Subsequent Surveillance Research Articles

Oncologic surveillance for subjects with biallelic mismatch repair gene mutations: 10 year follow‐up of a kindred

Heterozygous germline mutations in DNA mismatch repair (MMR) genes cause Lynch syndrome. Biallelic MMR mutations cause a distinct syndrome characterized by brain tumors, lymphoid malignancies, and gastrointestinal cancers during childhood. These children usually succumb to multiple cancers before adulthood. We developed a surveillance protocol aiming at early detection for these individuals and report the 10-year experience with a kindred. On the basis of genetic testing and early age tumors, the kindred started a cancer surveillance protocol based on the crude estimates of cancer risks and available cancer screening: imaging, endoscopy, and hematologic tests. Over the 10-year follow-up period, the screening protocol detected 15 tumors. These included three high-grade adenomatous colonic polyps and two colon cancers. In one child, MRI revealed an asymptomatic anaplastic astrocytoma which was treated by complete resection and radiation. All three cancers identified during surveillance were small and asymptomatic at diagnosis. The two sisters are currently 16 and 18 years of age with no evidence of malignant disease. Both parents have annual colonoscopies and the father at 43 years had two colonic adenomatous polyps. We report on the long-term outcome in patients with biallelic MMR mutations who benefited from prophylactic cancer surveillance. Genetic screening and subsequent surveillance led to earlier recognition of asymptomatic tumors at stages more amenable to resection and probable cure. Multicenter collaboration and implementation of surveillance guidelines is necessary to further determine genotype-phenotype correlations.

The impact of a cancer Survivorship Care Plan on gynecological cancer patient and health care provider reported outcomes (ROGY Care): study protocol for a pragmatic cluster randomized controlled trial

BackgroundThere is a need for improvement of information provision and post-treatment care for cancer survivors. A Survivorship Care Plan (SCP) is recommended by the American Institute of Medicine and the Dutch Health Council, which is a summary of patients' course of treatment as a formal document, and includes recommendations for subsequent cancer surveillance, management of late effects, and strategies for health promotion. Until now, evidence on the effects of implementing the SCP in clinical practice is lacking. The rationale and study design of a pragmatic cluster randomized trial, aiming to assess the impact of SCP care in routine clinical practice, is presented.Methods/DesignA web-based patient registration system 'Registrationsystem Oncological GYnecology' (ROGY) is used by gynecologists in the South of the Netherlands since 2006. A personalized SCP can automatically be generated out of ROGY. In this pragmatic cluster randomized controlled trial, 12 hospitals are randomized to either 'usual care' or 'SCP care'. In patients with 'usual care', the gynecologist provides care as usual. In patients with 'SCP care', information about the tumor stage and treatment is personally discussed with the patient and a document is handed to the patient. Prospectively, all patients diagnosed with endometrial or ovarian cancer in the participating hospitals will be approached for study participation. Patients will complete questionnaires after surgery, and before additional treatment, and after 6, 12, 18 and 24 months. In addition, health care providers will be asked their opinion about implementation of SCP care. Primary outcome is defined as patient satisfaction with information provision and care. Secondary outcomes are illness perception, health-related quality of life, health care use, prevalence, course and referral rate of survivors with psychosocial distress, and health care providers' evaluation of SCP care.DiscussionThe ROGY Care trial will help to gain insight into the impact of SCP care on patient reported outcomes, and on the evaluation of cancer survivors and health care providers of the different elements of the SCP. Therefore, results will contribute to efforts to improve quality of care for cancer survivors.Trial registrationTrial Registration: http://www.ClinicalTrials.gov. Identifier: NCT01185626Medical Research Ethics Committee Reference Number: NL33429.008.10 Grant Reference Number: UVT2010-4743

Pólipos sincrónicos en estómago y yeyuno en un paciente con poliposis adenomatosa familiar

The management of extracolonic gastrointestinal polyps is controversial in patients with familial adenomatous polyposis (FAP). The treatment of adenomatous polyps with severe dysplasia in the stomach through wide gastric resections can hamper subsequent surveillance of the development of new polyps in the duodenal-jejunal area. We report the exceptional case of a 45-year-old man with FAP who developed two synchronic adenomatous polyps, with severe dysplasia. The first was located in the gastric antrum and the second in the proximal jejunum. Given the preoperative diagnosis of gastric neoplasm with invasion of the gastric wall (T 2N 0), subtotal Roux-en-Y gastrectomy and resection of the proximal jejunal segment were performed.

