Interobserver variability in the classification of appendicitis during laparoscopy.

BACKGROUND: The intraoperative classification of appendicitis dictates the patient's postoperative management. Prolonged antibiotic prophylaxis is recommended for complex appendicitis (gangrenous, perforated, abscess), whereas preoperative prophylaxis suffices for simple appendicitis. Distinguishing these two conditions can be challenging. The aim of this study was to assess interobserver variability in the classification of appendicitis during laparoscopy. METHODS: Short video recordings taken during laparoscopy for suspected appendicitis were shown to surgeons and surgical residents. They were asked to: classify the appendix as indicative of no, simple or complex appendicitis; categorize the appendix as normal, phlegmonous, gangrenous, perforated and/or abscess; and decide whether they would prescribe postoperative antibiotics. Inter-rater reliability was evaluated using Fleiss' κ score and the S* statistic. RESULTS: Some 80 assessors participated in the study. Video recordings of 20 patients were used. Interobserver agreement was minimal for both the classification of appendicitis (κ score 0·398, 95 per cent c.i. 0·385 to 0·410) and the decision to prescribe postoperative antibiotic treatment (κ score 0·378, 0·362 to 0·393). Agreement was slightly higher when published criteria were applied (κ score 0·552, 0·537 to 0·568). CONCLUSION: There is considerable variability in the intraoperative classification of appendicitis and the decision to prescribe postoperative antibiotic treatment.

The impact of disease severity, age and surgical approach on the outcome of acute appendicitis in children.

PURPOSE: Although a national guideline has been implemented, the optimal approach for appendectomy in children remains subject of debate in the Netherlands. Opponents of laparoscopy raise their concerns regarding its use in complex appendicitis as it is reported to be associated with an increased incidence of intra-abdominal abscesses. The aim of this study was to evaluate the outcome of surgical approaches in both simple and complex appendicitis in paediatric patients. METHODS: A 10-year retrospective cohort study was performed (2001-2010) in paediatric patients treated for suspected acute appendicitis. Patients were divided into either simple or complex appendicitis and into different age groups. Primary outcome parameters were complication rate (intra-abdominal abscess (IAA), superficial surgical site infection (SSI) and readmission) and hospital stay. RESULTS: In total, 878 patients have been treated (median age 12, range 0-17 years). Two-thirds of the patients younger than 6 years had complex appendicitis, compared to one quarter in the group aged 13-18. In the complex appendicitis group, LA was associated with more IAA and early readmissions. In the simple appendicitis group, the complication rate was comparable between the two approaches. Significantly more IAAs were seen after LA in the youngest age group. CONCLUSION: This study demonstrates the unfavourable outcome of LA in the youngest age group and in patients with complex appendicitis. Therefore, we advise to treat these patients with an open approach.

Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas.

AIM: Comparison of transanal excision (TE) and transanal endoscopic microsurgery (TEM) of rectal adenomas (RA) has rarely been performed. METHOD: From 1990 to 2007, the results of TE (43 RA) and TEM (216 RA) were compared. Rectal adenomas were matched for diameter and distance from the anal verge. RESULTS: Operation time was 47.5 min for TE and 35 min for TEM (P < 0.001). Morbidity was 10% after TE and 5.3% after TEM (P < 0.001). Negative resection margins were observed in 50% after TE and 88% after TEM (P < 0.001). Fragmentation of the excised specimen was observed in 23.8% after TE and 1.4% after TEM (P < 0.001). In cases of fragmentation, positive resection margins were observed more frequently. Recurrence was 28.7% after TE and 6.1% after TEM (P < 0.001). After TE, RA with a negative resection margin had a local recurrence rate of 0%, compared with 59.6% with a positive margin (P < 0.001), and after TEM these rates were 3.2 and 7.7% (P = 0.3), respectively. CONCLUSION: Transanal endoscopic microsurgery is superior to transanal excision of RA.

The Drosophila cell cycle gene fizzy is required for normal degradation of cyclins A and B during mitosis and has homology to the CDC20 gene of Saccharomyces cerevisiae.

