bluuebunny/crossref_metadata_2025 huggingface dataset:
Adjuvant vs. neoadjuvant radiochemotherapy for locally advanced rectal cancer: the German trial CAO/ARO/AIO‐94
Authors: Sauer R. , Fietkau R. , Wittekind C. , Rödel C. , Martus P. , Hohenberger W. , Tschmelitsch J. , Sabitzer H. , Karstens J.‐H. , Becker H. , Hess C. , Raab R. ,   for the German Rectal Cancer Group
Published: August 2003

Aim  The standard treatment for patients with clinically resectable rectal cancer is surgery. Postoperative radiochemotherapy (RCT) is recommended for advanced disease (pT3/4 or pN+). In recent years, encouraging results of pre‐operative radiotherapy have been reported. This prospective randomized phase‐III‐trial (CAO/ARO/AIO‐94) compares the efficacy of neoadjuvant RCT to standard postoperative RCT. We report on the design of the study and first results with regard to toxicity of RCT and postoperative morbidity.

Patients and methods  Patients with locally advanced operable rectal cancer (uT3/4 or uN+, Mason CS III/IV) were randomly assigned to pre or postoperative RCT: A total dose of 50.4 Gy (single dose 1.8 Gy) was applied to the tumour and the pelvic lymph nodes. 5‐FU (1000 mg/m2/d) was administered concomitantly in the 1th and 5th week of radiation as 120 h‐continuous infusion. Four additional cycles of 5‐FU‐chemotherapy (500 mg/m2/d, i.v.‐bolus) were applied. RCT was identical in both arms except for a small‐volume boost of 5.4 Gy postoperatively. The time interval between RCT and surgery was 4–6 weeks in both arms. Techniques of surgery were standardized and included total mesorectal excision. Primary endpoints of the study are 5‐year survival and local and distant control. Secondary endpoints include the rate of curative (R0) resection and sphincter saving procedures, toxicity of RCT, surgical complications and quality of life.

Results  As of July 2002, 805 patients were randomized from 26 participating institutions. Acute toxicity (WHO) of RCT was low, with less than 15% of patients experiencing grade 3 or higher toxicity: The principal toxicity was diarrhea, with 12% in the postoperative RCT‐arm and 11% in the pre‐operative RCT‐arm having grade 3‐, and 1% in either arm having grade 4‐diarrhea. Erythema, nausea and leukopenia were the next common toxicities, with less than 3% of patients in either arm suffering grade 3 or greater leukopenia or nausea. Postoperative complication rates were similar in both arms, with 12% (postop. RCT) and 12% (pre‐op. RCT) of patients, respectively, suffering from anastomotic leakage, 3% (postop. RCT) and 3% (pre‐op. RCT) from postoperative bleeding, and 6% (postop. RCT) and 4% (pre‐op. RCT) from delayed wound healing.

Conclusion  The patient accrual to the trial is satisfactory. Neoadjuvant RCT is well tolerated and bears no higher risk for postoperative morbidity.
Anal and rectal cancer in Crohn's disease
Authors: Sjödahl R. I. , Myrelid P. , Söderholm J. D.
Published: August 2003

Several epidemiological studies have been published regarding the risk of Crohn's disease‐ associated colorectal cancer. The findings are, however, contradictory and it has been particularly difficult to obtain indisputable information on the incidence of cancer limited to the rectum and the anus. During 1987–2000 rectal or anal cancer was diagnosed in 335 patients in Sweden (153 males, 182 females). In other words, approximately 3 Crohn patients per million inhabitants were diagnosed with rectal or anal cancer every year during that time period which is 1% of the total number of cases. At diagnosis of cancer 36% were aged below 50 years and 58% below 60 years. Corresponding figures for all cases of anal and rectal cancer were 5% and 18%, respectively.

Present knowledge from the literature implies that there is an increased risk of rectal and anal cancer only in Crohn's disease patients with severe proctitis or severe chronic perianal disease. However, the rectal remnant must also be considered a risk factor. Multimodal treatment is similar to that in sporadic cancer but proctectomy and total or partial colectomy is added depending on the extent of the Crohn's disease. The outcome is the same as in sporadic cancer at a corresponding stage but the prognosis is often poor due to the advanced stage of cancer at diagnosis.

We suggest that six high‐risk groups should be recommended annual surveillance after a duration of Crohn's disease of 15 years including extensive colitis, chronic severe anorectal disese, rectal remnant, strictures, bypassed segments and sclerosing cholangitis.
Aggressive surgical treatment for patients with T4 rectal cancer
Authors: Moriya Y. , Akasu T. , Fujita S. , Yamamoto S.
Published: August 2003

Objective  To investigate the outcome of surgical treatment for patients with T4 rectal cancer and to evaluate prognostic factors influencing 5‐year disease‐free survival.

Patients  Of 1600 rectal cancers seen between 1985 and 1998, there were 197 patients with T4 of whom 128 were treated with curative intent. In this retrospective study organ invaded, the type of treatment and outcome were analysed.

