Thoracoscopic oesophageal atresia/tracheo-oesophageal fistula (OA/TOF) repair is associated with a higher stricture rate: a single institution's experience.

PURPOSE: Thoracoscopic OA/TOF repair was first described in 1999. Currently, less than 10% of surgeons routinely employ minimally access surgery. Our primary aim was to review our immediate-, early- and long-term outcomes with this technique compared with the open approach. METHODS: A retrospective review of all patients undergoing primary OA/TOF (Type C) repair at our institution from 2009 was conducted. Outcome measures included length of surgery, conversion rate from thoracoscopy, early complications such as anastomotic leak and post-operative complications such as anastomotic strictures needing dilatations. Fisher's exact and Kruskal-Wallis tests were used for statistical analysis. RESULTS: 95 patients in total underwent OA/TOF repair during the study period of which 61 (64%) were completed via an open approach. 34 were attempted thoracoscopically of which 11 (33%) were converted. There was only one clinically significant anastomotic leak in our series that took place in the thoracoscopic group. We identified a significantly higher stricture rate in our thoracoscopic cohort (72%) versus open surgery (43%, P < 0.05). However, the median number of dilations (3) performed was not significantly different between the groups. There was one recurrent fistula in the thoracoscopic converted to open group. Our median follow-up was 60 months across the groups. CONCLUSION: In our experience, the clinically significant leak rate for both open and thoracoscopic repair as well as recurrent fistula is much lower than has been reported in the literature. We do not routinely perform contrast studies and are, thus, reporting clinically significant leaks only. The use of post-operative neck flexion, ventilation and paralysis is likely to be protective towards a leak. Thoracoscopic OA/TOF repair is associated with a higher stricture rate compared with open surgery; however, these strictures respond to a similar number of dilatations and are no more refractory. Larger, multicentre studies may be useful to investigate these finding further.

Quality and effectiveness of osteoporosis treatment decision aids: a systematic review and environmental scan.

Decision aids (DAs) are evidence-based tools that support shared decision-making (SDM) implementation in practice; this study aimed to identify existing osteoporosis DAs and assess their quality and efficacy; and to gain feedback from a patient advisory group on findings and implications for further research. We searched multiple bibliographic databases to identify research studies from 2000 to 2019 and undertook an environmental scan (search conducted February 2019, repeated in March 2020). A pair of reviewers, working independently selected studies for inclusion, extracted data, evaluated each trial's risk of bias, and conducted DA quality assessment using the International Patient Decision Aid Standards (IPDAS). Public contributors (patients and caregivers with experience of osteoporosis and fragility fractures) participated in discussion groups to review a sample of DAs, express preferences for a new DA, and discuss plans for development of a new DA. We identified 6 studies, with high or unclear risk of bias. Across included studies, use of an osteoporosis DA was reported to result in reduced decisional conflict compared with baseline, increased SDM, and increased accuracy of patients' perceived fracture risk compared with controls. Eleven DAs were identified, of which none met the full set of IPDAS criteria for certification for minimization of bias. Public contributors expressed preferences for encounter DAs that are individualized to patients' own needs and risk. Using a systematic review and environmental scan, we identified 11 decision aids to inform patient decisions about osteoporosis treatment and 6 studies evaluating their effectiveness. Use of decision aids increased accuracy of risk perception and shared decision-making but the decision aids themselves fail to comprehensively meet international quality standards and patient needs, underpinning the need for new DA development.

What Exactly is Meant by "Loss of Domain" for Ventral Hernia? Systematic Review of Definitions.

Large ventral hernias are a significant surgical challenge. "Loss of domain" (LOD) expresses the relationship between hernia and abdominal volume, and is used to predict operative difficulty and success. This systematic review assessed whether different definitions of LOD are used in the literature. The PubMed database was searched for articles reporting large hernia repairs that explicitly described LOD. Two reviewers screened citations and extracted data from selected articles, focusing on the definitions used for LOD, study demographics, study design, and reporting surgical specialty. One hundred and seven articles were identified, 93 full-texts examined, and 77 were included in the systematic review. Sixty-seven articles were from the primary literature, and 10 articles were from the secondary literature. Twenty-eight articles (36%) gave a written definition for loss of domain. These varied and divided into six broad groupings; four described the loss of the right of domain, six described abdominal strap muscle contraction, five described the "second abdomen", five describing large irreducible hernias. Six gave miscellaneous definitions. Two articles gave multiple definitions. Twenty articles (26%) gave volumetric definitions; eight used the Tanaka method [hernia sac volume (HSV)/abdominal cavity volume] and five used the Sabbagh method [(HSV)/total peritoneal volume]. The definitions used for loss of domain were not dependent on the reporting specialty. Our systematic review revealed that multiple definitions of loss of domain are being used. These vary and are not interchangeable. Expert consensus on this matter is necessary to standardise this important concept for hernia surgeons.

