The ELECLA trial: A multicentre randomised control trial on outcomes of neoadjuvant treatment on locally advanced colon cancer

BACKGROUND

Colon cancer (CC) is a public health concern with increasing incidence in younger populations. Treatment for locally advanced CC (LACC) involves oncological surgery and adjuvant chemotherapy (AC) to reduce recurrence and improve overall survival (OS). Neoadjuvant chemotherapy (NAC) is a novel approach for the treatment of LACC, and research is underway to explore its potential benefit in terms of survival. This trial will assess the efficacy of NAC in LACC.

METHODS

This is a multicentre randomised, parallel-group, open label controlled clinical trial. Participants will be selected based on homogenous inclusion criteria and randomly assigned to two treatment groups: NAC, surgery, and AC or surgery followed by AC. The primary aim of this study is to evaluate the 2-year progression-free survival (PFS), with secondary outcomes including 5-year PFS, 2- and 5-year OS, toxicity, radiological and pathological response, morbidity, and mortality.

DISCUSSION

The results of this study will determine whether NAC induces a clinical and histological tumour response in patients with CCLA and if this treatment sequence improves survival without increasing morbidity and mortality.

REGISTRATION NUMBER

NCT04188158.

Survival and safety after neoadjuvant chemotherapy or upfront surgery for locally advanced colon cancer: meta-analysis

BACKGROUND

Neoadjuvant chemotherapy is increasingly used to treat locally advanced (T3-4 Nx-2 M0) colon cancer due to its potential advantages over the standard approach of upfront surgery. The primary objective of this systematic review and meta-analysis was to analyse data from comparative studies to assess the impact of neoadjuvant chemotherapy on oncological outcomes.

METHODS

A systematic review was conducted by searching the MEDLINE and Scopus databases. The search encompassed RCTs, propensity score-matched studies, and controlled prospective studies published up to 1 April 2023. As a primary objective, overall survival and disease-free survival were compared. As a secondary objective, perioperative morbidity, mortality, and complete resection were compared using the DerSimonian and Laird models.

RESULTS

A total of seven studies comprising a total of 2120 patients were included. Neoadjuvant chemotherapy was associated with a reduction in the hazard of recurrence (HR 0.73, 95% c.i. 0.59 to 0.90; P = 0.003) and death (HR 0.67, 95% c.i. 0.54 to 0.83; P < 0.001) compared with upfront surgery. Additionally, neoadjuvant chemotherapy was significantly associated with higher 5-year overall survival (79.9% versus 72.6%; P < 0.001) and disease-free survival (73.1% versus 64.5%; P = 0.028) rates. No significant differences were observed in perioperative mortality (OR 0.97, 95% c.i. 0.28 to 3.33), overall complications (OR 0.95, 95% c.i. 0.77 to 1.16), or anastomotic leakage/intra-abdominal abscess (OR 0.88, 95% c.i. 0.60 to 1.29). However, neoadjuvant chemotherapy was associated with a lower risk of incomplete resection (OR 0.70, 95% c.i. 0.49 to 0.99).

CONCLUSION

Neoadjuvant chemotherapy is associated with a reduced hazard of recurrence and death, as well as improved overall survival and disease-free survival rates, compared with upfront surgery in patients with locally advanced colon cancer.

Patient Reported Outcomes following Cancer of the Rectum (PROCaRe): protocol of a prospective multicentre international study

PURPOSE

Rectal cancer surgery presents challenges in achieving good oncological results and preserving functional outcomes. Different surgical approaches, including open, laparoscopic, robotic and transanal techniques, have been employed, but there is a lack of consensus on the optimal approach, particularly in terms of functional results. This study aims to assess bowel function and to compare outcomes of patients that had undergone surgery for mid-low rectal cancer across different surgical approaches.

METHOD

This is an international, multicentre, prospective cohort study. Inclusion criteria are patients diagnosed with rectal cancer below the peritoneal reflection, eligible for different surgical approaches for total mesorectal excision (TME). Data will be collected using validated questionnaires assessing bowel, sexual and urinary function, and quality of life (QOL). Secondary outcomes include short-term postoperative results. Data will be collected at baseline and 6, 12 and 24 months after index surgery or stoma reversal surgery.

CONCLUSION

This study will provide insights into the impact of different approaches for TME on bowel, sexual and urinary function, and overall QOL of patients undergoing rectal cancer surgery. The findings will provide important information to optimise the surgical strategy and to improve patient care in this population.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04936581 (registered 23 June 2021).

The role of transanal compared to laparoscopic total mesorectal excision (taTME vs. lapTME) for the treatment of mid-low rectal cancer in obese patients: outcomes of a multicenter propensity-matched analysis

To compare the rate of sphincter-saving interventions between transanal and laparoscopic Total Mesorectal Excision in this particular group of patients. A multicentre observational study was conducted using a prospective database, including patients diagnosed with rectal cancer below the peritoneal reflection and BMI ≥ 30 kg/m2, who underwent minimally invasive elective surgery over a 5-year period. Exclusion criteria were (1) sphincter and/or puborectalis invasion; (2) multi-visceral resections; (3) palliative surgeries. The study population was divided into two groups according to the intervention: transanal or laparoscopic total mesorectal excision. The primary outcome was the rate of sphincter-saving surgery. Secondary outcomes included conversion, postoperative complications, quality of the specimen, and survival. A total of 93 patients were included; 40 (43%) transanal total mesorectal excision were compared to 53 (57%) laparoscopic. In addition, 35 cases of transanal approach were case-matched with an equal number of laparoscopic approaches, based on gender, tumor's height, and neoadjuvant therapy. In both groups, 43% of the patients had low rectal cancer; however, the rate of sphincter-saving surgery was significantly higher in the transanal group (97% vs. 71%, p = 0.003). There were no conversions to open surgery in the transanal group, compared to 2 cases in the laparoscopic group (6%) (p = 0.246). The percentage of major complications was similar, including the rate of anastomotic leakage (10% transanal vs. 19% laparoscopic, p = 0.835). In our experience, higher percentages of sphincter-saving procedures and lower conversion rates are potential benefits of using the transanal approach in a complex surgical setting population of obese patients with mid-low rectal tumors when compared to laparoscopic.

ILEOSTIM trial: a study protocol to evaluate the effectiveness of efferent loop stimulation before ileostomy reversal

PURPOSE

A protective loop ileostomy is the most useful method to reduce sequelae in the event of an anastomotic leakage (AL) after rectal cancer surgery. However, it requires an additional stoma reversal surgery with its own potential complications. Postoperative ileus (POI) remains the most common complication after ileostomy reversal, which leads to an increase in morbidity, length of hospital stay (LOS) and overall healthcare costs. Several retrospective studies carried out in this field have concluded that there are insufficient evidence-based recommendations about the routine application of preoperative bowel stimulation in clinical practice. Here we discuss whether stimulation of the efferent limb before ileostomy reversal might reduce POI and improve postoperative outcomes.

