Transforming a head direction signal into a goal-oriented steering command

To navigate, we must continuously estimate the direction we are headed in, and we must correct deviations from our goal1. Direction estimation is accomplished by ring attractor networks in the head direction system2,3. However, we do not fully understand how the sense of direction is used to guide action. Drosophila connectome analyses4,5 reveal three cell populations (PFL3R, PFL3L and PFL2) that connect the head direction system to the locomotor system. Here we use imaging, electrophysiology and chemogenetic stimulation during navigation to show how these populations function. Each population receives a shifted copy of the head direction vector, such that their three reference frames are shifted approximately 120° relative to each other. Each cell type then compares its own head direction vector with a common goal vector; specifically, it evaluates the congruence of these vectors via a nonlinear transformation. The output of all three cell populations is then combined to generate locomotor commands. PFL3R cells are recruited when the fly is oriented to the left of its goal, and their activity drives rightward turning; the reverse is true for PFL3L. Meanwhile, PFL2 cells increase steering speed, and are recruited when the fly is oriented far from its goal. PFL2 cells adaptively increase the strength of steering as directional error increases, effectively managing the tradeoff between speed and accuracy. Together, our results show how a map of space in the brain can be combined with an internal goal to generate action commands, via a transformation from world-centric coordinates to body-centric coordinates.

Transforming representations of movement from body- to world-centric space

When an animal moves through the world, its brain receives a stream of information about the body's translational velocity from motor commands and sensory feedback signals. These incoming signals are referenced to the body, but ultimately, they must be transformed into world-centric coordinates for navigation1,2. Here we show that this computation occurs in the fan-shaped body in the brain of Drosophila melanogaster. We identify two cell types, PFNd and PFNv3-5, that conjunctively encode translational velocity and heading as a fly walks. In these cells, velocity signals are acquired from locomotor brain regions6 and are multiplied with heading signals from the compass system. PFNd neurons prefer forward-ipsilateral movement, whereas PFNv neurons prefer backward-contralateral movement, and perturbing PFNd neurons disrupts idiothetic path integration in walking flies7. Downstream, PFNd and PFNv neurons converge onto hΔB neurons, with a connectivity pattern that pools together heading and translation direction combinations corresponding to the same movement in world-centric space. This network motif effectively performs a rotation of the brain's representation of body-centric translational velocity according to the current heading direction. Consistent with our predictions, we observe that hΔB neurons form a representation of translational velocity in world-centric coordinates. By integrating this representation over time, it should be possible for the brain to form a working memory of the path travelled through the environment8-10.

Transrectal high-intensity focused ultrasonography is feasible as a new therapeutic option for advanced recurrent rectal cancer: report on the first case worldwide

High-intensity focused ultrasonography is the only completely non-invasive thermal therapy. To date its applications have been limited but clinical indications are expanding with enhanced technological advances that have increased the accuracy of targeting and decreased the duration of treatment times. We report its first use for rectal cancer.

THE PULSE PRESSURE AS AN INDEX OF THE SYSTOLIC OUTPUT

On the basis of these facts we feel justified in making the following assertion: Under normal conditions and during various procedures (namely, stimulation of the vagus centrally and peripherally, of the saphenus nerve centrally, and of the annulus Vieussentis, intravenous transfusion of 0.7 per cent. sodium chloride solution, intra-arterial transfusion of strong carbonate, bleeding and asphyxia) the pulse pressure is a reliable index of the systolic output.

The dedicated emergency surgeon: towards consultant-based acute surgical admissions

INTRODUCTION

The management of an efficient acute surgical service with conflicting pressures of managing elective and emergency work, compounded by waiting list targets and the maximum 4-h wait for patients in accident and emergency poses a significant challenge. We assess the impact of appointing a dedicated emergency surgeon on the delivery of our emergency surgery service.

PATIENTS AND METHODS

A comparative retrospective review was undertaken of all surgical admissions (n = 1622) over a 9-month period (between February and November) in the year before and after (2004 and 2005) the appointment of a dedicated emergency surgeon. The impact on service, training and possible financial consequences of this appointment was assessed.

RESULTS

A total of 798 surgical admissions in 2004 were compared with 824 admissions in 2005 for the 9-month periods of this study. In 2004, 258 patients were operated on compared with 286 in 2005 (NS). There was a significant increase in day-time operating from 57% in 2004 to 74% in 2005 (P < 0.001) and a significant increase in consultant-supervised operations from 14% to 52% (P < 0.001), with a consequent fall in out-of-hours operating (43% to 26%; P < 0.001). In addition, there was a significant increase in early (within 48 h) discharges from 41% to 53% (P < 0.001). The salary of the new appointment is more than offset by the quantifiable savings of approximately pound90,000 per annum based on the increased proportion of earlier discharges alone as well as the improved quality of care provided.

