A core competency framework for prostate cancer peer navigation.

PURPOSE: Trained peer navigators can offer valuable peer support and mentorship to cancer patients and caregivers due to their highly relevant and unique perspective about the disease experience. In order to define the role of prostate cancer (PC) peer navigators within the cancer care system, it is important to establish the essential competencies of a PC peer navigator. We systematically identified and verified a set of core competencies for PC peer navigators and present a competency framework for PC peer navigators. METHODS: In phase 1, we conducted formative research consisting of a literature review and environmental scan as well as a secondary analysis of qualitative interviews. In phase 2, we drafted and mapped competencies. Finally in phase 3, expert stakeholders completed an anonymous survey to indicate whether they endorsed the competencies and to rank the importance of each competency to the peer navigator role. Open-ended feedback was also provided for each competency. RESULTS: Six core competency domains emerged: (1) self as navigator, (2) communication, (3) knowledge/information, (4) facilitate patient-centred care, (5) eHealth/technology, and (6) caregiver needs. Forty-seven core competency statements were mapped to these domains. Expert stakeholders (n = 27) included cancer survivors, caregivers, and healthcare providers. Most (89%) of core competency statements were endorsed by stakeholders and received high priority ratings, whereas only five of the competencies were less uniformly endorsed. CONCLUSIONS: This is the first attempt to list core competencies for PC peer navigators and may offer guidance for standardizing the PC peer navigator role and training.

Rectal cancer: prognostic indicators of long-term outcome in patients considered for surgery.

PURPOSE: Patients and clinicians seek an accurate prognosis after resectional surgery for rectal cancer. The aim of this study was to determine long-term outcomes after potentially curative surgery for rectal cancer with particular focus on factors associated with longer-term survival that are available to surgeons in the early post-operative setting. METHODS: We conducted a retrospective review of a prospectively gathered database of all primary rectal adenocarcinomas considered for surgery in the University Hospitals of Leicester National Health Service (NHS) Trust between 1998 and 2007. Survival was calculated using a Kaplan-Meier method. Factors thought to be associated with survival were subjected to univariate analysis followed by Cox proportion regression. RESULTS: One thousand and twelve patients with primary rectal adenocarcinoma diagnosed between 1998 and 2007 were identified. Eight hundred and fifty three patients did not have metastases at the time of presentation and 726 patients underwent major resectional surgery. Five-year survival was 66 %. Patients' age, Dukes' stage, UICC stage, nodal involvement and circumferential resection margin status were independently associated with long-term survival on multivariate analysis. CONCLUSION: This is one of the largest series of rectal cancers from a single NHS trust. We have demonstrated that age, Dukes' stage and CRM status are associated with long-term survival. These clinical factors are readily available to the surgeon at the time of first post-operative review and can provide a good clinical guide to prognosis.

A transperineal approach to perineal hernia repair using suture anchors and acellular porcine dermal mesh.

Perineal hernia following major pelvic surgery is a rare but recognised complication. Various surgical approaches to the repair of a symptomatic perineal hernia have been described. We describe the first reported use of the Mitek suture anchors to secure an acellular porcine dermal graft to the ischia during the transperineal repair of a large perineal hernia.

Nonresectional palliative abdominal surgery for patients with advanced colorectal cancer.

OBJECTIVE: Nonresectional palliative abdominal surgery (e.g. defunctioning stoma/bypass) may be appropriate for patients unsuitable for curative resection, to deal with complications of advanced colorectal malignancy such as obstruction. Our aim was to review the outcome of surgery in these patients within our institution. METHOD: All patients undergoing palliative surgery without resection for colorectal carcinoma between July 1998 and January 2007 were identified from our prospectively compiled colorectal cancer database. Data were extracted related to patients' demographics, presentation, tumour site, operative intervention, complications, oncological therapies, length of hospital stay and postoperative survival. RESULTS: One hundred and ninety-three patients were identified with a median age of 79 years (31-94 years). Fifty per cent were operated on an emergent basis for obstruction or perforation, and 50% on an elective basis. One hundred and sixty-nine patients had defunctioning stomas formed of which 156 were loop stomas. Twenty-four patients underwent bypass procedures. Thirty-day mortality rate was 13.5% and postoperative morbidity rate 47%. Median survival was 247 days, with 1-year survival of 38%. Patients undergoing operation on an emergent basis had poorer long-term survival (127 vs 320 days, P = 0.002). CONCLUSION: Nonresectional palliative abdominal surgery is associated with relatively high morbidity and mortality, particularly when performed in the emergency setting. However, in this patient group with a very poor outlook, it may be offered with reasonable survival expectations.

