Electronic survey investigating UK veterinarians' perceptions of the potential for veterinary prescription medication misuse or abuse.

OBJECTIVE: To investigate veterinarians' experience and perception of the risk of veterinary prescription medication (VPM) misuse and abuse by the public and veterinary professionals and to determine the clinical context in which respondent veterinarians prescribed certain VPMs. STUDY DESIGN: Anonymous online voluntary survey. POPULATION: A total of 361 of 7126 veterinarians registered as practicing in the UK, who provided e-mail contact details to the Royal College of Veterinary Surgeons Knowledge for participation in research. Respondents included general practitioners, with or without further qualifications, and European specialists, covering charity, private or academic small, large or mixed animal practice. METHODS: The anonymous online survey, open from September to December 2021, posed 27 questions regarding personal experience and perception of VPM misuse or abuse, including which VPMs were considered most at risk of abuse by clients or veterinary staff. Thematic analysis was performed on free-text sections. RESULTS: The participation rate was 5% (361/7126), and the completion rate 60% (216/361 respondents). Of these, 88% of respondents somewhat agreed, agreed or strongly agreed that some VPMs were at risk of abuse. A third (29.9%; 107/358) had suspected an owner of taking VPMs, and one fifth (20.1%; 72/358) had suspected veterinary staff. Perceptions regarding the likelihood of public VPM abuse ranged from not suspecting a problem to having first-hand experience. Drugs considered most at risk of owner abuse were opioids, benzodiazepines and gabapentin, and those for veterinary staff were opioids, benzodiazepines and ketamine. Numerous 'red flags' prompting suspicion of VPM abuse were identified alongside ways of mitigating risk. CONCLUSIONS AND CLINICAL RELEVANCE: Veterinarians in the UK reported varied experiences with, awareness of, and attitudes towards VPM abuse by the public and veterinary staff. Although not quantified, the UK veterinary industry could be a source of abusable drugs.

Safety and efficacy of stereotactic body proton therapy for high-risk lung tumors.

Purpose: Stereotactic body proton therapy (SBPT) is an emerging treatment strategy for lung tumors that aims to combine the excellent local control benefits of ultra-hypofractionation with the physical advantages of protons, which reduce the integral dose to organs at risk (OARs) compared to photons. To date, however, very little data delivering SBPT in 5 or fewer fractions to lung tumors have been reported. Given that photon stereotactic body radiation therapy can struggle to deliver ablative doses to high-risk tumors (i.e., central/ultra-central location, prior in-field radiation, tumor size >5 cm, or the presence of severe pulmonary comorbidities) while adhering to OAR dose constraints, we hypothesized that SBPT would be an effective alternative for patients with high-risk tumors. Methods and Materials: Twenty-seven high-risk patients with 29 lung tumors treated with SBPT at the New York Proton Center between December 2019 and November 2022 were retrospectively identified. Patients were divided into three major subgroups: early-stage non-small cell lung cancer (NSCLC), locally recurrent NSCLC, and metastatic cancer from lung cancer or other histologies. Patient characteristics were reported using descriptive statistics, actuarial methods were used to quantify disease control rates, and toxicities were scored using CTCAE v 5.0. Results: The most common high-risk indications for SBPT were central/ultra-central tumor location (69.0%), severe COPD (48.1%), reirradiation (44.4%), significant pulmonary fibrosis (22.2%), and large tumor size > 5 cm (18.5%). In total, 96.6% of tumors were fully covered by the prescription dose without compromising target coverage. Three-year actuarial rates of local control for early-stage NSCLC, locally recurrent NSCLC, and metastatic patients were 89%, 100%, and 43%, respectively. Three-year actuarial rates of regional control were 89%, 67%, and 86%. Three-year actuarial rates of distant metastasis-free survival were 79%, 100%, and 0%. Two patients (7.4%), both of whom had clinically significant baseline interstitial lung disease and pre-treatment continuous oxygen demand, experienced grade ≥2 pulmonary toxicity (1 grade 3, 1 grade 5). There were no acute or late grade ≥2 toxicities related to esophagitis, cardiac injury, airway injury, pulmonary fibrosis, bronchopulmonary hemorrhage or brachial plexopathy. Conclusions: In the largest study of proton SBRT reported to date, SBPT has a favorable toxicity profile while being an effective approach for treating most high-risk tumors without requiring dose de-escalation or compromising tumor coverage and warrants further investigation.

