Oncologic outcomes of laparoscopic surgery for rectal cancer: a systematic review and meta-analysis of the literature

AIM

To review and compare the oncologic outcomes in patients with rectal cancer undergoing laparoscopic vs. open rectal surgery.

METHODS

An electronic literature search was performed for trials reporting oncologic outcomes for laparoscopic rectal resections. Variables of interest were survival, recurrence rates, margin status and nodal retrieval. Trials were excluded if variables were not specifically analysed for rectal resections. A meta-analysis was performed to assess the difference in oncologic outcomes between the two treatment approaches.

RESULTS

Data on a total of 1403 laparoscopic (LG) and 1755 open (OG) rectal resections were gathered from 24 publications. Overall survival at 3 years (LG=76%, OG=69%) was not statistically different between the two treatment groups. The mean local recurrence rates were 7% for laparoscopic and 8% for open procedures (NS). There was no difference in radial margin positivity, 5% of patients undergoing laparoscopic surgery compared to 8% for open surgery. Laparoscopic procedures harvested a mean of 10 nodes as compared to 12 for open procedures, p=0.001.

CONCLUSIONS

Data gathered in this meta-analysis indicate that there are no oncologic differences between laparoscopic and open resections for treatment of primary rectal cancer.

Resource utilization by palliative surgery patients: results of the decision and outcomes in palliative surgery (DOPS) trial

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Background: The number of cancer patients is increasing. Though many cancer treatments are successful at improving survival, most tumors recur and become incurable. A spectrum of symptoms then manifest, many requiring operations. As this happens and the focus becomes symptom management, health system resources used often differ from other scenarios. This study seeks to define the type and breadth of perioperative resource utilization after palliative operations. Methods: Prospectively, patients with advanced malignancies getting palliative operations were followed 3 months postoperatively. In addition to demographics, all encounters with any medical personnel and healthcare resources used were captured by a thorough chart audit and entered into a database. Results: Of the 106 patients entering the study, 67 remained after 3 months. Patients suffered from a mean of 2 symptoms, pain being most common. Patients had a mean of 25.4 encounters (range 1–94). Most commonly, the encounters were with the departments of surgery, medical oncology, and radiation oncology. Half of the encounters were with physicians while 47% were with physician extenders and 3% with supportive staff. Eighty-seven percent of encounters were scheduled. Half occurred in the clinics, 21% in urgent care, and 29% by phone. Fifteen patients were readmitted, most often for symptom management (52%). The 54 patients receiving supportive care referrals had a mean of 2 different referrals per patient and were primarily social work, nutrition, and rehabilitation. Two pain management referrals were initiated. Conclusions: Patients undergoing palliative operations use no more resources than those having curative procedures. Because of disease persistence, the types of resources used differ. Defining these differences is important as health systems plan for the increase in aged with incurable cancers. Early referral to supportive care specialists, vital as symptoms worsen, remains underutilized. Without inclusion of these professions, patient quality of life and distress are not being helped as much as possible. Medical and surgical oncologists should aggressively assess and manage symptoms and consult colleagues to comprehensive symptom management.

No significant financial relationships to disclose.

Effects of oral estrogen and progestin on the lower urinary tract among female nursing home residents

OBJECTIVE

To examine the effects of oral estrogen/progestin on incontinence and related lower urinary tract conditions among female nursing home (NH) residents.

DESIGN

Randomized placebo-controlled trial.

SETTING

Five NHs.

PARTICIPANTS

Thirty-two incontinent female residents of average age 88.

MEASUREMENTS

Subjects were randomized to receive either oral estrogen (0.625 mg) combined with progesterone (2.5 mg) or placebo, daily for 6 months. Measures of incontinence severity, the clinical appearance of the vagina, vaginal and urethral cytology, and urine and vaginal cultures were made at baseline, 3 months, and 6 months. In addition to active drug or placebo, all subjects received regular toileting assistance (prompted voiding) by trained research aides during 3-day data-collection periods to compensate for mobility and cognitive impairments.

RESULTS

At 3 and 6 months there were no significant differences between the groups in the severity of incontinence, the prevalence of bacteriuria, or the results of vaginal cultures. Several clinical findings associated with atrophic vaginitis improved more in the active than the placebo group and vaginal pH and vaginal and urethral cytology exhibited a partial estrogenic effect.

