High Rate of Positive Circumferential Resection Margin in Colon Cancer: A National Appraisal and Call for Action.

OBJECTIVE: To identify rates of positive circumferential resection margin (CRM) for colon cancer surgery in the US. SUMMARY BACKGROUND DATA: CRM is one of the most important determinants of local control in colorectal cancers. The extent to which CRM involvement exists after colon cancer surgery is unknown. METHODS: Colon cancer cases with resection 2010 to 2015 were identified from the National Cancer Data Base. Adjusting for patient and tumor characteristics, comparisons were made between cases with CRM > 1 mm (negative margin) and those with margin involved with tumor or ≤ 1 mm (positive margin, CRM+). Hospital-level analysis was performed, examining observed-to-expected CRM+ rates. RESULTS: In total, 170,022 cases were identified: 150,291 CRM- and 19,731 CRM+ (11.6%). Pathologic T-category was the greatest predictor of CRM+, with higher rates in pT4(25.8%), pT4A(24.7%), and pT4B(31.5%) versus pT1(4.5%), pT2(6.3%) and pT3 (10.9%, P < 0.001). Within pT4 patients, predictors of CRM+ included signet-ring histology (38.1% vs 26.7% nonmucinous, and 26.9% mucinous adenocarcinoma, P < 0.001), removing < 12 lymph nodes (36.5% vs 26.1% >12, P < 0.001), community facilities (32.7%) versus academic/research (23.6%, P < 0.001), year (30.1% 2010 vs 22.6% 2015, P < 0.001), and hospital volume (24.5% highest quartile vs 32.7% lowest, P < 0.001). Across 1288 hospitals, observed-to-expected ratios for CRM+ ranged from 0 to 7.899; 429 facilities had higher than expected rates. CONCLUSIONS: Overall rate of CRM+ in US colon cancer cases is high. Variation exists across hospitals, with higher than expected rates in many facilities. Although biology is a major influencing factor, CRM+ rates represent an area for multidisciplinary improvement in quality of colon cancer care.

An Investigation into the Growth of Lolium perenne L. and Soil Properties Following Soil Amendment with Phosphorus-Saturated Bauxite Residue.

Reuse options for bauxite residue include treatment of phosphorus (P)-enriched wastewaters where the P-saturated media offers fertiliser potential. However, few studies have assessed the impact on soil properties. Two types of spent P-saturated bauxite residue were applied to soil and compared to conventional superphosphate fertiliser as well as a control soil. Soil physico-chemical properties, worm Eisenia fetida L. choice tests, and Lolium perenne L. growth and elemental uptake were examined. Comparable biomass and plant content for L. perenne in the P-saturated bauxite residue treatments and those receiving superphosphate, indicated no phytotoxic effects. E. fetida L. showed a significant preference for the control soil (58 %± 2.1%) over the amended soils, indicating some form of salt stress. Overall, P-saturated bauxite residue was comparable to the superphosphate fertiliser in terms of the plant performance and soil properties, indicating the potential recycling of P from wastewaters using bauxite residue as a low-cost adsorbent.

Screening high-risk populations for colon and rectal cancers.

Currently, colorectal cancers accounted for the second-highest number of cancer deaths in the US. Hereditary syndromes, strong family history, and inflammatory bowel disease are all conditions that confer predisposition risks. In hereditary syndromes, screening must be more frequent and start earlier. With familial risk, screening should depend on the age of cancer onset and number of affected relatives. For inflammatory bowel disease, surveillance should depend on duration, severity, and extent of colitis.

The use of rapid, small-scale column tests to determine the efficiency of bauxite residue as a low-cost adsorbent in the removal of dissolved reactive phosphorus from agricultural waters.

