R0 Resection Margin, A New Quality Measure in the Era of National Bowel Screening?

Aims To determine the completeness of polyp resection (i.e. achieving an R0 margin) and its relation with Endoscopists, histopathologist, size, location and technique of polypectomy in an NSS cohort. The definition of R0 margin is complete macroscopic resection with a negative microscopic margin at polypectomy. Method NCCS (National Colon Cancer Screening) colonoscopies are offered to bowel cancer screening patients after a positive faecal immunochemical test (FIT) test in a Joint Advisory Group (JAG) accredited Gastrointestinal Endoscopy centre. We histologically evaluated the polyp margins for complete resection, which was defined as the absence of adenomatous or hyperplastic tissue in the resected polyp margins in a cohort of faecal immunochemical test positive patients. Results A total of 186 consecutive NCCS colonoscopies out of a total of 542 performed between 2013 and 2017 were included in this study. Of the polyps excised 152(27%) had a R0 margin histologically, and 30(5%) had involvement of the margin. Surprisingly in 373(67%) of polyps pathologists were unable to assess the margin. Conclusion Achieving an R0 margin should be a key performance indicator for endoscopists performing polypectomy. At the same time more studies on polyp margins are recommended.

Retromandibular transparotid approach compared with transmasseteric anterior parotid approach for the management of fractures of the mandibular condylar process: a prospective randomised study.

Fractures of the mandibular condyle lead to displacement of the condyle and loss of the height of the ramus. A retromandibular approach is the most commonly used for open reduction and internal fixation (ORIF) of such fractures. We aimed to compare the complications associated with a retromandibular transparotid approach with a retromandibular transmasseteric anterior parotid (TMAP) approach for their management. Thirty patients were randomly selected into two groups (15 in each): Group A comprised the retromandibular transparotid approach and Group B the retromandibular TMAP. The variables evaluated were: operating time, facial nerve injury, occurrence of Frey syndrome, and sialocoele at one week, four weeks, three months, and six months. The mean (SD) age in group A and B was 33.93 (17.97) years and 33.53 (16.15) years, respectively, and there were 28 men and two women. Mean (SD) exposure time in the transparotid approach was 26.93 (5.19) minutes and 25.4 (8.35) minutes in the TMAP approach. The incidence of facial nerve injury was 2/15 patients in the transparotid group and 3/15 in the TMAP group, all of which resolved within six months. The incidence of sialocoele was 2/15 in the transparotid group. The results did not show any significant difference in complications between the two approaches, but the retromandibular transparotid approach provided straight-line access in fractures of the condylar neck, with fewer incidences of nerve injury. The anterior parotid approach, on the other hand, provided easier access for fractures that were medially dislocated or of the condylar base but had an increased incidence of facial nerve injuries.

Combination of infliximab with thiopurines significantly reduces white cell and neutrophil counts in inflammatory bowel disease patients.

BACKGROUND: The effects of thiopurines on white cell count are well documented. OBJECTIVE: We compared the effects of infliximab 5 mg/kg monotherapy and combination of infliximab with thiopurines on the total and differential white cell count (WBC). METHODS: 13 IBD patients treated with infliximab monotherapy and 18 IBD patients treated with a combination of infliximab and thiopurines were included in the study. Using retrospective data, cell counts were examined prior to induction of infliximab, and at 6 weeks and 1 year post-induction. RESULTS: The patients on combination therapy had an absolute WBC at 52 weeks of 5.7 whereas that of patients on Infliximab monotherapy at the same time point was 8.3 with comparable neutrophil count of 3.4 and 5.4. The results showed a significant reduction in white cell count and neutrophils at 6 weeks which persisted at 52 weeks in both groups (p < 0.05) with a greater drop in patients on combination infliximab and thiopurine (p < 0.05) as compared to Infliximab monotherapy. There was no significant change in the lymphocyte count. CONCLUSION: Full blood counts should be closely monitored in all patients starting infliximab therapy, in particular patients receiving concomitant thiopurines.

Isolated anterior mediastinal tuberculosis in an immunocompetent patient.

