Explore the vast range of titles available.

Post-colonoscopy consults empower patients to make informed decisions around their subsequent treatment, and non-compliance with these consults (“no-shows”) hinders disease management. There is a paucity in the literature regarding self-adherence to post-colonoscopy consults in resource-limited settings such as South Africa. An understanding of self-adherence to post-colonoscopy consults in this setting is required to establish whether improved interventions are needed, and what specific elements of self-adherence should be addressed with these interventions. The objective of this hypothesis-generating, cross-sectional, quantitative survey was to conduct a baseline assessment of cognitive, motivational, social, and behavioural variables related to self-adherence to post-colonoscopy consults in patients who underwent diagnostic colonoscopy at a South African quaternary hospital. The Adherence Determinants Questionnaire (ADQ) was administered in 47 patients to establish a baseline assessment of elements related to self-adherence to post-colonoscopy consults, including interpersonal aspects of care, perceived utility, severity, susceptibility, subjective norms, intentions, and supports/barriers. ADQ scores were transformed to a percentage of the maximum score for each element (100.0%). The overall mean transformed ADQ score was 57.8%. The mean transformed scores for specific ADQ components were as follows: subjective norms (40.8%), perceived severity (55.4%), perceived utility (56.6%), intentions (59.4%), supports/barriers (59.9%), interpersonal aspects (62.2%), and perceived susceptibility (65.9%). There were no statistically significant differences in overall mean transformed ADQ scores and individual ADQ elements across categories of participant age (p-values ranging between 0.180 and 0.949 when compared between participants ≤40 years and >40 years old), gender (p-values ranging between 0.071 and 0.946 when compared between males and females), and race (p-values ranging between 0.119 and 0.774 when compared between Black Africans and non-Black Africans). Our findings suggest a general need for appropriate interventions to improve self-adherence to post-colonoscopy consults in our setting.

Background The elderly constitute the majority of both colorectal cancer and surgical volume. Despite established safety and feasibility, laparoscopy may remain underutilized for colorectal cancer resections in the elderly. With proven benefits, increasing laparoscopy in elderly colorectal cancer patients could substantially improve outcomes. Our goal was to evaluate utilization and outcomes for laparoscopic colorectal cancer surgery in the elderly. Methods A national inpatient database was reviewed for elective inpatient resections for colorectal cancer from 2010 to 2015. Patients were stratified into elderly (≥ 65 years) and non-elderly cohorts (< 65 years), then grouped into open or laparoscopic procedures. The main outcomes were trends in utilization by approach and total costs, length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models were used to control for differences across platforms, adjusting for patient demographics, comorbidities, and hospital characteristics. Results Laparoscopic adoption for colorectal cancer in the elderly increased gradually until 2013, then declined, with simultaneously increasing rates of open surgery. Laparoscopy significantly improved all primary outcomes compared to open surgery (all p  < 0.01). From the adjusted analysis, laparoscopy reduced complications by 30%, length of stay by 1.99 days, and total costs by $3276/admission. Laparoscopic patients were 34% less likely to be readmitted; when readmitted, the episodes were less expensive when index procedure was laparoscopic. Conclusion The adoption of laparoscopy for colorectal cancer surgery in the elderly is slow and even declining recently. In addition to the clinical benefits, there are reduced overall costs, creating a tremendous value proposition if use can be expanded. Precis This national contemporary study shows the slow uptake and recent decline in adaption of laparoscopic surgery for colorectal cancer in the elderly, despite the benefits in clinical outcomes and costs found. This data can be used to target education, regionalization, and quality improvement efforts in this expanding population.

BackgroundFactors associated with discharge destination after colectomy despite accounting for surgical morbidity have not previously been well characterized. This study aims to evaluate perioperative predictors for extended care after complicated and uncomplicated colectomy.MethodsPatients admitted from home for elective colectomy were identified from the American College of Surgeons, National Surgical Quality Improvement Program, 2012–2013 general and colectomy-targeted datasets. Patients who were discharged home (DH) were compared to those discharged to facility (DF) for patient, disease, treatment, and pre-discharge postoperative adverse events. Patients without any 30-day postoperative complication were similarly compared.ResultsOf 19,527 patients undergoing elective colectomy, 18,128 (92.8%) were discharged home and 1399 (7.2%) patients to other facilities. When there was no postoperative complication, these rates were 96.3 and 3.7%, respectively. On multivariable analysis, factors associated with DF included female gender, functional dependence, weight loss, ASA class ≥ 3, open and stoma surgery, and development of postoperative complications. For patients without postoperative complications, increasing age, functional dependence, and ASA score ≥ 3 were associated with DF. Preoperative bowel preparation, albumin, a minimally invasive surgical approach, and length of stay < 5 days were significantly associated with reduced DF.ConclusionThe majority of perioperative factors associated with extended care after colectomy are patient driven. The adoption of oral antibiotics as bowel preparation, minimally invasive surgery, and accelerated recovery protocols may reduce post-acute care placement after elective colectomy.