METHODS

This is a multicentre randomised controlled trial to determine whether mechanical stimulation of the efferent limb during the 2 weeks before the ileostomy reversal would help to reduce the development of POI after surgery. This study was registered on Clinicaltrials.gov (NCT05302557). Stimulation will consist of infusing a solution of 500 ml of saline chloride solution mixed with a thickening agent (Resource©, Nestlé Health Science; 6.4 g sachet) into the distal limb of the ileostomy loop. This will be performed within the 2 weeks before ileostomy reversal, in an outpatient clinic under the supervision of a trained stoma nurse.

CONCLUSION

The results of this study could provide some insights into the preoperative management of these patients.

Circulating CD200 is increased in the secretory phase of women with endometriosis as is endometrial mRNA, and endometrial stromal cell CD200R1 is increased in spite of reduced mRNA

PROBLEM

Estrogen-dependent extrauterine implantation and growth of menstrual endometrial tissue affects roughly 10% of reproductive age women and depends on suppression of local innate immune defenses to prevent ectopic tissue rejection. Immunohistochemistry has shown the immune check-point inhibitor CD200 which can suppress rejection is expressed in eutopic endometrium and in ectopic deposits. Soluble CD200 accumulated in venules draining eutopic and ectopic endometrium of endometriosis cases in the secretory phase but not proliferative phase of the menstrual cycle, and should be increased in the circulation.

METHOD OF STUDY

Sera from endometriosis and non-endometriosis controls were tested by ELISA for CD200. Endometrial CD200, CD200R1 and CD200R2 mRNA in eutopic was quantified by RT-PCR and localized by in situ hybridization. CD200R1 protein was quantified by immunohistochemistry.

RESULTS

Secretory phase serum CD200 was elevated in women with endometriosis compared to controls. Serum CD200 correlated with matched endometrial CD200 mRNA levels. Expression of mRNA for CD200R1 which signals immune suppression was decreased whereas mRNA for the CD200R2 activating receptor was increased. In situ staining of CD200R1 and CD200R2 mRNA showed both receptors were expressed and the fraction of CD200R that is CD200R1 was reduced in secretory and menstrual phase endometriosis endometrium consistent with the RT-PCR result. By contrast, CD200R1 protein and CD200R1 fraction of total CD200R protein were increased in endometriosis.

CONCLUSIONS

Failure to suppress circulating CD200 levels in the secretory phase had an 87% specificity and 90% sensitivity for endometriosis. CD200 and increased CD200R1 expression may facilitate development of ectopic deposits by suppressing rejection mechanisms.

How to perform an anastomosis following a low anterior resection by transanal total mesorectal excision surgery: from top to bottom techniques

AIM

The aim was to describe the range of possibilities and our group's clinical outcomes when performing different types of anastomosis during transanal total mesorectal excision (taTME).

METHOD

A retrospective analysis was performed based on four taTME series from 2016 to 2021. Inclusion criteria were patients with rectal cancer in whom a sphincter-saving low anterior resection by taTME was performed. Four different techniques were employed for the anastomosis construction: (A) abdominal view, (B) transanal view, (C) hand-sewn coloanal anastomosis and (D) pull-through. Intra-operative and postoperative data were collected and compared.

RESULTS

A total of 161 patients were included. Tumour height was lower in groups C and D (4 [3-5] vs. 7 [6-8] group A vs. 6 [5-7] group B, P = 0.000), requiring a hand-sewn anastomosis. A transanal extraction of the specimen was more commonly performed in groups C and D (over 60% vs. 30% in groups A and B, P = 0.000). The rate of temporary stoma was similar between groups A, B and C (ranging from 84% to 98%) but was significantly lower in group D (P = 0.000). The overall rate of complications was similar between groups; however, group D had longer length of stay (15 days vs. 5-6 in groups A, B and C, P = 0.026).

CONCLUSION

Every type of anastomosis construction after a taTME procedure seems to be safe and feasible and should be chosen based on surgeon's experience, tumour height and the length of the rectal cuff after the rectal transection. Colorectal surgeons should be familiar with these techniques in order to choose the one that benefits each patient the most.

Cohort profile: the Spanish Early-onset Colorectal Cancer (SECOC) cohort: a multicentre cohort study on the molecular basis of colorectal cancer among young individuals in Spain

Purpose

The Spanish Early-onset Colorectal Cancer (SECOC) study is a multicentre prospective cohort established in Spain to investigate the molecular basis of early-onset colorectal cancer (EOCRC), including metabolic alterations.

Participants

220 patients with EOCRC have been enrolled since January 2019 through 18 centres across Spain. Individual-level data were collected by questionnaire, including lifestyle and other colorectal cancer-related factors. Medical record review was performed to capture clinical, histopathological and familial cancer history data. Biospecimen collection (blood, stool, tissue) at diagnosis and at various time points across treatment, as applicable, is also completed.

Findings to date

Participants had a median age of 44 years (range 14–49), and the majority are men (60%), with individuals age 40–49 years at EOCRC diagnosis being over-represented. Forty-three per cent of participants were diagnosed with a tumour in the rectosigmoid junction/rectum. Nearly two-thirds of EOCRC cases (64%) were diagnosed with advanced stage (III–IV) disease, and 28% of cases had no reported familial history of cancer.

Future plans

We are actively recruiting and observing participants; we plan to administer follow-up questionnaires and perform additional biospecimen collection. This prospective cohort offers a unique, rich resource for research on EOCRC aetiologies and will contribute to larger international efforts to disentangle the rising disease burden.

