Mapping the colorectal tumor microbiota.

The gut microbiome in patients with colorectal cancer (CRC) is different than that of healthy controls. Previous studies have profiled the CRC tumor microbiome using a single biopsy. However, since the morphology and cellular subtype vary significantly within an individual tumor, the possibility of sampling error arises for the microbiome within an individual tumor. To test this hypothesis, seven biopsies were taken from representative areas on and off the tumor in five patients with CRC. The microbiome composition was strikingly similar across all samples from an individual. The variation in microbiome alpha-diversity was significantly greater between individuals' samples then within individuals. This is the first study, to our knowledge, that shows that the microbiome of an individual tumor is spatially homogeneous. Our finding strengthens the assumption that a single biopsy is representative of the entire tumor, and that microbiota changes are not limited to a specific area of the neoplasm.

Long-term cancer surveillance: results from the Forteo Patient Registry Surveillance Study.

The Forteo Patient Registry estimated the incidence of osteosarcoma in US patients treated with teriparatide and enrolled in the study between 2009 and 2019. No incident cases of osteosarcoma were identified among patients registered, and the crude incidence rate was 0 (95% confidence interval [CI], 0-10.2) cases per million person-years. PURPOSE: The prospective, voluntary Forteo Patient Registry was established to estimate the incidence of osteosarcoma in patients who have received treatment with teriparatide (Forteo). METHODS: Information on US adults prescribed teriparatide and enrolled in the Forteo Patient Registry 2009-2019 was linked with data from participating state cancer registries annually (2010-2019) to identify incident osteosarcoma cases using a standardized linkage algorithm. Teriparatide exposure was ascertained from self-reported data that included teriparatide initiation and demographics necessary to complete linkage. Osteosarcoma cases diagnosed on or after January 1, 2009, were identified by participating state cancer registries. The crude incidence rate (IR) and standardized incidence ratio (SIR) of observed cases to the expected number of cases adjusted to the background rate (3 per million person-years) and corresponding 95% CIs for the occurrence of osteosarcoma were calculated whereby the cumulative amount of person-time observed was adjusted for mortality. RESULTS: Data for 75,247 enrolled patients (representing 361,763 cumulative person-years) were linked to each of 42 participating state cancer registries (covering 93% of the US population), which included information on 6180 cases of osteosarcoma. No matches with incident cases of osteosarcoma following registry enrollment were found. The crude IR was 0 (95% CI, 0-10.2) cases per million person-years and the SIR was 0 (95% CI, 0-3.0). CONCLUSIONS: The ability to draw conclusions about the incidence of osteosarcoma among patients participating in the registry was limited due to the smaller than expected amount of patient follow-up time and the fact that no cases were identified.

Australasian ACPGBI risk prediction model for 30-day mortality after colorectal cancer surgery.

BACKGROUND: Postoperative mortality after colorectal cancer surgery varies across hospitals and countries. The aim of this study was to test the Association of Coloproctologists of Great Britain and Ireland (ACPGBI) models as predictors of 30-day mortality in an Australian cohort. METHODS: Data from patients who underwent surgery in six hospitals between 1996 and 2015 (CRC data set) were reviewed to test ACPGBI models, and patients from 79 hospitals in the Bi-National Colorectal Cancer Audit between 2007 and 2016 (BCCA data set) were analysed to validate model performance. Recalibrated models based on ACPGBI risk models were developed, tested and validated on a data set of Australasian patients. RESULTS: Of 18 752 patients observed during the study, 6727 (CRC data set) and 3814 (BCCA data set) were analysed. The 30-day mortality rate was 1·1 and 3·5 per cent in the CRC and BCCA data sets respectively. Both the original and revised ACPGBI models overestimated 30-day mortality for the CRC data set (observed to expected (O/E) ratio 0·17 and 0·21 respectively). Their ability to correctly predict mortality risk was poor (P < 0·001, Hosmer-Lemeshow test); however, the area under the curve for both models was 0·88 (95 per cent c.i. 0·85 to 0·92) showing good discriminatory power to classify 30-day mortality. The recalibrated original model performed well for calibration and discrimination, whereas the recalibrated revised model performed well for discrimination but not for calibration. Risk prediction was good for both recalibrated models. On external validation using the BCCA data set, the recalibrated models underestimated mortality risk (O/E ratio 3·06 and 2·98 respectively), whereas both original and revised ACPGBI models overestimated the risk (O/E ratio 0·48 and 0·69). All models showed similar good discrimination. CONCLUSION: The original and revised ACPGBI models overpredicted risk of 30-day mortality. The new Australasian calibrated ACPGBI model needs to be tested further in clinical practice.

