Prehabilitation in rectal surgery: a narrative review.

AIM: Neoadjuvant chemotherapy (NACRT) can make decompensated patients more vulnerable prior to rectal surgery. Prehabilitation is an intervention which enhances functional capacity to withstand the stress of surgery. The aim of this review was to evaluate the impact of prehabilitation for patients undergoing rectal surgery on physical fitness and clinical outcomes and to establish feasibility of prehabilitation. METHODS: An analysis of the literature was conducted of PubMed, the Cochrane Library, MEDLINE, EMBASE and ScienceDirect. Articles were initially included based on their title and abstracts reviewed. Full-text copies of those selected were obtained for confirmation of inclusion. RESULTS: Eight studies were included. Heterogenicity was observed in the structure of exercise programmes. Improvements in physical fitness were observed in six studies. One study demonstrated a statistically significant improvement in quality of life. The prehabilitation programmes were shown to be feasible, with high completion rates. No adverse events were reported. There was limited data regarding the impact of prehabilitation on postoperative outcomes. CONCLUSION: Current evidence on prehabilitation in rectal surgery has considerable heterogenicity in both structure of programmes and outcome measures. Standardisation is required for future evaluation of the impact on outcomes. A trimodal approach of exercise, nutritional and psychological interventions has been employed in similar programmes, and should be used in rectal surgery. The intervention should be tailored to the patient and environment. This review highlights the benefits, safety and feasibility of prehabilitation and provides a platform for consensus-building for international trials.

Lateral pelvic lymphadenectomy for low rectal cancer: a META-analysis of recurrence rates.

BACKGROUND: Locoregional recurrence (LR) remains a problem for patients with lower rectal cancer despite standardized surgery and improved neoadjuvant treatment regimens. Lateral pelvic lymph node dissection (LPLND) has been routine practice for some time in the Orient/East, but other regions have concerns about morbidity. As perioperative care and surgical approaches are refined, this has been revisited for selected patients. The question as to whether LPLND improves oncological outcomes was explored here. METHODS: A systematic review of patients who underwent TME with or without LPLND from 2000 to 2020 was performed. The primary endpoint was the rate of LR between the two groups. RESULTS: Seven papers met the predefined search criteria in which 2000 patients underwent TME alone, while 1563 patients had TME and LPLND. The rate of LR was marginally higher with TME alone when compared with TME plus LPLND, but this result was not statistically significant (9.8 vs 9.4%, odds ratio 0.75, 95% CI 0.41-1.38, *p = 0.35). In addition, four studies reported on distant recurrence rates, with TME and LPLND showing a slight reduction in overall rates (27.3 vs 29.9%, respectively, OR 0.65, 95% CI 0.45-0.92, *p = 0.02). CONCLUSION: The addition of LPLND to TME is not associated with a significantly lower risk of LR in patients who undergo surgery for lower rectal cancer.

Delayed discharge--a solvable problem? The place of intermediate care in mental health care of older people.

The National Service Framework for Older People envisages the development of intermediate care for older people. This study examined the possible role of intermediate care beds within mental health trusts. We interviewed senior clinicians in an inner city old age psychiatry service about the 91 current in-patients on the old age psychiatric wards. Sixty-five were classified as acute patients and the remaining 26 were continuing care patients. Structured instruments were used to collect information regarding neuropsychiatric symptoms, activities of daily living and current met and unmet needs. Where discharge was delayed an assessment was made regarding the appropriateness for an intermediate care setting according to the criteria set by the Department of Health guidelines. A total of 30 (46%) patients' discharges were delayed. Of these, 19 (29%) patients met the DOH criteria for intermediate care; 10 (53%) had dementia, five (26%) affective disorder, and four (21%) with schizophrenia. The 11 other delayed discharges were because of lack of availability of finance for placements. The study found that the prompt discharge of older patients from acute psychiatric care was a significant problem and many of those patients may benefit from the therapeutic and rehabilitative process afforded by intermediate care.

The needs and mental health of older people in 24-hour care residential placements.

