Tissue Oximetry as a Potential Alternative to Indocyanine Green (ICG) Perfusion Assessment in Colorectal Anastomotic Cases.

INTRODUCTION: Anastomotic margin tissue perfusion is recognized as critical to successful colorectal anastomosis creation. Near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) is the most common modality used by surgeons as an adjunct to clinical assessment in confirming the adequacy of tissue perfusion. Tissue oxygenation as a surrogate for tissue perfusion has been described in a variety of surgical specialties but its use in colorectal surgery has been limited. Here, we report our experience using a handheld tissue-oxygen meter, IntraOx, for the evaluation of colorectal tissue bed oxygen saturation (StO 2 ) and compared its utility with NIR-ICG in identifying the viability of colonic tissue before anastomosis in a range of colorectal procedures. MATERIALS AND METHODS: This was an institutional review board-approved multicenter trial consisting of 100 patients undergoing elective colon resections. After specimen mobilization, a clinical margin was chosen based on the oncologic, anatomic, and clinical assessment as per the clinicians' standard technique. The IntraOx device was then used to take a baseline reading of colonic tissue oxygenation on a normal segment of perfused colon. Following this, measurements were taken circumferentially at 5 cm intervals along the bowel proximally and distally to the clinical margin. A StO 2 margin was then determined based on the point at which the StO 2 dropped off by ≥10 percentage points. This was then compared with the NIR-ICG margin using the Spy-Phi system. RESULTS: StO 2 was found to have a sensitivity and specificity of 94.8% and 93.1%, respectively, and a positive predictive value and negative predictive value of 93.5% and 94.5%, respectively when compared with NIR-ICG. At the 4-week follow-up, no significant complications or leaks were reported. CONCLUSIONS: The IntraOx handheld device was found to be similar to NIR-ICG in identifying a well-perfused margin of colonic tissue while having the added benefits of high portability and reduced costs. Further studies looking at the effect of the IntraOx on preventing colonic anastomotic complications such as leak and stricture are warranted.

Parent wellbeing, family screen time and socioeconomic status during early childhood predict physical activity of Aboriginal and Torres Strait Islander children at ages 8-13.

OBJECTIVES: Physical activity is holistically linked to culture and wellbeing among Aboriginal and Torres Strait Islander peoples, the First Nation Peoples of Australia. Socioecological correlates of high physical activity among Indigenous children include living in a remote area and low screen time but little is known about early life determinants of physical activity. This paper examines sociodemographic, family, community, cultural, parent social and emotional wellbeing determinants of physical activity among Aboriginal and Torres Strait Islander children. DESIGN: Longitudinal cohort study. METHODS: The Longitudinal Study of Indigenous Children, the largest First Nations child cohort study in the world, primarily collects data through parental report. Multiple logistic regression analyses examined Wave 1 (age 0-5 years) predictors of achieving ≥1 h/day of physical activity at Wave 9 (aged 8-13 years). RESULTS: Of the 1181 children, 596 (50.5 %) achieved ≥1 h of physical activity every day. Achieving ≥1 h/day of physical activity at Wave 9 was associated with the following Wave 1 determinants: high parent social and emotional wellbeing (resilience; adjusted odds ratio 1.87 (95 % confidence interval: 1.32-2.65)), living in remote (odds ratio 3.66 (2.42-5.54)), regional (odds ratio 2.98 (2.13-4.18)) or low socioeconomic areas (odds ratio 1.85 (1.08-3.17)), main source of family income not wages/salaries (odds ratio 0.66 (0.46-0.97)), and if families played electronic games (odds ratio 0.72 (0.55-0.94)). CONCLUSIONS: To achieve high physical activity levels among Aboriginal and Torres Strait Islander children, high parental culture specific social and emotional wellbeing and low family screen time in early life may compensate for apparently low socio-economic circumstances, including living in remote areas.

The use of tissue oxygen measurements compared to indocyanine green imaging for the assessment of intraoperative tissue viability of human bowel.

