The Impact of the Length of the Common Intestinal Loop on Metabolic and Nutritional Outcomes of Patients with Severe Obesity Who Undergo of Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy: 5-Year Follow-Up.

Introduction: Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a recent bariatric surgery technique, highly effective in terms of weight loss. Nevertheless, data regarding the impact of SADI-S at mid-long term (after >5 years of follow-up) are scarce. Objectives: To evaluate the effect of lengths of common intestinal loop on the evolution of patients with morbid obesity (MO), who undergo SADI-S. Materials and Methods: Descriptive study (case series), including patients with MO who underwent SADI-S procedure between January 2012 and December 2015 with at least 5 years of follow-up. Patients were classified as "Old-SADI-S" (OS) when length of the common alimentary loop was <2.5 m and "New-SADI-S" (NS) when length was >2.5 m. Clinical parameters and nutritional parameters were included. Results: Twenty-nine cases were included (17 OS; 12 NS), 86.2% women and mean age 46.7 ± 1 years. After 12 months, OS had significantly lower body mass index (29.7 ± 4.8 kg/m2 versus 32.0 ± 5.1 kg/m2, P = .01), without significant differences in the resolution of comorbidities. Nevertheless, OS group had severe malabsorptive complications requiring surgical conversion of OS to NS in 7 patients after 8 months. At 5 years of follow-up, no significant difference was seen between the two groups and resolution of comorbidities was maintained during this period of time. Conclusions: SADI-S is effective in terms of weight loss and resolution of comorbidities at 5 years of follow-up, regardless of the length of the common intestinal loop. However, a common intestinal loop <2.5 m was associated with severe malabsorptive complications that determined the surgical re-conversion in all cases.

A Clinical-Genetic Score for Predicting Weight Loss after Bariatric Surgery: The OBEGEN Study.

Around 30% of the patients that undergo bariatric surgery (BS) do not reach an appropriate weight loss. The OBEGEN study aimed to assess the added value of genetic testing to clinical variables in predicting weight loss after BS. A multicenter, retrospective, longitudinal, and observational study including 416 patients who underwent BS was conducted (Clinical.Trials.gov- NCT02405949). 50 single nucleotide polymorphisms (SNPs) from 39 genes were examined. Receiver Operating Characteristic (ROC) curve analysis were used to calculate sensitivity and specificity. Satisfactory response to BS was defined as at nadir excess weight loss >50%. A good predictive model of response [area under ROC of 0.845 (95% CI 0.805-0.880), p < 0.001; sensitivity 90.1%, specificity 65.5%] was obtained by combining three clinical variables (age, type of surgery, presence diabetes) and nine SNPs located in ADIPOQ, MC4R, IL6, PPARG, INSIG2, CNR1, ELOVL6, PLIN1 and BDNF genes. This predictive model showed a significant higher area under ROC than the clinical score (p = 0.0186). The OBEGEN study shows the key role of combining clinical variables with genetic testing to increase the predictability of the weight loss response after BS. This finding will permit us to implement a personalized medicine which will be associated with a more cost-effective clinical practice.

Strengthening primary health care teams with palliative care leaders: protocol for a cluster randomized clinical trial.

