Seton or glue for trans‐sphincteric anal fistulae: a prospective randomized crossover clinical trial

Objective Fibrin glue treatment of anal fistulae has been proposed to minimize the risk of faecal incontinence but its acceptance by coloproctologists is still poor because the published data is controversial. Therefore, we carried out a prospective randomized crossover trial comparing treatment with a commercial fibrin glue to classical seton treatment, with healing rate, hospital stay, healing time, faecal incontinence and postoperative pain as study outcomes. Method Sixty‐four homogeneous patients with trans‐sphincteric anal fistulae referred to seven colorectal units were randomized to undergo fibrin glue (39 patients) or seton (25 patients) treatment. Patients failing to heal after treatment with fibrin glue were re‐randomized to undergo a second injection with glue or seton treatment. Results Sixty‐two of the 64 patients completed the minimum 1‐year follow‐up period. Twenty‐one of 24 patients healed in the seton group compared with 15/38 in the fibrin glue group (P = 0.0007). The 23 failures after glue treatment were re‐randomized to have a second glue injection (eight patients) or a seton treatment (15 patients). Four of the eight (50%) patients treated with a second injection of glue, and nine out of the 15 (60%) patients in the seton group, healed. Patients treated with fibrin glue reported less postoperative pain and had a shorter hospital stay than patients treated with a seton; furthermore, faecal continence and anal manometry significantly worsened after seton treatment. Conclusion Seton treatment has a significantly higher probability of success compared with fibrin glue treatment but poses a higher risk of faecal incontinence. Fibrin glue could be considered as a first line of treatment for patients at risk of faecal incontinence or other comorbidities.     

Dynamic ‘back‐off’ analysis: use of piecewise linear approximations

The operating point of a process is usually computed by optimizing an objective function, e.g. the profit, subject to some plant characteristics. Typically, the resulting point lies on the boundary of the operating region. At this point, the presence of disturbances can easily cause constraint violations and make the process move to the unfeasible region. Then, it is necessary to move the operating point away into the feasible region by considering the effect that the expected disturbances will have on the operation of the plant. The purpose of this paper is to present an efficient algorithm to modify the operating point in order to keep feasibility (both in steady‐state and along transitory) in the process operation against the disturbances. Copyright © 2003 John Wiley & Sons, Ltd.     

Acute diverticulitis in the young: a 5‐year retrospective study of risk factors,clinical presentation and complications

Aim Acute diverticulitis in the young is considered to follow an aggressive course, but there is a paucity of data on factors that could determine a complicated course. Method All patients of 18–40 years of age diagnosed with acute diverticulitis from 1 January 2003 to 31 December 2008 were identified. Patients were included if they had computed tomography (CT) evidence of acute diverticulitis and at least one clinical feature. Demographics, body mass index, presenting symptoms/signs, CT location of diverticulitis and complications were noted. Fisher’s exact test and a multivariate logistic regression analysis model were used to detect possible associations between clinical variables and complications. Results There were 76 patients, of whom 23 (30.2%) had fever (> 38°C) and 52 (68.4%) had leucocytosis (≥ 11 000/mm³). The majority [48 (63.1%)] were obese. A total of 29 (38.1%) patients had complications, with perforation [18 (62%)] being the most common. Twelve (15.7%) required surgical or radiological intervention. Fever of ≥ 38.0°C and a body mass index of ≥ 25 were independently associated with complications (P = 0.04 and P = 0.03, respectively). Conclusion Fever (≥ 38°C) at presentation and a body mass index of ≥ 25 may help to predict a complicated course of acute diverticulitis in patients under 40 years of age.     

Prostate‐specific antigen ‘bounce’ after permanent 125I‐implant brachytherapy in Japanese men: a multi‐institutional pooled analysis

OBJECTIVE

To examine the incidence, timing, and magnitude of the prostate‐specific antigen (PSA) level ‘bounce’ after permanent prostate brachytherapy (BT) and correlate the PSA bounce with clinical and dosimetric factors in Japanese patients with prostate cancer.