ANTECEDENTES: La mortalidad postoperatoria tras la cirugía del cancer colorrectal (colorectal cáncer, CRC) varía entre hospitales y países. El objetivo de este estudio era evaluar los modelos de la Asociación de Coloproctólogos de Gran Bretaña e Irlanda (Association of Coloproctologists of Great Britain and Ireland, ACPGBI) como predictores de mortalidad a los 30 días en una cohorte de pacientes de Australia. MÉTODOS: Se revisaron los datos de pacientes sometidos a cirugía en seis hospitales entre 1996-2015 (datos CRC) para evaluar los modelos ACPGBI, mientras que los datos recogidos en 79 hospitales en la auditoría bi-nacional de cáncer colorrectal (Bi-National Colorectal Cancer Audit) entre 2007-2016 (datos BCCA) se analizaron para validar el comportamiento del modelo. Se desarrollaron modelos recalibrados basados en los modelos de riesgo ACPGBI que fueron aplicados y validados en un conjunto de datos multi-institucionales de pacientes australianos. La mortalidad observada y estimada (tasa 0/E) a 30 días se calculó en los modelos ACPGBI original y revisados usando el test de Hosmer-Lemeshow y los análisis de la curva de las características operador-receptor (ROC) para evaluar la calibración y discriminación de los modelos. RESULTADOS: De un total de 18,752 pacientes observados durante el periodo de estudio, se analizaron 6.727 (datos CRC) y 3.814 (datos BCCA). La mortalidad en los pacientes del grupo de datos CRC fue del 1,1% y en los del grupo de datos BCCA del 3,5%. Para el grupo de datos CRC, los modelos ACPGBI sobreestimaron significativamente la mortalidad a los 30 días, tanto en el modelo original como en el modelo revisado (O/E 0,17 y 0,21). La capacidad de los modelos para predecir correctamente el riesgo de mortalidad también fue limitada (test de Hosmer-Lemeshow 23,1 y 22.9); sin embargo, el área bajo la curva ROC de ambos modelos fue de 0,88 (i.c. del 95% 0,85-0,92) con una buena capacidad discriminatoria para clasificar a los pacientes que fallecían durante los primeros 30 días tras la cirugía. El modelo original ACPGBI recalibrado presentó un buen comportamiento para la predicción de riesgo (tasa O/E 1,06), pero no fue así en el caso del modelo revisado ACPGBI recalibrado (tasa O/E 0,99). En la validación externa con los datos BCCA, los modelos recalibrados subestimaron el riesgo de mortalidad a los 30 días (tasa O/E 3,06 y 2,98), mientras que los modelos ACPGBI original y revisado sobreestimaron el riesgo (tasa O/E 0,48 y 0,69, respectivamente). Todos los modelos mostraron una buena discriminación en las curvas ROC. CONCLUSIÓN: Los modelos ACPGBI original y revisado sobreestimaron el riesgo de mortalidad a los 30 días. Se desarrolló un nuevo modelo, denominado modelo ACPGBI calibrado australiano o modelo ACACPGBI, cuya utilidad en la práctica clínica debe ser evaluada.

The Forteo Patient Registry linkage to multiple state cancer registries: study design and results from the first 8 years.

