Incidence of shoulder dystocia and risk factors for recurrence in the subsequent pregnancy-A historical register-based cohort study.

INTRODUCTION: Shoulder dystocia is a rare obstetric complication, and the risk of recurrence is important for planning future deliveries. MATERIAL AND METHODS: The objectives of our study were to estimate the incidence and risk factors for recurrence of shoulder dystocia and to identify women at high risk of recurrence in a subsequent vaginal delivery. The study design was a nationwide register-based study including data from the Danish Medical Birth Registry and National Patient Register in the period 2007-2017. Nulliparous women with a singleton fetus in cephalic presentation were included for analysis of risk factors in index and subsequent delivery. RESULTS: During the study period, 6002 cases of shoulder dystocia were reported with an overall incidence among women with vaginal delivery of 1.2%. Among 222 225 nulliparous women with vaginal births, shoulder dystocia complicated 2209 (1.0%) deliveries. A subsequent birth was registered in 1106 (50.1%) of the women with shoulder dystocia in index delivery of which 837 (77.8%) delivered vaginally. Recurrence of shoulder dystocia was reported in 60 (7.2%) with a six-fold increased risk compared with women without a prior history of shoulder dystocia (risk ratio [RR] 5.70, 95% confidence interval [CI]: 4.41 to 7.38; adjusted RR 3.06, 95% CI: 2.03 to 4.68). Low maternal height was a significant risk factor for recurrence of shoulder dystocia. In the subsequent delivery, significant risk factors for recurrence were birthweight >4000 g, positive fetal weight difference exceeding 250 g from index to subsequent delivery, stimulation with oxytocin and operative vaginal delivery. In the subsequent pregnancy following shoulder dystocia, women who underwent a planned cesarean (n = 176) were characterized by more advanced age and a higher prevalence of diabetes in the subsequent pregnancy. Furthermore, they had more often experienced operative vaginal delivery, severe perineal lacerations, and severe neonatal complications at the index delivery. CONCLUSIONS: The incidence of shoulder dystocia among nulliparous women with vaginal delivery was 1.0% with a 7.2% risk of recurrence in a population where about 50% had a subsequent birth and of these 78% had subsequent vaginal delivery. Important risk factors for recurrence were low maternal height, increase of birthweight ≥250 g from index to subsequent delivery and operative vaginal delivery.

Risk of Bowel Obstruction after Hysterectomy for Benign Indication According to Surgical Method in Denmark, 1984-2013.

STUDY OBJECTIVE: To estimate the risk of bowel obstruction (BO) after hysterectomy for benign indications depending on the surgical method (abdominal, vaginal, or laparoscopic) and identify risk factors for adhesive BO. DESIGN: A national registry-based cohort. SETTING: Danish hospitals during the period 1984-2013. PATIENTS: Danish women who underwent hysterectomy for benign indications (N = 125 568). INTERVENTIONS: Abdominal hysterectomies were compared with vaginal hysterectomies, laparoscopic hysterectomies, and minimally invasive (vaginal and laparoscopic) hysterectomies. MEASUREMENTS AND MAIN RESULTS: The incidence of BO according to the surgical method was compared using Cox proportional hazard regression. The covariates included were the time period, age, concomitant operations, previous abdominal surgery or disease, and socioeconomic factors. In a subanalysis (n = 35 712 women) of the period 2004-2013, detailed information from the Danish Hysterectomy Database enabled the inclusion of patient-, surgery-, and complication-related covariates. The overall crude incidence of BO was 17.4 of 1000 hysterectomies (2196 incident cases). The 10-year cumulative incidence of BO differed among the surgical routes (abdominal, 1.7%; laparoscopic, 1.4%; and vaginal, 0.9%). In multiple-adjusted analyses, the risk of BO was higher after abdominal hysterectomy than after vaginal (hazard ratio 1.64 [95% confidence interval, 1.39-1.93]) and minimally invasive (vaginal or laparoscopic) hysterectomy (hazard ratio 1.54 [1.33-1.79]). Additional pre-existing risk factors for BO at the time of hysterectomy were increased age, low education, low income, smoking, high American Society of Anesthesiologists comorbidity score, history of infertility, abdominal infection, and previous abdominal surgery (apart from cesarean section), penetrating lesions in abdominal organs, or operative adhesiolysis. Perioperative risk factors at the time of hysterectomy included concomitant removal of the ovaries, adhesiolysis, blood transfusion, readmission, and overall presence of perioperative complications. CONCLUSION: Abdominal hysterectomy is associated with a 54% higher risk of BO than minimally invasive (laparoscopic or vaginal) hysterectomy.

