Hospital volume following major surgery for gastric cancer determines in-hospital mortality rate and failure to rescue: a nation-wide study based on German billing data (2009-2017).

BACKGROUND: For many cancer resections, a hospital volume-outcome relationship exists. The data regarding gastric cancer resection-especially in the western hemisphere-are ambiguous. This study analyzes the impact of gastric cancer surgery caseload per hospital on postoperative mortality and failure to rescue in Germany. METHODS: All patients diagnosed with gastric cancer from 2009 to 2017 who underwent gastric resection were identified from nation-wide administrative data. Hospitals were grouped into five equal caseload quintiles (I-V in ascending caseload order). Postoperative deaths and failure to rescue were determined. RESULTS: Forty-six thousand one hundred eighty-seven patients were identified. There was a significant shift from partial resections in low-volume hospitals to more extended resections in high-volume centers. The overall in-house mortality rate was 6.2%. The crude in-hospital mortality rate ranged from 7.9% in quintile I to 4.4% in quintile V, with a significant trend between volume categories (p < 0.001). In the multivariable logistic regression analysis, quintile V hospitals (average of 29 interventions/year) had a risk-adjusted odds ratio of 0.50 (95% CI 0.39-0.65), compared to the baseline in-house mortality rate in quintile I (on average 1.5 interventions/year) (p < 0.001). In an analysis only evaluating hospitals with more than 30 resections per year mortality dropped below 4%. The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue (FtR) decreased significantly with increasing caseload. CONCLUSION: Patients who had gastric cancer surgery in hospitals with higher volume had better outcomes and a reduced failure to rescue rates for severe complications.

[Older patients in abdominal surgery]. / Ältere PatientInnen in der Viszeralchirurgie.

BACKGROUND: The aging society imposes special challenges on operative medicine. OBJECTIVE: Characteristics in the perioperative treatment of older patients. Consequences for the daily practice. MATERIAL AND METHODS: Evaluation and summary of existing literature including recommendations for the (peri)operative management of older patients. RESULTS: Despite the growing relevance there are only few studies focusing on older patients. The altered (patho)physiology and comorbidities are challenging and can lead to complications. CONCLUSION: The evaluation of the indications for surgery should meticulously take the improvement to be expected into account by weighing up the individual wishes of patients and special risks. The adequate perioperative care including early mobilization and sufficient analgesia are decisive.

Effective biasing schemes for duct streaming problems.

The effective use of biasing for the Monte Carlo solution of a void streaming problem is essential to obtaining a reasonable result in a reasonable amount of time. Most general purpose Monte Carlo shielding codes allow for the user to select the particular biasing techniques best oriented to the particular problem of interest. The biasing strategy for void streaming problems many times differs from that of a deep penetration problem. The key in void streaming is to bias particles into the streaming path, whereas in deep penetration problems the biasing is aimed at forcing particles through the shield. Until recently, the biasing scheme in the SCALE SAS4 shielding module was considered inadequate for void streaming problems due to the assumed one-dimensional nature of the automated bias prescription. A modified approach to the automated biasing in SAS4 has allowed for significant gains to be realised in the use of the code for void streaming problems. This paper applies the modified SAS4 procedures to a spent fuel storage cask model with vent ports. The results of the SAS4 analysis are compared with those of the ADVANTG methodology, which is an accelerated version of MCNP. Various options available for the implementation of the SAS4 methodology are reviewed and recommendations offered.

Hormone (pheromone) processing enzymes in yeast. The carboxy-terminal processing enzyme of the mating pheromone alpha-factor, carboxypeptidase ysc alpha, is absent in alpha-factor maturation-defective kex1 mutant cells.

Carboxy-terminal processing of the mating pheromone alpha-factor of the yeast Saccharomyces cerevisiae has been assumed to be due to the action of carboxypeptidase ysc alpha [(1985) EMBO J. 4, 173-177]. Here it is shown that a mutant (kex1) defective in alpha-factor maturation is defective in carboxypeptidase ysc alpha activity, indicating that the enzyme is indeed the processing catalyst. It is proposed that carboxypeptidase ysc alpha is the product of the KEX1 gene.

Some characteristics of hormone (pheromone) processing enzymes in yeast.

