Randomized clinical trial of accelerated enhanced recovery after minimally invasive colorectal cancer surgery (RecoverMI trial).

BACKGROUND: Minimally invasive surgery (MIS) and enhanced recovery protocols (ERPs) have improved postoperative recovery and shortened length of hospital stay (LOS). Telemedicine technology has potential to improve outcomes and patient experience further. This study was designed to determine whether the combination of MIS, ERP and a structured telemedicine programme (TeleRecovery) could shorten total 30-day LOS by 50 per cent. METHODS: This was a phase II prospective RCT at a large academic medical centre. Eligible patients aged 18-80 years undergoing minimally invasive colorectal resection using an ERP were randomized after surgery. The experimental arm (RecoverMI) included accelerated discharge on postoperative day (POD) 1 with or without evidence of bowel function and a televideoconference on POD 2. The control arm was standard postoperative care. The primary endpoint was total 30-day LOS (postoperative stay plus readmission/emergency department/observation days). Secondary endpoints included patient-reported outcomes measured by EQ-5D-5L™, Brief Pain Inventory (BPI) and a satisfaction questionnaire. RESULTS: Thirty patients were randomized after robotic (21 patients) or laparoscopic (9) colectomy, including 14 patients in the RecoverMI arm. Median 30-day total LOS was 28·3 (i.q.r. 23·7-43·6) h in the RecoverMI arm and 51·5 (43·8-67·0) h in the control arm (P = 0·041). There were no differences in severe adverse events or EQ-5D-5L™ score between the study arms. The BPI revealed low pain scores regardless of treatment arm. Satisfaction was high in both arms. CONCLUSION: In patients having surgery for colorectal neoplasms, the trimodal combination of MIS, ERP and TeleRecovery can reduce 30-day LOS while preserving patients' quality of life and satisfaction. Registration number: NCT02613728 ( https://clinicaltrials.gov).

ANTECEDENTES: La cirugía mínimamente invasiva (minimally invasive surgery, MIS) y los protocolos de recuperación intensificada (enhanced recovery protocols, ERP) han mejorado la recuperación postoperatoria y acortan la duración de la estancia (length of stay, LOS). La tecnología de la telemedicina tiene potencial para mejorar aún más los resultados y la experiencia del paciente. Este estudio se diseñó para determinar si la combinación de MIS, ERP y un programa estructurado de telemedicina (TeleRecovery) podría acortar la LOS total a los 30 días en un 50%. MÉTODOS: Se efectuó un ensayo controlado aleatorizado, prospectivo, de fase II en un gran centro médico académico. Los pacientes elegibles de 18-80 años de edad que se sometieron a resección colorrectal MIS mediante ERP se asignaron al azar después de la resección quirúrgica. El brazo experimental (RecoverMI) incluyó el alta acelerada en el día 1 del postoperatorio (postoperative day, POD) con o sin evidencia de recuperación del tránsito intestinal y una televideoconferencia en el día 2 POD. Los pacientes en el grupo control recibieron los cuidados postoperatorios habituales. El criterio de valoración principal fue la LOS total (estancia postoperatoria más reingreso/estancia en urgencias/días de observación) a los 30 días. Los criterios de valoración secundarios incluyeron los resultados referidos por los pacientes medidos por los cuestionarios EQ-5D-5L, el Cuestionario Breve del Dolor (Brief Pain Inventory, BPI) y un cuestionario de satisfacción. RESULTADOS: Treinta pacientes fueron aleatorizados después de una colectomía robótica (21) o laparoscópica (9), incluidos 14 pacientes en el grupo de RecoverMI. La mediana de la LOS total a los 30 días fue de 28,3 horas (rango intercuartílico, RIQ 23,7-43,6) en el grupo de RecoverMI y de 51,5 horas (RIQ 43,8-67,0) en el grupo control (P = 0,04). No hubo diferencias entre los grupos de estudio en los eventos adversos graves o en las puntuaciones del EQ-5D-5L. El BPI mostró puntuaciones bajas de dolor independientemente del grupo de tratamiento. La satisfacción fue alta en ambos grupos. CONCLUSIÓN: Entre los pacientes que se someten a cirugía por cáncer colorrectal, la combinación trimodal de MIS, ERP y TeleRecovery puede reducir la LOS a los 30 días, preservando la calidad de vida y la satisfacción del paciente.

