Major low anterior resection syndrome has equivalent health-related quality of life implications as having a permanent colostomy.

BACKGROUND: The literature is inconclusive when comparing health-related quality of life following restorative anterior resection (AR) compared with abdominoperineal resection (APR). Consideration of functional outcomes may explain this inconsistency. The aim of this study was to compare health-related quality of life in patients post-anterior resection, stratified by low anterior resection syndrome score, and post-abdominoperineal resection patients. METHODS: A cross-sectional study of consecutive patients post APR and AR for rectal or sigmoid adenocarcinoma at a tertiary centre in Sydney, Australia (Jan 2012- Dec 2021) was performed. HRQoL outcomes (SF36v2 physical [PCS] and mental component summary [MCS] scores) were compared between APR and AR patients, with subgroup analyses stratifying AR patients according to LARS score (no/minor/major). Age- and gender-adjusted comparisons were performed by linear regression. RESULTS: Overall, 248 post-AR patients (57.3% male, mean age 70.8 years, SD 11.6) and 64 post-APR patients (62.5% male, mean age 68.1 years, SD 13.1) participated. When stratified by LARS, 'major LARS' had a similar negative effect on age-and sex-adjusted PCS scores as APR. 'No LARS' (p < 0.001) and 'minor LARS' (p < 0.001) patients had higher PCS scores compared to post-APR patients. 'Major LARS' had a similarly negative effect on MCS scores compared with post-APR patients. MCS scores were higher in 'no LARS' (p = 0.006) compared with APR patients. CONCLUSIONS: Postoperative bowel dysfunction significantly impacts health-related quality of life. Patients with 'major LARS' have health-related quality of life as poor as those following APR. This requires consideration when counselling patients on postoperative health-related quality of life, especially where poor postoperative bowel function is anticipated following restorative surgery.

Supersolidity in Two-Dimensional Trapped Dipolar Droplet Arrays.

We theoretically investigate the ground states and the spectrum of elementary excitations across the superfluid to droplet crystallization transition of an oblate dipolar Bose-Einstein condensate. We systematically identify regimes where spontaneous rotational symmetry breaking leads to the emergence of a supersolid phase with characteristic collective excitations, such as the Higgs amplitude mode. Furthermore, we study the dynamics across the transition and show how these supersolids can be realized with standard protocols in state-of-the-art experiments.

Roton Excitations in an Oblate Dipolar Quantum Gas.

We observe signatures of radial and angular roton excitations around a droplet crystallization transition in dipolar Bose-Einstein condensates. In situ measurements are used to characterize the density fluctuations near this transition. The static structure factor is extracted and used to identify the radial and angular roton excitations by their characteristic symmetries. These fluctuations peak as a function of the interaction strength indicating the crystallization transition of the system. We compare our observations to a theoretically calculated excitation spectrum allowing us to connect the crystallization mechanism with the softening of the angular roton modes.

Colonic transit in patients after anterior resection: prospective, comparative study using single-photon emission CT/CT scintigraphy.

BACKGROUND: Bowel dysfunction after anterior resection is well documented, but its pathophysiology remains poorly understood. No study has assessed whether postoperative variation in colonic transit contributes to symptoms. This study measured colonic transit using planar scintigraphy and single-photon emission CT (SPECT)/CT in patients after anterior resection, stratified according to postoperative bowel function. METHODS: Symptoms were assessed using the low anterior resection syndrome (LARS) score. Following gallium-67 ingestion, scintigraphy was performed at predefined time points. Nine regions of interest were defined, and geometric centre (GC), percentage isotope retained, GC velocity index and colonic half-clearance time (T½ ) determined. Transit parameters were compared between subgroups based on LARS score using receiver operating characteristic (ROC) curve analyses. RESULTS: Fifty patients (37 men; median age 72·6 (range 44·4-87·7) years) underwent planar and SPECT scintigraphy. Overall, 17 patients had major and nine had minor LARS; 24 did not have LARS. There were significant differences in transit profiles between patients with major LARs and those without LARS: GCs were greater (median 5·94 (range 2·35-7·72) versus 4·30 (2·12-6·47) at 32 h; P = 0·015); the percentage retained isotope was lower (median 53·8 (range 6·5-100) versus 89·9 (38·4-100) per cent at 32 h; P = 0·002); GC velocity indices were greater (median 1·70 (range 1·18-1·92) versus 1·45 (0·98-1·80); P = 0·013); and T½ was shorter (median 38·3 (17·0-65·0) versus 57·0 (32·1-160·0) h; P = 0·003). Percentage tracer retained at 32 h best discriminated major LARS from no LARS (area under curve (AUC) 0·828). CONCLUSION: Patients with major LARS had accelerated colonic transit compared with those without LARS, which may help explain postoperative bowel dysfunction in this group. The percentage tracer retained at 32 h had the greatest AUC value in discriminating such patients.