Clinical outcomes in colorectal cancer (CRC) correlate with T cell infiltrates, but the specific contributions of heterogenous T cell types remain unclear. To investigate the diverse function of T cells in CRC, we profiled 37,931 T cells from tumors and adjacent normal colon of 16 patients with CRC with respect to transcriptome, TCR sequence, and cell surface markers. Our analysis identified phenotypically and functionally distinguishable effector T cell types. We employed single-cell gene signatures from these T cell subsets to query the TCGA database to assess their prognostic significance. We found 2 distinct cytotoxic T cell types. GZMK+KLRG1+ cytotoxic T cells were enriched in CRC patients with good outcomes. GNLY+CD103+ cytotoxic T cells with a dysfunctional phenotype were not associated with good outcomes, despite coexpression of CD39 and CD103, markers that denote tumor reactivity. We found 2 distinct Treg subtypes associated with opposite outcomes. While total Tregs were associated with good outcomes, CD38+ Tregs were associated with bad outcomes independently of stage and possessed a highly suppressive phenotype, suggesting that they inhibit antitumor immunity in CRC. These findings highlight the potential utility of these subpopulations in predicting outcomes and support the potential for novel therapies directed at CD38+ Tregs or CD8+CD103+ T cells.

Objective The objective of this study was to evaluate the efficacy of stricturoplasty and endoscopic balloon dilatation in the treatment for ileal pouch strictures. Method Consecutive inflammatory bowel disease patients with pouch strictures seen at our Pouch Center from 2002 to 2012 were studied. The efficacy and safety of stricturoplasty (vs. endoscopic balloon dilation) were evaluated with both univariate and multivariate analyses. Results A total of 167 patients met the inclusion criteria, including 16 (9.6 %) with surgical stricturoplasty and 151 (90.4 %) with endoscopic balloon dilation. Ninety-four patients (56.3 %) were male, with a mean age at the diagnosis of pouch stricture of 41.6 ± 13.2 years. Fifty-one patients (30.5 %) had multiple pouch strictures, while 100 (59.9 %) patients had strictures at the pouch inlet. The mean length of pouch strictures was 1.2 ± 0.6 cm. No difference was found between the stricturoplasty and endoscopic dilation groups in clinicopathological variables, except for the degree of strictures ( p  = 0.019). After a mean follow-up of 4.1 ± 2.6 years, pouch stricture recurred in 92 patients (55.1 %) and 21 (12.6 %) patients developed pouch failure. The time interval between the procedure and pouch stricture recurrence or pouch failure was longer in the stricturoplasty group than that in the endoscopic dilation group ( p  < 0.001). Patients in the two groups had similar overall pouch survival rates and stricture-free survival rates. In the multivariate analysis, stricturoplasty vs. endoscopic dilation was not significantly associated with either overall pouch survival or stricture-free survival. There was no difference in the procedure-associated complication rates between the two groups. Conclusion Surgical stricturoplasty and endoscopic dilation treatment are complimentary techniques for pouch strictures. Repeated endoscopic dilatations are often required, while surgical stricturoplasty appeared to yield a longer time interval to stricture recurrence or pouch failure.

Endoscopic management of ileal pouch strictures has not been systemically studied. The aim was to evaluate endoscopic balloon therapy of pouch strictures in inflammatory bowel disease (IBD) patients with ileal pouches and to identify risk factors for pouch failure for those patients.MethodsConsecutive IBD patients with pouches from the Pouchitis Clinic who underwent nonfluoroscopy-guided outpatient endoscopic therapy were studied. The location, number, degree (range 0–3), and length of strictures and balloon size were documented. Efficacy and safety were evaluated with univariate and multivariate analyses.ResultsA total of 150 patients with pouch strictures were studied. Stricture locations were at the pouch inlet (n = 96), outlet (n = 73), afferent limb (n = 33), and pouch body (n = 2). A cumulative of 646 strictures were endoscopically dilated, with a total of 406 pouchoscopies. The median stricture score was 1 (interquartile range [IQR] 1–2); the median stricture length was 1 (IQR 0.5–1.25) cm, and the median balloon size was 20 (IQR 18–20) mm. Of 406 therapeutic endoscopies performed, there were two perforations (0.46%) and four transfusion-required bleeding (0.98%). The 5-, 10-, and 25-year pouch retention rates were 97%, 90.6%, and 85.9%, respectively. In a median follow-up of 9.6 (IQR 6–17) years, 131 patients (87.3%) were able to retain their pouches. The number of strictures and underlying diagnosis were independent risk factors for pouch failure in the Cox regression model.ConclusionsEndoscopic treatment of pouch stricture appears to be efficacious and generally safe to perform in experienced hands. Underlying diagnosis of Crohn's disease of the pouch and surgery-related strictures and multiple strictures were the risk factors for pouch failure.

