Secondary forest fragments offer important carbon and biodiversity cobenefits.

Tropical forests store large amounts of carbon and high biodiversity, but are being degraded at alarming rates. The emerging global Forest and Landscape Restoration (FLR) agenda seeks to limit global climate change by removing carbon dioxide from the atmosphere through the growth of trees. In doing so, it may also protect biodiversity as a free cobenefit, which is vital given the massive shortfall in funding for biodiversity conservation. We investigated whether natural forest regeneration on abandoned pastureland offers such cobenefits, focusing for the first time on the recovery of taxonomic diversity (TD), phylogenetic diversity (PD) and functional diversity (FD) of trees, including the recovery of threatened and endemic species richness, within isolated secondary forest (SF) fragments. We focused on the globally threatened Brazilian Atlantic Forest, where commitments have been made to restore 1 million hectares under FLR. Three decades after land abandonment, regenerating forests had recovered ~20% (72 Mg/ha) of the above-ground carbon stocks of a primary forest (PF), with cattle pasture containing just 3% of stocks relative to PFs. Over this period, SF recovered ~76% of TD, 84% of PD and 96% of FD found within PFs. In addition, SFs had on average recovered 65% of threatened and ~30% of endemic species richness of primary Atlantic forest. Finally, we find positive relationships between carbon stock and tree diversity recovery. Our results emphasize that SF fragments offer cobenefits under FLR and other carbon-based payments for ecosystem service schemes (e.g. carbon enhancements under REDD+). They also indicate that even isolated patches of SF could help to mitigate climate change and the biodiversity extinction crisis by recovering species of high conservation concern and improving landscape connectivity.

The role of metacognition and its indirect effect through cognitive attentional syndrome on fear of cancer recurrence trajectories: A longitudinal study.

OBJECTIVE: This longitudinal study mapped distinct trajectories of fear of cancer recurrence (FCR) over 12 months among patients with breast (BC) or colorectal (CRC) cancer, and examined if metacognition, indirectly via attentional bias, intrusive thoughts and avoidance (hallmarks of cognitive attentional syndrome; CAS) predicted FCR trajectory membership. METHODS: Two hundred and seventy BC (n = 163) or CRC (n = 107) patients were assessed at 8-weeks, 3-, 6-, and 12-months postsurgery on a measure of FCR (FCRI-SF). Metacognition (MCQ-30), Intrusive and Avoidant Thoughts (CIES-R) and attentional bias (dot-probe tasks) were assessed at baseline. Latent growth mixture modeling identified FCR trajectories. Fully-adjusted Multinomial Logistic Regression identified whether direct and indirect effects of metacognition through CAS determined FCR trajectory membership. RESULTS: Three distinct FCR trajectories were identified, namely, low-stable (62.4%), high-stable (29.2%), and recovery (8.3%). Negative beliefs about worry, cognitive confidence, and age predicted FCR trajectories (χ2 (6) = 38.31, P<.001). Compared with Low-stable group, Recovery FCR patients held greater Negative beliefs about worry (OR = 1.13, P = .035) and High-stable FCR patients reported poorer Cognitive confidence (OR = 1.12, P = .004). The effect of Negative beliefs about worry was partially mediated by avoidance (ß = .06, 95% CIs 0.03-0.12) and fully mediated by intrusive thoughts (ß = .14, 95% CIs 0.08-0.20). Attentional bias did not predict FCR trajectories. CONCLUSIONS: While most patients experienced low level of FCR, 3 in 10 persistently worried about cancer returning over the first 12-months postsurgery. Modifying metacognitive knowledge to interrupt maladaptive cognitive processing including intrusion and avoidance may be an effective therapeutic intervention for patients at risk of persistent FCR.

Fear of cancer recurrence among Chinese cancer survivors: Prevalence and associations with metacognition and neuroticism.

