High efficacy and patient satisfaction with a nurse-led colorectal cancer surveillance programme with 10-year follow-up.

BACKGROUND: Surveillance after colorectal cancer resection remains contentious, and faces several contemporary issues. Patient-centred care, intensive surveillance programmes and patient complexity increase the burden of surveillance on consultant-led clinics. Recent years have seen reshaping of nursing roles to meet healthcare demand. Nurse-led follow-up after colorectal cancer has been piloted, but not validated. We report outcomes from a nurse-led colorectal cancer surveillance clinic functioning in our institution since 2008, the longest term follow-up in the published literature. METHODS: Included patients were surveilled through the clinic from 2008 to 2018 by credentialled nurses who performed history, examination and investigations as per the local protocol. Demographic, tumour-related, outcome-related and patient satisfaction data were extracted from a prospectively maintained database. Primary outcomes were compliance with surveillance protocol and patient satisfaction. RESULTS: A total of 138 patients were included in the analysis. Mean time in surveillance was 25.4 months. Surveillance investigation protocol compliance was 97.4% overall. Five recurrences (3.6%) were detected during surveillance. In patients who developed recurrence, protocol compliance was 100%, and no clinical features of recurrence were newly found when patients were reviewed by a consultant surgeon. All recurrences during surveillance were detected by nursing staff. Response rate to the patient satisfaction survey was 90%. 96.3% of patients reported receiving adequate explanation regarding cancer surveillance and nurse-led care. 90.7% of patients rated the clinic as 'excellent' and 9.3% as 'good'. CONCLUSION: Our results show a high level of efficacy and patient satisfaction associated with a nurse-led colorectal cancer surveillance clinic over a prolonged time period, the longest in the published literature.

Inferior load generated by preloaded versus manually loaded haemorrhoid banding devices: the effect of 'creep relaxation'.

BACKGROUND: The efficacy of rubber band ligation of haemorrhoids relies on the load generated on haemorrhoidal tissue by bands as they return to their preformed shape after being deployed. 'Preloaded' haemorrhoid banding devices are widely available, but the effect of the resultant prolonged stretch on bands while stored in this manner has never been examined by comparing these to manually loaded devices, which are stretch immediately prior to being deployed. A difference could have clinical relevance, potentially resulting in a higher rate of clinical failure. The present study aimed to investigate any difference in load generated by preloaded versus manually loaded devices. METHODS: A preloaded and a manually loaded device were selected for comparison. Each type was measured on a testing rig. The device type, load generated by each band and the time to expiry were recorded. RESULTS: A total of 137 haemorrhoid bands were tested: 66 preloaded and 71 manually loaded. There was a statistically significant overall reduction in load generated by preloaded versus manually loaded devices (284.0 versus 272.1 g, mean difference -11.9 g, 95% confidence interval -17.5 to -6.3 g, P = 0.0001). Adjusted for time, the load generated by preloaded bands fell 3.7 g (95% confidence interval 2.7-4.8, P < 0.001) for each month closer to the expiry date. CONCLUSIONS: The load generated by haemorrhoid bands from preloaded devices is lower and deteriorates significantly towards their expiry date compared with bands from manually loaded devices. This is mostly likely due to their storage in a stretched state. This should be considered by clinicians when using haemorrhoid banding devices.

Social and environmental determinants of malaria in space and time in Viet Nam.

The malaria burden in Viet Nam has been in decline in recent decades, but localised areas of high transmission remain. We used spatiotemporal analytical tools to determine the social and environmental drivers of malaria risk and to identify residual high-risk areas where control and surveillance resources can be targeted. Counts of reported Plasmodium falciparum and Plasmodium vivax malaria cases by month (January 2007-December 2008) and by district were assembled. Zero-inflated Poisson regression models were developed in a bayesian framework. Models had the percentage of the district's population living below the poverty line, percent of the district covered by forest, median elevation, median long-term average precipitation, and minimum temperature included as fixed effects, and terms for temporal trend and residual district-level spatial autocorrelation. Strong temporal and spatial heterogeneity in counts of malaria cases was apparent. Poverty and forest cover were significantly associated with an increased count of malaria cases but the magnitude and direction of associations between climate and malaria varied by socio-ecological zone. There was a declining trend in counts of malaria cases during the study period. After accounting for the social and environmental fixed effects, substantial spatial heterogeneity was still evident. Unmeasured factors which may contribute to this residual variation include malaria control activities, population migration and accessibility to health care. Forest-related activities and factors encompassed by poverty indicators are major drivers of malaria incidence in Viet Nam.

