The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Development of a core descriptor set for Crohn's anal fistula

AIM

Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research.

METHOD

Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting.

RESULTS

One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life.

CONCLUSION

The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Evaluating the association of the new National Surgical Quality Improvement Program modified 5-factor frailty index with outcomes in elective colorectal surgery

BACKGROUND

The 5-factor modified frailty index (mFI-5) is a new, NSQIP-based, predictive tool for mortality and postoperative complications. The mFI-5's predictive ability has been validated within the large-scale NSQIP database but applicability in institutional databases has not been investigated. We sought to assess the association between the mFI-5 and morbidity/mortality at the institutional level.

METHODS

A divisional database was queried for 2017 elective colorectal resections and an mFI-5 calculated. The main outcome measure was the association and predictive value of the mFI-5 with major morbidity/mortality and minor complications. Univariable analyses were performed via the Cochran-Armitage Test and Cramer's V. Logistic regression evaluated the relationship between the mFI-5 and morbidity/mortality while accounting for demographics and pre-operative risk factors. Receiver operating characteristic (ROC) curves were plotted to visualize the predictive strength for outcomes.

RESULTS

Four hundred and twelve patients were analyzed. 8.7% had major morbidity/mortality and 31.6% minor complications. The mFI-5 categorized patients into 0 (n = 335), 1 (n = 58), and 2+ (n = 19) groups. Univariable analysis showed a higher mFI-5 was associated significantly with major morbidity/mortality (P = 0.004), but not minor (P = 0.281). Multivariable logistic regression showed a strong association between an mFI-5 score of 2+ with major complications (Major: OR = 4.616, CI [1.442-14.776], P = 0.010). ROC curves showed the mFI-5 was poor for predicting outcomes and performed better when other risk factors were added to the model.

CONCLUSION

The mFI-5 tool has an independent association with major morbidity/mortality in an institutional dataset for elective colorectal surgery, but is not predictive. Its predictive ability is enhanced when other patient-specific risk factors are incorporated.

Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis(UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs.

RESULTS

Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9 years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA(81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups.

CONCLUSIONS

In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

Predictors of complications from stoma closure in elective colorectal surgery: an assessment from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP)

BACKGROUND

There is significant morbidity after diverting ileostomy closure, so identifying predictors of complications could be of great benefit. The aim of our study was to evaluate the incidence and risk factors for postoperative morbidity after elective ileostomy closure.

METHODS

The ACS-NSQIP dataset was evaluated for elective ileostomy closures from 1/1/2015 to 12/31/2016. Demographic characteristics, operative, and postoperative outcomes were evaluated. The primary outcome was 30-day major morbidity (Clavien class III and greater). Secondary outcomes were rates and predictors of major morbidity, superficial site infection (SSI), reoperation, and readmission from multivariate logistic regression modeling.

RESULTS

We retrospectively evaluated 1885 patients. The median operative time was 65 (IQR 50-90) minutes and median length of stay was 3 (IQR 2-5) days. Major morbidity was recorded in 6.7%, including mortality (1.0%), deep/organ space SSI (2.6%), dehiscence (0.8%), reintubation (0.5%), sepsis (1.7%), septic shock (0.8%), and reoperation (3.7%). Readmission was recorded in 9.7% and 6.2% had SSI. Multivariate logistic regression showed male sex (OR 1.584; 95% CI 1.068-2.347; p = 0.022) and longer operative time (OR 1.004; 95% CI 1.001-1.007; p = 0.009) were among those variables associated with increased odds of major morbidity. Dyspnea (OR 2.431; 95% CI 1.139-5.094; p = 0.021) and longer operative time (OR 1.003; 95% CI 1.001-1.007; p = 0.034) were among the independent risk factors for SSI. Male sex (OR 2.246; 95% CI 1.297-3.892; p = 0.004, chronic obstructive pulmonary disease (OR 2.959; 95% CI 1.153-7.591; p = 0.024), and longer operative time (OR 1.005; 95% CI 1.001-1.009; p = 0.011) were associated with increased odds of reoperation. Chronic obstructive pulmonary disease (OR 2.578; 95% CI 1.338-4.968; p = 0.005), wound infection (OR 2.680; 95% CI 1.043-6.890; p = 0.041), and inflammatory bowel disease (OR 2.565; 95% CI 1.203-5.463; p = 0.015) were associated with increased odds of readmission.

CONCLUSIONS

Elective stoma closure has significant risk of morbidity. Patients with longer operative times were at increased risk for major morbidity, overall SSI, and reoperation. From the analysis, factors specifically associated with major morbidity, overall infectious complications, readmissions, and reoperations were identified. This information can be used to prospectively prepare for these high-risk patients, potentially improving postoperative outcomes.

Frailty in older patients undergoing emergency colorectal surgery: USA National Surgical Quality Improvement Program analysis

Background

Frailty is associated with advancing age and may result in adverse postoperative outcomes. A suspected growing elderly population needing emergency colorectal surgery stimulated this study of the prevalence and impact of frailty.