CONCLUSIONS

The appointment of a dedicated emergency surgery consultant has resulted in an increase in day-time consultant-supervised operating, shorter hospital stay for emergency admissions, improved training for surgical trainees, as well as providing potential financial savings for the trust.

The long-term results of diltiazem treatment for anal fissure

The effects of diltiazem treatment on symptoms of chronic anal fissures and their long-term outcome were investigated. One hundred and twelve patients were supplied with 6-week course of 2% diltiazem cream for twice-daily topical application. The medical notes and extended follow-up by telephone for 112 patients were recorded and statistically analysed. The success rate and satisfaction of topical diltiazem were each over two thirds. Nearly 80% of patients reported no adverse effects, and it seems that those complaints attributed to diltiazem rarely led to reduced compliance. After diltiazem therapy for fissure, 59% of patients required further treatment (medical and/or surgical) over the average 2-year period of follow-up. The reported adverse effects of topical diltiazem treatment in patients with anal fissures were more common than previously thought, although compliance was rarely affected. During consultation regarding the advantages and disadvantages of surgical vs. chemical sphincterotomy, patients should be aware that the majority of patients receiving diltiazem as the primary treatment for anal fissure subsequently require further treatment.

Histological examination of circular stapled ‘doughnuts’: Questionable routine practice?

BACKGROUND

Left-sided colonic resections are often anastomosed by the use of the circular stapling gun. Most surgeons routinely submit the resulting set of 'doughnuts' for histological examination.

AIM

The aim of this study is to question the need for this practice by providing our own experience of the impact of 'doughnut' submission on patient management.

PATIENTS AND METHODS

Patients who had undergone a stapled anastomosis for colorectal cancer resection (1998-2004) were identified from the department cancer database and clinical records and histopathological reports were reviewed for all cases.

RESULTS

From a consecutive series of 100 sets of doughnuts only two showed histological abnormality (inflammatory change and a metaplastic polyp). Three patients had local recurrence over the follow-up period: 12, 14 and 36 months after surgery. Histological review of the 'doughnuts' in these patients did not show any abnormality. None of the above findings had any influence on subsequent management.

CONCLUSION

Histological examination of the 'doughnuts' has a considerable impact in terms of time and resource use. This study has shown no benefit in performing routine histological examination of the 'doughnuts'.

Comparison of CT and MRI in the pre-operative staging of rectal adenocarcinoma and prediction of circumferential resection margin involvement by MRI

OBJECTIVE

It has been suggested that MRI may be used as the sole modality of choice in pre-operative staging in rectal cancers. Knowledge of tumour stage and a threatened Circumferential Resection Margin (CRM) pre-operatively are essential for planning neo-adjuvant therapy and as predictors of local recurrence. At present most units utilize CT scanning to assess these parameters. The aim of our study was two fold: firstly to examine the accuracy of preop CT and MRI staging of rectal cancers compared with final histology and secondly to assess the accuracy of MRI in predicting penetration of the mesorectal envelope (ME).

PATIENTS AND METHODS

All patients with biopsy proven rectal adenocarcinoma underwent thin slice MRI and CT scan pre-operatively. Forty-seven patients have been prospectively entered into the study: 24 male (median age 68 years; range 38-91 years). Eleven patients were unsuitable for surgery leaving 36 patients available for study.

RESULTS

CT correctly staged patients with T1/T2 rectal cancers more often than MRI (77% vs. 43%, P = 0.226). Patients with T1/T2 tumours were overstaged more often by MRI compared with CT (54% vs. 23%, P = 0.226). A greater proportion of patients with T3 tumours were correctly staged by MRI than CT (76% vs. 41%, P = 0.08); and more T3 disease was understaged by CT than MRI (54 vs. 18%, P = 0.032). CT and MRI staged T4 disease equally. In the assessment of mesorectal envelope integrity, MRI had a sensitivity of 80% and a specificity of 84%. The positive predictive value was 44% and the negative predictive value 96%.

CONCLUSIONS

These results suggest significant differences between accurate pre-operative "T" staging by CT and MRI for rectal cancer. MRI has the potential however, to accurately assess mesorectal envelope invasion. Further analysis is required to assess whether MRI can be used as the sole modality in pre-operative staging of rectal cancers.

Unusual perianal tumours masquerading as abscesses

Tumours of the perianal region and anal canal are uncommon and can present in a variety of ways. Acute anorectal sepsis is a common condition that usually presents as a painful lump close to the anal margin. Tumours in the perianal region may mimic the symptoms and signs of anorectal sepsis, thereby leading to a delay in diagnosis and management. We report three patients who presented to our department with symptoms and signs suggestive of perianal abscess but which on further investigation were discovered to be due to unusual perianal tumours. Only one of the tumours was found to be malignant--a primary perianal mucinous adenocarcinoma; the other two were benign, a leiomyoma and an aggressive angiomyxoma. A high index of clinical suspicion is required to the diagnosis of perianal tumours when assessing patients with painful perianal lumps, particularly those with a long history and those of ethnic origin. Every effort should be made to establish a preoperative diagnosis so that correct treatment can be delivered.