The multi-disciplinary management of complex congenital and acquired tracheo-oesophageal fistulae.

AIM OF THE STUDY: Complex tracheo-oesophageal fistulae (TOF) are rare congenital or acquired conditions in children. We discuss here a multidisciplinary (MDT) approach adopted over the past 5 years. METHODS: We retrospectively collected data on all patients with recurrent or acquired TOF managed at a single institution. All cases were investigated with neck and thorax CT scan. Other investigations included flexible bronchoscopy and bronchogram (B&B), microlaryngobronchoscopy (MLB) and oesophagoscopy. All cases were subsequently discussed in an MDT meeting on an emergent basis if necessary. MAIN RESULTS: 14 patients were referred during this study period of which half had a congenital aetiology and the other half were acquired. The latter included button battery ingestions (5/7) and iatrogenic injuries during oesophageal atresia (OA) repair. Surgical repair was performed on cardiac bypass in 3/7 cases of recurrent congenital fistulae and all cases of acquired fistulae. Post-operatively, 9/14 (64%) patients suffered complications including anastomotic leak (1), bilateral vocal cord paresis (1), further recurrence (1), and mortality (1). Ten patients continue to receive surgical input encompassing tracheal/oesophageal stents and dilatations. CONCLUSIONS: MDT approach to complex cases is becoming increasingly common across all specialties and is important in making decisions in these difficult cases. The benefits include shared experience of rare cases and full access to multidisciplinary expertise.

Unmet needs in ankylosing spondylitis patients receiving tumour necrosis factor inhibitor therapy; results from a large multinational real-world study.

BACKGROUND: Symptoms and comorbidities of ankylosing spondylitis (AS) considerably reduce health-related quality of life (HRQoL) and ability to work. This real-world study assessed rates of tumour necrosis factor inhibitor (TNFi) use and switching, treatment failure, and associations between failing TNFi and HRQoL, work productivity and activity impairment (WPAI). METHODS: AS patients and their treating physicians completed questionnaires capturing patient demographics, clinical status, TNFi treatment history, reasons for switching TNFi, HRQoL and WPAI. Current TNFi was determined as "failing" if, after ≥3 months, physician-rated disease severity had worsened, remained severe, was "unstable/deteriorating", physicians were dissatisfied with disease control and/or did not consider treatment a "success". RESULTS: The analysis included 2866 AS patients from 18 countries. Of 2795 patients with complete treatment data, 916 (32.8%) patients had never received TNFi therapy, 1623 (58.1%) patients were receiving their 1st TNFi and 200 (7.2%) patients had ever received ≥2 TNFi (treatment switch). Primary or secondary lack of efficacy were the commonest reasons for switching, and the mean delay in switching after primary lack of efficacy was 11.1 months. 232 (15.4%) patients on TNFi were currently "failing" who, compared to those with treatment success, reported poorer HRQoL: 5-dimension EuroQoL (EQ-5D-3 L): 0.63 vs. 0.78; Medical Outcomes Study Short-Form Health Survey version 2 (SF-36v2) mental component summary (MCS): 41.8 vs. 46.3; physical component summary (PCS): 40.2 vs. 45.1; impaired work productivity: 46.4% vs. 25.0%; and activity: 44.5% vs. 29.6%; all P < 0.001. CONCLUSIONS: Among AS patients, switching TNFi is uncommon and delayed by nearly 1 year despite primary lack of efficacy. Patients currently failing TNFi experience worse physical function, HRQoL and work productivity.

Unmet needs in psoriatic arthritis patients receiving immunomodulatory therapy: results from a large multinational real-world study.