CONCLUSIONS

Our results must be interpreted with caution because of the size and the select nature of our subject sample. Up to 6 months of oral estrogen had only a partial estrogenic effect on vaginal and urethral epithelium and no clinical effects in this patient population. We believe that future studies of estrogen for urinary incontinence in frail NH residents should utilize a topical preparation and consider targeting urinary tract infection as an additional outcome measure.

Dignity in dying

Barriers to effective end-of-life care encompass patient, professional, and system issues. Learn the findings of a landmark study on how well nurses meet the needs of dying patients.

Beyond the Supreme Court decision: nursing perspectives on end-of-life care

PURPOSE/OBJECTIVES

To describe nurses' views of care of the terminally ill.

DESIGN

Descriptive cross-sectional survey.

SAMPLE

300 nurses who completed a survey published in Nursing98 and Nursing Management and 2,033 nurses randomly selected from the Oncology Nursing Society (N = 2,333).

METHODS

Mailed end-of-life (EOL) care survey.

MAIN RESEARCH VARIABLES

Dilemmas, barriers, and effectiveness of EOL care and education and attitudes regarding assisted suicide and euthanasia.

FINDINGS

EOL care dilemmas are common in nursing practice, and many barriers exist to providing quality EOL care. Issues of euthanasia and assisted suicide are particularly significant to nurses who struggle to provide pain and symptom relief amid a system characterized by deficiencies in EOL care.

CONCLUSIONS

Improved care is contingent on adequate education of nurses as the primary caregivers of patients and families who are facing the end of life. Study findings provide direction for improved care of the terminally ill.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses are centrally involved in care of the terminally ill. Major reform is needed to provide quality EOL care.

Evaluating the outcomes of parent-child family life education

Conducted in diverse sociocultural communities in Los Angeles County, the project implemented and evaluated a family life education program designed to prevent the negative outcomes of risky sexual behavior. A sample of 251 male and female early adolescents 9 through 14 years of age participated with their parents in this abstinence-based adolescent pregnancy prevention program. The project sought to improve parent-child communications and delay the onset of sex-related behaviors through direct involvement of parents in the education process. Naturally occurring community groups were randomly assigned by site to treatment or delayed treatment conditions in a longitudinal quasi-experimental evaluation design. The evaluation demonstrated significant improvements in communication between parents and children immediately following the intervention; however, these improvements were no longer present 12 months postintervention. The process and outcome evaluation methods employed in the study triangulated qualitative and quantitative data collection and analysis procedures. This combination provided other sources of data than the traditional outcome measures used in most evaluation studies, thus addressing some of the gaps in present program evaluations. Descriptions of the process evaluation, integrated with the outcome data, are intended to heighten nurses' awareness of the importance of this component of research and the rich qualitative data it may yield. The qualitative process components in the project captured the experience of the investigators when they encountered many of the complex challenges that confront researchers who implement and evaluate family life education programs among early adolescents. This experience provided the basis for suggested strategies that nurse clinicians and researchers can use in their work with early adolescents and their parents in clinical-, school-, and community-based settings.

Skin disorders and moisture in incontinent nursing home residents: intervention implications

OBJECTIVE

To provide data needed to design an intervention trial to prevent or treat skin disorders in a high risk, incontinent nursing home population.

DESIGN

The incidence and prevalence of nine common skin disorders were measured prospectively over a 60-day period using trained observers. Urinary and fecal incontinence frequency were measured over 24 hours, and mobility was measured with subjects both in and out of bed. Direct measures of skin moisture were taken with an impedance device in the presence and absence of urinary incontinence. Multiple regression analyses were used to relate the incontinence and mobility variables to the presence and development of skin disorders.

SETTING

Four nursing homes.

PARTICIPANTS

One hundred incontinent nursing home residents.

MAIN OUTCOME MEASURES

Prospective measures of nine common skin disorders and skin moisture in four perineal regions under continent and incontinent conditions.

RESULTS

All subjects had at least one skin condition identified during the 60-day data collection period. The most commonly observed skin condition was blanchable erythema, which occurred in 94% of the subjects, predominantly in the front and back regions that were closest to the urethra and rectum. Twenty-one percent of residents developed either a Stage 1 (nonblanchable erythema) or 2 pressure ulcer. All skin conditions were transient when measured every 3 weeks with the exception of blanchable erythema, which showed stability. Stage 3 or greater pressure ulcers and edema were not observed, and interrater reliability for the measure of papules was poor. Measures of urinary and fecal incontinence severity were correlated with blanchable erythema severity, and blanchable erythema and low bed mobility were predictive of pressure ulcer severity. Blanchable erythema severity was also predictive of Stage 1 and 2 pressure ulcers. Skin moisture levels in the back perineal farthest from the rectum (peripheral) were affected most by urinary incontinence.