ANTECEDENTES: La disfunción intestinal después de la resección anterior (anterior resection, AR) está bien documentada, pero su fisiopatología sigue siendo poco conocida. Ningún estudio ha evaluado si la variación postoperatoria en el tránsito colónico contribuye a los síntomas. Este estudio midió el tránsito colónico mediante gammagrafía planar con SPECT/CT en pacientes después de una AR, estratificados según la función intestinal postoperatoria. MÉTODOS: Los síntomas se evaluaron mediante el sistema de puntuación del síndrome de resección anterior baja (low anterior resection syndrome, LARS). Después de la administración oral de galio-67, se realizó una gammagrafía en tiempos predefinidos. Se establecieron nueve regiones de interés y se midió/calculó las siguientes variables: (i) centro geométrico (geometric centre, GC); (ii) porcentaje de isótopo retenido; (iii) velocidad del GC; y (iv) semivida de aclaramiento del colon (T1/2). Se compararon los parámetros de tránsito en diferentes subgrupos de pacientes de acuerdo con su puntuación LARS utilizando análisis de curva ROC RESULTADOS: La gammagrafía planar con SPECT se realizó en 50 pacientes con AR seleccionados al azar (37 varones, media de 72,3 años (DE 9,0)). En total, 17 pacientes presentaban un LARS mayor, 9 tenían un LARS menor y 24 no presentaban LARS. En comparación con los pacientes sin LARS, los pacientes con LARS mayor tenían perfiles de tránsito significativamente diferentes: a las 32 horas, (i) los GC fueron mayores (mediana 5,94 (rango 2,35-7,72) versus 4,30 (2,12-6,47), P = 0,015)); (ii) el porcentaje de isótopo retenido fue menor (mediana 53,8% (error estándar de la media 6,5) versus 89,9% (3,4), P = 0,002)); (iii) las velocidades del GC fueron mayores (1,70 (1,18-1,92) versus 1,45 (0,98-1,80), P = 0,013)); y (iv) las semividas T1/2 fueron más cortas (38,3 horas (17,0-65,0) versus 57,0 (32,1-160), P = 0,003)). El porcentaje de isótopo retenido a las 32 horas fue el parámetro que mejor discriminó los pacientes con LARS mayor de los pacientes sin LARS (AUC 0,828). CONCLUSIÓN: Los pacientes con LARS mayor presentaron un tránsito colónico acelerado en comparación con los pacientes sin LARS, lo que puede contribuir a explicar la disfunción intestinal postoperatoria en dichos pacientes. El marcador de porcentaje de isótopo retenido a las 32 horas tenía un valor de AUC más elevado en la discriminación de estos pacientes.

Patient-reported and physician-recorded bowel dysfunction following colorectal resection and radical cystectomy: a prospective, comparative study.

AIM: Bowel dysfunction following anterior resection (AR) is termed low anterior resection syndrome. It is unclear whether such dysfunction occurs following other bowel/pelvic operations as well. This study aimed to characterize and compare bowel dysfunction following AR, right hemicolectomy (RH) and radical cystectomy (RC). METHOD: A prospective study of consecutive patients undergoing AR, RH and RC (2002-2012) was performed at a tertiary referral centre in Sydney, Australia. Outcome measures included (i) patient-reported satisfaction with bowel function, self-described bowel function and self-reported change in bowel function; (ii) objective assessment of bowel function using validated criteria to identify symptoms and stratify patients into those with constipation and/or faecal incontinence (FI); and (iii) health-related quality of life (SF-36v2 Health Survey). RESULTS: Of 743 eligible patients, 70% participated [AR, n = 338, mean age 69.6 years (SD 11.9), 59% men; RH, n = 150, 75.8 years (SD 10.5), 54% men; RC, n = 34, 71.1 years (SD 14.1), 71% men]. AR patients were three times more likely to report change in bowel function post-surgery and self-judged their bowel function as abnormal more frequently (64%) than RH patients (35%) and RC patients (35%) (P < 0.01). AR patients were four times more likely to meet criteria for concomitant constipation and FI. Patients with concomitant constipation and FI had lower physical and mental SF-36v2 scores (P < 0.001). CONCLUSION: Bowel dysfunction occurred after RH and RC but rates were higher following AR. This suggests that low anterior resection syndrome occurs due to a direct impact of partial/complete loss of the rectum rather than just due to loss of bowel length and/or the consequence(s) of pelvic dissection.