At present one in five men and one in three women who reach the age of 65 in the UK today can expect to require 24-hour residential care. They are assessed according to needs as to the type of placement that is required. Little is known about the changing needs and symptoms of residential clients over 65 with mental health problems. The needs and neuropsychiatric symptoms of older people living in residential, nursing and hospital settings were assessed by standardized questionnaire. Seventy-seven residents were interviewed using the Camberwell Assessment of Needs for the Elderly (CANE) and the Neuropsychiatric Inventory (NPI). The mean CANE for all settings was high. The highest mean CANE was for a residential home and the lowest for a hospital setting. Similar settings had varying NPI and CANE. The data suggests that once placed, subjects needs and neuropsychiatric symptoms do not remain static. It may make both clinical and fiscal sense to reassess subjects. The development of more residential settings, which allow flexibility of degree of care, is recommended.

Effects of dioxin, an environmental pollutant, on mouse blastocyst development and apoptosis.

OBJECTIVE: To evaluate the effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD; dioxin) on mouse embryo development and apoptosis. DESIGN: Controlled animal study. SETTING: Academic research environment. ANIMAL(S): Female mice (CB6F1) at 3 to 6 weeks of age and proven breeders (C578B46). INTERVENTION(S): Mouse embryos were obtained at the morula stage and cultured to the blastocyst stage in a pharmacologic dose of TCDD (3.1 microM) or a control medium. The morphology was assessed, and staining for apoptosis was performed. Immunohistochemistry for the presence of aromatic hydrocarbon receptor (AhR) was performed in another set of morula-stage embryos. MAIN OUTCOME MEASURE(S): The number of embryos developing from the morula to the blastocyst stage and number of apoptotic blastomeres in control vs. TCDD culture conditions. RESULT(S): No statistically significant differences were observed in the percentage of embryos reaching the blastocyst stage: 80.9% (115 of 142) in the TCDD-treated group, vs. 82.9% (121 of 146) in the control group. There was also no difference in the degree of apoptosis: 22.6 +/- 7.3% apoptotic cells (TCDD) vs. 25.3 +/- 9.7% (controls). Staining indicated the slight presence of aromatic hydrocarbon receptor in the morula-stage mouse embryos. CONCLUSION(S): TCDD at 3.1 microM did not alter the development of early mouse morula to blastocysts and did not significantly induce apoptosis in vitro.

Oocyte maturation in rabbits: effects of calmodulin inhibitors.

Oocyte maturation in mammals follows a highly conserved pattern of release from arrest through to the extrusion of the first polar body and formation of the second metaphase spindle. Oscillations in cytoplasmic calcium concentration precede the events of maturation in many species. These calcium ions interact with and activate calcium-binding proteins, including calmodulin, within the cell. Thus, it was of interest to us to examine whether calcium acted through calmodulin in the initial stages of maturation in rabbit oocytes or whether calmodulin was required for continuation through metaphase I no to metaphase II. Using the calmodulin inhibitor W-7 we found a significant (p < 0.05) decrease in the percentage of oocytes that underwent germinal vesicle breakdown. Calmidazolium did not prevent germinal vesicle breakdown; however, it caused a significant (p < 0.05) decrease in the proportion of oocytes with fully elaborated spindles and taxol-induced cytoplasmic asters. Both inhibitors caused a significant (p < 0.05) reduction in the proportion of oocytes that extruded their first polar bodies. The kinase inhibitor 6-DMAP caused a significant reduction in the proportion of oocytes with spindles and condensed chromatin, indicating the necessity for phosphorylation events in the resumption of meiosis. In rabbit oocytes calmodulin may play a role in the release from prophase arrest, and it is necessary for spindle preservation and continuation through metaphase I to metaphase II. The varying effects of the two inhibitor stems from their different binding sites on the calmodulin molecule thus causing a differential effect on its downstream effectors.

Gastrin-releasing peptide is produced in the pregnant ovine uterus.

Our previous finding of appreciable quantities of a gastrin-releasing peptide (GRP)-like immunoreactive (GRPLI) entity in ovine fetal and maternal plasma led us to examine the ovine pregnant uterus as a possible source of this material. At term, intense immunohistochemical staining for GRPLI occurred in the endometrial epithelial cells, and the term ovine uterus also contained abundant GRP messenger RNA (mRNA). In contrast, GRP mRNA was not detected in fetal membranes. GRP mRNA was present in the uterus on gestational day 63; a significant increase in GRP mRNA had occurred by day 100. Thereafter, levels remained elevated until term, but 3 months postpartum, GRP mRNA levels were greatly reduced. As previous studies suggested the GRPLI entity to be of greater molecular size than GRP-(1-27), we deduced the primary structure of ovine uterus GRP by sequencing a complementary DNA clone isolated from a complementary DNA library constructed from term ovine uterus polyadenylated RNA. Ovine uterine GRP is composed of 27 amino acid residues and has a conserved C-terminal region, similar to GRP structures in other species. We conclude that during pregnancy, the ovine uterus produces considerable quantities of GRP, which may play an important but hitherto unrecognized role in utero-placental development and possibly in fetal development after transfer to the fetus.

