Implementation of the robotic abdominal phase during robot-assisted minimally invasive esophagectomy (RAMIE): results from a high-volume center.

BACKGROUND: Evidence on the added value of robotic-assistance in the abdominal phase during esophagectomy is scarce. In 2003, our center implemented the robotic thoracic phase for esophagectomy. In November 2018 the robot was also implemented in the abdominal phase. The aim of this study was to evaluate the implementation of the abdominal phase during robot-assisted minimally invasive esophagectomy (RAMIE). METHODS: Consecutive patients who underwent full RAMIE with intrathoracic anastomosis for esophageal cancer were included. Patients were extracted from a prospectively maintained institutional database. A cumulative sum (CUSUM) analysis was performed for abdominal operation time and abdominal lymph node yield. Intraoperative, postoperative and oncological outcomes including collected lymph nodes per abdominal lymph node station were reported. RESULTS: Between 2018 and 2021, 70 consecutive patients were included. The majority of the patients had an adenocarcinoma (n = 55, 77%) and underwent neoadjuvant chemo(radio)therapy (n = 65, 95%). The median operative time for the abdominal phase was 180 min (range 110-233). The CUSUM analysis for abdominal operation time showed a plateau at case 22. There were no intraoperative complications or conversions during the abdominal phase. The most common postoperative complications were pneumonia (n = 18, 26%) and anastomotic leakage (n = 14, 20%). Radical resection margins were achieved in 69 (99%) patients. The median total lymph node yield was 42 (range 23-83) and the median abdominal lymph node yield was 16 (range 2-43). The CUSUM analysis for abdominal lymph node yield showed a plateau at case 21. Most abdominal lymph nodes were collected from the left gastric artery (median 4, range 0-20). CONCLUSIONS: This study shows that a robotic abdominal phase was safely implemented for RAMIE without compromising intraoperative, postoperative and oncological outcomes. The learning curve is estimated to be 22 cases in a high-volume center with experienced upper GI robotic surgeons.

Indocyanine green fluorescence in robot-assisted minimally invasive esophagectomy with intrathoracic anastomosis: a prospective study.

Indocyanine green fluorescence angiography (ICG-FA) allows for real-time intraoperative assessment of the perfusion of the gastric conduit during esophagectomy. The aim of this study was to investigate the effect of the implementation of ICG-FA during robot-assisted minimally invasive esophagectomy (RAMIE) with an intrathoracic anastomosis. In this prospective cohort study, a standardized protocol for ICG-FA was implemented in a high-volume center in December 2018. All consecutive patients who underwent RAMIE with an intrathoracic anastomosis were included. The primary outcome was whether the initial chosen site for the anastomosis on the gastric conduit was changed based on ICG-FA findings. In addition, ICG-FA was quantified based on the procedural videos. Out of the 63 included patients, the planned location of the anastomosis was changed in 9 (14%) patients, based on ICG-FA. The median time to maximum intensity at the base of the gastric conduit was shorter (25 s; range 13-49) compared to tip (34 s; range 12-83). In patients with anastomotic leakage, the median time to reach the FImax at the tip was 56 s (range 30-83) compared to 34 s (range 12-66) in patients without anastomotic leakage (p = 0.320). The use of ICG-FA resulted in an adaptation of the anastomotic site in nine (14%) patients during RAMIE with intrathoracic anastomosis. The quantification of ICG-FA showed that the gastric conduit reaches it maximum intensity in a base-to-tip direction. Perfusion of the entire gastric conduit was worse for patients with anastomotic leakage, although not statistically different.

Quality of spirometry and related diagnosis in primary care with a focus on clinical use.

