Robotic versus laparoscopic distal pancreatectomy: multicentre analysis.

BACKGROUND: The role of minimally invasive distal pancreatectomy is still unclear, and whether robotic distal pancreatectomy (RDP) offers benefits over laparoscopic distal pancreatectomy (LDP) is unknown because large multicentre studies are lacking. This study compared perioperative outcomes between RDP and LDP. METHODS: A multicentre international propensity score-matched study included patients who underwent RDP or LDP for any indication in 21 European centres from six countries that performed at least 15 distal pancreatectomies annually (January 2011 to June 2019). Propensity score matching was based on preoperative characteristics in a 1 : 1 ratio. The primary outcome was the major morbidity rate (Clavien-Dindo grade IIIa or above). RESULTS: A total of 1551 patients (407 RDP and 1144 LDP) were included in the study. Some 402 patients who had RDP were matched with 402 who underwent LDP. After matching, there was no difference between RDP and LDP groups in rates of major morbidity (14.2 versus 16.5 per cent respectively; P = 0.378), postoperative pancreatic fistula grade B/C (24.6 versus 26.5 per cent; P = 0.543) or 90-day mortality (0.5 versus 1.3 per cent; P = 0.268). RDP was associated with a longer duration of surgery than LDP (median 285 (i.q.r. 225-350) versus 240 (195-300) min respectively; P < 0.001), lower conversion rate (6.7 versus 15.2 per cent; P < 0.001), higher spleen preservation rate (81.4 versus 62.9 per cent; P = 0.001), longer hospital stay (median 8.5 (i.q.r. 7-12) versus 7 (6-10) days; P < 0.001) and lower readmission rate (11.0 versus 18.2 per cent; P = 0.004). CONCLUSION: The major morbidity rate was comparable between RDP and LDP. RDP was associated with improved rates of conversion, spleen preservation and readmission, to the detriment of longer duration of surgery and hospital stay.

Golimumab improves health-related quality of life of patients with moderate-to-severe ulcerative colitis: Results of the go-care study.

BACKGROUND: In recent years, improvement of Health-Related Quality of Life (HRQoL) in Ulcerative colitis (UC) has become a relevant measure for treatment efficacy. METHODS: We report results from a multicenter prospective study in Italy investigating HRQoL in adult patients with UC treated with golimumab (GLM). Patients who had shown clinical response after a 6-week induction phase (w0), were followed for an additional 48 weeks (w48) (total 54-week treatment). RESULTS: Of the 159 patients enrolled 90 completed the study. Compared to values at the beginning of treatment (n = 137), significant improvements were observed for mean total Inflammatory Bowel Disease Questionnaire (IBDQ) scores at w0 (168.5) and w48 (181.7). Patients with baseline PMS above the median tended to have greater improvements in IBDQ at w0 (OR 2.037, p = 0.033) and w48 (OR 3.292, p = 0.027). Compared to beginning of GLM treatment, the mean Full Mayo Score (FMS) decreased by 5.9 points at w48, while mean Partial Mayo Score (PMS) decreased by 3.9 points at w0 and by 4.9 points at w48. CONCLUSIONS: GLM improved HRQoL, disease activity and inflammatory biomarkers in UC patients with moderate-to-severely active disease. The greater the burden of disease activity at baseline, the greater the improvement of HRQoL after 24 and 48 weeks of treatment.

Feasibility of an obesity intervention for paediatric primary care targeting parenting and children: Helping HAND.