The KEX2 gene-encoded, membrane-bound Ca2+-dependent thiol endoproteinase, proteinase yscF, responsible for processing of the precursor protein of the sex pheromone alpha-factor of the yeast Saccharomyces cerevisiae was solubilized from the membraneous fraction and partially purified. Gel filtration revealed an apparent Mr of the native protein of around 150,000. Ca2+ concentration for half-maximal activity was in the micromolar range and concentration of the substrate Cbz-Tyr-Lys-Arg-4-nitroanilide for half-maximal velocity was 0.05 mM. The enzyme able to cleave basic amino acids from the carboxy-terminus of peptides and probably involved in final maturation of the alpha-factor peptides generated by proteinase yscF is membrane-associated, active at neutral pH and responds strongly to the serine proteinase inhibitor phenyl-methylsulfonyl fluoride as well as to -SH group blocking agents.

Metabolic regulation of the trehalose content of vegetative yeast.

We have investigated the mechanism by which heat shock conditions lead to a reversible accumulation of trehalose in growing yeast. When cells of S. cerevisiae M1 growing exponentially at 30 degrees C were shifted to 45 degrees C for 20 min, or to 39 degrees C for 40 min, the concentration of trehalose increased by about 25-fold; an effect reversed upon lowering the temperature to 30 degrees C. This was compared to the more than 50-fold rise in trehalose levels obtained upon transition from the exponential to the stationary growth phase. Whereas the latter was paralleled by a 12-fold increase in the activity of trehalose-6-phosphate synthase, no significant change in the activities of trehalose-synthesizing and -degrading enzymes was measured under heat shock conditions. Accordingly, cycloheximide did not prevent the heat-induced accumulation of trehalose. However, the concentrations of the substrates for trehalose-6-phosphate synthase, i.e. glucose-6-phosphate and UDP-glucose, were found to rise during heat shock by about 5-10-fold. Since the elevated levels of both sugars are still well below the Km-values determined for trehalose-6-phosphate synthase in vitro, they are likely to contribute to the increase in trehalose under heat shock conditions. A similar increase in the steady-state levels was obtained for other intermediates of the glycolytic pathway between glucose and triosephosphate, including ATP. This suggests that temperature-dependent changes in the kinetic parameters of glycolytic enzymes vary in steady-state levels of intermediates of sugar metabolism, including an increase of those that are required for trehalose synthesis. Trehalose, glucose-6-phosphate, UDP-glucose, and ATP, were all found to increase during the 40 min heat treatment at 39 degrees C. Since this also occurs in a mutant lacking the heat shock-induced protein HSP104 (delta hsp104), this protein cannot be involved in the accumulation of trehalose under these heat shock conditions. However, mutant delta hsp104, in contrast to the parental wild-type, was sensitive towards a 20 min incubation at 50 degrees C. Since this mutant also accumulated normal levels of trehalose, we conclude that HSP104 function, and not towards a 20 min incubation at 50 degrees C. Since this mutant also accumulated normal levels of trehalose, we conclude that HSP104 function, and not the accumulation of trehalose, protects S. cerevisiae from the damage caused by a 50 degrees C treatment.

Preliminary observations of the effect of inhalation of PVC in man and experimental animals.

Attention has been focussed, both in man and experimental animals, on the effects of inhalation of the gas monomer, vinyl chloride. Recently, note is being taken of the possible effects of the inhalation of the polymer in man. The particles in question are those produced commercially as paste polymer or dispersion polymer or having an average diameter of 0.15 micrometers, and accounting for more than 10% of the production in Britain. There are now strict regulations for the control of the monomer gas, but the particles are regarded as nuisance dust and their emission is not covered by specific legislation. Our studies on rats, where both inhalation and implantation methods of exposure have been used, and examination of tissue from human cases exposed to paste polymers, indicate that these small particles can only be regarded as evidence of exposure, and on present evidence there is no indication of causation of significant pulmonary disease. Techniques have been developed by which these particles can be demonstrated in ordinary histological preparations and by transmission electron microscopy.

Fiber levels and disease in workers from a factory predominantly using amosite.

The Cape Boards Plant at Uxbridge produced insulation board containing amosite asbestos between 1947 and 1973 with only small amounts of chrysotile. After 1973 only amosite was used. In this study we examined lung samples from 48 workers who had been employed at the plant and who had come to autopsy. The study investigated the fiber levels against the lung pathology including amount of interstitial fibrosis and numbers of ferruginous bodies. The degree of interstitial fibrosis and number of asbestos bodies were graded and the tissues were analyzed by transmission electron microscopy and energy dispersive X-ray analysis and the fibers counted and typed. The 48 cases included 5 mesotheliomas and 14 lung cancers. The mineral analysis results were dominated by the amosite fiber levels. The amounts of chrysotile were relatively small. There were higher levels in lung cancer cases than mesotheliomas and higher levels in mesothelioma cases than those who had died from nonasbestos related diseases. Analysis of the lung tissues showed a consistent pattern of high amosite levels, which confirms the impression that amosite was the predominant form of asbestos used and also indicates that the factory had been a very dusty one.