Bauxite residue, the by-product produced in the alumina industry, is a potential low-cost adsorbent in the removal of phosphorus (P) from aqueous solution, due to its high composition of residual iron oxides such as hematite. Several studies have investigated the performance of bauxite residue in removing P; however, the majority have involved the use of laboratory "batch" tests, which may not accurately estimate its actual performance in filter systems. This study investigated the use of rapid, small-scale column tests to predict the dissolved reactive phosphorus (DRP) removal capacity of bauxite residue when treating two agricultural waters of low (forest run-off) and high (dairy soiled water) phosphorus content. Bauxite residue was successful in the removal of DRP from both waters, but was more efficient in treating the forest run-off. The estimated service time of the column media, based on the largest column studied, was 1.08 min g-1 media for the forest run-off and 0.28 min g-1 media for the dairy soiled water, before initial breakthrough time, which was taken to be when the column effluent reached approximately 5% of the influent concentration, occurred. Metal(loid) leaching from the bauxite residue, examined using ICP-OES, indicated that aluminium and iron were the dominant metals present in the treated effluent, both of which were above the EPA parametric values (0.2 mg L-1 for both Al and Fe) for drinking water.

The association of venous thromboembolism chemoprophylaxis timing on venous thromboembolism after major vascular surgery.

OBJECTIVE: Venous thromboembolism (VTE) is reported to occur in up to 33% of patients undergoing major vascular surgery. Despite this high incidence, patients inconsistently receive timely VTE chemoprophylaxis. The true incidence of VTE among patients receiving delayed VTE chemoprophylaxis is unknown. We sought to identify the association of VTE chemoprophylaxis timing on VTE risk, postoperative transfusion rates, and 30-day mortality and morbidity in patients undergoing major open vascular surgery. METHODS: Patients undergoing major open vascular surgery (open abdominal aortic aneurysm [oAAA] repair, aortofemoral bypass, and lower extremity infrainguinal bypass [LEB]) were identified using the Michigan Surgical Quality Collaborative (MSQC) between July 2012 and June 2015. The VTE rate was compared between patients receiving early versus delayed VTE chemoprophylaxis. VTE chemoprophylaxis delay was defined as therapy initiation more than 24 hours after surgery. The risk-adjusted association of the chemoprophylaxis timing and VTE development was determined using multivariable logistic regression. Blood transfusion rates, 30-day mortality, and postoperative complications were compared across groups. RESULTS: A total of 2421 patients underwent major open vascular surgery, including 196 oAAA repair, 259 aortofemoral bypass, and 1966 LEB. The overall incidence of 30-day VTE was 1.40%, ranging from 1.12% for LEB to 3.57% for oAAA repair. Among patients receiving early VTE chemoprophylaxis, the rate of VTE was 0.78% versus 2.26% among those with a delay in VTE chemoprophylaxis (P = .002). When accounting for the preoperative risk of VTE, delayed chemoprophylaxis was associated with a significantly higher risk of VTE (odds ratio, 2.38; 95% confidence interval, 1.12-5.06; P = .024). The early VTE chemoprophylaxis group was associated with a significantly decreased risk of bleeding compared with those with a delay (14.31% vs 18.90%; P = .002). Overall 30-day mortality and postoperative complications were similar with the exception of an associated higher rate of infectious complications in the delayed VTE chemoprophylaxis group, including superficial surgical site infection (6.00% vs 4.06%; P = .028), pneumonia (3.25% vs 1.85%; P = .028), urinary tract infection (2.95% vs 1.57%; P = .020), and severe sepsis (3.05% vs 1.71%; P = .029). CONCLUSIONS: Although patients undergoing major open vascular surgery have a low risk of VTE at baseline, there is a significantly greater risk of developing VTE among patients who have a delay in the administration of VTE chemoprophylaxis. Postoperative transfusion rates were significantly lower among patients receiving early chemoprophylaxis. There were no differences in the 30-day mortality and postoperative complications, except for infectious complications. Given these findings, surgeons should consider early chemoprophylaxis in the postoperative setting after major open vascular surgery without contraindication.

The accuracy of chemotherapy ascertainment among colorectal cancer patients in the surveillance, epidemiology, and end results registry program.