Results  Of the 128 patients, 89% had visceral involvement and 11% had pelvic wall involvement. The most frequently involved organ was bladder, followed by prostate and vagina. Low anterior resection was performed in 52, abdomino‐perineal resection in 35 and total pelvic exenteration in 41 patients. Of 81 with urinary tract invasion, 50% were treated with bladder‐sparing surgery. Pathological examinations showed bladder involvement in only 44 of these and overall 5‐year disease‐free survivial was 57%. Multivariate analysis revealed that body mass index, lymph node metastasis and inflammatory reaction were significant predictors of survivial.

Conclusion  Completeness of resection is the essential factor influencing oncological outcome.
Local curative treatment of rectal cancer by radiotherapy alone
Authors: Gérard J. P. , Romestaing P. , Baulieux J. , Benchimol
Published: August 2003

This paper is a short overview of the role of radiotherapy alone to locally control rectal cancer when surgery for any reason cannot be performed. High dose irradiation is necessary using endocavitary (contact X‐ray, iridium brachytheraphy) techniques. For T2‐3 lesions a combination of external beam radiotherapy and endocavitary irradiation can provide long term cure with limited toxicity.

Surgery remains, by far, the main treatment of rectal cancer, preoperative radiotherapy may be used in low rectal cancer to improve the chance of sphincter saving procedure.
Managing rectal cancer: the Dutch experience
Authors: Peeters K. C. M. J. , Kapiteijn E. , Van De Velde C. J. H. ,   on behalf of the Dutch ColoRectal Cancer Group
Published: August 2003

One of the major problems in the treatment of rectal cancer has been the inability to achieve local control. Traditional surgery, now outmoded, involves blunt digital dissection and was associated with a high incidence of local recurrence. In an attempt to improve local control and survival, many adjuvant treatment modalities have been investigated. In the context of conventional nonstandardized surgical procedures, pre‐operative radiotherapy has been shown to improve local control and overall survival.

In recent years treatment outcome has been extensively improved by the introduction of the TME technique first described by Heald. This has resulted in such low recurrence rates and improved survival that the question had to be answered whether pre‐operative short‐term radiotherapy is still beneficial in TME treated patients. The question was answered in the TME trial set up by the Dutch ColoRectal Cancer Group that randomised between standardized and quality‐controlled TME surgery alone and TME surgery preceded by short‐term pre‐operative radiotherapy.

This paper reviews the developments in the treatment of resectable rectal cancer, highlights the results from the Dutch TME trial, and considers future directions in improving outcome.
Resection of liver metastases from colorectal cancer – how can we improve results?
Authors: Nordlinger B. , Peschaud F. , Malafosse R.
Published: August 2003

Resection of liver metastases due to large bowel cancer has become an important part of treatment. In recent years, there have been advances in technique and the selection of patients has been extended. Surgery is the only modality which currently offers the possibility of long‐term survival. Resection combined with chemotherapy may offer improved survival, but more data are needed. Chemotherapy may cause regression of metastases to permit resection where initially they were considered unresectable. The data available from such studies are presented.
Predicting risk and diminishing the consequences of anastomotic dehiscence following rectal resection
Authors: Alberts J. C. J. , Parvaiz A. , Moran B. J.
Published: August 2003

Anastomotic dehiscence is a serious, life‐threatening complication of any rectal anastomosis and may be associated with an increased risk of local cancer recurrence. The leak rate following low anterior resection is in the region of 10% as supported by the recent randomised Dutch rectal cancer trial. Although accurate prediction of risk is impossible, certain factors are known to influence leak rates. There is an inverse relationship between the height of anastomoses from the anal verge and leak rate, with the lower anastomoses carrying the highest risk. Proximal defunctioning mitigates the consequences of leakage but does not abolish risk. There is little difference in rates of dehiscence between stapled and sutured colorectal anastomoses. A short colon pouch may reduce the chance of leakage. The highest risks are in unprotected anastomoses less than 5 cm from the anal verge in men who smoke and/or drink excessively, particularly if they have received pre‐operative chemotherapy or chemo‐radiotherapy. A high index of suspicion is required in detecting the early nonspecific signs of a leak and urgent surgical intervention is usually required to avert a life‐threatening situation. Judicious use of faecal diversion should never be regarded as surgical timidity.
Endorectal ultrasound in rectal cancer
Authors: Hünerbein M.
Published: August 2003

Accurate staging of rectal carcinoma is crucial for planning surgery and the indication for adjuvant therapy. Although computed tomography and magnetic resonance imaging are very sensitive in the detection metastastic disease, local staging of rectal cancer with these techniques has been disappointing.

Endorectal ultrasound (EUS) remains the most accurate method for staging of rectal cancer. High accuracy rates in the assessment of the depth of infiltration (T stage) (80–90%) and in the determination of the lymph node status (70–80%) have been confirmed in several studies. Continued research and development has made the instrumentation for EUS more accurate and user‐friendly. New techniques that have contributed significantly to the evolution of EUS include three‐dimensional EUS, high‐frequency miniprobes and transrectal ultrasound‐guided biopsy techniques. Further improvement can be expected by contrast enhancement with microbubbles and colour Doppler imaging.
FGD‐PET in the follow‐up of recurrent colorectal cancer
Authors: Selvaggi F. , Cuocolo A. , Sciaudone G. , Maurea S. , Giuliani A. , Mainolfi C.
Published: August 2003

Objective  The current methods of detection of recurrent colorectal cancer after surgical treatment are inaccurate using conventional imaging. This study set out to detect early recurrence by means of PET in patients treated surgically for colorectal cancer by curative resection.

