Guidelines on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy arising from colorectal or appendiceal neoplasms.

To meet the needs of patients, Canadian surgical and medical oncology leaders in the treatment of peritoneal surface malignancies (psms), together with patient representatives, formed the Canadian HIPEC Collaborative Group (chicg). The group is dedicated to standardizing and improving the treatment of psm in Canada so that access to treatment and, ultimately, the prognosis of Canadian patients with psm are improved. Patients with resectable psm arising from colorectal or appendiceal neoplasms should be reviewed by a multidisciplinary team including surgeons and medical oncologists with experience in treating patients with psm. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy should be offered to appropriately selected patients and performed at experienced centres. The aim of this publication is to present guidelines that we recommend be applied across the country for the treatment of psm.

Centrifugal spreader mass and nutrients distribution patterns for application of fresh and aged poultry litter.

A spin-type centrifugal spreader was evaluated using fresh and aged poultry litter upon dry mass, product nitrogen (N), phosphorus (P) and potassium (K), incubation study soil available N and particle size distribution patterns. Relative to the aged litter (37% moisture content), the fresh litter (17% moisture content) had greater <1.00 mm particle size fraction weights and atmospheric particulate was launched, which posed as a potential fallout to adjacent fields, waterways and residences. Relative to the aged litter, the broadcast fresh litter resulted in higher coefficients of variation (CV) over its transverse distance, a narrower calculated space distance between passes for uniform spread and lower soil available N concentrations. For nitrogen application over the broadcast transverse distance the fresh litter displayed a high R(2) best fit 4th order polynomial distribution pattern, while the aged litter showed high R(2) best fit 6th order polynomial distribution pattern. A soil incubation study of the fresh and aged broadcast litter resulted in a more variable or lower R(2) best fit 2nd order polynomial distribution pattern. For both the fresh and aged litter, the calculated distance between passes to achieve a uniform mass distribution was greater than that required for the broadcast of soil available N. For the fresh litter, the soil available N and litter P concentration levels strongly correlated (relatively high p and R(2) values) with the <1.00 mm fraction weight, while for the aged litter this relationship was not as significant. In addition to reducing the health risk (i.e. pathogens, antibiotic residues and resistant bacteria) and/or environment issues (particulate fallout onto waterways, adjacent fields and/or residences) our study mass, particulate and N distribution patterns results suggest that poultry litter should be allowed to age before broadcast application is attempted.

A catalyst for transforming health systems and person-centred care: Canadian national position statement on patient-reported outcomes.

Background: Patient-reported outcomes (pros) are essential to capture the patient's perspective and to influence care. Although pros and pro measures are known to have many important benefits, they are not consistently being used and there is there no Canadian pros oversight. The Position Statement presented here is the first step toward supporting the implementation of pros in the Canadian health care setting. Methods: The Canadian pros National Steering Committee drafted position statements, which were submitted for stakeholder feedback before, during, and after the first National Canadian Patient Reported Outcomes (canpros) scientific conference, 14-15 November 2019 in Calgary, Alberta. In addition to the stakeholder feedback cycle, a patient advocate group submitted a section to capture the patient voice. Results: The canpros Position Statement is an outcome of the 2019 canpros scientific conference, with an oncology focus. The Position Statement is categorized into 6 sections covering 4 theme areas: Patient and Families, Health Policy, Clinical Implementation, and Research. The patient voice perfectly mirrors the recommendations that the experts reached by consensus and provides an overriding impetus for the use of pros in health care. Conclusions: Although our vision of pros transforming the health care system to be more patient-centred is still aspirational, the Position Statement presented here takes a first step toward providing recommendations in key areas to align Canadian efforts. The Position Statement is directed toward a health policy audience; future iterations will target other audiences, including researchers, clinicians, and patients. Our intent is that future versions will broaden the focus to include chronic diseases beyond cancer.

Opening the black box of cancer surgery quality: WebSMR and the Alberta experience.

A web-based synoptic operative report, the WebSMR (Surgical Medical Record), was developed to define and improve the quality of cancer surgery. Surgeons accurately record the essential steps of an operation including important decision-making in an analyzable format. Outcomes can be reviewed with provincial aggregates for quality improvement and maintenance of certification. Future synoptic pathology and follow-up templates will open the "black box" of surgical processes to define quality indicators for the improvement of cancer outcomes.

The physician's Achilles heel-surviving an adverse event.

