The colostomy impact score: development and validation of a patient reported outcome measure for rectal cancer patients with a permanent colostomy. A population-based study

AIM

The aim was to develop and validate a simple scoring system evaluating the impact of colostomy dysfunction on quality of life (QOL) in patients with a permanent stoma after rectal cancer treatment.

METHOD

In this population-based study, 610 patients with a permanent colostomy after previous rectal cancer treatment during the period 2001-2007 completed two questionnaires: (i) the basic stoma questionnaire consisting of 22 items about stoma function with one anchor question addressing the overall stoma impact on QOL and (ii) the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30. Answers from half of the cohort were used to develop the score and subsequently validated on the remaining half. Logistic regression analyses identified and selected items for the score and multivariate analysis established the score value allocated to each item.

RESULTS

The colostomy impact score includes seven items with a total range from 0 to 38 points. A score of ≥ 10 indicates major colostomy impact (Major CI). The score has a sensitivity of 85.7% for detecting patients with significant stoma impact on QOL. Using the EORTC QLQ scales, patients with Major CI experienced significant impairment in their QOL compared to the Minor CI group.

CONCLUSION

This new scoring system appears valid for the assessment of the impact on QOL from having a permanent colostomy in a Danish rectal cancer population. It requires validation in non-Danish populations prior to its acceptance as a valuable patient-reported outcome measure for patients internationally.

Pelvic floor electrophysiology in spinal cord injury

OBJECTIVE

The study aimed to investigate sacral peripheral nerve function and continuity of pudendal nerve in patients with chronic spinal cord injury (SCI) using pelvic floor electrophysiological tests.

METHODS

Twelve patients with low cervical or thoracic SCI were prospectively included. Quantitative external anal sphincter (EAS) muscle electromyography (EMG), pudendal nerve terminal motor latency (PNTML) testing, bulbocavernosus reflex (BCR) testing and pudendal short-latency somatosensory-evoked potential (SEP) measurement were performed.

RESULTS

In EAS muscle EMG, two patients had abnormal increased spontaneous activity and seven prolonged motor unit potential duration. PNTML was normal in 10 patients. BCR was present with normal latency in 11 patients and with prolonged latency in one. The second component of BCR could be recorded in four patients. SEPs showed absent cortical responses in 11 patients and normal latency in one.

CONCLUSIONS

Pudendal nerve and sacral lower motor neuron involvement are significantly associated with chronic SCI, most prominently in EAS muscle EMG. The frequent finding of normal PNTML latencies supports earlier concerns on the utility of this test; however, BCR and pudendal SEPs may have clinical relevance.

SIGNIFICANCE

As intact peripheral nerves including pudendal nerve are essential for efficient supportive therapies, pelvic floor electrophysiological testing prior to these interventions is highly recommended.

Validation of the English translation of the low anterior resection syndrome score

AIM

Many patients having anterior resection for rectal cancer suffer from severe long-term bowel dysfunction, known as low anterior resection syndrome (LARS). The LARS score was developed in Denmark, and Swedish, Spanish and German versions have been validated. The aim of this study was to validate the English translation of the LARS score in British rectal cancer patients.

METHOD

Rectal cancer patients who underwent an anterior resection in 12 UK centres received the LARS score questionnaire, the EORTC QLQ-C30 and a single ad hoc quality of life question. A subgroup of patients received the LARS score questionnaire twice.

RESULTS

The response rate was 80% and 451 patients were included in the analyses. A strong association between LARS score and quality of life (convergent validity) was found (P < 0.01), discriminative validity was good (P < 0.02) and the test-retest reliability was high (intraclass correlation coefficient 0.83).

CONCLUSION

The English translation of the LARS score has shown good psychometric properties comparable with recently published results from an international multicentre study. Thus, the English translation of the LARS score can be considered a valid and reliable tool for measuring LARS.

