Maryam Alfa-Wali

Chemoradiotherapy for anal cancer in HIV patients causes prolonged CD4 cell count suppression

BACKGROUND Despite the advent of highly active antiretroviral therapy, anal cancer remains a significant health problem in human immunodeficiency virus (HIV) patients. We present the clinical features and treatment outcomes of anal cancer in 60 HIV-positive patients over a 20-year period. PATIENTS AND METHODS A prospective database of all HIV-positive individuals managed in a specialist unit since 1986 includes 11 112 patients (71 687 person-years of follow-up). Sixty patients with anal cancer were identified. Their clinicopathological and treatment details were analysed. RESULTS At anal cancer diagnosis, the mean age was 44 years (range: 28-75 years) and the median CD4 cell count was 305 mm-3 (range: 16-1252 mm-3). Fifty (83%) had chemoradiotherapy (CRT). Forty-six (92%) responded, of whom 10 (22%) subsequently relapsed with locoregional (70%), metastatic disease (10%) or both (20%). The overall 5-year survival is 65% (95% confidence interval 51% to 78%). The median CD4 count fell from 289 mm-3 before CRT to 132 mm-3 after 3 months and to 189 mm-3 after 1 year (P < 0.05). Six patients in remission of anal cancer died of acquired immunodeficiency syndrome defining illnesses. CONCLUSIONS The management of anal cancer with CRT achieves similar outcomes as the general population. CRT is associated with significant prolonged CD4 suppression that may contribute to late deaths of patients in remission.BACKGROUND Despite the advent of highly active antiretroviral therapy, anal cancer remains a significant health problem in human immunodeficiency virus (HIV) patients. We present the clinical features and treatment outcomes of anal cancer in 60 HIV-positive patients over a 20-year period. PATIENTS AND METHODS A prospective database of all HIV-positive individuals managed in a specialist unit since 1986 includes 11 112 patients (71 687 person-years of follow-up). Sixty patients with anal cancer were identified. Their clinicopathological and treatment details were analysed. RESULTS At anal cancer diagnosis, the mean age was 44 years (range: 28-75 years) and the median CD4 cell count was 305 mm(-3) (range: 16-1252 mm(-3)). Fifty (83%) had chemoradiotherapy (CRT). Forty-six (92%) responded, of whom 10 (22%) subsequently relapsed with locoregional (70%), metastatic disease (10%) or both (20%). The overall 5-year survival is 65% (95% confidence interval 51% to 78%). The median CD4 count fell from 289 mm(-3) before CRT to 132 mm(-3) after 3 months and to 189 mm(-3) after 1 year (P<0.05). Six patients in remission of anal cancer died of acquired immunodeficiency syndrome defining illnesses. CONCLUSIONS The management of anal cancer with CRT achieves similar outcomes as the general population. CRT is associated with significant prolonged CD4 suppression that may contribute to late deaths of patients in remission.

High-resolution anoscopy screening of HIV-positive MSM: longitudinal results from a pilot study.

Background:The ability to detect and treat pre-malignant anal lesions suggests screening may prevent anal cancer. The incidence of anal cancer in men who have sex with men (MSM) living with HIV exceeds that of cervical cancer before screening was introduced. Methods:High-resolution anoscopy (HRA) with intervention for high-grade squamous intraepithelial lesions (HSILs) was offered to asymptomatic HIV-positive MSM. Patients with HSILs were treated and follow-up HRA performed after 6 months, whilst patients with low-grade squamous intraepithelial lesions had a repeat HRA after 12 months. Results:Three hundred and sixty-eight asymptomatic MSM had a total of 1497 HRAs during a median follow-up of 4.2 years (maximum 13 years). At first HRA, 36% had normal appearances, 16% had no dysplasia, 15% anal intraepithelial neoplasia (AIN)-1, 19% AIN-2 and 13% AIN-3. During follow-up, five patients (1.4%) developed invasive anal cancer (incidence 2.7 per 1000 person-years). The 5-year cancer rate for the 368 patients was 0.3% [95% confidence interval (CI) 0–0.6%]. Progression to cancer was associated with higher age (P = 0.049) and AIN-3 (P = 0.024). Ninety patients had AIN-3 present at least at one HRA. The cumulative risk of cancer from first AIN-3 diagnosis was 3.2% (95% CI 0–7.8%) at 5 years. One hundred and seventy-one patients had HSILs (AIN-2 or 3) present at least once. The cumulative risk of cancer from first HSIL diagnosis was 0.6% (95% CI 0–1.8%) at 5 years. Conclusion:AIN-3 is a significant risk factor for subsequent anal cancer, although the tumours detected in screened patients were small localized, and generally the outcomes were favourable.

