Patient experiences of left-sided colorectal resection by robotic, conventional laparoscopic and open approaches: a qualitative study.

BACKGROUND: Robotic surgery (RS) is increasingly employed in colorectal surgical practice, widening the range of surgical techniques offered to patients. We investigated the perceptions of patients with colorectal cancer in relation to RS, open surgery (OS) and conventional laparoscopic surgery (CLS), to identify ideas or assumptions which, in the context of shared surgeon-patient decision-making, may affect the resultant choice of surgical technique. We also investigated salient factors affecting patients' perioperative experience, including those of RS patients, to guide improvements in care and preoperative patient preparation. METHODS: This study was conducted on patients who underwent resection of left-sided colorectal cancer at a large UK teaching hospital from November 2020 to July 2021. Purposive sampling was used to ensure a roughly equal proportion of patients who underwent RS, CLS and OS. The patients included in the study participated in semi-structured interviews six weeks postoperatively. The interview schedule allowed discussion around patients' experience of their surgery and postoperative recovery, and their perceptions of surgical techniques. Interview transcripts were coded manually using inductive thematic analysis, and analyst triangulation was employed to refine coding schemes and ensure reliability of emerging themes. RESULTS: Twenty-seven patients were recruited to the study; RS n = 9 (median age 69 [range 60-80] years); CLS n = 10 (median age 72 [range 32-82] years; OS n = 8 (median age 71 [range 60-75] years). Patients understood the technological benefits of RS but were concerned by a risk of technological failure causing patient harm. OS was understood to be associated with more pain and longer recovery than RS or CLS. Patients perceived CLS to be more technically challenging compared with OS. Less pain and smaller wounds than expected were significant positive factors in the experience of RS and CLS patients specifically. Complications and emotional impact were significant factors in the experience of all groups, for which many patients felt underprepared. CONCLUSIONS: Patients generally have a positive view of RS and technical innovation in surgery. Concerns mostly centred around failure of technology. Many patients felt unprepared for significant factors in their perioperative experience. Surgeons and healthcare providers should be prepared to address patients' perceptions and expectations of colorectal surgery preoperatively.

Establishing core outcome sets for gastrointestinal recovery in studies of postoperative ileus and small bowel obstruction: protocol for a nested methodological study.

INTRODUCTION: Gastrointestinal recovery describes the restoration of normal bowel function in patients with bowel disease. This may be prolonged in two common clinical settings: postoperative ileus and small bowel obstruction. Improving gastrointestinal recovery is a research priority but researchers are limited by variation in outcome reporting across clinical studies. This protocol describes the development of core outcome sets for gastrointestinal recovery in the contexts of postoperative ileus and small bowel obstruction. METHOD: An international Steering Group consisting of patient and clinician representatives has been established. As overlap between clinical contexts is anticipated, both outcome sets will be co-developed and may be combined to form a common output with disease-specific domains. The development process will comprise three phases, including definition of outcomes relevant to postoperative ileus and small bowel obstruction from systematic literature reviews and nominal-group stakeholder discussions; online-facilitated Delphi surveys via international networks; and a consensus meeting to ratify the final output. A nested study will explore if the development of overlapping outcome sets can be rationalized. DISSEMINATION AND IMPLEMENTATION: The final output will be registered with the Core Outcome Measures in Effectiveness Trials initiative. A multi-faceted, quality improvement campaign for the reporting of gastrointestinal recovery in clinical studies will be launched, targeting international professional and patient groups, charitable organizations and editorial committees. Success will be explored via an updated systematic review of outcomes 5 years after registration of the core outcome set.

Developing a national colorectal educational agenda: a survey of the Association of Coloproctology of Great Britain and Ireland.

AIM: In order to develop its education agenda, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) sought the opinion of its members on current coloproctology training needs. The aims of this study were to canvass multidisciplinary needs and explore the perceived gaps and barriers to meeting them. METHOD: A learner-needs analysis was performed between July 2015 and October 2016. A bespoke electronic survey was sent to 1453 colorectal healthcare professionals [ACPGBI membership (1173), colorectal nurse specialists and allied health professionals (NAHPs) (261) and regional chapter-leads (19)] seeking their needs, experiences and barriers to training across the coloproctology disciplines. RESULTS: In all, 390 responses were received [26.8% overall; 180 consultants/trainees (15%); 196 NAHPs (75%); 14 (74%) chapter-leads]. Lack of funding and difficulties in obtaining study leave were the most frequently reported barriers to course and conference attendance. Transanal total mesorectal excision and laparoscopic training were the top educational needs for consultants and trainees respectively. 79% of NAHP respondents reported education gaps on a broad range of clinical and non-clinical topics. NAHPs lacked information on relevant training opportunities and 27% felt available courses were insufficient to meet their educational needs. Wide heterogeneity in ACPGBI chapter composition and activity was reported. All groups felt the ACPGBI should increase the number of courses offered with coloproctology knowledge updates commonly requested. CONCLUSION: A series of training needs across the coloproctology disciplines have been identified. These will underpin the development of the educational agenda for the ACPGBI.

