Major low anterior resection syndrome has equivalent health-related quality of life implications as having a permanent colostomy

BACKGROUND

The literature is inconclusive when comparing health-related quality of life following restorative anterior resection (AR) compared with abdominoperineal resection (APR). Consideration of functional outcomes may explain this inconsistency. The aim of this study was to compare health-related quality of life in patients post-anterior resection, stratified by low anterior resection syndrome score, and post-abdominoperineal resection patients.

METHODS

A cross-sectional study of consecutive patients post APR and AR for rectal or sigmoid adenocarcinoma at a tertiary centre in Sydney, Australia (Jan 2012- Dec 2021) was performed. HRQoL outcomes (SF36v2 physical [PCS] and mental component summary [MCS] scores) were compared between APR and AR patients, with subgroup analyses stratifying AR patients according to LARS score (no/minor/major). Age- and gender-adjusted comparisons were performed by linear regression.

RESULTS

Overall, 248 post-AR patients (57.3% male, mean age 70.8 years, SD 11.6) and 64 post-APR patients (62.5% male, mean age 68.1 years, SD 13.1) participated. When stratified by LARS, 'major LARS' had a similar negative effect on age-and sex-adjusted PCS scores as APR. 'No LARS' (p < 0.001) and 'minor LARS' (p < 0.001) patients had higher PCS scores compared to post-APR patients. 'Major LARS' had a similarly negative effect on MCS scores compared with post-APR patients. MCS scores were higher in 'no LARS' (p = 0.006) compared with APR patients.

CONCLUSIONS

Postoperative bowel dysfunction significantly impacts health-related quality of life. Patients with 'major LARS' have health-related quality of life as poor as those following APR. This requires consideration when counselling patients on postoperative health-related quality of life, especially where poor postoperative bowel function is anticipated following restorative surgery.

A Case Report of Severe Hyponatremia Secondary to Coronavirus Disease 2019 Viral Pneumonia

As of December 2020, the coronavirus disease 2019 (COVID-19) pandemic has resulted in 82.2 million cases worldwide. We report the case of a 69-year-old South Asian female with a history of hypertension, hypothyroidism, meningiomatosis, and urinary incontinence who contracted COVID-19 and developed severe hyponatremia. She was initially medically managed with antibiotics, anti-parasitics, anti-coagulants, and steroids. After experiencing breathlessness, chest discomfort, high systolic blood pressure, and tachycardia, she was admitted and diagnosed with post-COVID pneumonia, and was conservatively treated with steroids. She showed improvement, and was discharged upon being declared hemodynamically stable. While the patient was at home, she experienced periods of breathlessness and acral edema. This case raises the question of the correlation between hyponatremia and COVID-19, especially in regards to symptomatic presentations, including altered mental status, headache, and nausea. As there are limited studies that show severe electrolyte disorders leading to mortality, more research is needed to understand hyponatremia in cases with COVID-19.

The rectal administration of lignocaine gel and periprostatic lignocaine infiltration during transrectal ultrasound-guided prostate biopsy provides effective analgesia

INTRODUCTION

Transrectal ultrasound guided prostate needle biopsy (TRUS) is the standard procedure to diagnose or exclude prostate cancer. This procedure can be associated with significant discomfort, both on insertion of the ultrasound probe as well as on taking the biopsy. We evaluated a new technique for pain relief during TRUS biopsy.

PATIENTS AND METHODS

In Group 1 (n = 60), the biopsies were taken without any analgesia. In Group 2 (n = 60), 11 ml of Instillagel (2% lignocaine) was administered rectally prior to probe insertion and 5 ml of 1% lignocaine periprostatic injection was administered before taking the biopsy. The discomfort encountered during the procedure was graded by the patient on a scale ranging from no discomfort to mild, moderate and severe pain.

RESULTS

In Group 2, there was a marked reduction in the pain experienced during the procedure. The Chi-squared test for trend showed a significant association between the rectal administration of local anaesthetic gel and reduction in pain on probe insertion (P = 0.0001). There was also a significant association between the use of periprostatic lignocaine injection and reduction in pain on taking the biopsy (P < 0.0001).

CONCLUSIONS

The use of lignocaine gel prior to probe insertion and periprostatic infiltration of lignocaine before taking the needle biopsy significantly reduces the pain experienced by the patient during TRUS-guided prostate biopsy.