The Forteo Patient Registry (FPR) aims to estimate the incidence of osteosarcoma in US patients treated with teriparatide. Enrollment began in 2009 and will continue through 2019, with linkage planned through 2024. To date, no incident cases of osteosarcoma have been identified among patients registered in the FPR. INTRODUCTION: The Forteo Patient Registry (FPR) was established in 2009 to estimate the incidence of osteosarcoma in US patients treated with teriparatide. The objective of this paper is to describe study methods, challenges encountered, and progress to date. METHODS: The FPR is a prospective US registry designed to link data from participants annually with state cancer registries. Patient enrollment is planned for 10 years (2009-2019) and annual linkage with US state cancer registries for 15 years (2010-2024). All US state cancer registries and DC were invited to participate. Patients are recruited using pre-enrollment materials included in teriparatide device packaging, kits, and brochures distributed by health-care providers; a toll-free number; and a study website. A linkage algorithm is used to match data from enrolled participants with cancer registry data. RESULTS: For the eighth annual linkage in 2017, information necessary for linkage with 63,270 patients in the FPR was submitted to each of the 42 participating registries. These patients contributed approximately 242,782 person-years of follow-up. A total of 5268 adult osteosarcoma cases diagnosed since January 1, 2009, were available for linkage from participating state cancer registries. To date, no incident cases of osteosarcoma have been identified among patients registered in the FPR. CONCLUSIONS: Based on the estimated 242,782 person-years of observation as of the eighth annual linkage and projecting current enrollment rate to study end in 2024, it is anticipated that the completed study will be able to detect a fourfold increase in the risk of osteosarcoma if one exists.

The impact of co-existing immune-mediated diseases on phenotype and outcomes in inflammatory bowel diseases.

BACKGROUND: Inflammatory bowel diseases lead to progressive bowel damage and need for surgery. While the increase in prevalence of other immune-mediated diseases in IBD is well recognised, the impact of this on the natural history of IBD is unknown. AIM: To determine the impact of concomitant immune-mediated diseases on phenotypes and outcomes in IBD. METHODS: Patients with IBD enrolled in a prospective registry were queried about the presence of other immune-mediated diseases, defined as those where immune dysregulation plays a role in pathogenesis. Demographics and disease-related information were obtained. Subjects also completed measures of quality of life. Multivariable regression models compared disease phenotype and outcomes of IBD patients with and without other immune-mediated diseases. RESULTS: The cohort included 2145 IBD patients among whom 458 (21%) had another immune-mediated disease. There was no difference in CD phenotype between the two groups. UC patients were more likely to have pancolitis in the presence of another immune-mediated disease (62%) compared to those without (52%, P = 0.02). IBD patients with another immune-mediated disease had higher rates of needing anti-TNF biologics [Odds ratio (OR) 1.31, 95% CI 1.05-1.63] and surgery (OR 1.26, 95% CI 0.99-1.61). The presence of another immune-mediated disease was also associated with lower disease-specific and general physical quality of life. CONCLUSIONS: The presence of another immune-mediated disease in IBD patients was associated with higher likelihood of pancolonic involvement in UC, and a modest increase in need for IBD-related surgery and anti-TNF biological therapy. Such patients also experienced worse quality of life.

An anomalous African dust event and its impact on aerosol radiative forcing on the Southwest Atlantic coast of Europe in February 2016.

A desert dust (DD) event that had its origin in North Africa occurred on the 20th-23rd of February 2016. The dust transport phenomenon was exceptional because of its unusual intensity during the coldest season. A historical dataset (2006-2015) of February meteorological scenarios using ECMWF fields, meteorological parameters, aerosol optical properties, surface O3 and AOD retrieved from MODIS at the El Arenosillo observatory (southwestern Spain) were analysed and compared with the levels during the DD event to highlight its exceptionality. Associated with a low-pressure system in western North Africa, flows transported air from the Sahel to Algeria and consequently increased temperatures from the surface to 700hPa by up to 7-9°C relative to the last decade. These conditions favoured the formation of a Saharan air layer. Dust was transported to the north and reached the Western Mediterranean Basin and the Iberian Peninsula. The arrival of the DD event at El Arenosillo did not affect the surface weather conditions or ozone but did impact the aerosol radiative forcing at the top of atmosphere (RFTOA). Aerosol radiative properties did not change relative to historical; however, the particle size and the amount of the aerosol were significantly higher. The DD event caused an increase (in absolute terms) of the mean aerosol RFTOA to a value of -8.1Wm-2 (long-term climatological value ~-1.5Wm-2). The aerosol RFTOA was not very large relative other DD episodes; however, our analysis of the historical data concluded that the importance of this DD event lay in the month of occurrence. European phenological datasets related to extreme atmospheric events predominantly reflect changes that are probably associated with climate change. This work is an example of this phenomenon, showing an event that occurred in a hotspot, the Saharan desert, and its impact two thousand km away.

