Screening practices of patients presenting for resection of a colorectal neoplasm

Multiple studies demonstrate the efficacy of colorectal cancer (CRC) screening in patients over 50 years of age. However, there is a lack of consensus regarding which screening method to use, and compliance has been poor. The objective of this study was to identify the CRC screening practices at two institutions and determine the relationship between screening and pathologic stage for patients presenting with a colorectal neoplasm. This study, conducted at the University of Virginia (UVA) Health System and the Salem Veterans Affairs Medical Center (VAMC) between October 30, 2000, and September 1, 2004, included 198 patients > or = 50 years who presented for resection of a primary colorectal neoplasm. Pathologic stage and prior screening were identified retrospectively through chart review and patient response to an anonymous survey. Prior screening was demonstrated in 71 per cent of patients. Colonoscopy was the most commonly used modality. There was a higher percentage of CRC screening at VAMC compared with UVA (80% vs 62%, P < 0.0008). Patients at UVA were more likely screened with colonoscopy, whereas fecal occult blood testing (FOBT) was most common at VAMC (P < 0.0001). Prior CRC screening and cancer stage were inversely related. Ninety-one per cent of patients with benign polyps had been screened prior to diagnosis, compared with 72 per cent of patients with stage I and II cancer and 54 per cent of patients with stage III and IV cancer (P < 0.05). Of patients presenting for surgery, 71 per cent underwent CRC screening. Variability exists in the methods employed for CRC screening. CRC screening facilitates diagnosis at an early stage.     

Simultaneous pancreas-kidney transplantation from donation after cardiac death: successful long-term outcomes

OBJECTIVE: The outcomes of simultaneous pancreas-kidney (SPK) transplantation with donor organs procured from donation after cardiac death (DCD) are compared with transplants performed with donor organs recovered from donation after brain death (DBD). SUMMARY BACKGROUND DATA: Concerns exist regarding the utilization of pancreata obtained from DCD donors. While it is known that DCD kidneys will have a higher rate of DGF, long-term functional graft survival data for DCD pancreata have not been reported. METHODS: A retrospective review of all DCD SPK transplants performed at a single center was undertaken. RESULTS: Patient, pancreas, and kidney survival at 5 years were similar between DCD and DBD organs. Pancreas function and outcomes were indistinguishable between the 2 modes of procurement. As expected, the DCD kidneys had an elevated rate of DGF, which had no significant long-term clinical impact. CONCLUSION: SPK transplantation using selected DCD donors is a safe and viable method to expand the organ pool for transplantation.     

Managing an acute pain crisis in a patient with advanced cancer: "this is as much of a crisis as a code"

Natalie Moryl, MD; Nessa Coyle, NP, PhD; Kathleen M. Foley, MD

JAMA. 2008;299(12):1457-1467.

The assessment and management of an acute pain crisis in the setting of advanced illness is challenging. Using the case of Mr X, a 33-year-old man with advanced metastatic mucinous adenocarcinoma of the appendix and "15 out of 10" pain, we explore the issues of acute pain and its management. We define a pain crisis as an event in which the patient reports pain that is severe, uncontrolled, and causing distress for the patient, family members, or both. Our management strategy focuses on making a pain diagnosis, differentiating reversible from intractable causes of pain, and making decisions about further workup; selecting the opioid and monitoring and treating opioid adverse effects; titrating and rotating opioid and coanalgesics; consulting experts to treat a pain crisis as quickly as possible to prevent unnecessary suffering; and co-opting the available institutional resources. The timely intervention of a palliative care team and its expertise can provide the staff, patients, and their families the benefit of an interdisciplinary approach and help the patients address goals of care; understand the benefits and risks of treatment decisions; and meet the psychological, social, and existential needs of the patient and the family commonly seen in this setting.

     

Role for interleukin-1 (IL-1) in benzene-induced hematotoxicity: inhibition of conversion of pre-IL-1 alpha to mature cytokine in murine macrophages by hydroquinone and prevention of benzene-induced hematotoxicity in mice by IL-1 alpha

Chronic exposure of humans to benzene (BZ), a myelotoxin, causes aplastic anemia and acute leukemia. The stromal macrophage that produces interleukin-1 (IL-1), a cytokine essential for hematopoiesis, is a target of BZ's toxicity. Monocyte dysfunction and decreased IL-1 production have been shown to be involved in aplastic anemia in humans. Hydroquinone (HQ), a toxic bone marrow (BM) metabolite of BZ, causes time- and concentration-dependent inhibition of processing of the 34-Kd pre-interleukin-1 alpha (IL-1 alpha) to the 17-Kd mature cytokine in murine P388D1 macrophages and BM stromal macrophages, as measured by Western immunoblots of cell lysate proteins using a polyclonal rabbit antimurine IL-1 alpha antibody. HQ over a 10-fold concentration range had no effect on the lipopolysaccharide (LPS)-induced production of pre- IL-1 alpha precursor or on cell viability or DNA and protein synthesis. Stromal macrophages obtained from the femoral BM of C57Bl/6 mice exposed to BZ (600 or 800 mg/kg body weight) for 2 days were incapable of processing the 34-Kd pre-IL-1 alpha to the mature 17-Kd cytokine when stimulated in culture with LPS. Stromal macrophages from mice coadministered BZ and indomethacin, a prostaglandin H synthase (PHS) inhibitor that has been shown to prevent BZ-induced myelotoxic and genotoxic effects in mice when coadministered with benzene were able to convert the pre-IL-1 alpha to mature cytokine. Administration of recombinant murine IL-1 alpha (rMuIL-1 alpha) to mice before a dose of BZ that causes severe depression of BM cellularity completely prevents BM depression, most probably by bypassing the inability of the stromal macrophage in BZ-treated animals to process pre-IL-1 alpha to the mature cytokine.     

Acquired cystic kidney disease in children undergoing long-term dialysis

Acquired cystic kidney disease (ACKD) occurs in adult patients undergoing long-term dialysis. Early detection is important because clinically significant hematuria and malignancies are associated with ACKD. We evaluated by magnetic resonance imaging (MRI) and ultrasonography (US) the incidence of ACKD in 15 patients aged 7.3–21.6 years (mean 15.9 years) with non-cystic primary renal disease. Nine patients had been treated with peritoneal dialysis only, and 6 with both hemodialysis and peritoneal dialysis for 24–73 months (mean 37 months). Three patients (20%) had no cysts. In 5 patients (33%) with bilateral multiple cysts, the diagnosis of ACKD was made by MRI and US. In another 5 patients, solitary cysts were localized to one kidney by MRI, and in 2 patients solitary cysts were seen in both kidneys. This study documents that ACKD is not limited to older patients with end-stage renal disease. Early detection of these cysts can be accomplished by MRI and is warranted since 1 patient developed neoplastic tubular changes which can precede tumor formation.     

The risk of nursing home admission in three communities

Beginning in 1982, the 3-year incidence of nursing home admission was determined for community-dwelling residents aged 65 and over in East Boston, Massachusetts (4%); New Haven, Connecticut (9%); and Iowa and Washington Counties, Iowa (12%). A common methodology was used to collect baseline risk factor and follow-up data on nursing home admissions among persons in each community as part of the National Institute on Aging's Established Populations for Epidemiologic Studies of the Elderly. A multivariate logistic regression model of baseline risk factors that included the participant's age, race, sex, history of prior admission, ADL limitations, cognitive function, living arrangements, and level of income predicted 80% of the users in each community.