Methods

Elderly patients (defined as aged at least 65 years by Medicare and the United States Census Bureau) who underwent emergency colorectal resection between 2012 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program population database. The five-item modified frailty index (mFI-5) score was calculated, and patients stratified into groups 0, 1 or 2 +. Main outcome measures were the prevalence of frailty, and its impact on 30-day postoperative morbidity, mortality, reoperation, duration of hospital stay (LOS), discharge destination and readmission.

Results

A total of 10 025 patients were identified with a median age 75 years, of whom 41·8 per cent were men. The majority (87·7 per cent) had an ASA fitness grade of III or greater and 3129 (31·2 per cent) were frail (mFI-5 group 2+). Major morbidity occurred in one-third of patients and the postoperative mortality rate was 15·9 per cent. Some 52·0 per cent of patients had a prolonged hospital stay and 11·0 per cent were readmitted. Although most patients (88·0 per cent) lived independently before surgery, only 45·4 per cent were discharged home directly. Frailty (mFI-5 2+) predicted mortality, overall and major morbidity, reoperation, prolonged LOS, discharge to an institution and readmission, but frailty was independent of sex.

Conclusion

Frailty is associated with morbidity, mortality and loss of independence in elderly patients needing emergency colorectal surgery.

Correction to: Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease

The affiliation of the author Silvio Danese has been incorrectly published in the original publication.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

Quartz, mica, and amphibole exsolution from majoritic garnet reveals ultra-deep sediment subduction, Appalachian orogen

Diamond and coesite are classic indicators of ultrahigh-pressure (UHP; ≥100-kilometer depth) metamorphism, but they readily recrystallize during exhumation. Crystallographically oriented pyroxene and amphibole exsolution lamellae in garnet document decomposed supersilicic UHP majoritic garnet originally stable at diamond-grade conditions, but majoritic precursors have only been quantitatively demonstrated in mafic and ultramafic rocks. Moreover, controversy persists regarding which silicates majoritic garnet breakdown produces. We present a method for reconstructing precursor majoritic garnet chemistry in metasedimentary Appalachian gneisses containing garnets preserving concentric zones of crystallographically oriented lamellae including quartz, amphibole, and sodium phlogopite. We link this to novel quartz-garnet crystallographic orientation data. The results reveal majoritic precursors stable at ≥175-kilometer depth and that quartz and mica may exsolve from garnet. Large UHP terranes in the European Caledonides formed during collision of the paleocontinents Baltica and Laurentia; we demonstrate UHP metamorphism from the microcontinent-continent convergence characterizing the contiguous and coeval Appalachian orogen.

Analysis of the impact of EEA stapler size on risk of anastomotic complications in colorectal anastomosis: does size matter?

BACKGROUND

Colorectal anastomotic complications are dreaded and dramatically affect outcomes. Causes are multifactorial, with the size of the end-to-end anastomosis (EEA) stapler a modifiable factor and potential target for risk reduction. Our goal was to examine the impact of the EEA stapler size on the risk of anastomotic complications in left-sided colorectal resections.

METHODS

A prospective divisional database was reviewed for consecutive elective left-sided resections with a colorectal anastomosis using an EEA stapler from January 2013 May 2018 inclusive. Patients were stratified into 25-29 mm or 30-33 mm cohorts. Patient and disease demographics, operative variables, and postoperative outcomes were evaluated. The main outcome measures were the rate and factors associated with anastomotic complications.

RESULTS

Four hundred seventy-three cases were evaluated, 185 ( 39.1%) were in the 25-29 mm group and 288 (60.9%) in the 30-33 mm group. Patients were comparable in demographics and operative variables. More males were anastomosed with the 30-33 mm than with the 25-29 mm stapler (57.6% vs 28.6%, p < 0.01). Significantly more patients developed an anastomotic stricture with the 25-29 mm than with the 30-33 mm staplers (7.1% vs. 2.1%; p = 0.007). There was no significant difference in leak rates or reoperation/interventions between groups. On logistic regression, neither gender, operative indication nor approach were associated with anastomotic leak, readmission, or reoperation/intervention. Stapler size remained significantly associated with stricture (p = 0.032).

CONCLUSIONS

The 25-29 mm EEA staplers were associated with an increased rate of anastomotic stricture compared to 30-33 mm staplers in left-sided colorectal anastomoses. As stapler size is a simple process measure that is easily modifyable, this is a potential target for improving anastomotic complication rates. Further controlled trials may help assess the impact of stapler size on improving patient and quality outcomes.

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

A National study on the adoption of laparoscopic colorectal surgery in the elderly population: current state and value proposition

BACKGROUND

The economic and clinical benefits of laparoscopic colorectal surgery are proven, yet may be underutilized in appropriate cases, especially in the elderly. Since the elderly constitute the greatest colorectal surgical volume, our goal was to identify trends in utilization and impact of laparoscopy in this cohort.

METHODS

A national review of elective inpatient colorectal resections from the Premier Inpatient Database between 2010 and 2015 was performed. Patients were included if elderly (≥ 65 years), then grouped into open or laparoscopic procedures. The main outcome measures were trends in utilization by approach and total costs for the episode of care, length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models controlled for differences across platforms, adjusting for patient demographic, comorbidities and hospital characteristics.

