Synthesis and summary of patient-reported outcome measures to inform the development of a core outcome set in colorectal cancer surgery

AIM

Patient-reported outcome (PRO) measures (PROMs) are standard measures in the assessment of colorectal cancer (CRC) treatment, but the range and complexity of available PROMs may be hindering the synthesis of evidence. This systematic review aimed to: (i) summarize PROMs in studies of CRC surgery and (ii) categorize PRO content to inform the future development of an agreed minimum 'core' outcome set to be measured in all trials.

METHOD

All PROMs were identified from a systematic review of prospective CRC surgical studies. The type and frequency of PROMs in each study were summarized, and the number of items documented. All items were extracted and independently categorized by content by two researchers into 'health domains', and discrepancies were discussed with a patient and expert. Domain popularity and the distribution of items were summarized.

RESULTS

Fifty-eight different PROMs were identified from the 104 included studies. There were 23 generic, four cancer-specific, 11 disease-specific and 16 symptom-specific questionnaires, and three ad hoc measures. The most frequently used PROM was the EORTC QLQ-C30 (50 studies), and most PROMs (n = 40, 69%) were used in only one study. Detailed examination of the 50 available measures identified 917 items, which were categorized into 51 domains. The domains comprising the most items were 'anxiety' (n = 85, 9.2%), 'fatigue' (n = 67, 7.3%) and 'physical function' (n = 63, 6.9%). No domains were included in all PROMs.

CONCLUSION

There is major heterogeneity of PRO measurement and a wide variation in content assessed in the PROMs available for CRC. A core outcome set will improve PRO outcome measurement and reporting in CRC trials.

A systematic review of outcome reporting in colorectal cancer surgery

AIM

Evaluation of surgery for colorectal cancer (CRC) is necessary to inform clinical decision-making and healthcare policy. The standards of outcome reporting after CRC surgery have not previously been considered.

METHOD

Systematic literature searches identified randomized and nonrandomized prospective studies reporting clinical outcomes of CRC surgery. Outcomes were listed verbatim, categorized into broad groups (outcome domains) and examined for a definition (an appropriate textual explanation or a supporting citation). Outcome reporting was considered inconsistent if results of the outcome specified in the methods were not reported. Outcome reporting was compared between randomized and nonrandomized studies.

RESULTS

Of 5644 abstracts, 194 articles (34 randomized and 160 nonrandomized studies) were included reporting 766 different clinical outcomes, categorized into seven domains. A mean of 14 ± 8 individual outcomes were reported per study. 'Anastomotic leak', 'overall survival' and 'wound infection' were the three most frequently reported outcomes in 72, 60 and 44 (37.1%, 30.9% and 22.7%) studies, respectively, and no single outcome was reported in every publication. Outcome definitions were significantly more often provided in randomized studies than in nonrandomized studies (19.0% vs 14.9%, P = 0.015). One-hundred and twenty-seven (65.5%) papers reported results of all outcomes specified in the methods (randomized studies, n = 21, 61.5%; nonrandomized studies, n = 106, 66.2%; P = 0.617).

CONCLUSION

Outcome reporting in CRC surgery lacks consistency and method. Improved standards of outcome measurement are recommended to permit data synthesis and transparent cross-study comparisons.

Mustard catch crop enhances denitrification in shallow groundwater beneath a spring barley field

Over-winter green cover crops have been reported to increase dissolved organic carbon (DOC) concentrations in groundwater, which can be used as an energy source for denitrifiers. This study investigates the impact of a mustard catch crop on in situ denitrification and nitrous oxide (N2O) emissions from an aquifer overlain by arable land. Denitrification rates and N2O-N/(N2O-N+N2-N) mole fractions were measured in situ with a push-pull method in shallow groundwater under a spring barley system in experimental plots with and without a mustard cover crop. The results suggest that a mustard cover crop could substantially enhance reduction of groundwater nitrate NO3--N via denitrification without significantly increasing N2O emissions. Mean total denitrification (TDN) rates below mustard cover crop and no cover crop were 7.61 and 0.002 μg kg(-1) d(-1), respectively. Estimated N2O-N/(N2O-N+N2-N) ratios, being 0.001 and 1.0 below mustard cover crop and no cover crop respectively, indicate that denitrification below mustard cover crop reduces N2O to N2, unlike the plot with no cover crop. The observed enhanced denitrification under the mustard cover crop may result from the higher groundwater DOC under mustard cover crop (1.53 mg L(-1)) than no cover crop (0.90 mg L(-1)) being added by the root exudates and root masses of mustard. This study gives insights into the missing piece in agricultural nitrogen (N) balance and groundwater derived N2O emissions under arable land and thus helps minimise the uncertainty in agricultural N and N2O-N balances.

