Screening and treating pre-operative anaemia and suboptimal iron stores in elective colorectal surgery: a cost effectiveness analysis.

Our study investigated whether pre-operative screening and treatment for anaemia and suboptimal iron stores in a patient blood management clinic is cost effective. We used outcome data from a retrospective cohort study comparing colorectal surgery patients admitted pre- and post-implementation of a pre-operative screening programme. We applied propensity score weighting techniques with multivariable regression models to adjust for differences in baseline characteristics between groups. Episode-level hospitalisation costs were sourced from the health service clinical costing data system; the economic evaluation was conducted from a Western Australia Health System perspective. The primary outcome measure was the incremental cost per unit of red cell transfusion avoided. We compared 441 patients screened in the pre-operative anaemia programme with 239 patients not screened; of the patients screened, 180 (40.8%) received intravenous iron for anaemia and suboptimal iron stores. The estimated mean cost of screening and treating pre-operative anaemia was AU$332 (£183; US$231; €204) per screened patient. In the propensity score weighted analysis, screened patients were transfused 52% less red cell units when compared with those not screened (rate ratio = 0.48, 95%CI 0.36-0.63, p < 0.001). The mean difference in total screening, treatment and hospitalisation cost between groups was AU$3776 lower in the group screened (£2080; US$2629; €2325) (95%CI AU$1604-5947, p < 0.001). Screening elective patients pre-operatively for anaemia and suboptimal iron stores reduced the number of red cell units transfused. It also resulted in lower total costs than not screening patients, thus demonstrating cost effectiveness.

The efficacy of selective arterial embolization in the management of colonic bleeding.

BACKGROUND: The aim of the present study was to determine the efficacy of mesenteric embolization in the management of acute haemorrhage from the colon. METHODS: A retrospective review was performed of a consecutive series of patients who underwent selective arterial embolization between 2002 and 2010 at two Australian institutions. An analysis was performed of each patient's present and past medical history, procedural details and subsequent post-procedural recovery. RESULTS: Seventy-one patients were reviewed in the study. Sixty-one patients (86 %) had immediate cessation of bleeding following embolization. In total, 20 % had some form of morbidity due to mesenteric embolization being performed, the three most common being worsening renal function, groin haematoma and contrast allergy (11, 9 and 7 %, respectively). Only one patient developed superficial bowel ischaemia. Overall, 11 patients (18 %) had recurrent bleeding. Of these patients, five had repeat embolization. Of the patients who underwent re-embolization, three stopped bleeding. Surgery was required in 5 patients 2 of whom died postoperatively of systemic complications. CONCLUSIONS: Colonic bleeding can be treated successfully in most patients by embolization, without causing ischaemia. Eighteen per cent of patients rebleed during the first hospital admission, and 20 % patients experienced a procedure-related complication. In those patients that proceed to surgery, the morbidity, mortality and length of hospital stay increase dramatically.

Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded?

BACKGROUND: It is routine practice to perform colonoscopy as a follow-up after an attack of diverticulitis, with the main aim to exclude any underlying malignancy. PURPOSE: This study aimed to determine whether colonoscopy is necessary and what additional information is gained from this procedure. DESIGN: This is a study of a retrospective cohort. SETTINGS AND PATIENTS: From January 2003 to June 2009, patients in whom left-sided diverticulitis was diagnosed on CT scan were matched with colonoscopy reports within 1 year from the date of CT by the use of radiology and endoscopy databases. Patients who had colonoscopy within 1 year before the CT scan were excluded. The Western Australian Cancer Registry was cross-referenced to identify patients who subsequently received diagnoses of cancers for whom colonoscopy reports were unavailable. MAIN OUTCOME MEASURES: The main outcome measures were the number of patients in whom colorectal cancers were diagnosed and other incidental findings, eg, polyps, colitis, and stricture. RESULTS: Left-sided diverticulitis was diagnosed in 1088 patients on CT scan, whereas follow-up colonoscopy reports were available for 319 patients. Eighty-two (26%) patients had incidental findings of polyps (9 polyps >1 cm), and 9 patients (2.8%) received diagnoses of colorectal cancers on colonoscopy. After cross-referencing with the cancer registry, the overall prevalence of colorectal cancer among the cohort within 1 year of CT scan was 2.1% (23 cases). The odds of a diagnosis of colorectal cancer were 6.7 times (95% CI 2.4-18.7) in patients with an abscess reported on CT, 4 times (95% CI 1.1-14.9) in patients with local perforation, and 18 times (95% CI 5.1-63.7) in patients with fistula compared with patients with uncomplicated diverticulitis. LIMITATIONS: This study was limited by the unavailability of data for private/interstate hospitals, and the relatively small number of cancer cases reduced the statistical power of the study. CONCLUSIONS: We recommend routine colonoscopy after an attack of presumed left-sided diverticulitis in patients who have not had recent colonic luminal evaluation. The rate of occult carcinoma is substantial in this patient population, in particular, when abscess, local perforation, and fistula are observed.