OBJECTIVE: There are limited data on therapy selection and switching in psoriatic arthritis (PsA). This 18 country, real-world study assessed use and switching of immunomodulatory therapy (biologic/apremilast), the extent of treatment failure and its association with reduced physical functioning, health-related quality of life (HRQoL), and work productivity and activity impairment (WPAI). METHODS: PsA patients under routine care and their treating physicians provided demographics, current therapy, reasons for switching, duration of first therapy, HRQoL, HAQ-DI, and WPAI. Current immunomodulatory therapy was determined as "failing" if, after ≥ 3 months, physician-rated disease severity had worsened, remained severe, was "unstable/deteriorating," or they were dissatisfied with disease control and/or did not consider treatment a "success." RESULTS: Included were 3714 PsA patients; 1455 (40.6%) had never received immunomodulatory therapy; 1796 (50.1%) had ever received 1 immunomodulatory therapy and 331 (9.2%) ≥ 1. Lack of efficacy with first immunomodulatory therapy was the most common reason for switching; patients whose physicians indicated "primary lack of efficacy" as the reason, switched after a mean of 9.4 months. Patients currently failing immunomodulator therapies (n = 246) had poorer HRQoL compared with treatment success (n = 1472) measured by EQ-5D-3L (0.60 vs 0.77%; P < 0.0001); SF-36 PCS (40.8% vs 46.1%; P < 0.0001) MCS (41.1% vs 45.3%; P < 0.0001). Physical functioning, activity, and work productivity were also more impaired (HAQ-DI: 0.88 vs 0.56; activity impairment: 46.7% vs 29.7%; overall work impairment: 35.4% vs 26.1%; all P < 0.0001). CONCLUSIONS: Poor treatment response in PsA is associated with substantial negative patient impact. In cases of primary treatment failure, timely switching is needed.

Continuous infusion of epoprostenol improves the net balance between pulmonary endothelin-1 clearance and release in primary pulmonary hypertension.

BACKGROUND: Primary pulmonary hypertension results from progressive narrowing of the precapillary pulmonary vasculature. A variety of endothelial abnormalities have been identified, including a net reduction in pulmonary clearance of the vasoconstrictor and smooth muscle mitogen endothelin-1. In many patients, net pulmonary release of endothelin-1 is observed. Chronic infusions of epoprostenol (prostacyclin) improve functional capacity, survival, and hemodynamics in patients with advanced primary pulmonary hypertension. We hypothesized that the epoprostenol infusions, as compared with conventional therapy, might alter the abnormal pulmonary endothelin-1 homeostasis. METHODS AND RESULTS: Using a subset of patients from a larger randomized study comparing epoprostenol plus conventional therapy (n=11 in the present study) with conventional therapy alone (n=7 in the present study), we determined the ratio of plasma endothelin-1 levels in systemic arterial blood leaving the lung to levels in mixed venous blood entering the lung both before randomization and after 88 days of continuous therapy. There were no differences between the 2 groups before therapy, but by day 88, the epoprostenol-treated group had a greater proportion of patients (82%) with an arterial/venous ratio <1 than did the conventional therapy group, in which only 29% of patients had a ratio <1 (P<0.05). CONCLUSIONS: These results suggest that continuous epoprostenol therapy may have a beneficial effect on the balance between endothelin-1 clearance and release in many patients with primary pulmonary hypertension and may provide one explanation for the salutary effect of epoprostenol in this disease.

When might an operative complication be regarded as acceptable? Part 2: Judicial factors that influence the finding of fault during surgical litigation.

In cases where surgeons face litigation over operative misadventure, the result of a trial is uncertain. In order to identify factors in cases of surgical litigation that have influenced the final decision of the courts, we have previously reviewed reported cases where the outcome turned on actions taken by surgeons. We now turn our attention to judicial attitudes to evidence that play a role in the determination of the case.

When might an operative complication be regarded as acceptable? Part 1: Surgical factors that influence courts when finding fault during litigation.

In cases where surgeons face litigation over operative misadventure, the result of a trial is uncertain. In order to identify factors in cases of surgical litigation that have influenced the final decision of the courts, we have reviewed recent reported cases, noting both surgical and evidential influences on outcome. Taken together, these reveal that among other influential factors, the acceptability of more than one reasonable operative approach, the court's approach to inappropriate delegation and the uncertainties of expert evidence all play a role in the determination of the case.

