An evaluation of a novel bowel preparation regimen and its effect on the utility of colon capsule endoscopy: a prospective cohort study with historical controls.

BACKGROUND: The aim of this study was to evaluate the efficacy of a novel bowel preparation and booster regimen for colon capsule endoscopy (CCE) using macrogol, phospho-soda and gastrografin, compared with a control regimen consisting of polyethylene glycol and sodium picosulfate. METHODS: This was a prospective cohort study using historical controls. Symptomatic patients undergoing CCE between 11/07/2021 and 21/12/2021 using the novel regimen were included. Symptomatic patients who underwent CCE in the ScotCap evaluation using the control regimen were used as historical controls. We measured the rate of complete test (visualisation of the whole colon and rectum), adequate bowel preparation, successful test (complete and adequate bowel preparation) and need for further test following CCE. The rate of adverse events was also collected. RESULTS: Patients undergoing CCE using the new and control regimen were 200 and 316, respectively. The median age, age range and proportion of female patients in the new and control regimen cohorts was 61 vs 60 years, 16-86 vs 20-83 years, and 60.5% vs 56.6%. The rate of complete test, adequate bowel reparation and successful test for the new and control regimen was 69% vs 72.2%, 86.6% vs 80.7% and 60.5% vs 65.8%. Comparing the new and control regimen, 39.5% vs 37.3% of patients required no test following CCE, 26% vs 32.6% required a colonoscopy, 31.5% vs 21.5% required a flexible sigmoidoscopy and 3% vs 2.9% required a computed tomography colonogram. No adverse events were reported using the new regimen compared to 2 (0.6%) in the control group. CONCLUSIONS: The rate of adequate bowel preparation has improved following the introduction of a new regimen. However, further work is needed to increase the complete test rate. A significant proportion of patients continue to avoid colonoscopy following CCE.

A colorectal cancer missed by colon capsule endoscopy: a case report.

BACKGROUND: Colon capsule endoscopy (CCE) is a non-invasive alternative to colonoscopy. The reported sensitivity and specificity of CCE for the detection of clinically significant colonic neoplasia is high. To date, there have been no reported cases of colorectal cancer (CRC) missed by CCE which were located in segments adequately visualised by the capsule. CASE PRESENTATION: We present the case of a 71-year-old female, who underwent CCE for new lower gastrointestinal symptoms. The CCE reported 17 polyps (largest size 10 mm) and angiodysplasia. A 40 mm caecal pole tumour, not detected by the CCE, was identified at follow up colonoscopy. Surgical resection was performed, and the pathology sample was reported as moderately differentiated adenocarcinoma, pT2 pN0 (0/19) M0, with no evidence of EMVI. The patient made an uneventful recovery. The caecal pole tumour was not definitively identified on retrospective review of the CCE images. CONCLUSION: To date, this is the first published case of a CRC missed entirely by CCE. Further research is required to allow calculation of the post CCE interval CRC rate to allow comparison with colonoscopy and CT colonogram.

Video consultation for new colorectal patients.

AIM: For patients, an outpatient review can lead to a stressful journey to hospital with the resultant risks associated with breaching social distancing. Despite this, video consultations (VCs) have not been frequently used in colorectal practice. We assessed outcomes, including the economic and environmental impact, of a VC clinic for new colorectal referrals. METHOD: This was a prospective observational study. Fifty consecutive patients attending a VC colorectal appointment were reviewed between March 2019 and February 2020. Face-to-face appointments during the same time period were also assessed. The distance, time, cost and carbon emissions of journeys were estimated using web-based resources. Estimated loss of earnings used data from the Office for National Statistics. The subsequent management plans were also recorded. RESULTS: Of 50 patients using VC, 40 used home devices and 10 used equipment in their local medical facility. Three patients had difficulties with the technology and converted to telephone review. Failure to attend VC appointments was less than for face-to-face appointments (4% vs 6.1%). VC appointments saved 6685 miles of travel (range 2-364 miles), 148 h travelling time and £1767 costs. Additional savings for loss of earnings were approximately £33.56 per patient. The carbon emissions saved was 4659 lb CO2 equivalent, corresponding to over 250 000 charges of a smartphone. CONCLUSION: The use of VC resulted in significant savings related to travel and reduced time and costs for patients who chose to use the service, in addition to the environmental benefits. In this current climate VC clinics have a central role in outpatient care for both new patients and follow-ups.

Exploring shared surgical decision-making from the patient's perspective: is the personality of the surgeon important?