Major colorectal cancer resection should not be denied to the elderly

AIMS

Adjuvant therapy after surgery for colorectal cancer is often denied to the elderly for various reasons. This study was to determine morbidity and mortality risk after surgery in the elderly and whether this is affected by adjuvant therapy.

METHODS

Data were collected prospectively and entered on a database for all patients undergoing resection of colorectal cancer between January 1994 and July 2000. A total of 304 patients were included, 65 aged 80 years and over.

RESULTS

There were 84 deaths, 21 (30%) in the over 80s, and 63 (26%) in the under 80s (P=0.51). The 'in-hospital' mortality was 10.1% in the over 80s and 3.8% in the under 80s (P=0.056). In the over 80s the colon was more affected than the rectum (P=0.002). The over 80s were less likely to be offered adjuvant therapy, 7.2% vs 42.1% (P<0.001). The 5 year survival (all-cause mortality) in the over 80s was 58.5% and 47.6% in the under 80s (P=0.25). Cox's regression analysis of all patients identified the following factors to be independently related to overall survival: age>80 years, post-operative leak, increasing Dukes stage and distant recurrence of disease.

CONCLUSION

This study has demonstrated that surgery should not be denied to elderly patients with colorectal cancer as despite a higher post-operative morbidity and mortality rate and with the absence of adjuvant therapy, favourable long-term outcome can be achieved by resectional surgery alone.

Reasons for failure of glyceryl trinitrate treatment of chronic fissure-in-ano: a multivariate analysis

PURPOSE

Although glyceryl trinitrate ointment has become the first-line treatment for chronic anal fissure, healing rates are lower than after lateral internal sphincterotomy. The purpose of this study was to identify which factors are associated with treatment failure of glyceryl trinitrate ointment.

METHODS

All patients who presented with chronic anal fissure from March 1997 to November 1998 were treated with 0.2 percent glyceryl trinitrate ointment. They were prospectively evaluated until healing or lateral internal sphincterotomy occurred, and long-term follow-up was obtained by standardized telephone questionnaire. A Cox model multivariate analysis was used with seven variables to determine significant factors related to healing.

RESULTS

Sixty-four patients (42 men and 22 women; mean age, 37.5 years) with chronic fissure-in-ano were treated with 0.2 percent glyceryl trinitrate ointment. Sentinel piles were observed in 19 patients (29.7 percent). Twenty-six patients (40.6 percent) were healed initially, but 12 (46.2 percent) experienced recurrence. Mean follow-up time was 15.6 (+/-5.5) months. Twenty-nine patients (45.3 percent) had known risk factors for anal fissure, including constipation (n = 21; 32.8 percent), recent childbirth (n = 6; 9.3 percent), colonoscopy (n = 1; 1.6 percent), and anoreceptive intercourse (n = 1; 1.6 percent). Fissures were significantly less likely to heal initially (P < 0.05), more likely to recur (P < 0.05), and more likely to remain unhealed in the long term (P < 0.05) in the presence of a sentinel pile. Fissures with a history of more than six months were less likely to heal initially (P < 0.05).

CONCLUSION

The presence of a sentinel pile adversely affects the outcome of treatment of chronic anal fissures with glyceryl trinitrate ointment, and a long history of the fissure reduces the rate of initial healing. Reasons for these findings are discussed.

A double-blind randomized placebo-controlled trial of oral indoramin to treat chronic anal fissure

BACKGROUND

Indoramin is an alpha1-adrenoceptor antagonist and has been shown to reduce anal resting pressure. Its therapeutic potential has not been explored. The aim of this study was to determine the outcome of treatment with oral indoramin on patients with chronic anal fissure in the setting of a double-blind randomized placebo-controlled trial.

METHODS

Twenty-three patients with chronic anal fissure were computer randomized to receive a 6-week course of oral indoramin (20 mg) or placebo in identical capsules, twice daily and with bulk-forming laxatives. Pain was assessed by a visual analogue scale from 0 to 10. Anal resting pressure, heart rate and blood pressure were recorded. Patients were reviewed 1 h after taking the capsule and at 2, 6 and 12 weeks thereafter.

