Hereditary colorectal cancer screening: A 10-year longitudinal cohort study following an educational intervention.

Family history (FH) of a first-degree relative with colorectal cancer (CRC) is associated with two to fourfold increased risk, yet screening uptake is suboptimal despite proven mortality reduction. We developed a FH-based CRC Risk Triage/Management tool for family physicians (FPs), and educational booklet for patients with CRC FH. This report describes physician referral and patient screening behavior 5 and 10 years post-educational intervention, and factors associated with screening. Longitudinal cohort study. FPs/patients in Ontario and Newfoundland, Canada were sent questionnaires at baseline (2005), 5 and 10 years (2015) following tool/booklet receipt. FPs were asked about CRC screening, patients about FH, screening type and timing. "Correct" screening was concordance with tool recommendations. Results reported for 29/121 (24%) FPs and 98/297 (33%) patients who completed all 3 questionnaires. Over 10 years 2/3 patients received the correct CRC screening test at appropriate timing (baseline 75%, 5-year 62%, 10-year 65%). About half reported their FP recommended CRC screening (5-year 51%, 10-year 63%). Fewer than half the patients correctly assessed their CRC risk (44%, 40%, 41%). Patients were less likely to have correct screening timing if female (RR 0.78; 95% CI 0.61, 0.99; p = 0.045). Patients were less likely to have both correct test and timing if moderate/high CRC risk (RR 0.66; 95% CI 0.47, 0.93; p = 0.017) and more likely if their physician recommended screening (RR1.69; 95% CI 1.15, 2.49; p = 0.007). Physician discussion of CRC risk and screening can positively impact patient screening behavior. Efforts are particularly needed for women and patients at moderate/high CRC risk.

Optimal local anesthetic regimen for saddle block in ambulatory anorectal surgery: an evidence-based systematic review.

BACKGROUND: Ambulatory anorectal surgery requires an anesthetic of short duration but profound depth. Saddle block anesthesia (SBA) can provide dense sacral anesthesia with minimal motor blockade, but the ideal local anesthetic agent remains undefined. This systematic review aims to identify the optimal SBA regimen for ambulatory anorectal surgery. METHODS: We sought randomized trials examining SBA for ambulatory anorectal surgery and stratified patients into four subgroups according to local anesthetic type and dose: (1) longer acting, higher dose; (2) longer acting, lower dose; (3) shorter acting, higher dose; and (4) shorter acting, lower dose. Longer acting agents included bupivacaine and levobupivacaine; shorter acting agents included chloroprocaine, mepivacaine, and prilocaine. Lower dose was defined as ≤5 mg and ≤20 mg for longer and shorter acting local anesthetics, respectively. The primary outcome was time to discharge; secondary outcomes included times to sensory and motor block regression, urine voiding, and ambulation, as well as block success. RESULTS: A total of 11 trials (1063 patients) were included. Overall study quality and reporting consistency was poor. Doses ranged from 1.5-7.5 mg to 3-30 mg of longer and shorter acting local anesthetics, respectively. Hyperbaric local anesthetics were used in eight trials (953 patients, 86%). The median time to discharge appeared similar across all subgroups with an overall time of 182 (IQR 102) min. The use of long-acting, lower dose regimens was associated with a faster median time to motor block regression. Block success approached 99% among all trials. CONCLUSIONS: There is presently insufficient qualitative and quantitative evidence to identify an optimal SBA regimen for ambulatory anorectal surgery. Nonetheless, we found that doses as low as 1.5 and 3 mg of longer and shorter acting hyperbaric local anesthetics, respectively, can achieve effective and reliable SBA with timely hospital discharge. Despite similar discharge times, longer acting, lower dose local anesthetics may produce faster motor block regression following SBA for ambulatory anorectal surgery.

Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part III: Local Instillation Analgesia-A Systematic Review and Meta-analysis.

BACKGROUND: Local infiltration analgesia offers effective postoperative analgesia after knee arthroplasty, but the role of its counterpart, local instillation analgesia (LIA), in anterior cruciate ligament reconstruction (ACLR) is unclear. This systematic review and meta-analysis evaluates the analgesic benefits of LIA for outpatient ACLR. METHODS: We sought randomized controlled trials investigating the analgesic effects of LIA versus control in adults having outpatient ACLR and receiving multimodal analgesia (excluding nerve blocks, which are examined in parts I and II of this project). Cumulative postoperative analgesic consumption at 24 hours was designated as a primary outcome. Analgesic consumption during postanesthesia care unit stay, proportion of patients requiring analgesic supplementation, time-to-first analgesic request, rest pain scores during the first 48 hours, hospital length of stay, and incidence of opioid-related side effects were analyzed as secondary outcomes and pooled using random effects modeling. RESULTS: Eleven randomized controlled trials (515 patients) were included. Analgesic consumption was selected as the primary outcome in 4 trials (36%). Compared to control, LIA reduced the 24-hour morphine consumption by a weighted mean difference (95% confidence interval) of -18.0 mg (-33.4 to -2.6) (P = .02). LIA reduced postanesthesia care unit morphine consumption by -55.9 mg (-88.4 to -23.4) (P < .05) and decreased the odds (odds ratio [95% confidence interval]) of analgesic supplementation during the first 24 hours by 0.4 (0.2-0.8) (P = .004). LIA also improved pain scores during the 0-24-hour interval, most notably at 4 hours (-1.6 [-2.2 to -1.0) (P < .00001). CONCLUSIONS: Administering LIA for outpatient ACLR improves postoperative analgesia by decreasing opioid consumption and improving pain control up to 24 hours, with minimal complications. These findings encourage integrating LIA into the care standard for ACLR. Questions regarding the ideal LIA components, location, and role in the setting of hamstring grafts require further research.