Brains striving for coherence: Long-term cumulative plot formation in the default mode network

Many everyday activities, such as engaging in conversation or listening to a story, require us to sustain attention over a prolonged period of time while integrating and synthesizing complex episodic content into a coherent mental model. Humans are remarkably capable of navigating and keeping track of all the parallel social activities of everyday life even when confronted with interruptions or changes in the environment. However, the underlying cognitive and neurocognitive mechanisms of such long-term integration and profiling of information remain a challenge to neuroscience. While brain activity is generally traceable within the short time frame of working memory (milliseconds to seconds), these integrative processes last for minutes, hours or even days. Here we report two experiments on story comprehension. Experiment I establishes a cognitive dissociation between our comprehension of plot and incidental facts in narratives: when episodic material allows for long-term integration in a coherent plot, we recall fewer factual details. However, when plot formation is challenged, we pay more attention to incidental facts. Experiment II investigates the neural underpinnings of plot formation. Results suggest a central role for the brain's default mode network related to comprehension of coherent narratives while incoherent episodes rather activate the frontoparietal control network. Moreover, an analysis of cortical activity as a function of the cumulative integration of narrative material into a coherent story reveals to linear modulations of right hemisphere posterior temporal and parietal regions. Together these findings point to key neural mechanisms involved in the fundamental human capacity for cumulative plot formation.

Effect of a 16 weeks weight loss program on osteoarthritis biomarkers in obese patients with knee osteoarthritis: a prospective cohort study

OBJECTIVE

Changes in biomarkers for bone and cartilage in knee osteoarthritis (KOA) may reflect changes in tissue turnover induced by interventions. The aim of this study was to assess the effect on osteoarthritis biomarkers of an intensive weight loss intervention in obese KOA patients.

METHODS

192 obese KOA patients followed a 16 weeks weight loss intervention (ClinicalTrials.gov: NCT00655941). Serum Cartilage Oligomeric Matrix Protein (sCOMP), Urine C-terminal telopeptide of collagen type II (uCTX-II) and type I (uCTX-I) were determined by enzyme-linked immunoassay (ELISA) at baseline and after 16 weeks. Patient-reported symptoms were assessed by the Knee Injury and Osteoarthritis Outcome Score (KOOS) Questionnaire without the sports and recreation score (KOOS-4). Change from baseline was analyzed using Analysis of CoVariance (ANCOVA) adjusting for sex, age, and body mass index (BMI). Bivariate associations were analyzed using Spearman's test of rank correlation.

RESULTS

175 patients completed the treatment and lost mean 13.4 (95% CI: 12.5-14.4) kg. sCOMP concentration decreased on average 1.1 (95% CI: -1.5 to -0.8) U/L with a correlation to weight loss (r = -0.17, P = 0.028), but not to change in KOOS-4 (r = -0.13, P = 0.091). uCTX-II increased significantly, mean 69 (95% CI: 31-106) ng/mmol creatinine, with no relation to weight loss (P = 0.14). Change in uCTX-II was reversely related to change in KOOS-4 (r = -0.28, P = 0.0003). uCTX-I increased, mean 67 (95% CI: 47-87) μg/mmol creatinine, and correlated to weight loss (r = 0.22, P = 0.0007), while not to KOOS-4 (P = 0.93).

CONCLUSION

A rapid substantial weight loss in obese KOA patients was weakly, while significantly associated with a reduction in sCOMP, and increases in both uCTX-II and uCTX-I.

Urine homogentisic acid and tyrosine: simultaneous analysis by liquid chromatography tandem mass spectrometry