OBJECTIVE: Fear of cancer recurrence (FCR) represents a chronic burden for many cancer survivors. We determined FCR prevalence and potential correlates, specifically metacognitive styles and neuroticism among Chinese cancer survivors with breast or colorectal cancer. METHODS: This study included 285 Chinese patients with breast (N = 173) and colorectal (N = 112) cancers at 8-week postsurgery. Participants completed a set of baseline questionnaires evaluating FCR (Fear of Cancer Recurrence Inventory-Short Form [FCRI-SF]), metacognition (Metacognitions Questionnaire-30), and neuroticism (Eysenck Personality Questionnaire). Scores of 13 to 21 were indicative of subclinical FCR on the FCRI-SF. Scores greater than or equal to 22 indicated clinically significant levels of FCR. Fully adjusted multinomial logistic regressions identified correlates of subclinical and clinically significant FCR. RESULTS: Respectively, 26.0% (n = 74) and 11.2% (n = 32) achieved scores indicating subclinical and clinically significant FCR. Expressing significantly more positive (OR = 1.21, P = .003) and negative (OR = 1.19, P = .005) beliefs about worry was associated with a higher likelihood of reporting subclinical FCR. Both higher neuroticism (OR = 1.28, P = .003) and more negative beliefs about worry (OR = 1.19, P = 0.035) were associated with an increased likelihood of experiencing clinically significant FCR. CONCLUSIONS: Positive and negative metacognitions may play an important role in the development of subclinical FCR. In particular, negative metacognition and neuroticism may elevate FCR from subclinical to a clinical level. The findings give insight into the identification of cancer survivors with subclinical or clinical FCR and aid the development of interventions aimed at changing metacognitive beliefs in order to manage FCR.

Characteristics of Fentanyl Overdose - Massachusetts, 2014-2016.

Opioid overdose deaths in Massachusetts increased 150% from 2012 to 2015 (1). The proportion of opioid overdose deaths in the state involving fentanyl, a synthetic, short-acting opioid with 50-100 times the potency of morphine, increased from 32% during 2013-2014 to 74% in the first half of 2016 (1-3). In April 2015, the Drug Enforcement Agency (DEA) and CDC reported an increase in law enforcement fentanyl seizures in Massachusetts, much of which was believed to be illicitly manufactured fentanyl (IMF) (4). To guide overdose prevention and response activities, in April 2016, the Massachusetts Department of Public Health and the Office of the Chief Medical Examiner collaborated with CDC to investigate the characteristics of fentanyl overdose in three Massachusetts counties with high opioid overdose death rates. In these counties, medical examiner charts of opioid overdose decedents who died during October 1, 2014-March 31, 2015 were reviewed, and during April 2016, interviews were conducted with persons who used illicit opioids and witnessed or experienced an opioid overdose. Approximately two thirds of opioid overdose decedents tested positive for fentanyl on postmortem toxicology. Evidence for rapid progression of fentanyl overdose was common among both fatal and nonfatal overdoses. A majority of interview respondents reported successfully using multiple doses of naloxone, the antidote to opioid overdose, to reverse suspected fentanyl overdoses. Expanding and enhancing existing opioid overdose education and prevention programs to include fentanyl-specific messaging and practices could help public health authorities mitigate adverse effects associated with overdoses, especially in communities affected by IMF.

Psychometric assessment of the Chinese version of the decisional conflict scale in Chinese women making decision for breast cancer surgery.

OBJECTIVE: The decisional conflict scale (DCS) measures the perception of uncertainty in choosing options, factors contributing to decision conflict and effective decision making. This study examined the validity and reliability of the Chinese version of the DCS in Hong Kong Chinese women deciding breast cancer (BC) surgery. METHOD: A Chinese version of the 16-item DCS was administered to 471 women awaiting initial consultation for BC diagnosis. Confirmatory factor analysis (CFA) assessed the factor structure. Internal consistency, and convergent and discriminant validities of the factor structure were assessed. RESULTS: CFA revealed the original factor structure of the DCS showed poor fit to this sample. Exploratory factor analysis revealed an alternative three-factor structure, Informed and Values Clarity, Uncertainty and Effective Decision and Support, was optimal. Cronbach's alpha ranged from 0.51 to 0.87. Correlations between decision-making difficulties and satisfaction with medical consultation demonstrated acceptable convergent validity. Construct validity was supported by correlations between decision regret and psychological distress. Discriminant validity was supported by differentiation between delaying and non-delaying decision-makers. CONCLUSIONS: The three-factor DCS-14 is a valid and practical measure for assessing decisional conflict in deciding BC surgery. It shows good potential for use in assessing decision satisfaction for women diagnosed with BC.

