Comparison of right hemicolectomies with and without complete mesocolic excision (CME)

Objective

Since the concept of complete mesocolic excision (CME) in right hemicolectomies was introduced, it is still under debate if all patients require this radical technique.

Methods

Patients with adenocarcinoma of the colon undergoing right hemicolectomies at our hospital were retrospectively analyzed and stratified in a non-CME group (08/2014-04/2018) and a CME group (05/2018-11/2021). Patients were compared in regard to clinical, histopathological and prognostic parameters. CME were classified according to Benz et al.

Results

A total of 130 right hemicolectomies were performed, 33 (25.4%) patients were excluded due to other pathologies or emergency patients. Finally, 97 patients were included (53 in the CME group, 39 in the non-CME group). No difference in patient's characteristics were found except more male patients in the CME group (20 vs. 6; p=0.02). Tumors in the CME group were mainly located in the colon ascendens (66.0%), in the non-CME group in the coecum (48.7%; n.s.). In the CME group, 26 of 53 (49.1%) patients were operated laparoscopically compared to 10 of 39 (25.6%) patients in the non-CME group. Da Vinci system were used exclusively in the CME group (5 of 53 (9.4%); p=0.003). TNM classification, histology and UICC stadium showed no significant difference. In total, 50 (94.3%) surgical specimen were classification either as CME 0 or 1. In average, 35.2 lymph nodes (8.2% positive) were found in the CME group compared to 32.7 (16.2% positive) lymph nodes in the non-CME group (p=0.9). No relevant intraoperative complications occurred in both groups. Distance of the mesocolon were available in 39 (73.6%) patients in the CME group and 34 (37.1%) in the non-CME group; the distance tended to be longer in the CME group (mean 116.0 mm in CME group vs. 96.6 mm in non-CME group; p=0.09). Follow-up were 336.4 days in CME-group and 1210.4 days in the non-CME group. In the follow-up, 2 (5.1%) patients in the non-CME group developed a local recurrence in the smaller pelvis. No local recurrence occurred in the CME group (p=0.18). Distant metastasis occurred in 5 of 53 (9.4%) patients in the CME group and in 2 of 39 (5.4%) patients in the non-CME group (p=0.7).

Conclusion

This study shows that the benefit for CME in all performed right hemicolectomies is marginal and that the surgical standards was already high in the pre-CME era.

A multifactorial intervention to reduce use of antibiotics in acute uncomplicated diverticulitis – a single centre feasibility study

Objective

Standard treatment for uncomplicated diverticulitis in our institution consists of antibiotics. However, current evidence suggests that bacterial infection has a less predominant role than previously thought, and that uncomplicated acute diverticulitis may be a self-limiting condition in which inflammation can be managed without antibiotics. With the support of a multidisciplinary team we developed an intervention in order to reduce the use of antibiotics for patients with uncomplicated diverticular disease.

Methods

Standard practice and knowledge of current evidence were investigated with a structured survey sent to general practitioners and gastroenterologists with private practice in the area. A clinical process model for treatment of uncomplicated left-sided diverticulitis was created and exclusion criteria were selected in order to define patients with a high risk of developing complications. An educational intervention based on current evidence and the new treatment pathway was conducted on hospital staff as well as primary care physicians in the area in order to raise awareness about the possibility of avoiding antibiotics in uncomplicated diverticulitis. Patients were also involved and received an informative sheet about the rationale of the new treatment, the planned follow up and warning signs warranting further investigations and referral in case of outpatient treatment. All patients from May 2021 to December 2021 with a computed tomography-verified left-sided acute uncomplicated diverticulitis were included in the study and evaluated prospectively.

Results

Of 60 patients with acute uncomplicated diverticulitis, 23 (38%) were eligible for treatment without antibiotics. High inflammatory markers on presentation were the main reason (84%) for giving antibiotics. Adherence to the new policy was 74%. None of the 17 patients initially managed without antibiotics failed conservative treatment.

Conclusion

This project confirmed that treatment of uncomplicated diverticulitis without antibiotics can successfully be offered to a selected group of patients without altering the course of the disease. Further efforts are needed in order to overcome existing barriers to rational antimicrobial use such as lack of trust in new guidelines, general uncertainty and risk avoidance, patients’ expectations for antibiotic treatment, and fear of legal consequences.

[Single Subcutaneous Palmar Injection vs. 2 Dorsal Injections for Finger Anaesthesia in Hand Surgery - Randomised Prospective Comparison of Application Pain and Efficacy]

PURPOSE

This randomised prospective study compared pain during application and efficacy of the palmar subcutaneous single injection block (PSSIB) and the traditional dorsal 2 injection block (DTIB).

METHODS

During a 2 year period, a total of 190 patients with an average age of 43 years (18-82) and an isolated finger injury were included in the study. The injection was applied by residents (n=29) of the emergency department. 96 patients received PSSIB (72 men, 24 women) and 94 DTIB (55 men, 39 women) with 3 ml of Mepicavain(®) 1%. Randomisation was performed by even/odd hospital admission number.

EXCLUSION CRITERIA

Thumb injury, progressive infection with visible redness at injection point. Application pain was recorded immediately after injection and registered on a VAS (0-10). Efficacy was checked 5 min after application. The patients quoted the efficacy as complete pain-free, almost pain-free and inadequate anesthesia (second injection was necessary). Statistical analysis was performed using the chi-quadrat and the t test; the level of significance was set at p<0.05.