Background: Of hospitalized patients in Canada, 7.5% experience an adverse event (ae). Physicians whose patients experience aes often become second victims of the incident. The present study is the first to evaluate how physicians in Canada cope with aes occurring in their patients. Methods: Survey participants included oncologists, surgeons, and trainees at the Foothills Medical Centre, Calgary, AB. The surveys were administered through REDCap (Research Electronic Data Capture, version 9.0: REDCap Consortium, Vanderbilt University, Nashville, TN, U.S.A.). The Brief cope (Coping Orientation to Problems Experienced) Inventory, the ies-r (Impact of Event Scale-Revised), the Causal Dimension Scale, and the Institutional Punitive Response scale were used to evaluate coping strategies, prevalence of post-traumatic stress, and institutional culture with respect to aes. Results: Of 51 responses used for the analysis, 30 (58.8%) came from surgeons and 21 (41.2%) came from medical specialists. On the ies-r, 54.9% of respondents scored 24 or higher, which has been correlated with clinically concerning post-traumatic stress. Individuals with a score of 24 or higher were more likely to report self-blame (p = 0.00026) and venting (p = 0.042). Physicians who perceive institutional support to be poor reported significant post-traumatic stress (p = 0.023). On multivariable logistic regression modelling, self-blame was associated with an ies-r score of 24 or higher (p = 0.0031). No significant differences in ies-r scores of 24 or higher were observed between surgeons and non-surgeons (p = 0.15).The implications of aes for physicians, patients, and the health care system are enormous. More than 50% of our respondents showed emotional pathology related to an ae. Higher levels of self-blame, venting, and perception of inadequate institutional support were factors predicting increased post-traumatic stress after a patient ae. Conclusions: Our study identifies a desperate need to establish effective institutional supports to help health care professionals recognize and deal with the emotional toll resulting from aes.

An investigation of colour discrimination with horses (Equus caballus).

The ability of four horses (Equus caballus) to discriminate coloured (three shades of blue, green, red, and yellow) from grey (neutral density) stimuli, produced by back projected lighting filters, was investigated in a two response forced-choice procedure. Pushes of the lever in front of a coloured screen were occasionally reinforced, pushes of the lever in front of a grey screen were never reinforced. Each colour shade was randomly paired with a grey that was brighter, one that was dimmer, and one that approximately matched the colour in terms of brightness. Each horse experienced the colours in a different order, a new colour was started after 85% correct responses over five consecutive sessions or if accuracy showed no trend over sessions. All horses reached the 85% correct with blue versus grey, three horses did so with both yellow and green versus grey. All were above chance with red versus grey but none reached criterion. Further analysis showed the wavelengths of the green stimuli used overlapped with the yellow. The results are consistent with histological and behavioural studies that suggest that horses are dichromatic. They differ from some earlier data in that they indicate horses can discriminate yellow and blue, but that they may have deficiencies in discriminating red and green.

Selective attention in dairy cattle.

In a replication of Reynolds (1961), two cows learned to discriminate between compound stimuli in a forced choice procedure where pushing through a one-way gate marked with a red cross (S+) gave access to food. Pushing through a one-way gate marked with a yellow triangle (S-) gave no access to food. To investigate whether shape or colour was controlling behaviour, probe tests varied either the shape or the colour of the stimuli (e.g., a red vs. a yellow cross, and a red cross vs. a red triangle). Results suggested control by colour rather than shape, as the gate marked with the red stimulus was chosen more than the gate marked with the yellow stimulus regardless of stimulus shape, and when two shapes of the same colour (either red or yellow) were presented, cows chose both equally. Further probe tests with painted red, white, and yellow stimuli showed that the cows had learned to avoid yellow rather than to approach red, suggesting discriminative behaviour was controlled by the colour of the negative stimulus and not by either aspect of the positive stimulus. It is not clear why the negative stimulus was more salient, but it may reflect a tendency for cows to learn to avoid farm handling practices which involve mainly negative stimuli.

Education is the key to quality of surgery for rectal cancer.

