Total mesorectal excision is optimal surgery for rectal cancer: a Scandinavian consensus.
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Colorectal Surgery↗
Biomedical subjects
O F Dent
Publications and source records attributed to O F Dent.
Are malnutrition and stress risk factors for accelerated cognitive decline? A prisoner of war study.
We set out to test the hypothesis that severe malnutrition and stress experienced by prisoners of war (POWs) are associated with cognitive deficits later in life. We assessed 101 former Australian POWs of the Japanese and 108 veteran control subjects using a battery of neuropsychological tests, a depression scale, a clinical examination for dementia, and CT. We divided the POWs into high weight loss (>35%) and low weight loss groups (<35%). We found no significant differences in cognitive performance between the POWs and control subjects or between high and low weight loss groups on any of the tests or in the prevalence of dementia. Scores on the depression scale showed that the former POWs had more depressive symptoms than the control subjects a decade previous, but the difference had diminished over time. This study does not support the hypothesis that malnutrition is a risk factor for accelerated cognitive decline nor the theory that severe stress can lead to hippocampal neuronal loss and cognitive deficits. Cognitive deficits in earlier studies of former POWs may have been associated with concurrent depression.
Aged↗
Survival after curative resection of lymph node negative colorectal carcinoma. A prospective study of 910 patients.
BACKGROUND: Approximately half of all patients treated for colorectal carcinoma by bowel resection have neither lymph node metastases nor known residual tumor (clinicopathologic Stages A and B). The aim of this study was to compare the survival of these patients with that of the general population and to explain any significant difference. METHODS: Prospectively collected data recorded for 910 patients from one institution during a period of 21.5 years were used in the analysis. Patient follow-up ranged from 6 months to 21.5 years. The "Survival" procedure, developed by the Finnish Cancer Registry, was used to compare the observed survival of patients with their expected survival, based on age- and sex-matched data from the population of New South Wales. Survival analysis was performed by the Kaplan-Meier method. Multivariate models were examined using Cox proportional hazards regression. RESULTS: Males with tumor spread beyond the muscularis propria (Stage B) was the only group with significantly poorer survival than expected. The reduced survival in this group was due to the effects of four clinical variables (cardiovascular complication, permanent stoma, urgent operation, respiratory complication) and one pathologic variable (direct spread involving a free serosal surface) acting independently. CONCLUSION: The survival of patients with clinicopathologic Stages A or B tumors closely matched their expected survival as predicted from the general population. Males with Stage B tumors were the only exception and their significantly reduced survival was largely due to clinical, as distinct from pathologic factors. These findings suggest that the risk of occult metastases is low for patients with Stages A and B tumors using this classification.
Adult↗
Transfusion does not influence patient survival after resection of colorectal cancer.
Two recent reviews reached opposing conclusions regarding the apparent detrimental effect of peri-operative blood transfusion on patient survival after resection of colorectal cancer. However, both sides agree that the influence of confounding variables has not been controlled adequately in most studies. The present study is based on 433 patients who had a curative resection for colorectal cancer between 1984 and 1989 and whose details and follow-up information were recorded in the Concord Hospital Colorectal Cancer Registry, Sydney. The association between peri-operative transfusion and patient survival after resection of colorectal cancer was examined taking into account 20 other prognostic variables. A proportional hazards regression model showed that transfusion did not have a statistically significant independent effect on survival after controlling for the patient's poor general condition, the complexity of the surgery and the occurrence of postoperative complications.
Blood Transfusion↗
Pathologic determinants of survival associated with colorectal cancer with lymph node metastases. A multivariate analysis of 579 patients.