Winter, spring, summer or fall: temporal patterns in placenta-mediated pregnancy complications-an exploratory analysis.

PURPOSE: Placenta-mediated pregnancy complications, like growth restriction and hypertensive disorders, are leading causes of maternal, fetal and neonatal morbidity and mortality in high-income countries. The purpose was to investigate if there is a seasonal variation in placenta-mediated pregnancy complications (small for gestational age, intrauterine growth restriction, preeclampsia, preterm birth and intrauterine fetal death). METHODS: This is a Danish cohort study including all singleton deliveries at gestational week 22 up to and including week 41 conceived from December 2006 to November 2016 (N = 555,459). We used statistical process control charts to visualize data and to test for patterns of non-random variation in data over time for pregnancies with risk factors (BMI, diabetes, in vitro fertilization, maternal age > 40 years, primipara, previous caesarean and smoking) and each of the following outcome: fetal growth restriction, hypertensive disorders, preterm birth and intrauterine fetal death. The study was approved by the Danish Data Protection agency; REG-039-2019. RESULTS: We found a seasonal pattern in hypertensive disorders during pregnancy with dips in pregnancies conceived in the fall season and highest risk by conception in the spring and summer season. We found no apparent seasonality in cases of preterm delivery, small for gestational age and intrauterine mortality. Individual risk factors (e.g. smoking and obesity) for placenta-mediated complicated over time were in consistency with the general trends. CONCLUSIONS: We found a significant seasonal variation in the risk of hypertensive disorders of pregnancy with highest risk by conception in the spring and summer season. This study found no seasonal variation in other placenta-mediated complications.

Local anaesthetic for pain post rubber band ligation of haemorrhoids: a prospective, single-blinded randomised controlled trial.

BACKGROUND: Rubber band ligation (RBL) is a widely accepted intervention for the treatment of haemorrhoids. However, post procedure pain is a common complaint. The aim of this study was to determine whether the addition of local anaesthetic (LA) to the haemorrhoid pedicle base, post RBL, aids in reducing early post-procedure pain. Additionally, to compare perceived perianal numbness, oral analgesia usage and total consumption, and adverse events. METHODS: This study was a prospective, single-blinded randomised controlled trial. Patients were recruited from colorectal clinics in two Australian hospitals between 2018-2019. Patients randomised to the intervention (LA) group received 2mls bupivacaine 0.5% with adrenaline 1:200,000 to each haemorrhoid base. Patients in the control group were not administered LA. Pain scores were recorded over 48 h using visual analogue scales. Analgesia consumption was documented and other secondary objectives were recorded dichotomously (yes/no). RESULTS: At 1 h post-procedure, patient reported pain scores were significantly lower in the LA group compared to the control group (p = 0.04). There were no significant differences in pain scores between the groups at 4, 24 or 48 h. Additionally, there were no significant differences between groups with respect to oral analgesia usage, perianal numbness or adverse events. CONCLUSIONS: LA to the haemorrhoid pedicle post RBL may significantly reduce early post procedure pain without any increased risk of adverse effects.

Maternal age and risk of cesarean section in women with induced labor at term-A Nordic register-based study.

INTRODUCTION: Over the last decades, induction of labor has increased in many countries along with increasing maternal age. We assessed the effects of maternal age and labor induction on cesarean section at term among nulliparous and multiparous women without previous cesarean section. MATERIAL AND METHODS: We performed a retrospective national registry-based study from Denmark, Finland, Iceland, Norway, and Sweden including 3 398 586 deliveries between 2000 and 2011. We investigated the impact of age on cesarean section among 196 220 nulliparous and 188 158 multiparous women whose labor was induced, had single cephalic presentation at term, and no previous cesarean section. Confounders comprised country, time-period, and gestational age. RESULTS: In nulliparous women with induced labor the rate of cesarean section increased from 14.0% in women less than 20 years of age to 39.9% in women 40 years and older. Compared with women aged 25-29 years, the corresponding relative risks were 0.60 (95% confidence interval [95% CI] 0.57 to 0.64) and 1.72 (95% CI 1.66 to 1.79). In multiparous induced women the risk of cesarean section was 3.9% in women less than 20 years rising to 9.1% in women 40 years and older. Compared with women aged 25-29 years, the relative risks were 0.86 (95% CI 0.54 to 1.37) and 1.98 (95% CI 1.84 to 2.12), respectively. There were minimal confounding effects of country, time-period, and gestational age on risk for cesarean section. CONCLUSIONS: Advanced maternal age is associated with increased risk of cesarean section in women undergoing labor induction with a single cephalic presentation at term without a previous cesarean section. The absolute risk of cesarean section is 3-5 times higher across 5-year age groups in nulliparous relative to multiparous women having induced labor.

