Background:Severe toxicity is experienced by a substantial minority of patients receiving fluoropyrimidine-based chemotherapy, with approximately 20% of these severe toxicities attributable to polymorphisms in the DPYD gene. The DPYD codes for the enzyme dihydropyrimidine dehydrogenase (DPD) important in the metabolism of fluoropyrimidine-based chemotherapy. We questioned whether prospective DPYD mutation analysis in all patients commencing such therapy would prove more cost-effective than reactive testing of patients experiencing severe toxicity.Methods:All patients experiencing severe toxicity from fluoropyrimidine-based chemotherapy for colorectal cancer in an Irish private hospital over a 3-year period were tested for 4 DPYD polymorphisms previously associated with toxicity. The costs associated with an index admission for toxicity in DPD-deficient patients were examined. A cost analysis was undertaken comparing the anticipated cost of implementing screening for DPYD mutations versus current usual care. One-way sensitivity analysis was conducted on known input variables. An alternative scenario analysis from the perspective of the Irish health-care payer (responsible for public hospitals) was also performed.Results:Of 134 patients commencing first-line fluoropyrimidine chemotherapy over 3 years, 30 (23%) patients developed grade 3/4 toxicity. Of these, 17% revealed heterozygote DPYD mutations. The cost of hospitalization for the DPYD-mutated patients was €232 061, while prospectively testing all 134 patients would have cost €23 718. Prospective testing would result in cost savings across all scenarios.Conclusions:The cost of hospital admission for severe chemotherapy-related toxicity is significantly higher than the cost of prospective DPYD testing of each patient commencing fluoropyrimidine chemotherapy.

BackgroundEntrapped rectal foreign bodies can be a challenge to manage and are being encountered by acute surgical teams with increasing frequency. The aims of our study were to (a) ascertain the population demographics of patients presenting with this problem in our local area of East Kent, (b) see if an association could be drawn between this presentation and proposed risk factors such as a psychiatric illness or socioeconomic deprivation, and (c) to review how foreign bodies are being removed in the East Kent Hospital University Foundation NHS Trust, United Kingdom and to highlight best practice with regards to this in line with the latest guidelines. MethodologyBetween 2017 and 2021, 32 cases of entrapped rectal foreign bodies were diagnosed and managed at our NHS Trust. Retrospective data taken from the theatre directory and electronic patient records were used to audit patient demographics, co-morbidities, the type of foreign body, and the extraction technique. ResultsThe majority of patients (90%) were male (n = 29). The patients' age ranged from 15 to 95 years, with a median age of 48 years. In total, 12 (37.5%) patients had a medical history of a psychiatric illness. The most common foreign bodies removed were sex toys or vibrators (n = 8) and roll-on deodorant bottles (n = 7). Kent Area B (n = 10) and Kent Area A (n = 9) were the areas with the highest number of cases. Twenty-two (68.8%) patients underwent examination under a general anaesthetic for removal, seven (21.8%) patients had the object manually removed without sedation, and three (9.4%) required a laparotomy with or without bowel resection. ConclusionsCases of an entrapped rectal foreign body in this local region typically involved male patients between 40 and 50 years old. A high proportion of this group had a history of a psychiatric illness supporting an association between this presentation and mental health. We have proposed some explanations for this association including the anal canal nervous system interplay with the "brain-gut axis." Lower socioeconomic status and unemployment may also be risk factors for this surgical problem. A trans-anal approach for management is successful in the majority of cases; however, almost 10% of patients required emergency surgical management. We have highlighted best practice guidelines for the investigation and management of the entrapped rectal foreign body as part of our discussion.

Aims Entrapped rectal foreign bodies (FB) are being encountered by acute surgical teams with increasing frequency and can be a challenge to manage. This study aims to highlight typical patient demographics, risk factors for presentation and management options for these patients. Methods Between 2017 and 2021, 29 cases of rectal FB were diagnosed and managed at East Kent Hospital University Foundation trust. Retrospective data taken from theatre directory and electronic notes was used to audit patient demographics, co-morbidities, the type of foreign body and the extraction technique. Results The majority of patients were male (87%). The patient's age ranged from 15 to 78 years, with a median age of 48 years. In the majority of cases, the FB had become entrapped during sexual activity. Nineteen patients (65%) underwent examination under GA for removal, seven patients (24%) were manually evacuated and three required a laparotomy (10.3%). Nine patients (31%) had a history of known mental health problems. The most common FB removed was a roll-on deodorant (n=5). Conclusion Cases of rectal FB's needing surgical management typically involve male patients in their 40's. While a small proportion can have manual evacuation, the majority require examination under anesthetic and in some cases a laparotomy. While a larger study would be required for significance, it appears a history of mental health problems may predispose patients to presenting with this problem. Patients present with a wide range of foreign body type, typically items commonly found in the home, the most common being roll on deodorant.

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