Management of small (T1-T2) anal margin squamous cell carcinoma: clinical outcomes following local excision alone

AIM

Squamous cell carcinomas of the anus are normally treated with synchronous chemoradiotherapy (CRT). Small, localized anal margin tumours may be adequately treated by local excision (LE) alone. This study aims to investigate the outcomes of patients with anal margin tumours treated with LE alone, reserving the use of CRT for salvage on local recurrence (LR).

METHODS

Patients with small, localized (stage I/IIA) anal margin tumours treated by LE from October 1999 to September 2018 were identified. The effect of tumour size and resection margin on LR risk was analysed. Outcomes of overall survival and disease-free survival were measured.

RESULTS

Fifty-five patients with anal margin tumours were identified. Overall 5-year LR, overall survival and disease-free survival rates were 8%, 86% and 82% respectively. Of the seven LRs, five were successfully salvaged with CRT with no further recurrence and two were not fit for CRT. Resection margins in non-fragmented tumours and tumour size did not significantly influence LR risk.

CONCLUSIONS

Most small, localized anal margin tumours can be adequately treated by LE alone with low LR rates. Most patients who developed LR were salvaged using CRT, with no cancer-related deaths reported.

Dietary inclusion of nano-phosphorus improves growth performance, carcass quality, and growth-related traits of Nile tilapia (Oreochromis niloticus) and alleviates water phosphorus residues

Supplementation of phosphorus nanoparticles is a promising strategy to reduce water pollution, improve phosphorus concentration in fish diet, and provide better production quality. We used 300 fingerlings of Nile tilapia that were randomly distributed into 3 groups; each one was attributed to 5 replicates of 20 fish per aquarium with initial weight (gm) (156 ± 1.25). The first diet contained traditional Di-calcium phosphate (D-group), the second supplemented with phosphorus nanoparticles in a dose equal to the previous conventional one (N-D group), and the last one included with phosphorus nanoparticles with the half dose of the conventional phosphorus group (1/2 N-D group). After 3 months of feeding, the N-D group showed the best growth performance including its feed conversion ratio (FCR), feed intake (FI), or body weight gain (BWG). Furthermore, the growth-related gene expression findings considering growth hormone receptor (GHR) and insulin-like growth factor-1 (IGF-1) were upregulated as well. Moreover, whole body chemical composition revealed higher Fe, Zn, P, and crude protein level in the N-D group than the other two groups. Lipoprotein lipase (LPL) and fatty acid synthetase (FAS) mRNA expression showed a significant increase in 1/2 N-D and N-D groups compared with the control group. To sum up, using of nano-phosphorus particles improved the growth rate and immunity response of Nile tilapia, besides decreasing water pollution.

Volumetric Pouch Study After Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is considerably utilized as a bariatric method for treating morbid obesity through the reduction of stomach volume. The present study attempted to assess the volumetric changes of the gastric reservoir 1 year after LSG using multi-slice spiral computed tomography (MSCT) as well as to verify their association with weight loss. The current study is a prospective study of 40 consecutive morbid obese patients managed with laparoscopic sleeve gastrectomy. All patients were referred to abdominal MSCT besides volumetric measurement of the gastric pouch 1 month and 12 months postoperatively after the LSG. There were statistically substantial differences throughout the whole period of follow-up (p value ≤ 0.05) regarding the ratio of excess weight loss, weight loss, and decreased BMI, in addition to the ratio of excess body mass index loss (% EBMIL) after LSG. Substantial elevation of the overall volume of the gastric reservoir (82.9 SD11 and 171.6 SD23.6 ml at 1 and 12 months, respectively) was observed. However, the current findings did not demonstrate any significant association (r = 0.131, p = 0.491) between excess weight loss percentage and the increase in gastric reservoir volume 1 year postoperatively. Sleeve dilatation is a common finding following sleeve gastrectomy (SG) even after conducting a narrow gastric pouch, yet dilatation was not correlated with insufficient weight loss after 1 year postoperatively. Trial registration number: NCT04880902.

The optimized inclusion level of Bacillus subtilis fermented Azolla pinnata in Nile tilapia (Oreochromis niloticus) diets: immunity, antioxidative status, intestinal digestive enzymes and histomorphometry, and disease resistance

A 95-day feeding trial was conducted to evaluate the outcomes of feeding Bacillus subtilis fermented Azolla (BSFA) on nonspecific immunity, antioxidative status, intestinal digestive enzymes and histomorphometry, and disease resistance in the Nile tilapia. We formulated five isonitrogenous and isocaloric experimental diets to incorporate BSFA at level of (0%, 15%, 30%, 45%, 60%). The growth performance parameters (FBW, BWG, SGR, PER, and FCR) revealed a significant increase in the BSFA30 tilapia group compared to the control group followed by BSFA45 (P < 0.05). The BSFA30 group exhibited the highest nonspecific immunity parameters including (lysozyme activity, phagocytic index, and phagocytic activity) compared to other groups (P < 0.05). SOD and GPx reported the highest values in the BSFA60 group. Nile tilapia carcass composition was not influenced by BSFA inclusion level (P > 0.05). Interestingly, Nile tilapia fed with BSFA15 diet exhibited the highest protease activity level (P < 0.05), while those fed on BSFA30 documented the highest amylase activity. Intestinal histomorphology was significantly enhanced with the gradual increase of administrated BSFA. Regarding the tilapia disease resistance against Aeromonas septicemia, BSFA significantly diminished the cumulative mortality compared to the control group. To sum up, BSFA was more effective in improving the growth performance and immunity of Nile tilapia.