BACKGROUND: The differential diagnosis of a mediastinal mass is a common challenge in clinical practice, with a wide range of differential diagnosis to be considered. One of the rarer causes is tuberculosis. Atypical presentations of tuberculosis are well documented in immunocompromised patients, but should also be considered in the immunocompetent. CASE PRESENTATION: This case outlines a previously healthy 22 year-old immunocompetent male presenting with worsening chest pain, positional dyspnea, dry cough and dysphagia. Chest x-ray showed evidence of an isolated anterior mediastinal mass, which was confirmed on computed tomography. A mediastinoscopy was diagnostic as histology revealed necrotizing granulomatous inflammation and the presence of acid-fast bacilli, indicating mediastinal tuberculosis. CONCLUSION: Typically the underlying presentation of mediastinal tuberculosis is mediastinal lymphadenitis. This case was unusual in that we detected an isolated large anterior mediastinal mass accompanied by a relatively small burden of mediastinal lymphadenitis. Cases similar to this have been documented in immunosuppressed patients however in our case no evidence of immunosuppression was found. This case report emphasizes the importance that a detailed and logical pathway of investigation is pursued when encountering a mediastinal mass.

Listeria meningitis complicating a patient with ulcerative colitis on concomitant infliximab and hydrocortisone.

Infliximab, a monoclonal antibody directed against tumour necrosis factor, is an effective therapy for moderate-to-severe ulcerative colitis and Crohn's disease. Uncommonly, serious opportunistic infections have occurred in patients after infliximab administration. Here, we describe meningitis caused by Listeria monocytogenes developing in a 37-year-old man with ulcerative colitis refractory to intravenous corticosteroids 10 days after receiving his first infusion of infliximab. With the increasing use of tumour necrosis factor-α-neutralizing agents, clinicians should be aware of the risk of opportunistic infections caused by L. monocytogenes in patients with inflammatory bowel disease following infliximab treatment. The half-life of infliximab is 9.5 days; therefore, patients tend to be more susceptible in the immediate period following infusion. Patients receiving anti-TNF therapy should be advised to avoid foods such as soft cheeses and unpasteurized dairy products.

Human isolates of Listeria monocytogenes in Sweden during half a century (1958-2010).

Isolates of Listeria monocytogenes (n = 932) isolated in Sweden during 1958-2010 from human patients with invasive listeriosis were characterized by serotyping and pulsed-field gel electrophoresis (PFGE) (AscI). Of the 932 isolates, 183 different PFGE types were identified, of which 83 were each represented by only one isolate. In all, 483 serovar 1/2a isolates were distributed over 114 PFGE types; 90 serovar 1/2b isolates gave 32 PFGE types; 21 serovar 1/2c isolates gave nine PFGE types; three serovar 3b isolates gave one PFGE type; and, 335 serovar 4b isolates gave 31 PFGE types. During the 1980s in Sweden, several serovar 4b cases were associated with the consumption of European raw soft cheese. However, as cheese-production hygiene has improved, the number of 4b cases has decreased. Since 1996, serovar 1/2a has been the dominant L. monocytogenes serovar in human listeriosis in Sweden. Therefore, based on current serovars and PFGE types, an association between human cases of listeriosis and the consumption of vacuum-packed gravad and cold-smoked salmon is suggested.

Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma.

Endoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.

Endoscopic vascular decompression of the trigeminal nerve.

BACKGROUND: Microvascular decompression is an effective method of treatment in trigeminal neuralgia. It may fail if a compressing vessel is overlooked during surgery. The endoscope has an edge over the microscope in visualizing such conflicts. MATERIALS AND METHODS: This is a prospective study of 51 patients. Preoperative computed tomography and magnetic resonance imaging scans were performed in all the cases. A 4 − 5 cm retroauricular skin incision was made and an about 3 cm craniectomy was performed. A 0° 4 mm telescope supported by the holder was used after the dural opening. A 2 by 6 cm sheet prepared from hand gloves was used to protect the brain. A Karl Storz 30° telescope was used for the visualization of the trigeminal nerve from the pons to Meckel's cave and dissection of the anterior conflict. Small pieces of dura patch were interposed between the nerve and the vessel. The microscope was not used at any stage. Post-operative infection, cerebrospinal fluid leak, cranial nerve deficit, failure of procedure in terms of pain relieves and recurrences of pain were recorded. The follow-up period ranged from 24 to 55 months with an average of 36 months. RESULTS: There was no mortality or any major permanent complications. The duration of stay ranged from 3 to 10 days with an average of 3.6 days. The pain was relieved in 48 patients. CONCLUSION: Endoscopic vascular decompression is an effective and safe alternative to endoscopic assisted microvascular decompression in trigeminal neuralgia.