Systematic review of definitions and outcome measures for return of bowel function after gastrointestinal surgery.

Background: Ileus is common after gastrointestinal surgery and has been identified as a research priority. Several issues have limited previous research, including a widely accepted definition and agreed outcome measure. This review is the first stage in the development of a core outcome set for the return of bowel function after gastrointestinal surgery. It aims to characterize the extent of variation in current outcome reporting. Methods: A systematic search of MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library was performed for 1990-2017. RCTs of adults undergoing gastrointestinal surgery, including at least one reported measure relating to return of bowel function, were eligible. Trial registries were searched across the same period for ongoing and completed (but not published) RCTs. Definitions of ileus and outcome measures describing the return of bowel function were extracted. Results: Of 5670 manuscripts screened, 215 (reporting 217 RCTs) were eligible. Most RCTs involved patients undergoing colorectal surgery (161 of 217, 74·2 per cent). A total of 784 outcomes were identified across all published RCTs, comprising 73 measures (clinical: 63, 86 per cent; radiological: 6, 8 per cent; physiological: 4, 5 per cent). The most commonly reported outcome measure was 'time to first passage of flatus' (140 of 217, 64·5 per cent). The outcomes 'ileus' and 'prolonged ileus' were defined infrequently and variably. Conclusion: Outcome reporting for the return of bowel function after gastrointestinal surgery is variable and not fit for purpose. An agreed core outcome set will improve the consistency, reliability and clinical value of future studies.

Diminished motor imagery capability in adults with motor impairment: An fMRI mental rotation study.

Recent research has demonstrated that adults with probable Developmental Coordination Disorder (pDCD) show similar behavioural deficits as those observed in children DCD when performing a motor imagery task. The aim of this study was to investigate whether the pattern of neural activation in adults with pDCD during motor imagery differed from adults without motor skill impairment. Twelve adults with pDCD (5 male; age M=24.5 yrs) and 11 adults without pDCD (6 male; age M=26.7 yrs) participated. The hand rotation task was used to assess motor imagery ability, while functional neural images were acquired using a 3T MR scanner. Performance on the hand task in both groups conformed to the biomechanical constraints of real movement, supporting the use of motor imagery to complete the task. Comparisons of response time and accuracy data showed no significant group differences. Comparison of the BOLD signal activation maps identified a significant parametric difference between groups. The% BOLD signal change for increasing angle of rotation showed greater activation in controls compared to the pDCD group in the occipito-parietal and parieto-frontal networks including the middle frontal gyrus bilaterally, the left superior parietal lobe as well as in the cerebellum (lobule VI). The pattern of reduced activation in adults with pDCD is consistent with recent studies of childhood DCD that suggest atypical activation in frontal, parietal and cerebellar areas, and supports the theory that this type of impairment may be associated with disruption of parieto-frontal and parieto-cerebellar networks.

A rapid luminescently monitored enzyme immunoassay for IgE.

A novel halophenol-enhanced luminol-peroxide luminescent detection method for horseradish peroxidase has been tested in an enzyme immunoassay for IgE. The luminescent enzyme immunoassay was reproducible (within-batch CV, 3.9-13.2%) and values obtained on serum samples showed good agreement with those obtained by colorimetric enzyme immunoassay. The major advantages of the luminescent detection method are that it is rapid, 30 s compared with 30 min for the colorimetric assay using o-phenylenediamine, and the luminescent signal is intense and stable for several minutes.

Enhanced chemiluminescent reactions catalyzed by horseradish peroxidase.

Enhancement of light emission from the horseradish peroxidase-catalyzed oxidation of diacyl hydrazides on addition of 6-hydroxybenzothiazole or phenol derivatives forms the basis of rapid, specific, and sensitive chemiluminescent assays for peroxidase. The advantages and wide applicability of the technique have been demonstrated in a range of ligand-binding assays. Careful selection of chemiluminescent reagents, enhancer, their relative proportions and reaction conditions, and more detailed knowledge of the mechanism of enhancement should enable further improvements in sensitivity and the intensity or constancy of light emission.

Enzyme-labeled antibodies in bioassays.