BACKGROUND: Patients with colorectal carcinoma found to have regional lymph node metastases after curative resection form a large and prognostically diverse group. This study aims to determine which pathology variables have independent prognostic effects. METHODS: The data from the 579 patients used in this analysis were collected prospectively during a period of 21.5 years. The patients were from one institution, and the pathologic documentation was standardized. Patient follow-up ranged between 6 months and 21.5 years. Survival analysis was by the Kaplan-Meier method. Multivariate models were examined using Cox proportional hazards regression. RESULTS: On univariate analysis, eight pathology variables had a significant association with survival. Six of these variables showed significant independent effects on survival on multivariate analysis. In diminishing potency, these variables were: apical lymph node involvement; spread involving a free serosal surface; invasion beyond the muscularis propria; location in the rectum; venous invasion; high tumor grade. Significant independent effects also were shown for patient age and gender. The number of involved lymph nodes added no significant independent prognostic information. CONCLUSION: Six pathology variables have been identified that act independently in determining the survival of patients with colorectal carcinoma and lymph node metastases. The most potent of these variables, apical lymph node involvement, was used by Dukes to subclassify Stage C tumors. Another variable, direct spread beyond the muscularis propria, defines the Astler-Coller subclassification. It is recommended that all six independent variables be included in any future protocol for stratifying this prognostically diverse group of patients.
Adult↗
Clinicopathologically diagnosed residual tumor after resection for colorectal cancer. A 20-year prospective study.
BACKGROUND: A lack of comprehensive information exists on the nature, incidence, and prognostic significance of known residual tumor in colorectal cancer patients treated by bowel resection. This study aims to provide this information. METHODS: A prospective series of 1766 consecutive patients from the Concord Hospital Colorectal Cancer Registry (Concord, Australia) was used for the analysis. Residual tumor was defined as distant metastases diagnosed clinically or pathologically or tumor demonstrated histologically in a line of resection. The pathologic study was highly standardized. Patient follow-up ranged from 6 months to 20.5 years. Survival analysis was by the Kaplan-Meier method. Multivariate models were examined using Cox proportional hazards regression. RESULTS: The prevalence of residual tumor was 20.9% and the median survival was 11.6 months. In 4.5%, tumor transection alone occurred, 14.5% had distant metastases alone, and 1.9% had both. The difference in survival between the first two groups was at marginal statistical significance (P = 0.076). When each of these two groups was compared with the third group, significant differences were noticed (P = 0.001 and P = 0.004, respectively). Five of 14 pathology variables examined had a significant effect on survival using univariate analysis. On multivariate analysis only tumor transection and distant metastases had significant independent effects. CONCLUSIONS: Known residual tumor was common in this series: one in five resections. Survival studies show that tumor transection, as defined, is a valid criterion for residual tumor. Survival is significantly reduced when tumor transection and distant metastases both are present. These findings should be heeded when staging colorectal cancer and when stratifying patients for postoperative adjuvant therapy.
Adult↗
Patient characteristics and pathology in colorectal adenomas removed by colonoscopic polypectomy.
Between September 1981 and August 1987 420 patients with 565 adenomas underwent colonoscopic polypectomy to produce a 'clean colon'. Data from these patients were analysed to identify associations between patient characteristics (age and sex), polyp characteristics (site, size, shape, multiplicity and villous content) and the degree of dysplasia in the index adenoma. In univariate analysis, severe dysplasia in the index adenoma was significantly but weakly associated with size (> or = 10 mm), peduncular shape and villous architecture. Logistic regression confirmed an independent effect only from villous architecture. These findings suggest that it is unlikely that strong predictors of a patient developing a metachronous adenoma or colorectal cancer can be identified on the basis of an index adenoma found at initial colonoscopy. These patients will continue to be followed to investigate this question.
Adenomatous Polyps↗
Intrapleural bupivacaine in the control of postthoracotomy pain.
