Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population

Objectives

Previous studies have shown that a single question may identify individuals with inadequate health literacy. We evaluated and compared the performance of 3 health literacy screening questions for detecting patients with inadequate or marginal health literacy in a large VA population.

Methods

We conducted in-person interviews among a random sample of patients from 4 VA medical centers that included 3 health literacy screening questions and 2 validated health literacy measures. Patients were classified as having inadequate, marginal, or adequate health literacy based on the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM). We evaluated the ability of each of 3 questions to detect: 1) inadequate and the combination of “inadequate or marginal” health literacy based on the S-TOFHLA and 2) inadequate and the combination of “inadequate or marginal” health literacy based on the REALM.

Measurements and Main Results

Of 4,384 patients, 1,796 (41%) completed interviews. The prevalences of inadequate health literacy were 6.8% and 4.2%, based on the S-TOHFLA and REALM, respectively. Comparable prevalences for marginal health literacy were 7.4% and 17%, respectively. For detecting inadequate health literacy, “How confident are you filling out medical forms by yourself?” had the largest area under the Receiver Operating Characteristic Curve (AUROC) of 0.74 (95% CI: 0.69–0.79) and 0.84 (95% CI: 0.79–0.89) based on the S-TOFHLA and REALM, respectively. AUROCs were lower for detecting “inadequate or marginal” health literacy than for detecting inadequate health literacy for each of the 3 questions.

Conclusion

A single question may be useful for detecting patients with inadequate health literacy in a VA population.

     

Variation in Estimates of Limited Health Literacy by Assessment Instruments and Non-Response Bias

Objectives

This paper compares estimates of poor health literacy using two widely used assessment tools and assesses the effect of non-response on these estimates.

Study Design and Setting

A total of 4,868 veterans receiving care at four VA medical facilities between 2004 and 2005 were stratified by age and facility and randomly selected for recruitment. Interviewers collected demographic information and conducted assessments of health literacy (both REALM and S-TOFHLA) from 1,796 participants. Prevalence estimates for each assessment were computed. Non-respondents received a brief proxy questionnaire with demographic and self-report literacy questions to assess non-response bias. Available administrative data for non-participants were also used to assess non-response bias.

Results

Among the 1,796 patients assessed using the S-TOFHLA, 8% had inadequate and 7% had marginal skills. For the REALM, 4% were categorized with 6th grade skills and 17% with 7–8th grade skills. Adjusting for non-response bias increased the S-TOFHLA prevalence estimates for inadequate and marginal skills to 9.3% and 11.8%, respectively, and the REALM estimates for ≤6th and 7–8th grade skills to 5.4% and 33.8%, respectively.

Conclusions

Estimates of poor health literacy varied by the assessment used, especially after adjusting for non-response bias. Researchers and clinicians should consider the possible limitations of each assessment when considering the most suitable tool for their purposes.KEY WORDS: health literacy, veterans, prevalence, measurement, non-response bias, REALM, S-TOFHLA     

Prevalence and Demographic and Clinical Associations of Health Literacy in Patients on Maintenance Hemodialysis

Summary

Background and objectives

Although limited health literacy is estimated to affect over 90 million Americans and is recognized as an important public health concern, there have been few studies examining this issue in patients with chronic kidney disease. We sought to characterize the prevalence of and associations of demographic and clinical characteristics with limited health literacy in patients receiving maintenance hemodialysis.

Design, setting, participants, & measurements

As part of a prospective clinical trial of symptom management strategies in 288 patients treated with chronic hemodialysis, we assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM). We defined limited health literacy as a REALM score ≤60 and evaluated independent associations of demographic and baseline clinical characteristics with limited health literacy using multivariable logistic regression.

Results

Of the 260 patients who completed the REALM, 41 demonstrated limited health literacy. African-American race, lower educational level, and veteran status were independently associated with limited health literacy. There was no association of limited health literacy with age, gender, serologic values, dialysis adequacy, overall symptom burden, quality of life, or depression.

Conclusions

Limited health literacy is common among patients receiving chronic hemodialysis. African-American race and socioeconomic factors are strong independent predictors of limited health literacy. These findings can help inform the design and implementation of interventions to improve health literacy in the hemodialysis population.     