BACKGROUND: Adequate tissue oxygenation and perfusion remain fundamental to safe bowel resection surgery. Near infrared (NIR) imaging using indocyanine green has proven itself superior to clinical evaluation alone in assessing bowel perfusion, but requires expensive equipment not readily available in many centers. METHODS: We studied the IntraOx device (Vioptix Inc, Newark, CA USA), a handheld, tissue oxygen saturation assessment tool, to assess whether tissue bed oxygen saturation (StO2) is comparable to NIR assessment of bowel viability. Patients undergoing elective colon resection for benign and malignant disease were included. After choosing a clinical margin (CM) and dividing the mesentery, StO2 was measured at 5-cm intervals along the colon. A tissue oxygen saturation margin (TOM) was assigned where StO2 dropped off by at least 10 percentage points. NIR perfusion was then assessed to determine NIR margin (NIRM). Intraoperative and postoperative data were collected. RESULTS: 32 consecutive patients undergoing colectomies were analyzed. IntraOx sensitivity was 90.6%, specificity was 94.3%. The mean StO2 difference across the NIRM was 23.1%. In all but one case, the TOM matched the NIRM. In 3 cases, the TOM and NIRM concurred, but were a mean of 3.3 cm proximal to the CM and altered the surgical plan. At 4-week follow-up, no significant complications were reported. CONCLUSIONS: The IntraOx device consistently identified a margin of significant saturation "drop-off" which correlated with the findings on NIR perfusion and clinical assessment. These early data indicate that StO2 measurement may be equivalent to NIR assessment of bowel perfusion. In addition, the IntraOx device may be a more cost-effective solution for surgeons looking for adjunctive evaluation of bowel viability. More study is warranted in a larger group of patients to confirm these preliminary findings and to judge the impact of StO2 assessment on reducing anastomotic leaks.

Fluorescence-guided surgery of the esophagus.

The use of indocyanine green (ICG) fluorescence near-infrared (NIR) imaging during gastrointestinal surgery has surged in recent years. Its use in esophageal surgery is actively being studied both in the clinical setting and in the lab. NIR imaging has several important applications in esophageal surgery including assessing perfusion of the gastrointestinal-esophageal anastomosis, lymphatic drainage and tracheal blood flow after mediastinal dissection. This is a review of the modern literature summarizing the current knowledge on fluorescence-guided surgery of the esophagus.

Rapid Adoption of an Interdisciplinary Care Team Model for Surgical Residents Managing Coronavirus Disease-19.

Introduction: Patients infected with SARS-Cov-2, the causative virus behind the coronavirus disease-19 (COVID-19) pandemic, have been increasing rapidly in New York City. New York City has the highest incidence in the United States and fully 45% of all deaths from COVID-19. Our medical center is located within a high-density region of cases in south Brooklyn and, in fact, three of our neighborhood zip codes are in the top seven in New York in incidence. As a result, our center has experienced a dramatic increase in hospitalizations, particularly respiratory distress secondary to COVID-19, which rapidly exceeded the capacity of our internal medicine service. This necessitated the formation of new COVID-19 units throughout the hospital, replacing all former service lines. These units employed management teams composed of residents from many medical and surgical disciplines, including general surgery residents. Methods: Our general surgery residency program established a surgical COVID-19 (SCOVID) management team. Initially, 4 surgical residents (2 senior and 2 junior), 1 attending surgeon, and 1 attending internal medicine physician were allocated to the initial SCOVID team. On day 3 of implementation, to achieve more rapid competence in the complex management of these patients, a senior medicine resident with direct experience in the care of COVID-19 patients was added in an advisory capacity. Results: The addition of an experienced senior medical resident and attending allowed for the quick adoption of uniform management protocols by surgical residents and attendings. Discussion: We describe a protocol for the establishment of COVID-19 management teams staffed with general surgical residents, as well as a strategy for the achievement of rapid increases in competency. The addition of a senior internal medicine resident and attending to our SCOVID team allowed for rapid achievement of competency in the care of COVID-19 patients in our large institution at the epicenter of the COVID-19 pandemic.