Gut immune-related gene expression, histomorphometry and hematoimmunological assays in Nile tilapia (Oreochromis niloticus) fed Aspergillus oryzae fermented olive cake

Fermentation strategy is well documented to improve the nutritional value of agricultural waste by-products such olive cake (OC), which, in turn, provides healthy, safe, and affordable feedstuff. This study assessed the combined impact of Aspergillus oryzae-fermented OC (AFOC) on the growth performance, intestinal morphometry, blood biochemistry, lysozyme activity, gut immune-related genes, and flesh quality of Nile tilapia. We divided 225 fish into five groups and further subdivided into three replicates (n = 15 each) and fed them five diets (Control, AFOC5, AFOC10, AFOC15, AFOC20) to determine AFOC nutritional value and its optimized incorporation level in the diet. The trial continued for 3 months. The crude protein content of OC improved by 7.77% after A. oryzae fermentation, while lipid content decreased by 14.19%. In addition, growth and feed utilization significantly improved at (10.8-11.2) % AFOC dietary level. High-density lipoprotein (HDL) significantly improved, and the serum lysozyme level was significantly higher in the AFOC10 group compared to other groups. Interestingly, gut-related inflammatory cytokines tumor necrosis factor alpha (TNF- α) and interleukin 1 beta (IL-1β) revealed higher relative mRNA expression in the AFOC10 group compared to other groups. The histomorphometric parameters was greatly influenced by the AFOC incorporation level (10%-20%). These findings suggested that A. orzae fermentation modifies the nutritional quality of OC, as seen through its positive impact on the growth performance, local and systemic immunity, and intestinal absorptive capacity of Nile tilapia. The recommended dose for dietary AFOC was around 11.

Irinotecan and temozolomide chemotherapy in paediatric and adult populations with relapsed Ewing Sarcoma

BACKGROUND

Irinotecan and temozolomide (IT) is a widely used regimen for relapsed Ewing sarcoma (ES), although studies are largely limited to paediatric populations.

METHODS

We retrospectively reviewed paediatric (< 18 years) and adult patients (≥ 18 years) treated with salvage IT at two institutions. Haematologic toxicities were graded according to common terminology criteria of adverse events. Survival was estimated by the Kaplan-Meier method and compared by the Log Rank test.

RESULTS

Fifty-three patients were treated with IT from Jan, 2010 to Dec, 2018 (n = 16 paediatric; n = 37 adult). IT was given as second-line (n = 34; 64%) or ≥ third-line (n = 19; 36%). There was no difference in ≥ grade 3/4 haematologic toxicity between paediatrics and adults (31% vs. 35% respectively; p = 0.76). The frequency of diarrhoea of any grade was similar (38% in each group). Of 43 patients assessable for response, 12 (28%) had objective response (1 CR, 11 PR), 12 (28%) stable disease and 19 (44%) disease progression. Objective response rate did not differ between the two groups (36% in paediatrics vs. 25% in adults; p = 0.47). Median PFS was superior in paediatrics vs. adults (7.4 vs. 2.2 months, p = 0.039).

CONCLUSION

Irinotecan and temozolomide (IT) chemotherapy has activity for relapsed ES, with favourable toxicity and equally observed objective responses in the paediatric and adult populations. The observed superior PFS for the paediatric cohort requires further confirmation in future studies.

Outcomes of extraskeletal vs. skeletal Ewing sarcoma patients treated with standard chemotherapy protocol

PURPOSE

To compare the outcomes of extraskeletal and skeletal Ewing sarcomas treated with standard chemotherapy protocol.

METHODS

We retrospectively collected data on primary localized skeletal and extraskeletal ES patients. Demographics and disease characteristics were compared between the two groups. The influence of presentation (skeletal vs. extraskeletal) on overall survival (OS) and local recurrence-free survival (LRFS) was assessed and compared by the log-rank test.

RESULTS

A total of 120 patients were included; 29 (24%) had extraskeletal and 91 (76%) had skeletal ES. All patients received vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide (VDC-IE) chemotherapy, with a plan for local control at week 12. At a median follow-up of 38 months, there was no difference in OS between skeletal and extraskeletal ES; 5-year OS 70% and 67% respectively, p = 0.96. Patients with extraskeletal ES had inferior 5-year LRFS compared to skeletal ES; 74% vs. 83%; p = 0.042. Local recurrence occurred at a higher frequency in the extraskeletal group; 28% vs. 11%, p = 0.034, although more extraskeletal patients received adjuvant radiotherapy; 73% vs. 36%, p = 0.01. Among patients who underwent surgery (n = 76), there was no difference in R0 resection rate (skeletal: 89%, extraskeletal: 86%, p = 0.52, or good ( ≥ 90%) tumor necrosis; skeletal: 54%, extraskeletal: 38%, p = 0.31.

CONCLUSION

Patients with localized extraskeletal ES have comparable OS outcomes to patients with skeletal ES utilizing the standard VDC-IE chemotherapy. However, extraskeletal patients are at significantly higher risk for local recurrence.

