Report of the Association of Coloproctology of Great Britain and Ireland/British Society of Gastroenterology Colorectal Polyp Working Group: the development of a complex colorectal polyp minimum dataset.

AIM: The management of large non-pedunculated colorectal polyps (LNPCPs) is complex, with widespread variation in management and outcome, even amongst experienced clinicians. Variations in the assessment and decision-making processes are likely to be a major factor in this variability. The creation of a standardized minimum dataset to aid decision-making may therefore result in improved clinical management. METHOD: An official working group of 13 multidisciplinary specialists was appointed by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG) to develop a minimum dataset on LNPCPs. The literature review used to structure the ACPGBI/BSG guidelines for the management of LNPCPs was used by a steering subcommittee to identify various parameters pertaining to the decision-making processes in the assessment and management of LNPCPs. A modified Delphi consensus process was then used for voting on proposed parameters over multiple voting rounds with at least 80% agreement defined as consensus. The minimum dataset was used in a pilot process to ensure rigidity and usability. RESULTS: A 23-parameter minimum dataset with parameters relating to patient and lesion factors, including six parameters relating to image retrieval, was formulated over four rounds of voting with two pilot processes to test rigidity and usability. CONCLUSION: This paper describes the development of the first reported evidence-based and expert consensus minimum dataset for the management of LNPCPs. It is anticipated that this dataset will allow comprehensive and standardized lesion assessment to improve decision-making in the assessment and management of LNPCPs.

British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps

These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs.

Colorectal cancer incidence and trend in UK South Asians: a 20-year study.

AIMS: South Asians comprise 13.6% of the Wolverhampton population. We aimed to compare the incidence and trend of colorectal cancer in this subgroup with the non South Asian population over a 20-year period. METHOD: Patients of South Asian origin diagnosed with colorectal cancer from 1989 to 2008 were identified from the hospital histopathology database and compared with those of non South Asian origin. 1991 and 2001 census data were used to standardize for differing age and sex distributions in the two study populations. RESULTS: The median unadjusted incidence of colorectal cancer from 1989 to 2008 was 6.17 per 100,000 per year in South Asians compared with 71.70 per 100,000 per year in non South Asians (77.79% white British). The age and sex adjusted odds ratio for colorectal cancer in South Asians was 0.2 (P < 0.001). There was an equal increased trend in the incidence in both the South Asians and non South Asians over the study period (0.8% per year). In patients < 50 years, the gender difference in the incidence of cancer was not significant, but as age increased this rose significantly (males > females). CONCLUSION: There was a markedly lower incidence of colorectal cancer in South Asians compared with non South Asians, maintained over 20 years. Colorectal cancer incidence increased by a small and similar amount over the period in both groups. There was a male preponderance of colorectal cancer in both populations over 50 years.

Downstaging of colorectal cancer by the National Bowel Cancer Screening programme in England: first round data from the first centre.

OBJECTIVE: Data from randomized controlled trials of Colorectal Cancer (CRC) screening in Nottingham, UK and Funen, Denmark and pilot data from the English and Scottish arms of the National Bowel Cancer Screening Programme (NBCSP) have demonstrated predominantly early-stage disease amongst the screened population. The aim of this study was to investigate whether downstaging of cancers occurred in the NBCSP in Wolverhampton. METHOD: A case-control study was performed to compare the staging of CRC diagnosed in the NBCSP-screened population during the prevalent round (2 years) of screening, with cancers diagnosed prior to the introduction of the NBCSP. RESULTS: The total population in the screening area is 899 000. A total of 108 346 FOB kits were sent out of which 55 931 were returned (51.6% uptake), A total of 1039 colonoscopies were performed with a 94.75% unadjusted caecal intubation rate. There were three complications (haemorrhages 3) and no perforations. The NBCSP in Wolverhampton identified 106 (75% male) CRC in the first 2 years with 45.3% Dukes A, 21.7% B, 29.2% C and 3.8% D. Two hundred and fifty-six (61% male) CRC were identified in the control group, 10.1% Dukes A, 50.0% B, 36.3% C and 3.5% D. There was a highly significant shift towards earlier stage disease in the screened group (P < 0.0001). CONCLUSION: The 2-year data from the first English centre to start bowel cancer screening demonstrates significant downstaging of cancer, consistent with both the RCT and pilot data.

Imaging the heart valves using ECG-gated 64-detector row cardiac CT.

