Increasing facility delivery through maternity waiting homes for women living far from a health facility in rural Zambia: a quasi-experimental study.

OBJECTIVE: To report on the effectiveness of a standardised core Maternity Waiting Home (MWH) model to increase facility deliveries among women living >10 km from a health facility. DESIGN: Quasi-experimental design with partial randomisation at the cluster level. SETTING: Seven rural districts in Zambia. POPULATION: Women delivering at 40 health facilities between June 2016 and August 2018. METHODS: Twenty intervention and 20 comparison sites were used to test whether MWHs increased facility delivery for women living in rural Zambia. Difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our identified outcomes. MAIN OUTCOME MEASURES: Differences in the change from baseline to study period in the percentage of women living >10 km from a health facility who: (1) delivered at the health facility, (2) attended a postnatal care (PNC) visit and (3) were referred to a higher-level health facility between intervention and comparison group. RESULTS: We detected a significant difference in the percentage of deliveries at intervention facilities with the core MWH model for all women living >10 km away (DID 4.2%, 95% CI 0.6-7.6, P = 0.03), adolescent women (<18 years) living >10 km away (DID 18.1%, 95% CI 6.3-29.8, P = 0.002) and primigravida women living >10 km away (DID 9.3%, 95% CI 2.4-16.4, P = 0.01) and for women attending the first PNC visit (DID 17.8%, 95% CI 7.7-28, P < 0.001). CONCLUSION: The core MWH model was successful in increasing rates of facility delivery for women living >10 km from a healthcare facility, including adolescent women and primigravidas and attendance at the first PNC visit. TWEETABLE ABSTRACT: A core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia.

Differential impact of thermal and physical permafrost disturbances on High Arctic dissolved and particulate fluvial fluxes.

Climate warming and changing precipitation patterns have thermally (active layer deepening) and physically (permafrost-thaw related mass movements) disturbed permafrost-underlain watersheds across much of the Arctic, increasing the transfer of dissolved and particulate material from terrestrial to aquatic ecosystems. We examined the multiyear (2006-2017) impact of thermal and physical permafrost disturbances on all of the major components of fluvial flux. Thermal disturbances increased the flux of dissolved organic carbon (DOC), but localized physical disturbances decreased multiyear DOC flux. Physical disturbances increased major ion and suspended sediment flux, which remained elevated a decade after disturbance, and changed carbon export from a DOC to a particulate organic carbon (POC) dominated system. As the magnitude and frequency of physical permafrost disturbance intensifies in response to Arctic climate change, disturbances will become an increasingly important mechanism to deliver POC from terrestrial to aquatic ecosystems. Although nival runoff remained the primary hydrological driver, the importance of pluvial runoff as driver of fluvial flux increased following both thermal and physical permafrost disturbance. We conclude the transition from a nival-dominated fluvial regime to a regime where rainfall runoff is proportionately more important will be a likely tipping point to accelerated High Arctic change.

Determinants of stoma reversal in rectal cancer patients who had an anterior resection between 2009 and 2012 in the English National Health Service.

AIM: The rate of ileostomy reversal was estimated in patients undergoing an elective anterior resection for rectal cancer and factors associated with reversal were identified. METHOD: The records of 4879 rectal patients who had an ileostomy created during anterior resection between 2009 and 2012 were identified in the National Bowel Cancer Audit database and linked to administrative records of the Hospital Episode Statistics. Patients were followed from surgery. Multivariable proportional hazards regression was used to estimate the impact of patient and cancer characteristics on ileostomy reversal with death as the competing risk. RESULTS: Within 18 months from anterior resection, 3536 (72.5%) patients had undergone ileostomy reversal. The reversal rate was lower in the following circumstances: older patients [hazard ratio (HR) 0.90; 95% CI 0.84-0.96, aged 80 vs 70 years], male gender (HR 0.90; 0.84-0.97), higher American Society of Anesthesiologists (ASA) grade (HR 0.64; 0.56-0.74, ASA 3+ vs 1), more advanced cancer (HR 0.77; 0.69-0.87, T3 vs T1), socioeconomic deprivation (HR 0.83; 0.74-0.93, most vs least deprived quintile), comorbidity (HR 0.92; 0.84-1.00, one vs no comorbidity) and open surgical procedure (HR 0.90; 0.84-0.97, open vs laparoscopic). CONCLUSION: Overall, two-thirds of ileostomies were reversed within 18 months. Reversal rates were linked to patient and cancer characteristics (age, sex, fitness and stage), mode of surgical access and socioeconomic deprivation. Observed lower reversal rates in patients from poorer backgrounds may indicate inequity in access.

