Plasma soluble vascular adhesion molecule-1 levels are persistently elevated during the first month after colorectal cancer resection.

INTRODUCTION: Plasma from the second and third weeks after minimally invasive colorectal resection (MICR) has high levels of the proangiogenic proteins VEGF and angiopoietin 2 and also stimulates, in vitro, endothelial cell (EC) proliferation and migration, which are critical to wound and tumor angiogenesis. Soluble vascular cell adhesion molecule-1 (sVCAM-1) stimulates EC chemotaxis and angiogenesis. The impact of MICR on blood levels of sVCAM-1 is unknown. This study's purpose was to determine plasma sVCAM-1 levels after MICR in colorectal cancer (CRC) patients. METHODS: Blood samples from 90 patients (26% rectal, 74% colon) were obtained preoperatively, on postoperative days (POD) 1 and 3, and at other points during the next 2 months. The late samples were bundled into 7-day time blocks. sVCAM-1 levels were determined in duplicate via ELISA and reported as ng/ml. Student's t test was used for data analysis (significance, P < 0.008 after Bonferroni correction). RESULTS: The mean incision length was 7.3 ± 3.1 cm, and the conversion rate was 3%. Compared with preoperative (PreOp) levels (811.3 ± 233.2), the mean plasma sVCAM-1 level was significantly higher on POD 1 (905.7 ± 292.4, P < 0.001) and POD 3 (977.7 ± 271.8, P < 0.001). Levels remained significantly elevated for the POD 7-13, POD 14-20, POD 21-27, and POD 28-67 time blocks. CONCLUSIONS: MICR for CRC is associated with a persistent increase in plasma sVCAM-1 levels during the first month. This sustained increase may promote angiogenesis and stimulate the growth of residual tumor cells early after surgery.

Perioperative polyphenon E, a green tea extract, does not affect the wound complication rate in mice after sham laparotomy yet has an inhibitory effect on wound healing.

INTRODUCTION: Major surgery is associated with physiologic alterations that may promote tumor growth, and catechins in green tea may inhibit tumor growth. This study's aim was to assess the impact of a green tea extract on laparotomy wound healing in mice. METHODS: Mice were randomized to daily oral catechins solution (n = 25) or placebo (n = 20), underwent sham laparotomy after 10 days, and were sacrificed on postoperative day 7 or 21. The peak force and total energy required to rupture the abdominal wall wound, wound collagen content, and histology were assessed. RESULTS: There were no wound complications in either group, and mean peak wound rupture forces and collagen concentration were similar. Mean energy was lower and more fibroblast proliferation was found in the treatment group on postoperative day 21. CONCLUSIONS: These results suggest that catechins has only mild clinically significant adverse effect on wound healing, and its perioperative use warrants further study.

Minimally invasive colon resection is associated with a persistent increase in plasma PlGF levels following cancer resection.

BACKGROUND: Minimally invasive colorectal resection (MICR) is associated with persistently elevated plasma VEGF levels that may stimulate angiogenesis in residual tumor foci. Placenta growth factor (PlGF) stimulates neovascularization in tumors by modulating VEGF's effects. This study's purpose was to determine the impact of MICR on blood PlGF levels in cancer patients (Study A) and to compare PreOp levels in patients with cancer and benign (BEN) disease (Study B). METHODS: Blood samples were collected preoperatively, on postoperative day (POD) 1, POD 3, and at various time points 2-4 weeks after surgery. Samples from 7-day periods after POD 6 were bundled to allow analysis. Plasma PlGF levels were determined via ELISA, results reported as mean±SD, and data analyzed via t test. Significance was set at p<0.008 after Bonferroni correction. RESULTS: Study A: 76 colorectal cancer (CRC) patients had MICR (laparoscopic, 59%; hand-assisted, 41%). The mean length of stay was 5.8±2.1 days. The mean PreOp PlGF level was 15.4±4.3 pg/ml. Significantly increased levels were noted on POD 1 (25.8±7.7 pg/ml, p<0.001), POD 3 (22.9±6.7, p<0.001), POD 7-13 (19.2±5.1, p<0.001), and POD 14-20 (19.5±6.7, p<0.002). The mean POD 21-27 level was not significantly different from baseline. Study B included 126 CRC and 111 BEN patients. PreOp levels were higher in the CRC patients (15.6±5.3 pg/ml) than in the BEN group (13.5±5.5 pg/ml, p=0.001). CONCLUSIONS: PlGF levels are elevated for 3 weeks after MICR and PreOp plasma levels are higher in CRC patients than in BEN disease patients. The cause of the postoperative increase is unclear. The persistently higher blood levels of PlGF and VEGF after MICR may stimulate angiogenesis in residual tumor foci. Further studies regarding late blood protein alterations after surgery appear to be indicated.

