Feasibility of perioperative volatile organic compound breath testing for prediction of paralytic ileus following laparoscopic colorectal resection.

BACKGROUND: Despite implementation of enhanced recovery after surgery (ERAS) and laparoscopic techniques, postoperative ileus (POI) remains frequent after colorectal surgery, impacting the patient, their recovery and health-care resources. Presently there are no tests that reliably predict or enable early POI diagnosis. Volatile organic compounds (VC) are products of human and microbiota cellular metabolism and we hypothesised that a detectable alteration occurs in POI. METHOD: This was a prospective observational study of patients undergoing laparoscopic colorectal resection within an established ERAS programme. Standardized end-expiratory breath sampling was performed on the morning of surgery and on the first three postoperative mornings. The concentrations of VCs commonly found in intestinal gas were analysed using selected ion flow tube mass spectrometry and GastroCH4 ECK®. Feasibility data, bowel preparation, postoperative oral intake, POI and 30-day morbidity were recorded. RESULTS: Of the 75 potentially eligible patients, 58 (77%) agreed to participate. Per-protocol breath sampling was successfully completed in 94%. There were no analytical failures. Baseline and postoperative concentrations of VCs were broadly comparable and were not altered by bowel preparation or postoperative oral intake. POI developed in 14 (29%) patients. Preoperative ammonia concentration was higher in patients who developed POI [830 parts per billion (ppb) vs 510 ppb, P = 0.027]. There was an increase in the concentration of acetic acid detected on day 2 in patients who developed POI (99 ppb vs 171 ppb, P = 0.021). CONCLUSION: Repeated VC breath sampling and analysis is feasible in the perioperative setting. An elevated ammonia concentration on the morning of surgery may be a potential predictor of POI.

Time from colorectal cancer diagnosis to laparoscopic curative surgery-is there a safe window for prehabilitation?

BACKGROUND: There is a growing interest in the adoption of formal prehabilitation programmes prior to elective surgery but regulatory targets mandate prompt treatment following cancer diagnosis. We aimed to investigate if time from diagnosis to surgery is linked to short- and long-term outcomes. METHODS: An exploratory analysis was performed utilising a dedicated, prospectively populated database. Inclusion criteria were biopsy-proven colorectal adenocarcinoma undergoing elective laparoscopic surgery with curative intent. Demographics, date of diagnosis and surgery was captured with patients dichotomised using 4-, 8- and 12-week time points. All patients were followed in a standardised pathway for 5 years. Overall survival was assessed with the Kaplan-Meier log-rank method. RESULTS: Six hundred sixty-eight consecutive patients met inclusion criteria. Mean time from diagnosis to surgery was 53 days (95% CI 48.3-57.8). Identified risk factors for longer time to surgery were males (OR 1.92 [1.2-3.1], p = 0.008), age ≤ 65 (OR 1.9 [1.2-3], p = 0.01), higher ASA scores (p = 0.01) stoma formation (OR 6.9 [4.1-11], p < 0.001) and neoadjuvant treatment (OR 5.06 [3.1-8.3], p < 0.001). There was no association between time to surgery and BMI (p = 0.36), conversion (16.3%, p = 0.5), length of stay (p = 0.33) and readmission or reoperation (p = 0.3). No differences in five-year survival were seen in those operated within 4, 8 and 12 weeks (p = 0.397, p = 0.962 and p = 0.611, respectively). Multivariate analysis showed time from diagnosis to surgery was not associated with five-year overall survival (HR 0.99, p = 0.52). CONCLUSION: Time from colorectal cancer diagnosis to curative laparoscopic surgery did not impact on overall survival. This finding may allow preoperative pathway alteration without compromising safety.

Can the combination of laparoscopy and enhanced recovery improve long-term survival after elective colorectal cancer surgery?

