Multicentre observational cohort study of implementation and outcomes of laparoscopic distal pancreatectomy.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is increasingly being performed as an alternative to open surgery. Whether the implementation and corresponding learning curve of LDP have an impact on patient outcome is unknown. The aim was to investigate the temporal trends in practice across UK centres. METHODS: This was a retrospective multicentre observational cohort study of LDP in 11 tertiary referral centres in the UK between 2006 and 2016. The learning curve was analysed by pooling data for the first 15 consecutive patients who had LDP and examining trends in surgical outcomes in subsequent patients. RESULTS: In total, 570 patients underwent LDP, whereas 888 underwent open resection. For LDP the median duration of operation was 240 min, with 200 ml blood loss. The conversion rate was 12·1 per cent. Neuroendocrine tumours (26·7 per cent) and mucinous cystic neoplasms (19·7 per cent) were commonest indications. The proportion of LDPs increased from 24·4 per cent in 2006-2009 (P1) to 46·0 per cent in 2014-2016 (P3) (P < 0·001). LDP was increasingly performed for patients aged 70 years or more (16 per cent in P1 versus 34·4 per cent in P3; P = 0·002), pancreatic ductal adenocarcinoma (6 versus 19·1 per cent; P = 0·005) and advanced malignant tumours (27 versus 52 per cent; P = 0·016). With increasing experience, there was a trend for a decrease in blood transfusion rate (14·1 per cent for procedures 1-15 to 3·5 per cent for procedures 46-75; P = 0·008), ICU admissions (32·7 to 19·2 per cent; P = 0·021) and median duration of hospital stay (7 (i.q.r. 5-9) to 6 (4-7) days; P = 0·002). After 30 procedures, a decrease was noted in rates of both overall morbidity (57·7 versus 42·2 per cent for procedures 16-30 versus 46-75 respectively; P = 0·009) and severe morbidity (18·8 versus 9·7 per cent; P = 0·031). CONCLUSION: LDP has increased as a treatment option for lesions of the distal pancreas as indications for the procedure have expanded. Perioperative outcomes improved with the number of procedures performed.

ANTECEDENTES: Cada día se utiliza más la pancreatectomía distal laparoscópica (laparoscopic distal pancreatectomy, LDP) como una alternativa a la cirugía abierta. Se desconoce si la implementación y la correspondiente curva de aprendizaje de la LDP tienen impacto en los resultados. El objetivo fue investigar las tendencias relacionadas con su implementación en los centros del Reino Unido a los largo del tiempo. MÉTODOS: Se realizó el estudio observacional retrospectivo y multicéntrico de una cohorte de LDP en once centros de referencia terciarios del Reino Unido entre 2006-2016. Se analizó la curva de aprendizaje agrupando los 15 primeros pacientes consecutivos de LDP y se compararon los resultados quirúrgicos con los obtenidos en los pacientes subsiguientes. RESULTADOS: En total, se incluyeron 570 pacientes con LDP y 888 con resección abierta. Para el LDP, la mediana de tiempo operatorio fue de 240 minutos con 200 ml de pérdida de sangre. La tasa de conversión fue del 12,2%. Las indicaciones más frecuentes fueron los tumores neuroendocrinos (26,7%) y las neoplasias quísticas mucinosas (19,7%). La proporción de LDP aumentó del 24% al 46% (de 2006-2009 a 2014-2016; P < 0,001). La LDP se realizó cada vez con mayor frecuencia en pacientes de ≥ 70 años (15,8% versus 34,4%, P = 0,002), en pacientes con adenocarcinoma ductal pancreático (6,5% versus 19,1%, P = 0,005) y en pacientes con tumores malignos avanzados (27,3% versus 51,85%, P = 0,016). Con el aumento de la experiencia, disminuyeron las tendencias de la tasa de transfusión sanguínea (14,1% al 3,5%, P = 0,008), los ingresos en la UCI (32,7% a 19,2%, P = 0.021) y la mediana de la duración de la estancia hospitalaria (7 (rango intercuartílico 5-9) a 6 (rango intercuartilico 4-7) días, P = 0,002). Tras 30 procedimientos, disminuyeron tanto la morbilidad global (57,7% versus 42,2%, P = 0,009) como las tasas de morbilidad grave (21,5% versus 14,6%, P = 0,022). CONCLUSIÓN: La pancreatectomía distal laparoscópica se ha incrementado como una opción de tratamiento para las lesiones del páncreas distal a medida que se han ido ampliando las indicaciones del procedimiento. Los resultados perioperatorios mejoran con el número de procedimientos realizados.