RESULTS

There was no significant difference in terms of analgesic efficacy (p=0,096), while the PSSIB required fewer second injections. Application pain was rated as being significantly (p=0.002) less painful for PSSIB (3.2) than for DTIB (4,0).

CONCLUSIONS

This study shows that PSSIB gives reliable analgesia and the application pain is significant less than during DTIB.

Persistent response to pneumococcal vaccine in individuals supplemented with a novel water soluble extract of Uncaria tomentosa, C-Med-100

A human intervention study was carried out using male volunteers attending a General Practice Clinic in New York City involving comparison of individuals supplemented with 350 mg x 2 C-Med-100 daily dose for two months with untreated controls for their abilities to respond to a 23 valent pneumococcal vaccine. C-Med-100 is a novel nutraceutical extract from the South American plant Uncaria tomentosa or Cat's Claw which is known to possess immune enhancing and antiinflammatory properties in animals. There were no toxic side effects observed as judged by medical examination, clinical chemistry and blood cell analysis. However, statistically significant immune enhancement for the individuals on C-Med-100 supplement was observed by (i) an elevation in the lymphocyte/neutrophil ratios of peripheral blood and (ii) a reduced decay in the 12 serotype antibody titer responses to pneumococcal vaccination at 5 months.

Radiation therapy in non-surgically-treated nonmetastatic prostate cancer: geographic and demographic variation

OBJECTIVES

To examine the geographic variation in the use of radiation to treat nonmetastatic prostate cancer and to identify factors that explain the variation in the United States.

METHODS

This study was based on data from the nine geographic regions of the Surveillance, Epidemiology, and End Results Program for 1983 through 1996. Patients with localized or regional prostate cancer who did not undergo surgical treatment were included in the analysis. Logistic regression analysis was used to investigate the influence of geographic and demographic factors on the use of radiation. The squared multiple correlation coefficient R(2) was used to measure the proportion of variation in the selection of radiation explained by each factor of interest.

RESULTS

Compared with San Francisco, the adjusted odds ratios for 6 of the 8 geographic areas had highly significant P values, suggesting the use of radiation therapy varies from region to region. However, geographic location only explained less than 3% of the total variation in the use of radiation. The geographic location explained a much higher proportion of variation in the youngest (younger than 55 years) and the oldest (80 years old or older) groups. Overall, age was the most important factor that influenced the use of radiation.

CONCLUSIONS

The finding that geographic location explains a significant proportion of the variation in the use of radiation in the youngest and oldest age groups demonstrates the outcome of longstanding controversies in the nonsurgical treatment of prostate cancer. Documenting the impact of the interaction of age and geographic location on the treatment approaches provides for better understanding of the impact of patients and physicians making clinical decisions in the management of nonmetastatic prostate cancer.

Radical prostatectomy: geographic and demographic variation

OBJECTIVES

Previous reports have documented a geographic variation in the use of radical prostatectomy. We examined whether this phenomenon can be explained by factors other than geography alone.

METHODS

This study was based on the data from nine geographic regions of the Surveillance, Epidemiology, and End Results (SEER) program for the years 1983 through 1994. Patients with localized or regional prostate cancer were included in the analysis. Logistic regression analysis was used to investigate the influence of geographic and demographic factors on the use of radical prostatectomy. The squared multiple correlation coefficient R(2) was used to measure the proportion of variation in the selection of radical prostatectomy explained by each factor of interest.

RESULTS

As previously reported, the use of radical prostatectomy was significantly associated with geographic location; the degree of geographic variation varied as a function of age and was most dramatic in the youngest (younger than 45 years) and the oldest (75 years or older) groups. Overall, however, geography explained less than 2% of the total variation in the use of radical prostatectomy. Age was the most important factor that influenced the use of radical prostatectomy.

CONCLUSIONS

Geography explains only a small proportion of the variation in the use of radical prostatectomy. In fact, of the factors examined, only age appeared to meaningfully explain the variation in the use of radical prostatectomy. Overall, our ability to explain the variation in the use of radical prostatectomy remains meager, and new factors must be identified if we are to better understand how patients and physicians make clinical decisions.

Stability and instability of sleep in older persons recorded in the home

Using a nonintrusive procedure for sleep monitoring, four 24-hour recordings of 40 independently living women, 65-94 years, were made during a 3-month period. Although the subjects distributed their sleep over much of the day, all measures showed significant reliability: with four recordings, reliabilities (r44 values) were > 0.70; and with only one recording, reliabilities (r11) were > 0.40 [r11 for the respiratory disturbance index (RDI) was lower but still significant]. Within-individual variability over recordings was low for total sleep time (TST), sleep (S), and sleep efficiency (SE) and high for sleep latency (SL) and RDI. The mean TST was 7.6 hours, which is not markedly different from that of younger adults. Within the age range studied, there was no relationship between age and any of the variables, including the amount of within-individual variability. These results, using the Home Monitoring System (HMS), indicate that both stability and instability of sleep parameters characterize the sleep of older women. The nature of specific forms of individual variability needs to be explored as possible indices of aging as distinct from indications of neurobiological abnormalities.