AIM: Enhanced recovery after surgery (ERAS) programmes and laparoscopic techniques both provide short-term benefits to patients undergoing colorectal cancer surgery. ERAS protocol compliance may improve long-term survival in those undergoing open colorectal resection but as laparoscopic data has not been reported. Therefore, we aimed to investigate the impact of the combination of laparoscopy and ERAS management on 5-year overall survival. METHODS: A dedicated prospectively populated colorectal cancer surgery database was reviewed. Patient inclusion criteria were biopsy-proven colorectal adenocarcinoma, undergoing elective surgery undertaken with curative intent. All patients were managed within an established ERAS programme and routinely followed up for 5 years. Overall survival was measured using the log-rank Kaplan-Meier method at 5 years. RESULTS: Eight hundred fifty-four patients met the inclusion criteria. Four hundred eighty-one (56%) cases were laparoscopic with 98 patients (20%) requiring conversion. There were no differences in patient or tumour demographics between the surgical groups. Median ERAS protocol compliance was 93% (range 53-100%). Five-year overall survival was superior in laparoscopic cases compared with that of converted and open surgery (78 vs 68 vs 70%, respectively, p < 0.007). An open approach (HR 1.55, 95%CI 1.16-2.06, p = 0.002) and delayed hospital discharge (> 7 days, HR 1.5, 95%CI 1.13-1.9, p = 0.003) were the only modifiable risk factors associated with poor survival. CONCLUSIONS: The use of a laparoscopic approach with enhanced recovery after surgery management appears to have long-term survival benefits following colorectal cancer resection.

Does hospital readmission following colorectal cancer resection and enhanced recovery after surgery affect long term survival?

AIM: Hospital readmission is undesirable for patients and care providers as this can affect short-term recovery and carries financial consequences. It is unknown if readmission has long-term implications. We aimed to investigate the impact of 30-day readmission on long-term overall survival (OS) following colorectal cancer resection within enhanced recovery after surgery (ERAS) care and explore the reasons for and the severity and details of readmission episodes. METHOD: A dedicated, prospectively populated database was reviewed. All patients were managed within an established ERAS programme. Five-year OS was calculated using the Kaplan-Meier method. The number, reason for and severity of 30-day readmissions were classified according to the Clavien-Dindo (CD) system, along with total (initial and readmission) length of stay (LoS). Multivariate analysis was used to identify factors predicting readmission. RESULTS: A total of 1023 consecutive patients underwent colorectal cancer resection between 2002 and 2015. Of these, 166 (16%) were readmitted. Readmission alone did not have a significant impact on 5-year OS (59% vs 70%, P = 0.092), but OS was worse in patients with longer total LoS (20 vs 14 days, P = 0.04). Of the readmissions, 121 (73%) were minor (CD I-II) and 27 (16%) required an intervention of which 16 (10%) were returned to theatre. Gut dysfunction 32 (19%) and wound complications 23 (14%) were the most frequent reasons for readmission. Prolonged initial LoS, rectal cancer and younger age predicted for hospital readmission. CONCLUSION: Readmission does not have a significant impact on 5-year OS. A broad range of conditions led to readmission, with the majority representing minor complications.

Factors predicting 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery programme.

AIM: Hospital readmission within 30 days of surgery has become a marker of poor quality patient care. This study aimed to investigate factors predictive of 30-day readmission after laparoscopic colorectal cancer surgery within an enhanced recovery after surgery (ERAS) programme. METHOD: Consecutive patients undergoing laparoscopic surgery for colorectal cancer within an ERAS programme between 2002 and 2009 were included. Data were collected relating to patient demographics, neoadjuvant chemoradiotherapy, ERAS compliance, and operative and postoperative outcomes. A logistic regression model was used to identify factors associated with readmissions after adjusting for the potential effect of covariables simultaneously. RESULTS: In all, 268 cancer patients underwent laparoscopic colorectal surgery (108 rectal resections), of whom 34 (12.7%) were readmitted due most commonly to bowel obstruction (29%) and surgical site infection (18%). The use of neoadjuvant therapy (odds ratio 4.49, 95% CI 1.41-14.35; P = 0.011) and ERAS compliance above 93% (odds ratio 0.38, 95% CI 0.18-0.84; P = 0.016) were independent predictors of readmission. CONCLUSION: Poor ERAS compliance and preoperative chemoradiotherapy were significant predictors of readmission following laparoscopic colorectal cancer surgery. Further research is required to expand the scope of ERAS beyond hospital discharge.

The use of artificial neural networks to predict delayed discharge and readmission in enhanced recovery following laparoscopic colorectal cancer surgery.