Eco-friendly laparoscopic home trainer.

Introduction: Laparoscopic surgery is becoming the main surgical technique in use today. Surgical trainees have to be able to practice these skills in a safe environment. This article describes the design of a novel cheap home laparoscopic trainer using recycled and reusable items. Methods: This novel home laparoscopic trainer is designed using a mobile phone, torch, and shoe box. Fifteen surgical trainees with variable laparoscopic experience used the device and provided feedback by filling in a Likert scale questionnaire. Results: This is a device that is easy to make and reuse with equipment that is easily accessible in most environments. All the trainees who used the device found it easy to use and helpful for practicing hand-eye coordination. Conclusions: This is simple and low-cost device allows trainees to practice laparoscopic skills in a safe environment. It provides a design that is accessible and recyclable, hence useful as a low-technology device in places where finances are limited.

Colorectal cancer in HIV positive individuals: The immunological effects of treatment

BACKGROUND AND OBJECTIVES Since the introduction of highly active antiretroviral therapy (HAART), non-AIDS defining malignancies including colorectal cancer (CRC) have emerged as major health concerns for people living with HIV. METHODS From a prospective database of 11,112 HIV seropositive individuals, we identified 11 patients with CRC. Clinicopathological details on the presentation, treatment and outcomes were collected. RESULTS All were male with a median age of 50 years (range 36-67) and median duration of HIV infection of 7.2 years (range 0-21). Five had metastatic disease at presentation, including 1 patient with a small cell cancer of the rectum. Patients were treated along conventional lines for CRC with concomitant HAART and opportunistic infection prophylaxis. During treatment, median CD4 cell counts fell from 357/mm(3) at CRC diagnosis to 199/mm(3), although no opportunistic infections were recorded. Three patients have died and the 5-year overall survival measured 65% (95% confidence interval 32-98%). CONCLUSIONS Treatment for CRC reduces cellular immunity and potentially puts HIV patients at risk of opportunistic infections; knowledge of HIV status prior to starting treatment is essential. This risk may be reduced by concomitant HAART and prophylaxis. Clinicians managing CRC should consider screening patients for HIV before starting chemotherapy or radiotherapy.