Factors associated with healing, reoperation and continence disturbance in patients following surgery for fistula-in-ano.

AIM: Fistula-in-ano (FIA) is associated with high treatment costs and has a deleterious impact on quality of life. A wide range of healing, incontinence and recurrence rates have been reported. This study aimed to identify operative, patient and disease factors that influence these outcomes after surgery for FIA. METHOD: An observational cohort study of consecutive patients who were managed for FIA at a tertiary colorectal practice (1999-2019) was performed. Outcome measures included healing, impaired continence and the need to reoperate. Clinico-pathological variables, including patient comorbidities, fistula anatomy and operative approach, were assessed for their association with these outcomes. RESULTS: Some 411 procedures were performed on 263 patients [median age 41.8 years (range 17.8-79.7 years), 184 men (70.0%)]. Some 77.9% of patients achieved complete healing, 9.5% experienced some deterioration in continence postoperatively and 37.6% required reoperation at a median time of 19.0 weeks. Poorer healing was associated with Crohn's disease, high trans-sphincteric fistulas, extrasphincteric fistulas and steroid usage. Poorer continence was associated with female sex, age > 40 years, posterior location, suprasphincteric fistulas, seton insertion and having more than three subsequent procedures. The need to reoperate was associated with female sex, high trans-sphincteric fistulas, suprasphincteric fistulas, inflammatory bowel disease and previous operations for FIA. CONCLUSION: Minimizing recurrence of FIA and preservation of continence can be competing management goals. More than one in three patients require reoperation, one in five fails to heal completely and one in ten suffers worsened continence following surgery. Awareness of the factors that contribute to these outcomes is important to the process of informed consent and managing patient expectations before surgery.

Brain responses to mechanical rectal stimulation in patients with faecal incontinence: an fMRI study.

AIM: Continence is dependent on anorectal-brain interactions. Consequently, aberrations of the brain-gut axis may be important in the pathophysiology of faecal incontinence (FI) in certain patients. The aim of this study was to assess the feasibility of recording brain responses to rectal mechanical stimulation in patients with FI using functional magnetic resonance imaging (fMRI). METHOD: A prospective, cohort pilot study was performed to assess brain responses during rectal stimulation in 14 patients [four men, mean (SD) age 62 (15) years]. Blood oxygen level dependent (BOLD) signals were measured by fMRI during rest and mechanical distension, involving random repetitions of isobaric phasic rectal distensions at fixed (15 and 45 mmHg) and variable (10% above sensory perception threshold) pressures. RESULTS: Increases in BOLD signals in response to high pressure rectal distension (45 mmHg) and maximum toleration were observed in the cingulate gyrus, thalamus, insular cortex, inferior frontal gyrus, cerebellum, caudate nucleus, supramarginal gyrus, putamen and amygdala. Additionally, activation of the supplementary motor cortex and caudate nucleus with inconsistent activity in the frontal lobe was observed. CONCLUSIONS: This study has demonstrated the feasibility of recording brain responses to rectal mechanical stimulation using fMRI in patients with FI, revealing activity in widespread areas of the brain involved in visceral sensory processing. The observed activity in the supplementary motor cortex and caudate nucleus, with relative paucity of activity in the frontal lobes, warrants investigation in future studies to determine whether aberrations in cerebral processing of rectal stimuli play a role in the pathogenesis of FI.

Prevalence of functional bowel disorders and faecal incontinence: an Australian primary care survey.

AIM: Interest in functional bowel disorders (FBDs) and faecal incontinence (FI) has increased amongst coloproctologists. The study aimed to assess the prevalence of FBDs and FI (including its severity) among Australian primary healthcare seekers using objective criteria. METHOD: A cross-sectional survey was conducted in a primary care setting in Sydney, Australia. A self-administered questionnaire was used to collect demographic information and diagnose FBDs (irritable bowel syndrome, constipation, functional bloating and functional diarrhoea) based on Rome III criteria. The severity of FI was determined using the Vaizey incontinence score. Associations with medical/surgical history and healthcare utilization were assessed. RESULTS: Of 596 subjects approached, 396 (66.4%) agreed to participate. Overall, 33% had FBD and/or FI. Irritable bowel syndrome was present in 11.1% and these participants were more likely to report anxiety/depression (P < 0.01) and to have had a previous colonoscopy (P < 0.001) or cholecystectomy (P = 0.02). Functional constipation was present in 8.1%, and functional bloating and functional diarrhoea were diagnosed in 6.1%, and 1.5%, respectively. FI was present in 12.1% with the majority (52%) reporting moderate/severe incontinence (Vaizey score > 8). Participants with FI were more likely to have irritable bowel syndrome, urinary incontinence and previous anal surgery (P < 0.01). CONCLUSION: FBDs and FI are prevalent conditions amongst primary healthcare seekers and the needs of those affected appear to be complex given their coexisting symptoms and conditions. Currently, the majority do not reach colorectal services, although increased awareness by primary care providers could lead to sufferers being referred for specialist management.

