Portal venous gas as a radiological sign in a sigmoid diverticular abscess and its non-surgical management: a case report.

A 62-year old man who presented unwell with no specific symptoms or signs was found to have portal venous circulation gas complicating a small diverticular abscess. He was successfully managed with a course of antibiotics and had full resolution of symptoms, therefore avoiding the need for surgical intervention. While most commonly associated with bowel ischaemia and therefore often warranting emergency laparotomy, portal venous gas within the context of other underlying pathology often presents opportunities for delayed surgery or more conservative management options.

Defining adaptive capacity in healthcare: A new framework for researching resilient performance.

Resilience principles show promise for improving the quality of healthcare, but there is a need for further theoretical development to include all levels and scales of activity across the whole healthcare system. Many existing models based on engineering concepts do not adequately address the prominence of social, cultural and organisational factors in healthcare work. Promising theoretical developments include the four resilience potentials, the CARE model and the Moments of Resilience Model, but they are all under specified and in need of further elaboration. This paper presents the Integrated Resilience Attributes Framework in which these three theoretical perspectives are integrated to provide examples of anticipating, responding, monitoring and learning at different scales of time and space. The framework is intended to guide researchers in researching resilience, especially the linkages between resilience at different scales of time and space across the whole healthcare system.

Beyond 'find and fix': improving quality and safety through resilient healthcare systems.

OBJECTIVE: The aim was to develop a method based on resilient healthcare principles to proactively identify system vulnerabilities and quality improvement interventions. DESIGN: Ethnographic methods to understand work as it is done in practice using concepts from resilient healthcare, the Concepts for Applying Resilience Engineering model and the four key activities that are proposed to underpin resilient performance-anticipating, monitoring, responding and learning. SETTING: Accident and Emergency Department (ED) and the Older People's Unit (OPU) of a large teaching hospital in central London. PARTICIPANTS: ED-observations 104 h, and 14 staff interviews. OPU-observations 60 h, and 15 staff interviews. RESULTS: Data were analysed to identify targets for quality improvement. In the OPU, discharge was a complex and variable process that was difficult to monitor. A system to integrate information and clearly show progress towards discharge was needed. In the ED, patient flow was identified as a complex high-intensity activity that was not supported by the existing data systems. The need for a system to integrate and display information about both patient and organizational factors was identified. In both settings, adaptive capacity was limited by the absence of systems to monitor the work environment. CONCLUSIONS: The study showed that using resilient healthcare principles to inform quality improvement was feasible and focused attention on challenges that had not been addressed by traditional quality improvement practices. Monitoring patient and workflow in both the ED and the OPU was identified as a priority for supporting staff to manage the complexity of the work.

Nursing teamwork in the care of older people: A mixed methods study.

Healthcare is increasingly complex and requires the ability to adapt to changing demands. Teamwork is essential to delivering high quality care and is central to nursing. The aims of this study were to identify the processes that underpin nursing teamwork and how these affect the care of older people, identify the relationship between perceived teamwork and perceived quality of care, and explore in depth the experience of working in nursing teams. The study was carried out in three older people's wards in a London teaching hospital. Nurses and healthcare assistants completed questionnaires (n = 65) on known dynamics of teamwork (using the Nursing Teamwork Survey) together with ratings of organisational quality (using an adapted AHRQ HSPS scale). A sample (n = 22; 34%) was then interviewed about their perceptions of care, teamwork and how good outcomes are delivered in everyday work. Results showed that many care difficulties were routinely encountered, and confirmed the importance of teamwork (e.g. shared mental models of tasks and team roles and responsibilities, supported by leadership) in adapting to challenges. Perceived quality of teamwork was positively related to perceived quality of care. Work system variability and the external environment influenced teamwork, and confirmed the importance of team adaptive capacity. The CARE model shows the centrality of teamwork in adapting to variable demand and capacity to deliver care processes, and the influence of broader system factors on teamworking.

