Transanal endoscopic microsurgery as day surgery - a single-centre experience with 500 patients.

AIM: Transanal endoscopic microsurgery (TEM) is the current treatment of choice for rectal adenomas and early rectal cancer. Postoperative admission to hospital is common but possibly unnecessary. Our objective was to analyse predictors and outcomes of TEM patients having same day discharge (TEM-D) compared with those who were admitted to hospital (TEM-A). METHOD: At St Paul's Hospital (SPH), demographic, surgical, pathological and follow-up data have been collected prospectively since TEM was started in 2007. Trends in admission and readmission rates were analysed using the Cochran-Armitage trend test, and predictors of admission were analysed using univariate and multivariate logistic regressions. RESULTS: Between 2007 and 2016, 500 patients were treated by TEM at SPH. The overall admission rate was 29% (145/500), but this decreased to 19% in the last 3 years of the study (P < 0.001). The readmission rate was 5.2% (n = 26/500) and did not change significantly over the study period (P = 0.30). Reasons for admission included the following: surgeon discretion/monitoring (35%), urinary retention (26%), haemorrhage (10%), breach of peritoneal cavity (7%), infection (7%) and other (15%). The most common reasons for readmission were haemorrhage (54%, n = 14), pain (19%, n = 5) and infection (12%, n = 3). Factors associated with admission were as follows: tumour height (OR 1.09, 1.02-1.17), prolonged operative time (OR 1.25, 1.14-1.37), unsutured surgical defect (OR 1.99, 1.22-3.25) and surgeon experience (OR 4.62, 2.75-7.77). CONCLUSION: Outpatient TEM is safe and carries a low risk of readmission. In centres with an outpatient TEM strategy, predictors of hospital admission include proximal tumours, prolonged surgical time and open management of the surgical defect.

Is neutrophilia the key to diagnosing appendicitis in pregnancy?

BACKGROUND: The diagnosis of acute appendicitis (AA) in pregnancy remains challenging. We investigated which preoperative clinical factors are most predictive of AA in pregnant women. METHODS: 164 pregnant patients undergoing magnetic resonance imaging for suspected AA were retrospectively reviewed. Logistic regression was used to compare those with pathologically confirmed AA and those without. RESULTS: 28 patients (17.1%) had pathologically confirmed AA. 42.9% (n = 12) were perforated at the time of operation. Factors associated with AA included history of emesis (p = 0.005), migratory abdominal pain (p = 0.006), rebound tenderness (p = 0.01), elevated white blood cell count (p = 0.003), elevated Alvarado Score (p < 0.001), elevated neutrophil count (p = 0.021), and left shift (p = 0.001). As a screening test, a left shift with neutrophils >70% provided a sensitivity and negative predictive value of 100.0%. DISCUSSION: Every patient in our series with AA had a left shift. Neutrophil count and percentage should be considered in the diagnostic evaluation of these patients to better guide resource utilization and treatment.

Superficial mycoses in the west of Scotland.

Ringworm formed almost 70 per cent of all superficial mycoses diagnosed. The feet and nails were most frequently affected and a single species, Trichophyton rubrum was responsible for the majority of infections that required specialist attention. Scalp ringworm which, until the middle of this century, was the most common form of the disease now constitutes only 5 per cent of infections and the majority of these are caused by the zoophilic fungus Microsporum canis. The anthropophilic dermatophytes which were once so prevalent as the cause of scalp infections are now rarely encountered. Yeasts, especially Candida albicans were most frequently encountered as a cause of mucosal infections but were not unimportant as a cause of disease of skin and nail.

The preservation of medically important fungi.

Details are given of a method, first described in 1962, for preservation of fungi in anhydrous silica gel. It is shown that the procedure is suitable for use with dermatophytes, yeasts and other fungi of medical importance and that they may be preserved for periods of 5 years or more.

Protothecosis of Atlantic salmon.