Cardiovascular disease risk factors in relation to suicide mortality in Asia: prospective cohort study of over one million Korean men and women

A potential role for cardiovascular disease (CVD) risk factors in the aetiology of suicide has not been comprehensively examined. In addition to being small in scale and poorly characterized, existing studies very rarely sample Asian populations in whom risk factor-suicide relationships may plausibly differ to Caucasian groups. We examined the association between a series of CVD risk factors and future mortality from suicide. The Korean Cancer Prevention Study is a prospective cohort study comprising 1 234 927 individuals (445 022 women) aged 30-95 years with extensive measurement of established CVD risk factors at baseline and subsequent mortality surveillance. Fourteen years of follow-up gave rise to 472 deaths (389 in men and 83 in women) from suicide. After adjustment for a range of covariates, in men, smoking hazard ratio; 95% CI: (current vs. never: 1.69; 1.27, 2.24), alcohol intake (1-24 g/day vs. none: 1.29; 1.00, 1.66), blood cholesterol (≥ 240 vs. <200 mg/dL: 0.54; 0.36, 0.80), body mass index (underweight vs. normal weight: 2.08; 1.26, 3.45), stature [quartile 1(lowest) vs. 4: 1.68; 1.23, 2.30], socioeconomic status [quartile 1(lowest) vs. 4: 1.65; 1.21, 2.24], and martial status (unmarried vs. other: 1.60; 0.83, 3.06) were related to suicide mortality risk. These associations were generally apparent in women, although of lower magnitude. Exercise and blood pressure were not associated with completed suicide. In this cohort of Korean men and women, a series of CVD risk factors were associated with an elevated risk of future suicide mortality.

Carcinoid and Other Neuroendocrine Tumors of the Colon and Rectum

Neuroendocrine tumors (NETs) are found throughout the intestinal tract and arise from the Kulchitsky cells located in the crypts of Lieberkühn. They are classified by site of origin and by degree of differentiation, with well-differentiated lesions representing those tumors formerly referred to as carcinoid tumors. The focus of this review is NETs of the appendix, colon, and rectum. The clinical presentation of these tumors is dependent on the primary site and many are discovered incidentally, either during screening or during the investigation of nonspecific abdominal complaints. Treatment is primarily via surgical removal as the response to chemotherapy has been traditionally poor. A noted exception to this has been with treatment of the carcinoid syndrome, which occurs almost exclusively in patients with liver metastases and is due to the release of bioactive peptides and amines directly into the systemic circulation. The use of somatostatin congeners to block the release of these substances has greatly ameliorated the devastating symptoms of this condition. Postresection follow-up is advocated, but specific recommendations are lacking an evidentiary basis. NETS, particularly those of the small bowel, colon, and appendix, are seen in association with other synchronous or metachronous malignancies, often of the gastrointestinal tract. However, the utility of subsequent screening and surveillance is unproven.

Pneumococcal antigen testing of blood culture broth to enhance the detection of Streptococcus pneumoniae bacteremia

The purpose of this investigation was to enhance the detection of pneumococcal bacteremia cases using the Binax NOW® immunochromatographic test (ICT) on blood culture broth as part of surveillance in two rural Thailand provinces. Blood cultures were collected as clinically indicated from hospitalized patients. ICT was performed on broth from culture bottles flagged as positive by BactT/ALERT® (alarm-positive) but which failed to grow organisms on subculture. During the period May 2005-June 2007, ICT was positive on 43 (24%) of 182 alarm-positive blood cultures with no growth on subculture. Compared to pneumococcal bacteremia cases confirmed by culture, cases detected only by ICT had a longer median time from culture collection to incubation and a longer median time from alarm positivity to subculture, and were more likely to be from patients pretreated with antibiotics. In a subsequent surveillance period (July 2007-December 2009), ICT continued to detect additional pneumococcal cases, but in a lower proportion of samples (7 of 221, 3.2%). Recently, as part of a separate study, ICT applied to uninoculated blood culture broth produced weak-positive results, mandating caution if testing broth from patient blood cultures. The antigen testing of blood culture broth appears to enhance the detection of pneumococcal bacteremia, but a controlled evaluation is needed.