Michelin-starred theatres

The recent universal adoption of pre-procedure surgical checklists illustrates how modern surgical practice has benefited from lessons in safety culture, courtesy of high-risk industries like commercial aviation1,2 and petroleum exploration.3 Such ideas are implemented to reduce risk and avert catastrophe, but perhaps surgery can also share tips with less hazardous professions. As celebrity chefs roll up their sleeves for more broadcasting of the perfect roast goose recipe, perhaps we can consider their more restaurant-tied comrades, and their skills and attributes. Cooking seems to have parallels with surgery. Modern surgical care and the finest commercial gastronomy have the shared aspiration of providing dependable excellence. Haute cuisine chefs and leading surgeons must deliver a personalized service which is self-critical and constantly improving in a high-pressure environment. A limp souffle may be less catastrophic to the recipient than a poorly-fashioned anastomosis, but errors must still be universally avoided. Knives apart, the working day in a Michelin-starred kitchen functions with the surgical precision of the most well-oiled theatre. There is a hierarchical division of labour from the kitchen assistant to the head chef. Even with exemplary assistance from the multidisciplinary team, ultimate responsibility for gastronomical governance rests with the chef. He or she must be an inspiring leader, effective communicator and proactive manager. The chef innovates with the menu and ingredients, audits the quality of dishes, deals with suppliers, monitors recruitment and staffing, still leaving time for communicating effectively with the occasional dissatisfied customer. He or she also ensures resources used are cost-effective without compromising quality, and oversees the safety and professional development of the team. Optimum success in surgery does not just require technical competence, but a Raymond Blanc style passion and work ethic to achieve the absolute best. With this personal focus, both professionals learn the importance of timing. Unplanned delays to surgery lead to poor outcomes,4 and glitches during operative lists create inefficiencies and frustration.5 Chefs also understand the sequelae of delays: spoilt food and hungry diners. They avoid this with meticulous timing as a product of anticipation, practice and clear communication. A restaurants success is judged by both reputation and, because of financial necessity, by the number of profitable diners fed. This is effectively ‘payment by performance’, and has been a strategy to shorten surgery waiting lists and improve care over the last decade.6 It remains to be seen how the proposed abolition of NHS targets will affect the reputation of surgical provision. While surgical training is changing,7 both professions are still taught through the apprenticeship model and necessarily dependent upon an effective teacher–apprentice dynamic. With reduced hours and the conversion to shift work patterns, many surgical trainees have no continuity with their trainers, and would be envious of the stable supervision that the head chef provides to underlings. Both experts pass on technical skills and understanding: the chef looks, smells and tastes; the surgeon looks, listens and feels. Admired techniques are adopted; others rejected. But with practice, careful supervision and encouragement, the successful trainee matures from assisting lipoma excisions to teaching endarterectomies, and the kitchen assistant graduates from peeling potatoes to demonstrating how to create sashimi and manage a restaurant. As the surgeon develops a subspecialist niche, the chef cultivates a signature dish. Cookery has even benefited from evidence-based practice. The structured methodological analysis of ‘molecular gastronomy’ elucidates which culinary dogma is relevant and why. It produces rationale for streamlining processes, improving outcome, reducing mishaps and facilitating innovation. There are international seminars and professorships in the discipline,8 and at El Bulli in Catalonia and the Fat Duck in Berkshire, virtual databases of structured culinary experiments.9 Surgeon scientists have modified practice, for example following the extensive investigation of the effect of temperature on patient outcome during surgery.10,11 Research has taught the gourmet chef to use liquid nitrogen to create smooth crystal-free ice cream, and sous-vide waterbaths to poach the perfect steaks.8 Technological developments provide novelty and excitement, and, as has been demonstrated with minimally invasive surgery, can improve patient care. Nevertheless, reminded that a well-honed traditional fruit crumble trumps any botched bacon and egg ice cream,12 we must be sure that surgical innovation provides a genuine improvement upon the status quo. For example, Da Vinci surgical robots (Intuitive Surgical, California) offer many theoretical advantages over open or laparoscopic surgery, but cost-effective clinical benefits must be proven before there is more widespread uptake.13 In some respects, the gourmet kitchen resembles the surgical firm of a previous era: extreme hours not protected by the European Working Time Directive, under the Ramsay-esque control of an autocratic consultant. But as surgery has learnt and borrowed concepts of incident reporting from aviation, and teamwork from the Ferrari pitlane,14 perhaps it can learn from high-end cuisine, even if just to marinate the thoughts and be reminded of the need for excellence and attention to detail.

Clinical leadership and clinical followership

In response to Abbasis editorial,1 we need situational clinical leadership. Leaders that rise to the occasion with managerial responsibility in the NHS. The relationship between doctors and managers depends on negotiation and effective communication about organizational goals. Clear reasoning behind clinical priorities and economical objectives would create the happy medium between the two. The growth of clinical leadership as well as clinical followership needs to be encouraged with openness and innovativeness, to universally benefit patient care.

Unusual case of a rectal tumour

A 48-year-old man presented as an emergency with a 3-week history of rectal bleeding. Examination of his rectum revealed a circumferential tumour, 2 cm from the anal verge. An MRI scan reported a locally infiltrative mid-lower rectal tumour staged as T3d/T4 N2 MX. A colonoscopy revealed appearances of severe proctitis and biopsies did not show any evidence of dysplasia or malignancy. The patient was discussed at the regional colorectal cancer multidisciplinary team meeting with a management plan for neoadjuvant chemoradiotherapy following repeat biopsies, which were again negative for malignancy. He tested positive for the HIV and was referred to genitourinary medicine. A positive Chlamydia trachomatis nucleic acid test from a rectal swab was serovar L2 consistent with a diagnosis of lymphogranuloma venereum. He was treated with doxycycline and subsequent MRI scans showed reduction in tumour size with eventual resolution. This case report highlights the importance of HIV testing in patients with newly diagnosed colorectal tumours.

