Life with a stoma across five European countries-a cross-sectional study on long-term rectal cancer survivors.

PURPOSE: Stoma-related problems are known to be important to patients and potentially affect everyday life. The prevalence of stoma-related problems in rectal cancer survivors remains undetermined. This study aimed to examine aspects of life with a long-term stoma, stoma management, and stoma-related problems and explore the impact of stoma-related problems on daily life. METHODS: In total, 2262 patients from 5 European countries completed a multidimensional survey. Stoma-related problems were assessed using the Colostomy Impact score. Multivariable regression analysis, after adjusting for potential confounding factors, provided odds ratio (OR) and 95% confidence intervals (CI) for stoma-related problems' association with restrictions in daily life. RESULTS: The 2262 rectal cancer survivors completed the questionnaire at a median of 5.4 years (interquartile range 3.8-7.6) after stoma formation. In the total sample, leakage (58%) and troublesome odour (55%) were most prevalent followed by skin problems (27%) and pain (21%). Stoma-related problems were more prevalent in patients with parastomal bulging. A total of 431 (19%) reported feeling restricted in daily activities in life with a stoma. Leakage, odour, skin problems, stool consistency, and frequent appliance changes were significantly associated with restrictions in daily life. The highest risk of experiencing restrictions was seen for patients having odour (OR 2.74 [95% CI: 1.99-3.78]) more than once a week and skin problems (OR 1.77 [95% CI: 1.38-2.27]). CONCLUSION: In this large cohort with rectal cancer, stoma-related problems were highly prevalent and impacted daily life. Supportive care strategies should entail outreach to patients with a long-term stoma.

Translation and international validation of the Colostomy Impact score.

AIM: Optimal oncological resection in cancers of the lower rectum often requires a permanent colostomy. However, in some patients a colostomy may have a negative impact on health-related quality of life (HRQoL). The Colostomy Impact (CI) score is a simple questionnaire that identifies patients with stoma dysfunction that impairs HRQoL by dividing patients into 'minor' and 'major' CI groups. This aim of this study is to evaluate construct and discriminative validity, sensitivity, specificity and reliability of the CI score internationally, making it applicable for screening and identification of patients with stoma-related impaired HRQoL. METHOD: The CI score was translated in agreement with WHO recommendations. Cross-sectional cohorts of rectal cancer survivors with a colostomy in Australia, China, Denmark, the Netherlands, Portugal, Spain and Sweden were asked to complete the CI score, the European Organization for Research and Treatment of Cancer (EORTC) quality of life 30-item core questionnaire, the stoma-specific items of the EORTC quality of life 29-item colorectal-specific questionnaire and five anchor questions assessing the impact of colostomy on HRQoL. RESULTS: A total of 2470 patients participated (response rate 51%-93%). CI scores were significantly higher in patients reporting reduced HRQoL due to their colostomy than in patients reporting no reduction. Differences in EORTC scale scores between patients with minor and major CI were significant and clinically relevant. Sensitivity was high regarding dissatisfaction with a colostomy. Regarding evaluation of discriminative validity, the CI score relevantly identified groups with differences in HRQoL. The CI score proved reliable, with equal CI scores between test and retest and an intraclass correlation coefficient in the moderate to excellent range. CONCLUSION: The CI score is internationally valid and reliable. We encourage its use in clinical practice to identify patients with stoma dysfunction who require further attention.

Systematic review of the impact of demographic and socioeconomic factors on quality of life in ostomized colorectal cancer survivors.