Systematic Implementation of Effective Quality Assurance Processes for the Assessment of Radiation Target Volumes in Head and Neck Cancer.

PURPOSE: Significant heterogeneity exists in clinical quality assurance (QA) practices within radiation oncology departments, with most chart rounds lacking prospective peer-reviewed contour evaluation. This has the potential to significantly affect patient outcomes, particularly for head and neck cancers (HNC) given the large variance in target volume delineation. With this understanding, we incorporated a prospective systematic peer contour-review process into our workflow for all patients with HNC. This study aims to assess the effectiveness of implementing prospective peer review into practice for our National Cancer Institute Designated Cancer Center and to report factors associated with contour modifications. METHODS AND MATERIALS: Starting in November 2020, our department adopted a systematic QA process with real-time metrics, in which contours for all patients with HNC treated with radiation therapy were prospectively peer reviewed and graded. Contours were graded with green (unnecessary), yellow (minor), or red (major) colors based on the degree of peer-recommended modifications. Contours from November 2020 through September 2021 were included for analysis. RESULTS: Three hundred sixty contours were included. Contour grades were made up of 89.7% green, 8.9% yellow, and 1.4% red grades. Physicians with >12 months of clinical experience were less likely to have contour changes requested than those with <12 months (8.3% vs 40.9%; P < .001). Contour grades were significantly associated with physician case load, with physicians presenting more than the median number of 50 cases having significantly less modifications requested than those presenting <50 (6.7% vs 13.3%; P = .013). Physicians working with a resident or fellow were less likely to have contour changes requested than those without a trainee (5.2% vs 12.6%; P = .039). Frequency of major modification requests significantly decreased over time after adoption of prospective peer contour review, with no red grades occurring >6 months after adoption. CONCLUSIONS: This study highlights the importance of prospective peer contour-review implementation into systematic clinical QA processes for HNC. Physician experience proved to be the highest predictor of approved contours. A growth curve was demonstrated, with major modifications declining after prospective contour review implementation. Even within a high-volume academic practice with subspecialist attendings, >10% of patients had contour changes made as a direct result of prospective peer review.

Identification of a promoter sequence from the BETL1 gene cluster able to confer transfer-cell-specific expression in transgenic maize

The maize (Zea mays L.) betl1 locus, encoding a basal endosperm transfer layer-specific protein, has been mapped and molecularly cloned in its entirety. The locus is shown to consist of three gene copies in the maize inbred line A69Y. To distinguish the three transcription units from the locus name, we have termed them BETL1a, BETL1b, and BETL1c. Two of the copies are expressed, whereas one is inactive and contains retrotransposon-like insertions in both promoter and intron regions. Based on this information, and a restriction site map covering 17 kb around the BETL1 locus, a DNA fragment putatively containing an active promoter sequence was identified. This fragment was tested for its ability to confer transfer-cell-specific expression in transient and stably transformed maize tissues. The transgenic maize plants obtained showed the predicted cell-type specificity of expression restricted to the basal endosperm transfer cells, although there were minor deviations in promoter strength and timing and accumulation of the transgene product from the corresponding BETL-1 endogene expression pattern.

Radiation damage, repopulation and cell recovery analysis of in vitro tumour cell megacolony culture data using a non-Poissonian cell repopulation TCP model.

The effects of radiation damage, tumour repopulation and cell sublethal damage repair and the possibility of extracting information about the model parameters describing them are investigated in this work. Previously published data on two different cultured cell lines were analysed with the help of a tumour control probability (TCP) model that describes tumour cell dynamics properly. Different versions of a TCP model representing the cases of full or partial cell recovery between fractions of radiation, accompanied by repopulation or no repopulation were used to fit the data and were ranked according to statistical criteria. The data analysis shows the importance of the linear-quadratic mechanism of cell damage for the description of the in vitro cell dynamics. In a previous work where in vivo data were analysed, the employment of the single hit model of cell kill and cell repopulation produced the best fit, while ignoring the quadratic term of cell damage in the current analysis leads to poor fits. It is also concluded that more experiments using different fractionation regimes producing diverse data are needed to help model analysis and better ranking of the models.

