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Biomedical subjects

D Cade

Publications and source records attributed to D Cade.

At least 19 recordsLinked to original sources
PubMed2006

The adenoma carcinoma sequence: an indoctrinated model for tumorigenesis, but is it always a clinical reality?

OBJECTIVE: Evidence exists to support alternative pathways to the adenoma carcinoma sequence. Some mutations in key onco-suppressor genes relate to the anatomical site of the tumour. This link is typified by microsatellite instability and proximal neoplasia. However, rectal tumours are rarely considered separately. We hypothesized that tumour behaviour in the rectum may differ in terms of pathogenesis and malignant propensity. Therefore, we aimed to look for an association between the histopathological features of adenomas and their anatomical location as compared with the distribution of cancers. METHODS: A single centre prospective study was undertaken over a four-year period. Patients referred to a colorectal assessment clinic with bowel symptoms underwent a minimum investigation of flexible sigmiodoscopy. Neoplastic lesions were either biopsied or removed after noting distance from the anal margin. Adenomas, differentiated by size, villous architecture and degree of dysplasia were compared to both early and advanced carcinomas. RESULTS: Of 4089 patients, polyps were identified in 8.0% and cancer in 4.2%. There was a clear difference between the distribution of cancer and adenomas > 1 cm, P < 0.001. All degrees of dysplasia in large adenomas were more prevalent in the sigmoid colon as compared to cancer, P < 0.001. Seventy-five percent of high risk diminutive adenomas were rectal in origin. CONCLUSION: Our data provides indirect evidence to support the concept that a significant proportion of rectal cancers may arise via an alternative pathway to the Vogelstein model. Polyp behaviour along with malignant propensity may actually be site dependent, with rectal polyps harbouring a more aggressive phenotype.

Adenoma↗
PubMed2006

Symptomatic presentation of early colorectal cancer.

INTRODUCTION: It is believed that increased detection of earlier stage colorectal cancer can only be achieved by screening asymptomatic individuals. We describe a referral pathway for a symptomatic population which achieves a 30% Dukes' A detection rate. PATIENTS AND METHODS: From October 1999, 4253 patients with distal colonic symptoms, referred by general practitioners, completed a patient consultation questionnaire (PCQ) linked to a computerised record. A weighted numerical score (WNS) was derived for each patient. Patients underwent flexible sigmoidoscopy, a diagnostic outcome was recorded and later Dukes' stage appended. Early and advanced colorectal cancers were separated and PCQ derived symptom profiles compared. Chi-square, Fisher exact, Student's t-test and logistic regression were used for statistical analysis. RESULTS: A total of 183 patients had cancer, 55 (30%) were Dukes' A early colorectal cancers, 112 were advanced colorectal cancers (Dukes' B-D) and 16 could not be staged. Early colorectal cancers had significant symptoms and comparable profile to advanced colorectal cancers. The tendency in advanced colorectal cancers was towards greater symptom prevalence for only a few primary and systemic symptoms, as reflected by a higher WNS of 75 (P = 0.001). CONCLUSIONS: Early colorectal cancers do have significant symptoms which can easily be captured by a PCQ and objective scoring tool in the secondary care setting. Detection of these cancers has the potential to improve survival.

Aged↗
PubMed2005

Variations in the evaluation of colorectal cancer risk.