The effect of spinal cord level on sexual function in the spina bifida population.

INTRODUCTION: Sexual dysfunction and infertility are prevalent in the spina bifida (SB) population; however, the mechanism of how they affect a person with spina bifida is poorly understood. Additionally, the management of children with spina bifida becomes more difficult as they exit from pediatric institutes. OBJECTIVE: The present study sought to evaluate sexual health (using validated questionnaires) and fertility in adults with spina bifida and to correlate spinal cord level and ambulatory status with degree of sexual function. STUDY DESIGN: After institutional board review approval, 199 adult patients with SB, aged 18 and older and who were followed in one pediatric institution, were identified. Patients who were non-English speaking, cognitively and/or developmentally delayed, or unable to be contacted were excluded. Surveys regarding demographics, sexual health and infertility were mailed to the patients and administered in the clinic with the option to opt-out of the survey. Survey questions regarding sexual health were constructed using validated questionnaires: Female Sexual Function Index (FSFI) for females, and International Index of Erectile Function (IIEF) and Sexual Health Inventory for Men (SHIM) for males. Sexual dysfunction scores were correlated to the patients' spinal level and ambulatory status. RESULTS: Of the 121 eligible patients, 45 replied, with a response rate of 39%. For females, using a cut-off value of 26.5 for FSFI scoring, 25 out of 28 (89%) had sexual dysfunction. No association was seen between spinal level or ambulatory status and overall FSFI, satisfaction, or desire scores. For males, 10 out of 17 (59%) had severe erectile dysfunction (ED), and one out of 17 (6%) had no ED. No association was seen between ambulatory status and sexual function scores for the males. However, SHIM, satisfaction, and ED scores were higher in males with lower spinal lesions. People with spina bifida of both genders tended to have more severe dysfunction compared to those with sexual dysfunction of other etiologies, except with similar sexual desire scores. Regarding questions on fertility, no participant attempted to have children; thus, there was no infertility reported. DISCUSSION: Few studies have been conducted on sexual health and fertility in adults with SB. Three studies have utilized validated questionnaires and found varying degrees of sexual dysfunction in this subset of patients; however, only one study found sexual activity to be more likely in patients with more caudal levels of neurologic impairment. The present study also showed that SHIM, satisfaction, and ED scores were higher in males with lower spinal lesions. Limitations to this study primarily included the small sample size and low survey response rate. CONCLUSION: Limited information is known about adults with SB, and sexual function and fertility. While expressing sexual desire, adults with SB appear to experience high rates of sexual dysfunction. Fertility rates were inadequately assessed; this was possibly due to the high rate of sexual dysfunction. Sexual health in the SB population is an important component of the myriad of urologic care issues for these people. Due to the disparity in their care after reaching adulthood, it is prudent to follow these patients and understand their pathophysiology as they continue to mature through life.

An evaluation of the relationship between Enterobius vermicularis infestation and acute appendicitis in a paediatric population--A retrospective cohort study.

BACKGROUND: Enterobius vermicularis is an often unexpected finding in appendectomy specimen, most commonly seen in paediatric cases. Predicting the presence of E. vermicularis in the setting of appendectomy is important to avoid unnecessary appendectomy and associated morbidity. We sought to identify the incidence of E. vermicularis in a paediatric population undergoing appendectomy for clinically suspected acute appendicitis and identify predictive factors for E. vermicularis. METHODS: This study was performed in an 800-bed University Teaching Hospital, in the Republic of Ireland. We identified all paediatric appendectomies performed at our institute from January to December 2012 using prospectively maintained operating theatre logbooks. In-hospital Histopathology database, medical notes and operative findings were reviewed for each patient and relevant data recorded. Statistical analysis was performed using IBM SPSS, version 21. RESULTS: In total 182 paediatric appendectomies were performed during the year 2012 for clinically suspected acute appendicitis. Demographics included: Mean age 11.14 years (3-16), gender 1M: 1F. 58.8% of procedures were completed laparoscopically, 39% open and 2.2% were converted. The negative appendectomy rate was 22.5%. The annual incidence of E. vermicularis in acute appendicitis specimen from a paediatric cohort at our institute was 7% (1 in 14). In specimen containing E. vermicularis, 69% had no evidence of appendicitis and of those that had, no gangrene or perforation was seen. The presence of E. vermicularis in paediatric patients with RIF pain may be predicted by Eosinophilia (p = 0.016), normal WCC (p = 0.034) and normal Neutrophil count (p = 0.014). CONCLUSIONS: E. vermicularis is responsible for 7% of acute appendicitis. It is responsible for a significantly higher negative appendectomy rate which if predicted may avoid unnecessary appendectomy and associated morbidity.

