Relation of intraoperative temperature to postoperative mortality in open colon surgery--an analysis of two randomized controlled trials.

INTRODUCTION: The open surgical wound is exposed to cold and dry ambient air resulting in heat loss mainly through radiation and convection. This cools the wound and promotes local vasoconstriction and hypoxia. Carbon dioxide (CO2) and water vapor are greenhouse gases with a warming effect. The aim was to evaluate if warm humidified CO2 insufflated in surgical wound can affect long-term overall mortality METHODS: This is a retrospective study of two clinical trials, where patients were randomized to warm humidified CO2 (n = 80) or not (n = 78). All patients underwent elective major open colon surgery. Patients in the treatment group received insufflation of warm humidified CO2 into the open wound cavity via a gas diffuser to create a local atmosphere of 100% CO2. Temperature in the wound cavity was measured with a heat-sensitive infrared camera. Core temperature was measured at the tympanic membrane. Median follow-up was 70.9 months. RESULTS: A multivariate analysis adjusted for age (p = 0.001) and cancer (p = 0.165) showed that the larger the temperature difference between final core temperature and wound edge temperature, the lower the overall survival rate (p = 0.050). Patients receiving insufflation of warm humidified CO2 had a tendency to a better overall survival compared with control patients (p = 0.508). End-of-operation wound edge temperature was negatively associated with mortality (OR = 0.80, 95% CI = 0.68-0.95, p = 0.011), whereas mortality was positively associated with age (10-year increase, OR = 1.78, 95% CI = 1.37-2.33, p < 0.001) and cancer (OR = 8.1, 95% CI = 1.95-33.7, p = 0.004). CONCLUSIONS: A small end-of-operation temperature difference between final core and wound edge temperature was positively associated with patient survival in open colon surgery.

Requirements for dose calculation on an active scanned proton beamline for small, shallow fields.

INTRODUCTION: A growing interest in using proton pencil beam scanning in combination with collimators for the treatment of small, shallow targets, such as ocular melanoma or pre-clinical research emerged recently. This study aims at demonstrating that the dose of a synchrotron-based PBS system with a dedicated small, shallow field nozzle can be accurately predicted by a commercial treatment planning system (TPS) following appropriate tuning of both, nozzle and TPS. MATERIALS: A removable extension to the clinical nozzle was developed to modify the beam shape passively. Five circular apertures with diameters between 5 to 34mm, mounted 72cm downstream of a range shifter were used. For each collimator treatment plans with spread-out Bragg peaks (SOBP) with a modulation of 3 to 30mm were measured and calculated with GATE/Geant4 and the research TPS RayStation (RS11B-R). The dose grid, multiple coulomb scattering and block discretization resolution were varied to find the optimal balance between accuracy and performance. RESULTS: For SOBPs deeper than 10mm, the dose in the target agreed within 1% between RS11B-R, GATE/Geant4 and measurements for aperture diameters between 8 to 34mm, but deviated up to 5% for smaller apertures. A plastic taper was introduced reducing scatter contributions to the patient (from the pipe) and improving the dose calculation accuracy of the TPS to a 5% level in the entrance region for large apertures. CONCLUSION: The commercial TPS and GATE/Geant4 can accurately calculate the dose for shallow, small proton fields using a collimator and pencil beam scanning.

Association studies on 11 published colorectal cancer risk loci.

BACKGROUND: Recently, several genome-wide association studies (GWAS) have independently found numerous loci at which common single-nucleotide polymorphisms (SNPs) modestly influence the risk of developing colorectal cancer. The aim of this study was to test 11 loci, reported to be associated with an increased or decreased risk of colorectal cancer: 8q23.3 (rs16892766), 8q24.21 (rs6983267), 9p24 (rs719725), 10p14 (rs10795668), 11q23.1 (rs3802842), 14q22.2 (rs4444235), 15q13.3 (rs4779584), 16q22.1 (rs9929218), 18q21.1 (rs4939827), 19q13.1 (rs10411210) and 20p12.3 (rs961253), in a Swedish-based cohort. METHODS: The cohort was composed of 1786 cases and 1749 controls that were genotyped and analysed statistically. Genotype-phenotype analysis, for all 11 SNPs and sex, age of onset, family history of CRC and tumour location, was performed. RESULTS: Of eleven loci, 5 showed statistically significant odds ratios similar to previously published findings: 8q23.3, 8q24.21, 10p14, 15q13.3 and 18q21.1. The remaining loci 11q23.1, 16q22.1, 19q13.1 and 20p12.3 showed weak trends but somehow similar to what was previously published. The loci 9p24 and 14q22.2 could not be confirmed. We show a higher number of risk alleles in affected individuals compared to controls. Four statistically significant genotype-phenotype associations were found; the G allele of rs6983267 was associated to older age, the G allele of rs1075668 was associated with a younger age and sporadic cases, and the T allele of rs10411210 was associated with younger age. CONCLUSIONS: Our study, using a Swedish population, supports most genetic variants published in GWAS. More studies are needed to validate the genotype-phenotype correlations.