A leucine-rich repeat peptide derived from the Drosophila Toll receptor forms extended filaments with a beta-sheet structure.

Leucine-rich repeats (LRRs) are 22-28 amino acid-long sequence motifs found in a family of cytoplasmic, membrane and extracellular proteins. There is evidence that LRRs function in signal transduction, cellular adhesion and protein-protein interactions. Here we report unusual properties of a synthetic LRR peptide derived from the sequence of the Drosophila membrane receptor Toll. In neutral solution the peptide forms a gel revealed by electron microscopy to consist of extended filaments approximately 8 nm in thickness. As the gel forms, the circular dichroism spectrum of the peptide solution changes from one characteristic of random coil to one associated with beta-sheet structures. Molecular modelling suggests that the peptide form an amphipathic structure with a predominantly apolar and charged surface. Based on these results, models for the gross structure of the peptides filaments and a possible molecular mechanism for cellular adhesion are proposed.

Age and education correction of Mini-Mental State Examination for English and Spanish-speaking elderly.

Previous research has shown that the Mini-Mental State Examination (MMS) is biased as a measure of cognitive impairment in minority and low-education patients. The purpose of this study was to (1) develop a statistical correction for effects of age and education and (2) test the efficacy of the statistically adjusted MMS (MMSAdj) as a screening test for dementia using different ethnic groups and education levels. We used a population-base community survey sample (n=590) composed of 46.6% Hispanics and 53.4% non-Hispanics to derive the statistical correction, defined as:MMSAdj = Raw MMS - (0.471 X [Education-12]) + (0.131 X [Age-70]). Ethnicity and language of test administration were not significantly related to MMSAdj in the community survey sample, but the raw MMS was strongly influenced by these factors. We used an independent sample (n=2,983) of patients evaluated through the California Alzheimer's Disease Diagnostic and Treatment Centers to test the diagnostic accuracy of the MMS and the MMSAdj across low- and high-education groups and across whites, Hispanics, and blacks. Results showed greater stability of sensitivity and specificity across education levels and ethnic groups for the MMSAdj than for the raw MMS and suggest that the MMSAdj is a preferable measure of cognitive impairment for low- education and minority individuals.

The influence of diabetes, hypertension, and stroke on ethnic differences in physical and cognitive functioning in an ethnically diverse older population.

Prevention of decline in cognitive and physical functioning in the elderly has become an important focus in geriatric medicine. Hispanics are among the fastest-growing group of elderly in the United States, yet few data are available on functional impairments in this group. We examined the association between ethnicity (non-Hispanic whites [NHW], English-speaking Hispanics [EH], and Spanish-speaking Hispanics [SH]) and cognitive status, self-assessed functional status, and physical performance in a community-dwelling sample of 589 people aged > or = 60 years. The purpose of this study was to examine the association between ethnicity and these measures of functional status and to evaluate the influence of comorbid stroke, diabetes, and hypertension on this association. We found that EH and SH had significantly lower scores on the MiniMental State Exam than NHW, but that this difference was almost entirely due to educational level. When SH whose educational attainment was grade 8 or higher were compared to NHWs, there were no differences in cognitive functioning. Those with diabetes and stroke had poorer cognitive functioning. Among those with stroke, EH and SH women had more self-assessed functional limitations (IADLs and ADLs) than NHW. Male SH and EH with diabetes also had more self-assessed functional limitations than NHW. SH with two or three of these conditions had more IADL limitations. Our results suggest that elderly community-dwelling Hispanics experience greater levels of disability and that this is due, in part, to lower socioeconomic status and higher prevalence of disabling conditions.

Review article: quantitative leucocyte scanning in the assessment of inflammatory bowel disease activity and its response to therapy.