Stereotactic body proton therapy for non-small cell lung cancer: Clinical indications and recommendations.

Stereotactic body radiation therapy (SBRT) has emerged as a standard treatment approach for early-stage lung cancer and intrathoracic oligometastatic or oligoprogressive disease. While local control is often excellent with this modality when delivered with photon therapy, toxicities for select patients can be significant. Proton therapy offers a unique opportunity to widen the therapeutic window when treating patients with thoracic malignancies requiring or benefitting from ultra-high doses per fraction. Thoracic proton SBRT may be particularly beneficial in cases requiring dose escalation, for tumors >5 cm, for central or ultra-central tumors, for reirradiation, in patients with interstitial lung diseases, and when combining radiation with immunotherapy. These clinical indications are detailed, along with supporting literature and clinical recommendations. Other considerations, future directions and potential benefits of proton SBRT, including sparing lymphocytes, when delivered as intensity-modulated proton therapy or as FLASH, and for the treatment of locally advanced non-small cell lung cancer or in patients with homologous recombination repair deficiencies, are also discussed.

Prescribe, Review, Now!: an assessment of adequate PRN analgesia and associated laxative prescribing using Hospital Electronic Prescribing and Medicines Administration (HEPMA).

INTRODUCTION: On HEPMA there is no way to notify a prescriber if patients are regularly accessing PRN (as-required) analgesia. We aimed to assess how well PRN analgesia use is identified, the WHO analgesic ladder and whether laxatives were prescribed with opioid analgesia. METHODS: 3 data collection cycles were carried out for all medical inpatients between February-April 2022. Medication was reviewed to determine: 1) PRN analgesia prescribed? 2) Is the patient accessing it >3 times in 24hours? 3) Con-current laxatives prescribed. Between each cycle, an intervention was implemented. Intervention 1: Posters were placed on each ward and circulated electronically as a cue to a review and change analgesia "Prescribe. REVIEW: Now!" Intervention 2: A presentation on data, the WHO analgesic ladder and laxative prescribing was created, and circulated. RESULTS: See Figure 1 - Comparison of prescribing per cycle. Cycle 1 - 167 inpatients surveyed, 58%female, 42%male, mean age 78(±13.4). Cycle 2 - 159 inpatients,65% female, 35% male, mean age of 77 (±15.7). Cycle 3 - 157 inpatients, 62% female, 38% male, mean age 78 (±15.7). Adequate prescriptions on HEPMA improved by a total of 31% (p<0.005), over 3 cycles and 2 interventions. CONCLUSIONS: After each intervention there was a significant statistical improvement in prescribing analgesia and laxatives. However, there is still room for further improvement, especially in ensuring adequate laxative cover is prescribed for all patients either >65 years old, or those on opioid-based analgesia. Visual reminders on wards of regularly checking PRN medication showed to be an effective intervention.

Local Therapy for Oligoprogressive Disease: A Systematic Review of Prospective Trials.

PURPOSE: The successes of local therapy for oligometastatic cancers cannot be extrapolated to oligoprogressive disease (OPD) because they are distinct clinical entities. Given the limited prospective data on OPD to date, summative analyses are urgently needed. METHODS AND MATERIALS: Inclusion criteria for this Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review were as follows. First, only prospective data were included. Second, progression had to have occurred on active/ongoing systemic therapy. Third, the number of progressing areas of disease had to be explicitly listed and ≤5 in number. Fourth, all progressing sites had to undergo local therapy (radiation therapy [RT] /surgery/nonradiation ablative procedures). RESULTS: Eight trials met criteria (summing 290 patients), the vast majority of which used stereotactic RT as the local modality (most commonly, 19-20 Gy in 1 fraction, 27-33 Gy in 3 fractions, or 35-50 Gy in 5 fractions). A study on non-small cell lung cancer (NSCLC) demonstrated that stereotactic RT improved progression-free survival (PFS) and overall survival compared with historical values with systemic therapy alone. Two additional studies on epidermal growth factor receptor mutated (EGFRm) NSCLC also showed acceptable PFS with local therapy, particularly in patients who oligoprogressed on osimertinib. The only randomized trial analyzed herein showed that local therapy improved PFS for NSCLC but not breast cancer. Two trials in castration-resistant prostate cancer illustrated that a substantial proportion of patients did not require any changes in hormonal therapy or delayed the need to change systemic therapies. Lastly, 2 trials of renal cell carcinoma showed high (90%-100%) local control and median PFS of 9 months, and potentially a prolonged time to change systemic therapy. Lastly, from all patients in all trials, local therapy was tolerated well, with only 7 instances of grade 3+ toxicities. CONCLUSIONS: Based on the limited data, local therapy for oligoprogression is safe and yields encouraging short-term preliminary outcomes, but trials with larger sample sizes and longer follow-up are required for more robust conclusions.

