Extended versus limited mesenteric excision for operative Crohn's disease: 30-Day outcomes from the ACS-NSQIP database.

PURPOSE: Recent studies have suggested that extended mesenteric excision (ME) may reduce surgical reintervention in Crohn's Disease (CD), but there remains clinical concerns regarding potential peri-operative morbidity. This retrospective study compares 30-day perioperative morbidity between limited and extended ME in segmental colectomies for CD. METHODS: Using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) colectomy-specific database, all patients with CD undergoing segmental colectomy for non-malignant indications between 2014-2019 were included. A lymph node harvest of 12 or more nodes was used as a surrogate for extended ME. The primary outcome was NSQIP major morbidity. Secondary outcomes included abdominal complications and perioperative bleeding. RESULTS: Of 3,709 patients included from the ACS-NSQIP database, 3,087 underwent limited ME and 622 underwent extended ME. On univariate analysis, those with limited mesenteric excision were less likely to be anemic (46.1% vs 55.0%, p < 0.001) and have undergone an open surgery (44.7% vs 34.7%, p < 0.001). On univariate comparison of limited and extended ME, there was no significant difference in major morbidity. On multiple logistic regression, controlling for age, sex, BMI, smoking, preoperative sepsis, preoperative anemia, surgical approach, emergency surgery, stoma creation, bowel preparation, and immunosuppression, the extent of ME was not an independent predictor of NSQIP major morbidity (OR 1.1, 95% CI 0.84-1.44). Likewise, the extent of ME was not associated with an increase in abdominal complications (OR 0.95, 95% CI 0.76-1.19) or post-operative bleeding (OR 1.89, 95% CI 0.75-1.53). CONCLUSION: Extended ME for CD was not associated with an increase in 30-day perioperative major morbidity.

Is the Hartmann's procedure for diverticulitis obsolete? National trends in colectomy for diverticulitis in the emergency setting from 1993 to 2018.

BACKGROUND: Historically, Hartmann's procedure (HP) has been the operation of choice for diverticulitis in the emergency setting. However, recent evidence has demonstrated the safety of primary anastomosis (PA) with or without diverting ileostomy. The purpose of this study was to evaluate the trends of, and factors associated with, HP compared to PA in emergency surgery for diverticulitis over 25 years. METHODS: Using the National Inpatient Sample database, we identified adult patients ≥ 18 years old who underwent emergency surgery for diverticulitis (HP or PA) between 1993 and 2018 using ICD-9 and ICD-10 codes. Patients with inflammatory bowel disease, gastrointestinal cancer or who underwent elective diverticulitis surgery were excluded. Trends in HP were analyzed using multivariable linear regression, and factors associated with HP were assessed with multiple logistic regression. RESULTS: Of 499,433 patients who underwent colectomy in the emergency setting for acute diverticulitis, 271,288 (54.3%) had a HP and 228,145 (45.7%) had a PA. Median age was 61 years (IQR: 50-73), 53% were women, and 70.5% were white. The proportion of HP slightly increased over the study period-HP comprised 52.6% of included cases in 1993-98 and 55.2% of cases in 2014-2018 (p = 0.017). Advanced age (reference = 18-44 years; 45-54 years: OR 1.16, 95% CI 1.10-1.22; 55-64 years: OR 1.26, 95% CI 1.20-1.33; 65-74 years: OR 1.33, 95% CI 1.25-1.42; ≥ 75 years: OR 1.51, 95% CI 1.41-1.62), complicated diverticulitis (OR 1.41, 95% CI 1.36-1.46), and severity of illness (reference = minor; moderate: OR 1.46, 95% CI 1.38-1.54; major/extreme: OR 3.43, 95% CI 3.25-3.63) were associated with increased odds of HP. CONCLUSIONS: Over a 26-year period, HP has remained the most performed procedure in the emergency setting for diverticulitis. Future work should focus on knowledge translation with a possible change in practice as more randomized controlled trials provide support for PA.

Low Anterior Resection Syndrome in a Reference North American Sample: Prevalence and Associated Factors.

BACKGROUND: Low anterior resection syndrome (LARS) is a well-described consequence of rectal cancer treatment. Studying the degree to which bowel dysfunction exists in the general population may help to better interpret to what extent LARS is related to disease and/or cancer treatment. Currently, North American LARS normative data are lacking. The aim of this study was to describe the prevalence of bowel dysfunction, as measured by the LARS score, and quality of life (QoL) in a reference North American sample. Quality of life was measured and associations between participant characteristics and LARS were identified. STUDY DESIGN: This was a single-institution cross-sectional study of asymptomatic adults who underwent screening and surveillance colonoscopies from 2018 to 2021 with no/benign endoscopic findings. Survey was conducted on select comorbidities, sociodemographic factors, LARS, and QoL. Outcomes were LARS and QoL. Multivariable linear regression accounting for a priori clinical factors associated with bowel dysfunction was performed. RESULTS: Of 1,004 subjects approached, 502 (50.0%) participated, and 135 (26.9%) participants had major/minor LARS. On multiple linear regression, female sex (ß = 2.15, 95% CI 0.30 to 4.00), younger age (ß = -0.10, 95% CI -0.18 to -0.03), White ethnicity (ß = 2.45, 95% CI 0.15 to 4.74), and the presence of at least one of the following factors: diabetes, depression, neurologic disorder, or cholecystectomy (ß = 3.54, 95% CI 1.57 to 5.51) were independently associated with a higher LARS score. Individuals with LARS had lower global QoL, functional subscales, and various symptom subscale scores. CONCLUSIONS: Our study identified the baseline prevalence of LARS in asymptomatic adults who have not undergone a low anterior resection. These normative data will allow for more accurate interpretation of ongoing studies on LARS in North American rectal cancer patients.

Bowel stimulation before loop ileostomy closure to reduce postoperative ileus: a multicenter, single-blinded, randomized controlled trial.