Inflammatory bowel disease (IBD) symptoms may be due not only to the effects of bowel inflammation, but also can result from many non-inflammatory consequences of the disease. Clinical scores and health questionnaire ratings produce a global assessment which is useful in the overall evaluation of the impact of the illness on the patient, and the effect of treatment. However many studies have failed to recognize the need to separately assess changes in the degree of bowel inflammation, in addition to a global clinical response. Radiolabelled white cell scanning using 111-indium has been shown to provide an accurate, quantitative and non-invasive method for assessing the degree of bowel inflammation in IBD and its response to therapy, using faecal collection or total body counts of radioactivity. More recently 99mTc hexamethyl propylene amine oxime (HMPAO) labelled white cell scanning has been introduced, which has advantages over the 111-indium method, including reduced radiation dosimetry and enhanced image quality. 99mTc-HMPAO scanning using three-dimensional white cell scanning (single photon emission computerized tomography; SPECT) allows visualization of the entire bowel separate from overlying structures. 99mTc-HMPAO white cell scanning with SPECT has now been computerized and automated to permit measurement of segmental and total bowel radiolabelled white cell infiltrate. This method could potentially provide the gold standard for objective assessment of the response of disease activity in Crohn's disease and ulcerative colitis, and merits application in clinical trials of novel therapies for IBD.

A seven-day Helicobacter pylori treatment regimen using clarithromycin, omeprazole and tripotassium dicitrato bismuthate.

AIM: To evaluate clarithromycin 500 mg t.d.s., tripotassium dicitrato bismuthate 240 mg b.d. and omeprazole 20 mg b.d. for 7 days as a Helicobacter pylori treatment regimen. METHODS: The H. pylori status of dyspeptic patients undergoing endoscopy was assessed by histology, culture and rapid urease testing of biopsies and by 13C-urea breath test. Fifty patients who were H. pylori-positive were treated with the above treatment regimen for 7 days. Those patients with active duodenal ulcers present at endoscopy were given omeprazole 20 mg nocte for a further 21 days. Not less than 28 days after completing treatment, all tests were repeated to reassess H. pylori status. Bacterial sensitivity of H. pylori cultures was determined and patients recorded any side-effects. RESULTS: On an intention-to-treat basis, H. pylori infection was cured in 90% (95% CI: 78-96%) of patients. Taste disturbance was experienced by 35% patients. Compliance was excellent, with 96% patients taking more than 95% of tablets. Metronidazole resistance was 41% but all cultures were sensitive to clarithromycin. CONCLUSIONS: This 7-day treatment achieved a high level of cure of H. pylori infection with relatively minor side-effects. It may have a role to play, particularly where there is a high level of metronidazole resistance.

Mechanisms underlying priming on perceptual tests.

Four experiments examined perceptual, lexical, and conceptual processing effects in priming on word fragment completion (WFC) and perceptual identification (PID). In Experiment 1, visual words produced more priming than auditory or generated words, and pictures produced the least priming, suggesting that the effects of different encoding processes can be distinguished. In Experiments 2 and 3, Ss studied anagrams (e.g., tripocs), but only Ss instructed to think of the original words by mentally interchanging the vowels exhibited significant priming. Thus, lexical access is more important than surface similarity in priming. In Experiment 4, Ss studied compounds that either preserved the target's meaning (e.g., scotch bottle) or altered its meaning (e.g., scotch tape). Encoded meaning affected priming on WFC but not on PID, suggesting that conceptual processing plays a larger role in WFC. Overall the results suggest that priming must be understood in terms of multiple processes.

The time course of perceptual and conceptual contributions to word fragment completion priming.

Two experiments examined the time course of the availability of perceptual and conceptual information in priming on the word fragment completion test. Subjects encoded primes as either visual words, auditory words, or pictures. In Experiment 1, word fragments were exposed for either 500 ms, 1 s, 5 s, or 12 s. Only the visual words produced priming at the 500-ms and 1-s exposure times. In Experiment 2, subjects were allowed up to 20 s to solve each fragment; response latencies were recorded and cumulative response curves were generated. Visually primed fragments were solved at a faster rate than either auditorily or pictorially primed fragments. The results suggest that although conceptual processing can contribute to word fragment priming, perceptual processes are recruited earlier and at a faster rate.

Group remembering: does social loafing underlie collaborative inhibition?