RESULTS

Fourteen patients were randomized to indoramin and 9 to placebo. Maximum anal resting pressure was reduced from a mean of 96.4 cm H2O (+/- 32) to 67.6 cm H2O (+/- 26), 1 h after indoramin (P=0.02) and there was no significant change after placebo. There were no significant changes in heart rate or blood pressure. Pain was reduced in the placebo group from a score of 4.9 to 2.0 after 6 weeks (P < 0.01) but not in the indoramin group. After 6 weeks, healing had occurred in one (7%) patient in the indoramin group and in 2 (22%) in the placebo group (P > 0.1). After 3 months, the chronic anal fissure in the indoramin group had recurred. The trial was terminated early because of poor healing rates.

CONCLUSION

An oral dose of indoramin (20 mg) administered twice daily reduced anal resting pressure by 30% compared with pretreatment levels but was ineffective in healing chronic anal fissures.

Oophorectomy in primary colorectal cancer

Colorectal cancer is a common cancer affecting women which may metastasize to the ovaries. We present five cases of ovarian metastases requiring surgery and review the debate regarding oophorectomy at the primary resection for colorectal cancer. Although prophylactic oophorectomy has not been proven to affect survival, further surgery for symptomatic ovarian metastases may be avoided and the increased risk of developing primary ovarian cancer is abolished.

Microvascular disease and anastomotic dehiscence in the colon

Platelet-derived serotonin released in response to tissue manipulation during surgery may contribute to mesenteric arterial vasospasm leading to postoperative anastomotic leakage after colorectal resection. Organ bath experiments were used to demonstrate the efficacy of naftidrofuryl fumarate (NFT) to oppose serotonin-induced vasoconstriction of human mesenteric arteries. Cumulative dose-response curves were derived with and without NFT at 10(-9) and 10(-6) mol/l concentrations. The difference in maximal contractility between the three sets of curves (n = 8 for each) was significant (P < 0.0001). Sensitivity to serotonin in each of the three curves was measured by calculating the concentration for half-maximal response; differences were again significant (P < 0.0001). NFT reduced serotonin-induced contractility in a dose-dependent fashion in rings of human mesenteric arteries in vitro. This suggests a possible role for NFT in reducing mesenteric vasospasm in colorectal surgery.

An abdominal cyst

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Prognostic value of nucleolar organizer regions in colorectal neoplasia

The aims of the study were, firstly, to determine the frequency of nucleolar organizer regions (NORs) in normal colonic mucosa, adenomas and carcinomas, secondly, to determine the relationship of NOR frequency to adenoma diameter, carcinoma stage, patient survival and tumour recurrence. NOR frequency was determined in invasive carcinoma and adjacent normal mucosa in resection specimens from 46 patients with colorectal carcinoma and in 15 colorectal adenomas obtained at colonoscopy. NOR frequency was correlated with conventional prognostic criteria: adenoma diameter and carcinoma stage, tumour recurrence and patient survival. NOR frequency was significantly (P = 0.02) greater in carcinoma (median = 3.64) and adenoma (median = 2.30) compared to non-neoplastic mucosa (median = 1.96). NOR frequency was not significantly related to adenoma diameter, carcinoma node status, patient survival or tumour recurrence. NOR frequency increases with progression through adenoma to carcinoma. The poor association with conventional prognostic factors suggests that NOR frequency is of no value in prediction of adenoma or carcinoma behaviour and therefore does not closely reflect factors determining malignant cell behaviour.

HER2 (c-erbB-2) oncoprotein expression in colorectal adenocarcinoma: an immunohistological study using three different antibodies

Paraffin wax sections of 70 surgically resected colorectal adenocarcinomas were examined for the overexpression of HER2/c-erbB-2 oncoprotein using three different specific antibodies and the avidin-biotin immunoperoxidase technique. The patients included 38 men and 32 women aged between 47 and 80 years. The tumours were derived from various parts of the large intestinal tract, and represented all three stages of Dukes' classification and the three histological grades of differentiation. Many tumour sections also included adjacent normal or transitional mucosa. Eight tubular adenomas found in the colectomy specimens in association with some carcinomas were also examined. No positive membrane staining was seen in any of the 70 carcinomas, four adenomas, two hyperplastic polyps, nor in the adjacent normal or transitional mucosa. It is suggested that the overexpression of c-erbB-2 gene product is unlikely to be as common and as pronounced in colorectal adenocarcinoma as it is in ductal carcinoma of the breast.