CONCLUSION

A trial to detect a 50% preventive effect on Stage 1 and 2 pressure ulcers would require that 167 subjects be monitored for 60 days. The transient nature of the skin effects require that skin be monitored at least once a week. Because blanchable erythema is so prevalent and appears to be associated with more severe skin conditions, it would make an excellent marker for beginning to assess the potential preventive effects of various interventions on the incidence of pressure ulcers and other related skin disorders in incontinent patients. It is likely that the back area peripheral to the urethra and rectum would experience the greatest benefit from an intervention trial to reduce moisture caused by incontinence.

Acculturation and its effects on self-esteem among immigrant Latina women

Relationships in the stress-process model, examining level of acculturation, social support, marital status, religion, education, and ethnicity associated with self-esteem in 491 immigrant women from Latin America at baseline and 1 year later were studied. The mediating/moderating effects of social support, marital status, religion, and education on the relation between level of acculturation and self-esteem were analyzed. Findings, based on correlations and various multiple regression analyses, showed that the Latina immigrant women experienced increases in both level of acculturation and self-esteem over the 1-year period. When baseline self-esteem was controlled for, only ethnicity and change in level of acculturation were significantly related to follow-up self-esteem; no significant mediators or moderators of acculturation change were found. Differences between Mexican and other Central American participants were noted.

Effects of prompted voiding on fecal continence among nursing home residents

OBJECTIVE

To determine the effects of prompted voiding on fecal continence in nursing home residents.

DESIGN

Prospective, uncontrolled trial of prompted voiding for urinary incontinence.

PARTICIPANTS

One hundred sixty-five nursing home residents who completed a 9 to 10-week trial.

MEASUREMENTS

Trained research aides performed physical checks for urinary and fecal incontinence hourly from 8 AM to 6 PM for 3 days (total of 33 checks) at baseline, for the last 3 days of a 1-week trial of prompted voiding, and after 9 to 10 weeks of prompted voiding.

RESULTS

After 9 to 10 weeks of prompted voiding, there was no significant change in the frequency of incontinent bowel movements per resident (1.1 [95% CI.83, 1.4] to .87 [95% CI.67, 1.1]; P = 0.140). There was a significant increase in the number of continent bowel movements per resident (.17 [95% CI.10, .24] to .62 [95% CI.45, .80]; P = .000). This increase occurred in residents whose urinary incontinence responded well to prompted voiding as well as those whose urinary incontinence did no respond. The percentage of bowel movements that were continent also increased significantly from 18% (95% CI 8,29) at baseline to 45% (95% CI 32,57) after 9 to 10 weeks of intervention (P = .000). In addition to these findings, we noted a marked increase in the total frequency of bowel movements after the first week of prompted voiding. This may have resulted from the relief of fecal impactions caused by the increased toileting, mobility, and fluid intake that occurred with prompted voiding.

CONCLUSION

Prompted voiding did not change the frequency of incontinent bowel movements significantly in this sample of nursing home residents. However, the number of continent bowel movements and the percentage of bowel movements that were continent did increase. Our data must be interpreted cautiously because our study was designed primarily as an intervention for urinary, not fecal, incontinence and the design was neither blinded nor controlled. Trials of systematic toileting schedules specifically directed at fecal incontinence, with attention to fecal impaction, diet, fluid intake and laxative use, should be conducted.

Does oxybutynin add to the effectiveness of prompted voiding for urinary incontinence among nursing home residents? A placebo-controlled trial

OBJECTIVE

To determine if oxybutynin, a bladder relaxant medication, adds to the effectiveness of prompted voiding (PV) in the management of urinary incontinence among nursing home residents.

DESIGN

Randomized, placebo-controlled, double-blinded, dose-adjusted, crossover trial of oxybutynin added along with PV.

SETTING

Seven nursing homes in Los Angeles County, California.

PARTICIPANTS

Seventy-five nursing home residents with predominantly urge incontinence, whose incontinence did not respond well to a trial of PV.

MAIN OUTCOME MEASURES

The frequency of incontinence, measured as the percentage of hourly (7 AM to 7 PM) physical checks over a 3-day period at which the resident was found wet.