Antibiotic sensitivity and the prescribing information sheet: assisting the prescribing physician.

The concept conceived 5 years ago is now a reality. Physicians have information readily available for empiric prescribing from the home, office, or hospital. The other two hospitals in the city have implemented the systems. The reaction of physicians has been extremely favorable. In fact, two new publications for the outpatient/community and for the pediatric populations are now under way at the suggestion of physicians. Plans are in place to assess physician satisfaction and use of the information sheet within the coming year. Presently, too little time has passed to evaluate whether changes in prescribing have actually occurred. In fact, it may never be possible to identify how many instances of inadvisable prescribing are prevented with good initial information. However, for the relatively low cost involved, this has been an exciting new opportunity for education, as well as a method to promote cost-effective and appropriate antibiotic therapy.

Enhancement of athletic performance with drugs. An overview.

Drug use among athletes has become a recognised problem in sports. Athletes may use drugs for therapeutic indications, for recreational or social reasons, as ergogenic aids or to mask the presence of other drugs during drug testing. Stimulants were some of the first drugs used and studied as ergogenic aids. Amphetamines may increase time to exhaustion by masking the physiological response to fatigue. Caffeine may improve utilisation of fatty acids as a fuel source thereby sparing muscle glycogen. Cocaine and other sympathomimetic drugs have little or no effect on athletic performance. Anabolic steroids appear to have the potential to increase lean muscle mass and strength under certain conditions. Human growth hormone may also be used for an anabolic effect, but data on this effect are lacking. Erythropoietin may represent a pharmacological alternative to blood doping by increasing red blood cell mass. The use of narcotic analgesics is not necessarily ergogenic but can be harmful if used to allow participation of an athlete with a severe injury. According to the American College of Sports Medicine alcohol does not possess an ergogenic effect. However, it may be used to reduce anxiety or tremor prior to competition. Marijuana does not increase strength. Tobacco products may produce psychomotor effects or control appetite which may be beneficial to some athletes. Other drugs used by athletes include beta-blocking agents, diuretics, and a variety of nutritional supplements. In addition, diuretics and probenecid may be taken to mask drug contents in the urine. Whether the ergogenic effects are real or perceived, the potential for adverse effects exists for all of these drugs. Potential health complications represent a serious risk to an otherwise healthy population. Further research on the long term health risks in athletes taking ergogenic drugs is needed.

Anabolic steroid use among adolescents in Nebraska schools.

The extent of anabolic steroid use among adolescent sports participants and nonparticipants in Nebraska schools was studied. The Nebraska Secondary School Survey administered in 1991 contained 19 new items designed to determine rates of use of anabolic steroids and to measure participation in school sports. Schools participating in the survey are part of the Toward a Drug Free Nebraska training project; when the 1991 survey was conducted, training did not address ergogenic drug use. The survey was administered on a voluntary and confidential basis to Nebraska students in grades 7 through 12. A total of 4722 students in 62 secondary schools were surveyed; 3183 (67.4%) identified themselves as participants in school-sponsored sports. Of all the respondents, 117 (2.5%) reported having used anabolic steroids in the preceding 30 days. Some 4.5% of all the male respondents were steroid users, versus 0.8% of all the females. Of the students who reported using anabolic steroids, 72.6% were sports participants. Steroid users, whether they participated in sports or not, were more likely to use alcohol, tobacco, and other drugs than were nonusers of steroids. Among sports participants and nonparticipants, anabolic steroid users were more likely than nonusers to report acting violently. Nebraska students (grades 7 through 12) who participated in school-sponsored sports were more likely than non-participants to use anabolic steroids. Steroid-using athletes were more likely to use alcohol, tobacco, and other drugs than athletes who did not use steroids.

Representing clinical narratives using conceptual graphs.

The analysis of medical narratives and the generation of natural language expressions are strongly dependent on the existence of an adequate representation language. Such a language has to be expressive enough in order to handle the complexity of human reasoning in the domain. Sowa's Conceptual Graphs (CG) are an answer, and this paper presents a multilingual implementation, using French, English and German. Current developments demonstrate the feasibility of an approach to natural Language Understanding where semantic aspects are dominant, in contrast to syntax driven methods. The basic idea is to aggregate blocks of words according to semantic compatibility rules, following a method called Proximity Processing. The CG representation is gradually built, starting from single words in a semantic lexicon, to finally give a complete representation of the sentence under the form of a single CG. The process is dependent on specific rules of the medical domain, and for this reason is largely controlled by the declarative knowledge of the medical Linguistic Knowledge Base.

