Managing perianal Crohn's fistula in the anti-TNFα era

Perianal fistulas in Crohn's disease are common and difficult to treat. Their aetiology is poorly understood. Assessment is clinical, endoscopic and radiological, and management is undertaken by a multidisciplinary team of gastroenterologists, surgeons and radiologists. Surgical drainage of the fistula tract system with the placement of loose setons precedes combined therapy with immunosuppressant and anti-TNFα agents in most patients. Proctitis should be rigorously eliminated where possible. Definitive surgical repair is sometimes possible and diversion or proctectomy are occasionally required. Combined medical and surgical management represents a promising avenue for the future.

Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey

Purpose

Evidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent.

Methods

Surgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined.

Results

The study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons’ personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these.

Conclusion

In the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.

Evidence-based review of enhancing postoperative recovery after breast surgery

BACKGROUND

The introduction of enhanced recovery after surgery (ERAS) protocols has revolutionized preoperative and postoperative care. To date, however, the principles of enhanced recovery have not been applied specifically to patients undergoing breast surgery.

METHODS

Based on the core features of ERAS, individual aspects of postoperative care in breast surgery were defined. A comprehensive search of MEDLINE, PubMed, Embase and the Cochrane Library database was performed from 1980 to 2010 to determine the best evidence for perioperative care in oncological breast surgery. A graded recommendation based on the best level of evidence was then proposed for each feature of ERAS.

RESULTS

Twelve core features of enhanced recovery after breast surgery were identified. Use of the thoracic block, from both analgesic and anaesthetic viewpoints, is well supported by evidence and should be encouraged. Trials specific to breast surgery regarding aspects such as perioperative fasting, preanaesthetic medication, prevention of hypothermia and postdischarge support are scarce, and evidence was extrapolated from non-breast trials. Trials on postoperative analgesia and prevention of postoperative nausea and vomiting in breast surgery are generally of small numbers. In addition, there is heterogeneity between studies.

CONCLUSION

This review suggests that the principles of enhanced recovery can be adopted in breast surgery. A 12-point protocol is proposed for prospective evaluation.

Incidence of Breast Cancer in Patients Undergoing Diagnostic Duct Excision for Pathological Nipple Discharge

BackgroundWomen with pathological nipple discharge (PND), defined as single duct, blood stained or serous discharge, usually undergo diagnostic surgery to exclude breast cancer. The purpose of this study was to ascertain the incidence of breast cancer in women undergoing such surgery in our unit and examine the use of nipple discharge cytology.MethodsPatients who underwent either total duct excision (Hadfield's procedure) or microdochectomy at City Hospital, Birmingham between January 2005 & April 2009 were identified from hospital computer records. In total 139 women were identified but 37 were excluded as they did not have PND and underwent surgery for indications such as recurrent episodes of sepsis due to peri-ductal mastitis, for symptomatic relief of nipple discharge and for correction of nipple inversion.Overall, 102 patients with PND and no other clinical signs of malignancy underwent diagnostic duct surgery. Data collected included patient age, laterality of surgery, radiological imaging undertaken, nipple discharge cytology results and final pathology from the resection specimen.ResultsThe majority of patients (99%) were female. Patient age ranged from 21 – 81 years, with a median of 50 years. Fifty nine patients (57.8%) had surgery for left breast symptoms, 41 (40.2%) for the right side and 2 patients (2%) had bilateral surgery. Most patients had imaging – 50 patients (49.0%) had mammography, 41 (40.2%) had mammography plus ultrasound whilst 7 (6.9%) had ultrasound alone. Only 4 patients (3.9%) had no imaging and all these patients were < 35 years. Imaging did not show any features of breast cancer in any of the patients.Nipple discharge cytology showed benign changes (C1/C2) in 65 patients (63.7%), atypical cells (C3) in 21 patients (20.6%) and suspicious or malignant cells (C4/C5) in 4 patients (3.9%) whilst 12 patients (11.8%) did not have cytology performed. Hadfield's was the most common operation (61.8%) and was performed in an older age group (median age 55yrs) compared to microdochectomy (median age 43 yrs) (p=0.02 Mann-Whitney test).The most frequent primary pathological findings were intraduct papilloma (39.2%) and duct ectasia (38.2%). Other benign changes including fibrocystic disease accounted for 8.9% whilst 14 patients (13.7%) had either invasive or in-situ breast cancer. All patients with suspicious or malignant cytology were found to have an underlying breast cancer, but of note, 13.8% of patients with benign cytology were found to have breast cancer. One male patient who did not have nipple cytology performed was found to have DCIS. Of the 14 patients diagnosed with breast cancer, 8 (57%) had pure ductal carcinoma in situ whilst 6 (43%) had foci of invasive disease in additional to the DCIS.Result of Nipple Discharge Cytology & Final PathologyCytology Resultn=No. Patients with breast cancerNo cytology121 (8.3%)Benign (C1/C2)659 (13.8%)Atypical (C3)210 (0%)Suspicious / Malignant (C4/C5)44 (100%) ConclusionsNipple discharge cytology is unreliable in diagnosing the cause of pathological nipple discharge and its routine use should be reconsidered. All patients with pathological nipple discharge require diagnostic surgery.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6014.