Bile duct reconstruction following laparoscopic cholecystectomy in England.

OBJECTIVES: To determine the incidence of bile duct reconstruction (BDR) following laparoscopic cholecystectomy (LC) and to identify associated risk factors. BACKGROUND: Major bile duct injury (BDI) requiring reconstruction is a serious complication of cholecystectomy. METHODS: All LC and attempted LC operations in England between April 2001 and March 2013 were identified. Patients with malignancy, a stone in bile duct or those who underwent bile duct exploration were excluded. This cohort of patients was followed for 1 year to identify those who underwent BDR as a surrogate marker for major BDI. Logistic regression was used to identify factors associated with the need for reconstruction. RESULTS: In total, 572,223 LC and attempted LC were performed in England between April 2001 and March 2013. Five hundred (0.09 %) of these patients underwent BDR. The risk of BDR is lower in patient that do not have acute cholecystitis [odds ratio (OR) 0.48 (95 % CI 0.30-0.76)]. The regular use of on-table cholangiography (OTC) [OR 0.69 (0.54-0.88)] and high consultant caseload >80 LC/year [OR 0.56 (0.39-0.54)] reduced the risk of BDR. Patients who underwent BDR were 10 times more likely to die within a year than those who did not require further surgery (6 vs. 0.6 %). CONCLUSIONS: The rate of BDR following laparoscopic cholecystectomy in England is low (0.09 %). The study suggests that OTC should be used more widely and provides further evidence in support of the provision of LC services by specialised teams with an adequate caseload (>80).

BioAssay Research Database (BARD): chemical biology and probe-development enabled by structured metadata and result types.

BARD, the BioAssay Research Database (https://bard.nih.gov/) is a public database and suite of tools developed to provide access to bioassay data produced by the NIH Molecular Libraries Program (MLP). Data from 631 MLP projects were migrated to a new structured vocabulary designed to capture bioassay data in a formalized manner, with particular emphasis placed on the description of assay protocols. New data can be submitted to BARD with a user-friendly set of tools that assist in the creation of appropriately formatted datasets and assay definitions. Data published through the BARD application program interface (API) can be accessed by researchers using web-based query tools or a desktop client. Third-party developers wishing to create new tools can use the API to produce stand-alone tools or new plug-ins that can be integrated into BARD. The entire BARD suite of tools therefore supports three classes of researcher: those who wish to publish data, those who wish to mine data for testable hypotheses, and those in the developer community who wish to build tools that leverage this carefully curated chemical biology resource.

Biliary boulders.

OBJECTIVE: To examine the outcome of endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones. DESIGN: A retrospective review of 100 consecutive ERCPs performed for CBD stones. RESULTS: 100 ERCPs were performed on 84 patients with a median cohort age of 77. Completion in this cohort, as defined by duct clearance, was achieved in 65% of cases. Completion rates fell rapidly after two ERCPs. 33% of the cohort had small stones <10 mm, and 67% had stones >10 mm. Size, but not number of stones, affected the completion rate and frequency of complications (16%). Presence of periampullary diverticulum did not affect completion or complication rates. MR cholangiopancreatography (MRCP) had a 90% sensitivity for detecting CBD stones compared with 56% for CT. DISCUSSION AND CONCLUSIONS: ERCP remains a high-risk procedure with a significant complication rate when performed to deal with CBD stones. MRCP should be the second choice of investigation for CBD stones. This cohort had an unusually high number of larger stones at ERCP of 67% compared with other published UK cohorts of 8%, and this was reflected in the completion and complication rate.

Definitive management of gallstone pancreatitis in England.