The Drosophila cell cycle gene fizzy (fzy) is required for normal execution of the metaphase-anaphase transition. We have cloned fzy, and confirmed this by P-element mediated germline transformation rescue. Sequence analysis predicts that fzy encodes a protein of 526 amino acids, the carboxy half of which has significant homology to the Saccharomyces cerevisiae cell cycle gene CDC20. A monoclonal antibody against fzy detects a single protein of the expected size, 59 kD, in embryonic extracts. In early embryos fzy is expressed in all proliferating tissues; in late embryos fzy expression declines in a tissue-specific manner correlated with cessation of cell division. During interphase fzy protein is present in the cytoplasm; while in mitosis fzy becomes ubiquitously distributed throughout the cell except for the area occupied by the chromosomes. The metaphase arrest phenotype caused by fzy mutations is associated with failure to degrade both mitotic cyclins A and B, and an enrichment of spindle microtubules at the expense of astral microtubules. Our data suggest that fzy function is required for normal cell cycle-regulated proteolysis that is necessary for successful progress through mitosis.

The confidential enquiry into maternal deaths: its role and importance for pathologists.

Comparatively few pathologists seem to know of the existence of the confidential enquiry into maternal deaths and fewer still know anything of its aims or its methods of obtaining confidential information. As the success of any such enquiry depends greatly on the accuracy and completeness of necropsy, histological, and other laboratory reports a brief account of the report itself and the role of pathologists in it may not be out of place.

Immunochemical studies of the endocrine cells of the gastrointestinal tract. II An immunoperoxide technique for the localization of secretin containing cells in human duodenum.

Endocrine cells containing secretin have been identified in the epithelium lining human duodenum by direct and indirect immunoperoxidase techniques using immune sera raised against pur natural secretin. The techniques were applied to sections of carbodiimide-fixed tissue embedded in polyethylene glycol. Some sections, stained by a modified indirect technique, were processed for electron microscopy; secretin-containing granules were present by ultrastructural preservation was too poor to be of value. The potential advantages of a peroxidase technique over fluorescein-coniugated antisera are discussed.

A formalin fixative for immunochemical and ultrastructural studies on gastrointestinal endocrine cells.

Using indirect immunofluorescence, indirect immunoperoxidase, and unlabelled antibody enzyme techniques, gastrin, pancreatic glucagon, insulin, and somatostatin were localised in sections of both wax- and resin-embedded tissues that had been fixed in a buffered formalin solution. Ultrastructural preservation of the resin-embedded samples was also adequate for combined electron microscopy and light microscope immunochemistry. As the fixative concerned is stable it can be permanently available in surgical units. It is suggested, therefore, that this fixative should prove useful as an alternative to buffered formaldehyde, which must be freshly prepared from paraformaldehyde powder, in institutions where specimen collection is difficult or which have to refer cases with an endocrine involvement to other laboratories for immunochemical and fine structural examination.

The maternal autopsy.

Careful study of reports prepared for the Confidential Enquiries into Maternal Deaths in England and Wales has made it clear that many maternal autopsy reports are not as informative as they might be. This is, in part at least, because no pathologist who does not work in a maternity unit can expect to see more than a handful of such deaths in a working lifetime. This paper describes briefly the particular features to look for at autopsy, stresses the importance of taking adequate material for histology and discusses some of the more significant histological findings, both of conditions which cause death and of those commonly associated with it.

Cesar: cervical smear analyser and reader. A new approach to evaluating cells in cytological preparations.

Cesar presents an automated multiparameter approach to pattern recognition in the rapid detection of malignant cells from cervical and other cancers. Cells are cybernetically classified. They are collected into a container into which a nuclear stain may be incorporated and laid as a track on 35 mm. film using a disposable mapping pen device. The film track (Cytotrack) may be scanned using conventional optics and provision may be made for electronic sensing devices measuring a number of parameters, some of which are not normally used in conventional microscopy.

An intracellular study of the action of NAN-190 on neurons in the dorsal raphe nucleus of the rat.