Stereotactical fields applied in proton spot scanning mode with range shifter and collimating aperture.

Some clinical indications require small fields with sharp lateral dose gradients, which is technically challenging in proton beam therapy. This holds especially true for low-range fields applied with the spot scanning technique, where large beam profiles entering from the beam-line or the insertion of range shifting blocks lead to large lateral gradients. We regard the latter case and solve it by shifting the range shifting block far upstream in conjunction with a collimating aperture close to the patient. The experiments of the current work are based on a commercial proton therapy treatment head designed for several delivery modes. In a research environment of the spot-scanning delivery mode a range shifter is inserted downstream of the scanning magnets in a slot which is usually employed only in a scattering delivery mode. This configuration is motivated by equations assuming a simple model of proton transport. In the experiments lateral dose planes are acquired with a scintillation screen and radiochromic films. Dose distributions are calculated with the Monte Carlo dose engine of the RayStation treatment planning system. We demonstrate that proton fields with 80%-20% lateral dose fall-off values between 1.4 mm and 4.0 mm can be achieved for water equivalent depths between 0 cm and 10 cm. The simulated lateral dose profiles agree with the experimental dose profiles. The sharpening of the field edges is set off by a broadening of the proton spots towards the center of the fields. This limits the clinical application mainly to small fields for which the distal and proximal conformality is of minor importance.

Collimated proton pencil-beam scanning for superficial targets: impact of the order of range shifter and aperture.

To assess if apertures shall be mounted upstream or downstream of a range shifting block if these field-shaping devices are combined with the pencil-beam scanning delivery technique (PBS). The lateral dose fall-off served as a benchmark parameter. Both options realizing PBS-with-apertures were compared to the uniform scanning mode. We also evaluated the difference regarding the out-of-field dose caused by interactions of protons in beam-shaping devices. The potential benefit of the downstream configuration over the upstream configuration was estimated analytically. Guided by this theoretical evaluation a mechanical adapter was developed which transforms the upstream configuration provided by the proton machine vendor to a downstream configuration. Transversal dose profiles were calculated with the Monte-Carlo based dose engine of the commercial treatment planning system RayStation 6. Two-dimensional dose planes were measured with an ionization chamber array and a scintillation detector at different depths and compared to the calculation. Additionally, a clinical example for the irradiation of the orbit was compared for both PBS options and a uniform scanning treatment plan. Assuming the same air gap the lateral dose fall-off at the field edge at a few centimeter depth is 20% smaller for the aperture-downstream configuration than for the upstream one. For both options of PBS-with-apertures the dose fall-off is larger than in uniform scanning delivery mode if the minimum accelerator energy is 100 MeV. The RayStation treatment planning system calculated the width of the lateral dose fall-off with an accuracy of typically 0.1 mm-0.3 mm. Although experiments and calculations indicate a ranking of the three delivery options regarding lateral dose fall-off, there seems to be a limited impact on a multi-field treatment plan.

Screening vs. non-screening detected colorectal cancer: Differences in pre-therapeutic work up and treatment.

Objectives To compare preoperative staging, multidisciplinary team-assessment, and treatment in patients with screening detected and non-screening detected colorectal cancer. Methods Data on patient and tumour characteristics, staging, multidisciplinary team-assessment and treatment in patients with screening and non-screening detected colorectal cancer from 2008 to 2012 were collected from the Stockholm-Gotland screening register and the Swedish Colorectal Cancer Registry. Results The screening group had a higher proportion of stage I disease (41 vs. 15%; p < 0.001), a more complete staging of primary tumour and metastases and were more frequently multidisciplinary team-assessed than the non-screening group ( p < 0.001). In both groups, patients with endoscopically resected cancers were less completely staged and multidisciplinary team-assessed than patients with surgically resected cancers ( p < 0.001). No statistically significant differences were observed between the screening and non-screening groups in the use of neoadjuvant treatment in rectal cancer (68 vs.76%), surgical treatment with local excision techniques in stage I rectal cancer (6 vs. 9%) or adjuvant chemotherapy in stages II and III disease (46 vs. 52%). Emergency interventions for colorectal cancer occurred in 4% of screening participants vs. 11% of non-compliers. Conclusions Screening detected cancer patients were staged and multidisciplinary team assessed more extensively than patients with non-screening detected cancers. Staging and multidisciplinary team assessment prior to endoscopic resection was less complete compared with surgical resection. Extensive surgical and (neo)adjuvant treatment was given in stage I disease. Participation in screening reduced the risk of emergency surgery for colorectal cancer.

