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Derivation of ambient water quality criteria for formaldehyde.

This paper describes the derivation of aquatic life water quality criteria for formaldehyde, developed in accordance with United States Environmental Protection Agency's (USEPA's) Guidelines for Deriving Numerical National Water Quality Criteria for the Protection of Aquatic Organisms and Their Uses. The initial step in deriving water quality criteria was to conduct an extensive literature search to assemble available acute and chronic toxicity data for formaldehyde. The literature search identified a large amount of information on acute toxicity of formaldehyde to fish and aquatic invertebrates. These acute data were evaluated with respect to data quality, and poor quality or uncertain data were excluded from the data base. The resulting data base met the USEPA requirements for criteria derivation by having data for at least one species in at least eight different taxonomic families. One shortcoming of the literature-derived data base, however, was that few studies involved analytical confirmation of nominal formaldehyde concentrations and reported toxicity endpoints. Also, there were relatively few data on chronic toxicity. The acute toxicity data set consisted of data for 12 species of fish, 3 species of amphibians, and 11 species of invertebrates. These data were sufficient, according to USEPA guidelines, to calculate a final acute value (FAV) of 9.15 mg/l, and an acute aquatic life water quality criterion (one-half the FAV) of 4.58 mg/l. A final acute-chronic ratio (ACR) was calculated using available chronic toxicity data and USEPA-recommended conservative default assumptions to account for missing data. Using the FAV and the final ACR (5.69), the final chronic aquatic life water quality criterion was determined to be 1.61 mg/l.

Amphibians↗

Studying parents and grandparents to assess genetic contributions to early-onset disease.

Suppose DNA is available from affected individuals, their parents, and their grandparents. Particularly for early-onset diseases, maternally mediated genetic effects can play a role, because the mother determines the prenatal environment. The proposed maximum-likelihood approach for the detection of apparent transmission distortion treats the triad consisting of the affected individual and his or her two parents as the outcome, conditioning on grandparental mating types. Under a null model in which the allele under study does not confer susceptibility, either through linkage or directly, and when there are no maternally mediated genetic effects, conditional probabilities for specific triads are easily derived. A log-linear model permits a likelihood-ratio test (LRT) and allows the estimation of relative penetrances. The proposed approach is robust against genetic population stratification. Missing-data methods permit the inclusion of incomplete families, even if the missing person is the affected grandchild, as is the case when an induced abortion has followed the detection of a malformation. When screening multiple markers, one can begin by genotyping only the grandparents and the affected grandchildren. LRTs based on conditioning on grandparental mating types (i.e., ignoring the parents) have asymptotic relative efficiencies that are typically >150% (per family), compared with tests based on parents. A test for asymmetry in the number of copies carried by maternal versus paternal grandparents yields an LRT specific to maternal effects. One can then genotype the parents for only the genes that passed the initial screen. Conditioning on both the grandparents' and the affected grandchild's genotypes, a third log-linear model captures the remaining information, in an independent LRT for maternal effects.

Age of Onset↗

A comparison of response rate, data quality, and cost in the collection of data on sexual history and personal behaviors. Mail survey approaches and in-person interview.

The authors examined differences in rate of response, data quality, and cost between mail approaches and in-person interview in the collection of data on sexual history and personal behaviors. A sample of women from a midwestern United States university (n = 342) was identified from health service medical records as having been seen for a sexually transmitted disease (cases) or a contraceptive visit (controls) during the latter half of 1985. The women were randomly assigned to one of three data collection strategies. A total of 268 subjects (78%) participated. Results indicated no differences in validity by method of data collection or by case-control status but there were significant differences in completeness, cost, and response rates. In-person interviews resulted in more complete data than mail approaches, although all instruments had low proportions of missing data (0.001-0.006). Response rate differences were not found when data collection methodologies were compared (75-82%) but were found in case-control analyses. Cases were consistently less likely to participate and significantly less likely to respond by mail (p less than 0.05). The cost of the in-person interview was approximately four times that of the mail survey for the data collection. Implications of the case-control response rate difference suggest that mail methodologies, although low in cost, may introduce sampling bias in studies of sexually transmitted diseases.

