Measuring the impact of oesophagectomy on physical functioning and physical activity participation: a prospective study.

BACKGROUND: Oesophagectomy remains the only curative intervention for oesophageal cancer, with defined nutritional and health-related quality of life (HR-QOL) consequences. It follows therefore that there is a significant risk of decline in physical wellbeing with oesophagectomy however this has been inadequately quantified. This study prospectively examines change in physical functioning and habitual physical activity participation, from pre-surgery through 6-months post-oesophagectomy. METHODS: Patients scheduled for oesophagectomy with curative intent were recruited. Key domains of physical functioning including exercise tolerance (six-minute walk test (6MWT)) and muscle strength (hand-grip strength), and habitual physical activity participation, including sedentary behaviour (accelerometry) were measured pre-surgery (T0) and repeated at 1-month (T1) and 6-months (T2) post-surgery. HR-QOL was measured using the EORTC-QOL C30. RESULTS: Thirty-six participants were studied (mean age 62.4 (8.8) years, n = 26 male, n = 26 transthoracic oesophagectomy). Mean 6MWT distance decreased significantly from T0 to T1 (p = 0.006) and returned to T0 levels between T1 and T2 (p < 0.001). Percentage time spent sedentary increased throughout recovery (p < 0.001) and remained significantly higher at T2 in comparison to T0 (p = 0.003). In contrast, percentage time spent engaged in either light or moderate-to-vigorous intensity activity, all reduced significantly (p < 0.001 for both) and remained significantly lower at T2 in comparison to T0 (p = 0.009 and p = 0.01 respectively). Patients reported deficits in multiple domains of HR-QOL during recovery including global health status (p = 0.04), physical functioning (p < 0.001) and role functioning (p < 0.001). Role functioning remained a clinically important 33-points lower than pre-operative values at T2. CONCLUSION: Habitual physical activity participation remains significantly impaired at 6-months post-oesophagectomy. Physical activity is a measurable and modifiable target for physical rehabilitation, which is closely aligned with patient-reported deficits in role functioning. Rehabilitation aimed at optimising physical health in oesophageal cancer survivorship is warranted.

Effect of neoadjuvant chemoradiation on preoperative pulmonary physiology, postoperative respiratory complications and quality of life in patients with oesophageal cancer.

BACKGROUND: It remains controversial whether neoadjuvant chemoradiation (nCRT) for oesophageal cancer influences operative morbidity, in particular pulmonary, and quality of life. This study combined clinical outcome data with systematic evaluation of pulmonary physiology to determine the impact of nCRT on pulmonary physiology and clinical outcomes in locally advanced oesophageal cancer. METHODS: Consecutive patients treated between 2010 and 2016 were included. Three-dimensional conformal radiation was standard, with a lung dose-volume histogram of V20 less than 25 per cent, and total radiation between 40 and 41·4 Gy. Forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and diffusion capacity for carbon monoxide (DLCO) were assessed at baseline and 1 month after nCRT. Radiation-induced lung injury (grade 2 or greater), comprehensive complications index (CCI) and pulmonary complications were monitored prospectively. Health-related quality of life was assessed among disease-free patients in survivorship. RESULTS: Some 228 patients were studied. Comparing pulmonary physiology values before with those after nCRT, FEV1 decreased from mean(s.d.) 96·8(17·7) to 91·5(20·4) per cent (-3·6(10·6) per cent; P < 0·001), FVC from 104·9(15·6) to 98·1(19·8) per cent (-3·2(11·9) per cent; P = 0·005) and DLCO from 97·6(20·7) to 82·2(20·4) per cent (-14·8(14·0) per cent; P < 0·001). Five patients (2·2 per cent) developed radiation-induced lung injury precluding surgical resection. Smoking (P = 0·005) and increased age (P < 0·001) independently predicted percentage change in DLCO. Carboplatin and paclitaxel with 41·4 Gy resulted in a greater DLCO decline than cisplatin and 5-fluorouracil with 40 Gy (P = 0·001). On multivariable analysis, post-treatment DLCO predicted CCI (P = 0·006), respiratory failure (P = 0·020) and reduced physical function in survivorship (P = 0·047). CONCLUSION: These data indicate that modern nCRT alters pulmonary physiology, in particular diffusion capacity, which is linked to short- and longer-term clinical consequences, highlighting a potentially modifiable index of risk.

