Anal cancer screening and prevention: a review for dermatologists

The incidence of and mortality from anal cancer, predominantly squamous cell carcinoma (SCC), have been increasing since the 1980s, during an era when many common malignancies have seen decreases in mortality. Dermatologists may be more likely to see patients at an increased risk for anal SCC, such as those living with HIV, MSM and those presenting for management of anogenital warts, yet there is little guidance in the field on how to manage these patients. We underwent a project to review the evidence surrounding screening and prevention of anal SCC. HPV vaccination, the main preventative measure for anal SCC, is often underutilized and may not be effective for those most at risk. Screening methods currently include high-risk HPV and anal cytology testing, with high-resolution anoscopy (HRA) reserved for biopsy and confirmatory testing. High-risk HPV testing has been associated with high sensitivity for intraepithelial neoplasia, but low specificity in high-risk groups. Recent meta-analyses examining AIN detection using anal cytology estimate a similarly high sensitivity of 74-87%, with a relatively higher specificity (44-66%) for identifying high-grade AIN. HRA is the gold standard for diagnosis, but its accessibility and cost are deterrents from its use as a screening tool. Cervical cancer screening, initially adopted without significant evidence of its impact, has significantly decreased cervical cancer rates. The argument can be made that rates of anal SCC may also benefit from appropriate screening methods, particularly anal cytology. It is prudent for dermatologists to be aware of the methods available to them in the management of at-risk patients, the data supporting them, and the potential benefits of screening in order to counsel patients appropriately and address the increasing burden of disease.

P5 A Cut Throat approach to post thyroidectomy care

Introduction

Across the UK, approximately 10,000 elective neck dissection surgeries (thyroidectomy/parathyroidectomy) are performed each year. The recognised post-operative complications of such surgeries range from mild post-operative hypocalcaemia to life threatening wound haematoma .

Aim

This project aimed to establish the awareness of the British Association of Endocrine and Thyroid Surgeons (BAETS) post thyroidectomy guidelines and provide targeted education in order to improve any identified failings in the management of this patient group.

Methods

A nine point questionnaire was generated based on the guidelines published by BAETS. This questionnaire was disseminated to the junior doctors and nurse practitioners based on the surgical unit of North Tees General Hospital.

Results

Results were analysed from twenty respondents. 92% opted to call a registrar or consultant during a critical airway emergency secondary to wound haematoma rather than attempt to open the wound on the ward. Respondents displayed poor understanding of the risks of thyroid surgery (55%) and struggled to identify symptoms of hypocalcaemia (25%).

Participants showed good understanding of the need for post-operative thyroxine (100%), the correct dose of calcium gluconate required for treatment of hypocalcaemia (90%) and normal calcium levels (85%).

A video was created and distributed which highlighted front of neck anatomy and steps involved in releasing a wound haematoma. This included the ‘SCOOP’ video created by Endocrine Surgery Oxford. Data collected following the session found 93% of respondents would be more confident to intervene in future.

Conclusion

It is vital that junior doctors are well educated and equipped to deal with post-operative patients, especially those who may develop imminent airway obstruction. Our “cut throat” approach aims to ensure our first responders are decisive and effective in carrying out life saving interventions.

Frailty Exists in Younger Adults Admitted as Surgical Emergency Leading to Adverse Outcomes

BACKGROUND

Frailty is prevalent in the older adult population (≥65 years of age) and results in adverse outcomes in the emergency general surgical population.

OBJECTIVE

To determine whether frailty exists in the younger adult emergency surgical population (<65 years) and what influence frailty may have on patient related outcomes.

DESIGN

Prospective observational cohort study.

SETTING

Emergency general surgical admissions.

PARTICIPANTS

All patients ≥40 years divided into 2 groups: younger adults (40-64.9 years) and older adult comparative group (≥65).

MEASUREMENTS

Over a 6-month time frame the following data was collected: demographics; Scottish Index of Multiple Deprivation (SIMD); blood markers; multi-morbidities, polypharmacy and cognition. Frailty was assessed by completion of the Canadian Study of Health and Ageing (CSHA). Each patient was followed up for 90 days to allow determination of length of stay, re-admission and mortality.

RESULTS

82 young adults were included and the prevalence of frailty was 16% (versus older adults 38%; p=0.001) and associated with: multi-morbidity; poly-pharmacy; cognitive impairment; and deprivation. Frailty in older adults was only significantly associated with increasing age.