Antibody-enzyme conjugates are widely utilized in all spheres of specific analyte detection and measurement, and several trends are evident that will sustain, or even extend, this in the coming years. Of principal importance are the trends toward the development of simplified formats for the rapid and sensitive quantitation of a wide range of analytes without expensive or cumbersome instrumentation, and the exploitation of different types of enzyme and antibody molecules. Advances in hybridoma and recombinant genetics are enabling the practical manipulation of the theoretical repertoire of these reagents, facilitating their availability for a myriad of applications.

Enhanced luminescence enzyme immunoassay for factor VIII related antigen.

A sandwich enzyme immunoassay for plasma factor VIII related antigen has been developed which exploits a para-iodophenol enhanced chemiluminescent reaction to detect the horseradish peroxidase label. The assay entailed 15 min incubations with sample and with conjugate and had a detection limit of 0.12 mU. It showed good within batch precision (coefficient of variation = 2.95-5.8%) and results on a series of 57 specimens agreed with results obtained by immunoelectrophoresis (correlation coefficient = 0.97).

A rapid chemiluminescent enzyme-linked immunosorbent assay for cytomegalovirus immunoglobulin G antibodies using instant photographic film.

A rapid and convenient chemiluminescent enzyme-linked immunosorbent assay (ELISA) for IgG antibodies to cytomegalovirus has been developed which uses low cost equipment. Assays were carried out on transparent microtitre plates and used an anti-human IgG horseradish peroxidase conjugate. Bound peroxidase was detected chemiluminescently using a p-iodophenol-luminol-peroxide reagent. Light emission from the wells of the microtitre plate was detected on instant photographic film (ASA 20,000) held in a specially designed shutter type camera. The semi-quantitative technique was tested in a routine laboratory for a period of 7 wk and the results obtained compared well (95.3% agreement) with those obtained by a conventional colorimetric ELISA using an alkaline phosphatase label.

A review of near patient testing in primary care.

AIMS AND OBJECTIVES: The aim was to identify publications relating to near patient testing (NPT), the use of alternative delivery systems between laboratory and general practice, including electronic data interchange (EDI), and computerised diagnostic decision support (CDDS), in the primary care setting to answer the following questions. What is the availability of NPT for primary care? What evidence is available to support the clinical effectiveness of NPT? What evidence is available on the accuracy and reliability of NPT within primary care? What evidence is available on the cost-effectiveness of different NPTs? How may CDDS improve the effectiveness of NPT? What evidence is available that compares NPT and existing laboratory services? What evidence is available on the cost-effectiveness of EDI or alternative delivery systems? HOW THE RESEARCH WAS CONDUCTED: Eight databases were searched, and the bibliographies from relevant publications checked for completeness. Unpublished work and publications not included in the databases were obtained by personal contact with collaborators, and from a postal survey sent to heads of academic departments of general practice and clinical chemistry and to researchers active or interested in the field worldwide. Questionnaires were also sent to 150 commercial organisations. Publications that met agreed definitions and reported original data were included in the systematic review. Of the 1057 publications identified, 102 (92 related to NPT, eight to CDDS, and two to EDI) were passed to the reviewers for appraisal of validity. The limited amount of published research relating to any particular NPT prohibited meta-analysis. Scoring systems to assess the validity of evaluations were also difficult to apply. RESEARCH FINDINGS: A wide variety of NPT systems have been developed. In general, the quality of the methods reported in the literature was poor. The issue of patient convenience and acceptability has not been adequately addressed. No evaluations of alternative delivery systems met the review criteria. No studies have evaluated the telephone or fax machine as a means of reporting results. For EDI, the majority of papers were descriptive. EDI and alternative delivery systems are not a replacement for NPT when the provision of an immediate result might have an impact on the quality of care. EDI may have clinical and cost advantages over traditional means of communication, but this has not been evaluated. The advisory role of the laboratory can be supported by CDDS. The use of CDDS and NPT has not, however, been fully evaluated. Few economic analyses have been conducted, and most were simple cost analyses. There are insufficient data for conclusions to be drawn on the cost-effectiveness of NPT in primary care. RECOMMENDATIONS: FURTHER SYSTEMATIC REVIEWS: Subject-specific systematic reviews are required that include laboratory and secondary care studies, and consider the potential for altering current management and patient acceptability. Priority topics include: biochemistry profiles on desktop analysers; cholesterol testing; urinalysis for the diagnosis of urinary tract infection; anticoagulation control; NPTs for the identification of acute infection. (ABSTRACT TRUNCATED)

An investigation of the antioxidant activity of black tea using enhanced chemiluminescence.