Methods  Thirty‐one disease‐free patients were recruited and underwent FDG‐PET. The results were verified by clinical, surgical and radiological follow up and/or biopsy to evaluate the accuracy for detecting recurrence.

Results  PET detected 6 sites of increased activity in 5 patients. Three of these underwent surgery. One was false positive with no evident tumour and two underwent an hepatic resection with removal of a homental metastasis. The sensitivity was 100% and specificity 83.3%. Clinical management was altered in two cases (6.4%).

Conclusions  This study demostrates that PET is more accurate than conventional imaging for the evaluation of recurrence in colorectal cancer patients. FDG‐PET should be considered in the follow‐up of patients after treatment for colorectal cancer in addition to other imaging methods.
MRI in rectal cancer: the T stage and circumferential resection margin
Authors: Beets‐Tan R. G. H.
Published: August 2003

Different stages of rectal cancer show differing degrees of risk for local recurrence. Paramount for the selection and differentiated treatment of the different risk groups is a reliable preoperative test that can distinguish between these subgroups. There is recent evidence suggesting that MRI can serve for this purpose, because it accurately predicts the circumferential resection margin. In this article the role of MRI in the preoperative management of rectal cancer patients will be discussed.
Palliative therapy of colorectal carcinoma: stent or surgery?
Authors: Bhardwaj R. , Parker M. C.
Published: August 2003

“Surgical” palliation of obstructing colorectal carcinomas may involve resection with or without stoma formation, formation of a stoma alone, a colonic bypass procedure, or no procedure at all. Palliative surgical procedures confer a significant morbidity and mortality. Factors associated with increased mortality for colorectal cancer include advancing age of patient, advancing stage of the disease and the necessity for an emergency procedure. Advanced obstructing malignant lesions pose a clinical dilemma as the risks and time of recovery from surgery have to be balanced against providing a dignified quality of remaining life. Self expanding metal stents (SEMS) for acutely obstructing advanced colorectal carcinomas provide a cost effective option that avoids surgery in a usually frail group of patients. They can be inserted under sedation, rapidly decompress the colon and lead to an early return of colonic function. The procedure is carried out endoscopically with radiological assistance to determine a lumen and to confirm adequate stent placement. SEMS are not suitable for low rectal lesions and are more difficult to place in those that traverse colonic flexures. Complications from successful SEMS placement include migration and stent occlusion. The morbidity associated with SEMS is associated with migration or perforation of the colon during placement, pain and less commonly haemorrhage. Despite these problems most patients can be successfully decompressed without further endoscopic or surgical reintervention and allow satisfactory palliation.
How to treat the persistent perineal sinus after rectal excision
Authors: Pemberton J. H.
Published: August 2003

As surgery for more advanced and complex pelvic malignancies continues to expand to include larger and more exenterative techniques, dealing with the resulting pelvic and perineal defect has become an increasingly frequent necessity. The goal is both to close the defect and to accomplish complete healing. Methodology for managing the perineal wound, which results after proctocolectomy for cancer and more recently, after exenterative resection of the rectum, sacrum, uterus, vagina, bladder and larger areas of soft tissue (i.e. perineum), varies between simple closure on one hand and creation of complex gluteal and rectus abdominus flaps on the other. We examined these methodologies in terms of indications, technical details, complications and outcomes. Finally, the newest techniques for eliminating persistent perineal sinus tracts are detailed.
Technical and oncological feasibility of laparoscopic total mesorectal excision with pouch coloanal anastomosis for rectal cancer
Authors: Bretagnol F. , Rullier E. , Couderc P. , Rullier A. , Saric J.
Published: August 2003

Aim  The aim of this study was to evaluate the technical and oncological feasibility of laparoscopic total mesorectal excision (TME) with coloanal anastomosis for mid and low rectal cancer.

Methods  During a 2‐year period, 50 patients underwent laparoscopic TME with coloanal anastomosis for rectal carcinoma located at a median of 4.5 (range 2–11) cm from the anal verge. Pre‐operative radiotherapy was used in 46 patients. Intersphincteric dissection was combined with the laparoscopic procedure to achieve sphincter preservation.

Results  Conversion to a laparotomy was necessary in six patients. Postoperative mortality and morbidity were 2% and 28%, respectively. Morbidity was lower in patients operated on during the second part of the study, who had extraction of the rectal specimen through a small laparotomy incision, than in those operated on during the first part of the study when removal of the specimen was by transanal extraction. Oncological quality of excision was safe in 44 patients with intact or almost intact rectal fascia in 88% and R0 resection in 90%. At a median follow‐up of 18 months, there was no local or port‐site recurrence.

