The prognostic value of tumour regression grade following neoadjuvant chemoradiation therapy for rectal cancer.

AIM: To date, there is no uniform consensus on whether tumour regression grade (TRG) is predictive of outcome in rectal cancer. Furthermore, the lack of standardization of TRG grading is a major source of variability in published studies. The aim of this study was to evaluate the prognostic impact of TRG in a cohort of patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation therapy (CRT). In addition to the Mandard TRG, we utilized four TRG systems modified from the Mandard TRG system and applied them to the cohort to assess which TRG system is most informative. METHOD: One-hundred and fifty-three patients with a T3/T4 and/or a node-positive rectal cancer underwent neoadjuvant 5-fluorouracil-based CRT followed by surgical resection. RESULTS: Thirty-six (23.5%) patients achieving complete pathological response (ypCR) had a 5-year disease-free survival (DFS) rate of 100% compared with a DFS rate of 74% for 117 (76.5%) patients without ypCR (P = 0.003). The Royal College of Pathologists (RCPath) TRG best condenses the Mandard five-point TRG by stratifying patients into three groups with distinct 5-year DFS rates of 100%, 86% and 67%, respectively (P = 0.001). In multivariate analysis, pathological nodal status and circumferential resection margin (CRM) status, but not TRG, remained significant predictors of DFS (P = 0.002, P = 0.035 and P = 0.310, respectively). CONCLUSION: Our findings support the notion that ypCR status, nodal status after neoadjuvant CRT and CRM status, but not TRG, are predictors of long-term survival in patients with locally advanced rectal cancer.

Early psychological interventions for prevention and treatment of post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms in post-partum women: A systematic review and meta-analysis.

BACKGROUND: Pre-term or full-term childbirth can be experienced as physically or psychologically traumatic. Cumulative and trans-generational effects of traumatic stress on both psychological and physical health indicate the ethical requirement to investigate appropriate preventative treatment for stress symptoms in women following a routine traumatic experience such as childbirth. OBJECTIVE: The objective of this review was to investigate the effectiveness of early psychological interventions in reducing or preventing post-traumatic stress symptoms and post-traumatic stress disorder in post-partum women within twelve weeks of a traumatic birth. METHODS: Randomised controlled trials and pilot studies of psychological interventions preventing or reducing post-traumatic stress symptoms or PTSD, that included women who had experienced a traumatic birth, were identified in a search of Cochrane Central Register of Randomised Controlled Trials, MEDLINE, Embase, Psychinfo, PILOTS, CINAHL and Proquest Dissertations databases. One author performed database searches, verified results with a subject librarian, extracted study details and data. Five authors appraised extracted data and agreed upon risk of bias. Analysis was completed with Rev Man 5 software and quality of findings were rated according to Grading of Recommendation, Assessment, Development, and Evaluation. RESULTS: Eleven studies were identified that evaluated the effectiveness of a range of early psychological interventions. There was firm evidence to suggest that midwifery or clinician led early psychological interventions administered within 72 hours following traumatic childbirth are more effective than usual care in reducing traumatic stress symptoms in women at 4-6 weeks. Further studies of high methodological quality that include longer follow up of 6-12 months are required in order to substantiate the evidence of the effectiveness of specific face to face and online early psychological intervention modalities in preventing the effects of stress symptoms and PTSD in women following a traumatic birth before introduction to routine care and practice. PROSPERO REGISTRATION: CRD42020202576, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=202576.

Incidence and prognostic influence of lymph node micrometastases in rectal cancer.