BACKGROUND: Surveillance, Epidemiology, and End Results (SEER) public research database does not include chemotherapy data due to concerns for incomplete ascertainment. To compensate for perceived lack of data quality many researchers use SEER-Medicare linked data, limiting studies to persons over age 65. We sought to determine current SEER ascertainment of chemotherapy receipt in two relatively large SEER registries compared to patient-reported receipt and to assess patterns of under-ascertainment. METHODS: In 2011-14, we surveyed patients with Stage III colorectal cancer reported to the Georgia and Metropolitan Detroit SEER registries. 1301/1909 eligible patients responded (68% response rate). Survey responses regarding treatment and sociodemographic factors were merged with SEER data. We compared patient-reported chemotherapy receipt with SEER recorded chemotherapy receipt. We estimated multivariable regression models to assess associations of under-ascertainment in SEER. RESULTS: Eighty-five percent of patients reported chemotherapy receipt. Among those, 10% (n = 104) were under-ascertained in SEER (coded as not receiving chemotherapy). In unadjusted analyses, under-ascertainment was more common for older patients (11.8% age 76+ vs. < 9% for all other ages, p = 0.01) and varied with SEER registries (10.2% Detroit vs. 6.8% Georgia; p = 0.04). On multivariable analyses, chemotherapy under-ascertainment did not vary significantly by any patient attributes. CONCLUSION: We found a 10% rate of under-ascertainment of adjuvant chemotherapy for resected, stage III colorectal cancer in two SEER registries. Chemotherapy under-ascertainment did not disproportionately affect any patient subgroups. Use of SEER data from select registries is an important resource for researchers investigating contemporary chemotherapy receipt and outcomes.

Discovery of {4-[4,9-bis(ethyloxy)-1-oxo-1,3-dihydro-2H-benzo[f]isoindol-2-yl]-2-fluorophenyl}acetic acid (GSK726701A), a novel EP4 receptor partial agonist for the treatment of pain.

A novel series of EP4 agonists and antagonists have been identified, and then used to validate their potential in the treatment of inflammatory pain. This paper describes these novel ligands and their activity within a number of pre-clinical models of pain, ultimately leading to the identification of the EP4 partial agonist GSK726701A.

Changes in the fractionation profile of Al, Ni, and Mo during bioleaching of spent hydroprocessing catalysts with Acidithiobacillus ferrooxidans.

Spent hydroprocessing catalysts are known to contain a variety of potentially toxic metals and therefore studies on the bioavailability and mobility of these metals are critical for understanding the possible environmental risks of the spent catalysts. This study evaluates the different chemical fractions/forms of aluminium (Al), nickel (Ni), and molybdenum (Mo) in spent hydroprocessing catalyst and the changes they undergo during bioleaching with Acidithiobacillus ferrooxidans. In the spent catalyst (prior to bioleaching), Al was primarily present in its residual form, suggesting its low environmental mobility. However, Ni comprised mainly an exchangeable fraction, indicating its high environmental mobility. Molybdenum was mainly in the oxidizable form (47.1%), which indicated that highly oxidizing conditions were required to liberate it from the spent catalyst. During bioleaching the exchangeable, reducible and oxidizable fractions of all the metals were leached, whereas the residual fractions remained largely unaffected. At the end of bioleaching process, the metals remaining in the bioleached sample were predominantly in the residual fraction (98.3-99.5%). The 'risk assessment code' (RAC) and IR analysis also demonstrated that the environmental risks of the bioleached residue were significantly lower compared to the untreated spent catalyst. The results of this study suggest that bioleaching is an effective method in removing the metals from spent catalysts and the bioleached residue poses little environmental risk.

Lymph Node Ratio Is Less Prognostic in Melanoma When Minimum Node Retrieval Thresholds Are Not Met.