A reduced gastric corpus microvascular blood flow during Ivor-Lewis esophagectomy detected by laser speckle contrast imaging technique.

BACKGROUND: Reduced microvascular blood flow is related to anastomotic insufficiency following esophagectomy, emphasizing a need for intraoperative monitoring of the microcirculation. This study evaluated if laser speckle contrast imaging (LSCI) was able to detect intraoperative changes in gastric microcirculation. METHODS: Gastric microcirculation was assessed prior to and after reconstruction of gastric continuity in 25 consecutive patients operated for adenocarcinoma with open Ivor-Lewis esophagectomy while hemodynamic variables were recorded. RESULTS: During upper laparotomy, microcirculation at the corpus decreased by 25% from baseline to mobilization of the stomach (p = .008) and decreased further (to a total decrease of 40%) following gastric pull to the thorax (p = .013). On the other hand, microcirculation at the antrum did not change significantly after gastric mobilization (p = .091). The decrease in corpus microcirculation took place unrelated to central cardiovascular variables. CONCLUSION: Using LSCI technique, we identified a reduced microcirculation at the corpus area during open Ivor-Lewis esophagectomy. LSCI provides an option for real-time assessment of gastric microcirculation and could form basis for intraoperative stabilization of the microcirculation.

Cesarean section trends in the Nordic Countries - a comparative analysis with the Robson classification.

INTRODUCTION: The cesarean rates are low but increasing in most Nordic countries. Using the Robson classification, we analyzed which obstetric groups have contributed to the changes in the cesarean rates. MATERIAL AND METHODS: Retrospective population-based registry study including all deliveries (3 398 586) between 2000 and 2011 in Denmark, Finland, Iceland, Norway and Sweden. The Robson group distribution, cesarean rate and contribution of each Robson group were analyzed nationally for four 3-year time periods. For each country, we analyzed which groups contributed to the change in the total cesarean rate. RESULTS: Between the first and the last time period studied, the total cesarean rates increased in Denmark (16.4 to 20.7%), Norway (14.4 to 16.5%) and Sweden (15.5 to 17.1%), but towards the end of our study, the cesarean rates stabilized or even decreased. The increase was explained mainly by increases in the absolute contribution from R5 (women with previous cesarean) and R2a (induced labor on nulliparous). In Finland, the cesarean rate decreased slightly (16.5 to 16.2%) mainly due to decrease among R5 and R6-R7 (breech presentation, nulliparous/multiparous). In Iceland, the cesarean rate decreased in all parturient groups (17.6 to 15.3%), most essentially among nulliparous women despite the increased induction rates. CONCLUSIONS: The increased total cesarean rates in the Nordic countries are explained by increased cesarean rates among nulliparous women, and by an increased percentage of women with previous cesarean. Meanwhile, induction rates on nulliparous increased significantly, but the impact on the total cesarean rate was unclear. The Robson classification facilitates benchmarking and targeting efforts for lowering the cesarean rates.

Severe Sepsis and Septic Shock Cases Meeting Guidelines Among Patients in a University Hospital Setting.