Complement fixation by pemphigus antibody. I. In vitro fixation to organ and tissue culture skin.

Although complement is often detected in the intercellular substance of pemphigus skin lesions, the ability of pemphigus antibodies to fix complement in vitro is controversial. The purpose of this study was to test in vitro complement fixation abilities of pemphigus antibodies further using organ and tissue culture methods. Epidermal cell monolayers from mouse tail were incubated with the purified IgG fraction of pemphigus serum followed by purified Clq. Binding of Clq, as well as IgG was demonstrated by immunofluorescence methods. When purified Clq was replaced with normal human serum as a complement source, positive C3 and C4 staining were also evident. When purified IgG of normal human serum was used in place of pemphigus IgG, similar immunofluorescence staining was not observed. Further evidence for complement fixation in vitro by pemphigus antibodies was obtained using organ cultures. Organ culture of normal human skin and monkey esophageal mucosa cultured in purified pemphigus IgG showed intercellular substance binding of IgG. No binding was observed when normal IgG was substituted for pemphigus IgG. Additional organ culture sections were then treated with complement (fresh normal human serum) and tested by in vitro complement staining. Fixation of Clq, C4, and C3 was noted in intercellular substance areas of organ cultured skin and mucosa incubated with pemphigus IgG but not those incubated with normal IgG. Prior treatment of pemphigus IgG organ cultured skin sections with unlabeled anti-C3, blocked positive C3 staining. These results suggest that some pemphigus antibodies are capable of activating complement in vitro.

Quantitative determination of platelet surface alloantigens using a monoclonal probe.

A monoclonal antibody with specificity for the Fc portion of IgG was used to determine the number of IgG alloantibody molecules bound at saturation to alloantigens of the PlA1 and HLA systems on normal human platelets. In preliminary studies, it was found that the number of cell-bound IgG molecules recognized by this probe correlates well with the number measured by electroimmunoassay, an independent measure of alloantibody binding. PlA1-positive platelets could be divided into two groups binding 34,000-43,000 or 19,000-24,000 alloantibody molecules. Family studies and studies with a cytolytic assay showed that the former group is homozygous and the latter heterozygous for PlA1. Because the number of glycoprotein IIIa (GPIIIa) molecules carrying the PlA1 determinant on the surface of normal platelets is thought to be about 40,000, these findings suggest that each GPIIIa molecule carries one PlA1 determinant. The number of class I HLA molecules expressed on normal platelets was considerably smaller than the number of PlA1 determinants, ranging from 4400 to 10,000 (HLA-A2), 870 to 8400 (Bw4), and 1300 to 5800 (Bw6). Preliminary analysis indicates that stronger or weaker expression of Bw4 and of Bw6 correlates with certain "private" HLA-B determinants carried on the HLA-B molecule as found in previous studies using an indirect method to measure alloantigen density. These findings appear to explain why antibodies reactive with platelet-specific antigens such as PlA1 react more strongly with platelets than HLA-specific antibodies in most serologic tests. The weak expression of HLA determinants on platelets of some subjects may account for the less than perfect correlation between in vitro compatibility tests and post-transfusion platelet survivals observed in most studies.

A novel frequency domain fluorescence technique for determination of triplet decay times.

Frequency domain fluorescence measurement using two diode lasers with amplitude modulation in the kHz range yields a signal component at the sum frequency. This intermodulation phenomenon was observed in an aqueous solution of haematoporphyrin (HP) and could be related to triplet state population kinetics. This indirect measurement technique may allow triplet decay time measurement during photodynamic therapy (PDT) enabling monitoring of the type II phototoxic damage rate.

Comparison of 0.5% intrathecal bupivacaine with 0.5% intrathecal ropivacaine in the treatment of refractory cancer and noncancer pain conditions: results from a prospective, crossover, double-blind, randomized study.