Evaluation of cover crop and reduced cultivation for reducing nitrate leaching in Ireland

Nitrate (NO(3)) loss from arable systems to surface and groundwater has attracted considerable attention in recent years in Ireland. Little information exists under Irish conditions, which are wet and temperate, on the effects of winter cover crops and different tillage techniques on NO(3) leaching. This study investigated the efficacy of such practices in reducing NO(3) leaching from a spring barley (Hordeum vulgare L.) system in the Barrow River valley, southeast Ireland. The study compared the effect of two tillage systems (plow-based tillage and noninversion tillage) and two over-winter alternatives (no vegetative cover and a mustard cover crop) on soil solution NO(3) concentrations at 90 cm depth over two winter drainage seasons (2003/04 and 2004/05). Soil samples were taken and analyzed for inorganic N. During both years of the study, the use of a mustard cover crop significantly reduced NO(3) losses for the plowed and reduced cultivation treatments. Mean soil solution NO(3) concentrations were between 38 and 70% lower when a cover crop was used, and total N load lost over the winter was between 18 and 83% lower. Results from this study highlight the importance of drainage volume and winter temperatures on NO(3) concentrations in soil solution and overall N load lost. It is suggested that cover crops will be of particular value in reducing NO(3) loss in temperate regions with mild winters, where winter N mineralization is important and high winter temperatures favor a long growing season.

Botulinum toxin: pharmacology and clinical developments: a literature review

Botulinum toxin is used as first line therapy for some muscular disorders, and is efficacious in treating hypersecretory and some pain syndromes. When used appropriately it has a good safety profile. It has been evaluated in treating a number of conditions that as yet do not have obvious effective or beneficial treatment. With the greater acceptance and use of botulinum toxin therapy for cosmetic purposes, botulinum toxin use will increase. An understanding of the pharmacology, and potential adverse effects is essential for the physician when managing patients having or who would benefit from botulinum toxin therapy.

Malnutrition and childhood epilepsy in developing countries

A high prevalence of epilepsy in children is frequently found in developing countries. Though high rates of acquired brain injury may contribute, the possibility that malnutrition may lower seizure threshold has rarely been examined. This review suggests potential biochemical mechanisms that could adversely affect seizure threshold, particularly the effect of malnutrition on inhibitory neurotransmitters and electrolytes. Supporting evidence from animal research and epidemiological findings in children are discussed.

Enuresis and encopresis in a south Indian population of children

INTRODUCTION

Though bladder and bowel control are important developmental milestones in all cultures, the prevalence of enuresis and encopresis has rarely been studied in developing countries despite there being factors in these countries that could affect it. This study reports the prevalence and associations of enuresis and encopresis in children in Kerala, India.

METHOD

The parents of 1403 randomly selected 8-12-year-old children were interviewed. The prevalence of enuresis and encopresis was ascertained using Rutter's A2 scale. Subsamples of children underwent psychiatric, physical and psychometric evaluations.

RESULTS

Of the children, 18.6% had had an episode of enuresis in the past year and 4.3% in the past week. Four per cent had had an episode of encopresis in the past year. Enuresis was associated with parents' education, physical and psychiatric symptoms in the child, poor academic achievement and lax parental attitudes to toilet training. Encopresis was associated with male sex, physical and psychiatric symptoms, poor academic achievement, early separation and not having a toilet.

DISCUSSION

The prevalence of enuresis compares with western countries, but encopresis is commoner. The associations of enuresis suggested a multifactorial model in which parental competence was prominent. This study de-emphasized the importance of neurodevelopmental factors in enuresis and encopresis in this age group.

Life events in a South Indian population and their association with psychiatric disorder in children

Western research suggests that life events contribute to childhood psychiatric disorder but no studies have examined this in developing countries. During a population-based study of 1,403 8-12 year old children in Kerala, South India, a life events schedule was administered to parents of children with ICD10 psychiatric disorders (n = 72) and controls. Life events were associated with lower social class, greater poverty, less educated parents, worse physical health and psychiatric disorder. Multivariate analysis confirmed the association of life events with psychiatric disorder, independent of indices of social adversity.

The prevalence and associations of psychiatric disorder in children in Kerala, South India

This study aimed to identify the prevalence and associations of childhood psychiatric disorder in Calicut District, South India. Among 1403 children aged 8 to 12 years selected by random cluster sampling, a projected prevalence of 9.4% (95% CI 7.9-10.8%) was found. Associations of disorder with male sex, the Muslim religion, lower social class, less parental education, school failure, and impaired reading and vocabulary were found, but not with malnutrition or perinatal problems. The similarity to associations of disorder in Western studies was noted. The discussion focuses on the validity of comparisons of prevalence across cultures.