Long-term clinical outcome of rescue balloon angioplasty compared with rescue stenting after failed thrombolysis

Failed thrombolysis following acute myocardial infarction is associated with a poor prognosis. Balloon angioplasty with or without stenting is an established procedure in acute myocardial infarction and for failed thrombolysis (rescue percutaneous transluminal coronary angioplasty [PTCA]). Intracoronary stenting improves initial success rates, decreases incidence of abrupt closure, and reduces the rate of restenosis after angioplasty. The purpose of this study was to compare the effect of rescue PTCA with rescue stenting in the treatment of acute myocardial infarction after failed thrombolysis. Clinical data are from a retrospective review of 102 patients requiring rescue balloon angioplasty or stenting after failed thrombolysis for acute myocardial infarction. There was a greater incidence of recurrent angina in 11 patients (22%) in the rescue PTCA group versus 2 patients (4%) in the rescue stenting group. The in-hospital recurrent myocardial infarction rate was 14% in the rescue PTCA group versus 2% in the stented group. In the rescue PTCA cohort, 11 patients (22%) required in-hospital repeat revascularization versus 2 patients in the stented group. The in-hospital mortality rate was higher in the PTCA group (10%) versus that in the stent group (2%). There was no significant difference in the incidence of postdischarge deaths. Rescue stenting is superior to rescue angioplasty. The procedure is associated with lower in-hospital angina and recurrent myocardial infarction, and the need for fewer repeat revascularizations. Long-term patients treated with stents required fewer revascularization procedures. Overall, rescue stenting was associated with a significantly lower mortality.

Percutaneous transluminal coronary angioplasty (PTCA) combined with stenting improves clinical outcomes compared with PTCA alone in acute myocardial infarction

Balloon angioplasty in acute myocardial infarction is an established procedure. The procedure is limited by the potential for early abrupt reocclusion (18-20%) and other complications. Coronary stenting improves the initial success rate, decreases the incidence of abrupt closure, and is associated with a reduced rate of restenosis. For these reasons, coronary stenting is increasingly utilized to treat acute myocardial infarction. The purpose of this study was to compare the effect of coronary stenting with percutaneous transluminal coronary angioplasty (PTCA) in the management of acute myocardial infarction. Clinical data from a retrospective review of 228 consecutive patients admitted with acute myocardial infarction who underwent primary or rescue coronary intervention were used. There was a significantly greater incidence of in-hospital recurrent myocardial infarction in the PTCA group (10%) versus the stented group (1%). In the PTCA cohort, 10 patients required in-hospital repeat revascularization by PTCA compared with one patient in the stented group. The in-hospital death rate was significantly higher in the PTCA group (8%) compared with the stented group (1%). There was no significant difference in the incidence of postdischarge death or repeated revascularization. The results suggest that patients who undergo PTCA with stent deployment have fewer episodes of in-hospital recurrent angina, myocardial infarctions, repeat angioplasties, and fewer in-hospital deaths. PTCA with stenting was associated with a low in-hospital mortality (1%). For patients who had PTCA alone and survived to be discharged, there was no significant difference in overall mortality or the need for revascularization over the 2-year follow-up period.

Long-term clinical outcome of stenting in primary and rescue angioplasty in acute myocardial infarction

Long-term clinical outcome after use of stents in primary and rescue coronary angioplasty for treatment of acute myocardial infarction has not been described in detail. This study was conducted to evaluate long-term (more than one year) outcome in patients treated for acute myocardial infarction with stents. Between January 1, 1997 and September 1997, 101 consecutive patients had coronary artery stents implanted either for primary treatment of myocardial infarction or after failed thrombolytic therapy. Medical records of these patients were reviewed and telephone follow-up was performed using a standard questionnaire. Mean duration of follow-up was 17.8 +/- 1.7 months. During initial hospitalization only one patient had emergent percutaneous transluminal coronary angioplasty due to stent thrombosis (1%); two patients underwent emergent coronary artery bypass surgery (2%) and two patients died (2%). During the follow-up period, ten patients (10%) had recurrent angina, eight patients were treated medically (8%), two required repeat angioplasty (2%), two patients died (2%), and three patients (3%) were lost to follow-up. Stenting of the culprit vessel during acute myocardial infarction appears to be a safe and effective treatment associated with favorable in-hospital and long-term outcomes.

High prevalence of low bone mass in thalassaemia major

Cooley's original description of beta-thalassaemia major included marked bone deformities as a characteristic feature. These were thought to be due to expansion of haemopoiesis attempting to compensate for the congenital anaemia. Regular blood transfusions from infancy prevents these skeletal problems. Nevertheless, symptoms due to bone disease frequently occur in adult patients. Osteoporosis has not previously been reported as a cause of severe morbidity in thalassaemia major. The present study shows a high prevalence of low bone mass among thalassaemia major patients and analyses the predisposing causes. Bone density scans were performed in 82 patients with transfusion-dependent beta thalassaemia. Factors known to be associated with low bone mass such as gender, endocrine disorders and lifestyle activities, together with factors specific to the thalassaemia and its management, were included in a series of univariate analyses to ascertain any significant associations. 42 (51%) of the patients had severely low bone mass and a further 37 (45%) had low bone mass. The three factors showing a statistically significant association with severely low bone mass were male sex, 24/38 (63%) males had severely low bone mass, compared with 18/44 (41%) females, the lack of spontaneous puberty, 22/32 (69%) who required therapeutic induction of pubertal development had severely low bone mass, compared with 19/47 (40%) with spontaneous puberty and diabetes, 8/10 (80%) diabetic patients had severely low bone mass, compared with 23/56 (41%) with normal glucose tolerance. There was no association between the bone mineral density measurements and the haematological characteristics or treatment details of these patients. Severely low and low bone mass are common findings in patients with beta-thalassaemia major despite optimal transfusion and iron chelation. The associated features suggest that the severely low bone mass is due to endocrine abnormalities, in contrast to the haematological causes of bone disease characteristically seen in untreated thalassaemics.