Natural language generation of surgical procedures.

A number of compositional Medical Concept Representation systems are being developed. Although these provide for a detailed conceptual representation of the underlying information, they have to be translated back to natural language for used by end-users and applications. The GALEN programme has been developing one such representation and we report here on a tool developed to generate natural language phrases from the GALEN conceptual representations. This tool can be adapted to different source modelling schemes and to different destination languages or sublanguages of a domain. It is based on a multilingual approach to natural language generation, realised through a clean separation of the domain model from the linguistic model and their link by well defined structures. Specific knowledge structures and operations have been developed for bridging between the modelling 'style' of the conceptual representation and natural language. Using the example of the scheme developed for modelling surgical operative procedures within the GALEN-IN-USE project, we show how the generator is adapted to such a scheme. The basic characteristics of the surgical procedures scheme are presented together with the basic principles of the generation tool. Using worked examples, we discuss the transformation operations which change the initial source representation into a form which can more directly be translated to a given natural language. In particular, the linguistic knowledge which has to be introduced--such as definitions of concepts and relationships is described. We explain the overall generator strategy and how particular transformation operations are triggered by language-dependent and conceptual parameters. Results are shown for generated French phrases corresponding to surgical procedures from the urology domain.

Intrapleural administration of vitreous high duty ceramic fibres and heated devitrified ceramic fibres does not give rise to pleural mesothelioma in rats.

In order to determine whether they are potentially carcinogenic to the pleural mesothelium, three samples of ceramic fibre have been administered to rats by the intrapleural route. These samples were a high-duty grade refractory ceramic fibre (manufactured by Thermal Ceramics Ltd) in the as-manufactured vitreous state and two devitrified samples produced by heating the same fibre for 2 weeks at 1200 degrees C and for two weeks at 1400 degrees C. The mean lifespans of the groups of rats treated with vitrified and devitrified ceramic fibres were not significantly different from that of the control rats. In these studies none of the treated or control rats developed pleural mesothelioma, making it unlikely that ceramic fibres of this type, whether vitreous or devitrified, are potentially carcinogenic to the pleural mesothelium.

Natural language generation of surgical procedures.

The GALEN-IN-USE project has developed a compositional scheme for the conceptual representation of surgical operative procedure rubrics. The complex representations which result are translated back to surface language by a tool for multilingual natural language generation. This generator can be adapted to the specific characteristics of the scheme by introducing particular definitions of concepts and relationships. We discuss how the generator uses such definitions to bridge between the modelling 'style' of the GALEN scheme and natural language.

[Double trans-suture technique in colorectal surgical anastomosis. Apropos of 45 cases]. / Anastomose double trans-suturaire dans la chirurgie colo-rectale. A propos de 45 observations.

The double trans-suture technique in colorectal anastomoses is an entirely mechanical one which consist of the transformation of two linear sutures in a circular one. During, 2 years, between March 1990 and March 1992, this technique was performed on 45 patients, of whom about two-third had a carcinoma of rectosigmoid. No postoperative mortality occurred. One patient developed an anastomatic stenosis, and another one a clinical leakage. The double trans-suture technique has not only the advantages of the double stapling technique but also avoids the incidents of performing a proximal purse.

Management of chronic cancer pain using a computerized ambulatory patient-controlled analgesia pump.

Chronic pain associated with neoplastic disease can be difficult to treat. The development of a computerized ambulatory, patient-controlled analgesia (PCA) pump may provide the patient and clinician with an alternate approach in management of chronic cancer pain. The pump delivers a constant infusion of analgesic and allows for additional on-command doses for breakthrough pain. Patients with chronic cancer pain poorly controlled with conventional narcotic regimens were eligible for this trial. Four patients were included in this trial. Upon admission, each patient was started on a morphine infusion via a peripheral site and titrated to an effective dose. Once the optimal dose was achieved, the patients were converted to the ambulatory pump. The pump was programmed to deliver identical morphine infusions and any PCA doses. Infusion access was provided by a long-term central venous catheter or subcutaneous infusion set. Final maintenance infusions ranged from 0.8 to 60 mg morphine per hour. Three patients required PCA doses. Patients and family members were trained on catheter care and operation of the infusion pump. At home, patients reported acceptable pain relief while engaging in many activities of daily living. Complications included constipation, possible drug tolerance, and accidental catheter removal. Overall, patient acceptance of the pump was good with improved pain control, minimal adverse reactions, and ease of use at home.