Neoadjuvant chemotherapy for locally advanced colon cancer patients: Long-term results from a single institutional experience

e15598

Background: Neoadjuvant chemotherapy (NAC) is an emerging alternative in the management of patients with locally advanced colorectal cancer (LACRC), with promising results in terms of R0 resection rates, compliance, postoperative morbidity and a trend towards reduced risk of relapse. However, more mature data are required. We evaluated the long-term outcome of this strategy in our institution. Methods: We retrospectively analysed LACRC patients treated preoperatively with either biweekly FOLFOX or XELOX at standard doses as a follow-up of our previous experience with this neoadjuvant approach. Patients were identified from a prospectively collected tumor registry database from our institution. Clinical staging was based on colonoscopy and CT-scan. Only patients with radiological signs of lymph node involvement and/or extramural invasion > 5 mm were included. The uracil/dihidrouracil ratio was calculated at baseline as a surrogate marker of DPD deficiency. Pathological tumor regression was graded according to the MSKCC and toxicity with the NCI-CTCAE 4.0. Results: From February 2006 to November 2019 91 pts with MSS LACRC (M/F: 62/29; median age 66. Clinical stage; T3: 60.4%, T4: 37.4%, N+: 75.8%; Sideness: 82.4% left located were analysed. Preoperative chemo was FOLFOX in 46 pts and CAPOX in 45 pts. Median number of preoperative cycles was 4 (range 1-10). Side effects profile included G3-4 diarrhea (3.3%), G2 sensitive neuropathy (12.1%) and G2 neutropenia (4.4%). 9 pts had a treatment delay due to haematological toxicity. No progressive disease was noted during neoadjuvant chemotherapy. All patients underwent surgery, most of them (63.7%) by a laparoscopic approach. pCR was found in 11 pts (12.1%). Grade 3, 3+ and 4 tumor regression according to MSKCC score was reached in 50.5% of the patients (Median number of harvested nodes was 17 (range 7-51), with 75.8% being ypN0. Lymphovascular and perineural invasion were found in 7.7% and 6.6% of the patients, respectively. The median hospital stay was 7 days (3-36) and 13 pts develop any surgical complication. 37.4% received adjuvant treatment. After a median follow-up of 63 months, median progression-free (PFS) and overall survival (OS) have not been reached. 5-year actuarial PFS for right and left LACRC was 77 and 87%, respectively. Conclusions: Our data add to the growing evidence suggesting that NAC may play a meaningful role in LACRC patients

The impact of SARS-CoV-2 infection on the surgical management of colorectal cancer: lessons learned from a multicenter study in Spain

OBJECTIVE

the aim of the study was to analyze the management of colorectal cancer (CRC) patients diagnosed with CRC or undergoing elective surgery during the period of the SARS-CoV-2 pandemic.

MATERIAL AND METHODS

a multicenter ambispective analysis was performed in nine centers in Spain during a four-month period. Data were collected from every patient, including changes in treatments, referrals or delays in surgeries, changes in surgical approaches, postoperative outcomes and perioperative SARS-CoV-2 status. The hospital's response to the outbreak and available resources were categorized, and outcomes were divided into periods based on the timeline of the pandemic.

RESULTS

a total of 301 patients were included by the study centers and 259 (86 %) underwent surgery. Five hospitals went into phase III during the peak of incidence period, one remained in phase II and three in phase I. More than 60 % of patients suffered some form of change: 48 % referrals, 39 % delays, 4 % of rectal cancer patients had a prolonged interval to surgery and 5 % underwent neoadjuvant treatment. At the time of study closure, 3 % did not undergo surgery. More than 85 % of the patients were tested preoperatively for SARS-CoV-2. A total of nine patients (3 %) developed postoperative pneumonia; three of them had confirmed SARS-CoV-2. The observed surgical complications and mortality rates were similar as expected in a usual situation.

CONCLUSIONS

the present multicenter study shows different patterns of response to the SARS-CoV-2 pandemic and collateral effects in managing CRC patients. Knowing these patterns could be useful for planning future changes in surgical departments in preparation for new outbreaks.

Pharmacokinetically-guided preoperative FOLFOX chemotherapy for locally advanced colon cancer patients

4104

Background: Preliminary results from ongoing randomised trials suggest that neoadjuvant chemotherapy (NAC) may be an alternative approach to conventional adjuvant therapy. We assessed the feasibility and activity of incorporating a pharmacokinetically (PK) guided dose adjustment of 5-FU within preoperative Folfox. Methods: Radiologically staged LACC pts, T4 or T3 with extramural depth >5mm beyond the muscularis propia, were planned to receive 4-6 biweekly cycles of Oxalipatin (85mg/m²), Leucovorin (400 mg/m²), bolus 5-FU (400 mg/m2) and infusional 5-FU (initial dose of 2400mg/m² in 46h and subsequent cycles tailored according to PK monitoring in order to reach a target 5-FU area under the curve (AUC) between 20-30 mg∙h∙L-1). Dihidrouracil deshidrogenase was determined before the first cycle in order to detect pts with 5-Fu intolerance. Three serum samples were obtained during the 5-Fu infusion in the first two cycles. Pathological tumor regression was graded according to the MSKCC classification and toxicity to the NCI-CTCAE 4.0. Results: From June 2012 to August 2017, 45 pts (M/F: 35/10; median age 63) with LACC (T3: 66.7%; T4: 31.1%; T2: 2.2%; N+:66.6%) were evaluated. Median dose of 5-FU was 4500 mg. 48.9% of the pts required a 5-FU dose increase to reach the target AUC. Side effects profile included G3 neutropenia (3 pts), G2 diarrhea (2 pts) and G2 asthenia (9 pts). NAC was discontinued in 3 pts due to small bowell obstruction requiring surgery (no progressive disease during NAC). R0 resection rate was 100% (93.3% laparoscopy-assited). MSKCC score included grades 4, 3+ and 3 in 11.1%, 26.7% and 28.9% of pts, respectively. A complete pathological response was found in 5 pts (11.1%). Median number of harvested nodes was 16 (7-51), 80% ypN0. Those pts with AUC 25-30 had a 3-fold higher likelihood of achieving a MSKCC 3, 3+ and 4 responses. Median time to hospital discharge was 7 days (range 4-22). After a median follow-up of 60 months (44-66), 5-year actuarial PFS is 88.8%. Conclusions: Preoperative PK-adjusted FOLFOX in LACC pts is safe and well tolerated, achieving remarkable rates of major pathological responses and R0 resections.

A173 RECOGNIZING RARE PRESENTATIONS OF POLYPOSIS SYNDROMES AND THEIR ASSOCIATED MALIGNANCIES IN PEDIATRIC PATIENTS

Background

There is a range of polyposis syndromes and presentations in pediatrics. There are also associated extra-colonic malignancies of which to be cognizant when orchestrating the initial work-up of the various polyposis syndromes.

Aims

To use case review to highlight the importance of recognizing the breadth of presentations of polyposis syndromes in pediatrics.

Methods

Two recent pediatric presentations of polyposis with extra-intestinal manifestations were identified, chart review completed, and compared with newly published ESPGHAN guidelines.

Results

Two patients with intestinal polyposis are presented, in which extra-colonic malignancies and genetic mutations were identified.

