Complications After Laparoscopic Cholecystectomy: A Video Evaluation Study of Whether the Critical View of Safety was Reached.

BACKGROUND: Achieving the critical view of safety (CVS) before transection of the cystic artery and duct is important to reduce biliary duct injury in laparoscopic cholecystectomy. To gain more insight into complications after laparoscopic cholecystectomy, we investigated whether the criteria for CVS were met during surgery by analyzing videos of operations performed at our institution. METHODS: All consecutive patients who underwent a completed laparoscopic cholecystectomy between 2009 and 2011 were included. The videos of the operations of patients with complications were independently reviewed and rated by two investigators with a third consulted in the event of a disagreement. The reviewers answered consecutive questions about whether the CVS criteria were met. Patients who underwent an elective laparoscopic cholecystectomy and had no complications were used as a control group for comparison. RESULTS: Of the 1108 consecutive patients who had undergone a laparoscopic cholecystectomy during the study period, 8.8 % developed complications (average age 51 years) and 1.7 % had bile duct injuries [six patients (0.6 %) had a major bile duct injury, type B, D, or E injury]. In the 65 surgical videos available for analysis, CVS was reached in 80 % of cases according to the operative notes. However, the reviewers found that CVS was reached in only 10.8 % of the cases. Only in 18.7 % of the cases the operative notes and video agreed about CVS being reached. CVS was not reached in any of the patients who had biliary injuries. In the control group, CVS was reached significantly more often in 72 %. CONCLUSIONS: In our institutional series of laparoscopic cholecystectomies with postoperative complications, CVS was reached in only a few cases. Evaluating surgical videos of laparoscopic cholecystectomy cases are important and we recommend its use to improve surgical technique and decrease the number of biliary injuries.

Hot topic: apparent total-tract nutrient digestibilities measured commercially using 120-hour in vitro indigestible neutral detergent fiber as a marker are related to commercial dairy cattle performance.

Measuring individual feed nutrient concentration is common practice for field dairy nutritionists. However, accurately measuring nutrient digestibility and using digestion values in total digestible nutrients models is more challenging. Our objective was to determine if in vivo apparent total-tract nutrient digestibility measured with a practical approach was related to commercial milk production parameters. Total mixed ration and fecal samples were collected from high-producing cows in pens on 39 commercial dairies and analyzed at a commercial feed and forage testing laboratory for nutrient concentration and 120-h indigestible NDF (iNDF) content using the Combs-Goeser in vitro digestion technique. The 120-h iNDF was used as an internal marker to calculate in vivo apparent nutrient digestibilities. Two samples were taken from each dairy and were separated in time by at least 3 wk. Samples were targeted to be taken within 7d of Dairy Herd Improvement (DHI) herd testing. Approved DHI testers measured individual cow milk weights as well as fat and protein concentrations. Individual cow records were averaged by pen corresponding to the total mixed ration and fecal samples. Formulated diet and dry matter intake (DMI) records for each respective pen were also collected. Mixed model regression analysis with dairy specified as a random effect was used to relate explanatory variables (diet nutrient concentrations, formulated DMI, in vivo apparent nutrient digestibilities, and fecal nutrient concentrations) to milk production measures. Dry matter intake, organic matter (OM) digestibility, fecal crude protein (CP) concentration, and fecal ether extract concentration were related to milk, energy-corrected milk, and fat yields. Milk protein concentration was related to CP digestibility, and milk protein yield was related to DMI, OM digestibility, CP digestibility, and ether extract digestibility. Although many studies have related DMI and OM digestibility to milk production under controlled experimental settings, very few have related practical in vivo measures to milk production. By documenting the practical OM digestibility relationship with milk production, nutritionists and scientists may have confidence in this approach for measuring diet performance and collecting nutritional data for commercial dairies.

At-risk for results: guaranteeing performance based on patient outcomes.

The author examines how managed care organizations can circumvent purchasers' overemphasis on price by proposing outcomes-based reimbursement arrangements. He explains the necessity for an organization to first develop an information system and outcomes measurement infrastructure that will support such an arrangement. He then explains the types of outcomes that purchasers express most interest in using for reimbursement, and several types of arrangements that have been proposed. He also speculates about how such arrangements might also be made between managed care organizations and contracted providers.

Adaptive multiresolution analysis based on synchronization.

We propose an adaptive multiscale approach to data analysis based on synchronization. The approach is nonlinear, data driven in the sense that it does not rely on a priori chosen basis, and automatically determines the data scale. Numerical results for one- and two-dimensional cases illustrate that the method works effectively for the usual modulated signals such as chirps, etc., as well as for more complicated data with multiple scales. The method extends straightforwardly to functions defined on weighted graphs and grids in high dimensions. Connections with some other recent approaches to multiscale analysis are briefly discussed.

Multiple host-specificity loci of the broad host-range Rhizobium sp. NGR234 selected using the widely compatible legume Vigna unguiculata.

Specificity in legume-Rhizobium symbiosis depends on plant and rhizobial genes. As our objective was to study broad host-range determinants of rhizobia, we sought a legume and a Rhizobium with the lowest possible specificity. By inoculating 12 different legumes with a heterogenous collection of 35 fast-growing rhizobia, we found Rhizobium sp. NGR234 to be the Rhizobium and Vigna unguiculata to be the plant with the lowest specificities. Transfer of cloned fragments of the Sym-plasmid pNGR234a into heterologous rhizobia, screening for extension of host-range of the transconjugants to include V. unguiculata, and restriction mapping of the Hsn- and overlapping clones, proved that there were at least three distinct Hsn-regions (HsnI, II, and III) on pNGR234a. HsnI is located next to nodD, HsnII is linked to nifKDH and HsnIII to nodC. In addition to nodulation of Vigna, HsnI conferred upon the transconjugants the ability to nodulate Glycine max, Macroptilium atropurpureum and Psophocarpus tetragonolobus. All three Hsn-regions, when transferred to the appropriate recipients, induced root-hair-curling on M. atropurpureum. Hsn-region III was able to complement a mutation in the host-range gene nodH of R. meliloti strain 2011. Homology to "nod-box"-sequences could be shown only for the sub-clones containing HsnII and HsnIII, thus suggesting different regulation mechanisms for HsnI and HsnII/III.