Factors influencing variability of localisation of antibodies to carcinoembryonic antigen (CEA) in patients with colorectal carcinoma--implications for radioimmunotherapy

Tumour localisation of anti-tumour antibodies varies greatly between patients. Factors which may be responsible for this have been investigated in 56 patients with colorectal carcinoma with a view to improving radioimmunotherapy. Thirty-seven to seventy-four MBq of 125-I labelled mouse monoclonal antibody to CEA, was given intravenously and tumour resected 70-480 h later. Percentage injected activity kg-1 (% inj.act kg-1) in tumour, was inversely correlated with the time interval between injection and operation (P = 0.004). To assess the influence of other parameters on localisation, patients were divided into two time groups according to time interval between injection and operation, 70-120 h (n = 33) and 144-480 h (n = 23). In neither group was there a significant correlation of % inj.act kg-1 with time. The % inj.act kg-1 in tumour showed a significant correlation with that in the blood for both groups (P = 0.005 and P = 0.01). There was no significant correlation for either time group between % inj.act kg-1 in tumour and serum CEA values, the per cent of tumour cells positive for CEA and vascularity. Tumour to blood ratios varied considerably (range 0.3-28.5:1) suggesting that factors other than time and persistence of activity in the blood contribute to efficient targeting. Tumour to blood ratios were inversely correlated with % inj.act kg-1 in blood for the 70-120 h group (P = 0.007), and were positively correlated with % inj.act kg-1 in tumour (P = 0.012). Autoradiography showed that antibody localised predominantly on tumour cells but was distributed heterogeneously, was not solely related to the expression of antigen and in some cases accumulated in necrotic more than viable areas of tumour. Penetration of antibody into malignant acinar structures was poor and CEA-positive cells closer to the blood supply were targeted to a greater extent than distant cells. Preoperative administration of radiolabelled antibody to CEA may be helpful in selecting patients with favourable localisation for radioimmunotherapy.

Cytoreductive surgery in disseminated non-seminomatous germ cell tumours of testis

Between 1977 and 1988, 67 patients underwent surgical removal of residual metastatic deposits following an aggressive chemotherapy regimen (cisplatin, vincristine, methotrexate and bleomycin alternating with etoposide, actinomycin D and cyclophosphamide) for disseminated germ cell tumours of the testis (stage IIB or above). Ninety-one surgical procedures were performed. There were 63 (69 per cent) retroperitoneal lymph node dissections, 16 (18 per cent) thoracotomies, three (3 per cent) hepatic resections, three (3 per cent) craniotomies, five (5 per cent) delayed orchidectomies and one anterolateral decompression of the vertebral column. Nine (13 per cent) patients required a repeat retroperitoneal node dissection and one patient needed a repeat thoracotomy to remove recurrent metastatic deposits during the period of follow-up. Multivisceral resections and vascular reconstruction procedures were required in 20 (30 per cent) patients undergoing retroperitoneal node dissection. Fifty-five (82 per cent) patients remain in complete remission with a mean follow-up period of 49.6 months (range 2-121 months). Nine (13 per cent) patients died with metastatic disease between 2 months to 4 years after operation. There were three deaths in the perioperative period (4 per cent). The histology of the resected metastases revealed undifferentiated active tumour in 20 (30 per cent) patients, differentiated mature teratoma in 29 (43 per cent) patients and fibrosis/necrosis in 18 (27 per cent) patients. Twelve (60 per cent) patients with undifferentiated elements and 15 patients (60 per cent) with raised preoperative tumour markers (poor prognostic categories) are in complete remission. Cytoreductive surgery in patients with metastatic germ cell tumours offers the best chance of remission following chemotherapy even in poor prognostic group categories.

Inflammatory fibroid polyp of the small intestine presenting as intussusception

We report a case of a 47-year-old woman presenting with small bowel obstruction due to intussusception of an inflammatory fibroid polyp. A review of the literature describes the clinical and pathological features.

Association between extent of colonic mucosal sialomucin change and subsequent local recurrence after curative excision of primary colorectal cancer

Two interrelated studies were carried out to determine whether extent of sialomucin change adjacent to a primary colorectal carcinoma predicted local tumour invasiveness and risk of local recurrence. In the first, depth of tumour penetration was correlated with the length of the sialomucin band adjacent to 72 primary colorectal cancers. There was a significant (P less than 0.05) increase in sialomucin band length adjacent to tumours invading adjacent structures compared with those which had not (Mann-Whitney U test), although there was no overall correlation between depth of penetration, Duke's classification or degree of differentiation (Kruskal-Wallis test). A sialomucin band of greater than 3 cm was associated with a 70 per cent probability of adjacent structure (T4) invasion. These observations were then tested prospectively in a second study involving 256 patients to determine whether the presence of a greater than 3 cm sialomucin band could predict local recurrence. Presence of a greater than 3 cm sialomucin band was a significant (x2 = 7.12, d.f. = 1, P less than 0.001) and independent predictor of local but not distant recurrence. In addition both the interval to local recurrence and survival were significantly shorter if a greater than 3 cm sialomucin band was present. However the accuracy of greater than 3 cm sialomucin band as a predictive test for local recurrence was only 70 per cent. The extent of sialomucin adjacent to a primary colorectal cancer does provide a crude assessment of tumour invasiveness and risk of local recurrence.

