A tailored approach to abdominoperineal resection for rectal cancer: multicentre analysis of short-term outcomes and impact on oncological survival.

PURPOSE: Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was introduced, which improved local disease control but resulted in a significant rise in perineal complications. We adopted a modified approach in which dissection was tailored according to magnetic resonance-defined tumour involvement. The aim of this study was to assess short-term and long-term oncological outcomes following a tailored abdominoperineal resection (APR) approach. METHODS: This study was a retrospective review of prospectively maintained databases at three centres: Portsmouth NHS Trust (UK), Poole General Hospital (UK) and Champalimaud's Cancer Foundation, Portugal. The study included consecutive patients who underwent abdominoperineal resection from October 2008 until April 2018 under the supervision of the senior author. Oncological outcomes, including overall survival and disease-free survival, were used as the main outcome measures. RESULTS: A total of 584 patients underwent rectal cancer surgery during the study period. The APR ratio was 65/584 (11%). The median age was 66 years. Neoadjuvant treatment was administered to 74% of patients. Of the patients, 91% underwent surgery via a minimally invasive approach. The median hospital stay was 7 days. Patients were followed up for a median of 41 months. Only four patients had positive resection margins. The 5-year overall and disease-free survival rates were 64% and 62%, respectively. CONCLUSION: Our data suggest that tailored APR has similar short-term and long-term oncological outcomes compared with extralevator abdominoperineal resection but reduced perineal wound complications. We believe this approach could be a safe alternative but recommend a larger sample size to accurately assess its effectiveness.

Expert consensus on a train-the-trainer curriculum for robotic colorectal surgery.

AIM: Robotic techniques are being increasingly used in colorectal surgery. There is, however, a lack of training opportunities and structured training programmes. Robotic surgery has specific problems and challenges for trainers and trainees. Ergonomics, specific skills and user-machine interfaces are different from those in traditional laparoscopic surgery. The aim of this study was to establish expert consensus on the requirements for a robotic train-the-trainer curriculum amongst robotic surgeons and trainers. METHOD: This is a modified Delphi-type study involving 14 experts in robotic surgery teaching. A reiterating 19-item questionnaire was sent out to the same group and agreement levels analysed. A consensus of 0.8 or higher was considered to be high-level agreement. RESULTS: Response rates were 93-100% and most items reached high levels of agreement within three rounds. Specific requirements for a robotic faculty development curriculum included maximizing dual-console teaching, theatre team training, nontechnical skills training, patient safety, user-machine interface training and telementoring. CONCLUSION: A clear need for the development of a train-the-trainer curriculum has been identified. Further research is needed to assess feasibility, effectiveness and clinical impact of a robotic train-the-trainer curriculum.

Comparative efficacy of ivermectin and Nigella sativa against helminths in Aseel chickens (Gallus gallus domesticus).

In this study, we evaluated the in vivo comparative efficacy of ivermectin and Nigella sativa extract against helminths in Aseel chickens, and the effects of helminths on blood parameters before and after treatment in Aseel chickens. Forty naturally infected adult Aseel chickens were randomly divided into four groups (n = 10 each): group A (ivermectin at 300 µg/kg); group B (N. sativa extract at 200 mg/kg); group C (ivermectin at 300 µg/kg + N. sativa extract at 200 mg/kg); group D was kept as a positive control to monitor time-related changes. On day 28 post treatment, the mean percentages of faecal egg-count reduction (FECR %) in groups A, B and C were recorded as 93.58, 88.09 and 100.00%, respectively. Further data analysis showed significantly higher efficacy in group C (100 ± 0.00%) than in groups A and B (P < 0.001). Highly significant (P < 0.001) improvements in mean percentage values of packed cell volume (PCV %) were recorded in groups A and C on days 14 and 28 post treatment. Meanwhile, the improvements in mean values of haemoglobin (Hb) concentration in groups A, B and C were highly significant (P < 0.001) when compared to that of group D on day 28 post treatment. The synergistic combination of ivermectin and N. sativa extract possessed greater efficacy than either ivermectin or N. sativa extract used alone. Furthermore, both PCV % and Hb concentration values gradually increased in the treated groups compared to the control group, in which PCV % and Hb concentration gradually decreased throughout the trial.

A systematic review and meta-analysis evaluating the role of laparoscopic surgical resection of transverse colon tumours.