Healthcare-use for Major Infectious Disease Syndromes in an Informal Settlement in Nairobi, Kenya

A healthcare-use survey was conducted in the Kibera informal settlement in Nairobi, Kenya, in July 2005 to inform subsequent surveillance in the site for infectious diseases. Sets of standardized questionnaires were administered to 1,542 caretakers and heads of households with one or more child(ren) aged less than five years. The average household-size was 5.1 (range 1-15) persons. Most (90%) resided in a single room with monthly rents of US$ 4.50-7.00. Within the previous two weeks, 49% of children (n=1,378) aged less than five years (under-five children) and 18% of persons (n = 1,139) aged > or = 5 years experienced febrile, diarrhoeal or respiratory illnesses. The large majority (> 75%) of illnesses were associated with healthcare-seeking. While licensed clinics were the most-frequently visited settings, kiosks, unlicensed care providers, and traditional healers were also frequently visited. Expense was cited most often (50%) as the reason for not seeking healthcare. Of those who sought healthcare, 34-44% of the first and/or the only visits were made with non-licensed care providers, potentially delaying opportunities for early optimal intervention. The proportions of patients accessing healthcare facilities were higher with diarrhoeal disease and fever (but not for respiratory diseases in under-five children) than those reported from a contemporaneous study conducted in a rural area in Kenya. The findings support community-based rather than facility-based surveillance in this setting to achieve objectives for comprehensive assessment of the burden of disease.

Investigation of a Cluster of Klebsiella Pneumoniae Carbapenemase-Producing Organisms on a Long-Term Care Ventilator Unit

The spread of isolates producing Klebsiella Pneumoniae Carpapenemase producing organsims has become a significant problem over the past 5 years. The incidence of such isolates has occurred with increasing frequency in the long term care setting. We report a cluster of Klebsiella Pneumoniae Carpapenemase producing organsims on our 10 bed long term care ventilator unit. Over a 3-week period, we isolated this organism from urine cultures on 3 separate patients. Analysis of pulse gel electrophesis (PFGE) indicated the same pattern on all 3 isolates. Subsequent surveillance cultures consisting of rectal swabs, sputum and urine cultures were obtained on all patients on that unit. 5 additional isolates from 3 of the other 7 patients were positive for the organism as well. (3 rectal swabs, 1 urine, 1 sputum).

Risk Factors for Metachronous Advanced Colorectal Neoplasia in a Cohort of Adenoma Patients: Advanced Morphology and Multiplicity

Background Surveillance of adenoma patients aims to prevent colorectal cancer (CRC) by removing recurrent adenomas. Adenoma removal and subsequent surveillance can reduce CRC incidence by 76-90%. Colonoscopy is however scarce, expensive and potentially harmful. To ensure efficient use of resources, surveillance colonoscopy should be targeted at patients who will benefit most from the procedure. Current surveillance guidelines use advanced morphology or multiplicity as criteria for surveillance interval. However, none of the guidelines have separate recommendations for patients with both multiple and advanced adenomas.AimTo assess the relative risks of advanced andmultiple (≥3) adenomas separately and combined on metachronous advanced colorectal neoplasia in a representative cohort of adenoma patients. Methods We collected prospective data on adenoma patients from 10 hospitals throughout the Netherlands, using a nationwide histopathology registry to select newly diagnosed adenoma patients from 1988 to 2002. Patients with CRC history or CRC at index colonoscopy, hereditary cancer syndromes or IBD were excluded. Electronic medical records were reviewed until December 1, 2008 for follow-up. Index colonoscopy was defined as colonoscopy with first adenoma diagnosis. Presence of advanced (≥10 mm, a villous histology or high-grade dysplasia) or multiple (≥3) adenomas and the combination at index colonoscopy were considered as potential risk factors for metachronous advanced colorectal neoplasia (advanced adenoma or CRC) at first follow-up endoscopy. To assess hazard ratios (HR) for the relative risk we performed a Cox-regression analysis, adjusted for age and gender. Results 3,041 adenoma patients (55% male, mean age 61 yrs (range 40 88)) were analyzed, of whom 1,351 (44%) patients had advanced adenomas at index endoscopy, and 161 (6%) ≥3 non-advanced adenomas. Median interval (interquartile range) to first surveillance endoscopy was 21 months (12-39); 15 months (11-35) for patients with advanced and/or ≥3 adenomas, and 27 months (13-45) for patients with 1-2 non-advanced adenomas at index endoscopy (p<0.01). At follow-up, 831 patients had any colorectal neoplasia (adenoma or CRC), of whom 182 patients had advanced colorectal neoplasia, including 26 CRC cases. Relative risks for metachronous advanced colorectal neoplasia are given in Table 1. Conclusion Advanced adenomas and ≥3 adenomas at index colonoscopy are equally important risk factors for metachronous advanced colorectal neoplasia, resulting in a 3-fold increased risk of developing advanced colorectal neoplasia during follow-up. However, having both risk factors results in a 6-fold increased risk. The results suggest that advanced morphology and multiplicity should be used to tailor surveillance guidelines with a separate recommendation for adenoma patients that have both these risk factors. Table 1. Relative risk of advanced and multiple (≥3) adenomas on metachronous advanced colorectal neoplasia