THE MODIFIED STAR EXCURSION BALANCE AND Y-BALANCE TEST RESULTS DIFFER WHEN ASSESSING PHYSICALLY ACTIVE HEALTHY ADOLESCENT FEMALES.

BACKGROUND: The modified Star Excursion Balance Test (mSEBT) and Y-Balance Test (YBT) are two common methods for clinical assessment of dynamic balance. Clinicians often use only one of these test methods and one outcome factor when screening for lower extremity injury risk. Dynamic balance scores are known to vary by age, sex and sport. The physically active adolescent female is at high risk for sustaining lower extremity injuries, specifically to the anterior cruciate ligament (ACL). Thus clarity regarding the use of dynamic balance testing results in adolescent females is important. To date, no studies have directly compared the various outcome factors between these two dynamic balance tests for this population. PURPOSE: To determine if there was an association between the mSEBT and YBT scores for measured reach distances, calculated composite score and side-to-side limb asymmetry in the ANT direction in physically active healthy adolescent females. STUDY DESIGN: Cross-sectional study. METHODS: Twenty-five healthy, physically active female adolescents (mean age, 14.0 ± 1.3 years) participated. Reach distances, a composite score and side-to-side limb asymmetry for the mSEBT and YBT, for each limb, were compared and examined for correlation. RESULTS: There were significant differences and moderate to excellent relationships between the measured reach directions between the mSEBT and the YBT. Injury risk classification, based on limb asymmetry in the anterior reach direction, differed between the tests. However, the calculated composite scores from the two tests did not differ. CONCLUSIONS: Performance scores on a particular reach direction should not be used interchangeably between the mSEBT and YBT in physically active adolescent females, and should not be compared to previously reported values for other populations. LEVEL OF EVIDENCE: Level 3.

Implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol.

BACKGROUND: Resilience engineering (RE) is an emerging perspective on safety in complex adaptive systems that emphasises how outcomes emerge from the complexity of the clinical environment. Complexity creates the need for flexible adaptation to achieve outcomes. RE focuses on understanding the nature of adaptations, learning from success and increasing adaptive capacity. Although the philosophy is clear, progress in applying the ideas to quality improvement has been slow. The aim of this study is to test the feasibility of translating RE concepts into practical methods to improve quality by designing, implementing and evaluating interventions based on RE theory. The CARE model operationalises the key concepts and their relationships to guide the empirical investigation. METHODS: The settings are the Emergency Department and the Older Person's Unit in a large London teaching hospital. Phases 1 and 2 of our work, leading to the development of interventions to improve the quality of care, are described in this paper. Ethical approval has been granted for these phases. Phase 1 will use ethnographic methods, including observation of work practices and interviews with staff, to understand adaptations and outcomes. The findings will be used to collaboratively design, with clinical staff in interactive design workshops, interventions to improve the quality of care. The evaluation phase will be designed and submitted for ethical approval when the outcomes of phases 1 and 2 are known. DISCUSSION: Study outcomes will be knowledge about the feasibility of applying RE to improve quality, the development of RE theory and a validated model of resilience in clinical work which can be used to guide other applications. Tools, methods and practical guidance for practitioners will also be produced, as well as specific knowledge of the potential effectiveness of the implemented interventions in emergency and older people's care. Further studies to test the application of RE at a larger scale will be required, including studies of other healthcare settings, organisational contexts and different interventions.

Preweaning mortality in group-housed lactating sows: hormonal differences between high risk and low risk sows.

