Squamous cell carcinoma arising from long‐standing perianal fistula

Perianal fistula is a very common problem in general population. Ninety percent of perianal fistulae arise from infected anal glands, and they often give rise to perianal abscesses. Very rarely perianal fistulae and abscesses undergo malignant transformation and give rise to carcinomas, mainly adenocarcinomas. We are reporting a case of squamous cell carcinoma arising from long‐standing perianal fistula and how we managed it surgically.     

Acute maternal stress in pregnancy and schizophrenia in offspring: A cohort prospective study

Background

The Mental Health Inventory (MHI-5) and the Mental Health Component Summary score (MCS) derived from the Short Form 36 (SF-36) instrument are well validated and reliable scales. A drawback of their construction is that neither has a clinically validated cutpoint to define a case of common mental disorder (CMD). This paper aims to produce cutpoints for the MHI-5 and MCS by comparison with the General Health Questionnaire (GHQ-12).

Methods

Data were analysed from wave 9 of the British Household Panel Survey (2000), providing a sample size of 14,669 individuals. Receiver Operating Characteristic (ROC) curves were used to compare the scales and define cutpoints for the MHI-5 and MCS, using the following optimisation criteria: the Youden Index, the point closest to (0,1) on the ROC curve, minimising the misclassification rate, the minimax method, and prevalence matching.

Results

For the MHI-5, the Youden Index and the (0,1) methods both gave a cutpoint of 76, minimising the misclassification rate gave a cutpoint of 60 and the minimax method and prevalence matching gave a cutpoint of 68. For the MCS, the Youden Index and the (0,1) methods gave cutpoints of 51.7 and 52.1 respectively, minimising the error rate gave a cutpoint of 44.8 and both the minimax method and prevalence matching gave a cutpoint of 48.9. The correlation between the MHI-5 and the MCS was 0.88.

Conclusion

The Youden Index and (0,1) methods are most suitable for determining a cutpoint for the MHI-5, since they are least dependent on population prevalence. The choice of method is dependent on the intended application. The MHI-5 performs remarkably well against the longer MCS.     

Complications from permanent hemodialysis vascular access

From 1981 to 1986 a total of 499 operations were performed for permanent hemodialysis vascular access in 230 patients. At least 1 year's follow-up was achieved in all cases. This series is divided into 326 primary procedures and 173 secondary procedures. Of the primary procedures, there were 160 autogenous fistulas and 166 expanded polytetrafluoroethylene (PTFE) fistulas. The 156 secondary procedures consisted of 124 thrombectomies, 20 repairs of pseudoaneurysm, 12 fistula ligations, and 17 fistula excisions. The infectious complication rate (29/482) was 6%. Mean length of patency was 3.1 years for autogenous wrist fistula, 2.6 years for elbow fistula, 1.9 years for forearm loop PTFE, 2.1 years for straight forearm PTFE, 1.6 years for femoral popliteal PTFE, and 1.4 years for femoral arteriovenous loop PTFE. A vascular steal syndrome occurred in 8% of patients with autogenous elbow fistulas (4/48), compared with 1.7% (2/112) of patients with wrist fistulas and 1.8% (3/166) of those with PTFE fistulas. All infected fistulas required excision, and all fistulas associated with the steal syndrome required ligation. Use of PTFE to construct permanent hemodialysis vascular access has a significantly higher incidence of thrombosis, infection, pseudoaneurysm formation, and limb loss (p less than 0.01 for all complications) and a significantly lower mean length of patency (p less than 0.0001) when compared with autogenous fistulas. Age, sex, hypertension, diabetes mellitus, and the use of perioperative antibiotics were not found to be related significantly to access complications.