Alkaptonuria (AKU) is a rare debilitating autosomal recessive disorder of tyrosine metabolism. Deficiency of homogentisate 1,2-dioxygenase results in increased homogentisic acid (HGA) which although excreted in gram quantities in the urine, is deposited as an ochronotic pigment in connective tissues, especially cartilage. Ochronosis leads to a severe, early-onset form of osteoarthritis, increased renal and prostatic stone formation and hardening of heart vessels. Treatment with the orphan drug, Nitisinone, an inhibitor of the enzyme 4-hydroxyphenylpyruvate dioxygenase has been shown to reduce urinary excretion of HGA, resulting in accumulation of the upstream pre-cursor, tyrosine. Using reverse phase LC-MS/MS, a method has been developed to simultaneously quantify urinary HGA and tyrosine. Using matrix-matched calibration standards, two product ion transitions were identified for each compound and their appropriate isotopically labelled internal standards. Validation was performed across the AKU and post-treatment concentrations expected. Intrabatch accuracy for acidified urine was 96-109% for tyrosine and 94-107% for HGA; interbatch accuracy (n=20 across ten assays) was 95-110% for tyrosine and 91-109% for HGA. Precision, both intra- and interbatch was <10% for tyrosine and <5% for HGA. Matrix effects observed with acidified urine (12% decrease, CV 5.6%) were normalised by the internal standard. Tyrosine and HGA were proved stable under various storage conditions and no carryover, was observed. Overall the method developed and validated shows good precision, accuracy and linearity appropriate for the monitoring of patients with AKU, pre and post-nitisinone therapy.

Autonomic dysreflexia during bowel evacuation procedures and bladder filling in subjects with spinal cord injury

STUDY DESIGN

Randomized, controlled clinical trial.

OBJECTIVES

Bladder and bowel management may cause serious autonomic dysreflexia (AD) in subjects with high spinal cord injury (SCI). We aimed at investigating autonomic responses to digital rectal evacuation (DE), transanal irrigation (TAI) with 500 ml and filling cystometry (FC) in SCI.

SETTING

Aarhus University Hospital, Denmark.

METHODS

Eight subjects with SCI (AIS A) at or above T6 (high SCI) and a previous history of AD were compared with three subjects with SCI (AIS A) between T10 and L2 (low SCI). In randomized order, DE, TAI and FC were performed. AD was defined as an acute rise in systolic blood pressure (sBP) of ⩾30 mm Hg above baseline. Blood levels of norepinephrine and epinephrine were determined before and shortly after the procedures.

RESULTS

During all three procedures, AD occurred in all patients with high SCI but not in those with low SCI. In high SCI subjects, DE increased median sBP from 127 (range: 86-154) to 188 (range: 140-206) mm Hg (P<0.02), TAI from 126 (range: 91-146) to 163 (range: 130-188) mm Hg (P<0.02) and FC from 125 (range: 106-149) to 200 (range: 179-220) mm Hg (P<0.01). The sBP increase was lower during TAI than during DE (P<0.05) or FC (P<0.02). In high SCI subjects, the blood levels of norepinephrine, but not those of epinephrine, increased significantly during all three stimuli (all P<0.05).

CONCLUSION

Bowel and bladder management caused AD in high SCI. The response is less severe during TAI than during FC or DE.

Colorectal transport during defecation in subjects with supraconal spinal cord injury

STUDY DESIGN

Clinical study.

OBJECTIVES

To explore how supraconal spinal cord injury (SCI) affects colorectal emptying at defecation. Further, to relate findings to subject symptomatology expressed by bowel function scores and gastrointestinal transit time (GITT).

SETTING

Aarhus University Hospital, Denmark.

METHODS

Colorectal contents were marked by oral intake of (111)In-coated resin pellets. Movement of stools at defecation was assessed by comparing scintigrams performed before and just after defecation. Results from 15 subjects with SCI (14 males, median age=47 years (range: 22-74 years), SCI level: C5-Th9) were compared with those from 16 healthy volunteers (12 males, median age=31 years (range: 24-42 years)). Bowel symptoms were described from standard symptom scores, and GITT was assessed by radiopaque markers.

RESULTS

Median emptying at defecation was 31% of the rectosigmoid (range: 0% to complete emptying of the rectosigmoid and 49% of the descending colon) in subjects with SCI and 89% of the rectosigmoid (range: 53% to complete emptying of the rectosigmoid and the descending colon, and 3% of the transverse colon) in the control group (P<0.01). Colorectal emptying at defecation was associated with the St Mark's fecal incontinence score (P=0.02) but not with the Cleveland constipation score (P=0.17), the neurogenic bowel dysfunction score (P=0.12) or GITT (P=0.99).