PATIENTS AND METHODS

A multi‐institutional pooled analysis was carried out in 388 consecutive patients with T1–T2N0M0 prostate cancer treated with ¹²⁵I‐seed implant BT with no hormonal therapy or external beam radiotherapy. All patients had ≥1 year of follow‐up and at least three follow‐up PSA level measurements. Three definitions of PSA bounce were used: definition A, a PSA level rise of 0.1 ng/mL; definition B, a PSA level rise of 0.4 ng/mL; and definition C, a PSA level rise of 35% over the previous value, followed by a subsequent fall.

RESULTS

The actuarial likelihood of having PSA bounce at 24 months was 50.8% for definition A, 23.5% for definition B, and 19.4% for definition C. The median time to develop PSA bounce was 12 months for definition A, 18 months for definition B, and 18 months for definition C. There was a PSA bounce magnitude of 2 ng/mL in 5.3% of patients, and 95.3% of PSA bounce occurred within 24 months after ¹²⁵I‐BT. Among the before and after ¹²⁵I‐BT factors, clinical stage, initial PSA level, and Gleason score did not predict for PSA bounce using any definition; only being younger predicted for PSA bounce on multivariate analysis (P < 0.001).

CONCLUSIONS

PSA bounce is a common phenomenon after ¹²⁵I‐BT and occurred at a rate of 19–51% in the Japanese men who underwent ¹²⁵I‐BT, depending on the definition used. It is more common in younger patients, and early PSA bounce should be considered when assessing a patient with a rising PSA level after ¹²⁵I‐BT, before implementing salvage interventions. Furthermore, PSA bounce magnitude might be lower in Japanese than in Caucasian patients.     

The ‘go‐between’ study: a simulation study comparing the ‘Traffic Lights’ and ‘SBAR’ tools as a means of communication between anaesthetic staff

Communicating non‐urgent, urgent and frank emergency requests for assistance between anaesthetists in theatre often requires a ‘go‐between’ – frequently a non‐anaesthetic healthcare professional – to transmit information. We compared the currently recommended situation, background, assessment, recommendation (SBAR) tool with a newly devised Traffic Lights tool (‘red alert’, ‘amber assist’ and ‘green query’) in a simulation study to assess communication quality using 12 validated clinical scenarios of varying urgency. Compared to SBAR, Traffic Lights was used more consistently (‘very clear’ or ‘clear’ Traffic Lights 94% vs SBAR 69%); transferred information better (two or three pieces of information correctly transferred Traffic Lights 85%, SBAR 44%; and was judged to lead to greater clarity (all p < 0.0001). Message delivery time was significantly reduced (Traffic Lights 20.5 s vs SBAR 45.5 s, median (95% CI) difference 25 (19–30) s, p < 0.001). Users rated the Traffic Lights system as significantly more useful than SBAR, with 96% of participants preferring the Traffic Lights tool. Results were independent of go‐between training. We recommend the adoption of this communication tool as standard practice for anaesthetic teams.     

Comparative genomic analysis reveals an ‘open’ pan‐genome of African swine fever virus

The worldwide transmission of African swine fever virus (ASFV) drastically affects the pig industry and global trade. Development of vaccines is hindered by the lack of knowledge of the genomic characteristics of ASFV. In this study, we developed a pipeline for the de novo assembly of ASFV genome without virus isolation and purification. We then used a comparative genomics approach to systematically study 46 genomes of ASFVs to reveal the genomic characteristics. The analysis revealed that ASFV has an ‘open’ pan‐genome based on both protein‐coding genes and intergenic regions. Of the 151–174 genes found in the ASFV strains, only 86 were identified as core genes; the remainder were flexible accessory genes. Notably, 44 of the 86 core genes and 155 of the 324 accessory genes have been functionally annotated according to the known proteins. Interestingly, a dynamic number of taxis‐related genes were identified in the accessory genes, and two potential virulence genes were identified in all ASFV isolates. The ‘open’ pan‐genome of ASFV based on gene and intergenic regions reveals its pronounced natural diversity concerning genomic composition and regulation.     