Laparoscopic assisted colectomy: experience from a rural centre.

BACKGROUND: This study presents an audit of the first 50 elective laparoscopic assisted colorectal resections carried out at the Launceston General Hospital, Tasmania, particularly in comparison with the 33 elective open resections carried out in the same 18-month period. METHODS: This was a retrospective review and analysis of prospectively recorded data on an intention-to-treat basis using non-parametric methods. RESULTS: With respect to case selection, patients in the laparoscopic group were younger (median = 63 years (range 19-98 years) vs 69 years (33-93 years), P = 0.0392) and more patients had benign pathology (22/50, 44% vs 4/33, 12%, P = 0.002). There was no significant difference in sex or American Society of Anesthesiologists status (P = 0.499 and 0.517, respectively). There were more left-sided than right-sided resections (28/50, 56% vs 14/33, 42%, P = 0.118), along with more total colectomies in the laparoscopic group (7 vs 2). Operation times in the laparoscopic group were longer (197.5 min (87-452 min) vs 144 min (70-260 min), P = 0.0002) and no significant reduction was recorded over the study period (P = 0.50). There were five conversions from laparoscopic to open procedure (a 10% incidence). Compared with the open colectomy group, patients who underwent laparoscopic resections required less parenteral analgesia (2 days (1-5 days) vs 3 days (0-6 days), P < 0.0001). They had earlier first flatus (3 days (1-7 days) vs 4 days (1-6 days), P = 0.0069) and bowel movement (3 days (1-7 days) vs 4 days (2-9 days), P = 0.0021), tolerated solid diet earlier (3 days (1-9 days) vs 4 days (1-30 days), P = 0.0001) and had shorter hospital stay (5 days (3-12 days) vs 7 days (4-37 days), P = 0.0009). Less major perioperative complications were recorded for the laparoscopic group (2/50 vs 4/33, P = 0.162), but very little difference was found with respect to minor complications (17/50 vs 10/33, P = 0.725). For carcinoma resections, there were no positive resection margins. In the laparoscopic group, tumour size was smaller (3.25 cm (1-7 cm) vs 5 cm (2-15 cm), P = 0.0014) and less lymph nodes were harvested (6 (2-16) vs 8 (3-23), P = 0.101). CONCLUSION: Laparoscopic colectomy allowed early postoperative recovery and shorter hospital stay. This was at the expense of a longer operation. It can be taken up by relatively laparoscopically naive surgeons without extra major morbidity/mortality associated with the learning curve. It is technically feasible and safe in small centres.

Anal manometry: a comparison of techniques.

PURPOSE: Methods of anal manometry vary between centers, resulting in potential difficulties in interpretation of results. This study compared several accepted manometric techniques in healthy control subjects and in patients with fecal incontinence. METHODS: Eleven patients with fecal incontinence (M:F = 3:8; mean age = 67 years) and ten healthy control subjects (M:F = 3:7; mean age = 64 years) underwent anal manometry using five different methods: 1) water-perfused side hole; 2) water-perfused end hole; 3) microtransducer; 4) microballoon; 5) portable Peritron. Using a station pull-through technique, anal pressures (resting, squeeze, and cough pressures) were recorded at 1-cm intervals from rectum to anal verge, as well as radial pressures in four quadrants for Methods 1 and 2. RESULTS: Water perfusion side hole recorded slightly higher maximal resting pressures; however, there were no significant differences between any of the methods. In healthy control subjects, distal maximal squeeze pressures were significantly higher (P < 0.05) than proximally as measured by microtransducer. There were slight (nonsignificant) variations in radial pressures with water perfusion and microtransducer. Peritron values for maximum resting pressure and maximum squeeze pressure were lower than those recorded by water perfusion side hole by a factor of 0.8. CONCLUSIONS: There is no significant variation in anal pressure recordings using standard manometry techniques. Variations in radial pressures are slight and not significant in clinical studies. Results obtained with portable nonperfusion systems must be interpreted appropriately.