Impact of obesity on the cost of major colorectal surgery

BACKGROUND

The incidence of obesity is increasing in New Zealand. The aim of the study was to determine whether obesity impacts on the cost of treating patients undergoing major colorectal surgery.

METHODS

Between 1 February 2008 and 31 July 2009, consecutive patients undergoing major colorectal surgery at Christchurch Hospital, New Zealand, were enrolled in the study. Body mass index (BMI) and waist-to-hip ratios were assessed using standardized techniques. Patients with a high surgical risk were identified using established criteria and all patients were assessed using the Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM). Cost analysis was performed using a structured query language database. Patients were analysed using accepted groupings for BMI, waist circumference and waist-to-hip ratio.

RESULTS

A total of 372 patients were enrolled in the study, of whom 345 were included in the analysis. The incidence of diabetes was significantly higher with increased BMI (P = 0·002), whereas all other co-morbidities, and P-POSSUM values, did not differ between BMI groups. The groups were similar in terms of case mix. Treatment of obese patients (BMI at least 30 kg/m(2)) was significantly more expensive than that of normal weight patients (BMI 20-24·9 kg/m(2)): €10,036 versus €7390 (P = 0·005). Treatment costs for patients with a BMI of 25-29·9 kg/m(2) were next highest (€9048) followed by those for patients whose BMI was less than 20 kg/m(2) (€8884). Patients with a waist circumference above recognized standards for men and women also cost significantly more to treat (€10,063 versus €7836; P = 0·014).

CONCLUSION

Excess body fat was associated with higher costs of major colorectal surgery.

Investigating changes in anger and aggression in offenders with high levels of psychopathic traits attending the Chromis violence reduction programme

BACKGROUND

Chromis was accredited by the Correction Services Accreditation Panel in 2005 as an intervention designed to reduce violence in offenders whose level or combination of psychopathic traits disrupts their ability to engage in treatment and change. It runs as part of the regime in the dangerous and severe personality disorder unit in HM Prison Frankland (Westgate). A multiple case study investigation into changes over time in participants is currently underway, part of which is reported here.

AIMS

This paper reports on information relating to changes in anger and aggression in Chromis completers.

METHODS

Change in psychometrics and observed incidents of verbal and physical aggression are considered for five case study participants who have completed Chromis and progressed from Westgate to a different location.

RESULTS

Findings suggest that cases experienced a reduction in self-reported anger, and expected incidents of physical aggression but had higher than expected levels of verbal aggression after leaving Westgate.

CONCLUSIONS

These findings offer cautious optimism for the effectiveness of Chromis, although methodological limitations must also be considered. Findings may be seen as positive indicators of Chromis, or at least the approach to working with these offenders across Westgate, in reducing violence.

IMPLICATIONS FOR PRACTICE

Findings support the continued delivery and evaluation of Chromis. There may be benefit in exploring ways to further understand and address verbal aggression in participants.

The process and outcomes of a nurse-led colorectal cancer follow-up clinic

AIM

Evidence suggests that follow-up after colorectal cancer improves survival. Colorectal cancer is so common that patient follow-up can overwhelm a service, affecting the ability to see new referrals and reassess patients seen previously who have new symptoms. In order to cope with this demand a nurse-led follow-up service was started in 2004. We aimed to review the results of a nurse-led colorectal cancer follow-up clinic.

METHOD

Between 1 December 2004 and 31 January 2011, patients who underwent resection for colorectal cancer were followed up by a nurse specialist according to a protocol determined by the colorectal surgeons in the unit. All patient details were recorded prospectively in a purpose designed database.

RESULTS

Nine hundred and fifty patients were followed up over 7 years. Some 368 patients were discharged from the follow-up programme, 474 patients remain actively involved in the programme and 108 patients died. Of the patients discharged from the follow-up scheme 269 (73%) were discharged to their general practitioner free of disease after 5 years. Of the 108 who patients died, 98 were as a result of colorectal cancer. Twenty patients (2.1%) were identified with local (peri-anastomotic) disease recurrence and 93 patients (9.8%) were found to have developed distant metastatic disease. Of these, 65 patients (6.8%) were referred for palliative care and 28 (2.9%) had surgery for focal metastatic disease of whom 18 were still alive at the time of this analysis.