INTRODUCTION: The objective of this study was to evaluate the impact of preoperative bowel stimulation on the development of postoperative ileus (POI) after loop ileostomy closure. METHODS: This was a multicenter, randomized controlled trial (NCT025596350) including adult (≥ 18 years old) patients who underwent elective loop ileostomy closure at 7 participating hospitals. Participants were randomly assigned (1:1) using a centralized computer-generated sequence with block randomization to either preoperative bowel stimulation or no stimulation (control group). Bowel stimulation consisted of 10 outpatient sessions within the 3 weeks prior to ileostomy closure and was performed by trained Enterostomal Therapy nurses. The primary outcome was POI, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, on or after postoperative day 3, that either (a) required nasogastric tube insertion; or (b) was associated with two of the following: nausea/vomiting, abdominal distension, or the absence of flatus. RESULTS: Between January 2017 and November 2020, 101 patients were randomized, and 5 patients never underwent ileostomy closure; thus, 96 patients (47 stimulated vs. 49 control) were analyzed according to a modified intention-to-treat protocol. Baseline characteristics were well balanced in both groups. The incidence of POI was lower among patients randomized to stimulation (6.4% vs. 24.5%, p = 0.034; unadjusted RR: 0.26, 95% CI 0.078-0.87). Stimulated patients also had earlier median time to first flatus (2.0 days (1.0-2.0) vs. 2.0 days (2.0-3.0), p = 0.025), were more likely to pass flatus on postoperative day 1 (46.8% vs. 22.4%, p = 0.022), and had a shorter median postoperative hospital stay (3.0 days (2.0-3.5) vs. 4.0 days (2.0-6.0), p = 0.003). CONCLUSIONS: Preoperative bowel stimulation via the efferent limb of the ileostomy reduced POI after elective loop ileostomy closure.

MORPHEUS Phase II-III Study: A Pre-Planned Interim Safety Analysis and Preliminary Results.

BACKGROUND: We explored image-guided adaptive endorectal brachytherapy patients electing non-operative management for rectal cancer. We present the first pre-planned interim analysis. METHODS: In this open-label phase II-III randomized study, patients with operable cT2-3ab N0 M0 rectal cancer received 45 Gy in 25 fractions of pelvic external beam radiotherapy (EBRT) with 5-FU/Capecitabine. They were randomized 1:1 to receive either an EBRT boost of 9 Gy in 5 fractions (Arm A) or three weekly adaptive brachytherapy (IGAEBT) boosts totaling 30 Gy (Arm B). Patient characteristics and toxicity are presented using descriptive analyses; TME-free survival between arms with the intention to treat the population is explored using the Kaplan-Meier method. RESULTS: A total of 40 patients were in this analysis. Baseline characteristics were balanced; acute toxicities were similar. Complete clinical response (cCR) was 50% (n = 10/20) in Arm A and 90% in Arm B (n = 18/20). Median follow-up was 1.3 years; 2-year TME-free survival was 38.6% (95% CI: 16.5-60.6%) in the EBRT arm and 76.6% (95% CI: 56.1-97.1%) in the IGAEBT arm. CONCLUSIONS: Radiation intensification with IGAEBT is feasible. This interim analysis suggests an improvement in TME-free survival when comparing IGAEBT with EBRT, pending confirmation upon completion of this trial.

The impact of delaying colonoscopies during the COVID-19 pandemic on colorectal cancer detection and prevention.

PURPOSE: The COVID-19 pandemic resulted in a partial to total shutdown of endoscopy in many healthcare centers. This study aims to quantify the impact of the reduction in colonoscopies on colorectal cancer (CRC) detection and screening. METHODS: After institutional ethics board approval, the endoscopy database at an academic tertiary-care center in Montreal, Canada, was searched for all colonoscopies performed from during the first wave locally (March-June 2020), and during the ramp up period where endoscopy service resumed (July to August 2020). We compared these periods to the same periods in 2019, the pre-pandemic periods. The indications, CRC and adenoma detection rates, as well as the prioritization of urgent procedures were compared. RESULTS: In the first wave, only 462 colonoscopies were performed, compared to 2515 in the same period in 2019, an 82% reduction. The ramp up period saw 843 colonoscopies performed compared to 1328 in 2019, a 35% reduction. Urgent and inpatient colonoscopies numbers increased (324 (24.8%) vs. 220 (5.7%)) while surveillance and high-risk screening colonoscopies fell (376 (28.8%) vs 1869 (48.6%)). Emergency access to colonoscopy was preserved with a median time to endoscopy of < 1 day (IQR 0,1) in both pandemic periods. During the pandemic periods, there was an absolute reduction in CRC diagnosis of 28, despite the CRC detection per colonoscopy rate increasing slightly in the first wave from 1.7% (44) to 3.9% (18), and in the ramp up period from 2.5% (33) to 3.6% (31). The rate of adenoma detection per colonoscopy did not increase significantly between the pre- and pandemic periods, resulting in reduction in adenoma removal in 723 patients. DISCUSSION: The restriction of access to colonoscopy resulted in a significant reduction in screening and surveillance of high-risk patients, adenomas removed, and CRCs diagnosed. Clinicians and patients will face the oncologic ramifications this the coming years.

Early discharge after colorectal cancer resection: trends and impact on patient outcomes.