A review of dengue research in malaysia.

Dengue infection is a major cause of morbidity and mortality in Malaysia. To date, much research on dengue infection conducted in Malaysia have been published. One hundred and sixty six articles related to dengue in Malaysia were found from a search through a database dedicated to indexing all original data relevant to medicine published between the years 2000-2013. Ninety articles with clinical relevance and future research implications were selected and reviewed. These papers showed evidence of an exponential increase in the disease epidemic and a varying pattern of prevalent dengue serotypes at different times. The early febrile phase of dengue infection consist of an undifferentiated fever. Clinical suspicion and ability to identify patients at risk of severe dengue infection is important. Treatment of dengue infection involves judicious use of volume expander and supportive care. Potential future research areas are discussed to narrow our current knowledge gaps on dengue infection.

Frequency-dependent cell death by optical tweezers manipulation.

Optical tweezers were used to scan individual Chronic Myelogenous Leukemia cells to determine if the cell death depends on the scanning conditions. Although increasing the scanning frequency or amplitude means greater force applied to the cells, their effects on cell death are not a simple increasing trend, as observed in the optical microscopy. Indeed, cell death sharply increased at particular screening frequencies and amplitudes, whereas other frequencies or amplitudes were less detrimental. These results suggest that cell damage was more sensitive to certain scanning conditions, rather than simply high-applied forces.

Emergency gastroduodenal artery embolization by sandwich technique for angiographically obvious and oblivious, endotherapy failed bleeding duodenal ulcers.

AIM: To determine the feasibility, safety, and efficacy of adopting a standardized protocol for emergency transarterial embolization (TAE) of the gastroduodenal artery (GDA) with a uniform sandwich technique in endotherapy-failed bleeding duodenal ulcers (DU). MATERIALS AND METHODS: Between December 2009 and December 2010, 15 patients with endotherapy-failed bleeding DU were underwent embolization. Irrespective of active extravasation, the segment of the GDA supplying the bleeding DU as indicated by endoscopically placed clips was embolized by a uniform sandwich technique with gelfoam between metallic coils. The clinical profile of the patients, re-bleeding, mortality rates, and response time of the intervention radiology team were recorded. The angioembolizations were reviewed for their technical success, clinical success, and complications. Mean duration of follow-up was 266.5 days. RESULTS: Active contrast-medium extravasation was seen in three patients (20%). Early re-bleeding was noted in two patients (13.33%). No patient required surgery. There was 100% technical success, while primary and secondary clinical success rates for TAE were 86.6 and 93.3%, respectively. Focal pancreatitis was the single major procedure-related complication. There was no direct bleeding-DU-related death. The response time of the IR service averaged 150 min (range 60-360 min) with mean value of 170 min. CONCLUSION: Emergency embolization of the GDA using the sandwich technique is a safe and highly effective therapeutic option for bleeding DUs refractory to endotherapy. A prompt response from the IR service can be ensured with an institutional protocol in place for such common medical emergencies.

Relapse of amoebic infection 10 years after the infection.

A 52-year-old man with schizophrenia, who had a history of amoebic liver abscess treated with combination antimicrobial agents, presented 10 years later with severe rectal bleeding. Diagnosis of amoebic colitis was confirmed by histological examination of endoscopic biopsy. Doctors treating patients with amoebic infection should be aware of the risk of eradication failure. Post-treatment stool testing, preferably by antigen testing or polymerase chain reaction, should be performed after antimicrobial treatment.

Cardiac arrhythmia triggered by diuretic-induced hyponatremia.

Diuretics have a long and distinguished history in the treatment of hypertension and heart failure. Clinical practice guidelines recommend that diuretics should be considered to be as suitable as other antihypertensive agents for the initiation and maintenance of antihypertensive treatment. However, diuretics may potentially cause electrolyte disturbances and metabolic side effects. Diuretic-induced hyponatremia is probably more prevalent than generally acknowledged. We present an unusual case of indapamide-induced hyponatremia and hypokalemia complicated by cardiac arrhythmia. The adverse drug reaction was reversible and non-life-threatening, but this case serves as a reminder that careful evaluation and constant monitoring are necessary when prescribing diuretics.