Effects of an Acute Physical Activity Break on Test Anxiety and Math Test Performance.

(1) Background: Test anxiety has been found to negatively affect students' mental health and academic performance. A primary explanation for this is that anxiety-related thoughts occupy working memory resources during testing that cannot be used for test-related processes (such as information retrieval and problem-solving). The present intervention study investigated whether physical activity could decrease anxiety levels and improve maths test performance in sixth-grade children. (2) Methods: Sixty-eight children of 11-12 years from two primary schools in New South Wales, Australia were categorised as low or high anxious from their scores on a trait-anxiety questionnaire. After this assessment, they were randomly assigned to the activity break condition, in which they had to do several physical activities of moderate intensity (i.e., star jumps) for 10 min, or the control condition, in which they played a vocabulary game for 10 min. The outcome measures were children's anxiety levels at the beginning, during, and at the end of the test, invested mental effort, perceived task difficulty and maths test performance. (3) Results: Results showed that regardless of the condition, low anxious students performed better on the maths test than high anxious children. No differences were found for any of the variables between the activity break condition and the control condition. (4) Conclusions: Although test anxiety was not reduced as expected, this study showed that short physical activity breaks can be used before examinations without impeding academic performance.

'Jump start' childcare-based intervention to promote physical activity in pre-schoolers: six-month findings from a cluster randomised trial.

BACKGROUND: Participation in adequate levels of physical activity during the early years is important for health and development. We report the 6-month effects of an 18-month multicomponent intervention on physical activity in early childhood education and care (ECEC) settings in low-income communities. METHODS: A cluster randomised controlled trial was conducted in 43 ECEC settings in disadvantaged areas of New South Wales, Australia. Three-year-old children were recruited and assessed in the first half of 2015 with follow-up 6 months later. The intervention was guided by Social Cognitive Theory and included five components. The primary outcome was minutes per hour in total physical activity during ECEC hours measured using Actigraph accelerometers. Intention-to-treat analysis of the primary outcome was conducted using a generalized linear mixed model. RESULTS: A total of 658 children were assessed at baseline. Of these, 558 (85%) had valid accelerometer data (mean age 3.38y, 52% boys) and 508 (77%) had valid accelerometry data at 6-month follow-up. Implementation of the intervention components ranged from 38 to 72%. There were no significant intervention effects on mins/hr. spent in physical activity (adjusted difference = - 0.17 mins/hr., 95% CI (- 1.30 to 0.97), p = 0.78). A priori sub-group analyses showed a greater effect among overweight/obese children in the control group compared with the intervention group for mins/hr. of physical activity (2.35mins/hr., [0.28 to 4.43], p = 0.036). CONCLUSIONS: After six-months the Jump Start intervention had no effect on physical activity levels during ECEC. This was largely due to low levels of implementation. Increasing fidelity may result in higher levels of physical activity when outcomes are assessed at 18-months. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614000597695.

Prevalence and risk factors of gross motor delay in pre-schoolers.

AIM: Gross motor skills are important for children's health and development. Delays in these skills are a concern for healthy developmental trajectories and therefore early identification of delay is important. This study screened for gross motor delay in children from low-income communities and investigated potential risk factors associated with gross motor delay. METHODS: This cross-sectional study involved 701 pre-schoolers (Mage = 54.1 ± 8.6 months, 52.8% boys) from childcare services in low-income and remote communities in Australia. Gross motor delay was assessed using the Ages and Stages Questionnaire - third edition. Potential risk factors included: sex, age, birthweight, prematurity status, weight status, childcare service, postcode, parent's education, parent's marital status, parent's employment and family income. RESULTS: Results showed 4.4% of the children were delayed in gross motor skills and 8.8% were at risk of delay. Logistic regression showed being a boy (odds ratio (OR) 1.78, 95% confidence interval (CI) 1.12-2.84), underweight (OR 2.72, 95% CI 1.18-6.30) or overweight (OR 1.83, 95% CI 1.00-3.33), and parental unemployment (OR 1.79, 95% CI 1.01-3.16) were factors associated with a higher odds of children being delayed or at risk of gross motor delay. A higher family income (OR 0.35, 95% CI 0.13-0.93) was associated with lower odds of delay. CONCLUSION: This unique study demonstrated children in low-income communities, especially boys, underweight and overweight children, have higher odds of being at risk of gross motor delay. Therefore, early screening is vital in this population in order to identify delays and potentially intervene with appropriate motor skill interventions.