BACKGROUND AND OBJECTIVES: Intrathecal (IT) administration of bupivacaine (BUP) for treatment of "refractory" pain has sometimes been associated with unacceptable side effects. This study was undertaken to determine if IT-ropivacaine (ROP) can reduce the rate and intensity of these side effects e.g., urinary retention, paresthesia, and particularly, paresis with gait impairment. A prospective, crossover, double-blind, randomized study. METHODS: Twenty-one patients were enrolled, 9 dropped out of the study, and data were analyzed from 12 patients. Patients were treated by insertion of IT tunneled nylon catheters, continuous infusion of 0.5% ROP followed by 0.5% BUP or 0.5% BUP followed by 0.5% ROP solutions from an external electronic pump. Each local anesthetic was infused for 7 days, and their order of infusion randomized. The comparative efficacy of the ROP and BUP IT infusions was assessed from the daily doses of IT ROP and IT BUP, oral and parenteral opioids, and daily scores of nonopioid analgetic and sedative drug consumption. Self-reported pain intensity (visual analogue scale [VAS] mean scores) and scores of Bromage relaxation, ambulation, nocturnal sleep pattern, rates of side-effects attributable to the IT drugs, the patients' assessment of the IT ROP v the IT BUP periods of the trial, and the comparative daily cost of IT ROP v IT BUP were recorded. RESULTS: The daily doses of the local anesthetics used were 23% higher for ROP than for BUP. Further, the daily cost was approximately equals 3 times higher for ROP than for BUP. No other significant differences between IT ROP and IT BUP were found. CONCLUSION: The results of this study do not support the hypothesis that IT infusion of 0.5% ROP has advantages over IT infusion of 0.5% BUP when administered for relief of "refractory" pain.

Local excision in early rectal cancer-outcome worse than expected: a population based study.

BACKGROUND: Considering the morbidity and mortality after abdominal surgery for rectal cancer, our aim was to determine whether local excision in Stage I rectal cancer provides long-term survival equivalent to TME surgery, particularly in elderly patients. METHODS: Data on 3694 consecutive patients with Stage I rectal cancer operated 1995-2006, were collected from the Swedish Rectal Cancer Register, a population-based, prospectively sampled data-base. Risk factors for death within 5 years after surgery, local recurrence rates, cumulative relative and overall survival rates were calculated for patients ≥ and <80 years-of-age. ASA grading related to surgical technique was analysed in a separate sample. RESULTS: Local excision (LE) was associated with an increased mortality risk both ≥80 (HR 1.55) and <80 years-of-age (HR 1.45). After LE the 5-year local recurrence rate was 11.2% and the total and relative cumulative 5-year survival was 0.62 and 0.81 respectively. Hartmann's procedure (HA) showed an increased mortality risk only in younger patients (HR 2.15). The overall local recurrence rate was 7.2% with HA. Male gender (HR 1.70) and age (HR 1.06) were associated with a significantly increased mortality risk in all age groups. The ASA-grade was higher among patients operated with LE compared to Anterior Resection/Abdominoperineal resection. CONCLUSION: Local excision has a poor outcome in the elderly. A negative selection bias towards old age and high co-morbidity could explain this. Hartmann's procedure has a high risk for mortality and local recurrence in younger patients.

Consulting for substance abuse: mental disorders among adolescents and their parents.

Studies conducted outside of Scandinavia indicate that most adolescents with substance misuse problems suffer from co-morbid mental disorders. The present study assessed the mental health of adolescents seeking help for substance misuse problems in a large Swedish city. Parents' mental health was also examined. The sample included 97 girls with their 90 mothers and 52 fathers, and 81 boys with their 72 mothers and 37 fathers. The adolescents completed a diagnostic interview, either the Kiddie-SADs or the Structured Clinical Interview for DSM-IV (SCID) depending on their age. Their parents underwent diagnostic interviews with the SCID. Ninety per cent of the girls and 81% of the boys met criteria for at least one disorder other than substance misuse, and on average, they suffered from three other disorders, most of which had onset before substance misuse began. Almost 80% of the mothers and 67% of the fathers met criteria for at least one mental disorder other than alcohol and drug-related disorders. The findings concur with those reported from studies conducted in North America. The results suggest that in Sweden mental disorders are not being identified and effectively treated among some children and young adolescents who subsequently abuse alcohol and/or illicit drugs. Adolescents who consult for substance abuse problems require assessments and treatment by mental health professionals.