Adolescent↗

Primary care, infant mortality, and low birth weight in the states of the USA.

STUDY OBJECTIVE: The study tests the extent to which primary care physician supply (office based primary care physicians per 10 000 population) moderates the association between social inequalities and infant mortality and low birth weight throughout the 50 states of the USA. DESIGN: Pooled cross sectional, time series analysis of secondary data. Analyses controlled for state level education, unemployment, racial/ethnic composition, income inequality, and urban/rural differences. Contemporaneous and time lagged covariates were modelled. SETTING: Eleven years (1985-95) of data from 50 US states (final n = 549 because of one missing data point). MAIN RESULTS: Primary care was negatively associated with infant mortality and low birth weight in all multivariate models (p<0.0001). The association was consistent in contemporaneous and time lagged models. Although income inequality was positively associated with low birth weight and infant mortality (p<0.0001), the association with infant mortality disappeared with the addition of sociodemographic covariates. CONCLUSIONS: In US states, an increased supply of primary care practitioners-especially in areas with high levels of social disparities-is negatively associated with infant mortality and low birth weight.

Black or African American↗

Maximum a posteriori estimation with Good's roughness for three-dimensional optical-sectioning microscopy.

The three-dimensional image-reconstruction problem solved here for optical-sectioning microscopy is to estimate the fluorescence intensity lambda(x), where x epsilon R3, given a series of Poisson counting process measurements [Mj(dx)]jJ = 1, each with intensity [formula: see text] with [formula: see text] being the point spread of the optics focused to the jth plane and sj(y) the detection probability for detector point y at focal depth j. A maximum a posteriori reconstruction generated by inducing a prior distribution on the space of images via Good's three-dimensional rotationally invariant roughness penalty [formula: see text] It is proven that the sequence of iterates that is generated by using the expectation maximization algorithm is monotonically increasing in posterior probability, with stable points of the iteration satisfying the necessary maximizer conditions of the maximum a posteriori solution. The algorithms were implemented on the DECmpp-SX, a 64 x 64 parallel processor, running at < 2 s/(64(3), 3-D iteration). Results are demonstrated from simulated as well as amoebae and volvox data. We study performance comparisons of the algorithms for the missing-data problems corresponding to fast data collection for rapid motion studies in which every other focal plane is removed and for imaging with limited detector areas and efficiency.

Algorithms↗

[The role of environmental and epidemiological surveys of ambient pollution in the evaluation of a risk for "acute" mortality].

The paper provides evidence that there is a relationship of daily death rates to variations in the concentrations of total dust and some gaseous ambient pollutants. The great advantage of a procedure to analyze temporary variables is that it makes it possible to retrospectively use the available materials of routine monitoring of air pollution and to consider these effects (cases of death in particular). Along with the high informative value of environmental and epidemiological surveys (EES) based on the analysis of time series, this advantage allows one to recommend them for widely use within the sociohygienic monitoring system. At the same time the paper shows it necessary to control the quality of available data and to chose monitoring centers comparable in this regard. Inevitable missing data on the concentrations of different pollutants on days off and on some working days are of particular value under the actual conditions of monitoring of air pollution. The approach applied in this study to the choice of the most effective ways of filling of such gaps may be recommended. Nevertheless, incomplete data and the need for their artificial reproduction should be regarded as a source of uncertainty of specific results of EES of this type. Increments in mortality rates for a certain increase in the concentrations of pollutants may be used in the risk assessment projects when a dose-response relationship is analyzed. The larger number of EES based on the analysis of time series will be conducted in the regions of Russia, the more reliable the use of EES-grounded single risks will be at the regional and federal level.

Air Pollutants↗

Studies on occupational health: a critique.

