Influence of the Enhanced Recovery After Surgery Protocol on Postoperative Inflammation and Short-term Postoperative Surgical Outcomes After Colorectal Cancer Surgery

Purpose@#Many studies have shown that the enhanced recovery after surgery (ERAS) protocols improve postoperative surgical outcomes. The purpose of this study was to observe the effects on postoperative inflammatory markers and to explore the effects of a high degree of compliance and the use of epidural anesthesia on inflammation and surgical outcomes. @*Methods@#Four hundred patients underwent colorectal cancer surgery at 2 hospitals during 2 different periods, namely, from January 2006 to December 2009 and from January 2017 to July 2017. Data related to the patient’s clinicopathological features, inflammatory markers, percentage of compliance with elements of the ERAS protocol, and use of epidural anesthesia were collected from a prospectively maintained database. @*Results@#The complication rate and the length of hospital stay (LOS) were less in the ERAS group than in the conventional group (P = 0.005 and P ≤ 0.001, respectively). The postoperative white blood cell count and the duration required for leukocytes to normalize were reduced in patients following the ERAS protocol (P ≤ 0.001). Other inflammatory markers, such as lymphocyte count (P = 0.008), neutrophil/lymphocyte ratio (P = 0.032), and C-reactive protein level (P ≤ 0.001), were lower in the ERAS protocol group. High compliance ( ≥ 70%) was strongly associated with the complication rate and the LOS (P = 0.008 and P ≤ 0.001, respectively). @*Conclusion@#ERAS protocols decrease early postoperative inflammation and improves short-term postoperative recovery outcomes such as complication rate and the LOS. High compliance ( ≥ 70%) with the ERAS protocol elements accelerates the positive effects of ERAS on surgical outcomes; however, the effect on inflammation was very small.

Evaluation of satisfaction with three different cervical cancer screening modalities: clinician-collected Pap test vs. HPV test by self-sampling vs. HPV test by urine sampling / 부인종양

OBJECTIVE: Human papillomavirus testing by self-sampling and urine sampling might be alternatives to Papanicolaou test (Pap test) for cervical cancer screening (CCS), and may increase compliance and adherence thereto. The present study aimed to explore satisfaction and preferences for cervical screening modalities among Korean women. METHODS: In total, 732 women aged between 20 and 69 years responded to a questionnaire designed to survey the women's perceived satisfaction for the 3 CCS modalities: clinician-collected Pap test, self-collected vaginal sampling (self-sampling) and urine sampling. RESULTS: Overall satisfaction was significantly higher with both the self-sampling and urine sampling than the clinician-collected Pap test (odds ratio [OR]=2.01; 95% confidence interval [CI]=1.48–3.00 and OR=2.47; 95% CI=1.75–3.48, respectively). Psychological distress, including embarrassment, pain, anxiety, discomfort, and stress, with self-sampling and urine sampling were significantly lower than that with the Pap test. 52% of participants reported preferences for self-sampling in the next screening round. CONCLUSIONS: Korean women were more likely to report satisfaction with alternative modalities (self-sampling and urine sampling) for CCS in comparison to the Pap test. This suggests that self-collected modalities may help with improving CCS uptake rates by eliminating burden related with the Pap test. However, further studies for test accuracy and cost-effective analysis of the alternative modalities should be conducted in order to apply CCS.

Budget Impact of the Accreditation Program for Clinical Laboratories on Colorectal Cancer Screening via Fecal Immunochemical Testing: Results from the National Cancer Screening Program in Korea

BACKGROUND: False-positive fecal immunochemical test (FIT) results in the National Cancer Screening Program (NCSP) for colorectal cancer may lead to unnecessary procedures, such as colonoscopies, increasing the medical costs. We estimated reductions in the cost of National Health Insurance according to the accreditation status of screening facilities participating in the NCSP for colorectal cancer. METHODS: We used data collected between 2007 and 2010 from NCSP and the Korea Central Cancer Registry to identify patients with colorectal cancer. We also ascertained the history of the accreditation of each facility by the Korean Laboratory Accreditation Program (KLAP). Budget impact was defined as a reduction in medical costs achieved when the false-positive rate of the non-accredited facilities decreased relative to that of the accredited facilities. RESULTS: A total of 3,285 screening facilities participated in the NCSP. Of these, 196 were accredited by the KLAP. The false-positive rate of the accredited facilities was 2.47%, and that of the non-accredited facilities was 6.83%. Medical costs were estimated to be reduced by approximately 19 million US dollars (USD), and the cost of detecting one case of colorectal cancer was estimated to decrease from 9,212 USD to 7,332 USD if the false-positive rate of non-accredited facilities were decreased to that of the accredited facilities. Clinics were estimated to have the largest associated cost reduction. CONCLUSIONS: Quality assurance in clinical laboratories could lower false-positive rates and prevent the use of unnecessary procedures, ensuring patient safety and increasing the cost-effectiveness of FIT screening in the NCSP for colorectal cancer.

