Physiological, psychological and behavioural characteristics of men and women with faecal incontinence.

BACKGROUND: The factors leading to faecal incontinence in males are less well understood than those in females. In this prospective study we aimed to compare the physiological, anatomical, psychological and behavioural characteristics of male and female patients presenting with symptoms of faecal incontinence. METHOD: One hundred and nine patients presenting with symptoms of faecal incontinence were studied. They underwent anorectal physiological studies, endoanal ultrasonography, and completed a St Mark's Incontinence Score, a locally developed pad questionnaire, a bowel symptom questionnaire, the Short Form 36 (SF-36) Health Survey questionnaire, the Hospital Anxiety and Depression Scale and the Maudsley Obsessive Compulsive Inventory. RESULTS: Thirty-four men (mean age 59 years, SD 14 years, range 33-80) and 75 women (mean age 55 years, SD 15 years, range 21-86) participated in the study. Twenty-one patients (38% of men and 11% of women) had normal manometry and endoanal ultrasonography. There was no significant difference in the resting pressures of men compared with women, but men had significantly higher squeeze pressures. Rectal capacity was significantly higher in men but anal and rectal electrosensitivities were the same. Men placed a tissue at the anus more commonly than women while women were more likely to use a pad and to carry a spare pair of underwear around with them. Psychological profiles were very similar in the two sexes. CONCLUSIONS: Nearly 40% of men with faecal incontinence report it in the absence of a definable functional or structural sphincter abnormality. There are differences in physiological characteristics and coping behaviours of men and women with faecal incontinence.

An analysis of predictive factors for healing and mortality in patients with enterocutaneous fistulas.

BACKGROUND: Most studies of enterocutaneous fistula report management and outcome. Few studies examine factors predicting healing and mortality. AIM: To identify factors predicting healing and mortality in patients with ECF managed either with a definitive attempt at surgical closure or conservatively. METHODS: The case notes of 277 patients with enterocutaneous fistula, treated at our institution over a 10 year period, were retrospectively reviewed. Patients were divided into those managed operatively or conservatively. Eleven factors were examined for their relationship to fistula healing and fistula-related mortality. RESULTS: For patients treated operatively, successful enterocutaneous fistula closure related only to the complexity of the fistula (multiple fistula or presence of an internal abscess cavity) (P = 0.03), whereas fistula-related mortality related only to the presence of comorbidity (P = 0.02). In patients managed conservatively, a decreased likelihood of enterocutaneous fistula closure was associated with a high fistula output (P = 0.01), comorbidity (P = 0.03) and being referred from an external institution (P < 0.001). Fistula related-mortality in this group was related to a high output (P = 0.003) and an increased age (P = 0.001). CONCLUSION: In patients managed operatively, fistula healing and fistula-related mortality are each associated with only one factor, whereas in patients managed conservatively healing and mortality are predicted by three and two factors, respectively.

Breeding for abiotic stresses for sustainable agriculture.

Using cereal crops as examples, we review the breeding for tolerance to the abiotic stresses of low nitrogen, drought, salinity and aluminium toxicity. All are already important abiotic stress factors that cause large and widespread yield reductions. Drought will increase in importance with climate change, the area of irrigated land that is salinized continues to increase, and the cost of inorganic N is set to rise. There is good potential for directly breeding for adaptation to low N while retaining an ability to respond to high N conditions. Breeding for drought and salinity tolerance have proven to be difficult, and the complex mechanisms of tolerance are reviewed. Marker-assisted selection for component traits of drought in rice and pearl millet and salinity tolerance in wheat has produced some positive results and the pyramiding of stable quantitative trait locuses controlling component traits may provide a solution. New genomic technologies promise to make progress for breeding tolerance to these two stresses through a more fundamental understanding of underlying processes and identification of the genes responsible. In wheat, there is a great potential of breeding genetic resistance for salinity and aluminium tolerance through the contributions of wild relatives.

A high-density genetic map of hexaploid wheat (Triticum aestivum L.) from the cross Chinese Spring x SQ1 and its use to compare QTLs for grain yield across a range of environments.

A population of 96 doubled haploid lines (DHLs) was prepared from F1 plants of the hexaploid wheat cross Chinese Spring x SQ1 (a high abscisic acid-expressing breeding line) and was mapped with 567 RFLP, AFLP, SSR, morphological and biochemical markers covering all 21 chromosomes, with a total map length of 3,522 cM. Although the map lengths for each genome were very similar, the D genome had only half the markers of the other two genomes. The map was used to identify quantitative trait loci (QTLs) for yield and yield components from a combination of 24 site x treatment x year combinations, including nutrient stress, drought stress and salt stress treatments. Although yield QTLs were widely distributed around the genome, 17 clusters of yield QTLs from five or more trials were identified: two on group 1 chromosomes, one each on group 2 and group 3, five on group 4, four on group 5, one on group 6 and three on group 7. The strongest yield QTL effects were on chromosomes 7AL and 7BL, due mainly to variation in grain numbers per ear. Three of the yield QTL clusters were largely site-specific, while four clusters were largely associated with one or other of the stress treatments. Three of the yield QTL clusters were coincident with the dwarfing gene Rht-B1 on 4BS and with the vernalisation genes Vrn-A1 on 5AL and Vrn-D1 on 5DL. Yields of each DHL were calculated for trial mean yields of 6 g plant(-1) and 2 g plant(-1) (equivalent to about 8 t ha(-1) and 2.5 t ha(-1), respectively), representing optimum and moderately stressed conditions. Analyses of these yield estimates using interval mapping confirmed the group-7 effects on yield and, at 2 g plant(-1), identified two additional major yield QTLs on chromosomes 1D and 5A. Many of the yield QTL clusters corresponded with QTLs already reported in wheat and, on the basis of comparative genetics, also in rice. The implications of these results for improving wheat yield stability are discussed.