Communicative characteristics of interactions between surgeons and Chinese women with breast cancer in oncology consultation: a conversation analysis.

BACKGROUND: While previous studies have analysed features of interaction in cancer consultations using observational coding frames, relatively little attention is being given to how actual interactions are sequentially organized and achieved by participants in the course of talk-in-interaction. Research into the interactional practices in consultations, which involves Chinese patients, is largely absent. OBJECTIVE: To provide insight into the talk-in-interaction in surgical-oncology consultations in the context of a Chinese medical setting. METHODS: Thirty-one consultations involving 31 patients with breast cancer and eight surgeons were videotaped. The recordings were transcribed verbatim and analysed using conversation analysis. RESULTS: The manner in which surgeons delivered the diagnostic results was fairly similar across all the consultations. Most surgeons gave the diagnosis in a very straightforward and abrupt manner at the outset of the consultation with no mitigation. While patients in our study conformed to the traditional information giving and receiving roles, how information was presented by surgeons shaped the subsequent sequential organization of surgeon-patient interaction and turn-taking patterns. More importantly, there was a tendency by the surgeons to move from issues of psychosocial nature to clinical matters regardless of the topics taken up in the specific encounter. CONCLUSIONS: This study demonstrated the potential of conversation analysis as a context-sensitive method that enabled researchers to gain a more thorough understanding of dynamics of interaction in cancer consultations, thereby informing training interventions for surgeons. Our findings underscore the importance of discursive practices in shaping and encouraging (or discouraging) patient participation in oncology consultation.

Study protocol of ConquerFear-HK: a randomised controlled trial of a metacognition-based, manualised intervention for fear of cancer recurrence among Chinese cancer survivors.

INTRODUCTION: Fear of cancer recurrence (FCR) is a prevalent and frequently debilitating response to a cancer diagnosis, affecting a substantial proportion of cancer survivors. Approximately 30% of local Hong Kong Chinese cancer survivors in a recent survey reportedly experienced persistent high FCR over the first-year post-surgery. This was associated with lower levels of psychological well-being and quality of life. A manualised intervention (ConquerFear) developed primarily based on the Self-Regulatory Executive Function Model and the Rational Frame Theory, has been found to reduce FCR effectively among Caucasian cancer survivors. The intervention now has been adapted to a Chinese context; ConquerFear-HK. The primary aim of this study is to evaluate its efficacy vs a standard-survivorship-care control (BasicCancerCare) in FCR improvement in a randomised control trial (RCT). METHODS AND ANALYSIS: In this RCT, using the sealed envelope method, 174 eligible Chinese cancer survivors will be randomised to either the ConquerFear-HK or BasicCancerCare intervention. Both interventions include six sessions over 10 weeks, which will be delivered via face to face or online by trained therapists. The ConquerFear-HK intervention incorporates value classification, metacognitive therapy, attentional training, detached mindfulness and psychoeducation; BasicCancerCare includes relaxation training, dietary and physical activity consultations. Participants will be assessed at prior randomisation (baseline; T0), immediately postintervention (T1), 3 months (T2) and 6 months postintervention (T3) on the measures of FCR (Fear of Cancer Recurrence Inventory) as a primary outcome; metacognition (30-item Metacognitions Quesionnaire) and cognitive attentional syndrome (Cognitive-attentional Syndrome Questionnaire) as process outcomes; psychological distress (Hospital Anxiety and Depression Scale), cancer-related distress (Chinese Impact of Events Scale), quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire) and treatment satisfaction are secondary outcomes. ETHICS AND DISSEMINATION: Ethics approval has been obtained from HKU/HA HKW Institutional Review Board (ref: UW19-183). The patients/participants provide their written informed consent to participate in this study. The study results will be disseminated through international peer-review publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT04568226.

Trajectories of body image and sexuality during the first year following diagnosis of breast cancer and their relationship to 6 years psychosocial outcomes.

