A comparison of methods for increasing compliance within a general practitioner based screening project for colorectal cancer and the effect on practitioner workload.

Screening for colorectal cancer by testing for faecal occult blood (FOBT) is effective for early diagnosis, but the success of a screening programme also depends on compliance. The aims of this study were to assess the effect of health education on compliance and to assess any addition to general practitioner workload that resulted. Altogether 3860 patients were recruited and randomly allocated to test or control group. The test group was further divided into subgroups, some of which received health education. Compliance with FOBT was 54.7% (210/384) in the subgroup receiving only the doctor's letter, which fell to 48.1% (743/1544) in the group receiving health education. General practitioner consultation rates were similar in test and control groups.

Haemoccult screening for colorectal cancer: the effect of dietary restriction on compliance.

The aim of this study was to examine the effect of dietary restrictions on compliance with Haemoccult screening for colorectal carcinoma. One-hundred-and-fifty-three individuals were randomly allocated to perform Haemoccult tests with or without dietary restrictions, over 3 or 6 days. Those who failed to return completed tests within 6 weeks were sent a reminder letter. A small but significant improvement in compliance when testing over a 3-day period has been previously demonstrated but this difference was not seen in this study because of the small sample size. Overall, 72.8% compliance was achieved in those who were not asked to exclude certain foods during the test period compared with 51.8% in those in whom dietary restriction was requested (chi 2 = 7.45, P < 0.01). In a British population compliance with Haemoccult screening is adversely affected by the imposition of dietary restrictions.

An evaluation of Fecatwin/Feca EIA; a faecal occult blood test for detecting colonic neoplasia.

A combination guaiac and immunological test Fecatwin/Feca EIA for the detection of faecal occult blood was used in the investigation of 535 symptomatic patients in order to assess the value of this combined test in the detection of colorectal neoplasia. The addition of the immunological part of the test led to an improvement in specificity for colorectal cancer from 80% to 91% and an increase in the positive predictive value of the test for colorectal cancer from 14% to 24%. However, there was a fall in sensitivity from 75% to 67%. There was no substantial advantage in the addition of the immunological part of the test to justify the extra laboratory workload incurred.

Is dietary restriction always necessary in Haemoccult screening for colorectal neoplasia?

Certain dietary constituents may cause guaiac-based faecal occult blood tests to be positive in the absence of blood loss. In a randomized controlled study of Haemoccult screening for the early detection of colorectal cancer, a policy of retesting with appropriate dietary restriction is used to minimize false-positive results. Delay associated with the retesting protocol may cause considerable anxiety. The aim of the study was to determine the likelihood of an initial positive result remaining positive after retesting. One-hundred-and-thirteen of 137 (35.6%) subjects whose initial test was < 5 squares positive remained positive in contrast to 52/59 (88.1%) with > or = 5 squares positive, a significantly higher proportion (P < 0.001). This suggests that if five or more test squares are positive, then dietary interference is unlikely to be responsible. We conclude that, if dietary restriction retesting is practiced, individuals with strongly positive tests may be offered investigation without retesting, thus reducing their delay to further investigation.

Hepatic perfusion index in the diagnosis of overt metastatic colorectal cancer.

The hepatic perfusion index (HPI) was measured in 180 patients with colorectal cancer: 109 with primary colorectal cancer, 38 with suspected recurrent colorectal cancer and 33 following curative resection of colorectal cancer. In 21 patients with proven metastatic disease serial imaging studies were performed. HPI was determined using the peak of the left kidney time-activity curve to define the division of arterial and portal blood flow. HPI was elevated (greater than 0.37) in 54 of 115 patients (47%) with no evidence of hepatic metastases, 17 of 27 patients (63%) with hepatic metastases at initial presentation and 21 of 25 (84%) with metastatic disease detected during follow-up. Only 4 of 13 patients (31%) with local recurrence but no evidence of liver metastases had an elevated HPI. Serial imaging of patients with metastatic liver disease demonstrated a rising HPI with clinical disease progression in 18 of 21 patients (86%). This study confirms the association of an elevated HPI with hepatic metastases and suggests that a rising HPI in serial studies is associated with progression of disease but highlights the deficiency of one single HPI estimation in the identification of patients with overt hepatic metastases.

Pathology of experimental mycoplasmosis in American alligators.