CONCLUSION

Supraconal SCI results in significantly reduced emptying of stools at defecation. This is independent of changes in GITT.

A Flow Cytometric Method for Rapid Determination of Sperm Concentration and Viability in Mammalian and Avian Semen

A new flow cytometric method has been developed to rapidly determine sperm concentration and viability in semen from bulls and boars. Sperm viability was determined on the basis of staining with SYBR-14 and propidium iodide (PI), and this allowed detection of live (membrane-intact) sperm, dying (moribund) sperm, as well as dead cells. Fluorescent microspheres (beads) were used to determine sperm concentration. The use of SYBR-14 at 50 nM and PI at 12 micro M in combination with the FACSCount diluent in the counting tubes resulted in a uniform staining after 2.5-5 minutes at room temperature. Reagent staining was reproducible enough to allow subsequent semiautomated analysis of data using Attractors software. In experiment 1, this method was used to analyze semen from boars, rams, rats, rabbits, humans, and turkeys. In experiment 2, Attractors analysis was performed by the FACSCount AF flow cytometer, and sperm concentration determination with this system was compared with results obtained by a spectrophotometer and an electronic cell counter, which is routinely used by bull artificial insemination centers. When compared to microscopic counting in a hemocytometer, the FACSCount AF flow cytometer was two and four times more accurate than the spectrophotometer and the electronic cell counter, respectively. In addition, the FACSCount AF flow cytometer determined both sperm concentration (coefficient of variation 3.3%) and sperm viability (coefficient of variation 0.7%) with high precision.

Weight loss is effective for symptomatic relief in obese subjects with knee osteoarthritis independently of joint damage severity assessed by high-field MRI and radiography

OBJECTIVE

With an increasing prevalence of older and obese citizens, the problems of knee osteoarthritis (KOA) will escalate. Weight loss is recommended for obese KOA patients and in a majority of cases this leads to symptomatic relief. We hypothesized that pre-treatment structural status of the knee joint, assessed by radiographs, 1.5 T magnetic resonance imaging (MRI) and knee-joint alignment, may influence the symptomatic changes following a significant weight reduction.

DESIGN

Patients were recruited from a Department of Rheumatology. Eligibility criteria were age above 50 years, body mass index ≥ 30 kg/m(2), primary KOA diagnosed according to the American College of Rheumatology (ACR) criteria and having verified structural damage. Patients underwent a 16 weeks dietary programme with formula products and counselling. MRI and radiographs of the most symptomatic knee were obtained at baseline and assessed for structural damage using the Boston-Leeds Osteoarthritis of the Knee Score, minimum joint space width and Kellgren-Lawrence score. Imaging variables, muscle strength and degree of alignment, were examined as predictors of changes in Knee Osteoarthritis Outcome Score (KOOS) and Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) - Osteoarthritis Research Society International (OARSI) Responder Criterion.

RESULTS

Structural damage at baseline assessed by imaging, muscle strength or knee-joint alignment showed no statistically significant association to changes in KOOS pain and function in daily living (r ≤ 0.13; P>0.05) or the OMERACT-OARSI Responder Criterion (OR 0.48-1.68; P-values ≥ 0.13).

CONCLUSIONS

Presence of joint damage did not preclude symptomatic relief following a clinically relevant weight loss in older obese patients with KOA. Neither muscle strength nor knee-joint alignment was associated with the degree of symptomatic relief.

The consultation as an interpretive dialogue about the child's health needs

BACKGROUND

Though uniquely placed in the health care system, GPs only become aware of a small number of children with behavioural and emotional problems. Research evaluating the challenges and barriers in general practice for identifying children with problems is therefore important.

OBJECTIVES

To identify and articulate GPs' experiences and perceptions of the GP-parent dialogue about children's health problems, in order to broaden our understanding of the challenges inherent to the dialogue.

METHODS

The GPs' experiences and recollections were explored in a qualitative study comprising four focus group discussions and nine individual interviews. The focus of study was to explore GP consultations with children 0-5 years of age and their parent/s.