The RAPID protocol enhances patient recovery after both laparoscopic and open colorectal resections.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs can accelerate recovery and shorten the hospital stay after colorectal resections. The RAPID (remove, ambulate, postoperative analgesia, introduce diet) protocol is a simplified ERAS program that consists of a simplified, user-friendly single-page pro forma schedule. This study aimed to evaluate the impact of the RAPID protocol on patients undergoing both laparoscopic and open colorectal resections in two specialized colorectal units. METHODS: A prospective, two-center study assessed 117 age-matched patients undergoing open or laparoscopic colorectal resection to compare the postoperative course for patients using the RAPID protocol with those treated in a traditional manner. RESULTS: Of the 117 patients studied, 70 underwent laparoscopic resection (55 with the RAPID protocol) and 47 underwent open resection (25 with the RAPID protocol). Patients undergoing laparoscopic resections with the RAPID protocol had a significantly shorter hospital stay (p = 0.01) and tolerance of a full diet (p = 0.002). Similarly, patients undergoing open resections with the RAPID protocol also have a significantly shorter hospital stay (p = 0.04). CONCLUSION: The RAPID protocol is a user-friendly, easy, and effective tool that facilitates earlier tolerance of diet and discharge from the hospital for patients undergoing laparoscopic or open colorectal resections.

Colorectal cancer: presentation and outcome in British South Asians.

AIM: Colorectal cancer (CRC) has a lower incidence in patients of South Asian origin compared with British Caucasians. There are however little data available regarding the demographics of these patients, their presentation and outcome. Leicester has a high South Asian immigrant population, and we aim to define any potential differences in presentation, pathogenesis and outcome between our Caucasian and South Asian ethnic groups. METHOD: All patients of South Asian origin were identified from the Leicester CRC database between June 1998 and April 2007. Data were analysed regarding the patients' demographics, the presentation and treatment details, tumour characteristics and clinical outcome. Data were compared with Caucasian patients from the same database. Patients from an ethnic background other than South Asia or Caucasians were excluded from analysis. RESULTS: 3435 patients were included in the analysis, of which 134 (3.9%) were of South Asian ethnicity. 61.9% of South Asian patients were male compared with 56% of Caucasians. South Asians were significantly younger at presentation (61.4 vs 70.6 years, P < 0.001). South Asian patients had significantly more rectal tumours than their Caucasian counterparts (P = 0.002). South Asian patients were more likely to require initial oncological therapy, and were less likely to have resectional surgery than Caucasians (P = 0.006). Of the patients undergoing resectional surgery, the ASA grade, mode of surgery, tumour characteristics and Dukes' stage were similar. There was no difference in 5-year survival between the South Asian and Caucasian patients. CONCLUSION: Patients of South Asian ethnicity are younger at their age of presentation and have a higher proportion of rectal tumours compared with British Caucasian patients. They are more likely to require initial oncological treatment and are less likely to undergo resectional surgery, therefore suggesting more advanced disease at presentation. Overall 5-year survival is the similar.

Enteral Clostridium difficile, an emerging cause for high-output ileostomy.

The loss of fluid and electrolytes from a high-output ileostomy (>1200 ml/day) can quickly result in dehydration and if not properly managed may cause acute renal failure. The management of a high-output ileostomy is based upon three principles: correction of electrolyte disturbance and fluid balance, pharmacological reduction of ileostomy output, and treatment of any underlying identifiable cause. There is an increasing body of evidence to suggest that Clostridium difficile may behave pathologically in the small intestine producing a spectrum of enteritis that mirrors the well-recognised colonic disease manifestation. Clinically this can range from high-output ileostomy to fulminant enteritis. This report describes two cases of high-output ileostomy associated with enteric C difficile infection and proposes that the management algorithm of a high-output ileostomy should include exclusion of small bowel C difficile.

Restorative proctocolectomy. Does ethnicity affect outcome?

