Constipation Scoring System to Portuguese language in assessing severity of intestinal chronic constipation

Introdução: A constipação intestinal crônica está entre os distúrbios gastrointestinais mais frequentes na prática clínica geral. Em nosso meio há escassez de índices específicos e validados para a avaliação da sua gravidade. O escore escolhido, Constipation Scoring System, é instrumento validado e difundido mundialmente. Objetivo: Validar o instrumento Constipation Scoring System para a avaliação da gravidade da constipação intestinal em pacientes do nosso meio. Métodos: A validação seguiu as seguintes etapas: tradução, adaptação cultural e validação propriamente dita (confiabilidade e validação convergente e divergente). A versão definitiva para a língua portuguesa falada no Brasil foi obtida a partir da tradução da versão original e avaliação por especialistas da versão consensual e de suas traduções reversas. A adaptação cultural consistiu na avaliação do conteúdo do índice pela aplicação da versão definitiva do instrumento por meio de entrevista a pacientes constipados. A confiabilidade interobservador foi obtida pela comparação da aplicação da versão definitiva por dois pesquisadores no mesmo dia, e a confiabilidade intraobservador, na comparação dos resultados de duas entrevistas pelo mesmo pesquisador em tempos diferentes, com intervalo de 7 dias. Na validação divergente: a entrevista foi realizada com voluntários não-constipados. Finalmente, prosseguiu-se com a validação convergente de dois grupos de pacientes, os com boa resposta ao tratamento clínico e os refratários ao tratamento. Resultados: A versão definitiva do instrumento foi aplicada na etapa de adaptação cultural a 81 pacientes, sendo 73 (89%) do sexo feminino. A média de idade foi de 55 (+14) anos e a escolaridade foi de 7(±5) anos; o índice de validade de conteúdo global foi de 96,5%. O estudo da confiabilidade inter e intraobservador incluiu 60 pacientes, sendo 52 (86,7%) do sexo feminino, com média de idade de 56 (+16) anos e a escolaridade de 6 (±5) anos. O coeficiente de correlação intraclasse para a avaliação interobservadores foi 0,991 e a intraobservador foi 0,987, ambos com p<0,001. Na validação divergente de 40 voluntários, 25 (62,5%) eram do sexo masculino, com média de idade de 49 (±20) anos; a pontuação global média foi 0 (+2). Na validação convergente dos pacientes com boa resposta do tratamento clínico foram avaliados 47 pacientes, sendo 39 (83%) do sexo feminino, com média de idade de 60 (±16) anos e escolaridade de 6 (±5) anos. Os Índice pré e pós-tratamento foram 19 (±3) e 8 (±3), respectivamente (p<0,001). Na validação convergente dos pacientes refratários ao tratamento clínico, 75 pacientes foram entrevistados, sendo 70 do sexo feminino (93%), com média de idade de 53 (±13) anos, escolaridade de 7 (±5) anos. A pontuação média foi de 22 (±3). A comparação entre a pontuação média da validação divergente e da validação dos pacientes refratários ao tratamento clínico demonstra a sensibilidade e a acurácia do índice na aferição dos extremos clínicos os assintomáticos e os pacientes com sintomas mais graves. Conclusão: O Constipation Scoring System, traduzido para a língua portuguesa do Brasil, adaptado e validado para sua população, é instrumento confiável para a aferição da gravidade da constipação intestinal crônicaIntroduction: Chronic constipation is one of the most common gastrointestinal complaints in everyday clinical practice. There is a lack of valid and specific tools to measure its severity in Portuguese spoken in Brazil. The Constipation Scoring System is a worldwide spread and valid score to measure constipation severity. Objective: To validate the Constipation Scoring System to Brazilian spoken Portuguese in order to assess severity of symptoms of chronic idiopathic constipation. Methods: This validation comprised the following steps: translation, cultural adaptation and validation itself (reliability and convergent and divergent validation). The definitive version for Portuguese language spoken in Brazil was obtained from the original version translation and evaluation by specialists of the consensus version and its reverse translations. Cultural adaptation consisted of score content analysis by applying the definitive version, as an interview, to chronic constipated patients. Interobserver validity was obtained by comparing the definitive version application by two researchers on the same day, and the intraobserver reliability, by comparing the results of two interviews by the same researcher at different times, with an interval of 7 days. In divergent validation the interview was performed with non-constipated volunteers. Finally, convergent validation was proceeded with two groups of patients, those with good response to clinical treatment and those refractory to this treatment. Results: The definitive version was applied in the cultural adaptation step to 81 patients, 73 (89%) of whom were female. Mean age was 55 (±14) years and schooling was 7 (±5) years; the overall content validity index was 96.5%. The inter and intraobserver reliability analysis included 60 patients, 52 (86.7%) female, with a mean age of 56 (±16) years and schooling of 6 (±5) years. The intraclass correlation coefficient for the interobserver assessment was 0.991 and for the intraobserver was 0.987, both with p<0.001. In the divergent validation of 40 volunteers, 25 (62.5%) were male, with a mean age of 49 (±20) years; the mean global score was 0 (+2). In the convergent validation of patients with good response to clinical treatment, 47 patients were evaluated, 39 (83%) female, with a mean age of 60 (±16) years and schooling of 6 (±5) years. Pre-treatment and post-treatment scores were 19 (± 3) and 8 (±3), respectively (p<0.001). In the convergent validation of patients refractory to clinical treatment, 75 patients were interviewed, 70 female (93.3%), with a mean age of 53 (±13) years and schooling of 7 (±5) years. Global average score was 22 (±3). Comparison between average scores from divergent validation and convergent validation of refractory patients to clinical treatment demonstrates the sensitivity and accuracy of the index in measuring the clinical extremes - asymptomatic people and patients with more severe symptoms. Conclusion: Constipation Scoring System translated to Brazilian spoken Portuguese, adapted and validated to its population, is a reliable instrument for measuring the severity of intestinal chronic constipatio