DNA-PK Inhibition and Radiation Promote Antitumoral Immunity through RNA Polymerase III in Pancreatic Cancer.

Targeting the DNA damage response in combination with radiation enhances type I interferon (T1IFN)-driven innate immune signaling. It is not understood, however, whether DNA-dependent protein kinase (DNA-PK), the kinase critical for repairing the majority of radiation-induced DNA double-strand breaks in cancer cells, is immunomodulatory. We show that combining radiation with DNA-PK inhibition increases cytosolic double-stranded DNA and tumoral T1IFN signaling in a cyclic GMP-AMP synthase (cGAS)- and stimulator of interferon genes (STING)-independent, but an RNA polymerase III (POL III), retinoic acid-inducible gene I (RIG-I), and antiviral-signaling protein (MAVS)-dependent manner. Although DNA-PK inhibition and radiation also promote programmed death-ligand 1 (PD-L1) expression, the use of anti-PD-L1 in combination with radiation and DNA-PK inhibitor potentiates antitumor immunity in pancreatic cancer models. Our findings demonstrate a novel mechanism for the antitumoral immune effects of DNA-PK inhibitor and radiation that leads to increased sensitivity to anti-PD-L1 in poorly immunogenic pancreatic cancers. IMPLICATIONS: Our work nominates a novel therapeutic strategy as well as its cellular mechanisms pertinent for future clinical trials combining M3814, radiation, and anti-PD-L1 antibody in patients with pancreatic cancer.

Injury and Injury Prevention in United States Para Swimming: A Mixed-Methods Approach.

BACKGROUND: Para swimming has experienced increased participation in recent years. Injury and injury prevention research on Para swimmers is lacking compared to swimmers without impairment. PURPOSE: This study aimed to gather data in Para swimmers on typical injuries, injury prevention programs, and attitudes toward injury and injury prevention in this population. STUDY DESIGN: Cross-sectional, mixed-methods design evaluating injuries, injury management, and injury prevention in elite Para swimmers in United States (U.S.). METHODS: Para swimmers on the U.S. Paralympics Swimming National teams at multiple competition levels were invited to complete an online survey. Qualitative interviews with six U.S. Paralympics National team Para swimmers were conducted to provide detail on athlete experiences with injury and prevention. RESULTS: Twenty-one of 56 surveys were returned: 11 of 21 participants (52.4%) reported experiencing an injury that altered their weekly training. All (21/21) reported participating in strength training and 19 of 21 (90.5%) reported incorporating stretching into their training regimen, although strengthening/stretching regimens included routines that may not have been specifically targeted toward injury prevention. Six of 21 (28.6%) reported participation in an injury prevention program. Qualitative interview themes included the impact of swimmers' compensated body mechanics on injury risk, the value of individualized injury prevention programs, and the importance of knowledgeable coaching and rehabilitation staff. CONCLUSIONS: Injury prevention programs are important components in Para swimming training although they are underutilized based on responses in this study. These programs should be individualized to address swimming biomechanics and athlete-specific impairments. Increasing coaching knowledge and access to individualized programs may reduce injury prevalence among this at-risk population. LEVEL OF EVIDENCE: 3.

The Fistula Risk Score Catalog: Toward Precision Medicine for Pancreatic Fistula After Pancreatoduodenectomy.

