Watch and wait for Rectal Cancer: A 9 year Experience.

Background: Neoadjuvant long course chemoradiotherapy has become the standard treatment for locally advanced rectal cancer. It can reduce tumour bulk, downstage, reduce the risk of local recurrence, and increase the possibility of clear resection margins. The aim of our study is to evaluate all patients over a 9 year period who underwent neoadjuvant chemoradiotherapy for rectal cancer and entered our watch and wait programme. Methods: Data were analysed from a prospective database for all patients diagnosed with rectal cancer over a 9 year period (2011-2019 inclusive). Findings: Over a 9 year period, 532 patients were treated for rectal cancer, with 180 patients receiving long course chemoradiotherapy. 61 (11%) patients entered a watch and programme as they had a complete clinical and radiological response following chemoradiotherapy. Within this programme, 40 patients (65%) remain disease free over the follow-up period (mean 38 months); 12 (20%) patients had regrowth and proceeded to surgery; and 9 (15%) proceeded to palliation due to being unfit for surgery or had distant metastatic disease. Overall (all cause) mortality was 18% during follow-up period in the watch and wait group. Conclusions: Neoadjuvant long course chemoradiotherapy is the standard treatment for locally advanced rectal cancer. 34% of our patient group who received long course chemoradiotherapy entered a watch and wait programme with the majority avoiding major rectal surgery.

Laparoscopic restorative proctocolectomy with and without previous subtotal colectomy.

INTRODUCTION: Laparoscopic techniques have been applied to the procedure of restorative proctocolectomy (RPC). The aim of this study was to compare the outcomes of patients after laparoscopic ileal pouch-anal anastomosis (IPAA) with restorative proctocolectomy (RPC) and without previous colectomy [restorative proctectomy (RP)] and to highlight some technical tips. METHOD: Data were collected prospectively from all patients who underwent laparoscopic IPAA from July 2006 to December 2007. RESULTS: Thirty-six patients underwent IPAA either with total proctocolectomy (n = 25) or after previous emergency colectomy (n = 11). Postoperative morbidity occurred in 22% of patients. The overall median operative time was 210 (range 120-325), 240 (170-325) and 180 (120-240) min for RPC and RP respectively (P < 0.05). The median length of stay for all patients was 6 (3-26), 6 (4-26) and 4 (3-13) days for RPC and RP respectively (P < 0.05). There was no correlation between BMI, age, use of immunosuppressive agents and length of stay. The operative procedure was facilitated by the use of specific devices at particular stages of the operation. CONCLUSION: Laparoscopic IPAA is not only safe and feasible for the virgin abdomen but also for patients with a previous emergency colectomy through a midline laparotomy incision.

Re-Staging Following Long-Course Chemoradiotherapy For Rectal Cancer: Does It Influence Management?

BACKGROUND: In patients with locally advanced or low rectal cancers, long-course chemoradiotherapy (LCCRT) is recommended prior to surgical management.1 The need for restaging afterwards has been questioned as it may be difficult to interpret imaging due to local tissue effects of chemoradiotherapy. The purpose of this study was to determine if restaging affected the management of patients receiving long-course chemoradiotherapy for rectal cancer. METHODS: A retrospective review of patients with rectal cancer discussed at the South Eastern Health and Social Care Trust Lower Gastrointestinal Multi-Disciplinary Team Meeting (LGIMDT) in 2013 who had received long-course chemoradiotherapy was performed. Patients were identified from the Trust Audit Department, LGIMDT notes and patient records. Imaging results and outcomes from meetings were obtained through the Northern Ireland Picture Archiving and Communications System® (NIPACS) and Electronic Care Record® (ECR). Data including patient demographics, initial radiological staging and LGIMDT discussion, restaging modality and result, outcome from post-treatment LGIMDT discussion and recorded changes in management plans were documented using a proforma. RESULTS: Seventy-one patients with rectal cancer were identified as having LCCRT in 2013 (M:F 36:35; age range 31 - 85 years). Fifty-nine patients were restaged following long-course treatment with computed tomography (CT) and magnetic resonance imaging (MRI). Twelve patients did not undergo restaging. Data was not available for 6 patients, one patient underwent emergency surgery, two patients were not fit for treatment, one failed to attend for restaging and two patients died prior to completion of treatment. Of the 59 patients restaged, 19 patients (32%) had their management plan altered from that which had been proposed at the initial LGIMDT discussion. The most common change in plan was not to operate. Ten patients had a complete clinical and radiological response to treatment and have undergone intensive follow-up. Nine patients had disease progression, with 3 requiring palliative surgery and 6 referred for palliative care. CONCLUSION: Of those patients who were restaged, 32% had their management plan altered from that recorded at the initial LGIMDT discussion. Seventeen per cent of patients in this group had a complete clinical and radiological response to treatment. Fifteen percent demonstrated disease progression. We recommend, therefore, that patients with rectal cancer be restaged with CT and MRI following long-course chemoradiotherapy as surgery may be avoided in up to 27% of cases.