Minimally invasive colorectal resection is associated with a rapid and sustained decrease in plasma levels of epidermal growth factor (EGF) in the colon cancer setting.

BACKGROUND: Epidermal growth factor (EGF) stimulates tumor growth directly via tumor cell EGF receptors or indirectly via its proangiogenic effects. This study's purpose was to determine the impact of minimally invasive colorectal resection (MICR) on postoperative (postop) plasma EGF levels in the colorectal cancer (CRC) and benign disease settings and to see if preoperative (PreOp) EGF levels are altered in cancer patients. METHODS: MICR patients with benign pathology (n = 40) and CRC (n = 48) had blood samples taken PreOp and on postoperative days (POD) 1 and 3. In some patients, late samples were taken between POD7 and POD60; these were bundled into 7-day blocks and considered as single time points. EGF levels were determined by enzyme-linked immunosorbent assay (ELISA) and results were reported as mean ± SD after logarithmic transformation. The Student t test was used (p < 0.008 after Bonferroni correction). RESULTS: The cancer and benign groups were comparable except for age. The mean PreOp CRC plasma EGF level (122.9 ± 75.9 pg/ml) was significantly higher than that of the benign group (85.3 ± 38.5 pg/ml) (p = 0.015). The cancer group's EGF levels were significantly decreased on POD1 and POD3 and for the POD31-55 time point (mean EGF level = 63.1 ± 42.2 (n = 10). The benign group's POD3 and POD7-14 EGF levels were significantly lower than the PreOp level; later levels returned toward baseline. Small late sample size limited analysis. CONCLUSION: Plasma EGF levels are significantly higher in cancer patients. MICR is associated with a significant decrease in EGF levels early postop in both cancer and benign settings. Unlike the benign group, EGF blood levels in cancer patients remain low during the second postop month. A larger study with more late samples is needed to verify these results. EGF may have value as a tumor marker.

Making better use of the policies and funding we already have.

The potential for population health reform could be enhanced by assessing whether we have made the most of policies and resources already available. Opportunities to promote population health independent of major changes in resources or public authority include the following: enforcing laws already in effect; clarifying and updating the application of long-standing policies; leveraging government's and the private sector's purchasing and investment clout; facilitating access to programs by everyone who is eligible for them; evaluating the effectiveness of population health programs, agencies, and policies; and intervening to stop agencies and policies from operating at cross-purposes.

Is there a role for a strict incision length criterion for determining conversions during laparoscopic colorectal resection?

PURPOSE: There's no consensus about what defines a conversion for laparoscopic-assisted colorectal resection (LACR). This study's goal was to assess the utility of a strict incision length (IL) definition of conversion (incision > 7 cm) and compare it with results obtained when the surgeon determined (SD) if a LACR had been successfully completed. METHODS: The demographic and perioperative data for 580 elective LACRs were reviewed. The short-term outcomes for each conversion definition were determined and compared. RESULTS: Conversion rates were 22% using the IL definition and 16% via the SD method. Both methods detected significant differences between completed and converted groups regarding the following: incision size, hospital stay, time to flatus, bowel movement, and regular diet as well as rate of wound infection and ileus. The IL method alone detected significant differences in the rate of pulmonary complications and BMI between the completed and converted groups. CONCLUSIONS: The 2 methods yielded similar results for most parameters. The IL method better separated the patients in regard to 2 parameters. This method is objective and easy to apply; however, it may discriminate against obese patients whose extraction incisions are often longer. A conversion definition that considers BMI and IL is needed.