Comparison of hemorrhoidal treatment modalities

PURPOSE: The purpose of this study was to assess whether any method of hemorrhoid therapy has been shown to be superior in randomized, controlled trials. METHOD: A meta-analysis was performed of all randomized, controlled trials assessing two or more treatment modalities for symptomatic hemorrhoids. Outcome variables included response to therapy, need for further therapy, complications, and pain. RESULTS: A total of 18 trials were available for analysis. Hemorrhoidectomy was found to be significantly more effective than manual dilation of the anus (P=0.0017), with less need for further therapy (P=0.034), no significant difference in complications (P=0.60), but significantly more pain (P<0.0001). Patients undergoing hemorrhoidectomy had a better response to treatment than did patients treated with rubber band ligation (P=0.001), although complications were greater (P=0.02) as was pain (P<0.0001). Rubber band ligation was better than sclerotherapy in response to treatment for all hemorrhoids (P=0.005) as well as for hemorrhoids stratified by grade (Grades 1 to 2;P=0.007; Grade 3 hemorrhoids,P=0.042), with no difference in the complication rate (P=0.35). Patients treated with sclerotherapy (P=0.031) or infrared coagulation (P=0.0014) were more likely to require further therapy than those treated with rubber band ligation, although pain was greater after rubber band ligation (P=0.03 for sclerotherapy;P<0.0001 for infrared coagulation).CONCLUSION: Rubber band ligation is recommended as the initial mode of therapy for Grades 1 to 3 hemorrhoids. Although hemorrhoidectomy showed better response rates, it is associated with more complications and pain than rubber band ligation, thus should be reserved for patients who fail to respond to rubber band ligation.     

Simplified solid sphere test to investigate anal sphincter strength in patients with anorectal diseases

PURPOSE: The solid sphere test has not gained general acceptance to investigate anal sphincters, despite its simplicity and low cost. We studied continent and incontinent patients to evaluate whether the solid sphere test is suitable in assessment of anal sphincter function. METHODS: Seventy colorectal patients with anal incontinence of varying severity were studied by means of incontinence grading, solid sphere test, and anal manometry. RESULTS: Anal sphincter strength, studied using the solid sphere test, declined gradually with increasing severity of anal incontinence from 1,186 (±334, SD) g in 28 continent patients to 619 (±256, SD) g in 13 patients with daily soiling (P<0.001). The test also correlated with anal manometry; there was positive correlation with maximum basal pressure (tr=0.643,P<0.001) and maximum voluntary contraction pressure (r=0.393,P<0.01). CONCLUSION: The solid sphere test is useful in the primary assessment of patients with anal incontinence as a screening test, but alone it is too inaccurate for clinical decision making.     

Prospective study of circulating T-lymphocyte subpopulations and disease progression in colorectal cancer

PURPOSE: It has recently been reported that CD4 ⁺ T-lymphocytes are reduced in advanced colorectal cancer patients. However, it is not clear whether such changes in T-lymphocyte subsets are an early or late event in such patients. The aim of this study was to examine the relationship between these subsets and disease progression in colorectal cancer. METHODS: Flow cytometric analysis of T-lymphocyte subsets was performed in 39 patients who, approximately 12 months previously, had undergone surgery for colorectal cancer. These patients were grouped according to whether they developed a recurrence in the following two years. A group of healthy subjects was studied as controls. RESULTS: There was a significant increase in the median neutrophil count (4.3 vs.3.7 10 ⁶ /ml) and the median numbers of platelets (282 vs.216 10 ⁶/ml)of the recurrence group compared with the control group, respectively (P <0.05). The median numbers (0.28 vs.0.73 10 ⁶/ml)and percentage (29 vs.38 percent) of CD4 ⁺ T-lymphocytes of the recurrence group were significantly reduced compared with that of the control group (P <0.05). There were also reductions in the median percentage of CD3 ⁺ cells (67 vs.74 percent) and the median numbers of CD4 ⁺ T-lymphocytes (0.28 vs.0.46 10 ⁶ /ml) of the recurrence group compared with the no recurrence group (P < 0.05). CONCLUSIONS: Reduction of CD4 ⁺ T-lymphocytes occurs before detectable recurrence of colorectal cancer. Results of the present study are consistent with impaired immunity, as measured by such lymphocyte subset populations, being important in tumor recurrence in colorectal cancer.     