OBJECTIVES: To test the variability in estimating cancer risk and demonstrate the consequences that subjectivity has on patient care. SUBJECTS AND METHODS: Forty-three clinicians were each asked to assess 40 symptomatic colorectal referrals. Each clinician was provided with a comprehensive history on the 40 patients. The clinicians graded the referral according to a malignancy risk score, decided on the required first line investigation and the priority of that investigation. The main outcome measures used was accuracy in cancer detection and appropriateness of investigations selected. RESULTS: There was a wide degree of variation among all clinicians grading both benign and malignant disease with the overall correct classification of 54% (P-value of <0.001). On average, the clinicians correctly diagnosed 71.3% of the cancer patients as compared to 44% of the benign patients. Of the cancer patients, 47% were correctly classified as an urgent referral whilst 52% of the benign patients were over classified and graded as an urgent referral. The mean number chosen by clinicians to have a flexible sigmoidoscopy as the appropriate first investigation was 13 (of 40 patients); this was despite the diagnosis being possible in all cases with a flexible sigmoidoscopy. The choice to use full colonic investigation was seen throughout all disciplines. Junior doctors demonstrated the highest tendency choosing full colonic investigation in 92.3%. Consultants and senior grades showed the least tendency to choose full colonic imaging although even here colonoscopy or barium enema represented 48.5%. CONCLUSION: Subjective assessment of cancer referrals is a significant problem that needs to be confronted. Improvements are needed to resolve the inherent problems of subjectivity and operator bias if uniform quality of patient care and best use of resources is to be achieved.

Adult↗
PubMed2005

Pitfalls in the construction of cancer guidelines demonstrated by the analyses of colorectal referrals.

INTRODUCTION: The aim of this study was to develop a system to compare and validate cancer referral guidelines, identifying the pitfalls in their development and provide a mechanism to evaluate their efficacy. PATIENTS AND METHODS: 3302 patients referred from primary care with colorectal symptoms over a 3-year period were assessed. All participants had a comprehensive history obtained via a questionnaire that incorporated all colorectal symptoms. The questionnaires were completed prior to assessment at the hospital. All patients were then assessed at the Colorectal One Stop Clinic (CROSC), underwent investigation and diagnosis achieved. All data were entered into a databank. Current prioritisation guidelines and tools that are used to assess colorectal referrals were applied to this colorectal databank to test their efficacy for cancer detection and referral prioritisation. Sensitivity and specificity for cancer detection and referral rates were assessed. RESULTS: Cancer was detected in 156 patients (4.7%). All prioritisation models (NHS guidelines, Weighted Numerical Score [WNS], Netherlands, Harvard, Mersey, and Somerset) differentiated cancer from non-cancer patients. The use of a few symptoms as risk predictors (e.g. NHS guidelines) causes a decrease in specificity in contrast to a comprehensive risk tool, for example, the WNS at a score of 50 (NHS 54.1%, WNS 62.9%). This results in a significantly higher referral rate (NHS 47.6%, WNS 39.4%) and identifies fewer cancers (NHS 80.1%, WNS 85.9%). Non-evidence based modifications of the NHS guidelines (Somerset and Mersey) caused a further deterioration in specificity, which was reflected in an increased referral rate. Using the WNS, which is objective and a continuous scale, allows adaptation of the referral threshold, balancing sensitivity and specificity to the resources available within a hospital. For example, the WNS of > or = 40 has a sensitivity of 96.8% for cancer detection. CONCLUSIONS: Accurate prospective data collection into a data bank allows testing of referral guidelines as well as providing an adjunct to guideline construction.

Aged↗
PubMed2002

Prediction of colorectal cancer by a patient consultation questionnaire and scoring system: a prospective study.

BACKGROUND: Current NHS guidelines for referral of patients with colorectal symptoms classify many as high risk but fail to identify a significant number of cancers in the low-risk group. We describe a practical scoring method to predict colorectal cancers. METHODS: From October, 1999, 2268 patients with distal colonic symptoms, referred by general practitioners, completed a patient consultation questionnaire linked to a computerised record. Referrals were prioritised with a malignancy risk score by a senior colorectal surgeon separately from the general practitioner's letter and from the questionnaire. A weighted numerical score was derived from weighting of primary symptoms and symptom complexes and was calculated automatically when the questionnaire data were entered into the computer program. Analysis by receiver-operating characteristics assessed the scoring systems. Sensitivities and specificities of scoring systems were compared with McNemar's test. FINDINGS: Of the 2268 patients, 95 had colorectal cancer. The average weighted numerical score was significantly higher for patients with cancer than for non-cancer patients (mean 76.5 [95% CI 72.2-80.9] vs 44.5 [43.6-45.4]; p<0.0001). At similar cancer detection rates, the malignancy risk score derived from the patient consultation questionnaire and the weighted numerical score graded lower proportions of referrals as urgent than did the current NHS guidelines (43.1% and 39.8% vs 49.8%; p<0.0001). INTERPRETATION: The patient consultation questionnaire depends on history alone and is easily reproducible. In conjunction with the weighted numerical score, which removes operator bias, it can be used as an accurate system for prediction of symptomatic colorectal cancer.