Surgical quality assurance is a central issue in the treatment of rectal cancer and has led to substantial improvements in sphincter preservation, local control, and overall survival. Education or training as well as volume of practice are often cited as the major predictors of quality outcomes. While volume is a simple measure to analyze, it is likely a superficial or surrogate measure of quality surgery. It has been conclusively demonstrated that education, from total mesorectum excision workshops to nation-wide educational initiatives are effective methods of improving quality of care for the rectal cancer patient. New methods of quality assurance and improvement are being developed including prospective quality registers, the synoptic operative report, and pathology audits. It is imperative that improved measures of quality, other than volume, be implemented to audit our own practices, hospitals and regions with the goal of identifying issues that will improve outcomes for rectal cancer patients.

Concurrent second-order schedules: some effects of variations in response number and duration.

To examine the effects on concurrent performance of independent manipulations of response-unit duration and number, 6 hens were exposed to concurrent second-order schedules of reinforcement. Each first-order operant unit required completion of a fixed-ratio schedule within the time specified by a fixed-interval schedule, with one further response completing the fixed-interval schedule. The fixed-ratio and fixed-interval requirements comprising the first-order operant units were systematically and independently varied under three pairs of concurrent variable-interval schedules to produce differences in the first-order response and duration requirements (response and duration differentials). These manipulations produced consistent changes in response, time, and operant-unit biases. A 1:4 response differential biased the time and operant-unit measures towards the smaller fixed ratio, but to a degree less than the imposed response differential. The response-based biases favored the larger fixed ratio. Duration differentials of 4:1 and 8:1 biased the response and operant-unit measures towards the shorter fixed interval, again less than the imposed duration differential, but the time biases remained close to zero. Both sorts of differentials acted to bias operant-unit completions more systematically than the other measures, but undermatching to the differentials occurred. The undermatching appears to have arisen from a pattern of fix and sample (in which visits to the less preferred alternative involved only a single completed operant unit) under combinations of unequal operant-unit requirements and reinforcer rates. The response and time bias measures appeared to arise as by-products of the changes in operant-unit completions.

Adiposity, lipids, alcohol consumption, smoking, and gender.

Indices of obesity, plasma lipids, and lipoprotein levels, plasma cholesteryl ester fatty acid composition, reported alcohol consumption and smoking habits were measured in 88 men and 87 women, ages over 15 years, randomly selected from the total respondents (1192) to a health survey. Most indices of obesity were related to plasma triglycerides and high-density lipoprotein levels in both sexes; to very low-density lipoprotein levels in men only; and to plasma cholesteryl ester fatty acid linoleic acid proportions in women only. The correlations with high-density lipoprotein cholesterol levels were dependent on very low-density lipoprotein triglyceride levels in men but not in women. Indices of obesity were significantly higher in nonsmoking women and reported alcohol consumption correlated with Quetelet's index (body mass index) in men. Smoking habits, but not alcohol consumption, influenced correlations between indices of obesity and plasma triglycerides and very low-density lipoprotein triglyceride levels in men. The present results showed several sex-related differences in relationships with indices of obesity. Lower very low-density lipoprotein levels, higher skinfold measurements, higher cholesteryl ester fatty acid linoleic acid proportions and lower alcohol intake in women than in men may be responsible. The data suggested that in women, altered diet composition may be linked with obesity.

Lecithin:cholesterol acyltransferase activity, plasma and lipoprotein lipids and obesity in men and women.

Lecithin:cholesterol acyltransferase (LCAT) activity, lipid concentration, lipoprotein lipid concentrations and cholesteryl ester linoleic acid proportion were determined in the plasma of 85 subjects randomly selected from a population during a health screen survey. Mean fractional LCAT rate was significantly higher in men than in women. Molar LCAT rate correlated with low density lipoprotein (LDL) cholesterol concentration in men and with nearly all lipoprotein lipid concentrations in women. Most of these relationships were dependent on plasma unesterified cholesterol (UC) concentration. Fractional LCAT rate was correlated only with HDL cholesterol concentration in women and this relation was dependent on the influence of obesity. An inverse relationship between plasma cholesteryl ester (PCE) linoleic acid proportion and molar LCAT rate in women was also explained by influences of obesity on the data. Both fractional and molar LCAT rates were positively correlated with obesity (Quetelet's Index and subscapular skinfold thickness) in women but not in men. This study showed the influence of sex on nearly all correlations involving LCAT activity in combined groups of men and women.

Prediction of normal spirometric values for adults incapable of standing.

A significant problem exists in predicting normal values for pulmonary function in subjects unable to stand for measurement of height. We studied 196 normal men and women to determine the relationship between sitting and standing height. Two predictors of standing height are recommended: (1) standing-to-sitting height ratio; and (2) multiple regression equations using sitting height and age. Either of these relationships can be selected as a predictor of height for substitution into any standard spirometric prediction equations. Spirometric prediction equations using age and sitting height are also presented.

