Charles Maxwell-Armstrong

Are we teaching sufficient anatomy at medical school? The opinions of newly qualified doctors.

In recent decades wide‐ranging changes have occurred in medical school curricula. Time spent studying gross anatomy has declined amidst controversy as to how, what, and when teaching is best delivered. This reduced emphasis has led to concerns amongst clinicians that a new generation of doctors are leaving medical school with insufficient anatomical knowledge. Previous studies have established that medical students value their anatomy teaching during medical school. None have sought to establish views on the sufficiency of this teaching. We investigate the opinions of newly qualified doctors at a UK medical school and relate these opinions to career intentions and academic performance in the setting of a traditional dissection and prosection‐based course. Overall nearly half of respondents believe they received insufficient anatomy teaching. A substantial proportion called for the integration of anatomy teaching throughout the medical school course. Trainees intent on pursuing a surgical career were more likely to believe anatomy teaching was insufficient than those pursuing a nonsurgical career; however, overall there was no statistical difference in relation to the mean for any individual career group. This study adds to the current debates in anatomical sciences education, indicating that overall, regardless of career intentions, new doctors perceive the need for greater emphasis on anatomical teaching. Clin. Anat. 21:718–724, 2008.

Colonic tattooing in laparoscopic surgery – making the mark?

Objective  Laparoscopic surgery for colorectal cancer is now widespread. Small lesions in the colon can be difficult to palpate and with lack of tactile sensation, it is essential to accurately localize them preoperatively. This is a review article on current methods of tattooing including the use of different agents and associated complications.

Randomized double-blind phase II survival study comparing immunization with the anti-idiotypic monoclonal antibody 105AD7 against placebo in advanced colorectal cancer

The cancer vaccine 105AD7 is an anti-idiotypic monoclonal antibody that mimics the tumour-associated antigen 791T/gp72 (CD55, Decay Accelerating Factor) on colorectal cancer cells. Phase I studies in patients with advanced disease confirmed that 105AD7 is non-toxic, and that T cell responses could be generated. A prospective, randomized, double-blind, placebo-controlled survival study in patients with advanced colorectal cancer was performed. 162 patients were enrolled between April 1994 and October 1996. Patients attended at trial entry, and at 6 and 12 weeks, where they received 105AD7 or placebo. Study groups were comparable in terms of patient demographics, and time from diagnosis of advanced colorectal cancer (277.1 v 278.6 days). Baseline disease was similar, with 50% of patients having malignancy in at least 2 anatomic sites. Compliance with treatment was poor, with only 50% of patients receiving 3 planned vaccinations. Median survival from randomization date was 124 and 184 days in 105AD7 and placebo arms respectively (P=0.38), and 456 and 486 days from the date of diagnosis of advanced disease (P=0.82). 105AD7 vaccination does not prolong survival in patients with advanced colorectal cancer. The reasons for lack of efficacy are unclear, but may reflect the high tumour burden in the patient population, and poor compliance with immunization. Further vaccine studies should concentrate on patients with minimal residual disease.

Laparoscopic colorectal cancer surgery.

BACKGROUND A number of controversies exist in the laparoscopic treatment of colorectal cancer, and thus the technique has so far failed to gain widespread acceptance throughout the United Kingdom. This review aims to discuss these issues in the context of ongoing published trials, assessing both purported advantages and disadvantages. METHODS The United States National Library of Medicine Medline database, and the Bath Information Data Service (BIDS) were searched using keywords related to laparoscopic colorectal cancer surgery. Recent surgical journals were also reviewed for relevant publications. Attempts have been made to quote only the most recent work from institutions with multiple publications using the same group of patients, in order to present the most coherent picture. The data are presented as randomized controlled trials, nonrandomized controlled studies, and series comprising more than 10 patients. CONCLUSIONS This review confirms that laparoscopic colorectal cancer surgery is technically feasible. In addition patients lose less blood, have less immunosuppression, and have shorter postoperative ileus, in-patient stay, and require less analgesia. However, concerns still remain as to the development of port-site metastases, the longer operating times, and the overall cost of the equipment. In view of these concerns, the place of laparoscopically assisted colorectal cancer surgery is likely to remain controversial for some years yet. Randomized, controlled trials are as yet too few to provide definitive answers to all these issues.

A Neoadjuvant/Adjuvant Randomized Trial of Colorectal Cancer Patients Vaccinated with an Anti-Idiotypic Antibody, 105AD7, Mimicking CD55

Purpose: To assess the tolerability and effectiveness of 105AD7 vaccination in colorectal cancer patients. 105AD7 is a human anti-idiotypic antibody mimicking CD55, a glycoprotein, which is more than expressed on colorectal cancer cells and protects them from attack by complement. Experimental Design: Colorectal cancer patients (n = 67) eligible for primary surgery were randomized to receive the anti-idiotypic antibody 105AD7±Bacillus Calmette-Guerin/alum or to no treatment (control group). The immunizations were given i.d./i.m. before surgery and continued for a period of 2 years. The patients were monitored in enzyme-linked immunospot (ELISPOT; γ-IFN), proliferation assay, and Luminex cytokine assays. Results: No serious adverse events were recorded. Of the 32 investigated immunized patients, 14 (44%) were considered to be responders in the ELISPOT assay. Induced proliferative responses were noted in 17 of 40 (43%) monitored patients. There was no correlation between the ELISPOT and proliferation assays. Luminex analyses revealed tumor necrosis factor-α and granulocyte macrophage colony-stimulating factor responses not only to the vaccine but also toward the native antigen CD55 in 9 of 13 (69%) patients. Conclusions: Immune responses to vaccination were induced in a majority of monitored patients measured by ELISPOT and proliferation assay. The lack of correlation between the ELISPOT and proliferation assays may reflect the fact that the two methods measure different T-cell responses and highlights the importance of multiple readouts in evaluating a potential cancer vaccine. Responses to both the anti-idiotype and the CD55 antigen were measurable, adding support to the use of CD55 as a target in cancer treatment.