Sustained internal sphincter hypertonia in patients with chronic anal fissure

PURPOSE: This study was designed to determine whether functional variations of internal sphincter activity occur in order to differentiate between patients with anal fissures from those with hemorrhoids. METHODS: Thirty patients with chronic anal fissure (median age, 28 years; 12 females), 22 patients with hemorrhoids (median age, 37 years; 7 females), and 33 control volunteers (median age, 48.5 years; 21 females) underwent ambulatory anal sphincter fine-needle electromyography and anorectal manometry. RESULTS: The median internal sphincter electromyography frequency was similar: fissure group, 0.49 Hz; hemorrhoid group, 0.46 Hz (P>0.05), and control group, 0.44 Hz (P>0.05). Median anal resting pressures were similar in the fissure group (132 cm. H ₂ O) and the hemorrhoids group (116 cm of H ₂ O) (P>0.05), but significantly greater than those in the control group (94 cm. H ₂ O) (P<0.05). The median number of transient relaxations of the internal anal sphincter with an associated rise in rectal pressure and fall in anal pressure was 1 (range, 0–4) per hour in the fissure group, 6 (range, 4–7) per hour in the hemorrhoid group, and 4 (range, 3–6) per hour in the control group. Six patients with fissures were reassessed following lateral internal sphincterotomy. Median anal pressure was 102 cm of H ₂ O (P>0.1 vs. controls) and the number of internal sphincter relaxations increased to 4 per hour (P<0.01 vs.preoperative number). CONCLUSIONS: Internal anal sphincter relaxation occurs on fewer occasions in patients with chronic anal fissures that have failed to heal in comparison to patients with hemorrhoids and normal controls. This evidence further supports the hypothesis that internal sphincter hypertonia may be relevant to the pathogenesis of this disorder.     

Cytokine production in pouchitis is similar to that in ulcerative colitis

PURPOSE: Controversy exists as to whether pouchitis represents a reactivation of the immunologic mechanisms that lead to ulcerative colitis (UC). The aims of this study were to determine local levels of the cytokines: interleukin-1 β (IL-1 β ), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor alpha (TNF α ) in the mucosa of patients with “asymptomatic” ileoanal pouch (n=25), pouchitis (n=9), active UC (n=20), normal ileum (n=15), proctitis (n=10), and normal colon (n=15). METHODS: Lamina propria mononuclear cells were isolated from mucosal biopsies by enzymatic dispersion and cultured for 48 hours. Proinflammatory cytokine levels were measured in the supernatants by enzyme-linked immunosorbent assay. RESULTS: IL-1 β,IL-6, IL-8, and TNF α secretions were significantly greater in pouchitis and active UC than in the noninflamed ileoanal pouch and normal controls ( P <0.001). There was significant correlation ( r =0.63,P < 0.05) between levels of cytokines expressed in pouchitis and active UC. CONCLUSIONS: Increased cytokine expression occurs in both active UC and pouchitis and to a lesser extent in the long-standing ileoanal pouch.     