A randomized, double-blind trial was conducted to determine the effectiveness of intrapleural bupivacaine hydrochloride in the management of pain after thoracotomy. Thirty-three men and 7 women with a mean age of 62 years (range, 21 to 76 years) undergoing elective posterolateral thoracotomy were randomly allocated preoperatively to either a study group receiving 20 mL of 0.25% bupivacaine or a control group receiving 20 mL of 0.9% saline solution through a pleural catheter every 4 hours. Patients received supplementary doses of intramuscular papaveretum as required. Assessment of pain, somnolence, and breathing capacity was performed after the intrapleural injections at 4, 24, 48, and 72 hours postoperatively. Pain assessment, as measured by a linear analog scale, was lower in the bupivacaine group at all times, reaching significance at 4, 24, and 72 hours (p less than 0.05). The forced vital capacity and forced expiratory volume in 1 second at 6 weeks postoperatively remained significantly lower than preoperatively (p less than 0.05). The fall in forced vital capacity from this postoperative level was significantly less in the bupivacaine group at 4, 24, and 48 hours, and the fall in forced expiratory volume in 1 second was significantly less at 4 and 48 hours in the treated group. When used in conjunction with doses of parenteral narcotic, intrapleural bupivacaine gives better pain control with less respiratory depression than intermittent doses of narcotic alone.
Adult↗
Use of H2-receptor antagonists in patients with dyspepsia and heartburn: a cost comparison.
OBJECTIVE: Under the Pharmaceutical Benefits Scheme, the use of H2-receptor antagonists (H2A) in the treatment of dyspepsia and heartburn is only subsidised when there is a proven diagnosis of ulcer. This study compared the costs of this Australian practice with a simulation of British practice, which allows unrestricted prescribing of subsidised H2A. DESIGN: Patients with heartburn and/or dyspepsia were prospectively randomised to either a "British" group treated freely at the discretion of their general practitioner without necessarily being investigated or an "Australian" group where use of H2A was allowed only after gastroscopy or a barium meal had demonstrated a peptic ulcer or ulcerative oesophagitis. The patients were followed up for six months and all direct and indirect costs were recorded. SETTING: Forty-nine Sydney general practitioners recruited primary care patients for the study. PATIENTS: Any patient with heartburn or dyspepsia was considered for recruitment; 139 patients entered the study and 137 completed it. MAIN OUTCOME MEASURES: The outcome measures were the costs of general practitioner consultations, specialist consultations, radiology and gastroscopy, other tests, H2A, other medications, personal costs, and total cost per patient. RESULTS: The cumulative total cost per patient at the end of the study was equivalent in the "Australian" ($392) and "British" ($406) groups. A higher initial cost per patient of H2A in the "British" group was offset by a rapid decrease in the proportion that continued to use H2A and by the cost of specialist consultations and investigations in the "Australian" group. CONCLUSION: Over a six-month period the cost of early investigation of heartburn and dyspepsia was equivalent to the cost of a therapeutic trial of H2A.
Adult↗
Exocrine pancreatic function and chronic unexplained dyspepsia. A case-control study.
The aim of this study was to determine the prevalence of diminished mean tryptic activity (MTA) in duodenal juice of patients with nonulcer dyspepsia following injection of a Lundh test meal. Two separate studies were undertaken. The first examined a consecutive group of 100 patients with suspected pancreatic disease referred over a period of 2 yr. In these patients, receiver-operating-characteristic analysis was used to determine the point of best discrimination, which occurred at 7 microEq/mL/min when non-pancreatic disease patients were compared with those with chronic pancreatitis or pancreatic cancer. The second study involved 22 patients with endoscopically confirmed nonulcer dyspepsia. The MTA for the patients with unexplained dyspepsia did not differ from 17 healthy controls, but a further 16 pancreatic disease control patients had significantly decreased values (p less than 0.01). Six patients with unexplained dyspepsia (27%) had an MTA of 7 microEq/min/mL or less, indicating impaired pancreatic function, which was more frequent than in healthy controls (p = 0.02). These six patients had significantly different symptoms, being more likely to have pain radiating through to the back (p = 0.017) and pain waking them from sleep (p = 0.002), and less likely to have postprandial pain (p = 0.045). It was of interest that the alcohol intake was not greater in these six patients. It is concluded that pancreatic disease may explain the symptoms of some patients with nonulcer dyspepsia.