BACKGROUND: The objective of the Balearic Islands Palliative Care (PC) Program is to improve the quality of PC through a shared model consisting of primary health care professionals, home-based PC teams, and PC units in hospitals. According to the World Health Organization (WHO), patients with advanced cancer and other terminal diseases benefit from early identification and proactive PC. We will evaluate the effectiveness of an intervention in which a PC leader is established in the primary health care center, and assess the effect of this intervention on the early identification of patients in need of PC, the efficient use of health care services, and direct health care costs. METHODS: Design: A two-arm cluster randomized clinical trial of 30 Primary Health Care Centers (PHCC) in Mallorca (Spain), in which each center was randomized to an intervention arm or a usual care arm. We expect that the number of patients identified as suitable for PC (including non-oncological PC) is at least 5% greater in the intervention arm. SAMPLE SIZE: A total of 4640 deceased patients. Outcomes will be assessed by a blinded external review of the electronic records. INTERVENTIONS: General practitioners (GPs) and nurse leaders in PC for each PHCC will be appointed. These leaders will help promote PC training of colleagues, improve symptom management and psychological support of patients, and evaluate the complexity of individual cases so that these cases receive assistance from PC home-based teams. MEASUREMENTS: Early identification (>90 days before death), evaluation of case complexity, level of case complexity (with referral to a home-based PC team), use and cost of hospital and primary care services, and quality of life during the last month of life (≥2 emergency room visits, ≥2 hospital admissions, ≥14 days of hospitalization). DISCUSION: PC leaders in primary care teams will improve the early identification of patients eligible for PC. This initiative could improve the quality of end-of-life care and utilization of hospital resources. TRIAL REGISTRATION: ISRCTN Registry identifier: ISRCTN92479122 . Retrospectively registered on 28 February 2017.

Age differences in presentation, diagnosis pathway and management of colorectal cancer.

BACKGROUND: The gap in survival between older and younger European cancer patients is getting wider. It is possible that cancer in the elderly is being managed or treated differently than in their younger counterparts. This study aims to explore age disparities with respect to the clinical characteristics of the tumour, diagnostic pathway and treatment of colorectal cancer patients. METHODS: We conducted a multicenter cross sectional study in 5 Spanish regions. Consecutive incident cases of CRC were identified from pathology services. MEASUREMENTS: From patient interviews, hospital and primary care clinical records, we collected data on symptoms, stage, doctors investigations, time duration to diagnosis/treatment, quality of care and treatment. RESULTS: 777 symptomatic cases, 154 were older than 80 years. Stage was similar by age group. General symptoms were more frequent in the eldest and abdominal symptoms in the youngest. No differences were found regarding perception of symptom seriousness and symptom disclosure between age groups as no longer duration to diagnosis or treatment was observed in the oldest groups. In primary care, only ultrasound is more frequently ordered in those <65 years. Those >80 years had a significantly higher proportion of iron testing and abdominal XR requested in hospital. We observed a high resection rate independently of age but less adjuvant chemotherapy in Stage III colon cancer, and of radiotherapy in stage II and III rectal cancer as age increases. CONCLUSION: There are no relevant age disparities in the CRC diagnosis process with similar stage, duration to diagnosis, investigations and surgery. However, further improvements have to be made with respect to adjuvant therapy.

Factors related with symptom duration until diagnosis and treatment of symptomatic colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) survival depends mostly on stage at the time of diagnosis. However, symptom duration at diagnosis or treatment have also been considered as predictors of stage and survival. This study was designed to: 1) establish the distinct time-symptom duration intervals; 2) identify factors associated with symptom duration until diagnosis and treatment. METHODS: This is a cross-sectional study of all incident cases of symptomatic CRC during 2006-2009 (795 incident cases) in 5 Spanish regions. Data were obtained from patients' interviews and reviews of primary care and hospital clinical records. MEASUREMENTS: CRC symptoms, symptom perception, trust in the general practitioner (GP), primary care and hospital examinations/visits before diagnosis, type of referral and tumor characteristics at diagnosis. Symptom Diagnosis Interval (SDI) was calculated as time from first CRC symptoms to date of diagnosis. Symptom Treatment Interval (STI) was defined as time from first CRC symptoms until start of treatment. Nonparametric tests were used to compare SDI and STI according to different variables. RESULTS: Symptom to diagnosis interval for CRC was 128 days and symptom treatment interval was 155. No statistically significant differences were observed between colon and rectum cancers. Women experienced longer intervals than men. Symptom presentation such as vomiting or abdominal pain and the presence of obstruction led to shorter diagnostic or treatment intervals. Time elapsed was also shorter in those patients that perceived their first symptom/s as serious, disclosed it to their acquaintances, contacted emergencies services or had trust in their GPs. Primary care and hospital doctor examinations and investigations appeared to be related to time elapsed to diagnosis or treatment. CONCLUSIONS: Results show that gender, symptom perception and help-seeking behaviour are the main patient factors related to interval duration. Health service performance also has a very important role in symptom to diagnosis and treatment interval. If time to diagnosis is to be reduced, interventions and guidelines must be developed to ensure appropriate examination and diagnosis during both primary and hospital care.