BACKGROUND: Artificial neural networks (ANNs) can be used to develop predictive tools to enable the clinical decision-making process. This study aimed to investigate the use of an ANN in predicting the outcomes from enhanced recovery after colorectal cancer surgery. METHODS: Data were obtained from consecutive colorectal cancer patients undergoing laparoscopic surgery within the enhanced recovery after surgery (ERAS) program between 2002 and 2009 in a single center. The primary outcomes assessed were delayed discharge and readmission within a 30-day period. The data were analyzed using a multilayered perceptron neural network (MLPNN), and a prediction tools were created for each outcome. The results were compared with a conventional statistical method using logistic regression analysis. RESULTS: A total of 275 cancer patients were included in the study. The median length of stay was 6 days (range 2-49 days) with 67 patients (24.4 %) staying longer than 7 days. Thirty-four patients (12.5 %) were readmitted within 30 days. Important factors predicting delayed discharge were related to failure in compliance with ERAS, particularly with the postoperative elements in the first 48 h. The MLPNN for delayed discharge had an area under a receiver operator characteristic curve (AUROC) of 0.817, compared with an AUROC of 0.807 for the predictive tool developed from logistic regression analysis. Factors predicting 30-day readmission included overall compliance with the ERAS pathway and receiving neoadjuvant treatment for rectal cancer. The MLPNN for readmission had an AUROC of 0.68. CONCLUSIONS: These results may plausibly suggest that ANN can be used to develop reliable outcome predictive tools in multifactorial intervention such as ERAS. Compliance with ERAS can reliably predict both delayed discharge and 30-day readmission following laparoscopic colorectal cancer surgery.

Artificial Neural Network Individualised Prediction of Time to Colorectal Cancer Surgery.

AIM: Colorectal cancer pathway targets mandate prompt treatment although practicalities may mean patients wait for surgery. This variable period could be utilised for patient optimisation; however, there is currently no reliable predictive system for time to surgery. If individualised surgical waits were prospectively known, tailored prehabilitation could be introduced. METHODS: A dedicated, prospectively populated elective laparoscopic surgery for colorectal cancer with a curative intent database was utilised. Primary endpoint was the prediction of the individualised waiting time for surgery. A multilayered perceptron artificial neural network (ANN) model was trained and tested alongside uni- and multivariate analyses. RESULTS: 668 consecutive patients were included. 8.5% underwent neoadjuvant chemoradiotherapy. The mean time from diagnosis to surgery was 53 days (95% CI 48.3-57.8). ANN correctly identified those having surgery in <8 (97.7% and 98.8%) and <12 weeks (97.1% and 98.8%) of the training and testing cohorts with area under the receiver operating curves of 0.793 and 0.865, respectively. After neoadjuvant treatment, an ASA physical status score was the most important potentially modifiable risk factor for prolonged waits (normalised importance 64%, OR 4.9, 95% CI 1.5-16). The ANN findings were accurately cross-validated with a logistic regression model. CONCLUSION: Artificial neural networks using demographic and diagnostic data successfully predict individual time to colorectal cancer surgery. This could assist the personalisation of preoperative care including the incorporation of prehabilitation interventions.

Is Month of Birth a Risk Factor for Colorectal Cancer?

Introduction. The developmental origins of health and disease hypothesis and season of birth have been linked to a wide variety of later life conditions including cancer. Whether any relationship between month and season of birth and colorectal cancer exists is unknown. Methods. A case-control study was performed with month of birth extracted from a dedicated colorectal cancer database. Age and gender matched patients were used as a control group. Generalised linear models were fitted with Poisson and negative binomial responses and logarithmic links. A forward stepwise approach was followed adding seasonal components with 6- and 12-month periods. Results. 1019 colorectal cancer patients and 1277 randomly selected age and gender matched controls were included. For both men and women there is an excess of colorectal cancer in those born in autumn and a corresponding reduction of risk among those born in spring (p = 0.026). For the identified September peak, the excess risk for colorectal cancer was 14.8% (95% CI 5.6-32.3%) larger than the spring trough. Conclusion. There is a seasonal effect in the monthly birth rates of people who are operated for colorectal cancer with a disproportionate excess of cancer in those born in September. Further large studies are required to validate these findings.

Predictors of coroner's verdict: a logistic regression model.

This study is an attempt to understand the effect of various factors that are likely to have influenced North Cheshire's Coroners during a five-year period in their decision to return a 'suicide' or an 'open' verdict. Based on the logistic model, the main factors that appeared to have influenced a Coroners decision are: intimation of intent, method of death and alcohol problem.

Audit of the use of nurses' holding power under section 5(4) of the Mental Health Act 1983.