Palliative excisional surgery for primary colorectal cancer in patients with incurable metastatic disease. Is there a survival benefit? A systematic review.

AIM: Patients with stage IV colorectal cancer with unresectable metastases can either receive chemotherapy or palliative resection of the primary lesion. In the absence of any randomized data the choice of initial treatment in stage IV colorectal cancer is not based on firm evidence. METHOD: A search of MEDLINE, Pubmed, Embase and the Cochrane Library database was performed from 1980 to 2010 for studies comparing palliative resection in stage IV colorectal cancer with other treatment modalities. Audits and observational studies were excluded. Median survival was the primary outcome measure. The morbidity and mortality of surgical and nonsurgical treatments were compared. RESULTS: Twenty-one studies (no randomized controlled trials) were identified. Most demonstrated a survival benefit for patients who underwent palliative resection. Multivariate analysis indicates that tumour burden and performance status are both major independent prognostic variables. Selection bias, incomplete follow up and nonstandardized reporting of complications make the data difficult to interpret. CONCLUSION: The studies indicate that there may be a survival benefit for primary resection of colorectal cancer in stage IV disease. The findings suggest that resection of the primary tumour should be based on tumour burden and performance status rather than on the presence or absence of symptoms alone.

Metachronous bilateral adrenal metastases following curative treatment for colorectal carcinoma.

A delayed, metachronous presentation of bilateral adrenal metastases following colorectal cancer has never previously been reported. We describe the case of a 68-year-old man who underwent curative surgery and adjuvant chemotherapy for a locally invasive sigmoid adenocarcinoma, only to be diagnosed with metachronous bilateral adrenal metastasis necessitating further resection and chemotherapy. We discuss the literature surrounding this pathology and highlight the importance of continual, vigilant radiological surveillance of the adrenal glands after curative treatment of colorectal carcinoma with or without subsequent adrenal metastasis.

Strain differences in neurogenesis and activation of new neurons in the dentate gyrus in response to spatial learning.

Adult neurogenesis continues throughout life in the mammalian hippocampus and evidence suggests that adult neurogenesis is involved in hippocampus-dependent learning and memory. Numerous studies have demonstrated that spatial learning enhances neurogenesis in the hippocampus but few studies have examined whether enhanced neurogenesis is related to enhanced activation of new neurons in response to spatial learning. Furthermore, the majority of these studies have utilized Sprague-Dawley (SD) rats. However, Long-Evans and Sprague-Dawley rats have been reported to have different learning abilities. In order to determine whether these strains exhibit a similar enhancement of neurogenesis and new neuronal activation in response to spatial learning we tested both strains in a hippocampus-dependent or hippocampus-independent version of the Morris water task (MWT) and then compared levels of neurogenesis and activation of these new cells in the hippocampus. Here we show that despite equivalent performance in the MWT, spatial learning produced a different effect on neurogenesis in each strain. Spatial learning increased cell survival and the number of immature neurons in SD rats compared to cage control and cue-trained rats. In Long-Evans (LE) rats however, spatial learning increased cell survival (BrdU-labeling) but did not increase the number of immature neurons (doublecortin-labeling). Furthermore, we report here an intriguing difference in the activation of new neurons (using the immediate early gene product zif268) in SD versus LE rats. In SD rats we show that spatial learning increases the percentage of doublecortin-labeled cells that are activated during a probe trial. Conversely, in LE rats spatial learning increased the activation of BrdU-labeled but not doublecortin-labeled cells. This interesting difference suggests that different ages or maturational stages of cells are recruited by spatial learning in the two strains. These findings may lead to a better understanding of how and why neurogenesis is regulated by spatial learning.