Adult↗
Frequency of intermediate admissions and place of death of patients with advanced colorectal cancer.
An analysis was made of the place of death and the degree of institutional support required following surgery in patients with colorectal cancer (CRC) who had distant metastases. There was a high incidence of intermediate admissions to an acute hospital, and most patients died in an acute hospital bed. The number of readmissions and the place of death were not influenced by the patients' age, sex, site of tumour or their home situation at the time of diagnosis. In view of the high demand for acute surgical beds, there is a need to develop more appropriate facilities to care for patients in the terminal phase of this disease.
Aged↗
Rectal bleeding. Patient delay in presentation.
Patient delay in presentation of rectal bleeding has been identified as a factor in delayed diagnosis among patients with colorectal cancer. The aim of this study was to identify demographic or psychological factors, or beliefs or behaviors related to delay in presentation of rectal bleeding. In 93 patients presenting with this symptom to their general practitioner, delay ranged from 0 to 249 days with a median of 7 days; 27 (29 percent) delayed more than 14 days. Delay was unrelated to age, sex, ethnic origin, competence in English, length of schooling, social status, availability of social support, measured psychologic traits, and to the belief that the cause might be cancer. The proportions delaying more than 14 days were statistically significantly elevated among those who were not worried by the bleeding (47 percent delayed); those who did not regularly look at their feces or the toilet paper after use (37 percent); and those who took some other action before presenting to their general practitioner (43 percent).
Adult↗
Current perspectives in staging large bowel cancer.
Today, a standardized method of staging that is internationally accepted is urgently needed for the management of patients with colorectal cancer. The use of a uniform, sensitive staging system would greatly improve case selection and avoid unnecessary bias when entering patients into adjuvant therapy trials. This would allow a more accurate evaluation of new treatment protocols and assist in the development of more effective follow-up programmes.
Colorectal Neoplasms↗
The prevalence of serological markers for hepatitis B virus infection in Australian Naval personnel.
In order to determine the prevalence of hepatitis B virus infection in Royal Australian Navy personnel and to formulate policies for their education, screening and vaccination, a voluntary survey was undertaken. Seven hundred and forty-eight subjects completed a questionnaire that provided details of age, sex, rank, ethnic origin, service abroad, length of service, history of tattooing, liver disease and blood transfusions. Serum was assayed by radioimmunoassay for the presence of hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (antiHBs) and antibody to hepatitis B core antigen (antiHBc). The presence of markers of hepatitis B virus infection was correlated with "risk factors" by means of the chi 2 test of independence. Fourteen (74%) of 19 personnel from the Pacific Islands, Asia and Africa who were excluded from analysis showed one-or-more such markers. The prevalence of any marker of hepatitis B virus infection was 4.4% (95% confidence interval [CI], 2.9%-5.9%). The individual markers HBsAg, antiHBs and antiHBc were found in 0.4% (95% CI, 0.1%-1.2%), 3.6% (95% CI, 2.2%-4.9%) and 3.9% (95% CI, 2.5%-5.3%) of subjects, respectively. The annual attack rate was estimated to be less than 1%. Factors which had a significant correlation with an increased prevalence of markers of hepatitis B virus infection included tattooing (especially if this had been performed in Asia), age, the duration of service and service abroad. Based on these data, and given the reduced cost of hepatitis B vaccines, vaccination now is considered worth while. A policy of vaccinating all personnel who may be required for service at sea, and others at risk, now is in effect. Educational programmes that are aimed at minimizing the risk of exposure to hepatitis B and other viral infections have been instituted.
Adolescent↗
Postwar mortality among Australian World War II prisoners of the Japanese.