Quantification and neurochemical coding of the myenteric plexus in humans: No regional variation between the distal colon and rectum.

BACKGROUND: It remains unclear whether regional variation exists in the human enteric nervous system (ENS) ie, whether intrinsic innervation varies along the gut. Recent classification of gastrointestinal neuropathies has highlighted inadequacies in the quantification of the human ENS. This study used paired wholemounts to accurately quantify and neurochemically code the hindgut myenteric plexus, comparing human distal colon and rectum. METHODS: Paired human descending colonic/rectal specimens were procured from 15 patients undergoing anterior resection. Wholemounts of myenteric plexi were triple-immunostained with anti-Hu/NOS/ChAT antibodies. Images were acquired by motorized epifluorescence microscopy, allowing assessment of ganglionic density/size, ganglionic area density, and neuronal density. 'Stretch-corrected' values were calculated using stretched/relaxed tissue dimensions. KEY RESULTS: Tile-stitching created a collage with average area 99 300 000 µm2 . Stretch-corrected ganglionic densities were similar (colon: median 510 ganglia/100 mm2 [range 386-1170], rectum: 585 [307-923]; P = .99), as were average ganglionic sizes (colon: 57 593 µm2 [40 301-126 579], rectum: 54 901 [38 701-90 211], P = .36). Ganglionic area density (colon: 11.92 mm2 per 100 mm2 [7.53-18.64], rectum: 9.84 [5.80-17.19], P = .10) and stretch-corrected neuronal densities (colon: 189 neurons/mm2 [117-388], rectum: 182 [89-361], P = .31) were also similar, as were the neurochemical profiles of myenteric ganglia, with comparable proportions of NOS+ and ChAT+ neurons (P > .10). CONCLUSIONS AND INFERENCES: This study has revealed similar neuronal and ganglionic densities and neurochemical profiles in human distal colon and rectum. Further investigation of other components of the ENS, incorporating additional immunohistochemical markers are required to confirm that there is no regional variation in the human hindgut ENS.

Trans Arterial Embolization of Spontaneous Intra-Abdominal Haemorrhage from Omental Lipoma.

We describe 3 cases of omental lipoma of whom 2 presented with symptomatic haemorrhage. Notably the haemorrhage in the 2 reported cases was from foregut arteries. Thorough knowledge of anatomy and embryology is critical in identifying the source of haemorrhage and differentiating this condition from other common causes of mesenteric haemorrhage. To the best of our knowledge, this is the first case series reporting this uncommon cause for abdominal haemorrhage. The successful management of this condition using superselective embolization is discussed. Clinicians need to exercise diligence and caution in omental lipomas presenting with spontaneous haemorrhage and this notion is exemplified in our reported cases.

Application of immersed MF (IMF) followed by reverse osmosis (RO) membrane for wastewater reclamation: A case study in Malaysia.

A pilot scale membrane plant was constructed and monitored in Shah Alam, Malaysia for municipal wastewater reclamation for industrial application purposes. The aim of this study was to verify its suitability under the local conditions and environmental constraints for secondary wastewater reclamation. Immersed-type crossflow microfiltration (IMF) was selected as the pretreatment step before reverse osmosis filtration. Secondary wastewater after chlorine contact tank was selected as feed water. The results indicated that the membrane system is capable of producing a filtrate meeting the requirements of both WHO drinking water standards and Malaysian Effluent Standard A. With the application of an automatic backwash process, IMF performed well in hydraulic performance with low fouling rate being achieved. The investigations showed also that chemical cleaning is still needed because of some irreversible fouling by microorganisms always remains. RO treatment with IMF pretreatment process was significantly applicable for wastewater reuse purposes and promised good hydraulic performance.

Electrocardiographical case. A case of wide complex tachycardia.

A 43-year-old Chinese woman complained of a one week history of irregular rapid palpitations associated with chest discomfort and dyspnoea. Her heart rate was more than 160 beats per minute and blood pressure was 154/95 mmHg. 12-lead electrocardiogram (ECG) showed a wide complex tachycardia with a slightly irregular rhythm. Delta waves were also present. She was treated appropriately with intravenous procainamide but developed torsades de pointes secondary to prolonged QT interval. Electrophysiology study revealed atrial tachycardia with a left-sided accessory pathway which was successfully ablated.