Intracorporeal vs extracorporeal anastomosis following neoplastic right hemicolectomy resection: a systematic review and meta-analysis of randomized control trials.

PURPOSE: While minimally invasive surgery is the preferred approach for right hemicolectomy, the choice of anastomotic technique is still debated. Both intracorporeal (ICA) and extracorporeal anastomosis (ECA) are described, with conflicting reports on safety and efficacy seen. This study aimed to examine impact of ICA and ECA on outcomes in right hemicolectomy. METHODS: A meta-analysis of randomized control trials (RCT) was performed. The primary outcome was overall morbidity. The secondary outcomes included both perioperative and post-operative outcomes. RESULTS: Four RCTs were included incorporating 399 patients (199 patients (49.9%) ICA Vs 200 (50.1%) ECA). There was no significant difference in overall morbidity (RR 0.79, 95% CI 0.43, 1.48, p = 0.47), anastomotic leak (RR 1.34, 95% CI 0.58, 3.13, p = 0.5) or surgical site infections (RR 0.53, 95% CI 0.17, 1.64, p = 0.27). ICA patients had a significantly less post-operative ileus (RR 0.53, 95% CI 0.3-0.94, p = 0.03) quicker return to first flatus (WMD - 0.71, 95% CI - 1.12, 0.31, p = 0.0005), first bowel motion (WMD - 0.53, 95% CI - 0.69, - 0.37, p < 0.00001) and first meal (WMD - 0.68, 95% CI - 1.33, - 0.03, p = 0.04). Pain scores were significantly better for ICA patients on POD 3 (WMD - 0.76, 95% CI - 1.23, - 0.28, p = 0.002), POD 4 (WMD - 0.90, 95% CI - 1.71, - 0.09, p = 0.03) and POD 5 (WMD - 0.67, 95% CI - 1.22, - 0.13, p = 0.01). Length of hospital stay was similar (WMD - 0.46, 95% CI - 1.14, 0.22, p = 0.19). CONCLUSION: ICA is associated with a quicker return to normal physiological function with equivalent post-operative morbidity. Both ECA and ICA are safe and feasible for restoring normal bowel continuity.

Changes in Multidisciplinary Tracheostomy Team Practice Over Time.

Aim Increasing numbers of tracheostomy patients are discharged from the Intensive Care Unit (ICU) to general hospital wards. There is evidence that a Multidisciplinary Tracheostomy Team (MTT) can have a positive impact on the care of tracheostomy patients discharged from the ICU. We compared tracheostomy management and patient outcome in two time periods, at the start of our MTT practice in 2009-2011 and again in 2017. Methods In a retrospective audit, we compared tracheostomy management and patient outcome in 117 patients who had a tracheostomy in 2009-2011 with 81 patients who had a tracheostomy in 2017. Results The duration of tracheostomy cannulation was significantly shorter (21 vs 31 days, p=0.0005) in 2017 compared to 2009-2011. A Mini-Trach was used after tracheostomy decannulation in 56 of the 81 (69%) tracheostomy patients in 2017. Conclusions The continued development of our MTT service over 8 years was associated with a significantly shorter duration of tracheostomy cannulation and the introduction of Mini-Trach use after tracheostomy decannulation. These results support the importance of maintaining an active MTT service to manage tracheostomy patients after discharge from the ICU.

[ANALYSIS OF THE SIZE OF THE CEPHALOMETRIC VALUES OF THE FACE AND THE ODONTOMETRIC PARAMETERS OF THE JAWS DURING THE PERIOD OF OCCLUSION CHANGE OF THE DENTAL ROWS].

115 respondents aged 7-11 with occlusive pathology were examined anthropometrically and biometrically. The sizes of the craniofacial complex were studied using the parameters of the width and diagonal of the face. The jaw indices of the face were calculated. The mesio-distal, vestibulo-oral and vertical dimensions of the crowns of primary and permanent teeth were measured. The widths and lengths of dental arches during the period of tooth change were determined by the method of Pont and Korkhaus. Diagnosed mesognathic, dolichognathic and brachygnathic face types with normodont, macrodont and microdontic variants of dental arches. Regardless of the type of dental arches, the ratio of the width of the upper dental arch in the molar region to the similar parameters of the lower one was determined and is 1.02±0.05. The results of the study of the length of the anterior part of the dental arches also indicate that the odontometric indicators are commensurate with each other and this correlation is equal to 1.23±0.05. The correlation of the value of the sum of 14 upper teeth to the sum of 14 lower teeth is 1.15±0.05. The data obtained are used to predict the results of orthodontic treatment.

[The modern methods of evaluation of implementing personalized programs of prevention of age-associated diseases].