Conclusion  This study confirms our preliminary results of oncological feasibility of laparoscopic TME with sphincter preservation for mid and low rectal cancer, and showed that morbidity can be decreased by using a standardized surgical procedure.
Treatment of T4 tumours: the role of radiotherapy
Authors: Sebag‐Montefiore David
Published: August 2003

Patients with T4 rectal cancer may be increasingly defined by the use of pelvic MRI. This approach has the potential to classify patients who have tumour extending beyond the mesorectal fascia and those very close to but not beyond the mesorectal fascia (for example 1–2 mm). Prospective studies of MRI are required to validate such an approach.

It is important that the full extent of local disease is defined prior to the commencement of radiation. Assessment after radiation is much more difficult. Even if tumour regression has occurred, if invasion of another organ was originally present, then surgical removal is required as only a small minority of patients will have a histopathologically complete response after CRT.

Many investigators are developing improved CRT regimens that integrate either oxaliplatin or irinotecan with a fluoropyrimidines and radiation. There are two choices that allow intensification of pre‐operative radiation. One approach is to escalate the dose of radiation and the other is to exploit the interaction between chemotherapy and radiation by adding more chemotherapy during the period of irradiation. Current interest predominantly is focused on the latter approach. Future studies are likely to assess agents directed against molecular targets. Careful consideration is required to define the best end points for successful pre‐operative chemo‐radiation leading to surgical excision.
Isolated chemotherapeutic perfusion of the pelvis for advanced rectal cancer
Authors: Wanebo H. J. , Belliveau J. , Begossi G. , Levy A.
Published: August 2003

Objective  Isolated pelvic perfusion exposes tissue to high doses of drug without the toxicity of high‐dose systemic therapy and may benefit patients with advanced malignancy.

Patients and methods  There were 32 patients with locally advanced, previously irradiated cancer of the rectum and 5 patients with anal canal cancer. These patients underwent a total of 65 isolated pelvic perfusions using 5‐Fu (1500 mg/m2) for 60 min; cisplatinum (100 mg/m2) and mitomycin (10–20 mg/m2) were added to some perfusions. Hospital stay averaged 3–5 days.

Results  Palliative perfusion in 15 patients with advanced rectal cancer resulted in symptomatic relief from 1 to 4 months in 11 of 14 with pelvic pain and limited benefit in 6 patients with mass, but no pain. Pre‐operative perfusion in 16 rectal cancer patients achieved a complete response (no tumour in pelvis) in 1 patient and significant tumour regression in 8 patients rendering them potentially resectable. Five were resected with clear margins. Three patients with recurrent epidermoid cancer had significant tumour regression and were resected with clear margins.

Conclusion  Isolated chemotherapeutic perfusion of the pelvis provides excellent palliation for patients with advanced or pelvic recurrence of rectal cancer or epidermoid cancer of anorectum and may potentiate resection in selected patients.
Transverse coloplasty pouch and colonic J‐pouch for rectal cancer – a comparative study
Authors: Pimentel J. M. , Duarte A. , Gregório C. , Souto P. , Patrício J.
Published: August 2003

Objectives  The introduction of the colonic J‐pouch has markedly improved the functional outcome of restorative rectal cancer surgery. However colonic J‐pouch surgery can be problematic and may present some late evacuatory problems. To overcome these limitations a novel pouch has been proposed: the transverse coloplasty pouch. The purpose of our study was to compare the functional outcomes of these two different types of pouches – the transverse coloplasty pouch (TCP) and the colonic J‐pouch (CJP) – during the first 12 months postoperatively.

Patients and methods  A prospective randomized trial was conducted in which a total of 30 patients with mid and low rectal cancer were submitted either to a transverse coloplasty pouch or a colonic J‐pouch. Clinical defaecatory function was assessed and anorectal physiological assessment was carried out, pre‐operatively and at 3, 6 and 12 months postoperatively, by means of a standard clinical questionnaire and by anorectal manometry.

Results  No statistically significant differences were found between the two groups regarding bowel function. The postoperative frequency of daily bowel movements was lower in the TCP group in all the phases of the study (3.9 vs. 4.1 at 3 months; 3.1 vs. 3.4 at 6 months; 2.1 vs. 2.8 at 12 months), the same occurring with fragmentation (33%vs. 40% at 3 months; 26.6%vs. 33.3% at 6 months; 7.1%vs. 14.3% at 12 months). Less urgency was also seen in the TCP group during the first 6 months (20%vs. 26.7%), with identical values at 12 months (14.3%vs. 14.3%). No significant differences were also found concerning incontinence grading and scoring, with TCP patients having less nocturnal leaks. At one year two CJP patients (14.3%) needs the use of enemas to evacuate the pouch and provoke defaecation, a problem never seen in TCP patients. The anorectal manometry data was similar in both types of pouches. The local complication rates were also identical in the two groups (20%); more anastomotic leaks were seen in TCP patients (13.2%vs. 6.6%), without reaching a statistical significance.

Conclusion  The transverse coloplasty pouch has similar functional results but fewer evacuation problems than the J‐Pouch, making it a safe and reliable alternative to the colonic J‐pouch.
Can neoadjuvant radiochemotherapy improve the results of multivisceral resections in advanced rectal carcinoma (cT4a)
Authors: Göhl J. , Merkel S. , Rödel C. , Hohenberger W.
Published: August 2003

Objective  To investigate the influence of neoadjuvant radiochemotherapy (nRCT) in advanced rectal carcinoma (cT4a), the prospectively collected data of all patients treated by extended multivisceral resections during the last 16 years were analysed.