Laser-induced chorioretinal venous anastomosis for treatment of nonischemic central retinal vein occlusion.

OBJECTIVES: To determine whether a chorioretinal venous anastomosis could be created in humans and to evaluate the influence this has on patients with nonischemic central retinal vein occlusions in whom progressive visual loss developed. DESIGN: Retrospective study. PATIENTS: A total of 24 patients with nonischemic central retinal vein occlusions and progressive visual loss. INTERVENTION: An attempt was made to create a chorioretinal venous anastomosis using laser photocoagulation to enable obstructed venous blood to enter the choroid, thus bypassing the site of occlusion. MAIN OUTCOME MEASURES: Visual acuity, funduscopic appearance, and rapid sequence fluorescein angiograms. RESULTS: A successful chorioretinal venous anastomosis was created in eight cases (33%), with improvement in visual acuity and resolution of the funduscopic appearance of venous occlusion in all eight cases. Of the 16 patients (67%) in whom an anastomosis was not successfully created, the ischemic form of central retinal vein occlusion developed in five (31%), and eight (50%) were left with various degrees of macular damage and reduced visual acuity. CONCLUSIONS: Peripheral chorioretinal venous anastomoses can be created in a nonischemic central retinal vein occlusion and appear to be well tolerated. This technique may have some value in the treatment of patients with this condition; however, to address this fully, a properly constructed randomized prospective clinical trial will need to be performed.

Treatment of retinal detachments with multiple breaks by pneumatic retinopexy.

Pneumatic retinopexy is a recent innovation in the treatment of uncomplicated retinal detachments due to a superior retinal break extending for 30 degrees or less. We describe four patients with retinal detachments involving multiple breaks who were successfully treated by a modification of this technique. One case involved a calculation of the size of the gas bubble required to achieve tamponade of both breaks simultaneously. The gas was then administered in two sequential injections, as the volume was too large to be given in a single dose. In the remaining three cases, the gas bubble was rotated from the position of tamponade for one break into a position where tamponade of the second break or groups of breaks was achieved.

Severe corneoscleral infection. A complication of beta irradiation scleral necrosis following pterygium excision.

OBJECTIVE: To assess the precipitating factors, clinical course, and treatment of 11 cases of severe intraocular infections of radionecrosis after pterygium excision in an attempt to minimize the devastating ocular sequelae. DESIGN AND SETTING: From the database of cases of radionecrosis at Royal Perth (Australia) Hospital and Lions Eye Institute, Perth, we identified 11 cases of severe intraocular infection complicating radionecrosis. We reviewed the case notes and the available radiotherapy records (n = 8). PATIENTS: Eleven patients admitted during an 8-year period. RESULTS: Mean (+/- SD) dose of radiotherapy was 22.7 +/- 1.0 Gy and mean latency period, 14.45 +/- 2.5 years. Among the six proven bacterial cases, Pseudomonas was identified in four, Staphylococcus aureus in one, and Streptococcus pneumoniae was involved in one bilateral case. Among the four fungal cases, Petriellidium boydii was indicated in two, and Fusarium and Scedosporium inflatum in one each. The condition may remain undiagnosed for some time and mimic a posterior scleritis, serous retinal detachment, or pseudotumor. INTERVENTIONS: Early débridement and culture; close microbiological assistance; and systemic antimicrobials for a prolonged period. Perforation or incipient perforation necessitated penetrating keratoplasties in seven patients and repeated keratoplasties in three. MAIN OUTCOME MEASURES: The use of radiotherapy following pterygium excision should be limited and only low doses used. Ulcer beds and calcific plaques at sites of radionecrosis should not be directly covered without first performing adequate sterilization. Removal of plaques may precipitate sepsis; ulcer beds and plaques harbor infective agents. CONCLUSION: Severe radionecrosis may expose a patient to a lifelong risk of intraocular sepsis and profound visual morbidity. Conjunctival autografting is a safer method to reduce recurrence rate after pterygium excision.