Psychiatric disorder and cognitive function in children with epilepsy in Kerala, South India

The cognitive and psychiatric associations of childhood epilepsy have not been studied in developing countries. Children with epilepsy were identified during a population-based epidemiological study of 1403 8- to 12-year-old children in Kerala, South India. They were compared with age-, sex- and social class-matched controls on measures of reading, vocabulary, non-verbal reasoning and school performance. In addition, psychiatric symptoms were measured using standard questionnaires and the presence or absence of psychiatric disorder was established by interview. Patients performed as well as controls on the non-verbal test, but performed worse on tests of vocabulary and reading, suggesting a specific disadvantage in the area of education. Psychiatric disorder was more prevalent in the children with epilepsy. It was concluded that epilepsy in the population studied is accompanied by a significant burden of cognitive and psychiatric disorders which need recognition and adequate service provision.

Stereotactic core biopsy reduces the reexcision rate and the cost of mammographically detected cancer

The management of patients with mammographic abnormalities is rapidly shifting from needle-localized surgical biopsy (NLB) to stereotactic core biopsy (SCB). The precise role of SCB in the management of nonpalpable breast cancer remains to be defined. The purpose of this study was to compare SCB to NLB in the diagnosis of mammographically detected breast cancer in women who underwent breast-conserving surgery. The records of all patients with nonpalpable breast cancer who underwent breast-conserving surgery from 1/1/95 to 6/1/97 were analyzed with respect to method of diagnosis, time interval from detection to diagnosis and breast-conserving surgery, volume of breast tissue excised, margin status and reexcision rate, number of surgical procedures, and total charges and costs per patient. During a 30-month period, 117 patients with nonpalpable breast cancer underwent breast-conserving surgery. The diagnosis was made by NLB in 69 patients and SCB in 48 patients. The time from detection to diagnosis and breast-conserving surgery was 1.7 +/- 0.5 and 8.1 +/- 1.2 days for SCB patients and 6. 8 +/- 1.3 and 16.9 +/- 2.3 days for NLB patients (P < 0.01). The volume of breast tissue removed was 117.9 +/- 5.6 cm3 for SCB patients versus 75.2 +/- 2.9 cm3 for NLB patients (P < 0.01). Three SCB patients (6%) had positive margins, while 38 NLB patients (55%) had positive margins (P < 0.01). Only 1 SCB patient (2%) was reexcised, while 34 NLB patients (50%) were reexcised (P < 0.01). Eighty-nine percent of SCB patients had a single surgical procedure compared to 39% of NLB patients (P < 0.001). Patients who underwent SCB had reduced total charges and total costs per patient compared to NLB patients ($11,700 +/- $554 and $3537 +/- $167 per SCB patient versus $15,654 +/- $706 and $4853 +/- $198 per NLB patient, P < 0. 0001). Stereotactic core biopsy shortens the time from detection at mammography to diagnosis and breast-conserving therapy, permits appropriate discussion of treatment alternatives, reduces the positive margin rate and reexcision rate, and may represent a significant cost savings in the management of nonpalpable breast cancer.

Febrile seizures in a south Indian district: incidence and associations

One thousand four hundred and three children participated in a home-based survey of psychiatric disorders in 8- to 12-year-old children in Calicut District, Kerala, India. One thousand one hundred and ninety-two consecutive children underwent neurological and psychometric assessments. The projected number of children with a history of febrile seizures was 120 giving a lifetime incidence of 10.1%. Recurrent febrille seizures predominated and these were strongly associated with a history of perinatal adversity. Febrile seizures were independently association with indices of infective illness and mothers' education. Epilepsy developed in 2.7% of children with febrile seizures, but no evidence was found that febrile seizures had adverse intellectual or behavioural sequelae.

