Providers' Perceptions Versus Practices Inform Pediatric Colorectal Enhanced Recovery After Surgery Implementation.

INTRODUCTION: There are many barriers to the implementation of an enhanced recovery after surgery (ERAS) pathway. The aim of this study was to compare surgeon and anesthesia perceptions with current practices prior to the initiation of an ERAS protocol in pediatric colorectal patients and to use that information to inform ERAS implementation. METHODS: This was a mixed method single institution study of barriers to implementation of an ERAS pathway at a free-standing children's hospital. Anesthesiologists and surgeons at a free-standing children's hospital were surveyed regarding current practices of ERAS components. A retrospective chart review was performed of 5- to 18-y-old patients undergoing colorectal procedures between 2013 and 2017, followed by the initiation of an ERAS pathway, and a prospective chart review for 18 mo postimplementation. RESULTS: The response rate was 100% (n = 7) for surgeons and 60% (n = 9) for anesthesiologists. Preoperative nonopioid analgesics and regional anesthesia were rarely used. Intraoperatively, 54.7% of patients had a fluid balance of <10 cc/kg/h and normothermia was achieved in only 38.7%. Mechanical bowel prep was frequently utilized (48%). Median nil per os time was significantly longer than required at 12 h. Postoperatively, 42.9% of surgeons reported that patients could have clears on postoperative day zero, 28.6% on postoperative day one, and 28.6% after flatus. In reality, 53.3% of patients were started on clears after flatus, with a median time of 2 d. Most surgeons (85.7%) expected patients to get out of bed once awake from anesthesia; however, median time that patients were out of bed was postoperative day one. While most surgeons reported frequent use of acetaminophen and/or ketorolac, only 69.3% received any nonopioid analgesic postoperatively, with only 41.3% receiving two or more nonopioid analgesics. Nonopioid analgesia showed the highest rates of improvement from retrospective to prospective: preoperative use of analgesics increased from 5.3% to 41.2% (P < 0.0001), postoperative use of acetaminophen increased by 27.4% (P = 0.5), Toradol by 45.5% (P = 0.11), and gabapentin by 86.7% (P < 0.0001). Postoperative nausea/vomiting prophylaxis with >1 class of antiemetic increased from 8% to 47.1% (P < 0.001). The length of stay was unchanged (5.7 versus 4.4 d, P = 0.14). CONCLUSIONS: For the successful implementation of an ERAS protocol, perceptions versus reality must be assessed to determine current practices and identify barriers to implementation.

Causes of Mortality of Dairy Cattle Diagnosed by Complete Necropsy.

This retrospective case series summarized the primary causes of death in 857 dairy cattle necropsied from 2008 to 2019 at the Utah Veterinary Diagnostic Laboratory, from dairy farms in Utah (76%), Idaho (16%) or other states (8%), primarily in the U.S. Intermountain West. Of cattle with age provided, 74% matched with body weight based estimates for those with no age stated. Cattle ranged from fetuses at 60 days of gestation to 9 years old. Primary cause of mortality was diagnosed in 833 cattle (97%); no cause was evident in 24 cattle (3%). Sexes were female 620 (72%), male 214 (25%), not recorded 23 (3%). Seven diseases killed 80% of the animals: gastrointestinal disease (most enteritis/colitis) 318 (37%); pneumonia 166 (19%); abortion 96 (11%), peritonitis 30 (4%), omphalophlebitis (navel ill) 27 (3%), abomasitis 23 (3%), and metritis 23 (3%). Etiologic agents and specific causes varied with age categories of the animals. Young calves that died from dystocia, omphalophlebitis, or congenital abnormality often presented with no suspicion of those causes by the owners because of no external signs. Some important fatal diseases of adult dairy cows that are often diagnosed ante-mortem were diagnosed at necropsy with no suspicion by those submitting the carcasses: metritis, hardware disease, and displaced abomasum. Multicentric lymphoma was a relatively important cause of death in cows more than 4 years old. Despite use of a toxicology laboratory, toxicity was only diagnosed as causing 1% of the deaths across all ages of dairy cattle. There were numerous other causes of mortality diagnosed as well. Necropsy is a vital tool to diagnose causes of death in dairy cattle and can guide changes in management or preventive practices to reduce the rate of deaths in dairy herds.

Treatment of Paradoxical Adipose Hyperplasia following Cryolipolysis: A Single-Center Experience.