P6134Understanding non-attendance to an inner city tertiary centre heart failure clinic: a pilot project

Background

Tackling health inequalities is a priority in heart failure (HF). We do not fully understand why some patients do not attend their hospital HF clinic appointments. Currently when a patient DNAs (does not attend) they are offered a repeat appointment often months later or are discharged from the service with a request to the primary care physician to re-refer. Non-attendance represents a missed opportunity to improve patients' health.

Purpose

The purpose of this pilot was to look at the demographics and patient factors that contribute to non-attendance. The aim is to understand and personalise our DNA policy to reduce health inequality, improve outcomes, and reduce inefficiencies in our service.

Methods

The last consecutive 45 patients who DNAd HF clinic were identified and for each, a patient who did attend the same clinic date (Attender), was chosen at random (random.org). The demographics were obtained (age, ethnicity, contact details) and medical notes reviewed (LVEF%, co-morbidities). The patient address was scored for its Index of Multiple Deprivation (IMD) – a UK government dataset measuring relative deprivation by ranking 32,844 neighbourhoods nationally using 37 indicators across 7 domains of deprivation where neighbourhood 1 is the most deprived nationally. Patients were phoned up to three times to establish the patient's mode, duration and cost of their last journey to clinic and, for those patients who DNAd, to ascertain the reason for non-attendance.

Results

Demographic and medical history was obtained for all patients. It was not possible to contact 2/45 of the Attenders, and 13/45 of the DNA patients. There was no significant difference in age, gender, number of comorbidities, LVEF%, travel time, or travel cost between DNAs and attenders. The mean one-way journey time was 53.4 mins (range 15–210 mins) and the mean return journey cost was GBP ≤10.95 (range ≤0–≤80). Common reasons for non-attendance were not receiving appointment details, forgetting appointments, being unwell on the day and difficulties with travel. The IMD score for the patients who DNAd was significantly lower confirming these patients lived in more deprived areas (9436±5863 vs. 15414±7801, p<0.001) with 71% of DNA patient's addresses in the bottom third most deprived neighbourhoods nationally.

Figure 1

Conclusions

There was a significant difference in deprivation score between patients who attended and DNAd their clinics. In addition, we found that all patients were travelling up to an hour each way to attend clinic, and that the cost of travel may be a barrier to attendance, even in a healthcare system that is free at the point of delivery. Despite calling three times, we were unable to speak to 29% of patients who DNAd and 4% of the patients who attended their appointments. Work is ongoing to reduce our DNA rates and personalise our response in this deprived population, with the aim of improving engagement and health inequality.

The learning curve to achieve satisfactory completion rates in upper GI endoscopy: an analysis of a national training database

OBJECTIVE

The aim of this study was to determine the number of OGDs (oesophago-gastro-duodenoscopies) trainees need to perform to acquire competency in terms of successful unassisted completion to the second part of the duodenum 95% of the time.

DESIGN

OGD data were retrieved from the trainee e-portfolio developed by the Joint Advisory Group on GI Endoscopy (JAG) in the UK. All trainees were included unless they were known to have a baseline experience of >20 procedures or had submitted data for <20 procedures. The primary outcome measure was OGD completion, defined as passage of the endoscope to the second part of the duodenum without physical assistance. The number of OGDs required to achieve a 95% completion rate was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine which factors were independently associated with OGD completion, a mixed effects logistic regression model was constructed with OGD completion as the outcome variable.

RESULTS

Data were analysed for 1255 trainees over 288 centres, representing 243 555 OGDs. By moving average method, trainees attained a 95% completion rate at 187 procedures. By LC-Cusum analysis, after 200 procedures, >90% trainees had attained a 95% completion rate. Total number of OGDs performed, trainee age and experience in lower GI endoscopy were factors independently associated with OGD completion.

CONCLUSIONS

There are limited published data on the OGD learning curve. This is the largest study to date analysing the learning curve for competency acquisition. The JAG competency requirement for 200 procedures appears appropriate.

20 EFFECT OF PENICILLAMINE, HYPOTAURINE, AND EPINEPHRINE TREATMENT ON MOTILITY, HYPERACTIVITY AND ACROSOME REACTION OF RAM SPERMATOZOA

The aim of this study was to determine the effects of in vitro treatment of freshly ejaculated ram spermatozoa with different concentrations of penicillamine, hypotaurine, and epinephrine (PHE) at different incubation times on motility, hyperactivity (HA) and acrosome reaction (AR). Freshly ejaculated spermatozoa collected from three rams were pooled and then subjected to swim up technique in modified sperm Tyrode’s albumin lactate pyruvate (S-TALP) medium supplemented with different concentrations of PHE (0, 10, 20, 30, 40, 50, 75, and 100 mM). Following incubation (0, 1, 2, 3 and 4 h), sperm motility and hyperactivity were examined under the phase contrast microscope and acrosome reaction was detected by staining of the spermatozoa with silver nitrate. Results showed that treatment of spermatozoa with high concentrations of PHE (30, 40, 50, 75, and 100 mM) significantly increased the motility when compared with the control immediately after dilution (82.0, 82.0, 81.0, 82.0, 82.0 v.76.0%, respectively).This increase existed for the first and second hours of incubation. However, when the incubation time was increased for more than 2 h total motility significantly decreased (P < 0.05, ANOVA) as compared with the control. The same trend was observed in hyperactive motility. Treatment of spermatozoa with 50 and 75 mM of PHE for 1 h significantly increased the percentage of sperm with incomplete AR (20.0 and 27.0% respectively). At 4 h incubation, (49.0%) of spermatozoa treated with 75 mM PHE had undergone complete AR. Furthermore, the maximum value of total acrosome reaction (73.0%) was achieved at 4 h post incubation after addition of 75 mM PHE to ram sperm. In conclusion, under our experimental conditions, 75 mM PHE for 4 h was considered the best concentration of PHE for treatment of ejaculated ram spermatozoa for in vitro induction of acrosome reaction.