Comparison of anti-fetal colonic microvillus and anti-CEA antibodies in peroperative radioimmunolocalisation of colorectal cancer

Local recurrence of colorectal cancer may result from failure to assess accurately the extent of tumour at operation. It has been suggested that peroperative radioimmunolocalisation may improve this assessment. The degree to which this is possible has been studied using a hand-held gamma detecting probe and comparing two 125I-labelled monoclonal antibodies to colorectal tumours. The antibodies were to fetal colonic microvillus membrane (FM1D10) and to carcinoembryonic antigen (A5B7). Sixty-nine per cent (9/13) of the FM1D10 and 98% (43/44) of A5B7 labelled tumours took up significant amounts of antibody with a tumour to normal colon ratio of more than 1.5:1. The uptake was significantly better for A5B7 with a median tumour to normal colon ratio of 3.3 (1.1-13.8) compared to 1.85 (0.75-7.7) for FM1D10 (P less than 0.001). The tumour: colon ratio of both antibodies was independent of the serum CEA, Dukes' stage or the degree of histological differentiation. There was a linear correlation for tumour to normal colon ratios between the gamma detecting probe and the same tissue examined in a conventional well counter (correlation coefficient r = 0.78, P less than 0.001). Colorectal tumours demonstrate a rapid and reliable uptake of anti-CEA monoclonal antibody A5B7. This antibody can be detected with a peroperative gamma detecting probe and has the potential to improve the surgeon's appreciation of the extent of tumour and therefore may influence the surgery performed. Detailed clinical studies are now being carried out.

Cystic dysplasia in ectopic kidney associated with absent vas deferens and congenital inguinal hernia

We report a case of congenital cystic dysplasia of a kidney associated with an absent vas deferens and congenital inguinal hernia on the same side. The findings are explained in embryologic terms. Congenital abnormalities of the kidney are often associated with other abnormalities of the urogenital system and should be looked for when managing children with this condition.

Oestrogen receptors in colorectal carcinoma

The oestrogen receptor content of colorectal adenocarcinoma was investigated using an established ligand binding biochemical assay and two more recently introduced techniques using specific monoclonal antibodies (Abbott ER-EIA and ER-ICA assay kits). Twenty nine tumours were investigated by the ligand binding assay. Only one (3.4%) tumour gave a weakly positive result (11 fmol/mg cytosol protein); the rest were all negative. Where sufficient tissue was available, the receptors were also determined by a quantitative immunoassay in 18 patients and an immunohistochemical method in 13 patients. The results were similarly all negative. It is concluded that most colorectal carcinomas, irrespective of sex, are oestrogen receptor negative, and it is thus unlikely that hormonal manipulation would have an influence on the course of the disease.

Combined medical and psychological treatment of hospitalized children with encopresis

Sixteen children, all inpatients at a state psychiatric hospital, received combined medical and psychological treatment for encopresis. One-year follow-up showed significant improvement. The results suggest that encopresis can be treated in severely emotionally disturbed children with a multifaceted and multidisciplinary approach.

Mucinous carcinoma of the breast: further characterization of its three subtypes

Nineteen cases of mucinous carcinoma of the breast were studied. Twelve tumours were of the pure type, and seven were mixed. All had abundant neutral and acidic mucin, and stained strongly with CAM 5.2. Of the 12 pure mucinous tumours, six were devoid of argyrophilic granules and were S-100 negative, and only one was CEA positive. All six patients are alive with no evidence of recurrence (mean follow-up 42 months). The other six pure mucinous tumours were rich in argyrophilic granules. Five of these showed S-100 positivity and all were CEA positive. One patient developed local recurrence and one died of myocardial infarction with no evidence of tumour recurrence (mean follow-up 80 months). Of the seven mixed tumours, only one contained an occasional cell with argyrophilic granules and four had variable degrees of CEA positivity. Two patients died and one developed bony metastasis (mean follow-up 40 months). Our findings emphasise the microscopic and prognostic differences between the three subtypes of mucinous carcinoma of the breast, and support the concept of dividing pure mucinous tumours into two distinct subtypes. We suggest that the latter subtyping can be qualitatively made on the basis of the presence or absence of argyrophilic granules in the tumour cells.

Cardiac dysrhythmia with the use of clonidine in explosive disorder

Clonidine has been used in the management of hypertension in adults with few cases of cardiac dysrhythmia reported. These appear to occur most frequently in association with preexisting cardiac disease or toxic concentrations of the drug. We observed a case of clonidine-induced bradycardia and irregular firing of the sinoatrial node in a child who does not have cardiac disease given low doses of the drug in the treatment of intermittent explosive disorder.

