Evaluating whether KRAS/BRAF mutation status, anaemia and obstruction are associated with recurrence and mortality in non-metastatic colorectal cancer

BACKGROUND

KRAS and BRAF testing is currently recommended in metastatic colorectal cancer. There is evidence that KRAS and BRAF mutation status may act as a prognostic biomarker in patients with non-metastatic colorectal cancer. Data is limited on whether KRAS and BRAF mutation status impacts recurrence and mortality in patients with non-metastatic colorectal cancer.

METHODS

A retrospective cohort study was conducted in a tertiary hospital examining outcomes in patients who had KRAS and BRAF testing for colorectal cancer in 2017. Primary outcomes were all-cause mortality and recurrence. Multivariable analysis for both outcomes, used cause specific Cox proportional hazards models with KRAS/BRAF status as exposure. For time to recurrence, a sensitivity analysis was performed with a weighted Fine-Grey model with death as a competing risk.

RESULTS

KRAS mutation status was not associated with all-cause mortality (average Hazard Ratio (aHR) = 0.78, 95% CI 0.28-2.21) or recurrence (aHR = 0.96, 95% CI 0.32-2.86). BRAF mutation status was not associated with time to all-cause mortality (aHR = 3.06, 95% CI 0.79-11.8) or recurrence (aHR = 0.94, 95% CI 0.13-6.57). Increased risk of recurrence was significantly associated with large bowel obstruction (aHR = 2.73, 95% CI 1.16-6.45) and anaemia (aHR = 3.39, 95% CI 1.06-10.8) at time of surgery.

CONCLUSION

This study did not demonstrate an association between KRAS and BRAF mutations and all-cause mortality or recurrence. A significantly increased risk of cancer recurrence was found in patients with large bowel obstruction and in patients with anaemia at time of surgery. Anaemia should be promptly investigated and corrected prior to colorectal cancer surgery.

Are we using best practice to guide laxative use in post-partum patients with obstetric anal sphincter injuries - A retrospective review

OBJECTIVE

Obstetric anal sphincter injury (OASI) is the leading cause of anal incontinence (AI) in young women. Laxatives are recommended to enhance recovery, however there are no consistent guidelines to guide best practice on the type, frequency, and dose of laxative should be used. This study aimed to evaluate the current use of laxatives following repair of OASIs, and to determine any association with AI. Study design A retrospective cohort study of 356 women who sustained OASIs between January 2016 and June 2020, at a single tertiary centre in Adelaide. Data regarding the type, dose and frequency of laxatives prescribed was extracted from each patient. The degree of OASIs was determined by clinical examination and endoanal ultrasound, and AI was measured by the St Marks incontinence score.

RESULTS

Multiple combinations and classes of laxatives were prescribed including bulking agent (Metamucil and Fybogel), emollients (Coloxyl), and osmotic laxatives (lactulose and Movicol). Bulking agents were prescribed for 245 women (68.8%), which is contrary to the current recommendations based on two previous randomised controlled trials. AI reported by 51 (14.3%) women. There were no statistical differences between AI and laxative type, dose, or frequency.

CONCLUSION

Considerable variation existed in laxatives prescription. Bulking agents was not associated with higher rates of AI. Further research is required to improve post-partum care in women following repair of OASIs.

Understanding what impacts on disclosing anal incontinence for women when comparing bowel-screening tools: a phenomenological study

Background

There is limited research defining the true prevalence of anal incontinence (AI) in women of childbearing age. Understanding the limitations of the current assessment tools in the identification of AI is paramount for identifying the prevalence of AI and improving the care and management for women of childbearing age. The aim of this research was to explore and develop an understanding of women’s experiences in disclosing AI when completing a new bowel-screening questionnaire when compared to two established AI tools.

Methods

A phenomenological qualitative research study was undertaken in a maternity setting in a large tertiary hospital. Parous women in the first trimester of a subsequent pregnancy were recruited to complete a specifically designed screening tool (BSQ), St Marks Faecal incontinence score (Vaizey) and Cleveland (Wexner) score. Qualitative semi-structured interviews were utilised to identify experiences in disclosing AI.