The Expression of Multiple Proteins as Prognostic Factors in Colorectal Cancer: Cathepsin D, p53, COX-2, Epidermal Growth Factor Receptor, C-erbB-2, and Ki-67

BACKGROUND/AIMS: A single gene mutation alone cannot explain the poor prognosis of colorectal cancer. This study aimed to establish a correlation between the expression of six proteins and the prognosis of colorectal cancer patients. METHODS: Tissue samples were collected from 266 patients who underwent surgery for colorectal cancer at our institution from January 2006 to December 2007. The expression of six proteins were determined using immunohistochemical staining of specimens. RESULTS: Cathepsin D, p53, COX-2, epidermal growth factor receptor, c-erbB-2, and Ki-67 expression were detected in 38.7%, 60.9%, 37.6%, 35.7%, 30.1%, and 74.4% of the samples, respectively. The expression of cathepsin D was significantly correlated with reduced cancer-free survival (p=0.036) and colorectal cancer-specific survival (p=0.003), but the other expression levels were not. In a multivariate analysis, cathepsin D expression was found to be an independent prognostic factor for poorer colorectal cancer-specific survival (hazard ratio, 8.55; 95% confidence interval, 1.07 to 68.49). Furthermore, patients with tumors expressing four or more of the proteins had a significantly decreased cancer-free survival rate (p=0.006) and colorectal cancer-specific survival rate (p=0.002). CONCLUSIONS: Patients with cathepsin D positivity had a poorer outcome than patients who were cathepsin D-negative. Thus, cathepsin D may provide an indicator for appropriate intensive follow-up and adjuvant chemotherapy.

Clinical Implications of Systemic Inflammatory Response Markers as Independent Prognostic Factors in Colorectal Cancer Patients / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Cancer-related inflammation affects many aspects of malignancy. We confirm the effects of early postoperative systemic inflammation on cancer prognosis. MATERIALS AND METHODS: Six hundred consecutive patients underwent surgery for colorectal cancer from 2006 to 2009. Measurements of white blood cells, neutrophils, lymphocytes, monocytes, and platelet counts were performed preoperatively, daily until the fourth postoperative day, and subsequently every two days. Patients were divided into three groups based on the days spent on the leukocyte count to drop below 10,000/mm3 after surgery. RESULTS: Preoperative white blood cell (WBC) counts correlated with stage of disease. In univariate survival analyses, tumor, node, metastasis (TNM) stage, and monocyte count were associated with cancer-free survival. In addition, cancer-free survival outcomes were worse in patients who required more than four days for the normalization of WBC count. A TNM stage greater than II and the neutrophil lymphocyte ratio were associated with the duration of overall survival. In a multivariate analysis of these significant variables, TNM stage, an interval longer than four days for normalization of WBC counts and monocyte count independently associated with cancer-free survival. CONCLUSION: Postoperative early inflammatory phase and preoperative monocyte count correlate with poor colon cancer prognosis. We can conclude that preoperative and postoperative inflammatory response and period unfavorably affect the metastatic microenvironment.

Clinical Implications of Systemic Inflammatory Response Markers as Independent Prognostic Factors in Colorectal Cancer Patients / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Cancer-related inflammation affects many aspects of malignancy. We confirm the effects of early postoperative systemic inflammation on cancer prognosis. MATERIALS AND METHODS: Six hundred consecutive patients underwent surgery for colorectal cancer from 2006 to 2009. Measurements of white blood cells, neutrophils, lymphocytes, monocytes, and platelet counts were performed preoperatively, daily until the fourth postoperative day, and subsequently every two days. Patients were divided into three groups based on the days spent on the leukocyte count to drop below 10,000/mm3 after surgery. RESULTS: Preoperative white blood cell (WBC) counts correlated with stage of disease. In univariate survival analyses, tumor, node, metastasis (TNM) stage, and monocyte count were associated with cancer-free survival. In addition, cancer-free survival outcomes were worse in patients who required more than four days for the normalization of WBC count. A TNM stage greater than II and the neutrophil lymphocyte ratio were associated with the duration of overall survival. In a multivariate analysis of these significant variables, TNM stage, an interval longer than four days for normalization of WBC counts and monocyte count independently associated with cancer-free survival. CONCLUSION: Postoperative early inflammatory phase and preoperative monocyte count correlate with poor colon cancer prognosis. We can conclude that preoperative and postoperative inflammatory response and period unfavorably affect the metastatic microenvironment.