A critique of 48 recent articles dealing with occupational health was undertaken by two readers using a set of questions devised to assess adherence to selected methodologic principles concerning data quality. Articles were read independently, responses to assessment questions were discussed and differences between readers reconciled. The greatest inattention to principles was found in the areas of sample size; definition of exposure; description, standardization, and validation of data sources; use of "blind" observers; and the possible effect of missing data on the results. Rigorus attention to these methodologic principles is necessary if the results of studies are to be accepted and applied in the prevention and control of occupational hazards.

Occupational Medicine↗

[Treatment of convulsions in newborn infants].

OBJECTIVE: Measurement of incidence of neonatal seizures and evaluation of the therapeutic strategy used. SETTING: Neonatal intensive care unit, University Hospital, Groningen, the Netherlands. DESIGN: Retrospective, descriptive. METHODS: All patients admitted in a period of 5.5 years who had clinical seizures within 28 days from birth received pharmacological treatment in 4 steps. When a seizure remained clinically uncontrolled, the next step was taken. Step 1: methylphenobarbital 15-35 mg/kg i.v. Step 2: phenytoin 15-35 mg/kg i.v. After an initial loading dose of 15 mg/kg i.v., both the methylphenobarbital and the phenytoin loading dose were stepwise increased until reaching the maximum of 35 mg/kg. Step 3: clonazepam 1-2 x 0,15 mg/kg i.v. Step 4: thiopental 1-2 mg/kg/hour i.v. RESULTS: The incidence of neonatal seizures was 121/2068 (5.9%). For assessment of the efficacy of the therapeutic strategy used, data of 37 patients were not available: 16 patients because of missing data, 11 because of deviation from the strategy and 10 because they died during the strategy. Cases of 84 patients could be evaluated for treatment response. The cumulative response rates were 68% (57/84) controlled seizures for methylphenobarbital, 87% (73/84) for phenytoin, 94% (79/84) for clonazepam, and 96% (81/84) for thiopental. For both methylphenobarbital and phenytoin a marked increase in clinical response was seen at increasing loading doses. CONCLUSION: The stepwise therapeutic strategy used in this study proved to be successful in most cases of neonatal seizures. The anticonvulsive action of both methylphenobarbital and phenytoin appeared to be dose-related.

Anticonvulsants↗

Comparison of imputation and modelling methods in the analysis of a physical activity trial with missing outcomes.

BACKGROUND: Longitudinal studies almost always have some individuals with missing outcomes. Inappropriate handling of the missing data in the analysis can result in misleading conclusions. Here we review a wide range of methods to handle missing outcomes in single and repeated measures data and discuss which methods are most appropriate. METHODS: Using data from a randomized controlled trial to compare two interventions for increasing physical activity, we compare complete-case analysis; ad hoc imputation techniques such as last observation carried forward and worst-case; model-based imputation; longitudinal models with random effects; and recently proposed joint models for repeated measures data and non-ignorable dropout. RESULTS: Estimated intervention effects from ad hoc imputation methods vary widely. Standard multiple imputation and longitudinal modelling agree closely, as they should. Modifying the modelling method to allow for non-ignorable dropout had little effect on estimated intervention effects, but imputing using a common imputation model in both groups gave more conservative results. CONCLUSIONS: Results from ad hoc imputation methods should be avoided in favour of methods with more plausible assumptions although they may be computationally more complex. Although standard multiple imputation methods and longitudinal modelling methods are equivalent for estimating the treatment effect, the two approaches suggest different ways of relaxing the assumptions, and the choice between them depends on contextual knowledge.

Bias↗

Transmission/disequilibrium test when neither parent is available in some families: a non-iterative approach.