Familial Barrett’s Esophagus: Clues to Genetic Risks for Esophageal Adenocarcinoma

Esophageal adenocarcinoma is a particularly deadly neoplasm, and the incidence of it has been rising at an alarming rate in recent decades in Western countries [1, 2]. Barrett’s esophagus has been recognized as a precursor lesion for cancer, and screening and subsequent surveillance or other intervention for this lesion is an attractive proposition. Despite the rising incidence, the cancer still remains relatively uncommon. Therefore, selecting highrisk patients for screening, surveillance, or intervention is important in order to make the practice economically reasonable. Risk factors have been established for the cancer and for Barrett’s esophagus, including male gender, white race, older age, symptoms of gastroesophageal reflux, obesity, tobacco use, and absence of infection with Helicobacter pylori. However, most of these factors are highly prevalent in Western societies, so more specific risk factors would improve the efficiency of clinical practice. The association with white race might be because of environmental differences among races, but also suggests that genetic factors play an important role. Obviously, humans are not evolving rapidly enough to explain the rising incidence of esophageal adenocarcinoma, which is certainly because of relatively recent changes in environment or behavior. However, those changes in environment and behavior may interact with genetic factors, such that only genetically predisposed individuals develop the cancer in the modern setting of obesity and low prevalence of Helicobacter pylori. Indeed, a family history of esophageal adenocarcinoma or Barrett’s esophagus has been associated with the presence of both of those diagnoses [3]. A number of case reports of individual families suggest an autosomal dominant pattern of inheritance with incomplete penetrance [4–6]. Familial effects on the risk of esophageal adenocarcinoma may act via the promotion of other known risk factors (such as obesity or gastroesophageal reflux), via the promotion of Barrett’s esophagus among those with the recognized risk factors, via the promotion of neoplastic transformation within Barrett’s esophagus, or combinations of these loci of effects. In this issue of Digestive Diseases and Sciences, Ash and colleagues have begun to address these effects by studying their cohort of patients with Barrett’s esophagus [7]. Records of nearly 1,000 patients with Barrett’s esophagus were abstracted regarding their family history of either Barrett’s esophagus or esophageal cancer, and those with a positive history were interviewed for details. Nearly 6% of patients with Barrett’s esophagus were found to have a positive family history. The investigators then compared these familial cases of Barrett’s esophagus with the non-familial cases, seeking differences in demographics or clinical characteristics. Of note, they found no difference in gender, race, smoking history, presence of Helicobacter pylori, hiatal hernia, or length of Barrett’s esophagus. The investigators did find that familial cases were younger, and less likely to harbor neoplasia; however, they attribute these differences to referral bias, because patients with neoplasia are frequently referred to their center from outside practices, and patients with familial Barrett’s esophagus without neoplasia may be more likely to be referred to them than other non-neoplastic Barrett’s esophagus patients. The younger age of the familial Barrett’s J. H. Rubenstein (&) Veterans Affairs Center for Clinical Management Research, VA Medical Centre, 111-D, 2215 Fuller Road, Ann Arbor, MI 48105, USA e-mail: jhr@med.umich.edu

