Discrepancy between gastroenterologists’ and general surgeons’ perspectives on repeat endoscopy in colorectal cancer

BackgroundA myriad of localization options are available to endoscopists for colorectal cancer (CRC); however, little is known about the use of such techniques and their relation to repeat endoscopy before CRC surgery. We examined the localization practices of gastroenterologists and compared their perceptions toward repeat endoscopy to those of general surgeons.MethodsWe distributed a survey to practising gastroenterologists through a provincial repository. Univariate analysis was performed using the χ² test.ResultsGastroenterologists (n = 69) reported using anatomical landmarks (91.3%), tattooing (82.6%) and image capture (73.9%) for tumour localization. The majority said they would tattoo lesions that could not be removed by colonoscopy (91.3%), high-risk polyps (95.7%) and large lesions (84.1%). They were equally likely to tattoo lesions planned for laparoscopic (91.3%) or open (88.4%) resection. Rectal lesions were less likely to be tattooed (20.3%) than left-sided (89.9%) or right-sided (85.5%) lesions. Only 1.4% agreed that repeat endoscopy is the standard of care, whereas 38.9% (n = 68) of general surgeons agreed (p < 0.001). General surgeons were more likely to agree that an incomplete initial colonoscopy was an indication for repeat endoscopy (p = 0.040). Further, 56% of general surgeons indicated that the findings of repeat endoscopy often lead to changes in the operative plan.ConclusionDiscrepancies exist between gastroenterologists and general surgeons with regards to perceptions toward repeat endoscopy and its indications. This is especially significant given that repeat endoscopy often leads to change in surgical management. Further research is needed to formulate practice recommendations that guide the use of repeat endoscopy, tattoo localization and quality reporting.     

The SDF-1 3′A Genetic Variation of the Chemokine SDF-1α (CXCL12) in Parallel with its Increased Circulating Levels is Associated with Susceptibility to MS: A Study on Iranian Multiple Sclerosis Patients

Immune system-related factors are important in pathogenesis of multiple sclerosis. The CXC chemokine SDF-1α (CXCL12) is involved in the immune responses. Hence, the aim of this study was to investigate the association between serum levels of SDF-1α (CXCL12) and its gene polymorphisms at position +801 with multiple sclerosis. In this experimental study, blood samples were collected from 100 multiple sclerosis patients and 100 healthy controls on EDTA pre-coated tubes. DNA was extracted and DNA samples were analyzed for SDF-1α (CXCL12) polymorphisms using PCR-RLFP in patients and controls. The serum levels of SDF-1α (CXCL12) were measured by ELISA. Demographic data were also collected by a questionnaire which was designed specifically for this study. Our results showed a significant difference between the A/A, A/G, and G/G genotype and A and G alleles of polymorphisms at position +801 of SDF-1α (CXCL12). Our results also showed that serum levels of SDF-1α (CXCL12) were markedly higher in patients than healthy controls, but no association was observed between SDF-1α (CXCL12) polymorphism and its serum levels. The results of this study might suggest the serum levels of SDF-1α (CXCL12) and its polymorphism play an important role in pathogenesis of multiple sclerosis. It is also worth noting that these factors could probably use as pivotal biological markers in the diagnosis of MS.     

Tubulin binding, protein-bound conformation in solution, and antimitotic cellular profiling of noscapine and its derivatives

Noscapine and its 7-hydroxy and 7-amino derivatives were characterized for their binding to tubulin. A solution NMR structure of these compounds bound to tubulin shows that noscapine and its 7-aniline derivative do not compete for the same binding site nor does its small molecule crystal structure match its tubulin-bound conformation. These compounds were also tested for their antiproliferative effects on a panel hepatocellular carcinoma cell lines.     