Saving the sphincter in rectal cancer: are we prepared to change practice?

Total mesorectal excision and preoperative radiation with or without chemotherapy has led to a reduction in local recurrence rates in patients with rectal cancer. This article examines the effect such treatment has on the rate of sphincter preservation in patients with rectal cancers close to the anal sphincter mechanism and looks at the evidence for changing clinical practice.

A randomised, double blind, placebo controlled study of celecoxib, a selective cyclooxygenase 2 inhibitor, on duodenal polyposis in familial adenomatous polyposis.

BACKGROUND: Non-selective cyclooxygenase (COX) inhibitors (non-steroidal anti-inflammatory drugs) inhibit large bowel carcinogenesis in patients with familial adenomatous polyposis (FAP). Their role in the duodenum of these patients is less certain. The disease modifying activity of specific COX-2 inhibitors has not been explored in humans. PATIENTS AND METHODS: This was a randomised, double blind, placebo controlled study of celecoxib (100 mg twice daily (n=34) or 400 mg twice daily (n=32)) versus placebo (n=17), given orally twice daily for six months to patients with FAP. Efficacy was assessed qualitatively by blinded review of shuffled endoscopy videotapes comparing the extent of duodenal polyposis at entry and at six months and quantitatively by measurement of the percentage change in duodenal area covered by discrete and plaque-like adenomas from photographs of high and low density polyposis. RESULTS: Shuffled and blinded video review showed a statistically significant effect of 400 mg twice daily celecoxib compared with placebo treatment (p=0.033) with all five independent observers scoring a beneficial effect. Overall, patients taking celecoxib 400 mg twice daily showed a 14.5% reduction in involved areas compared with a 1.4% for placebo (p=0.436). However, patients with clinically significant disease at baseline (greater than 5% covered by polyps) showed a 31% reduction in involved areas with celecoxib 400 mg twice daily compared with 8% on placebo (p=0.049). CONCLUSIONS: A panel of five endoscopists found a significant reduction in duodenal polyposis after six months of treatment with celecoxib 400 mg twice daily. COX-2 inhibition may help this otherwise untreatable condition.

Randomized, placebo-controlled trial of gastric acid-lowering therapy on duodenal polyposis and relative adduct labeling in familial adenomatous polyposis.

PURPOSE: Bile has been implicated in the pathogenesis of duodenal polyps in patients with familial adenomatous polyposis. In vitro experiments have shown that familial adenomatous polyposis bile is capable of producing DNA adducts. This effect can be ameliorated by increasing the pH of the incubate. The aim of this double-blind randomized placebo-controlled trial was to examine the effect of oral ranitidine on duodenal polyposis in a group of patients with familial adenomatous polyposis. METHODS: Twenty-six patients with familial adenomatous polyposis were randomly assigned to ranitidine 300 mg daily or placebo for six months after baseline endoscopy. Polyp counts were performed and biopsy specimens taken to detect DNA adducts by 32P-postlabeling. RESULTS: No difference was seen in polyp numbers (P = 0.9) or relative adduct labeling (P = 0.7) after treatment with ranitidine or placebo. DISCUSSION: Acid suppression therapy does not seem to improve duodenal polyposis despite in vitro findings. On the other hand, ranitidine does not exacerbate actual (or markers of) neoplasia in this highly tumor-prone condition.