Intracellular recordings have been made from neurons in the dorsal raphe (DR) nucleus of the rat to determine the mechanism of action of the arylpiperazine compound NAN-190. Application of NAN-190 (50 microM) alone most frequently caused a hyperpolarization accompanied by a fall in RM and reduced the response to 5-HT and 8-OH-DPAT. After pretreatment of the preparation with the 5-HT-uptake blocker citalopram (10 microM) NAN-190 exerted an excitatory effect. It is concluded that NAN-190 is a partial agonist in the DR nucleus.

[Replacement of the femoral head due to fracture of the hip: prognostic factors for the duration of hospitalisation, institutionalisation and mortality]. / Vervanging van de dijbeenkop wegens een heupfractuur; prognostische factoren voor opnameduur, opname in een verpleeg- of verzorgingshuis en sterfte.

OBJECTIVE: To identify preoperative factors affecting length of hospital stay, residential status and mortality after replacement of the femoral head for a hip fracture. DESIGN: Prospective. METHOD: Of the 146 consecutive patients who had hemiarthroplasty for a displaced femoral neck fracture in the period 1996-1998, data were recorded on age, sex, the residential situation, ambulation, ADL dependency, the presence of dementia and the classification according to the American Society of Anesthesiologists (ASA). The operations were carried out in the IJsselland Hospital, Capelle aan den IJssel, the Netherlands. The study was terminated in October 2001. With the aid of uni- and multivariate analysis, the relationship was determined between the pre-operative factors and the length of hospital stay, need for institutional care, and mortality within 3 years after the operation. RESULTS: The study population consisted of 146 patients: 33 men and 113 women with an average age of 82 years (range: 60-98). The length of hospital stay averaged 21 days (range: 2-98). Independent pre-operative predictors for a longer period of hospitalisation were ADL dependency (OR: 1.3; 95% CI: 1.1-15.2), residence at home (0.7; 0.6-0.8), and poor ambulation (1.1; 1.0-1.3). The predictors for permanent institutionalisation were: prior stay in an institution (4-7; 1.1-19.5) and the presence of dementia (3.9; 1.0-1.5). Compared to the general Dutch population of the same age and sex, there was a significant excess mortality during the 3 years after the operation and especially during the first 12 months. Unfavourable prognostic factors for mortality within 3 years after the operation were: poor ambulation before the fracture (3.1; 1.8-5.3), an ASA classification of 3 or 4 (2.0; 1.2-3.1) and an age over 80 years (2.0; 1.2-3.3). CONCLUSION: The risk factors for a longer stay in hospital, placement in an institution or decreased survival in patients who underwent hemiarthroplasty as part of the treatment of a hip fracture can already be identified at the time of admission. The patients with these risk factors should be given special attention during the period of hospitalisation and after-care.

Do farmers reduce genetic diversity when they domesticate tropical trees? A case study from Amazonia.

Agroforestry ecosystems may be an important resource for conservation and sustainable use of tropical trees, but little is known of the genetic diversity they contain. Inga edulis, a widespread indigenous fruit tree in South America, is used as a model to assess the maintenance of genetic diversity in five planted vs. five natural stands in the Peruvian Amazon. Analysis of five SSR (simple sequence repeat) loci indicated lower allelic variation in planted stands [mean corrected allelic richness 31.3 (planted) and 39.3 (natural), P = 0.009]. Concerns regarding genetic erosion in planted Amazonian tree stands appear valid, although allelic variation on-farm is still relatively high.

Immunochemical studies of the endocrine cells of the gastrointestinal tract. I. The use and value of peroxidase-conjugated antibody techniques for the localization of gastrin-containing cells in the human pyloric antrum.