Methods  Between 1985 and 2000, 113 patients with clinical T4a rectal carcinoma (invasion of adjacent organs or structures), were treated by extended multivisceral surgery. In 1995 nRCT was introduced as a standardized treatment modality in cT4a carcinomas and applied in 32 patients. Six weeks after completion of nRCT, resection was performed. In all patients at least one additional organ was removed because of clinically evident tumour infiltration. In one third of patients (36/113) more than one organ had to be removed.

Results  The rate of curative (R0) resections was 89% (101/113). It was similar in patients with and without nRCT (91 vs. 89%). In 40 (35%) patients histopathological examination could verify tumour invasion in adjacent organs (34% with vs. 36% without nRCT). The 3‐year rate of locoregional recurrence after R0‐resection was 12.7%. In multivariate Cox regression analysis the regional lymph node status was the most important prognostic factor (relative risk 5.8, P = 0.007). Neoadjuvant or adjuvant treatment reduced the risk by factor 0.4 (P = 0.211). The 3‐year cancer‐related survival rate of all patients with curative resection was 72.9%. It was 89.4% in the series treated with nRCT, while it was only 66.7% in patients with neither neoadjuvant nor adjuvant therapy. The relative risk for patients with lymph node metastases was 7.0 (P < 0.001) while it was only 0.2 in patients treated with nRCT (P = 0.049).

Conclusions  Together with curative extended multivisceral resection nRCT can improve prognosis in patients with advanced rectal carcinoma (cT4a).
Comparison of CT and MRI in the pre‐operative staging of rectal adenocarcinoma and prediction of circumferential resection margin involvement by MRI
Authors: Mathur P. , Smith J. J. , Ramsey C. , Owen M. , Thorpe A. , Karim S. , Burke C. , Ramesh S. , Dawson P. M.
Published: August 2003

Objective  It has been suggested that MRI may be used as the sole modality of choice in pre‐operative staging in rectal cancers. Knowledge of tumour stage and a threatened Circumferential Resection Margin (CRM) pre‐operatively are essential for planning neo‐adjuvant therapy and as predictors of local recurrence. At present most units utilize CT scanning to assess these parameters. The aim of our study was two fold: firstly to examine the accuracy of preop CT and MRI staging of rectal cancers compared with final histology and secondly to assess the accuracy of MRI in predicting penetration of the mesorectal envelope (ME).

Patients and methods  All patients with biopsy proven rectal adenocarcinoma underwent thin slice MRI and CT scan pre‐operatively. Forty‐seven patients have been prospectively entered into the study: 24 male (median age 68 years; range 38–91 years). Eleven patients were unsuitable for surgery leaving 36 patients available for study.

Results  CT correctly staged patients with T1/T2 rectal cancers more often than MRI (77%vs. 43%, P = 0.226). Patients with T1/T2 tumours were overstaged more often by MRI compared with CT (54%vs. 23%, P = 0.226). A greater proportion of patients with T3 tumours were correctly staged by MRI than CT (76%vs. 41%, P = 0.08); and more T3 disease was understaged by CT than MRI (54 vs. 18%, P = 0.032). CT and MRI staged T4 disease equally. In the assessment of mesorectal envelope integrity, MRI had a sensitivity of 80% and a specificity of 84%. The positive predictive value was 44% and the negative predictive value 96%.

Conclusions  These results suggest significant differences between accurate pre‐operative ‘T’ staging by CT and MRI for rectal cancer. MRI has the potential however, to accurately assess mesorectal envelope invasion. Further analysis is required to assess whether MRI can be used as the sole modality in pre‐operative staging of rectal cancers.
Rectal resection with low anastomosis: functional outcome
Authors: Matzel K. E. , Bittorf B. , Günther K. , Stadelmaier U. , Hohenberger W.
Published: August 2003

Objective  Function after anterior, low anterior and intersphincteric resection for rectal cancer was studied.

Method  Of 139 patients 122 responded to a standardized questionnaire (Cleveland Clinic Continence Score) 108 ± 46 weeks postoperatively and 70 underwent anorectal manometry at 26 ± 15 weeks.

Results  The postoperative continence score was dependent on the procedure (anterior resection 4.1 ± 4.6, low anterior resection 6.9 ± 5.6, intersphincteric resection 11.5 ± 5.2; P < 0.0001). It was poorer after radiochemotherapy (9.0 vs. 5.7; P = 0.030), but after colonic pouch reconstruction there was no significant difference between low anterior resection (5.6 vs. 7.3) and intersphincteric resection (10.0 vs. 12.5). Mean and maximal resting pressures were significantly reduced after intersphincteric resection (24 ± 9 and 40 ± 13 mmHg, respectively, P < 0.001) and further reduced by radiochemotherapy. Squeeze pressure was unaffected by the operative procedures and radiochemotherapy. Maximum tolerable volume and rectal compliance were reduced, after both low anterior and intersphincteric resection. Statistical correlation between continence score and maximal resting pressure (P = 0.014), mean resting pressure (P = 0.002), urge volume (P = 0.037), and neorectal compliance (P = 0.0018) reached significance. Satisfaction with the functional outcome was expressed by 71% of patients.