We examined degree and determinants of change in body image and sexuality over the first year following breast cancer diagnosis to differentiate body image and sexuality trajectories, and then explored if differences in trajectories predicted 6 years' psychosocial outcomes. 363/405 (90%) Chinese women receiving surgery for BC were assessed at 5-days (Baseline), 1-month, 4-months, and 8-months post-surgery. Psychological distress, treatment decision making (TDM) difficulties, satisfaction with treatment outcome, optimism, and self-efficacy were assessed at Baseline. Self-image and sexuality were recorded at each follow-up assessment. Latent growth mixture modeling identified trajectories of self-image and sexuality. Multinominal logistic regression identified factors predicting trajectory patterns. Six years later 211/363 (58%) of the original patients were successfully traced and their psychosocial status assessed. Three distinct trajectories of self-image and sexuality were identified: high-stable, recovery, and high-deteriorating. Most women (64% self-image; 58% sexuality) showed stable levels of self-image and sexuality scores. TDM difficulties, satisfaction with treatment outcomes, physical symptom and psychological distress predicted trajectory patterns. Self-image trajectories over the first year diagnosis predicted 6-years psychosocial outcomes. Women with high-stable level of self-image had the best 6-year self-image and sexuality; women with initial low level of self-image had significantly greater long-term psychological distress. Low TDM difficulties and high treatment outcome satisfaction predicted high and stable self-image and sexuality. Type of surgery showed little impacts on self-image and sexuality. Self-image during acute illness phase predicted long-term outcomes. Interventions should focus on minimizing self-image decrement.

Waiting to see the doctor: understanding appraisal and utilization components of consultation delay for new breast symptoms in Chinese women.

BACKGROUND: Delayed consultation for potential cancer symptoms influences treatment outcomes and remains problematic. Delay components (Appraisal versus Utilization) and respective associations are poorly understood. METHODS: Eligible participants were Cantonese-speaking Chinese women, ≥21 years old, with self-discovered breast symptoms, recruited in surgical clinics before their first consultation, and naïve to their diagnosis. Overall 425/433 (98%) women completed a questionnaire on psychosocial, demographic and medical factors, how and when women discovered their breast symptom(s), and their subsequent decision making; 135/425 women (32%) were later diagnosed with breast cancer. RESULTS: Twenty-two per cent of women delayed >3 months before consultation. Women with breast cancer (28%) more often had prolonged delay than women with benign disease (19%). Attributing symptom to a non-cancerous condition, low fear on symptom discovery, not disclosing symptoms to others, and no prior breast symptom history predicted prolonged (>60 days) Appraisal Delay. Low fear on symptom discovery, seldom thinking about the symptom, and consultation for other reasons predicted prolonged (>14 days) Utilization Delay. Factors predicting Appraisal and Utilization Delays differentiated cancer from non-cancer groups. CONCLUSIONS: Indecision over symptom meaning comprised the main component of Appraisal and Total Delay, suggesting that educational strategies targeting atypical symptoms should reduce avoidable delays following self-discovered breast symptoms.

Key process features of personalized diet counselling in metabolic syndrome: secondary analysis of feasibility study in primary care.

BACKGROUND: Personalized diet counselling, as part of lifestyle change programs for cardiometabolic risk conditions (combinations of prediabetes or type 2 diabetes, hypertension, dyslipidemia and high waist circumference) has been shown to reduce progression to type 2 diabetes overall. To identify key process of care measures that could be linked to changes in diet, we undertook a secondary analysis of a Canadian pre-post study of lifestyle treatment of metabolic syndrome (MetS). Diet counselling process measures were documented and association with diet quality changes after 3 months were assessed. Results of the primary study showed 19% reversal of MetS after 1 year. METHODS: Registered dietitians (RDs) reported on contact time, specific food behaviour goals (FBG), behaviour change techniques (BCT; adapted from the Michie CALO-RE taxonomy) and teaching resources at each contact. Diet quality was measured by 2005 Canadian Healthy Eating Index (HEI-C) and assessed for possible associations with individual BCT and FBG. RESULTS: Food behaviour goals associated with improved HEI-C at 3 months were: poultry more than red meat, increased plant protein, increased fish, increased olive oil, increased fruits and vegetables, eating breakfast, increased milk and alternatives, healthier fats, healthier snacks and increased nuts, with an adverse association noted for more use (> 2 times/ 3 months) of the balanced meal concept (F test; p < 0.001). Of 16 BCT, goal setting accounted for 15% of all BCT recorded, yet more goal setting (> 3 times/3 months) was associated with poorer HEI-C at 3 months (F test; p = 0.007). Only self-monitoring, feedback on performance and focus on past success were associated with improved HEI-C. CONCLUSIONS: These results identify key aspects of process that impact diet quality. Documentation of both FBG and BCT is highly relevant in diet counselling and a summary diet quality score is a promising target for assessing short-term counselling success.