Clinical Presentation Resembling Mucosal Disease Associated with ‘HoBi’‐like Pestivirus in a Field Outbreak

The genus Pestivirus of the family Flaviviridae consists of four recognized species: Bovine viral diarrhoea virus 1 (BVDV‐1), Bovine viral diarrhoea virus 2 (BVDV‐2), Classical swine fever virus (CSFV) and Border disease virus (BDV). Recently, atypical pestiviruses (‘HoBi’‐like pestiviruses) were identified in batches of contaminated foetal calf serum and in naturally infected cattle with and without clinical symptoms. Here, we describe the first report of a mucosal disease‐like clinical presentation (MD) associated with a ‘HoBi’‐like pestivirus occurring in a cattle herd. The outbreak was investigated using immunohistochemistry, antibody detection, viral isolation and RT‐PCR. The sequence and phylogenetic analysis of 5′NCR, N^pro and E2 regions of the RT‐PCR positive samples showed that four different ‘HoBi’‐like strains were circulating in the herd. The main clinical signs and lesions were observed in the respiratory and digestive systems, but skin lesions and corneal opacity were also observed. MD characteristic lesions and a pestivirus with cytopathic biotype were detected in one calf. The present study is the first report of a MD like presentation associated with natural infection with ‘HoBi’‐like pestivirus. This report describes the clinical signs and provides a pathologic framework of an outbreak associated with at least two different ‘HoBi’‐like strains. Based on these observations, it appears that these atypical pestiviruses are most likely underdiagnosed in Brazilian cattle.     

Single‐port ‘scarless’ laparoscopic nephrectomies: the United Kingdom experience

OBJECTIVE

To present the UK experience to date with laparoendoscopic single‐site surgery (LESS) simple nephrectomy.

PATIENTS AND METHODS

Five female patients underwent LESS nephrectomy; three procedures were carried out with the umbilicus as the port of entry (U‐LESS).

RESULTS

All cases were completed uneventfully. The operative duration was 45–150 min and blood loss was negligible. There were no conversions to conventional multi‐port laparoscopy or open surgery. Recovery was uneventful with only minor complications in two patients; convalescence was rapid.

CONCLUSION

LESS nephrectomy offers a safe, cosmetic alternative to conventional multi‐port laparoscopy, with younger female patients being especially happier with the ‘scarless’ outcome of U‐LESS. LESS certainly appears to be more in these situations.     

The ‘Draw‐the‐Family Test’ in the preoperative assessment of patients with anorectal diseases and psychological distress: a prospective controlled study

Aim Some benign anorectal diseases may have psychosomatic aetiology, but patients often refuse direct psychological counselling. The Draw‐the‐Family Test (DFT) is a simple indirect investigation. The aim of this study was to evaluate the DFT in patients with psychological problems undergoing surgery for benign anorectal disease and to correlate the results with surgical outcome. Method DFT was administered prior to surgery to 62 patients with benign anorectal disease who admitted psychological problems at the time of the outpatient visit. Of these 18 (29%) had functional disease, mainly obstructed defecation (OD) while 44 (71%) had organic disease (haemorrhoids, fissures, pilonidal sinus or fistula). DFT was also administered to 40 healthy control subjects. Each DFT was judged as normal or pathological according to 10 parameters. Patients were followed up for a median of 12 months (range 3–64) and divided into two outcome groups, success (n = 58) and failure (n = 12) according to the results of a questionnaire. The DFT of all patients was then correlated with the outcome. Results None of the patients refused DFT. All DFT parameters but one (animal/things instead of human beings) were more frequent in patients compared with controls (P < 0.05). When comparing separately organic or functional disease patients with controls, one parameter (absence of patient in the drawing) was only pathological in the organic disease group (P < 0.05). Another parameter (schematic figures) was more frequently altered in the organic disease group compared with the functional disease group (P = 0.01). Eight out of 10 parameters were more frequently pathological in patients who failed after treatment, but none reached statistical significance. Conclusion Results of DFT in patients with anorectal disease admitting to psychological problems are markedly different from healthy controls. Patients with organic disease and those with functional bowel disease have different DFT profiles. In our study group, DFT had an excellent compliance but could not predict the outcome of surgery.     