The first patient presented at age 16 with a history of fatigue and abdominal pain, and was found to have pancytopenia and splenomegaly. Initial work up included a bone marrow biopsy that was normal. The patient then underwent upper and lower endoscopic evaluation for increasing abdominal pain and persistent anemia and was found to have polymorphic polyps in the duodenum, sigmoid and rectum. On pathology, polyps were mostly inflammatory, but one was found to be hamartomatous. Additional screening revealed a thyroid nodule, found to be follicular carcinoma, requiring hemithyroidectomy. The patient was confirmed to have a PTEN mutation and was diagnosed with Cowden syndrome; following this diagnosis proceeded with a prophylactic bilateral mastectomy.

The second patient was referred at age 15 with a strong family history of APC-associated FAP. At the time of consultation she was asymptomatic and she remained so throughout her work-up. Screening endoscopy revealed 70–90 recto-sigmoid adenomatous polyps as well as scattered gastric and duodenal polyps. Her initial work-up also uncovered an early papillary thyroid carcinoma. Her treatment included a total thyroidectomy and total proctocolectomy with J-pouch and ileoanal anastomosis. Follow-up endoscopy continues for surveillance of numerous gastric adenomas which to this point have not progressed to high-grade dysplasia or malignancy.

Conclusions

These 2 cases highlight the importance of recognizing that neoplastic conditions typically diagnosed in adulthood can also present in the pediatric age group. Ideally, further guidelines in pediatrics would be beneficial to ensure a consistent approach to investigating polyposis and associated malignancies. Pertaining to our specific patients, each had identification of a thyroid malignancy before the recommended screening age of 18 as per the currently accepted guideline, and neither were symptomatic. More cases are needed to establish if this earlier recognition of disease is meaningful in postulating potential mortality associated with a later diagnosis.

Funding Agencies

None

Behavioral Responses and Pupa Development Patterns After Hypoxia or Anoxia in a Desiccation-Resistant Anastrepha ludens Strain

The aim of this study was to experimentally test for adult cross-resistance to hypoxia or anoxia in a desiccation-resistant population of Anastrepha ludens Loew. We compared desiccation resistant flies with unselected (control) flies by measuring the effect of pre-emergence hypoxia on some fitness parameters (emergence, flight ability, copulation success, latency to copulation, copulation duration, ovary size). Anoxia effects were determined using eye color changes during pupa development and fly emergence after re-oxygenation. Both strains were negatively affected in all measured parameters when exposed to hypoxia for more than 48 h. However, after hypoxia, control flies showed, in general, shorter latency to mate and longer copula duration than desiccation-resistant flies. Anoxia-induced arrest of pupa development, whereas returning to normoxia conditions induced resumption of development. Anoxia period length (longer than 72 h) increased mortality to 100% in the control line, whereas the desiccation-resistant line survived even at 120 h of anoxia. Thus, pre-release hypoxia must not exceed 24 h in order to maintain insect quality independently of fly type.

Rectal cancer treatment by transanal total mesorectal excision: Results in 100 consecutive patients

INTRODUCTION

The aim of this study is to describe and evaluate our clinical short-term surgical results of laparoscopic transanal total mesorectal excision.

METHODS

Analysis of 100 consecutive patients with mid and lower rectal cancer who underwent transanal total mesorectal excision from November 2013 to September 2018. Main outcomes described are operative data, morbidities, mortality and quality of the specimen. A comparative analysis was done between gender and simultaneous vs. non simultaneous abdominal-perineal surgery.

RESULTS

Mean patient age was 67 years (56-75), and 67% were male. On MRI, 50% were stage T3 tumors, and 52% had positive nodes. Mean distance of the tumor from anal verge was 4.9±1.3cm. A total of 58% underwent neoadjuvant treatment. Mean operative time was 262±40.7min; it was shorter in females (P<.001) and in simultaneous 2-field surgery. Median specimen distal free margin was 1.5cm (0.5-2.4). A total of 89% of the specimens were with complete mesorectum, with better results when a simultaneous approach was used (P=.047). The mean number of retrieved lymph-nodes was 15.2±11.6, and 26% of patients had positive nodes. Median length of stay was 5.5 days (4-8). Morbidities occurred in 36% of cases, and one patient died.

CONCLUSIONS

According to our experience, laparoscopic transanal total mesorectal excision is safe and effective with adequate circumferential and distal free margins and high quality of the resected mesorectum specimen. Post-operative morbidity is acceptable, according to the current literature.

RAFT-mediated polymerisation of dialkylaminoethyl methacrylates in tert-butanol

Dialkylaminoethyl methacrylates were polymerised by RAFT in tert-butanol to make macro-chain transfer agents for subsequent grafting onto various substrates.

The law on the streets: Evaluating the impact of Mexico's drug decriminalization reform on drug possession arrests in Tijuana, Mexico

BACKGROUND

In 2009, Mexican Federal Government enacted "narcomenudeo" reforms decriminalizing possession of small amounts of drugs, delegating prosecution of retail drug sales to the state courts, and mandating treatment diversion for habitual drug users. There has been insufficient effort to formally assess the decriminalization policy's population-level impact, despite mounting interest in analagous reforms across the globe.

METHODS

Using a dataset of municipal police incident reports, we examined patterns of drug possession, and violent and non-violent crime arrests between January 2009 and December 2014. A hierarchical panel data analysis with random effects was conducted to assess the impact of narcomenudeo's drug decriminalization provision.

RESULTS

The reforms had no significant impact on the number of drug possession or violent crime arrests, after controlling for other variables (e.g. time trends, electoral cycles, and precinct-level socioeconomic factors). Time periods directly preceding local elections were observed to be statistically associated with elevated arrest volume.

CONCLUSIONS

Analysis of police statistics parallel prior findings that Mexico's reform decriminalizing small amounts of drugs does not appear to have significantly shifted drug law enforcement in Tijuana. More research is required to fully understand the policy transformation process for drug decriminalization and other structural interventions in Mexico and similar regional and international efforts. Observed relationship between policing and political cycles echo associations in other settings whereby law-and-order activities increase during mayoral electoral campaigns.

Measuring improvement in knowledge of drug policy reforms following a police education program in Tijuana, Mexico

Background

Mexico’s 2009 “narcomenudeo reform” decriminalized small amounts of drugs, shifting some drug law enforcement to the states and mandating drug treatment diversion instead of incarceration. Data from Tijuana suggested limited implementation of this harm reduction-oriented policy. We studied whether a police education program (PEP) improved officers’ drug and syringe policy knowledge, and aimed to identify participant characteristics associated with improvement of drug policy knowledge.

Methods

Pre- and post-training surveys were self-administered by municipal police officers to measure legal knowledge. Training impact was assessed through matched paired nominal data using McNemar’s tests. Multivariable logistic regression was used to identify predictors of improved legal knowledge, as measured by officers’ ability to identify conceptual legal provisions related to syringe possession and thresholds of drugs covered under the reform.