CONCLUSION

This paper shows that a nurse-led clinic for colorectal cancer follow-up can achieve satisfactory results with detection rates of recurrent or metastatic disease comparable to consultant follow-up. A nurse-led clinic provides the benefits of follow-up without overwhelming the consultant colorectal surgical clinic practice.

Prevalence of vertebral fractures on chest radiographs of elderly African American and Caucasian women

The prevalence of vertebral fractures on routine chest radiographs of elderly Caucasian women was only 1.3 times higher than in African American (AA) women, a difference considerably smaller than reported in population studies. AAs with medical problems may have higher risk of vertebral fractures than previously suspected.

INTRODUCTION

Earlier studies noted a 1.9- to 3.7-fold higher prevalence of vertebral fractures in Caucasian (CA) compared to African American (AA) women. These studies, however, may have suffered from selection bias. We reported that among women referred for bone density testing, the prevalence of vertebral fractures in AA was the same as in CA women. Suspecting that the latter might have been due to a referral bias, we examined the racial difference in the prevalence of vertebra fractures on chest radiographs of patients seeking general medical care, not selected for osteoporosis.

METHODS

Consecutive chest radiographs (N = 1,200) of women over age 60 were evaluated using Genant's semi-quantitative method. Patients' race and the presence of diseases or medications associated with increased fracture risk were ascertained from the electronic medical records.

RESULTS

Among 1,011 women (76% AA) with usable radiographs, 11% had moderate or severe vertebral fractures. The prevalence of vertebral fractures was 10.3% in 773 AA and 13% in 238 CA women (p = 0.248 for difference between races). The lack of difference persisted after controlling for age, smoking, use of glucocorticoids, or presence of cancer, rheumatoid arthritis, organ transplantation, and end-stage renal disease. Among all subjects, CA women were more likely to be diagnosed and treated for osteoporosis (p <0.001).

CONCLUSION

Among subjects seeking medical care, the difference in the prevalence of vertebral fractures between AA and CA women is smaller than previously suspected. Greater attention to the detection of vertebral fractures and the management of osteoporosis is warranted in AA women with medical problems.

Natural history of small duct primary sclerosing cholangitis: a case series with review of the literature

BACKGROUND AND AIMS

Information about the natural history of small duct primary sclerosing cholangitis (SDPSC) remains scant despite literature suggesting that it constitutes 6-16% of all cases of primary sclerosing cholangitis (PSC). We combined clinical data on SDPSC cases from two tertiary care institutions with liver transplantation programs with the aim of studying the natural history of SDPSC.

METHODS

Medical records of 25 individuals with SDPSC were reviewed. Diagnosis of SDPSC was based on liver biopsy findings consistent with PSC, a normal cholangiogram, and elimination of known causes of secondary sclerosing cholangitis. Demographic information, symptoms, past medical history, laboratory values, and histologic data were evaluated. Our primary outcome measure was liver transplantation or death. Secondary outcome measures included evidence of end-stage liver disease, development of cholangiocarcinoma, and/or the development of classic PSC on a repeat cholangiogram.

RESULTS

Data on 25 individuals (13 males, 12 females; mean age 40 ± 15 years) diagnosed with SDPSC were analyzed. Upon presentation, 11 patients had symptoms including abdominal pain, fatigue, and pruritus. Inflammatory bowel disease was present in 14 patients (56%) at diagnosis. On initial liver biopsy, 60% had early-stage disease (I or II) and none had cirrhosis. On follow-up (1-168 months, median 17 months), malignancy or progression to classic large duct PSC was not noted. Two (8%) patients had evidence of varices and one of the two also developed ascites; one of these patients underwent liver transplantation and the other one died due to sepsis.

CONCLUSIONS

SDPSC, a mild disease at presentation typically runs a benign course and likely is not an early stage of classic PSC. Further studies with a control group of classic PSC and longer follow-up are needed to study the natural history of SDPSC.