BACKGROUND: The primary care setting offers the opportunity to reach children and parents to encourage healthy lifestyle behaviours, and improve weight status among children. OBJECTIVE: Test the feasibility of Helping HAND (Healthy Activity and Nutrition Directions), an obesity intervention for 5- to 8-year-old children in primary care clinics. METHODS: A randomized controlled pilot study of Helping HAND, a 6-month intervention, targeted children with body mass index 85-99%tile and their parents. Intervention group attended monthly sessions and self-selected child behaviours and parenting practices to change. Control group received regular paediatric care and was wait-listed for Helping HAND. Session completion, participant satisfaction, child anthropometrics, dietary intake, physical activity, TV viewing and behaviour-specific parenting practices were measured pre and post intervention. RESULTS: Forty parent-child dyads enrolled: 82.5% were Hispanic, 80% had a girl and 65% reported income ≤ $30, 000/year. There was 20% attrition from Helping HAND (attended <4/6 sessions). Families self-selected 4.35 (SD 1.75) behaviours to target during the 6-month programme and each of the seven behaviours was selected by 45-80% of the families. There were no between group differences in the child's body mass index z-score, dietary intake or physical activity post intervention. Intervention group viewed 14.9 (SE 2.3) h/week of TV post intervention versus control group 23.3 (SE 2.4) h/week (P < 0.05). CONCLUSION: Helping HAND is feasible, due to low attrition, good programme attendance, and clinically relevant improvements in some child and parenting behaviours.

Combined modality treatment for patients with locally advanced pancreatic adenocarcinoma.

BACKGROUND: Radiofrequency ablation (RFA) is an emerging treatment for patients with locally advanced pancreatic carcinoma, and can be combined with radiochemotherapy and intra-arterial plus systemic chemotherapy. METHODS: This observational study compared two groups of patients with locally advanced pancreatic carcinoma treated with either primary RFA (group 1) or RFA following any other primary treatment (group 2). RESULTS: Between February 2007 and May 2010, 107 consecutive patients were treated with RFA. There were 47 patients in group 1 and 60 in group 2. Median overall survival was 25·6 months. Median overall survival was significantly shorter in group 1 than in group 2 (14·7 versus 25·6 months; P = 0·004) Patients treated with RFA, radiochemotherapy and intra-arterial plus systemic chemotherapy (triple-approach strategy) had a median overall survival of 34·0 months. CONCLUSION: RFA after alternative primary treatment was associated with prolonged survival. This was further extended by use of a triple-approach strategy in selected patients. Further evaluation of this approach seems warranted.

Parenting stress in US families: implications for paediatric healthcare utilization.

OBJECTIVE: According to family stress models, parental responses to stress disrupt interactions between parent and child and may lead to parental inability to seek timely medical care for their child. The objective of this study was to quantitatively assess the relationship between high parenting stress and child healthcare utilization. METHODS: We used the 2003-2004 National Survey of Children's Health to determine the prevalence of parenting stress in US families and associated socio-demographic variables. We used weighted logistic regression to investigate associations between parenting stress and healthcare utilization, controlling for other parental psychosocial and socio-demographic variables. The primary independent variables were parenting stress, parental mental health, parental coping and social support. The main dependent variables were emergency care, sick visits to primary care and preventive care in the past 12 months. RESULTS: Nationally, 13% of children lived in households with at least one parent experiencing high parenting stress. Socio-demographic variables associated with the highest odds of parenting stress included Black race, special needs status and non-English primary language. Parents with high parenting stress had a higher odds (adjusted odds ratio 1.24, 95% confidence interval 1.10-1.41) of seeking emergency care for their children compared with parents with low parenting stress, controlling for other parental psychosocial factors and socio-demographic variables. CONCLUSIONS: Having a parent who is experiencing high parenting stress is associated with greater utilization of paediatric emergency care. Interventions targeted at parenting stress may provide families with needed support and reduce unnecessary emergency care utilization.

[MRI and CT in the evaluation of congenital heart diseases]. / RM e TC nella valutazione delle cardiopatie congenite.

Magnetic resonance imaging (MRI) allows a static and cinetic study of congenital heart diseases avoiding patient exposure to ionizing radiation. It allows for evaluating cardiac morphology, heart function with accurate ventricular volume estimation, flow quantification with gradient and regurgitant fraction estimation, and vascular anatomy (aortic, pulmonary and proximal coronary vessels). Computed tomography (CT), with greater spatial resolution, allows for evaluating proximal and distal coronary arteries, vascular and pericardial calcifications, metal structures such as stents and prosthetic valves. The use of MRI or CT in young and adult patients with congenital heart diseases should be assessed case by case through a close collaboration between cardiologists and radiologists, aiming at an optimal tradeoff between expected diagnostic gain and biological cost in terms of ionizing radiation exposure and contrast material administration.

