Letters to the Editor
295
Dear Editor, Re: Ward safety checklist in the acute surgical unit Blucher et al.1 concluded that their study is clinically important in illustrating that deficiencies in the non-standardized post-take surgical ward round can be overcome using the ward safety checklist (WSC). However, there are issues in the authors’ method of analysis. The most striking feature in the table 1 of the said paper is the absence of an analysis for individual items ‘before WSC and after WSC’. Re-analysis of the individual items revealed that 11 out of the 21 items showed no difference. Summing up the frequencies of the items in the three phases and then performing a χ2 test is inappropriate. The results of the authors’ analyses is tantamount to a type I error (claiming a difference when there is not one). Regarding the use of χ2 test in comparative trials, John Ludbrook (a former editor of this journal) has strongly argued that it should almost never be used to analyse the results of surgical studies.2 The authors should have used procedures that are designed to detect inequality of proportions or a ratio of proportions that differs from unity. References 1. Blucher KM, Dal Pra SE, Hogan J, Wysocki AP. Ward safety checklist in the acute surgical unit. ANZ J. Surg. 2014; 84: 745–7. 2. Ludbrook J. Is there still a place for Pearson’s chi-squared test and Fisher’s exact test in surgical research? ANZ J. Surg. 2011; 81: 923–6.
Amalia Karahalios, PhD, MPH Steven T. F. Chan, PhD, FRACS NorthWest Academic Centre, The University of Melbourne, Western Health, Melbourne, Victoria, Australia doi: 10.1111/ans.12994
Dear Editor, Metastatic colorectal cancer presenting with haematochezia and disseminated intravascular coagulation A 64-year-old woman presented with an 8-h history of haematochezia, 3 weeks after ultra-low anterior resection of a rectal tumour with covering loop ileostomy. The diagnosis of T3 rectal carcinoma was made 4 months prior to admission, with subsequent neoadjuvant chemoradiotherapy. Pre-treatment computed tomography (CT) and magnetic resonance imaging showed no metastases. Post-operative histopathology suggested a complete response. Examination revealed haematochezia and hypertension. There was no abdominal pain or abnormal stoma output. Laboratory investigations confirmed disseminated intravascular coagulation (DIC): elevated international normalized ratio (INR) (1.9), D-dimer (20 μg/ mL) and prothrombin time (20.5 s), low fibrinogen (1.0 g/L) and platelet count (58 × 109/L). The patient’s INR remained elevated despite IV vitamin K, four units of fresh frozen plasma and one unit of platelets. Colonoscopy revealed generalized colitis, widespread contact bleeding, but an intact anastomosis. © 2015 Royal Australasian College of Surgeons
Fig. 1. Histochemical stain of bone marrow trephine showing infiltration of CK20 positive cells (brown) suggesting colorectal origin.
Abdominal CT showed lytic lesions within the T8 vertebral body. Biopsy revealed malignant gastrointestinal cells (Fig. 1). Despite full treatment, the DIC could not be reversed and the decision to palliate was made. The patient died within days. DIC occurs in 6.8% of patients with solid tumours,1 although there are no frequency data in association with colorectal cancer (CRC).2 In a series of 1117 patients with solid tumours, 104 had CRC, eight with DIC.1 Advanced disease and bone marrow invasion have been reported to increase the risk of DIC.3 While the prognosis for CRC with DIC is unclear, there is consensus that treatment of the underlying cause is essential, as most cases prove fatal within 7–21 days.3 Heparin treatment is recommended only in compensated DIC. Decompensated DIC should be treated with plasma, cryoprecipitate and platelets.4 In one series of 22 chemotherapy-naïve patients, those with DIC receiving chemotherapy had a median survival of 90 days versus 30 days for those without.2 To our knowledge, this is the first reported case of an apparently disease-free patient representing with metastatic-induced DIC. There has been one in which DIC presented after 18 months of chemotherapy, which resolved after two cycles of FOLFOX plus bevacizumab.2 References 1. Sallah S, Wan JY, Nguyen NP, Hanrahan LR, Sigounas G. Disseminated intravascular coagulation in solid tumors: clinical and pathologic study. Thromb. Haemost. 2001; 86: 828–33. 2. Mizota A, Shitara K, Kondo C et al. A case of heavily pretreated rectal cancer with disseminated intravascular coagulation that improved following reintroduction of FOLFOX plus bevacizumab. Int. J. Clin. Oncol. 2011; 16: 766–9. 3. Huang WT, Chang KC, Shan YS, Tsao CJ, Lee JC. Successful initial treatment with weekly 24-hour infusion of 5-fluorouracil and leucovorin in a rectal cancer patient with acute disseminated intravascular coagulation. Hepatogastroenterology 2005; 52: 1436–9.