Average African American three-dimensional computed tomography skull images: the potential clinical importance of ethnicity and sex

The production of average 'normative' three-dimensional (3D) computed tomography surface images of the bony skull has only recently been explored. The authors wish to determine the effect of using sex- and ethnicity-specific adult average 3D skull images for comparisons with patient images at various stages of craniofacial surgical management (i.e., diagnosis, treatment planning, prosthetic design, image-guided operative procedures, and outcomes assessment). Craniofacial surgical reconstruction for abnormal patterns of development, cancer resection, or trauma are most likely to benefit from these comparisons. To morphometrically test the significance of separating normative 3D skull data by sex and ethnicity, the authors collected 52 3D, anatomical landmarks from 3D computed tomography scans of dry skulls of 20 Americans of European ethnicity and 20 Americans of primarily African (i.e., primarily African and some European) ethnicity. A Procrustes-based morphometric analysis of shape detects 1.2 times as much interethnic variance as intersex variance. The African American sample presents 4.2% more dolichocephaly, wider orbits, flatter nasal area, larger gnathic anatomy, and more procumbent dentition. Pooling the sexes across both groups, it is seen that men tend to have less bulbous crania, more protruding brows, noses, and masticatory muscle attachments, and relatively less protrusive palettes and anterior mandibles. Despite a small sample size (N = 40), the authors' results are statistically significant (P approximately 0.001 overall) for both of the main factors, sex and ethnicity, separately.

Pyogenic hepatic abscess in a community hospital

Pyogenic hepatic abscesses are rare lesions and are most commonly the result of biliary tract disease. During a 3-year period at our institution, 15 patients were diagnosed with pyogenic hepatic abscess. Ten cases were related to biliary disease. Of these, five were associated with previous biliary tract operations. The remaining five were due to metastases, infection at another site, or cryptogenic causes. Most abscesses were multiple. Treatment consisted of antibiotics alone for three patients, percutaneous drainage and intravenous antibiotics for seven patients, open drainage with intravenous antibiotics for three patients, and papillotomy with intravenous antibiotics for one patient. The single untreated patient died. The other death occurred among those patients treated with intravenous antibiotics alone. Four patients initially treated by percutaneous drainage required subsequent open drainage. All of these patients had multiple abscesses. The mean length of stay in the hospital was least among the group treated by operative drainage. Our review suggests that pyogenic hepatic abscesses may be treated by several different modalities, the choice of management should be individualized, and the length of stay may be decreased by operative drainage.

Controlled delivery of krypton-81m boli in normal subjects: results and implications

Interregional sequential filling potentially affects lung ventilation imaging, depending on the distribution of the tracer within the inspired volume. We investigated its importance quantitatively under near tidal breathing conditions in the upright lung using a short-lived radioactive tracer. Ten normal volunteers performed two runs of 900-ml breaths (from functional residual capacity) in which 100 ml of 81mKr boli were delivered "early" or "late" in inspiration, i.e., 50 ml or 450 ml volumetric depth. Apex-to-base gradients in the vertical profile were -106 +/- 22 (s.e.) counts/cm (early) and -187 +/- 24 (s.e.) counts/cm (late). Ratios of upper-to-lower regional ventilation (U/L) were 0.88 +/- 0.01 (s.e.) (early) and 0.81 +/- 0.01 (s.e.) (late). Simulations with a compartment model show that a simple pattern of sequential filling can by itself account for the experimental results observed. Control over 81mKr delivery can be important to physiologically accurate assessment of ventilation-perfusion matching. Controlled delivery techniques could also modify effectiveness and targeting of other inhaled agents including therapeutic aerosols.

Bone-derived serum enzymes and bone density in perimenopausal Caucasian women

Serum levels of bone-origin alkaline phosphatase and of tartrate-resistant acid phosphatase were measured in Caucasian women aged 41-69 years who had volunteered for bone densitometry. Bone alkaline phosphatase and tartrate-resistant acid phosphatase were inversely correlated with vertebral bone density and with femoral neck bone density. Bone alkaline phosphatase and acid phosphatase were also significantly correlated, consistent with the concept of 'coupling' between osteoblast and osteoclast activity.