RESULTS

Though expressing a family-focused approach to the child consultation, the GPs often did not succeed in making the consultation family focused. The analysis revealed that the GPs often were 'stuck' in the traditional role of expert and this made it difficult for them to explore the child's well-being. The consultation became more family focused when the GPs moved away from the role of expert. The GPs experienced that by sharing their uncertainty with parents, they often got more insight into the child's everyday life and family circumstances.

CONCLUSION

The study indicates that through open reflective dialogue the GP is able to assess the child and strengthen mutual trust in the doctor-parent relationship to the benefit of children with special needs.

Relationship among seminal quality measures and field fertility of young dairy bulls using low-dose inseminations

Optimal use of genetically superior bulls through artificial insemination (AI) is highly dependent on precise assessment of seminal quality which allows for reasonable estimations of field fertility with normal or low-dose inseminations. In the present study, seminal measures such as sperm motility and morphology, sperm viability, sperm DNA fragmentation, and the ability of the sperm to display an acrosome reaction were tested. The relationships between field fertility and the seminal measures were investigated using 3 ejaculates from each of 195 bulls (156 Holstein and 39 Jersey) participating in a progeny test program. A range of AI doses, varying from 2×10(6) to 15×10(6) sperm/straw, was obtained by a controlled dilution process applied to each ejaculate. The different AI doses were distributed at random among 75,610 experimental first inseminations in 4,721 herds and 208 AI technicians. Most of the seminal measures appeared to contain a predictive value for the nonreturn to estrus at 56 d post-AI (NRR56) regardless of the number of sperm per AI dose and can be regarded as noncompensable sperm traits. But, due to correlations between the individual measures, the best model for describing (and predicting) NRR56 was based on sperm concentration and viability in the neat (raw) semen, and post-thaw sperm viability. The statistical models for describing NRR56 included the following explanatory variables: strength of the estrus, number of sperm per AI dose, breed, parity, and random components representing herds and AI technicians. The present results show that the most precise estimation of a bull's NRR56 can be achieved through flow cytometric detection of sperm concentration and viability in neat semen as well as flow cytometric detection of post-thaw sperm viability.

Reliability of the international spinal cord injury bowel function basic and extended data sets

STUDY DESIGN

This study was designed as an international validation study.

OBJECTIVE

The objective of this study was to assess the inter-rater reliability of the International Spinal Cord Injury Bowel Function Basic and Extended Data Sets.

SETTING

Three European spinal cord injury centers.

METHODS

In total, 73 subjects with spinal cord injury and a history of bowel dysfunction, out of which 77% were men and median age of the subjects was 49 years (range 20-81), were studied. The inter-rater reliability was estimated by having two raters complete both data sets on the same subject. First and second tests were separated by 14 days. Cohen's kappa was computed as a measure of agreement between raters.

RESULTS

Inter-rater reliability assessed by kappa statistics was very good (≥0.81) in 5 items, good (0.61-0.80) in 11 items, moderate (0.41-0.60) in 20 items, fair (0.21-0.40) in 11 and poor (<0.20) in 5 items.

CONCLUSION

Most items within the International Spinal Cord Injury Bowel Function Data sets have acceptable inter-rater reliability and are useful tools for data collection in international clinical practice and research. However, minor adjustments are recommended.

Osteoarthritis - a role for weight management in rheumatology practice: an update

Osteoarthritis (OA) and obesity are related diseases, which occur in a large proportion of the population. Epidemiological evidence show that weight is of great importance for the development of OA in the knee, and to some extent also in hip and finger joints. Once acquired, the OA contributes to further weight problems by decreasing the daily activity level. Weight loss will be beneficial for the knee and experimental data point at a highly significant effect on knee function and recent results even point at a positive effect on the cartilage of the knee joint. Recommending patients with a combination of knee OA and obesity to lose at least 5% body weight, and aim for 10% is predicted to correspond to 26% improvement in physical function. A programme for this weight loss has been tested with good results applying an initial formula diet with maintenance therapy in groups during follow-up.