Antioxidants are important species which possess the ability to protect the body from damage caused by free radical-induced oxidative stress. A variety of free radical-scavenging antioxidants exist within the body many of which are derived from dietary sources. There is currently much interest in the antioxidant role of flavonoids and other polyphenols found in tea, wine, fruit and vegetables. Enhanced chemiluminescence is a simple technique which can be used as a rapid and sensitive assay for measuring the antioxidant activity of beverages such as green and black tea. This article examines the impact of water temperature, stewing time, leaf concentration and the addition of milk upon the antioxidant activity of black tea solutions. The antioxidant activity of a range of commercially available black and green teas has also been measured.

Antioxidant status in controlled and uncontrolled hypertension and its relationship to endothelial damage.

Hypertension is associated with an increased risk of atherosclerosis. Free radical oxidative damage has been implicated in the atherogenic process. We measured levels of the antioxidants uric acid, thiols, vitamins C, A and E as well as the total antioxidant capacity in 21 normotensive controls, 22 patients whose hypertension was controlled on drugs and 30 patients with uncontrolled hypertension. Mean BPs in the groups were 125/76, 132/80 and 181/98 mmHg, respectively. When compared with controls, both hypertensive groups had significantly lower serum ascorbic acid (54 +/- 5 vs. 37 +/- 6 vs. 38 +/- 5 mumol/l, P < 0.05) and albumin-corrected thiol levels (9.91 +/- 0.18 vs. 8.69 +/- 0.20 vs. 8.92 +/- 0.19 mumol/g, P < 0.05). The levels of the other antioxidants did not differ significantly between the groups. Levels of von Willebrand factor, a marker of endothelial damage, were correlated with SBP but not with antioxidant status. We conclude that hypertensive subjects have lower levels of the antioxidants vitamin C and thiols and this may reflect greater oxidative consumption. The implications for atherogenesis and endothelial function and integrity in hypertension are discussed.

An enhanced chemiluminescence enzyme immunoassay for serum progesterone.

A competitive enhanced luminescent enzyme immunoassay for serum progesterone is described, which is based on a 11 alpha-hydroxyprogesterone 11-hemisuccinyl-horseradish peroxidase conjugate and a black polystyrene microtitre plate sensitised with anti-progesterone IgG. Bound label was determined using a mixture of 4-iodophenol, luminol and peroxide, and the light emitted from the wells of the plate quantitated using a luminescent plate reader. The assay was sensitive (detection limit 0.5 pg), precise (CV 2.7 - 9.0% in the concentration range 4.3-67.7 nM) and showed good correlation (r = 0.99) with a conventional radioimmunoassay.

Serum and tissue antioxidant capacity in cervical intraepithelial neoplasia investigated using an enhanced chemiluminescent reaction.

Depleted antioxidant defence has been implicated in the pathogenesis of cervical neoplasia. We determined the systemic and local antioxidant status of women with this condition. Thirty-four women with varying grades of cervical intraepithelial neoplasia, 25 patients who had been treated successfully with diathermy loop excision, and 56 women who had no evidence of cervical abnormality acted as controls. Total antioxidant capacity of serum and protein-free serum, and of neat and protein-free homogenized cervical punch biopsies were determined using enhanced chemiluminescence. Mean serum antioxidant capacity of patients with current neoplasia and treated patients was not significantly different from that of controls. However, mean antioxidant capacity of homogenized cervical tissue from women with neoplasia was significantly lower than control means (P < 0.005), while results for treated patients were intermediate between those from diseased and normal samples (P < 0.05). The enhanced chemiluminescence technique has potential as a suitable method for measuring total antioxidant capacity of cervical tissue, and warrants further investigations using other tissue types. Significant antioxidant depletion in cervical intra-epithelial neoplasia appears to be confined to the local cervical mucosa.

Enhanced luminescent quantitation of horseradish peroxidase conjugates: application in an enzyme immunoassay for digoxin.

A p-iodophenol-enhanced luminescent end-point has been incorporated into a commercially available heterogeneous competitive enzyme immunoassay for digoxin based on a horseradish peroxidase-digoxin conjugate. The luminescent end-point could be completed in less than 1 min and significantly reduced overall assay time. Results for the assay obtained using enhanced luminescence showed good agreement with those obtained using a colorimetric end-point (correlation coefficient 0.98). Both assays gave acceptable precision within the therapeutic range. The incubation time for the luminescent immunoassay was reduced to 15 min and still gave differentiation between sub-therapeutic, therapeutic and toxic levels of digoxin.

An enhanced chemiluminescence enzyme immunoassay for serum oestradiol.

