Patients with Community Acquired Pneumonia Exhibit Depleted Vitamin C Status and Elevated Oxidative Stress.

Pneumonia is a severe lower respiratory tract infection that is a common complication and a major cause of mortality of the vitamin C-deficiency disease scurvy. This suggests an important link between vitamin C status and lower respiratory tract infections. Due to the paucity of information on the vitamin C status of patients with pneumonia, we assessed the vitamin C status of 50 patients with community-acquired pneumonia and compared these with 50 healthy community controls. The pneumonia cohort comprised 44 patients recruited through the Acute Medical Assessment Unit (AMAU) and 6 patients recruited through the Intensive Care Unit (ICU); mean age 68 ± 17 years, 54% male. Clinical, microbiological and hematological parameters were recorded. Blood samples were tested for vitamin C status using HPLC with electrochemical detection and protein carbonyl concentrations, an established marker of oxidative stress, using ELISA. Patients with pneumonia had depleted vitamin C status compared with healthy controls (23 ± 14 µmol/L vs. 56 ± 24 µmol/L, p < 0.001). The more severe patients in the ICU had significantly lower vitamin C status than those recruited through AMAU (11 ± 3 µmol/L vs. 24 ± 14 µmol/L, p = 0.02). The pneumonia cohort comprised 62% with hypovitaminosis C and 22% with deficiency, compared with only 8% hypovitaminosis C and no cases of deficiency in the healthy controls. The pneumonia cohort also exhibited significantly elevated protein carbonyl concentrations compared with the healthy controls (p < 0.001), indicating enhanced oxidative stress in the patients. We were able to collect subsequent samples from 28% of the cohort (mean 2.7 ± 1.7 days; range 1-7 days). These showed no significant differences in vitamin C status or protein carbonyl concentrations compared with baseline values (p = 0.6). Overall, the depleted vitamin C status and elevated oxidative stress observed in the patients with pneumonia indicates an enhanced requirement for the vitamin during their illness. Therefore, these patients would likely benefit from additional vitamin C supplementation to restore their blood and tissue levels to optimal. This may decrease excessive oxidative stress and aid in their recovery.

Urinalysis orders and yield among General Medicine patients: a single-centre's experience in New Zealand.

BACKGROUND: Urinalysis performed by dipstick testing is an aid to diagnosing urinary tract infections (UTI), and a tool in selecting patients who require urine culture and antibiotic treatment. Previous studies have demonstrated that UTI, especially in the elderly, are over-diagnosed and over-treated. We sought to study the pattern and yield of urinalysis and urine culture at our service in a tertiary institution. METHODS: A convenience sampling method was utilised to prospectively collect clinical data, through a pre-designed pro forma, from patients admitted to the General Medicine service at Christchurch Hospital between March and June 2016. RESULTS: The study included 395 patients, with a median age of 76 (range 15-100 years). The presence of urinary tract symptoms was documented in 94 patients (24%) and a non-specific syndrome of elevated temperature, confusion or subjective feverishness in 69 (17%). In symptomatic patients, 121 (74%) had a dipstick performed and 104 (86%) urine samples cultured. In the remaining patients, 181 (78%) had a dipstick performed and 81 (35%) had a urine sample sent for culture. CONCLUSIONS: We found a large number of urine dipsticks is being ordered unnecessarily in asymptomatic patients. A more useful test is urine microscopy and culture that is done on symptomatic patients only following careful clinical evaluation. Performing 'routine' urinalysis in patients presenting a wide variety of symptoms may lead to unnecessary urine cultures and treatment of asymptomatic bacteriuria. Efforts to reduce unnecessary tests and antibiotic treatment are a vital component of diagnostic stewardship programmes.