BACKGROUND: Implementation of early discharge in colorectal surgery has been effective in improving patient satisfaction and reducing healthcare costs. Readmission rates following early discharge among colorectal cancer patients are believed to be low, however, remain understudied. The objectives of this study were: (i) to describe trends in early post-operative discharge and the associated hospitalization costs; (ii) to explore patient outcomes and resource utilization following early discharge; and (ii) to identify predictors of readmission following early discharge. METHODS: This was a retrospective cohort study using the Nationwide Readmissions Database. Adult patients admitted with a primary colorectal neoplasm who underwent colectomy or proctectomy between 2010 and 2017 were identified using ICD-9/10 codes. The exposure of interest was early post-operative discharge defined as ≤ 3 days from surgery. Main outcome measures were 30-day readmissions, post-operative complication rates, LOS and cost. RESULTS: In total, 342,242 patients were identified, and of those, 51,977 patients (15.2%) had early discharges. During the study period, the proportion of early discharges significantly increased (R2 = 0.94), from 9.9 to 23.4%, while readmission rates in this group remained unchanged (mean 7.3% ± 0.5). Complications that required bounceback readmission (within 7 days) after early discharge, rather than during index admission, were an independent predictor of longer overall LOS (ß = 0.044, p < 0.001) and higher hospitalization costs (ß = 0.031, p < 0.001). On multiple logistic regression, factors independently associated with bounceback readmission following early discharge were: male gender (OR = 1.47, 95%CI 1.33-1.63); open surgery (OR = 1.37, 95%CI 1.23-1.52); presence of stoma (OR = 1.51, 95%CI 1.22-1.87); transfer to facility or discharge with home health service (OR = 1.53, 95%CI 1.34-1.75); and Medicare/Medicaid insurance (OR = 1.34, 95%CI 1.14-1.57), among others. CONCLUSION: Early post-operative discharge of colorectal cancer patients is increasing despite a lack of improvement in readmission rates and an overall increase in hospitalization costs. Premature discharge of select patients may result in readmissions due to critical complications related to surgery resulting in increased resource utilization.

Observational versus antibiotic therapy for acute uncomplicated diverticulitis: A non-inferiority meta-analysis based on a Delphi consensus.

BACKGROUND: The purpose of this study was to determine if observational therapy is noninferior to antibiotics for acute uncomplicated diverticulitis according to clinically relevant margins. METHODS: MEDLINE, EMBASE, and Cochrane were systematically searched by 2 independent reviewers to identify comparative studies of observational therapy versus antibiotics for acute uncomplicated diverticulitis. Non-inferiority margins (ΔNI) for each outcome were based on Delphi consensus including 50 patients and 55 physicians: persistent diverticulitis (ΔNI = 4.0%), progression to complicated diverticulitis (ΔNI = 3.0%), and time to recovery (ΔNI = 5 days). Risk differences and mean differences were pooled using random-effects meta-analysis. One-sided 90% confidence intervals and Z-tests were used to determine non-inferiority. A sensitivity analysis was performed, excluding patients post hoc determined to have complicated diverticulitis. RESULTS: Nine studies (3 randomized controlled trials, 6 observational studies) met inclusion criteria: observational therapy (n = 2,011) versus antibiotics (n = 1,144). Observational therapy was noninferior to antibiotics regarding the risk of persistent diverticulitis (pooled risk differences: -0.39%, 90% CI -3.22 to 2.44%, ΔNI: 4.0%, PNI < 0.001; I2 = 66%) and progression to complicated diverticulitis (pooled risk differences: -0.030%, 90% CI -0.99 to 0.92%, ΔNI: 3.0%, PNI < 0.001; I2 = 0%). On sensitivity analysis, observational therapy remained noninferior for both outcomes. When stratified by study design, observational therapy also remained noninferior for both outcomes among randomized controlled trials only. Only 1 study reported on time to recovery as a continuous outcome, with no statistical difference between antibiotics and observational therapy. CONCLUSION: According to clinically relevant ΔNIs, observational therapy was noninferior to antibiotics for the treatment of acute uncomplicated diverticulitis with regard to persistent diverticulitis and progression to complicated diverticulitis.

Understanding the Burden of Colorectal Adenomas in Patients Younger Than 50 Years: A Large Single-Center Retrospective Cohort Study.