Laser-induced chorioretinal venous anastomosis for nonischemic central retinal vein occlusion: evaluation of the complications and their risk factors.

PURPOSE: To evaluate the complications of laser-induced chorioretinal venous anastomosis in nonischemic central retinal vein occlusion (CRVO) and to identify the associated risks. METHODS: A retrospective consecutive series of 91 eyes (91 patients) with nonischemic CRVO with a mean +/- SD duration of 15.0 +/- 15.2 weeks (range, 3 to 72 weeks )and corrected visual acuity reduced to 20/100 or less because of perfused macular edema were reviewed. All eyes had one or more anastomotic attempts using argon laser (combined with Nd-YAG laser in 46 eyes) and a minimum of 12 months of follow-up. RESULTS: Successful chorioretinal venous anastomoses were created in 49 eyes (54%). Eighteen eyes (20%) had neovascular complications. These consisted of intravitreal, intraretinal, and subretinal neovascular membranes and were significantly associated with retinal ischemia (P < .001). There was avascular fibrous tissue proliferation at the anastomotic site in eight eyes (9%), and it was not associated with retinal ischemia (P = .727). No eye developed further capillary nonperfusion once an anastomosis became functional. A chorioretinal venous anastomosis was associated with improved vision (P < .001); 84% of eyes had an average +/- SD improvement of 4.3 +/- 3.8 lines (range, 2 to 20 lines), with the remaining 16% having no improvement or reduced vision. CONCLUSION: The major vision-threatening complication of laser-induced chorioretinal venous anastomosis for nonischemic CRVO is neovascular membranes occurring at the anastomotic site; these are associated with retinal ischemia. Prompt laser photocoagulation to areas of retinal ischemia that develop after the anastomotic attempt has been made may reduce the risk and severity of this complication.

Alcohol consumption across the lifecycle in Australia, 1985-1988.

National studies show an overall decline in alcohol consumption across a range of developed countries. Using national population survey data collected in 1985 and 1988 in Australia indicate a decline in alcohol consumption with a differential impact upon particular age and sex groups. In particular, the results support Ledermann's prediction that as consumption declines, heavy drinkers will decline disproportionately. This trend is particularly notable among women. While overall levels of alcohol consumption have remained stable among the young, the pattern for women is for a uniform decrease in consumption, for men, a decrease in the older age groups. Various possible explanations for these trends are discussed.

Retinal toxicity of intravitreal tenecteplase in the rabbit.

AIM: To investigate the retinal toxicity of intravitreal injection of a novel fibrinolytic tenecteplase in rabbit eyes. METHODS: Tenecteplase (25-350 micro g in 0.1 ml BSS) was injected into the vitreous cavity of normal rabbit eyes. Control (fellow) eyes received 0.1 ml of BSS. One day, 1 week, and 2 months post-injection, the eyes were examined by slit lamp biomicroscopy, indirect ophthalmoscopy, and electroretinography, and then harvested for histopathological examination. RESULTS: No evidence of retinal toxicity was seen with tenecteplase doses up to and including 50 micro g. At a dose of 150 micro g ophthalmoscopy was normal, but histology showed mild retinal damage in the inner nuclear layer and electroretinography showed a temporary reduction in B-wave amplitude. At doses of 200 micro g and above, there was evidence of retinal toxicity on electroretinography, ophthalmoscopy, and histology. Ophthalmoscopic findings included vitreal fibrosis, retinal necrosis and tractional retinal detachment and light microscopy revealed necrosis of retinal pigment epithelium and other retinal layers. Damage was centred around the injection site but was more widespread with the higher doses. CONCLUSION: A dose of 50 micro g tenecteplase appears safe for intravitreal injection in the rabbit. Tenecteplase could have potential applications in the treatment of submacular haemorrhage and retinal vein occlusion.

