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Background: Sedentary behaviour (SB) research has grown exponentially but efficacy for interventions to reduce sedentary behaviour is often contaminated by interventions primarily or co-targeting other behaviours and outcomes. The primary aim of this research therefore, was to systematically review the efficacy of interventions specifically targeting sedentary behaviour reduction, as a sole primary outcome, from randomised control trials in healthy ambulatory adults. This research also sought to identify the successful interventions characteristics, behaviour change techniques (BCT's) and underlying theories, and their relation to intervention effectiveness., Methods: We followed PRISMA reporting guidelines for this systematic review. Six electronic databases were searched and a grey literature review conducted. Only randomised or cluster randomised controlled trials, from 2000 to 2020, in adult populations with a sole primary outcome of change in sedentary behaviour were included. Data codebooks were developed, data were extracted, and a narrative synthesis and meta-analysis was conducted using mixed methods random effects models., Results: Of 5589 studies identified, 7 studies met the inclusion criteria. Six studies reported activPAL3 measures of mean daily sitting time, and four reported mean daily standing time, stepping time and number of sedentary breaks. Pooled analysis of weighted mean differences revealed a reduction in mean daily sitting time of -32.4mins CI (-50.3, -14.4), an increase in mean daily standing time of 31.75mins CI (13.7, 49.8), and mean daily stepping time of 9.5mins CI (2.8, 16.3), and an increase in rate of sedentary breaks per day of 3.6 (CI 1.6, 5.6). BCTs used exclusively in two of the three most effective interventions are 'feedback on behaviour' and 'goal setting behaviour' whilst all three most effective interventions included 'instruction on how to perform the behaviour' and 'adding objects to the environment', BCTs which were also used in less effective interventions., Conclusions: Although limited by small sample sizes and short follow up periods, this review suggests that interventions specifically designed to change sedentary behaviour, reduce overall daily sitting time by half an hour, with an equivalent increase in standing time, in the short to medium term. Effective characteristics and behaviour change strategies are identified for future development of high quality interventions targeting change in sedentary behaviour., Prospero Registration: PROSPERO 2020 CRD42020172457 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172457., Competing Interests: The authors have declared that no competing interests exist.

Aim: To evaluate prognostic pathological factors associated with early metachronous disease and adverse long-term survival in these patients., Methods: Clinical and histological features were analysed retrospectively over an eight-year period for prognostic impact on recurrent disease and overall survival in patients undergoing curative resection of a primary colorectal cancer., Results: A total of 266 patients underwent curative surgery during the study period. The median age of the study cohort was 68 year (range 26 to 91) with a follow-up of 7.9 years (range 4.6 to 12.6). Resection was undertaken electively in 225 (84.6%) patients and emergency resection in 35 (13.2%). Data on timing of surgery was missing in 6 patients. Recurrence was noted in 67 (25.2%) during the study period and was predominantly early within 3 years (82.1%) and involved hepatic metastasis in 73.1%. Emergency resection (OR = 3.60, P = 0.001), T4 stage (OR = 4.33, P < 0.001) and lymphovascular invasion (LVI) (OR = 2.37, P = 0.032) were associated with higher risk of recurrent disease. Emergency resection, T4 disease and a high lymph node ratio (LNR) were strong independent predictors of adverse long-term survival., Conclusion: Emergency surgery is associated with adverse disease free and long-term survival. T4 disease, LVI and LNR provide strong independent predictive value of long-term outcome and can inform surveillance strategies to improve outcomes., Competing Interests: Conflict-of-interest statement: The authors have no conflict of interest.