The development of preventive programs targeting specific groups of consumers of medical social services having age-related health and lifestyle characteristics is one of the most prospective methods to improve quality of medical care of the elderly and senile patients. The previously developed by Russian and foreign scientists programs of personalized prevention of age-related diseases make it possible to organize target groups of patients seeking medical services in both state and private health care organizations to be screened for conditions of medical and social significance from the point of view of preventive medicine. This permits to achieve a real integration of various components of preventive care that improves health of elderly and senile patients in terms of morphofunctional indices of patient's physical status, quality of life, degree of independence, and, as a result, quality and scope of implementation of preventive programs for elderly population. Therefore, the development of the basics of personalized programs preventing age-related diseases in elderly population is actual.

HIV and Pneumocystis Jiroveci Pneumonia (PJP) Managed With Extracorporeal Membrane Oxygenation (ECMO).

Presentation A 40-year-old Irish female presented with a new diagnosis of HIV, advanced immunosuppression and severe respiratory failure. Diagnosis Patient was subsequently diagnosed with Pneumocystis jiroveci Pneumonia (PJP). Treatment The patient was treated for HIV and PJP and required mechanical ventilation. She continued to deteriorate and veno-venous Extracorporeal Membrane Oxygenation (V-V ECMO) was deployed in her management after 18 days of mechanical ventilation. Conclusion HIV presenting with extensive pneumonia secondary to PJP and advanced immunosuppression is still a treatable condition. All available respiratory support including ECMO should be considered for patients even if they have been on mechanical ventilation for more than 7 days.

Knowledge, Skills and Experience Managing Tracheostomy Emergencies: A Survey of Critical Care Medicine trainees >.

Since the development of percutaneous tracheostomy, the number of tracheostomy patients on hospital wards has increased. Problems associated with adequate tracheostomy care on the wards are well documented, particularly the management of tracheostomy-related emergencies. A survey was conducted among non-consultant hospital doctors (NCHDs) starting their Critical Care Medicine training rotation in a university affiliated teaching hospital to determine their basic knowledge and skills in dealing with tracheostomy emergencies. Trainees who had received specific tracheostomy training or who had previous experience of dealing with tracheostomy emergencies were more confident in dealing with such emergencies compared to trainees without such training or experience. Only a minority of trainees were aware of local hospital guidelines regarding tracheostomy care. Our results highlight the importance of increased awareness of tracheostomy emergencies and the importance of specific training for Anaesthesia and Critical Care Medicine trainees.

A Quality Improvement Approach to Reducing the Caesarean section Surgical Site Infection Rate in a Regional Hospital.

Surgical site infection (SSI) rates are used extensively by hospitals as a basis for quality improvement. A 30-day post-discharge SSI programme for Caesarean section operations has been implemented in Our Lady of Lourdes Hospital since 2011. It has been shown that skin antisepsis and antibiotic prophylaxis are key factors in the prevention of SSI. Using quality improvement methodology, an infection prevention bundle was introduced to address these two factors. Skin antisepsis was changed from povidone-iodine to chlorhexidine-alcohol. Compliance with choice of antibiotic prophylaxis increased from 89.6% in 2014 to 98.5% in 2015. Compliance with timing also improved. The SSI rate of 7.5% was the lowest recorded to date, with the majority of SSIs (64%) diagnosed after hospital discharge. The level of variation was also reduced. However, the continued presence of variation and possibility of lower infection rates from the literature imply that further improvements are required.

Complications of an uncovered metallic tracheal stent managed by veno-venous extracorporeal membrane oxygenation: a case report.

Airway stents are primarily inserted for the management of airway obstruction associated with an inoperable malignancy and are rarely indicated in benign disease. We outline the complications associated with tracheal stents and describe the use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) to facilitate open tracheal surgery in an apnoeic patient who had an uncovered metallic tracheal stent left in place for an inappropriately long period. Computerised tomography imaging of the neck and thorax provided information for operative planning and described of the stent in addition to the extensive granulation tissue at the distal end of the stent. Veno-venous extracorporeal membrane oxygenation was used to facilitate open tracheal surgery, removal of the tracheal stent and formation of a surgical tracheostomy. Prolonged use of an uncovered metallic airway stent in younger patients with benign disease may lead to the stent being difficult to remove. There may be an accumulation of granulation tissue with the risk of airway obstruction.

Anaesthetic management of patients with severe sepsis.