CONCLUSIONS

This novel study has found that frailty exists in 16% of younger adults admitted to emergency general surgical units, potentially leading to adverse short and long-term outcomes. Strategies need to be developed that identify and treat frailty in this vulnerable younger adult population.

The practice accreditation and improvement survey (PAIS). What patients think

BACKGROUND

The Practice Accreditation and Improvement Survey (PAIS) is an endorsed instrument by the Australian General Practice Accreditation Limited (AGPAL) for seeking patient views as part of the accreditation of Australian general practices.

METHOD

From September 1998 to August 2000, a total of 53,055 patients completed the PAIS within 449 general practices across Australia, which is about 8% of all Australian general practices. The validity and reliability of the PAIS instrument was assessed during the study. Patient views were also analysed via 27 items relating to doctors' interpersonal skills, access, availability and patient information.

RESULTS

PAIS was found to have sound validity and reliability measures. Patient evaluations showed a range of scores for the 27 items (69-91%). Lower scoring areas were issues about access, availability and availability of information for patients.

DISCUSSION

Users of general practice rate the doctors' interpersonal skills (capability) more highly than other practice service issues (capacity). There is, in patients' views, much more room for improving these capacity aspects of general practice.

CONCLUSION

Future research should explore how practices act on the results of patient feedback, and which practice based strategies are more effective in raising standards of care from a patient's perspective.

Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders

OBJECTIVE

Comorbidity of substance abuse disorders with schizophrenia is associated with a greater risk for serious illness complications and poorer outcome. Methodologically sound studies investigating treatment approaches for patients with these disorders are rare, although recommendations for integrated and comprehensive treatment programs abound. This study investigates the relative benefit of adding an integrated psychological and psychosocial treatment program to routine psychiatric care for patients with schizophrenia and substance use disorders.

METHOD

The authors conducted a randomized, single-blind controlled comparison of routine care with a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family or caregiver intervention.

RESULTS

The integrated treatment program resulted in significantly greater improvement in patients' general functioning than routine care alone at the end of treatment and 12 months after the beginning of the study. Other benefits of the program included a reduction in positive symptoms and in symptom exacerbations and an increase in the percent of days of abstinence from drugs or alcohol over the 12-month period from baseline to follow-up.

CONCLUSIONS

These findings demonstrate the effectiveness of a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family intervention over routine psychiatric care alone for patients with comorbid schizophrenia and alcohol or drug abuse or dependence.

Impact of patient feedback on the interpersonal skills of general practice registrars: results of a longitudinal study

CONTEXT

A general practice vocational training program.

OBJECTIVES

To examine the impacts and implications of different models of systematic patient feedback on the development of general practice (GP) registrars' interpersonal skills as they progressed through a GP vocational training program.

DESIGN

A longitudinal study in which GP registrars were randomly assigned to three models of patient feedback: a control group and two intervention groups. The major source of data gathering was through the Doctors' Interpersonal Skills Questionnaire (DISQ) which was administered to patients immediately after their consultation.

SUBJECTS

210 GP registrars, 104 GP supervisors and 28 156 patients.

RESULTS

Multivariate analysis techniques (including repeated-measures analysis) tested the effectiveness of the interventions. Findings showed that systematic patient feedback at regular intervals throughout GP training resulted in sustained levels of interpersonal skills. The most significant gains in interpersonal skills for both intervention groups occurred in the earlier stages of general practice training. Most registrars found the experience of patient feedback useful for gaining a better understanding of their interpersonal skills and for identifying areas in which they needed to improve. GP supervisors valued the opportunity to receive patient feedback themselves and found the activity a useful adjunct to their preceptor role.

CONCLUSIONS

Patients, by providing feedback on doctors' interpersonal skills, have been able to contribute to improving the quality of the patient-doctor interaction. GP registrars and their supervisors value highly the role of patient feedback in interpersonal skill development.

Consumers as educators: implementation of patient feedback in general practice training

There is growing interest in the adoption of patient-based assessments for the training of general practitioners. Consumers are in a unique position to comment on the quality of the doctor-patient interaction. Involving consumers as partners with general practice (GP) registrars and GP educators in the development of a patient feedback instrument enhances the relevance and acceptability of consumers as educators in GP training. It also demonstrates that social and medical agendas can be harmonized. Two patient feedback instruments on interpersonal skills were trialed in a training program for general practitioners in Australia. It was found that one of the instruments was more discriminating than the other because of its different response scale.