AIMS: The aim of this study was to determine the rate of lymph node micrometastases and evaluate their prognostic significance in rectal cancer. METHODS: Patients with either Dukes A or B rectal carcinoma who had undergone curative resection by either low anterior resection or abdominal perineal resection between 1991 and 2000 were selected from a prospectively collated database. None of the patients had metastasis at the time of surgery and none received adjuvant or neoadjuvant therapy. A single section from each lymph node was stained with haematoxylin and eosin (H+E) and with CAM 5.2 by immunohistochemistry. Statistical analyses were performed with Chi-square test. RESULTS: A total of 774 lymph nodes with a median of 14 lymph nodes per patient were examined, from a cohort of 56 patients with a median age of 66 years. In the 56 patients in whom lymph node metastases were not detected by haematoxylin-eosin staining, cytokeratin staining was positive in 15 lymph nodes from 10 patients. Nine patients had disease recurrence at a median follow-up of 98 months. The presence of lymph node micrometastases by immunohistochemistry did not predict either disease-free (p=0.44) or overall survival (p=0.63). CONCLUSION: Immunohistochemical staining detects micrometastases in rectal cancer which are not observed with H+E staining. However, no significant relationship was observed between disease relapse and rectal micrometastases detected by immunohistochemistry.

Status report, The Public Health and Planning 101 project: strengthening collaborations between the public health and planning professions. / Rapport d'étape, Projet Santé publique et planification 101 : renforcer la collaboration entre les secteurs de la santé publique et de la planification urbaine.

INTRODUCTION: Land use planning is a complex field comprised of legislation, policies, processes and tools. A growing body of evidence supports the relationship between land use planning decisions, community design and health. The built environment has been shown to be associated with physical inactivity, obesity, cardiovascular disease, respiratory disease and mental illness. Consequently, there is a growing interest within public health to work with planners on land use planning initiatives such as official plans and transportation master plans. METHODS: Two surveys were developed: one for public health professionals and the other for planning professionals (survey questions available upon request to the corresponding author). The surveys were pilot tested in two separate focus group sessions with public health and planning professionals. Focus group volunteers helped to validate the surveys by verifying survey questions, design and overall flow. RESULTS: In early 2012, 304 public health professionals and 301 planning professionals completed the two separate surveys, comprising the total survey respondents for each respective profession used to calculate proportions. The survey results represent a convenience sample and are not generalizable to the entire population of public health and planning professionals in Ontario. Results compare survey responses from both groups where appropriate. Most respondents worked either as public health staff (78%) or planners/senior planners (58%). A smaller percentage of public health and planning professionals worked either as managers (15% and 11%, respectively) or directors (5% and 9%, respectively). CONCLUSION: Health is associated with how communities are planned and built, and the services and resources provided within them. Inspired by the results of our survey and based on user feedback from the pilot tests, a free online training program entitled "Public Health and Planning 101: An Online Course for Public Health and Planning Professionals to Create Healthier Built Environments" was launched in 2016 by OPHA as a collaborative project with OPPI and PHAC. This course is designed to bridge the gaps between the two professions, as well as provide greater opportunities for developing collaborative partnerships to help create and foster healthy built environments.