BACKGROUND: Lymph node ratio (LNR), positive nodes divided by nodes examined, has been proposed for prognostication in melanoma to mitigate problems with low node counts. However, it is unclear if LNR offers superior prognostication over total counts of positive nodes and nodes examined. Additionally, the prognostic value of LNR may change if a threshold number of nodes are examined. We evaluated whether LNR is more prognostic than positive nodes and nodes examined, and whether the prognostic value of LNR changes with minimum thresholds. METHODS: Using the National Cancer Data Base Participant User File, we identified 74,692 incident cases with nodal dissection during 2000-2006. We compared LNR versus counts of examined and positive nodes based on Harrell's C, a measure of predictive ability. We then stratified by total nodes examined: greater versus fewer than ten for axillary lymph node dissection (ALND) and greater versus fewer than five for inguinal lymph node dissection (ILND). RESULTS: Overall, LNR had a Harrell's C of 0.628 (95 % confidence interval [CI] 0.625-0.631). Examined and positive nodes were not significantly different from this, with a Harrell's C of 0.625 (95 % CI 0.621-0.630). In ALND, LNR had a Harrell's C of 0.626 (95 % CI 0.610-0.643) with ≥10 nodes versus 0.554 (95 % CI 0.551-0.558) < 10 nodes. In ILND, LNR had a Harrell's C of 0.679 (95 % CI 0.664-0.694) with ≥5 nodes versus C of 0.601 (95 % CI 0.595-0.606) < 5 nodes. CONCLUSIONS: LNR provides no prognostic superiority versus counts of examined and positive nodes. Moreover, the prognostic value of LNR diminishes when minimum node retrieval thresholds are not met.

Long-term Outcomes of Laparoscopic Versus Open Surgery for Clinical Stage I Gastric Cancer: The LOC-1 Study.

BACKGROUND: Clinical trials comparing laparoscopic gastrectomy (LG) versus traditional open gastrectomy (OG) have been planned, their surgical outcomes reported but their oncologic outcomes are still pending. Consequently, we have conducted this large-scale historical cohort study to provide relevant information rapidly to guide our current practice. METHODS: Through a consensus meeting involving surgeons, biostatisticians, and epidemiologists, 30 variables of preoperative information possibly influencing surgeons' choice between LG versus OG and potentially associating with outcomes were identified to enable rigorous estimation of propensity scores. A total of 4235 consecutive patients who underwent gastrectomy for gastric adenocarcinoma were identified and their relevant data were gathered from the participating hospitals. After propensity score matching, 1848 patients (924 each for LG and OG) were selected for comparison of long-term outcomes. RESULTS: In the propensity-matched population, the 5-year overall survival was 96.3% [95% confidence interval (CI) 95.0-97.6] in the OG as compared with 97.1% (95% CI, 95.9-98.3) in LG. The number of all-cause death was 33/924 in the OG and 24/924 in the LG through the entire period, and the hazard ratio (LG/OG) for overall death was 0.75 (95% CI, 0.44-1.27; P = 0.290). The 3-year recurrence-free survival was 97.4% (95% CI, 96.4-98.5) in the OG and 97.7% (95% CI, 96.5-98.8) in the LG. The number of recurrence was 22/924 in the OG and 21/924 in the LG through the entire period, and the hazard ratio was 1.01 (95% CI, 0.55-1.84; P = 0.981). CONCLUSIONS: This observational study adjusted for all-known confounding factors seems to provide strong enough evidence to suggest that LG is oncologically comparable to OG for gastric cancer.

Analysis of Prognostic Factors from 9387 Merkel Cell Carcinoma Cases Forms the Basis for the New 8th Edition AJCC Staging System.

BACKGROUND: The first consensus Merkel cell carcinoma (MCC) staging system was published in 2010. New information on the clinical course prompts review of MCC staging. METHODS: A total of 9387 MCC cases from the National Cancer Data Base Participant User File with follow-up and staging data (1998-2012) were analyzed. Prognostic differences based on clinical and pathological staging were evaluated. Survival estimates were compared by disease extent. RESULTS: Sixty-five percent of cases presented with local disease, whereas 26 and 8 % presented with nodal and distant disease. Disease extent at presentation was predictive of 5-year overall survival (OS) with estimates of 51, 35, and 14 % for local, nodal, and distant disease. Tumor burden at the regional nodal basin was predictive of 5-year OS with estimates of 40 and 27 % for clinically occult and clinically detected nodal disease. For local disease, we confirm improved prognosis when the regional nodal basin was negative by pathological compared with clinical staging. We identified 336 cases with clinically detected nodal disease and unknown primary tumor and showed improved prognosis over cases presenting with concurrent primary tumor (OS estimates of 42 vs. 27 %). CONCLUSIONS: Analysis of a national dataset of MCC cases validates the predictive value of disease extent at presentation. Separation of clinical and pathological stage groups and regrouping of unknown primary tumors are supported by the analysis. The revised staging system provides more accurate prognostication and has been formally accepted by the AJCC staging committee for inclusion in the 8th edition.