A Narrative Review of School-Based Physical Activity for Enhancing Cognition and Learning: The Importance of Relevancy and Integration.

Engaging in regular physical activity can have substantial cognitive and academic benefits for children, and is generally promoted for its beneficial effects on children's physical and mental health. Although embodied cognition research has convincingly shown the integral relationship of the human body and mind, in schools physical activity and cognitive activity are typically treated as unrelated processes. Consequently, most physical activities used are neither sufficiently relevant for nor fully integrated into the learning tasks. In reviewing the literature regarding the integration of physical activity into education to promote cognition and learning, two main lines of research emerged: exercise and cognition research vs. embodied cognition research. In this narrative review, we describe these two separately evolved schools of thought, highlighting their differences and commonalities. In categorising the existing studies on a 2 × 2 matrix, concerning the two main categories of relevance for and integration into the learning task, it becomes clear where the different foci lie, and how both lines of research could profit from learning from each other. Finally, a new instructional model that integrates task-relevant physical activities into the cognitive/learning task is proposed to inform both further research and educational practice.

Adenomyomatous hyperplasia of distal common bile duct: a case report and review of the literature.

Adenomyomatous hyperplasia (AH) is commonly found in the gallbladder and is considered a tumor-like inflammatory lesion arising from Rokitansky-Aschoff sinus. It is extremely rare in the extrahepatic bile duct and only 15 cases have been reported to date. We describe a 63-year-old male patient who presented with cholangitis, underwent an extensive diagnostic workup, and ultimately had a Whipple procedure. Final pathology showed a 2.0 × 1.5 × 0.5 cm3 granular lesion in the distal common bile duct. There was prominent biliary epithelial proliferation with tubular-papillary architecture and minimal nuclear atypia in association with chronic inflammation, stroma reaction and smooth muscle proliferation. AH of the extrahepatic bile duct is a benign process but often requires a major operation to definitively diagnose.

Immediate and delayed effects of integrating physical activity into preschool children's learning of numeracy skills.

A cluster-randomized controlled trial was conducted to examine the effects of a 4-week program that integrated movements into cognitive tasks related to numerical skills. Participants (N = 120, Mage = 4.70 years, SD = 0.49; 57 girls) were assigned to one of the following four conditions: performing integrated physical activity (task relevant), performing nonintegrated physical activity (task nonrelevant), observing integrated physical activity, or conventional sedentary teaching (without performing or observing physical activity). Results showed that children who performed task-relevant integrated physical activity performed better than children in all other conditions. In addition, children who performed physical activity, either integrated or nonintegrated, reported higher scores for enjoyment of the instructional method than the two sedentary learning conditions. Implications for educational theory and practice are discussed.

Increasing physical activity among young children from disadvantaged communities: study protocol of a group randomised controlled effectiveness trial.