First Report of Orange Rust of Sugarcane Caused by Puccinia kuehnii in Ivory Coast and Cameroon

Orange rust of sugarcane caused by Puccinia kuehnii was detected in Florida in 2007 (1). It was hypothesized that the pathogen originated from Africa because brown rust of sugarcane (synonym common rust) was introduced to the Western Hemisphere from Africa (3). Requests for rust-infected sugarcane samples were made to several western and central African countries to investigate if orange rust of sugarcane was present but as yet undetected. Orange rust had not previously been reported from western or central Africa. At Zuénoula, Ivory Coast in July 2009, symptoms of sugarcane rust were observed on cvs. SP 71-6180 and Co 997 and appeared distinct to those of brown rust of sugarcane. A year later (May 2010), rust-infected specimens of SP 71-6180 and Co 997 from the same location and also from Borotou in Ivory Coast were sent to the USDA-ARS Systematic Mycology and Microbiology Laboratory in Beltsville, MD for identification. Also in May 2010, sugarcane rust was observed at Mbandjock and Nkoteng in Cameroon on cvs. D 88172, FR 87482, and RB 72-454 and on breeding clones RCmr 08/319 and RCmr 08/1121. All specimens had orange uredinial lesions that ranged from 0.6 to 6.5 mm × 200 to 300 μm and were ellipsoidal to elongate. Urediniospores were consistent with P. kuehnii E.J. Butler observed on specimens from Florida (1). DNA isolated from all samples was successfully amplified with P. kuehnii specific primers targeting ITS1 of rDNA (2). The nuclear large subunit region of rDNA of the rust specimens from Ivory Coast (BPI 881015-881017, GenBank Accession No. HQ666888) and Cameroon (BPI 881010-881014, GenBank Accession Nos. HQ666889-HQ666891) were sequenced. DNA sequences for all were identical to sequences of P. kuehnii and distinct from known sequences of P. melanocephala available in GenBank. To our knowledge, this is the first confirmed report of orange rust of sugarcane in western and central Africa. There is evidence that brown rust of sugarcane was introduced to the Western Hemisphere from this region of Africa (3) making it also the likely source of introduction of orange rust. Further experimentation is required to confirm this hypothesis. References: (1) J. C. Comstock et al. Plant Dis. 92:175, 2008. (2) N. C. Glynn et al. Plant Pathol. 59:703. 2010. (3) H. L. Purdy et al. Plant Dis. 69:689, 1985.

Patterns of recurrence in patients with acute diverticulitis

Background

The natural history of acute diverticulitis remains unclear, with the role of prophylactic surgery following conservatively managed diverticulitis increasingly controversial. This study investigated recurrence rates, patterns and complications after conservatively managed diverticulitis.

Methods

This was a retrospective chart review of all patients admitted with diverticulitis between June 1997 and June 2002. Demographic data, management, recurrence rates, complications and subsequent surgery were recorded.

Results

Some 502 patients were identified, 337 with uncomplicated and 165 with complicated diverticulitis. Median follow-up was 101 (range 60–124) months. Of 320 patients with uncomplicated diverticulitis managed conservatively, 60 (18·8 per cent) had one episode of recurrence, whereas 15 (4·7 per cent) had two or more episodes. After an initial attack of uncomplicated diverticulitis, only 5·0 per cent developed complicated disease. Complicated disease recurred in 24 per cent, compared with a recurrence rate of 23·4 per cent in those with uncomplicated diverticulitis (P = 0·622). When recurrence occurred, it usually did so within 12 months of the initial episode.

Conclusion

Acute diverticulitis has a low recurrence rate and rarely progresses to complications. Any recurrence is usually early, in a pattern more consistent with failure of the index episode to settle. Subsequent elective surgery to prevent recurrence and the development of complications should be used sparingly.

Gemcitabine alone or in combination with cisplatin in patients with advanced or metastatic cholangiocarcinomas or other biliary tract tumours: a multicentre randomised phase II study - The UK ABC-01 Study

BACKGROUND

We assessed the activity of gemcitabine (G) and cisplatin/gemcitabine (C/G) in patients with locally advanced (LA) or metastatic (M) (advanced) biliary cancers (ABC) for whom there is no standard chemotherapy.

METHODS

Patients, aged > or =18 years, with pathologically confirmed ABC, Karnofsky performance (KP) > or =60, and adequate haematological, hepatic and renal function were randomised to G 1000 mg m(-2) on D1, 8, 15 q28d (Arm A) or C 25 mg m(-2) followed by G 1000 mg m(-2) D1, 8 q21d (Arm B) for up to 6 months or disease progression.

