TP1.2.3Oncological Outcomes of Organ Preservation Strategies - Local Excision Procedures and ‘Watchful Waiting’ In Management of Low Rectal Cancers – A Systematic Review And Meta-Analysis

Objective

To evaluate local recurrence, metastases, and survival outcomes of `wait and watch’ (WW) strategy and local excision (LE) of tumours, in comparison to the present standard practice of total mesorectal excision (TME) for locally advanced rectal cancers.

Data Sources

MEDLINE, EMBASE, PubMed databases, and sources of Grey literature.

Study Selection

Randomised and non-randomised prospective studies, retrospective studies with propensity-score-matched analyses.

Data Extraction and Synthesis

These were carried out independently by two reviewers. A random-effects methodology was used for meta-analyses. Data was presented keeping with the 27-item PRISMA checklist.

Main Outcomes

The primary outcomes of interest were local recurrence, distant metastases, disease-free-survival and overall-survival, which were assessed in comparison to those associated with radical surgeries (TME).

Results

7 of the 16 studies in the systematic review were included for the quantitative synthesis and meta-analysis. Local recurrence rates were comparable amongst patients in WW group and LE group to those undergoing TME. [Risk ratio (RR) 3.07/1.41; 95% Confidence Interval (CI) 0.86-10.95/0.66-3.01; P = 0.08/P=0.89 respectively]. Rates of distant metastases in the WW group and LE group were comparable to those undergoing TME [RR = 0.71/0.94; 95% CI 0.22-2.30/0.55-1.61; P = 0.56/ P = 0.83 respectively]. The median 3-year disease-free survival among patients undergoing WW, LE procedure, and TME were 88%, 80%, and 78.2% respectively; and the median 3-year overall survival among the three groups were 96%, 93%, and 89.5% respectively.

Conclusions and Relevance

Organ-preservation strategies appear to be a viable treatment option in the management of rectal-cancers. Further research is warranted to provide stronger levels of evidence on organ-preservation strategies.

TP1.2.6Functional Outcomes of Organ Preservation Strategies - Local Excision Procedures and 'Watchful-Waiting' In Management of Low Rectal Cancers - A Systematic Review

Objective

To evaluate functional outcomes and quality of life (QOL) associated with `wait-and-watch’ (WW) strategy and local-excision (LE) of rectal tumours after neo-adjuvant therapy, in comparison to the standard practice of total-mesorectal-excision (TME) for locally-advanced-rectal-cancers.

Data Sources

Medline, EMBASE, PubMed databases, and sources of Grey literature.

Study Selection

Randomised and non-randomised prospective studies, and retrospective studies with propensity-score-matched analyses analysing outcomes of WW and LE procedures for rectal cancer.

Data Extraction and Synthesis

Risk of bias assessments and data extraction were carried out independently by two reviewers. A narrative synthesis of data was presented keeping with the 27-item PRISMA checklist.

Main Outcomes

The outcomes of interest were those of faecal-incontinence (FI), bowel and rectal-evacuatory function, sexual-function, stoma-free-survival, and quality-of-life scores, which were assessed in comparison to those associated with radical surgeries.

Results

7 studies reported functional outcomes. Faecal-incontinence, bowel, and rectal-evacuatory-function assessed by various scoring systems were found to be least affected among patients on WW strategy, followed by those undergoing local excision and most in patients undergoing TME. These reflected on the quality of life assessments (FIQOL and FACT-C questionnaires). Sexual dysfunction was not higher among patients who underwent LE compared to TME. Advantage of stoma-free-survival with organ preservation strategies was realised for up to 2 years after treatment.

Conclusions

Organ-preservation strategies appear to have a favourable functional outcome compared to the gold standard of TME for up to 2 years after the commencement of treatment. Further research is warranted to provide stronger levels of evidence regarding the same.

Survey of pertussis morbidity in adults in western Sydney

OBJECTIVE

To estimate morbidity due to Bordetella pertussis infection in a representative population of Australian adults.

DESIGN

Telephone survey using structured questionnaire.