Can high serum anti-Mullerian hormone levels predict the phenotypes of polycystic ovary syndrome (PCOS) and metabolic disturbances in PCOS patients? / 대한생식의학회지

OBJECTIVE: To evaluate correlations between serum anti-Mullerian hormone (AMH) levels, phenotypes of polycystic ovary syndrome (PCOS), obesity, and metabolic parameters in patients with PCOS. METHODS: A total of 175 patients with PCOS were diagnosed according to the Rotterdam Consensus were included. Exclusion criteria were age over 40, FSH>25 mIU/mL, and 17a-OHP>1.5 ng/mL. The Phenotypes of PCOS were divided into a severe form (oligo-anovulation, ANOV/hyperandrogenism/polycystic ovary morphology [PCOM]; n=59) and a mild form without HA (ANOV/PCOM, n=105). The serum AMH levels were classified into 3 groups (10 ng/mL). Obesity was defined as body mass index (BMI) > or =25 kg/m2 (n=34). RESULTS: The mean age was 25.9+/-5.7 year and mean AMH level was 10.1+/-5.4 ng/mL. The BMI (kg/m2) was higher in group 1 (24.2+/-6.3) than in group 2 (21.9+/-4.3, p=0.046) or group 3 (21.6+/-3.3, p=0.019). There was no difference among the three groups in age, menstrual interval, antral follicle counts, androgens, or other metabolic parameters. The obesity group showed significantly lower AMH (7.7+/-3.9 ng/mL vs. 10.7+/-5.6 ng/mL), p=0.004) and low-density lipoprotein levels (93.1+/-21.2 mg/dL vs. 107.5+/-39.3 mg/dL, p=0.031), and showed higher total T (0.74+/-0.59 ng/mL vs. 0.47+/-0.36 ng/mL, p=0.001), free T (2.01+/-1.9 vs. 1.04+/-0.8 pg/mL, p=0.0001), and free androgen index (6.2+/-7.9 vs. 3.5+/-3.0, p=0.003). After controlling for age factors and BMI, the serum AMH levles did not show any significant correlations with other hormonal or metabolic parmeters. CONCLUSION: For PCOS patients under the age 40, serum AMH is not negatively correlated with age. High serum AMH levels can not predict the phenotype of PCOS and metabolic disturbances in PCOS patients in the non-obese group. Further study might be needed to define the relation more clearly.

The Prevalence and Features of Korean Gout Patients Using the National Health Insurance Corporation Database

OBJECTIVE: We wanted to evaluate the prevalence of gout and its features in Korean people using the National Health Insurance Corporation (NHIC) database. METHODS: Using the NHIC database from 2001 to 2008, we selected the gout patients who were coded as having gout as a main diagnosis. From the total number of gout patients, we evaluated the prevalence of gout and its features. RESULTS: The prevalence of gout prevalence was 0.171% in 2001 and 0.397% in 2008, and there was a 2.317 fold increased during over the 7 years. In 2008, the percentage of fifth and sixth decade patients was 48.5% and that of the male patients were 89.8% of the total gout patients. The increasing rate of the prevalence of gout during the same period was also higher in males (the male vs. female ratio was 5.3:1 in 2001 and 8.8:1 in 2008). The gout prevalence increased year by year to the eighth decade, and the peak prevalence age group was the ninth decade in 2001, the eighth decade in 2002-2005 and the seventh decade in 2006-2008. The prevalence ratio of 2008 to 2001 was higher for the males and the younger age group; that of third decade for males was 9.87 , which was over the 10 times higher compared to that of the ninth decade (9.87 vs. 0.89, respectively). CONCLUSION: The prevalence of gout in 2008 using the NHIC database was 0.397%, so the prevalence of gout increased 2.317 fold over the 7 years, and nearly 90% of the gout patients were male. The increasing rate of gout prevalence was higher in the males and the younger age group.

Clinical Features of Hospitalized Adult Patients with Pneumonia in Novel Influenza A (H1N1) Infection / 결핵및호흡기질환

BACKGROUND: A novel 2009 influenza A (H1N1) virus emerged and disseminated to all over the world. There are few reports on the clinical characteristics of patients with complications. We describe the clinical features of pneumonia in adult patients hospitalized, who have novel influenza infection. METHODS: There were 43 adult patients enrolled into the study with pneumonia of 528 hospitalized patients confirmed influenza A (H1N1) virus infection by real-time reverse transcriptase polymerase chain reaction testing, between 24 August 2009 and 31 January 2010. The clinical data of patients with pneumonia were collected retrospectively. RESULTS: There were 22 of 43 (51.2%) influenza patients with pneumonia that had higher risk factors for complications. Compared to 28 patients with influenza A (H1N1) viral pneumonia and 15 patients, who had isolated bacteria from cultures, those with mixed viral and bacterial pneumonia were significantly more likely to have unilobar consolidations on chest radiographs (53.3 vs. 10.7%, p<0.01) and higher scores of pneumonia severity index (PSI; 90 [66~100] vs. 53 [28~90], p=0.04). Six patients required mechanical ventilation support in an Intensive Care Unit and were more likely to have dyspnea (83.3 vs. 29.3%, p=0.02) and low levels of PaO2 (48.3 [37.0~70.5] vs 64.0 [60.0~74.5] mm Hg, p=0.02) and high levels of pneumonia severity index (PSI) score (108.0 [74.5~142.8] vs. 56.0 [40.5~91.0], p=0.03). CONCLUSION: The majority of pneumonia patients infected with novel influenza improved. Chest radiographic findings of unilobar consolidations suggest that mixed pneumonia is more likely. Initial dyspnea, hypoxemia, and high levels of PSI score are associated with undergoing mechanical ventilation support.