[Distribution of primary care expenditure according to sex and age group: a retrospective analysis]. / Distribución del gasto sanitario en atención primaria según edad y sexo: un análisis retrospectivo.

OBJECTIVE: To study the primary care expenditure per person and the weight of different health resources within sex and age groups. DESIGN: Cost analysis. Retrospective descriptive study. SETTING: 14 urban primary care centers (assigned population: 313,000). PARTICIPANTS: All patients who visited during 2008 (227,235). STUDY PERIOD: January to December 2008. MAIN MEASUREMENTS: Age, sex, visits, laboratory, radiology and complementary tests and referrals to specialists were obtained from patient electronic files. Pharmacy expenditure was obtained from invoices sent to the national health system by pharmacists. Fixed/semi-fixed costs were distributed among visits and a mean cost/visit was obtained. Costs were assigned for laboratory (mean application cost), for radiology and complementary tests (rate per type of test) and for referrals (adjusted rate). Descriptive analysis of data (median, interquartile range and coefficient of variance). RESULTS: Median expenditure was 362 € (321 € for men and 396 € for women). For the up to 2 year-old group it was 410 €, for aged 15-44 203 € and 75 and above 1,255 €.). The up to 2 years old visits represented 81% of total cost while pharmacy was 8%, while for those aged 75 and above visits accounted for 21% of the total cost and pharmacy 63%. CONCLUSIONS: Expenditure in primary care is higher in women, although the greatest differences were observed with age. In older than 74 years the median expenditure was six-fold higher than that for 3-44 years old group. In pediatrics the main source of expenditure was visits, representing 80% of the total in up to 2 years old. From 45 years old, pharmacy was the main source of expenditure and in those older than 74 it represented over 60% of the total.

Lack of association between diagnostic and therapeutic delay and stage of colorectal cancer.

BACKGROUND: A recent review suggests that there is no association between diagnostic and therapeutic delays and survival in colorectal cancer patients. However, the effect of tumour stage on the relationship between delay and survival in CRC should be clarified. We review here the evidence on the relationship between diagnostic and therapeutic delays and stage in colorectal cancer. METHODS: We conducted a systematic review of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1965 and 2006 dealing with delay, stage and colorectal cancer. A meta-analysis was performed based on the estimation of the odds ratios (OR) and on a random effects model. RESULTS: We identified 50 studies, representing 18,649 patients. Thirty studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction or who died 1-3 months after surgery) or because they studied only a portion of the delay. Of the 37 remaining studies, great variability was noted in connection with the type of classification used for disease stage and the type of measurement used for the delay. Meta-analysis was performed based on 17 studies that included 5209 patients. The combined OR was 0.98 (95% confidence interval (CI): 0.76-1.25), suggesting a lack of association between delay and disease stage. In four studies, cancers of the colon and rectum were dealt with separately, and a meta-analysis was performed using the data for colon cancer (1001 patients) and for rectal cancer (799 patients). In both cases, the combined ORs overlapped 1.0, and showed opposite associations when studied separately: 0.86 (95% CI: 0.63-1.19) for the colon (i.e. more delay is associated with the earlier stage at diagnosis) and 1.93 (95% CI: 0.89-4.219) for the rectum (i.e. less delay is associated with the earlier stage). CONCLUSIONS: When colorectal cancers are taken as a whole, there appears to be no association between diagnostic delay and disease stage when diagnosis is made. However, when cancers of the colon and the rectum are studied separately, there may be an opposite association. More studies about this issue are needed with larger and unrestricted samples.