OBJECTIVE: This study aims to present a full spectrum of individual patient presentations of pancreatic fistula risk, and to define the utility of mitigation strategies amongst some of the most prevalent, and vulnerable scenarios surgeons encounter. BACKGROUND: The FRS has been utilized to identify technical strategies associated with reduced CR-POPF incidence across various risk strata. However, risk-stratification using the FRS has never been investigated with greater granularity. By deriving all possible combinations of FRS elements, individualized risk assessment could be utilized for precision medicine purposes. METHODS: FRS profiles and outcomes of 5533 PDs were accrued from 17 international institutions (2003-2019). The FRS was used to derive 80 unique combinations of patient "scenarios." Risk-matched analyses were conducted using a Bonferroni adjustment to identify scenarios with increased vulnerability for CR-POPF occurrence. Subsequently, these scenarios were analyzed using multivariable regression to explore optimal mitigation approaches. RESULTS: The overall CR-POPF rate was 13.6%. All 80 possible scenarios were encountered, with the most frequent being scenario #1 (8.1%) - the only negligible-risk scenario (CR-POPF rate = 0.7%). The moderate-risk zone had the most scenarios (50), patients (N = 3246), CR-POPFs (65.2%), and greatest non-zero discrepancy in CR-POPF rates between scenarios (18-fold). In the risk-matched analysis, 2 scenarios (#59 and 60) displayed increased vulnerability for CR-POPF relative to the moderate-risk zone (both P < 0.001). Multivariable analysis revealed factors associated with CR-POPF in these scenarios: pancreaticogastrostomy reconstruction [odds ratio (OR) 4.67], omission of drain placement (OR 5.51), and prophylactic octreotide (OR 3.09). When comparing the utilization of best practice strategies to patients who did not have these conjointly utilized, there was a significant decrease in CR-POPF (10.7% vs 35.5%, P < 0.001; OR 0.20, 95% confidence interval 0.12-0.33). CONCLUSION: Through this data, a comprehensive fistula risk catalog has been created and the most clinically-impactful scenarios have been discerned. Focusing on individual scenarios provides a practical way to approach precision medicine, allowing for more directed and efficient management of CR-POPF.

Extended Experience with a Dynamic, Data-Driven Selective Drain Management Protocol in Pancreaticoduodenectomy: Progressive Risk Stratification for Better Practice.

BACKGROUND: Intraoperative drain use for pancreaticoduodenectomy has been practiced in an unconditional, binary manner (placement/no placement). Alternatively, dynamic drain management has been introduced, incorporating the Fistula Risk Score (FRS) and drain fluid amylase (DFA) analysis, to mitigate clinically relevant postoperative pancreatic fistula (CR-POPF). STUDY DESIGN: An extended experience with dynamic drain management was used at a single institution for 400 consecutive pancreaticoduodenectomies (2014 to 2019). This protocol consists of the following: drains omitted for negligible/low-risk FRS (0 to 2) and drains placed for moderate/high-risk FRS (3 to 10) with early (postoperative day [POD] 3) removal if POD1 DFA ≤5,000 U/L. Adherence to this protocol was prospectively annotated and outcomes were retrospectively analyzed. RESULTS: The overall CR-POPF rate was 8.7%, with none occurring in the negligible/low-risk cases. Moderate/high-risk patients manifested an 11.9% CR-POPF rate (n = 35 of 293), which was lower on-protocol (9.5% vs 21%; p = 0.014). After drain placement, POD1 DFA ≥5,000 U/L was a better predictor of CR-POPF than FRS (odds ratio 14.7; 95% CI, 4.3 to 50.3). For POD1 DFA ≤5,000 U/L, early drain removal was associated with fewer CR-POPFs (2.8% vs 23.5%; p < 0.001), and substantiated by multivariable analysis (odds ratio 0.09; 95% CI, 0.03 to 0.28). Surgeon adherence was inversely related to CR-POPF rate (R = 0.846). CONCLUSIONS: This extended experience validates a dynamic drain management protocol, providing a model for better drain management and individualized patient care after pancreaticoduodenectomy. This study confirms that drains can be safely omitted from negligible/low-risk patients, and moderate/high-risk patients benefit from early drain removal.

Survey on conduct of anaesthetic monitoring in small animal practice in the UK.