Induced chorioretinal venous anastomosis in experimental retinal branch vein occlusion.

Iatrogenic retinal vein to choroidal vein anastomoses were created using laser photocoagulation in six of seven dog eyes in which a partial branch retinal vein occlusion had previously been created photochemically. A similar attempt to create an anastomosis was made in six control eyes in which no branch vein occlusion was present. In the eyes in which a branch retinal vein had been created, a venous chorioretinal anastomosis appeared to be present by 3 to 6 weeks. In three control eyes similar venous anastomosis was created; however this took 6 to 8 weeks to develop and was of much smaller calibre than the one that developed in the presence of a partial branch retinal vein occlusion. No adverse complications were noted in the period of the study (3 months). This study demonstrates that chorioretinal venous anastomoses can be created and may be of use in the treatment of partial retinal vein occlusions that show signs of progression.

Retinal detachment and its relation to cataract surgery.

In Western Australia during the period 1 January 1976 to 31 December 1987 1089 eyes of 1044 patients in hospital were operated upon for primary rhegmatogenous retinal detachment due to causes other than penetrating trauma. Of these eyes 295 (27%) were aphakic or pseudophakic. During this period the annual number of cataract operations in the State increased by a factor of 245%, while aphakic and pseudophakic retinal detachment operations rose by only 55%. The declining risk of retinal detachment following cataract surgery is attributed to improvements in microsurgical techniques. In 1983 and 1984 the incidence of aphakic and pseudophakic retinal detachments dropped significantly (p less than 0.05). At about this time extracapsular cataract surgery became widespread in the State, and this may explain the observed fall in retinal detachment operations. Since 1984 the incidence has risen owing to the rapidly increasing prevalence of pseudophakia in the resident population.

Vascular endothelial growth factor levels in serum and plasma following esophageal cancer resection--relationship to platelet count.

In patients with cancer circulating vascular endothelial growth factor (VEGF) may be tumor-derived and have prognostic significance. Activated platelets may also be a source of VEGF, releasing it in serum formation. Debate exists as to whether serum or plasma VEGF (S-VEGF, P-VEGF) is the most appropriate surrogate marker of tumor angiogenesis. As healing wounds produce VEGF that can spill over into the circulation, we aimed to investigate the potential confounding effects of cancer surgery on both perioperative S-VEGF and P-VEGF levels and to evaluate their relationship with platelet count. S-VEGF, P-VEGF and platelet counts were measured in 23 patients undergoing esophageal cancer resection. Samples were taken preoperatively and six weeks following surgery. Seven patients were also sampled on postoperative days 1, 5 and 10. VEGF was assayed using a commercial enzyme linked immunosorbent assay. S-VEGF and P-VEGF both rose after surgery (S-VEGF; day 5: 1017 [446-1224] pg/mL and day 10: 1231 [626-2046] pg/mL versus pre-op: 329 [189-599] pg/mL. P-VEGF; day 1: 55 [46-104] pg/mL and day 10: 58 [20-154] pg/mL versus pre-op: 23 [13-46] pg/mL), falling towards preoperative levels by six weeks. Platelet count correlated with S-VEGF (rho=0.281; p<0.05, Spearman's rank) and P-VEGF (rho=0.330; p<0.01, Spearman's rank). Platelets may contribute to VEGF levels in plasma as well as in serum. The effects of surgery on S-VEGF or P-VEGF levels are mainly transient. Care must be exercised when interpreting circulating VEGF levels in the early postoperative period.

Optimal conditions required for the creation of an iatrogenic chorioretinal venous anastomosis in the dog using argon green laser photocoagulation.