Background: Haemorrhoids are a benign anorectal condition and are highly prevalent in the UK population. Treatments involve clinic-based procedures and surgery. The surgical procedures available include stapled haemorrhoidopexy (SH) and traditional haemorrhoidectomy (TH), and over 25,000 operations are performed for haemorrhoids annually in the UK. The disease is therefore important both to patients and to health service commissioners. Debate remains as to which of these surgical procedures is the most clinically effective and cost-effective., Objective: The aim of this study was to compare the clinical effectiveness and cost-effectiveness of SH with that of TH., Design: A large, open two-arm parallel-group pragmatic multicentre randomised controlled trial involving 32 UK hospitals and a within-trial cost-benefit analysis. A discrete choice experiment was conducted to estimate benefits (willingness to pay)., Participants: Patients with grades II-IV haemorrhoids who had not previously undergone SH or TH were included in the study., Interventions: Participants were randomised to receive either SH or TH. Randomisation was minimised at 1 : 1, in accordance with baseline EuroQol-5 Dimensions, three-level version (EQ-5D-3L) score, haemorrhoid grade, sex and centre, via an automated system., Main Outcome Measures: The primary outcome was area under the quality-of-life curve measured using the EQ-5D-3L descriptive system over 24 months, and the primary economic outcome was the incremental cost-effectiveness ratio. Secondary outcomes included disease-specific quality of life, recurrence, complications, further interventions and costs., Results: Between January 2011 and August 2014, 777 patients were randomised (389 to receive SH and 388 to receive TH). There were 774 participants included in the analysis as a result of one post-randomisation exclusion in the SH arm and two in the TH arm. SH was less painful than TH in the short term. Surgical complications were similar in both arms. EQ-5D-3L score was higher for the SH arm in the first 6 weeks after surgery, but over 24 months the TH group had significantly better EQ-5D-3L scores (-0.073, 95% confidence interval -0.140 to -0.006; p  = 0.0342). Symptoms and further interventions were significantly fewer in the TH arm at 24 months. Continence was better in the TH arm and tenesmus occurred less frequently. The number of serious adverse events reported was 24 out of 337 (7.1%) for participants who received SH and 33 out of 352 (9.4%) for those who received TH. There were two deaths in the SH arm, both unrelated to the eTHoS (either Traditional Haemorrhoidectomy or Stapled haemorrhoidopexy for haemorrhoidal disease) study. Patient preference did not seem to influence the treatment difference. SH was dominated by TH as it cost more and was less effective. The net benefit for the TH arm was higher than that for the SH arm., Limitations: Neither the participants nor the assessors were masked to treatment assignment and final recruitment was slightly short of the total target of 800. There were also substantial missing follow-up data., Conclusions: While patients who received SH had less short-term pain, after 6 weeks, recurrence rates, symptoms, re-interventions and quality-of-life measures all favoured TH. In addition, TH is cheaper. As part of a tailored management plan for haemorrhoids, TH should be considered over SH as the surgical treatment of choice for haemorrhoids refractory to clinic-based interventions., Future Work: Perform an updated meta-analysis incorporating recently conducted European trials [eTHoS, HubBLe (haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids) and LingaLongo (Cost-effectiveness of New Surgical Treatments for Haemorrhoidal Disease)]., Trial Registration: Current Controlled Trials ISRCTN80061723., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 21, No. 70. See the NIHR Journals Library website for further project information.

Background: Current interventions for haemorrhoidal disease include traditional haemorrhoidectomy (TH) and stapled haemorrhoidopexy (SH) surgery. However, uncertainty remains as to how they compare from a clinical, quality of life (QoL) and economic perspective. The study is therefore designed to determine whether SH is more effective and more cost-effective, compared with TH., Methods/design: eTHoS (either Traditional Haemorrhoidectomy or Stapled Haemorrhoidopexy for Haemorrhoidal Disease) is a pragmatic, multicentre, randomised controlled trial. Currently, 29 secondary care centres are open to recruitment. Patients, aged 18 year or older, with circumferential haemorrhoids grade II to IV, are eligible to take part. The primary clinical and economic outcomes are QoL profile (area under the curve derived from the EuroQol Group's 5 Dimension Health Status Questionnaire (EQ-5D) at all assessment points) and incremental cost per quality adjusted life year (QALY) based on the responses to the EQ-5D at 24 months. The secondary outcomes include a comparison of the SF-36 scores, pain and symptoms sub-domains, disease recurrence, complication rates and direct and indirect costs to the National Health Service (NHS). A sample size of n =338 per group has been calculated to provide 90% power to detect a difference in the mean area under the curve (AUC) of 0.25 standard deviations derived from EQ-5D score measurements, with a two-sided significance level of 5%. Allowing for non-response, 400 participants will be randomised per group. Randomisation will utilise a minimisation algorithm that incorporates centre, grade of haemorrhoidal disease, baseline EQ-5D score and gender. Blinding of participants and outcome assessors is not attempted., Discussion: This is one of the largest trials of its kind. In the United Kingdom alone, 29,000 operations for haemorrhoidal disease are done annually. The trial is therefore designed to give robust evidence on which clinicians and health service managers can base management decisions and, more importantly, patients can make informed choices., Trial Registration: Current Controlled Trials ISRCTN80061723 (assigned 8 March 2010).