Paradoxical adipose hyperplasia is a rare adverse event associated with cryolipolysis. No evidence of spontaneous resolution has been described and little has been written about its treatment. The purpose of this report is to share the authors' experience treating patients with paradoxical adipose hyperplasia after cryolipolysis. A retrospective chart review was performed for all paradoxical adipose hyperplasia patients seen in the authors' practice between May of 2013 and May of 2016. The treatment parameters, demographics, onset of findings, and subsequent treatment were chronicled. Eleven cases of paradoxical adipose hyperplasia were identified (eight men and three women). All patients were of Hispanic background. Seven patients were treated surgically (six cases of liposuction alone and one case of liposuction and abdominoplasty). Average follow-up was 9.6 months (range, 2 to 32 months). Three of the patients treated with liposuction required a secondary procedure. All surgically treated patients were very satisfied with their final appearance. Paradoxical adipose hyperplasia is a rare complication of cryolipolysis that may occur more frequently than in the manufacturer's reported data. Treatment is best delayed until the affected area has softened, which normally occurs in 6 to 9 months after the initial cryolipolysis procedure. Power-assisted liposuction is the preferred method of treatment, but in some cases, abdominoplasty may be necessary. Secondary treatments might be needed for recurrence or persistent bulge. One must be sensitive to heightened patient concerns when offering an invasive procedure to correct the complications from a noninvasive one. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Cancer Trials Ireland (ICORG) 06-34: A multi-centre clinical trial using three-dimensional conformal radiation therapy to reduce the toxicity of palliative radiation for lung cancer.

TITLE: Cancer Trials Ireland (ICORG) 06-34: A multi-centre clinical trial using three-dimensional conformal radiation therapy to reduce the toxicity of palliative radiation for lung cancer. NCT01176487. BACKGROUND & PURPOSE: Trials of radiation therapy for the palliation of intra-thoracic symptoms from locally advanced non-small cell lung cancer (NSCLC) have concentrated on optimising fractionation and dose schedules. In these trials, the rates of oesophagitis induced by this "palliative" therapy have been unacceptably high. In contrast, this non-randomised, single-arm trial was designed to assess if more technically advanced treatment techniques would result in equivalent symptom relief and reduce the side-effect of symptomatic oesophagitis. MATERIALS & METHODS: Thirty-five evaluable patients with symptomatic locally advanced or metastatic NSCLC were treated using a three-dimensional conformal technique (3-DCRT) and standardised dose regimens of 39 Gy in 13 fractions, 20 Gy in 5 fractions or 17 Gy in 2 fractions. Treatment plans sought to minimise oesophageal dose. Oesophagitis was recorded during treatment, at two weeks, one month and three months following radiation therapy and 3-6 monthly thereafter. Mean dose to the irradiated oesophagus was calculated for all treatment plans. RESULTS: Five patients (14%) had experienced grade 2 oesophagitis or dysphagia or both during treatment and 2 other patients had these side effects at the 2-week follow-up. At follow-up of one month after therapy, there was no grade two or higher oesophagitis or dysphagia reported. 22 patients were eligible for assessment of late toxicity. Five of these patients reported oesophagitis or dysphagia (one had grade 3 dysphagia, two had grade 2 oesophagitis, one of whom also had grade 2 dysphagia). Quality of Life (QoL) data at baseline and at 1-month follow up were available for 20 patients. At 1-month post radiation therapy, these patients had slightly less trouble taking a short walk, less shortness of breath, did not feel as weak, had better appetite and generally had a better overall quality of life than they did at baseline. They did report being slightly more tired. CONCLUSIONS: This trial is the first of its kind showing that 3-DCRT provides patients with lower rates of oesophageal toxicity whilst yielding acceptable rates of symptom control. (Sponsored by Cancer Trials Ireland (ICORG) Study number 06-34, the Friends of St. Luke's and the St. Luke's Institute of Cancer Research.).

Periareolar augmentation mastopexy with interlocking gore-tex suture, retrospective review of 50 consecutive patients.

BACKGROUND: Periareolar Augmentation Mastopexy is one of the most challenging operations in plastic surgery. Problems with scar quality, areolar widening, and distortion are frequent problems that interfere with a predictable result. METHODS: A retrospective review was performed on fifty consecutive patients who underwent a periareolar augmentation mastopexy with the interlocking approach. Of the 50 patients, 30 had both preoperative and postoperative photographs and were the basis of the study. RESULTS: The age of the patients ranged from 19 to 56 years with the average age being 39 years. The postoperative follow-up averaged 9.5 months and the implants averaged 316 mL. There were no deaths, pulmonary embolism, deep vein thrombosis, or infected implants. Four patients had complications following surgery for an overall complication rate of 13%. Two patients developed an infected Gore-Tex suture. Two of these complications were treated with revision surgery. Five patients required reoperation for an overall reoperative rate of 16% (one patient was converted to a full mastopexy). CONCLUSIONS: As a result of this retrospective study, we have found the interlocking approach to periareolar augmentation/mastopexy to be a safe and reliable operation.