BACKGROUND: A diagnosis of severe sepsis or septic shock has been shown to significantly increase mortality rate independent of other factors. Research has revealed all cause hospital case fatality rates have declined yet the percentage of severe sepsis cases continues to increase and age-adjusted mortality rates from severe sepsis and septic shock has significantly increased during the same time period. Patients with severe sepsis demonstrate ongoing mortality rate increases for up to 2 years following hospitalization when compared to aged matched controls of nonseptic patients. International guidelines with mortality benefit for the management of severe sepsis and septic shock have been illustrated in the latest surviving sepsis campaign. OBJECTIVE: The objective of this study was to increase the percentage of patients admitted to the hospital with a diagnosis of severe sepsis or septic shock who met guidelines based on surviving sepsis campaign. METHODOLOGY: A retrospective chart review was conducted for patients admitted to UHC from January 2016 to present to identify cases with a diagnosis of severe sepsis or septic shock, and whether they met guidelines set forth by surviving sepsis campaign both before and after an intervention program which included interviews with providers failing to meet protocol, educational sessions on guidelines to meet protocol, resident led quality improvement workshops to address barriers to meeting protocol, and development of an EMR power plan to assist providers on meeting protocol. RESULTS: 139 cases with a diagnosis, or meeting criteria for, severe sepsis or septic shock were identified during the period of 1/1/2016-9/30/2016 with an average of 43 percent of total cases which met guidelines. Trend analysis revealed increased compliance following resident lead intervention program with 31 percent and 49 percent before and after intervention, respectively. ICU data is currently being analyzed for meeting guidelines and have not been included in current data. The most common reason for failing guidelines was failure to obtain or repeat lactic acid on time (46 percent ); and failure to give timely antibiotics (22 percent );. CONCLUSIONS: The percentage of patients admitted to the hospital with a diagnosis of severe sepsis or septic shock at UHC meeting guidelines set forth by surviving sepsis campaign has improved following resident lead intervention program. Intervention strategies to further improve compliance with guidelines with a goal >60 percent are currently being analyzed.

Performance on Paced Auditory Serial Addition Test and cerebral blood flow in multiple sclerosis.

BACKGROUND: To assess the relationship between performance on the Paced Auditory Serial Addition Test (PASAT) and both cerebral blood flow (CBF) and axonal metabolic integrity in normal appearing white matter (NAWM) of the centrum semiovale in patients with multiple sclerosis (MS). METHODS: Normal appearing white matter of the centrum semiovale was investigated with magnetic resonance (MR) imaging in 28 non-depressed individuals (18 patients with MS and 10 healthy controls). CBF was assessed with pseudo-continuous arterial spin labeling. N-acetylacetate/creatine (NAA/Cr) ratios (a metabolic axonal marker) were measured using (1) H-MR spectroscopy. CBF was also measured in frontoparietal cortices and cerebellar hemispheres. RESULTS: In subjects with MS, we found a positive correlation between performance on the PASAT and CBF to the left centrum semiovale (P = 0.008), but not with the NAA/Cr ratio. There were no correlations between PASAT scores and CBF to the right centrum semiovale, frontoparietal cortices, and cerebellar hemispheres. There was no correlation between PASAT scores and NAA/Cr ratios. CONCLUSIONS: Our preliminary results suggest that performance on the PASAT in subjects with MS correlates with CBF to the left centrum semiovale, which contains left frontoparietal white matter association tracts involved in information processing speed and working memory.

T2 lesions and rate of progression of disability in multiple sclerosis.

BACKGROUND AND PURPOSE: To assess the predictive value of T2 lesions on the rate of progression of disability in multiple sclerosis (MS). METHODS: We reanalyzed T2 lesion number and load on brain MRI scans, performed before 1997, of 186 MS patients, who were clinically followed. There were 90 patients with progressive MS (35 secondary progressive and 55 primary progressive), and 96 with relapsing remitting MS. The rate of progression of disability was measured by time to sustained progression of disability (defined as an increase in ≥ 1 point when the Expanded Disability Status Scale (EDSS) was 5.5 or less and an increase in EDSS of ≥ 0.5 point when the EDSS was 6.0 or higher), and by the Multiple Sclerosis Severity Score (MSSS). RESULTS: During follow-up (median 15 years, IQR 12-17 years), 94% of the patients with progressive MS and 50% of the patients with relapsing remitting MS had progression of disability. Higher T2 lesion number and load were modestly associated with a higher rate of disease progression on the MSSS and a shorter time to progression of disability in relapsing remitting MS, but not in progressive MS. CONCLUSIONS: Our findings indicate that the amount of T2 lesions has a small predictive value for progression of disability in relapsing remitting MS, but has no influence on the rate of progression in progressive MS.