INTRODUCTION: The aim of this study was to investigate whether definitive treatment of gallstone pancreatitis (GSP) by either cholecystectomy or endoscopic sphincterotomy in England conforms with British Society of Gastroenterology (BSG) guidelines and to validate these guidelines. METHODS: Hospital Episode Statistics data were used to identify patients admitted for the first time with GSP between April 2007 and April 2008. These patients were followed until April 2009 to identify any who underwent definitive treatment or were readmitted with a further bout of GSP as an emergency. RESULTS: A total of 5,454 patients were admitted with GSP between April 2007 and April 2008, of whom 1,866 (34.2%) underwent definitive treatment according to BSG guidelines, 1,471 on the index admission. Patients who underwent a cholecystectomy during the index admission were less likely to be readmitted with a further bout of GSP (1.7%) than those who underwent endoscopic sphincterotomy alone (5.3%) or those who did not undergo any form of definitive treatment (13.2%). Of those patients who did not undergo definitive treatment before discharge, 2,239 received definitive treatment following discharge but only 395 (17.6%) of these had this within 2 weeks. Of the 505 patients who did not undergo definitive treatment on the index admission and who were readmitted as an emergency with GSP, 154 (30.5%) were admitted during the 2 weeks immediately following discharge. CONCLUSIONS: Following an attack of mild GSP, cholecystectomy should be offered to all patients prior to discharge. If patients are not fit for surgery, an endoscopic sphincterotomy should be performed as definitive treatment.

Early laparoscopic cholecystectomy service provision is feasible and safe in the current UK National Health Service.

INTRODUCTION: Despite increasing evidence of the benefits and safety of early laparoscopic cholecystectomy (LC) in acute gallstone disease, it is not widely practised in England. The Royal College of Surgeons of England support the separation of emergency and elective surgical care. The aim of this prospective study was to examine the impact of the implementation of 'Surgeon of the Week (SoW)' model on the number of early LCs performed and the efficiency of the emergency theatre activity in our hospital. This study also looked into its implications on specialist registrar training for early LC, and the financial impact to the hospital. PATIENTS AND METHODS: Between January 2007 and May 2008, demographic data, admission and discharge dates, complications, conversions to an open operation and deaths were collected for all patients who underwent early laparoscopic cholecystectomies. For ease of comparison, patients were divided into Group A representing before introduction of SoW (1 January 2007 to 30 August 2007) and Group B representing after introduction of SoW (1 October 2007 to 31 May 2008). The total numbers of operations performed in the emergency theatre list in the two groups were also calculated. RESULTS: A total of 1361 emergency operations were performed on the emergency theatre list in Group A, of which 951 were general surgical procedures. In Group B, the numbers of emergency procedures were 1537, of which 1138 were general surgical operations. There was a significant increase in the number of general surgical operations after introduction of SoW (P = 0.013). Before introduction of the SoW rota, 45 early LCs were performed. This increased to 118 after SoW which was significant (P < 0.001). In Group A, the number of early LCs performed by surgical trainees was 10 (22%). In Group B, the number of LCs performed by surgical trainees was 35 (30%; not significant). CONCLUSIONS: This study has demonstrated an increase in the efficiency of the emergency theatre with an increase in the number of early LCs on their index admission without extra morbidity following implementation of the SOW model in our hospital. We recommend the introduction of a suitable emergency surgical consultant on-call model separating emergency and elective surgical care depending on local circumstances. This can lead to significant cost savings and reduce re-admissions with gallstone-related complications.

Hepatic resection for breast cancer metastases.