C-Reactive Protein and Procalcitonin as Predictors of Postoperative Inflammatory Complications After Pancreatic Surgery.

BACKGROUND: The association between postoperative inflammatory markers and risk of complications after pancreaticoduodenectomy (PD) is controversial. We sought to assess the diagnostic value of perioperative C-reactive protein (CRP) and procalcitonin (PCT) levels in the early identification of patients at risk for complications after PD. METHODS: In 2014, 84 patients undergoing elective PD were enrolled in a prospective database. Clinicopathological characteristics, CRP and PCT, as well as short-term outcomes, such as complications and pancreatic fistula, were analyzed. Complications and pancreatic fistula were defined based on the Clavien-Dindo classification and the International Study Group on Pancreatic Fistula (ISGPF) classification, respectively. High CRP and PCT were classified using cut-off values based on ROC curve analysis. RESULTS: The majority (73.8 %) of patients had pancreatic adenocarcinoma. CRP and PCT levels over the first 5 postoperative days (POD) were higher among patients who experienced a complication versus those who did not (p < 0.001). Postoperative CRP and PCT levels were also higher among patients who developed a grade B or C pancreatic fistula (p < 0.05). A CRP concentration >84 mg/l on POD 1 (AUC 0.77) and >127 mg/l on POD 3 (AUC 0.79) was associated with the highest risk of overall complications (OR 6.86 and 9.0, respectively; both p < 0.001). Similarly patients with PCT >0.7 mg/dl on POD 1 (AUC 0.67) were at higher risk of developing a postoperative complication (OR 3.33; p = 0.024). On POD 1, a CRP >92 mg/l (AUC 0.72) and a PCT >0.4 mg/dl (AUC 0.70) were associated with the highest risk of pancreatic fistula (OR 5.63 and 5.62, respectively; both p < 0.05). CONCLUSIONS: CRP and PCT concentration were associated with an increased risk of developing complications and clinical relevant pancreatic fistula after PD. Use of these biomarkers may help identify those patients at highest risk for perioperative morbidity and help guide postoperative management of patients undergoing PD.

Residents on the transport team. Balancing service and education.

OBJECTIVES: To describe an educational program for pediatric house staff who participate in interhospital transport and to present an evaluation of the educational program. DESIGN: Educational program evaluation that used multiple confidential surveys of participating pediatric house staff. SETTING: The interhospital transport team of a large, urban pediatric hospital. PARTICIPANTS: Twenty-six pediatric second-year residents who participated in required rotations with the transport service. INTERVENTION: The institution of an educational program designed specifically for the clinical transport rotation. RESULTS: Before their service with the transport team, residents have doubts about their clinical skills, fund of knowledge, and ability to practice independently in a mobile environment. These doubts decrease as the residents participate in the educational program during their transport clinical service. All residents perceive service on the transport rotation to be of educational benefit with regard to communications or cognitive skills. Alternatively, transport service provides little opportunity for residents to improve technical skills. Among the various skills that residents could obtain during transport service, improvement in clinical judgement was most commonly cited by residents who performed more than 10 transports. Among the specific curricular components in the educational program, interactive teaching methods were judged to be more valuable than written materials. CONCLUSIONS: Serving as a physician on interhospital transports can be an important educational opportunity for pediatric house staff when that experience is concentrated in a designated rotation and combined with a focused educational program. Contrary to expectations, there was little opportunity for residents to develop technical skills on transport. Therefore, educators should focus on the development of communications and cognitive skills. Interhospital transport programs that debate the use of residents as members of the service should consider the potential educational benefit of the clinical service to house staff.

Experiences and reflections of former pediatric chief residents.