RESULTS

In 70,655 elderly patients evaluated, laparoscopic adoption remained lower than open throughout the study period. Rates increased until 2013, then declined, with increasing rates of open surgery. Laparoscopy was associated with significantly lower mean total costs ($4012 less/case), complications and readmissions (36% and 33% less, respectively), and shorter LOS (2.6 less days) than open cases (all p < 0.0001). When complications occurred, they were less severe and the readmission episodes were less costly with laparoscopy than open colorectal surgery.

CONCLUSION

The adoption of laparoscopy in the elderly has lagged behind open surgery and even declined in recent years despite being associated with improved clinical outcomes and reduced cost. With this tremendous value proposition to increase use of laparoscopic surgery in the elderly, further work needs to evaluate root causes of the disparity.

Serological biomarker profiles of rapidly progressive osteoarthritis in tanezumab-treated patients

There is a need for efficacious and safe pain treatments for OA (osteoarthritis). The nerve growth factor (NGF) antibody tanezumab is associated with high efficacy, but when combined with chronic NSAID treatment shows an increased risk of rapidly progressive osteoarthritis (RPOA) in a small group of patients.

AIM

The aim of this study was to phenotype with biochemical biomarkers of bone, cartilage, soft tissue, synovial metabolism OA patients who are at risk of developing RPOA type-2, for both limited and chronic NSAIDs users.

MATERIAL AND METHODS

The dataset consisted of OA patients participating in tanezumab trials who used NSAIDs <90 days (limited NSAID users) or chronic users (NSAIDs ≥90 days) over an average 10 month period. Biomarker data were available for 47 cases (RPOA type-2) and 92 controls. Non-linear and linear multivariable predictive models were developed.

RESULTS

By use of two biomarkers at baseline the receiver operating characteristic (ROC) curve area for RPOA type-2 in limited NSAID users was 71%, [CI] (60-83%). OA subjects with this biomarker phenotype had 8-fold higher confidence interval [CI][(2-33)] relative risk of developing RPOA type-2 as compared to OA patients without this phenotype. The AUC of the model in chronic NSAIDs users based on 5 biomarkers was 78%, [CI](69-88%), with 4-fold [CI (2-6)] relative risk of developing RPOA type-2.

CONCLUSION

In this hypothesis generating and exploratory study, we identified combinations of biomarkers associated with OA patients who develop RPOA type-2, which may be related to the pathology of the RPOA type-2 joint.

Patient-reported functional and quality-of-life outcomes after transanal total mesorectal excision

Follow-up of more than 1 year after transanal total mesorectal excision for rectal cancer demonstrated improved quality of life and stable or improved functional outcomes. Continued experience and operative efficiency hold promise for improved overall outcomes with this emerging technology. Key patient-reported outcomes.

Colorectal cancer in inflammatory bowel disease: review of the evidence

Inflammatory bowel disease (IBD)-related colorectal cancer (CRC) is responsible for approximately 2% of the annual mortality from CRC overall, but 10-15% of the annual deaths in IBD patients. IBD-related CRC patients are also affected at a younger age than sporadic CRC patients, and have a 5-year survival rate of 50%. Despite optimal medical treatment, the chronic inflammatory state inherent in IBD increases the risk for high-grade dysplasia and CRC, with additional input from genetic and environmental risk factors and the microbiome. Recognizing risk factors, implementing appropriate surveillance, and identifying high-risk patients are key to managing the CRC risk in IBD patients. Chemoprevention strategies exist, and studies evaluating their efficacy are underway. Once dysplasia or invasive cancer is diagnosed, appropriate surgical resection and postoperative treatment and surveillance are necessary. Here, we discuss the current state of IBD-related CRC, prevalence, risk factors, and evidence for surveillance, prophylaxis, and treatment recommendations.

Feasibility of fluorescence lymph node imaging in colon cancer: FLICC

BACKGROUND

In colon cancer, appropriate tumour excision and associated lymphadenectomy directly impact recurrence and survival outcomes. Currently, there is no standard for mesenteric lymphadenectomy, with a lymph node yield of 12 acting as a surrogate quality marker. Our goal was to determine the safety and feasibility of indocyanine green (ICG) fluorescence imaging to demonstrate lymphatic drainage in colon cancer in a dose-escalation study.

METHODS

A prospective pilot study of colon cancer patients undergoing curative laparoscopic resection was performed. At surgery, peritumoural subserosal ICG injection was done to demonstrate lymphatic drainage of the tumour. A specialized fluorescence system excited the ICG and assessed lymphatics in real time. The primary outcome was the feasibility of ICG fluorescent lymphangiography for lymphatic drainage in colon cancer. Secondary outcomes were the optimal protocol for dose, injection site, and ICG lymphatic mapping timing.