BACKGROUND: The transmission/disequilibrium test (TDT) is a simple method of detecting linkage between a marker locus and a disease-susceptibility locus. The test requires genotype data from the affected individuals (the probands) and their parents, the 'case-parents triads'. However, missing data from parents often complicate the situations. Several non-iterative methods, such as the sibling-based TDT, the reconstruction-combined TDT, and the 1-TDT have been proposed to deal with the problem. But when the father, the mother, and other non-proband siblings in a family are all unavailable for study, that family has to be excluded from analysis by any of the above methods. METHODS: The author proposes a new non-iterative method to deal with the situation when the data contain some 'orphaned' probands. The method utilises the complete data from case-parents triads to infer probabilistically the missing parental genotypes, under the assumption that the missingness is independent of genotype and ethnic origin. The methods can be tailored to specific genetic models, such as the gene-dose, dominance, and recessive alternatives. RESULTS: Simulation analysis shows that, under the null hypothesis of no linkage, the proposed method is not prone to produce an excess of false positive results, even in complex situations such as population stratification or assortive mating. Under the linkage alternative, the new method recaptures much of the information that would be lost by discarding the orphaned probands. DISCUSSION: The method provides a way for dealing with the situation where neither parents nor siblings are available in a TDT study.

Algorithms↗

A method for assessing patterns of familial resemblance in complex human pedigrees, with an application to the nevus-count data in Utah kindreds.

An analytic method is described for estimating phenotypic correlations between pairs of members of specific relationships in pedigrees. In estimating correlations, this new method allows simultaneous adjustment for available covariates such as age, gender, environmental factors, and variables reflecting ascertainment mode, through mean- and variance-regression models. The estimated correlations and regression coefficients corresponding to covariates are consistent and asymptotically normally distributed. Differing from a full-likelihood approach, this new method does not require the assumption of a particular joint distribution of phenotypes from a pedigree, such as the multivariate normal distribution, but instead only requires correct specification of mean- and variance-regression models. Within this framework, missing data, if they are missing completely at random, can be ignored without biasing estimates. The method is illustrated by an application using nevus-count data from 28 Utah kinships. The results from the analysis are that covariate-adjusted nevus counts are correlated between parents and children (correlation .22; P less than .001) and between siblings (correlation .32; P less than .001), while the correlation of -.04 between husband and wife is not significantly different (P = .31) from 0. This result is consistent with a genetic etiology of nevus count.

Dysplastic Nevus Syndrome↗

Closed-form estimates for missing counts in two-way contingency tables.

One method for analyzing contingency tables with missing observations is to model the missing-data mechanism using log-linear models. Previous methods for obtaining estimates (of missing counts and parameters) have required an iterative algorithm. In many cases, however, one can obtain estimates by use of a simple algebraic formula. We illustrate the method with data on smoking and birth weight.

Algorithms↗

Antibiotics for preterm labour with intact membranes.

BACKGROUND: There may be a link between infection and preterm birth. OBJECTIVES: Since rupture of the membranes is an important factor in the progression of preterm labour, it is important to see if antibiotics are of any benefit prior to membrane rupture. The objective of this review was to assess the effects of antibiotics administered to women in preterm labour with intact membranes, on maternal and neonatal outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and reference lists of articles. We contacted experts in the field. SELECTION CRITERIA: Randomised trials which compared antibiotic treatment with placebo or no treatment for women in preterm labour (between 20 and 36 weeks gestation) with intact membranes. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for missing data. MAIN RESULTS: Meta-analysis of the ten included trials demonstrated a statistically significant prolongation of pregnancy associated with the use of antibiotics (5. 4 days, 95% confidence interval (CI) 0.9- 9.8 days). Antibiotic treatment was also associated with a statistically significant reduction in maternal infection (odds ratio (OR) 0.59, 95% CI 0.36, 0.97) and neonatal necrotising enterocolitis (OR 0.33, 95% CI 0.13, 0.88). No statistically significant effect was detected on the neonatal outcomes of respiratory distress syndrome and neonatal sepsis, although there was a trend towards the latter (OR 0.67, 95% CI 0.42, 1.07). An increase in perinatal mortality was observed in the group receiving antibiotics (OR 3.36, 95% CI 1.21, 9.32). REVIEWER'S CONCLUSIONS: Although a prolongation in time to delivery and a trend towards a reduction in neonatal sepsis was detected, this review fails to demonstrate a clear overall benefit from antibiotic treatment for preterm labour with intact membranes on neonatal outcomes and raises concerns about increased perinatal mortality for those who received antibiotics. This treatment cannot therefore be currently recommended for routine practice. Further research is required to identify a subgroup of women (and their babies) who are more likely to experience benefit from antibiotic treatment for preterm labour prior to membrane rupture, and to identify which antibiotic or combination of antibiotics is most effective. The results of the ongoing ORACLE trial should help resolve some of the uncertainties revealed by this review.