Nonagenarian surgical admissions for the acute abdomen: who benefits?

INTRODUCTION: Patients 90 years and older form an increasing proportion of the general population. Outcomes of their acute surgical admissions are not well documented. METHODS AND MATERIALS: Surgical management of 49 consecutive nonagenarian admissions (median age: 92 years) with an acute abdomen was compared with the management and outcome of 50 younger patients (median age: 53.5) admitted with a suspected acute abdomen over the same period. RESULTS: Nonagenarian group consisted of mainly women (71% vs. 50%; p = 0.003). The use of laboratory investigations and imaging was similar for the patients aged over 90 and the younger patients, although proportionately fewer nonagenarians were investigated by abdominal CT scan (8% vs. 24%). Of the 49 nonagenarian patients admitted, only 4% (n = 2) were operated on. In contrast, 38% (n = 19) of patients aged 50-59 (p = 0.0001) underwent a surgical intervention. A much greater proportion of nonagenarians died in hospital than patients in the 50-59 comparator group (16% nonagenarians vs. 4% comparator patients; p = 0.04). The very large majority of survivors in both age groups were discharged back to their preadmission domicile [39 (95%) nonagenarians vs. 46 (96%) comparator 50-59 year group]. CONCLUSIONS: In this study, when compared with younger patients, very few nonagenarian patients (2%) with a suspected acute abdomen benefited from surgical admission. Instead, the large majority of nonagenarians either died or were discharged back to their home address without surgery.

Hotel NHS and the acute abdomen - admit first, investigate later.

AIM: To determine the financial consequences of a policy of admission first, followed by definitive investigation for patients with an admission diagnosis of suspected acute abdomen. RESULTS: Over a 1-month period, 122 patients were admitted with a suspected surgical diagnosis of acute abdomen (55 men, 67 women); age range 16-95 years (median: 56.5). Based on surgical operation required (n = 36), death after admission (n = 6, three postoperative deaths) and/or severe surgical illness (n = 17), 56 required surgical inpatient admission, while 66 did not. The patients who did not require admission spent significantly shorter time in hospital than those who required admission (median: 5 days vs. 8.5 days; p = 0.0000). Total hospital hotel and investigation cost (not including ITU or theatre costs) for all 122 patients was 330,468 pounds. Overall, 205,468 pounds was consumed by these 56 patients who required admission, while 125,000 pounds was spent on 66 patients whose clinical course did not justify admission; 92% of which was spent on hospital hotel costs and 8% on the cost of imaging and/or endoscopy. DISCUSSION AND CONCLUSION: On a national basis, emergency General Surgery admissions account for 1000 Finished Consultant Episodes per 100,000 population. The findings of this study suggest that this equates to a national NHS spend of 650 million pounds each year, for the hotel costs of patients that could arguably avoid surgical admission altogether. Continuing to admit patients with a suspected acute abdomen first and then requesting definitive investigation makes neither clinical nor economic sense.

Preoperative neo-adjuvant therapy for curable rectal cancer--reaching a consensus 2008.

OBJECTIVE: Our aim was to determine the range of neo-adjuvant therapy the multidisciplinary team (MDT) currently offers patients with curable (M(0)) rectal cancer. METHOD: A senior oncologist from each of the four oncology centres in north Wales and the north-west of England (approximate target population 8 million - Glan Clwyd, Clatterbridge, Christie and Preston) reviewed his/her understanding of the current evidence of neo-adjuvant therapy in rectal cancer. Then a representative from each centre was asked to identify which of three neo-adjuvant options (no neo-adjuvant therapy, short-course radiotherapy 25 Gy over five fractions and long-course chemoradiotherapy) he/she would use for a rectal cancer in the upper, middle or lower third of the rectum staged by magnetic resonance imaging as being T(2)-T(4) and/or N(0)-N(2). RESULTS: In all cases of locally advanced rectal cancer (T(3a) N(1)-T(4)), oncologists from the four oncology centres recommended long-course chemoradiotherapy before rectal resection. This consensus was maintained for cases of lower third T(3a) N(0) cancers. Thereafter, the majority of patients with rectal cancer are offered adjuvant short-course radiotherapy. CONCLUSION: Neo-adjuvant therapy is less likely to be offered if the tumour is early (T(2), N(0)) and/or situated in the upper third of the rectum.