Severe sepsis, a syndrome characterized by systemic inflammation and acute organ dysfunction in response to infection, is a major healthcare problem affecting all age groups throughout the world. Anaesthetists play a central role in the multidisciplinary management of patients with severe sepsis from their initial deterioration at ward level, transfer to the diagnostic imaging suite, and intraoperative management for emergency surgery. The timely administration of appropriate i.v. antimicrobial therapy is a crucial step in the care of patients with severe sepsis who may require surgery to control the source of sepsis. Preoperative resuscitation, aimed at optimizing major organ perfusion, is based on judicious use of fluids, vasopressors, and inotropes. Intraoperative anaesthesia management requires careful induction and maintenance of anaesthesia, optimizing intravascular volume status, avoidance of lung injury during mechanical ventilation, and ongoing monitoring of arterial blood gases, lactate concentration, haematological and renal indices, and electrolyte levels. Postoperative care overlaps with ongoing management of the severe sepsis syndrome patient in the intensive care unit. These patients are by definition, high risk, already requiring multiple supports, and require experienced and skilful decision-making to optimize their chances of a favourable outcome. Similar to acute myocardial infarction, stroke, or acute trauma, the initial hours (golden hours) of clinical management of severe sepsis represent an important opportunity to reduce morbidity and mortality. Rapid clinical assessment, resuscitation and surgical management by a focused multidisciplinary team, and early effective antimicrobial therapy are the key components to improved patient outcome.

Use of recombinant factor VIIa in massive post-partum haemorrhage.

BACKGROUND AND OBJECTIVE: Massive post-partum haemorrhage continues to be one of the world's leading causes of maternal morbidity and mortality. Any new treatment that potentially helps at risk parturients should be thoroughly investigated. Recombinant factor VIIa (rVIIa) is increasingly being used in the treatment of massive haemorrhage. We performed a case-matched analysis of its use since 2003 in the treatment of massive post-partum haemorrhage at our hospital. METHODS: Twenty-eight cases of massive post-partum haemorrhage were identified over a 3-yr period since 2003. In six of these cases, rVIIa was used as part of their management. Six case-matched controls were sought. The six women with the greatest requirement for packed red cell transfusion who also had a deranged prothrombin time were included. The groups were then compared for differences. The worst prothrombin time in each group was noted as was the best prothrombin time within 6 h, this was used as our measure of response to treatment. RESULTS: There was no statistical difference in age, gestation, parity, transfusion requirements, mode of delivery or the severity of the coagulopathy between the two groups. In both groups the prothrombin time improved with management. There was no significant difference in either the magnitude of the improvement in the value of the prothrombin time or the absolute value of the best prothrombin time (P = 0.09). Five out of the six women in the rFVIIa group had normal or low prothrombin times within 6 h yet only one woman who did not receive rFVIIa had a normal prothrombin time within 6 h though this was not significant (P = 0.08). CONCLUSIONS: This case-matched analysis supports the management of massive post-partum haemorrhage with appropriate resuscitation, surgical intervention and use of blood and blood products. This study does not support the routine use of rFVIIa in the management of massive obstetric haemorrhage. rFVIIa may have a role to play in this management but further studies and analyses will be required.

Relation between plasma trough concentration of abiraterone and prostate-specific antigen response in metastatic castration-resistant prostate cancer patients.

BACKGROUND: Abiraterone (ABI) is a major oral agent for the treatment of metastatic castration-resistant prostate cancer (mCRPC) patients but its systemic exposure is subject to a large inter-individual variability. We aimed to explore the relationship between ABI trough plasma concentration and prostate-specific antigen (PSA) response in mCRPC patients and to identify the critical determinants for its activity. PATIENTS AND METHODS: This is a monocentric prospective observational study in mCRPC patients treated with ABI. The plasmatic concentration of ABI at steady state was measured using liquid chromatography with fluorescence detection. The primary objective was to study the relationship between mean ABI plasma exposure (ABI Cmin) and 3-month PSA response. RESULTS: From 2012 to 2016, 61 mCRPC patients were eligible for pharmacokinetic/pharmacodynamic assessment. Thirty-eight patients experienced PSA response (62%, [confidence interval {CI} 95% 50-78]). In univariate analysis, ABI Cmin was 1.5-fold higher in responders: 12.0 ng/mL (CI 95% 9.4-15.6) versus 8.0 ng/mL (CI 95% 5.8-11.6; P = 0.0015). In multivariate analysis, only ABI Cmin was independently associated with PSA response (odds ratio = 1.12 [CI 95% 1.01-1.25], P = 0.004). By receiver operating characteristic analysis, the optimal threshold for ABI Cmin was 8.4 ng/mL. Progression-free survival (PFS) was significantly higher in patients with ABI Cmin above 8.4 ng/mL (hazard ratio 0.55, [CI 95% 0.31-0.99], 12.2 [CI 95% 9.2-19.5] versus 7.4 [CI 95% 5.5-14.7] months otherwise, P = 0.044). CONCLUSIONS: We showed that ABI trough concentration correlates with PSA response and PFS. Moreover, we could determine a cut-off value of plasmatic concentration for PSA response. Altogether, ABI concentration monitoring appears as a new approach to improve clinical outcome in mCPRC patients.