This paper describes and immunochemical localization of gastrin-containing endocrine cells in the human pyloric antrum using antibodies conjugated to horseradish peroxidase. With pre-fixed cryostat sections, a distinct clear-cut staining of gastrin-containing cells can be obtained either by direct or indirect single stain procedures, but may cells containing endogenous peroxidase activity also stain. In order to abolish staining due to endogenous peroxidase, sections were pretreated with a number of inhibitors prior to incubation in immune sera, but the inhibitors used appeared to interfere with the antigenicity of the gastrin molecule since subsequent immunochemical localization was impossible. The application of a double-staining technique, however, allowed us to distinguish easily between those cells which contained endogenous peroxidase and those on to which labelled antibody had been adsorbed. No labelled cells were found in post-fixed cryostat sections of fresh-frozen tissue. The technique is of value because preparations are permanent, a fluorescence microscope is not required, and the same technique can be adapted for use with the electron microscope.

Complete acromioclavicular dislocations: treatment with a Dacron ligament.

A series of 20 patients was treated for a complete acromioclavicular dislocation (Tossy III). Reduction of the clavicle is maintained by a Dacron ligament, which provides dynamic fixation. The mean follow-up period was 3.9 years. For 19 patients the results were good or excellent; in one case the result was poor. Advantages of the method described are ease of the procedure, absence of pins and a 1-week period of immobilization. An important result is the short sick leave with an average of 3.3 weeks, which is favourable compared with other operative and non-operative methods. The recent tendency to treat complete acromioclavicular dislocations non-operatively is based on the poor results of the Phemister and Bosworth operation; however, cerclage with a Dacron ligament has a low complication rate and gives a high percentage of anatomical reduction. It is therefore considered an effective method to treat complete acromioclavicular dislocations.

Traumatic anterior dislocation of the hip.

A discussion is presented of traumatic anterior dislocation of the hip joint on the basis of three representative case reports. One patient had an iliac or pubic dislocation, the other two were obturator dislocations, including one with an associated femoral head fracture. All three patients were treated without surgery. After an average follow-up time of twenty-seven months, the results were excellent. Therapeutic guide-lines and recommendations are given for this infrequent type of injury.

Morphology and staining patterns of endocrine cell tumours in the gut, pancreas and bronchus and their possible significance.

We have studied 109 endocrine cell tumours of the gastrointestinal tract, pancreas and bronchus in terms of histological pattern and histochemical staining with immunocytochemical studies on seven tumours. As a result we believe that previous histological classifications need modification. 5-Hydroxytryptamine secreting tumours have a carcinoid (A1) pattern with, in some cases, an additional tubuloacinar element (A1A2) and definable histochemical reactions; well differentiated gastrinomas, insulinomas and glucagonomas are associated commonly, but not exclusively, with particular histological patterns and argyrophilia, but no such association exists for less differentiated tumours. This may be related to the synthesis of precursor hormones by less differentiated tumours. Mixed patterns are common, particularly in tumours of foregut derivation. Prospective studies planned to correlate histology, histochemistry, immunocytochemistry and ultrastructure are needed on all endocrine cell tumours.

An investigation into the enzyme histochemistry of adenocarcinomas of human large intestine and of the transitional epithelium immediately adjacent to them.

Histochemical enzymatic studies were performed on 30 freshly resected large bowel carcinomas, 30 samples of normal colonic epithelium, and six samples of the histologically normal epithelium (so-called transitional epithelium) immediately adjacent to a carcinoma. Five enzymes were studied: nicotine adenine dinucleotide tetrazolium reductase (NADH-TR), glucose-6-phosphate dehydrogenase, succinate dehydrogenase, monoamine oxidase, and acid phosphatase. QUANTITATIVE AND QUALITATIVE DIFFERENCES IN ENZYME ACTIVITY WERE OBSERVED BETWEEN NORMAL, TRANSITIONAL, AND CARCINOMATOUS MUCOSA AS FOLLOWS: monoamine oxidase activity was moderate in normal mucosa, high in transitional mucosa, and low in carcinoma. Succinate dehydrogenase activity was high in transitional mucosa and low or moderate in normal and carcinomatous mucosa. Glucose-6-phosphate dehydrogenase activity showed a gradation from low in normal mucosa to high in carcinoma while acid phosphatase showed the reverse of this pattern. The tetrazolium reductase activity was low or moderate in normal and transitional mucosa and high in carcinoma. These differences in enzyme activity and their possible clinical and metabolic significance are discussed.