Openvs. closed sphincterotomy for chronic anal fissure

PURPOSE: This study was undertaken to compare the healing rate and long-term effects on continence of open and closed lateral internal sphincterotomy. METHODS: Charts of 864 patients with chronic anal fissure who underwent internal sphincterotomy as a single procedure over five years by a group of 12 colorectal surgeons were reviewed. Open internal sphincterotomy (OIS) was performed in 521 patients, whereas 343 had closed internal sphincterotomy (CIS). There was no difference in sex or age between the groups. A questionnaire inquiring about clinical outcome, changes in continence, and degree of satisfaction with the procedure was mailed to all patients. A total of 549 (63.5 percent) patients, 324 (62.2 percent) with OIS and 225 (65.6 percent) with CIS, returned their questionnaires. Average follow-up was three (range, 1–6) years. RESULTS: Differences in persistence of symptoms (3.4 OIS vs. 5.3 percent CIS), recurrence of the fissure (10.9 vs. 11.7 percent CIS), and need for reoperation (3.4 percent OIS tvs. 4 percent CIS) were statistically not significant. However, statistically significant differences were seen in the percentage of patients with permanent postoperative difficulty controlling gas (30.3 vs. 236 percent;P 0.062), soiling underclothing (26.7 vs. 16.1 percent;P < 0.001), and accidental bowel movements (11.8 vs. 3.1 percent;P < 0.001) between those who underwent OIS and those who had CIS. Although 90 percent of patients reported general overall satisfaction, more patients undergoing CIS (64.4 percent) than OIS (49.7 percent) were very satisfied with the results of the procedure. CONCLUSIONS: Lateral internal sphincterotomy is highly effective in treatment of chronic anal fissure but is associated with significant permanent alterations in continence. CIS is preferable to OIS because it effects a similar rate of cure with less impairment of control.     

Patterns of anismus and the relation to biofeedback therapy

PURPOSE: A study was undertaken to assess physiologic characteristics and clinical significance of anismus. Specifically, we sought to assess patterns of anismus and the relation of these findings to the success of therapy. METHODS: Sixty-eight patients were found to have anismus based on history and diagnostic criteria including anismus by defecography and at least one of three additional tests: anorectal manometry, electromyography, or colonic transit time study. Interpretation of defecography was based on the consensus of at least three of four observers. Anal canal hypertonia (n=32) was defined when mean and maximum resting pressures were at least 1 standard deviation higher than those in 63 controls. There were two distinct defecographic patterns of anismus: Type A (n=26), a flattened anorectal angle without definitive puborectalis indentation but a closed anal canal; Type B (n=42), a clear puborectalis indentation, narrow anorectal angle, and closed anal canal. Outcomes of 57 patients who had electromyographybased biofeedback therapy were reported as either improved or unimproved at a mean follow-up of 23.7 (range, 6–62) months. These two types of anismus were compared with biofeedback outcome to assess clinical relevance. RESULTS: Patients with Type A anismus showed greater perineal descent at rest (mean, 5.1 vs. 3.5 cm;P < 0.01), greater dynamic descent between rest and evacuation (mean, 2.7 vs. 1.4 cm;P <0.01), greater difference of anorectal angle between rest and evacuation (mean, 14.6 vs. ?3.1°;P <0.001), higher mean resting pressure (mean, 77.1 vs. 62.8 mmHg;P <0.05), lower mean squeeze pressure (58.8 vs. 80.7 mmHg;P <0.05), and a higher incidence of anal canal hypertonia (69.2 vs. 33.3 percent;P <0.01) than did patients with Type B anismus. Only 25 percent of patients who had Type A anismus with anal canal hypertonia were improved by biofeedback therapy. Conversely, 86 percent of patients with Type B anismus without anal canal hypertonia were successfully treated with biofeedback (P <0.001; Fisher's exact test). CONCLUSIONS: These two distinct physiologic patterns of anismus correlate with the success of biofeedback treatment. Therefore, knowledge of these patterns may help direct therapy.     

Anorectal manometric examination in encopretic-constipated children

PURPOSE: We have investigated the use of anorectal manometry to distinguish encopretic-constipated children (n=88) from sibling controls (n=16) and nonsibling controls (n=11). METHODS: Study variables included manometrically determined resting and maximum voluntary anal sphincter pressure, depth and speed of rectoanal inhibitory reflex, minimum rectal volume sensation, critical distending volume for fecal urgency, rectal and anal pressure responses during attempted defecation, and ability to defecate a water-filled balloon. RESULTS: Change in anal sphincter pressure during attempted defecation (P=0.03), gradient between rectal and sphincter pressure during attempted defecation (P=0.02), critical distending volume for fecal urgency (P=0.02), and ability to defecate a water-filled balloon (P=0.05) distinguished encopretic-constipated from control children. The change in rectal pressure associated with the rectoanal inhibitory reflex just escaped significance at P=0.07. CONCLUSIONS: Anal sphincter spasm and megacolon are pathophysiologic abnormalities associated with pediatric constipation-encopresis.     