‘Suspended in a paradox’—patient attitudes to wait‐listing for kidney transplantation: systematic review and thematic synthesis of qualitative studies

Patients on waiting lists for kidney transplantation have higher mortality rates and have specific anxieties about their eligibility, process, and outcomes of wait‐listing. We aimed to describe patient experiences and attitudes to wait‐listing for kidney transplantation. Electronic databases were searched to September 2014. Thematic synthesis was used to analyze the findings. From 22 studies (n = 795 patients), we identified six themes: accepting the only option (chance to regain normality, avoiding guilt, impulsive decision‐making); maintaining hope (determined optimism, appreciating a fortuitous gift, enduring for optimal outcomes, trust in clinical judgment); burden of testing (strenuous commitment, losing the battle, medical mistrust); permeating vulnerability (eligibility enigma, being threatened, angst of timing uncertainty, desperate urgency, living in limbo, spiraling doubt and disappointment, residual ambivalence); deprived of opportunity (unfairly dismissed, unexpected disqualification, self‐resignation and acceptance, jealousy, suspicious of inequity); and moral guilt (awaiting someone's death, questioning deservingness). The waiting list offered hope of restored normality. However, the demands of workup, uncertainty about eligibility, and waiting times that exceeded expectations impelled patients to disillusionment, despair, and suspicion of inequity. Managing patient expectations and ensuring transparency of wait‐listing and allocation decisions may allay patient disappointment and skepticism, to improve patient satisfaction and treatment outcomes.     

‘Workaholism’ and potential outcomes in well‐being and health in a cross‐occupational sample

This study examined ‘workaholism’ components (work involvement, drive, enjoyment of work) and potential outcomes in terms of psychological well‐being and health. A sample of 661 Norwegian cross‐occupational employees from six different organizations completed an online questionnaire measuring ‘workaholism’, job satisfaction, life satisfaction, insomnia and subjective health complaints. A short version of the Norwegian‐translated Workaholism Battery showed significant relationships with reports of psychological well‐being and subjective health. Enjoyment of work was positively associated with job and life satisfaction and negatively associated with symptoms of poor health. Work involvement and drive were the strongest predictors of job dissatisfaction. Both were positively related to symptoms of poor health. Drive was, in addition, negatively associated with life satisfaction. The results showed that it is important to discriminate between different ‘workaholic’ features when investigating associations between ‘workaholism’ and potential outcomes, which were related in predictable ways to outcomes in terms of psychological well‐being and health. Copyright © 2010 John Wiley & Sons, Ltd.     

Death of recipients after kidney living donation triples donors’ risk of dropping out from follow‐up: a retrospective study

Although kidney transplantation from the donation of a living donor is a safe treatment for end‐stage renal disease, inferences about safety of living kidney donors might be biased by an informative censoring caused by the noninclusion of a substantial percentage of donors lost to follow‐up. With the aim of assessing the presence of a potential informative censoring in living kidney donation outcomes of Catalan donors for a period of 12 years, 573 donors followed and lost to follow‐up were compared. Losses of follow‐up over time were also assessed by univariate and multivariate survival analysis, along with Cox regression. Younger and older ages, and the death of their recipient differentiated those donors who were lost to follow‐up over time. The risk of dropping out from follow‐up was more than twofold for the youngest and oldest donors, and almost threefold for those donors whose recipient died. Results of studies on postdonation outcomes of Catalan living kidney donors might have overlooked older and younger cases, and, remarkably, a percentage of donors whose recipient died. If these donors showed a higher incidence of psychological problems, conclusions about living donors’ safety might be compromised thus emphasizing the necessity of sustained surveillance of donors and prompt identification of these cases.