OBJECTIVE: To compare actual and ideal time commitments of pediatric chief residents between 1972 and 1992 and to determine if actual time commitments have changed. DESIGN: Descriptive, cross-sectional survey. PARTICIPANTS: One thousand two hundred eighty-four former pediatric chief residents. RESULTS: Chief residents between 1972 and 1982 spent a greater percentage of time teaching and providing patient care than chief residents between 1983 and 1992. Chief residents between 1983 and 1992 spent a greater percentage of time scheduling and performing other administrative tasks. In general, chief residents desired more time to teach, to conduct research, and to provide outpatient care and desired less time for scheduling and for performing other administrative duties. CONCLUSIONS: Although chief residents desire to spend more time teaching and less time performing administrative tasks, administrative duties have increased at the expense of teaching and patient care responsibilities over the past 20 years.

A methodology to maximize resident input in improving a pediatric rotation.

OBJECTIVE: To develop a structured process to gain resident input into the improvement of their educational experience by (1) taking a small amount of resident time and effort, (2) fostering the generation of new ideas, (3) allowing the prioritization of ideas, (4) generating implementation plans for the ideas, and (5) offering the participants relative anonymity. DESIGN: Cross-sectional survey and group sessions. SETTING: Urban, university-based children's hospital. PARTICIPANTS: Members of the pediatric residency program in the 1993-1994 academic year. INTERVENTIONS AND RESULTS: The process was piloted for an emergency department rotation and borrows aspects of the Delphi Technique, Nominal Group Technique, and focus group methods. A survey regarding an emergency department rotation was distributed to all pediatric residents, and the 10 most commonly noted problems were compiled. These problems were brought to group sessions held for each level of training. Problems not listed were added if they were mentioned during the session; however, no problem was removed from the list. The sessions, designed to offer relative anonymity to the residents, included an initial clarification period, a round-robin prioritization of ideas, and an open discussion designed to generate solutions. Resident-generated solutions resulting from the group sessions were reviewed by the attending staff, and changes were implemented during the next year. CONCLUSION: The technique that we developed is a practical and time-efficient method of incorporating resident perspectives into the improvement of a rotation.

Teaching resuscitation to pediatric residents: the effects of an intervention.

OBJECTIVE: To evaluate the effectiveness of an educational intervention on pediatric residents' resuscitation fund of knowledge, technical skills, confidence, and overall performance. DESIGN: Prospective, nonconcurrent, controlled interventional trial. SETTING: Urban pediatric tertiary care hospital. PARTICIPANTS: An intervention group (IG) of 28 pediatric residents graduating in 1997, and a control group (CG) of 30 pediatric residents graduating in 1996. INTERVENTIONS: Resuscitation course with didactic lectures and skills practice stations, as well as a minimum of 3 practice mock resuscitations with immediate feedback throughout postgraduate year 3. MAIN OUTCOME MEASURES: Fund of knowledge, using the Pediatric Advanced Life Support test and short answer test; technical skills, using the Airway and Vascular Access Skills Assessment; experience and confidence, using an anonymous survey; and overall performance, evaluated using a videotaped mock resuscitation test. RESULTS: The IG scored better on the short answer test (P<.001). A larger number of IG residents were successful in the completion of ancillary airway maneuvers and femoral vascular access (P =.02), as well as endotracheal intubation (P =.004) and intraosseous access (P =.002). The IG was more confident in their leadership role (P =.0001) and technical skills (P =.05). Trends toward improved overall performance were noted for the IG mock resuscitations. Residents in the IG were more likely to assess the airway in fewer than 2 minutes (P =.02), recognize the threat to life in fewer than 5 minutes (P =.02), and complete the primary survey in a timely fashion (P =.05). They required fewer prompts (P =.04) and made fewer mistakes (P =.07). CONCLUSIONS: A structured, formal curriculum can improve the necessary fund of knowledge, skills, confidence, and leadership required for resuscitation.

Perforated coated tablets for controlled release of drugs at a constant rate.

Tablets with a central hole and a water-impermeable coating were prepared. These perforated coated tablets (PCTs) dissolve and release drug through the central hole only. In vitro release of the model drugs sodium benzoate and benzamide from PCTs occurred at a constant rate up to 80% release. The zero-order release rate varies with hole size, drug solubility, drug concentration, diluent solubility, and binder concentration. These results demonstrate that the PCT design can be used to prepare drug delivery devices which release at controllable constant rates.