Clinical Features of Hospitalized Adult Patients with Pneumonia in Novel Influenza A (H1N1) Infection / 결핵및호흡기질환

BACKGROUND: A novel 2009 influenza A (H1N1) virus emerged and disseminated to all over the world. There are few reports on the clinical characteristics of patients with complications. We describe the clinical features of pneumonia in adult patients hospitalized, who have novel influenza infection. METHODS: There were 43 adult patients enrolled into the study with pneumonia of 528 hospitalized patients confirmed influenza A (H1N1) virus infection by real-time reverse transcriptase polymerase chain reaction testing, between 24 August 2009 and 31 January 2010. The clinical data of patients with pneumonia were collected retrospectively. RESULTS: There were 22 of 43 (51.2%) influenza patients with pneumonia that had higher risk factors for complications. Compared to 28 patients with influenza A (H1N1) viral pneumonia and 15 patients, who had isolated bacteria from cultures, those with mixed viral and bacterial pneumonia were significantly more likely to have unilobar consolidations on chest radiographs (53.3 vs. 10.7%, p<0.01) and higher scores of pneumonia severity index (PSI; 90 [66~100] vs. 53 [28~90], p=0.04). Six patients required mechanical ventilation support in an Intensive Care Unit and were more likely to have dyspnea (83.3 vs. 29.3%, p=0.02) and low levels of PaO2 (48.3 [37.0~70.5] vs 64.0 [60.0~74.5] mm Hg, p=0.02) and high levels of pneumonia severity index (PSI) score (108.0 [74.5~142.8] vs. 56.0 [40.5~91.0], p=0.03). CONCLUSION: The majority of pneumonia patients infected with novel influenza improved. Chest radiographic findings of unilobar consolidations suggest that mixed pneumonia is more likely. Initial dyspnea, hypoxemia, and high levels of PSI score are associated with undergoing mechanical ventilation support.

Clinicopathological Analysis of Antibiotic Treatment after Appendectomy: A Randomized Prospective Trial

PURPOSE: The optimal antibiotic regimen for appendicitis still remains poorly defined. The aim of this study was to define the optimal duration and route of antibiotics after an appendectomy, with regard to the clinicopathololgical aspects. METHODS: This study was performed on 73 consecutive patients who underwent an appendectomy. Groups A and B, which were composed of cases of simple appendicitis (phlegmonous and suppurative type) and complicated appendicitis (gangrenous and perforated type), respectively. Group A was randomized after the appendectomy into either A1 (n=17), a 1-day course of a combination of IV first generation cephalosporin and tobramycin; or to A2 (n=26), a 3-day course of the same regimen. Group B was randomized into either B1 (n=16), a 3-day course of a combination of IV cephalosporin, tobramycin, and metronidazole, followed by conversion to a 4-day course of a combination of PO third generation cephalosporin and metronidazole; or B2 (n=7), a 7-day course of a combination of IV cephalosporin and metronidazole, along with a 5-day course of tobramycin. The total leukocyte count (WBC), neutrophil count, and C-reactive protein (CRP) were analyzed preoperatively and on POD #3 and #7. An intraoperative culture of the surface of the appendix was also performed. RESULTS: The most common cultured organism was Escherichia coli (n=30). Ampicillin and first generation cephalosporin were 73% and 49% resistant to Gram-negative organisms, respectively. Third generation cephalosporin and imipenem were 100% sensitive. The subjects in group A were all under normal limits in the postoperative laboratory analyses, and had no complication. Groups B1 and B2 showed no significant differences in their WBC (P=0.301), neutrophil count (P=0.730), and complications (P=0.907), with the exception of CRP (P=0.040). CONCLUSION: After the appendectomy, simple appendicitis was treated with antibiotics for 24 hrs, with no complications. For complicated appendicitis, a 3-day IV course, followed by a conversion to 4-day PO antibiotics, was found to be safe. Surveillance of the WBC and neutrophil counts, CRP values, and body temperature permitted safe utilization of this regimen.