INTRODUCTION: La planification de l'aménagement du territoire est un domaine complexe fait de réglementations, de politiques, de processus et d'outils. De plus en plus de données probantes renforcent la validité du lien entre décisions sur l'aménagement du territoire, design urbain et santé. On sait désormais que l'environnement bâti est associé à l'inactivité physique, à l'obésité ainsi qu'aux maladies cardiovasculaires, respiratoires et mentales. Il y a de ce fait un intérêt croissant chez les professionnels de la santé publique pour participer aux initiatives de planification de l'aménagement du territoire, comme les plans officiels et les plans directeurs des transports. MÉTHODOLOGIE: Deux sondages ont été préparés : l'un pour les professionnels de la santé publique et l'autre pour les professionnels de l'aménagement (les questions des sondages sont disponibles sur demande auprès de l'auteur ressource). Les sondages ont fait l'objet d'essais pilotes dans deux groupes de discussion avec des professionnels de la santé publique et de l'aménagement. Des bénévoles des groupes de discussion ont aidé à valider les sondages en vérifiant les questions, la conception et la fluidité générale des sondages, lesquels ont ensuite été remaniés en fonction de la rétroaction fournie. La version finale a été envoyée en janvier et février 2012 aux membres permanents (planificateurs professionnels agréés) et provisoires de l'IPPO (par courriel) et aux professionnels de la santé publique (par l'intermédiaire des listes de diffusion du secteur de la santé publique). Les deux sondages avaient des questions similaires, visant à déterminer les connaissances, l'opinion et les croyances des répondants sur l'environnement bâti ou la santé, la réglementation et le mandat des professionnels de l'autre groupe, ainsi que le type de ressources nécessaires pour pouvoir mieux collaborer aux projets sur la santé et les environnements bâtis. RÉSULTATS: Début 2012, 304 professionnels de la santé publique et 301 professionnels de l'aménagement ont rempli leur sondage, constituant le nombre total de répondants utilisé pour le calcul des proportions pour chaque profession. Les résultats du sondage correspondent à un échantillon de commodité et ne sont pas généralisables à l'ensemble de la population de professionnels de la santé publique ou de la planification de l'aménagement du territoire de l'Ontario. CONCLUSION: La santé est liée à la manière dont les collectivités sont planifiées et construites, ainsi qu'aux services et aux ressources qu'on y trouve. Inspiré par les résultats de notre sondage et la rétroaction des participants aux essais pilotes, un programme gratuit de formation en ligne intitulé « Projet Santé publique et planification 101 : Cours en ligne pour les professionnels de la santé publique et de la planification urbaine en vue de la création d'environnements bâtis plus sains ¼ a été lancé en 2016 par l'ASPO en collaboration avec l'IPPO et l'ASPC. Le cours a été conçu pour combler les écarts entre les deux professions et pour fournir de meilleures occasions de bâtir des partenariats en vue de la création et de la promotion d'environnements bâtis sains.

Laparoscopic Nissen fundoplication: predicting outcome from peri-operative evaluation.

BACKGROUND: Although laparoscopic Nissen fundoplicaton is a safe, effective treatment for gastrooesophageal reflux (GOR), questions remain about the durability of the procedure and patient selection criteria. AIMS: To review a single surgeon's experience of laparoscopic Nissen fundoplicaton and to determine which factors, if any are likely to influence long term outcome. METHODS: Data were collected on all 124 patients who underwent laparoscopic Nissen fundoplication over a five-year period, and a detailed questionnaire was used to evaluate outcome. RESULTS: Eighty-nine per cent of patients were satisfied with the results of surgery whilst 8.8% of patients had significant recurrence of symptoms. Time since surgery was longer in those patients with symptom recurrence who were also more likely to be female. Pre-operative age, body mass index (BMI),Visick Score, endoscopic findings or pH analysis scores were not predictive of outcome, nor were intra-operative findings or post-operative complications. CONCLUSION: Although laparoscopic Nissen fundoplication is a safe and effective treatment for GOR, it is difficult to predict the small but significant group of patients with poor longterm outcome based on pre-operative assessment and peri-operative parameters alone.

Mechanisms of columnar metaplasia and squamous regeneration in experimental Barrett's esophagus.

BACKGROUND: This study examined the effect of the lower esophageal milieu on the healing of a mucosal defect. METHODS: With a canine model a mucosal defect was created in the lower esophagus, and acid reflux was promoted by a cardioplasty and pentagastrin injection in 10 animals. At 3 months the regenerated mucosa was excised and underwent histologic examination. Six of these animals underwent an antireflux procedure, had their acid secretion suppressed, and were followed up for a further 3 months, at which time they were killed and the entire esophagus underwent histologic examination. RESULTS: When reflux was stimulated, healing of the mucosal defect was by columnar epithelium alone in seven of 10 animals. After reflux control in six animals healing was again by columnar epithelium, but in all six cases islands of squamous epithelium occurred. Histologic examination showed both types of regenerating epithelium to be in continuity with the ducts of the esophageal glands, lined in their proximal two thirds by columnar and in their distal one third by squamous cells. CONCLUSIONS: It is suggested that the type of regenerating epithelium is determined by the depth of injury to mucosa or gland ducts. If both cell types survive, a mixed pattern of regeneration may occur, but columnar repair will usually predominate because of its more rapid turnover. If the squamous cells of the mucosa and ducts are destroyed, however, repair will be by columnar epithelium alone.