American and European societies' (ATS/ERS) criteria for spirometry are often not met in primary care. Yet, it is unknown if quality is sufficient for daily clinical use. We evaluated quality of spirometry in primary care based on clinical usefulness, meeting ATS/ERS criteria and agreement on diagnosis between general practitioners (GPs) and pulmonologists. GPs included ten consecutive spirometry tests and detailed history questionnaires of patients who underwent spirometry as part of usual care. GPs and two pulmonologists assessed the spirometry tests and questionnaires on clinical usefulness and formulated a diagnosis. In total, 149 participants covering 15 GPs were included. Low agreements were found on diagnosis between GPs and pulmonologists 1 (κ = 0.39) and 2 (κ = 0.44). GPs and pulmonologists rated >88% of the tests as clinically useful, although 13% met ATS/ERS criteria. This real-life study demonstrated that clinical usefulness of routine primary care spirometry tests was high, although agreement on diagnosis was low.

Exhaled Breath Profiles Before, During and After Exacerbation of COPD: A Prospective Follow-Up Study.

Many patients with chronic obstructive lung disease (COPD) experience exacerbations. The diagnosis of an exacerbation is solely based on symptoms. We hypothesized that exhaled breath profiles, measured by Gas Chromatography-Mass Spectrometry (GC-MS) or electronic nose (eNose), are different between stable disease and exacerbations and may have the potential to serve as biomarkers for COPD exacerbations. In this prospective follow-up study, breath samples were taken during stable COPD, during a subsequent exacerbation and after recovery. Samples were analyzed by GC-MS and eNose. CCQ symptom scores were associated with univariate outcomes of GC-MS and eNose using analysis of covariance (ANCOVA). After multivariate modeling by Principal Component Analysis (PCA), paired student t-tests were performed. Sixty-eight patients were included, 31 had an exacerbation and 16 patients had breath sampled at all three time points. Significant differences were found in breathprints taken during exacerbation as compared to baseline and recovery for both GC-MS and eNose. Breath profiles obtained by GC-MS as well as by eNose showed a correct classification of 71% (10/14) for baseline vs exacerbation and of 78% (11/14) for exacerbation vs recovery. These results provide proof of principle that exhaled breath can serve as a noninvasive biomarker for the diagnosis of COPD exacerbations.

Optimization of pulmonary emphysema quantification on CT scans of COPD patients using hybrid iterative and post processing techniques: correlation with pulmonary function tests.

OBJECTIVES: The aim of this study was to assess the effect of hybrid iterative reconstruction and post processing on emphysema quantification in low-dose CT scans of COPD patients using pulmonary function tests (PFT) as a reference. METHODS: CT scans of 23 COPD patients diagnosed with GOLD I or higher were reconstructed with iDose4 level 1 to 7 in IntelliSpace Portal (ISP) 6 and 7. ISP7 was used with and without specific denoising filter for COPD. The extent of emphysema was measured as percentage of lung voxels with attenuation < - 950 Hounsfield units (%LAA-950). The correlation between %LAA-950 and PFT, age, BMI, pack years, and the Clinical COPD Questionnaire (CCQ) and Medical Research Council dyspnea scale (MRC) was determined. RESULTS: Denoising significantly reduced %LAA-950 as was demonstrated by lower %LAA-950 in ISP7 with denoising filter and a significant reduction in %LAA-950 with higher iDose4 levels. All PFT except forced vital capacity (FVC) were significantly inversely correlated with %LAA-950. There was a trend toward a stronger correlation at higher iDose4 levels. %LAA-950 was also significantly correlated with BMI, GOLD class, and CCQ scores. CONCLUSIONS: Our study showed that hybrid iterative reconstruction and use of post processing denoising can optimize the use of emphysema quantification in CT scans as a complimentary diagnostic tool to stage COPD in addition to PFT.

Oesophagectomy: The expanding role of minimally invasive surgery in oesophageal cancer.

Historically, open oesophagectomy was the gold standard for oesophageal cancer surgery. This was associated with a relatively higher morbidity. In the last two decades, we have seen significant improvements in short and long term outcomes due to centralisation of oesophagectomy, multidisciplinary approach, enhanced recovery after surgery programmes, neoadjuvant treatments and advances in minimally invasive oesophagectomy (MIO) techniques. MIO has significantly reduced postoperative morbidity and improved functional recovery, while maintaining comparable long-term oncological outcomes. MIO is technically demanding, and requires a long learning curve. However, it has been proven to be safe and successful in expert centres. This is a review on the current role of MIO in the management of oesophageal cancer.