Real-patient evaluation of communication skills teaching for GP registrars

BACKGROUND

Five thousand eight hundred and eighty-five patient-completed questionnaires were used to evaluate the effectiveness of an interpersonal skills module designed for a vocational training programme for GPs.

OBJECTIVES

It was anticipated that patient-based assessments would detect a significant improvement in the interpersonal skills of GP Registrars who undertook the module.

METHOD

A quasi-experimental design using an intervention and control group (comprising 68 GP Registrars) was used to monitor the outcomes of the interpersonal skills module.

RESULTS

Patient ratings of interpersonal skills were significantly higher for those GP Registrars who participated in the interpersonal skills module.

CONCLUSIONS

Patient-based assessments are a useful evaluation method for assessing the quality of the doctor-patient relationship.

Refractory hypoxemia due to intrapulmonary shunting associated with bronchioloalveolar carcinoma

Bronchioloalveolar carcinoma caused severe refractory hypoxemia due to intrapulmonary shunting in a patient. Preoperative evaluation by occlusion of the pulmonary lobar artery supplying the tumor showed normalization of the arterial oxygen saturation. Resection of the involved lobe corrected the intrapulmonary shunting, and the patient required no further supplemental oxygen. However, with recurrence of the tumor over the next 6 months the patient became progressively more hypoxemic and died.

EXTEND: a prototype expert system for teaching nursing diagnosis

In this article, the development and uses of EXTEND (Expert system for Education in Nursing Diagnosis), a computer assisted instruction package for teaching nursing diagnosis using the categories proposed by the North American Nursing Diagnosis Association, are described. EXTEND provides a knowledge base that is able to deduce a nursing diagnosis from case factors and extends the normal use of expert systems beyond diagnosis to diagnosis education by providing answers to student questions about a simulated client and by guiding them through the diagnostic task. Furthermore, EXTEND allows the teacher to record the steps taken by students in the assessment and diagnosis of the simulated client, and use this as the focus of further discussion. The system is a response to the problems of teaching nursing diagnoses cited in the professional literature.

Adenovirus E1b-58 kD antigen binds to p53 during infection of rodent cells: evidence for an N-terminal binding site on p53

We show using mild extraction procedures that the p53 proto-oncogene forms a complex with adenovirus 5 E1b-58 kD during infection. These complexes are detected as coimmunoprecipitates from radiolabeled extracts of adenovirus infected cells on SDS-PAGE. Furthermore, adenovirus mutants with defects in E1b-58 kD fail to form complexes, whereas mutants in other early region genes still show evidence of complex. Using a panel of monoclonal antibodies to mouse p53, we show that antibodies reacting with N-terminal epitopes on p53, displace E1b-58 kD. This result suggests that E1b-58 kD binds to an N-terminal region of mouse p53. In addition, in a transient transfection assay in monkey COS cells, we show that an N-terminal deletion mutant of mouse p53 does not bind to E1b-58 kD but wild-type mouse p53 does bind. This result again suggests that E1b-58 kD binds an N-terminal determinant on p53.

Algammulin (gamma inulin/alum hybrid adjuvant) has greater adjuvanticity than alum for hepatitis B surface antigen in mice

Algammulin is a new vaccine adjuvant comprising a stable suspension of 1-2 microns ovoids of the immune stimulant gamma inulin in which alum (Alhydrogel) is embedded as a protein carrier. Adjuvanticity tests in mice with Algammulin show that the presence of gamma inulin on the alum particles has synergistically enhanced their adjuvanticity for low doses of hepatitis B surface antigen. The primary-response titres of HBsAg-specific antibody from a given low dose of alum injected as Algammulin were 3- to 5.6-fold greater than those from the same alum dose injected as free alum. This corresponds closely with more extensive previous work using keyhole limpet haemocyanin as antigen.