This study used an endocrinological approach to explain the differences between sows that have higher vs. lower preweaning mortality in a group-farrowing system. The association between sows that had 2 or more piglets die within the first 72 h postfarrowing (high risk) or sows that had 1 or no piglets die within the first 72 h postfarrowing (low risk) with changes in serum hormone concentrations was investigated. Multiparous sows (n = 63; parity 2 to 7) from 4 contemporary breeding groups, each mated within a week, were used. Sows were housed in a group-farrowing system where 8 sows farrowed in individual pens and shared a communal feeding and dunging area in each room. Reproductive performance, including total born, born alive, and stillborn per litter, individual weight of piglets at birth and weaning (at 5 wk postfarrowing), litter size at weaning, preweaning mortality of piglets, and sow BW before farrowing and after weaning, were recorded for all sows. Of these sows, 14 sows from 2 breeding groups were selected randomly for blood sampling through an indwelling ear vein catheter. A blood sample was collected daily from each sow 2 d prefarrowing through 2 d postfarrowing. Serum samples were analyzed for prolactin, oxytocin, cortisol, and urocortin concentrations using RIA. Among the 14 sows, 7 sows lost 2 or more piglets during the first 72 h after farrowing and were classified as high risk sows, and the other 7 sows lost 0 or 1 piglet during the same period and were classified as low risk sows. Catheters in 11 sows (5 high risk sows and 6 low risk sows) remained functional for the entire sampling period. Results indicate that high risk sows farrowed larger litters (live born = 13.8 ± 0.50 vs. 11.3 ± 0.48 piglets; P = 0.03) with lighter piglets (1.4 ± 0.04 vs. 1.7 ± 0.05 kg; P < 0.001) compared with low risk sows. In addition, high risk sows had greater oxytocin concentrations (0.09 vs. 0.07 ng/mL; SE = 0.02, P = 0.01), which might be associated with larger litters farrowed, compared with low risk sows. There were no differences between high risk and low risk sows (P > 0.30) in terms of serum prolactin, cortisol, or urocortin concentrations. These results suggest that litter size and birth weight of piglets played an important role in preweaning mortality of piglets and hormone concentrations in sows were not associated with piglet mortality in the group-farrowing system used.

Are hepatocellular carcinoma patients more likely to receive liver resection in regions with longer transplant wait times?

In areas with longer liver transplantation (LT) wait times, liver resection (LR) offers an appropriate alternative in selected patients with hepatocellular carcinoma (HCC). We identified adults with HCC undergoing LT or LR from the United States Nationwide Inpatient Sample from 1998-2008. United Network for Organ Sharing regions were assigned lower rank indicating shorter wait time for patients with Model for End-Stage Liver Disease (MELD) scores of 19-24 or ≥ 25. We used multivariate adjusted analysis to assess the odds of LR versus LT comparing patients by region. Of 4,516 patients, 40% received LT and 60% received LR. When ranked by wait times for MELD 19-24, the 3rd, 8th, and 11th ranked regions had decreased odds of LR versus LT (region 3: odds ratio [OR] 0.3, 95% confidence interval [CI] 0.2-0.6; region 8: OR 0.5, 95% CI 0.3-0.9; region 5: OR 0.3, 95% CI 0.2-0.6), whereas the 10th ranked region had increased odds (region 1: OR 1.9, 95% CI 1.1-3.4) compared with the region with the shortest wait time, region 10. When ranked by wait times for MELD ≥25, all regions except the 10th ranked region (region 5) had increased odds compared with the region with the shortest wait time, region 3 (OR 1.6-5.6; P < .001). Regional variations of LT versus LR are not completely explained by transplant wait times.

Review of simulation studies in anaesthesia journals, 2001-2010: mapping and content analysis.