BACKGROUND: Colorectal cancer is increasing in young adults. Our understanding of the adenoma-carcinoma sequence in young patients aged <50 years is lacking. The yield obtained by lowering the age of screening colonoscopy remains unclear. OBJECTIVE: The goal of this study was to understand the burden and histology of colorectal polyps in young adults and to explore predictors of adenoma detection in this population. DESIGN: This is a retrospective cohort study. SETTING: Colonoscopies were performed at a single university-affiliated tertiary care center. PATIENTS: This study included adults aged <50 years who underwent a colonoscopy between 2014 and 2019. Patients with inflammatory bowel disease and genetic disorders were excluded. MAIN OUTCOME MEASURES: Adenoma detection rates were analyzed according to age. Predictors of adenoma detection were investigated by multiple logistic regression. RESULTS: A total of 4475 patients were analyzed. The mean age was 40.2 ± 8.0 years, 56.4% were female, and the mean BMI was 26.3 ± 5.5 kg/m2. A family history of colorectal cancer was reported in 23.8% of patients. The overall polyp and adenoma detection rates were 22% and 14%. The majority of polyps were adenomatous (58.9% of all polypectomies) and located in the left colon or rectum (61.4%). The detection rates of adenomas, advanced neoplasias, and adenocarcinomas were highest in patients aged 45 to 49 (19.3%, 4.8%, and 1.3%). On multivariate analysis, variables independently associated with adenoma detection included age (OR 1.08, 95% CI, 1.06-1.1), female sex (OR 1.80, 95% CI, 1.44-2.27), BMI (OR 1.01, 95% CI, 1.01-1.05), and having undergone a diagnostic colonoscopy (OR 1.81, 95% CI, 1.44-2.29). On subgroup analysis of patients aged 45 to 49, the same variables remained associated with adenoma detection except for age. LIMITATIONS: The study was limited due to the retrospective nature with heterogenous data. CONCLUSIONS: Adenoma detection in young adults aged 45 to 49 approaches the current adenoma detection of older adults. Predictors of adenoma detection in these young adults are female gender and BMI, which may help guide colorectal cancer screening guidelines in the future. See Video Abstract at http://links.lww.com/DCR/B843. COMPRENDER DE LA CARGA DE LOS ADENOMAS COLORRECTALES EN PACIENTES AOS UN ESTUDIO DE COHORTE RETROSPECTIVO DE UN SOLO CENTRO: ANTECEDENTES:El cáncer colorrectal está aumentando en adultos jóvenes. No se conoce la secuencia adenoma-carcinoma en pacientes jóvenes <50 años. El rendimiento obtenido al reducir la edad de la colonoscopia de detección sigue sin estar claro.OBJETIVO:Comprender la carga y la histología de los pólipos colorrectales en adultos jóvenes y explorar los predictores de detección de adenomas en esta población.DISEÑO:Estudio de cohorte retrospectivo.AJUSTE:Las colonoscopias se realizaron en un único centro de atención terciario afiliado a la universidad.PACIENTES:Adultos jóvenes <50 años que se sometieron a una colonoscopia entre 2014-2019. Se excluyeron los pacientes con enfermedad inflamatoria intestinal y trastornos genéticos.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron las tasas de detección de adenomas según la edad. Los predictores de la detección de adenomas se investigaron mediante regresión logística múltiple.RESULTADOS:Se analizaron 4475 pacientes. La edad media fue de 40,2 ± 8,0 años, el 56,4% eran mujeres y el IMC medio fue de 26,3 ± 5,5 kg / m2. Se informó de antecedentes familiares de cáncer colorrectal en el 23,8% de los pacientes. Las tasas generales de detección de pólipos y adenomas fueron del 22% y el 14%, respectivamente. La mayoría de los pólipos eran adenomatosos (58,9% de todas las polipectomías) y estaban localizados en colon izquierdo o recto (61,4%). Las tasas de detección de adenomas, neoplasias avanzadas y adenocarcinomas fueron más altas en pacientes de 45 a 49 años (19,3%, 4,8% y 1,3%, respectivamente). En el análisis multivariado, las variables asociadas de forma independiente con la detección de adenomas incluyeron: edad (OR 1.08; IC del 95%: 1,06-1,1), sexo femenino (OR 1,80; IC del 95%: 1,44-2,27), IMC (OR 1,01; IC del 95%: 1,01-1,05)) y haber sido sometido a una colonoscopia diagnóstica (OR 1,81; IC 95% 1,44-2,29). En el análisis de subgrupos de pacientes de 45 a 49 años, las mismas variables permanecieron asociadas con la detección de adenomas, excepto la edad.LIMITACIONES:Carácter retrospectivo con datos heterogéneos.CONCLUSIONES:La detección de adenomas en adultos jóvenes de 45 a 49 años se acerca a la detección actual de adenomas en adultos mayores. Los predictores de la detección de adenomas en estos adultos jóvenes son el sexo femenino y el IMC, que pueden ayudar a guiar las pautas de detección del cáncer colorrectal en el futuro. Consulte Video Resumen en http://links.lww.com/DCR/B843. (Traducción-Dr. Hagerman).

Assessment of long-term bowel dysfunction after restorative proctectomy for neoplastic disease: A population-based cohort study.

BACKGROUND: The purpose of this study was to describe postoperative bowel dysfunction after restorative proctectomy, and to identify factors associated with its development. METHODS: Patients who underwent restorative proctectomy for rectal cancer between April 1998 and November 2018 were identified from the Hospital Episode Statistics database and linked to the Clinical Practice Research Datalink for postoperative follow-up. Bowel dysfunction was defined according to relevant symptom-based read codes and medication prescription-product codes. A Cox proportional hazards model was performed to identify factors associated with postoperative bowel dysfunction, adjusting for relevant covariates. RESULTS: In total, 2,197 patients were included. The median age was 70.0 (interquartile range: 62.0-77.0) years old, and the majority (59.2%) of patients were male. After a median follow-up of 51.6 (24.0-90.0) months, bowel dysfunction was identified in 620 (28.2%) patients. Risk factors for postoperative bowel dysfunction included extremes of age (<40 years old: adjusted hazards ratio 2.35, 95% confidence interval 1.18-4.65; 70-79 years old: adjusted hazards ratio 1.25, 95% confidence interval 1.03-1.52), radiotherapy (adjusted hazards ratio 1.94, 95% confidence interval 1.56-2.42), distal tumors (adjusted hazards ratio 1.62, 95% confidence interval 1.34-1.94), history of diverting ostomy (adjusted hazards ratio 1.58, 95% confidence interval 1.33-1.89), and anastomotic leak (adjusted hazards ratio 1.48, 95% confidence interval 1.06-2.05). A minimally invasive surgical approach was protective for postoperative bowel dysfunction (adjusted hazards ratio 0.68, 95% confidence interval 0.53-0.86). CONCLUSION: Bowel dysfunction was common after restorative proctectomy, and several patient, disease, and treatment-level factors were associated with its development.

Dental care during the COVID-19 pandemic: an integrative review / Cuidados odontológicos durante a pandemia do COVID-19: uma revisão integrativa

ABSTRACT Objective: The study and enactment of dental preventive measures, in response to the COVID-19 pandemic, are necessary to prevent cross-infections between professionals and patients. The objective of this integrative review was to identify the COVID-19 preventive practices in dentistry. Methods: The electronic search was conducted on these databases: Pubmed / Medline, Web of Science, Cochrane Library, Scopus, LILACS and Scielo, using the following descriptors and / or words: "Coronavirus disease 2019"; "Coronavirus 2019"; "Covid-19"; "2019-ncov"; "Sars-cov2"; "Dental practice"; "Dental care"; "Dentistry"; "Dental medicine" and "Oral medicine". PRISMA was used as a reference for designing it. Results: A total of 11 articles were included and the preventive measures against COVID-19 were based on guidelines from health agencies and consisted of: perform only emergency treatments; reschedule patients with suspected disease; hand washing; disinfection of surfaces with 70% alcohol; testing dental professionals for the disease; use the N95 mask; disposable lab coats, and face shields. Children, in addition to the measures mentioned above, should routinely drink a lot of water and be provided with healthy diets. No study has evaluated the efficacy and effectiveness of these measures. There is a lack of scientific evidence on the preventive protocols adopted against COVID-19 in dentistry since preventive measures are recommended by health agencies. Conclusion: Consequently, professionals are recommended to follow the guidelines by these organizations until effective and efficient preventive protocols tailored to dentistry are established.