Background: Formation of a fecal stoma may be necessary to ensure radical resection in colorectal cancer (CRC) patients but will substantially impact the health-related quality of life (HRQoL) in about 20% of cases. Little is known about patient-related risk factors for reduced HRQoL in patients with a permanent stoma. We, therefore, reviewed the current literature on how demographic and socioeconomic factors affect HRQoL in CRC survivors with a stoma. Material and methods: The databases Pubmed, Embase, CINAHL, and PsycINFO were systematically searched. Two independent reviewers extracted and quality-assessed eligible publications. Studies assessing HRQoL using a validated questionnaire at least 6 months after surgery for CRC were included if data on the impact of demographic and/or socioeconomic, factors on HRQoL were analyzed and presented. Results: Eligible studies predominantly presented small cross-sectional cohorts. Age showed equivocal results; hence, some studies found younger patients had inferior HRQoL compared with older patients, and others found no difference. Subdivision into age groups differed widely. Several studies found that both generic and stoma-specific HRQoL was lower in females compared with males. Most studies found that socioeconomic factors did not affect HRQoL while one study found lower education correlated to reduced HRQoL. Categorization of these factors also varied widely. Conclusions: This is to our knowledge the first systematic review on the impact of patient-related factors on HRQoL in long-term CRC survivors. We found that a stoma had more impact in younger ostomates than older and that HRQoL in females was reduced more than in males. Conclusions regarding other factors were difficult due to few studies and contradictory results. Further research in this subject is much needed in order to target preventive measures when planning surgery in patients in high risk of reduced HRQoL.

The Rectal Cancer Female Sexuality Score: Development and Validation of a Scoring System for Female Sexual Function After Rectal Cancer Surgery.

BACKGROUND: Sexual dysfunction and impaired quality of life is a potential side effect to rectal cancer treatment. OBJECTIVE: The objective of this study was to develop and validate a simple scoring system intended to evaluate sexual function in women treated for rectal cancer. DESIGN: This is a population-based cross-sectional study. SETTINGS: Female patients diagnosed with rectal cancer between 2001 and 2014 were identified by using the Danish Colorectal Cancer Group's database. Participants filled in the validated Sexual Function Vaginal Changes questionnaire. Women declared to be sexually active at follow-up were randomly assigned to 2 groups: one for development and one for validation. Logistic regression analyses identified items for the score, and multivariate analysis established a weighted-score value allocated to each item, adding up to the total score. The validity of the score was tested in the validation group. PATIENTS: Female patients with rectal cancer above the age of 18 who underwent abdominoperineal resection, Hartmann procedure, or total/partial mesorectal excision were selected. MAIN OUTCOME MEASURES: The primary outcome measured was the quality of life that was negatively affected because of sexual problems. RESULTS: A total of 466 sexually active women responded. The score includes 7 items with a range of 0 to 29 points. Score ≥9 indicates sexual dysfunction. The score has a sensitivity/specificity of 76%/75% detecting patients bothered by sexual dysfunction with a negative impact on quality of life. LIMITATIONS: This study was limited by the large amount of nonresponders. CONCLUSIONS: Living up to our demands for a short and easy-to-use validated tool, we have developed the Rectal Cancer Female Sexuality score. It captures, with high sensitivity, the essential problems of female sexuality seen from the perspective of a surviving rectal cancer patient. See Video Abstract at http://links.lww.com/DCR/A576.

Surviving rectal cancer at the cost of a colostomy: global survey of long-term health-related quality of life in 10 countries.