The organism causing sporadic outbreaks of a visceral disease of salmon parr in fresh water stocks of a fish farm was identified by histological examination as a Prototheca species. Cultures confirmed the diagnosis and the organism, which does not conform to the characteristics of known Prototheca spp., is described as a new species Prothotheca salmonis.

Foot infections in swimming baths.

A 10% random sample of all bathers at a public swimming bath were examined for tinea pedis and verruca.The overall incidence of tinea pedis was 8.5% and of verruca 4.8%. The incidence of tinea pedis in 205 male adults was 21.5%, in 288 boys 6.3%, in 60 adult females 3.3%, and in 220 girls 0.9%. The incidence of verruca in juveniles ranged from 4.2% in boys to 10.5% in girls.It was clear that both infections spread within the baths, and since a relatively small proportion of users admitted to taking precautions to avoid contracting or developing infections it seems advisable that more publicity about recommendations on foot care should be provided.

Efficacy of miconazole in the topical treatment of tinea pedis in sportsmen.

A double-blind trial of 2% miconazole in a cream and in a powder base and of the respective vehicles was done in a group of forty-five young sportsmen regularly training and using the showers in a gymnasium. After 4 weeks treatment, the mycological cure rate using the active preparation was 60% compared to 24% for the placebo (P less than 0-05).

Control of tinea pedis in a swimming bath.

Random samples of the weekly entry of bathers to a swimming pool were examined for tinea pedis and verruca before and at intervals after the supply of individual sachets of foot powder to all bathers.Over three and a half years the overall incidence of tinea pedis decreased from 8.5% to 2.1%, and in adult males it decreased from 21.5% to 6.9%. The incidence of infection with Trichophyton mentagrophytes var. interdigitale decreased from 5.3% to 0.5%, and the incidence of infection with T. rubrum (1.2%-1.1%) and Epidermophyton floccosum (0.9%-0.5%) did not change significantly. The incidence of verruca decreased from 4.8% to 1.2%. Issuing foot powder clearly minimizes the spread of infection and is recommended for general use.

Unusual response of a yeast to imidazole antifungals.

Thiamin was shown to relieve preferentially the toxicity of econazole for a yeast which showed an unusual response to imidazole drugs. The possible role of this vitamin in the response of the yeast to imidazoles is discussed. An investigation of the effect of a second exposure of yeasts to imidazole drugs showed that there is an increase in sensitivity when the cells are transferred directly to fresh medium containing the same concentrations of the drug, and a decrease in sensitivity following transfer via drug-free medium.

Experimental infection of guinea-pigs with atypical and dysgonic strains of microsporum canis.

Pathogenicity tests with one dysgonic and six atypical strains of Microsporum canis were carried out on guinea-pigs. Five of the atypical strains were laboratory mutants from dysgonic strains isolated from living hosts. As sporulation and viability varied greatly between the strains, inocula consisted of suspensions of fungal fragments of known viable count. When a sufficiently active inoculum was used, lesions and fluorescent hairs were induced in the guinea-pigs by all but one of the strains tested. In each case the strain inoculated was reisolated from the lesions in pure culture. The significance of the results is discussed in the light of the unusual nature and origin of the strains.

Comparison of ketoconazole and griseofulvin in the treatment of tinea pedis.

Twenty-nine patients with mycologically proven tinea pedis were randomly allocated to oral treatment with either ketoconazole 200 mg daily or griseofulvin 1 g daily for a period of up to 8 weeks. Mycological cure rate at 4 weeks was 33% for ketoconazole and 29% for griseofulvin, and at 8 weeks was 53% and 57% respectively. The efficacy of both drugs in the treatment of interdigital tinea pedis is similar, and is considerably lower than that found with topical imidazole preparations where cure rates of over 70% are generally expected.

Growth of Hansenula holstii on cadavers.

Growth of a yeast was observed on prosected cadavers used for demonstration purposes in a medical school. An asporogenous yeast was isolated and identified as an atypical form of Hansenula holstii by analysis of the extracellular polysaccharide. The isolate showed resistance to embalming fluid but was eventually eradicated by addition of picloxidine digluconate to the fluid.