RESUMO Objetivo: O estudo e a adoção de medidas preventivas odontológicas, em resposta à pandemia do COVID-19, são necessárias para evitar infecções cruzadas entre profissionais e pacientes. O objetivo desta revisão integrativa foi identificar as práticas preventivas do COVID-19 em odontologia. Métodos: A busca eletrônica foi realizada nas seguintes bases de dados: Pubmed / Medline, Web of Science, Cochrane Library, Scopus, LILACS e Scielo, utilizando os seguintes descritores e / ou palavras: "Coronavirus disease 2019"; "Coronavirus 2019"; "Covid-19"; "2019-ncov"; "Sars-cov2"; "Dental practice"; "Dental care"; "Dentistry"; "Dental medicine" and "Oral medicine". O PRISMA foi utilizado como referência para sua realização. Resultados: Um total de 11 estudos foram incluídos e as medidas preventivas contra COVID-19 foram baseadas em diretrizes dos órgãos de saúde e consistiram em: realizar apenas tratamentos de emergência; reagendar pacientes com suspeita de doença; lavar as mãos; desinfetar superfícies com álcool a 70%; testar profissionais de odontologia para a doença; usar a máscara N95; jalecos descartáveis e protetores faciais. As crianças, além das medidas mencionadas acima, devem rotineiramente beber muita água e receber dietas saudáveis. Nenhum estudo avaliou a eficácia e a efetividade dessas medidas preventivas. Faltam evidências científicas sobre os protocolos preventivos adotados contra o COVID-19 em odontologia, uma vez que medidas preventivas são recomendadas pelos órgãos de saúde. Conclusão: Consequentemente, recomenda-se aos profissionais que sigam essas organizações até que sejam estabelecidos protocolos preventivos eficazes e eficientes, adaptados à odontologia.

Fatores associados ao não uso da prótese total inferior e seu impacto em idosos brasileiros / Factors associated with not using the lower denture and its impact on elderly Brazilians / Factores asociados con la no utilización de la dentadura postiza inferior y su impacto en los ancianos brasiliños

Introdução:Grande parte dos idosos caracteriza a reabilitação com prótese total como satisfatória. Entretanto, algunsse mostram insatisfeitos devido a dificuldades com a adaptação, principalmente em relação a prótese total mandibular. Objetivo:Identificar a prevalência e os fatores associados ao não uso da prótese total inferior em idosos. Ademais, verificou-se o impacto do não uso dessa prótese na autopercepção de saúde bucal e na dificuldade de se alimentar. Método:Trata-se de um estudo de base populacional e transversal. Para a sua realização, foi utilizado a base de dados da última Pesquisa Nacional de Saúde realizada no Brasil. Inicialmente, o teste Qui-quadrado foi usado para a análise dos dados. Em seguida, uma análise multivariada do tipo regressão múltipla de Poisson foi realizada para o ajuste das razões de prevalência. Resultados:Participaram 4.582 idosos brasileiros, dos quais 27,1% não faziam uso da prótese total inferior. Onão uso da prótese esteve associada aos idosos mais velhos (p=0,001), aos sem instrução (p=0,001), aos que não possuem plano de saúde (p=0,019), aos que fumam (p=0,012) e aos que não realizavam higiene bucal todos os dias (p<0,001). O não uso da prótese total inferior impactou em uma pior autopercepção de saúde bucal (p=0,001) e em maiores dificuldades de se alimentar (p<0,001). Conclusões:Onão uso de prótese total inferior está associado a piores condições socioeconômicas e a um pior estilo de vida, fortemente ligado ao ato de fumar. Ademais, o não uso da prótese impacta negativamente na autopercepção de saúde bucal e na alimentação (AU).

Introduction:A large part of the elderly characterizes rehabilitation with total prosthesis as satisfactory. However, some are dissatisfied due to difficulties with adaptation, mainly in relation to total mandibular prosthesis.Objective:To identify the prevalence and factors associated with not using the lower denture in the elderly. In addition, the impact of not using this prosthesis on self-perceived oral health and the difficulty of eating was verified.Methods:This is a population-based and cross-sectional study. For its realization, the database of the last National Health Survey carried out in Brazil was used. Initially, the Chi-square test was used for data analysis. Then, a multivariate analysis using Poisson multiple regression was performed to adjust the prevalence ratios.Results:4,582 elderly Brazilians participated, of which 27.1% did not use the lower total prosthesis. Failure to use the prosthesis was associated with older elderly people (p=0.001), those without education (p=0.001), those who do not have health insurance (p=0.019), those who smoke (p=0.012) and those who they did not perform oral hygiene every day (p<0.001). Failure to use the lower denture impacted worse self-perceived oral health (p=0.001) and greater difficulties in eating (p<0.001). Conclusions:Failure to use a lower denture is associated with worse socioeconomic conditions and a worse lifestyle, strongly linked to smoking. In addition, the non-use of the prosthesis has a negative impact on self-perception of oral health and food (AU).

Introducción:Una gran parte de los ancianos caracteriza la rehabilitación con prótesis total como satisfactoria. Sin embargo, algunos están insatisfechos por dificultades de adaptación, principalmente en relación con la prótesis total mandibular.Objetivo:Identificar la prevalencia y los factoresasociados a la no utilización de la prótesis inferior en el anciano. Además, se verificó el impacto de no utilizar esta prótesis sobre la salud bucal autopercibida y la dificultad para comer. Método:Se trata de un estudio poblacional y transversal. Para su realización se utilizó la base de datos de la última Encuesta Nacional de Salud realizada en Brasil. Inicialmente, se utilizó la prueba de Chi-cuadrado para el análisis de datos. Luego, se realizó un análisis multivariado utilizando regresión múltiple de Poisson para ajustar las razones de prevalencia.Resultados:Participaron 4.582 ancianos brasileños, de los cuales el 27,1% no utilizó la prótesis total inferior. La falta de uso de la prótesis se asoció con ancianos (p=0,001), sin educación (p=0,001), sin seguro médico (p=0,019), con tabaquismo (p=0,012) y con los que no realizaban tratamiento oral. higiene todos los días (p<0,001). La no utilización de la dentadura inferior repercutió en una peor salud bucal autopercibida (p=0,001) y mayores dificultades para comer (p<0,001).Conclusiones:La no utilización de una dentadura inferior se asocia con peores condiciones socioeconómicas y un peor estilo de vida, fuertemente ligado al tabaquismo. Además, la no utilización de la prótesis tiene un impacto negativo en la autopercepción de la salud bucal y la alimentación (AU).