ANTECEDENTES: El tema de si en el cáncer de esófago la quimiorradioterapia neoadyuvante (neoadjuvant chemoradiation, nCRT) repercute sobre la morbilidad postoperatoria, especialmente sobre la morbilidad pulmonar y la calidad de vida de los pacientes que sobreviven sigue siendo controvertido. Este estudio combina datos sobre resultados clínicos con una evaluación sistemática de la fisiología pulmonar para determinar el impacto de la nCRT sobre la fisiología pulmonar y los resultados clínicos en el cáncer de esófago localmente avanzado. MÉTODOS: Se incluyeron pacientes consecutivos tratados entre 2010-2016. La radioterapia conformal 3D fue la estándar, con un histograma dosis-volumen del pulmón V20 < 25% y radiación entre 40-41,4 Gy. Se evaluaron el volumen espiratorio forzado (forced expiratory volume, FEV1), la capacidad vital forzada (forced vital capacity, FVC) y la capacidad de difusión del monóxido de carbono (diffusion capacity for carbon monoxide, DLCO) al inicio y un mes tras la nCRT. La lesión pulmonar inducida por la radioterapia (EORTC grado ≥ 2), el índice de complicaciones integral (comprehensive complications index, CCI), grado de Clavien-Dindo, y complicaciones pulmonares fueron analizadas de manera prospectiva. Se evaluó la calidad de vida relacionada con la salud entre los pacientes supervivientes libres de enfermedad (EORTC QLQ-C30, OG25, OES18). RESULTADOS: Se estudiaron un total de 228 pacientes. Al comparar los valores de la fisiología pulmonar antes y después de la nCRT respectivamente, la FEV1 disminuyó de 96,8 ± 17,7% a 91,5 ± 20,4% (-3,6 ± 10,6%, P = 0,0002), la FVC de 104,9 ± 15,6 a 98,1 ± 19,8% (-3,2 ± 11,9%, P = 0,005) y la DLCO de 97,6 ± 20,7 a 82,2 ± 20,4% (-14,8 ± 14,0%, P < 0,0001). Cinco pacientes (2,2%) desarrollaron lesión pulmonar relacionada con la radioterapia impidiendo la resección quirúrgica. Los factores predictores independientes de %ΔDLCO fueron el hábito tabáquico (P = 0,005) y la edad avanzada (P < 0,001). El tratamiento con carboplatino/paclitaxel/41,4Gy determinó un mayor descenso de la DLCO en comparación con cisplatino/5-fluorouracilo/40Gy (P = 0,001). En el análisis multivariable, la DLCO tras el tratamiento fue una variable predictora de CCI (P = 0,006), fracaso respiratorio/intubación prolongada (P = 0,020) y reducción de la función física en los supervivientes (P = 0,047). CONCLUSIÓN: Estos datos indican que la moderna nCRT altera la fisiología pulmonar, especialmente la difusión pulmonar, con consecuencias clínicas a corto y largo plazo. La DLCO podría constituir un factor de riesgo potencialmente modificable.

Exercise Rehabilitation Services Provided by Physiotherapy Departments in Cancer Care in Ireland

Aims This study aimed to identify the physiotherapy exercise rehabilitation services available to patients with cancer in Ireland and to identify barriers to the provision of services. Methods Physiotherapy department managers in specialised cancer centres, public and private hospitals and palliative care settings were surveyed to establish the availability of exercise rehabilitation services for patients with cancer. Results Of 40 managers contacted, 24 responded providing information about 26 services. Ten services employed a dedicated oncology physiotherapist. Exercise classes were offered to patients with cancer by five services, primarily within the palliative care setting. In the 17 hospitals which provided surgery, ten provided oncology specific post-operative exercise rehabilitation and one offered a prehabilitation programme. Limited human and physical resources and absence of established physiotherapy pathways were cited barriers to service provision. Conclusion Exercise rehabilitation is not an element of standard care for patients with cancer in Ireland.

Measuring the migration of the components and polyethylene wear after total hip arthroplasty: beads and specialised radiographs are not necessary.