Oestradiol in serum was determined with a simple enhanced chemiluminescent enzyme immunoassay. The assay is based on oestradiol labelled with horseradish peroxidase and the IgG fraction of an oestradiol antiserum coated on a black polystyrene microtitre plate. The enzyme activity of bound label was determined using a p-hydroxycinnamic acid-enhanced chemiluminescent reaction. The assay was sensitive (1.8 fmol/well), precise (intra- and inter-assay CV 4-10% and 8-12%, respectively for sample concentration in the range 122-1330 pmol/L) and showed good agreement with conventional radioimmunoassays (r = 0.99).

Enhanced chemiluminescent assay for measuring the total antioxidant capacity of serum, saliva and crevicular fluid.

This paper reports the development of an enhanced chemiluminescent (ECL) assay for measuring the total antioxidant (AO) capacity of serum, saliva and a fluid collectable from the gum margin called gingival crevicular fluid (GCF). The theory behind the assay is explained, and the optimum conditions for the assay, and for storage of reagents and clinical samples is described. Calibration lines were linear (R > or = 0.99; P < 0.0001) and the within batch coefficient of variations for a water soluble vitamin E analogue (Trolox), serum and saliva samples were < 5%. In saliva and GCF, a characteristic AO response not seen in serum of the same patients, was identified. Total peripheral (serum) and local (saliva) AO capacities (mumol/L Trolox) were investigated in patients with (n = 18) and without (n = 16) adult periodontitis. Serum AO status did not differ between groups. Salivary total AO concentrations were lower in the peridontitis (P) group [175 (53) mumol/L] than in the non-periodontitis (NP) group [254 (110) mumol/L1: P < 0.01], as were saliva:serum AO ratio's [0.37 (0.11) versus 0.5 (0.18): P < 0.01]. Periodontitis patients may have a reduced salivary AO concentration, which could result from, or predispose to, the damaging effects of reactive oxygen species (ROS). The potential for ROS production in the oral and periodontal environment may explain the presence of a specific antioxidant in oral fluids that is not detectable in serum. The ECL assay described provides a rapid, simple and reproducible method of measuring total antioxidant defence in small volumes of biological fluids.

Poor glycaemic control is associated with reduced serum free radical scavenging (antioxidant) activity in non-insulin-dependent diabetes mellitus.

The diabetic patient is at significantly increased risk of developing vascular disease. Its aetiology may involve oxidative damage by free radicals and protection against such damage can be offered by radical-scavenging antioxidants. We investigated whether there was a relationship between glycaemic control as assessed by measurement of glycated haemoglobin (HbA1c) and serum antioxidant status in a population of 118 diabetic outpatients with either insulin-dependent or non-insulin-dependent diabetes. Amongst patients with non-insulin-dependent diabetes mellitus there was a significant inverse correlation between levels of glycated haemoglobin and total free radical scavenging activity (r = -0.456, P < 0.0001). This association resulted primarily because of a similar correlation with uric acid (r = -0.421, P = 0.0003). There was also a weak inverse correlation with vitamin A but no significant association with vitamin C or vitamin E levels. There were no significant associations found amongst the patients with insulin-dependent diabetes. These results indicate that poor diabetic control is associated with reduced serum free radical scavenging (antioxidant) activity in non-insulin-dependent diabetes mellitus. By implication improved glycaemic control may preserve serum antioxidant status in diabetes.

Comparison of the use of four desktop analysers in six urban general practices.

There is little data on the advantages and disadvantages of using desktop analysers in general practice. This prospective trial compared four of the analysers available in the United Kingdom, in six urban general practices, over a six month period. Of the 2619 tests where the time was noted, 55.8% were performed outside the hours when routine transport to a hospital laboratory was possible (after 12.00 hours). Of the 3530 tests performed the commonest were measurements of cholesterol (14.4 tests per 5000 patients per 30 days), glucose (6.0 tests) and haemoglobin (5.6 tests). Less than 5% of the tests were performed as an emergency despite the speed at which results are available. The main reasons for requesting the tests were screening or case finding (56.9%), with the remainder for monitoring chronic disease, especially diabetes and hypercholesterolaemia. There was evidence that the use of the machines in the four practices reduced requests for hospital laboratory blood tests by 24-40% of pre-study levels. However, there was a considerable increase in testing for cholesterol (three fold) and haemoglobin (eight fold) on the desktop analysers, compared with the number of laboratory tests requested before the study. The cost per test of using such machines is closely related to the level of activity and probably does not compete favourably with hospital testing unless several tests are performed each day. Quality control tests were within the specified limits on at least 98% of occasions, however these tests also identified the need for laboratory back up where a problem was found.