Multi-detector row cardiac CT imaging demonstrates clinical usefulness in valvular heart disease, for which CT has not been traditionally used. Electrocardiographic (ECG)-gated CT coronary angiography also has an established clinical role with an increasingly solid evidence base, and the same data set in these patients also provides valuable information about chamber and valvular structure and function; this information should also be considered when interpreting cardiac CT and non-ECG gated thoracic imaging. Although true flow data cannot be achieved using CT, as with echocardiography and MRI, there are a number of imaging features that may be used when interpreting and inferring valve pathology. This article discusses the role of currently available imaging modalities and the rationale for cardiac CT, while focusing on the CT interpretation of valvular heart disease with respect to the relevant pathophysiology and management options that have importance to the radiologist. A suggested method of post-processing image review is provided with reference to a variety of normal and pathological pictorial illustrations.

Protostrongylid parasites and pneumonia in captive and wild thinhorn sheep (Ovis dalli).

We describe health significance of protostrongylid parasites (Parelaphostrongylus odocoilei and Protostrongylus stilesi) and other respiratory pathogens in more than 50 naturally infected Dall's sheep (Ovis dalli dalli) from the Mackenzie Mountains, Northwest Territories (1998-2002) as well as in three Stone's sheep (O. d. stonei) experimentally infected with P. odocoilei (2000-2002). Histological lesions in the brain and distribution of P. odocoilei in the muscles of experimentally and naturally infected sheep were consistent with a previously hypothesized "central nervous system to muscle" pattern of migration for P. odocoilei. Dimensions of granulomas associated with eggs of P. odocoilei and density of protostrongylid eggs and larvae in the cranial lung correlated with intensity of larvae in feces, and all varied with season of collection. Prevalence of P. stilesi based on the presence of larvae in feces underestimated true prevalence (based on examination of lungs) in wild Dall's sheep collected in summer and fall. Similarly, counts of both types of protostrongylid larvae in feces were unreliable indicators of parasitic infection in wild Dall's sheep with concomitant bacterial pneumonia associated with Arcanobacterium pyogenes, Pasteurella sp., and Mannheimia sp. Diffuse, interstitial pneumonia due to P. odocoilei led to fatal pulmonary hemorrhage and edema after exertion in one experimentally infected Stone's sheep and one naturally infected Dall's sheep. Bacterial and verminous pneumonia associated with pathogens endemic in wild Dall's sheep in the Mackenzie Mountains caused sporadic mortalities. There was no evidence of respiratory viruses or bacterial strains associated with domestic ruminants, from which this population of wild sheep has been historically isolated.

Climate change and the epidemiology of protostrongylid nematodes in northern ecosystems: Parelaphostrongylus odocoilei and Protostrongylus stilesi in Dall's sheep ( Ovis d. dalli ).

We describe the epidemiology of the protostrongylid parasites Parelaphostrongylus odocoilei and Protostrongylus stilesi in Dall's sheep (Ovis dalli dalli) from the Mackenzie Mountains, Northwest Territories, Canada (65 degrees N; 128 degrees W). Peak numbers of 1st-stage larvae of both parasites were shed by Dall's sheep on their winter range from March until May. In larval development experiments in the Mackenzie Mountains, peak numbers of infective 3rd-stage larvae of P. odocoilei were available in gastropod intermediate hosts in August-September. For both protostrongylids, the majority of transmission likely occurs on the winter range, with infection of gastropods when they emerge from hibernation in spring, and infection of Dall's sheep upon their return in fall. We validated a degree-day model for temperature-dependent development of larval P. odocoilei in gastropods, and applied degree-day models to describe and predict spatial and temporal patterns in development of P. odocoilei and P. stilesi in northern North America. Temperature-dependent larval development may currently limit northward range expansion of P. odocoilei into naïve populations of Dall's sheep in the Arctic, but climate warming may soon eliminate such constraints. In Subarctic regions where both P. odocoilei and P. stilesi are endemic, the length of the parasite 'growing season' (when temperatures were above the threshold for larval development) and amount of warming available for parasite development has increased over the last 50 years. Further climate warming and extension of the seasonal window for transmission may lead to amplification of parasite populations and disease outbreaks in host populations.

Tropical enteropathy: a T-cell-mediated crypt hyperplastic enteropathy.

OBJECTIVE: Tropical enteropathy is widespread throughout the tropics, but its pathogenesis is unknown. T-cell activation has been demonstrated to result in enteropathy in vitro and in animal models, and occurs in untreated patients with coeliac disease. We have therefore examined the hypothesis that T-cell activation is important in the pathogenesis of tropical enteropathy. PATIENTS AND METHODS: Healthy black Zambian subjects were compared with black and white South Africans. Quantitative microscopy was conducted on distal duodenal biopsies. Mucosal T-cell activation was quantitated by dual colour immunofluorescence staining for CD3 plus CD69 or HLA-DR. Crypt proliferation was measured by direct counting of Feulgen-stained mitotic figures, and systemic immune activation by assay of serum tumour necrosis factor alpha (TNF-alpha). RESULTS: Villous height was reduced (P = 0.0004), crypt depth increased (P < 0.0001), and mitoses per crypt increased (P = 0.014) in black Zambians compared with black and white South Africans. Mucosal thickness was similar. Intraepithelial lymphocyte count was increased in the black groups compared with whites (P = 0.03). CD3+CD69+ (P = 0.0007) and CD3+HLA-DR+ (P < 0.0001) expression was increased in black Zambians compared with black and white South Africans. Serum TNF-alpha was similar in all groups. CONCLUSIONS: Tropical enteropathy is associated with mucosal T-cell activation and crypt hyperplasia. Tropical enteropathy occurs in the absence of malnutrition, diarrhoea or systemic illness.