Leaving a mark: the frequency and accuracy of tattooing prior to laparoscopic colorectal surgery

Aim  Intra‐operative localization of small cancers and polyps during laparoscopic colorectal surgery is difficult due to reduced tactile feedback. The consequences of failing to identify the lesion for resection can result in open conversion or removal of the wrong segment of bowel.

Gender-related perceptions of careers in surgery among new medical graduates: results of a cross-sectional study

BACKGROUND Despite promotional measures at a national level, female surgeons account for only 10% of the consultant workforce in the United Kingdom. With rising proportions of female medical graduates, it is important that surgery continues to recruit the most able candidates regardless of sex. This study investigates the differing perceptions of surgical careers among recent medical school graduates and identifies factors discouraging female doctors from pursuing a career in surgery. METHODS Newly qualified graduates from the University of Nottingham Medical School, Nottingham, UK, were invited to complete a nonmandatory questionnaire investigating career intentions and factors influencing this. RESULTS Two hundred and eight questionnaires were returned (a 66% response rate). Male respondents were significantly more likely to rate surgery as an attractive or very attractive career (P = .0116). Overall, only 33 (25%) female doctors expressed interest in a surgical career as opposed to 33 (42%) male doctors (P = .010). Frequently cited reasons included no interest in surgery itself (21%) and negative attitudes toward women in surgery among the surgical teams (18%). Irrespective of career interests, 59% of male and 68% of female respondents believed surgery was not a career welcoming women (P = .186). Reasons included difficulty maintaining family life, limited flexible training, and lack of role models. CONCLUSIONS This study identifies significant sex differences in the perception of surgical careers. The majority believes surgery does not welcome female trainees. Future strategies to promote surgery must address attitudes and behaviors in both sexes while taking active steps to support female surgeons during their training and in the workplace.

Fibrin glue for the treatment of fistulae in ano--a method worth sticking to?

Objective  The current evidence for fibrin glue as a treatment for anal fistulae is mixed. This study reviews the experience of fibrin glue as a treatment for anal fistulae in a single tertiary referral centre and attempts to identify factors related to failure of therapy and the length of follow‐up required.

Raised intraocular pressure (IOP) and perioperative visual loss in laparoscopic colorectal surgery: a catastrophe waiting to happen? A systematic review of evidence from other surgical specialities

BackgroundCase reports of healthy patients experiencing total perioperative visual loss (POVL) after elective laparoscopic surgery, including colorectal resection, are appearing increasingly frequently in the literature. We reviewed the literature exploring the relationship between patient positioning and intraocular pressure (IOP) across all surgical specialties. This was then applied to the potential risk of developing POVL in patients undergoing laparoscopic colorectal surgery.MethodsA systematic review of the relevant literature was performed to identify all studies exploring the relationship between intraocular pressure and patient positioning.ResultsEight relevant studies on both elective patients and healthy non-anaesthetised volunteers in the spinal, neurosurgical and urological fields were identified which explore the changes in IOP according to patient positioning. These all reported significant rises in IOP in both head-down positioning and prone positioning, and the strongest effects were seen in those patients placed in combined head-down and prone position (such as prone jackknife). Rises in IOP were time-dependent in all studies.ConclusionsPatients undergoing laparoscopic colorectal surgery in a prolonged head-down position are likely to experience raised IOP and thus are at risk of POVL. Those having a laparoscopic abdominoperineal excision with prone positioning for the perineal component are probably those in the greatest danger. Surgeons need to be aware of this under-recognised but potentially catastrophic complication.

Increased activation of lymphocytes infiltrating primary colorectal cancers following immunisation with the anti-idiotypic monoclonal antibody 105AD7

BACKGROUND The anti-idiotypic monoclonal antibody 105AD7 mimics the tumour associated antigen 791Tgp72, expressed on 70–80% of colorectal cancers. Phase I studies have shown that the vaccine is non-toxic, and a number of patients have been immunised prior to resection of their primary tumours. AIMS To assess lymphocyte activation at the tumour site by measuring expression of the α subunit of the interleukin 2 receptor (CD25). METHODS Nineteen patients with primary colorectal cancer were immunised with varying doses of 105AD7 prior to resection of their primary tumours. Samples of normal bowel and tumour edge/centre from 16 patients were available for immunohistochemical staining with a monoclonal antibody against CD25. Samples from a matched control group were also stained. Fresh tumours from 14 immunised patients and 31 unimmunised control patients were disaggregated, and the lymphocytes obtained labelled for CD25. Samples were analysed blindly by flow cytometry. RESULTS Median infiltration of lymphocytes expressing CD25, measured immunohistochemically, was higher in trial patients, as was the ratio of tumour to normal bowel infiltration. Flow cytometric analysis of fresh tumour from immunised patients showed a significantly higher percentage of lymphocytes expressing CD25 tumour infiltrating lymphocytes than their matched and unmatched controls. DISCUSSION The α subunit of the interleukin 2 receptor is increased on tumour infiltrating lymphocytes, in patients immunised with the colorectal cancer vaccine 105AD7. This suggests a population of activated lymphocytes capable of targeting 791Tgp72 expressing tumour cells, such as circulating micrometastases. 105AD7 may have a role as adjuvant therapy in early stage disease.