AIMS: This paper describes the methodology, validation and reliability of a new computer-assisted method which uses models of the patient's bones and the components to measure their migration and polyethylene wear from radiographs after total hip arthroplasty (THA). MATERIALS AND METHODS: Models of the patient's acetabular and femoral component obtained from the manufacturer and models of the patient's pelvis and femur built from a single computed tomography (CT) scan, are used by a computer program to measure the migration of the components and the penetration of the femoral head from anteroposterior and lateral radiographs taken at follow-up visits. The program simulates the radiographic setup and matches the position and orientation of the models to outlines of the pelvis, the acetabular and femoral component, and femur on radiographs. Changes in position and orientation reflect the migration of the components and the penetration of the femoral head. Validation was performed using radiographs of phantoms simulating known migration and penetration, and the clinical feasibility of measuring migration was assessed in two patients. RESULTS: Migration of the acetabular and femoral components can be measured with limits of agreement (LOA) of 0.37 mm and 0.33 mm, respectively. Penetration of the femoral head can be measured with LOA of 0.161 mm. CONCLUSION: The migration of components and polyethylene wear can be measured without needing specialised radiographs. Accurate measurement may allow earlier prediction of failure after THA. Cite this article: Bone Joint J 2017;99-B:1290-7.

Current practice in the treatment of AO type 31-A2 hip fractures: does sub-specialty and experience of surgeon determine type of fixation?

BACKGROUND: Debate surrounds the optimal treatment of AO type 31-A2 fractures of the hip. Two principal treatment modalities are the compression hip screw (CHS) and cephallomedullary device (CMD). The use of CMD's is steadily increasing, for fixation of this fracture type, despite a lack of supportive evidence. METHODS AND MATERIALS: 100 trauma consultants were asked for their opinion towards treatment of an AO type 31-A2 fracture. Subspecialty and length of time in post were also recorded. RESULTS: A significant proportion of consultants opted to use a CMD. Consultants who had been in post for a shorter time, and those in specialties other than lower limb were more likely to use a CMD. DISCUSSION: NICE guidelines suggest CHS for AO type 31-A2 fractures. CONCLUSION: CMD accounts for a large percentage of treatment in our study, despite NICE guidelines, and other studies suggest their use is rising. We suggest there is a trend of less experienced consultants, and consultants whose specialties are those other than lower limb, using CMD more often. This may be creating an increased cost burden to the NHS, with no evidence to support their use.

The Rib Vertebra Angle Difference and its Measurement in 3D for the evaluation of early onset scoliosis.

The Rib Vertebra Angle Difference (RVAD) as defined by Mehta (1972) is used to predict the progression of early onset scoliosis. No clear physical significance has been established for this measurement. The purpose of this study was to evaluate the RVAD along the thoracic spine and the equivalent measurement on 3D reconstructions of the spine and rib cage of early onset scoliosis patients in order to determine their relationship with the geometry of the chest wall and evolution along the spine. The RVAD was measured on PA radiographs of 42 infantile scoliotic patients (Cobb >20°) from T4 to T10 according to the method described by Mehta. The RVAD 3D was computed using the same landmarks from the 3D reconstruction generated from the calibrated biplanar radiographs. Cases were divided into Phase I and Phase II using Mehta's classification based on the rib head overlap with the apical vertebral body on coronal plane radiographs. A linear relationship exists between the Metha (2D) and 3D RVAD for both Phase I (r = 0.87) and Phase II (r = 0.78) patients. For more severe deformities (RVAD 3D ≥ 35°), a relationship was found between RVAD 3D and the axial rotation of the thoracic vertebrae (r = 0.51) in Phase II patients. However, no significant relationship exists between axial rotation and RVAD 3D for Phase I patients as well as Mehta's RVAD. Maximal RVAD measurements were located 2 &frac12; levels above the apical vertebra. Results indicated that RVAD 3D provides additional information to Mehta's RVAD on the torsional nature of the deformity. Considering the importance of clinical indices to assess the progression of early onset scoliosis, this study raises some questions on looking solely at the RVAD measured on radiographs at the apical vertebra of Phase I patients and suggests considering also levels above the apex of the scoliotic curve and 3D measurements. Further investigation is required to fully understand the 3D nature of the spine and rib cage deformities.

Ligament tissue engineering and its potential role in anterior cruciate ligament reconstruction.

Tissue engineering is an emerging discipline that combines the principle of science and engineering. It offers an unlimited source of natural tissue substitutes and by using appropriate cells, biomimetic scaffolds, and advanced bioreactors, it is possible that tissue engineering could be implemented in the repair and regeneration of tissue such as bone, cartilage, tendon, and ligament. Whilst repair and regeneration of ligament tissue has been demonstrated in animal studies, further research is needed to improve the biomechanical properties of the engineered ligament if it is to play an important part in the future of human ligament reconstruction surgery. We evaluate the current literature on ligament tissue engineering and its role in anterior cruciate ligament reconstruction.