Improved survival for rectal cancer compared to colon cancer: the four cohort study.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer worldwide. This study was undertaken to evaluate survival outcomes and changes of disease outcomes of CRC patients over the last decades. METHODS: A retrospective analysis of CRC patients in Christchurch was performed in four patient cohorts at 5 yearly intervals; 1993-94, 1998-99, 2004-05 and 2009. Data on cancer location, stage, surgical and oncological treatment and survival were collected. Univariate, multivariate and Kaplan-Meier survival analysis were performed. RESULTS: There were 1391 patients (355, 317, 419 and 300 per cohort), 1037 colon and 354 rectal cancers, respectively. For colon cancer, right-sided cancers appeared more common in later cohorts (P = 0.01). There was a significant decrease in the number of permanent stomas for colon cancer patients (P = 0.001). There was an analogous trend for rectal cancers (P = 0.075). More CRC patients with stage IV disease were treated surgically (P = 0.001) and colon cancer stages I and II tended to have increased survival if operated by a colorectal surgeon (P = 0.06). Oncology referrals have increased remarkably (P = 0.001). Overall 56% of patients were alive at 5 years however rectal cancer patients had significantly better 5-year survival than those with colon cancer (P < 0.05). DISCUSSION: This four cohort study shows that modern CRC survival continues to improve and is comparable to international standards. Furthermore, rectal cancer patients have a better 5-year survival than colon cancer patients. The improved survival with early stage colon cancers operated on by specialist colorectal surgeons needs further exploration.

Colonization with enterotoxigenic Bacteroides fragilis is associated with early-stage colorectal neoplasia.

BACKGROUND: Enterotoxigenic Bacteroides fragilis (ETBF) is a toxin-producing bacteria thought to possibly promote colorectal carcinogenesis by modulating the mucosal immune response and inducing epithelial cell changes. Here, we aim to examine the association of colonic mucosal colonization with ETBF and the presence of a range of lesions on the colonic neoplastic spectrum. METHODS: Mucosal tissue from up to four different colonic sites was obtained from a consecutive series of 150 patients referred for colonoscopy. The presence and relative abundance of the B. fragilis toxin gene (bft) in each tissue sample was determined using quantitative PCR, and associations with clinicopathological characteristics were analysed. FINDINGS: We found a high concordance of ETBF between different colonic sites (86%). Univariate analysis showed statistically significant associations between ETBF positivity and the presence of low-grade dysplasia (LGD), tubular adenomas (TA), and serrated polyps (P-values of 0.007, 0.027, and 0.007, respectively). A higher relative abundance of ETBF was significantly associated with LGD and TA (P-values of < 0.0001 and 0.025, respectively). Increased ETBF positivity and abundance was also associated with left-sided biopsies, compared to those from the right side of the colon. CONCLUSION: Our results showing association of ETBF positivity and increased abundance with early-stage carcinogenic lesions underlines its importance in the development of colorectal cancer, and we suggest that detection of ETBF may be a potential marker of early colorectal carcinogenesis.

Hinchey I and II diverticular abscesses: long-term outcome of conservative treatment.

BACKGROUND: The management of diverticular disease and its complications are an increasing burden to the health system. The natural history of conservatively managed diverticular abscesses (Hinchey I and II) is poorly described and it remains open to debate whether subsequent sigmoid resection is indicated after conservative management. This observational study compares outcomes of patients treated with conservative management (antibiotics +/- percutaneous drainage) and surgery. METHODS: All patients admitted at Christchurch Hospital with diverticulitis between 1 January 1998 and 31 December 2009 were recorded in a database. A retrospective analysis of patients with an abscess due to complicated diverticulitis was undertaken. Initial management, recurrence and subsequent surgery were recorded. The patients were followed until 1 January 2014. RESULTS: Of 1044 patients with diverticulitis, 107 with diverticular abscess were included in this analysis. The median age was 66 ± 16 and 60 were male. All patients had sigmoid diverticulitis and were diagnosed with a computed tomography. The median abscess size was 4.2 ± 2.1 cm. During median follow-up of 110 months, the overall recurrence rate was 20% (21/107). Recurrence varied according to initial treatment; namely antibiotics (30%), percutaneous drainage plus antibiotics (27%) and surgery (5%) (P = 0.004). The median time to recurrence was 4 ± 11.7 months, and most recurrences were treated conservatively; four patients underwent delayed surgery. CONCLUSION: Recurrence after diverticular abscess is higher after initial conservative treatment (antibiotics +/- percutaneous drainage) compared with surgery, however, patients with recurrent disease can be treated conservatively with similar good outcomes and few patients required further surgery.

Management of malignant colorectal polyps in New Zealand.