Conclusion  After rectal resection the degree of impaired continence depended on the operative procedure and the form of reestablishment of intestinal continuity. Radiochemotherapy affected the outcome adversely. Despite reduced function, overall patient satisfaction was high.
The consumer monoculture
Authors: Norberg‐Hodge Helena
Published: August 2003

‘Development’ and the globalization of consumption is leading to a breakdown of biological and cultural diversity, erosion of food security, an increase in violence and devastation for the global biosphere. We urgently need to shift away from economic globalization and homogenization towards localization and diversification.
Localization – an alternative to corporate‐led globalization
Authors: Lucas Caroline
Published: August 2003

In the aftermath of 11 September, there has been a growing recognition that an increasingly unequal world is not only morally unacceptable but also deeply insecure. This paper defines globalization as economic, corporate‐led globalization, a process that impacts every facet of our life. For illustrative purposes, this paper will briefly examine the role played by the globalization process in exacerbating the gap between rich and poor. It will make the case that, contrary to popular wisdom, there is nothing inevitable about this process. One such alternative is localization – a set of interrelated and self‐reinforcing policies that actively discriminate in favour of the more local, whenever it is feasible and reasonable.
Biotechnology in the agricultural sector: a challenge to consumer welfare
Authors: Smith David E. , Skalnik J. Robert
Published: August 2003

The promises and pitfalls of agricultural biotechnology have long been debated. The public is often thwarted because consumers frequently perceive as risky, and therefore undesirable, those advances that they do not understand or of which they are unaware. A comparative study of the introduction of a biotechnology innovation in the United States (US) and in the European Union (EU) is a case in point. In the US, despite concerns of consumer protection and environmental groups that the use of genetically produced growth hormone in milk‐producing cows will adversely impact the safety of the milk supply, scientific evidence and governmental findings appear to indicate that milk from treated cows is identical in quality, taste and nutritional value to milk from untreated cows. Experience to date in the US demonstrates some consumer resistance to milk from those cows that have received the growth hormone, which typically leads to a 10% increase in milk production. In fact, if there is no perceived differentiation between the two forms of milk, the issue offers little choice to consumers at large, and may result in economic benefit only to selected dairy farmers, as well as the producers of the genetically produced growth hormone. This situation in the US is an example of dysfunctional technology transfer, with perceived desirable benefits to a few, and perceived undesirable benefits to society‐at‐large. The information suggests that the US may have reacted hastily in approving the use of bovine growth hormone in milk‐producing cows. The EU has taken a divergent approach by enacting moratoriums against its use. The differences identified in this study, contrasting responses to the bovine somatotrophin issue in the US and EU – driven in part by general consumer attitudes towards biotechnology – may provide insights into the issues and challenges that will be faced by both advocates and opponents of global proliferation of certain advances in biotechnology.
A comparative analysis of patients’ rights: an international perspective
Authors: Rider Mary Ellen , Makela Carole J.
Published: August 2003

Consumer rights are used as a framework comparing the patients’ rights of selected countries. Patients’ right documents of geographically dispersed countries, regional coalitions and international organizations were selected for analysis and comparison reflecting health and consumer policy. The content of patients’ rights policies, including populations addressed, basic consumer rights, dignity and privacy or confidentiality were analysed. The inclusion of consumer responsibilities and enforcement of patients’ rights was evaluated. Countries used comprehensive laws and charters to address patients’ rights. The consumer rights most often noted in the patients’ rights analysed were the rights to information, choice and redress. Five countries lacked inclusion of consumer responsibilities and the responsibility for enforcement. Suggestions for action on the part of family and consumer educators and scientists were offered.
Understanding the factors related to concerns over generically engineered food products: are national differences real?
Authors: Kolodinsky Jane , DeSisto Thomas Patrick , Labrecque Joanne
Published: August 2003

Along with the rapid introduction of genetically engineered (GE) foods into the marketplace have come concerns about possible risks associated with this new technology. This study expands on previous research by exploring the relationships between certain sociodemographic, attitudinal and behavioural variables and North American college students’ levels of concern over GE foods. Six index scales are created from the data and a series of anovas are conducted, and displayed visually using bar graphs, to examine the relationships between the explanatory variable and the students’ levels of concern. The findings indicate that attitudinal and behavioural variables should be included in future models for predicting levels of concern for GE foods in addition to the sociodemographic variables currently used.
Family meals and disparities in global ecosystem dependency. Three examples: Ghana, Russia and Sweden
Authors: Shanahan Helena , Carlsson‐Kanyama Annika , Offei‐Ansah Christina , Ekström Marianne P. , Potapova Marina
Published: August 2003

