Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis.

PURPOSE: Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis. METHODS: Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence. RESULTS: Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients). CONCLUSIONS: There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.

Abdominal stab wounds with retained knife: 15 years of experience from a major trauma centre in South Africa.

INTRODUCTION: This study reviews our cumulative experience with the management of patients presenting with a retained knife following an abdominal stab wound (SW). METHODS: A retrospective study was conducted at a major trauma centre in South Africa over a 15-year period from July 2006 to December 2020 including all patients who presented with a retained knife in the abdomen following a SW. RESULTS: A total of 42 cases were included: 37 males (93%) with a mean age of 26 years. A total of 18 knives (43%) were in the anterior abdomen and 24 were posterior abdomen. Plain radiography was performed in 88% (37/42) of cases and computed tomography was performed in 81% (34/42); 90% (38/42) underwent extraction in the operating theatre. Laparotomy was performed in 62% (26/42). Of all the laparotomies performed, 77% (20/26) were positive for intra-abdominal organ or visceral injury. Overall morbidity was 31%. There were two mortalities (5%). Laparotomy was less commonly required for the posterior abdomen (33% (8/24) vs 100% (18/18), p<0.001). For retained knives in the anterior abdomen, 72% (13/18) of the laparotomies were positive for intra-abdominal organ or visceral injury. For the posterior abdomen, 7 of the 8 (88%) were positive for intra-abdominal organ or visceral injury. There were no differences in the need for intensive care unit admission, length of hospital stay, morbidities or mortalities. CONCLUSIONS: Uncontrolled extraction of a retained knife in the abdomen outside of the operating theatre must be avoided. Retained knives in the anterior abdomen usually require formal laparotomy, but this is generally not required for posterior abdomen.

Barriers to uptake of cervical cancer screening services in low-and-middle-income countries: a systematic review.

OBJECTIVES: Low-and-middle-income countries (LMICs) bear a disproportionate burden of cervical cancer mortality. We aimed to identify what is currently known about barriers to cervical cancer screening among women in LMICs and propose remedial actions. DESIGN: This was a systematic review using Medical Subject Headings (MeSH) terms in Google Scholar, PubMed, Scopus, and Web of Science databases. We also contacted medical associations and universities for grey literature and checked reference lists of eligible articles for relevant literature published in English between 2010 and 2020. We summarized the findings using a descriptive narrative based on themes identified as levels of the social ecological model. SETTING: We included studies conducted in LMICs published in English between 2010 and 2020. PARTICIPANTS: We included studies that reported on barriers to cervical cancer screening among women 15 years and older, eligible for cervical cancer screening. RESULTS: Seventy-nine articles met the inclusion criteria. We identified individual, cultural/traditional and religious, societal, health system, and structural barriers to screening. Lack of knowledge and awareness of cervical cancer in general and of screening were the most frequent individual level barriers. Cultural/traditional and religious barriers included prohibition of screening and unsupportive partners and families, while social barriers were largely driven by community misconceptions. Health system barriers included policy and programmatic factors, and structural barriers were related to geography, education and cost. Underlying reasons for these barriers included limited information about cervical cancer and screening as a preventive strategy, poorly resourced health systems that lacked policies or implemented them poorly, generalised limited access to health services, and gender norms that deprioritize the health needs of women. CONCLUSION: A wide range of barriers to screening were identified across most LMICs. Urgent implementation of clear policies supported by health system capacity for implementation, community wide advocacy and information dissemination, strengthening of policies that support women's health and gender equality, and targeted further research are needed to effectively address the inequitable burden of cervical cancer in LMICs.

Management of penetrating thoracic trauma with retained knife blade: 15-year experience from a major trauma centre in South Africa.