Isotope-guided surgery for nonpalpable breast cancer.

BACKGROUND: The hook-wire technique is used to guide surgical excision of nonpalpable breast lesions. Recently, isotope has been used to guide the excision, and when sentinel node biopsy is performed during the same operation, the procedure is termed Sentinel Node and Occult Lesion Localization (SNOLL). We evaluated the use of this procedure for nonpalpable cancers in Chinese women. METHODS: Seventy-four patients underwent SNOLL before breast-conserving surgery. Intratumoral injection of sulfur colloid and lymphoscintigraphy (LSG) were performed. A gamma probe was used for resection planning and localization of the sentinel node (SN). Blue dye mapping was used in patients with negative LSG. Complete excision was defined as a tumor-free margin greater than 1 mm. RESULTS: The primary breast lesion was successfully removed in 73 patients (99%). Complete excision was achieved in 61 patients (82%). Drainage to axilla was detected by LSG in 53 patients (72%). The gamma probe was more sensitive than LSG and had an 82% SN identification rate. Patients with a positive LSG had a higher chance of SN localization by gamma probe than patients with a negative LSG (100% vs. 38%, p < 0.001). In patients with a negative LSG, supplementary blue dye mapping increased the SN localization rate from 38 to 90%. The SN identification rate was 97% in the whole series. CONCLUSION: Isotope-guided surgery was reliable, with a 99% localization rate for nonpalpable breast lesions and an 82% SN localization rate. The success rate of SN identification could be improved to 97% with the addition of blue dye mapping for patients with negative drainage on lymphoscintigraphy.

Development and pilot-testing of a Decision Aid for use among Chinese women facing breast cancer surgery.

BACKGROUND: Women choosing breast cancer surgery encounter treatment decision-making (TDM) difficulties, which can cause psychological distress. Decision Aids (DAs) may facilitate TDM, but there are no DAs designed for Chinese populations. We developed a DA for Chinese women newly diagnosed with breast cancer, for use during the initial surgical consultation. AIMS: Conduct a pilot study to assess the DA acceptability and utility among Chinese women diagnosed with breast cancer. METHODS: Women preferred the DA in booklet format. A booklet was developed and revised and evaluated in two consecutive pilot studies (P1 and P2). On concluding their initial diagnostic consultation, 95 and 38 Chinese women newly diagnosed with breast cancer received the draft and revised draft DA booklet, respectively. Four-day post-consultation, women had questionnaires read out to them and to which they responded assessing attitudes towards the DA and their understanding of treatment options. RESULTS: The original DA was read/partially read by 66/22% (n = 84) of women, whilst the revised version was read/partially read by 74/16% (n = 35), including subliterate women (χ(2) = 0.76, P = 0.679). Knowledge scores varied with the extent the booklet was read (P1: F = 12.68, d.f. 2, P < 0.001; P2: F = 3.744, d.f. 2, P = 0.034). The revised, shorter version was graphically rich and resulted in improved perceived utility, [except for the 'treatment options' (χ(2) = 5.50, P = 0.019) and 'TDM guidance' (χ(2) = 8.19, P = 0.004) sections] without increasing anxiety (F = 0.689, P = 0.408; F = 3.45, P = 0.073). CONCLUSION: The DA was perceived as acceptable and useful for most women. The DA effectiveness is currently being evaluated using a randomized controlled trial.

Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study.