Tranexamic acid therapy for postoperative bleeding after bariatric surgery.

BACKGROUND: Tranexamic acid reduces blood loss associated with various surgical procedures. Postoperative bleeding caused by dissection or bleeding of the enteric staple lines is a well-known complication following bariatric surgery. Reoperation in order to restore hemostasis is frequently necessary (up to 2.5% in literature). The effect of conservative therapy using tranexamic acid for postoperative hemorrhage after bariatric surgery is still very much a novel technique. The aim is to present our results (reoperation rate and thrombo-embolic complication rate) of tranexamic acid therapy for postoperative bleeding after bariatric surgery in comparison to those in existing literature. METHODS: We retrospectively reviewed 1388 patients who underwent bariatric surgery (laparoscopic gastric bypass or laparoscopic gastric sleeve). Use of tranexamic acid, reoperation rate, transfusion rate and rate of thrombo-embolic complications were reviewed. RESULTS: Forty-five of 1388 (3.2%) total patients experienced significant hemorrhage after bariatric surgery. Tranexamic acid was administered in 44 of these patients. A failure of the treatment with tranexamic acid was observed in four patients. The incidence of reoperation was 0.4% for the entire population. No thrombo-embolic complications were registered for patients receiving tranexamic acid. CONCLUSION: These findings suggest that the administration of tranexamic acid appears to be safe in reducing the reoperation rate for bleeding after bariatric surgery.

[A man with abdominal pain, diarrhoea and rectal bleeding]. / Een man met buikpijn, diarree en rectaal bloedverlies.

A 49-year-old man came to the emergency room with abdominal pain, vomiting, diarrhoea and rectal bleeding. Both colonoscopy and CT of the abdomen showed cecocolic intussusception caused by an appendiceal mucocele. An ileocecal resection was performed via a laparoscopic approach and microscopy of the tissue showed a low-grade mucinous neoplasm.

[Diagnostic delay of pulmonary embolism]. / Diagnostische delay bij longembolie.

OBJECTIVE: To quantify the different stages of diagnostic delay of pulmonary embolism (PE) in patients and to identify other clinical factors associated with this delay. DESIGN: Case series. METHOD: Medical records were reviewed for all patients diagnosed with PE in the period 1 January 2008 and 31 December 2009 in Isala Hospital in Zwolle (the Netherlands), and data was collated for: the dates of symptom onset, presentation to a GP, referral to secondary care, and diagnosis respectively. The relationship between diagnostic delay and other clinical parameters such as gender, age, risk factors, symptoms and co-morbidities was tested using multivariate logistic regression analysis. RESULTS: For the 261 patients included in the analysis, the average total delay was 8.6 days. Patient delay (4.2 days average) and delay in primary care (3.9 days) were the major contributors to this delay. Chest pain and symptoms of deep venous thrombosis were associated with an early diagnosis. Patient delay was shorter in patients with chest pain and longer in patients with dyspnoea. In primary care, chest pain and rales were associated with an early referral, whereas the presence of co-morbidity led to a delayed referral. Delay in secondary care was shorter when the patient presented with dyspnoea. CONCLUSION: The diagnostic delay of PE is substantial, especially patient delay and delays originating in primary care. Further research is needed to identify clinical factors that raise suspicion of PE in primary care, to aid the development of improved diagnostic models.

A qualitative interview study on the positive well-being of medical school faculty in their teaching role: job demands, job resources and role interaction.