A low-fat diet but not food restriction improves lactational performance in obese rats.

Rats fed a high-fat diet before and during lactation have difficulty initiating lactation and have high pup mortality rates, low milk production and, consequently, poor pup growth. To determine if these adverse outcomes can be mitigated with dietary changes made after delivery, obese Sprague-Dawley rats (who had previously been fed a high-fat diet [AIN-93M, modified to contain 35% fat, w/w]) were assigned at parturition to continue to be fed this diet (HF) or switched to free access to a corresponding low-fat (LF) diet (AIN-93M, 4% fat w/w) or switched to the LF diet and restricted to consuming only 75% of ad libitum intake (LF/R). Dams lost weight during lactation, but weight loss was much less in the LF group (19g) than in the other two groups (47 and 59g, HF and LF/R, respectively). There was no appreciable change in body water; body fat decreased by about half in all groups, but most substantially in the LF/R group. Compared with the HF group, milk production was 50% higher in the LF group and 12% lower in the LF/R group. Milk lipid concentration tended to be higher and milk water concentration lower in the HF compared with the other two groups. Growth of the litters of the LF dams was significantly higher than both HF and LF/R dams. These results indicate that switching to a low-fat diet mitigates the negative effects of obesity and continued high-fat feeding on lactational performance and pup growth. Consumption of restricted quantities of a low-fat diet negatively affected milk production and failed to improve pup growth, despite the dams' mobilization of body fat in support of lactation.

The effect of celecoxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis.

BACKGROUND: Patients with familial adenomatous polyposis have a nearly 100 percent risk of colorectal cancer. In this disease, the chemopreventive effects of nonsteroidal antiinflammatory drugs may be related to their inhibition of cyclooxygenase-2. METHODS: We studied the effect of celecoxib, a selective cyclooxygenase-2 inhibitor, on colorectal polyps in patients with familial adenomatous polyposis. In a double-blind, placebo-controlled study, we randomly assigned 77 patients to treatment with celecoxib (100 or 400 mg twice daily) or placebo for six months. Patients underwent endoscopy at the beginning and end of the study. We determined the number and size of polyps from photographs and videotapes; the response to treatment was expressed as the mean percent change from base line. RESULTS: At base line, the mean (+/-SD) number of polyps in focal areas where polyps were counted was 15.5+/-13.4 in the 15 patients assigned to placebo, 11.5+/-8.5 in the 32 patients assigned to 100 mg of celecoxib twice a day, and 12.3+/-8.2 in the 30 patients assigned to 400 mg of celecoxib twice a day (P=0.66 for the comparison among groups). After six months, the patients receiving 400 mg of celecoxib twice a day had a 28.0 percent reduction in the mean number of colorectal polyps (P=0.003 for the comparison with placebo) and a 30.7 percent reduction in the polyp burden (the sum of polyp diameters) (P=0.001), as compared with reductions of 4.5 and 4.9 percent, respectively, in the placebo group. The improvement in the extent of colorectal polyposis in the group receiving 400 mg twice a day was confirmed by a panel of endoscopists who reviewed the videotapes. The reductions in the group receiving 100 mg of celecoxib twice a day were 11.9 percent (P=0.33 for the comparison with placebo) and 14.6 percent (P=0.09), respectively. The incidence of adverse events was similar among the groups. CONCLUSIONS: In patients with familial adenomatous polyposis, six months of twice-daily treatment with 400 mg of celecoxib, a cyclooxygenase-2 inhibitor, leads to a significant reduction in the number of colorectal polyps.

Preventative strategies for periampullary tumours in FAP.