Maternal plasma concentrations of magnesium, calcium, zinc and copper in normal and pathological pregnancies.

In this study, plasma levels of magnesium, calcium, zinc and copper were simultaneously determined in pregnancies complicated by either abortion, intrauterine growth retardation (IUGR), diabetes or EPH (edema, proteinuria, hypertension) gestosis. The levels of the four cations in non-pregnant women and in healthy, pregnant women were also determined. Compared with controls, a significant decrease in magnesium, with increase of the Ca/Mg ratio, was found in spontaneous abortions, but not when patients had a successful continuation of pregnancy. In EPH gestosis, total calcium was reduced, with a significant decrease of the plasma Ca/Mg ratio. A slight, but significant, increase in plasma zinc was observed in women affected by either diabetes or IUGR, probably as a result of reduced zinc uptake by the fetus. In addition, higher copper levels were found in the pathologies studied, with the exception of missed abortions. The possible role of an altered Ca/Mg ratio homeostasis in relation to gestational pathologies is discussed.

Perceptions of pediatric chief residents on minority house staff recruitment and retention in large pediatric residency programs.

This study examined methods of recruiting and retaining minority house staff at US residency training programs. A 28-item questionnaire was mailed to pediatric chief residents at 78 US training programs with more than 35 residents. The response rate was 74%. Programs were characterized by patient populations served, number of ethnic/racial minority house staff and faculty, and the presence of minority house staff support systems within the institution. In this largely urban sample, minority recruitment and retention was reported as an explicit priority by 40% of pediatric chief residents. The majority (71%) reported that their house staff recruitment committees had no explicitly defined recruitment goals regarding minority house staff. Seventy-seven percent reported that within their departments, recruitment efforts toward minorities were no different than for nonminorities. Overall, few minority house staff and minority faculty were identified in the responding institutions. The most frequently reported intra-institutional support systems for minority house staff included individual pairing with faculty advisors from the same minority group (29%), an affirmative-action office located at the institution (8%), and the existence of a minority faculty support group (4%). These results indicate that pediatric chief residents may not be fully aware of the specific challenges related to the recruitment and retention of minority physicians, and most house staff recruitment committees do not have explicit goals in this regard.

Reimbursement and insurance coverage in cases of suspected sexual abuse in the emergency department.

OBJECTIVE: To characterize third party payor types and rates of reimbursement for hospital costs in emergency department (ED) evaluations of preadolescents presenting as suspected victims of sexual abuse (SSA). DESIGN AND METHODS: Retrospective chart review, comparing a set of 186 SSA patients with 623 evaluated for upper limb fracture and cumulative reimbursement and insurance data for all patients presenting to the ED during a 12-month period. RESULTS: A greater percentage of SSA patients was uninsured (N = 96, 52%) as compared to patients with fractures (N = 9, 1%); 23% of all ED billing came from the uninsured. Of the 96 self-pay SSA patients' bills only 4% reimbursement was received. Of the insured, a greater percentage of the SSA patients was covered by publicly-funded plans (n = 59, 66%) as compared to fracture patients (N = 327, 52%). A lower percentage of insured SSA bill reimbursement was received from publicly-funded insurance than from commercial insurance (28% vs. 58%). CONCLUSIONS: Hospital costs of SSA patients are more often and to a greater degree underwritten by the hospital itself as a result of lower reimbursement and a higher percentage of uninsured and publicly-funded plans in that group, raising critical questions about how care for children with serious socially-based diagnoses is delivered and funded.

Funding realities: child abuse diagnostic evaluations in the health care setting.

OBJECTIVE: This study examines staffing, funding sources, reimbursement, and financing of medically-oriented child protection teams. METHOD: A 16-item questionnaire on the composition, size, and services of the team, program costs, revenue sources, reimbursement rates, and perceptions of funding stability was mailed to a sample of 118 medically-oriented child protection teams. RESULTS: After excluding 10 programs, an overall response rate of 68% was obtained. Teams varied in configuration, services, charges, and funding. Over 50% identified funding as being important, yet, demonstrated varying levels of awareness of budget and reimbursement issues. Many generally relied on patient care reimbursement from health care and government payers. Some programs seemed to be doing well financially while others were struggling. Approximately one-third of the respondents indicated that funding was unstable. CONCLUSIONS: Many programs are innovatively knitting together patch-works of funding and support to serve children and families in need. Team leaders should increase their knowledge of fiscal issues in order to be effective advocates at the institutional level for continued team support. A potential way of accomplishing this would be to utilize the existing structure of a national professional association and its national meeting to provide a forum for relatively successful programs to showcase their "ideal models" of team financing.

