Conditional risk of diverticulitis after non-operative management.

BACKGROUND: The objective of this study was to describe conditional recurrence-free survival (RFS) of patients after an index episode of diverticulitis managed without surgery, and to estimate the difference in conditional RFS for diverticulitis according to specific risk factors. METHODS: This was a multicentre retrospective cohort study including all patients managed without surgery for acute sigmoid diverticulitis at two university-affiliated hospitals in Montreal, Quebec, Canada. Conditional RFS for diverticulitis was estimated over 10 years of follow-up. A Cox proportional hazards model was performed at the index episode and again 2 years later. RESULTS: In total, 991 patients were included for analysis. The 1, 2- and 3-year actuarial diverticulitis RFS rates were 81·1, 71·5 and 67·5 per cent respectively. Compared with the 1-year actuarial RFS rate of 81·1 per cent, the 1-year conditional RFS increased with each additional year survived recurrence-free, reaching 96·0 per cent after surviving the first 4 years recurrence-free. A similar phenomenon was observed for 2-year diverticulitis conditional RFS. Lower age (hazard ratio (HR) 0·98, 95 per cent c.i. 0·98 to 0·99), Charlson Co-morbidity Index score of 2 or above (HR 1·78, 1·32 to 2·39) and immunosuppression (HR 1·85, 1·38 to 2·48) were independently associated with recurrence of diverticulitis from the index episode. At 2 years from the index episode, immunosuppression was no longer associated with diverticulitis recurrence (HR 1·02, 0·50 to 2·09). CONCLUSION: The conditional RFS of patients with diverticulitis improved with each year that was survived recurrence-free. Although several factors at index presentation may be associated with early recurrence, the conditional probability of recurrence according to many of these risk factors converged with time.

ANTECEDENTES: El objetivo de este estudio fue describir la supervivencia condicional libre de recidiva de diverticulitis (diverticulitis recurrence-free survival, Div-RFS) en pacientes tras un episodio de diverticulitis tratado de forma conservadora, y calcular la diferencia en la Div-RFS condicional de acuerdo con factores de riesgo específicos. MÉTODOS: Estudio de cohorte retrospectivo multicéntrico que incluyó a todos los pacientes tratados de forma no quirúrgica por diverticulitis sigmoidea aguda en dos hospitales afiliados a la universidad en Montreal, Quebec, Canadá. La supervivencia condicional libre de recidiva de la diverticulitis se calculó durante 10 años de seguimiento. Se realizó un análisis mediante un modelo de riesgos proporcionales de Cox en el episodio índice y nuevamente 2 años después. RESULTADOS: En total, se incluyeron 991 pacientes en el análisis. La Div-RFS actuarial a 1, 2 y 3 años fue del 81,1%, 71,5% y 67,5%, respectivamente. En comparación con la Div-RFS actuarial a 1 año del 81,1%, la Div-RFS condicional a 1 año aumentó con cada año adicional sobrevivido sin recidiva, alcanzando el 96,0% después de sobrevivir los primeros 4 años sin recidiva. Se observó un fenómeno similar para Div-RFS condicional a los 2 años. Una menor edad (cociente de riesgos instantáneos, hazard ratio, HR: 0,98; i.c. del 95%: 0,98 a 0,99), la puntuación de comorbilidad de Charlson ≥ 2 (HR: 1,78; i.c. del 95%: 1,32 a 2,39) y la inmunosupresión (HR: 1,85; i.c. del 95%: 1,38 a 2,48) se asociaron de forma independiente con la recidiva de la diverticulitis desde el episodio índice. En la regresión de Cox a los 2 años del episodio índice, la inmunosupresión ya no se asoció con recidiva de diverticulitis (HR: 1,02; i.c. del 95% 0,50-2,09). CONCLUSIÓN: La Div-RFS condicional mejoró con cada año de supervivencia sin recidiva. Si bien varios factores en la presentación del episodio índice pueden estar asociados con una recidiva precoz, la probabilidad condicional de recidiva en relación con muchos de estos factores de riesgo coincidió con el tiempo.

Prediction model and web-based risk calculator for postoperative ileus after loop ileostomy closure.