1638 EFFECTS OF 5-ALPHA REDUCTASE INHIBITOR USE IN MONITORED MEN WITH VERY-LOW RISK PROSTATE CANCER

You have accessJournal of UrologyProstate Cancer: Localized1 Apr 20111638 EFFECTS OF 5-ALPHA REDUCTASE INHIBITOR USE IN MONITORED MEN WITH VERY-LOW RISK PROSTATE CANCER Ashley E. Ross, Feng Zhaoyong, Phillip M. Pierorazio, Patricia Landis, Patrick C. Walsh, H. Ballentine Carter, Bruce J. Trock, and Edward M. Schaeffer Ashley E. RossAshley E. Ross Baltimore, MD More articles by this author , Feng ZhaoyongFeng Zhaoyong Baltimore, MD More articles by this author , Phillip M. PierorazioPhillip M. Pierorazio Baltimore, MD More articles by this author , Patricia LandisPatricia Landis Baltimore, MD More articles by this author , Patrick C. WalshPatrick C. Walsh Baltimore, MD More articles by this author , H. Ballentine CarterH. Ballentine Carter Baltimore, MD More articles by this author , Bruce J. TrockBruce J. Trock Baltimore, MD More articles by this author , and Edward M. SchaefferEdward M. Schaeffer Baltimore, MD More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1747AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Trials using 5-alpha reductase inhibitors (5-ARIs) in populations monitored for the development of prostate cancer suggest that these drugs may suppress the growth of low-risk prostate cancer. In this study we examine whether 5-ARI treatment delays cancer progression in a carefully followed active surveillance cohort. METHODS We evaluated 587 men enrolled in our institutional prostate cancer active surveillance (AS) program that met all entry criteria and had no history of 5-ARI use prior to diagnosis. Data regarding 5-ARI use was collected prospectively. Follow-up consisted of twice-yearly DRE and PSAs and yearly biopsy. Unfavorable surveillance biopsy results included those indicating progression by grade (Gleason score ≥ 7) or volume (> 2 positive cores, or > 50% core involvement). Features of men using 5-ARIs during surveillance were compared to non-users using chi-squared and t-tests. Univariate and multivariable proportional hazard models treating 5-ARI use as a time dependent co-variate were used to evaluate the influence of 5-ARIs on subsequent unfavorable surveillance biopsy. RESULTS 5-ARI use was initiated in 47 men while on surveillance, with a median time from diagnosis to initiation of 1.2 years (range 0–10) and a median period of 5-ARI use of 1.8 years (0.1–9.3). Men using 5-ARIs had, on average, larger prostates and higher PSAs at diagnosis compared to non-users (71 vs 53 ccs and 5.7 vs 4.7 ng/ml respectively, p<0.001 for both). During 5-ARI use, PSA decreased by 47% (−2 to 81%) and prostate volume decreased by 11% (−62 to 57%). Men using 5-ARIs had on average 2.6 surveillance biopsies during drug use and 5 biopsies overall, compared to 3.7 biopsies among non-users. Unfavorable surveillance biopsies occurred in 17% of 5-ARI users compared to 31% of non-users. Multivariable models (adjusting for age, alpha blocker use, PSA, %free PSA, PSA density, prostate volume and number/percent biopsy core involvement at diagnosis) demonstrated statistically non-significant risk reductions for the occurrence of an unfavorable surveillance biopsy in 5-ARI users as determined by either volume (hazard ratio (HR) of 0.37 (95% CI=0.12 to 1.13), p=0.08) or grade criteria (HR of 0.80 (95% CI=0.25–2.59), p=0.7). CONCLUSIONS In our cohort of carefully monitored men with very low-risk prostate cancer, treatment with 5-ARIs for a median time of 2 years did not significantly delay progression of disease as assessed by yearly biopsies. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e657-e658 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ashley E. Ross Baltimore, MD More articles by this author Feng Zhaoyong Baltimore, MD More articles by this author Phillip M. Pierorazio Baltimore, MD More articles by this author Patricia Landis Baltimore, MD More articles by this author Patrick C. Walsh Baltimore, MD More articles by this author H. Ballentine Carter Baltimore, MD More articles by this author Bruce J. Trock Baltimore, MD More articles by this author Edward M. Schaeffer Baltimore, MD More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Diagnostic and therapeutic strategies for small abdominal aortic aneurysms