Standard and double dose ipratropium bromide and combined ipratropium bromide and inhaled metaproterenol in COPD.

Inhaled ipratropium bromide (IPR) is effective in the management of COPD. The purpose of this study was to determine if doubling the standard dose of IPR resulted in greater bronchodilation and if the addition of an inhaled beta-agonist was superior to standard dose IPR alone. Twelve male patients with stable COPD completed a double blind, randomized trial. On each of three consecutive days, following baseline spirometry, all patients inhaled two puffs of IPR. This was followed by either two additional puffs of IPR, two puffs of metaproterenol (META), or two puffs of placebo. All inhalants were delivered by an InspirEase spacer. Spirometry was repeated at 30, 60, 120, and 180 minutes. The group mean percentage increases in the FEV1 and FVC from baseline were similar at all times tested for the three protocols. In conclusion, for the group, there was no objective benefit to doubling the standard dose of IPR or combining IPR with META. Two of 12 patients benefited from combining the two bronchodilators. A potential sequence for bronchodilator testing is suggested.

Fifteen-year interval spirometric evaluation of the Oregon predictive equations.

The 1969 Oregon spirometric predictive equations were evaluated by retesting 199 of the 988 original sample population after 15 years. The 1969 data were used to test for sample bias between the retested and not-retested groups. There was no significant difference in mean values for age, height, or test results except for a five-year age difference in men. Regression analysis of residuals and the differences between calculated and predicted values of annual decrements of FVC, FEV1, and FEF25-75% on age revealed no statistically significant age trend. Although residual means were statistically significant for FVC and FEV1 for men and FVC and FEF25-75% for women, the differences between calculated and predicted annual decrements were significant only for women in FEF25-75%. Although group performance was accurately predicted for most tests, test SDs and SEMs demonstrated considerable individual variation. Lower limits of normality are suggested to assist in evaluating previously-tested patients.

Benefit of aggressive multimodality therapy with autologous stem cell support for intra-abdominal desmoplastic small round cell tumor.

A case is described of a 19-year-old man with poor prognosis intra-abdominal desmoplastic small round cell tumor, who achieved a durable complete remission after aggressive multimodality treatment. He was diagnosed with a large peri-rectal mass and bulky metastases to the peritoneum, omentum and liver. He achieved a partial response to six courses of chemotherapy with VAC (vincristine, adriamycin, actinomycin, cyclophosphamide) and VIP (VP-16, ifosfamide, cisplatin). This was followed by resection of the omentum and cryotherapy to six of the liver lesions. He then achieved a complete response following high-dose busulfan 16 mg/kg and melphalan 140 mg/m2 with autologous stem cell support. Finally, pelvic radiotherapy was given to consolidate the remission. Twenty-six months following his diagnosis, and 19 months after the transplant, he remains well with no clinical or radiologic evidence of recurrent disease. This case report suggests a role for autologous stem cell transplantation as part of multimodality therapy for this unusual and aggressive malignancy.

High-dose melphalan +/- total body irradiation and autologous hematopoietic stem cell rescue for adult patients with Ewing's sarcoma or peripheral neuroectodermal tumor.

The role of high-dose therapy and autologous stem cell transplantation (ASCT) in the treatment of patients with Ewing's sarcoma (EWS) remains uncertain. From November 1985 to September 1994, 13 patients aged 16-30 years (median 20.5) received high-dose melphalan (HDM) 140-200 mg/m2 +/- 500 cGy TBI followed by ASCT for relapsed/refractory (n = 4), metastatic (n = 2), or non-metastatic (n = 6) EWS, or for peripheral neuroectodermal tumor (PNET) (n = 1). This regimen was well tolerated with no transplant-related mortality and no toxicity requiring life sustaining measures. Three of the four patients treated for relapsed/refractory EWS had progression-free survivals (PFS) less than 5 months. The only long-term survivor of these four patients received HDM while in complete remission following pulmonary irradiation. Both patients with pulmonary metastases at presentation died just 5 and 6 months post-ASCT. All four patients with non-metastatic, bulky (> 8 cm) osseous EWS progressed at a median of 11 months (range 7-22 months) while the two patients with non-bulky EWS remain progression-free 25+ and 28+ months post-HDM/TBI + ASCT. The 19-year-old patient with a PNET of the thoracoabdominal wall relapsed 4 months post-ASCT. Overall, only three of these 13 patients remain progression-free at 25+, 28+, and 108+ months following HDM +/- TBI and ASCT. In conclusion, HDM +/- TBI did not obviously improve the outcome of these 13 patients relative to that expected following conventional dose therapy alone.