Restoration of function after brain damage using a neural prosthesis

Neural interface systems are becoming increasingly more feasible for brain repair strategies. This paper tests the hypothesis that recovery after brain injury can be facilitated by a neural prosthesis serving as a communication link between distant locations in the cerebral cortex. The primary motor area in the cerebral cortex was injured in a rat model of focal brain injury, disrupting communication between motor and somatosensory areas and resulting in impaired reaching and grasping abilities. After implantation of microelectrodes in cerebral cortex, a neural prosthesis discriminated action potentials (spikes) in premotor cortex that triggered electrical stimulation in somatosensory cortex continuously over subsequent weeks. Within 1 wk, while receiving spike-triggered stimulation, rats showed substantially improved reaching and grasping functions that were indistinguishable from prelesion levels by 2 wk. Post hoc analysis of the spikes evoked by the stimulation provides compelling evidence that the neural prosthesis enhanced functional connectivity between the two target areas. This proof-of-concept study demonstrates that neural interface systems can be used effectively to bridge damaged neural pathways functionally and promote recovery after brain injury.The view of the brain as a collection of independent anatomical modules, each with discrete functions, is currently undergoing radical change. New evidence from neurophysiological and neuroanatomical experiments in animals, as well as neuroimaging studies in humans, now suggests that normal brain function can be best appreciated in the context of the complex arrangements of functional and structural interconnections among brain areas. Although mechanistic details are still under refinement, synchronous discharge of neurons in widespread areas of the cerebral cortex appears to be an emergent property of neuronal networks that functionally couple remote locations (1). It is now recognized that not only are discrete regions of the brain damaged in injury or disease but, perhaps more importantly, the interconnections among uninjured areas are disrupted, potentially leading to many of the functional impairments that persist after brain injury (2). Likewise, plasticity of brain interconnections may partially underlie recovery of function after injury (3).Technological efforts to restore brain function after injury have focused primarily on modulating the excitability of focal regions in uninjured parts of the brain (4). Purportedly, increasing the excitability of neurons involved in adaptive plasticity expands the neural substrate potentially involved in functional recovery. However, no methods are yet available to alter the functional connectivity between spared brain regions directly, with the intent to restore normal communication patterns. The present paper tests the hypothesis that an artificial communication link between uninjured regions of the cerebral cortex can restore function in a rodent model of traumatic brain injury (TBI). Development of such neuroprosthetic approaches to brain repair may have important implications for the millions of individuals who are left with permanent motor and cognitive impairments after acquired brain injury, as occurs in stroke and trauma.For the present experiment, we used a rodent model of focal brain injury to the caudal forelimb area (CFA), a region that is part of the cortical sensorimotor system. This area in the frontal cortex shares many properties with primary motor cortex (M1) of primates; injury to M1 results in long-term impairment in reaching and grasping functions (5). Traditionally, it has been thought that impairment occurs because M1 provides substantial outputs to the motor apparatus in the spinal cord, thus directly affecting motor output function. However, M1 also has important interconnections with the primary somatosensory cortex (S1) located in the parietal lobe (Fig. 1A). Long-range corticocortical fibers from S1 provide critical information to M1 about the position of the limb in space. Thus, injury to M1 results in impaired motor performance due, at least in part, to disruption in communication between the somatosensory and motor cortex (6).Open in a separate windowFig. 1.Theoretical model of neuroprosthetic treatment approach after brain injury. (A) Normal connectivity of M1, S1, and PM. Both M1 (CFA in rat) and PM (RFA in rat) send substantial outputs to the spinal cord via the corticospinal tract. Also, extensive reciprocal connections exist between M1 and PM, as well as between M1 and S1. (B) Effects of focal M1 injury on brain connectivity and the hypothetical effect of a BMBI to restore somatosensory-motor communication. An injury to M1, as might occur in stroke or brain trauma, results in a focal area of necrosis, as well as loss of M1 outputs to the spinal cord. Corticocortical communication between M1 and S1 (and between M1 and PM) is also disrupted, further contributing to functional impairment. Because the uninjured PM also contains corticospinal neurons, it might have the ability to serve in a vicarious role. The dotted line indicates enhanced functional connection between PM and S1 that we propose is established after treatment with a BMBI. (C) Location of target areas in rat cerebral cortex. A topographic map of the somatosensory representation in S1 is superimposed on the cortex.To test our hypothesis that functional recovery can be facilitated by creating an artificial communication link between spared somatosensory and motor regions of the brain, we focused on the rat’s premotor cortex (PM). The rostral forelimb area (RFA) is a premotor area in the rodent’s frontal cortex that shares many properties with PM of primates and is thought to participate in recovery of function after injury to M1 (5, 7–9). PM areas are so-named because the principal target of their output fibers is M1 (10). PM areas also have long-range corticocortical connections with somatosensory areas, but at least in intact animals, they appear to be relatively weak compared with M1’s connections with the somatosensory cortex (9, 11, 12).Our approach was to link the neural activity of the PM forelimb area (RFA) functionally with activation of the S1 forelimb area following a controlled cortical impact (CCI) to M1 (Fig. 1 B and C). To this end, a microdevice was developed with the ability to deliver activity-dependent stimulation (ADS) through recording and digitizing extracellular neural activity from an implanted microelectrode, discriminating individual action potentials (spikes), and delivering small amounts of electrical current to another microelectrode implanted in a distant population of neurons (13, 14). This closed-loop system was similar, in principle, to the “Neurochip” used previously by other investigators to demonstrate the effects of local ADS in intact animals (15), but it was miniaturized for head-mounted, wireless operation (Fig. 2A and Fig. S1). By linking the activity of one area of the cortex with that of a distant area of the cortex, a closed-loop brain–machine–brain interface (BMBI) for artificial corticocortical communication between PM and S1 was created.Open in a separate windowFig. 2.ADS protocol. After injury to the CFA, a recording microelectrode was placed in the RFA, whereas a stimulating microelectrode was placed in the distal forelimb field of S1. A BMBI discriminated action potentials in the RFA, and after a 7.5-ms delay, it delivered a low-level electrical current pulse to S1 (13). (A) Sketch of a rat retrieving a food pellet with a BMBI attached to the skull. (B) Sample traces of recordings from the RFA showing action potentials and stimulus artifacts from an ICMS current delivered to S1. Time-amplitude window discriminators are indicated by red boxes. A total of 100 superimposed traces are shown.Individual spikes were detected in PM, and subsequent stimulation was delivered to S1 after a 7.5-ms delay (Fig. 2B). (Because connections between distant cortical areas are commonly reciprocal, enhanced communication theoretically could be established by ADS in either direction.) After the M1 injury, rats were implanted with microelectrodes connected to the BMBI microdevice (Fig. 2A). The microdevice delivered ADS 24 h per day up to 28 d postinjury, except for brief motor assessment sessions on predetermined days. Behavioral recovery in ADS rats was compared with recovery in rats with open-loop stimulation (OLS), in which S1 stimulation was uncorrelated with spikes in PM, and with control rats that had no microdevice implanted.     