Analysis of direct costs of anesthesia-related materials between spinal and venous anesthesia with propofol associated with local perianal block in hemorrhoidectomy

There is no consensus on the ideal anesthesia for hemorrhoidectomy in ambulatory facilities. Spinal anesthesia and venous propofol associated with local perianal block (combined anesthesia) are frequently used, and their direct costs may be crucial for the anesthesia type selection. The objective of this study was to compare the direct costs of anesthesia-related materials in hemorrhoidectomy between these two anesthetic techniques.Retrospective and cross-section analysis, comparing the direct costs of the materials of spinal and venous anesthesia with propofol associated with local perianal block, in hemorrhoidectomy. Twenty patients were included, ten submitted to each anesthesia type (five from each gender). The mean age in the spinal anesthesia group was 46.5 years and in the combined anesthesia group, 42.5 years (p=0.334). The mean cost of anesthesia-related materials was R$58.50 (R$ 36.48 - R$85.79) in the first group versus R$ 190.31 (R$98.16 - R$ 358.51) in the second - 69.27% difference between them (p<0.001). The mean costs according to gender analysis were R$50.32 and R$ 66.69 (p=0.263) in the spinal anesthesia group versus R$222.52 and R$ 158.10 (p=0.221) in the combined anesthesia group, respectively. The direct costs of anesthesia-related materials were significantly lower in patients submitted to hemorrhoidectomy using spinal anesthesia. No difference was observed between the genders in each group analyzed

IS THE PHYSICIAN EXPERTISE IN DIGITAL RECTAL EXAMINATION OF VALUE IN DETECTING ANAL TONE IN COMPARISON TO ANORECTAL MANOMETRY?