RESULTS

Ten consecutive patients were evaluated (six males, mean age 69.5 years). In all, lymphatic channels were seen around the tumour to a varying extent. Eight (80%) had drainage to the sentinel node. In all cases where the lymphatic map was seen, there was no further spread 10 min after injection. In 2 patients (20%), additional lymph nodes located outside of the proposed resection margins were demonstrated. In both cases the resection was extended to include the nodes and in both patients these nodes were positive on histopathology. Factors contributing to reduced lymphatic visualization were inadequate ICG concentrations, excess India ink blocking drainage, and inflammation from tattoo placement.

CONCLUSIONS

ICG can be safely injected into the peritumoural subserosal and demonstrate lymphatic drainage in colon cancer. This proof of concept and proposed standards for the procedure can lead to future studies to optimize the application of image-guided precision surgery in colon cancer. Furthermore, this technique may be of value in indicating the need for more extended lymphadenectomy.

Identification of serological biomarker profiles associated with total joint replacement in osteoarthritis patients

OBJECTIVE

Establish a biomarker panel associated with all-cause total joint replacement (TJR) through identification of patients with osteoarthritis (OA) who do or do not progress to TJR and investigate effects of nonsteroidal anti-inflammatory drugs (NSAIDs).

DESIGN

Serum samples from patients enrolled in phase III trials of tanezumab who experienced TJR (n = 174) or matched patients who did not (n = 321) were analyzed for bone, cartilage, soft tissue, and inflammation markers. Classification and Regression Tree (CART) analysis was used to identify biomarker phenotypes associated with TJR.

RESULTS

At baseline, biomarker combinations for patients who did not use NSAIDs before starting tanezumab and used NSAIDs during tanezumab treatment <90 days ("nonNSAID"), identified 77% (95% confidence interval [CI]: 71-84%) of patients who experienced TJR and 77% (95% CI: 65-86%) who did not over a 6-month study period (on average). These biomarker combinations increased odds of identifying patients to remain free of a TJR by 3.3-fold. In patients who used NSAIDs continuously (during screening and ≥90 days during tanezumab treatment), 64% (95% CI: 54-73%) who had TJR and 75% (95% CI: 68-83%) who did not were identified by biomarker combinations different from nonNSAID patients, with an increase in odds of identifying patients to remain free of a TJR by two-fold.

CONCLUSIONS

Although validation on other cohorts is necessary, biomarkers may assist in identifying patients who will need TJR. The profiles suggest NSAID use increases importance of bone metabolism in TJR pathology.

Transanal Minimally Invasive Surgery: State of the Art

The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.

Minimally invasive colorectal surgery: status and technical specifications

Laparoscopy was the most significant technologic advance in colorectal surgery in the last quarter century. The safety, feasibility and oncologic equivalence have been proven, and undisputed clinical benefits have also been demonstrated over open approaches. Despite proven benefits, laparoscopic has not dominated the market, especially for colon and rectal cancer cases. Adaptations in laparoscopic technique were developed to increase use of minimally invasive surgery. Concurrently, there has been a paradigm shift toward less invasive technologies to further optimize patient outcomes. From these needs, hand assisted laparoscopic surgery (HALS), single incision laparoscopic surgery (SILS), and robotic assisted laparoscopic surgery (RALS) were applied to colorectal surgery. Each platform has unique costs and benefits, and similar outcomes when likened to each other in comparative studies. However, conventional laparoscopy, HALS, SILS, and RALS actually serve a complementary role as tools to increase the use of minimally invasive colorectal surgery. The goal of this paper is to review the history, current status, technical specifications, and evolution of the major minimally invasive platforms for colorectal surgery.

MRI-defined height of rectal tumours

Background

There is no standard for reporting rectal cancer distances from the distal resection margin in the literature. The objective was to demonstrate the importance of rectal cancer measurement from a standardized point.

Methods

Review of databases at two international institutions identified 50 patients with rectal adenocarcinoma within 15 cm of the anal verge (AV), who had preoperative magnetic resonance imaging (MRI) and underwent surgery with curative intent. Expert radiologists reviewed the magnetic resonance images for anatomical distances from the anorectal ring (ARR) to the AV, from the ARR to the dentate line (DL), and from the DL to the AV. Anatomical measurements were compared with preoperative measurements to assess reporting inconsistencies.

Results

Fifty patients with rectal adenocarcinoma were included in the study. The mean(s.d.) anatomical distance was 1·66(0·61) cm from the ARR to the DL, 3·78(0·61) cm from the ARR to the AV (maximum 5·5 cm) and 2·11(0·10) cm from the DL to the AV. The mean radiological distance from the distal tumour was 2·90(1·60) (median 3·2, range 0–7·5) cm to the ARR, 4·36(3·20) (median 4·2, range −0·5 to 12·8) cm to the DL and 6·13(3·39) (median 6·0, range 0–14·1) cm to the AV. There was a significant difference in the distal tumour margin between measurements made by the expert radiologists and reported preoperative measurements (P &lt; 0·001). Significant differences were also found between the expert radiologists' MRI and rigid proctoscopic measurements (P = 0·025).

Conclusion

There was up to 5·5 cm variation, depending on which landmark was chosen for reporting the distal margin of rectal cancer. This has potential implications for surgical planning, interpreting radiological images and comparative studies.