PARTICIPANTS

Adults (aged 20 years and over) notified with pertussis to a public health unit in western Sydney between 1 December 1997 and 31 May 1998.

MAIN OUTCOME MEASURES

Duration of cough; time to improvement; symptoms and complications; time to diagnosis; health resource use; lost work days.

RESULTS

Of 90 eligible patients, 73 (81%) completed questionnaires. Cough lasted a median of 60 days, but persisted over 90 days in 20 people (27%). Presentation was within a median of seven days of symptom onset, but diagnosis of pertussis took a median of 21 days. Participants reported a mean of 3.7 general practitioner visits and 1.2 prescription drugs. Of those employed, 17 (35%) missed more than five work days (range, 0-93 days).

CONCLUSIONS

B. pertussis infection in adults can result in prolonged, significant disruption to social and working life. Results suggest that, in 1998, there were more than 8000 general practitioner visits and 15,000 lost work days caused by pertussis in Australian adults.

Psychiatric morbidity and compulsory admission among UK-born Europeans, Afro-Caribbeans and Asians in central Manchester

Psychiatric admissions in Central Manchester of Europeans, Afro-Caribbeans, and Asians (within three age-bands) were studied over four years. Among the Afro-Caribbean group there were more single or unemployed persons than in either the Asian or European groups, which suggested greater socio-economic disadvantage. Rates for first admissions and readmissions among Afro-Caribbeans were greater; among Asians they were similar except for the 16-29-year age-group, who tended to have lower rates than Europeans. A higher proportion of Afro-Caribbeans and Asians were psychotic. In the Afro-Caribbean group, the raised rates of admission were largely attributable to increased rates of schizophrenia. The highest rate occurred in second-generation (UK-born) Afro-Caribbeans and was nine times that among Europeans. The police were more frequently involved in the admissions of Afro-Caribbeans compared with Europeans or Asians. Higher proportions of Afro-Caribbeans and Asians who were readmitted were detained under the Mental Health Act 1983, when compared with Europeans.

Fragment D-dimer levels: an objective marker of vaso-occlusive crisis and other complications of sickle cell disease

Although abnormalities in coagulation tests have been reported during vaso-occlusive crises in patients with sickle cell disease, objective, readily performed laboratory tests that document the occurrence of this complication have not been available. We examined the relationship between fibrin D-dimer levels and the occurrence of complications in patients with sickle cell disease, using a commercially available latex bead agglutination assay. The patients were either asymptomatic, hospitalized for vaso-occlusive crisis, or had other complications of sickle cell disease including leg ulcers, chronic cholecystitis, aseptic necrosis, joint pain and infection. Fifty-seven percent of 187 samples on 96 patients had elevated levels of fibrin D-dimer. Ninety percent of 75 samples from asymptomatic patients were negative for fibrin D-dimer (less than 1 microgram/ml) but 97% of 29 samples from patients with vaso-occlusive crisis and 85% of 83 samples from patients with other complications of sickle cell disease were positive. In serial studies, worsening or amelioration in clinical complications were reflected in increasing or decreasing levels of fibrin D-dimer, respectively. The molecular species of fibrin identified by the latex agglutination test was shown to be fragment D-dimer by successive immunoprecipitation and protein blot analysis. We conclude that the complications of sickle cell disease, including vaso-occlusive crisis, result in the production of fibrin D-dimer, and its detection may be used as a marker for the presence of the complication.

Postnatal depression and child development. A three-year follow-up study

This study investigates whether three-year-old children whose mothers had been depressed after their birth showed more behaviour disturbance than children of mothers who were not depressed at that time. Ninety-one of 103 mothers who took part in an earlier prospective study of postnatal depression were reinterviewed three years later to determine their present mental state, and to assess their child's behaviour, using Richman's Behavioural Screening Questionnaire. No relationship was found between a prolonged postnatal depression and behaviour disturbance in the child, but children whose mothers had brief postnatal depressive episodes showed more behaviour disturbance than those whose mothers had not been depressed since childbirth.