BACKGROUND: The management of colorectal polyps containing a focus of malignancy is problematic, and the risks of under- and over-treatment must be balanced. The primary aim of this study was to describe the management and outcomes of patients with malignant polyps in the New Zealand population; the secondary aim was to investigate prognostic factors. METHODS: Retrospective review of relevant clinical records at five New Zealand District Health Boards. RESULTS: Out of the 414 patients identified, 51 patients were excluded because of the presence of other relevant colorectal pathology, leaving 363 patients for analysis. Of these, 182 had a polypectomy, and 181 had a bowel resection as definitive treatment. The overall 5-year survival was not altered with resection but was improved with re-excision of any form (repeat polypectomy or bowel resection). There were 110 rectal lesions and 253 colonic lesions. A total of 16% of patients who had resection after polypectomy were found to have residual cancer in the resected specimen. Ischaemic heart disease, chronic obstructive pulmonary disease and metastatic disease were found to negatively impact overall survival (P < 0.001). Resection was more likely to follow polypectomy if polypectomy margins were positive, fragmentation occurred for sessile lesions and for pedunculated lesions with a higher Haggitt level. CONCLUSION: Polypectomy is oncologically safe in selected patients. Re-excision improves overall survival and should be considered in patients with low comorbidity (American Society of Anesthesiologists score 1 and 2) and where there is concern about margins (sessile lesions and positive polypectomy margins). In the majority of patients, however, no residual disease is found.

Elective surgical outcomes of patients in Christchurch, New Zealand.

AIM: Most studies assessing mortality after surgery have been undertaken in major public hospitals or are procedure specific. The aim of this study was to determine mortality after elective surgery at a total community level with inclusion of all patients undergoing elective surgery. METHOD: This was a prospective study of all patients that underwent elective surgery in Christchurch, New Zealand, within a calendar month. For each patient, we collected demographic data, American Society of Anaesthesiologists physical status classification (ASA), type of anaesthetic and surgical specialty. The primary outcome was 30-day mortality and the secondary outcome was 90-day mortality. RESULTS: Four thousand seven hundred and fifteen patients were included in this study. Two thousand five hundred and seventy-eight (55%) were female and the median age was 56 years (range 0-99 years). Three thousand one hundred and forty-two (67%) patients had a general anaesthetic. By day 30, 11 (0.2%) patients had died and by day 90, 27 (0.6%) patients had died. Of the 27 deaths within 90 days after surgery, one was possibly anaesthesia-related (0.02%), while the majority were due to progression of disease (18). CONCLUSION: This study shows a lower mortality than what has previously been reported for elective surgical procedures when the denominator is the total community number of operations.

The Outcomes and Patterns of Treatment Failure After Surgery for Locally Recurrent Rectal Cancer.

OBJECTIVE: To assess the outcomes and patterns of treatment failure of patients who underwent pelvic exenteration surgery for recurrent rectal cancer. BACKGROUND: Despite advances in the management of rectal cancer, local recurrence still occurs. For appropriately selected patients, pelvic exenteration surgery can achieve long-term disease control. METHODS: Prospectively maintained databases of 5 high volume institutions for pelvic exenteration surgery were reviewed and data combined. We assessed the combined endpoints of overall 5-year survival, cancer-specific 5-year mortality, local recurrence, and the development of metastatic disease. RESULTS: Five hundred thirty-three patients who had undergone surgery for locally recurrent rectal cancer were identified. Five-year cancer-specific survival for patients with a complete (R0) resection is 44%, which was achieved in 59% of patients. For those with R1 and R2 resections, the 5-year survival was 26% and 10%, respectively. Radical resection required sacrectomy in 170 patients (32%), and total cystectomy in 105 patients (20%). Treatment failure included local recurrence alone in 75 patients (14%) and systemic metastases with or without local recurrence in 226 patients (42%). Chemoradiotherapy before exenteration was associated with a significant (P < 0.05) improvement in overall 5-year cancer-specific survival for those patients with an R0 resection. Postoperative chemotherapy did not alter outcomes. CONCLUSIONS: R0 resection of the pelvic recurrence is the most significant factor affecting overall and disease-free survival. The surgery is complex and often highly morbid, and where possible patients should be given perioperative chemoradiotherapy. Further investigations are required to determine the role of adjuvant chemotherapy.

Cystoprostatectomy versus prostatectomy alone for locally advanced or recurrent pelvic cancer.