OBJECTIVE: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is well-established in the management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We review outcome of pouch surgery from a single centre, comparing non-South Asian and South Asian Caucasian populations. METHOD: Patients undergoing RPC for UC and FAP during a 10-year period between January 1997 and January 2007 were identified from hospital records. Data were collected retrospectively from case notes on early and long-term results. RESULTS: A total of 107 patients underwent pouch formation for UC (94%) or FAP (6%) and 22 (21%) were from the Asian subcontinent. Eighty-seven (81%) underwent a three-stage procedure and 20 (19%) a two-stage procedure. Postoperative complications occurred in 40 (37%) patients, being major in 11 (10%) patients with relaparotomy required in 9 (8%) with no difference between South Asian and non-South Asian Caucasian patients. Long-term pouch function, with a median of five times over 24 h (range 2-15), was similar between the two groups. The incidence of pouchitis was 57 (53%) and this was significantly greater in the South Asian population [17/21 (77%); 39/86 (46%); P = 0.006]. CONCLUSION: Surgical results were similar in South Asian and non-South Asian Caucasian patients, but the incidence of pouchitis was greater in the former group.

Terminal Ileum Perforation as a Consequence of a Migrated and Fractured Oesophageal Stent.

Covered self-expanding metallic stents are commonly employed to relieve malignant oesophageal obstruction. We report a case of a patient with oesophageal cancer treated by stent insertion and curative chemoradiotherapy with subsequent stent migration to the stomach. The stent fractured with the distal fragment migrating as far as the terminal ileum where it caused perforation of the bowel.

Assessment of a patient consultation questionnaire-based scoring system for stratification of outpatient risk of colorectal cancer.

BACKGROUND: The UK government's fast-track 2-week wait (2WW) rule and colorectal cancer guidelines aimed to detect patients at high risk of having colorectal cancer, but the yield has been poor. A patient consultation questionnaire (PCQ)-based scoring system may be an effective tool for prioritizing colorectal referrals. The aim of this study was to validate the system in a large and ethnically diverse population and to compare it with 2WW referrals. METHODS: Over a 1-year period, all colorectal referrals (2WW and traditional letters) at nine hospitals in Leicestershire were sent a PCQ to complete and return. A weighted numerical score (WNS), which reflects the patient's risk of having colorectal cancer, was calculated and compared with the hospital diagnosis. RESULTS: Of a total of 1422 PCQs returned, 83 patients were diagnosed with colorectal cancer. The 2WW referrals constituted 35.7 per cent of all referrals. The mean WNS of patients with colorectal cancer was significantly higher than that of the other patients (mean 76.3 versus 48.9 respectively; P < 0.001). For similar cancer detection rates (or sensitivity), the specificity of a WNS cut-off of 70 was significantly better than that of the 2WW system (82.7 versus 66.1 per cent; P < 0.001). CONCLUSION: The PCQ-based WNS system improves specificity for detecting colorectal cancer, particularly when the WNS exceeds 70.

Factors that influence the adequacy of total mesorectal excision for rectal cancer.

OBJECTIVE: In 1997 with the start of CRO7 trial it was agreed that adequacy of surgical resection of rectal cancer would be determined by a pathologically determined grading of the mesorectum the so called total mesorectal excision score (TME score). Scores ranged from 1-3 with 3 being a perfect specimen. The aim of this study was to investigate factors which may influence TME scores and establish if local recurrence is related to them. METHOD: Data on all patients undergoing resectional surgery for rectal cancer in our unit are entered prospectively onto a database. Pathology reports of those patients who underwent total mesorectal excision were examined and the TME scores added to the database. Categorical variables were analysed using the chi2 test, continuous variables using ANOVA. Statistical significance was taken as P < 0.05. RESULTS: Between January 2000 and June 2005, 518 patients underwent surgery for adenocarcinoma of the rectum, of these, 287 patients had a total mesorectal excision for mid or lower third tumours under the care of seven colorectal surgeons. All resected specimens were scored by a Consultant GI pathologist. Two hundred and fourteen patients underwent anterior resection and 73 underwent abdomino-perineal resection. The median age of the patients was 73 years (range 38-95 years). One hundred and ninety-four patients were male. Seventy-eight patients were treated with preoperative radiotherapy, 59 short course and 19 long course. TME scores were TME1 n = 30, TME2 n = 99, TME3 n = 158. Fifteen patients developed local pelvic recurrence at 2 years. Total mesorectal excision scores were not statistically influenced by Dukes' stage, width of tumour, preoperative radiotherapy or grade of surgeon. Male patients were statistically more likely to have a TME score of 2 or 3 compared with female P = 0.04. Patients undergoing an anterior resection were statistically more likely to have a TME score of 2 or 3 compared with abdomino-perineal resection P = 0.0001. Tumours with a circumferential resection margin (CRM) of more than 1 mm were more likely to have a TME score of 2 or 3 score (P = 0.0001). There was no relationship between TME and local recurrence (P = 0.966). CONCLUSION: There is no relationship between the TME score in patients undergoing resectional surgery for adenocarcinoma of the rectum and the development of local recurrence at 2 years. Other factors such as CRM involvement are more likely to have an impact on local recurrence. The factors that influence the quality of TME are the operative procedure of anterior resection, male gender and CRM positivity. There appear to be no deleterious effects on the TME score by Specialist Registrars performing the operation under Consultant supervision. While TME scores may be an index of a technical performance, they appear to have little role in predicting future outcomes.