Untangling the Complexity of Liver Fluke Infection and Cholangiocarcinoma in NE Thailand Through Transdisciplinary Learning

This study demonstrates how a transdisciplinary learning approach provided new insights for explaining persistent Opisthorchis viverrini infection in northern Thailand, as well as elucidating problems of focusing solely on the parasite as a means of addressing high prevalence of cholangiocarcinoma. Researchers from diverse backgrounds collaborated to design an investigative homestay program for 72 Singaporean and Thai university students in five northeast Thai villages. The students explored how liver fluke infection and potential cholangiocarcinoma development are influenced by local landscape dynamics, aquatic ecology, livelihoods, food culture and health education. Qualitative fieldwork was guided daily by the researchers in a collaborative, co-learning process that led to viewing this health issue as a complex system, influenced by interlinked multidimensional factors. Our transdisciplinary experience has led us to believe that an incomplete understanding of these linkages may reduce the efficacy of interventions. Further, viewing liver fluke infection and cholangiocarcinoma as the same issue is inadvisable. Although O. viverrini infection is an established risk factor for the development of cholangiocarcinoma, multiple factors are known to influence the likelihood of acquiring either. Understanding the importance of the current livelihood transition, landscape modification and the resulting mismatch between local cultures and new socio-ecological settings on cholangiocarcinoma initiation and liver fluke transmission is of critical importance as it may help readjust our view of the respective role of O. viverrini and other socioeconomic risk factors in cholangiocarcinoma etiology and refine intervention strategies. As demonstrated in this study, transdisciplinary approaches have the potential to yield more nuanced perspectives to complex diseases than research that focuses on specific aspects of their epidemiology. They may therefore be valuable when designing effective solutions to context-sensitive diseases such as liver fluke infection and cholangiocarcinoma.

The effects of CCR5 inhibition on regulatory T-cell recruitment to colorectal cancer

BACKGROUND

Regulatory T cells (Treg) are enriched in human colorectal cancer (CRC) where they suppress anti-tumour immunity. The chemokine receptor CCR5 has been implicated in the recruitment of Treg from blood into CRC and tumour growth is delayed in CCR5-/- mice, associated with reduced tumour Treg infiltration.

METHODS

Tissue and blood samples were obtained from patients undergoing resection of CRC. Tumour-infiltrating lymphocytes were phenotyped for chemokine receptors using flow cytometry. The presence of tissue chemokines was assessed. Standard chemotaxis and suppression assays were performed and the effects of CCR5 blockade were tested in murine tumour models.

RESULTS

Functional CCR5 was highly expressed by human CRC infiltrating Treg and CCR5(high) Treg were more suppressive than their CCR5(low) Treg counterparts. Human CRC-Treg were more proliferative and activated than other T cells suggesting that local proliferation could provide an alternative explanation for the observed tumour Treg enrichment. Pharmacological inhibition of CCR5 failed to reduce tumour Treg infiltration in murine tumour models although it did result in delayed tumour growth.

CONCLUSIONS

CCR5 inhibition does not mediate anti-tumour effects as a consequence of inhibiting Treg recruitment. Other mechanisms must be found to explain this effect. This has important implications for anti-CCR5 therapy in CRC.

A pilot study of extralevator abdominoperineal excision for primary melanoma of the anorectum

Melanoma of the anorectum represents <2 % of all anorectal cancers and 0.3 % of all primary melanomas. Prognosis is poor, and optimal surgical management is controversial. This series details the surgical management of patients with anorectal melanoma presenting between 2002 and 2013 to the Queen Elizabeth Hospital in Birmingham, UK, a tertiary referral centre for colorectal disease. A retrospective review of patient notes, histology reports, and clinical letters was used to assess perioperative course and long-term outcome of all surgical methods. Eight patients with a median age of 65.5 presented with primary anorectal melanoma during the study period. Six cases were staged as T4 pre-operatively, with two referred as incompletely excised polyps. All eight patients underwent abdominoperineal excision of the rectum (APER), with the most recent four cases undergoing extralevator APER. Clear resection margins were achieved in three out of the four patients in the extralevator APER group with no nodal spread detected at histological assessment. Extralevator APER appears to be feasible and safe in the treatment of melanoma of the anorectum, with 75 % medium-term survival (median 38 months) in selected patients. As it is known that clear margins at surgery are associated with disease-free survival, the wider excision margin at the level of the pelvic floor offered by extralevator APER could result in more favourable surgical outcomes in this prognostically poor malignancy.

Evaluation of serum lysyl oxidase as a blood test for colorectal cancer

AIMS

Lysyl oxidase (LOX) expression is elevated in colorectal cancer (CRC) tissue and associated with disease progression. A blood test may form a more acceptable diagnostic test for CRC although LOX has not previously been measured in the serum. We therefore sought to determine the clinical usefulness of a serum LOX test for CRC in a symptomatic population.