Parity and secondary progression in multiple sclerosis.

BACKGROUND: Pregnancy has a well-documented effect on relapses in multiple sclerosis (MS), whereas little is known about the impact of pregnancy and childbirth on the risk of secondary progression. OBJECTIVE: To investigate the association of parity and secondary progression in women with MS. METHODS: The association of the number of births and secondary progression was studied in a hospital-based cohort of 277 women with MS. Data were analysed in a multivariable logistic regression model, with adjustment for possible confounders. RESULTS: Parity was not independently associated with secondary progression, while the factors disease duration (OR per year increase: 1.05, 95% CI 1.03 to 1.09) and use of immunomodulatory treatments (OR 0.23, 95% CI 0.08 to 0.65) were independently associated with secondary progression. CONCLUSION: We found no evidence that parity influences the risk of secondary progression in MS. Further population-based studies on the association of pregnancy and childbirth on the long-term prognosis of MS are needed.

A retrospective analysis of the use of tap water iontophoresis for focal hyperhidrosis at a district general hospital: the patients' perspective.

Objective: Tap water iontophoresis as a treatment for focal hyperhidrosis is given as an initial series of treatments in hospital, followed by home maintenance treatments. Our study assessed quality of life and perception of hyperhidrosis with the use of iontophoresis. Materials and methods: All patients treated with iontophoresis at our hospital from 2012 to 2017 were retrospectively assessed (n = 82, mean age 34 years; 60% female). Fifty of the 82 patients (mean age 34 years; 60% female) had a pre-treatment DLQI (mean 12.6). Twenty-three of these patients (mean age 33 years; 60% female) had a paired pre- and post-treatment DLQI recorded. The average DLQI pre-treatment was 14.1 and post-treatment was 2.2. Therefore, the average reduction (improvement) was 11.9 (p < .05). Results: Thirty-eight of the 82 patients (46%) completed a telephone interview (mean age 35 years; 65% female). Of this cohort, 24 had an improvement in HDSS following treatment, and the remaining 14 patients had no change. Nine patients (24%) bought their own iontophoresis machine. In these patients, there was a higher average improvement in HDSS (1.8), compared to the total interviewed cohort (1.0). Conclusion: In conclusion, tap water iontophoresis can result in a significant improvement in perceived severity of hyperhidrosis and quality of life.

Pediculus humanus capitis: an update.

Head lice infestation, or pediculosis capitis, caused by Pediculus humanus capitis, is a common health concern. In the US, where pediculosis capitis is the most prevalent parasitic infestation of children, 6 to 12 million people are affected every year. Pediculosis capitis remains confined to the scalp. Scalp pruritus is the cardinal symptom, although patients with lice can be asymptomatic. Pruritus with impetiginization should prompt the physician to look for lice or viable nits. All close contacts should be examined. Treatment directed at killing the lice and the ova should be considered only if active lice or viable eggs are observed. The three fundamental effective treatment options for head lice are topical pediculicides, wet combing, and oral therapy. Spraying or fogging a home with insecticides or pediculicides is not recommended.

Single-operator cholangioscopy is useful for visual assessment of bile duct pathology.

INTRODUCTION: Single-operator cholangioscopy (SOC) is increasingly used for evaluation of the biliary tree following endoscopic retrograde cholangiopancreaticography (ERCP). This study aimed to determine the visual and histological success rates of SOC at a single Danish tertiary referral centre. METHODS: All patients undergoing SOC between 2008 and 2015 were retrospectively included from a prospectively maintained database. Patient characteristics and proced-ure-related variables were obtained from medical records. A visual and a histological success rate were determined according to predefined criteria. RESULTS: In total, 54 patients underwent SOC, most often due to suspicion of malignancy (n = 53; 98%). In one case, access to the common bile duct failed, and in six cases malignant disease was missed. Thus, the cholangioscopies were successful in 47 of 54 procedures corresponding to a visual success rate of 87%. Nine patients (17%) had a mean of 1.3 ± 1.0 SOC-guided biopsies taken. The extracted tissue was inadequate for histological evaluation in seven of nine cases, corres-pond-ing to a histological success rate of 22% (two out of nine tissue samples were eligible for histological diagnosis). CONCLUSIONS: Considering the reasonable visual success rate, SOC seems to be a useful extension of ERCP during diagnostic work-up for detection of malignant disease in the biliary tree. However, one biopsy per patient is insufficient for histological verification of common bile duct malignancy. TRIAL REGISTRATION: The Danish Health Authority (3-3013-1299/1) and The Danish Data Protection Agency (RH-2015-229). FUNDING: none.