INTRODUCTION: This study reviews our experience with the management a retained knife in the setting of thoracic stab wounds. METHODS: A retrospective study was conducted at a major trauma in South Africa over a 15-year period from January 2004 to December 2018. RESULTS: There were 40 patients, of whom 37 were males (93%). Median age was 24 years; 78% of cases (31 of 40) were a retained knife and 23% (9 of 40) were a retained blade. The locations of the stab wounds were 19 (48%) anterior and 21 (53%) posterior. Plain x-ray was performed in 85% (34) of patients and computed tomography angiography was performed in 85% (34). Six patients had haemodynamic instability and were expedited to the operating room without further imaging. Three of these had cardiac tamponade and three a massive haemothorax. Simple extraction and wound exploration were performed in 58% (23 of 40) of cases and the remaining 43% (17 of 40) required operative exploration and extraction. The operative approach was anterolateral thoracotomy in nine cases, posterolateral thoracotomy in four and median sternotomy in three cases. One patient required extraction and concurrent vertebral laminectomy due to cord compression. Twelve patients (30%) experienced complications (nine wound sepsis and three hospital-acquired pneumonia). There was one mortality (3%). The median length of hospital stay was 6 days. CONCLUSION: Uncontrolled extraction of a retained thoracic knife outside the operating room must be avoided. An unstable patient should proceed directly for operative exploration. For stable patients, cross-sectional imaging will allow for planned extraction in operating room.

Mobile health technology for remote home monitoring after surgery: a meta-analysis.

BACKGROUND: Mobile health (mHealth) technology has been proposed as a method of improving post-discharge surveillance. Little is known about how mHealth has been used to track patients after surgery and whether its use is associated with differences in postoperative recovery. METHODS: Three databases (PubMed, MEDLINE and the Cochrane Central Registry of Controlled Trials) were searched to identify studies published between January 1999 and February 2021. Mobile health was defined as any smartphone or tablet computer capable of electronically capturing health-related patient information and transmitting these data to the clinical team. Comparable outcomes were pooled via meta-analysis with additional studies compiled via narrative review. The quality of each study was assessed based on Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. RESULTS: Forty-five articles met inclusion criteria. While the majority of devices were designed to capture general health information, others were specifically adapted to the expected outcomes or potential complications of the index procedure. Exposure to mHealth was associated with fewer emergency department visits (odds ratio 0.42, 95 per cent c.i. 0.23 to 0.79) and readmissions (odds ratio 0.47, 95 per cent c.i. 0.29 to 0.77) as well as accelerated improvements in quality of life after surgery. There were limited data on other postoperative outcomes. CONCLUSION: Remote home monitoring via mHealth is feasible, adaptable, and may even promote more effective postoperative care. Given the rapid expansion of mHealth, physicians and policymakers need to understand these technologies better so that they can be integrated into high-quality clinical care.

A systematic review was performed to determine how mobile health (mHealth) technology is being used to track surgical patients after hospital discharge, and whether exposure to mHealth is associated with differences in postoperative recovery. Remote home monitoring via mHealth is feasible and flexible enough to meet the demands of a variety of patients and clinical teams. Exposure to mHealth also appears to be associated with a reduction in both emergency department visits and hospital readmissions as well as accelerated improvements in quality of life. mHealth represents an important next step in postoperative surveillance, although better performance data, targeted incentives and clearer guidelines are still needed.

Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials.

INTRODUCTION: Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Several RCTs have explored operative strategies to minimize DGE, however, the optimal combination of gastric resection approach, anastomotic route, configuration and the use of enteroenterostomy remains unclear. METHODS: MEDLINE, Embase and CENTRAL databases were systematically searched for RCTs comparing gastric resection (classic Whipple, pylorus-resecting, pylorus-preserving), anastomotic route (antecolic, retrocolic), configuration (loop gastroenterostomy/Billroth II, Roux-en-Y), and use of enteroenterostomy (Braun). A random-effects, Bayesian network meta-analysis with non-informative priors was conducted to determine the optimal combination of approaches to PD for minimizing DGE. RESULTS: Twenty-four RCTs, including 2526 patients and 14 approaches were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6 per cent (647 patients). Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy was associated with the lowest rates of DGE and ranked the best in 35 per cent of comparisons. Classic Whipple, retrocolic, Billroth II with Braun ranked the worst for DGE in 32 per cent of comparisons. Pairwise meta-analysis of retrocolic versus antecolic route for gastrojejunostomy found increased risk of DGE with the retrocolic route (odds ratio 2.10, 95 per cent credibility interval (cr.i.) 0.92 to 4.70). Pairwise meta-analysis of enteroenterostomy found a trend towards lower DGE rates when this was used (odds ratio 1.90, 95 per cent cr.i. 0.92 to 3.90). Having a Braun enteroenterostomy ranked the best in 96 per cent of comparisons. CONCLUSION: Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy seems to be associated with the lowest rates of DGE. PREREGISTRATION: PROSPERO submitted 23 December 2020. CRD42021227637.

Network meta-analysis of local and regional analgesia following colorectal resection.