Mycoplasma alligatoris was the suspected etiology of an epidemic of acute multisystemic inflammatory disease which emerged in captive American alligators (Alligator mississippiensis) in Florida (USA) in 1995. In an experimental inoculation study conducted from April through October 1999, 18 alligators were inoculated with 10(2), 10(4), or 10(6) colony forming units (CFU) of M. alligatoris by instillation into the glottis. As early as 1 wk post-inoculation (PI), mycoplasma were cultured from blood of three of six alligators inoculated with 10(6) CFU. Two of those died and the third was euthanatized within 4 wk PI. Necropsy gross findings included fibrinous polyserositis and polyarthritis. Histopathologic changes in affected individuals included pulmonary edema, interstitial pneumonia, pericarditis, myocarditis, meningitis, and synovitis. Mycoplasma were cultured quantitatively in high numbers from trachea, lung, coelomic cavity, liver, spleen, interior of pericardial sac, heart, blood, brain, and limb joints. In alligators inoculated with 10(6) CFU, heterophilia and moderate hyperglycemia peaked about 4 wk PI, and seroconversion occurred by 6 to 8 wk PI. Necropsy gross and histologic findings were generally unremarkable for the surviving alligators inoculated with 10(6) CFU, alligators inoculated with 10(2) or 10(4) CFU, and four uninoculated control alligators. Mycoplasma were not cultured at any time point from those alligators. The findings confirm that M. alligatoris can cause fulminant inflammatory disease and rapid death of alligators.

Marsupial, insectivore, and chiropteran anesthesia.

This article covers the manual restraint and anesthesia of marsupials, insectivores, and chiroptera. Marsupials commonly kept as pets in the U.S. [e.g., eastern gray kangaroos (Macropus giganteus), Bennett's wallabies (Macropus rufogriseus), and sugar gliders (Petaurus breviceps)] are covered in detail. Marsupial species kept in zoological parks [e.g., Tasmanian devils, koalas (Phascolarctos cinereus), and common wombats (Vombatus ursinus)] are covered in less detail. Of the insectivores, only the African hedgehog (Atelerix albiventris) and the European hedgehog (Erinaceus europaeus) are commonly kept as pets and, consequently, the insectivore section concentrates on discussing these two species. The section on chiropteran anesthesia is divided into two broad categories: the megachiropterans (flying foxes and fruit bats) and the microchiropterans (insectivorous bats). Most of the information on the species covered in this article is anecdotal, and this should be kept in mind when using the anesthesia protocols described.

Surgery of the avian respiratory system.

The avian respiratory system is different from that of mammals. Although some surgical techniques can be adapted from those used in mammals, many are unique to avian patients (e.g., choanal atresia correction and air sac cannulation). This article reviews the common surgeries of the upper and lower respiratory systems and describes surgical techniques for the treatment of chronic sinusitis and cranial coelomic mass removal.

Thoracic vertebral chordoma in a domestic ferret (Mustela putorius furo).

A castrated adult male 1.0-kg domestic ferret (Mustela putorius furo) was referred for evaluation of a mass of >5 mo duration that was associated with the thoracic spine. The ferret had motor dysfunction and no conscious proprioception or pain perception in either hind limb. Segmental reflexes were present. Survey radiography, myelography, and magnetic resonance imaging showed a mass involving the ninth and 10 thoracic vertebrae and compressing the spinal cord. Decompressive surgery was performed, but clinical signs persisted. A diagnosis of chordoma was made using histopathology and immunohistochemistry. This is the first reported case of a chordoma involving the thoracic vertebrae in a domestic ferret.

Experimental inoculation of broad-nosed caimans (Caiman latirostris) and Siamese crocodiles (Crocodylus siamensis) with Mycoplasma alligatoris.

An outbreak of mycoplasmosis caused by Mycoplasma alligatoris resulted in the death or euthanasia of 60 American alligators (Alligator mississippiensis) from a population of 74 captive bull alligators in Florida in 1995. The natural reservoir, routes of transmission, and host range of M. alligatoris are unknown. This study was undertaken to determine whether crocodilian species other than American alligators are susceptible to M. alligatoris. Six broad-nosed caimans (Caiman latirostris) and six Siamese crocodiles (Crocodylus siamensis) were experimentally inoculated with 10(6) colony forming units (CFU) of M. alligatoris instilled through the glottis. Two caimans and two crocodiles were used as negative controls. Six and four American alligators were used as positive and negative controls, respectively. Three of six (50%) inoculated caimans died within 10 wk postinoculation (PI) of severe mycoplasmosis. Gross necropsy, histopathologic, and culture results were similar for broad-nosed caimans and American alligators. None of the inoculated Siamese crocodiles developed mycoplasmosis, though M. alligatoris was isolated from the tonsils in three of six (50%) animals at necropsy. All the inoculated crocodilians that survived showed significant seroconversion by 6-8-wk PI (P < 0.05). The infective dose 50% (ID50) and lethal dose 50% (LD50) of M. alligatoris for the broad-nosed caiman are 10(6) CFU when instilled through the glottis, which is similar to that of the American alligator. Although the host range of M. alligatoris is not restricted to the American alligator, the organism does not appear to be pathogenic for Siamese crocodiles. Other species of crocodilians may be susceptible to infection with M. alligatoris, and this organism should be considered when the rapid onset of clinical signs of pneumonia, polyarthritis, pericarditis, and death occur.