Abdominal aortic aneurysms (AAA) affect 5% of the population in developed countries and are characterized by progressive aortic dilatation with an unpredictable time course. This condition is more common in men than in women, and in smokers than in nonsmokers. If left untreated, AAA can result in aortic rupture and death. Pathologically, aortic extracellular matrix degradation, inflammation, and neovascularization are hallmarks of AAA. Diagnosis of AAA and subsequent surveillance utilize established aortic imaging methods, such as ultrasound, CT, and MRI. More-speculative diagnostic approaches include molecular and cellular imaging methods that interrogate the underlying pathological processes at work within the aneurysm. In this Review, we explore the current diagnostic and therapeutic strategies for the management of AAA. We also describe the diagnostic potential of new imaging techniques and therapeutic potential of new treatments for the management of small AAA.

Identification and surveillance of 19 Lynch syndrome families in southern Italy: report of six novel germline mutations and a common founder mutation

Lynch syndrome (LS), or hereditary non-polyposis colorectal cancer (HNPCC), is an autosomal dominant condition responsible for early onset cancer mostly in the colonrectum and endometrium as well as in other organ sites. Lynch syndrome is caused by germline mutations in mismatch repair genes, prevalently in hMSH2, hMLH1, and less frequently in hMSH6 and hPMS2. Twenty-nine non-related index cases with colorectal cancer (CRC) were collected from a region in southeast Italy (Apulia). Among this set of patients, fifteen fulfilled the Amsterdam criteria II. The presence of tumor microsatellite instability (MSI) was assessed in all index cases and 19 (15 AC+/4 AC-) were classified as MSI-H. Mutation analysis performed on all patients, identified 15 pathogenic mutations in hMLH1 and 4 in hMSH2. 4/15 mutations in hMLH1 and 2/4 hMSH2 mutations have not been previously reported. Three previously reported mutations were further investigated for the possibility of a common founder effect. Genetic counseling was offered to all probands and extended to 183 relatives after molecular testing and 85 (46%) mutation carriers were identified. Eighty mutation carriers underwent an accurate clinical and instrumental surveillance protocol. Our results confirm that the identification of LS patients based exclusively on family history may miss patients carrying germline mutations in the MMR genes. Moreover, our results demonstrated that molecular screening and subsequent instrumental surveillance are very effective in identifying CRCs at earlier stages and reducing the number of deaths from secondary cancers in HNPCC patients.

A campaign to eradicate bovine babesiosis from New Caledonia

In December 2007, Babesia bovis was introduced to New Caledonia through the importation of cattle that had been vaccinated with a live tick fever (babesiosis and anaplasmosis) vaccine. Although the tick Rhipicephalus ( Boophilus) microplus is common in New Caledonia, the territory had previously been free of tick-borne diseases of cattle. This paper describes the initial extent of the outbreak, the measures and rationale for disease control, and the progress to date of the eradication campaign. Initially, 22 properties were affected involving approximately 2300 cattle in ‘high risk’ zones and 1600 in adjoining ‘suspect’ zones. Rather than slaughtering infected herds or attempting to eliminate the tick vector, the campaign was based on quarantine of affected properties, and aggressive tick control in conjunction with 3-monthly treatments of the high risk cattle with the antiprotozoal drug imidocarb dipropionate. Subsequent surveillance by ELISA and PCR showed a progressive and dramatic decline in seroprevalence among infected herds and the absence of new infections. All 22 properties were considered to be free of Babesia within 12 months of the start of the disease control program. These results indicate that the strategy was effective in eliminating Babesia from infected herds and feasible as an eradication strategy on a moderately large scale. Unfortunately, early in the campaign, babesiosis spread to a herd of feral cattle on a property in the ‘suspect’ zone, and this reservoir of infection subsequently resulted in the infection (or reinfection) of cattle on several neighbouring commercial farms. The eradication campaign in New Caledonia is currently focussed on destocking the feral cattle – extensive surveillance suggests that this is the only remaining nidus of infection.