Association between antibodies to the MR 67,000 isoform of glutamate decarboxylase (GAD) and type 1 (insulin-dependent) diabetes mellitus with coexisting autoimmune polyendocrine syndrome type II

By using an immunoprecipitation assay, we analysed reactivity of autoantibodies to human recombinant GAD65 and GAD67 in sera from patients with autoimmune polyendocrine syndrome Type II (APS II) with and without Type 1 (insulin-dependent) diabetes mellitus (IDDM) compared to patients with organ-specific autoimmunity. Overall antibodies to GAD65 were correlated with IDDM in all study groups, whereas GAD67 antibodies were associated with IDDM when APS II coexists. Antibodies to GAD65 and GAD67 were detected in 13 (44.8%) and 7 (24.1%) out of 29 APS II patients with IDDM, but in only 4 (13.8%) and 2 (6.9%) out of 29 APS II patients without IDDM, respectively (p < 0.05). In short-standing IDDM (< 1 year), antibodies to GAD67 were significantly more frequent in patients with APS II (5 of 9 [55.6%] subjects) compared to matched diabetic patients without coexisting polyendocrinopathy (1 of 18 [5.6%] subjects) (p < 0.02). The levels of GAD65 (142 +/- 90 AU) and GAD67 antibodies (178 +/- 95 AU) were significantly higher in patients with polyglandular disease than in patients with isolated IDDM (91 +/- 85 AU and 93 +/- 57 AU) (p < 0.02). Interestingly, all 11 GAD67 antibody positive subjects also had GAD65 antibodies (p < 0.0001), and in 10 of 11 anti-GAD67 positive sera the GAD67 antibodies could be blocked by either GAD67 or GAD65, suggesting the presence of cross-reactive autoantibodies. No correlation was observed between GAD antibodies and age, sex or any particular associated autoimmune disease, besides IDDM.(ABSTRACT TRUNCATED AT 250 WORDS)

A multiplicity of protein antigens in subcellular fractions of rat insulinoma tissue are able to stimulate T cells obtained from non-obese diabetic mice

Type 1 (insulin-dependent) diabetes mellitus is a T-cell mediated autoimmune disease with a number of different proteins being implicated as target autoantigens. A 38 kDa protein residing in the insulin secretory granule of insulinoma tissue is recognized by T-cell clones from a newly-diagnosed Type 1 diabetic patient. We have investigated the capacity of normal rat pancreatic beta-cell extracts and various subcellular fractions of transplantable RIN tissue to induce proliferation of T cells from non-obese diabetic (NOD) mice and H-2 identical NON.NOD-H-2g7 control mice. Normal rat islet beta-cell protein fractions induced intense, dose-dependent proliferation of NOD splenic T cells, but only marginal proliferative responses of NON.NOD-H-2g7 splenic T cells. To further localize the target antigens, four different subcellular fractions from RIN tissue were used as a source of antigen; here in particular the cytosolic proteins showed dose-dependent activation capacity with splenic T cells in NOD animals. These activities were absent in control mice. There was no proliferation after incubation with microsome preparations from other rat endocrine tissues. Purified carboxypeptidase H did not have any stimulatory activity on NOD T cells. Fractionation of the RIN cytosolic proteins showed a large number of different fractions eliciting proliferative activity. These results demonstrate that NOD T cells respond to a large number of potential islet beta-cell target antigens and it will be necessary to utilize NOD T-cell clones to identify the number and nature of these antigens.