Anti-Bacterial Agents↗

Magnesium sulfate for treating exacerbations of acute asthma in the emergency department.

BACKGROUND: Treatment of acute asthma is based on rapid reversal of bronchospasm and arresting airway inflammation. There is some evidence that intravenous magnesium can provide additional bronchodilation when given in conjunction with standard bronchodilating agents and corticosteroids. No systematic review of this literature has been completed on this topic. OBJECTIVES: To examine the effect of additional intravenous magnesium sulfate in patients with acute asthma managed in the emergency department. SEARCH STRATEGY: Randomised controlled trials were identified from the Cochrane Airways Review Group register. Bibliographies from included studies, known reviews and texts were searched. Primary authors and content experts were contacted. SELECTION CRITERIA: Randomised controlled trials or quasi-randomised trials were eligible for inclusion. Studies were included if patients presented with acute asthma and were treated with IV magnesium sulfate vs placebo. DATA COLLECTION AND ANALYSIS: Data were extracted and methodological quality was assessed independently by two reviewers. Missing data were obtained from authors. MAIN RESULTS: Seven trials were included (5 adult, 2 pediatric). A total of 665 patients were involved. Patients receiving magnesium sulfate demonstrated non-significant improvements in peak expiratory flow rates when all studies were pooled (weighted mean difference: 29.4 L/min; 95% confidence interval: -3.4 to 62). In studies of people with severe acute asthma, peak expiratory flow rate improved by 52.3 L/min (95% confidence interval: 27 to 77.5). The forced expiratory volume in one second also improved by 9.8 % predicted (95% confidence interval: 3.8 to 15.8). Overall, admission to hospital was not reduced, odds ratio: 0.31 (95% confidence interval: 0.09 to 1.02). In the severe subgroup, admissions were reduced in those receiving magnesium sulfate (odds ratio: 0.10, 95% confidence interval: 0.04 to 0.27). No clinically important changes in vital signs or adverse side effects were reported. REVIEWER'S CONCLUSIONS: Current evidence does not support routine use of intravenous magnesium sulfate in all patients with acute asthma presenting to the emergency department. Magnesium sulfate appears to be safe and beneficial in patients who present with severe acute asthma.

Acute Disease↗

Intravenous beta2-agonists for acute asthma in the emergency department.

BACKGROUND: Inhaled beta-agonist therapy is central to the management of acute asthma. The use of intravenous beta-agonist agents may also be beneficial in this setting. OBJECTIVES: To determine the benefit of intravenous (IV) beta2-agonists for severe acute asthma treated in the emergency department. SEARCH STRATEGY: Randomised controlled trials (RCT) were identified using the Cochrane Airways Group Register which is a compilation of systematic searches of MEDLINE, EMBASE, CINAHL, and CENTRAL as well as hand searching of 20 respiratory journals. Bibliographies from included studies and known reviews were also searched. Primary authors and content experts were contacted to identify eligible studies. SELECTION CRITERIA: Only RCTs were considered for inclusion. Studies were included if patients presented to the emergency department with acute asthma and were treated with IV selective or nonselective beta2-agonists versus placebo, inhaled beta2-agonists, or other standard of care. Pulmonary function, vital signs, arterial gasses, adverse effects, and/or clinical success could be reported as outcome measures. Two reviewers independently selected potentially relevant articles and selected articles for inclusion. Methodological quality was independently assessed using two scoring systems and two reviewers. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two reviewers, and confirmed with corresponding authors. Missing data were obtained from authors or calculated from data present in the papers. Trials were combined using a random effects model for odds ratios (OR) or weighted mean differences (WMD) and reported with 95% confidence intervals (95% CI). MAIN RESULTS: From 746 identified references, 55 potentially relevant articles were identified and 15 were included. The trials included 584 patients. Overall, selective IV beta2-agonist use conferred no advantage over the comparator regimes. For example, it was associated with a lower PEFR after 60 mins compared to inhaled beta2-agonist, although the difference was not statistically significant (-24.7 l/min; 95%CI 2.9, -52.3). There was no difference in heart rate (4.5 bpm; 95% CI -4.9, 14.0). In the well performed blinded studies there was no difference in autonomic side effects between treatments (Odds Ratio 2.2 (95%CI 0.9, 5.7). REVIEWER'S CONCLUSIONS: There is no evidence to support the use of IV beta2-agonists in patients with severe acute asthma. These drugs should be given by inhalation. No subgroups were identified in which the IV route should be considered.