Rural health issues are increasingly recognized as needing attention, but many health policies in Canada are developed for the urban context and universally applied to rural settings. Addressing rural nurses' opportunities for involvement in policy will contribute to our general understanding of rural health while improving community health services. Rural nurses are in a unique position to assist because of their intimate knowledge of their communities and their position as informal community leaders. Challenges to their involvement include decreased numbers and lack of educational preparation about policy. A strength is the higher percentage of rural nurses who are managers compared to their urban counterparts. Nursing education programs need to include theoretical content and practical opportunities related to health policy. Managers need to support rural nurses' attempts in policy development by providing opportunities for membership on policy committees. Finally, once obtaining skills in the policy arena, rural nurses need to work within their communities and workplaces to help develop and implement more appropriate rural-based policies.

The development of acute pancreatitis occurs in 4-8% of patients with symptomatic gallstones. Individuals predisposed to acute pancreatitis tend to have small gallstones (with or without larger gallstones), a wide cystic duct and a common channel between the biliary and pancreatic ducts. The importance of this relationship is demonstrated by the ability of urgent endoscopic sphincterotomy (ES) to improve the outcome of a predicted severe attack and to virtually abolish recurrent attacks in patients who are unable to undergo cholecystectomy. Cholesterolosis is an established cause of acute pancreatitis, occurring in up to 29% of cases with cholesterolosis. Biliary crystals are an important marker of microlithiasis or a propensity to form further gallstones following their passage into the duodenum following an attack. A combination of ultrasonography and a serum liver transaminase of > 60 IU/I (< 48 hr o an attack) are necessary to provide optimum sensitivity and specificity for gallstones as a prompt for the use of ERCP and ES in severe cases. Biliary sludge as a cause of acute pancreatitis is not proven. 25-30% of patients will develop complications with a mortality of around 8%. Urgent diagnosis of gallstones and treatment by ES can result in substantial improvement in outcome.

We studied the occurrence of nocturnal disordered breathing events and O2 desaturations in 12 patients with late-stage Duchenne muscular dystrophy (DMD) using negative pressure ventilators. We also assessed the effects of O2 supplementation and nasal continuous positive airway pressure (CPAP) on disordered breathing events in selected patients and examined sleep quality in a small subgroup. Average age was 23 + 2 years and FVC was 293 + 33 ml. Eleven of the 12 patients had more than five disordered breathing events per hour during nocturnal monitoring, and the lowest O2 saturation was < 85 percent in nine patients. Nasal O2 (2 L/min) during negative pressure ventilation in four patients did not alter the frequency of disordered breathing events, prolonged the mean and maximum durations of events, and failed to eliminate severe O2 desaturations in two patients. Nasal CPAP was used in two patients during negative pressure ventilation and completely eliminated disordered breathing events in both. Overnight polysomnography during negative pressure ventilation in three patients demonstrated frequent awakenings that fell in frequency following elective tracheostomy in two patients and use of nasal CPAP in one. We conclude that negative pressure ventilation in patients with late-stage DMD is associated with frequent disordered breathing events and severe O2 desaturations in many patients. Concomitant use of O2 supplementation may prolong the events, but a switch to positive pressure ventilation or addition of nasal CPAP is effective therapy.

The development of stapling instruments has obviated the need to perform anal mucosectomy for ulcerative colitis, but the potential exists for continued inflammation and, perhaps, malignant change. We reviewed the pathology specimens of patients who had had restorative proctocolectomy, to determine the incidence and severity of inflammation in the anal mucosa.

Body protein and fat stores were measured in four long-term survivors both before Whipple's procedure for malignancy at the ampulla of Vater and at a mean of 40 months (range 20-64 months) later. The results were compared with predicted well values. At follow-up patients also underwent dietary assessment and measurement of faecal fat losses. A dietary intake of mean (s.d) of 2690 (733) kcal per day and 85 (21) g protein per day met the patients' requirements. There was notable steatorrhoea (faecal fat 28 (21) g per day) but faecal protein losses were normal. Before surgery, body-weight was significantly lower than well-weight (P less than 0.0005), three patients having body fat stores lower than predicted well values. After surgery, body-weight and protein stores did not change significantly but fat stores fell in each patient (P less than 0.04). A curative Whipple's procedure prevents further weight loss in ampullary malignancy but weight gain does not occur because of steatorrhoea, perhaps a result of the accompanying truncal vagotomy.