Basilic vein transposition fistula: a good option for maintaining hemodialysis access site options?

PURPOSE: The primary use of autogenous arteriovenous access for chronic hemodialysis is recommended by the National Kidney Foundation-Dialysis Outcomes Quality Initiative practice guidelines. We review the outcomes of basilic vein transposition (BVT) to assess its value as a primary upper arm arteriovenous access option. METHODS: A retrospective review of 56 patients undergoing BVT was performed. Thirty patients were men; average age was 56 years. Etiology of end-stage renal disease, complications, and time to maturation were tabulated. Primary and secondary patency rates were determined by using life table methods. Multivariate regression analysis was performed to assess risk factors for fistula failure. RESULTS: Renal failure was associated with diabetes in 32 (57%) patients, and BVT was the primary access procedure in 22 (39%) patients. Perioperative complications occurred in 5 (9%) patients and included hematoma (n = 3), myocardial infarction (n = 1), and death (n = 1). The average time to maturation was 74 days (range, 12-265 days), and maturation failure occurred in 21 (38%) patients. Logistic regression analysis showed that age older than 60 years was associated with poorer maturation and patency rates. On an intent-to-treat basis, 1-year primary and secondary patencies were 35% and 47%, respectively, but only 18% and 28%, respectively, for age >60 years. Forty-two percent of failed BVT were subsequently replaced with a prosthetic graft by using the same upper arm vessels. CONCLUSION: BVT frequently do not mature in patients older than 60 years, which compromises its utility as a primary access. However, fistulas that mature provide acceptable patency rates, and subsequent conversion to a prosthetic access is frequently possible. Selective use of BVT might improve the utilization of available access sites.     

