Access to Care and Satisfaction in Colorectal Cancer Patients

This study described the various components of access to care for resectable colorectal cancer, and correlated the timeliness of these components with patient satisfaction. With a prospective/retrospective cohort design, all patients undergoing surgical resection for primary colorectal cancer from 2/1/01 to 15/12/01, were identified during their admission for surgery. A comprehensive, standardized method of ascertaining specific time intervals, which included a patient interview, was used. A patient satisfaction questionnaire was developed, tested, and used in consenting patients. Over the study period, 118 patients underwent colorectal cancer resection. Of these, 110 (93%) consented to participate and 101 (86%) completed the satisfaction questionnaire, including test-retest. The median time intervals (interquartile range) for the various components of access to care were as follows: symptoms to first physician visit, 32 days (10-75); first physician visit to diagnosis, 88 days (44-218); diagnosis to surgery, 19 days (10-44); surgery to chemotherapy (where applicable), 54 days (47-72). On multivariate analysis, tumor location in the rectum was associated with longer prediagnosis intervals, whereas increasing tumor stage was associated with shorter intervals from diagnosis to surgery. Variation in the time interval from diagnosis to surgery was associated with patient satisfaction (r = 0.49; P < 0.0001). Substantially less correlation was identified between patient satisfaction and the time from first physician visit to diagnosis (r = 0.25, P = 0.04). No significant correlation was identified between patient satisfaction scores and the time interval from symptoms to first physician visit (r = 0.11; P = 0.7). Despite concerns regarding surgical waitlists, the longest time intervals experienced by colorectal cancer patients precede diagnosis. However, variations in the relatively short time period from diagnosis to surgery appeared to have the most impact on patient satisfaction. Interventions which improve the timeliness of specific components of access to care may not necessarily result in improved patient satisfaction.     

Ventral hernia repair: a study of current practice

Ventral wall hernias are common; despite this, there are no guidelines on the best surgical management. The aim of this study was to examine the types of repair in use for abdominal wall hernias in the West of Scotland over a 3-month period. Data were gathered on 120 patients. There were 60 incisional, 32 umbilical, and 28 epigastric hernias. The main indication for repair was pain (78%), while 12 patients (10%), presented acutely with incarceration or strangulation. The most common method of repair was sutured (55%), followed by mesh (29%) and Mayo repair (16%). There was no correlation between use of mesh and hernia size or whether repair was for a recurrent hernia. Surgical practice varies widely in the repair of ventral wall hernias. Clinical trials are required to establish the best method of repair for this common condition. Electronic Publication     

The association between ulnar length and forearm movement in patients with multiple osteochondromas

PURPOSE: To determine the relationship between the length of the ulna as a proportion of height (proportional ulnar length [PUL]), forearm and wrist ranges of motion, and degree of observable deformity in people with hereditary multiple exostoses. METHODS: One hundred forty-two people with hereditary multiple exostoses were examined; 35 were under the age of 15 years and therefore were presumed to be skeletally immature. Elbow, forearm, and wrist motion were measured, and the radius and ulna were palpated for osteochondromas. Ulnar length was estimated as a proportion of height (PUL) in skeletally immature subjects. The relationships between total active motion, number of palpable osteochondromas, and proportional length were examined for one randomly selected limb from each subject. RESULTS: A negative correlation was found between the number of palpable osteochondromas and range of forearm rotation. The degree of forearm motion in those under the age of 15 years was directly related to PUL and indirectly related to the number of palpable osteochondromas. Children whose PUL is within the normal range have a normal range of motion. CONCLUSIONS: In a child with hereditary multiple exostoses affecting the forearm, the PUL is associated with the range of movement and deformity, and it can be a useful adjunct in deciding the appropriate management.     

Relationship between vitamin D status, parathyroid hormone levels and bone mineral density in patients with chronic kidney disease stages 3 and 4

AIM: Low vitamin D status is associated with secondary hyperparathyroidism and increased bone turnover in the general population and can aggravate the hyperparathyroidism of chronic kidney disease (CKD) patients. It is also correlated to low bone mineral density (BMD), but this correlation is less clear in CKD patients. Aims of our study were to investigate these associations in CKD stages 3 and 4 patients, and to identify significant predictors of BMD in this population. METHODS: Serum 25-hydroxyvitamin D (25OHD) levels, BMD at the femur and radius, and bone mineral metabolism parameters were measured in 89 CKD stages 3 and 4 patients. Vitamin D status was defined according to the NKF/KDOQI guidelines. RESULTS: Mean 25OHD levels were 53.8+/-32.1 nmol/L and correlated to the severity of proteinuria. Thirty-five patients (39%) had vitamin D insufficiency, 29 (33%) had vitamin D deficiency and five (6%) had severe deficiency. Of the 89 patients, two had osteoporosis and 31 had osteopenia either at femur or radius. Independent predictors for the total femur BMD were the intact parathyroid hormone (iPTH) levels and the body mass index (BMI). For the total radius BMD, independent predictor was only the BMI. Serum 25OHD levels were not directly associated with BMD, but they were independent predictors of iPTH. CONCLUSION: Vitamin D insufficiency and deficiency are very common in CKD stages 3 and 4 population and may indirectly affect, via effects on iPTH, the BMD of these patients.     

Current Experience with Computed Tomographic Cystography and Blunt Trauma

We present our experience with computed tomographic (CT) cystography for the diagnosis of bladder rupture in patients with blunt abdominal and pelvic trauma and compare the results of CT cystography to operative exploration. We identified all blunt trauma patients diagnosed with bladder rupture from January 1992 to September 1998. We also reviewed the radiology computerized information system (RIS) for all CT cystograms performed for the evaluation of blunt trauma during the same time period. The medical records and pertinent radiographs of the patients with bladder rupture who underwent CT cystography as part of their admission evaluation were reviewed. Operative findings were compared to radiographic findings. Altogether, 316 patients had CT cystograms as part of an initial evaluation for blunt trauma. Of these patients, 44 had an ultimate diagnosis of bladder rupture; 42 patients had CT cystograms indicating bladder rupture. A total of 28 patients underwent formal bladder exploration; 23 (82%) had operative findings that exactly (i.e., presence and type of rupture) matched the CT cystogram interpretation. The overall sensitivity and specificity of CT cystography for detection of bladder rupture were 95% and 100%, respectively. For intraperitoneal rupture, the sensitivity and specificity were 78% and 99%, respectively. CT cystography provides an expedient evaluation for bladder rupture caused by blunt trauma and has an accuracy comparable to that reported for plain film cystography. We recommend CT cystography over plain film cystography for patients undergoing CT evaluation for other blunt trauma-related injuries.