The impact of managed care on substance abuse treatment: a report of the American Society of Addiction Medicine

This report examines the impact of managed care (MC) and related developments on substance abuse treatment, and evaluates how it has been associated with a decline in the availability of proper treatment for many addicted patients. A trend toward carve-out and for-profit MC organizations is associated with lower financial incentives for intensive treatment than in earlier staff-model and not-for-profit MC organizations. The value of substance abuse insurance coverage has declined by 75% between 1988 and 1998 for employees of mid-to large-size companies, compared with only an 11.5% decline for general health insurance. The shift towards MC has also been associated with a drastic reduction in frequency and duration of inpatient hospitalization, and there is no clear evidence that this reduction has been offset by a corresponding increase in outpatient support. In a survey of physicians treating addiction, the majority felt that MC had a negative impact on detoxification and rehabilitation, and on their ethical practice of addiction medicine.

Manual-guided cognitive-behavioral therapy training: a promising method for disseminating empirically supported substance abuse treatments to the practice community

A gap exists between empirically supported substance abuse treatments and those used in community settings. This study examined the feasibility of training substance abuse counselors to deliver cognitive-behavioral treatment (CBT) using treatment manuals. Participants were 29 counselors. Counselors were randomly assigned to receive CBT training or to a control group. Counselor attitudes were assessed pre- and posttraining. In addition, CBT therapy sessions were videotaped and rated for adherence and skillfulness. CBT counselors reported high levels of satisfaction with the training, intention to use CBT interventions, and confidence in their ability to do so. Ratings indicated that 90% of counselors were judged as having attained at least adequate levels of CBT skillfulness. Findings demonstrate the feasibility of using psychotherapy technology tools as a means of disseminating science-based treatments to the substance abuse practice community.

Efficacy of topically administered doramectin against eyeworms, lungworms, and gastrointestinal nematodes of cattle

OBJECTIVE

To evaluate efficacy of topically administered doramectin against eyeworms, lungworms, and gastrointestinal nematodes of cattle.

ANIMALS

400 cattle (20 cattle in each of 20 trials).

PROCEDURE

Trials were conducted in North America; natural and experimentally induced infections were used. In each trial, cattle were allocated randomly to control (placebo [saline [0.9% NaCl] solution at 1 ml/10 kg of body weight] or untreated; n = 10) or doramectin-treated (500 microg/kg of body weight; 10) groups. Treatments were applied in a single passage along the midline of the back, from the withers to the tailhead. Cattle were euthanatized > or =14 days after treatment, and worm burdens were determined by use of standard techniques.

RESULTS

Efficacy of doramectin was > or =95.3% against adults of Thelazia gulosa, T skrjabini, Dictyocaulus viviparus, Haemonchus contortus, H placei, Ostertagia lyrata, O ostertagi, Trichostrongylus axei, Bunostomum phlebotomum, Capillaria spp, Cooperia oncophora, C pectinata, C punctata, C spatulata, C surnabada, Nematodirus spathiger, Strongyloides papillosus, T colubriformis, Oesophagostomum radiatum, and Trichuris spp. Efficacy was 95.1% against fourth-stage larvae of D viviparus, H placei, O lyrata, O ostertagi, T axei, C oncophora, C punctata, C spatulata, C surnabada, N helvetianus, T colubriformis, O radiatum, and Trichuris spp. In addition, efficacy against inhibited fourth-stage larvae of O ostertagi and Ostertagia spp was > or =98.1%.

CONCLUSIONS AND CLINICAL RELEVANCE

A single topical application of doramectin pour-on was efficacious against a broad range of nematode species in cattle.

Persistent efficacy of doramectin injectable against artificially induced infections with Cooperia punctata and Dictyocaulus viviparus in cattle

Three studies were conducted to evaluate the persistent efficacy of doramectin injectable solution against experimental challenges with infective larvae of Cooperia punctata and Dictyocaulus viviparus. In each study, four groups of ten randomly-assigned calves, negative for trichostrongyle-type eggs on fecal examination, were treated subcutaneously in the midline of the neck with saline (1 ml/50 kg) on Day 0 or doramectin (200 microg/kg = 1 ml/50 kg) on Day 0, 7, or 14. Two additional calves from the same pool of animals were randomly assigned as larval-viability monitors and received no treatment. On Days 14-28, approximately 1000 and 50 infective larvae of Cooperia spp. and D. viviparus, respectively, were administered daily by gavage to each animal in Groups T1-T4. On Day 28, the two larval-viability monitor calves were inoculated in a similar manner with a single dose of approximately 30000 and 2000 larvae of Cooperia spp. and D. viviparus, respectively. Equal numbers of calves from each treatment group were killed on Days 42-45, as well as the two viability monitor animals to enumerate worm numbers. A 2% or 5% aliquot of small intestinal contents and washings were examined for worm quantification and identification, while 100% of the lung recoveries were quantified and identified. For each study and across the three studies, geometric mean worm recoveries for each treatment group were calculated from the natural log transformed data (worm count + 1) and were used to estimate percentage reduction. In the three studies, doramectin injectable solution was 97.5% efficacious against lungworms for up to 28 days and was 99.8% efficacious in reducing infection resulting from challenge with infective larvae of C. punctata for at least 28 days post-treatment.