Use of polylactic acid microvessel to obtain microplantlets of Eucalyptus microcorys through indirect organogenesis.

Microplants of Eucalyptus microcorys were produced through indirect organogenesis, and the interaction of plant growth regulators (PGRs) (TDZ-thidiazuron and NAA-α-naphthalene acetic acid), juvenile tissues (cotyledon and hypocotyl) and different types of polylactic acid (PLA) microvessels on plant production were evaluated. Cotyledon-derived callus induction increased by 30-60% in all tested combinations of TDZ and NAA concentrations compared the absence of PGRs. Hypocotyl-derived callus induction was improved in most tested combinations of TDZ and NAA concentrations. Moreover, 100% callus induction from both tissues was achieved with TDZ (1, 2 and 3 mg L-1) + NAA (0 mg L-1). Bud induction from cotyledon tissues was improved with TDZ (1 and 3 mg L-1) + NAA (0 mg L-1) and from hypocotyl with TDZ (1 and 2 mg L-1) + NAA (0 mg L-1). Shoot elongation from cotyledon tissues was not improved from any combination of PGRs, whereas TDZ (1 mg L-1) + NAA (0 mg L-1), TDZ (1 mg L-1) + NAA (4 mg L-1), TDZ (2 mg L-1) + NAA (4 mg L-1) and TDZ (3 mg L-1) + NAA (2 mg L-1) improved shoot elongation from hypocotyl tissues. Adventitious rooting and acclimatization of microcuttings ranged from 40 to 70% in three of the tested microvessels. The acclimatized microcuttings had low genetic variability. Successful production of E. microcorys microplants was achieved in this study using hypocotyl tissue and cultivated a culture medium supplemented with TDZ and NAA, using PLA-based microvessels.

Financial and occupational impact of low anterior resection syndrome in rectal cancer survivors.

AIM: The aim of this study was to assess bowel-related financial stress and strain and to evaluate its association with global quality of life. METHOD: This was a retrospective cohort study with cross-sectional follow-up including consecutive patients who underwent restorative proctectomy for neoplastic disease of the rectum at a single university-affiliated hospital in Montreal, Quebec, Canada. Bowel-related financial impact and occupational impact were compared between patients with major low anterior resection syndrome (LARS) and those with minor/no LARS. The association between LARS, bowel-related financial impact and global quality of life (QoL) was then assessed in a multiple logistic regression model. RESULTS: Of 180 eligible rectal cancer survivors who were contacted, 154 completed the questionnaires (response rate 47.1%) at a median follow-up of 57.5 months (interquartile range 34.1-98.1) after proctectomy. Individuals with major LARS reported a higher prevalence of bowel-related financial stress (53.2% vs 5.6%, p < 0.001) and strain (42.2% vs 5.6%, p < 0.001) compared with those with minor/no LARS. Among those who were working preoperatively (n = 100), the majority of participants with major LARS reported an impact of their new bowel function on their ability to work (70.6%), including delayed return to work (44.1%), the need to change schedules (35.3%) or roles (20.6%), and complete long-term medical absence from work (14.7%). On multiple logistic regression, major LARS with financial impact (OR 4.50, 95% CI 1.57-13.77) was associated with low global QoL compared with minor/no LARS. CONCLUSION: Major LARS was associated with considerable financial stress and strain and difficulties in returning to work.

Interactive online informational and peer support application for patients with low anterior resection syndrome: patient survey and protocol for a multicentre randomized controlled trial.

AIM: Low anterior resection syndrome (LARS) refers to a constellation of bowel symptoms that affect the majority of patients following restorative proctectomy. LARS is associated with poorer quality of life (QoL), and can lead to distress, anxiety and isolation. Peer support could be an important resource for people living with LARS, helping them normalize and validate their experience. The aim of this work is to describe the development of an interactive online informational and peer support app for LARS and the protocol for a randomized controlled trial. METHOD: A multicentre, randomized, assessor-blind, parallel-groups pragmatic trial will involve patients from five large colorectal surgery practices across Canada. The trial will evaluate the impact of an interactive online informational and peer support app for LARS, consisting of LARS informational modules and a closed forum for peers and trained peer support mentors, on patient-reported outcomes of people living with LARS. The primary outcome will be global QoL at 6 months following app exposure. The treatment effect on global QoL will be modelled using generalized estimating equations. Secondary outcomes will include patient activation and bowel function as measured by LARS scores. RESULTS: In order to better understand patients' interest and preferences for an online peer support intervention for LARS, we conducted a single institution cross-sectional survey study of rectal cancer survivors. In total, 35/69 (51%) participants reported interest in online peer support for LARS. Age <65 years (OR 9.1; 95% CI 2.3-50) and minor/major LARS (OR 20; 95% CI 4.2-100) were significant predictors of interest in LARS online peer support. CONCLUSION: There is significant interest in the use of online peer support for LARS among younger patients and those with significant bowel dysfunction. Based on results of the needs assessment study, the app content and features were modified reflect patients' needs and preferences. We are now in an optimal position to rigorously test the potential effects of this initiative on patient-centered outcomes using a randomized controlled trial.