AIM: The aim was to determine the importance of a colorectal surgeon's personality to patients and its influence on their decision-making. METHODS: We present a two-part mixed methods study using the Guidance for Reporting Involvement of Patients and the Public (GRIPP-2) long form. Part 1 was an online survey (25 questions) and Part 2 a face-to-face patient and public involvement exercise. Part 1 included patient demographics, details of surgery, overall patient satisfaction (net promoter score) and patient views on surgeon personality (Gosling 10 Item Personality Index). The thematic analysis of free-text responses generated four themes that were taken forward to Part 2. These themes were used to structure focus group discussions on surgeon-patient interactions. RESULTS: Part 1 yielded 296 responses: 72% women, 75.3% UK-based and 55.1% aged 40-59 years. Inflammatory bowel disease (45.3%) and cancer (40.2%) were the main indications. 84.1% of respondents reported satisfaction with their surgical experience (net promoter score). Four key themes were generated from Part 1 and validated in Part 2: (i) surgeon personality stereotypes (media differed from patients' perspective); (ii) favourable and unfavourable surgical personality traits (openness, conscientiousness, emotional stability preferred over risk-taking and narcissism); (iii) patient-surgeon interaction (mutual respect and rapport valued); (iv) impact of surgeon personality on decision-making (majority unaware of second opinion option; management of postoperative complications). CONCLUSION: Patients believe surgeon personality influences shared decision-making. Low levels of emotional stability and conscientiousness are perceived by patients to increase the likelihood of postoperative adverse events. Further work is required to explore the potential influence of surgeon personality on shared decision-making and postoperative outcomes.

Limited preoperative physical capacity continues to be associated with poor postoperative outcomes within a colorectal ERAS programme.

AIM: Enhanced recovery after surgery (ERAS) programmes aim to standardise perioperative care leading to optimal patient outcomes. Despite these programmes, variation in outcomes still persists. This study aimed to assess the influence of lifestyle factors on short-term outcomes after colorectal surgery within this optimal recovery programme. METHODS: Consecutive patients enrolled on an ERAS pathway who underwent elective colorectal surgery (June 2013 to July 2014) at one site were included. We used data routinely collected by ERAS nurse specialists and during preassessment to analyse association between patient and lifestyle factors and likelihood of developing postoperative complications or having an increased length of stay. RESULTS: A total of 199 patients were included: mean age 61.8 years (range 17-90 years) and 53.8% male. Age, sex, deprivation, smoking status, alcohol intake, body mass index or level of comorbidity were not associated with postoperative complications. Patients reporting limited preoperative physical capacity (unable to climb two flights of stairs) were more than four times as likely to have a postoperative complication on univariate analysis and were found to still have increased risk of postoperative complications on multivariate analysis. Patients reporting limited preoperative physical capacity were shown to have significantly longer hospital stay on univariate analysis. In the multivariate analysis, limited physical capacity was not associated with prolonged length of stay due to confounding factors of age and deprivation. CONCLUSIONS: Limited physical capacity was the only patient and lifestyle factor associated with poorer postoperative complications and prolonged hospital stay after elective colorectal surgery within an ERAS programme. Consideration should be given to individualised prehabilitation that aims to increase physical capacity pre-operatively to improve patient outcomes.

Contribution of surgical specialization to improved colorectal cancer survival.

BACKGROUND: Reorganization of colorectal cancer services has led to surgery being increasingly, but not exclusively, delivered by specialist surgeons. Outcomes from colorectal cancer surgery have improved, but the exact determinants remain unclear. This study explored the determinants of outcome after colorectal cancer surgery over time. METHODS: Postoperative mortality (within 30 days of surgery) and 5-year relative survival rates for patients in the West of Scotland undergoing surgery for colorectal cancer between 1991 and 1994 were compared with rates for those having surgery between 2001 and 2004. RESULTS: The 1823 patients who had surgery in 2001-2004 were more likely to have had stage I or III tumours, and to have undergone surgery with curative intent than the 1715 patients operated on in 1991-1994. The proportion of patients presenting electively who received surgery by a specialist surgeon increased over time (from 14·9 to 72·8 per cent; P < 0·001). Postoperative mortality increased among patients treated by non-specialists over time (from 7·4 to 10·3 per cent; P = 0·026). Non-specialist surgery was associated with an increased risk of postoperative death (adjusted odds ratio 1·72, 95 per cent confidence interval (c.i.) 1·17 to 2·55; P = 0·006) compared with specialist surgery. The 5-year relative survival rate increased over time and was higher among those treated by specialist compared with non-specialist surgeons (62·1 versus 53·0 per cent; P < 0·001). Compared with the earlier period, the adjusted relative excess risk ratio for the later period was 0·69 (95 per cent c.i. 0·61 to 0·79; P < 0·001). Increased surgical specialization accounted for 18·9 per cent of the observed survival improvement. CONCLUSION: Increased surgical specialization contributed significantly to the observed improvement in longer-term survival following colorectal cancer surgery.