Distribution and concentrations of 5-aminosalicylic acid in rectosigmoid biopsy specimens after rectal administration

PURPOSE: Using the autofluorescent properties of 5-aminosalicylic acid (5-ASA), we studied the penetration and distribution of this molecule in human colonic biopsies at different time intervals after administration of 5-ASA enemas. METHODS: Fluorescence scores of rectosigmoidal biopsy specimens were compared with 5-ASA and acetyl-5-aminosalicylic (Ac-5-ASA) concentrations, determined by high-performance liquid chromatography, in adjacent biopsies and in serum samples. RESULTS: 5-ASA penetrates into the rectal mucosa and into the epithelial cells after local application by means of an enema. We found a characteristic 5-ASA staining of two intramucosal structures that need further identification: intraepithelial triangular configurations and “5-ASA scavengers” in the lamina propria. Fluorescence scores correlate well with 5-ASA concentrations in adjacent biopsies (r =0.67;P <0.005) and correlate even better with serum concentrations of 5-ASA (r =0.84;P <0.005) and Ac-5-ASA (r=0.80;P <0.005), hence reflecting the amount of systemically absorbed and metabolized 5-ASA. CONCLUSION: 5-ASA penetrates into the rectal mucosa after local application. Local availability, assessed by means of fluorescence microscopy, correlates well with serum concentrations.     

Blood transfusion and survival in colorectal cancer

PURPOSE: This study examined the effect of blood transfusion on the prognosis of patients undergoing surgery for colorectal cancer. METHODS: Potentially curative resections for colorectal cancer were performed in 266 patients who were followed prospectively, with a minimum follow-up of 41 months. They were divided into transfused (n=121) and nontransfused (n=145) groups according to their perioperative blood transfusion requirements. RESULTS: There were significantly more rectal tumors (χ²=9.5, df=1, P=0.002) and fixed tumors (χ ² =4.5, df=1,P=0.03) in the transfused group. There was no statistically significant difference between the two groups with regard to recurrence-free survival (χ ² =1.1, df=1,P=0.3) and overall survival (χ ² =2.8, df=1,P=0.09). CONCLUSION: In this study we have found no statistically significant effect of perioperative blood transfusion on the prognosis of colorectal cancer patients.     

Proliferating cell nuclear antigen expression and its relationship to malignancy potential in invasive colorectal carcinomas

PURPOSE: Cellular proliferative activity is a useful indicator of biologic aggressiveness in colorectal carcinoma. Immunohistochemical analysis of proliferating cell nuclear antigen (PCNA) has important advantages of maintaining tissue architecture and technical simplicity. The aim of this study was to investigate the correlation between proliferative activity and malignancy potential in colorectal carcinomas to determine whether proliferative index of cancer cells has prognostic significance using immunohistochemical technique. METHODS: Proliferation index at the invasive tumor margin of 86 paraffin sections of advanced colorectal carcinomas was assessed by immunohistochemical study using a mouse monoclonal antibody to PCNA (PC-10) and was compared with conventional clinicopathologic factors and other possible prognostic parameters, including p53 over-expression, tissue carcinoembryonic antigen immunoreactivity pattern, and flow cytometric DNA ploidy. In addition, recurrence and survival were analyzed in accordance with degree of PCNA expression. RESULTS: PCNA labeling index (PCNA-LI) increased significantly as the Astler-Coller stage advanced (P =0.0001). Strong correlations were observed between PCNA-LI and various pathologic parameters, including histologic differentiation (P = 0.0027), lymphatic invasion (P = 0.0001), vascular invasion (P = 0.0001), lymph node metastasis (P = 0.0001), and liver metastasis (P = 0.0036). Mean PCNA-LI was also significantly higher in tumors with DNA aneuploidy (P = 0.0006) and negative and cytoplasmic patterns of carcinoembryonic antigen immunoreactivity (P = 0.01). Linear relationships were demonstrated between PCNA-LI and clinical outcomes; recurrence rate was significantly greater in the group with higher than the mean PCNA-LI, who underwent curative resection (P < 0.01), and four-year survival rates for both overall and curative cases with higher than the mean PCNA-LI were significantly poorer than those with lower than mean PCNA-LI (P < 0.005 and P < 0.01, respectively). CONCLUSION: Evaluation of PCNA-LI at the invasive tumor margin in colorectal carcinomas is suggested to be valuable in predicting those people with a higher potential for metastasis and recurrence after surgery; thus, the evaluation is helpful in planning reasonable adjuvant therapy, even in the earlier stages.     