BACKGROUND: There is minimal published data evaluating the oncological outcome of rectal resection with prostatectomy alone versus rectal resection with cystoprostatectomy in patients undergoing pelvic exenteration for locally advanced or recurrent pelvic cancer. This study aims to evaluate the oncological and functional outcomes of performing rectal resection with prostatectomy alone compared with rectal resection with cystoprostatectomy in patients undergoing pelvic exenteration. METHODS: Consecutive patients undergoing pelvic exenteration for locally advanced or recurrent pelvic cancer between 1998 and 2012 were identified from a prospectively maintained database. Patients undergoing rectal resection with prostatectomy alone were compared with a control group who underwent rectal resection with cystoprostatectomy and urostomy formation. The primary outcome was overall survival. Secondary outcomes analysed in the prostatectomy group included completeness of resection, continence and erectile function. RESULTS: Eleven rectal resections with prostatectomy were compared with 20 rectal resections with cystoprostatectomy. R0 resection was achieved in 73 and 65% respectively. There was no difference in overall survival (P = 0.40). Urinary continence was achieved in 36% of prostatectomy alone patients, while 27% experienced mild incontinence. Erectile function was poor, with only one patient able to maintain normal erections. CONCLUSION: In appropriately selected patients with invasive pelvic tumours, rectal resection with prostatectomy alone provides adequate oncological outcomes. The ability to achieve an R0 resection was not compromised and overall survival is comparable with cystoprostatectomy. Urinary function is reasonable in most patients, although sexual function is compromised in almost all.

Skin closure after laparotomy with staples or sutures: a study of the mature scar.

BACKGROUND: Surgeons are divided in their method of choice for skin closure following laparotomy. We suggest that the most important determinant should be the resulting scar. This study aims to compare both patients' and independent observers' assessment of mature laparotomy scars that had been closed with either subcuticular sutures or external staples. METHODS: Consecutive patients were enrolled at least 1 year following colorectal surgery. Scars were assessed with the validated Patient and Observer Scar Assessment Scoring (POSAS) tool. Photographs were assessed by a blinded independent panel. RESULTS: Overall, 232 patients were enrolled (90 suture, 143 staples). The two groups were well matched by factors affecting wound healing. Patients' overall opinion of their scar was significantly better for the Suture group than the Staples group (P = 0.028) despite there being no difference in their self-assessment of the components of their scar score (pain, itch, colour, stiffness, thickness, irregularity). The panel recorded similar overall scores for the Suture and Staples groups (P = 0.059). There was a significant lower (better) score recorded for the scar area component for the Suture group than the Staples group (P = 0.008) but no differences for the other components (vascularity, pigmentation or thickness). DISCUSSION: This study has shown that independent of skin closure method, patients who have undergone major abdominal surgery have a positive opinion of their mature scars. The patients' overall impression of the wound favours a sutured closure due to a smaller scar area (no staple marks). In all other respects, skin closure with staples would appear acceptable.

Continued progress with stage III colorectal cancer--a triple cohort study.

INTRODUCTION: Colorectal cancer is a common cause of death in New Zealand and its burden is projected to increase in the future. Oncological outcomes from modern treatment have improved, but evidence from the published literature is conflicting. We studied survival outcomes from a series of patients at our local health board. METHODS: A retrospective analysis of disease patterns, surgical procedures, adjuvant therapy and oncological outcomes was performed in three patient cohorts; January 1993-December 1994, January 1998-June 1999, and January 2004-December 2005 at Christchurch Hospital. Univariate, multivariate and Kaplan-Meier survival analysis was performed to identify differences between the three cohorts. RESULTS: There were 1091 patients [(355, 317, 419 per cohort, 808 colon (281,227,300) and 283 rectal (74,90,119)] with cancer over the 3 cohorts. Median age was 76 (IQR 67-84) years. Median follow-up was 44 (IQR 13-81) months. For both colon and rectal cancer, patients in later cohorts had early disease, were more likely to have the operation performed by a consultant, were more likely to be referred for an oncological opinion and were more likely to receive adjuvant treatment (p<0.05 respectively). Differences in survival were particularly marked in the later cohort of patients with Stage III colonic cancer. DISCUSSION: There have been significant improvements in oncological outcome with stage three colon and rectal cancer over the study period. Greater specialisation of surgeons, more operations by consultants and use of chemotherapy are all likely contributing factors.

Survival outcome in New Zealand after resection of colorectal cancer lung metastases.