The contribution of hospitals and health care systems to community health.

This article reviews evidence on hospitals' and health systems' impacts on community health improvement. We begin with an overview of the history of community benefit and then discuss the lack of a widely accepted definition and measurement of community benefit activities as well as the expectations and accountability of tax-exempt not-for-profit hospitals and health systems in community initiatives. We highlight the approaches of two systems and identify strategic, cultural, technical, and structural challenges associated with increasing community benefit and health-improvement activities. We conclude by offering recommendations for policy and practice.

Does prior abdominal surgery influence conversion rates and outcomes of laparoscopic right colectomy in patients with neoplasia?

PURPOSE: The study investigated the impact of prior abdominal surgery on conversions and outcomes of laparoscopic right colectomy. METHODS: A consecutive series of 414 patients with cancer or adenomas who underwent a laparoscopic right colectomy from March 1996 to November 2006 were studied for surgical conversions and outcomes. Conversion was defined as an incision length > 7 cm. RESULTS: Patients with prior abdominal surgery (n = 191) were compared with patients with no prior abdominal surgery (n = 223), and showed no significant differences in age, ASA classification, length of stay, operative time, blood loss, harvested nodes, tumor size, and specimen length. Significantly more wound infections occurred in the prior abdominal surgery group (22 vs.12, P = 0.023). Body mass index > 30 showed a three-fold increased risk of conversion. Fifteen percent of the no prior abdominal surgery patients and 17 percent of the prior abdominal surgery patients were converted (P > 0.05). Conversion was associated with a longer mean length of stay (8.8 days) relative to laparoscopically completed cases (6.3 days) regardless of prior abdominal surgery history (P < 0.0001). CONCLUSIONS: Laparoscopic right colectomy for neoplasia was not associated with a higher conversion rate or morbidity in patients with prior abdominal surgery. Prior abdominal surgery is not a contraindication to laparoscopic right colectomy.

Comparative effectiveness topics from a large, integrated delivery system.

OBJECTIVE: To identify high-priority comparative effectiveness questions directly relevant to care delivery in a large, US integrated health care system. METHODS: In 2010, a total of 792 clinical and operational leaders in Kaiser Permanente were sent an electronic survey requesting nominations of comparative effectiveness research questions; most recipients (83%) had direct clinical roles. Nominated questions were divided into 18 surveys of related topics that included 9 to 23 questions for prioritization. The next year, 648 recipients were electronically sent 1 of the 18 surveys to prioritize nominated questions. Surveys were assigned to recipients on the basis of their nominations or specialty. High-priority questions were identified by comparing the frequency a question was selected to an "expected" frequency, calculated to account for the varying number of questions and respondents across prioritization surveys. High-priority questions were those selected more frequently than expected. RESULTS: More than 320 research questions were nominated from 181 individuals. Questions most frequently addressed cardiovascular and peripheral vascular disease; obesity, diabetes, endocrinology, and metabolic disorders; or service delivery and systems-level questions. Ninety-five high-priority research questions were identified, encompassing a wide range of health questions that ranged from prevention and screening to treatment and quality of life. Many were complex questions from a systems perspective regarding how to deliver the best care. CONCLUSIONS: The 95 questions identified and prioritized by leaders on the front lines of health care delivery may inform the national discussion regarding comparative effectiveness research. Additionally, our experience provides insight in engaging real-world stakeholders in setting a health care research agenda.

America's health care safety net: revisiting the 2000 IOM report.

The committee that wrote the 2000 Institute of Medicine report on the health care safety net reconvened in 2006 to reflect on the safety net from the perspective of rising numbers of uninsured and underinsured people, the aftermath of Hurricane Katrina, high immigration levels, and new fiscal and policy pressures on care for vulnerable populations. Safety-net providers now participate in Medicaid managed care but find it difficult to meet growing needs for specialty services, particularly mental health care and affordable prescription drugs. How current state reforms and coverage expansions will affect care for the poor and uninsured is a critical issue.