BACKGROUND: Postoperative ileus (POI) is a significant complication after loop ileostomy closure given both its frequency and impact on the patient. The purpose of this study was to develop and externally validate a prediction model for POI after loop ileostomy closure. METHODS: The model was developed and validated according to the TRIPOD checklist for prediction model development and validation. The development cohort included consecutive patients who underwent loop ileostomy closure in two teaching hospitals in Montreal, Canada. Candidate variables considered for inclusion in the model were chosen a priori based on subject knowledge. The final prediction model, which modelled the 30-day cumulative incidence of POI using logistic regression, was selected using the highest area under the receiver operating characteristic curve (AUC) criterion. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. The model was then validated externally in an independent cohort of similar patients from the University of British Columbia. RESULTS: The development cohort included 531 patients, in whom the incidence of POI was 16·8 per cent. The final model included five variables: age, ASA fitness grade, underlying pathology/treatment, interval between ileostomy creation and closure, and duration of surgery for ileostomy closure (AUC 0·68, 95 per cent c.i. 0·61 to 0·74). The model demonstrated good calibration (P = 0·142). The validation cohort consisted of 216 patients, and the incidence of POI was 15·7 per cent. On external validation, the model maintained good discrimination (AUC 0·72, 0·63 to 0·81) and calibration (P = 0·538). CONCLUSION: A prediction model was developed for POI after loop ileostomy closure and included five variables. The model maintained good performance on external validation.

ANTECEDENTES: El íleo postoperatorio (postoperative ileus, POI) es una complicación importante tras el cierre de la ileostomía en asa, dada su frecuencia e impacto en el paciente. El propósito de este estudio fue desarrollar y validar externamente un modelo de predicción para el POI después del cierre de la ileostomía en asa. MÉTODOS: El modelo fue desarrollado y validado de acuerdo con la lista de verificación TRIPOD para el desarrollo y validación de un modelo de predicción. La cohorte de desarrollo incluyó pacientes consecutivos en los que se realizó el cierre de la ileostomía en asa en dos hospitales universitarios en Montreal, Canadá. Las variables candidatas consideradas para su inclusión en el modelo se seleccionaron a priori en función del conocimiento del problema. El modelo de predicción final, que modeló la incidencia acumulada a 30 días de POI mediante regresión logística, se seleccionó según el criterio del área más alta bajo la curva operativa del receptor (area under the receiver operating curve, AUC). La calibración del modelo se evaluó utilizando la prueba de bondad de ajuste de Hosmer-Lemeshow. El modelo fue posteriormente validado externamente en una cohorte independiente de pacientes similares de la Universidad de British Columbia. RESULTADOS: La cohorte de desarrollo incluyó a 531 pacientes, y la incidencia de POI fue de 16,7%. El modelo final incluyó cinco variables: edad, clasificación ASA (American Society of Anaesthesiologists), patología inicial y tratamiento, tiempo entre las dos intervenciones quirúrgicas y tiempo operatorio del cierre de ileostomía (AUC = 0,68; i.c. del 95%: 0,61 a 0,74). El modelo demostró buena calibración (P = 0,142). La cohorte de validación consistió en 216 pacientes, y la incidencia de POI fue de 15,7%. En la validación externa, el modelo mantuvo una buena discriminación (AUC = 0,72; i.c. del 95%: 0,63 a 0,81) y calibración (P = 0,538). CONCLUSIÓN: Se ha desarrollado un modelo de predicción de POI después del cierre de la ileostomía en asa que incluía cinco variables. El modelo mantuvo un buen funcionamiento en la validación externa.

Assessing the readability, quality and accuracy of online health information for patients with low anterior resection syndrome following surgery for rectal cancer.

AIM: Management of low anterior resection syndrome (LARS) requires a high degree of patient engagement. This process may be facilitated by online health-related information and education. The aim of this study was to systematically review current online health information on LARS. METHOD: An online search of Google, Yahoo and Bing was performed using the search terms 'low anterior/anterior resection syndrome' and 'bowel function/movements after rectal cancer surgery'. Websites were assessed for readability (eight standardized tests), suitability (using the Suitability Assessment of Materials instrument), quality (the DISCERN instrument), accuracy and content (using a LARS-specific content checklist). Websites were categorized as academic, governmental, nonprofit or private. RESULTS: Of 117 unique websites, 25 met the inclusion criteria. The median readability level was 10.4 (9.2-11.7) and 11 (44.0%) websites were highly suitable. Using the DISCERN instrument, seven (28.0%) websites had clear aims, two (8.0%) divulged the sources used and four (16.0%) had high overall quality. Only eight (32.0%) websites defined LARS and ten (40.0%) listed all five major symptoms associated with the LARS score. There was variation in the number of websites that discussed dietary modifications (80.0%), self-help strategies (72.0%), medication (68.0%), pelvic floor rehabilitation (60.0%) and neuromodulation (8.0%). The median accuracy of websites was 93.8% (88.2-96.7%). Governmental websites scored highest for overall suitability (P = 0.0079) and quality (P < 0.001). CONCLUSIONS: Current online information on LARS is suboptimal. Websites are highly variable, important content is often lacking and material is too complex for patients.