Lack of evidence for small intestinal mucosal T-cell activation as a pathogenic mechanism in African HIV-associated enteropathy.

The role of mucosal T-cell activation in HIV-associated enteropathy is uncertain. Twenty Zambian patients with AIDS and chronic diarrhea were studied, as were nine controls. Distal duodenal biopsies were taken at endoscopy. Morphometric analysis and dual color immunofluorescence staining were performed. Villous height was reduced [177 (118-228) vs 305 (244-358) microm P = 0.002] and crypt depth increased [220 (164-202) vs 194 (164-202) microm P = 0.008] in AIDS patients compared to controls. CD3+CD4+ T cells were reduced in AIDS patients compared to controls [12.9 (5.7-25.2) vs 47.6 (33.4-65.5)% P = 0.04]. There was no significant difference in expression of CD8, CD25, CD69, HML-1, or HLA-DR on T cells between the AIDS patients and controls, with the exception of CD3+HML-1+ cells, which were increased in AIDS patients (P = 0.05). Small intestinal T-cell activation was similar between AIDS patients and controls. We conclude, therefore, that this mechanism is not likely to be important in the pathogenesis of HIV-associated enteropathy.

New host and geographic records for two protostrongylids in Dall's sheep.

Biodiversity survey and inventory have resulted in new information on the distribution of Protostrongylidae in Dall's sheep (Ovis dalli dalli) from the Northwest Territories (NT, Canada) and from Alaska (AK, USA). In 1998, Parelaphostrongylus odocoilei adults were found for the first time in the skeletal muscles of Dall's sheep in the Mackenzie Mountains (NT). Adult P. odocoilei were associated with petechial and ecchymotic hemorrhages and localized myositis; eggs and larvae in the lungs were associated with diffuse granulomatous pneumonia. Experimental infections of the slugs Deroceras laeve and Deroceras reticulatum with dorsal-spined first-stage larvae assumed to be P. odocoilei, from ground-collected feces from Dall's sheep in the Mackenzie Mountains, yielded third-stage larvae by at least 28 (in D. laeve) and 48 (in D. reticulatum) days post-infection. Third-stage larvae emerged from D. laeve between days 19 and 46 post-infection and emergence occurred both at room temperature and at 10 to 12 C. Protostrongylus stilesi were definitively identified from the lungs of Dall's sheep collected in the Mackenzie Mountains, NT in 1998. Specimens collected from sheep in the Mackenzie Mountains, NT in 1971-72, and the Alaska Range, AK in 1972 were also confirmed as P. stilesi. Lung pathology associated with adults, eggs, and larvae of P. stilesi was similar to that described in bighorn sheep (Ovis canadensis). Concurrent infections with P. odocoilei and P. stilesi in a single host have not been previously reported.

Bacterial valvular endocarditis in a black bear from Labrador.

In fall 1991, a radio-collared black bear (Ursus americanus) in northern Labrador (Canada) died from valvular endocarditis caused by coagulase-positive Staphylococcus aureus, with widespread dissemination of the infection to other organs shortly before death. Apparently, this is the first reported case of bacterial valvular endocarditis in a wild black bear.

Recently recognised microbial enteropathies and HIV infection.

Persistent diarrhoea and small bowel enteropathy are important features of HIV infection. At least 80% of cases of persistent diarrhoea in patients with HIV/AIDS can be attributed to a specific enteropathogen. The coccidian parasites Cryptosporidium parvum, Isospora belli and Cyclospora and the Microsporidia account for at least 50% of cases of persistent diarrhoea in the industrialised and developing world with major contributions from Mycobacterium avium complex and other bacteria and cytomeglovirus. The intracellular protozoa can be detected on faecal microscopy although confirmation may be required by intestinal mucosal biopsies. Although up to 20% of cases of persistent diarrhoea can not be attributed to a specific infection, the question as to whether HIV infection itself can produce enteropathy remains uncertain. Recent developments in the treatment of persistent diarrhoea in HIV include the use of albendazole for microsporidial diarrhoea and co-trimoxazole for the treatment and eradication of Cyclospora.