Factors influencing delay in the diagnosis of colorectal cancer: a study protocol.

BACKGROUND: Colorectal cancer (CRC) is the second most frequent tumor in developed countries. Since survival from CRC depends mostly on disease stage at the time of diagnosis, individuals with symptoms or signs suspicious of CRC should be examined without delay. Many factors, however, intervene between symptom onset and diagnosis. This study was designed to: 1) Describe the diagnostic process of CRC from the onset of first symptoms to diagnosis and treatment. 2) Establish the time interval from initial symptoms to diagnosis and treatment, globally and considering patient's and doctors' delay, with the latter due to family physician and/or hospital services. 3) Identify the factors related to defined types of delay. 4) Assess the concordance between information included in primary health care and hospital clinical records regarding onset of first symptoms. METHODS: Descriptive study, coordinated, with 5 participant groups of 5 different Spanish regions (Balearic Islands, Galicia, Catalunya, Aragon and Valencia Health Districts), with a total of 8 acute public hospitals and 140 primary care centers. Incident cases of CRC during the study period, as identified from pathology services at the involved hospitals. A sample size of 896 subjects has been estimated, 150 subjects for each participant group. Information will be collected through patient interviews and primary health care and hospital clinical records. Patient variables will include sociodemographic variables, family history of cancer, symptom perception, and confidence in the family physician; tumor variables will include tumor site, histological type, grade and stage; symptom variables will include date of onset, type and number of symptoms; health system variables will include number of patient contacts with family physician, type and content of the referral, hospital services attending the patient, diagnostic modalities and results; and delay intervals, including global delays and delays attributed to the patient, family physician and hospital. DISCUSSION: To obtain a nonrestricted sample of patients with CRC we have minimized selection risk by identifying the patients from pathology services. A greater constraint may be associated with information sources based on clinical records. Due to inherent features of coordinated studies, it is important to standardize the collection of information.

Anastomotic dehiscence after resection and primary anastomosis in left-sided colonic emergencies.

PURPOSE: There is no consensus about the risk factors for anastomotic failure after elective or emergency colorectal surgery. The purpose of this study was to analyze the factors that may contribute in anastomotic dehiscence. METHODS: A total of 208 patients who underwent left colonic resection and primary anastomosis for distal colonic emergencies were studied. Preoperative and operative variables analyzed for each patient were gender, age, American Society of Anesthesiologists score, comorbidities, indication for surgery, etiology of the disease, presence and grade of peritonitis, preoperative creatinine, hematocrit, hemoglobin, and leukocyte count, need for preoperative and operative transfusion. The end point was the clinical evident incidence of anastomotic leak. Bivariate comparisons of those patients with or without anastomotic leak were unpaired, and all tests of significance were two-tailed. A multivariate analysis, in which presentation of anastomotic leak was the dependent outcome variable, was performed by forward stepwise logistic regression model. RESULTS: One hundred five patients (50.4 percent) had one or more complications. Anastomotic leak was diagnosed in 12 patients (5.7 percent). Seventeen patients (8.2 percent) needed a reoperation for complication. The overall mortality was 6.2 percent (13 patients). Obesity was significant as a predictor of anastomotic leak. CONCLUSIONS: Obesity is a factor predicting anastomotic leak risk after resection and primary anastomosis for left-sided colonic emergencies.

[Results and prognostic factors in the Hartmann procedure]. / Resultados y factores pronósticos de mortalidad en la intervención de Hartmann.