BACKGROUND: Sacral nerve stimulation has been approved for use in treating urinary incontinence in the United States since 1997, and in Europe for both urinary and fecal incontinence (FI) since 1994. The purpose of this study was to determine the safety and efficacy of sacral nerve stimulation in a large population under the rigors of Food and Drug Administration-approved investigational protocol. METHODS: Candidates for SNS who provided informed consent were enrolled in this Institutional Review Board-approved multicentered prospective trial. Patients showing > or =50% improvement during test stimulation received chronic implantation of the InterStim Therapy (Medtronic; Minneapolis, MN). The primary efficacy objective was to demonstrate that > or =50% of subjects would achieve therapeutic success, defined as > or =50% reduction of incontinent episodes per week at 12 months compared with baseline. RESULTS: A total of 133 patients underwent test stimulation with a 90% success rate, and 120 (110 females) of a mean age of 60.5 years and a mean duration of FI of 6.8 years received chronic implantation. Mean follow-up was 28 (range, 2.2-69.5) months. At 12 months, 83% of subjects achieved therapeutic success (95% confidence interval: 74%-90%; P < 0.0001), and 41% achieved 100% continence. Therapeutic success was 85% at 24 months. Incontinent episodes decreased from a mean of 9.4 per week at baseline to 1.9 at 12 months and 2.9 at 2 years. There were no reported unanticipated adverse device effects associated with InterStim Therapy. CONCLUSION: Sacral nerve stimulation using InterStim Therapy is a safe and effective treatment for patients with FI.

Trajectories of psychological distress among Chinese women diagnosed with breast cancer.

BACKGROUND: The distinct trajectories of psychological distress over the first year of the diagnosis with breast cancer (BC) and its determinants have not been explored. METHODS: 285 of 405 Chinese women receiving surgery for BC were assessed at 5-day, 1-month, 4-month, and 8-month post-surgery on measures of psychological distress, optimism, treatment decision-making (TDM) difficulties, satisfaction with treatment outcome, satisfaction with medical consultation, and physical symptom distress. Latent growth mixture modelling identified trajectories of psychological response to BC. Multinominal logistic regression compared TDM difficulties, satisfaction with treatment outcome, satisfaction with medical consultation, optimism, and physical symptom distress, by distress pattern adjusted for age, education, employment status, and stage of disease. RESULTS: Four distinct trajectories of distress were identified, namely, resilience (66%), chronic distress (15%), recovered (12%), and delayed-recovery (7%). TDM difficulties, optimism, satisfaction with consultation, and physical symptom distress predicted distress trajectories. Psychologically resilient women had less physical symptom distress at early post-surgery compared with women with other distress patterns. Compared with the resilient group, women in the recovered or chronic distress groups experienced greater TDM difficulties, whereas women in the delayed-recovery group reported greater dissatisfaction with the initial medical consultation. Women in the chronic distress group reported greater pessimistic outlook. CONCLUSION: Optimism and better early post-operative treatment outcomes predicted resilience to distress. Pre-operative interventions helping women to establish a realistic expectation of treatment outcome may minimize disappointment with treatment outcome and resultant distress, whereas post-operative rehabilitation should focus on symptom management.

Social adjustment among Chinese women following breast cancer surgery.

BACKGROUND: How breast cancer surgery affects social adjustment among Chinese women is unknown, as are factors predicting such adjustment. METHODS: 405 Chinese women receiving surgery for localized breast cancer completed Social Adjustment Scales (Ch-SAS) at 1-, 4- and 8-months post-operatively. Subscale scores were regressed on baseline (days 3-12 post-operatively) measures of treatment decision-making difficulty (TDMD), self-efficacy (GSeS), consultation satisfaction (C-MISS-R), psychological (CHQ-12) and physical distress (PD), and 1-month follow-up optimism (C-LOT-R), and disappointment (E-OI), fully adjusted for demographic and clinical factors. RESULTS: All Ch-SAS subscales except appearance & sexuality changed significantly over 8-months follow-up: Enjoyment of social activities (F=27.38, df 2, p<0.001) and self-image (F=3.63, df 2, p=0.027) improved slightly. Family interaction (F=26.63, df 2, p<0.001) and interaction with friends (F=3.37, df 2, p=0.035) declined slightly. Family and friends interaction subscales were predominantly predicted by high self-efficacy and optimism, whereas self-image and appearance & sexuality subscales were predominantly predicted by low treatment outcome disappointment, TDM difficulties, baseline psychological morbidity and high self-efficacy. Enjoyment of social activities was predicted by low baseline psychological distress and concurrent physical symptom distress. CONCLUSION: High self-efficacy and optimism predicted women who have better social relationships with friends and family. Higher self-efficacy, low TDM difficulties, less disappointment with treatment outcome and low psychological and physical distress predicted better adjustment to self-image and body image.