METHODS

Adult patients referred to a hospital colorectal clinic with bowel symptoms completed a questionnaire and provided a blood sample for serum LOX measurement. Associations between presenting symptoms, serum LOX concentrations and outcomes of investigations were tested by univariate and multivariate analyses to determine if serum LOX was clinically useful in the prediction of CRC. LOX expression in CRC and adjacent colon biopsies was evaluated by ELISA and immunohistochemistry.

RESULTS

Thirty-one cases of colorectal cancer and 16 high-risk polyps were identified from a total of 962 participants. There was no association between serum LOX concentration and the presence of CRC, high-risk polyps or cancers at any site. LOX expression was significantly increased in CRC tissue compared to adjacent colon.

CONCLUSION

Despite overexpression of LOX in CRC tissue, elevated serum levels could not be demonstrated. Serum LOX measurement is therefore not a clinically useful test for CRC.

Patients newly diagnosed with ulcerative colitis receive earlier treatment in surgical clinics

AIM

The diagnosis and treatment of ulcerative colitis (UC) is traditionally the realm of gastroenterologists. However, the symptoms of UC overlap with those of bowel cancer and patients may be initially referred to colorectal surgery clinics. The aims of this study were to define which specialty most frequently diagnoses UC and to determine if there were differences in management between the two specialities.

METHOD

The demographics, presenting symptoms and clinical management of patients with newly diagnosed UC were determined and compared by speciality clinic of initial referral. Histopathology reports and clinic letters were reviewed to identify patients newly diagnosed with UC at a large university teaching hospital from January 2007 to January 2012.

RESULTS

Patients were more commonly referred to colorectal surgeons (74 vs 41 patients) than gastroenterologists. Patients referred to gastroenterology were younger (36.0 vs 59.6 years, P < 0.01) but there were no significant differences in gender, presenting symptoms or disease extent. Rigid sigmoidoscopy ± biopsy was more commonly performed in colorectal clinic (93.2 vs 31.7%, P < 0.01). There was a significantly shorter delay in starting disease-specific treatment for those patients referred initially to colorectal surgery (13.8 vs 33.6 days, P = 0.01). Performing rigid sigmoidoscopy in clinic was associated with starting disease-specific treatment at this visit.

CONCLUSION

Patients with first presentation UC are more commonly seen in colorectal surgery clinics where rigid sigmoidoscopy is more frequently undertaken, allowing earlier commencement of UC treatment.

[Usefulness and predictive value of PSA density, adjusted by transition zone volume, in men with PSA levels between 2 and 4 ng/ml]

OBJECTIVE

To assess the diagnostic significance of prostate-specific antigen (PSA), density (PSAD) accuracy, and PSAD adjusted by transition zone volume (PSATZD) in men with PSA levels between 2.0 and 4.0 ng/ml.

MATERIAL AND METHODS

Between 2000 and 2010, 138 men with PSA levels between 2 and 4.0 ng/ml underwent transrectal ultrasonography (TRUS) and 12-core prostate biopsy. Diagnostic accuracies for various cut-offs of PSAD and PSATZD were investigated according to subdivided PSA levels of 2.0 to 3.0 ng/ml and 3.1 to 4.0 ng/ml.

RESULTS

The detection rate of prostate cancer was 23,8% (32/134). The percentage of patients with extracapsular disease was 28.1% (10/32) and primary Gleason grade 4 or 5 was obtained in 8/32 (25%) patients. The transition zone volume and PSATZD in cancer cases were significantly different in comparison with those in non-cancer cases. The area under the receiver operating characteristic curve for PSATZD was significantly higher in comparison with that for PSAD in the same subdivided PSA ranges. The diagnostic efficiency for PSATZD was higher than that for PSAD. The diagnostic efficiency showed the highest value at the cut-off level for PSATZD of 0.23 and 0.28 in men with PSA levels of 2.0 to 3.0 ng/ml and 3.1 to 4.0 ng/ml, respectively.

CONCLUSIONS

The use of PSATZD cut-offs as a biopsy indication may reduce many unnecessary biopsies without missing most prostate cancer cases in the PSA range of 2.0 to 4.0 ng/ml.

[Bone mineral density change: comparison between prostate cancer patients with or without metastases and healthy men (a North African ethnic group)]

AIM

To evaluate total body bone mineral density and regional bone mineral density in patients with prostate cancer with and without metastases, and to correlate them with bone scintigraphy findings.

PATIENTS AND METHODS

135 patients with prostatic carcinoma and 50 healthy subjects were investigated with bone scintigraphy and dual-energy X-ray absorptiometry. The bone scintigraphic findings were classified as normal (score 0: n=55), abnormal but not typical for metastases (score 1: n=45), and typical pattern of metastases (score 2: n=35).

RESULTS

: The patients with bone metastases prostate cancer had significantly higher total bone mineral density and regional bone mineral density of trunk and pelvis than healthy controls and prostate cancer patients without bone metastases. There was a significant positive correlation between bone scan score and total bone mineral density and regional bone mineral density of trunk and pelvis (r=0.328; P<0.05; r=0.60; P<0.001; r=0.480; P<0.001, respectively).

CONCLUSION

Bone metastasis is a major cause of morbidity in prostatic cancer, bone loss during hormonal treatment is currently effective. Our results show that patients of prostate cancer with bone metastases have increased bone mineral density (BMD) in the pelvis and trunk, possibly because of a predominance of osteoblastic over osteolytic metastases demonstrated by (99m)Tc MDP bone scan.