BACKGROUND: Colorectal cancer management may require an ostomy formation; however, a stoma may negatively impact health-related quality of life (HRQoL). This study aimed to compare generic and stoma-specific HRQoL in patients with a permanent colostomy after rectal cancer across different countries. METHOD: A cross-sectional cohorts of patients with a colostomy after rectal cancer in Denmark, Sweden, Spain, the Netherlands, China, Portugal, Australia, Lithuania, Egypt, and Israel were invited to complete questionnaires regarding demographic and socioeconomic factors along with the Colostomy Impact (CI) score, European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and five anchor questions assessing colostomy impact on HRQoL. The background characteristics of the cohorts from each country were compared and generic HRQoL was measured with the EORTC QLQ-C30 presented for the total cohort. Results were compared with normative data of reference European populations. The predictors of reduced HRQoL were investigated by multivariable logistic regression, including demographic and socioeconomic factors and stoma-related problems. RESULTS: A total of 2557 patients were included. Response rates varied between 51-93 per cent. Mean time from stoma creation was 2.5-6.2 (range 1.1-39.2) years. A total of 25.8 per cent of patients reported that their colostomy impairs their HRQoL 'some'/'a lot'. This group had significantly unfavourable scores across all EORTC subscales compared with patients reporting 'no'/'a little' impaired HRQoL. Generic HRQoL differed significantly between countries, but resembled the HRQoL of reference populations. Multivariable logistic regression showed that stoma dysfunction, including high CI score (OR 3.32), financial burden from the stoma (OR 1.98), unemployment (OR 2.74), being single/widowed (OR 1.35) and young age (OR 1.01 per year) predicted reduced stoma-related HRQoL. CONCLUSION: Overall HRQoL is preserved in patients with a colostomy after rectal cancer, but a quarter of the patients interviewed reported impaired HRQoL. Differences among several countries were reported and socioeconomic factors correlated with reduced quality of life.

PAPP-A, IGFBP-4 and IGF-II are secreted by human adipose tissue cultures in a depot-specific manner.

OBJECTIVE: Adipose tissue secretes pregnancy-associated plasma protein-A (PAPP-A), which may increase local IGF action through cleavage of IGF-binding protein-4 (IGFBP-4). We tested whether this mechanism was operational in human visceral and subcutaneous adipose tissue (i.e. VAT and SAT). DESIGN: Explants of VAT and SAT from 26 obese subjects (hereof 17 women, BMI 39.5 (37.2; 42.8) kg/m2 (median (25%; 75% confidence interval) and SAT from eight lean, age-matched women (BMI 23.6 (22.4; 24.9) kg/m2) were incubated with or without GH (100 µg/L) and the media were harvested. METHODS: Media were assessed for concentrations of PAPP-A, intact and PAPP-A-cleaved IGFBP-4, IGF-I and IGF-II, and IGF-I receptor (IGF-IR) activation by bioassay. RESULTS: In obese subjects, VAT media contained higher concentrations than SAT of PAPP-A (4.4-fold) and both PAPP-A-generated IGFBP-4 fragments (C-terminal: 3.3-fold, N-terminal: 1.5-fold) (all P < 0.0005). Intact IGFBP-4 levels were similar in SAT and VAT. VAT media contained elevated IGF-II (1.4-fold; P < 0.005), but similar IGF-I concentrations compared with SAT. Still, VAT media contained a 1.8-fold increased ability to stimulate the IGF-IR (P < 0.005). IGF-I protein concentration and IGF-IR activation increased more in VAT media than SAT media following GH stimulation (both P < 0.05). At baseline, SAT media protein levels from lean and obese women were similar, with the exception of PAPP-A being 1.8-fold elevated in VAT media (P < 0.05). GH induced a similar increase in IGF-I media levels in SAT from obese and lean women. CONCLUSION: Human adipose tissue cultures secrete enzymatically active PAPP-A, IGFBP-4 and IGF-II in a depot-specific manner, suggesting differential regulation of IGF activity. Further, IGF-II appears to be more prominent than IGF-I. Finally, VAT appears more GH responsive than SAT.

[Addison's disease causing acute abdomen]. / Mb. Addisonii som årsag til akut abdomen.

A 15 year-old girl with three days of upper abdominal pain was admitted to hospital. Vital parametres were within normal limits. Blood samples and abdominal computed tomography were normal. As pain increased diagnostic laparoscopy was performed and mesenteriel lymphadenitis was found. Thorough examinations were performed including laparotomy. A synachtentest showed an insufficient level of cortisol. The patient was diagnosed with Addison's disease and responded well to treatment with cortisone. Symptoms of adrenal insufficiency can be vague, and it is important to keep the diagnosis in mind in patients with unexplained abdominal pain.