The impact of socio-economic circumstances on overall and grade-specific prostate cancer incidence: a population-based study.

BACKGROUND: If the observed increasing incidence of prostate cancer and higher incidence in more affluent men are due to differences in diagnostic sensitivity, an excess of asymptomatic low-grade tumours might be expected. METHODS: We conducted a descriptive population-based study of incident cases of prostate cancer (International Classification of Diseases version 10 codes for prostate cancer) in the West of Scotland, using the Scottish Cancer Registry data from 1991 to 2007. Socio-economic circumstances were measured using the Carstairs score, and disease grade measured using the Gleason score. Deprivation-specific European age-standardised incidence rates were calculated, and joinpoint regression analysis were used to identify significant changes in trends over time. RESULTS: A total of 15 519 incident cases of prostate cancer were diagnosed. Incidence increased by 70% from 44 to 75 per 100 000 cases between 1991 and 2007, an average annual growth of 3.6%. Men aged <65 years experienced the largest increase in incidence. A widening socio-economic deprivation gap in incidence appeared from 1998 onwards in low-grade disease only. From 2003 to 2007, the deprivation gap (affluent to deprived) was 40.3 per 100 000 cases (P<0.001; trend), with rates 37% lower among the most deprived compared with the most affluent. This deprivation gap represents an estimated 1764 cases of prostate cancer over a 5-year period. CONCLUSION: Prostate cancer incidence continues to increase; an increase in low-grade disease in affluent men may suggest that prostate-specific antigen testing is responsible, but it does not explain the overall increases in all grades of disease.

The changing association between socioeconomic circumstances and the incidence of colorectal cancer: a population-based study.

BACKGROUND: There is emerging evidence to suggest that the association between socioeconomic circumstances and colorectal cancer incidence has changed over recent decades. METHODS: We conducted a descriptive population-based study to describe the relationship between socioeconomic circumstances and the incidence of colorectal cancer in a pre-screened population. Incident cases of colorectal cancer from the West of Scotland were identified from the Scottish Cancer Registry and European age-standardised incidence rates (EASR) were calculated. Socioeconomic circumstances were measured using the area-based Scottish Index of Multiple Deprivation (SIMD). RESULTS: In total, 14,051 incident cases of colorectal cancer were recorded from 1999 to 2007. Incidence of colorectal cancer was associated with increased deprivation in men but not among women; an association that became evident from 2005 onwards. From 2005 to 2007, the deprivation gap in incidence among men was 13.3 per 100,000 (95% confidence interval 3.2-23.4), with rates 19.5% lower among the least deprived compared with the most deprived. This deprivation gap now accounts for an estimated 75 excess cases per year of male colorectal cancer in the West of Scotland. CONCLUSION: Deprivation was associated with higher incidence rates of male, but not female, colorectal cancer before the implementation of a national bowel screening programme.

Bilateral temporomandibular joint dislocation following pulmonary function testing: a case report and review of closed reduction techniques.

Temporomandibular joint dislocation is not a common presentation to the emergency department but it is one that requires prompt diagnosis and reduction. This is thought to be the first reported case of spontaneous bilateral temporomandibular joint dislocation after routine pulmonary function testing. The management of the case is discussed and a review of closed reduction techniques commonly used in the emergency department is presented.

Bilateral temporomandibular joint dislocation following pulmonary function testing: a case report and review of closed reduction techniques.

Temporomandibular joint (TMJ) dislocation is not a common presentation to the emergency department (ED) but one that requires prompt diagnosis and reduction. This is the first reported case of spontaneous bilateral TMJ dislocation after routine pulmonary function testing. The management of the case is discussed and a review of closed reduction techniques commonly used in the ED is presented.