A biomechanical study of suture pullout in linea alba.

The relationship of suture bite size, suture diameter, and fascial thickness to strength of wound closure was studied in cadaveric linea alba. All soft tissue was removed from the fascia of 12 abdominal walls that were cut into 346 test sections. A single suture loop was placed in each section, simulating laparotomy closure with interrupted technique. Suture bite size (0.3, 0.6, 0.9, 1.2, 1.5, and 1.8 cm) and gauge (00, 0, 1, and 2) were randomly assigned. The force and energy required to pull out suture loops were measured. Mean linea alba thickness was greater above the linea semicircularis than below (1.19 vs 0.77 mm; p less than 0.001). Similarly, mean pullout force was greater above the linea semicircularis (58.2 vs 31.6 N; p less than 0.001). Regression analysis found that fascial thickness and bite size accounted for 68% of observed variability in pullout force. Suture diameter was unrelated to pullout force. Optimum security was obtained with bites of at least 1.2 to 1.5 cm.

Combination regional therapy for extremity sarcoma. A tricenter study.

Patients with extremity sarcomas were treated with a neoadjuvant therapy protocol that had originated within the Southeastern Cancer Study Group. Major objectives were to determine tolerance of therapy and its effects on tumor control and survival. After undergoing biopsy, patients received intra-arterial infusion with doxorubicin hydrochloride (Adriamycin) (30 mg every 24 hours) for 3 days and were allocated by institution to receive irradiation of 30 or 35 Gy in 10 fractions or 46 Gy in 23 to 25 fractions. Surgery was done within 7 to 10 days or 30 days pending irradiation dose. Postoperative chemotherapy was given to 31 patients. There were 60 patients, 29 women and 31 men with a median age of 48 years, with 53 soft-tissue tumors and 7 malignant bone tumors. Stages (American Joint Committee on Cancer) included stage IB, 2 patients; stages IIA and IIB, 9 patients; stage IIIA, IIIB, or IIIC, 39 patients; and stages IVA or IVB, 10 patients. Limb salvage surgery was done in 57 patients, including radical resection in 23 with large extensive tumors, wide local excision in 30, excision with narrow margins in 7, primary amputation in 3, and delayed amputation in 2 because of wound complications. There was one local recurrence in the 57 patients who had limb salvage surgery. Disease-free and overall survival at 48 months were 47% and 56%, respectively. We conclude that combined therapy for extremity sarcomas in a multicenter setting resulted in excellent local control, good function, and reasonable long-term survival in patients having limb salvage surgery.

Determination of auditory thresholds in the brushtail possum (Trichosurus vulpecula).

The auditory abilities of the brushtail possum (Trichosurus vulpecula) have been measured by cochlear potential readings, but no behavioural determinations of their auditory abilities have been published. Six experimentally naive possums were trained to perform a two-response conditional discrimination between the presence and absence of an 880-Hz tone (at 80 dB). All six possums readily learned this task. The behavioural threshold for this tone was determined using a modified tracking procedure and found to be similar to that reported using cochlear microphonic potentials. One concern with the current method was the communal nature of the experimental environment so a further threshold determination in a sound-attenuating chamber was conducted. No substantial difference was noted between the results obtained in the two threshold determinations. The success of the current method means that a full, behavioural audiogram for the brushtail possum, which would complement the existing cochlear potential data, is now possible.

Sacral resection for control of pelvic tumors.

A surgical approach for treating patients with resected, recurrent, posterior pelvic visceral tumors involving the sacrum is detailed. Of 11 patients, 9 had rectal cancers, 1 had chordoma, and 1 had cancer of the cervix. Five total pelvic exenterations and five posterior exenterations were performed en bloc with involved sacrum. One patient had a sacral resection only. Surgical mortality was 9%, and the average hospital stay was 1 month. Mean disease-free survival was 1 year, and mean survival was 3 years. Absolute cure rate was 18% with a complete 5-year follow-up. This experience confirms the value of this procedure in selected patients.