Reproducibility of occlusal findings. A comparison between clinical and articulator analyses.

The occlusal relationship may be examined clinically in the patient's mouth and on models mounted in an articulator. For the purpose of comparing the reproducibility of the two methods, the occlusion of 10 subjects was analyzed twice with at least 1 week's interval. Certain variations were demonstrated with both methods. Overall reproducibility of tooth contact was observed more frequently in the articulator than in the mouth. The methods showed an equal degree of consistency for measurements of slide in centric. However, when subjects were classified by the extent of occlusal interference, the findings of the clinical analysis seemed to be more reproducible than those recorded by means of the articulator.

A comprehensive bereavement program.

This case study illustrates how one woman was able to take advantage of a variety of hospice bereavement services. In addition to attending monthly social support group meetings and six therapeutic support group sessions, Lillian received 12 home visits or approximately 18 hours of individual support. Not all hospice survivors became so intensely involved in the follow-up services programs offered by Hilltop Hospice. During the five-year period, 1980-1984, approximately 80% of the hospice survivors, or 200 clients, received some form of direct bereavement services; most of the others were provided with supportive correspondence throughout their first year of bereavement. Although approximately 10% of the hospice survivors became involved in the social and the therapeutic support groups, in addition to receiving individual support, most survivors found the individual support services to be sufficient. However, in hospice programs where resources are limited and not all survivors can be assigned a volunteer, support groups can be designed to compensate for a lack of available volunteers. A comprehensive hospice bereavement program takes into account not only the varying resources of the hospice but the individual characteristics of survivors as well. Because clients' grief experiences differ, as well as their personalities, coping styles, and circumstances, a hospice should be prepared to offer a variety of bereavement services. In addition, surviving family members may be more likely to accept follow-up support from the hospice team if they can choose a particular service to meet their individual needs.(ABSTRACT TRUNCATED AT 250 WORDS)

A constitutional mutation within the retinoblastoma gene detected by PFGE.

Retinoblastoma may be caused by constitutional mutations in the retinoblastoma gene which segregates as an autosomal dominant inherited predisposition for developing retinoblastoma tumours. Since 75% of these cases are new mutations, there is a need for methods to identify carriers of such germ-line mutations, so that informed genetic counselling is available to patients and close relatives. We have used pulsed-field gel electrophoresis in screening 20 unrelated cases with bilateral retinoblastoma. One constitutional mutation could be detected, and was found to be caused by a balanced chromosome (4;13) translocation with the breakpoint within intron 17 of the retinoblastoma gene.

Constitutional deletions predisposing to retinoblastoma.

Patients with the heritable form of retinoblastoma carry a constitutional mutation in the retinoblastoma locus in heterozygous form. The majority of such cases are the result of new mutations, which may be inherited by their offspring. We have identified such constitutional mutations within the retinoblastoma locus in 3 out of 66 investigated unrelated gene carriers, using Southern blot analysis and Rb-gene cDNA-probes. The identified mutations were found to be located in different regions of the gene. These analyses may be used to identify or exclude close relatives at risk for the disease. In 2 of the 3 cases, the identified aberrations were used for informed genetic counselling of relatives.

[Experiences with active oral hygiene as a preventive treatment in patients with deciduous and mixed dentition]. / Erfahrungen mit aktiver Mundhygiene als Vorsorgebehandlung bei Patienten mit Milch- und Wechselgebiss.

The results of a study of active oral hygiene treatment in children between the ages of 4 and 12 was reported. It is absolutely imperative that both the children and the parents be highly motivated to carry out consistant oral hygiene. The basic level of oral hygiene for children can be considerably improved if the children are instructed in the appropiate technique for tooth brushing and allowed to practice; the children should be regularly checked by the dentist.

[Heterotopic pancreatic cyst of the stomach wall]. / Heterotope Pankreaszyste der Magenwand.

A 28 year old female was admitted to the hospital with dolorous postprandial swelling of the left upper epigastrium, occurring since the recent death of her husband. After an asymptomatic interval of eight years pains similar to biliary colics occurred increasing in duration, intensity and frequency during the following year. Sonography and computer-tomography indicated a pseudocyst of the pancreascauda adjacent to the left lobe of the liver, spleen and gastric wall. Laparotomy revealed the diagnosis of a heterotopic cyst of the pancreas of fist-size localized intramurally in the gastric corpus which was totally resected. Histologically a granulomatous partially transformed cyst in a heterotopic pancreas was identified. The patient became symptom-free after the operation.