BACKGROUND: An online survey was used to investigate current anaesthetic monitoring practices and the confidence level of personnel monitoring anaesthetics in small animal practices within the UK. METHODS: Veterinary surgeons (VSs), registered veterinary nurses (RVNs) and student veterinary nurses (SVNs) working in the UK were invited to participate in an anonymous, internet-based survey. To gather data, the questions used free text, multiple choice or scales measuring respondent attitude or opinion. No questions were mandatory and data were analysed with descriptive statistics or inductive thematic analysis. RESULTS: 524 valid surveys were completed and included in the data analysis (VS n=136, RVN n=307, SVN n=81). The results indicated mainly RVNs perform pre-anaesthetic monitoring equipment checks, set-up the monitoring equipment and monitor anaesthesia and are more confident than VSs monitoring anaesthetics. VSs, RVNs and SVNs were all recognised to interpret and address changes in parameters monitored. Critical tasks pertaining to anaesthetic monitoring are being performed by personnel other than a VS, RVN or SVN. Respondents recognised the importance of monitoring in relation to patient outcome; however, a considerable proportion of respondents indicated that improving standards of monitoring was not a priority in their practice. Most respondents felt that standards of monitoring could be improved and that financial constraints were the major factor limiting improvement. Most respondents felt they would benefit from further training in anaesthetic monitoring. CONCLUSION: Variability exists in how anaesthetic monitoring is conducted. Workplace pressures afflicting veterinary staff can influence the conduct of anaesthetic monitoring and initiating change within a veterinary practice can be difficult.

Decoding Grade B Pancreatic Fistula: A Clinical and Economical Analysis and Subclassification Proposal.

OBJECTIVE: The aim of this study was to describe characteristics and management approaches for grade B pancreatic fistula (B-POPF) and investigate whether it segregates into distinct subclasses. BACKGROUND: The 2016 ISGPS refined definition of B-POPF is predicated on various postoperative management approaches, ranging from prolonged drainage to interventional procedures, but the spectrum of clinical severity within this entity is yet undefined. METHODS: Pancreatectomies performed at 2 institutions from 2007 to 2016 were reviewed to identify B-POPFs and their treatment strategies. Subclassification of B-POPFs into 3 classes was modeled after the Fistula Accordion Severity Grading System (B1: prolonged drainage only; B2: pharmacologic management; B3: interventional procedures). Clinical and economic outcomes, unique from the ISGPS definition qualifiers, were analyzed across subclasses. RESULTS: B-POPF developed in 320 of 1949 patients (16.4%), and commonly required antibiotics (70.3%), prolonged drainage (67.8%), and enteral/parenteral nutrition (54.7%). Percutaneous drainage occurred in 79 patients (24.7%), always in combination with other strategies. Management of B-POPFs was widely heterogeneous with a median of 2 approaches/patient (range 1 to 6) and 38 various strategy combinations used. Subclasses B1-3 comprised 19.1%, 52.2%, and 28.8% of B-POPFs, respectively, and were associated with progressively worse clinical and economic outcomes. These results were confirmed by multivariable analysis adjusted for clinical and operative factors. Notably, distribution of the B-POPF subclasses was influenced by institution and type of resection (P < 0.001), while clinical/demographic predictors proved elusive. CONCLUSION: B-POPF is a heterogeneous entity, where 3 distinct subclasses with increasing clinical and economic burden can be identified. This classification framework has potential implications for accurate reporting, comparative research, and performance evaluation.

Ethical dilemmas in clinical practice: a perspective on the results of an electronic survey of veterinary anaesthetists.

Medical progress has greatly advanced our ability to manage animals with critical and terminal diseases. We now have the ability to sustain life even in the most dire of circumstances. However, the preservation of life may not be synonymous with providing 'quality of life', and worse, could cause unnecessary suffering. Using the results of an electronic survey, we aim to outline and give examples of ethical dilemmas faced by veterinary anaesthetists dealing with critically ill animals, how the impact of these dilemmas could be mitigated, and what thought processes underlie decision-making in such situations.

Ipsilesional Mu Rhythm Desynchronization and Changes in Motor Behavior Following Post Stroke BCI Intervention for Motor Rehabilitation.