The Mini Mental Status Exam as a Surrogate Measure of Health Literacy

BACKGROUND

Studies have documented strong associations between cognitive function, health literacy skills, and health outcomes, such that outcome performance may be partially explained by cognitive ability. Common cognitive assessments such as the Mini Mental Status Exam (MMSE) therefore may be measuring the same latent construct as existing health literacy tools.

OBJECTIVES

We evaluated the potential of the MMSE as a surrogate measure of health literacy by comparing its convergent and predictive validity to the three most commonly used health literacy assessments and education.

SUBJECTS

827 older adults recruited from an academic general internal medicine ambulatory care clinic or one of five federally qualified health centers in Chicago, IL. Non-English speakers and those with severe cognitive impairment were excluded.

MEASURES

Pearson correlations were completed to test the convergent validity of the MMSE with assessments of health literacy and education. Receiver Operating Characteristic (ROC) curves and the d statistic were calculated to determine the optimal cut point on the MMSE for classifying participants with limited health literacy. Multivariate logistic regression models were completed to measure the predictive validity of the new MMSE cut point.

KEY RESULTS

The MMSE was found to have moderate to high convergent validity with the existing health literacy measures. The ROC and d statistic analyses suggested an optimal cut point of ≤ 27 on the MMSE. The new threshold score was found to predict health outcomes at least as well as, or better than, existing health literacy measures or education alone.

CONCLUSIONS

The MMSE has considerable face validity as a health literacy measure that could be easily administered in the healthcare setting. Further research should aim to validate this cut point and examine the constructs being measured by the MMSE and other literacy assessments.     

Relationship between manometric anal waves and fecal incontinence

PURPOSE: The significance of manometric anal waves is uncertain, and their fate and diagnostic importance are unknown. It is conceivable that in neurogenic fecal incontinence (NFI) the frequency and amplitude of these waves may be altered into specific, recognizable patterns. Evaluation of this unexplored relationship between fecal incontinence and anal manometric waves has potential diagnostic use. METHODS: Anal motility was studied in 20 patients, each with NFI and traumatic fecal incontinence (TFI), and results were compared with findings in 20 control subjects to determine changes in frequency and amplitude of anal waves in fecal incontinence. RESULTS: Frequency of slow waves when present (NFI=9.5/minute; TFI=9.5/minute; control subjects=9.1/minute) was identical in the three groups (P>0.05). Amplitude of slow waves (NFI=mean, 4.3 mmHg; TFI=mean, 3.9 mmHg; control subjects =mean, 6.6 mmHg) was reduced in patients who were incontinent compared with control subjects but failed to reach statistical significance (P>0.05). Frequency of ultraslow waves when present (NFI=mean, 0.75/minute; TFI =mean, 0.6/minute; control subjects=mean, 1.2/minute) was not statistically different between the three groups (P>0.05). Amplitude of ultraslow waves (NFI=mean, 10.5 mmHg; TFI=mean, 23.4 mmHg; control subjects=mean, 29.6 mmHg) was significantly reduced in NFI vs.control subjects (P<0.01) and between TFI vs.control subjects (P<0.05). CONCLUSIONS: Manometric slow and ultraslow waves, when present, retain their frequency characteristics, irrespective of underlying disease. Amplitude of slow waves was not statistically different from control subjects, but the amplitude of ultraslow waves was significantly decreased in patients who were incontinent.     