OBJECTIVES: A meta-analysis of published literature comparing outcomes after laparoscopic resection (LR) with open resection (OR) for transverse colon tumours. METHODS: Medline, PubMed, CINAHL, EMBASE and Cochrane were searched from inception to October 2013. The text words "minimally invasive", "keyhole surgery" and "transverse colon" were used in combination with the medical subject headings "laparoscopy" and "colon cancer". Outcome variables were chosen based upon whether the included articles reported results. A meta-analysis was performed to obtain a summative outcome. RESULTS: Six comparatives involving 444 patients were analysed. Of them 245 patients were in the LR group and 199 in the OR group. There was a significant increase in operative time in the LR group compared with the OR group [random effects model: SMD = -0.65, 95% CI (-1.01, -0.30), z = -3.60, p < 0.001] but there was significant heterogeneity amongst trials (Q = 15.51, df = 5, p = 0.008, I(2) = 68). There was less blood loss in the LR group [fixed effects model: SMD = 0.70, 95% CI (0.47, 0.93), z = 6.01, p < 0.001] and patients returned to oral diet earlier [random effects model: SMD = 0.78, 95% CI (0.40, 1.16), z = 4.01, p < 0.001] and had a reduced time to functioning bowel [fixed effects model: SMD = 0.86, 95% CI (0.60, 1.11), z = 6.63, p < 0.001]. No difference was seen for overall morbidity (p = 0.76) or mortality (p = 0.58). CONCLUSIONS: LR of transverse colon tumours is a safe and effective technique. Although there is an increase in operating time, operative and clinical outcomes of intraoperative blood loss and faster recovery are seen with laparoscopic procedures.

Angiotensin I-converting enzyme-inhibitory activity of the Norwegian autochthonous cheeses Gamalost and Norvegia after in vitro human gastrointestinal digestion.

The angiotensin I-converting enzyme (ACE) inhibitory activity of Gamalost cheese, its pH 4.6-soluble fraction, and Norvegia cheese was monitored before and after digestion with human gastric and duodenal juices. Both Gamalost and Norvegia cheeses showed an increased ACE-inhibitory activity during gastrointestinal digestion. However, only Norvegia showed pronounced increased activity after duodenal digestion. More peptides were detected in digested Gamalost compared with digested Norvegia. Most of the peptides in Gamalost were derived from ß-casein (CN), some originated from α(s1)-CN, and only a very few originated from α(s2)-CN and κ-CN. In general, the number of peptides increased during gastrointestinal digestion, whereas some peptides were further degraded and disappeared; however, surprisingly, a few peptides remained stable. The aromatic amino acids, such as Tyr, Phe, and Trp; the positively charged amino acids (Arg and Lys); and Leu increased after simulated gastrointestinal digestion of Gamalost and Norvegia. After in vitro gastrointestinal digestion, both Gamalost and Norvegia showed high ACE-inhibitory activity, which may contribute in lowering of mild hypertension.

Seasonal variation in physicochemical parameters and heavy metals in water of Upper Lake of Bhopal.

Heavy metal pollution of fresh water is the single most important environmental threat to the future. Upper Lake is a freshwater lake, which is the major source of drinking water in the city of Bhopal, the capital city of M.P., the central province of India, but due to anthropogenic activities this lake is being polluted. During the investigation heavy metals and physicochemical parameters were analyzed to determine the water quality seasonally in the year of 2006 and 2007. All the physicochemical parameters except DO (6.50-6.97 mg l⁻¹), Free CO2 (0.8-1.6 mg l⁻¹) and BOD (5.47-6.85 mg l⁻¹) were below the prescribed limit as recommended by Bureau of Indian Standards (BIS) for drinking water standards. In case of heavy metals, Ni (0.173-0.253 mg l⁻¹) and Cr (0.047-0.087 mg l⁻¹) were found beyond the prescribed limits (0.02 and 0.05 mg l⁻¹, respectively), whereas Pb (0.057-0.087 mg l⁻¹), Cu (0.016-0.020 mg l⁻¹) and Hg (0.0006-0.0011 mg l⁻¹) were within the safe limit. This study reveals that water of upper lake is partially polluted with heavy metals. It is recommended that strict vigilance and constant monitoring are needed to maintain water quality of the lake, which is a major source of potable water for the Bhopal city.

Bioaccumulation of heavy metals in fish tissues of a freshwater lake of Bhopal.

Contamination of heavy metals, namely, lead, cadmium, zinc, nickel, copper, chromium and mercury was evaluated in the samples of water and tissues of Labeo rohita and Ctenopharyngodon idella of Upper Lake of Bhopal collected during summer, rainy and winter seasons of 2005-2006. Different organs of the fishes accumulated varying quantities of different heavy metals. In L. rohita, accumulation of heavy metals was in the sequence liver>kidney>gills>muscles, and in C. idella, it was gills>liver>kidney>muscles. Zn was the highest accumulating metal in fish, whilst Hg was the lowest and was well corroborated with those of water. The values of heavy metals were so far well within the maximum permissible standard value of heavy metals for drinking water and for fish culture as prescribed by various national and international agencies.

Pathological effect on naturally infected kidneys of freshwater murrels by Euclinostomum heterostomum metacercariae.

Present investigation was carried out to study the histo-pathological alterations induced by metacercariae of digenetic trematode, Euclinostomum heretostomum on the kidney of Channa striatus and Channa marulius in natural condition. Histo-architectural alterations induced by parasite included reduced size of glomeruli, severe degeneration and necrosis of haemopoietic tissue and tubule cells with hypertrophied nuclei in C. striatus. Whereas, infected kidney of C. marulius exhibited the development of several melano-macrophage centers, hypertrophied nuclei of tubule cells and detached epithelial cells of renal tubules. Therefore an attempt has been made to record the first naturally occurring pathogenicity of E. heterostomum in kidney of freshwater murrels.