Cloning and characterization of tomato leaf senescence-related cDNAs

Senescence-related cDNA clones designated SENU1, 4, 5 (senescence up-regulated) and SEND32, 33, 34, 35 and 36 (senescence down-regulated) isolated from a tomato leaf cDNA library [9] were characterized. Southern analysis showed that SEND32 is encoded by a single-copy gene while SEND33, 34, 35, 36 and SENU1 and SENU5 are members of small gene families. DNA and protein database searches revealed that SEND32, SEND35, SENU1 and SENU5 are novel cDNAs of unknown function. SEND33 encodes ferredoxin, SEND34 encodes a photosystem II 10 kDa polypeptide and SEND36 encodes catalase. The SENU4 sequence is identical to the P6 tomato protein previously reported to be pathogenesis-related [46]. The mRNA levels of SENU1, 4 and 5 increased during leaf senescence and SENU1 and SENU5 were also expressed at high levels during leaf development and in other plant organs. The SENU4 mRNA was associated more specifically with leaf senescence, although low expression was also detected in green fruit. The mRNAs for all SEND clones decreased during tomato leaf development and senescence and all except SEND32 were expressed at low levels in other plant organs. The accumulation of mRNA homologous to SENU4 and the decrease in abundance of SEND32 provide good molecular markers for leaf senescence.

Cloning and expression of a long form of the beta subunit of the interferon alpha beta receptor that is required for signaling

The interferon alpha beta receptor (IFN alpha R) or type I IFN-R is formed by a 110-kDa alpha subunit or IFNAR and by a beta subunit, which has short and long forms (molecular masses of 55 and 95-100 kDa, respectively). In this report, we demonstrate that the IFN alpha/beta R cDNA recently cloned corresponds to the 55-kDa or short form of the beta subunit, while the 95-100-kDa species reported here corresponds to a longer form of the IFN alpha/beta R cDNA that is probably produced by alternative splicing of the same gene. Stable transfection of the alpha subunit with either form of the beta subunit results in the expression of low and high affinity receptors, while expression of either form of the beta subunit alone only produces low affinity receptors. More important, only expression of the alpha and long form of the human beta subunits in mouse L-929 cells reconstitutes the activation of the Jak kinases and the Stat factors, as well as the antiviral response to human type I IFNs.

Low maternal serum unconjugated estriol during prenatal screening as an indication of placental steroid sulfatase deficiency and X-linked ichthyosis

Placental sulfatase deficiency is an X-linked metabolic defect that occurs in about 1 in 2,000 to 5,000 males. It is associated with congenital ichthyosis. In this report, the authors document a case of placental sulfatase deficiency detected during routine prenatal screening of maternal serum by the triple test: serum alpha-fetoprotein (AFP), unconjugated estriol (uE3), and human chorionic gonadotropin (hCG). At 16-weeks gestation, her AFP was 20.9 IU/mL (multiple of the median [MOM] 0.83), hCG was 14.4 mIU/L (MOM 0.42) and her uE3 was 0.01 nmol/L (MOM 0.01). The extremely low uE3 indicated a possible placental sulfatase deficiency, congenital adrenal hypoplasia, or other unknown abnormality. On receiving this information, the obstetrician obtained a family history that was consistent with ichthyosis in the maternal grandfather and his siblings. Biochemical analysis of placenta documented the lack of sulfatase activity. This case illustrates that an extremely low level of maternal uE3 should prompt investigation of the family for evidence of X-linked ichthyosis associated with placental sulfatase deficiency.

Parental ideas of normal and deviant child behaviour. A comparison of two ethnic groups

The parents of Gujarati and English children were interviewed and their attitudes to a wide range of child behaviour elicited. Differences in their ideas of normal and deviant behaviour were found in areas such as conduct and bedwetting, but not in self-care.

Histopathological and ultrastructural changes in simulated large colonic torsion and reperfusion in ponies

This investigation examines the histological and ultrastructural lesions of the colonic mucosa during terminal experimental infarction and subsequent reperfusion. Four ponies were anaesthetised and subjected to surgical torsion of the colon. Biopsies were collected at hourly intervals for 3 h, at which point the torsions were corrected. Circulation was re-established for 2 h and the bowel was re-biopsied at hourly intervals. The ponies were killed while under anaesthesia. During the 3 h experimental infarction, the bowel became macroscopically thickened and dark purple. Histologically, the mucosa degenerated from Grade 0 to Grade 3. Ultrastructurally, there was progressive micro-vascular distension with erythrodiapedesis and damage to the interstitial cells. Spaces developed between the bases and sides of the columnar epithelial cells and sloughing followed subsequently. During the 2 h reperfusion interval, the mucosa continued to degenerate rapidly to a Grade 5, and was characterised by extensive interstitial damage, oedema, cellular swelling, necrosis and mitochondrial damage. The results showed that the experimentally infarcted colonic mucosa degenerated sequentially. Following circulatory reestablishment, continued rapid mucosal degeneration characteristic of reperfusion injury occurred. Reperfusion injury is probably responsible, at least in part, for the often poor outcome of infarcted bowel in horses following surgical correction.