Neutrophil motility in normal subjects and Crohn's disease patients was assessed using both double and single filter assay systems with n-formylmethionylleucylphenylalanine (FMLP) as the attractant, and in a single filter assay with Candida albicans in 10% serum as the attractant. Assays were performed in triplicate and included controls to eliminate the effect of random (non-stimulated) locomotion. After incubation at 37 degrees C, filters were fixed and stained and the numbers of neutrophils per filter field counted under the microscope. Stimulated migration was calculated by subtracting random from total migration. Compared to normal neutrophils, 56% more Crohn's disease neutrophils migrated towards FMLP in the double filter system (p = 0.01). With the single filter technique using FMLP as the attractant 58% more Crohn's disease neutrophils migrated (p = 0.002). With the single filter technique using C. albicans as the attractant 47% more Crohn's disease neutrophils migrated (p = 0.02). Neutrophil motility in patients with Crohn's disease is enhanced and results were not related to disease activity.

Fifty ileo-anal J pouches were constructed in 26 males and 24 females for ulcerative colitis (n = 45) and familial adenomatous polyposis (n = 5). Two-thirds had proctocolectomy and pouch formation as a one-stage procedure. Thirty patients had a handsewn pouch and anastomosis and 20 were stapled. Forty-five patients had their defunctioning ileostomy closed for at least 2 months, of whom three have not been recently reviewed. One pouch was defunctioned for ischaemic stricture. The median time between pouch construction and ileostomy closure was 15 weeks and the time between closure and assessment ranged from 2 to 50 months (median 18 months). Median stool frequency was six per 24h in both the handsewn and stapled groups. Faecal incontinence occurred in 20% of patients with a handsewn anastomosis but in no patient with a stapled anastomosis (P less than 0.02). Soiling was also more common in the former group. Some 76% of patients noted an improvement in pouch function with time. In all, 67% of males and 78% of females reported unchanged or increased sexual activity since pouch surgery. Pouchitis has occurred in 20% of patients; 10% have had complications related to the pouch or anastomosis; 10% related to the ileostomy; and 6% have had small bowel obstruction. There have been no deaths. Overall, 88% of patients have had a good result, but none of the five patients with a poor result will revert to an ileostomy.

A program of respiratory muscle sparing in 9 patients with late stage Duchenne muscular dystrophy is presented. Results indicate that regular efficient night-time support by body respirator provides a constant significant improvement in daytime gas exchange for periods averaging up to 2 years following the occurrence of moderately severe respiratory failure. Until now, the longest survival is more than 4 years at the age of 28. the average PaCO2 and PaO2 before night ventilation were 60.8mmHg and 59.3mmHg, respectively. The levels after the program was begun were 45.5 (PaCO2) and 74.6 (PaO2). These arterial blood gas levels are acceptable for good cardiopulmonary homeostasis. There have been no deaths or episodes of cardiac failure since the program began. The ease of integrating the program into the patient's lifestyle and home are important advantages. Cost of equipment is discussed. The view that these patients are terminal must be qualified. A case is also made for early aggressive conservative measures including body respirators, postural drainage, chest physiotherapy with abdominal assisted coughing, intratracheal suctioning and bronchoscopy to combat respiratory infection, and decreasing the need of tracheostomy and volume ventilators which can be so disabling to the chronic restrictive lung disease (CRLD) patient. Research and development into better design of body respirators is vitally needed. Acute care hospitals must prepare themselves for such patients who now attain more independent living and longer lifespan. For this reason there is a growing need for these facilities to acquire tank ventilators for handling such patients who may need hospitalization for acute medical complications.

Malakoplakia is a disease which most commonly affects the bladder. It is probably more common than is realised because the appearance of the lesions is variable and the diagnosis can be difficult to make histologically. It should be considered in patients with recurring Escherichia coli infections and is also associated with immunosuppression and carcinoma. Three patients with malakoplakia of the bladder are reported: two had recurrent Esch. coli urinary tract infections and one had widespread urological malignancy. The pathogenesis is discussed and a simple treatment regime, which was rapidly successful in the patient who received it, is recommended.

The ventilator management protocol followed over the last 12 years in 23 patients with Duchenne muscular dystrophy (DMD) and six polio survivors with chronic respiratory failure (CRF) secondary to the late effects of poliomyelitis or postpolio syndrome (PPS) is reviewed. After the onset of respiratory failure, patients with DMD continued to show a classic course of progressive, generalized muscle weakness and a steadily declining vital capacity from an average of 482mL to 336mL. The DMD group required an average increase of 0.95 hours in their daily use of assisted ventilation per year. Their overall average length of survival was increased from 19 years 9 months to 25 years 9 months. Members of the postpolio group, to date, have shown no significant decrease in muscle strength nor have they needed more than nocturnal ventilation. Recommended evaluation and pulmonary follow-up for patients with CRF secondary to neuromuscular disease is outlined. Most of these patients can be managed for a number of years with body ventilators before a tracheotomy is necessary.