RESULTS

Sixty-three (84%) of the residents completed the study. Among those completing the trial, the percent of checks wet went from 26.5% to 23.7% on placebo to 20.2% on active drug. These changes were statistically significant but not clinically meaningful. A clinically significant decrease in the frequency of incontinence, which we defined as a relative reduction in the percent of checks wet of > 33%, occurred in 20 subjects (32%) while on active drug and in 12 subjects (19%) while on placebo (P = .48 by chi-square). Twenty-five subjects (40%) met our "continence criteria" of an average of one or less wet per day while on active drug, and 11 subjects (18%) achieved this goal on placebo (P = .005 by chi-square).

CONCLUSION

Oxybutynin does not add to the clinical effectiveness of PV in the majority of nursing home residents with urge type urinary incontinence. Selected residents may, however, become more responsive to PV while on oxybutynin. Our data are consistent with other studies of bladder relaxant medications in functionally impaired populations. New drugs and/or other interventions are needed for the large number of incontinent nursing home residents who do not respond well to PV.

Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents?

OBJECTIVE

To determine the effects of eradicating otherwise asymptomatic bacteriuria on the severity of chronic urinary incontinence among nursing home residents.

DESIGN

Residents were categorized as nonbacteriuric or bacteriuric on the basis of urine cultures. Bacteriuric residents were then randomly assigned to immediate and delayed treatment groups. The delayed treatment group was included to control for spontaneous changes in the severity of incontinence. The immediate treatment group received antimicrobial therapy for 7 days; after outcome measures had been repeated, the delayed treatment group was treated.

SETTING

6 community-based nursing homes.

PATIENTS

Nursing home residents with chronic urinary incontinence.

MEASUREMENTS

The frequency and volume of urinary incontinence were determined by physical checks for wetness by trained research aides hourly between 7 a.m. and 7 p.m. for 3 days in all patient groups (non-bacteriuric, bacteriuric with immediate treatment, and bacteriuric with delayed treatment) at baseline, after the immediate treatment group was treated, and again after the delayed treatment group was treated.

RESULTS

191 residents were enrolled, and 176 completed the study. Bacteriuria was eradicated by antimicrobial therapy in 71 residents (40%), and 17 residents (10%) had bacteriuria before and after therapy. The percentage of hourly checks at which the residents were found wet and other measures of incontinence severity remained essentially the same after bacteriuria was eradicated. In the nonbacteriuric group, the percentage of checks that were wet increased from 29% (95% CI, 26% to 32%) at baseline to 30% (CI, 27% to 34%) on repeated measurement. In the bacteriuric groups, the percentage increased from 34% (CI, 30% to 38%) before treatment to 35% (CI, 31% to 39%) after bacteriuria was eradicated. The presence of pyuria did not affect the results.

CONCLUSION

Eradicating bacteriuria has no short-term effects on the severity of chronic urinary incontinence among nursing home residents. Our data support the practice of not treating asymptomatic bacteriuria in this population and validate the recommendations in the Health Care Financing Administration's Resident Assessment Protocol for urinary incontinence.

Predictors of successful prompted voiding among incontinent nursing home residents

OBJECTIVE

To develop a simple, noninvasive assessment strategy that will enable nursing home staff to identify incontinent residents who respond well to prompted voiding.

DESIGN

Incontinent nursing home residents underwent an extensive clinical and functional assessment and then 7 days of prompted voiding. Data from the assessment and the first 3 days of prompted voiding were used to predict responsiveness to the intervention.

SETTING

Seven nursing homes.

PATIENTS

A cohort of 191 incontinent, long-stay nursing home residents who passed a simple behavioral screen (able to state their name or reliably point to one of two named objects).

INTERVENTION

Prompted voiding was carried out by trained research nurse's aides from 7 AM to 7 PM for 7 days. The intervention was maintained in responsive residents 5 days per week for an additional 9 weeks.

MAIN OUTCOME MEASURES

Physical checks for wetness were done by research staff hourly from 7 AM to 7 PM for 3 days in a baseline condition, during days 5 through 7 of the 7-day prompted voiding intervention, and for 3 days at the end of 9 weeks of prompted voiding in the responsive group. Outcome measures were percentage of checks wet and response to prompted voiding, with "responders" defined as residents with an average of one or fewer wet episode per day on days 5 through 7 of prompted voiding.