Adult↗
PubMed2001

Synchronous colonic tumours of dual pathology.

Synchronous colonic tumours of dual pathology are extremely rare. A review of the literature revealed that few cases have been reported to date. Because of their rarity and lack of specific symptoms, preoperative diagnosis is not easy and there is no protocol as yet for the ideal management of these cases. We present such a case which was treated by a combination of surgery and chemotherapy.

Adenocarcinoma↗
PubMed2001

Impact of questionnaires and telephone screening on attendance for ambulatory surgery.

The purpose of this study was to determine whether patient questionnaires along with pre-operative telephone screening could help to reduce the number of cancellations or postponements of patients listed for day case endoscopy and local anaesthetic procedures and thereby provide cost effective and more efficient patient care management. A total of 566 questionnaires were sent out with a return figure of 477 (84.27%). Of those not returning the questionnaires, 56 (9.89%) were contacted by telephone giving an overall figure of 533 (94.16%) patients contacted. The cancellation rate for this group was only 2.25% compared to figures between 8-12% as noticed in the previous year. We conclude questionnaires along with telephone screening are a very effective tool in reducing cancellations and postponements of day case patients.

Ambulatory Surgical Procedures↗
PubMed1998

False family history of breast cancer in the family cancer clinic.

AIMS: Awareness of hereditary breast and ovarian cancer in both the general public and the medical profession is increasing. Individuals who may be at risk on the basis of a family history are requesting risk determination and appropriate management in a variety of settings. Risk determination relies largely on pedigree analysis and epidemiological data. METHODS: We describe five individuals presenting in the family cancer or genetic counselling clinic where a factitious family or personal history led to erroneous risk estimation. Common factors in these families are a history of benign breast disease, poor communication within families, long survival with early onset or bilateral disease, a lack of detailed knowledge of the illness and treatment in close relatives and inconsistencies in the history in repeated consultations.

Adult↗
PubMed1981

Complications of anterior resection of the rectum using the EEA stapling device.

Fifty patients had anterior resection of the rectum performed with end-to-end anastomosis using the EEA stapling device. The instrument certainly facilitated low anastomoses, but anastomotic dehiscence occurred in 3 cases, stenosis in 2, wound sepsis in 10, some degree os incontinence (usually only temporary) in 7 and anal fissure in 4 cases.

Adult↗
PubMed1980

Dependent proximal loop colostomy: does it defunction the distal colon?

The operation of dependent proximal loop colostomy is described. This colostomy avoids the complications of prolapse and paracolostomy hernia and is easy to close. It appears clinically to totally defunction the distal colon; his ability was studied by means of a radioactive tracer. Ten patients were given chromium-51 by mouth and it was found that none of this spilled over into the distal loop. It is concluded that dependent proximal loop colostomies effectively defunction the distal colon.

Colon↗
PubMed1980

Congenital central hypoventilation and sleep state.

Congenital central hypoventilation (Ondine's curse) is described in an infant with persistant symptoms throughout the first nine months of life. Respiratory control was most severely affected in quiet sleep, although abnormalities were present in rapid eye movement (REM) sleep and while awake. Failure of metabolic control in quiet sleep led to profound hypoventilation. Behavioral or "behavioral-like" inputs in the awake state and REM sleep increased ventilation, but not to expected normal levels. The ventilatory response to inhaled 4% CO2 was markedly depressed in all states.

Carbon Dioxide↗