BACKGROUND: Postoperative pain management after colorectal surgery remains challenging. Systemic opiates delivered on demand or via a patient-controlled pump have traditionally been the mainstay of treatment. Opiate analgesia is associated with slower gastrointestinal recovery and unpleasant side-effects; many regional and local analgesic techniques have been developed as alternatives. METHODS: MEDLINE, Embase and CENTRAL databases were searched systematically for RCTs comparing analgesic techniques after major colorectal resection. A network meta-analysis was performed using a Bayesian random-effects framework with a non-informative prior. Primary outcomes included pain at rest and cumulative opiate consumption 24 h after surgery. Secondary outcomes included pain at rest and cumulative opiate consumption at 48 h, pain on movement and cough at 24 and 48 h, time to first stool, time to tolerance of oral diet, duration of hospital stay, nausea and vomiting, and postoperative complications. RESULTS: Seventy-four RCTs, including 5101 patients and 11 different techniques, were included. Some inconsistency and heterogeneity was found. SUCRA scores showed that spinal analgesia was the best intervention for postoperative pain and opiate reduction at 24 h. Transversus abdominus plane blocks were effective in reducing pain and opiate consumption 24 h after surgery. Subgroup analysis showed similar results for open versus minimally invasive surgical approaches, and enhanced recovery after surgery programmes. CONCLUSION: Spinal analgesia and transversus abdominus plane blocks best balanced pain control and opiate minimization in the immediate postoperative phase following colorectal resection. Multimodal analgesia reduces pain, minimizes systemic opiate use and optimizes postoperative recovery.

ANTECEDENTES: El tratamiento del dolor postoperatorio después de cirugía colorrectal sigue siendo difícil. Los opiáceos sistémicos administrados a demanda o mediante una bomba controlada por el paciente ha sido tradicionalmente el principal tratamiento. Sin embargo, la analgesia con opiáceos se asocia con una recuperación gastrointestinal más lenta y con efectos secundarios desagradables, lo que dado lugar al desarrollo de numerosas técnicas analgésicas regionales y locales como modalidades alternativas. MÉTODOS: Se realizaron búsquedas sistemáticas en las bases de datos Medline, Embase y CENTRAL para identificar ensayos controlados aleatorizados (randomized controlled trials, RCTs) que compararan técnicas analgésicas después de una resección colorrectal mayor. Se realizó un metaanálisis en red utilizando un marco bayesiano de efectos aleatorios con una distribución a priori no informativa. Los criterios de valoración primarios incluyeron dolor en reposo y el consumo de opiáceos a las 24 horas después de la operación. Los criterios de valoración secundarios incluyeron dolor en reposo y el consumo de opiáceos a las 48 horas, dolor con el movimiento y al toser (a las 24 y 48 horas), tiempo hasta la primera deposición, tiempo hasta tolerar la dieta oral, duración de la estancia hospitalaria, náuseas y vómitos, y complicaciones postoperatorias. RESULTADOS: Se incluyeron 74 RCTs, con un total de 5.101 pacientes y 11 técnicas diferentes. Se encontró cierta inconsistencia y heterogeneidad. Las puntuaciones de dolor en reposo más bajas y la menor ingesta de opiáceos postoperatorios a las 24 horas correspondieron a la analgesia espinal. Los bloqueos del plano transverso del abdomen fueron efectivos para reducir el dolor y el consumo de opiáceos a las 24 horas después de la cirugía. El análisis de subgrupos mostró resultados similares para los abordajes quirúrgicos abiertos versus mínimamente invasivos y para los programas de recuperación intensificada después de la cirugía (Enhanced Recovery After Surgery, ERAS). CONCLUSIÓN: La analgesia espinal y el bloqueo del plano transverso del abdomen consiguieron un mejor control del dolor y una disminución de los opiáceos en el postoperatorio inmediato tras la cirugía colorrectal. La analgesia multimodal reduce el dolor, minimiza el uso de opiáceos sistémicos y optimiza la recuperación postoperatoria.

Seasonal Influenza Vaccine Uptake in a Respiratory Outpatients Clinic.

Influenza is an acute viral respiratory illness that continues to cause significant morbidity and mortality in Ireland. Despite well-established national and international guidelines1 and increased public awareness campaigns, vaccine uptake rates are well below target worldwide2. We performed an audit of influenza vaccine uptake at a Respiratory outpatient clinic in a tertiary referral centre. 54% (n=41) of patients received the annual vaccine, well below the target of 75% set by the European Centre for Disease Prevention and Control (ECDC).