ABSTRACT BACKGROUND: Digital rectal examination (DRE) is part of the physical examination, is also essential for the colorectal surgeon evaluation. A good DRE offers precious information related to the patient’s complaints, which will help in decision making. It is simple, quick and minimally invasive. In many centers around the world, the DRE is still the only method to evaluate the anal sphincter prior to patient’s management. On the other hand, anorectal manometry (ARM) is the main method for objective functional evaluation of anal sphincter pressures. The discrepancy of DRE depending on the examiner to determine sphincter tonus in comparison to ARM motivated this study. OBJECTIVE: To compare the DRE performed by proficient and non-experienced examiners to sphincter pressure parameters obtained at ARM, depending on examiners expertise. METHODS: Thirty-six consecutive patients with complaints of fecal incontinence or chronic constipation, from the anorectal physiology clinic of the University of São Paulo School of Medicine, were prospectively included. Each patient underwent ARM and DRE performed by two senior colorectal surgeons and one junior colorectal surgeon prior to the ARM. Patient’s history was blinded for the examiner’s knowledge, also the impressions of each examiner were blinded from the others. For the DRE rest and squeeze pressures were classified by an objective scale (DRE scoring system) that was compared to the parameters of the ARM for the analysis. The results obtained at the ARM were compared to the DRE performed by the seniors and the junior colorectal surgeons. STATISTICAL ANALYSIS: Descriptive analysis was performed for all parameters. For the rest and squeeze pressures the Gamma index was used for the comparison between the DRE and ARM, which varied from 0 to 1. The closer to 1 the better was the agreement. RESULTS: The mean age was 48 years old and 55.5% of patients were female. The agreement of rest anal pressures between the ARM and the DRE performed by the senior proficient examiners was 0.7 (CI 95%; 0.32-1.0), while for the junior non-experienced examiner was 0.52 (CI 95%; 0.09-0.96). The agreement of squeeze pressures was 0.96 (CI 95%; 0.87-1.0) for the seniors and 0.52 (CI 95%; 0.16-0.89) for the junior examiner. CONCLUSION: More experienced colorectal surgeons used to DRE had a more significant agreement with the ARM, thereafter would have more appropriate therapeutic management to patients with sphincter functional problems. ARM, therefore, persists as an important exam to objectively evaluate the sphincter complex, justifying its utility in the clinical practice

Delayed colorectal cancer care during covid-19 pandemic (decor-19). Global perspective from an international survey

Background The widespread nature of coronavirus disease 2019 (COVID-19) has been unprecedented. We sought to analyze its global impact with a survey on colorectal cancer (CRC) care during the pandemic. Methods The impact of COVID-19 on preoperative assessment, elective surgery, and postoperative management of CRC patients was explored by a 35-item survey, which was distributed worldwide to members of surgical societies with an interest in CRC care. Respondents were divided into two comparator groups: 1) ‘delay’ group: CRC care affected by the pandemic; 2) ‘no delay’ group: unaltered CRC practice. Results A total of 1,051 respondents from 84 countries completed the survey. No substantial differences in demographics were found between the ‘delay’ (745, 70.9%) and ‘no delay’ (306, 29.1%) groups. Suspension of multidisciplinary team meetings, staff members quarantined or relocated to COVID-19 units, units fully dedicated to COVID-19 care, personal protective equipment not readily available were factors significantly associated to delays in endoscopy, radiology, surgery, histopathology and prolonged chemoradiation therapy-to-surgery intervals. In the ‘delay’ group, 48.9% of respondents reported a change in the initial surgical plan and 26.3% reported a shift from elective to urgent operations. Recovery of CRC care was associated with the status of the outbreak. Practicing in COVID-free units, no change in operative slots and staff members not relocated to COVID-19 units were statistically associated with unaltered CRC care in the ‘no delay’ group, while the geographical distribution was not. Conclusions Global changes in diagnostic and therapeutic CRC practices were evident. Changes were associated with differences in health-care delivery systems, hospital’s preparedness, resources availability, and local COVID-19 prevalence rather than geographical factors. Strategic planning is required to optimize CRC care