BACKGROUND: Participation in regular physical activity (PA) during the early years helps children achieve healthy body weight and can substantially improve motor development, bone health, psychosocial health and cognitive development. Despite common assumptions that young children are naturally active, evidence shows that they are insufficiently active for health and developmental benefits. Exploring strategies to increase physical activity in young children is a public health and research priority. METHODS: Jump Start is a multi-component, multi-setting PA and gross motor skill intervention for young children aged 3-5 years in disadvantaged areas of New South Wales, Australia. The intervention will be evaluated using a two-arm, parallel group, randomised cluster trial. The Jump Start protocol was based on Social Cognitive Theory and includes five components: a structured gross motor skill lesson (Jump In); unstructured outdoor PA and gross motor skill time (Jump Out); energy breaks (Jump Up); activities connecting movement to learning experiences (Jump Through); and a home-based family component to promote PA and gross motor skill (Jump Home). Early childhood education and care centres will be demographically matched and randomised to Jump Start (intervention) or usual practice (comparison) group. The intervention group receive Jump Start professional development, program resources, monthly newsletters and ongoing intervention support. Outcomes include change in total PA (accelerometers) within centre hours, gross motor skill development (Test of Gross Motor Development-2), weight status (body mass index), bone strength (Sunlight MiniOmni Ultrasound Bone Sonometer), self-regulation (Heads-Toes-Knees-Shoulders, executive function tasks, and proxy-report Temperament and Approaches to learning scales), and educator and parent self-efficacy. Extensive quantitative and qualitative process evaluation and a cost-effectiveness evaluation will be conducted. DISCUSSION: The Jump Start intervention is a unique program to address low levels of PA and gross motor skill proficiency, and support healthy lifestyle behaviours among young children in disadvantaged communities. If shown to be efficacious, the Jump Start approach can be expected to have implications for early childhood education and care policies and practices, and ultimately a positive effect on the health and development across the life course. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry No: ACTRN12614000597695 , first received: June 5, 2014.

Battling the challenges of training nurses to use information systems through theory-based training material design.

The attempts to train nurses to effectively use information systems have had mixed results. One problem is that training materials are not adequately designed to guide trainees to gradually learn to use a system without experiencing a heavy cognitive load. This is because training design often does not take into consideration a learner's cognitive ability to absorb new information in a short training period. Given the high cost and difficulty of organising training in healthcare organisations, there is an urgent need for information system trainers to be aware of how cognitive overload or information overload affect a trainee's capability to acquire new knowledge and skills, and what instructional techniques can be used to facilitate effective learning. This paper introduces the concept of cognitive load and how it affects nurses when learning to use a new health information system. This is followed by the relevant strategies for instructional design, underpinned by the principles of cognitive load theory, which may be helpful for the development of effective instructional materials and activities for training nurses to use information systems.

The effect of written text on comprehension of spoken English as a foreign language.

Based on cognitive load theory, this study investigated the effect of simultaneous written presentations on comprehension of spoken English as a foreign language. Learners' language comprehension was compared while they used 3 instructional formats: listening with auditory materials only, listening with a full, written script, and listening with simultaneous subtitled text. Listening with the presence of a script and subtitles led to better understanding of the scripted and subtitled passage but poorer performance on a subsequent auditory passage than listening with the auditory materials only. These findings indicated that where the intention was learning to listen, the use of a full script or subtitles had detrimental effects on the construction and automation of listening comprehension schemas.

When redundant on-screen text in multimedia technical instruction can interfere with learning.

It is frequently assumed that presenting the same material in written and spoken form benefits learning and understanding. The present work provides a theoretical justification based on cognitive load theory, and empirical evidence based on controlled experiments, that this assumption can be incorrect. From a theoretical perspective, it is suggested that if learners are required to coordinate and simultaneously process redundant material such as written and spoken text, an excessive working memory load is generated. Three experiments involving a group of 25 technical apprentices compared the effects of simultaneously presenting the same written and auditory textual information as opposed to either temporally separating the two modes or eliminating one of the modes. The first two experiments demonstrated that nonconcurrent presentation of auditory and visual explanations of a diagram proved superior, in terms of ratings of mental load and test scores, to a concurrent presentation of the same explanations when instruction time was constrained. The 3rd experiment demonstrated that a concurrent presentation of identical auditory and visual technical text (without the presence of diagrams) was significantly less efficient in comparison with an auditory-only text. Actual or potential applications of this research include the design and evaluation of multimedia instructional systems and audiovisual displays.