Effects of lithium chloride on rabbit blastocyst expansion, and accumulation of phosphoinositides and inositol phosphates.

The effects of lithium, an inhibitor of the recycling of inositol in the phosphatidylinositol cycle, on rabbit blastocyst growth and metabolism of phosphoinositides were investigated. Day 2 rabbit morulae were first cultured for 2 days in basic culture medium and then transferred to medium containing myo-[2-3H]inositol for culture for a further 3 days. At the end of culture, the resulting blastocysts were incubated with LiCl (0, 1, 5, 10, 20 mmol l-1) for 1 h. The blastocysts were then lysed and both the aqueous and lipid portions were analysed for incorporated radioactivity. Thin layer chromatographic separation of the lipid portion indicated that lithium had no significant effect on formation of radiolabelled phosphoinositides. However, high performance anion exchange chromatography indicated that lithium significantly stimulated accumulation of radiolabelled inositol monophosphate and inositol 1,4,5-trisphosphate. This result indicates that the phosphatidylinositol cycle is turning over in rabbit blastocysts. Continuous culture of rabbit embryos for 5 days in media containing LiCl (5, 10, 15 and 20 mmol l-1) significantly decreased blastocyst growth as measured by blastocyst expansion and incorporation of [3H]thymidine. However, supplementing the medium with excess inositol (up to 9375 mumol l-1), in an attempt to increase the intracellular uptake of inositol and thus compensate for the inhibitory effect of lithium on inositol recycling, did not reverse the inhibitory effect of lithium on blastocyst growth.

N-methyl-D-aspartate receptor gene expression in the hamster hypothalamus and in immortalized luteinizing hormone-releasing hormone neurones.

Although the excitatory amino acid (EAA) receptor agonist N-methyl-D-aspartate (NMDA) can exert profound stimulatory effects on the neuroendocrine reproductive axis of Syrian hamsters, the exact relationship between NMDA receptors and LHRH neurones is unclear. In the present study, in situ hybridization histochemistry was performed on sections of hamster brain using an 35S-labelled riboprobe to the EAA receptor gene, NMDAR1. A high content of NMDA receptor mRNA was detected not only in brain areas classically associated with specific NMDA binding (for example, hippocampus and cerebral cortex) but also in the hypothalamus, in particular the ventromedial-arcuate area; diffuse hybridization of the riboprobe also occurred in the medial-septal area and diagonal band of Broca, regions of the hamster brain in which the LHRH neuronal perikarya are primarily located. In a separate experiment, RNA was extracted from immortalized LHRH neurones (GT1-1 and GT1-7 cells) and used for northern analysis with a 32P-labelled NMDAR1 riboprobe. Clear-cut hybridization occurred with RNA bands of approximately 4.2 and 4.4 kb from the two LHRH neuronal subtypes. These findings suggest that at least some of the stimulatory action of EAAs on LHRH secretion is likely to be exerted directly at the level of the LHRH neurones rather than being mediated through interneurones. Furthermore, the demonstration of abundant NMDA receptor gene expression within hypothalamic areas that lie outside the blood-brain barrier adds plausibility to the concern that EAAs of dietary origin, such as monosodium glutamate, have the capacity to perturb the normal secretory activity of neuroendocrine circuits of the hypothalamus.

Influence of N-methyl-D-aspartate on the reproductive axis of male Syrian hamsters.