Antineutrophil cytoplasmic autoantibodies (ANCA) in acute pancreatitis

Antineutrophil cytoplasmic autoantibodies, which are now considered reliable serological markers of acute necrotizing vasculitic diseases, were measured in 11 patients with acute necrotizing pancreatitis and 12 patients with acute interstitial pancreatitis. When tested by indirect immunofluorescence, none of the sera was positive for diffuse cytoplasmic staining, and none was positive for perinuclear staining of antineutrophil cytoplasmic antibodies. Also by the sensitive enzyme-linked immunosorbent assay, none of the sera was positive when purified alpha-granule fraction of granulocytes was used as an antigen. We can therefore conclude that neither the diffuse cytoplasm-reacting, nor the perinuclear form of antineutrophil cytoplasmic antibodies, is involved in cases of acute pancreatitis.

Antibodies to the M(r) 64,000 (64K) protein in islet cell antibody positive non-diabetic individuals indicate high risk for impaired beta-cell function

A prospective study of a normal childhood population identified 44 islet cell antibody positive individuals. These subjects were typed for HLA DR and DQ alleles and investigated for the presence of antibodies to the M(r) 64,000 (64K) islet cell antigen, complement-fixing islet cell antibodies and radiobinding insulin autoantibodies to determine their potency in detecting subjects with impaired Beta-cell function. At initial testing 64K antibodies were found in six of 44 islet cell antibody positive subjects (13.6%). The same sera were also positive for complement-fixing islet cell antibodies and five of them had insulin autoantibodies. During the follow-up at 18 months, islet cell antibodies remained detectable in 50% of the subjects studied. In all six cases who were originally positive, 64K antibodies were persistently detectable, whereas complement-fixing islet cell antibodies became negative in two of six and insulin autoantibodies in one of five individuals. HLA DR4 (p less than 0.005) and absence of asparic acid (Asp) at position 57 of the HLA DQ beta chain (p less than 0.05) were significantly increased in subjects with 64K antibodies compared with control subjects. Of 40 individuals tested in the intravenous glucose tolerance test, three had a first phase insulin response below the first percentile of normal control subjects. Two children developed Type 1 (insulin-dependent) diabetes mellitus after 18 and 26 months, respectively. Each of these subjects was non-Asp homozygous and had persistent islet cell and 64K antibodies.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin autoantibodies as determined by competitive radiobinding assay are positively correlated with impaired beta-cell function--the Ulm-Frankfurt Population Study

Out of a random population of 4208 non-diabetic pupils without a family history of Type I diabetes 44 (1.05%) individuals had islet cell antibody (ICA) levels greater or equal to 5 Juvenile Diabetes Foundation (JDF) units. 39 of these ICA-positives could be repeatedly tested for circulating insulin autoantibodies (CIAA) using a competitive radiobinding assay. The results were compared with the insulin responses in the intravenous glucose tolerance tests (IVGTT) and with HLA types. Six pupils were positive for CIAA. All of them had complement-fixing ICA, and 5 of them were HLA-DR4 positive. Three of the 6 showed a first-phase insulin response below the first percentile of normal controls. Our data indicate that in population-based studies CIAA can be considered as a high risk marker for impaired beta-cell function in non-diabetic ICA-positive individuals.

[Epidemiologic studies of the recognition of the preclinical phase of type I diabetes in school children]

Sera of 4208 schoolchildren in Ulm and surrounding areas (1916 boys, 2292 girls; mean age 13.9 [7-21] years) were analysed for the presence of cytoplasmatic islet-cell antibodies (ICA). ICA were demonstrated in 44 children (1.05%). Complement-fixing ICA (CF-ICA) were found in six of them, insulin autoantibodies (IAA) in seven. The early phase of insulin response in the intravenous glucose tolerance test was below the 1st percentile of normal controls in two of the ICA-positive children. In the course of the subsequent 6-9 months the ICA disappeared in half of the previously positive children. In the two with abnormal glucose tolerance tests ICA, CF-ICA and abnormal insulin secretion persisted during the observation period of 9 months. In another CF-ICA-positive schoolchild insulin response to the glucose tolerance test fell below the 1st percentile after 6 months. These results indicate that, even in an unselected group of children, persisting ICA and CF-ICA are high-risk markers for abnormal insulin secretion, which precedes the onset of type I diabetes.