Predictable chronic mild stress improves mood, hippocampal neurogenesis and memory.

Maintenance of neurogenesis in adult hippocampus is important for functions such as mood and memory. As exposure to unpredictable chronic stress (UCS) results in decreased hippocampal neurogenesis, enhanced depressive- and anxiety-like behaviors, and memory dysfunction, it is believed that declined hippocampal neurogenesis mainly underlies the behavioral and cognitive abnormalities after UCS. However, the effects of predictable chronic mild stress (PCMS) such as the routine stress experienced in day-to-day life on functions such as mood, memory and hippocampal neurogenesis are unknown. Using FST and EPM tests on a prototype of adult rats, we demonstrate that PCMS (comprising 5 min of daily restraint stress for 28 days) decreases depressive- and anxiety-like behaviors for prolonged periods. Moreover, we illustrate that decreased depression and anxiety scores after PCMS are associated with ~1.8-fold increase in the production and growth of new neurons in the hippocampus. Additionally, we found that PCMS leads to enhanced memory function in WMT as well as NORT. Collectively, these findings reveal that PCMS is beneficial to adult brain function, which is exemplified by increased hippocampal neurogenesis and improved mood and cognitive function.

Water jet dissection technique for endoscopic third ventriculostomy minimises the risk of bleeding and neurological complications in obstructive hydrocephalus with a thick and opaque third ventricle floor.

BACKGROUND: Endoscopic third ventriculostomy (ETV) is a procedure of choice in the treatment of obstructive hydrocephalus. Neurovascular injury while perforating the ventricular floor can occur when using a conventional probe, especially in patients with a thick and opaque third ventricle floor. The water jet dissection technique can be useful in such cases to perform an initial perforation. PATIENTS/MATERIAL AND METHODS: The water jet dissection technique was used to perform ETV in 36 patients with obstructive hydrocephalus with a thick and opaque third ventricle floor over a 3-year period. A water jet was generated using a syringe connected to a 2-mm catheter. RESULTS: The water jet dissection technique successfully created a patent ETV stoma in 31 patients. 5 patients needed a re-operation due to a blocked stoma. There were no complications related to the procedure. An improvement in clinical function was seen in 28 (83.3%) patients at a median follow-up of 29 months. CONCLUSION: The water jet dissection is a useful technique while performing ETV to prevent neurovascular injury. Our improvised technique of creating a water jet is safe, inexpensive, readily available and can be practiced at any centre performing ETV.

Aging alters properties of the circadian pacemaker controlling the locomotor activity rhythm in males of Drosophila nasuta.

Effects of aging on the circadian rhythm of locomotor activity in males of Drosophila nasuta were investigated. The adult life of males was divided in 1-3 stages according to spontaneous changes in free-running period tau in constant darkness (DD): stage 1, days 1-19; stage 2, days 20-36; stage 3, days 37-43. Stage 1 was characterized by a bimodal activity pattern with a short light-induced morning peak and a prolonged evening peak when the flies were entrained to light-dark cycles of 12 hours of light, 12 hours of darkness (LD 12:12). The morning peak had a phase angle difference psi m (psi, the time from lights on in LD 12:12 cycles to the onset of morning peak) of about 0.1 h, while psi e (psi of evening peak) was about 9 h at stage 1. The transient morning peak was curtailed at the end of stage 1. At stage 2, the psi e was about 10 h, and the activity end was delayed by an addition of about 3 h of activity in the scotophase. The changes in tau during DD free runs were determined in two groups of flies: flies reared in LD 12:12 and flies reared in DD. In both groups, tau increased from about 23 h at stage 1 to about 25 h at stage 2. Stage 3 was characterized by arrhythmicity associated with highest mean activity level (total number of passes/fly/day) in the entrained and both free-running groups. The mean activity level increased significantly from stage 1 to stage 3 in all three groups of flies.