Efficacy of a pour-on formulation of doramectin against lice, mites, and grubs of cattle

OBJECTIVE

To determine effectiveness of a pour-on formulation of doramectin against Damalinia bovis, Haematopinus eurysternus, Linognathus vituli, Solenopotes capillatus, Chorioptes bovis, Sarcoptes scabiei, Hypoderma bovis, and Hypoderma lineatum.

ANIMALS

Cattle of various ages with naturally acquired or artificial infestations with 1 or more species of lice, mites, or grubs.

PROCEDURE

In 10 louse and 6 mite studies, cattle were treated with doramectin (500 microg/kg, topically) on day 0, and parasite counts were performed approximately weekly from days 0 to 35. In 6 grub studies, cattle expected to harbor Hypoderma spp were treated before emergence of warbles. After warbles began to emerge, they were counted every 2 weeks, and grubs were collected and identified by species.

RESULTS

Burdens of D bovis, H eurystemus, L vituli, and S capillatus on doramectin-treated cattle were 0 by 28 days after treatment. Burdens of C bovis and S scabiei decreased to 0 in naturally infested cattle and approximately 0 in artificially infested cattle by day 14 to 15. In grub studies, 107 of 136 control cattle had warbles, whereas 2 of 136 doramectin-treated cattle had 1 warble each, which represented a cure rate of 98.5%.

CONCLUSION AND CLINICAL RELEVANCE

One topical application of doramectin was highly efficacious against common species of lice, mites, and grubs known to affect performance, health, and appearance of cattle.

Technology transfer of Network Therapy to community-based addictions counselors

This paper describes a technology transfer initiative in which Network Therapy (NT), a substance abuse treatment that utilizes peer and family support, was disseminated to a cohort of addictions counselors located in an outpatient community-based addictions treatment center. Training methods included a didactic seminar, role-playing, use of videotaped illustrations, and clinical supervision, and are described in detail. Counselors then implemented the NT approach with a sample of cocaine-abusing patients (N = 10) who were being treated concurrently with the standard program provided by the treatment setting. NT patients were compared by chart review with a cohort of cocaine abusers who received community treatment--as-usual (TAU) (N = 20). The groups did not differ on demographic variables or the amount of TAU received at the community program. However, NT patients had significantly less positive urinalyses than TAU patients, though they were not significantly different in terms of treatment retention. Implications for technology transfer are discussed.

Field efficacy of doramectin pour-on against naturally-acquired, gastrointestinal nematodes of cattle in North America

Seven studies were conducted under field conditions in North America to evaluate the therapeutic efficacy of doramectin in a pour-on formulation at a dosage of 500 microg/kg (1 ml/10 kg) for cattle harboring naturally-acquired infections of gastrointestinal nematodes, including species of Haemonchus, Ostertagia, Trichostrongylus, Bunostomum, Cooperia, and Oesophagostomum. In each study, 40 to 100 cattle were randomly allocated to a saline- or doramectin-treated group in a tiered manner based on Day -7 bodyweight. On Day 0, the cattle received either saline or doramectin topically, according to their treatment group. Weather and safety observations were made following treatment. No adverse reaction to treatment was observed at any time during these studies. Fecal egg count (FEC) determinations were carried out on each animal on Days -7, 0, 7, 14, and 21. Reductions in FEC for the doramectin-treated animals compared to saline-treated cattle were > or = 96.0% by Day -7 and > or = 99.0% on Days 14 and 21 for each study. Across all studies regardless of weather conditions, the reduction by Day 21 for the doramectin-treated animals compared to saline controls was 99.7% (p < or = 0.0001) and compared to pretreatment levels in doramectin-treated cattle was 99.9% (p < or = 0.0001). Doramectin pour-on should provide a useful new treatment for controlling nematode parasites of cattle.

Use of the Internet for addiction education. Combining network therapy with pharmacotherapy

The authors prepared a course in addiction psychiatry for the Internet that combines a psychosocial and a medication modality for alcoholism; namely, network therapy and naltrexone. Responses of those who accessed the course revealed 679 counts (visits) at the Web Site. A group of 210 unique respondents, of whom 154 were psychiatrists, answered a demographic question set. Over half of these psychiatrists completed the course and evaluated it. The majority indicated that it helped them understand "a good deal" about the management of alcoholism and the use of network therapy and naltrexone. This result suggests the feasibility of using the Internet as a vehicle for teaching in addiction psychiatry, an area where needs for training are often unmet.