Results

Of 1750 respondents comparing pre- versus post training, officers reported significant improvement (p < 0.001) in their technical understanding of syringe possession (56 to 91%) and drug amounts decriminalized, including marijuana (9 to 52%), heroin (8 to 71%), and methamphetamine (7 to 70%). The training was associated with even greater success in improving conceptual legal knowledge for syringe possession (67 to 96%) (p < 0.001), marijuana (16 to 91%), heroin (11 to 91%), and methamphetamine (11 to 89%). In multivariable modeling, those with at least a high school education were more likely to exhibit improvement of conceptual legal knowledge of syringe possession (adjusted odds ratio [aOR] 2.6, 95% CI 1.4–3.2) and decriminalization for heroin (aOR 2.7, 95% CI 1.3–4.3), methamphetamine (aOR 2.2, 95% CI 1.4–3.2), and marijuana (aOR 2.5, 95% CI 1.6–4).

Conclusions

Drug policy reform is often necessary, but not sufficient to achieve public health goals because of gaps in translating formal laws to policing practice. To close such gaps, PEP initiatives bundling occupational safety information with relevant legal content demonstrate clear promise. Our findings underscore additional efforts needed to raise technical knowledge of the law among personnel tasked with its enforcement. Police professionalization, including minimum educational standards, appear critical for aligning policing with harm reduction goals.

Mid-term oncologic outcome of a novel approach for locally advanced colon cancer with neoadjuvant chemotherapy and surgery

PURPOSE

Neoadjuvant chemotherapy is being actively tested as an emerging alternative for the treatment of locally advanced colon cancer (LACC) patients, resembling its use in other gastrointestinal tumors. This study assesses the mid-term oncologic outcome of LACC patients treated with oxaliplatin and fluoropyrimidines-based preoperative chemotherapy followed by surgery.

METHODS AND PATIENTS

Patients with radiologically resectable LACC treated with neoadjuvant therapy between 2009 and 2014 were retrospectively analyzed. Radiological, metabolic, and pathological tumor response was assessed. Both postoperative complications, relapse-free survival (RFS), and overall survival (OS) were studied.

RESULTS

Sixty-five LACC patients who received treatment were included. Planned treatment was completed by 93.8 % of patients. All patients underwent surgery without delay. The median time between the start of chemotherapy and surgery was 71 days (65-82). No progressive disease was observed during preoperative treatment. A statistically significant tumor volume reduction of 62.5 % was achieved by CT scan (39.8-79.8) (p < 0.001). It was also observed a median reduction of 40.5 % (24.2-63.7 %) (p < 0.005) of SUV_max (Standard Uptake Value) by PET-CT scan. Complete pathologic response was achieved in 4.6 % of patients. Postoperative complications were observed in 15.4 % of patients, with no cases of mortality. After a median follow-up of 40.1 months, (p ₂₅-p ₇₅: 27.3-57.8) 3-5 year actuarial RFS was 88.9-85.6 %, respectively. Five-year actuarial OS was 95.3 %.

CONCLUSION

Preoperative chemotherapy in LACC patients is safe and able to induce major tumor regression. Survival times are encouraging, and further research seems warranted.

What Does It Mean to Be “Mexican”? Social Construction of an Ethnic Identity

To better understand the impact of ethnic identity, it is important to examine people’s social construction, or definition, of that identity. In this study, the social construction of ethnic identity of predominantly low-acculturated, first-and second-generation U.S. Mexicans and Mexican Americans was examined by asking focus group participants to talk about what it meant to them to be members of their ethnic groups. These open-ended responses then were coded along Phinney’s aspects of ethnicity. Several interesting patterns emerged, some of which have not been emphasized in previous literature, such as conflict with African Americans and Chicanas/Chicanos. Discussion centers on the value of listening to people’s social constructions of their ethnic identity to better understand their social realities.

Spatial patterns of arrests, police assault and addiction treatment center locations in Tijuana, Mexico

AIMS

In the context of a public health-oriented drug policy reform in Mexico, we assessed the spatial distribution of police encounters among people who inject drugs (PWID) in Tijuana, determined the association between these encounters and the location of addiction treatment centers and explored the association between police encounters and treatment access.

DESIGN

Geographically weighted regression (GWR) and logistic regression analysis using prospective spatial data from a community-recruited cohort of PWID in Tijuana and official geographical arrest data from the Tijuana Municipal Police Department.

SETTING

Tijuana, Mexico.

PARTICIPANTS

A total of 608 participants (median age 37; 28.4% female) in the prospective Proyecto El Cuete cohort study recruited between January and December 2011.

MEASUREMENTS

We compared the mean distance of police encounters and a randomly distributed set of events to treatment centers. GWR was undertaken to model the spatial relationship between police interactions and treatment centers. Logistic regression analysis was used to investigate factors associated with reporting police interactions.

FINDINGS

During the study period, 27.5% of police encounters occurred within 500 m of treatment centers. The GWR model suggested spatial correlation between encounters and treatment centers (global R(2)  = 0.53). Reporting a need for addiction treatment was associated with reporting arrest and police assault [adjusted odds ratio = 2.74, 95% confidence interval (CI) = 1.25-6.02, P = 0.012].

CONCLUSIONS

A geospatial analysis suggests that, in Mexico, people who inject drugs are at greater risk of being a victim of police violence if they consider themselves in need of addiction treatment, and their interactions with police appear to be more frequent around treatment centers.

Clinical and Serologic Patterns in a Large Canadian Paediatric Cohort with Celiac Disease, At Presentation and Follow-Up

BACKGROUND: Celiac Disease (CD) is a chronic illness involving an autoimmune response to gluten, leading to small intestinal inflammation in genetically susceptible individuals. A weakness in the North American pediatric CD literature exists around serologic outcomes after initiation of a gluten free diet (GFD). Only one published North American pediatric study looks at normalization of TTG after initiation of a GFD and only assessed TTG normalization at 6 months post diagnosis. Data is also limited on other clinical patters such as levels of anemia and BMI over the course of treatment of CD.

OBJECTIVES: We sought to characterize serologic and clinical patterns in CD over an extended course using one of the largest databases of pediatric CD in North America.

