Proximal and distal rectal cancers differ in curative resectability and local recurrence

AIM: To evaluate patients with proximal rectal cancer (PRC) (> 6 cm up to 12 cm) and distal rectal cancer (DRC) (0 to 6 cm from the anal verge). METHODS: Two hundred and eighteen patients (120 male, 98 female, median age 58 years, range 19-88 years) comprised 100 with PRC and 118 with DRC. The proportion of T1, T2 vs T3, T4 stage cancers was similar in both groups (PRC: T1+T2 = 29%; T3+T4 = 71% and DRC: T1+T2 = -31%; T3+T4 = 69%). All patients had cancer confined to the rectum -those with synchronous distant metastasis were excluded. Surgical resection was with curative intent with or without pre-operative chemoradiation (c-RT). Follow-up was for a median of 35 mo (range: 12 to 126 mo). End points were: 30 d mortality, complications of operation, microscopic tumour-free margins, resection with a tumour-free circumferential margin (CRM) of 1 to 2 mm and > 2 mm, local recurrence, survival and the permanent stoma rate. RESULTS: Overall 30-d mortality was 6% (12): PRC 7 % and DRC 4%. Postoperative complications occurred in 14% with PRC compared with 21.5% with DRC, urinary retention was the complication most frequently reported (PRC 2% vs DRC 9%, P = 0.04). Twelve percent with PRC compared with 37% with DRC were subjected to preoperative c-RT (P = 0.03). A tumour-free CRM of 1 to 2 mm and > 2 mm was reported in 93% and 82% with PRC and 88% and 75% with DRC respectively (PRC vs DRC, P > 0.05). However, local recurrence was 5% for PRC vs 11% for DRC (P < 0.001). Three and five years survival was 65.6% and 60.2% for PRC vs 67% and 64.3% for DRC respectively. No patient with PRC and 23 (20%) with DRC received an abdomino-perineal resection. CONCLUSION: PRC and DRC differ in the rate of abdomino-perineal resection, post-operative urinary retention and local recurrence. Survival in both groups was similar.     

Use of direct observed therapy to confirm compliance in a warfarin clinic

Anticoagulation therapy poses multiple risks to patients and contributes to thousands of health-care dollars in treating complications. These risks have been shown to decrease when patients are monitored in a warfarin clinic. Even in the setting of a warfarin clinic, complications can occur, most of which are related to patient compliance. Warfarin clinics have limited options for addressing issues of compliance. Direct observed therapy is a technique that warfarin clinics can use to highlight issue of noncompliance to more safely manage patients on warfarin. A short course of direct observed therapy is a feasible method to confirm compliance with anticoagulation medication. Direct observed therapy allows providers to adjust medication based on real data and not just patient statements of compliance. Direct observed therapy also allows providers to confront patients with tangible evidence of noncompliance that cannot be refuted.     

Isolation and mapping of plasmids containing the Salmonella typhimurium origin of DNA replication.

A purified EcoRI restriction endonuclease fragment that determines resistance to kanamycin and is incapable of self-replication was used to select autonomously replicating fragments from an EcoRI digest of a Salmonella typhimurium F' plasmid containing the chromosomal region believed to include the S. typhimurium origin of DNA replication. Both the F factor and S. typhimurium chromosome replication origins were cloned by this procedure. The EcoRI fragmentment containing the S. typhimurium origin of replication is 19.4 kilobase pairs long and includes functional asp+ and uncB+ genes. Restriction endonuclease analysis of deletions obtained from the S. typhimurium origin plasmid indicated that the replication origin (ori region) is contained within a 3.3-kilobase pair region. Comparison with Escherichia coli origin plasmids shows colinearity of gene arrangement on the chromosomes in this region and suggests that some, but not all, regions of the nucleotide sequence in the origin region may be conserved (identical) in these two bacterial species.     

Bundled Payment “Creep”: Institutional Redesign for Primary Arthroplasty Positively Affects Revision Arthroplasty

Background

Revision total joint arthroplasty (TJA) is associated with increased readmissions, complications, and expense compared to primary TJA. Bundled payment methods have been used to improve value of care in primary TJA, but little is known of their impact in revision TJA patients. The purpose of this study is to evaluate the impact of a care redesign for a bundled payment model for primary TJA on quality metrics for revision patients, despite absence of a targeted intervention for revisions.

Symptoms of 100 patients with electromyographically verified carpal tunnel syndrome.

To determine the symptoms of carpal tunnel syndrome (CTS), screening evaluations were performed in 244 consecutive patients with sensory symptoms in the hand and unequivocal slowing of median nerve conduction at the wrist. This yielded 100 patients thought to have no explanation other than CTS for their upper limb complaints. These patients completed a hand symptom diagram (HSD) and questionnaire (HSQ) about their symptoms. CTS symptoms were most commonly reported in median and ulnar digits, followed by median digits only and a glove distribution. Unusual sensory patterns were reported by some patients. Based on the HSQ, paresthesias or pain proximal to the wrist occurred in 36.5% of hands. The usefulness of the HSD and HSQ for diagnosis was determined by asking three physicians, blinded to the diagnosis, to rate the likelihood of CTS in the patients with CTS and in 50 patients with other causes of upper extremity paresthesia. The sensitivities of the instruments ranged from 54.1% to 85.5%. Combining the HSD and HSQ ratings increased the range of sensitivities to 79.3% to 93.7%.     

Radiation-induced DNA double-strand breaks and rejoining in malignant glioma cells.

PURPOSE: This study was performed to standardize experimental conditions for the quantification by pulsed-field gel electrophoresis (PFGE) of radiation-induced DNA double-strand breaks (dsb) and rejoining in a human malignant brain tumour xenograft model. MATERIALS AND METHODS: Because no correlation was found between DNA dsb induction or rejoining and clinical radiation response for six fresh glioblastoma (GBM) specimens, assay conditions were examined in detail. SF-767 human GBM cells were implanted into the flanks of athymic mice. Resulting tumours were irradiated in vivo, dissociated mechanically or using an enzyme cocktail, and assayed for DNA dsb induction and repair. In other experiments, excised tumour portions were irradiated and allowed to repair either as chunks (>50 mm3 pieces), as minced tumour (approximately 1 mm3 pieces), or as single-cell suspensions. Finally, the effect of holding excised tumours in vitro for times of up to 72 h before irradiation and assay for DNA dsb and cell survival was studied. RESULTS AND CONCLUSIONS: The method of tumour dissociation had no effect on results; however, both the configuration of specimens during irradiation and the in vitro maintenance time markedly affected the experimental outcome. Chunks irradiated in vitro had DNA dsb results that were very similar to those obtained when tumours were irradiated in situ, while minced pieces or single-cell suspensions resulted in steeper dose-response curves. When tumour chunks were maintained at 4 degrees C in medium, DNA dsb induction was not affected for 24 h and DNA dsb rejoining remained constant for 48 h but then decreased. Cell survival, however, decreased continually during the 72 h in vitro maintenance time.