Evaluacion del estado estructural de cañerias de grandes diametros

A pesar de la importancia de las cañerias maestras de grandes diametros, la ingenieria les niega el mantenimiento periodico movida por la hipotesis de que si no se rompe, su reparacion no es necesaria. Por muy enfatica que sea tal aseveracion, el riesgo de rotura que implica la hace inaplicable para las cañerias maestras. Los procesos de privatizacion de servicios en todo el mundo requieren informacion sobre las cañerias maestras para estimar inversiones de capital que permitan al concesionario estructurar su oferta comercial. Ademas, muchos sistemas nuevos pueden sufrir problemas de corrosion significativos en el corto plazo

Evaluacion del estado estructural de cañerias de grandes diametros

A pesar de la importancia de las cañerias maestras de grandes diametros, la ingenieria les niega el mantenimiento periodico movida por la hipotesis de que si no se rompe, su reparacion no es necesaria. Por muy enfatica que sea tal aseveracion, el riesgo de rotura que implica la hace inaplicable para las cañerias maestras. Los procesos de privatizacion de servicios en todo el mundo requieren informacion sobre las cañerias maestras para estimar inversiones de capital que permitan al concesionario estructurar su oferta comercial. Ademas, muchos sistemas nuevos pueden sufrir problemas de corrosion significativos en el corto plazo

An immunologic and genetic study of asthma in workers in an aluminum smelter.

The cause or causes of asthma among employees in aluminum smelters is unknown. We attempted to ascertain whether such workers who developed asthma differed in respect to indices of immunological function and certain genetic markers. Data were collected from 33 asthmatic and 127 nonasthmatic potroom workers. Asthmatic workers had significantly lower mean serum levels of immunoglobulin (Ig)M; however, mean levels of IgG and IgA, median levels of IgE, the capacity for recall of delayed type hypersensitivity, levels of immune complexes, and frequency of antinuclear or other autoantibodies did not differ from values for nonasthmatic workers. Asthma was found to develop on a background of atopy in 21 workers (64%), whereas there were no features of atopy in 12 workers (36%). Cigarette smoking had independent effects on immunological function. In respect to genetic markers, there was a higher frequency among asthmatic workers of the alpha-1-anti-trypsin deficiency phenotype MS, but the frequency of blood groups, Gm allotypes, or human leucocyte antigen types was similar. The study established that the profile of immune function, or genetic markers tested, did not differ essentially for workers in an aluminum smelter who did or did not develop asthma; however, there was an indication of heterogeneity in causation, as judged by "atopy-related" and "non-atopy-related" groups in the asthma population.

Fatty acid pattern outcomes of a nutritional program for overweight and hyperlipidemic Australian men.

There is growing recognition of the value of changing tissue fatty acid patterns in their own right as coronary risk factors. To examine the effects of a conventional nutritional program on plasma triglyceride (TG), cholesterol ester, and phospholipid fatty acid patterns, a group of 20 hyperlipidemic men and a control group (n = 6) of normolipidemic men were followed for 6 months. As an index of change in energy balance in the hyperlipidemic men, body mass index decreased from 26.5 to 24.4 kg m-2 (an 8% decrease) at 6 months. Saturated fat intake fell from 46.7 to 25.3 g/day (a 46% decrease). Dietary polyunsaturated:saturated fat ratio (P:S) rose from 0.38 and to 0.70 (an 84% increase) at the 6-month review. Ethanol intake fell from 18 to 15 g/day (a 17% decrease). Changes in plasma fatty acid (FA) patterns were found in TG, cholesterol ester, and phospholipid fractions at the 6-week to 3-month period, and these changes were maintained at 6 months. Of the factors possibly contributory to plasma FA pattern change in these men, dietary FA intake underwent the greatest percentage shift and therefore probably makes an important contribution to the change. It was of interest that fatty acid patterns in plasma neutral lipids (triglyceride, cholesterol ester, and phospholipid) significantly predicted body mass index and serum total cholesterol, triglyceride, and high-density-lipoprotein cholesterol.

Assessment of delayed-type hypersensitivity in man: a comparison of the "Multitest" and conventional intradermal injection of six antigens.

Recall of delayed type hypersensitivity (DTH) as a test for cell-mediated immune competence was assessed in 254 subjects using the Multitest device which delivers seven skin-test antigens intradermally; 77 subjects were tested concurrently by Multitest and a conventional panel of six antigens. Similar results were obtained with Multitest and the conventional panel (R = 0.65). Reproducibility of Multitest between three observers, who independently assessed the aggregate size of reactions (the reaction score) in 45 subjects, was high (R = 0.89). Twenty-four subjects were tested twice 3 months apart; the correlation for the reaction score was high (R = 0.88), demonstrating the suitability of Multitest for serial studies of immune function. Anergy was infrequent (1%) among 110 healthy male controls but was more frequent (8%) among a group of 101 healthy male homosexuals (P less than 0.05). The response rate to particular test antigens differed for the three Australian groups tested and a previously studied French group. Hence there is a need to establish normal profiles of DTH responsiveness for different geographic areas, as well as among subjects of known age and sex, when assessing cell-mediated immunity by the level of DTH responsiveness to multiple skin test antigens.