Postoperative Outcomes and Quality of Life After Left Thoracoabdominal Esophagogastrectomy: Contrasting Esophagogastrostomy with Esophagojejunostomy.

BACKGROUND: Following left thoracoabdominal (LTA) esophagogastrectomy, gastrointestinal continuity can be re-established via esophagogastrostomy or esophagojejunostomy. We explored how the method of reconstruction impacted postoperative outcomes and quality of life (QoL). METHODS: From January 2007 to January 2022, patients undergoing LTA were identified from a single center's prospectively maintained database. Following esophagogastrectomy or extended total gastrectomy, an esophagogastrostomy (GAS) or Roux-en-Y esophagojejunostomy (R-Y) was fashioned. Postoperative outcomes were compared according to the method of reconstruction. The Functional Assessment of Cancer Therapy-Esophagus (FACT-E) questionnaire compared QoL. RESULTS: Of the 147 LTA patients identified, 135 (92%) were included-97 GAS (72%) and 38 R-Y patients (28%). R-Y patients had more ypT3/4 lesions (97% vs. 61%, p ≤ 0.001) and a similar incidence of ypN+/M+ disease. Anastomotic leaks were more common among GAS patients (17% vs. 3%, p = 0.023), however grade 3/4 complications (26.6% vs. 19.4%, p = 0.498), reoperation, intensive care admission, hospital representation and readmission were similar. FACT-E data were available for 68/97 (70%) GAS patients and 22/38 (58%) R-Y patients, with scores for 80/21/24/18/23/24 patients at baseline/preoperatively/1 month/3-6 months/1-3 years/3+ years postoperatively, respectively. Comparing between the groups, the scores were similar at each timepoint. FACT-E improved between baseline and preoperatively (79, 34-124 vs. 102, 81-123, p = 0.027). Only at 3+ years were postoperative scores equivalent to preoperative values. GAS patients had more reflux and esophagitis >6 months postoperatively (54% vs. 13%, p = 0.048; 62% vs. 0%, p ≤ 0.001). CONCLUSION: While the type of reconstruction did not affect QoL, it did affect the postoperative course.

Fidaxomicin to prevent recurrent Clostridioides difficile: what will it cost in the USA and Canada?

Importance: Recent changes in guidelines for managing Clostridioides difficile infections (CDI) have placed fidaxomicin as a first-line treatment. Objective: To estimate the net cost of first-line fidaxomicin compared to vancomycin in the American and Canadian healthcare systems and to estimate the price points at which fidaxomicin would become cost saving for the prevention of recurrence. Data sources and study selection: We identified randomized, placebo-controlled trials directly comparing fidaxomicin with vancomycin that reported on recurrence. Medication costs were obtained from the Veterans Affairs Federal Supply Schedule (US) and the Quebec drug formulary (Canada). The average cost of a CDI recurrence was established through a systematic review for each country. Data extraction synthesis and outcome measures: For efficacy, data on CDI recurrence at day 40 were pooled using a restricted maximal likelihood random effects model. For the cost review, the mean cost across identified studies was adjusted to reflect May 2022 dollars. These were used to estimate the net cost per recurrence prevented with fidaxomicin and the price point below which fidaxomicin would be cost saving. Results: The estimated mean system costs of a CDI recurrence were $15 147USD and $8806CAD, respectively. Preventing one recurrence by using first-line fidaxomicin over vancomycin would cost $38 222USD (95%CI $30 577-$57 332) and $13 760CAD (95%CI $11 008-$20 640), respectively. The probability that fidaxomicin was cost saving exceeded 95% if priced below $1140USD or $860CAD, respectively. Conclusions and Relevance: An increased drug expenditure on fidaxomicin may not be offset through recurrence prevention unless the fidaxomicin price is negotiated.

Career and Leadership Education in Anesthesia Residency Training.

Being a well-rounded physician requires competencies that extend beyond traditional medical training. This study explores one residency program's attempt to address the need to foster career management and leadership skills. A year-long didactic program was initiated to tackle both career management and leadership development. At the conclusion of the program, a survey revealed an increase in perceived competency in the domains taught. There was also a measurable increase in the amount of scholarly and quality improvement projects done in the department where the program was implemented. To support and develop physician competencies, healthcare organizations may derive immense benefit from a program that fosters both career management and leadership skills.

Diagnosis of acute malaria by laser based cell counter with comparison of conventional and recent techniques in Indian scenario.

UNLABELLED: Malaria is one of the most important parasitic diseases in humans affecting 103 countries worldwide. AIMS: The present study aims to determine the diagnostic utility of cell counter data--hemoglobin, total leukocyte count, platelet count and depolarized laser light (DLL)-based purple-coded events (PCEs) in detection of acute malaria. This is a retrospective study of 523 patient data that came for complete blood count for the first time. RESULTS: One hundred thirty-five of the 523 patients showed microscopic evidence of malaria. Platelet count showed the highest sensitivity of 77.77% (105/135). PCEs (> or = 1) showed 43.7% (59/135) sensitivity. CONCLUSIONS: It is concluded that a low platelet count (< 150 x 109/L) is a good hematological parameter for presumptive diagnosis of malaria. If we change the cut-off for PCEs from > or = 1 to > or = 2, the sensitivity would be 56.29% (76/135) and the specificity would be 94.58% (367/388), respectively. The sensitivity of DLL was low, particularly with a low parasitic index (PI). The number of PCEs does not correlate with the PI. The cut-off number of PCEs in DLL-based malaria detection should be modified in highly endemic areas.