Results

Women (n = 16, 22–42 years) with a history of anal incontinence either following the first birth (n = 12) or the second (n = 4) provided differing responses between the three assessment tools. All women answered the BSQ while the Vaizey and Wexner scores were more difficult to complete due to clinical language and participants level of comprehension. Women identified three major themes that were barriers for disclosing incontinence, which included social expectations, trusted space and confusion.

Conclusion

There are barriers for disclosing AI in the pregnant and post-natal population, which can be improved with the use of an easy assessment tool. The BSQ may facilitate discussion on AI between the patient and health professional leading to earlier identification and improvement in short and long-term health outcomes.

Do women of reproductive age presenting with pelvic floor dysfunction have undisclosed anal incontinence: A retrospective cohort study

BACKGROUND

Indirect and direct trauma following vaginal birth can negatively impact on the pelvic floor function increasing the risk of anal incontinence. It is often difficult for women to openly disclose that they have anal incontinence and there are limited data collection tools available for the identification of these women in a clinical setting.

AIM

This study aims to describe the prevalence of undisclosed anal incontinence in antenatal and postnatal women with pelvic floor dysfunction.

METHODS

Retrospective cohort study of 230 antenatal and postnatal women referred to a Continence Nursing Service in a large tertiary hospital in South Australia, Australia, with pelvic floor dysfunction. A criteria list was utilised to access the primary reason for referral, anal incontinence assessments and attendance to an appointment.

RESULTS

Anal incontinence was identified in 26% of women (n=59). Anal incontinence was the primary reason for referral amongst 8 women, with the remaining 51 women identified as having anal incontinence following clinical screening via phone consultation. Eighty six percent of women stated they had not previously disclosed anal incontinence to health professionals. Overall, 71% of symptomatic women (n=28 antenatal and n=14 postnatal women) attended appointments to a service specialising in pelvic floor dysfunction.

CONCLUSION

Women presenting with urinary incontinence or other markers of pelvic floor dysfunction should be actively screened for anal incontinence as the prevalence of this condition is high amongst childbearing women.

Quantification of subclasses of human colonic myenteric neurons by immunoreactivity to Hu, choline acetyltransferase and nitric oxide synthase

An accurate method to count human enteric neurons is essential to develop a comprehensive account of the classes of nerve cells responsible for gut function and dysfunction. The majority of cells in the enteric nervous system utilize acetyl choline, or nitric oxide, or a combination of these, as neurotransmitters. Antisera raised against the RNA-binding protein Hu, were used to identify nerve cell bodies in whole mounts of the myenteric plexus of human colon, and then were utilized to analyse cells immunoreactive for combinations of choline acetyltransferase and nitric oxide synthase. Antisera to Hu provided a reliable means to count apparently all enteric nerve cell bodies, revealing 10% more cell bodies than labelling with neuron specific enolase, and no labelling of glial cells as revealed by S100. ChAT+/NOS- neurons accounted for 48% (+/-3%) of myenteric neurons and ChAT-/NOS+ neurons accounted for 43% (+/-2.5%). ChAT+/NOS+ neurons comprised 4% (+/-0.5) of the total number of neurons, and a novel class of small ChAT-/NOS- neurons, making up 5% (+/-0.9%) of all cells, was described for the first time.

Management of an unexpected appendiceal neoplasm

BACKGROUND

Appendiceal neoplasms are rare and most present unexpectedly as acute appendicitis. The classification and management are confusing, and there are few substantial reports in the literature.

METHODS

A systematic literature review was performed to access relevant publications on the presentation, pathology and management of appendiceal tumours.

RESULTS

Appendiceal tumours account for 0.4 to 1 per cent of all gastrointestinal tract malignancies and are found in 0.7 to 1.7 per cent of appendicectomy specimens. Carcinoid tumours are most common. Most are cured by simple appendicectomy if the tumour is less than 2 cm in size and does not involve the resection margin or mesoappendix. Epithelial tumours may present with, or in time develop, pseudomyxoma peritonei, the optimal management of which involves complete tumour resection and intraperitoneal chemotherapy, usually available only in specialized centres.

CONCLUSION

Suggested algorithms for the management of unexpected appendiceal tumours are provided. Recommendations are made for follow-up of patients with a perforated appendiceal epithelial tumour.