Despite widespread adoption of simulation-based training in medical education, there remains scepticism about its cost-effectiveness and long-term impact on patient outcomes. Medical simulation is well established in anaesthesia where it is considered an important educational tool. This review of key clinical anaesthesia literature is used as a case study of clinician uptake within a specialty and to investigate evidence for translational impact using both qualitative and quantitative data. We examined high-impact journal publications from 2001 to 2010 and extracted data covering authors, institutions, simulation modality, purposes of simulation, and various aspects of study design/methodology used. A total of 320 papers containing primary data were included. We found broad acceptance and uptake in anaesthesia with an increase in publications over the time period, mainly attributable to a steady increase in manikin studies. Studies using manikin technology (130/320; 41%) are distinguished as skills/performance studies (76; 58%) and studies focused on the use, testing, and validation of equipment (52; 40%). A total of 110 papers (34%) assessed the performance of technical and non-technical skills (68% and 32%, respectively). Growth in the use of structured checklists/validated tools to assess performance is mainly observed in the non-technical domain. Only 10% of these papers include follow-up data from the clinical environment. There is a lack of research examining performance transfer, sustainability, and direct patient outcomes and experiences. These publication patterns are instructive for those involved in medical educational and for other clinical specialties developing simulation.

Corn ethanol production, food exports, and indirect land use change.

The approximately 100 million tonne per year increase in the use of corn to produce ethanol in the U.S. over the past 10 years, and projections of greater future use, have raised concerns that reduced exports of corn (and other agricultural products) and higher commodity prices would lead to land-use changes and, consequently, negative environmental impacts in other countries. The concerns have been driven by agricultural and trade models, which project that large-scale corn ethanol production leads to substantial decreases in food exports, increases in food prices, and greater deforestation globally. Over the past decade, the increased use of corn for ethanol has been largely matched by the increased corn harvest attributable mainly to increased yields. U.S. exports of corn, wheat, soybeans, pork, chicken, and beef either increased or remained unchanged. Exports of distillers' dry grains (DDG, a coproduct of ethanol production and a valuable animal feed) increased by more than an order of magnitude to 9 million tonnes in 2010. Increased biofuel production may lead to intensification (higher yields) and extensification (more land) of agricultural activities. Intensification and extensification have opposite impacts on land use change. We highlight the lack of information concerning the magnitude of intensification effects and the associated large uncertainties in assessments of the indirect land use change associated with corn ethanol.

Assessment of energy content of low-solubles corn distillers dried grains and effects on growth performance, carcass characteristics, and pork fat quality in growing-finishing pigs.

Two studies were conducted to assess the energy content of low-solubles distillers dried grains (LS-DDG) and their effects on growth performance, carcass characteristics, and pork fat quality in grow-finish pigs. In Exp. 1, 24 barrows (Yorkshire-Landrace × Duroc; 80 to 90 d of age) in 2 successive periods were assigned to 1 of 6 dietary treatments. In individual metabolism stalls, pigs were fed a corn-soybean meal diet (control); control replaced by 30, 40, or 50% LS-DDG; or control replaced by 30 or 40% distillers dried grains with solubles (DDGS) at 3% of their initial BW for 12 d. All diets contained 0.25% CrO(2). During the 5-d collection period, feces and urine were collected from each pig. Feed, feces, and urine were analyzed for DM, GE, and N concentrations, and feed and feces were analyzed for Cr content. The ME content of LS-DDG (2,959 ± 100 kcal/kg of DM) was similar to that determined for DDGS (2,964 ± 81 kcal/kg of DM). In Exp. 2, 216 Yorkshire-Landrace × Duroc pigs were blocked by initial BW (18.8 ± 0.76 kg) and assigned to 1 of 24 pens (9 pigs/pen). Pens within block were allotted to 1 of 3 dietary treatments (8 pens/treatment) in a 4-phase feeding program: a corn-soybean meal control (control), control containing 20% LS-DDG, or control containing 20% DDGS. Treatment had no effect on final BW, ADG, ADFI, or HCW. Pigs fed LS-DDG had similar G:F (0.367) compared with pigs fed DDGS (0.370), but tended (P = 0.09) to have decreased G:F compared with pigs fed the control (0.380; pooled SEM = 0.004). Dressing percent was less (P < 0.01) for pigs fed LS-DDG (72.8%) and DDGS (72.8%) compared with the control (73.8%; pooled SEM = 0.22). Pigs fed LS-DDG (54.8%) had greater (P = 0.02) carcass lean compared with pigs fed DDGS (53.4%), but were similar to pigs fed control (54.1%; pooled SEM = 0.33). Bellies from pigs fed DDGS (12.9°) were softer (P < 0.01) than those from pigs fed control (17.7°; pooled SEM = 1.07) as determined by the belly flop angle test. Feeding LS-DDG (14.1°) tended (P < 0.10) to create softer bellies compared with control-fed pigs. The PUFA content of belly fat was reduced (P < 0.01) by LS-DDG (14.0%) compared with DDGS (15.4%), but was increased (P < 0.05) compared with pigs fed the control (9.4%; pooled SEM = 0.34). In conclusion, LS-DDG and DDGS had similar ME values and inclusion of 20% LS-DDG in diets for growing-finishing pigs supports ADG and ADFI similar to that of diets containing 20% DDGS, and may reduce negative effects on pork fat compared with DDGS.