Functional and residential status transitions among nursing home residents.

BACKGROUND: The present study examines transitions in the functional status and discharge destination of new nursing home admissions who remain at least 100 days, and ascertains baseline covariates associated with transition patterns. METHODS: Using a fully observed, continuous-time Markov chain model for maximum likelihood estimation of probability intensities, transition processes are characterized. The long-stay cohort (n = 9,541) was derived from a sample of elders newly admitted to 48 National Health Corporation (NHC) nursing homes between 1983 and 1987. Assessment of functional status, using a modified Katz ADL scale, occurred during the first, second, and third months, and the second, third, and fourth quarters after admission. Four types of residential changes (e.g., mortality) were examined for the latter three quarters. RESULTS: While stability was the predominant pattern during the first 90 days in the nursing home, 51.5% of residents experienced a change in function. The probability of change was higher for modest (one level) rather than substantial change, and for such change to represent improvement rather than decline. Over 25% of this long-stay sample exited in the second quarter, 37% of them returning home. The rates for returns to home and for mortality were strongly related to functional level. Several sociodemography variables (e.g., age, source of payment), diagnostic indicators (e.g., cancer), and orientation status were consistently associated with transition rates within functionally homogeneous groups. CONCLUSIONS: Overall, findings underscore the heterogeneity and complexity of transition patterns for a subgroup historically treated as likely to decline or remain stable, and viewed as "permanent" residents. The model was useful in describing the volatile transition process among older long-stayers.

Results of a prospective randomized trial using DTIC and interferon as adjuvant therapy for stage I malignant melanoma.

This prospective randomized trial evaluated the effect of DTIC and interferon as adjuvant therapy for high risk stage 1 malignant melanoma in 26 patients. Both groups were well matched for depth of disease, site of melanoma and other prognostic criteria. Like other studies the findings of 2.6 times increased relative risk of mortality in the treatment arm do not support a rationale for adjuvant immuno-chemotherapy even in patients at high risk of recurrence.

Oesophageal resection in the elderly.

The outcome of transthoracic resection for carcinoma of the oesophagus and cardia was compared in seventy six patients over seventy years of age with that of 179 patients under seventy. A resectability rate of 89% was achieved in the over 70 group and 91% in the under seventy group. Hospital mortality at 3 months was 21% in the elderly group and 14% in the younger age group (P = NS). Postoperative pulmonary infection and cardiac arrhythmias were more frequent in the elderly but postoperative hospital stay was almost identical in both groups. There were three fatal anastomotic leaks in the over seventy group and six in the under seventies. Survival figures at one and five years showed no significant difference between the groups. We conclude that age alone is not a contraindication to surgical resection of carcinoma of the oesophagus and cardia.

A prospective randomised controlled trial of mezlocillin versus netilmicin in biliary surgery.

A prospective randomised controlled trial of mezlocillin versus netilmicin in 133 patients undergoing biliary surgery at a district hospital is reported. Sixty-four patients received mezlocillin and 69 received netilmicin. The two groups of patients were comparable with regard to age, sex, underlying pathology and operative procedures performed. The incidence of infected bile at operation was 14.2% and both antibiotics were equally effective in reducing postoperative bacteraemia (0.75%) and wound infection (4.5%) to acceptable levels. It is concluded that netilmicin is a more cost-effective antibiotic in biliary surgery than mezlocillin.

Duodenal ulcer perforation: the effect of H2 antagonists?

One hundred and two patients with perforated duodenal ulcers over a 13 year period (1970 to 1982) have been prospectively followed-up at a special gastric clinic. Of the 37 patients with perforation of their acute ulcer, 34 were treated by oversew and three had an initial definitive operation (vagotomy and drainage). The remaining 65 patients presented with perforation of a chronic ulcer and 54 were treated by oversew and 11 underwent definitive surgery--nine had vagotomy and drainage and two had partial gastrectomies. Seven of the 34 patients (20.5%) with acute ulcer perforation treated by simple oversew subsequently required definitive ulcer surgery at a mean 17.5 months after perforation and 31 of the 54 patients (57.4%) with chronic ulcer perforations required definitive surgery at a mean 27.4 months after perforation. The introduction of H2 antagonists in 1977 did not alter the re-operation rate in patients with chronic ulcer perforation managed by oversew. Results of this study provide further evidence in favour of treating patients with perforation of their chronic duodenal ulcer by definitive surgery whenever possible.