Mammary duct ectasia and pituitary adenomas

Mammary duct ectasia developed in three postmenopausal patients who had had pituitary chromophobe adenomas. The first patient had bilateral duct ectasia that developed 8 and 11 years after hypophysectomy. The second patient, who also had bilateral ectasia, had a prolactin-producing pituitary adenoma for which bromocriptine was prescribed. The ectasia developed in one breast before commencing bromocriptine therapy, and in the other breast 2 years later. The third patient also had a prolactin-producing pituitary adenoma. Unilateral duct ectasia developed while bromocriptine was taken. The ectasia in all patients was very marked and affected all excised ducts. Cholesterol granulomas were sometimes very extensive. These cases suggest a relationship between certain hypothalamic/pituitary disorders, possibly related to prolactin secretion and the development of mammary duct ectasia in postmenopausal patients.

Influence of sialomucins at the resection margin on survival of patients with colorectal cancer

In a multicentre prospective trial, 281 patients undergoing "curative" resection for colorectal cancer were followed for a mean of 13.6 months (SD 7.2 months). The presence or absence of sialomucin at the resection margin was studied histochemically using the high iron diamine-alcian blue (HID-AB) stain. There were 49 deaths relating to tumour recurrence: 21 in the sialomucin positive group (n = 77) and 28 in the sialomucin negative group (n = 204) (p less than 0.02). Life table survival was correlated against the presence or absence of sialomucin in the resection margin. At the mean follow-up (13.6 months) 85.6% of patients were alive in the sialomucin negative group, and 76.4% of patients were alive in the sialomucin positive group. Regression analysis predicts 32.8% and 18.9% five year survivals for sialomucin negative and positive groups respectively. There was no significant statistical correlation between the presence of sialomucin in the resection margin and the Dukes staging, site or tumour differentiation. The appearance of sialomucin in either resection margin appears to be an early marker of poor prognosis for patients with colorectal cancer.

Influence of sialomucin at the resection margin on local tumour recurrence and survival of patients with colorectal cancer: a multivariate analysis

In a multicentre prospective trial 358 patients undergoing curative surgery for colorectal cancer were followed for a median 18.0 months (+/- 7.2 months). The presence or absence of sialomucin in either resection margin was studied using the high iron diamine-alcian blue stain. There was evidence of excess sialomucin at one or other resection margin in 106 patients (29.6 per cent). Apart from sigmoid carcinomas occurring more often in the sialomucin positive group, there were no significant differences in any histological or clinical parameters between groups. Survival analysis for the events 'death', 'local recurrence', and 'all recurrence' was undertaken using the Cox regression model. The best prognostic variables selected in a stepwise fashion for death and all recurrence were 'Dukes' classification', 'sialomucin present' and 'histological differentiation'. The best prognostic variables selected for local recurrence were 'sialomucin present', 'Dukes' classification' and 'histological differentiation'. Sialomucin in a resection margin is an important independent prognostic variable for the development of local tumour recurrence and of subsequent survival for patients with colorectal carcinoma.

Mucosal field change in colorectal cancer

One hundred surgically excised colorectal carcinomas were examined histochemically using the high-iron diamine-alcian blue stain. Transitional mucosa surrounding the tumor was identified in 90 cases. The extent varied from 0 to 17 cm (mean 3.1 cm). In addition, the appearance of multiple patch lesions of increased sialomucin production was confirmed at sites far removed from the tumor in 35 cases. A predominant sialomucin pattern was seen in the proximal resection margin in 14 cases (17.9 percent), occurring as an isolated patch in 6 (43 percent). Sialomucin was also seen in the distal resection margin in 15 cases (15.9 percent), occurring as a direct extension of transitional mucosa surrounding the tumor in 12 (80 percent). These findings suggest that sialomucin production is a primary phenomenon that occurs as part of a field change in the human colon that develops cancer, and that these changes may occur in a resection margin and, by inference, remain at an anastomosis after resection.

Jejunum versus colon for free oesophageal reconstruction: an experimental radiological assessment

The reconstruction of the cervical oesophagus and the hypopharynx by revascularised bowel grafts has become a frequently described treatment option. Problems with the standard jejunal grafts have led us to suggest that the colon provides a suitable alternative. Experimental work in dogs demonstrates clear functional differences between colon and jejunum as free oesophageal grafts, and shows how structurally and functionally the colon integrates into the new position in the oesophagus better than the jejunum.