Network Therapy for addiction: assessment of the clinical outcome of training

Mental health practitioners in the office setting are often seen as deficient in addiction treatment skills. Relevant training in often quite limited, and trainees are generally not introduced in an effective office-based modality. We studied the feasibility of teaching beginning therapists how to apply Network Therapy, a cognitive-behavioral approach to achieving abstinence and preventing relapse that augments individual therapy with support from family and friends. The therapists were 19 psychiatric residents without experience in substance abuse treatment or outpatient therapy, and the patients were 24 cocaine-dependent patients who received a 24-week course of Network treatment. The patients remained in treatment for an average of 15.4 weeks. Seventy-nine percent of their observed weekly urine toxicologies were negative for cocaine, and 42% of patients produced clean urines in the 3 weeks immediately before termination. The overall outcome compares favorably with that reported in studies on cocaine treatment where experienced therapists were employed. Our results suggest that naive mental health trainees can be taught to apply Network Therapy for effective substance abuse management. This is particularly relevant to technology transfer for general mental health trainees, who are often thought to be perceived to be refractory to learning about the outpatient management of addiction.

Comparison of the BacT/Alert FAN aerobic and the Difco ESP 80A aerobic bottles for pediatric blood cultures

We compared the BacT/Alert system using the aerobic FAN bottle with the ESP system using the 80A aerobic bottle for the detection of pediatric bloodstream pathogens at a children's hospital. From 6,636 blood culture sets complying with the inclusion criteria, 308 pathogens were detected, including 177 that were detected by both systems, 69 that were detected by BacT/Alert FAN only, and 62 that were detected by ESP 80A only (P = 0.6; not significant). BacT/Alert FAN detected more isolates of Staphylococcus aureus (47 versus 34; P = 0.02), while ESP 80A detected more episodes of streptococcal and enterococcal infection. BacT/Alert FAN detected more pathogens from patients receiving antibiotic therapy (107 versus 93; P = 0.04). Of 248 separate episodes of bacteremia or fungemia, 146 were detected by both systems, 56 were detected by ESP 80A only, and 46 were detected by BacT/Alert FAN only (P = 0.37; not significant). The median times to detection were 13.6 h for ESP 80A and 15.7 h for BacT/Alert FAN (P < 0.001). Both systems were considered easy to operate and were free from significant mechanical difficulties. False-positive or false-negative signals were rare or nonexistent with both systems. We conclude that both systems rapidly detect a broad range of pediatric bloodstream pathogens. BacT/Alert FAN provides better detection of Staphylococcus aureus, especially from patients receiving antibiotics. ESP 80A provides better detection of streptococci and enterococci.

Validation of a scale for network therapy: a technique for systematic use of peer and family support in addition treatment

Substance abuse treatments are increasingly employing standardized formats. This is especially the case for approaches that utilize an individual psychotherapy format but less so for family-based approaches. Network therapy, an approach that involves family members and peers in the patient's relapse prevention efforts, is theoretically and clinically differentiated in this paper from family systems therapy for addiction. Based on these conceptual differences, a Network Therapy Rating Scale (NTRS) was developed to measure the integrity and differentiability of network therapy from other family-based approaches to addiction treatment. Seven addictions faculty and 10 third- and fourth-year psychiatry residents recently trained in the network approach used the NTRS to rate excerpts of network and family systems therapy sessions. Data revealed the NTRS had high internal consistency reliability when utilized by both groups of raters. In addition, network and nonnetwork subscales within the NTRS rated congruent therapy excerpts significantly higher than noncongruent therapy excerpts, indicating that the NTRS subscales measure what they are designed to measure. Implications for research and training are discussed.

An intensive program for collegiate substance abusers. Progress six months after treatment entry

The New Jersey Collegiate Substance Abuse Program (NJCSAP) provided intensive substances abuse treatment to college students requiring treatment for severe substance use disorders. This study reports the progress of students who received 6 months of treatment of NJCSAP and participated in a research evaluation of the program. Overall, 74.5% of participants who completed the follow-up were abstinent at the 6-month assessment. Including participants who did not complete the follow-up as user yielded a 52.6% rate of abstinence. Students who completed the follow-up experienced decreases in the number of current psychiatric diagnoses met, depressive symptomatology, alcohol and drug problem severity, and family and psychiatric problem severity over the 6 month period. Most students rated the program components as very or moderately helpful and most were attending AA at the 6-month assessment. Result are compared to findings from other programs for adolescents and young adults.

Comparison of automated Difco ESP blood culture system with biphasic BBL Septi-Chek system for detection of bloodstream infections in pediatric patients

We compared the Difco ESP 384 blood culture system with the pediatric Septi-Chek system for the detection of bloodstream infections in pediatric patients. A total of 10,762 blood culture sets included an ESP aerobic bottle and a Septi-Chek bottle. From these cultures, a total of 278 organisms classified as probable pathogens were isolated, including 237 from ESP bottles and 221 from Septi-Chek bottles. This difference was not statistically significant. More organisms classified as possible contaminants were also isolated from ESP bottles (for ESP, 480 bottles; for Septi-Chek, 418 bottles; P < 0.01). The time to detection was shorter for probable pathogens isolated from ESP bottles (median times for organisms isolated from both systems: ESP, 14.0 h; Septi-Chek, 34.5 h; P < 0.001). The proportions of all probable pathogens detected by 24 and 48 h after inoculation were 78 and 96%, respectively, for ESP compared with 31 and 74%, respectively, for Septi-Chek. The time to final identification was also shorter for organisms grown in ESP bottles (median times for organisms isolated from both systems: ESP, 48.8 h; Septi-Chek, 58.5 h; P < or = 0.001). A subset of 4,442 cultures also included an ESP anaerobic bottle in addition to an ESP aerobic bottle and a Septi-Chek bottle. There were no significant differences in the recovery of probable pathogens by any of the possible two bottle combinations, but five anaerobic pathogens were recovered only in the anaerobic bottle. We conclude that the ESP 384 is an excellent system for culturing pediatric blood samples and that it provides for the very rapid detection of bloodstream pathogens.