Robot-Assisted Hybrid Esophagectomy Is Associated with a Shorter Length of Stay Compared to Conventional Transthoracic Esophagectomy: A Retrospective Study.

AIM: To compare the peri- and postoperative data between a hybrid minimally invasive esophagectomy (HMIE) and the conventional Ivor Lewis esophagectomy. METHODS: Retrospective comparison of perioperative characteristics, postoperative complications, and survival between HMIE and Ivor Lewis esophagectomy. RESULTS: 216 patients were included, with 160 procedures performed with the conventional and 56 with the HMIE approach. Lower perioperative blood loss was found in the HMIE group (600 ml versus 200 ml, p < 0.001). Also, a higher median number of lymph nodes were harvested in the HMIE group (median 28) than in the conventional group (median 23) (p = 0.002). The median length of stay was longer in the conventional group compared to the HMIE group (11.5 days versus 10.0 days, p = 0.03). Patients in the HMIE group experienced fewer grade 2 or higher complications than the conventional group (39% versus 57%, p = 0.03). The rate of all pulmonary (51% versus 43%, p = 0.32) and severe pulmonary complications (38% versus 18%, p = 0.23) was not statistically different between the groups. CONCLUSIONS: The HMIE was associated with lower intraoperative blood loss, a higher lymph node harvest, and a shorter hospital stay. However, the inborn limitations with the retrospective design stress a need for prospective randomized studies. Registration number is DRKS00013023.

EGF-like module pair 3-4 in vitamin K-dependent protein S: modulation of calcium affinity of module 4 by module 3, and interaction with factor X.

Calcium-binding epidermal growth factor (EGF)-like modules are found in numerous extracellular and membrane proteins involved in such diverse processes as blood coagulation, lipoprotein metabolism, determination of cell fate, and cell adhesion. Vitamin K-dependent protein S, a cofactor of the anticoagulant enzyme activated protein C, has four EGF-like modules in tandem with the three C-terminal modules each harbouring a Ca(2+)-binding consensus sequence. Recombinant fragments containing EGF modules 1-4 and 2-4 have two Ca(2+)-binding sites with dissociation constants ranging from 10(-8) to 10(-5) M. Module-module interactions that greatly influence the Ca(2+) affinity of individual modules have been identified. As a step towards an analysis of the structural basis of the high Ca(2+) affinity, we expressed the Ca(2+)-binding EGF pair 3-4 from human protein S. Correct folding was shown by (1)H NMR spectroscopy. Calcium-binding properties of the C-terminal module were determined by titration with chromophoric chelators; binding to the low-affinity N-terminal site was monitored by (1)H-(15)N NMR spectroscopy. At physiological pH and ionic strength, the dissociation constants for Ca(2+) binding were 1.0x10(-6) M and 4. 8x10(-3) M for modules 4 and 3, respectively, i.e. the calcium affinity of the C-terminal site was about 5000-fold higher than that of the N-terminal site. Moreover, the Ca(2+) affinity of EGF 4, in the pair 3-4, was about 9000-fold higher than that of synthetic EGF 4. The EGF modules in protein S are known to mediate the interaction with factor Xa. We have now found modules 3-4 to be involved in this interaction. However, the individual modules 3 and 4 manifested no measurable activity.

Intrathoracic anastomotic leakage after gastroesophageal cancer resection is associated with increased risk of recurrence.