INTRODUCTION: Hepatic resection is an established modality of treatment for colorectal cancer metastases. Resection of breast cancer liver metastases remains controversial, but has been shown to be an effective treatment in selected cases. This study reports the outcome of 8 patients with liver metastases from breast cancer. PATIENTS & METHODS: 8 patients with liver metastases from previously treated breast cancer were referred for hepatic resection between September 1996 and December 2002. Six were eligible for liver resection. The mean age was 45.8 years. The resections performed included 1 segmentectomy and 5 hemihepatectomies of which one was an extended hemihepatectomy. One patient had a repeat hepatectomy 44 months after the first resection. RESULTS: There were no postoperative deaths or major morbidity. The resectability rate was 75%. Follow-up periods range from 6 to 70 months with a median survival of 31 months following resection. There have been 2 deaths, one died of recurrence in the residual liver at 6 months and one died disease-free from a stroke. Of the remaining 4 patients, 1 has had a further liver resection at 44 months following which she is alive and 'disease-free' at 70 months. The one patient with peritoneal recurrence is alive 49 months after her liver resection with 2 patients remaining disease-free. CONCLUSION: Hepatic resection for breast cancer liver metastases is a safe procedure with low morbidity and mortality.

Experimental dynamics of a vortex within a vortex.

We report the experimental dynamics of a new two-dimensional (2D) fluid phenomenon that occurs when an intense, pointlike vortex is placed within a diffuse, circular vortex. Our observations, made using strongly magnetized electron columns to model the 2D fluid, support the analysis performed by Jin and Dubin.

Dual-opposite injection electrokinetic chromatography for the unbiased, simultaneous separation of cationic and anionic compounds.

The concept of dual opposite injection in capillary electrophoresis (DOI-CE) for the simultaneous separation, under conditions of suppressed electroosmotic flow, of anionic and cationic compounds with no bias in resolution and analysis time, is extended to a higher pH range in a zone electrophoresis mode (DOI-CZE). A new DOI-CE separation mode based on electrokinetic chromatography is also introduced (DOI-EKC). Whereas conventional CZE and DOI-CZE are limited to the separation of charged compounds with different electrophoretic mobilities, DOI-EKC is shown to be capable of separating compounds with the same or similar electrophoretic mobilities. In contrast to conventional EKC with charged pseudostationary phases that often interact too strongly with analytes of opposite charge, the neutral pseudostationary phases appropriate for DOI-EKC are simultaneously compatible with anionic and cationic compounds. This work describes two buffer additives that dynamically suppress electroosmotic flow (EOF) at a higher pH (6.5) than in a previous study (4.4), thus allowing DOI-CZE of several pharmaceutical bases and weakly acidic positional isomers. Several DOI-EKC systems based on nonionic (10 lauryl ether, Brij 35) or zwitterionic (SB-12, CAS U) micelles, or nonionic vesicles (Brij 30) are examined using a six-component test mixture that is difficult to separate by CZE or DOI-CZE. The effect of electromigration dispersion on peak shape and efficiency, and the effect of surfactant concentration on retention, selectivity, and efficiency are described.

Capillary electrophoretic determination of carboxyhemoglobin concentrations in postmortem blood samples.

The use of capillary electrophoresis (CE) as an alternative to existing methods of quantitation of carbon monoxide (CO) in hemoglobin from postmortem blood samples is presented. The isolation of heme (the portion of the hemoglobin molecule in which CO binding takes place) from hemoglobin is described. Reduced (containing no gas molecules) heme and CO-heme isolated from hemoglobin standards were successfully separated using CE. Heme and CO-heme were also isolated from blood samples of accident victims and analyzed using CE. A quantifiable difference in the CO-heme signals from blood samples containing fatal and nonfatal levels of CO was observed.

Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral intravenous catheter colonization in neonates: a prospective trial.

The purpose of the study was to compare the efficacy of 10% povidone-iodine with that of 0.5% chlorhexidine gluconate in 70% isopropyl alcohol for the prevention of peripheral intravenous catheter colonization in neonates. This was a multicenter, nonrandomized prospective study in a tertiary neonatal intensive care setting in which povidone-iodine and chlorhexidine gluconate were each used as antiseptic skin preparations over sequential 6-month periods. During the first 6 months of the study when povidone-iodine was in use 9.3% (38 of 408) of catheters were colonized. During the second 6 months of the study when chlorhexidine gluconate was in use, catheter colonization occurred in 4.7% (20 of 418, P = 0.01). Catheter-related bacteremia occurred during only 0.2% (2 of 826) of all catheterizations. Heavy skin colonization before catheter insertion (relative risk, 3.6; 95% confidence interval, 1.9, 7.0), catheterization > or = 72 hours (relative risk. 2.0; 95% confidence interval, 1.01, 3.8) and gestational age < or = 32 weeks (relative risk, 1.8; 95% confidence interval, 1.02, 3.3) increased colonization risk. Ampicillin infusion (relative risk, 0.4; 95% confidence interval, 0.2, 0.7) and 0.5% chlorhexidine gluconate cutaneous antisepsis (relative risk, 0.4; 95% confidence interval, 0.2, 0.8) were factors associated with decreased colonization risk. We conclude that 0.5% chlorhexidine gluconate in 70% isopropyl alcohol appears to be more efficacious than 10% povidone-iodine for the prevention of peripheral intravenous catheter colonization in neonates.