RESULTS

Seventy-eight (41%) of the residents were responders. Their wet percentage went from 26.7% to 6.4% at the end of 1 week and was maintained at 9.6% after 9 weeks of prompted voiding. The best predictors of responsiveness were the wet percentage and the appropriate toileting percentage during the first 3 days of prompted voiding, the self-care subscale score of the Multidimensional Observational Scale for the Elderly, and the ability to ambulate without human assistance. The best sensitivity and specificity in identifying responders was achieved when either the wet percentage was lower than 20% or the appropriate toileting percentage was higher than 66% during the first 3 days of prompted voiding (sensitivity, 87%; specificity, 69%). Those residents falsely identified as responders by these criteria still had a 46% relative reduction in wetness.

CONCLUSIONS

A substantial proportion of nursing home residents respond well to prompted voiding. The most responsive residents can be easily identified using data collected during a 3-day trial of the intervention. The assessment strategy is consistent with federal guidelines and could be used to facilitate quality control by assessing changes in percentage of wetness from the expected norm.

Safety assessment for the frail elderly: a comparison of restrained and unrestrained nursing home residents

OBJECTIVE

To facilitate clinicians' judgement concerning physical restraint decisions by identifying potentially reversible injury risk factors that differentiate representative samples of restrained and unrestrained nursing home residents.

DESIGN

Comparison of restrained and unrestrained nursing home residents on a safety assessment for the frail elderly (SAFE) protocol.

SETTING

Long-term care facilities in the Greater Los Angeles Area.

PARTICIPANTS

One hundred eight physically restrained and 111 unrestrained nursing home residents.

INTERVENTION

None.

MAIN OUTCOME MEASURES

(1) Internal, Interrater, and test/retest reliability of the overall SAFE protocol and of the four major factors measured by SAFE; (2) The relationship of SAFE scores to expert judgment of resident injury risk; (3) Differences between large samples of restrained and unrestrained residents on specific SAFE score factors.

RESULTS

Two walking, one transition, and one judgment factor are reliably measured by the SAFE protocol. SAFE scores were significantly correlated with expert judgment of risk for injury and showed large differences between restrained and unrestrained residents, even after differences in ambulation ability between the two groups were accounted for.

CONCLUSION

The SAFE is a reliable protocol that measures behavioral factors related to falls and risk for injury among nursing home residents with a broad range of cognitive impairment. Factors that significantly differentiate restrained and unrestrained groups should be targeted for rehabilitation and remediation in physical restraint reduction efforts. Removing or changing restraints for the large sample (50%) of restrained residents who were not ambulatory will not significantly increase their mobility, since the majority of this group could not independently propel their wheelchairs. Increased mobility for the large group of both restrained and unrestrained residents will likely be realized only if restraint reduction programs are combined with interventions to improve both mobility and the specific behavioral performance factors measured by SAFE.

Self-care, psychological distress, and HIV disease

Self-care behaviors may be positive (healthy) or negative (unhealthy). Many factors may influence whether individuals choose healthy or unhealthy self-care behaviors. This study examined the relationships of perceived impact of HIV status, distress, and subsequent changes in self-care activities among men and women who were at risk for or infected with HIV. Significant findings included a positive correlation between the number of symptoms experienced and both depression and change toward unhealthy self-care behaviors. The impact of event avoidance and depression were associated with changes to unhealthy self-care behaviors, although hopelessness was associated with fewer unhealthy changes.

Directions for AIDS education for Hispanic women based on analyses of survey findings

In 1988 and again in 1990, the National Center for Health Statistics conducted a survey of the AIDS related knowledge and beliefs of Hispanic and non-Hispanic adults in the United States. A survey of Los Angeles Hispanic women was conducted in 1990, using the 1988 survey instrument. This study is an examination of the trends in knowledge and beliefs by comparing those of Hispanic Los Angeles women in 1990 to Hispanic and non-Hispanic female respondents in the 1988 national sample. Despite intense public health, local community, and media efforts to educate the public about AIDS, the women in the Los Angeles sample did not show appreciable differences in knowledge and beliefs compared with the 1988 national sample, and in many areas they were less knowledgeable. These results may be related to differing education and acculturation levels as well as possible differences in ethnicity. Hispanic groups will need focused prevention efforts which take into account specific areas of knowledge, educational level of information, adherence to traditional beliefs and practices, and ethnicity of the targeted community.