Obstructive sleep apnoea hypopnea syndrome - an overview

Obstructive sleep apnoea hypopnoea syndrome (OSAHS) is a common cause of breathing-related sleep disorder, causing excessive daytime sleepiness. Common clinical features of OSAHS include snoring, fragmented sleep, daytime somnolence and fatigue. This article aims to provide a comprehensive review of the condition, including its management.

Iron deficiency anaemia and delayed diagnosis of colorectal cancer: a retrospective cohort study

AIM

The extent to which different referral pathways following a primary care diagnosis of iron deficiency anaemia (IDA) are associated with delay in diagnosis of colorectal cancer (CRC) was determined.

METHOD

Eligible patients aged 40 or more years, with IDA diagnosed in primary care, and a subsequent diagnosis of CRC, were studied retrospectively. Referral pathways were identified using the specialty of first recorded GP referral following IDA diagnosis. Differences in time to diagnosis of CRC were assessed by referral specialty. Differences in the proportion of cases referred before and after the re-issue of the NICE urgent referral guidelines for suspected lower gastrointestinal (GI) cancer were also assessed.

RESULTS

Of 628,882 eligible patients, 3.1% (n = 19,349) were diagnosed with IDA during the study period; 3.0% (n = 578) were subsequently diagnosed with CRC. Two hundred and fifty-nine (44.8%) patients had no recorded referral or a referral unrelated to anaemia or the GI tract. Only 35% (n = 201) of patients were referred to a relevant specialty. Median time to CRC diagnosis ranged from 2.5 months (referral to a relevant surgical specialty) to 31.9 months (haematology). Time to diagnosis was longer in patients referred to a medical compared with a relevant surgical specialty (P = 0.024). There was no significant difference in time to CRC diagnosis before and after the NICE guidelines were re-issued in 2005.

CONCLUSION

Significant differences exist between referral specialties in time to CRC diagnosis following a primary care diagnosis of IDA. Despite NICE referral recommendations, a significant proportion of patients are still not managed within recommended care pathways to CRC diagnosis.

HIV Associated Opportunistic Pneumonias

Opportunistic pneumonias are major causes of morbidity and mortality in HIV infected individuals. The majority of new HIV infections in Malaysia are adults aged 20 to 39 years old and many are unaware of their HIV status until they present with an opportunistic infection. HIV associated opportunistic pneumonias can progress rapidly without appropriate therapy. Therefore a proper diagnostic evaluation is vital and prompt empiric treatment of the suspected diagnosis should be commenced while waiting for the results of the diagnostic studies. Tuberculosis, Pneumocystis pneumonia (PCP) and recurrent bacterial pneumonias are common causes of AIDS-defining diseases and are discussed in this article.

A survey on the initial management of spontaneous pneumothorax

Spontaneous pneumothorax (SP) is a common medical condition but continues to be a frequent management problem among doctors. Despite the availability of guidelines on management of SP, studies have shown that the compliance with the guidelines is low. The various treatment options available in treating this condition further confuse doctors on the right approach in managing SP. The objective of this study is to investigate the awareness of the availability of these existing guidelines and to investigate how the doctors involved in the initial management of SP would manage this condition. A self completed questionnaire which included three case scenarios were distributed among doctors in two teaching university hospitals and two large Ministry of Health hospitals. This study showed that there is a lack of awareness of the existing guidelines even among the senior doctors and there is a variation in the initial management of SP. Therefore a locally produced guideline may be beneficial to standardise and improve the management of SP.

Fast targeted multidimensional NMR metabolomics of colorectal cancer

The study of small molecules in body fluids has become an important tool to monitor the state of biological organisms. Applications range from model studies using cell lines to applications where human body fluids are used to monitor disease states or drug responses. NMR spectroscopy has been an important tool for metabolomics although severe overlap of signals has limited the number of compounds, which can be unambiguously identified and quantified. Therefore, deconvolution of NMR spectra is one of the greatest challenges for NMR-based metabolomics. This has commonly been achieved by using multidimensional spectra that have the disadvantage of requiring significantly longer acquisition times. Recently, a number of methods have been described to record NMR spectra much faster. Here, we explore the use of Hadamard-encoded TOCSY spectra to simultaneously select multiple lines from crowded NMR spectra of blood serum samples to acquire pseudo-two-dimensional spectra in minutes which would otherwise require many hours. The potential of this approach is demonstrated for the detection of a signature for colorectal cancer from human blood samples.

Factors affecting attitudes toward colorectal cancer screening in the primary care population

Background:

Colorectal cancer (CRC) is a major cause of death in the United Kingdom. Regular screening could significantly reduce CRC-related morbidity and mortality. However, screening programmes in the United Kingdom have to date seen uptake rates of less than 60%. Attitudes towards screening are the primary factors determining patient uptake.

Methods:

A questionnaire was sent to people aged 50–69 years who were registered with general practices in the West Midlands. A total of 11 355 people (53%) completed the questionnaire. Multivariable logistic regression analyses were performed to identify those factors (gender, age, ethnicity, deprivation, number of symptoms, and their duration) that most strongly contributed to negative/positive attitudes in the primary care population.