Design and performance of an in-line surface-induced dissociation device in a four-sector mass spectrometer.

A new in-line surface-induced dissociation device has been designed and characterized in a high performance four-sector tandem mass spectrometer. The design incorporates a target electrode parallel to the ion beam axis and an angled deflector plate (45° relative to the ion beam) to provide large collision angles. In addition, an extraction electrode (parallel to the target electrode) is employed to efficiently extract product ions from the target surface. Results obtained with this device indicate high internal energy deposition (up to 16. 3 eV) as measured with the thermometer ions W(CO) 6 (+·) and Si(C2H5)4/+·, as evidenced by extensive dissociation of the refractory pyrene molecular ion, and as indicated by the b 3/y 2 ratio in the product ion spectrum of leucine enkephalin. High resolution provided by the four-sector instrument for both precursor ions and product ions allows the observation of previously unobserved dissociation products in the surface-induced dissociation spectra of Si(C2H5)4/+· and novel ion-surface reaction products in spectra of W(CO)6/+· ions after collisions with hydrocarbon-covered surfaces. Both hydrogen atom and hydrocarbon abstraction products are observed. The dissociation efficiencies measured with the in-line device are approximately 1% when hydrocarbon-coated surfaces are used and increase fivefold with a fluorinated surface.

Recruitment of participants in the Lung Health Study, I: Description of methods.

The recruitment experience is described for a large multicenter clinical trial, the Lung Health Study, which required the screening of more than 73,000 male and female smokers aged 35-60. This paper summarizes the plans, methods, and recruiting experience of the 10 participating clinical centers. Recruitment proposals were prepared by each clinical center as part of the contract application process. Recruitment directors and staff were appointed whose primary responsibility was recruitment. Only one clinical center retained its original plan throughout; most clinical centers achieved their recruitment goals by supplementing their originally proposed strategies with one or more methods. The most frequently used methods were worksite, public site, mass mail, telephone, media, and referral strategies. The most significant contributions to the success of the recruitment process were the willingness and initiative of the clinical centers' staff to explore alternative techniques that would take advantage of local circumstances and their ability to incorporate as many workable recruitment methods as necessary to achieve the goal.

Quality control aspects of pulmonary function testing in the Multiple Risk Factor Intervention Trial.

Pulmonary function testing was used in MRFIT to monitor the presence of airways disease and to assess changes in pulmonary function over time. The pulmonary function indices that were measured were FEV1, FVC, and MMEF, (FEF25-75). Quality control of technician training, equipment maintenance, data collection, and data measurement were essential to ensure that results, over time and from various clinics, could be compared. Based on the MRFIT experience, it is strongly recommended that centralized training in testing techniques and spirometer maintenance take place before a clinical trial begins, and periodically throughout a trial. Such training, combined with quality control follow-up, should prevent the loss of data due to inadequate spirometer maintenance and invalid testing procedures.

Pulmonary fat embolism: a complication of fracture.

Medical personnel must be aware of the possibility of fat embolism as a complicating factor of fractures. Ambulance, emergency room, orthopedic, and intensive-care personnel may frequently be involved in the care of these patients. Fat embolism should be suspected any time a patient exhibits bizarre mental, pulmonary, or circulatory symptoms following a fracture. Prevention may be achieved by as near immobilization of a fracture as possible. When fat embolism does occur, the course of the illness may or may not be complex. The treatment is supportive and the patient should be made as comfortable as possible.