The influence of excitatory amino acids (EAAs) on reproductive neuroendocrine function was investigated in adult male Syrian hamsters of the LSH/Ss Lak strain. Before the study, the animals were maintained in a sexually regressed condition, under short days (SD) and subsequently were either transferred to long days (LD) or kept under SD, for a further 4 weeks. In the former group, photostimulation produced a predictable elevation in the hypophysial contents and serum concentrations of FSH and LH. This was accompanied by an increase in testicular size, an elevation in serum testosterone levels and an increase in spermatogenic activity; the SD hamsters remained sexually quiescent throughout the study. In contrast, SD hamsters that were given daily injections of the EAA agonist, N-methyl-D,L-aspartate (NMA; 50 mg/kg body weight, s.c.), showed stimulatory responses that were generally even more pronounced than those shown by the LD group. Surprisingly, an identical NMA treatment paradigm failed to cause a similar activation of the reproductive axis in LD hamsters that were given daily afternoon injections of melatonin (25 micrograms, s.c.), even though the inhibitory effect of this melatonin treatment is generally regarded as being comparable with that produced by exposure to SD. Although EAAs can acutely stimulate the neurocircuitry that controls LH-releasing hormone secretion, the present findings suggest that EAAs might also exert a long-term stimulatory action by acting further upstream in the photoneuroendocrine pathway.

Incorporation of [3H]inositol into phosphoinositides and inositol phosphates by rabbit blastocysts.

Preimplantation rabbit embryos collected at the early morula stage were cultured to blastocysts in the presence of [3H]inositol. The blastocysts were lysed, and both the aqueous and lipid portions were analysed for incorporated radioactivity. Thin-layer chromatographic separation of the lipid portion indicated that [3H]inositol was incorporated into phosphatidylinositol, phosphatidylinositol 4-phosphate, and phosphatidylinositol 4,5-bisphosphate. HPLC anion-exchange chromatography indicated that [3H]inositol was incorporated into inositol phosphates, including the two second messengers, inositol 1,4,5-triphosphate and inositol 1,3,4,5-tetrakisphosphate, and also inositol monophosphate and inositol 1,4-bisphosphate. These results provide evidence that rabbit blastocysts may have an active phosphatidylinositol second messenger system, which may be responsive to intrauterine factors or intraembryonic paracrine factors.

Inositol stimulates DNA and protein synthesis, and expansion by rabbit blastocysts in vitro.

The effect of different concentrations (0, 0.6, 3, 15, 75 and 375 microM) of myo-inositol on the development of rabbit morulae to expanded blastocysts was investigated in terms of blastocyst expansion and synthesis of DNA and protein, as measured by incorporation of [3H]thymidine and [14C]amino acids into acid-precipitable material. A concentration of 15 microM inositol caused a 2.8-fold increase in blastocyst expansion (P less than 0.01), a 9.9-fold increase in thymidine incorporation into DNA (P less than 0.01) and a 3.6-fold increase in amino acid incorporation into protein (P less than 0.01). There were no significant differences in the range from 15 to 375 microM inositol.

A retrospective study of pregnancy complications among 828 cases of arthrogryposis.

828 cases with multiple congenital contractures (arthrogryposis) were categorized and histories were reviewed to identify pregnancy complications. 53.0% of cases had a specified diagnosis or known cause and no diagnosis was found for 47.0% of which 27.2% were though to probably have a genetic basis and 19.8% were of unknown etiology. Our data provides no evidence to support the suggestion that arthrogryposis is frequently a result of environmental or structural causes including uterine structural anomaly, intra-uterine infection, etc. Normal frequencies of bleeding, hormone treatment during gestation, amniotic fluid leakage, uterine anomaly, maternal illness, and maternal and paternal age were noted. Apparent, increased frequencies of twinning, severe nausea, polyhydramnios and oligohydramnios were observed. In particular, the frequency of polyhydramnios was dramatically increased among lethal cases (vs survivors) and thus, polyhydramnios appears to be a poor prognostic sign when associated with decreased fetal movement. Large case control studies with complete pregnancy histories are needed to confirm these results and to definitively identify pregnancy complications that are useful "flags" to indicate decreased fetal movement in utero and thus, aid in the identification of primary causes of arthrogryposis.

Different options for prenatal testing for Huntington's disease using DNA probes.

The discovery of DNA markers closely linked to the gene for Huntington's disease (HD) has allowed development of predictive and prenatal testing programmes for HD. This report describes four different approaches to prenatal testing for HD which have arisen during a pilot predictive and prenatal testing program in British Columbia, Canada. In the first approach (exclusion testing), the at risk parent cannot or prefers not to learn of his/her HD status. Two other approaches involve definitive testing of a fetus when a parent is determined to be at increased risk to have inherited the HD gene or is affected with Huntington's disease. The fourth approach is a stepwise combination of the above two methods which we refer to as 'exclusion-definitive' testing. These different approaches introduce a variety of challenging counselling and ethical issues. The role of each approach to prenatal testing in the management of Huntington's disease awaits the results of this and other predictive and prenatal testing programmes.