When people collaborate to recall information, they experience collaborative inhibition, a deficit in recall relative to nominal groups (the pooled, nonredundant recall of individuals working alone). That is, people recalling in groups do not perform up to their potential. Collaborative inhibition may be due to retrieval interference (e.g., B. H. Basden, D. R. Basden, S. Bryner, & R. L. Thomas, 1997) or to motivational factors such as social loafing in the group situation. Five experiments examined the role of motivational factors by varying monetary incentives, recall criterion, personal accountability, group cohesion, and group gender. Increasing motivation sometimes increased the overall level of recall but failed to eliminate the collaborative inhibition effect. The results suggest that collaboration interferes with an individual's ability to reconstruct his or her knowledge.

Integration of orthographic and semantic information in memory retrieval.

Our central goal was to determine how multiple sources of information are evaluated and integrated during memory retrieval. An expanded factorial design was used to vary two sources of information independently of one another and to present each source alone. Subjects solved crossword-like puzzles with varying numbers of orthographic and semantic cues. The results of the experiment indicated that (a) performance is better given two sources of information relative to just one; (b) evaluation of each source of information provides continuous rather than just categorical (all-or-none) information; and (c) the two sources are integrated multiplicatively rather than simply used independently of one another as claimed by nonintegration models. A fuzzy logical model of perception (FLMP)-taken from the pattern recognition domain--gave a good description of the memory results. A single channel model, an averaging model, and an adding model produced poor descriptions of the results.

Direct comparison of two implicit memory tests: word fragment and word stem completion.

In 3 experiments, the implicit memory tests of word fragment and word stem completion showed comparable effects over several variables: Study of words produced more priming than did study of pictures, no levels-of-processing effect occurred for words, more priming was obtained from pictures when Ss imaged the pictures' names than when they rated them for pleasantness, and forgetting rates were generally similar for the tests. A different pattern of results for the first 3 variables occurred under explicit test conditions with the same word fragments or word stems as cues. We conclude that the 2 implicit tests are measuring a similar form of perceptual memory. Furthermore, we argue that both tests are truly implicit because they meet Schacter, Bowers, & Booker's (1989) retrieval intentionality criterion: Levels of processing of words have a powerful effect on explicit versions of the tests but no effect on implicit versions.

Dissociating the generation stage in implicit and explicit memory tests: Incidental production can differ from strategic access.

An assumption of the generate/recognize model of direct and indirect memory is that the generation stage is identical on explicit and implicit tests. Two experiments were conducted to examine the generation stage by requiring subjects to write down every word-stem solution they could generate on either an implicit test, a cued-recall test, or a generate/recognize test. In Experiment 1, the subjects studied words and anagrams; target generation was not significantly different on the three tests. However, in Experiment 2, the subjects studied the target words with a context word, and saw either thesame ordifferent context with the test stem. Now the generation stages dissociated, such that the context manipulation had no significant effect on the implicit test, but on the cued-recall test, more targets were generated with the same context words than were generated with different context words. The results argue against the claim that dissociations between implicit and explicit tests are due only to the addition of recognition processes on the explicit test, because the generation processes themselves can be dissociated.

Prevalence of antibody to hepatitis A virus in drinking water workers and wastewater workers in Texas from 1996 to 1997.

To determine if wastewater workers had a higher prevalence of antibody to hepatitis A virus (anti-HAV) than drinking water workers, a convenience sample of Texas wastewater and drinking water workers was evaluated for risk factors by questionnaire and tested for anti-HAV. A total of 359 wastewater and 89 drinking water workers participated. Anti-HAV positivity was 28.4% for wastewater and 23.6% for drinking water workers. After adjustment for age, educational attainment, and Hispanic ethnicity, the odds ratio for the association between anti-HAV positivity and wastewater industry employment was 2.0 (95% confidence interval, 1.0 to 3.8). Among wastewater workers, never eating in a lunchroom, > or = 8 years in the wastewater industry, never wearing face protection, and skin contact with sewage at least once per day were all significantly associated with anti-HAV positivity in a model that adjusted for age and educational attainment. Wastewater workers in this study had a higher prevalence of anti-HAV than drinking water workers, which suggested that wastewater workers may have been at increased risk of occupationally acquired hepatitis A. Work practices that expose workers to wastewater may increase their risk.

Pediatric living-related and cadaveric liver transplantation: a single center experience.