INTRODUCTION: The introduction of one-stage procedures in emergency colonic surgery many years ago has relegated the use of the Hartmann procedure to the most seriously-ill patients, which has led to the high morbidity and mortality rates associated with this surgical technique. The aim of our study was to investigate our results using Hartmanns procedure and to evaluate several prognostic factors of postoperative mortality in this group of patients. PATIENTS AND METHODS: From January 1995 to December 2000, 79 patients (34 men and 45 women) with a mean age of 71.5 years underwent Hartmanns operation. Almost all the series (91.1%) had comorbidities. In this group of patients, morbidity and mortality were analyzed retrospectively, and a multivariate logistic regression analysis was performed to study prognostic factors of postoperative mortality. RESULTS: The indications for surgery were acute peritonitis (77.2%), intestinal obstruction (18.9%), and lower gastrointestinal hemorrhage (3.7%). The most frequent etiology was acute diverticulitis (36 patients), followed by complicated colorectal carcinoma (18 patients). In 70.9% of the patients (56 patients) one or more postoperative complications was observed. Reoperation was performed in 15 patients (18.9%) and overall postoperative mortality was 45.5%. Renal failure (creatinine > or = 120 micromol/l) and high surgical ASA score (III or IV) reached statistical significance as predictive factors of mortality in these patients (p=.001 and p=.005, respectively). CONCLUSION: The patients who underwent Hartmanns procedure with high surgical ASA score and/or renal failure were at significantly higher risk of mortality.

Melhoria da Atenção ao Programa de Detecção e Prevenção dos Cânceres de Mama e de Colo de Útero na ESF União, Santo Ângelo-RS

O programa de detecção e prevenção do câncer de mama e de colo de útero tem assumido uma grande relevância nas políticas de saúde pública brasileira por serem doenças de desenvolvimento lento, que podem cursar sem sintomas na fase inicial e evoluir para quadros graves mais avançados. A partir da necessidade de melhorar a atenção aos programas de detecção e prevenção do câncer de mama e de colo de útero na ESF União, do município Santo Ângelo-RS, foi implementado uma intervenção com o objetivo principal de melhorar a atenção ao programa de detecção e prevenção do câncer de mama e de colo de útero na unidade, que teve duração de 16 semanas, com início no mês de fevereiro e término no mês de junho do corrente ano, e contou com o envolvimento de toda a equipe para ampliar a cobertura de detecção precoce do câncer de colo de útero e do câncer de mama na comunidade, melhorar a qualidade do atendimento das mulheres que realizam detecção precoce de câncer de colo de útero e de mama, melhorar a adesão das mulheres à realização de exame citopatológico de colo de útero e mamografia, melhorar o registro das informações, e demais ações preconizadas pelo Ministério da Saúde. De acordo com os registros na unidade, a área de abrangência da ESF União possui um total de 399 mulheres entre 25 a 64 anos de idade, e 293 mulheres entre 50 a 69 anos de idade, no entanto, como esses registros estão desatualizados desde a fase da Análise Situacional, foi utilizado à estimativa de VIGITEL (2011), que está mais condizente com a nossa realidade para a análise dos resultados, sendo 918 mulheres na faixa etária de 25 a 64 anos para a prevenção ao câncer de Colo de Útero, e 293 mulheres na faixa etária de 50 a 69 anos para a prevenção ao câncer de mama. Em relação ao programa de prevenção do câncer de colo de útero, no primeiro mês foram atendidas 25 usuárias (2,7%) com idade entre 25 a 64 anos; no segundo mês essa quantidade foi de 61 usuárias (6,6%); no terceiro mês a quantidade de mulheres acompanhadas, incluindo os novos cadastramentos realizados pela equipe chegou a 123 usuárias (13,4%); e no quarto e último mês da intervenção, a quantidade geral de atendimento correspondeu a 157 usuárias (17,1%). Já para a cobertura de detecção e controle do câncer de mama, no primeiro mês a quantidade de mulheres com idade entre 50 a 69 anos que foram acompanhadas na UBS foi de 12 usuárias (4,1%); no segundo mês esse total correspondeu a 26 usuárias (8,9%); no terceiro mês o total de atendimento realizado foi 42 usuárias (14,3%); e no quarto mês obteve-se o total geral de 60 usuárias (20,5%) com idade entre 50 a 69 anos atendidas pela equipe. Toda a equipe se mantêm comprometida para dar continuidade às ações desenvolvidas e buscar mais melhorias para a população assistida.