Intra-operative pathological diagnosis of chronic ulcerative colitis in the two stage ileal pouch anal anastomosis.

OBJECTIVE: The definitive diagnostic biopsy for chronic ulcerative colitis (CUC) is the colon itself. Simultaneous colectomy and ileal pouch anal anastomosis (IPAA) means that the colon only becomes available for pathological assessment intra-operatively. We examined the role of intra-operative pathological assessment including frozen section in distinguishing between CUC and Crohn's colitis, inpatients undergoing simultaneous colectomy and IPAA. METHOD: Prospective study of 13 patients undergoing simultaneous colectomy and IPAA between Jan 1992 and April 1999. Resected colon was sent for pathological assessment intra-operatively in all 13 patients. Comparison was made between final histology and frozen section. Patient outcome and pouch function was recorded prospectively. RESULTS: Thirteen patients, M:F 5:8, mean age 41 years (range 20-56). Intra-operative pathological assessment including frozen section diagnosed CUC in nine patients, Crohn's disease in two patients and indeterminate colitis in two patients. The two Crohn's patients had subtotal colectomy and ileostomy. The nine CUC patients and two indeterminate colitis patients underwent IPAA. There was complete agreement between intra-operative assessment including frozen section and the final histopathology. At a median follow up of 31 months (8-58 months) all pouches were intact with good function. There has been no evidence of Crohn's disease on subsequent pouchoscopy and pouch biopsy. CONCLUSIONS: Pathological assessment, including frozen section of the colon, intra-operatively is a useful adjunct to surgical decision making in those patients undergoing simultaneous colectomy and IPAA.

Desmoid tumours in patients with familial adenomatous polyposis and desmoid region adenomatous polyposis coli mutations.

BACKGROUND: :The aim of this study was to determine the proportion of patients with familial adenomatous polyposis (FAP) who had mutations in the desmoid region of the adenomatous polyposis coli (APC) gene that phenotypically expresses desmoid disease, and to determine the role for surgery in these patients. METHODS: Data from the North West Region FAP database and case notes were analysed retrospectively. RESULTS: Of 363 patients with FAP, 47 from ten families had APC mutations in the desmoid region 3' to codon 1399. Of 22 patients undergoing surgery, 16 developed desmoids, and of these 12 had mesenteric desmoid disease. Complications from mesenteric desmoids were death (two patients), enterectomy (three), local resection (three), fistula (one), cholangitis and local resection (one), bowel obstruction (one) and bowel and ureteric obstruction (one). Preoperative polyp burden ranged from 0 to 100 in eight patients (median age 24.5 (range 16-39) years) and more than 100 in seven (median age 39 (range 31-64) years). One patient had no record of polyp burden. CONCLUSION: In individuals with 3' APC mutations, abdominal surgery is associated with a 65 per cent risk of developing mesenteric desmoids. An alternative strategy might be to attempt to manage the polyps endoscopically.

Preoperative radiotherapy for operable rectal cancer--is a lower dose to a reduced volume acceptable?