The impact of detention as a prisoner of war on postwar survival and disease-specific mortality was examined in Australian veterans of World War II. A random sample of 908 ex-prisoners and 797 other veterans of the same theatre of war, all of whom had returned to Australia alive, was traced over the 40 years since the war. The date and cause of death were recorded for those who were found to have died. By means of the subject-years method, the mortality of the prisoners of war was compared with that of the non-prisoners of war while the analysis controlled for the length of follow-up and the subject's age at the close of the war. The prisoners of war showed a higher over-all mortality rate than did the non-prisoners of war. This difference was pronounced in the period from five to 14 years after the war but diminished subsequently. There also was an indication that this effect varied with the subject's age at the end of the war: prisoners of war who were aged 25-29 years at that time had the highest mortality differential from non-prisoners of war, followed by prisoners of war who were aged 30-34 years. However, log-linear modelling, which controlled for age and the follow-up period, did not suggest that these mortality differences could be attributed to particular causes of death.
Adult↗
Rectal bleeding. Do other symptoms aid in diagnosis?
It has been shown previously that it is difficult for a general practitioner to predict anal vs. colorectal sources of bleeding in patients presenting with rectal bleeding. The aim of the present study was to determine whether there are any aspects of such a patient's history or clinical features that strongly indicate bleeding from a colorectal cancer or polyp. One hundred forty-five consecutive patients, aged 40 years and older, who had complained of rectal bleeding to a general practitioner, were referred to a specialist for full colonic investigation. Among 15 symptoms and clinical features examined, few had any statistically significant association with the source of bleeding. There was an elevated probability of colorectal cancer (21 percent) in patients who had seen blood mixed with feces. Most bowel symptoms and clinical features are not helpful in deciding whether to proceed with full colorectal assessment in patients aged 40 and older who have rectal bleeding of recent onset.
Adult↗
Evidence of hepatitis virus infection among Australian prisoners of war during World War II.
A sample of Australian male veterans of World War II was surveyed after 40 years. One hundred and seventy veterans had been held by the Japanese as prisoners of war and 172 veterans had served in southeast Asia but had not been taken captive (non-prisoners of war). A medical history was obtained and a physical examination undertaken. Blood was drawn and analysed for standard liver biochemistry and serological markers of hepatitis A and B virus (HAV, HBV) infections. The prevalence of immunoglobulin (Ig)G class antibodies to HAV was 95.2% in non-prisoners of war and 93.3% in prisoners of war. Only three cases of hepatitis B surface antigen (HBsAg) seropositivity were identified (two cases from the prisoner-of-war group). Thirty-six (21.8%) prisoners of war were seropositive for the presence of antibodies to HBsAg (anti-HBs) and 34 (20.0%) prisoners of war for that of antibodies to hepatitis B core antigen (anti-HBc), compared with 16 (9.8%) and eight (4.7%) of the non-prisoners of war, respectively (P = 0.002 and P = 0.0001, respectively). Those veterans who reported jaundice during World War II had a higher prevalence of antibodies to HBV. Among prisoners of war who were forced to work on the Burma-Thailand railway, 24.1% were seropositive for anti-HBc compared with 11.1% of the remaining prisoners of war (P = 0.048). It would appear that hepatitis B was common in prisoners of war but that those who survived 40 years were able to clear the virus and do not appear to have significant liver disease.
Asia, Southeastern↗
Precursors of depression in World War II veterans 40 years after the war.
The impact of wartime stress and other psychosocial and health variables on depressive illness in the 40 years since the Second World War is examined in this study of Australian male prisoners of the Japanese and other veterans. A random sample of 170 surviving members of the captured Eighth Division of the Australian Army residing in Sydney in 1983 (POWs) was compared with a similar sample of 172 veterans who fought in Southeast Asia during the war but were not imprisoned (non-POWs). Multiple regression analysis involving nine predictor variables revealed that self-reported nervous illness during the war and depressive illness since the war had pronounced independent effects on current depression as measured by the Zung Scale. Being married and better educated had significant protective effects against depression for the non-POWs while being employed and having higher socioeconomic status were protective for POWs. A clear linkage was shown from wartime nervous illness to postwar depressive illness to present-day depression.
Aged↗