Effects of tryptophan supplementation on aggression among group-housed gestating sows.

The objective of this study was to determine the effects of dietary Trp supplementation on mixing-induced aggression and the associated stress, and on reproductive performance in gestating sows. After weaning, sows were mixed in pens with electronic sow feeders on concrete-slatted floors. Each pen housed 21 ± 2.8 sows, with approximately 2.7 ± 0.43 m(2)/sow of floor space allowance. Multiparous sows (n = 168) from 8 breeding groups were used, with 4 groups assigned to a control diet and 4 groups assigned to a high-Trp diet. Control sows received corn- and soybean meal-based diets throughout gestation (0.15% Trp) and lactation (0.21% Trp). Three days before and after mixing, sows assigned to the high-Trp treatment received approximately 2.3 times the dietary Trp (0.35% in the gestation diet and 0.48% in the lactation diet) fed to control sows. Six focal sows (2 sows from each of parity 1, 2, and 3 or greater) in each pen were designated and videotaped for 72 h after mixing to determine the type and number of aggressive interactions among sows. Before and 48 h after mixing, saliva samples were collected from focal sows, and scratches were assessed on all sows. Data were analyzed using the FREQ and GLIMMIX procedures (SAS Inst. Inc., Cary, NC). Aggression among sows was intense during the initial 6 h and decreased between 6 and 72 h after mixing. The initial aggression caused scratches and increased cortisol concentrations (P < 0.05). Mature sows tended to fight for longer periods (112 vs. 52 s/h per sow, SE = 23.8; P < 0.10) but had fewer scratches caused by aggression (injury score = 4.3 vs. 6.5, SE = 1.13; P < 0.01) than parity-1 sows. Supplementation of dietary Trp reduced the total duration of head-to-head knocking (P < 0.05) but did not affect other aggressive behaviors. There was no difference between dietary treatments in injury scores or saliva cortisol concentrations. Sows in the high-Trp treatment had more total piglets born (12.5 vs. 10.5 pigs/litter, SE = 0.55; P < 0.05) and more stillborn piglets (1.5 vs. 0.8 pigs/litter, SE = 0.20; P < 0.05), but had no significant change (P = 0.12) in piglets born alive (10.8 vs. 9.7 pigs/litter, SE = 0.42) compared with control sows. The results indicate that the initial aggression after mixing caused more injuries in young sows than in mature sows. Supplementation of dietary Trp at 2.3 times the control amount for a short period did not effectively reduce aggression and the associated stress in sows at mixing.

Proposed follow up programme after curative resection for lower third oesophageal cancer.

The incidence of oesophageal adenocarcinoma has risen throughout the Western world over the last three decades. The prognosis remains poor as many patients are elderly and present with advanced disease. Those patients who are suitable for resection remain at high risk of disease recurrence. It is important that cancer patients take part in a follow up protocol to detect disease recurrence, offer psychological support, manage nutritional disorders and facilitate audit of surgical outcomes. Despite the recognition that regular postoperative follow up plays a key role in ongoing care of cancer patients, there is little consensus on the nature of the process. This paper reviews the published literature to determine the optimal timing and type of patient follow up for those after curative oesophageal resection.