AIMS: A retrospective audit was carried out to determine the rate of local recurrence (recurrent tumour within the lesser pelvis or the perineal wound) in 88 rectal cancer patients treated with 20 Gy/four fractions of adjuvant preoperative radiotherapy and curative surgery. MATERIALS AND METHODS: All patients were followed-up by clinical examination with rigid sigmoidoscopy at 6 monthly intervals if the rectum was intact, and computed tomography of the pelvis at 1, 2 and 5 years after surgery. In total, 171 patients with rectal cancer were identified under the care of one surgeon over a period of 11 years from May 1992 to April 2003. We excluded patients with rectal cancer from preoperative adjuvant radiotherapy if they had evidence at presentation of distant metastases, if they had fixed rectal tumours, were treated by local excision and had previous radiotherapy to the pelvis. On this basis, only 88 were considered for preoperative radiotherapy and curative resection with a median follow-up of 5.16 years. RESULTS: The 5-year survival by stage was Dukes A 96%, Dukes B 65% and Dukes C 36%. Overall, four patients (of 88) developed a recurrence within the lesser pelvis or the perineal wound, giving a local recurrence of 4.2% at 3 years (from a Kaplan-Meier graph). CONCLUSIONS: This single-centre audit suggests that a lower dose of radiotherapy to a smaller volume provides an acceptable local recurrence rate that compares very favourably with the well-publicised Swedish and Dutch trials of 25 Gy/five fractions. It was not the intention of this audit to suggest that this dose should be widely adopted. However, given the long-term gastrointestinal morbidity and risk of second malignancies, we advise caution when formulating even more intensive radiotherapy and chemoradiotherapy regimens for rectal cancer.

Proximal loop jejunostomy is a useful adjunct in the management of multiple intestinal suture lines in the septic abdomen.

BACKGROUND: Bowel repair in the septic abdomen can be problematic. This study investigated the use of a proximal loop jejunostomy to protect injured or fistulated bowel that had been returned to the abdomen after repair and/or anastomosis. METHODS: Ten patients who underwent laparotomy for intra-abdominal sepsis and/or fistulation, followed by distal enteric repair and/or anastomosis and construction of a proximal defunctioning loop jejunostomy, were studied retrospectively. Seven patients had 21 intestinal suture lines returned to the peritoneal cavity in the presence of intra-abdominal sepsis (14 anastomoses, two enterotomy closures and five serotomy repairs). Two patients had a difficult relaparotomy for pelvic abscess (two distal anastomoses, one enterotomy closure and three serotomy repairs). The final patient had pelvic sepsis and radiation enteritis; the distal anastomosis was defunctioned by a loop jejunostomy. RESULTS: The median distance from the duodenojejunal flexure to the loop stoma was 80 (range 30-170) cm. All jejunostomies were closed via a local approach, a median of 11 (range 9-18) months after formation. There was no significant postoperative morbidity and no postoperative death. At a median follow-up of 7 (range 0.5-56) months eight patients had no requirement for nutritional support. CONCLUSION: Use of a loop jejunostomy to protect suture lines in the septic abdomen justifies consideration of this procedure in selected patients.

Targets and elective colorectal cancer: outcome and symptom delay at surgical resection.

OBJECTIVE: To determine, for elective patients with colorectal cancer, if associations exist between the length of symptom history at surgical resection and Dukes stage, completeness of the surgical procedure and patient survival. PATIENTS AND METHODS: A prospective cohort study was undertaken. Five hundred and eighty-two patients with colorectal cancer, admitted for surgical resection after outpatient consultation, divided into four equal quartiles according to length of symptom history (short: n = 131, 0-103 days; medium: n = 136, 104-177 days; long: n = 136, 178-318 days; very long: n = 137, 319-1997 days). The main outcome measures used were the Extent of tumour (Dukes stage) at resection, completeness of resectional surgery (curative vs palliative), patient survival after resection. RESULTS: For patients undergoing elective surgical resection of colorectal cancer we did not find an association between Dukes stage and duration of patient history (Dukes stage C tumours were seen in 37% (CI: 26.2%-48.0%) of patients with a short symptomatic history as opposed to 34% (CI: 32%-62%) with a very long symptomatic history). Elective curative resection was not associated with a significantly different symptom duration than elective palliative resection (Palliative resections were performed in 24% (CI: 11.7%-36.4%) of patients with a short symptomatic history as opposed to 16% (CI: 2.4%-29.9%) with a very long symptomatic history). The median survival time for the four elective colorectal patient groups defined by length of symptomatic history was not significantly different - (short: n = 131, 4.3 years; medium: n = 136, 5.9 years; long: n = 136, 7.1 years; very long: n = 137, 5.0 years). CONCLUSION: Tumour extent, completeness of resection and patient outcome after elective colorectal cancer resection was not found to have an association with length of patient history at the time of surgery.