Transactivation of the p53 oncogene by E1a gene products

Infection of quiescent rat kidney cells with human adenovirus is shown to transcriptionally stimulate (transactivate) the p53 oncogene. The increased transcription results in an accumulation of p53-specific mRNA in parallel with an increase in p53 protein levels, although there is a considerable delay between transcriptional activation and the detection of stable p53 mRNA and protein. The induction of p53 is detectable with two monoclonal antibodies recognizing different epitopes. The induction of p53 by adenovirus is delayed compared to induction by serum, and it occurs after the onset of adenovirus-induced cellular DNA replication. Thus, adenovirus-induced DNA replication bypasses a G0/G1 control point. Experiments with hydroxyurea show that p53 activation does not require continued cell cycling and thus is likely to be a direct consequence of viral gene expression. Finally, the induction of p53 is shown to be dependent on expression of the 289-residue product encoded by the viral E1a gene.

Gangliosides in the brain in adult Down's syndrome and Alzheimer's disease

Quantitative analysis of total gangliosides and of ganglioside composition by HPTLC has been carried out on the gray matter of frontal cerebral cortex of six brains from Down's syndrome (DS) adults, six age-matched controls, six Alzheimer's disease (AD) adults, and six controls matched for age with the AD brains, as well as on three DS and six control cerebellum specimens. In addition, the analyses were carried out on specimens of corpus callosum of five adult DS and five control brains. No abnormalities were found in the gangliosides of DS corpus callosum. In DS frontal cortex, the concentration of total gangliosides was reduced, and there was a decrease in the fraction of GT1b and GD1b, and an increase in those of GT1a, GD3, GM1 and GM2; the ratio of total b-series to a-series gangliosides was decreased. Very similar abnormalities were found in the gangliosides of DS cerebellum. In AD frontal cortex, by contrast, the total gangliosides and their composition were normal by comparison with age-matched controls, with the minor exception of reductions in the fractions of GQ1b and GT1L. It is concluded that abnormalities in gangliosides exist in the brain in DS that are unrelated to AD-type pathology and may reflect developmental disturbances.

Immunohistochemical localization of cells containing nerve growth factor receptors in the different regions of the adult rat forebrain

Conditions have been optimized for an immunohistochemical procedure for the localization of nerve growth factor receptor-containing cells in the brain. Using this immunohistochemical procedure, the normal morphology and distribution of the nerve growth factor receptor-containing neurons of the adult rat forebrain have been studied, and the findings compared with observations on the choline acetyltransferase-positive neurons present either in the immediately-adjacent sections or in the medially-divided half of the same section. Unlike in the peripheral nervous system, only neurons showed immunoreactivity to the nerve growth factor receptor in the brain. Both the nerve growth factor receptor- and choline acetyltransferase-immunoreactive cells appear to form a continuous anteroposterior band, which includes the olfactory tubercle, the medial septal nucleus, the vertical and horizontal limbs of the diagonal band and the basal nucleus. In each subdivision of the basal forebrain, the topographic organization, the localization, the intensity of the immunoreaction and the total cell number of nerve growth factor receptor- and of choline acetyltransferase-immunoreactive neurons were strikingly similar, indicating that nearly all nerve growth factor receptor-containing cells were cholinergic neurons. However, in the striatum, only about half the number of the choline acetyltransferase-positive cells showed immunopositive reactions to the nerve growth factor receptor, and, also, in the nerve growth factor receptor-containing neurons the intensity of the reaction product was much less than the choline acetyltransferase immunoreactivity. In the neurons of the basal forebrain nuclei, the choline acetyltransferase immunoreaction product was uniformly distributed on the cell bodies, while the nerve growth factor receptor immunoreaction product was present also as intensely stained granules on the cell somata and the dendrites. The mean diameter and the mean cross-sectional area of the nerve growth factor receptor-containing neurons were least in the medial septal nucleus and were greatest in the basal nucleus, and showed a gradation in cell size going from the medial septal nucleus through the nucleus of the diagonal band and extending more posteriorly to the basal nucleus.