End of life in ICU--care of the dying or 'pulling the plug'?

This study, a modified subsection of the European ETHICUS study on End-of-Life (EOL) Decision Making in the Intensive Care Unit (ICU), examines the pattern of limiting futile life-sustaining therapies in an Irish ICU including the practice of withdrawing mechanical ventilation in anticipation of death. 1146 patients were admitted to the Mater Hospital, Dublin ICU from 1/9/1999 to 30/6/2000 and all 126 patients who died in ICU were included. EOL categories were prospectively defined (by Ethicus methodology) as cardiopulmonary resuscitation (CPR); brain death; withholding (WH); withdrawing (WD) life sustaining therapy and active shortening of the dying process (SDP). Complete data were obtained for 122 of the 126 patients who died during this period. 45 patients (36%) had therapy withheld, 40 (33%) had therapy withdrawn, 26 (21%) had unsuccessful CPR and 11 (10%) were Brain Dead. SDP was not performed. In total, 85 patients had a limitation of life sustaining therapy. CPR was the main therapy withheld (96% of WH/WD patients). Inotropic infusions were limited (WH or WD) in 40/85 (47%) of patients. Fluids, feeding and oxygen were rarely withdrawn (2.4%, 6%, 4.8% respectively). Twenty-two patients had two or more EOL decisions. Tracheal extubation or withdrawal of ventilation was less frequent (16.4%) but more common if a second EOL decision was made. No patient had sedation withdrawn or decreased. Eight patients of 85 (9%) had sedation increased. The study demonstrates that EOL decision making is common (69% of deaths and 7.4% of ICU admissions) in Ireland and demonstrates that the pattern of treatment limitation relates primarily to cardiovascular and other treatments and less to respiratory life sustaining treatment. Artificial nutrition and hydration were rarely withdrawn.

Ratio of hepatic arterial-to-portal venous blood flow--validation of radionuclide techniques in an animal model.

The ratio of hepatic arterial-to-portal venous blood flow can be determined from the analysis of a first-pass bolus through the liver by a number of techniques. This study examines the validity of four radiotracer techniques in an animal model. Thirty-four flow studies (3 mCi 99mTc-DTPA/study) were performed in seven anesthetized pigs. Images were acquired for 200 sec and time-activity curves were generated from lung, liver and kidney ROIs. These curves were analyzed using a slope-based (HPI), a height-based (mHAR) and two deconvolution-based methods employing exponential or gamma variate fits. There was an excellent correlation (r greater than 0.9) between results obtained with flow probes and the radiotracer techniques, with the exception of the HPI technique (r = 0.75). The mHAR and deconvolution techniques were inaccurate at very low and high arterial flows, due respectively to noise limitations and hemodynamic instability in the animal. Nevertheless, these techniques appear to be the most promising for routine clinical use.

Specialized intestinal metaplasia: analysis of prevalence, risk factors and association with gastro-oesophageal reflux disease

AIMS: There is an increasing awareness that short (less than 3 cm) segments of Barrett's epithelium and macroscopically normal cardia epithelium may harbour specialized intestinal metaplasia (SIM), a premalignant phenotype. This was a prospective study of both the prevalence of SIM in an unselected population of patients attending for endoscopy, and the association of SIM with symptoms, lifestyle, medication, endoscopic oesophagitis and carditis. METHODS: Two hundred consecutive patients underwent endoscopy. Biopsies taken from just below the squamocolumnar junction were stained for SIM, and were analysed for carditis and Helicobacter pylori infection. A detailed questionnaire of symptoms, tobacco consumption and the use of proton pump inhibitors was completed. RESULTS: Forty-two patients (21 per cent) had SIM, 19 of 126 (15 per cent) in an endoscopically normal oesophagus, 15 of 63 (24 per cent) in a short segment of Barrett's epithelium and eight of 11 in classical Barrett's oesophagus. Comparative analysis between the SIM positive and negative groups with respect to potential risk factors is outlined below. Table 1. CONCLUSION: SIM is prevalent in patients undergoing endoscopy, does not correlate with symptoms or with H. pylori infection, but is significantly associated with endoscopic and pathological markers of gastro-oesophageal reflux.

The relation of nonverbal processing ability of faces and voices and children's feelings of depression and competence.

The relation between nonverbal processing ability and feelings of depression and competence was evaluated in children between the ages of 7 and 11 years (N = 142). They were administered tests to measure their receptive nonverbal ability and feelings of depression and competence. Hierarchical regression analyses revealed that nonverbal ability was related to feelings of competence in boys and girls, but to feelings of depression only in boys. It was concluded that specific nonverbal deficits are associated with generalized negative feelings in children. Implications for adjustment are discussed.