Magnesium and potassium status in elderly subjects with and without dementia of the Alzheimer type.

Magnesium status was evaluated in healthy elderly people, and in patients affected from dementia of the Alzheimer type. Magnesium levels were determined in plasma, erythrocytes (RBC), lymphocytes (MNC), and granulocytes (PMN), and were compared with measurements in young healthy adults. Significantly lower plasma Mg concentrations were found in elderly people compared to controls, with no difference between cognitively normal and demented subjects. Mg levels in healthy elderly people were higher in MNC and lower in PMN, compared to the younger group. No difference was observed between demented patients and young controls in Mg content of white blood cells, but the patients had higher Mg/K ratios. In addition, significant correlations were found between cognitive impairment and the Mg/K ratio in MNC. When we assessed the philothermal response of granulocytes, a significant correlation was observed in demented subjects between the migration rate of PMNs and the PMN Mg/K ratio.

Mesenteric cyst neoformation. A case report.

Mesenteric cysts are rare lesions, with 1 case per 100,000 hospital admission reported. They have to be differentiated from ovarian cysts, gastrointestinal duplications and desmoid cysts. The symptoms are variable, ranging from asymptomatic cases with incidental discovery to chronic abdominal discomfort and acute abdomen. They are usually correlated to the location and the size of the lesion. Abdominal ultrasonography and computed tomography may lead to a correct diagnosis, which is regularly made at the time of abdominal exploration. Surgery is the treatment of choice, consisting with the removal of the cyst, eventually associated with bowel resection. It has to be radical in order to prevent the recurrence of the disease. A case of mesenteric cyst in a sixty-nine-years-old woman hospitalized for chronic abdominal pain is reported. In this case the cyst has been enucleated from the mesentery with open surgery without the need for bowel resection.

[A nutrition survey of a group of athletes with particular reference to magnesium, zinc and copper intake, and to the relative intra- and extra-cellular levels]. / Indagine alimentare in un gruppo di sportivi con particolare riferimento agli introiti di magnesio, zinco e rame, ed ai relativi livelli intra ed extra cellulari.

The aim of the present study was to evaluate the dietary habits in a group of athletes (footballers) compared with sedentary subjects matched for sex, age and body mass index. All subjects kept a record of food eaten for seven consecutive days using various models for portion sizes. Daily nutrient intake was then computed and was expressed as either total intake, or percent of the recommended daily dietary allowances (LARN). For each subject, a 20-ml blood sample and a 24h urine sample was collected for analysis of magnesium, zinc and copper. The three elements were measured both in plasma and in erythrocytes, monocytes and neutrophils. The athletes eat significantly more sheets than controls (22.5% of total kcal vs 15.2%, p less than 0.01) and significantly less cereals (22.5% vs 31.7%, p less than 0.01). Concerning the nutrient composition, in both groups the lipid intake was higher than that recommended and this trend was more pronounced in the athletes (+ 43.2% vs + 16.1% in the controls). In addition, the diet was particularly rich in animal fats with a mean intake of 21.0% of total kcal in the athletes and 20.9% in the sedentary group (recommended value was 12.5% and 14%, respectively). A parallel reduction in vegetal protein intake was observed in the trained group, and the difference was significant (4.3% of kcal in the athletes and 5.2% in the controls, p less than 0.01). Furthermore, in the athletes the soluble carbohydrate intake was higher than the recommended levels (+ 110%) and significantly higher than that eaten by the controls (21.0% vs 16.4% of kcal, p less than 0.01), with parallel decrease of polysaccharides intake.(ABSTRACT TRUNCATED AT 250 WORDS)