DESIGN/METHODS: A retrospective review of all patients diagnosed with CD at our institution from 1996-2014 was completed. Patients required biopsy-proven CD according to the Marsh criteria. Data abstracted included age at diagnosis, gender, reason for referral, comorbidities, family history of CD and autoimmune conditions, BMI, hemoglobin, MVC, fer-ritin, IgA and anti-TTG levels. A Cochran-Armitage trend test was used to trend anti-TTG and hemoglobin normalization over time

RESULTS: 227 patients were identified who met study criteria. Visits with associated anti-TTG or hemoglobin analysis were categorized by time since diagnosis. At 6-12 months, 12-17 months, 18-23 months, 24-29 months, 30-35 months and 36-41 months from diagnosis 66.7% (n=144), 75% (n=40), 85.6% (n= 76), 86.9 (n= 23), 93.5 (n=62) and 95% (n= 20) of patients had normalized their anti-TTG levels respectively from a baseline of 100% abnormal TTG and 5.7% (n=140), 7.3% (n=41), 5.1% (n=77), 5.0% (n=20), 1.6% (n=60) and 5.0% (n=20) had anemia versus 18% at presentation.

CONCLUSION: The small p-value (p=&lt;0.0001) for the Cochran-Armitage test for anti-TTG normalization indicates the increased probability of a normalized anti-TTG as time from diagnosis increases. Knowledge of the slope of this trend could assist clinicians with better understanding the effectiveness of treatment for their patients. In this cohort, anti-TTG levels normalized over a broad time span, with increasing numbers of patients normalizing their anti-TTG through to the end of the study period. Further research goals aim to determine predictors of early anti-TTG normalization. In this cohort, the proportion of patient with anemia quickly decreased from a baseline of 18%, to general pediatric population levels between 6-12 months after treatment initiation and remained stable in this range through to the end of the study period with a non-significant p value (p=0.06) for trend over time.

Collapse

Patterns and management of distant failure in locally advanced rectal cancer: a cohort study

PURPOSE

To determine the long-term outcomes of locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiation (CRT) and surgery, and to analyze the management and survival once distant failure has developed.

METHODS

Data from LARC patients treated from 2000 to 2010 were retrospectively reviewed. CRT protocols were based on fluoropirimidines ± oxaliplatin. Follow-up consisted of physical examination, carcinoembryonic antigen levels, and chest-abdominal-pelvic CT scan.

RESULTS

The study included 228 patients with a mean age of 59 years. Forty-eight (21.1 %) patients had distant recurrence and 6 patients (2.6 %) had local recurrence. Median follow-up was 49 months. The 5- and 10-year actuarial disease free survival was 75.3 and 65.0 %, respectively. The 5- and 10-year actuarial overall survival (OS) was 89.6 and 71.2 %, respectively. Patients were classified as having liver (14 patients) or lung (27 patients) relapse according to the organ firstly metastasized. The variables significantly associated by univariate Cox analysis to survival were the achievement of an R0 metastases resection and the Köhne risk index, while the metastatic site showed a statistical trend. By multivariate Cox analysis, the only variable associated with survival was a R0 resection (HR = 16.3, p < 0.001). Median OS for patients undergoing a R0 resection was 73 months (95 % CI 67.8-78.2) compared to 25 months (95 % CI 5.47-44.5) in those non-operated patients (p < 0.001).

CONCLUSIONS

Combined treatment for LARC obtains a 5-year OS rounding 90 %. Follow-up based on thoracic-abdominal CT scan allows an early diagnosis of metastatic lesions. Surgical resection of metastases, regardless of their location, greatly increases the patient's survival rate.

[Small bowel intussusception in the adult caused by ileal submucous lipoma]

We present the case of a 68 year-old male patient with secondary intestinal intussuspection due to a submucous li-poma of the ileum. This is a rare entity in adults and is usually due to an organic lesion. The clinical manifestation is characterized by vomiting, abdominal pain and melenas. In our case the patient, following a colonoscopy and an abdominal CT-scan, was subjected to an extended resection of caecum and terminal ilium. At present, the precision of the etiological diagnosis of intussuspections has increased thanks to the development of image tests, like CT-scan. Early surgical treatment is recommended, without intraoperative deintussuspection given the high risk of presenting a malign or ischemic lesion in the adult.

Long-term oncologic results in cancer of the rectum treated by preoperative chemoradiotherapy and surgery: An analysis of 500 cases

BACKGROUND

The standard treatment for locally advanced cancer of the rectum (LACR) and selective cases of stage IV disease is preoperative chemoradiotherapy (CRT) followed by total mesorectal excision (TME). Despite reductions in local recurrence, disease-free survival (DSF) has remained stable in recent years.

OBJECTIVE

The objective of this study is to analyze patterns of recurrence, long-term survival and prognostic factors in a program of neoadjuvant CRT and surgery in LACR.

METHODS

Between January 1992 and December 2011, 446 patients with LACR and 54 patients (with single metastases) were treated with pre-operative long course CRT and surgery. Three hundred forty four (66.8%) anterior resections of the rectum and 123 (24.6%) abdomino-perineal resections were performed.

RESULTS

With a mean follow-up of 70.06 months, local recurrence was 4.8% and distant recurrence 25.5%. No differences were found in the histopathologic prognostic factors across the three groups studied depending on distance (cm) from the analmargin. Involvement of the circumferential resection margin (CRM+) was significantly greater in tumors in the distal third of the rectum (8.5%; p = 0.04). 67 patients (13.4%) showed a complete pathologic response. DSF at 5 and 10 years was significantly lower in patients with tumors affecting the distal third as compared to the middle third of the rectum (61.9% vs. 57.7%; p = 0.04). Tumors at this distal location resulted in a significantly higher incidence of lung metastases (p = 0.016).

Pleura nodosum: fetal squamous debris in an unusual location

We present a pathologic-radiologic case of a fetus with a right extralobar bronchopulmonary sequestration that required intervention in the form of a thoraco-amniotic shunt for management of a right pleural effusion. The intervention was successful in reducing the pleural effusion and the infant was born at 39 weeks gestational age but required some respiratory support for the 1st day of life. The pulmonary sequestration was excised on day 7 of life and demonstrated several small nodules on its pleural surface. Histologic examination demonstrated that the nodules consisted of granulomatous plaques containing squamous epithelium and hairs. The nodules are similar to those described in amnion nodosum, when the amniotic membrane incorporates fetal skin within the superficial tissue layers of the placenta in cases of oligohydramnios. To our knowledge, this is the 1st reported case of nodules containing amniotic fetal squamous debris to occur on lung visceral pleura.