Nucleolar organiser regions in normal, cirrhotic, and carcinomatous livers

A series of 54 liver biopsy specimens was studied by means of the argyrophil (AgNOR) technique for nucleolar organiser region (NOR)-associated proteins. These included normal livers and livers affected by chronic active hepatitis, cirrhosis, hepatocellular carcinoma and adenoma. Four of the cases of cirrhosis showed liver cell dysplasia. The mean numbers of NOR sites in normal, cirrhotic, and carcinomatous livers were significantly different: adenoma had similar mean counts to those in chronic active hepatitis (CAH). There was no overlap between the ranges of NOR counts in normal, cirrhotic, and malignant liver specimens. Where cirrhosis and hepatocellular carcinoma were present in the same specimen, the AgNOR counts were higher in the carcinomatous than cirrhotic areas. To investigate the prospective value of the method a further seven biopsy specimens were studied; in these it had not been possible to decide on a diagnosis between normality and cirrhosis or cirrhosis and hepatocellular carcinoma. In all seven specimens a repeat biopsy or necropsy gave results as predicted by AgNOR staining. It is therefore proposed that quantitation of staining for NOR-associated proteins is a diagnostically useful method in liver disease.

Nucleolar organiser regions in small cell carcinoma of the bronchus

An argyrophil technique for the demonstration of nucleolar organiser regions has been applied to routinely processed paraffin sections of 15 specimens of small cell carcinoma and 15 biopsy specimens infiltrated by lymphocytes. To avoid tautological problems, the nature of the specimens was confirmed by means of immunohistochemical staining for neurone specific enolase and leucocyte common antigen. The specimens of small cell carcinoma were readily differentiated from those containing lymphocytes by the argyrophil method, the range of mean number of nucleolar organiser regions per nucleus being 4.2-7.3 for small cell carcinoma cells and 0.9-1.7 for lymphocytes. This method separates malignant epithelial cells from benign lymphocytic cells and has potential in both clinical and research investigation of respiratory tumours.

The effect of melanin pigment removal on the peroxidase-antiperoxidase immunoperoxidase technic

With the increasing use of immunoperoxidase technics, it may be difficult to differentiate between the dark staining of 3,3'-diaminobenzidine (DAB) compound reaction product and melanin pigment. The latter may be particularly observed in skin. Samples of both normal skin and melanotic malignant melanoma were treated for the removal of melanin by standard technics both before and after a peroxidase-antiperoxidase (PAP) immunohistologic sequence. Many methods for the removal of melanin pigment resulted in diminished DAB staining intensity. Some also caused cellular disruption. However, the method of choice was found to be treatment with 0.25 g/dL potassium permanganate and 1 g/dL oxalic acid before the immunoperoxidase sequence.

Effect of formalin pigment removal on peroxidase-antiperoxidase immunoperoxidase technique

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Immunohistochemical analysis of the early ontogeny of the neuropeptide Y system in rat brain

The distribution of neuropeptide Y in the developing rat brain was studied with immunocytochemistry, using the peroxidase-antiperoxidase method. Immunoreactive perikarya were first seen on embryonic day 13 and staining of fibres appeared from embryonic day 15 onwards: perikaryal staining was generally more intense prenatally than after birth. Areas rich in neuropeptide Y immunostaining included the monoaminergic regions of the brain stem from embryonic day 13 (especially the lateral reticular nucleus and the medullary reticular formation), the dorsal mesencephalon (with spots of immunoreactivity in the outer subventricular zone at embryonic days 13 or 14 and many cells and fibres in the inferior colliculus from embryonic days 16-20) and the olfactory tubercle/ventral striatum from embryonic day 15 until birth. The period of development of cortical neurones extended from embryonic day 19 until postnatal day 21. A hitherto unreported feature unique to neuropeptide Y was the presence in certain parts of the cerebral cortex of transient cells at the base of the cortical plate bearing radial processes which transverse its width. They were present from embryonic day 17 until postnatal day 4 and were maximally developed at embryonic days 20 or 21, contributing at this age a substantial fibre projection through the immature corpus callosum. The abundance of neuropeptide Y in the prenatal rat brain suggests it may play an important role in development.

An analysis of different techniques for distal hypospadias repair: the price of perfection

We discuss the risks of total surgical correction of distal hypospadias with chordee, review 42 such cases and analyze 4 common surgical procedures that were used. The over-all complication rate was 16.6 per cent (7 of 42), with 9.5 per cent (4 of 42) of the cases requiring addition urethral reconstruction. All complications occurred following procedures designed to extend the urethral meatus to the tip of the glans (Horton-Devine 5 of 15 and Ombrédanne 2 of 8). In contrast, no complications occurred following urethral advancement or Allen-Spence repairs (0 of 19). The physician and family should be aware of the increased risk attendant with total anatomical urethral correction in contrast to less extensive surgery, which gives an excellent functional result with minimal risk.