Factors influencing recurrence in Crohn's disease

PURPOSE: This study was undertaken to investigate the factors that influenced the risk of symptomatic recurrence in patients with Crohn's disease who were treated with primary resective surgery. METHODS: Data regarding age, gender, time from diagnosis to surgery, medication, preoperative infectious complications, laboratory values, emergency/elective surgery, location and extent of disease, and resection margins were analyzed in relation to recurrence in 353 patients who were undergoing a “curative” resection in 1969 to 1986. RESULTS: Univariate analyses showed a higher risk of recurrence in women with ileal and ileocolonic disease than in men ( P <0.05), in patients with ileocolonic disease compared with those with isolated ileal disease ( P <0.05), and in ileal disease patients with an increased disease extent ( P <0.05). In a multivariate analysis performed on patients with ileal disease, increased disease extent, limited resection on the colonic side, and referral from other hospitals were three independent variables that indicated an increased risk of recurrence ( P < 0.05). Length of disease-free resection margins did not influence the risk of recurrence either in univariate or in multivariate analysis ( P >0.05). CONCLUSIONS: Disease extent has prognostic value regarding the risk of symptomatic recurrence in Crohn's disease, whereas the length of resection margins does not influence the risk of relapse. These results favor a conservative approach, particularly in patients with extensive disease.     

Flow cytometric DNA ploidy and S-phase fraction correlate with histopathologic indicators of tumor behavior in colorectal carcinoma

BACKGROUND: The clinical behavior of colorectal carcinoma is highly variable without reliable predictive biomarkers. Previous reports have shown that flow cytometric DNA analysis may provide valuable prognostic information in these tumors. PURPOSE AND METHODS: This study evaluates the DNA ploidy and the S-phase fraction (SPF) on frozen samples obtained from 61 patients with colorectal carcinoma by using flow cytometry, and it correlates the data with histopathologic features known to affect disease prognosis. Tumors were classified using the World Health Organization's histologic criteria and were staged according the American Joint Committee on Cancer's classification system. Grade of the neoplasm, vascular invasion, and perineural tumor spread were evaluated in every case. RESULTS: Fifty-nine percent of tumors were aneuploid and showed statistically significant higher S-phase values than diploid tumors (22.5 vs. 11.2 percent; P < 0.00001). Mean SPF of the whole series was 17.9 (range, 4.2–44.2) percent. A statistically significant association was found between SPF values and histologic grade (P < 0.0016), nodal status (P <0.0007), distant metastasis(P < 0.0001), tumor stage (P <0.0001), venous invasion (P < 0.0002), and lymphatic permeation (P < 0.01) but not with perineural growth and infiltration of the neoplasm through the bowel wall (T). DNA ploidy correlated positively with tumor stage (P <0.03), and the association between aneuploidy and advanced stages of the disease was statistically significant. CONCLUSIONS: These findings showed that flow cytometric DNA ploidy and SPF, evaluated in fresh samples, are potentially useful parameters to estimate colorectal carcinoma biopathology. Aneuploidy and high replicative neoplastic activity correlated with histopathologic features that are commonly associated with the prognosis of colorectal carcinoma, being SPF-related to disease dissemination and, therefore, an indicator of clinical relevance.     

Inhibitory effect of calcium on carcinogenesis at the site of colonic anastomosis

PURPOSE: A study was made to assess the effect of oral calcium supplementation on colorectal carcinogenesis at the colocolic suture line and in the rest of the colon following administration of a carcinogen. METHODS: Fifty-nine rats were randomly divided into two groups: control (given a standard diet for rats and mice containing 0.8 percent calcium) and treatment (given the same diet as before but with 2 percent calcium). Carcinogenesis was induced by 26 weekly injections of 1,2-dimethylhydrazine. All animals were subjected to an end-to-end colonic anastomosis at the beginning of the experiment using five stitches of steel wire. RESULTS: The control group developed significantly more tumors per animal at both the anastomosis ( P < 0.001) and in the rest of the colon ( P <0.001). In addition, the percentage of rats with tumors was significantly higher in the control group at both the anastomosis (chi-squared=12; df=1,P <0.001) and in the rest of the colon (chisquared=7.12; df=1,P <0.01). The mean surface of tumors was likewise greater in the control group at the anastomosis ( P <0.001) and throughout the rest of the colon ( P <0.001). Finally, there were significantly more small-bowel tumors (excluding the duodenum) in the control group ( P <0.05). CONCLUSIONS: It is concluded that calcium supplementation decreases the tumor yield at the site of end-to-end colonic anastomosis and in the rest of the colon and small bowel (excluding the duodenum).