Anastomotic technique and survival after right hemicolectomy for colorectal cancer.

AIM: To compare the long-term outcome of patients after right hemicolectomy for colorectal cancer undergoing ileocolonic reconstruction either by a sutured technique or by side-to-side stapled anastomosis. METHODS: Single surgeon series from 1992 to 2001 comprising 100 consecutive patients, 59 with hand sutured reconstruction and 41 undergoing TLC 55mm stapled side-to-side anastomosis. Details of gender, patient age, and elective versus emergency presentation, Dukes stage, and curative versus palliative resection were recorded prospectively. In addition, post-operative hospital stay and subsequent survival were determined by prospective protocol follow-up. RESULTS: Overall 24% of the patients studied presented as emergencies and underwent a palliative procedure. There were no anastomotic leaks in either the stapled or sutured groups. Hospital mortality was also not significantly different--stapled reconstruction, 7%, sutured reconstruction, 10% (p value 0.624). Overall long-term cancer outcome was the same for both anastomotic techniques, both stapled and sutured groups having a median survival of 2.9 years. CONCLUSIONS: Stapled ileocolonic reconstruction after right hemicolectomy for colonic carcinoma is a safe and reliable surgical technique associated with long-term cancer outcomes comparable with those obtained by the sutured anastomotic technique.

Systematic review of genetic influences on the prognosis of colorectal cancer.

BACKGROUND: In terms of genetics, colorectal cancer is one of the best understood of all malignant diseases. Genetic influences on prognosis may have far-reaching implications, especially for the design of surgical and chemoradiotherapeutic regimens. However, their significance in determining prognosis remains unclear. This study aimed to review the literature on the specific role of key genes in determining the survival of patients with colorectal cancer. METHODS: A Medline search was carried out to identify all original scientific papers relating colorectal cancer genetics to patient survival, up to December 2002. Cochrane and Embase databases were also searched. Identified articles were retrieved and searched carefully for additional information. This review includes K-ras, p53, DCC, NM23 and DNA mismatch repair genes. RESULTS AND CONCLUSION: Conflicting evidence exists as to the prognostic significance of genes commonly implicated in the pathogenesis of colorectal carcinoma. Possible causes for such discrepancy include differences in study methods and laboratory techniques, variable duration of follow-up, statistical differences in study power, and heterogeneity in study populations. Future studies should adopt standardized protocols to define clinically relevant genetic observations.

Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula.

BACKGROUND: Use of total parenteral nutrition (TPN) in patients with acute intestinal failure due to enteric fistulation might be avoided if a simpler means of nutritional support was available. The aim of this study was to determine whether feeding via an intestinal fistula (fistuloclysis) would obviate the need for TPN. METHODS: Fistuloclysis was attempted in 12 patients with jejunocutaneous or ileocutaneous fistulas with mucocutaneous continuity. Feeding was achieved by inserting a gastrostomy feeding tube into the intestine distal to the fistula. Infusion of enteral feed was increased in a stepwise manner, without reinfusion of chyme, until predicted nutritional requirements could be met by a combination of fistuloclysis and regular diet, following which TPN was withdrawn. Energy requirements and nutritional status were assessed before starting fistuloclysis and at the time of reconstructive surgery. RESULTS: Fistuloclysis replaced TPN entirely in 11 of 12 patients. Nutritional status was maintained for a median of 155 (range 19-422) days until reconstructive surgery could be safely undertaken in nine patients. Two patients who did not undergo surgery remained nutritionally stable over at least 9 months. TPN had to be recommenced in one patient. There were no complications associated with fistuloclysis. CONCLUSION: Fistuloclysis appears to provide effective nutritional support in selected patients with enterocutaneous fistula.