Acute Disease↗

Amino acids for amyotrophic lateral sclerosis / motor neuron disease.

BACKGROUND: Amyotrophic lateral sclerosis, also known as motor neuron disease, is a progressive neuromuscular disease that causes disability and eventual death. Various amino acid preparations, the three branched-chain amino acids (L-leucine, L-valine and L-isoleucine) or, alternatively, L-threonine have been used as experimental therapy. OBJECTIVES: To examine the efficacy of amino acid therapies in prolonging survival and/or slowing the progression of amyotrophic lateral sclerosis/motor neuron disease. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group trials register (searched February 2003), MEDLINE (from January 1966 to December 2002) and EMBASE (from January 1980 to December 2002) databases and reports of specialist conferences. Authors of known studies were contacted. SELECTION CRITERIA: We included randomised or quasi-randomised trials of participants with a clinical diagnosis of amyotrophic lateral sclerosis/motor neuron disease treated with all combinations of amino acids. Our primary outcome measure was survival determined by a pooled hazard ratio of all studies. Our secondary outcome measures were (in order of priority): survival at six and 12 months, muscle strength, any validated rating scale of physical function, quality of life, proportion of patients completing therapy and proportion of patients reporting adverse events attributable to treatment. DATA COLLECTION AND ANALYSIS: We identified six eligible trials and rejected a further seven because of incomplete data or inadequate duration. Eligible studies were rated for methodological quality and missing data sought from the authors. After this examination two studies were excluded from analysis. Our pooled survival analysis was performed by the Parmar method, other statistical calculations were done using the Review Manager 4.2 software package. MAIN RESULTS: No benefit could be demonstrated for either branched-chain amino acids or L-threonine in improving survival in amyotrophic lateral sclerosis/motor neuron disease. Neither could we find evidence of an effect of either treatment on muscle strength or disability as measured by functional rating scales. No study assessed quality of life. Both branched-chain amino acids and L-threonine appeared well tolerated and caused a degree of adverse events comparable to that of the control medication. REVIEWER'S CONCLUSIONS: There is no evidence to support a beneficial effect of either branched-chain amino acids or L-threonine in amyotrophic lateral sclerosis/motor neuron disease.

Amino Acids, Branched-Chain↗

Quality of life after rectal resection for cancer, with or without permanent colostomy.