Quantum transport through hierarchical structures.

The transport of quantum electrons through hierarchical lattices is of interest because such lattices have some properties of both regular lattices and random systems. We calculate the electron transmission as a function of energy in the tight-binding approximation for two related Hanoi networks. HN3 is a Hanoi network with every site having three bonds. HN5 has additional bonds added to HN3 to make the average number of bonds per site equal to five. We present a renormalization group approach to solve the matrix equation involved in this quantum transport calculation. We observe band gaps in HN3, while no such band gaps are observed in linear networks or in HN5. We provide a detailed scaling analysis near the edges of these band gaps.

Primary haemophagocytic syndrome in a young girl.

Haemophagocytic syndrome is a life-threatening systemic illness characterized by an uncontrolled inflammatory response. Patients present with fever, hepatosplenomegaly, jaundice and liver dysfunction, neurological manifestations and often pancytopenla. Bone marrow, lymph node, hepatic or splenic biopsy shows macrophages with Ingested blood cells or their precursors. Laboratory markers include elevated triglycerides and ferritin, low fibrinogen with normal or low erythrocyte sedimentation rate (ESR). Familial haemophagocytic lymphohistiocytosis (HLH) is an autosomal recessive disorder. Secondary haemophagocytic syndrome results from infections, malignancy and collagen vascular disorders. We describe a young girl with primary haemophagocytic syndrome.

Epidemiology of type 2 diabetes: Indian scenario.

India leads the world with largest number of diabetic subjects earning the dubious distinction of being termed the "diabetes capital of the world". According to the Diabetes Atlas 2006 published by the International Diabetes Federation, the number of people with diabetes in India currently around 40.9 million is expected to rise to 69.9 million by 2025 unless urgent preventive steps are taken. The so called "Asian Indian Phenotype" refers to certain unique clinical and biochemical abnormalities in Indians which include increased insulin resistance, greater abdominal adiposity i.e., higher waist circumference despite lower body mass index, lower adiponectin and higher high sensitive C-reactive protein levels. This phenotype makes Asian Indians more prone to diabetes and premature coronary artery disease. At least a part of this is due to genetic factors. However, the primary driver of the epidemic of diabetes is the rapid epidemiological transition associated with changes in dietary patterns and decreased physical activity as evident from the higher prevalence of diabetes in the urban population. Even though the prevalence of microvascular complications of diabetes like retinopathy and nephropathy are comparatively lower in Indians, the prevalence of premature coronary artery disease is much higher in Indians compared to other ethnic groups. The most disturbing trend is the shift in age of onset of diabetes to a younger age in the recent years. This could have long lasting adverse effects on nation's health and economy. Early identification of at-risk individuals using simple screening tools like the Indian Diabetes Risk Score (IDRS) and appropriate lifestyle intervention would greatly help in preventing or postponing the onset of diabetes and thus reducing the burden on the community and the nation as a whole.

Enlarged vestibular aqueduct in two male siblings.

This report describes the case history of two male siblings with sensorineural hearing loss and an enlarged vestibular aqueduct (EVA). Sibling 1 presented with a history of intermittent self-limiting ataxia and hearing loss at the age of 25 months and sibling 2 presented with a similar history at the age of 18 months. MRI showed an enlarged endolymphatic duct and sac bilaterally in both children. Perchlorate discharge tests were positive in both infants leading to a diagnosis of Pendred syndrome. A number of conditions associated with EVA are discussed with a view to devising management strategies.

Childhood cancer in the south Asian population of England (1990-1992).

Cancer incidence in 1990-92 among English south Asian (residents with ethnic origins in India, Pakistan or Bangladesh) and non-south Asian children is compared. Standardized incidence ratios show significant overall excesses in south Asians (131), largely due to higher rates in south Asian boys, and specific excesses for leukaemia (141), lymphoid leukaemia (141), lymphoma (172) and hepatic tumours (375). Aetiological investigation is required.

Proliferating cell nuclear antigen and epidermal growth factor receptor (EGFr) status in renal cell carcinoma patients with polysomy of chromosome 7.