Results:

Fourteen percent of respondents had a negative attitude towards screening. Men, older people, and those with Indian ethnic backgrounds were more likely to have negative attitudes toward screening, whereas people with Black-Caribbean ethnic background, people with multiple symptoms and those reporting abdominal pain, bleeding, and tiredness were more likely to have a positive attitude.

Conclusion:

Culturally relevant screening strategies should aim to increase knowledge of the symptoms and signs related to bowel cancer among South Asian ethnic groups in the United Kingdom. It is also important to find ways to increase the acceptability of screening among asymptomatic patients.

Prognostic factors predicting successful response to sildenafil after radical cystoprostatectomy

OBJECTIVES

To assess the efficacy and safety of sildenafil citrate in the management of erectile dysfunction (ED) following radical cystectomy (RC) and to define the different prognostic factors predicting the response to sildenafil in such a challenging group of patients.

MATERIAL AND METHODS

One hundred patients with ED following RC participated in an open-label, non-randomized, prospective, dose-escalation study. The median age of the patients was 53 years and the mean period after RC was 80.7 +/- 54.8 months. The study duration was 12 weeks, comprising a 4-week run-in period followed by two active treatment periods of 4 weeks each with 50 and 100 mg of sildenafil. Patients were assessed by means of the International Index of Erectile Function (IIEF) questionnaire at baseline and after each treatment period. At the end of the study, the Global Efficacy Assessment Question was used to evaluate treatment satisfaction. Factors affecting the patient's response to sildenafil were assessed by means of uni- and multivariate analysis.

RESULTS

The entire study group was suffering from severe ED at baseline, with a mean erectile function (EF) domain score of 6.5 +/- 0.93. EF scores improved to 12.2 +/- 7.76 and 18 +/- 10.3 with 50 and 100 mg of sildenafil, respectively. Sildenafil therapy significantly improved the ability of many patients to achieve and maintain an erection. The mean scores for question 3 of the IIEF were 1 +/- 0.14, 2.1 +/- 1.4 and 3 +/- 1.8 at baseline and with 50 and 100 mg of sildenafil, respectively, while the corresponding scores for question 4 were 1 +/- 0.10, 1.9 +/- 1.35 and 3 +/- 1.85. The satisfaction rate was 54%. The response was dose-dependent but the incidence of adverse effects increased from 6% with 50 mg of sildenafil to 34% with 100 mg. In univariate analysis, tumor histology and grade and postoperative partial tumescence were found to significantly impact the patient's response to sildenafil. In multivariate analysis, postoperative partial tumescence was the only independent predictive variable. CONCLUSIONS. Sildenafil was found to be a safe and satisfactory treatment for post-RC ED. The effect was dose-related. Patients with postoperative partial tumescence were the best responders.

Elevated serum matrix metalloproteinase 9 (MMP-9) concentration predicts the presence of colorectal neoplasia in symptomatic patients

Early detection of polyps or colorectal carcinoma can reduce colorectal carcinoma-associated deaths. Previous studies have demonstrated raised serum levels of matrix metalloproteinase 9 (sMMP-9) in a range of cancers. The aim of this study was to investigate the role of sMMP-9 levels in identifying colorectal neoplasia. Consenting patients donated a blood sample and were assessed by proforma-led history and physical examination. Samples were analysed for sMMP-9 concentration (enzyme-linked immuno-sorbant assay) and compared to final diagnoses. Logistic regression modelling determined independent factors associated with neoplasia. A total of 365 patients were recruited of whom 300 were analysed, including 46 normal controls. A total of 27 significant adenomas and 63 malignancies were identified. The median sMMP-9 concentration was 443ng ml⁻¹ (IQR: 219–782; mean: 546). Patients with neoplasia had significantly elevated sMMP-9 levels (P<0.001). Logistic regression modelling identified elevated log(sMMP-9) as the most significant predictor of neoplasia (χ²=38.33, P<0.001). Other significant factors were age, sex, smoking history, abdominal pain and weight loss. The model accurately predicted neoplasia in 77.3% of cases. Sensitivity and specificity were 77.9 and 77.1%. sMMP-9 estimation can accurately stratify patient to low- or high-risk cohorts. Serum sampling is a potential means of avoiding unnecessary colonoscopy and reducing patient anxiety, iatrogenic morbidity and mortality, and cost.

PPARG locus haplotype variation and exacerbations in asthma

The peroxisome proliferator-activated receptor gamma (PPARgamma) regulates inflammation and may play a role in asthma. Using mouthwash-derived DNA and clinical interviews and measurements, we investigated the association of previously characterized single-nucleotide polymorphisms in the PPARG gene (Pro12Ala, C1431T, and C-681G) with asthma exacerbations in patients aged 3-22 years (n=569). The common homozygous haplotype combination of the Pro12 and C1431 alleles was associated with increased risk for asthma exacerbations (ProC, odds ratio (OR) 1.87, 95% confidence interval 1.25-2.79; P=0.002). The ProC genotype was associated with increased school absences (OR 1.82, 95% confidence interval 1.21-2.76; P=0.004) and hospital admissions (OR 2.32, 95% confidence interval 1.18-4.58; P=0.015) over the preceding 6 months. The population-attributable risk of this genotype was 33%. Common genetic variation at the PPARG locus may play an important role in modulating the long-term control of asthma in children and young adults.