Living-related liver transplantation is becoming more commonplace worldwide in the treatment of end-stage liver disease in the pediatric age group. Our LRD experience has resulted in patient and graft survival rates comparable to our cadaveric donor recipients. The incidence and severity of acute rejection episodes were similar. This differs from the clear immunologic advantage of living-related donation in kidney transplantation. It may, however, reflect the relatively small numbers in our LRD group. Overall, however, the technical complications are manageable with early intervention, yielding acceptable results.

Immediate breast reconstruction: why the free TRAM over the conventional TRAM flap?

Use of the transverse rectus abdominis myocutaneous (TRAM) flap for immediate breast reconstruction is controversial because of fear of flap loss and concern that a high complication rate could interfere with adjuvant therapy. One common complication of the TRAM, partial flap necrosis, can interfere with both institution of postoperative therapy and evaluation for recurrence. In an attempt to minimize this problem, we began using the free TRAM flap based on the inferior deep epigastric vessels. This study compares our experience with conventional superior-pedicled (cTRAM) flaps and free TRAM (fTRAM) flaps. A total of 68 breasts were reconstructed in 63 patients, of which 48 of 68 (71 percent) were conventional TRAM flaps and 20 of 68 (29 percent) were free TRAM flaps. Of the 48 conventional TRAM flaps, 26 (54 percent) were unipedicled and 22 (46 percent) were bipedicled. There were 39 of 48 (81 percent) conventional TRAM flaps and 17 of 20 (85 percent) free TRAM flaps with T1 or T2 lesions. Node-positive patients occurred in 14 of 48 (29 percent) conventional TRAM flaps and 2 of 20 (10 percent) free TRAM flaps. One-fourth of patients in both groups smoked cigarettes. Twenty-one of 48 patients (44 percent) with conventional TRAM flaps required postoperative chemotherapy, and 6 of 21 (29 percent) were delayed because of complications of the TRAM flap. Of the 7 of 20 (35 percent) free TRAM flap patients who required post-operative chemotherapy, only 1 of 7 (14 percent) was delayed because of TRAM flap complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of the AO plate for immediate mandibular reconstruction in cancer patients.

Free vascularized bone grafts have revolutionized mandibular reconstruction, yet their use in all mandibulectomy patients is not always necessary. A recently developed alternative to bony reconstruction has been the use of the AO reconstruction plate. We compared the use of the AO reconstruction plate with immediate free bone graft mandibular reconstruction in 31 patients. Reconstruction plates were used in 20 and immediate free bone grafts were used in 11 patients. The overall success rate for use of the plate was 15 of 20 (75 percent). There were 6 anterior reconstructions, of which only 2 (33 percent) were successful. This is opposed to 13 of 14 (93 percent) lateral reconstructions that were successful in lateral plate placements. There were 11 immediate composite free flaps: 4 iliac crest, 4 scapula, 2 fibula, and 1 composite radial forearm flaps. Six repairs were for anterior defects, and there were 5 full-thickness defects, 3 of which were in the anterior position. All 11 flaps were successful. In conclusion, we believe the reconstruction plates are a useful adjunct for mandibular replacement in the head and neck cancer patient but should be reserved for lateral defects. For anterior reconstructions, even in patients with locally advanced disease, free-tissue transfer of composite osteocutaneous flaps is the reconstructive method of choice.

Integration of orthographic, conceptual, and episodic information on implicit and explicit tests.

An experiment was conducted to determine how orthographic and conceptual information are integrated during incidental and intentional retrieval. Subjects studied word lists with either a shallow (counting vowels) or deep (rating pleasantness) processing task, then received either an implicit or explicit word fragment completion (WFC) test. At test, word fragments contained 0, 1, 2, or 4 letters, and were accompanied by 0, 1, 2, or 3 semantically related words. On both the implicit and explicit tests, performance improved with increases in the numbers of letters and words. When semantic cues were presented with the word fragments, the implicit test became more conceptually drive. Still, conceptual processing had a larger effect in intentional than in incidental retrieval. The Fuzzy Logical Model of Perception (FLMP) provided a good description of how orthographic, semantic, and episodic information were combined during retrieval.