Impacto da multimorbidade nas condições de saúde bucal em idosos brasileiros / Impact of multimorbidity on oral health conditions in Brazilian elderly / Impacto de la multimorbilidad en lascondiciones de salud bucal en ancianos brasileños

Introdução: A ocorrência de multimorbidade, a qual corresponde ao acúmulo de doenças crônicas, é considerada um problema de saúde pública e suas consequências na saúde bucal carecem de evidências científicas em grandes populações. Objetivo: Avaliar o impacto da multimorbidade nas condições de saúde bucal em idosos brasileiros. Método: Realizou-se um estudo transversal e de base populacional, utilizando a base de dados da Pesquisa Nacional de Saúde. A presença de multimorbidade em idosos foi considerada quando o mesmo possuía um diagnóstico de duas ou mais doenças crônicas. Com relação às condições de saúde bucal, essas foram coletadas a partir das variáveis estudadas na referida pesquisa. O teste Qui-quadrado foi utilizado para a análise dos dados e em seguida as razões de prevalência foram ajustadas por meio da regressão múltipla de Poisson. Resultados: Participaram 11.697 idosos e, desses, 53,1% possuíam multimorbidade. Na análise multivariada, observou-se que a presença de multimorbidade em idosos predispôs a um relato negativo da autopercepção de saúde bucal (p=0,025), à dificuldade de se alimentar devido a problemas dentários (p0,001), a perder totalmente os dentes superiores (p0,001) e a escovar os dentes ou próteses pelo menos uma vez ao dia (p=0,025). Conclusão:Diante dos resultados, conclui-se que a maioria das condições de saúde bucal, assim como a autopercepção das mesmas apresentam-se piores na presença de multimorbidade na população idosa (AU).

Introduction:The occurrence of multimorbidity, which corresponds to the accumulation of chronic diseases, is considered a public health problem and its consequences on oral health lack scientific evidence in large populations.Objective:To evaluate the impact of multimorbidity on oral health conditions in elderly Brazilians.Methods:A cross-sectional and population-based study was carried out, using the database of the National Health Survey. The presence of multimorbidity in the elderly was considered when they had adiagnosis of two or more chronic diseases. Regarding oral health conditions, these were collected from the variables studied in the National Health Survey. The Chi-square test was used for data analysis and then the prevalence ratios were adjusted using Poisson multiple regression.Results:11,697 elderly people participated and, of these, 53.1% had multimorbidity. In the multivariate analysis, it was observed that the presence of multimorbidity in the elderly predisposed to a negative report of self-perceived oral health (p=0.025), the difficulty of eating due to dental problems (p0.001), to lose teeth completely (p0.001)and brushing teeth or dentures at least once a day (p=0.025). Conclusions:In view of the results, it is concluded that most oral health conditions, as well as their self-perception, are worse in the presence of multimorbidity in the elderly population (AU).

Introducción:La aparición de multimorbilidad, que corresponde a la acumulación de enfermedades crónicas, se considera un problema de salud pública y sus consecuencias sobre la salud bucalcarecen de evidencia científica en grandes poblaciones. Objetivo:Evaluar el impacto de la multimorbilidad en las condiciones de salud bucal en los brasileños de edad avanzada. Método:Se realizó un estudio transversal y basado en la población, utilizando la base de datos de la Encuesta Nacional de Salud. Se consideró la presencia de multimorbilidad en los ancianos cuando tenían un diagnóstico de dos o más enfermedades crónicas. En cuanto a las condiciones de salud bucal, se obtuvieron de las variables estudiadas en el Encuesta Nacional de Salud. La prueba de Chi-cuadrado se usó para el análisis de datos y luego las razones de prevalencia se ajustaron mediante regresión múltiple de Poisson. Resultados:Participaron 11.697 personas mayores y, de estos, 53.1% tenían multimorbilidad. En el análisis multivariante, se observó que la presencia de multimorbilidad en los ancianos predispone a un informe negativo de autopercepción de la salud bucal (p=0,025), la dificultad de comer debido a problemas dentales (p0,001), para perder los dientes por completo (p0,001) y cepillarse los dientes o las dentaduras postizas al menos una vez al día (p=0,025).Conclusiones:En vista de los resultados, se concluye que la mayoría de las afecciones de salud bucal, así como su autopercepción, son peores en presencia de multimorbilidad en la población de edad avanzada (AU).

Optimizing treatment sequencing of chemotherapy for patients with rectal cancer: The KIR randomized phase II trial.

BACKGROUND: Randomized studies have shown low compliance to adjuvant chemotherapy in rectal cancer patients receiving preoperative chemotherapy and external beam radiation (CT/EBRT) with total mesorectal excision. We hypothesize that giving neoadjuvant CT before local treatment would improve CT compliance. METHODS: Between 2010-2017, 180 patients were randomized (2:1) to either Arm A (AA) with FOLFOX x6 cycles prior to high dose rate brachytherapy (HDRBT) and surgery plus adjuvant FOLFOX x6 cycles, or Arm B (AB), with neoadjuvant HDRBT with surgery and adjuvant FOLFOX x12 cycles. The primary endpoint was CT compliance to ≥85% of full-dose CT for the first six cycles. Secondary endpoints were ypT0N0, five-year disease free survival (DFS), local control and overall survival (OS). RESULTS: Patients were randomized to either AA (n = 120, median age (MA) 62 years) or AB (n = 60, MA 63 years). 175/180 patients completed HDRBT as planned (97.2%). In AA, two patients expired during CT; three patients post-randomization received short course EBRT because of progression under CT (n = 2, AA) or personal preference (n = 1, AB). ypT0N0 was 31% in AA and 28% in AB (p = 0.7). CT Compliance was 80% in AA and 53% in AB (p = 0.0002). Acute G3/G4 toxicity was 35.8% in AA and 27.6% in AB (p = 0.23). With a median follow-up of 48.5 months (IQR 33-72), the five-year DFS was 72.3% with AA and 68.3% with AB (p = 0.74), the five-year OS 83.8% for AA and 82.2% for AB (p = 0.53), and the five-year local recurrence was 6.3% for AA and 5.8% for AB (p = 0.71). CONCLUSION: We confirmed improved compliance to neoadjuvant CT in this study. Although there is no statistical difference in ypT0N0 rate, local recurrence, and DFS between the two arms, a trend towards favourable oncological outcomes is observed.