Predictive testing for Huntington disease: I. Description of a pilot project in British Columbia.

The discovery of DNA markers linked to the gene causing Huntington disease (HD) has allowed the development of predictive testing programs for persons at-risk. A pilot program was established in British Columbia in November 1986. Ninety-five persons are currently enrolled. The major objective of this project is to introduce and evaluate a protocol for the delivery of test results to persons at-risk for HD. The criteria for entry and details of the psychosocial assessment before and after receiving a modified risk are presented. The guidelines that are developed from this project will have major applications for predictive testing programs for other late onset autosomal dominant disorders.

Predictive testing for Huntington disease: II. Demographic characteristics, life-style patterns, attitudes, and psychosocial assessments of the first fifty-one test candidates.

Predictive testing was offered to individuals at-risk for Huntington disease living within a 100-mile radius of Vancouver, BC. Ninety-five at-risk individuals, representing approximately 12.6% of eligible candidates in this area, have enrolled in its first 16 months. This paper reports on the psychosocial characteristics of the first 51 at-risk individuals to complete the initial assessment. Two-thirds of the candidates are female with a mean age 39.3 years. They derive from higher socioeconomic backgrounds. Reasons for taking the test included planning for the future, concern for their children, and reducing uncertainty. Only 29.4% of candidates would both desire prenatal testing and terminate a high-risk pregnancy. Results on the SCL 90(R), General Well-Being, and other scales indicate that the candidates' mental health is representative of the population, but as a group, they are more resourceful. The tests identified individuals who needed further assessment on the basis of previous and current psychiatric functioning and social support. No candidate was a high immediate suicidal risk. The process of personal assessment has had beneficial effects on personal growth. The self-selection of a healthy group of candidates emphasizes the need for continued assessment and support as possibly less healthy candidates register for predictive testing programs in the future.

Prenatal diagnosis and the Canadian collaborative randomized trial of chorionic villi sampling: the physician's view.

Women eligible for the Canadian randomized trial of chorionic villi sampling (CVS) often cite physician influence as a reason for refusing to participate. To measure directly physicians' attitudes to and knowledge of prenatal diagnosis (PND), amniocentesis, CVS, randomized trials, and the Canadian trial, a 3-page questionnaire was mailed to all registered obstetricians in British Columbia (BC) and in Montreal (Mtl). The overall response rate was 70%. Most physicians thought PND was important and that it was their role to discuss and advise PND to their patients. Physicians were split in their preferences for amniocentesis or CVS (32% vs. 34%); reasons for their preferences paralleled those given by women studied previously by us. Physicians who thought CVS was too experimental, who were hesitant about the trial or who were less likely to discuss the study with patients were older, less likely to have participated in a randomized trial previously and less comfortable with randomization and discussing uncertain risks with patients. Mtl physicians were less aware and more hesitant about the Canadian trial than those in BC. Moreover, Mtl physicians were more likely to consider the ongoing trial inappropriate and too experimental than BC physicians. Because physicians act as "gatekeepers," educating them about new technologies and about randomized studies is essential for ensuring both participant's access to a new procedure and success of the randomized trial.

Improved predictive testing for Huntington disease by using three linked DNA markers.

Eighty-five persons at risk for Huntington disease (HD) have enrolled in a predictive-testing pilot program. Informativeness of the test has been determined for 41 of these candidates by using linked DNA probes. Nine (21.9%) of these persons have been excluded from the test as a result of the unavailability of DNA from crucial family relatives. Homozygosity for all of the three DNA markers (D4S10, D4S62, and D4S95) was not found in any affected parent. Only one (2%) of the 41 test candidates has had an uninformative result. Results have been given to 20 persons, of whom 12 (60%) received a decreased risk and eight (40%) received an increased risk of having inherited the mutant gene for HD. The combined use of three DNA markers significantly increases the informativeness of family structures such that some change in the estimation of genetic risk is now possible for approximately 75% of all persons who request predictive testing.