Intraoperative Fluid Resuscitation Strategies in Pancreatectomy: Results from 38 Hospitals in Michigan.

BACKGROUND: Fluid administration practices may affect complication rates in some abdominal surgeries, but effects in patients undergoing pancreatectomy are not understood well. We sought to determine whether amount of intraoperative fluid administered to patients undergoing pancreatectomy is associated with postoperative complication rates and to determine whether hospitals vary in their fluid administration practices. METHODS: Data for 504 patients undergoing pancreatectomy at 38 hospitals between 2012 and 2015 were evaluated. The main exposure was intraoperative fluid administration (≤10, 10-15, >15 mL/kg/h). Mortality, complications, and length of stay were the main outcomes of interest. Patient-level associations between exposure and outcome were tested, with adjustment for potentially confounding patient and surgical factors, using random intercept, mixed-effects linear or logistic regression models. Hospitals were then categorized as having a restrictive, intermediate, or liberal resuscitation practice, and adjusted outcomes were compared. RESULTS: A total of 167 (33.1 %), 185 (36.7 %) and 152 (30.2 %) patients received restrictive, intermediate, or liberal fluid administration, respectively. Hospitals with more restrictive practices had significantly lower adjusted 30-day mortality than those with more liberal practices (2.7 vs. 6.6 %; P < 0.001). Hospitals with more restrictive practices had the lowest rates of severe (Grade 2 and 3) complications (15.4 % restrictive vs. 25.3 % intermediate vs. 44.3 % liberal; P < 0.001). More restrictive hospitals had decreased adjusted mean length of stay (9.5 days vs. 12.7 days intermediate vs. 11.6 days liberal; P < 0.001). CONCLUSIONS: More restrictive intraoperative resuscitation practices in pancreatectomy are associated with decreased hospital-level mortality, severe complications, and length of stay.

Insurance Status and Hospital Payer Mix Are Linked With Variation in Metastatic Site Resection in Patients With Advanced Colorectal Cancers.

BACKGROUND: Despite substantially improved survival with metastatic site resection in colorectal cancers, uptake of aggressive surgical approaches remains low among certain patients. It is unknown whether financial determinants of care, such as insurance status, play a role in this treatment gap. OBJECTIVE: We sought to evaluate the effect of insurance status on metastasectomy in patients with advanced colorectal cancers. DESIGN: This was a retrospective cohort study. SETTINGS: Using the National Cancer Data Base Participant User File, incident cases of colorectal cancer metastatic to the lung and/or liver with diagnosis from 2010 to 2013 were identified. PATIENTS: We identified 42,300 patients in our cohort with a mean age 64 years. MAIN OUTCOME MEASURES: Controlling for patient, tumor, and hospital characteristics, hierarchical regression was used to examine associations between hospital payer mix and metastatic site resection. Metastatic site resection occurred in 12.3% of all patients. RESULTS: Adjusting for patient and hospital fixed effects, we found that patients who were uninsured or on Medicaid were 38% less likely to undergo metastasectomy (OR = 0.62 (95% CI, 0.56-0.66)). Patients in hospitals with staff treating a high percentage of uninsured patients or patients with Medicaid were less likely to undergo metastasectomy, even after controlling for individual patient insurance status. LIMITATIONS: The study was limited by its retrospective design and the granularity and accuracy of the National Cancer Data Base. CONCLUSIONS: Differences in insurance status and hospital payer mix are associated with differences in rates of metastatic site resection in patients with colorectal cancer that is metastatic to the lung and/or liver. There is a need for improved access to metastatic site resection for individual patients who are uninsured or who have Medicaid insurance, as well as for all patients who seek care at hospitals treating a large proportion of patients who are uninsured or on Medicaid. Remedies for individual patients could include improved access to private insurance through employment or individual plans or improved reimbursement from Medicaid for this procedure. Strategies for patients at low-performing hospitals include selective referral to centers that perform mestastectomy more frequently when appropriate.