Increasing rates of cervical cancer in young women in England: an analysis of national data 1982-2006.

BACKGROUND: In England, cervical cancer is the second most common cancer in women aged under 35 years. Overall incidence of cervical cancer has decreased since the introduction of the national screening programme in 1988 but recent trends of incidence in young women have not been studied in detail. METHODS: Information on 71,511 incident cases of cervical cancer in England, 1982-2006, in 20-79-year-olds was extracted from a national cancer registration database. Changes in incidence were analysed by age group, time period and birth cohort. Poisson regression was used to estimate annual percentage change (APC). RESULTS: Overall incidence, during 1982-2006, fell significantly from 213 to 112 per million person years. However, in 20-29-year-olds, after an initial fall, incidence increased significantly during 1992-2006, (APC 2.16). In 30-39-year-olds incidence stabilised during the latter part of the study period. The pattern was most marked in the North East, Yorkshire and the Humber and East Midlands regions. Birth cohorts that were initially called for screening between 60-64 and 35-39 years of age show an incidence peak soon after the age of presumed first screen, whereas younger birth cohorts show a peak at about 35 years of age. Incidence in the 1977-1981 birth cohort has increased relative to that among women born between 1962 and 1976. CONCLUSION: These results have implications for cervical screening, human papilloma virus vaccination and other public health interventions targeting young people.

University students' notebook computer use: lessons learned using e-diaries to report musculoskeletal discomfort.

The objective of this pilot study was to identify if notebook accessories (ergonomic chair, desktop monitor and notebook riser) combined with a wireless keyboard, mouse and participatory ergonomics training would have the greatest impact on reducing self-reported upper extremity musculoskeletal discomfort in university students. In addition to pre-post computing and health surveys, the Ecological Momentary Assessment was used to capture change in discomfort over time using a personal digital assistant (PDA) as the e-diary. The PDA was programmed with a survey containing 45 questions. Four groups of university students were randomised to either intervention (three external computer accessories) or to control. Participants reported less discomfort with the ergonomic chair and notebook riser based on the pre-post survey data and the e-diary/PDA ANOVA analysis. However, the PDA data, adjusted for the effect of hours per day of computer use, showed no benefit of the chair and limited benefit from the riser. Statement of Relevance:University students' use of notebook computers has increased. This study found evidence of a positive effect of an adjustable chair or notebook riser when combined with ergonomic training on reducing discomfort. Daily notebook computer use of 4 h was confirmed as a risk factor. Without some form of ergonomic intervention, these students are likely to enter the workforce with poor computing habits, which places them on the road to future injuries as technology continues to play a dominant role in their lives.

Successful treatment of a large Buschke-Lowenstein tumour with chemo-radiotherapy.

We report the case of a patient with a large Buschke-Lowenstein tumour which had previously recurred following local excision. A preferred treatment modality for this rare variant of human papillomavirus has not been clearly defined. Treatment with chemo-radiotherapy in this case resulted in complete resolution of the disease without the need for further surgical intervention.

Morbidity and mortality after closure of loop ileostomy.

BACKGROUND: A temporary loop ileostomy is commonly used to protect low pelvic anastomoses. Closure is associated with morbidity and mortality. This study investigated patterns of complications after loop ileostomy closure and factors associated with morbidity and mortality. METHOD: A review was performed of patients who underwent loop ileostomy closure between 1999 and 2005. RESULTS: Three hundred and twenty-five patients underwent closure of loop ileostomy. Reasons for primary surgery were: anterior resection for cancer (n = 160, 49%), ileal pouch-anal anastomosis (n = 114, 35%), diverticular disease (n = 25, 8%), Crohn's colitis (n = 4, 1%) and other conditions (n = 22, 7%). Overall mortality was 2.5% (n = 8) and morbidity was 22.8% (n = 74). Thirty-two patients (10%) developed small bowel obstruction, of whom seven required operative intervention. Overall, the re-operation rate in this series was 28 patients (8.6%). Thirteen (4%) patients had an anastomotic leak of whom 12 patients had re-operation. Preoperative anaemia was significantly associated with leakage (Hb < 11 g/dl; n = 65, P = 0.033). The leakage rate was lower after a stapled anastomosis than a hand-sutured anastomosis (4/203 vs 9/122; P = 0.039). Hypo-albuminaemia (albumin < 34 g/l) was significantly associated with mortality (n = 46, P < 0.001). CONCLUSIONS: Loop ileostomy closure is associated with morbidity and mortality. Anaemia and hypo-albuminaemia may be associated with poor outcome.