A sprayable hydrogel adhesion barrier facilitates closure of defunctioning loop ileostomy: a randomized trial.

PURPOSE: Closure of defunctioning loop ileostomy often is associated with division of complex peristomal adhesions through a parastomal incision with limited exposure. The goal was to determine whether sprayable hydrogel adhesion barrier (SprayGel) will reduce peristomal adhesions and facilitate closure of ileostomy. METHODS: Patients undergoing closure of loop ileostomy were randomized to have hydrogel adhesion barrier sprayed around both limbs of ileostomy for 20 cm (SprayGel group, n = 19), or to control without adhesion barrier (control group, n = 21). Ileostomy was reversed at ten weeks after construction. Extent of peristomal adhesions was scored in blinded manner (each quadrant, range, 1-3: 3 = most severe; total, range, 4-12: 12 = most severe). RESULTS: Use of adhesion barrier was associated with significant reduction in overall adhesion scores (mean, 6.11 vs. 9.67; P < 0.0005), four-quadrant adhesion scores (Quadrant A: 1.68 vs. 2.52, P = 0.002; Quadrant B: 1.42 vs. 2.33, P < 0.0005; Quadrant C: 1.42 vs. 2.24, P < 0.0005; Quadrant D: 1.58 vs. 2.48, P = 0.002), and proportion of patients with dense (scores > or = 8) adhesions (0.11 vs. 0.71; P < 0.0005). Time taken to mobilize (16.53 vs. 21.67 minutes; P = 0.008) and close ileostomy (35.37 vs. 41.90 minutes; P = 0.008) was significantly reduced. Postoperative complications were comparable. CONCLUSIONS: A sprayable hydrogel adhesion barrier placed around the limbs of a defunctioning loop ileostomy reduced peristomal adhesions and might facilitate closure of ileostomy.

Sacral nerve stimulation for fecal incontinence: external anal sphincter defect vs. intact anal sphincter.

PURPOSE: This prospective study was designed to assess the effectiveness of sacral nerve stimulation for fecal incontinence in patients with external anal sphincter defect and to evaluate its efficacy regarding presence and size of sphincter defect. METHODS: Fifty-three consecutive patients who underwent sacral nerve stimulation for fecal incontinence were divided into two groups: external anal sphincter defect group (n = 21) vs. intact sphincter group (n = 32). Follow-up was performed at 3, 6, and 12 months with anorectal physiology, Wexner's score, bowel diary, and quality of life questionnaires. RESULTS: The external anal sphincter defect group (defect <90 degrees:defect 90 degrees-120 degrees = 11:10) and intact sphincter group were comparable with regard to age (mean, 63 vs. 63.6) and sex. Incidence of internal anal sphincter defect and pudendal neuropathy was similar. All 53 patients benefited from sacral nerve stimulation. Weekly incontinent episodes decreased from 13.8 to 5 (P < 0.0001) for patients with external anal sphincter defects and from 6.7 to 2 (P = 0.001) for patients with intact sphincter at 12-month follow-up. Quality of life scores improved in both groups (P < 0.0125). There was no significant difference in improvement in functional outcomes after sacral nerve stimulation between patients with or without external anal sphincter defects. Clinical benefit of sacral nerve stimulation was similar among patients with external anal sphincter defects, irrespective of its size. Presence of pudendal neuropathy did not affect outcome of neurostimulation. CONCLUSIONS: Sacral nerve stimulation for fecal incontinence is as effective in patients with external anal sphincter defects as those with intact sphincter and the result is similar for defect size up to 120 degrees of circumference.

Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study.

PURPOSE: This randomized study was designed to compare the effect of sacral neuromodulation with optimal medical therapy in patients with severe fecal incontinence. METHODS: Patients (aged 39-86 years) with severe fecal incontinence were randomized to have sacral nerve stimulation (SNS group; n = 60) or best supportive therapy (control; n = 60), which consisted of pelvic floor exercises, bulking agent, and dietary manipulation. Full assessment included endoanal ultrasound, anorectal physiology, two-week bowel diary, and fecal incontinence quality of life index. The follow-up duration was 12 months. RESULTS: The sacral nerve stimulation group was similar to the control group with regard to gender (F:M = 11:1 vs. 14:1) and age (mean, 63.9 vs. 63 years). The incidence of a defect of < or = 120 degrees of the external anal sphincter and pudendal neuropathy was similar between the groups. Trial screening improved incontinent episodes by more than 50 percent in 54 patients (90 percent). Full-stage sacral nerve stimulation was performed in 53 of these 54 "successful" patients. There were no septic complications. With sacral nerve stimulation, mean incontinent episodes per week decreased from 9.5 to 3.1 (P < 0.0001) and mean incontinent days per week from 3.3 to 1 (P < 0.0001). Perfect continence was accomplished in 25 patients (47.2 percent). In the sacral nerve stimulation group, there was a significant (P < 0.0001) improvement in fecal incontinence quality of life index in all four domains. By contrast, there was no significant improvement in fecal continence and the fecal incontinence quality of life scores in the control group. CONCLUSIONS: Sacral neuromodulation significantly improved the outcome in patients with severe fecal incontinence compared with the control group undergoing optimal medical therapy.

Laparoscopic intragastric approach for stromal tumours located at the posterior gastric wall.

Surgical resection is indicated for gastrointestinal stromal tumour (GIST). Laparoscopic resection with clear margins is effective in gastric GIST. However, GIST located in the posterior gastric wall with close proximity to the oesophagogastric junction poses special challenges. Laparoscopic intragastric resection offers a new approach to the management of these tumours. The surgical technique, our experience and a summary of the literature are presented.

Randomized trial comparing pantoprazole infusion, bolus and no treatment on gastric pH and recurrent bleeding in peptic ulcers.

BACKGROUND: To study the effects of pantoprazole on gastric pH and recurrent bleeding after endoscopic treatment for bleeding peptic ulcers. METHODS: After endoscopic haemostasis, patients were randomly assigned to infusion group (pantoprazole 80 mg i.v. bolus followed by continuous infusion of 8 mg/h for 3 days), bolus group (pantoprazole 80 mg i.v. bolus followed by 40 mg i.v. bolus every 12 h for 3 days) and no-treatment group (no acid suppression in the first 3 days). Gastric pH was monitored. Rebleeding rate within 30 days, the need for surgery, transfusion requirement, total hospital stay, mortality rate and gastric pH were compared. RESULTS: One hundred and sixty-eight patients were included, with 15 patients excluded from the analysis. There were 54 patients in the infusion group, 49 in the bolus group and 50 in the no-treatment group. There was fewer rebleeding (3.7 vs 16.0%, P = 0.034), less operative intervention (0 vs 8.0%, P = 0.034) and shorter hospital stay (6.4 vs 8.2 days, P = 0.040) in the infusion group compared with that in no-treatment group. When the bolus group was compared with no-treatment group, there were fewer rebleed (4.1 vs 16.0%, P = 0.049) and less blood transfusion (1.5 vs 2.9 units, P = 0.007). There was no difference in mortality among the three groups. Patients who received either pantoprazole infusion or bolus had significantly higher mean pH and longer duration of pH above 6 compared with the no-treatment group. There was no difference in the rebleeding rate, transfusion requirement, need for operation and hospital stay between the infusion and bolus groups. The mean pH and the duration of pH above 6 were also similar. CONCLUSION: Pantoprazole either as infusion or bolus decreased rebleeding after endoscopic treatment for bleeding peptic ulcer.