A Significant Number of Sessile Serrated Adenomas Might Not Be Accurately Diagnosed in Daily Practice

The diagnosis of hyperplastic polyps (HPs) may involve a conglomeration of subgroups of serrated polyps. The diagnosis of HPs may therefore be revisited if this is sessile serrated adenoma (SSA). The aim of this study was to determine clinically and endoscopically relevant information associated with reclassification to SSA. After reviewing the data from 1,372 patients who underwent colonoscopic polypectomy, 49 HPs larger than 10 mm were analyzed in this study. Two gastrointestinal pathologists reclassified each of the original 49 HPs as conventional HPs, SSAs, and others. Among the 49 initially diagnosed HPs, 18.4% were reclassified into SSAs or mixed polyps. Overall architectural features were useful for the diagnosis of SSA, but cytological features were less useful. The patient and polyp characteristics did not differ between HPs with and without reclassification of the initial pathological diagnosis. A significant number of SSAs might not be accurately diagnosed in daily clinical practice without any predilection for size, shape, and location. Therefore, when large HPs are diagnosed in clinical practice, it is necessary for physicians to have greater awareness of the diagnosis of SSA and to individualize subsequent surveillance.

Imaging appearance of bulk fat within an oncocytic adrenocortical neoplasm, a rare and potentially malignant tumour

Oncocytic adrenocortical neoplasm is a rare adrenal tumour that usually follows a benign clinical course. In some cases, however, these tumours have exhibited malignant behaviour. Here, we present the first published case showing bulk fat within an oncocytic adrenocortical neoplasm on CT and MRI, a finding that mimics fat within an adrenal myelolipoma. The distinction between these entities is important, as the current suggested management of an oncocytic adrenocortical neoplasm is resection with subsequent imaging surveillance.

Different mutation patterns of Plasmodium falciparum among patients in Jimma University Hospital, Ethiopia

BackgroundThe emergence of drug resistance is a major problem in malaria control. Combination of molecular genotyping and characterization of mutations or single nucleotide polymorphisms (SNPs) correlated with drug resistance can provide information for subsequent surveillance of existing and developing drug resistance patterns. The introduction of artemether/lumefantrine (AL) as first-line treatment, never used before in Ethiopia, allowed the collection of baseline data of molecular polymorphisms before a selection due to AL could occur.Method97 patients with uncomplicated falciparum malaria were recruited from April to June 2006 and treated with either AL, quinine (Q) or atovaquone/proguanil (AP) in Jimma University Hospital, Ethiopia. Mutations or SNPs associated with resistance to these drugs were analysed by RFLP (pfdhfr, pfmdr1) and sequencing of the target genes (pfcytb, pfserca ).ResultsSNPs previously reported to be associated with resistance to the study drugs were identified in recrudescent and treatment sensitive isolates. A total of seven recrudescences were obtained. The pfmdr1 N86Y mutation was found in 84.5% of isolates. The triple mutation 51I,59R,108N of the pfdhfr gene occured in high frequency (83.3%) but no pfcytb mutation was detected. Sequencing showed a variety of previously described and new mutations in the pfserca gene.ConclusionThe prevalence of mutations was in accordance with the expected patterns considering recent drug regimens. The broad introduction of AL and the cessation of former drug regimens might probably change the current distribution of polymorphisms, possibly leading to decreased sensitivity to AL in future. Continuous surveillance of molecular patterns in this region is, therefore, recommended.