What does general paediatric surgery involve? An audit of paediatric cases in 1 year.

BACKGROUND: As all tertiary paediatric hospitals are based in the capital of Dublin, it is therefore necessary for general surgeons in centres outside of Dublin to undertake routine elective and emergency paediatric surgery to provide children with care close to home. The aim of this study is to assess the volume and type of procedures this entails. METHODS: Prospective analysis of the elective and emergency paediatric surgical services provided by a single surgeon in a regional university hospital to determine the volume and nature of general paediatric operative procedures performed. RESULTS: There were 126 operative procedures performed on patients less than 16 years of age during a 12-month period, accounting for 22.8 % of all operations. There were 56 emergency (44.4 %) and 70 elective procedures (55.5 %). The median age was 4.7 years (median age for emergencies 5.4 years, median age for elective surgery 3.8 years). Paediatric operations accounted for 23.4 % of all emergency and 26.2 % of all elective operations. The most commonly performed emergency operations were appendicectomies and pyloromyotomies, representing 73 % of all emergency cases. Inguinal hernia repair, excision of ingrown toenail and percutaneous endoscopic gastrostomy (PEG) tube insertion represented 61 % of elective procedures. CONCLUSIONS: The range of procedures in general paediatric surgery is small with only five procedures representing the majority of all elective and emergency procedures performed. This suggests that a period of specialist paediatric surgery training would enable more general surgeons to provide this vital service.

'I didn't know why you had to wait': an evaluation of NHS infant-feeding workshops amongst women living in areas of high deprivation.

BACKGROUND: Inappropriate maternal and infant-feeding practices are known to have a major impact on morbidity in infancy, childhood and later life. Ring-fenced funding over 3 years from the Scottish Government to the National Health Service (NHS) in Scotland has allowed the development of a range of nutrition interventions for women of childbearing age and infants living in areas of deprivation to help address these issues. The present study aimed to determine mothers' knowledge of appropriate infant-feeding practices, opinions about feeding advice and any changes in practice following attendance at workshops. METHODS: Fifteen semi-structured interviews with women who participated in NHS infant-feeding workshops. Verbatim transcripts were analysed using framework analysis. RESULTS: Participants appreciated the opportunity to enhance their knowledge and there was evidence of a reasonable understanding and awareness of appropriate infant-feeding behaviours following workshop attendance. However, the findings highlight the challenge of multiple sources of advice and identify persistent uncertainties about feeding practice. Reported feeding behaviour following workshops was encouraging (e.g. delayed weaning, increased use of -prepared fruits and vegetables), although there was also evidence of resistance to change. The legacy of the workshop in terms of reported confidence in infant feeding was also apparent. CONCLUSIONS: The workshops appears to aid current knowledge and practice about infant feeding but further work is needed to examine the long term impact of these interventions on maternal and infant dietary behaviours.

"Is general surgery still relevant to the subspecialised trainee?" A 10 year comparison of general versus specialty surgical practice.

