of publication (43 and 24 months post-surgery). FGESF should be considered as a differential for intestinal masses in cats.

Biological cost of tolerance to heavy metals in the mosquito Anopheles gambiae

The global rate of heavy metal pollution is rapidly increasing in various habitats. Anopheles malaria vector species (Diptera: Culicidae) appear to tolerate many aquatic habitats with metal pollutants, despite their normal proclivity for 'clean' water (i.e. low levels of organic matter). Investigations were conducted to establish whether there are biological costs for tolerance to heavy metals in Anopheles gambiae Giles sensu stricto and to assess the potential impact of heavy metal pollution on mosquito ecology. Anopheles gambiae s.s. were selected for cadmium, copper or lead tolerance through chronic exposure of immature stages to solutions of the metals for three successive generations. Biological costs were assessed in the fourth generation by horizontal life table analysis. Tolerance in larvae to cadmium (as cadmium chloride, CdCl(2)), copper [as copper II nitrate hydrate, Cu(NO(3))(2) 2.5 H(2)O] and lead [as lead II nitrate, Pb(NO(3))(2)], monitored by changes in LC(50) concentrations of the metals, changed from 6.07 microg/L, 12.42 microg/L and 493.32 microg/L to 4.45 microg/L, 25.02 microg/L and 516.69 microg/L, respectively, after three generations of exposure. The metal-selected strains had a significantly lower magnitude of egg viability, larval and pupal survivorship, adult emergence, fecundity and net reproductive rate than the control strain. The population doubling times were significantly longer and the instantaneous birth rates lower in most metal-selected strains relative to the control strain. Our results suggest that although An. gambiae s.s. displays the potential to develop tolerance to heavy metals, particularly copper, this may occur at a significant biological cost, which can adversely affect its ecological fitness.

An international comparison study of stage of colorectal cancer at diagnosis: how does New Zealand compare?

AIM

The high incidence rates of colorectal cancer (CRC) in New Zealand (NZ) are well publicised. Minimal information is available comparing national extent of this disease at time of diagnosis with other countries, especially countries now performing screening for CRC. Just how late do our cancers present? What is the difference compared with other countries now performing screening?

METHOD

Data were retrieved and analysed from the World Health Organization and Cancer Registries in New Zealand and five other countries from 2001-2004. Extent of disease was classified as localised, regional, distant and unknown.

RESULTS

NZ has the lowest percentage of surgically curable localised disease (28%) when compared with Australia (New South Wales) (34%), United Kingdom (42%), American (SEER-9) (40%) and Hong Kong (35%) data. 20% of disease at diagnosis in NZ is metastatic.

CONCLUSION

By international standards, NZ has a marked and previously undefined low rate of early stage diagnosis of CRC. Extent of disease is more advanced in New Zealand patients than in other countries with recently commenced screening programmes (e.g. Australia and the UK). In 2001, NZ also had the highest age-specific incidence of colorectal cancer in the 50-70 years age group, when compared with Australia, USA, UK and Japan. Colorectal cancer will continue to be a significant health issue for the NZ population, with predicted increasing total numbers of people affected, and increasing costs of chemotherapy for advanced cancer. The concerning international comparisons shown in this article further emphasize the need for more immediate strategies to improve rates of early stage colorectal cancers at time of diagnosis.

Lipid-rich pleural mesothelioma in a dog

An 11-year-old, neutered, male Golden Retriever cross dog was euthanized following a history of recurrent pericardial effusions. At necropsy, blood-tinged pericardial and intrathoracic effusions were seen along with numerous firm to hard plaque-like masses that studded the epicardial, pericardial, mediastinal, and costal pleural surfaces. Within the right thorax, the lesions coalesced into a large mass that occupied most of the cavity. Histologically, the masses were composed of solid sheets and papillary aggregates of medium-sized polygonal cells that contained abundant vacuolated to clear cytoplasm. Some of the cytoplasmic vacuoles stained positive with oil red O. The stroma contained metaplastic trabeculae of woven and lamellar bone. Immunohistochemically, the neoplastic cells expressed vimentin, pancytokeratin, and S-100 protein. Transmission electron microscopy corroborated the presence of intracytoplasmic vacuoles and demonstrated prominent intercellular junctional complexes and apically located microvilli. These findings are consistent with a lipid-rich variant of mesothelioma. To the authors' knowledge, this is the first report of a lipid-rich mesothelioma in a dog.