Effects of feed restriction on fertility in female rats.

BACKGROUND: Feed restriction with its resultant body weight loss impacts the rodent estrous cycle; however, the manifestation of these changes in a regulatory study design has not been documented. This study reports the effects of feed restriction in the context of an FDA regulatory submission. METHODS: Adult female rats (n = 20/group; weighing approximately 200 g each) were provided rodent chow ad lib (control) or at 20, 15, 10, or 7.5 g/rat/day (g/day) during a 2-week pre-mating phase, throughout the mating phase, and up to gestation day (GD) 7. On GD 8, all animals were provided ad lib feed until necropsy on GD 14. Estrous cyclicity, mating, and fertility parameters were evaluated. RESULTS: Ad lib rats consumed approximately 20 and 28 g/day during the pre-mating and gestation phases, respectively. All measured fertility parameters in the 20 g/day group were similar to control values. In the 15 g/day group, body weight was reduced by 16% at 2 weeks, prolonged diestrus occurred, and fertility was compromised due to reductions in corpora lutea. Within 2 weeks, mean body weight in groups receiving < or = 10 g/day was reduced by > or = 29% compared to ad lib values, and overt changes in estrous cyclicity, mating, and fertility occurred. The 7.5 g/day group was not sustainable beyond the pre-mating phase. CONCLUSIONS: For this study type, feed intake at < or = 50% ad lib values (< or = 10 g/day) was inadequate due to the magnitude and rapidity of body weight effects. Estrous parameters appeared slightly more sensitive than functional measures, as body weight changes of approximately 16% appeared near the threshold of changing routinely calculated estrous cycle parameters and were later associated with reduced fertility. In general, body weight differences of 10-15% by themselves were not adverse to normal reproduction (20 g/day).

Overview of male reproductive pathology.

An understanding of form and function is important for examination of the male reproductive tract. A basic understanding of spermatogenesis and hormonal function in the reproductive tract is essential for the pathologists in this evaluation. Gross and histologic reproductive changes need to be distinguished from normal variation and correlated with the reproductive status of the animal. This is especially important when correlating histologic changes with organ weight and other reproductive parameters, such as seminal analysis data. Sexual maturity of animals and tissue handing can impact interpretation. Sexual immaturity of preclinical safety animals can present challenges for accurate identification of compound-related changes. Likewise, proper handling of unfixed reproductive tissues and appropriate selection of a fixation protocol are important in avoiding artifacts that may interfere with the microscopic evaluation. The histopathology technician needs to recognize testicular landmarks that allow for correct orientation at trimming so the pathologist can assess not only the morphology of seminiferous tubules but also the outflow tract. For the most effective evaluation of the male reproductive tract, the testes and epididymides should be examined concurrently. Although the term "staging" is often used inappropriately, the pathologist should review testicular tissues in a "stage-aware" manner. This article reviews gross and histologic changes of the male reproductive tract as well as tissue orientation and fixation to assist in accurate interpretation of potential treatment-related changes in male reproduction.

Clinical implications of rhinoceros reproductive tract anatomy and histology.

Reproductive tracts or tissues from five male black rhinoceroses (Diceros bicornis), two male white rhinoceroses (Ceratotherium simum), two male one-horned Asian rhinoceroses (Rhinoceros unicornis), seven female black rhinoceroses, and six female white rhinoceroses from multiple institutions were examined to characterize their anatomy and histology. Some observations and measurements were obtained from in situ tracts of intact animals before or during necropsy. Formalin-fixed tissues were dissected and examined histologically. Retrospective reproductive data from each rhinoceros was obtained from the institutions of origin. Reproductive histology of these species was similar to that of other mammals. Male accessory gland structure varied among species, and the Asian rhinoceros epididymis was more loosely attached and had larger duct diameters than did the epididymides of the African species. Although histology was typically mammalian, rhinoceros reproductive morphology combined characteristics of several different mammals. Defining this unique morphology of rhinoceroses may help in understanding their reproductive physiology and will effect the development of appropriate reproductive techniques.