OBJECTIVE: Intrathoracic anastomotic leakage after intended curative resection for cancer in the esophagus or gastroesophageal junction has a negative impact on long-term survival. The aim of this study was to investigate whether an anastomotic leakage was associated with an increased recurrence rate. METHODS: This nationwide study included consecutively collected data on patients undergoing curative surgical resection with intrathoracic anastomosis, alive 8 weeks postoperatively, between 2003 and 2011. Patients with incomplete resection, or metastatic disease intraoperatively, were excluded. Only biopsy-proven recurrences were accepted. RESULTS: In total, 1085 patients were included. The frequency of anastomotic leakage was 8.6%. The median follow-up time was 29 months (interquartile range [IQR]: 13-58 months). Overall, 369 (34%) patients had disease recurrence, of which 346 patients died of recurrent gastroesophageal carcinoma. Twenty-three patients were alive with recurrence at the censoring date. In the study period, 333 patients died without signs of recurrent disease. The overall median time to recurrence was 66 weeks (IQR: 38-109 weeks). Distant metastases were found in 267 (25%), and local disease recurrence in 102 (9%) patients. Overall, 5-year disease-free survival in patients with leakage was 27%, versus 39% in those without leakage (P = .017). Anastomotic leakage was independently associated with higher risk of recurrence (hazard ratio [HR] = 1.63; 95% confidence interval [CI]: 1.17-2.29, P = .004) and all-cause mortality (HR = 1.57; 95% CI: 1.23-2.05, P < .0001). CONCLUSIONS: Intrathoracic anastomotic leakage increased the risk of recurrence in patients who underwent curative gastroesophageal cancer resection.

Effect of high oxygen modified atmosphere packaging on microbial growth and sensorial qualities of fresh-cut produce.

The application of High Oxygen Atmospheres (HOA) (i.e. > 70% O2) for packaging ready-to-eat vegetables was evaluated as an alternative technique for low O2 Equilibrium Modified Atmosphere (EMA) packaging (3% O2-5% CO2-balance N2) for respiring products. Comparative experiments between both techniques were performed in-vitro and in-vivo. Typical spoilage causing microorganisms (Pseudomonas fluorescens, Candida lambica), the moulds Botrytis cinerea, Aspergillus flavus and the opportunistic psychrotrophic human pathogenic microorganism associated with refrigerated minimally processed vegetables. Aeromonas caviae (HG4), showed a retarded growth during the conducted in-vitro studies at 4 degrees C in 70%, 80% and 95% O2 as examples of HOA compared to the in-vitro experiments in 5% O2 (as example of EMA packaging) and the effect was more pronounced in 95% O2. The effect of the high O2-concentrations on the human pathogen Listeria monocytogenes resulted in an extended lag phase (95% O2). The plant pathogen Erwinia carotovora was increasingly stimulated by increasing high O2-concentrations. During a storage experiment of three types of ready-to-eat vegetables (mushroom slices, grated celeriac and shredded chicory endive), which are sensitive to enzymatic browning and microbial spoilage, the effect of EMA and HOA (95% O2-5% N2) on their quality and shelf life was compared. High O2 atmospheres were found to be particularly effective in inhibiting enzymatic browning of the tested vegetables. Also, the microbial quality was better as a reduction in yeast growth was observed. The HOA can be applied as an alternative for low O2 modified atmospheres for some specific types of ready-to-eat vegetables, sensitive to enzymatic browning and spoilage by yeasts.

Therapist habituation and purported client progress in articulation therapy.

Ten graduate student clinicians, in their final year of training, evaluated the tape recorded pretherapy performances of 10 /s/-defective children on the 68 /s/ items of the McDonald Deep Test of Articulation (1964). Five of the 10 clinicians were randomly selected and assigned one of these /s/-defective children as part of their regular case load. The children were seen for 1 hr per week for a 5-week period. The clinicians were not informed as to the nature of the study or that the composition of their case load was in any way connected with the tapes that they had previously evaluated. The five remaining clinicians and children did not participate in therapy during this 5-week period. Immediately following this 5-week period, an additional tape recording was made of all 10 children's responses to the /s/ items of the McDonald Deep Test (1964). Both pre- and posttreatment tapes were then evaluated by all 10 clinicians in independent listening sessions. Significant between-tape differences, indicative of both habituation and sensitization to client errors within the in-therapy clinicians only, are discussed in terms of their clinical applications.

Cystic fibrosis: inheritance, genetics and treatment.

Cystic fibrosis (CF) is a genetically inherited and potentially fatal disease. In the Western world, 1 in 23 people carry the defective gene. This article outlines the genetics of CF and its mode of inheritance and examines what types of carrier screening are available. The carrier frequency is calculated using the Hardy-Weinberg equilibrium. Current treatments are evaluated, with a description and critique of gene therapy, the treatment of the future for respiratory failure.