Clinical significance of cellular and acellular mucin pools in rectal carcinoma following preoperative chemoradiotherapy

718

Background: Currently, the standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (CRT) followed by surgery. Pathological findings in post-treated specimens remain the most significant prognostic factor. The presence of mucin pools and their prognostic significance is a controversial issue. Methods: The aim of this study was to analyze the incidence of cellular and acellular mucin pools and their clinical significance in 446 consecutive prospectively collected specimens from patients with stages II/III treated with preoperative CRT and surgery. Results: Mucin pools were present in 182 specimens (40.8%); 66 (14.7%) were acellular, and viable tumor cells were identified in 116 (26.0%). If acellular mucin is considered as a type of response and not residual tumor, the complete pathological response rate was 12.8% (57 of 446). With a median follow-up of 79.0 months, the 5- and 10-year disease-free survivals for patients with acellular and cellular mucin pools, were 81.8% and 63.4%, respectively (p < 0.0225). The presence of cells in the colloid response to treatment was associated with a 2.5-fold increase in the possibility of dying of rectal cancer (HR = 2.5 [1.1 − 5.76], p= 0.028 univariant Cox regression analysis). Conclusions: Thus, our results suggest that cellular mucin pools are an indicator of an aggressive phenotype and harbingers of a worse prognosis.

Analysis of recurrence pattern and survival in locally advanced rectal cancer treated with neoadjuvant chemoradiation and surgery: 25 years of experience

744

Background: The standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiation (CRT) followed by total mesorectal excision (TME). Despite the significant reduction (~ 40%) in local recurrence, the overall survival (OS) and disease free survival (DFS) remain stable during last decade. We aimed to study the pattern of recurrence and it’s relationship with clinico-pathological data in 356 patients with LARC treated with CRT and TME in last 25 years. Methods: From a total of 621 patients, 356 with LARC were analyzed. In 55 (15.4%) the tumor was localized in upper third, in 120 (33.7%) in middle third and in 181 (50.8%) in distal third. The median dose of radiotherapy for the 3 groups was between 47.5 - 48.52 Gy. Chemotherapy was based on 5-FU or capecitabine combined with oxaliplatin. Type of surgery, pathological response grade, circumferential resection margin, lymphovascular invasion, colloid response, local recurrence incidence, distal relapse, OS and DFS were analyzed. Results: The median interval between the end of CRT and surgery was 40 days. 52 low anterior resection were carried-out in upper third (94.5%), 112 (93.3%) in middle third and 92 (50.8%) in distal third. Four patients from the middle third (3.3%) underwent abdominoperineal resection and 72 (39.8%) in the distal location. No differences were observed in number of lymphoid nodes, vascular perineural invasion, and pathological response grade. A pathological complete response was assessed in 5 patients (9.1%) in upper third, in 12 (10%) in middle third, as well in 32 (17.7%) in distal third. Median follow-up of 187 months. The 5-10 year DFS for the 3 groups was 75%, 76%, and 69%, and 75%, 71%, and 66% respectively. The local recurrence rate was 3.6%, 4.2%, and 6.1%. The distal recurrence was more frequent in the lung, 10.9%, 16.7%, 23.8%, with tendency to be significant (p<0.007) in distal third. Conclusions: In spite of the good local control with the association of preoperative CRT and TME in treatment of LARC, the development of distant metastases, especially in distal third, gives rise to new therapeutics schemes. Further research is warranted as to the benefits of adjuvant chemotherapy.

Impact of perineural and lymphovascular invasion on oncological outcomes in rectal cancer treated with neoadjuvant chemoradiotherapy and surgery

695

Background: The prognostic significance of perineural and/or lymphovascular invasion (PLVI) and its relationship with tumor regression grade (TRG) in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (CRT) and surgery. Methods: A total of 324 patients with LARC treated with CRT were operated on between January 1992 and June 2007. Tumors were graded using a quantitative 5-grade TRG classification, and the presence of PLVI was studied histologically. Results: At a median follow-up of 79.0 months (range 3–250 months), a total of 80 patients (24.7%) relapsed. The observed 5- and 10-year overall survival (OS) was 83.2% and 74.9% respectively. The 5- and 10-year disease-free survival (DFS) was 75.1% and 71.4%, respectively. A significant correlation was found between the TRG and survival (log rank, p<0.001). The 10-year OS and DFS was 32.7% and 31.8% for grade 1; 63.8% and 58.6% for grade 2; 75.0% and 70.4% for grade 3; 90.4% and 88.4% for grade 3+, and 96.0% and 97.1% for grade 4. In patients with PLVI, the TRG had no impact on survival. When excluding patients with PLVI, TRG was an independent prognostic factor for OS and DFS. Conclusions: The presence of PLVI is a more powerful prognostic factor than TRG in LARC patients treated with neoadjuvant CRT followed by surgery. PLVI denotes an aggressive phenotype, suggesting that these patients may benefit from adjuvant systemic therapy.

Effects of size, sex and teneral resources on the resistance to hydric stress in the tephritid fruit fly Anastrepha ludens

Water availability is recognized as one of the most important factors in the distribution and activity of terrestrial organisms. In the case of insects, hydric stress imposes a major challenge for survival because of the small surface-area-to-volume ratio they exhibit. In general, stress resistance is expected to co-vary positively with size; however, this pattern can become obscured in insects that exhibit sexual size dimorphism, as sexes differ in size and/or shape and have dissimilar resource allocations. In the present study, we use an allometric-based approach to (i) assess the desiccation and starvation stress resistance of teneral Anastrepha ludens flies, (ii) disentangle the relationships between resistance, size and sex and (iii) examine the adult fly body differences in water and lipid contents before and after exposure to stress. After controlling for sexual size dimorphism, an allometric increase of resistance with overall size was observed for all stress-based treatments. The scaling exponents that define the proportion of increase resistance varied with size traits and with type and degree of hydric stress. In this allometric relationship, and also in the relationships between mass and wing length and between size and teneral resources, the sexes maintained similar scaling exponents but differed in the intercepts. Males were more resistant to stress than females; this competitive advantage is probably linked to greater amounts of teneral lipids and more water use during stress.

Impact of perineural and lymphovascular invasion on oncological outcomes in rectal cancer treated with neoadjuvant chemoradiotherapy and surgery

BACKGROUND

The prognostic significance of perineural and/or lymphovascular invasion (PLVI) and its relationship with tumor regression grade (TRG) in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (CRT) and surgery.

METHODS

A total of 324 patients with LARC were treated with CRT and operated on between January 1992 and June 2007. Tumors were graded using a quantitative 5-grade TRG classification and the presence of PLVI was histologically studied.

RESULTS

At a median follow-up of 79.0 months (range 3-250 months), a total of 80 patients (24.7%) relapsed. The observed 5- and 10-year overall survival (OS) was 83.2 and 74.9 %, respectively. The 5- and 10-year disease-free survival (DFS) was 75.1 and 71.4%, respectively. A significant correlation was found between the TRG and survival (log rank, p < 0.001). The 10-year OS was 32.7% for grade 1, 63.8% for grade 2, 75.0% for grade 3, 90.4% for grade 3+, and 96.0%,for grade 4. The 10-year DFS was 31.8% for grade 1, 58.6% for grade 2, 70.4% for grade 3, 88.4% for grade 3+, and 97.1% for grade 4. In patients with PLVI, the TRG had no impact on survival. When excluding patients with PLVI, the TRG was an independent prognostic factor for OS and DFS.