We investigated 40 cases of renal cell carcinoma (RCC) to study the polysomy 7 status in papillary and clear-cell types (nonpapillary RCC) and relationship with clinical, pathological, and biological features such as grade, stage, tumor proliferation rate (PCNA expression) and epidermal growth factor receptor (EGFr) expression and thereby to understand the prognostic significance of polysomy 7 and EGFr expression. In a prospective study, chromosome 7 copy number was analyzed in tumor cells by using fluorescence in situ hybridization (FISH) with an alpha-satellite DNA probe for chromosome 7. Both proliferating cell nuclear antigen (PCNA) and EGFr expression were examined in paraffin sections by immunostaining. The relationship between clinicopathological and clinicobiological parameters was evaluated by appropriate statistical methods. Polysomy 7 was present in 100% of papillary and 56.2% of clear-cell types RCC. In clear-cell RCC, in comparison with polysomy 7-dominant (D) category (20-50% polysomy-7 cells), polysomy 7-major (M) category (>50% polysomy 7 cells) was associated with higher tumor grade (P = 0.05). Polysomy 7 was also correlated with stage of the disease (P = 0.006). The PCNA index ranged between 12.8-89.6% and was comparatively high in high-grade tumors (P = 0.001). The PCNA index was also correlated with polysomy 7 (P = 0.002), and the association was stronger in tumors with polysomy M versus polysomy D category (P = 0.02). The EGFr expression did not correlate with either grade, stage, PCNA, or polysomy 7. The correlation of polysomy 7 with less favorable prognostic factors such as higher tumor grade, stage, and higher proliferative index in the present study indicates that polysomy 7 might be used as a prognostic predictor in clear-cell RCC. Evaluation of clinical end points will confirm the prognostic potential of the genetic marker polysomy 7 in our study.

Diet and stomach cancer: a case-control study in South India.

A prospective case-control study was conducted in Trivandrum, India, to evaluate the dietary risk factors for stomach cancer. One hundred and ninety-four patients with stomach cancer registered at the Regional Cancer Centre (RCC), Trivandrum, Kerala, India, during the period 1988-1991 were considered as cases. A minimum of one control (n = 305), matched for age (+/- 5 years), sex, religion and residential area was selected from the visitors to RCC during the same period. Interviews were carried out using a predetermined structured food frequency questionnaire. The information collected also included socio-demographic/economic background, tobacco chewing, tobacco smoking and alcohol habits. Data were analysed using a multiple logistic regression model. Odds ratios for all dietary variables were estimated. Increased risks were observed with higher consumption of rice (OR 3.9; 95% CI 1.6-10.0). Risk was high for those consuming spicy food (OR 2.3; 95% CI 1.1-5.0), high consumption of chilli (OR 7.4; 95% CI 4.0-13.5) and consumption of high-temperature food (OR 7.0; 95% CI 3.7-12.9). On multivariate analysis, high consumption of rice, high consumption of chilli and consumption of high-temperature food were found to be independent risk factors.

Hyperfractionation in carcinoma of the cervix: tumor control and late bowel complications.

PURPOSE: Hyperfractionation has been advocated to improve local tumor control by increasing radiation dose without increasing late normal tissue complications. The aim of this study was to determine if hyperfractionation decreased late bowel complications. METHODS AND MATERIALS: Thirty patients with Stage II and III cervical cancer were randomized to receive either hyperfractionation or conventional fractionation. Patients were followed for 5 years and monitored for tumor control, recurrence, and bowel complications. The relative risks of tumor control and bowel complications were computed at 1 year and 5 years of follow-up. Kaplan-Meier survival curves were plotted to determine probabilities of being tumor-free and bowel complication-free. RESULTS: There were 15 patients in each group. At 1 year of follow-up, 2 patients in the hyperfractionation group (13%) and 7 patients in the conventional treatment group (45%) had tumor (relative risk [RR] 0.3; 95% confidence interval [CI] 0.1, 1.1; p = 0.054). Delayed bowel complications were seen in 8 patients in the hyperfractionation group and 1 patient in the conventional treatment group (RR 7.5; 95% CI 1.1, 52; p = 0.014). At 5 years, 2 patients in the hyperfractionation group and 8 patients in the conventional treatment group had tumor (RR 0.3; 95% CI 0.1, 1.1; p = 0.04). Delayed bowel complications (Grades 2 and 3) occurred in 9 women in the hyperfractionation group and 2 patients in the conventional group (RR 5.4; 95% CI 1.5, 19.5; p = 0.0006). Kaplan-Meier analysis showed that the hyperfractionation group had significantly more bowel complications over the 5 years of follow-up (p = 0.024). CONCLUSION: Hyperfractionation may result in better tumor control both at 1 year and at 5 years following treatment of cervical cancer. However, hyperfractionation could lead to increased late bowel complications and must be used judiciously in the treatment of cervical cancer.