Emergency detention of psychiatric patients by doctors under s. 5(2) of the Mental Health Act 1983 is not always preceded by the use of nurses' holding power under s. 5(4). In this review of patients in North Cheshire, all applications of s. 5(4), allowing the emergency detention of voluntary in-patients by registered psychiatric nurses for a maximum period of six hours, were reviewed to examine the extent of its use and to assess its effect on s. 5(2) outcome. Of the 877 detentions under s. 5(2) implemented during the 11-year review period, 140 (16%) were preceded by s. 5(4). There was no significant difference in age, sex, clinical diagnosis, day of the week, reason for detention and length of hospital stay before section application between those who had s. 5(4) applied before 5(2) and those who did not. The latter were less likely to be converted to other sections (53%) compared to a much higher rate of 80% if s. 5(4) preceded s. 5(2). The review has also found that time of section application and length of hospital stay prior to detention may have influenced the use of nurses' holding power. It suggests that s. 5(4) may be a useful predictor of s. 5(2) outcome.

Passive euthanasia in dementia: killing ... or letting die?

A sample of carers was asked to complete a self-administered questionnaire designed to collect information about carers' characteristics and obtain their views on passive euthanasia. Each carer was given an information sheet about the study, which included a detailed and clear account for the different types of euthanasia. The study showed a strong support for passive euthanasia from the non-professional carers of dementia patients. The strongest support was for the idea of a 'Living Will'. Having previous experience in looking after other people with dementia would appear to influence carers' perception of passive euthanasia. The subject of passive euthanasia and its ramifications for sufferers, carers and professionals warrants further exploration.

Detention of in-patients under section 5(2) of the Mental Health Act 1983.

All applications of s.5(2) of the Mental Health Act 1983, allowing the emergency detention of voluntary in-patients in North Cheshire between 1985 and 1995, were reviewed to examine general trends in its use and to assess variables likely to influence its outcome. Of the 877 applications implemented (4% of all admissions), 500 (57%) were converted to longer-term detention under the Act, 396 (45%) were converted to s.2 and 104 (12%) to s.3. The other 377 (43%) detained patients under s.5(2) regained informal status. The review found that time of application of section, length of hospital stay prior to application, medical officer's grade, use of s.5(4) and clinical diagnosis are best predictors of s.5(2) outcome. The results are similar to other published studies and seem to reflect a national pattern, possibly implying that patients detained under this short-term detention order have an almost equal chance of either regaining their voluntary status or being detained under another section by the end of the 72 hours. This may raise questions about the purpose of s.5(2) as expressed by the Mental Health Act Commission.

Elderly suicide and attempted suicide: one syndrome.

In this study we explore whether elderly suicide victims who had a previous history of attempted suicide differ from those with no similar history. A group of the elderly, who ended their lives with fatal self-harm (FSH) and had a history of deliberate self-harm (DSH) was compared to a matching group of the elderly who also ended their lives with FSH, but who were not known to have had any history of DSH. The comparison was in respect of epidemiological, social, psychological characteristics, service input and methods of suicide. The elderly, with a history of DSH, were more likely to have been known to the mental health services than the elderly who did not have such a history (P<.05). The two groups used similar methods in their final FSH act. The elderly victims of FSH with or without a previous history of DSH share the same characteristics. The two groups appear to be part of one syndrome. Deliberate self-harm in the elderly should be taken seriously as an unsuccessful suicide rather than a manipulative act or a cry for help and attention.

History of deliberate self harm may predict methods of fatal self harm in the elderly.

In this study we examined the association between methods of Deliberate Self Harm (DSH) by the elderly and their subsequent methods of Fatal Self Harm (FSH). Data was collected from the files of inquests into suicide by the elderly in Birmingham and Cheshire Coroner's Courts. All the subjects were above the age of 60, had history of deliberate self harm before the final act of fatal self harm and attracted either suicide or open verdict returned by the Coroners over a period of four years 1995-1998. We compared the methods of Deliberate Self Harm (DSH) to the methods of Fatal Self Harm (FSH) used by all the included elderly. 18 per cent of elderly victims of FSH had a previous history of DSH and in 35 per cent of the sample, the last known attempt of DSH occurred more than one year prior to the FSH. The majority of the methods that had been used in elderly DSH were used again in their final act of FSH. Nearly two thirds of all the elderly who died of an overdose had attempted suicide earlier by an overdose and one in five of those who died by hanging or drowning used the same method in an unsuccessful attempt of FSH within 12 months. A detailed history of DSH can improve the quality of risk assessment of self harm in the elderly. As more than one in three elderly victims of FSH attempted DSH more than a year prior to the final act, it is important when assessing an elderly DSH attempt that we obtain any previous case notes and question informants about the distant as well as the recent past.