Almost all patients with familial adenomatous polyposis develop duodenal polyps most of which occur in a cluster around the ampulla of Vater. Between 5 and 10% of FAP patients will die from upper gastrointestinal cancer, usually periampullary in origin. In an attempt to prevent cancer a screening programme has been developed using a well defined staging system to detect those patients most at risk of developing the disease. Treatment options are limited, with endoscopic clearance being contraindicated in most cases. The only certain method of preventing duodenal cancer is prophylactic radical surgery which has its own associated morbidity and mortality. Future developments may include new drug treatments or even gene therapy. Until then patients with FAP should all be considered for clinical trials as research continues.

Attenuated adenomatous polyposis coli: the role of ascertainment bias through failure to dye-spray at colonoscopy.

PURPOSE: The aim of this study is to show that the diagnosis of attenuated adenomatous polyposis coli must be made with caution and certainly only after adequate colonic examination with dye-spray. METHODS: Four patients thought to have attenuated adenomatous polyposis coli on the basis of family history and the identification of fewer than 100 polyps on simple colonoscopy underwent colonoscopy with dye-spray. RESULTS: All four individuals were found to have more than 100 polyps when dye-spray was used, confirming a diagnosis of classical familial adenomatous polyposis. CONCLUSIONS: The diagnosis of familial adenomatous polyposis may be missed altogether or incorrectly assigned as attenuated adenomatous polyposis coli if dye-spray is not used at colonoscopy. Patients with a family history of familial adenomatous polyposis or colorectal cancer should be considered for dye-spray before the diagnosis of familial adenomatous polyposis is excluded or one of attenuated adenomatous polyposis coli is made.

Upper gastrointestinal disease in patients with familial adenomatous polyposis.

BACKGROUND: Upper gastrointestinal disease has become an important aspect in the management of patients with familial adenomatous polyposis (FAP). METHODS: A review of the literature was carried out using Medline. Epidemiology, pathology and treatment options are considered. RESULTS AND CONCLUSION: Despite the fact that over 90 per cent of patients with FAP develop duodenal adenomas, only 5 per cent go on to develop cancer. In the absence of methods to detect who is at risk of cancer, all patients undergo regular endoscopic surveillance at present. Chemoprevention in the form of drug therapy may be the answer to controlling the disease.

Effect of gestation-lactation diet calcium and zinc levels and of parenteral vitamins A, D and E during gestation on ewe body weight and on lamb weight and survival.

Data on ewe body weights and on lamb birth and weaning weights and survival rates were recorded on a total of 557 multiparous Rambouillet, Hampshire X Suffolk and Synthetic I (composite of Finnish Landrace, Rambouillet and Polled Dorset) ewes in two experiments started after the first trimester of gestation. In Exp. 1, a 2 X 2 factorial arrangement of treatments included all combinations of low (.24% in gestation and .48% in lactation), or high (.80%) dietary Ca and low (20 ppm) or high (74 ppm) dietary Zn. No effect of dietary Ca or Zn level and no Ca X Zn interaction with respect to number of lambs born or weaned, birth weight, weaning weight or survival rate of the lambs or body weight of the ewes was shown. Mean number of lambs born was 1.63 +/- .71 with a survival rate of 85.0 +/- .3% and a weaning weight (59 d) of 19.4 +/- 4.4 kg. Experiment 2 was a repeat of Exp. 1 except that two intramuscular injections of vitamins A, D and E (d 65 and 93 of experiment) were given to one-half of the ewes in each diet group. There was no effect of dietary Ca or Zn level or of vitamin administration on ewe body weight changes, number of lambs born (1.89 +/- .55), survival rate (86.6 +/- .3%), lamb birth weight 4.6 +/- 1.5 kg) or lamb weaning weight (23.2 +/- 7.2 kg). Blood plasma Ca, inorganic P and Mg concentrations of ewes in late pregnancy were unaffected by diet or vitamin injections.(ABSTRACT TRUNCATED AT 250 WORDS)