Treating college substance abusers. The New Jersey Collegiate Substance Abuse Program

University students with serious substance use disorders may require specialized treatment. The New Jersey Collegiate Substance Abuse Program (NJCSAP) was a treatment center developed for this population that allowed students to receive treatment while remaining in the university environment and continuing school. NJCSAP was structured into three levels of care so that clients could be matched to treatment of appropriate intensity. In addition, NJCSAP helped students develop a network of supportive recovering peers and activities on the Rutgers University campus. An evaluation of the client population revealed a group of students with a history of severe substance use and related problems. Implications of the evaluation results are discussed.

Affectivity in cocaine and opiate abusers

Psychoanalytic theorists concerned with substance abuse suggest that the affect tolerance and affect expression of addicts are impaired due to preverbal influences. However, psychoanalytic contributions have largely been limited to clinical speculations and case study reports. The present study investigated the hypotheses that opiate abusers will demonstrate more impaired affect tolerance and affect expression than cocaine abusers, and that both groups would appear more impaired than a sample of normals. To investigate these hypotheses, a recently developed instrument, the Epigenetic Assessment Rating System (EARS), was employed. The EARS empirically measures verbal and preverbal phenomena theoretically linked with stages of development. The subjects were 25 opiate, 25 cocaine abusers, and 25 normals, matched according to age, gender, and SES criteria. Results supported the hypotheses that opiate and cocaine abusers' affect tolerance and affect expression were significantly impaired as compared to normals. Although affect tolerance did not distinguish between opiate and cocaine abusers, affect expression did. Cocaine abusers were less impaired than opiate abusers by preverbal modes of affect expression, although under stress cocaine abusers regressed to similar states.

Resistance to penicillin and non-beta-lactam antibiotics of Streptococcus pneumoniae at a children's hospital

During a 12-month period we tested all isolates of Streptococcus pneumoniae recovered from patients at St. Louis Children's Hospital for resistance to penicillin and other antibiotics. Twenty-seven (20%) of 136 had relative penicillin resistance (minimum inhibitory concentration 0.1 to 1.0 microgram/ml) and 8 (6%) were fully resistant (minimum inhibitory concentration > or = 2.0 micrograms/ml). Sixteen percent from blood and cerebrospinal fluid were resistant, compared with 30% from other body sites. The resistant isolates were of diverse serotypes and included 38% intermediate and 6% resistant to cefotaxime, 40% resistant to trimethoprim-sulfamethoxazole and 20% resistant to erythromycin. Patients with resistant isolates were more likely to have taken antibiotics of the aminopenicillin class and to be of the white race. We conclude that penicillin-resistant pneumococci, including some with resistance to third generation cephalosporins and some with multidrug resistance to non-beta-lactam antibiotics, are widespread in the St. Louis area. The presence of these stains requires reconsideration of current approaches to the antibiotic therapy of a variety of infectious diseases in which pneumococci play a prominent role.

Identifying young adult substance abusers: the Rutgers Collegiate Substance Abuse Screening Test

Substance abuse is a serious problem in the young adult population, yet there exists a lack of reliable screening measures for use in identifying problem users in this age group. The Rutgers Collegiate Substance Abuse Screening Test (RCSAST) is a 25-item, true/false questionnaire that was created to provide a reliable means of identifying young adult substance abusers. Three groups completed the RCSAST: a clinical sample of 84 young adult, problem substance users; a group of 33 young adults who were referred to an assistance program but were judged not to have a substance use problem; and a control sample of 87 young adult, nonproblem substance users. The RCSAST correctly classified 94% of the clinical subjects as problem users, and 89% of the control subjects as nonproblem users. The difference between the average total scores for the two groups was highly significant. In addition, the RCSAST was able to distinguish between problem and nonproblem users within the sample of subjects who were referred for evaluation. The findings support the use of the RCSAST in identifying young adult substance abusers.

Relapse prevention strategies for the treatment of cocaine abuse

A variety of promising pharmacotherapies, psychotherapies, and other treatments for cocaine abuse have recently been developed, many of which may facilitate the initiation of abstinence in cocaine abusers. This paper describes specific interventions and therapeutic strategies used in the treatment of cocaine abuse, adapted from Marlatt's theory of relapse prevention. These strategies extend Marlatt's primarily psychoeducational approach to address the unique difficulties presented in the treatment of cocaine abuse, which may include wide variations in patients' severity of abuse, available psychosocial resources, and coexistent psychopathology. This approach attempts to integrate relapse prevention techniques into a psychotherapeutic, rather than a purely psychoeducational approach, in order to enhance its effectiveness with cocaine abusers.