The value of HIDA scanning in intestinal fistulae.

Intestinal fistulae have been outlined using the delayed phase of Tc-99m labelled HIDA. The technique involved is simple, safe and easily reproducible. This method has advantages over conventional radiography particularly for the leaking duodenal stump and involves minimal disturbance to the patient.

Limitations of thyroid scanning in solitary thyroid nodules.

During an 8-year period, 104 patients (19 males, 85 females) underwent surgery for a solitary thyroid nodule. There were 19 (18.3%) malignant nodules and 85 (81.7%) benign nodules. Malignancy occurred in 3 (15.8%) males and 16 (18.8%) females. Pre-operative scanning was performed prior to referral in 59 patients (52 had ultrasound, 41 had isotope scanning; the majority had both). Of the scanned patients, 12 (20%) had a malignant nodule while 7 (15.5%) of the 45 patients who did not have scanning had a malignant nodule. In patients who had an ultrasound scan, malignancy was found in 5 (23.8%) of the 21 solid nodules and 7 (22.7%) of the 31 cystic (or solid/cystic) nodules. In patients who had thyroid isotope scanning, malignancy was found in 6 (17.5%) of the 34 cold (non-functioning) nodules and 3 (43%) of the 7 warm or hot (functioning) nodules. Ultrasound and isotope scanning may be misleading and neither help to differentiate benign from malignant thyroid nodules which require surgical excision.

Late presentation of small bowel obstruction following blunt abdominal trauma.

BACKGROUND: Motor vehicle accidents have increasingly become a major cause of serious blunt abdominal and chest injury, the pattern and mechanism of which has changed in recent years largely due to seatbelt legislation. AIM: A case of blunt abdominal and chest trauma is reported which resulted in a mesenteric tear--the small bowel subsequently herniated through and strangulated. CONCLUSION: This case highlights the need for clinical suspicion, serial physical examination and early surgery in the management of these injuries.

Cryptorchidism: a general surgical perspective.

BACKGROUND: The treatment of cryptorchidism has changed, with surgery now advocated before the age of two years. Delayed treatment affects fertility, malignant potential and psychological stress. AIMS: To assess the pattern of referral of cryptorchid patients to a surgical clinic, management and follow-up. METHODS: A four-year review of 114 cryptorchid patients examined age at presentation, waiting time, timing of surgery and length of follow-up. RESULTS: The mean age at presentation to the surgical clinic was 6.7 years (neonatal to 71). The mean age at orchidopexy was 5.6 years. Seventy per cent had a surgical procedure within eight weeks of presentation to a surgeon. Seven per cent were kept under surveillance until a maximum age of three years before orchidopexy was considered. Only 29% proceeded to surgery before the age of two. Seventeen were referred to a paediatric urology unit for further management. CONCLUSIONS: Orchidopexy seems prudent between one and two years of age. Only one-quarter of patients underwent early orchidopexy. It is vital that it is detected early, by paediatricians at birth or the general practitioners (GPs) at the six-week check up. Prompt referral to a surgeon with a paediatric interest is essential in order to permit surveillance or surgery.

Supportive therapy with extracorporeal membrane oxygenation for acute respiratory distress syndrome.

Acute respiratory distress syndrome is a severe form of respiratory failure characterized by acute onset of significant hypoxaemia (PaO2:FiO2<200mmHg) with diffuse bilateral pulmonary air-space shadowing on chest X-ray, without clinical signs of heart failure (Bernard et al, 1994). It has a heterogeneous aetiology with wide-ranging pulmonary and extra-pulmonary causes.