Trends in Colectomies for Colorectal Neoplasms in Ulcerative Colitis: a National Inpatient Sample Database Analysis over Two Decades.

BACKGROUND: Rates of colectomy for ulcerative colitis have been decreasing, particularly since the advent of biologics, but the subsequent impact of reduced colectomy rates on the development of neoplasms in chronically treated ulcerative colitis colons is unknown. PURPOSE: To determine trends in colectomy for colorectal neoplasms in adult patients with ulcerative colitis. METHODS: Adult admissions with ulcerative colitis were identified from the National Inpatient Sample from 1993 to 2015. The rate of colectomy with concurrent colorectal neoplasm served as the primary outcome and was evaluated using time trend linear and multivariable regression. RESULTS: There were 366,286 admissions with ulcerative colitis including 16,556 (4.5%) total colectomies. Of those undergoing colectomy, 2018 (12.2%) had a concurrent diagnosis of colorectal neoplasm. The proportion of colectomies for ulcerative colitis with concurrent colorectal neoplasm increased from 10.3 to 12.5% (pTrend = 0.004). Specifically, the proportion of colectomies performed for dysplasia/benign neoplasm and rectal cancer increased from 3.5 to 5.6% (pTrend < 0.001) and from 2.6 to 3.0% (pTrend = 0.028) respectively, and those for colon cancer remained stable (4.5 to 3.9%, pTrend = 0.423). On multivariate regression, year of colectomy was a significant predictor of colectomy for colorectal neoplasm (OR = 1.044, 95% CI = 1.025-1.062). DISCUSSION: Operative management of ulcerative colitis appears to be slowly increasing in oncological indications. The rising proportions of colectomies performed for colorectal neoplasms suggest the need for continued screening in these patients, including rectal surveillance.

Development and evaluation of a patient-centred program for low anterior resection syndrome: protocol for a randomized controlled trial.

INTRODUCTION: Low anterior resection syndrome (LARS) is described as disordered bowel function after rectal resection that leads to a detriment in quality of life, and affects the majority of individuals following restorative proctectomy for rectal cancer. The management of LARS includes personalised troubleshooting and effective self-management behaviours. Thus, affected individuals need to be well informed and appropriately engaged in their own LARS management. This manuscript describes the development of a LARS patient-centred programme (LPCP) and the study protocol for its evaluation in a randomised controlled trial. METHODS AND ANALYSIS: This will be a multicentre, randomised, assessor-blind, parallel-groups, pragmatic trial evaluating the impact of an LPCP, consisting of an informational booklet, patient diaries and nurse support, on patient-reported outcomes after restorative proctectomy for rectal cancer. The informational booklet was developed by a multidisciplinary LARS team, and was vetted in a focus group and semistructured interviews involving patients, caregivers, and healthcare professionals. The primary outcome will be global quality of life (QoL), as measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30), at 6 months after surgery. The treatment effect on global QoL will be modelled using generalised estimating equations. Secondary outcomes include symptom change, patient activation, bowel function measures, emotional distress, knowledge about LARS and satisfaction with the LPCP. ETHICS AND DISSEMINATION: The Research Ethics Committee (REC) at the Integrated Health and Social Services Network for West-Central Montreal (health network responsible for the Jewish General Hospital) is the overseeing REC for all Quebec sites. They have granted ethical approval (MP-05-2019-1628) for all Quebec hospitals (Jewish General Hospital, McGill University Health Center, CHU de Quebec) and have granted full authorisation to begin research at the Jewish General Hospital. Patient recruitment will not begin at the other Quebec sites until inter-institutional contracts are finalised and feasibility/authorisation for research is granted by their respective REC. The results of this study will be presented at national and international conferences, and a manuscript with results will be submitted for publication in a high-impact peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT03828318; Pre-results.

Short- and Long-Term Outcomes of Right-Sided Diverticulitis: Over 15 Years of North American Experience.

BACKGROUND: Right-sided colonic diverticulitis represents less than 5% of diverticulitis cases in North America. The purpose of this study was to describe the management and outcomes for patients with a first episode of right-sided diverticulitis in a North American center. METHODS: This was a retrospective cohort study, including all patients managed for right-sided diverticulitis at a single tertiary-care institution from 2000 to 2017. Patient demographics, disease characteristics, and treatment strategies were described. Short- (emergency surgery, operative morbidity, treatment failure) and long-term (recurrence, elective operation) outcomes were reported. Patients with right-sided diverticulitis were then compared to a cohort of patients with left-sided diverticulitis. RESULTS: Sixty-seven patients were managed for a first episode of right-sided diverticulitis, three (4.5%) of which were subsequently diagnosed with right-sided colon cancer; 64 patients therefore formed the population. Mean age was 51.2 ± 17.7 years. Eight patients (12.5%) self-identified as being Asian. The majority of patients had uncomplicated disease (90.6%); six (9.4%) presented with complicated diverticulitis. Most cases were diagnosed by computed tomography (78.1%), while 17.2% were diagnosed intra-operatively and 4.7% by pathology. Almost all patients diagnosed by computed tomography were managed nonoperatively. Fifteen patients (23.4%) were managed surgically: ten for suspected appendicitis, three for suspected colon mass, and two for diffuse peritonitis. After a median follow-up of 74.8 months (IQR 30.2-130.5), only two patients (3.1%) developed recurrent right-sided diverticulitis. Among patients managed nonoperatively, recurrence was significantly lower in patients with right-sided diverticulitis relative to left-sided diverticulitis (4.1% vs. 32.8%, p < 0.001). CONCLUSIONS: Right-sided diverticulitis can be successfully managed nonoperatively with low rates of recurrence. In populations in which this condition is more seldom observed, underlying colon cancers should be considered.