Multidisciplinary treatment of colorectal cancer in New Zealand: survival rates from 1997-2002

INTRODUCTION

The surgical and oncological treatment of colorectal cancer has undergone steady evolution over the last 20 years, however nationally derived survival figures have been disappointingly slow to improve. This study is an analysis of prospectively collected data (taken over a 6-year period) on the outcome of colorectal cancer management from a single university surgical unit in New Zealand.

METHODS

A comprehensive dataset was prospectively collected on all patients seen with colorectal cancer by a single surgical team, and complete follow-up was obtained. Details of surgical and oncology treatment of the primary lesion and of any subsequent disease and treatment were recorded. Survival was analysed by clinical and pathological variables.

RESULTS

Over 6 years, 244 new patients with a total of 263 primary colorectal cancers were seen.; 97% of these patients had an operation and 95% had the primary tumour resected. The mortality after elective operation was 0.5% (1/197) and 8% (3/39) after urgent or emergency surgery. After a median follow-up of 32 months, recurrence in the pelvis was apparent in 1 of 72 patients after curative resection of rectal cancer and 4 of 18 after palliative resection, thus giving a total pelvic recurrence rate of 6% at 30 months. The 5-year survival rate of all new patients seen with a rectal cancer was 58% and 56.5 % for patients with a colon cancer.

CONCLUSIONS

A combination of low operative mortality rates, low local recurrence rates in rectal cancer, the increasing use of adjuvant therapies, and careful follow up to detect (and where possible resect) metastatic disease at an early stage is associated with good cancer-specific survival figures. However further improvement in survival will need a shift to earlier stage at diagnosis and more effective chemotherapy (both in the adjuvant setting and for advanced disease) if significant gains in survival are to be made.

Peripheral pulmonary artery stenosis in a four-month-old West Highland White Terrier

A 4-month-old West Highland White Terrier was evaluated for dyspnea. Severe cardiac silhouette enlargement was present radiographically. Severe right ventricular hypertrophy and dilation with a dilated pulmonary trunk and a stenosis of the right pulmonary artery were diagnosed via echocardiography. Additional areas of peripheral pulmonary artery stenosis were diagnosed with nonselective computed tomography (CT) angiography and selective fluoroscopic angiography. Balloon dilation therapy was unsuccessful and the imaging findings were confirmed at necropsy.

Grading the evidence: levels of evidence and grades of recommendation

Evidence-based medicine is using the best available evidence in order to make accurate and knowledgeable treatment decisions. It is not the automatic gainsay of "low quality" evidence and acceptance of randomized controlled trials (RCT's). To be able to make a sound recommendation for a therapy based on the best available evidence, it is necessary to follow steps in acquiring literature, appraising it for study design and quality, and to assess its results, as well as look at the net benefits and net harms.

The pharmacokinetics of a single rectal dose of paracetamol (40 mg x kg(-1)) in children with liver disease

BACKGROUND

The aim of our study was to measure the serum paracetamol concentrations achieved following a single rectal loading dose of 40 mg x kg(-1) in children with chronic liver disease.

METHODS

We recruited 17 children (3-15 years, 10.6-75 kg) undergoing minor surgical procedures under general anesthesia. Paracetamol was administered at the end of surgery and blood samples were taken for analysis at 2, 3, 4, 6 and 8 h postdose.

RESULTS

The mean Cmax of 11.4 mg x l(-1) [coefficient of variation (CV) 66%] was achieved at a Tmax of 2.7 h (CV 42%). The relative bioavailability (F) of the suppository formulation was not estimated, but clearance (Cl/F) estimates 0.73 l x kg(-1) x h(-1) (CV 87%) and time-concentration profiles for these children were similar to the normal pediatric population.

CONCLUSIONS

There are currently no biologic markers available for monitoring possible hepatotoxicity in this cohort of patients with liver disease, but our data suggest that a single-dose suppository is a satisfactory analgesic alternative.