CONCLUSIONS

The presence of PLVI is a more powerful prognostic factor than TRG in LARC patients treated with neoadjuvant CRT followed by surgery. PLVI denotes an aggressive phenotype, suggesting that these patients may benefit from adjuvant systemic therapy.

Analysis of surgical complications of primary tumor resection after neoadjuvant treatment in stage IV colon cancer

PURPOSE

Assess the surgical complications of primary tumor resection in stage IV colon cancer patients previously treated with neoadjuvant chemotherapy.

METHODS

Between July 2001 and September 2010, 67 consecutive patients received preoperative chemotherapy. Clinical and surgical complications were obtained from the medical records. This study was retrospective in design.

RESULTS

All patients were affected with liver metastasis, and 29.8% had metastasis in additional organs. Three different schemes of preoperative chemotherapy were employed, based on FOLFIRI, XELOXIRI or XELOX plus cetuximab. Eighteen patients (26.8%) reported some side effects to the chemotherapy, without contraindicating any intervention. All patients underwent colon surgery and within those, eight patients (11.9%), underwent liver surgery simultaneously. Median hospital admission was 8 [3-29] days. The perioperative complication rate was 16.2%, when the estimated physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) was 58.3%. There was not perioperative mortality, despite the mortality prediction for Portsmouth-POSSUM (P-POSSUM) being 5.07%. No differences were observed between the chemotherapy regimen (P=0.72) or the kind of the surgery-simple or combined (P=0.58).

CONCLUSIONS

Neoadjuvant chemotherapy as a systemic treatment for stage IV colon cancer does not indicate surgery contraindication nor increases postoperative morbimortality by a significant amount.

Tumor response assessment in locally advanced colon cancer after neoadjuvant chemotherapy

BACKGROUND

Preoperative chemotherapy followed by radical surgery is a novel therapeutic approach for locally advanced colon cancer (LACC). Neoadjuvant strategies require highly accurate diagnostic tests for a proper selection of candidate patients, allowing a low risk of overtreatment. This paper assesses the radiological, metabolic and pathological findings induced by preoperative oxaliplatin and fluoropyrimidines-based chemotherapy in LACC.

METHODS

Forty-four consecutive patients with a confirmed diagnosis of LACC who received neoadjuvant chemotherapy and colon surgery were included. All patients were staged at baseline and before surgery. Clinical diagnosis consisted of physical examination, endoscopy with biopsy and computed tomography (CT) scan. In selected cases, a positron emission tomography/CT (PET/CT) scan was also performed. Accuracy and correlations between CT scan findings and pathologic report was assayed for T stage, N stage and TN stage. This study is retrospective in design.

RESULTS

After chemotherapy, a statistical significant tumor volume reduction of 62.5% was achieved by CT-scan (P<0.001; Wilcoxon test) and a 38.9% decrease of standard uptake value (SUVmax) was observed on PET/CT (P=0.004). No progressive disease was reported during neoadjuvant treatment. Accuracy for T and N classification was 62% and 87%, respectively. Accuracy for TN stage was 77%, with 13.6% and 9.1% of the patients being under or overstaged, respectively. Pathologic stage II and III disease was observed in 29/44 (65.9%) and 15/44 (34.1%) of the patients, respectively. Pathologic complete response was achieved in three patients.

CONCLUSIONS

Oxaliplatin/fluorpyrimidine neoadjuvant chemotherapy induces major tumour shrinkage at both the pathological and radiological levels. The CT scan shows a high accuracy and a low overstaged rate in LACC patients treated by means of a neoadjuvant approach.

Distal migration of a transanastomotic pancreatic stent resulting in bowel perforation 19 years after pancreatoduodenectomy: report of a case

A 75-year-old woman who had undergone pancreatoduodenectomy 19 years earlier was referred to us for investigation of progressive abdominal pain without conclusive preliminary complementary tests. Computed tomography enabled us to identify that the transanastomotic pancreatic stent had migrated distally, resulting in bowel perforation. She underwent surgery and the foreign body was removed.

Susceptibility of 15 mango (Sapindales: Anacardiaceae) cultivars to the attack by Anastrepha ludens and Anastrepha obliqua (Diptera: Tephritidae) and the role of underdeveloped fruit as pest reservoirs: management implications

We evaluated the susceptibility of 15 mango cultivars to the attack of Anastrepha ludens (Loew) and Anastrepha obliqua (Macquart) (Diptera: Tephritidae), the main tephritid pests of this crop in Mexico. In a field experiment, bagged fruit-bearing branches were exposed to gravid females of both fly species. Infestation rates, developmental time, adult eclosion, and F1 adult longevity, fecundity, and fertility were recorded, ranking cultivars in terms of susceptibility to fly attack and development. We also compared the volatile profile in selected resistant and susceptible cultivars in search of possible correlations. In a second experiment, clutch size for A. ludens was determined in each cultivar. Infestation rates, developmental time, and F1 demographic parameters varied sharply among cultivars and between fly species for bagged fruit. Cultivars 'Vishi,' '74-82,' and 'Brooks' were most susceptible to A. ludens infestation while "Tommy,' 'Sensation,' and 'Ataulfo "niño"' (parthenocarpic fruit) were most susceptible to A. obliqua infestation. 'Edward,' 'Kent,' 'Brooks late,' 'Palmer, and 'Ataulfo' exhibited tolerance to attack of both fly species. Fruit of susceptible and resistant cultivars exhibited unique volatile profiles. Fly development and F1 adult demographic parameters varied significantly among cultivars. A. ludens females laid larger clutches in larger and harder fruit. We highlight the important role of Ataulfo "niño" as pest reservoir if fruit is left unharvested on trees. We discuss the possible use of highly resistant cultivars as trap crops or egg sinks.

[DIEP flap reconstruction after palliative curettage mastectomy in locally advanced breast cancer]

BACKGROUND

Curettage mastectomy is indicated as a palliative treatment in locally advanced breast cancer. We present our experience with the use of a DIEP flap reconstruction following extensive mastectomy.

METHODS

We report the case of a patient with very advanced local breast cancer that was subsidiary to aggressive palliative surgery after chemotherapy.

RESULTS

It was considered that the closure that could be performed with the latissimus dorsi muscle was unsuitable, therefore a DIEP flap was performed. The patient was discharged uneventfully.

CONCLUSION

The DIEP reconstruction offers great cutaneous extension. It can be a resource in highly selected cases of locally advanced breast cancer in which surgery becomes the main treatment.