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
295
Dear Editor, Re: Ward safety checklist in the acute surgical unit Blucher et al.1 concluded that their study is clinically important in illustrating that deficiencies in the non-standardized post-take surgical ward round can be overcome using the ward safety checklist (WSC). However, there are issues in the authors’ method of analysis. The most striking feature in the table 1 of the said paper is the absence of an analysis for individual items ‘before WSC and after WSC’. Re-analysis of the individual items revealed that 11 out of the 21 items showed no difference. Summing up the frequencies of the items in the three phases and then performing a χ2 test is inappropriate. The results of the authors’ analyses is tantamount to a type I error (claiming a difference when there is not one). Regarding the use of χ2 test in comparative trials, John Ludbrook (a former editor of this journal) has strongly argued that it should almost never be used to analyse the results of surgical studies.2 The authors should have used procedures that are designed to detect inequality of proportions or a ratio of proportions that differs from unity. References 1. Blucher KM, Dal Pra SE, Hogan J, Wysocki AP. Ward safety checklist in the acute surgical unit. ANZ J. Surg. 2014; 84: 745–7. 2. Ludbrook J. Is there still a place for Pearson’s chi-squared test and Fisher’s exact test in surgical research? ANZ J. Surg. 2011; 81: 923–6.
Amalia Karahalios, PhD, MPH Steven T. F. Chan, PhD, FRACS NorthWest Academic Centre, The University of Melbourne, Western Health, Melbourne, Victoria, Australia doi: 10.1111/ans.12994
Dear Editor, Metastatic colorectal cancer presenting with haematochezia and disseminated intravascular coagulation A 64-year-old woman presented with an 8-h history of haematochezia, 3 weeks after ultra-low anterior resection of a rectal tumour with covering loop ileostomy. The diagnosis of T3 rectal carcinoma was made 4 months prior to admission, with subsequent neoadjuvant chemoradiotherapy. Pre-treatment computed tomography (CT) and magnetic resonance imaging showed no metastases. Post-operative histopathology suggested a complete response. Examination revealed haematochezia and hypertension. There was no abdominal pain or abnormal stoma output. Laboratory investigations confirmed disseminated intravascular coagulation (DIC): elevated international normalized ratio (INR) (1.9), D-dimer (20 μg/ mL) and prothrombin time (20.5 s), low fibrinogen (1.0 g/L) and platelet count (58 × 109/L). The patient’s INR remained elevated despite IV vitamin K, four units of fresh frozen plasma and one unit of platelets. Colonoscopy revealed generalized colitis, widespread contact bleeding, but an intact anastomosis. © 2015 Royal Australasian College of Surgeons
Fig. 1. Histochemical stain of bone marrow trephine showing infiltration of CK20 positive cells (brown) suggesting colorectal origin.
Abdominal CT showed lytic lesions within the T8 vertebral body. Biopsy revealed malignant gastrointestinal cells (Fig. 1). Despite full treatment, the DIC could not be reversed and the decision to palliate was made. The patient died within days. DIC occurs in 6.8% of patients with solid tumours,1 although there are no frequency data in association with colorectal cancer (CRC).2 In a series of 1117 patients with solid tumours, 104 had CRC, eight with DIC.1 Advanced disease and bone marrow invasion have been reported to increase the risk of DIC.3 While the prognosis for CRC with DIC is unclear, there is consensus that treatment of the underlying cause is essential, as most cases prove fatal within 7–21 days.3 Heparin treatment is recommended only in compensated DIC. Decompensated DIC should be treated with plasma, cryoprecipitate and platelets.4 In one series of 22 chemotherapy-naïve patients, those with DIC receiving chemotherapy had a median survival of 90 days versus 30 days for those without.2 To our knowledge, this is the first reported case of an apparently disease-free patient representing with metastatic-induced DIC. There has been one in which DIC presented after 18 months of chemotherapy, which resolved after two cycles of FOLFOX plus bevacizumab.2 References 1. Sallah S, Wan JY, Nguyen NP, Hanrahan LR, Sigounas G. Disseminated intravascular coagulation in solid tumors: clinical and pathologic study. Thromb. Haemost. 2001; 86: 828–33. 2. Mizota A, Shitara K, Kondo C et al. A case of heavily pretreated rectal cancer with disseminated intravascular coagulation that improved following reintroduction of FOLFOX plus bevacizumab. Int. J. Clin. Oncol. 2011; 16: 766–9. 3. Huang WT, Chang KC, Shan YS, Tsao CJ, Lee JC. Successful initial treatment with weekly 24-hour infusion of 5-fluorouracil and leucovorin in a rectal cancer patient with acute disseminated intravascular coagulation. Hepatogastroenterology 2005; 52: 1436–9.
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