Malignancy load on general surgeons: the need to change the general surgical training curriculum.

AIMS: With the advent of newer diagnostic modalities more and more cancer patients are being diagnosed each year. The rising detection rate and greater public awareness have immensely increased the load on already overburdened and increasingly fewer surgical oncology units. As a result a large number of these cases are being dealt with by general surgeons. METHODS: We have used a retrospective case count from a single surgical unit, based at the University Hospital, Varanasi, and data from the Hospital Based Cancer Registry (HBCR), Regional Cancer Centre (RCC), Trivandrum, from 1990 to 1994, to define the malignancy load on general surgical units and to define the number and sites of malignancies commonly encountered by general surgeons. RESULTS: A total of 28,136 patients were registered at the RCC, the commonest malignancy being oral cavity (16.35%), followed by lung (12.7%) and breast (23.8%) among men and women, respectively. On the other hand, in the 2123 patients with malignancy who were treated at the Medical College (MCH) in Trivandrum, the commonest sites encountered were stomach (11.68%), thyroid (10.31%) and colorectal (9.5%). This was quite similar to the frequencies observed at Varanasi, where colorectal cancer constituted 10.26% and stomach 6.98%. Only 13.6% of the patients reporting to RCC were treated by surgery alone or in combination, while this figure was 48. 1% for MCH. Similarly 2056 (7.3%) patients presenting to RCC had completed treatment prior to being referred to RCC; almost all of these patients were treated by surgery at referral institutions by general surgeons. CONCLUSIONS: The results clearly indicate an increased demand on the surgical oncology units, or alternatively an urgent need to redefine the postgraduate curriculum for the better training of general surgeons in understanding malignant disease, especially in the developing countries. We recommend a minimum of 6 months training in surgical oncology for each general surgery postgraduate.

Clinical significance of cytogenetic findings at diagnosis and in remission in childhood and adult acute lymphoblastic leukemia: experience from India.

We report cytogenetic findings in 114 patients of acute lymphoblastic leukemia (ALL), which includes 78 children (< or = 15 years) and 36 adults (16-60 years). Chromosome aberrations were detected in 109 (95%) cases. A lower frequency of hyperdiploidy (15%) in children and a higher frequency of hypodiploidy both in children (38.4%) and adults (44.4%) were found, in contrast to literature. Translocations were detected in one third of adult and pediatric cases. The incidence of t(9;22) was comparatively low in adults (7.7%). Frequency of t(1:19) was also low in overall ALL cases. Various other recurrent abnormalities such as del(6q), abn(11q23), i(9p), abn(12q13), del(7q), and i(17q) were seen in our cases; a striking difference in the incidence of del(6q) (41%) and abn(11q23) (30%) was found in our series versus reported literature. Ploidy distribution indicated association of pseudo- and hypodiploidy with B-lineage, and hypodiploidy with T-lineage in children. The occurrence of del(6q) was more frequent in pediatric ALL with highly aberrant pattern and also with lymphadenopathy. Abn(11q23) was found to be early-B and pre-B specific. Kaplan-Meier analysis of overall survival revealed prognostic value of sex, FAB, immunophenotype, and cytogenetic findings. Females and T-ALL patients had a better prognosis, whereas males and B-ALL patients had poor outcome in overall and pediatric age groups. Prognostic evaluation of cytogenetics indicated translocations as an independent high-risk predictor in childhood (P < 0.008) and adult ALL (P < 0.01). Childhood ALL with t(8;14) and t(4;11) and adults with t(9;22) had poor survival. Cytogenetics of remission marrows demonstrated disappearance of abnormal clones in 31.4%, and expansion in normal clones in 50% of patients. Persistence of original clones and development of new clones were observed in 20% and 33% of patients, respectively; whereas karyotype evolution was identified in 10% of patients. The prognostic significance of cytogenetic findings at diagnosis, and differential cytogenetic response in so-called clinical remission in our study indicated the utmost need for more intensive therapy for eradication of resistant clones, and necessity of sequential cytogenetic follow-up in these patients for identification of minimal residual disease.