A discerning approach to simple aesthetic orthodontics.

There is currently considerable interest from general dental practitioners (GDPs) in the use of simple orthodontics to treat adult malocclusions. There is controversy in this, particularly in relation to 'quick fixes', simple orthodontics and 'straight teeth in six months' as opposed to more conventional treatment where the whole malocclusion is treated. This article will present a case for the use of simple aesthetic adult orthodontics in a measured and planned way. It will discuss the processes, planning and the importance of consent. It will also highlight how digital technology is used to preview, consent and execute an aesthetic result. Many of the recent systems emerging, have been as a result of the demand and supply of cosmetic dentistry. This, to a degree, has not helped since the implication of a 'quick-fix' is associated with this field. There has also been discussion on what the limits of GDP orthodontics should be. There is variability in how GDPs approach orthodontics, their experience, skill and ability to treat to an acceptable standard. Short courses may be one way of delivering orthodontic training but some of these courses are not regulated and the amount of internal mentoring is variable. This article highlights some of the systems in use, and potential upsides and downsides of this approach.

Pemphigus vulgaris in older adults.

OBJECTIVE: Pemphigus vulgaris (PV) affects primarily middle-aged persons in North America. Conventional therapy suggests use of high doses of systemic corticosteroids and immunosuppressive agents. We have observed a group of older patients with PV and determined their clinical characteristics, treatment, and clinical course. DESIGN, SETTING, AND PARTICIPANTS: Eighteen patients with PV, in whom the onset of the disease was at age 65 or older, were observed and followed at the New England Baptist Hospital in Boston, Massachusetts, between 1985 and 1992. We determined sex and race distribution, disease severity, clinical presentation, autoantibody levels, treatment, response to treatment, and clinical course in these patients. RESULTS: Men and women were affected equally. All the patients were white, and 50% were Jewish. Extensive disease was observed in only 27.8%. The disease was localized in 44.4%; in eight patients (44.4%), the use of sublesional corticosteroid (SLS) injection alone produced satisfactory clinical response. In patients with severe disease, the maximum dose of 60 mg/day of prednisone was sufficient. Patients with moderate disease responded to 20 to 40 mg/day of prednisone. Immunosuppressive agents were used in only four patients. The patients were followed for 3 to 15 years (mean 5.2 years). None of them died of the disease or the complications of therapy. At the time we reported this experience, most of the patients were in clinical remission without any therapy. CONCLUSIONS: Our observations suggest that prognosis for older patients with PV is favorable. In several older patients, PV was controlled by SLS or lower doses of systemic corticosteroids. Systemic agents should be used cautiously and judiciously, and supportive measures should be offered frequently and aggressively.

Partial protection against oral challenge with Mycobacterium bovis in ferrets (Mustela furo) following oral vaccination with BCG.

SETTING: Ferrets (Mustela furo) are important wildlife vectors of bovine tuberculosis (TB) in New Zealand. Protective vaccination of ferrets may limit the potential of transmission to livestock. OBJECTIVE: To determine whether orally-delivered Mycobacterium bovis BCG can confer protection against oral challenge with virulent M. bovis. DESIGN: Ten ferrets were vaccinated by feeding measured doses of live BCG, and subsequently challenged with virulent M. bovis via the oral route. Ten non-vaccinated (control) ferrets were similarly challenged. Live body weights and lymphocyte reactivity were monitored longitudinally, and ferrets were killed 20 weeks following challenge. Necropsy, histological examination and bacterial culture of alimentary tract lymphatic tissues were undertaken. RESULTS: There was a significant reduction in the incidence of gross tuberculous lesions among vaccinated ferrets compared to control animals, and fewer vaccinated ferrets had histologically-detectable acid-fast organisms in mesenteric lymph node (LN) tissues. There were significantly fewer vaccinated ferrets with culture-positive retropharyngeal LNs, and the mean bacterial burden was significantly lower for retropharyngeal LNs isolated from vaccinated animals than from controls. CONCLUSION: These results demonstrate that oral BCG vaccination of ferrets can confer partial protection against M. bovis, and suggest that systemic immune responses may be less important in mediating this degree of protection than local immunity.

Management of patients with intermediate (C3) cytology and a solitary breast lump.

The records of all patients who had a C3 result on fine needle aspiration cytology (FNAC) over a 3-year period were reviewed. Clinical and mammographic findings at presentation were correlated with histopathological diagnosis. Of 43 patients, 32 patients underwent excision biopsy. Histology was benign in 25 patients, eight patients had an invasive breast carcinoma, two a phyllodes tumour and one had widespread ductal carcinoma in situ (DCIS). All but two of the patients with invasive tumours had abnormalities on clinical examination or imaging. In two patients there was no clinical or mammographic suspicion of malignancy. A C3 breast cytology result must be taken seriously as it is frequently an indicator of underlying malignancy. These results suggest that definite histology should be obtained in all patients because of the unacceptably high false-negative rate of clinical and radiological assessment in this group.