BACKGROUND: Attention for the well-being of medical school faculty is not only important for the prevention of attrition and burnout, but may also boost performance in their tasks in medical education. Positive well-being can be conceptualized as work engagement and this is associated with increased performance. In this study we explore how demands and resources from different tasks affect work engagement specifically for education. METHODS: Between June and September 2013, we conducted a multisite semi-structured interview study with a diverse group of medical school faculty and used an open-coding strategy within the Work Engagement Model on the transcribed interviews. RESULTS: We interviewed 16 faculty members whose teaching experience ranged from 7 to 38 years and whose professional tasks ranged from being solely an educator to being a physician, researcher, educator and administrator simultaneously. All participants were clear on the perceived demands and resources, although similar aspects of the work environment could be perceived oppositely between participants. Overarching themes were perceptions related to the organization or department, often described as a general and long-term effect and perceptions directly related to a task, often described as a direct and short-term effect on well-being. Furthermore, the demands and resources as resultant of fulfilling multiple tasks were described clearly by participants. CONCLUSIONS: The ambiguous nature of the work environment in terms of demands and resources requires an individualized approach to supporting work engagement. Furthermore, faculty members perceive many resources from fulfilling multiple tasks in relation to their tasks in education. Faculty developers and administrators alike could use these findings to apply the concept of work engagement to their daily support of faculty in medical education.

Fast spin-orbit qubit in an indium antimonide nanowire.

Because of the strong spin-orbit interaction in indium antimonide, orbital motion and spin are no longer separated. This enables fast manipulation of qubit states by means of microwave electric fields. We report Rabi oscillation frequencies exceeding 100 MHz for spin-orbit qubits in InSb nanowires. Individual qubits can be selectively addressed due to intrinsic differences in their g factors. Based on Ramsey fringe measurements, we extract a coherence time T(2)(*)=8±1 ns at a driving frequency of 18.65 GHz. Applying a Hahn echo sequence extends this coherence time to 34 ns.

Electrical control of single hole spins in nanowire quantum dots.

The development of viable quantum computation devices will require the ability to preserve the coherence of quantum bits (qubits). Single electron spins in semiconductor quantum dots are a versatile platform for quantum information processing, but controlling decoherence remains a considerable challenge. Hole spins in III-V semiconductors have unique properties, such as a strong spin-orbit interaction and weak coupling to nuclear spins, and therefore, have the potential for enhanced spin control and longer coherence times. A weaker hyperfine interaction has previously been reported in self-assembled quantum dots using quantum optics techniques, but the development of hole-spin-based electronic devices in conventional III-V heterostructures has been limited by fabrication challenges. Here, we show that gate-tunable hole quantum dots can be formed in InSb nanowires and used to demonstrate Pauli spin blockade and electrical control of single hole spins. The devices are fully tunable between hole and electron quantum dots, which allows the hyperfine interaction strengths, g-factors and spin blockade anisotropies to be compared directly in the two regimes.

Spectroscopy of spin-orbit quantum bits in indium antimonide nanowires.

A double quantum dot in the few-electron regime is achieved using local gating in an InSb nanowire. The spectrum of two-electron eigenstates is investigated using electric dipole spin resonance. Singlet-triplet level repulsion caused by spin-orbit interaction is observed. The size and the anisotropy of singlet-triplet repulsion are used to determine the magnitude and the orientation of the spin-orbit effective field in an InSb nanowire double dot. The obtained results are confirmed using spin blockade leakage current anisotropy and transport spectroscopy of individual quantum dots.

Suppression of Zeeman gradients by nuclear polarization in double quantum dots.

We use electric dipole spin resonance to measure dynamic nuclear polarization in InAs nanowire quantum dots. The resonance shifts in frequency when the system transitions between metastable high and low current states, indicating the presence of nuclear polarization. We propose that the low and the high current states correspond to different total Zeeman energy gradients between the two quantum dots. In the low current state, dynamic nuclear polarization efficiently compensates the Zeeman gradient due to the g-factor mismatch, resulting in a suppressed total Zeeman gradient. We present a theoretical model of electron-nuclear feedback that demonstrates a fixed point in nuclear polarization for nearly equal Zeeman splittings in the two dots and predicts a narrowed hyperfine gradient distribution.

Potential of integrated [18F] fluorodeoxyglucose positron-emission tomography/CT in identifying vulnerable carotid plaques.