An 11-year experience of enterocutaneous fistula.

BACKGROUND: Enterocutaneous fistula has traditionally been associated with substantial morbidity and mortality, related to fluid, electrolyte and metabolic disturbance, sepsis and malnutrition. METHODS: A retrospective review of enterocutaneous fistula in 277 consecutive patients treated over an 11-year period in a major tertiary referral centre was undertaken to evaluate current management practice and outcome. RESULTS: Most fistulas occurred secondary to abdominal surgery, and a high proportion (52.7 per cent) occurred in association with inflammatory bowel disease. A low rate of spontaneous healing was observed (19.9 per cent). The healing rate after definitive fistula surgery was 82.0 per cent, although more than one attempt was required to achieve surgical closure in some patients. Definitive fistula resection resulted in a mortality rate of 3.0 per cent. In addition, one patient died after laparotomy for intra-abdominal sepsis and an additional 24 patients died from complications of fistulation, giving an overall fistula-related mortality rate of 10.8 per cent. CONCLUSION: Early recognition and control of sepsis, management of fluid and electrolyte imbalances, meticulous wound care and nutritional support appear to reduce the mortality rate, and allow spontaneous fistula closure in some patients. Definitive surgical management is performed only after restitution of normal physiology, usually after at least 6 months.

A prospective randomized trial of day-stay only versus overnight-stay laparoscopic cholecystectomy.

BACKGROUND: Although the feasibility of laparoscopic cholecystectomy performed as day surgery has been established, cost and recovery time have not previously been evaluated in a prospective comparative fashion. METHODS: Patients were randomized to day stay only or overnight stay, and a nurse assessed the former postoperatively at home. All patients were reviewed weekly or as required if problems occurred. Costing comparisons were made between the two groups using Trendstar software. RESULTS: A total of 131 patients were evaluated after randomization (60 day-stay only patients and 71 overnight-stay patients). A total of 18.3% of the day-stay patients required in-hospital admission for nausea, vomiting, or pain, or after conversion to open operation; 18.3% of the overnight group required an extended length of stay for similar reasons. After discharge, two day-stay and three overnight-stay patients required readmission, only one had a significant complication. The mean times to return to normal activity averaged 1.8 weeks (SE: 0.1 weeks) and 1.9 weeks (SE: 0.1 weeks) for day-stay and overnight-stay groups, respectively (P = 0.63), and costs of $2732 (SE: $76) compared to $2835 (SE $110), respectively (P = 0.94). CONCLUSIONS: In the present randomized controlled study, day-stay management did not compromise postoperative patient outcome. In the setting of a major teaching hospital there was no cost advantage when compared to overnight-stay management.

Acute heart failure: determinants of outcome.

We prospectively studied 69 consecutive patients hospitalized with a primary diagnosis of acute left ventricular failure so as to assess the impact of vasodilators on incidence and morbidity of acute symptomatic left ventricular failure. The determinants of duration of hospitalization, in-hospital mortality and symptomatic status 2 months after discharge were examined. There were 9 in-hospital deaths (13%), and survival at 60 days was 77%. Median duration of hospitalization was 9 days, and 33% of the surviving patients remained in New York Heart Association functional class III-IV 60 days subsequent to discharge. Of the patients, 49 (76%) had previously received treatment for left ventricular failure: 30 (61%) of these had received vasodilators, most commonly angiotensin converting enzyme inhibitors and nitrates. Ischaemic chest pain was present in 34 (49%) of the patients. Acute utilization of vasodilators (45% of patients) was largely limited to nitrate therapy associated with ischaemic chest pain (P less than 0.01). Multiple logistic regression revealed previous left ventricular failure, advanced age and hypokalaemia as significant correlates of prolonged hospitalization (greater than 9 days). Previous left ventricular failure was also predictive of persistent severe disability two months subsequent to discharge. No factor was a significant predictor of in-hospital death. Although preceding treatment with digoxin and incremental angiotensin converting enzyme inhibitor therapy tended to predict brief hospitalization, the parameter of acute ischaemia, other biochemical anomalies and modes of acute or chronic therapy were not significant correlates of any end point. We conclude that preceding disability, rather than mode of treatment, predicts an adverse outcome in acute left ventricular failure.