Multimodal cancer care in poor prognosis cancers: Resection drives long-term outcomes.

BACKGROUND AND OBJECTIVES: Hospitals with high complex oncologic surgical volume have improved short-term outcomes. However, for long-term outcomes, the influence of other therapies must be considered. We compared effects of resection with other therapies on long-term outcomes across U.S. hospitals. METHODS: We examined claims in the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset for patients with esophageal (EC) and pancreatic (PC) cancers between 2005-2009, with follow-up through 2011, performing multivariable Cox proportional hazards analyses. We stratified hospitals by volume and compared rates of treatments in the context of survival. RESULTS: We studied 905 EC and 3,293 PC patients at 138 and 375 hospitals, respectively. For EC, resection rates were significantly higher (32.9% vs. 9.5%, P < 0.001) in the highest versus lowest volume hospitals. Adjusted survival was also statistically significantly better (48.5% vs. 43.1%, P < 0.001). For PC, resection rates were also statistically significantly higher (30.1% vs. 12.0%, P < 0.001) with higher adjusted survival (21.5% vs. 19.9%, P = 0.01). We did not find variation in rates of other cancer treatments across hospitals. CONCLUSIONS: A significant association exists between long-term survival and rates of cancer-directed surgery across hospitals, without variation in rates of other therapies. Access to resection appears to be key to reducing variation in long-term survival. J. Surg. Oncol. 2016;113:599-604. © 2016 Wiley Periodicals, Inc.

Food and beverage cues in children's television programmes: the influence of programme genre.

OBJECTIVE: The link between childhood obesity and both television viewing and television advertising have previously been examined. We sought to investigate the frequency and type of food and beverage placements in children-specific television broadcasts and, in particular, differences between programme genres. METHOD: Content of five weekdays of children-specific television broadcasting on both UK (BBC) and Irish (RTE) television channels was summarized. Food and beverage placements were coded based on type of product, product placement, product use and characters involved. A comparison was made between different programme genres: animated, cartoon, child-specific, film, quiz, tween and young persons' programming. RESULTS: A total of 1155 (BBC=450; RTE=705) cues were recorded giving a cue every 4·2 min, an average of 12·3 s/cue. The genre with most cues recorded was cartoon programming (30·8%). For the majority of genres, cues related to sweet snacks (range 1·8-23·3%) and sweets/candy (range 3·6-25·8%) featured highly. Fast-food (18·0%) and sugar-sweetened beverage (42·3%) cues were observed in a high proportion of tween programming. Celebratory/social motivation factors (range 10-40 %) were most common across all genres while there were low proportions of cues based on reward, punishment or health-related motivating factors. CONCLUSIONS: The study provides evidence for the prominence of energy-dense/nutrient-poor foods and beverages in children's programming. Of particular interest is the high prevalence of fast-food and sugar-sweetened beverage cues associated with tween programming. These results further emphasize the need for programme makers to provide a healthier image of foods and beverages in children's television.

Holistic Evaluation of Field-Scale Denitrifying Bioreactors as a Basis to Improve Environmental Sustainability.