BACKGROUND: The splintering of general surgery into subspecialties in the past decade has brought into question the relevance of a continued emphasis on traditional general surgical training. With the majority of trainees now expressing a preference to subspecialise early, this study sought to identify if the requirement for proficiency in managing general surgical conditions has reduced over the past decade through comparison of general and specialty surgical admissions at a tertiary referral center. METHODS: A cross-sectional review of all surgical admissions at Cork University Hospital was performed at three individual time points: 2002, 2007 & 2012. Basic demographic details of both elective & emergency admissions were tabulated & analysed. Categorisation of admissions into specialty relevant or general surgery was made using International guidelines. RESULTS: 11,288 surgical admissions were recorded (2002:2773, 2007:3498 & 2012:5017), showing an increase of 81 % over the 10-year period. While growth in overall service provision was seen, the practice of general versus specialty relevant emergency surgery showed no statistically significant change in practice from 2002 to 2012 (p = 0.87). General surgery was mostly practiced in the emergency setting (84 % of all emergency admissions in 2012) with only 28 % elective admissions for general surgery. A reduction in length of stay was seen in both elective (3.62-2.58 bed days, p = 0.342) & emergency admissions (7.36-5.65, p = 0.026). CONCLUSIONS: General surgical emergency work continues to constitute a major part of the specialists practice. These results emphasize the importance of general surgical training even for those trainees committed to sub-specialisation.

Microbial communities within field-collected Culiseta melanura and Coquillettidia perturbans.

Although mosquitoes are well-known vectors of human and animal diseases, pathogens are only minor components of their total endogenous microbial communities. The midguts of many insects, including mosquitoes, contain diverse microbial communities. In this study, we used denaturing gradient gel electrophoresis to identify the diversity of bacteria in field-collected adult female Culiseta melanura (Diptera: Culicidae) (Coquillett) and Coquillettidia perturbans (Diptera: Culicidae) (Walker). Few significant differences in bacterial fauna between the two mosquito species were found, but the results suggest that host life history may be a determinant of the endogenous bacterial communities in mosquitoes. In the present study, the dominant bacteria are frequently identified as major components of other mosquito species' microbial flora, suggesting the establishment of a stable association between the mosquitoes and the microbes after initial acquisition from the environment.

Successful management of presacral ganglioneuroma: A case report and a review of the literature.

INTRODUCTION: Presacral ganglioneuromas are rare, usually benign lesions. Patients typically present when the mass is very large and becomes symptomatic. PRESENTATION OF CASE: This report describes the case of a 42 year old lady presenting with back pain who was subsequently diagnosed with a presacral ganglioneuroma based on MR imaging and a CT guided biopsy of the lesion. DISCUSSION: After counselling regarding nonoperative management, the patient opted for surgical resection. Open resection was performed with preservation of the neurovascular pelvic anatomy and an uneventful postoperative recovery. A review of the relevant literature was also performed using a search strategy in the online literature databases PUBMED and EMBASE. CONCLUSION: Surgical resection of a presacral ganglioneuroma is reasonable given their propensity for local effects and reported potential malignant transformation.

Multivariate analysis of MLH1 c.1664T>C (p.Leu555Pro) mismatch repair gene variant demonstrates its pathogenicity.

Genetic testing of an Irish kindred identified an exonic nucleotide substitution c.1664T>C (p.Leu555Pro) in the MLH1 mismatch repair (MMR) gene. This previously unreported variant is classified as a "variant of uncertain significance" (VUS). Immunohistochemical (IHC) analysis and microsatellite instability (MSI) studies, genetic testing, a literature and online MMR mutation database review, in silico phenotype prediction tools, and an in vitro MMR activity assay were used to study the clinical significance of this variant. The MLH1 c.1664T>C (p.Leu555Pro) VUS co-segregated with three cases of classic Lynch syndrome-associated malignancies over two generations, with consistent loss of MLH1 and PMS2 protein expression on IHC, and evidence of the MSI-High mutator phenotype. The leucine at position 555 is well conserved across a number of species, and this novel variant has not been reported as a normal polymorphism in the general population. In silico and in vitro analyses suggest that this variant may have a deleterious effect on the MLH1 protein and abrogate MMR activity. Evidence from clinical, histological, immunohistochemical, and molecular genetic data suggests that MLH1 c.1664T>C (p.Leu555Pro) is likely to be the pathogenic cause of Lynch syndrome in this family.

Persistent perforation in non-faeculant diverticular peritonitis--incidence and clinical significance.