A mass more ordinary

An 88-year-old woman presented with sudden onset sharp upper abdominal pain associated with anorexia, vomiting and weight loss. Examination revealed a tender palpable mass in the epigastrium without any abnormal blood tests. A CT scan showed a 12 cm cystic mass in the epigastrium with the gallbladder not identified, and separate from the liver and pancreas (figure 1). Ultrasound confirmed the cystic lesion as the gallbladder with sludge. A cholecystostomy was initially performed, draining 600 mL …

Scarless surgery: a warning for shortcut history-taking

The examination of the abdomen from the end of the bed provides vital information to the medical student and the clinician alike. It can give a picture of the problems inside from its size, shape and sometimes even its colour before palpation. Since the first successful laparotomy in the early 1800s by Ephraim McDowell,1 the midline scar seen from the end of the bed examination of the abdomen has been a good indicator to the clinician that the patient has had a previous surgical procedure. The tell-tale signs of exact surgical procedures were apparent from the location of a scar such as the Kochers incision for an open cholecystectomy or McBurneys incision for an open appendicectomy. As surgical innovation and technology advance,the skills involved in deciphering a patients previous operations are going back to first principles. The first laparoscopic cholecystectomy dates back to 1985 over 100 years after the first open procedure.2 As we have just begun to be familiar with the locations of laparoscopic scars for various procedures, single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) for common procedures have now come into play. The first NOTES procedure demonstrated that abdominal surgical interventions can be carried without abdominal wall incisions.3 Shortly after that the first transvaginal cholecystectomy was reported in 2007 by Zorron et al.4 Hence, the common scars once seen are now disappearing. The goal, especially for medical students and junior surgical trainees, is to understand the presentation of surgical disease.5 Medical students easily get distracted with the primary skill they are required to master is the physical examination. Without effective history-taking it is not possible to elicit the necessary signs to make differential diagnoses. Learning about patients as clinicians still comes from the history that we take which captures not only the physical problems but also sometimes the underlying psychological concerns. We naturally learn through story-telling when we present our patients to others or as we live our own lives. The history-taking and presenting forms an integral part of medicine. Data processing to make a diagnosis comes from taking the story and the history of the story. Our observational skills go hand in hand with the stories that form part of our life cycle. Hence, clinical reasoning can be challenging without a proper history. The history-taking is not only about making a diagnosis but also being able to communicate and build rapport with your patient. The multidisciplinary approach to patient care relies heavily on the history elicited by different health professionals and the communication between them is all about ‘story-telling’. Invariably, listening to the patients story usually reveals the answer. The examination and investigation part of our management is guided by the story. History teaches us many things, once bitten with brief history-taking when examining a patient that has undergone a SILS or NOTES procedure the individual will not shy away from taking a full history next time. A change to medical history-taking is yet to come, till a chip-and-pin approach to medical notes becomes commonplace, clinicians have to rely on the patients memory to recall parts of their anatomy removed. The evolution of operative surgery means the telling tales of the long lines of surgical incisions will be no more. Hunting the facts of human activity can lead to profound understanding.6 The approach to patient management will continue for a while yet to be in the traditional three-step approach of history, examination and diagnostic tests.7 Despite the sophistication and innovation of technology as scarless surgery and robotic surgical procedures become the norm in the future, taking the patients history has no short cuts. The emphasis from clinical teachers should continue to be history before examination.

Change in healthcare.

Following your Podium ‘Change? Yes we can’, my thoughts within the NHS are for palliative care patients who wish to die at home. These patients need to have rapid access services to aid their discharge home. If we cannot do more for them medically or surgically, we can at least deliver their last wishes of dying at home rather than delaying discharge sometimes without real reason. Change is efficient social services so acute services are not mismanaged.