RESULTS

In total, 86 patients (A/B, n=44/42) were randomised between February 2002 and May 2004. Median age (64/62.5 years), KP, primary tumour site, earlier surgery, indwelling biliary stent and disease stage (LA: 25/38%) are comparable between treatment arms. Grade 3-4 toxicity included (A/B, % patients) anaemia (4.5/2.4), leukopenia (6.8/4.8), neutropenia (13.6/14.3), thrombocytopenia (9.1/11.9), lethargy (9.1/28.6), nausea/vomiting (0/7.1) and anorexia (2.3/4.8). Responses (WHO criteria, % of evaluable patients: A n=31 vs B n=36): no CRs; PR 22.6 vs 27.8%; SD 35.5 vs 47.1% for a tumour control rate (CR+PR+SD) of 58.0 vs 75.0%. The median TTP and 6-month progression-free survival (PFS) (the primary end point) were greater in the C/G arm (4.0 vs 8.0 months and 45.5 vs 57.1% in arms A and B, respectively).

CONCLUSION

Both regimens seem active in ABC. C/G is associated with an improved tumour control rate, TTP and 6-month PFS. The study has been extended (ABC-02 study) and powered to determine the effect on overall survival and the quality of life.

Long-term storage at tropical temperature of dried-blood filter papers for detection and genotyping of RNA and DNA viruses by direct PCR

In tropical countries the diagnosis of viral infections of humans or animals is often hampered by the lack of suitable clinical material and the necessity to maintain a cold chain for sample preservation up to the laboratory. This study describes the use of filter papers for rapid sample collection, and the molecular detection and genotyping of viruses when stored over long periods at elevated temperatures. Infected blood was collected on filter papers, dried and stored at different temperatures (22, 32 and 37 degrees C) for various periods (up to 9 months). Two animal viruses, African swine fever, a large double-stranded DNA virus and Peste des Petits Ruminants, a negative single-stranded RNA virus, were used to validate the method. Filter papers with dried blood containing virus or control plasmid DNA were cut in small 5mm(2) pieces and added directly to the PCR tube for conventional PCR. Nucleic acid from both viruses could still be detected after 3 months at 32 degrees C. Moreover, the DNA virus could be detected at least 9 months after conservation at 37 degrees C. PCR products obtained from the filter papers were sequenced and phylogenetic analysis carried out. The results were consistent with published sequences, demonstrating that this method can be used for virus genotyping.

Role of the rapA gene in controlling antibiotic resistance of Escherichia coli biofilms

By using a high-throughput screening method, a mutant of a uropathogenic Escherichia coli strain affected in the rapA gene was isolated. The mutant formed normal-architecture biofilms but showed decreased penicillin G resistance, although the mutation did not affect planktonic cell resistance. Transcriptome analysis showed that 22 genes were down-regulated in the mutant biofilm. One of these genes was yhcQ, which encodes a putative multidrug resistance pump. Mutants with mutations in this gene also formed biofilms with decreased resistance, although the effect was less pronounced than that of the rapA mutation. Thus, an additional mechanism(s) controlled by a rapA-regulated gene(s) was involved in wild-type biofilm resistance. The search for this mechanism was guided by the fact that another down-regulated gene in rapA biofilms, yeeZ, is suspected to be involved in extra cell wall-related functions. A comparison of the biofilm matrix of the wild-type and rapA strains revealed decreased polysaccharide quantities and coverage in the mutant biofilms. Furthermore, the (fluorescent) functional penicillin G homologue Bocillin FL penetrated the mutant biofilms more readily. The results strongly suggest a dual mechanism for the wild-type biofilm penicillin G resistance, retarded penetration, and effective efflux. The results of studies with an E. coli K-12 strain pointed to the same conclusion. Since efflux and penetration can be general resistance mechanisms, tests were conducted with other antibiotics. The rapA biofilm was also more sensitive to norfloxacin, chloramphenicol, and gentamicin.

Adherence rates with infliximab therapy in Crohn's disease

BACKGROUND

Inflammatory bowel disease is associated with non-adherence to treatment with oral medications.

AIM

To assess the intravenous infliximab adherence rate and identify risk factors for non-adherence to treatment.