BACKGROUND: Non-resectional strategies (NRS) have improved outcomes for a sub-group of patients with perforated diverticulitis. NRS are applicable to patients with non-faeculant peritonitis (Hinchey II and III). Success is dependent on the initial perforation sealing, which Hinchey estimated occurred 'most of the time'. An exact percentage remains ill-defined. OBJECTIVE: We aimed to define the percentage and clinical significance of a persistent perforation in non-faeculant diverticular peritonitis. DESIGN: A retrospective review was conducted of all patients admitted with a diagnosis of perforated diverticulitis between January 1999 and July 2010. Patients undergoing an emergency operation were analysed according to Hinchey and physiological and operative severity scores and compared with histological findings. RESULTS: One hundred fifteen patients were identified. Fifty-three patients underwent a 'resectional' procedure. At surgery, 15 patients had faeculent peritonitis, 27 patients had purulent peritonitis and 11 patients had a contained abscess. Of the patients with non-faeculant peritonitis, 2/9 (22.2 %) Hinchey II and 10/27 (37.1 %) Hinchey III patients had persistent perforation on review of histology. Persistent perforation was associated with a significant increase in morbidity, length of stay, physiological and operative severity score (p = 0.015, 0.011, 0.049 and 0.002, respectively). CONCLUSION: A proportion of patients with non-faeculant peritonitis have a persistent perforation which is associated with a poorer outcome and is likely to result in failure of a non-resectional management strategy. Updated classification systems and tailored peri-operative investigations are required to identify this sub-group of patients and improve patient outcomes.

Age differences in simulated driving performance: compensatory processes.

In the context of driving, the reported experiment examines compensatory processes for age-related declines in cognitive ability. Younger (26-40 years) and older (60+ years) participants (n=22 each group) performed a car following task in a driving simulator. Several performance measures were recorded, including assessments of anticipation of unfolding traffic events. Participants also completed a range of measures of cognitive ability - including both fluid and crystallised abilities. Three examples of age-related compensation are reported: (i) older drivers adopted longer headways than younger drivers. Data were consistent with this being compensation for an age-related deficit in complex reaction time; (ii) older drivers with relatively higher cognitive ability anticipated traffic events more frequently, whereas the reverse pattern was found for younger drivers; and, (iii) older drivers with greater crystallised ability were less reliant on spatial ability to maintain lane position. Consistent with theories of 'cognitive reserve', interactions between crystallised ability and age for self-report workload suggested that compensation for age-related cognitive ability deficits required investment of additional effort. Results are considered in the context of the prospects of further assessment of older drivers.

Changes in outcome and management of perforated diverticulitis over a 10 year period.

INTRODUCTION: Aggressive non-operative intervention and evolving surgical strategies have altered the treatment of perforated diverticulitis in the acute setting. These strategies have predominantly been implemented over the last decade. The aim of this study was to assess the impact of this on patient outcome during their index admission and subsequently. METHODS: Consecutive patients admitted with acute diverticulitis between 1999 and 2010 were identified. Patient demographics, treatment strategies and outcomes were collected and analysed. Patients who had an episode of perforated diverticulitis during their index admission were followed. RESULTS: 739 patients were admitted with acute diverticulitis. Of these, 115 (15.7%) had perforated diverticulitis. 53 (47.8%) underwent an intervention. There was a reduction in the mean age of patients admitted with acute diverticulitis of 8.9% over the study period (p = 0.002). There was a significant increase in the use of CT scanning pre-operatively (p < 0.001). 'Non-resectional' interventions have emerged in the form of laparoscopic lavage (n = 5) and percutaneous abscess drainage (n = 14). There was associated improved length of stay (p < 0.001). CONCLUSION: Outcomes for patients with perforated diverticulitis have improved, contributed to in part by an increased use of non-resectional management strategies.

Enhanced recovery after elective colorectal surgery: now the standard of care.

Enhanced recovery programmes have been studied in randomised trials with evidence of quicker recovery of gut function, reduced morbidity, mortality and hospital stay and improved physiological and nutritional outcomes. They aim to reduce the physiological and psychological stress of surgery and consequently the uncontrolled stress response. The key elements, reduced pre-operative fasting, intravenous fluid restriction and early feeding after surgery, are in conflict with traditional management plans but are supported by strong clinical evidence. Given the strength of the current data enhanced recovery should now be the standard of care.