This article highlights globalization in terms of dependency on local and global ecosystems when it comes to family diets. In an exploratory case study, one typical meal in three household settings in different parts of the world: Ghana, Russia and Sweden, is examined. Food paths are traced to compare the scale of ecosystem dependency. The result shows that ecosystem dependency varies greatly with implications for environmental impact. The Swedish household, as opposed to the Ghanaian and the Russian, is not dependent on local ecosystems for food provision, but increasingly on global systems. Opportunities and constraints for lowering environmental impacts related to diets in different economies are discussed. It is concluded that it is of great importance to create awareness in high‐income countries of the dependency on the global ecosystem and the resulting environmental impacts. It is in these countries that opportunities are available for change towards more sustainable diets. It is suggested that further research need to explore in greater depth how ecosystem dependency differs and how that translates into broad spectra of environmental impacts, considering other dimensions of sustainable development as well.
Changes in food provision in Russian households experiencing perestroika
Authors: Ekström Karin M. , Ekström Marianne P. , Potapova Marina , Shanahan Helena
Published: August 2003

The purpose of this article is to describe how households in Novgorod the Great, Russia, deal with food provision in everyday life. The study focuses on changes experienced in food provision and consumption in Russian society, in order to illustrate how households respond to the transformation towards a market economy. The study reflects women's perspective on food provision. Students from Novgorod the Great visited 105 households and asked the women in the household to answer a questionnaire. Results from the study show that in order to cope with changes in society related to economic reforms, Russian households had changed both their food consumption and food production patterns. There was no big difference between urban and rural households. Nearly all of the households were self‐sufficient in the provision of vegetables and potatoes. Many households had a ‘dacha’ (plot), where they produced most of what they needed. Among the changes experienced during recent years (i.e. during the end of the 1990s), a decade after perestroika was initiated, households mentioned the rise in food prices and the decrease of income. Households reported that they consumed less fruit and/or meat. Some households also mentioned that the quality of nourishment had decreased, thereby indicating lower general quality, lower nutrition value, or less healthy foodstuffs.
Fair Trade and the consumer interest: a personal account
Authors: Gould Nicholas J.
Published: August 2003

Abject poverty and rampant consumerism are twin ills of global capitalism. This short paper serves to encourage discussion on the role of Fair Trade in healing those ills. After describing the benefits of Fair Trade for producers, a paradox concerning the joys and blights of contemporary consumption is presented. Drawing on an autoethnographic method, the author indicates how Fair Trade resolves this paradox in the consumer interest.
From the margins: globalization with(out) home economics
Authors: Pendergast Donna
Published: August 2003

Pies and peas, noughts and crosses, fish and chips, chicken and egg, teaching and learning, home economics and . . .  globalization? In psychotherapy, this simple technique of providing a word and another automatically coming to mind is called free association and some of the internationally accepted pairings are noted above. Do we want ‘home economics’ and ‘globalization’ to have an automatic association? In this paper, I argue that home economics must make a shift from the margins of patriarchy by re‐thinking the ways in which the field is legitimized and positioned if it is to be a key player in taking on the challenges and dilemmas raised by globalization.
Bringing a perspective of transformative learning to globalized consumption
Authors: O'Sullivan Edmund
Published: August 2003

This article examines the development of market‐driven values and the creation of consumer‐driven lifestyles. It critically examines the effect of market globalization and its creation of negative quality of life indicators. Several resistance movements are given as examples as to how market values are challenged. The movement away from market desires involves a deep change in perspective which is identified as transformative learning.
Food or ‘virtual’ food? The construction of children's food in a global economy
Authors: Coakley Anne
Published: August 2003

This paper explores the pattern of change and development in the marketization and reconstitution of food products for children. It is in the past few decades that global corporations’ search for new markets has come to focus intensely on children. In the eyes of global corporations, children are a huge, multibillion dollar market. Childhood may be understood as a social construction but its form is historically specific. At present, the market is defining and reconstituting cultural meanings of childhood without being contested by other significant groups in society. The paper goes on to explore how transnational corporations have transformed the production and marketing of food. The paper discusses the food risks and the challenges faced by the fast food industry which specifically targets children. The reconstitution and the rebranding of popular children's food is producing ‘virtual’ food rather than real food. We live in an era where childhood offers untold opportunities in the northern hemisphere. However, the global market has come to dominate and define the social construction of childhood. Other cultural forms of identity outside of consumerism are not making the same impression. The food risks associated with the global processing of food and the health risks that have been linked to these new food forms ultimately has consequences not only for children but for society as a whole.
Localization: A Global Manifesto
Authors: McGregor Sue
Published: August 2003

Localization: A Global Manifesto. Ed. by Colin Hines (2000). London. Published by Earthscan Publishing. ISBN 1‐85383‐612‐5 (softcover). In Canada, the book is available from http://www.renoufbooks.com for Can$29.00. In the UK, the book is available at http://www.earthscan.co.uk for £10.99 or earthinfo@earthscan.co.uk
Standardized Quality‐Assessment System to Evaluate Pressure Ulcer Care in the Nursing Home
Authors: Bates‐Jensen Barbara M. , Cadogan Mary , Jorge Jennifer , Schnelle John F.
Published: August 2003

Objectives: To demonstrate reliability and feasibility of a standardized protocol to assess and score quality indicators relevant to pressure ulcer (PU) care processes in nursing homes (NHs).

Design: Descriptive.

Setting: Eight NHs.

Participants: One hundred ninety‐one NH residents for whom the PU Resident Assessment Protocol of the Minimum Data Set was initiated.