BACKGROUND AND PURPOSE: There is a need for improved risk stratification of patients with TIA/stroke and carotid atherosclerosis. The purpose of this study was to prospectively investigate the potential of integrated (18)F-FDG PET/MDCT in identifying vulnerable carotid plaques. MATERIALS AND METHODS: Fifty patients with TIA/stroke with an ipsilateral carotid plaque causing <70% stenosis and a plaque on the contralateral asymptomatic side underwent integrated (18)F-FDG PET/MDCT within 36.1 ± 20.0 days (range, 9-95 days) of the last symptoms. Carotid plaque (18)F-FDG uptake was measured as both the mean and maximum blood-normalized SUV, known as the TBR. Using MDCT, we assessed volumes of vessel wall and individual plaque components. RESULTS: Mean TBR was only significantly larger in the ipsilateral plaques of patients who were imaged within 38 days (1.24 ± 0.04 [SE] versus 1.17 ± 0.05, P = .014). This also accounted for maximum TBR (1.53 ± 0.06 versus 1.42 ± 0.06, P = .015). MDCT-assessed vessel wall and LRNC volumes were larger in ipsilateral plaques of all patients (982.3 ± 121.3 versus 811.3 ± 106.6 mm(3), P = .016; 164.7 ± 26.1 versus 134.3 ± 35.2 mm(3), P = .026, respectively). CONCLUSIONS: In the present study, (18)F-FDG PET only detected significant differences between ipsilateral and contralateral asymptomatic plaques in patients with TIA/stroke who were imaged within 38 days, whereas MDCT detected larger vessel wall and LRNC volumes, regardless of time after symptoms. In view of the substantial overlap in measurements of both sides, it remains to be determined whether the differences we found will be clinically meaningful.

[Risk assessment with intellectual disabled forensic psychiatric patients: how useful are risk assessment instruments?]. / Risicotaxatie bij forensisch psychiatrische patiënten met een lichte verstandelijke handicap: hoe bruikbaar zijn risicotaxatieinstrumenten?

BACKGROUND: Instruments for assessing the risk of violent behaviour have proved their worth in the field of forensic psychiatry. However, it is not certain whether such instruments provide an accurate assessment of recidivism when used with psychiatric patients who have an intellectual disability. AIM: To find out whether these instruments - or which of these instruments - can provide a reliable assessment of the risk of violent sexual recidivism if used with forensic psychiatric patients who have an intellectual disability. method We searched PubMed, PsycINFO and Google Scholar for studies in English or Dutch, published between 1980 and 2010, concerning the reliability of instruments for assessing the risk of recidivism in forensic psychiatric patients with an intellectual disability. RESULTS: The studies show that several of the risk assessment instruments currently in use provide reliable predictions concerning patients with an intellectual disability. CONCLUSIONS: The HCR-20 and HKT-30 are recommended for assessing the risk of violent recidivism in patients with an intellectual disability. The Static-99 is the preferred instrument for assessing the risk of sexual recidivism. Further research is needed for assessing to what extent SVR-20, ARMIDILO, DROS, and PCL-R are applicable to forensic psychiatric patients in the Netherlands who have an intellectual disability.

Glossopharyngeal neuralgia triggered by non-noxious stimuli at multiple cephalic and extracephalic sites.

Glossopharyngeal neuralgia (GN) triggered by non-noxious stimuli at multiple cephalic and extracephalic sites with positron emission tomography (PET) evidence for involvement of the upper brainstem has never been reported. We present such a patient, a 73-year-old man who since the age of 50 had suffered from GN with a high recurrence rate and very severe unilateral, non-familial GN episodes with very easy trigger zones widely extending beyond the n IX territory. Extensive neuroimaging and neurophysiological tests detected no precise underlying cause. PET scan revealed activation in the upper brainstem on extracephalic triggers. Single-fibre electromyography data will be discussed. We hypothesize that deficient inhibition as seen in trigeminal nociceptive reflexes on the level of brainstem interneurons, a functional lesion in the primary somatosensory cortex-sensory thalamic nuclei circuit and the dorsal column-thalamic pathway both activated by light touch may in part be involved in the extracephalic triggering.