Sialomucins at resection margin and likelihood of recurrence in colorectal carcinoma

Oncogenic transformation of colonic epithelium is accompanied by changes in surface carbohydrate, notably an increased secretion of sialomucins at the expense of the normally predominant sulphomucins. In a multicentre prospective trial the correlation between the presence of sialomucins at the resection margin and the subsequent development of local recurrence was studied in 250 patients who had undergone "curative" resection for colorectal carcinoma with a mean follow up period of 14 months. Nineteen of 70 patients (27.1%) with a sialomucin predominant pattern at either resection margin developed local recurrence compared with 15 of 180 patients (8.3%) with a mixed or sulphomucin predominant pattern (p less than 0.01). Increased sialomucin staining at the resection margins was associated with reduced survival in these patients (p less than 0.01). At a mean of 14 months of follow up 153 patients (85%) were alive in the sulphomucin group and 53 patients (76%) were alive in the sialomucin group. Regression analysis predicted five year survivals of 32.8% and 18.9% for the sulphomucin and sialomucin groups respectively. Abnormal mucus production at the resection margin in patients treated for colorectal carcinoma appears to identify those with a higher risk of local recurrence and reduced survival.

Patient survival with liver metastases from colorectal cancer--a district hospital experience

In a retrospective review of 301 newly diagnosed tumours of the colon and rectum, 61 patients (20%) presented with liver metastases. The mean survival for this group was 7.4 months. Five patients with solitary metastases were found who may have been helped by further surgery. There was a 20% operative mortality. No significant association between the grade, differentiation, lymph node status or venous invasion of the primary lesion was demonstrated. Operative palliative resection of the primary lesion did not improve survival. These results confirm the poor prognosis for patients with liver metastases, justifying all efforts into the earlier detection and prevention of colorectal carcinoma.

A study of histochemical changes in mucus from patients with ulcerative colitis, Crohn's disease, and diverticular disease of the colon

The colonic mucosa produces a protective and lubricating layer of mucus. In certain conditions, the quantity and quality of this mucus is impaired. This study assessed the histochemical changes in mucus in inflammatory bowel disease compared with the severity and extent of the condition. Biopsy specimens were taken from 62 patients (32 with ulcerative colitis; ten with colonic Crohn's disease; ten with diverticular disease; ten with normal controls) and sections stained with high iron diamine-alcian blue to distinguish sulphated mucins from sialomucins. Normal subjects showed a predominance of sulphated mucins. The patients with Crohn's and diverticular disease also demonstrated this normal pattern. Of the 20 patients with ulcerative colitis, and without demonstrable dysplastic changes, only one showed a moderate increase in sialomucins. However, of the 12 patients with extensive colitis and dysplastic changes, ten had an increase in sialomucins. Thus, the predominant sialomucin pattern was seen mainly in patients with dysplasia. It may, therefore, indicate patients at high risk of malignancy.

Metastatic carcinoma of the breast in the anal canal

We present a case of metastatic carcinoma of the breast in the anal canal. Recurrence in this site has not been previously reported.

Study of the histochemical changes in mucus from normal and tumour bearing mucosa in patients with colorectal cancer

The prognosis in colorectal cancer is related to the stage of the tumour. Thus, early detection of developing tumours will significantly improve the overall prognosis. This study assessed the histochemical changes in mucus from normal and tumour bearing mucosa to determine possible premalignant changes. Eighty patients with colorectal cancer and ten normal subjects were studied. Biopsies were taken from the tumour and from adjacent 'normal' mucosa and from both resection edges. Sections were stained with high iron diamine-alcian blue to distinguish sulphated from sialomucins. All normal mucosal biopsies showed a predominantly sulphated mucin pattern. By contrast, all 70 tumour mucosal biopsies showed a marked sialomucin staining. In transitional mucosa adjacent to the tumour, 30 patients showed marked increase in sialomucin (2+), 42 a moderate increase (+) and the remaining eight a normal pattern (-ve). Twenty-one (15%) patients had increased sialomucin at either surgical resection margins, all of whom had similar changes adjacent to the tumour, suggesting a wide field change in the mucus pattern. Since these changes in mucus are associated with malignant transformation then estimation of mucus pattern may give early prediction of malignant change in patients at risk of developing primary or recurrent carcinoma.

The sialomucin content of colonic resection margins

In a prospective trial, the resection margins of 130 patients who underwent apparently curative resection for colorectal cancers were examined. Sialomucin was markedly increased in 17.0 percent of proximal resection margins and 17.3 percent in distal resection margins. Clinical follow-up has demonstrated four patients who have developed local recurrence of their disease. Three of these patients had increased sialomucin staining in the resection margins at the time of initial surgery. High iron diamine-alcian blue staining of resection margin may identify those patients at risk of developing local recurrence of colorectal cancer or metachronous tumor following apparently curative resection.

The anatomical relationship between the retropancreatic part of the bile duct and the main pancreatic duct

The main pancreatic duct lies posteriorly within the head of the pancreas and adjacent to the retropancreatic part of the common bile duct. In 17 out of 25 (68%) autopsy specimens which were studied, the two ducts ran within 5 mm of each other for a mean distance of 3.9 cm. The pancreatitis which sometimes develops as a complication of instrumentation of the bile duct could be a result of damage to the main pancreatic duct.