Measurements: Nine quality indicators (two related to screening and prevention of PU, two focused on assessment, and five addressing management) were scored using medical record data, direct human observation, and wireless thigh monitor observation data. Feasibility and reliability of medical record, observation, and thigh monitor protocols were determined.

Results: The percentage of participants who passed each of the indicators, indicating care consistent with practice guidelines, ranged from 0% to 98% across all indicators. In general, participants in NHs passed fewer indicators and had more problems with medical record accuracy before a PU was detected (screening/prevention indicators) than they did once an ulcer was documented (assessment and management indicators). Reliability of the medical record protocol showed kappa statistics ranging from 0.689 to 1.00 and percentage agreement from 80% to 100%. Direct observation protocols yielded kappa statistics of 0.979 and 0.928. Thigh monitor protocols showed kappa statistics ranging from 0.609 to 0.842. Training was variable, with the observation protocol requiring 1 to 2 hours, medical records requiring joint review of 20 charts with average time to complete the review of 20 minutes, and the thigh monitor data requiring 1 week for training in data preparation and interpretation.

Conclusion: The standardized quality assessment system generated scores for nine PU quality indicators with good reliability and provided explicit scoring rules that permit reproducible conclusions about PU care. The focus of the indicators on care processes that are under the control of NH staff made the protocol useful for external survey and internal quality improvement purposes, and the thigh monitor observational technology provided a method for monitoring repositioning care processes that were otherwise difficult to monitor and manage.
The Minimum Data Set Pressure Ulcer Indicator: Does It Reflect Differences in Care Processes Related to Pressure Ulcer Prevention and Treatment in Nursing Homes?
Authors: Bates‐Jensen Barbara M. , Cadogan Mary , Osterweil Dan , Levy‐Storms Lené , Jorge Jennifer , Al‐Samarrai Nahla , Grbic Valena , Schnelle John F.
Published: August 2003

Objectives: To determine whether nursing homes (NHs) that score in the extreme quartiles of pressure ulcer (PU) prevalence as reported on the Minimum Data Set (MDS) PU quality indicator provide different PU care.

Design: Descriptive, cohort.

Setting: Sixteen NHs.

Participants: Three hundred twenty‐nine NH residents at risk for PU development as determined by the PU Resident Assessment Protocol of the MDS.

Measurements: Sixteen care process quality indicators (10 specific to PU care processes, five related to nutrition, and one related to incontinence management) were scored using medical record data, direct human observation, interviews, and data from wireless thigh movement monitors.

Results: There were no differences between homes with low‐ and high‐PU prevalence rates reported on the MDS PU quality indicator on most care processes. NHs with high PU prevalence rates used pressure‐reduction surfaces more frequently and were better at documentation of four wound characteristics when PUs were present. No measure of PU care processes was better in low‐PU NHs. Neither low‐ nor high‐PU prevalence NHs routinely repositioned residents every 2 hours, even though 2‐hour repositioning was documented in the medical record for nearly all residents.

Conclusion: The assumption that homes with fewer PUs and thus low PU prevalence according to the MDS PU quality indicator are providing better PU care was not supported in this sample. NHs that scored low on the MDS PU quality indicator did not provide significantly better care than NHs that scored high. All NHs could improve PU prevention, as evidenced by the poor performance on prevention care processes by low‐ and high‐PU NHs. The MDS PU quality indicator is not a useful measure of the quality of PU care in NHs and can be misleading if not presented with an explanation of the meaning of the indicator.
Dementia as a Risk Factor for Falls and Fall Injuries Among Nursing Home Residents
Authors: Van Doorn Carol , Gruber‐Baldini Ann L. , Zimmerman Sheryl , Richard Hebel J. , Port Cynthia L. , Baumgarten Mona , Quinn Charlene C. , Taler George , May Conrad , Magaziner Jay ,   for the Epidemiology of Dementia in Nursing Homes Research Group
Published: August 2003

Objectives: To compare rates of falling between nursing home residents with and without dementia and to examine dementia as an independent risk factor for falls and fall injuries.

Design: Prospective cohort study with 2 years of follow‐up.

Setting: Fifty‐nine randomly selected nursing homes in Maryland, stratified by geographic region and facility size.

Participants: Two thousand fifteen newly admitted residents aged 65 and older.

Measurements: During 2 years after nursing home admission, fall data were collected from nursing home charts and hospital discharge summaries.

Results: The unadjusted fall rate for residents in the nursing home with dementia was 4.05 per year, compared with 2.33 falls per year for residents without dementia (P<.0001). The effect of dementia on the rate of falling persisted when known risk factors were taken into account. Among fall events, those occurring to residents with dementia were no more likely to result in injury than falls of residents without dementia, but, given the markedly higher rates of falling by residents with dementia, their rate of injurious falls was higher than for residents without dementia.

Conclusion: Dementia is an independent risk factor for falling. Although most falls do not result in injury, the fact that residents with dementia fall more often than their counterparts without dementia leaves them with a higher overall risk of sustaining injurious falls over time. Nursing home residents with dementia should be considered important candidates for fall‐prevention and fall‐injury‐prevention strategies.