Molecular alterations of the IDH1 gene in AML: a Children's Oncology Group and Southwest Oncology Group study.

Recent whole-genome sequencing efforts led to the identification of IDH1(R132) mutations in acute myeloid leukemia (AML) patients. We studied the prevalence and clinical implications of IDH1 genomic alterations in pediatric and adult AML. Diagnostic DNA from 531 AML patients treated on Children's Oncology Group trial COG-AAML03P1 (N=257), and Southwest Oncology Group trials SWOG-9031, SWOG-9333 and SWOG-9500 (N=274), were tested for IDH1 mutations. Codon R132 mutations were absent in the pediatric cohort, but were found in 12 of 274 adult patients (4.4%, 95% CI 2.3-7.5). IDH1(R132) mutations occurred most commonly in patients with normal karyotype, and those with FLT3/ITD and NPMc mutations. Patients with IDH1(R132) mutations trended toward higher median diagnostic white blood cell counts (59.2 x 10(9) vs 29.1 x 10(9) per liter, P=0.19) than those without mutations, but the two groups did not differ significantly in age, bone marrow blast percentage, overall survival or relapse-free survival. Eleven patients (2.1%) harbored a novel V71I sequence alteration, which was found to be a germ-line polymorphism. IDH1 mutations were not detected in pediatric AML, and are uncommon in adult AML.

Outcomes associated with serum phosphorus level in males with non-dialysis dependent chronic kidney disease.

BACKGROUND/AIMS: Hyperphosphatemia is associated with higher mortality and increased incidence of end-stage renal disease in patients with non-dialysis dependent CKD (NDD-CKD), but there has not been a concomitant assessment of mortality and progressive kidney disease that would also account for cumulative effects of hyperphosphatemia. METHODS: In order to account for the cumulative effects of abnormal serum phosphorus we examined associations of not only baseline, but also time-averaged serum phosphorus levels with all-cause mortality, the composite of mortality or ESRD and the slopes of estimated glomerular filtration rate (eGFR), by using Cox models and mixed effects models in a contemporary cohort of 713 males with moderate and advanced NDD-CKD. RESULTS: Higher baseline and time-averaged serum phosphorus were both associated with mortality and with the composite outcome. A 1 mg/dl higher time-averaged serum phosphorus was associated with a multivariable adjusted hazard ratio of all-cause mortality (95% CI) of 1.56 (1.19 - 2.05), p = 0.001. Higher serum phosphorus was associated with a steeper slope of eGFR in unadjusted analyses, but this association became non-significant after multivariable adjustments. CONCLUSION: The cumulative burden of hyperphosphatemia is associated with increased mortality in patients with moderate and advanced NDD-CKD. Clinical trials are needed to determine if lowering serum phosphorus can result in improved mortality in this population.

Low-CO(2) electricity and hydrogen: a help or hindrance for electric and hydrogen vehicles?

The title question was addressed using an energy model that accounts for projected global energy use in all sectors (transportation, heat, and power) of the global economy. Global CO(2) emissions were constrained to achieve stabilization at 400-550 ppm by 2100 at the lowest total system cost (equivalent to perfect CO(2) cap-and-trade regime). For future scenarios where vehicle technology costs were sufficiently competitive to advantage either hydrogen or electric vehicles, increased availability of low-cost, low-CO(2) electricity/hydrogen delayed (but did not prevent) the use of electric/hydrogen-powered vehicles in the model. This occurs when low-CO(2) electricity/hydrogen provides more cost-effective CO(2) mitigation opportunities in the heat and power energy sectors than in transportation. Connections between the sectors leading to this counterintuitive result need consideration in policy and technology planning.