T-cell-rich B-cell lymphoma in a ring-tailed lemur (Lemur catta).

A 13-yr-old ring-tailed lemur (Lemur catta) was evaluated for depression, anorexia, polyuria, and polydipsia. The lemur was in poor body condition and was anemic, hypoalbuminemic, and hyponatremic. Cytologic examination of aspirates of the spleen, liver, and bone marrow and histopathologic examination of liver and bone marrow biopsies revealed a disseminated round cell tumor. After euthanasia, necropsy revealed hepatomegaly, splenomegaly, and mesenteric lymphadenomegaly. Neoplastic cells were present within the spleen, liver, kidneys, multiple lymph nodes, bone marrow, lung, small intestine, pancreas, and testicle and were composed of large anaplastic round cells in a background of small well-differentiated lymphocytes. Immunohistochemical analysis revealed that the small well-differentiated lymphocytes labeled for the anti-human T-cell marker, CD3, and the large anaplastic round cells labeled with the anti-human B-cell marker, CD79a. On the basis of the immunohistochemical staining results and morphologic appearance, a diagnosis of a T-cell-rich B-cell lymphoma was made.

Screening for colorectal cancer: a critical review.

This article discusses the place of symptom detection, endoscopy, and fecal occult blood testing in population screening for colorectal cancer. There is now considerable evidence that screening the population over the age of 50 years for occult blood in the feces will result in an increased yield of tumors localized to the bowel at the time of surgical treatment. These tumors also have other favorable prognostic features and it is likely that the prognosis of this group will be better than the prognosis of patients presenting with symptoms in the usual way. Because of the biases that result from the selection and detection of tumors in screening studies, the mortality results of the control trials now underway must be awaited until it is known whether population screening is of real value. In chemical fecal occult blood screening tests, a compromise has to be made between sensitivity and specificity. The fecal occult blood test most widely used and the one that has been subjected to the most evaluation in screening studies is the guaiac-based slide test, Hemoccult. The predictive value of a positive test for invasive cancer is 11-17%, and for adenomas, 36-41%. This specificity is achieved at a loss of sensitivity, the interval cancer rate reported in screening studies being over 20%. Newly developed immunological techniques appear to be more sensitive and specific, but require further evaluation in population screening studies.

Anastomoses involving the colon and rectum: an 8-year experience.

From January 1987 to May 1995, 214 anastomoses involving the rectum or colon were fashioned using single-layer, interrupted serosubmucosal 3/0 braided polyamide. There were six deaths, one clinically evident anastomotic leak, and one wound infection. These results lend further support to the use of a single layer of serosubmucosal sutures for anastomoses involving the colon and rectum.

Screening for colorectal carcinoma: an analysis of the sensitivity of haemoccult.

The sensitivity of Haemoccult for asymptomatic colorectal carcinoma has been estimated in a large randomized controlled trial of mass population screening, with a minimum follow-up of 2 years. A total of 111 cancers were diagnosed in those who completed the screening tests; of these, 36 appear to have been missed by Haemoccult and 75 were detected by the test, giving an overall sensitivity of 67.6 per cent. Haemoccult was shown to be significantly more sensitive for carcinoma of the sigmoid and descending colon than for rectal or right-sided cancers (81 versus 45 and 47 per cent, respectively). The sensitivity was higher when tests were completed over 6 rather than 3 days (74 versus 65 per cent), but this difference was not statistically significant. There was no evidence for a detrimental effect on tumour stage of a false-negative Haemoccult test; indeed, a higher proportion of the interval cancers were Dukes' A tumours than cancers in the control group.

Epidemiological study of asymptomatic inflammatory bowel disease: the identification of cases during a screening programme for colorectal cancer.

An asymptomatic population of 37,000 people in the Nottingham area were offered faecal occult blood tests in a screening study for colorectal cancer. Seventeen thousand nine hundred and thirty people completed the tests and 481 individuals with positive tests underwent full investigation of the colon. Eight people with previously undiagnosed inflammatory bowel disease were identified. In five cases there was total ulcerative colitis; in one a proctitis and in two Crohn's disease. Two further patients with ulcerative colitis were identified; they had been lost to follow up for 25 and 45 years respectively. The combined prevalence of inflammatory bowel disease was 56/10(5) and it is likely that current studies of the epidemiology of these conditions may underestimate the true prevalence by between 27% and 38%.

Screening and the costs of treating colorectal cancer: some preliminary results.

This paper describes a hospital costing analysis of 85 colorectal cancer patients treated in the context of a randomised control trial at the Queen's Medical Centre, Nottingham. Estimates are presented for investigation, surgical and inpatients costs. Comparisons between study and control group patients reveal only a small difference in overall costs of treatment.