Unreasonable expectations in emergency colorectal cancer surgery.

OBJECTIVES: The recently published ACPGBI colorectal cancer (ACPGBI CRC) scoring system for predicting operative mortality has been suggested as an instrument to improve patient consent procedures and to compare results between centres. This study compares the results of a surgical unit against the standards set by the ACPGBI colorectal cancer model and for emergency surgery, against the p-POSSUM instrument. METHODS: Data for the ACPGBI CRC model were collected prospectively through 2003 at the Leicester Royal Infirmary. Additional data needed for the p-POSSUM was retrospectively collected from case records. The actual mortality was compared with that predicted by the models. RESULTS: Seventy-two colorectal cancer operations were performed during the study period. The observed operative mortality in elective cases was lower, and in emergency cases higher, than predicted by the ACPGBI CRC model. With emergency cases the predicted mortality using P-POSSUM was significantly higher than that using the ACPGBI CRC model, particularly in the presence of faecal contamination. CONCLUSION: The ACPGBI CRC model may be accurate for elective cases, but appears to significantly underestimate predicted mortality in the emergency setting, both actual and predicted by p-POSSUM. This may be due to a failure to incorporate adequate weighting for faecal peritonitis and the associated systemic insult into the ACPGBI model.

Pemphigus vulgaris: clinicopathologic review of 33 cases in the oral cavity.

A retrospective study was conducted on all cases of pemphigus vulgaris occurring on oral mucosal surfaces in the files of the Oral Pathology Laboratory at Temple University from 1974 to 1996. A total of 35 biopsies from 33 patients were reviewed, 25 female and eight male. Patient ages ranged from 27 to 79 years; the mean age was 56.5. The most common clinical complaint was of painful ulcers that failed to resolve within several weeks. Thirty patients had no known history of pemphigus, while in three patients a history of pemphigus was known. The most common clinical impression was that of mucous membrane pemphigoid, but the differential diagnosis included other vesiculoerosive conditions.

Screening and surveillance. OSHA's medical surveillance provisions.

The OSH Act requires OSHA to include provisions for medical examinations of employees in its standards. However, the specific test and examinations criteria are not outlined in the OSH Act. Instead, each standard has specific medical surveillance requirements. These are specific to the adverse health effects triggered by exposure to the hazardous substance. The OSHA uses the term medical surveillance to refer to its employee examination and testing provisions. Most occupational health professionals call this activity employee screening and reserve the term surveillance for aggregate analysis of population data. It is important to remember this distinction when referring to OSHA standards. Many standards are challenged in court resulting in changes to medical surveillance provisions of the standards. Some court decisions support OSHA's language. In either case, the court often sets precedents for future standards.

CD22 forms a quaternary complex with SHIP, Grb2, and Shc. A pathway for regulation of B lymphocyte antigen receptor-induced calcium flux.

CD22 is a cell surface molecule that regulates signal transduction in B lymphocytes. Tyrosine-phosphorylated CD22 recruits numerous cytoplasmic effector molecules including SHP-1, a potent phosphotyrosine phosphatase that down-regulates B cell antigen receptor (BCR)- and CD19-generated signals. Paradoxically, B cells from CD22-deficient mice generate augmented intracellular calcium responses following BCR ligation, yet proliferation is decreased. To understand further the mechanisms through which CD22 regulates BCR-dependent calcium flux and proliferation, interactions between CD22 and effector molecules involved in these processes were assessed. The adapter proteins Grb2 and Shc were found to interact with distinct and specific regions of the CD22 cytoplasmic domain. Src homology-2 domain-containing inositol polyphosphate-5'-phosphatase (SHIP) also bound phosphorylated CD22, but binding required an intact CD22 cytoplasmic domain. All three molecules were bound to CD22 when isolated from BCR-stimulated splenic B cells, indicating the formation of a CD22.Grb2.Shc.SHIP quaternary complex. Therefore, SHIP associating with CD22 may be important for SHIP recruitment to the cell surface where it negatively regulates calcium influx. Although augmented calcium responses in CD22-deficient mice should facilitate enhanced c-Jun N-terminal kinase (JNK) activation, BCR ligation did not induce JNK activation in CD22-deficient B cells. These data demonstrate that CD22 functions as a molecular "scaffold" that specifically coordinates the docking of multiple effector molecules, in addition to SHP-1, in a context necessary for BCR-dependent SHIP activity and JNK stimulation.