METHODS

Infliximab infusion dates for 1 June 2002-30 October 2003 were obtained. Additional information was obtained from two other administrative and patient-based databases. Non-adherence was defined as a 'No Show' designation for a scheduled appointment. Non-adherence rate, odds ratios for associations to 'No Show' appointments and analysis were performed to identify patient characteristics associated with non-adherent behaviour.

RESULTS

One thousand hundred and eighty-five infliximab infusions were scheduled for 274 patients. Forty-eight (4%) of appointments were classified as 'No Show'. Six patients accounted for 13/48 (27%) of failed appointments; another 35 patients missed one appointment. 'No Show' appointments were more likely to be for female patients, those on concomitant immunomodulators and those >18 weeks from initial infusion. Patients who missed >1 appointment were more likely to be female and have Medicaid vs. those with only one missed appointment (P < 0.05). Indication, patient area code and race were not significantly associated with single or repeated No Show behaviour.

CONCLUSIONS

Overall, the non-adherence rate for infliximab is low. Risk factors that may contribute to non-adherence to treatment include female gender and maintenance dosing.

Outcomes of the peer-taught 12-week family-to-family education program for severe mental illness

OBJECTIVE

Family-to-Family Education Program (FFEP) is a 12-week course for family members of adults with serious mental illness (SMI). This study evaluates the effectiveness of FFEP for several family member outcomes.

METHOD

The FFEP enrollees on a > or =3-month waiting list were eligible; 95 consenting family members agreed to four interviews (waitlist, pre-FFEP, post-FFEP, and 6 months post-FFEP) regarding subjective and objective burden, empowerment, and depression. Mixed effects ANOVA models tested hypotheses of decreased burden and increased empowerment after FFEP.

RESULTS

The FFEP was associated with reduced subjective burden (P < 0.01) and increased empowerment (P < 0.01) without changes in objective burden. Knowledge about SMI, understanding the mental health system, and self-care also improved. There was no significant decay at 6-month followup.

CONCLUSION

This study provides evidence that FFEP is helpful to relatives of persons with SMI by reducing subjective burden and worry, and increasing empowerment, knowledge about SMI, understanding the mental health system, and self-care.

Screening for psychiatric symptoms: PAS-ADD Checklist norms for adults with intellectual disabilities

BACKGROUND

The Psychiatric Assessment Schedule for Adults with Developmental Disabilities Checklist (PAS-ADD Checklist) is a screening instrument designed to help carers recognize likely mental health problems in people with intellectual disabilities (ID). To date there are no published PAS-ADD Checklist data on a large nonpsychiatric population of adults with ID, an important step towards developing norms for comparative purposes.

METHODS

Informants who had known participants for a median 24 months completed the PAS-ADD Checklist on 1155 adults with ID living in community, residential care and hospital settings in a county district in the North-east of England.

RESULTS

Normative data were obtained for the PAS-ADD Checklist for the study population with reference to gender, age, and type of residence. The overall prevalence of mental health problems was 20.1%, and the rates for affective/neurotic, organic and psychotic disorders were 14%, 3.9%, and 10.2%, respectively. Significant differences in the rates for particular disorders were found across gender, age and, residence type.

CONCLUSIONS

The rates of mental disorders found in the study population were consistent with previous studies of general populations of people with ID using over-inclusive screening instruments. The PAS-ADD Checklist appears to be an easy-to-use and sensitive tool for identifying mental health cases in ID populations, but further investigation is required concerning the specificity of the instrument.

Planar amplitudes in maximally supersymmetric Yang-Mills theory

The collinear factorization properties of two-loop scattering amplitudes in dimensionally regulated N=4 super-Yang-Mills theory suggest that, in the planar ('t Hooft) limit, higher-loop contributions can be expressed entirely in terms of one-loop amplitudes. We demonstrate this relation explicitly for the two-loop four-point amplitude and, based on the collinear limits, conjecture an analogous relation for n-point amplitudes. The simplicity of the relation is consistent with intuition based on the anti-de Sitter/conformal field theory correspondence that the form of the large-N(c) L-loop amplitudes should be simple enough to allow a resummation to all orders.