[Comments on screening spirometry for detection of COPD]. / Kanttekeningen bij screenend longfunctieonderzoek voor detectie van COPD.

World COPD day is an annual event intended to increase awareness of chronic obstructive pulmonary disease. During this day, in November 2006, free spirometry testing was offered to the public in approximately 100 places including hospitals, pharmacies, offices of GPs and tents on main squares throughout the Netherlands. The objective of this action is laudable. However, screening for COPD is generally considered ineffective. Furthermore, the application of a fixed ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) (FEV1/FVC < 0.70) as recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) to detect airflow limitation, required for a diagnosis of COPD, may lead to underdiagnosis of COPD in the young and to overdiagnosis in the elderly. In addition, spirometry was generally performed without bronchodilation, thus further increasing the likelihood of a false-positive diagnosis ofCOPD. Smoking cessation is important in halting the progression of COPD. Therefore, identifying smokers at risk for developing COPD seems a logical reason for screening or case finding for COPD. However, it has not been clearly demonstrated that early detection of COPD may contribute to improved smoking cessation rates. Also, smokers with normal spirometry may be led to believe that smoking has no adverse effects on their health. Therefore, a different strategy should be adopted to increase awareness of COPD on the next World COPD day.

Albumin and whole-body protein synthesis respond differently to intraperitoneal and oral amino acids.

Patients with peritoneal dialysis are at risk for malnutrition and hypoalbuminemia, which are indicators of poor outcome. Recently, it was shown that dialysis solutions containing amino acids (AAs) and glucose improve protein anabolism in peritoneal dialysis patients. We determined if the same solutions could increase the fractional synthesis rate of albumin along with whole-body protein synthesis. Changes in the fractional albumin synthetic rate reflect acute change in hepatic albumin synthesis. A random-order cross-over study compared the effects of Nutrineal (AA source) plus Physioneal (glucose) dialysate with Physioneal alone dialysate. Eight patients in the overnight fasting state were compared to 12 patients in the daytime-fed state. Fractional albumin synthetic rate and whole-body protein synthesis were determined simultaneously using a primed-continuous infusion of L-[1-(13)C]-leucine. Fractional albumin synthesis on AAs plus glucose dialysis did not differ significantly from that on glucose alone in the fasting or the fed state. Protein intake by itself (fed versus fasting) failed to induce a significant increase in the fractional synthetic rate of albumin. Conversely, the oral protein brought about a significant stimulation of whole-body protein synthesis. Our findings show that the supply of AAs has different effects on whole-body protein synthesis and the fractional synthetic rate of albumin.

Health status measurement in COPD: the minimal clinically important difference of the clinical COPD questionnaire.

BACKGROUND: Patient-reported outcomes (PRO) questionnaires are being increasingly used in COPD clinical studies. The challenge facing investigators is to determine what change is significant, ie what is the minimal clinically important difference (MCID). This study aimed to identify the MCID for the clinical COPD questionnaire (CCQ) in terms of patient referencing, criterion referencing, and by the standard error of measurement (SEM). METHODS: Patients were > or = 40 years of age, diagnosed with COPD, had a smoking history of >10 pack-years, and were participating in a randomized, controlled clinical trial comparing intravenous and oral prednisolone in patients admitted with an acute exacerbation of COPD. The CCQ was completed on Days 1-7 and 42. A Global Rating of Change (GRC) assessment was taken to establish the MCID by patient referencing. For criterion referencing, health events during a period of 1 year after Day 42 were included in this analysis. RESULTS: 210 patients were recruited, 168 completed the CCQ questionnaire on Day 42. The MCID of the CCQ total score, as indicated by patient referencing in terms of the GRC, was 0.44. The MCID of the CCQ in terms of criterion referencing for the major outcomes was 0.39, and calculation of the SEM resulted in a value of 0.21. CONCLUSION: This investigation, which is the first to determine the MCID of a PRO questionnaire via more than one approach, indicates that the MCID of the CCQ total score is 0.4.