BACKGROUND: For almost one hundred years abdominoperineal excision has been the standard treatment of choice for rectal cancer. With advances in the techniques for rectal resection and anastomosis, anterior resection with preservation of the sphincter function has become the preferred treatment for rectal cancers, except for those cancers very close to the anal sphincter. The main reason for this has been the conviction that the quality of life for patients with a colostomy after abdominoperineal excision was poorer than for patients undergoing a sphincter-preserving technique. However, patients having sphincter-preserving operations may experience symptoms affecting their quality of life that are different from those withstoma-patients. OBJECTIVES: To compare the quality of life in rectal cancer patients with or without permanent colostomy. SEARCH STRATEGY: We searched PubMed, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Colorectal Cancer Group's specialised register. Abstracts books from major gastroenterological and colorectal congresses were searched. Reference lists of the selected articles were scrutinized. SELECTION CRITERIA: All controlled clinical trials and observational studies in which quality of life was measured in patients with rectal cancer having either abdominoperineal excision or low anterior resection, using a validated quality of life instrument, were considered. DATA COLLECTION AND ANALYSIS: One reviewer (JP) checked the titles and abstracts identified from the databases and hand search. Full text copies of all studies of possible relevance were obtained. The reviewer decided which studies met the inclusion criteria. Both reviewers independently extracted data. If information was insufficient the original author was contacted to obtain missing data. Extracted data were crosschecked and discrepancies resolved by consensus. MAIN RESULTS: Twenty five potential studies were identified. Eight of these, all non-randomised and representing 620 participants, met the inclusion criteria. Four trials found that people undergoing abdominoperineal excision did not have poorer quality of life measures than patients undergoing anterior resection. One study found that a stoma only slightly affected the persons quality of life. Three studies found that patients receiving abdominoperineal excision had significantly poorer quality of life than after anterior resection. Due to heterogeneity, meta-analysis of the included studies was not possible. REVIEWERS' CONCLUSIONS: The studies included in this review do not allow firm conclusions as to the question of whether the quality of life of people after anterior resection is superior to that of people after abdominoperineal excision. The included studies challenged the assumption that anterior resection patients fare better.Larger, better designed and executed prospective studies are needed to answer this question.

Colostomy↗

Quality of life after rectal resection for cancer, with or without permanent colostomy.

BACKGROUND: For almost one hundred years abdominoperineal excision has been the standard treatment of choice for rectal cancer. With advances in the techniques for rectal resection and anastomosis, anterior resection with preservation of the sphincter function has become the preferred treatment for rectal cancers, except for those cancers very close to the anal sphincter. The main reason for this has been the conviction that the quality of life for patients with a colostomy after abdominoperineal excision was poorer than for patients undergoing a sphincter-preserving technique. However, patients having sphincter-preserving operations may experience symptoms affecting their quality of life that are different from those with stoma-patients. OBJECTIVES: To compare the quality of life in rectal cancer patients with or without permanent colostomy. SEARCH STRATEGY: We searched PUBMED, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Colorectal Cancer Group's specialised register. Abstract books from major gastroenterological and colorectal congresses were searched. Reference lists of the selected articles were scrutinized. SELECTION CRITERIA: All controlled clinical trials and observational studies in which quality of life was measured in patients with rectal cancer having either abdominoperineal excision or low anterior resection, using a validated quality of life instrument, were considered. DATA COLLECTION AND ANALYSIS: One reviewer (JP) checked the titles and abstracts identified from the databases and hand search. Full text copies of all studies of possible relevance were obtained. The reviewer decided which studies met the inclusion criteria. Both reviewers independently extracted data. If information was insufficient the original author was contacted to obtain missing data. Extracted data were crosschecked and discrepancies resolved by consensus. MAIN RESULTS: Thirty potential studies were identified. Eleven of these, all non-randomised and representing 1412 participants met the inclusion criteria. Six trials found that people undergoing abdominoperineal excision did not have poorer quality of life measures than patients undergoing anterior resection. One study found that a stoma only slightly affected the person's quality of life. Four studies found that patients receiving abdominoperineal excision had significantly poorer quality of life than after anterior resection. Due to heterogeneity, meta-analysis of the included studies was not possible. AUTHORS' CONCLUSIONS: The studies included in this review do not allow firm conclusions as to the question of whether the quality of life of people after anterior resection is superior to that of people after abdominoperineal excision. The included studies challenged the assumption that anterior resection patients fare better.Larger, better designed and executed prospective studies are needed to answer this question.

Colostomy↗