Tetracycline rapidly reaches all the constituent cells of uropathogenic Escherichia coli biofilms

We have developed a method for visualizing Escherichia coli cells that are exposed to tetracycline in a biofilm, based on a previous report that liposomes containing the E. coli TetR(B) protein fluoresce when exposed to this antibiotic. By our method, cells devoid of TetR(B) also exhibited tetracycline-dependent fluorescence. At 50 microg of tetracycline ml(-1), planktonic cells of a uropathogenic E. coli (UPEC) strain developed maximal fluorescence after 7.5 to 10 min of exposure. A similar behavior was exhibited by cells in a 24- or 48-h UPEC biofilm, as examined by confocal laser microscopy, regardless of whether they lined empty spaces or occupied densely packed regions. Further, a comparison of phase-contrast and fluorescent images of corresponding biofilm zones showed that all the cells fluoresced. Thus, all the biofilm cells were exposed to tetracycline and there were no pockets within the biofilm where the antibiotic failed to reach. It also appeared unlikely that niches of reduced exposure to the antibiotic existed within the biofilms.

Chlamydia trachomatis infection and non-gonococcal urethritis in homosexual and heterosexual men in Edinburgh

In 1998, when ligase chain reaction testing for chlamydial infection was introduced in our clinic in Edinburgh, routine clinic protocol included the testing of all heterosexual, but not homosexual, men for urethral chlamydial infection. We audited all new homosexual and bisexual male attendees with a diagnosis of chlamydial infection or non-gonococcal urethritis (NGU) in 1999, together with heterosexual men with the same diagnoses attending in alternate months of the same year. Urethral Chlamydia trachomatis infection was detected in 14.6% (350/2402) of heterosexual men and 2.4% (11/465) of homosexual men tested. Fifty percent of chlamydial infections were asymptomatic. In this population 44% (84/190) of NGU in heterosexual men is attributable to C. trachomatis as opposed to only 10% (6/59) of that in homosexual men. These rates of chlamydial infection differ from previous reports in Scotland and recent studies from the USA. Our clinic protocol has been revised to include routine testing for chlamydial infection in all men.

The spectrum of DNA damage in human sperm assessed by single cell gel electrophoresis (Comet assay) and its relationship to fertilization and embryo development

BACKGROUND

The integrity of sperm DNA is important for the success of natural or assisted fertilization, as well as normal development of the embryo, fetus and child. ICSI, by bypassing sperm selection mechanisms, increases the risk of transmitting damaged DNA and the significance of this requires investigation.

METHODS

DNA damage in sperm from an unselected group of 60 men undergoing IVF treatment was measured by single cell gel electrophoresis (Comet assay) and correlated with semen and treatment cycle parameters.

RESULTS

Wide spectra of sperm DNA damage were found both within and between men but no specific subgroups were identified. Semen and treatment cycle parameters were not different in men grouped according to high or low sperm DNA damage. However, regression analysis showed that DNA damage was positively associated with age (29-44 years), abnormal sperm and motility and negatively associated with sperm concentration. In ICSI cycles DNA damage was positively associated with impairment of post-fertilization embryo cleavage.

CONCLUSIONS

This study contributes to the evidence of DNA damage within sperm. High loads of DNA damage measured by the Comet assay were predictive of failure of embryo development after ICSI. As it is likely that sperm with DNA damage contributed to successful fertilization and in-vitro development, potential adverse effects remain to be clarified.

Reason for medical hospitalization among adult alcohol and drug abusers

This study attempts to identify the associations between types of substance use and particular medical problems as causes of acute hospital admission on an inpatient substance abuse consultation service. Records of all consultations performed from 1994 to 1998 were analyzed. A total of 4,526 complete records were available. Cocaine (p < .01), heroin (p < .001), and injection drug (p < .001) users were more likely to be admitted to the hospital for infection. Both alcohol (p < .001) and marijuana (p < .001) users were more likely to be hospitalized for trauma related injuries. Individuals that used alcohol were also more likely to be admitted for the treatment of gastrointestinal disorders (p < .001). Clinicians who treat patients with these diagnoses should have a high index of suspicion of co-morbid substance use disorders. Effective treatment of substance use disorders can lead to a decrease in medical morbidity, improved outcomes for individual patients, and decreased costs for the health care system.