We have previously reported iatrogenic retinal to choroidal vein anastomosis, developed as a potential method of by-passing the site of obstruction to venous outflow in retinal venous occlusion in dogs (1), and in rats (2). In order to minimise tissue damage to the retina and choroid and increase the rate of success in these experiments, we investigated in the dog model the factors that would promote an anastomosis and compare the effects of three different power levels. A small spot size (50 microns) argon green laser beam of 514 nm at power levels of 0.5w, 1.5w and 2.5w were used. Spaced serial sections from each lesion were examined by light and by transmission electron microscopy. Morphometric measurements of the corresponding retinal pigment epithelium (RPE)/glial scar was computed using IBMPC digitising pad and sigma scan software and the extent of tissue damage at the different power levels assessed. At the lowest power level of 0.5w the damage to the retina was mild and there was an absence of anastomosis formation. At the 1.5w power level an anastomosis formed in 40% of the lesions. At the highest power level of 2.5w a 71% rate of success was obtained however, the damage to the retina tended to be severe. The results of this study also indicate that disruption of Bruch's membrane and vein rupture at the time of irradiation are essential for anastomosis formation, which may be further enhanced by necrotic tissue, retinal pigment epithelial and glial scar formation and inflammation. These findings are useful in establishing optimal conditions for the creation of a chorioretinal venous anastomosis, for consideration in human trials.

Significance of Bruch's membrane in the creation of iatrogenic chorioretinal venous anastomosis.

Iatrogenic retinal to choroidal vein anastomoses, as a method of bypassing retinal venous occlusions has been reported in dogs in which Bruch's membrane is poorly formed. In order to determine whether chorioretinal venous anastomoses can be induced in an animal with a Bruch's membrane that is well developed as in humans, pigmented rats were chosen. A high intensity, small spot size argon green laser beam of 514 nm was used to induce the anastomosis. Three out of 5 rat eyes developed a retinal vein to choroidal vein anastomosis. The success rate of iatrogenic retinal to choroidal vein anastomoses in the rat was comparable to that obtained in the dog. This study suggests that Bruch's membrane was not significant in the creation of an iatrogenic chorioretinal venous anastomosis.

Public attitudes to the regulation of alcohol.

Public support for the regulation of alcohol is central to government policies aimed at reducing consumption. This study uses a nationally representative population survey conducted in 1993 (n = 3500) to examine public support for 11 separate policies designed to reduce alcohol consumption. The results show that the respondents see these 11 policies in terms of three distinct approaches to alcohol regulation: availability (for example, reducing the number of retail outlets); control (for example, stricter enforcement of laws against serving underage customers); and promotion (for example, restricting alcohol advertising on television). There is strong public support for policies that control alcohol use and, with the exception of restricting alcohol sponsorship of sporting events, for moves to curb the promotion of alcohol. However, public opinion is evenly divided on moves to restrict availability, with the single exception of raising the minimum legal drinking age, which attracts majority support. Women, older people, the less educated, immigrants and abstainers or less frequent drinkers are generally most likely to support more restrictions. By state and territory, Tasmanians are most restrictive in their views, residents of the Northern Territory most liberal. The findings highlight the difficulties that governments will face in restricting the availability of alcohol.

Health beliefs relating to alcohol and other drug use in the Australian population.

This study uses data from a nationally representative population survey conducted in March and April 1993 to examine alcohol and other drug-related health beliefs within the Australian population. The results show widespread ignorance about the causes of drug-related mortality, with 43 percent of respondents believing that alcohol is the major cause of drug-related premature death. Only 32 percent of the respondents mentioned tobacco as the major cause of death. Those who identified tobacco as the drug causing the greatest number of deaths were more likely to be male, young, Australian or British-born, and better educated. Women were more accurate in their assessment of the risk levels associated with alcohol consumption than men, as were the young and the better educated. There is widespread public knowledge about the risks that are associated with passive smoking. Overall, the results point to the need to focus health promotion and awareness campaigns on the groups that have so far proved most immune to health messages, namely, heavy drinkers and smokers.

Occupational mobility among immigrants: the impact of migration on economic success in Australia.

"By analyzing national survey data collected among immigrants to Australia, this article examines immigrant occupational mobility. For immigrants, the results show economic disadvantages are caused by the act of migration itself rather than by economic experiences in their new country. Occupational status is depressed at the beginning of the immigrants' Australian working career, and this in turn diminishes occupational status throughout the working lives of the immigrants and accounts for the economic disadvantages they face."