Study protocol evaluating the use of bowel stimulation before loop ileostomy closure to reduce postoperative ileus: a multicenter randomized controlled trial.

AIM: Postoperative ileus is the most commonly observed morbidity following ileostomy closure. Studies have demonstrated that the defunctionalized bowel of a loop ileostomy undergoes a series of functional and structural changes, such as atrophy of the intestinal villi and muscular layers, which may contribute to ileus. A single-centre study in Spain demonstrated that preoperative bowel stimulation via the distal limb of the loop ileostomy decreased postoperative ileus, length of stay and time to gastrointestinal function. METHOD: A multicentre randomized controlled trial involving patients from Canadian institutions was designed to evaluate the effect of preoperative bowel stimulation before ileostomy closure on postoperative ileus. Stimulation will include canalizing the distal limb of the ileostomy loop with an 18Fr Foley catheter and infusing it with a solution of 500 ml of normal saline mixed with 30 g of a thickening agent (Nestle© Thicken-Up© ). This will be performed 10 times over the 3 weeks before ileostomy closure in an outpatient clinic setting by a trained Enterostomal Therapy nurse. Surgeons and the treating surgical team will be blinded to their patient's group allocation. Data regarding patient demographics, and operative and postoperative variables, will be collected prospectively. Primary outcome will be postoperative ileus, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, that either requires nasogastric tube insertion or is associated with two of the following on or after post-operative day 3: nausea/vomiting; abdominal distension; and the absence of flatus. Secondary outcomes will include length of stay, time to tolerating a regular diet, time to first passage of flatus or stool and overall morbidity. A cost analysis will be performed to compare the costs of conventional care with conventional care plus preoperative stimulation. DISCUSSION: This manuscript discusses the potential benefits of preoperative bowel stimulation in improving postoperative outcomes and outlines our protocol for the first multicenter study to evaluate preoperative bowel stimulation before ileostomy closure. The results of this study could have considerable implications for the care of patients undergoing ileostomy closure.

Effect of extraction in the late mixed dentition on the eruption of the first premolar in Macaca nemestrina.

The effect of deciduous tooth extraction in the late mixed dentition on the eruption of succedaneous teeth was studied in ten Macaca nemestrina. Nineteen deciduous teeth were extracted: nine maxillary and ten mandibular left deciduous first molars. Regardless of sex, arch, chronologic or dental age, all first premolars on the experimental side erupted before those on the control side and this pattern was statistically significant. Extraction of deciduous molars in the late mixed dentition is seen to accelerate eruption of first premolars in Macaca nemestrina. This could be the result of eliminating the need for deciduous tooth root resorption during the normal process of eruption.

Discriminating between generalized anxiety disorder and anxiety disorder not otherwise specified in a Hispanic population: is it only a matter of worry?

One hundred and two Hispanic persons who presented for treatment at a specialized anxiety disorders clinic were evaluated at intake using the Anxiety Disorders Interview Schedule-Revised (ADIS-R; DiNardo and Barlow [1988] Albany: Center for Stress and Anxiety Disorders, State University of New York at Albany). Results indicated that 14% of these patients suffered from anxiety and/or affective disorders that were not adequately captured by our current diagnostic system. Given that the majority of these cases were characterized by predominantly anxious features, further investigation was undertaken to determine the degree of overlap between these patients (anxiety disorder, not otherwise specified; NOS) and those with generalized anxiety disorder (GAD). The two groups differed only with regard to the number of excessive worries they reported and not in terms of somatic symptomatology, psychosocial stressors, or demographic variables. These data suggest that excessive worry may be a discriminating factor between the GAD and NOS groups, providing support for the notion of GAD as a disorder of chromic worry. Future research is needed to tease apart the relative influences of culture and socioeconomic status on our findings.