This study aims to report trends in healthcare resource utilization and costs after colorectal surgery in the US. From all-payer inpatient data, patients who were discharged after elective colorectal procedures (2002–2011) were identified. Trends in postoperative hospital stay, costs and post-acute care were evaluated. Of 251,583 included patients, median length of stay was 6 days. Trends over time suggested a progressive reduction in hospital stay after surgery until 2008 after which there was an increase (6.6 days in 2002, 5.9 days in 2008 and 6.1 days in 2010). Costs (peak:2011, $51,731) and post-acute care (peak:2011, 19.4%) continued to increase throughout. While length of stay over the last decade reduced, a further reduction may not be feasible. Meanwhile, inpatient costs as well as the use of post-acute care programs have continued to rise. Healthcare planning needs to focus on patients who cannot be discharged early, and more comprehensively evaluate the interplay between length of stay, readmissions, inpatient and post-acute care utilization if we are to contain overall healthcare costs.

The aim of this study was to determine factors associated with deviation in length of hospital stay (LOS) from that determined by diagnosis-related groups. A cohort study from a prospectively collected database was conducted, including consecutive patients undergoing surgery in a high-volume colorectal surgery department in 2009. For 1,461 included patients, average expected and actual LOS were 8.17 days (interquartile range, 4.7 to 11.9 days) and 8.31 days (interquartile range, 4 to 10 days), respectively. The most prominent factors associated with an increase of LOS from expected were parenteral nutrition (5.11 days), emergency room admittance (3.67 days), and ileus (3.45 days) (P ≤ .001 for all). Other independently associated factors included blood transfusion, anastomotic leak, sepsis, pulmonary embolism, and surgeon. Patients with higher severity illness indexes and longer postoperative intensive care stay had lower than expected LOS. After colorectal surgery, several modifiable factors are associated with deviation of LOS from expected. An opportunity hence exists to reduce both LOS and financial burden for hospitals in an era of pay for performance.

Continent ileostomy (CI) was once a prevalent surgical technique for patients who required total proctocolectomy but then gave way to ileal pouch-anal anastomosis (IPAA) after 1980. Although IPAA has been the gold standard procedure preferred by most patients when total proctocolectomy is required, due to its imitation of physiological function of rectum and preserved function of anus, various complications have been observed with a relatively high rate of morbidity that could affect pouch longevity. Once serious complications such as pelvic abscesses and/or fistula occur, the pouch often needs to be removed. In addition, for some patients with a shortened small intestine or foreshortened mesentery, it is impossible for the ileal pouch to reach the pelvic floor, thus making the creation of an IPAA difficult. Previously, most of these patients would be referred for an end ileostomy, with an associated poor quality of life. In this circumstance, we propose that CI may deserve a reappraisal and serve as an alternative. In this article, we review the indications, contraindications, technique evolution, and outcomes of CI.

Malware Security Intelligence constitutes the analysis of applications and their associated metadata for possible security threats. Application Programming Interfaces (API) calls contain valuable information that can help with malware identification. The malware analysis with reduced feature space helps for the efficient identification of malware. The goal of this research is to find the most informative features of API calls to improve the android malware detection accuracy. Three swarm optimization methods, viz., Ant Lion Optimization (ALO), Cuckoo Search Optimization (CSO), and Firefly Optimization (FO) are applied to API calls using auto-encoders for identification of most influential features. The nature-inspired wrapper-based algorithms are evaluated using well-known Machine Learning (ML) classifiers such as Linear Regression (LR), Decision Tree (DT), Random Forest (RF), K–Nearest Neighbor (KNN) & Support Vector Machine (SVM). A hybrid Artificial Neuronal Classifier (ANC) is proposed for improving the classification of android malware. The experimental results yielded an accuracy of 98.87% with just seven features out of hundred API call features, i.e., a massive 93% of data optimization.