Search

Summary Background Whole-body magnetic resonance imaging (WB-MRI) could be an alternative to multi-modality staging of non-small-cell lung cancer (NSCLC), but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in NSCLC. Methods The Streamline L trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed NSCLC that was potentially radically treatable on diagnostic chest CT (defined as stage IIIb or less). Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or histologies other than NSCLC. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs) and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN50436483, and is complete. Findings Between Feb 26, 2013, and Sept 5, 2016, 976 patients were screened for eligibility. 353 patients were recruited, 187 of whom completed the trial; 52 (28%) had metastasis at baseline. Pathway sensitivity was 50% (95% CI 37–63) for WB-MRI and 54% (41–67) for standard pathways, a difference of 4% (−7 to 15, p=0·73). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (93% [88–96]) and standard pathways (95% [91–98], p=0·45). Agreement with the multidisciplinary team's final treatment decision was 98% for WB-MRI and 99% for the standard pathway. Time to complete staging was shorter for WB-MRI (13 days [12–14]) than for the standard pathway (19 days [17–21]); a 6-day (4–8) difference. The number of tests required was similar WB-MRI (one [1–1]) and standard pathways (one [1–2]). Mean per-patient costs were £317 (273–361) for WBI-MRI and £620 (574–666) for standard pathways. Interpretation WB-MRI staging pathways have similar accuracy to standard pathways, and reduce the staging time and costs. Funding UK National Institute for Health Research.

Background EMR has been well accepted as one of the management options for superficial colorectal tumours requiring minimal invasion, better patient tolerance and significantly lower morbidity compared to surgery. However, lesions≥20 mm can be tricky. Method Retrospective medical record analysis was performed for a period of 24 months between Jan 2015 – Dec 2016. The data was collected on patient demographics, polyp characteristics, complications and follow up endoscopy at the 3 months and 12 months intervals where applicable. Results A total of 212 patients had 264 procedures. The mean age of the population was 68. All of the procedures were performed by experienced endoscopists using hot/cold snare and Methylene blue/Volplex solution. 22 (8%) of all polypectomies were ≥40 mm in size. The rate of complications in accordance with polyp size and colonic sites are illustrated below (table 1 and 2). The perforation was managed with endoclips and required a day of admission. The immediate bleeding had been managed with clipping ±adrenaline injection. The overall 30 days mortality was zero. 9 (4%) patients had prophylactic endoclips. The adenocarcinoma detection rate was 2.8% (6) and all of them had had either repeat scope at the 3 and 12 months intervals or had surgery. 12 (5.6%) had tubular/tubulovillous adenoma with high grade dysplasia. 8 (66%) of these patients had repeat scope at 3 months, whilst 1 (8%) underwent surgery and 3 (25%) made an informed choice to not have further colonoscopic examination. Our rescope rate for the polyp size ≥20 mm at 3 months and 12 months was 69% and 78% respectively. The main reasons for not having the scope were either patient choice or having surgery/other forms of cancer treatment. Conclusions EMR is an effective and safe approach in the expert hands for the management of colonic polyps. The role of prophylactic endoclips is still unclear in reducing the risk of post-procedural bleeding and it is highly dependent on the operator’s preference and experience. Total character count 2817.

Numerous surgical options exist for the correction of rectal prolapse, with the optimal choice remaining controversial. The laparoscopic approach has proved to be popular and effective. Concern exists about nonresectional rectopexy in the form of intractable postoperative constipation. The authors present their experience with nonresectional laparoscopic suture rectopexy. All patients presenting with a full-thickness rectal prolapse between August 1994 and August 2009 who proved to be fit for a general anesthesia were offered a laparoscopic repair. Data were entered into a database, then prospectively and retrospectively analyzed. The data recorded included patient demographics, preoperative symptoms, conversion to open procedure, length of hospital stay, and postoperative complications. Preoperative Cleveland Clinic Incontinence Scores (CCIS) were calculated. Follow-up evaluation was by telephone questionnaire. Postoperative constipation, recurrence, and CCIS were noted. The series included 72 patients (71 women, 98%) with a median age of 72 years (range, 24–88 years). The median follow-up period was 48 months (range, 5–144 months). A total of 13 patients were lost to follow-up evaluation. The median operating time was 98 min (range, 35–200 min), and the median hospital stay was 2 days (range, 1–29 days). Three conversions to open procedure (5%) were performed. The median preoperative CCIS was 9.54 compared with 4.44 postoperatively (p = 0.024). The complications included one postoperative bleed requiring transfusion, one port-site abscess requiring incision and drainage, one postoperative retention of urine, and one chest infection. Postoperatively, 10 patients (17%) reported occasional constipation not requiring intervention, and an additional 10 patients (17%) reported more severe constipation, all managed successfully with regular laxatives. The patients followed up experienced six recurrences (9%). No postoperative deaths occurred. Laparoscopic abdominal suture rectopexy without resection is safe and effective for the treatment of full-thickness rectal prolapse.

The diagnosis of premalignant conditions of the anus remains a challenge, in particular differentiating between lesions which have a malignant potential and those which are of no concern. The use of anal cytology and high-resolution anoscopy (HRA) has helped to diagnose clinically suspicious lesions. In addition, HRA allows biopsy and treatment of clinically suspicious lesions. These investigations can be used to screen high-risk patients, such as HIV-positive men who have sex with men. The human papillomavirus is implicated in the aetiology of many premalignant lesions, and vaccination against it in at-risk populations may reduce the prevalence of these lesions.

A patient with genetic hemachromatosis presented with a clinical picture suggesting malignancy and CT evidence of lesions in the right colon and liver. Colonoscopy failed to confirm the suspected diagnosis. Blood and stool cultures were positive for yersinia enterocolittica infection. This case illustrates the need to confirm clinically and radiologically suspected malignancy. It also serves as a model of how localized gastrointestinal pathology can result from the interaction of host genetic factors and specific microbial species.

Electromyographic biofeedback therapy has demonstrated subjective improvement in patients with fecal incontinence that is comparable to surgery. We assessed the efficacy of biofeedback therapy in a consecutive heterogeneous group of patients using both subjective and objective assessment criteria. These 28 patients with fecal incontinence were studied retrospectively. Patients were assessed using a quality-of-life questionnaire (QOL), the Vaizey and Wexner incontinence scoring systems, and anorectal manometry for efficacy of treatment, before and after biofeedback therapy. Eighty-six percent of patients completed the study. Median follow-up was 18 months. Eighty percent of patients demonstrated significant improvements in their Vaizey and Wexner scores (P

Monkeys infected with the Asibi strain of yellow fever virus developed multiple coagulation abnormalities 3-4 days after viral inoculation. These coagulation abnormalities occurred almost simultaneously with the development of fever, clinical illness and pathologic changes in the liver. The haemorrhagic manifestation of yellow fever and the rapid development of multiple coagulation abnormalities cannot be explained solely by impaired production of coagulation proteins and suggested that there was accelerated intravascular coagulation. Heparin therapy in one group of infected animals decreased the severity of coagulation abnormalities but did not prolong the life of these animals.