Denitrifying bioreactors convert nitrate-nitrogen (NO-N) to di-nitrogen and protect water quality. Herein, the performance of a pilot-scale bioreactor (10 m long, 5 m wide, 2 m deep) containing seven alternating cells filled with either sandy loam soil or lodgepole pine woodchip and with a novel "zig-zag" flow pattern was investigated. The influent water had an average NO-N concentration of 25 mg L. The performance of the bioreactor was evaluated in two scenarios. In Scenario 1, only NO-N removal was evaluated; in Scenario 2, NO-N removal, ammonium-N (NH-N), and dissolved reactive phosphorus (DRP) generation was considered. These data were used to generate a sustainability index (SI), which evaluated the overall performance taking these parameters into account. In Scenario 1, the bioreactor was a net reducer of contaminants, but it transformed into a net producer of contaminants in Scenario 2. Inquisition of the data using these scenarios meant that an optimum bioreactor design could be identified. This would involve reduction to two cells: a single sandy loam soil cell followed by a woodchip cell, which would remove NO-N and reduce greenhouse gas (GHG) emissions and DRP losses. An additional post-bed chamber containing media to eliminate NH-N and surface capping to reduce GHG emissions further is advised. Scenario modeling, such as that proposed in this paper, should ideally include GHG in the SI, but because different countries have different emission targets, future work should concentrate on the development of geographically appropriate weightings to facilitate the incorporation of GHG into a SI.

Performance and surface clogging in intermittently loaded and slow sand filters containing novel media.

Slow sand filers are commonly used in water purification processes. However, with the emergence of new contaminants and concern over removing precursors to disinfection by-products, as well as traditional contaminants, there has recently been a focus on technology improvements to result in more effective and targeted filtration systems. The use of new media has attracted attention in terms of contaminant removal, but there have been limited investigations on the key issue of clogging. The filters constructed for this study contained stratified layers comprising combinations of Bayer residue, zeolite, fly ash, granular activated carbon, or sand, dosed with a variety of contaminants (total organic carbon (TOC), aluminium (Al), ammonium (NH4(+)-N), nitrate (NO3(-)-N) and turbidity). Their performance and clogging mechanisms were compared to sand filters, which were also operated under two different loading regimes (continuous and intermittently loaded). The study showed that the novel filter configurations achieved up to 97% Al removal, 71% TOC removal, and 88% NH4(+)-N removal in the best-performing configuration, although they were not as effective as sand in terms of permeability. Deconstruction of the filters revealed that the main clogging mechanism was organic matter build-up at the uppermost layer of the filters. The clogging layer formed more quickly on the surface of the novel media when compared to the sand filters, but extended further into the sand filters, the extent dependent on the loading regime. The study shows the potential for an alternative filtration configuration, harnessing the adsorption potential of industrial waste products and natural media.

Pancreatic Resection Results in a Statewide Surgical Collaborative.

BACKGROUND: A strong relationship between hospital caseload and adverse outcomes has been demonstrated for pancreatic resections. Participation in regional surgical collaboratives may mitigate this phenomenon. This study sought to investigate changes over time in adverse outcomes after pancreatectomy across hospitals with different caseloads in a statewide surgical collaborative. METHODS: The study investigated patients undergoing pancreatic resection from January 2008 to August 2013 at Michigan Surgical Quality Collaborative (MSQC) hospitals (1007 patients in 19 academic and community hospitals). Risk-adjusted rates of major complications, mortality, and failure to rescue were compared between hospitals based on caseloads (low, medium, and high) in early (2008-2010) and later (2011-2013) periods. Finally, the degree to which different complications explained changes in hospital outcome variation was assessed. RESULTS: Adjusted rates of major complications and mortality decreased over time, driven largely by improvements at low-caseload hospitals. In 2008-2010, risk-adjusted major complication rates were higher for low-caseload than for high-caseload hospitals (27.8 vs. 17.8 %; p = 0.02). However, these differences were attenuated in 2011-2013 (22.2 vs. 20.0 %; p = 0.74). Similarly, adjusted mortality rates were higher in low-caseload hospitals in 2008-2010 (6.2 vs. 0.8 %; p = 0.02), but these differences were attenuated in 2011-2013 (3.3 vs. 1.1 %; p = 0.18). Variation in major complications decreased, largely due to decreased variation in "medical" complication rates, with less change in surgical-site complications. CONCLUSION: Participation in regional quality collaboratives by lower-volume hospitals can attenuate the volume-outcome relationship for pancreatic surgery. Continued work in collaboratives with an emphasis on technical and intraoperative aspects of care may improve overall quality of care.