Absence of longitudinal changes in rheumatologic parameters after silicone breast implantation: a prospective 13-year study.

There have been numerous questions regarding the association of polysiloxane with connective tissue disease and alteration of host immune response. C-reactive protein, rheumatoid factor, and anti-streptolysin-O titers were measured in 218 patients. These studies are routinely used in the diagnosis of autoimmune disease and mixed connective tissue disease. This prospective study has been in progress since 1985. The first patients were seen in July of 1985, and those individuals willing to participate were followed from 1985 to 1998. The implants included saline-filled elastomer shells and polysiloxane gel-filled elastomer shells. These groups were examined separately and in combination for changes between preoperative and postoperative states. In each instance, there was no statistical increase or decrease. Each patient underwent a physical examination and completed a questionnaire focusing on signs and symptoms of autoimmune and connective tissue diseases. The laboratory data and subjective clinical results demonstrated no significant differences between a nonimplanted group versus the saline group alone, the gel group alone, or the combined groups. The data failed to suggest any causal relationship between implants and autoimmune or connective tissue diseases over the study period of 13 years (since 1985).

Squamous cell carcinoma of gingiva and edentulous alveolar ridge: a clinicopathologic study.

All oral squamous cell carcinomas were retrieved from the files of Temple University's Oral Pathology Laboratory from 1967 through 1994 for a clinicopathologic study of those occurring on the gingiva. A total of 1,193 cases had sufficient data for tabulation and statistical analysis, of which 300 (25%) arose on the gingiva or alveolar ridge. The largest number of these cases (211/300) occurred on the mandibular gingiva or alveolar ridge. The mean age of the patients was 66.66 years, with males accounting for 57% of cases. Many case comparison analyses of oral squamous cell carcinomas do not separate oral subsites or specifically address carcinoma of the gingiva. The results were compared with other published series and suggest that further studies are needed because of the wide range of reported figures on the incidence of gingival squamous cell carcinomas.

Paradoxical high anal resting pressures in men with idiopathic fecal seepage.

PURPOSE: Fecal incontinence has been a matter of concern for many years, but seepage is poorly understood, especially in men. METHODS: We compared the results of anorectal physiologic tests in a group of 16 male patients who complained of fecal soiling but had no previous history of anorectal surgery or disease and had normal clinical examinations with findings of 16 normal male controls. Physical examination and proctosigmoidoscopy were normal in each patient. RESULTS: Maximum anal resting pressure (median interquartile range) was 136 (120-145) cm H2O in the "seepage" group and 104 (83-112) cm H2O in controls (P < 0.01). Inflation volumes at which patients and controls experienced rectal sensation were 45 (35-80) and 90 (75-100) ml of air, respectively (P < 0.01). Maximum tolerated volumes in the rectum were 130 (85-180) ml of air in the seepage group and 190 (140-240) ml of air in controls (P < 0.01). Median length of the anal sphincter was 3.75 (3.5-4) cm in patients and 3 (3-3.5) cm in controls (P < 0.01). Maximum squeeze pressures, sensation in the anal canal, and sphincter relaxation in response to rectal distention were similar in the two groups. CONCLUSION: Male patients with "idiopathic" fecal seepage have a long anal sphincter with abnormally high resting tone.

Alteration of fibrous capsule formation by use of immunomodulation.

The formation of symptomatic capsular contractures remains both a mystery to the plastic surgeon and a significant clinical challenge. Ninety Sprague-Dawley rats had 2 ml dimethylpolysiloxane gel-filled implants placed in two dorsal pockets. The animals were randomly assigned to three groups. One group received daily cyclosporine injections, the second group received the saline control, and the third an active human cytokine injection. One month after surgery, the intact implants and surrounding capsules were harvested. Subjective gross examination of the capsules by three different researchers showed the cyclosporine-treated capsules to be uniformly softer, looser, and thinner than those in the other groups. The cyclosporine-treated group showed a marked decrease in absolute capsular thickness (72.4 microm) as compared with both the saline solution- (97.3 microm) and the cytokine-treated (112.4 microm) control subjects. Perivascular cuffing, lymphocytic infiltrates, and collagen organization all were also significantly affected. In this article we demonstrate how alteration of T-cell function significantly affects the cellular population and collagen organization of a typical capsule.