Loss of motor function is a common deficit following stroke insult and often manifests as persistent upper extremity (UE) disability which can affect a survivor's ability to participate in activities of daily living. Recent research suggests the use of brain-computer interface (BCI) devices might improve UE function in stroke survivors at various times since stroke. This randomized crossover-controlled trial examines whether intervention with this BCI device design attenuates the effects of hemiparesis, encourages reorganization of motor related brain signals (EEG measured sensorimotor rhythm desynchronization), and improves movement, as measured by the Action Research Arm Test (ARAT). A sample of 21 stroke survivors, presenting with varied times since stroke and levels of UE impairment, received a maximum of 18-30 h of intervention with a novel electroencephalogram-based BCI-driven functional electrical stimulator (EEG-BCI-FES) device. Driven by spectral power recordings from contralateral EEG electrodes during cued attempted grasping of the hand, the user's input to the EEG-BCI-FES device modulates horizontal movement of a virtual cursor and also facilitates concurrent stimulation of the impaired UE. Outcome measures of function and capacity were assessed at baseline, mid-therapy, and at completion of therapy while EEG was recorded only during intervention sessions. A significant increase in r-squared values [reflecting Mu rhythm (8-12 Hz) desynchronization as the result of attempted movements of the impaired hand] presented post-therapy compared to baseline. These findings suggest that intervention corresponds with greater desynchronization of Mu rhythm in the ipsilesional hemisphere during attempted movements of the impaired hand and this change is related to changes in behavior as a result of the intervention. BCI intervention may be an effective way of addressing the recovery of a stroke impaired UE and studying neuromechanical coupling with motor outputs. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT02098265.

The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy.

OBJECTIVE: The aim of this study was to elucidate the impact of intraoperative blood loss on outcomes following pancreatoduodenectomy (PD). BACKGROUND: The negative impact of intraoperative blood loss on outcomes in PD has long been suspected but not well characterized, particularly those factors that may be within surgeons' control. METHODS: From 2001 to 2015, 5323 PDs were performed by 62 surgeons from 17 institutions. Estimated blood loss (EBL) was discretized (0 to 300, 301 to 750, 751 to 1300, and >1300 mL) using optimal scaling methodology. Multivariable regression, adjusted for patient, surgeon, and institutional variables, was used to identify associations between EBL and perioperative outcomes. Factors associated with both increased and decreased EBL were elucidated. The relative impact of surgeon-modifiable contributors was estimated through beta coefficient standardization. RESULTS: The median EBL of the series was 400 mL [interquartile range (IQR) 250 to 600]. Intra-, post-, and perioperative transfusion rates were 15.8%, 24.8%, and 37.2%, respectively. Progressive EBL zones correlated with intra- but not postoperative transfusion in a dose-dependent fashion (P < 0.001), with a key threshold of 750 mL EBL (8.14% vs 40.9%; P < 0.001). Increasing blood loss significantly correlated with poor perioperative outcomes. Factors associated with increased EBL were trans-anastomotic stent placement, neoadjuvant chemotherapy, pancreaticogastrostomy reconstruction, multiorgan or vascular resection, and elevated operative time, of which 38.7% of the relative impact was "potentially modifiable" by the surgeon. Conversely, female sex, small duct, soft gland, minimally invasive approach, pylorus-preservation, biological sealant use, and institutional volume (≥67/year) were associated with decreased EBL, of which 13.6% was potentially under the surgeon's influence. CONCLUSION: Minimizing blood loss contributes to fewer intraoperative transfusions and better perioperative outcomes for PD. Improvements might be achieved by targeting modifiable factors that influence EBL.

Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy: Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group.

OBJECTIVE: To identify a clinical fistula risk score following distal pancreatectomy. BACKGROUND: Clinically relevant pancreatic fistula (CR-POPF) following distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to reduce its occurrence remain elusive. METHODS: This multinational, retrospective study of 2026 DPs involved 52 surgeons at 10 institutions (2001-2016). CR-POPFs were defined by 2016 International Study Group criteria, and risk models generated using stepwise logistic regression analysis were evaluated by c-statistic. Mitigation strategies were assessed by regression modeling while controlling for identified risk factors and treating institution. RESULTS: CR-POPF occurred following 306 (15.1%) DPs. Risk factors independently associated with CR-POPF included: age (<60 yrs: OR 1.42, 95% CI 1.05-1.82), obesity (OR 1.54, 95% CI 1.19-2.12), hypoalbuminenia (OR 1.63, 95% CI 1.06-2.51), the absence of epidural anesthesia (OR 1.59, 95% CI 1.17-2.16), neuroendocrine or nonmalignant pathology (OR 1.56, 95% CI 1.18-2.06), concomitant splenectomy (OR 1.99, 95% CI 1.25-3.17), and vascular resection (OR 2.29, 95% CI 1.25-3.17). After adjusting for inherent risk between cases by multivariable regression, the following were not independently associated with CR-POPF: method of transection, suture ligation of the pancreatic duct, staple size, the use of staple line reinforcement, tissue patches, biologic sealants, or prophylactic octreotide. Intraoperative drainage was associated with a greater fistula rate (OR 2.09, 95% CI 1.51-3.78) but reduced fistula severity (P < 0.001). CONCLUSIONS: From this large analysis of pancreatic fistula following DP, CR-POPF occurrence cannot be reliably predicted. Opportunities for developing a risk score model are limited for performing risk-adjusted analyses of mitigation strategies and surgeon performance.