BACKGROUND: Colorectal cancer is the second most common type of solid organ cancer in New Zealand behind prostate cancer. Even with treatment, distant disease may develop in the liver and lungs. Surgical resection of isolated liver and/or lung metastasis is now commonly considered, but survival outcomes from the latter are not well described. This study aims to review the 5-year survival and prognostic factors of patients who have resection for lung metastasis of colorectal origin. METHODS: A retrospective audit of surgical resection for lung metastasis performed by thoracic departments of several tertiary referral centres within New Zealand was performed. The study period was between 1997 and 2011. Patients were identified through operative logs, audit databases, clinical case mix codes and pathology databases. Patient demographics, preoperative and post-operative variables were recorded. All patients were followed up for survival analysis. Mann-Whitney and chi-square tests were performed for data analysis. A P-value of less than 0.05 was significant. RESULTS: There were 106 (59 male) patients. Median age was 64 (inter-quartile range (IQR) 57-73) years. Median follow-up period was 30 (IQR 16-46) months. The 5-year overall and cancer-specific survival was 40% and 43%, respectively. The only good prognostic factor for survival after lung resection was a long disease-free interval (P = 0.04) between surgery for the colorectal primary and lung metastasis. CONCLUSION: Lung resection for isolated colorectal metastases provides a reasonable 5-year survival. Outcomes from lung resection for colorectal metastases in New Zealand are comparable to that from international series.

Mesenteric panniculitis: a paraneoplastic phenomenon?

BACKGROUND: Mesenteric panniculitis is an inflammatory condition of mesenteric adipose tissue with characteristic features on abdominal CT imaging. Although its cause is unknown, it has been associated with malignancy. OBJECTIVE: The aim of this study was to determine the prevalence of malignancy in patients identified as having mesenteric panniculitis on CT imaging and to identify demographic, clinical, and radiological features that may predict an unknown underlying malignancy. DESIGN: This study is a retrospective analysis of medical records and imaging. SETTING: This study was conducted at Christchurch Hospital, Canterbury District Health Board, New Zealand. PATIENTS: Individuals with mesenteric panniculitis on abdominal CT imaging performed between 2003 and 2010 were included. RESULTS: One hundred eighteen (92 male; median age, 61 years; range, 20-88 years) patients were identified with mesenteric panniculitis. Malignancy was identified in 45 patients (38%) (34 male). The most common malignancies were colorectal (14), lymphoma (13), and urogenital tract (7). Malignancies were diagnosed after the detection of mesenteric panniculitis in 13 patients. Univariate analysis of demographic, clinical, and radiological features revealed that lymph node size >12 mm (relative risk 4.5 (CI 1.4-14.6); p = 0.0266) and the absence of the fat ring sign (relative risk 0.6 (0.3-1.1); p = 0.047) were associated with the subsequent diagnosis of malignancy in patients with mesenteric panniculitis. LIMITATIONS: This review was limited by its retrospective nature and the small number of individuals with diagnosis of malignancy after the detection of mesenteric panniculitis. CONCLUSION: Mesenteric panniculitis is often associated with an underlying malignancy. In most cases, malignancy is diagnosed before mesenteric panniculitis. Lymph node size (>12 mm) and the absence of the fat ring sign were identified as predictors of subsequent diagnosis of malignancy in patients with mesenteric panniculitis. Identification of mesenteric panniculitis on imaging should prompt an awareness for possible malignancy in these patients.

Reconstruction with Vertical Rectus Abdominus Myocutaneous flap in advanced pelvic malignancy.

Pelvic extenuative surgery produces good long term outcomes in advanced pelvic malignancies. We evaluate the use and clinical outcomes of the Vertical Rectus Abdominus Myocutaenous (VRAM) flap as a reconstruction technique in a heterogenic cohort of patients with advanced colorectal cancer in whom neo-adjuvant chemo-radiotherapy had been performed pre-operatively. Analysis of patients having VRAM flaps for pelvic reconstruction in a tertiary referral centre from 2001 to 2010 was conducted. 37 patients (23 female, 14 male) underwent pelvic extenuative surgery of which 22 (60%) had recurrent pelvic disease. All surgical and medical complications were analysed. Major flap complications were defined as 'requiring return to the operating theatre at any stage' and these occurred in 6 (16%) patients. There were 7 (19%) minor flap complications defined as 'requiring conservative non surgical treatment' The total global re-intervention rate of patients requiring return to theatre for re-operation as a result of their exenteration and reconstruction was 6 (16%). We highlight the merits and versatility of the VRAM flap in advanced pelvic malignancy in obtaining stable and supple reconstructive cover and the relative low morbidity in this difficult group confirms out strong support for immediate VRAM reconstruction in pelvic exenterative procedures.