Frequency and impact of extracolonic findings detected at computed tomographic colonography in a symptomatic population

Background

Extracolonic findings are frequently recognized alongside colonic pathology at computed tomographic colonography (CTC). This study assessed the clinical impact of extracolonic findings in a symptomatic population at high risk of colorectal cancer.

Methods

CTC was performed in a consecutive cohort of patients assessed in a fast-track colorectal cancer clinic as being at high risk of colorectal cancer. A review of CTC findings and case notes was undertaken. Patients with extracolonic findings were followed up for at least 12 months.

Results

Thirty-one (13·8 per cent) of 225 patients investigated by CTC had colorectal cancer. Extracolonic findings were identified in 81 (53·3 per cent) of 152 patients with normal or non-neoplastic bowel findings, compared with 27 (37 per cent) of 73 patients with colorectal neoplasia (P = 0·025). Twenty-four patients (10·7 per cent) with extracolonic findings underwent further investigation or treatment. The median duration of investigation was 19·5 weeks. Seventy-five clinical events were recorded, including 14 surgical procedures.

Conclusion

A prospective cost–benefit analysis of diagnostic CTC should be performed before it is established as a first-line investigation for colonic symptoms.

Arginine-16 beta2 adrenoceptor genotype predisposes to exacerbations in young asthmatics taking regular salmeterol

BACKGROUND

The homozygous presence of the arginine-16 variant of the beta(2) adrenoceptor gene ADRB2 reverses the benefits from the regular use of short acting beta(2) agonists in asthmatic adults compared with the homozygous glycine-16 genotype. We studied the effect of this polymorphic variation on asthma exacerbations in children and young adults and its relation to long acting beta(2) agonists.

METHODS

A cross-sectional survey was undertaken using electronic records, direct interviews, and genotype determination of position 16 and 27 of the ADRB2 gene in DNA from mouthwash samples of 546 children and young asthmatics attending paediatric and young adult asthma clinics in Tayside, Scotland during 2004-5. The primary outcome measure was asthma exacerbations over the previous 6 months.

RESULTS

There was an increased hazard of asthma exacerbations across all treatment steps of the British Thoracic Society (BTS) asthma guidelines when the homozygous genotypes Arg/Arg and Gly/Gly were compared (OR 2.05, 95% CI 1.19 to 3.53, p = 0.010), particularly in patients treated with salmeterol (OR 3.40, 95% CI 1.19 to 9.40, p = 0.022). The Glu27Gln polymorphism had no significant effect on asthma exacerbations in any treatment group.

CONCLUSIONS

The arginine-16 genotype of ADRB2 predisposes to exacerbations in asthmatic children and young adults, particularly in those exposed to regular salmeterol. This may be explained by genotype selective salmeterol induced downregulation and impaired receptor coupling, and associated subsensitivity of the response.

Modulation of iron transport proteins in human colorectal carcinogenesis

BACKGROUND AND AIMS

Total body iron and high dietary iron intake are risk factors for colorectal cancer. To date there is no comprehensive characterisation of iron transport proteins in progression to colorectal carcinoma. In this study, we examined expression of iron import (duodenal cytochrome b (DCYTB), divalent metal transporter 1 (DMT1), and transferrin receptor 1 (TfR1)) and export (hephaestin (HEPH) and ferroportin (FPN)) proteins in colorectal carcinoma.

METHODS

Perl's staining was used to examine colonocyte iron content. Real time polymerase chain reaction (PCR) and western blotting were used to examine mRNA and protein levels of the molecules of interest in 11 human colorectal cancers. Semiquantitative immunohistochemistry was used to verify protein levels and information on cellular localisation. The effect of iron loading on E-cadherin expression in SW480 and Caco-2 cell lines was examined by promoter assays, real time PCR and western blotting.

RESULTS

Perl's staining showed increased iron in colorectal cancers, and there was a corresponding overexpression of components of the intracellular iron import machinery (DCYTB, DMT1, and TfR1). The iron exporter FPN was also overexpressed, but its intracellular location, combined with reduced HEPH levels, suggests reduced iron efflux in the majority of colorectal cancers examined. Loss of HEPH and FPN expression was associated with more advanced disease. Iron loading Caco-2 and SW480 cells caused cellular proliferation and E-cadherin repression.

CONCLUSIONS

Progression to colorectal cancer is associated with increased expression in iron import proteins and a block in iron export due to decreased expression and aberrant localisation of HEPH and FPN, respectively. This results in increased intracellular iron which may induce proliferation and repress cell adhesion.

Identification of serum biomarkers for colon cancer by proteomic analysis

Colorectal cancer (CRC) is often diagnosed at a late stage with concomitant poor prognosis. Early detection greatly improves prognosis; however, the invasive, unpleasant and inconvenient nature of current diagnostic procedures limits their applicability. No serum-based test is currently of sufficient sensitivity or specificity for widespread use. In the best currently available blood test, carcinoembryonic antigen exhibits low sensitivity and specificity particularly in the setting of early disease. Hence, there is great need for new biomarkers for early detection of CRC. We have used surface-enhanced laser desorbtion/ionisation (SELDI) to investigate the serum proteome of 62 CRC patients and 31 noncancer subjects. We have identified proteins (complement C3a des-arg, α1-antitrypsin and transferrin) with diagnostic potential. Artificial neural networks trained using only the intensities of the SELDI peaks corresponding to identified proteins were able to classify the patients used in this study with 95% sensitivity and 91% specificity.