Identification of an Optimal Cut-off for Drain Fluid Amylase on Postoperative Day 1 for Predicting Clinically Relevant Fistula After Distal Pancreatectomy: A Multi-institutional Analysis and External Validation.

OBJECTIVE: The aim of this study was to investigate the relationship between drain fluid amylase value on the first postoperative day (DFA1) and clinically relevant fistula (CR-POPF) after distal pancreatectomy (DP), and to identify the cut-off of DFA1 that optimizes CR-POPF prediction. BACKGROUND: DFA1 is a well-recognized predictor of CR-POPF after pancreatoduodenectomy, but its role in DP is largely unexplored. METHODS: DFA1 levels were correlated with CR-POPF in 2 independent multi-institutional sets of DP patients: developmental (n = 338; years 2012 to 2017) and validation cohort (n = 166; years 2006 to 2016). Cut-off choice was based on Youden index calculation, and its ability to predict CR-POPF occurrence was tested in a multivariable regression model adjusted for clinical, demographic, operative, and pathological variables. RESULTS: In the developmental set, median DFA1 was 1745 U/L and the CR-POPF rate was 21.9%. DFA1 correlated with CR-POPF with an area under the curve of 0.737 (P < 0.001). A DFA1 of 2000 U/L had the highest Youden index, with 74.3% sensitivity and 62.1% specificity. Patients in the validation cohort displayed different demographic and operative characteristics, lower values of DFA1 (784.5 U/L, P < 0.001), and reduced CR-POPF rate (10.2%, P < 0.001). However, a DFA1 of 2000 U/L had the highest Youden index in this cohort as well, with 64.7% sensitivity and 75.8% specificity. At multivariable analysis, DFA1 ≥2000 U/L was the only factor significantly associated with CR-POPF in both cohorts. CONCLUSION: A DFA1 of 2000 U/L optimizes CR-POPF prediction after DP. These results provide the substrate to define best practices and improve outcomes for patients receiving DP.

Aspects of in vivo endotracheal tube intracuff pressure in cats.

OBJECTIVES: To determine the endotracheal tube cuff pressure produced with two inflation techniques, in two brands of endotracheal tube in cats. To determine the inspiratory pressure which produces an audible leak when the intracuff pressure is 30 cmH2O. STUDY DESIGN: Prospective, clinical, randomized study. ANIMALS: A total of 40 client-owned healthy adult cats. METHODS: Following induction of anaesthesia, endotracheal intubation was performed with a Parker Flex-Tip PFLP (Parker; n = 20) or Flexicare VentiSeal (Flexicare; n = 20) endotracheal tube. For each cat, the endotracheal tube cuff was inflated using two methods, minimum occlusive volume (MOV) and pilot balloon palpation (PBP). Intracuff pressure was recorded. Cuff pressure was then set at 30 cmH2O and the pressure within the breathing system when a manual breath first caused an audible leak was measured. RESULTS: PBP pressure was lower for Parker (36 ± 13 cmH2O) compared with Flexicare (45 ± 13 cmH2O, p = 0.048). MOV pressure was not different between tube types (56 ± 28 versus 66 ± 25 cmH2O for Parker and Flexicare, respectively, p = 0.247). MOV produced a higher pressure than PBP for Parker (56 ± 28 versus 36 ± 13 cmH2O, p = 0.001) and Flexicare (66 ± 25 versus 45 ± 13 cmH2O, p = 0.007). When intracuff pressure was set at 30 cmH2O, 95% of cats did not develop an audible leak until the inspiratory pressure was greater than 10 and 12 cmH2O for Parker and Flexicare tubes, respectively. CONCLUSIONS: PBP produced lower cuff pressures than MOV, although both techniques produced a cuff pressure above that at which mucosal blood flow is believed to be restricted. A cuff pressure of 30 cmH2O may be sufficient to prevent audible leak in most cats if respiratory pressures are kept at 10-12 cmH2O or below. CLINICAL RELEVANCE: To ensure a safe endotracheal tube cuff pressure, use of a specifically designed pressure gauge is recommended.