Quality of life among patients treated for achalasia

The present study is an attempt to capture the quality of life of achalasia patients after a successful treatment. It is also an effort to assess the extent of the subsequent restrictions achalasia may have imposed upon the patients' life-style. All achalasia patients who were successfully treated between 1984 and 1992 were identified. Qualified patients were supplied with a 12-item quality-of-life questionnaire that had been designed to assess the patients' perceptions of their swallowing function and their general health; the restrictions achalasia had imposed on five areas of performance, which encompassed social activities, family relationships, travel experiences, sports and housework activities, were also assessed. Sixty-six patients were offered the questionnaire and 52 (77.6%) returned a completed form. Forty-one of the group had pneumatic dilatation and the remaining 11 had cardiomyotomy. Some form of dysphagia was reported by 36 patients (69%) and a dietary modification was exercised by 29 (56%) of them. Heartburn was reported by 31 (59%) of the patients. Fifteen percent of the patients felt that the disease interfered with their social activities, 8% experienced difficulty in their family relations, 13% believed that the disease restricted travel and athletics, and finally, 9% stated that their symptoms placed restrictions on their ability to do housework. The group that received pneumatic dilatation experienced less restriction in the performance areas of sports, travel, and housework. However, this difference was only significant in the area of sports (P=0.04). It is concluded that: (1) The restoration of the normal swallowing mechanism is not often achieved after treatment for achalasia. The majority of patients who have been treated continue to have a component of difficulty for the rest of their lives. (2) These residual symptoms leave an impact on the patients' life-style. This impact is least important in the performance area of family relationship and most impressive in the area of sports. (3) Finally, those patients who have been treated with cardiomyotomy are more restricted in sport activities than those who received pneumatic dilatation.     

Knowledge and Perception of Bariatric Surgery Among Primary Care Physicians: a Survey of Family Doctors in Ontario

Purpose

The primary objective of this study was to identify Ontario family physicians’ knowledge and perceptions of bariatric surgery.

Methods

The study population included all physicians practicing family medicine in Ontario who were listed in the Canadian Medical Directory. A self-administered questionnaire consisting of 28 questions was developed and validated using a focus group of seven primary care physicians. The questionnaire was distributed to 1328 physicians.

Results

One hundred sixty-five surveys were completed. 8.8 % of physicians did not have any bariatric surgical patients, and 71.3 % had no more than five in their practice. 70.2 % referred no more than 5 % of their morbidly obese patients for surgery. Only 32.1 % had the appropriate equipment and resources to manage obese patients. 92.5 % of physicians would like to receive more education about bariatric surgery. Physicians with no history of referral (n?=?21) were earlier into their practices and had less morbidly obese patients than physicians with previous referrals (n?=?141). They were also less likely to discuss bariatric surgery with their patients (30 vs. 79.3 %; p?<?0.001) and less likely to feel comfortable explaining procedure options (5.6 vs. 33.9 %; p?=?0.013) and providing postoperative care (26.7 vs. 64.2 %; p?=?0.005). 55.6 % would refer a family member for surgery, compared to 85.4 % of physicians with previous referrals; p?=?0.002.

Conclusion

There appears to be a knowledge gap in understanding the role of bariatric surgery in the treatment of obesity. There is an opportunity to improve education and available resources for primary care physicians surrounding patient selection and follow-up care. This may improve access to treatment.