Unexpected death of psychiatric patients: suicide, misadventure, accident or unsolved mystery?

We examined the association between the psychiatric history of patients who were the subjects of a coroner's inquest and the recorded verdict, in a seven-year retrospective review. A suicide verdict was less frequently returned on patients who had inpatient psychiatric treatment compared to other unexpected deaths. History and diagnosis of an alcohol-related condition, method of death and intimation of intent were the main factors that appeared to be associated with the coroner's verdict. Age, sex, duration of illness, time and number of admissions, previous suicide attempts and treatment received did not appear to be significantly associated with the recorded verdict.

Autopsy in elderly psychiatric inpatients: a retrospective review of autopsy findings of deceased elderly psychiatric inpatients in north Cheshire 1980-1996.

In this 17-year review of death certificates of elderly inpatients of a large psychiatric hospital in North Cheshire, the frequency, trend and value of performing autopsies were examined. Details of death certificates were compared with certificates issued after post-mortem examination to see whether an autopsy yielded any additional or relevant information about conditions that are not directly related to death but might well be of importance to public health. The rate of post-mortem examination, at 9.5% of total hospital deaths, did not show any significant trend over most of the review period. The vast majority of autopsies examined had been requested by the coroner and not by the clinicians. The review showed that an autopsy may be of some value in providing more information regarding any underlying causes of death in elderly psychiatric patients, but has no value in ensuring higher rate of the recording of conditions such as dementia, in particular Alzheimer's disease. Selective hospital autopsy in elderly psychiatric patients to verify, neuropathologically, the clinical diagnosis of Alzheimer's disease, will improve our diagnostic accuracy and provide valid statistics to be used in estimating prevalence, trends, risk factors and for use in all aspects of future research into Alzheimer's disease.

The khat users: a study of khat chewing in Liverpool's Somali men.

This study reports the demographic and social characteristics and level of psychological dysfunction in regular khat users compared with matched non-users. The results indicate that khat users resemble non-users on a number of psychosocial variables and GHQ scores, with no evidence to suggest higher morbidity amongst users. The two groups appear to differ only in the level of their use of nicotine and also in their perception of the harmful effects associated with khat use.

Their last words: a review of suicide notes in the elderly.

Suicide notes are considered as markers of the severity of a suicide attempt and are said to provide valuable insight into the thinking of suicide victims before the fatal act. However, very few studies have described elderly suicide note-writers and their final thoughts. In this retrospective review of suicide notes obtained from coroners' records in North Cheshire over a period of 13 years from 1989-2001 we examined the content of suicide notes and their clinical significance. Suicide note-writers may not be typical of the average suicide and information elicited from the study of suicide notes may only apply to note-writers and not to suicide in general. However, the absence of a suicide note must not be considered an indicator of a less serious attempt. Future studies of suicide notes need to provide insight into the unique nature of these documents and to allow better understanding of the suicidal mind.

Detention of elderly psychiatric inpatients under section 5(2) of the Mental Health Act 1983.

Emergency detention of elderly psychiatric inpatients appears to have attracted very little or no attention in published studies. In this retrospective review, all applications of sections 5(2) and 5(4) of the Mental Health Act 1983, detaining elderly inpatients in North Cheshire between 1985 and 1997 were reviewed. Forty-three percent of elderly inpatients under s.5(2) regained their voluntary status, while 57% were detained under another section by the end of the 72 hours (p < 0.05). Duration in hospital prior to applying s.5(2), clinical diagnosis of functional mental illness and use of s.5(4) appear to increase the likelihood of converting s.5(2) into other sections. The high rate of non-conversion of s.5(2) in the elderly to s.2 or 3 may imply that in almost half of the cases, emergency detention may have been used to control isolated incidents of disturbed behaviour in otherwise co-operative patients. Educating doctors and nurses in guidance put forward by the Code of Practice (1993) remains, probably, the main key to a better use of emergency holding powers.