Quality measures and credentialing in gastrointestinal endoscopy

Quality assessment and improvement are now mainstream activities in medicine. This review presents recent publications pertaining to quality, proposed quality measures, and associated topics in credentialing and delivery of endoscopic services. The literature continues to focus primarily on colonoscopy services. Surveillance colonoscopy continues to suffer from underuse in high-risk patients and overuse in average to moderate-risk patients, based upon current guidelines for application. Several series update and add to our understanding of adenoma detection rates as measures of quality. One study confirmed an inverse association between adenoma detection rates at screening endoscopy and the risk for identification of colorectal cancer at a subsequent diagnostic or surveillance procedure. Credentialing guidelines proposed for worldwide application are becoming uniform and similar to those from several national societies. Quality measures for use in endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography are just beginning to be assessed in large series. Proposed quality measures for colonoscopy are maturing, with increasing emphasis on adenoma detection rates rather than indirect proxies for neoplasia detection. Personal and unit-based benchmarking appears to be gaining favor and is facilitated by use of automated reporting systems. Greater attention is being focused on individual performance and assuring competence of the endoscopy workforce.

Focal ground-glass opacities in non-small cell lung carcinoma resection patients

To retrospectively determine the frequency, natural progression, radiographic characteristics, and primary cancer cell type of focal ground-glass opacities (GGOs) identified on serial radiographic examinations in patients with prior non-small cell lung carcinoma (NSCLC) resection. One thousand three hundred and seventy-nine CT examinations in 154 patients with NSCLC resection between 1997 and 2008 were reviewed by two radiologists to determine the frequency of postoperative focal GGOs. Percentages, imaging characteristics and primary cancer cell types of GGOs that persisted, resolved, or resected were recorded. For persistent GGOs, growth rate was determined. Of 154 patients, 67 (44%) developed 174 GGO during a mean follow-up of 2.7 years (standard deviation 2.23 years, range 1 month to 10 years). Of these 174 opacities, 110 (63%) spontaneously resolved within 6 months. Of the remaining 64 lesions, 5 (3%) were resected and 59 (34%) persisted and demonstrated indolent growth with a median annual growth rate of 2.02 mm. Of the 59 persistent GGOs, 41 (69%) were nodularly shaped, 58 (95%) indistinctly marginated, 17 (29%) with pseudocavitation and 25 (42%) contained solid elements. Adenocarcinoma was the original resected cancer in more than half of these lesions (37 of 59, 63%). In individuals who have undergone NSCLC resection, approximately 44% will develop focal GGO on follow-up CT examination. A majority of these GGOs will spontaneously resolve by 6 months after initial identification. As most persistent GGOs are indolent, we propose an initial 6-month interval reimaging once postoperative GGOs are detected followed by subsequent annual surveillance.

Proximal and Large Hyperplastic and Nondysplastic Serrated Polyps Detected by Colonoscopy Are Associated With Neoplasia

The family of serrated lesions includes hyperplastic polyps and sessile serrated adenomas without dysplasia, as well as traditional serrated adenoma with dysplasia. We investigated whether detection of proximal nondysplastic serrated polyps (ND-SP) at screening and surveillance colonoscopies is associated with advanced neoplasia. The study included 3121 asymptomatic patients (aged 50-75 years) who had screening colonoscopies; 1371 had subsequent surveillance. The proximal colon was defined as segments proximal to the descending colon. Large ND-SP were defined as ≥ 10 mm. We compared rates of detection of any neoplasia and advanced neoplasia at screening and surveillance colonoscopies (within 5.5 years) in patients with and without proximal or large ND-SP. At baseline screening, 248 patients (7.9%) had at least 1 proximal ND-SP. They were more likely than patients with no proximal ND-SP to have advanced neoplasia (17.3% vs 10.0%; odds ratio [OR], 1.90; 95% confidence interval [CI], 1.33-2.70). Patients with large ND-SP (n = 44) were also more likely to have synchronous advanced neoplasia (OR, 3.37; 95% CI, 1.71-6.65). During surveillance, 39 patients with baseline proximal ND-SP and no neoplasia were more likely to have neoplasia compared with subjects who did not have polyps (OR, 3.14; 95% CI, 1.59-6.20). Among patients with advanced neoplasia at baseline, those with proximal ND-SP (n = 43) were more likely to have advanced neoplasia during surveillance (OR, 2.17; 95% CI, 1.03-4.59). Detection of proximal and large ND-SP at a screening colonoscopy is associated with an increased risk for synchronous advanced neoplasia. Detection of proximal ND-SP in a baseline colonoscopy is associated with an increased risk for interval neoplasia during surveillance.