Interrater agreement for diagnosis of Alzheimer's disease: the MIRAGE study.

There are standardized criteria to assist in the diagnosis of Alzheimer's disease (AD), a disorder that lacks unique clinical, morphologic, or biochemical features. Diagnostic reliability of single groups of investigators using these criteria is moderate to substantial. In this study, seven clinicians at separate sites established a criteria-based diagnosis in 42 consecutive memory disorder patients participating in a national genetic epidemiologic study using a quantitative multiaxis AD rating scale (ADRS) that incorporates NINCDS/ADRDA criteria, reliability of information, and comorbidity. Reliability, measured by a generalized kappa statistic for more than two raters, was substantial (0.63 +/- 0.13) when the subjects were grouped as "AD" (probable or possible) versus "not AD," but somewhat lower (0.52 +/- 0.10) when subjects were classified as probable AD, possible AD, or not AD. There was unanimous agreement for two-thirds of the subjects using a dichotomous classification scheme. These findings suggest that the ADRS is a useful diagnostic instrument for multicenter studies.

Factors influencing the distributions of polyunsaturated terpenoids in the diatom, Rhizosolenia setigera.

Polyunsaturated highly branched isoprenoid (HBI) hydrocarbon distributions of laboratory cultures of five strains of the planktonic diatom Rhizosolenia setigera (Brightwell) are shown herein to be highly variable. Some strains produced both haslenes with from three to five double bonds and rhizenes. The haslenes comprised not only Delta5 alkenes but also those with C7(20) unsaturation, including hasla-7(20),9E,Z, 23-trienes and hasla-7(20),9E,Z-13, 23-tetraenes. The rhizenes contained C7(25) unsaturation and the vinyl moiety common to all algal haslenes so far characterised. The effects of temperature and salinity on HBI composition, along with isotopic content, were determined in strain CS 389/A. Increase in growth temperature from 18 to 25 degrees C increased the degree of unsaturation in the haslenes and E to Z isomerisation in the triene. There was also an increase in unsaturation in the rhizenes at the highest growth temperature, with hexaenes dominant over the pentaenes but in the rhizenes, Z to E isomerisation increased. Increased salinity from 15 to 35 psu increased cell growth and rhizene production but decreased haslene production. Unsaturation in haslenes was not changed by increased salinity but unsaturation in the rhizenes decreased. These may reflect growth rate differences. The carbon isotopic compositions of the haslenes and rhizenes were similar to that of the major sterol at 18 degrees C, but the major HBI isomers were 3-4 per mil depleted relative to phytol released by saponification from chlorophyll a. This suggests biosynthesis of HBIs from a different isotopic pool of isopentenyl biphosphate to that from which phytol is biosynthesised. At 25 degrees C, further isotopic differences were observed. The variables controlling HBI distributions in R. setigera are still not fully understood and rationalisation of the environmental controls on the sedimentary distributions of the HBIs from R. setigera may only be possible once such factors are established.

Antiepileptics and blood dyscrasias: a cohort study.

We conducted a cohort study to investigate the frequency of serious blood dyscrasias in patients age 10-74 years, taking antiepileptic drugs between January 1, 1990, and October 31, 1994. Main outcome measures were validated diagnoses of neutropenia, agranulocytosis, hemolytic anemia, thrombocytopenia, bicytopenia, pancytopenia, or aplastic anemia. A total of 29,357 recipients of antiepileptic therapy received 684,706 prescriptions. Among them there were 21 cases of serious blood dyscrasia of which only 18 could be considered to have a temporal relationship to drug use. Seventeen cases occurred in current users of carbamazepine, phenobarbital, phenytoin or valproate, and 7 in patients taking two or more drugs. Twenty of the 21 patients recovered. The overall rate of blood dyscrasias was 3-4/100,000 prescriptions. The rate in those age less than 60 years was 2.0 (range 0.9-3.6)/100,000 prescriptions compared with 4.0 (range 1.6-8.2) for those age 60 or older. The overall rate of neutropenia was 1.2 (0.5-2.3)/100,000 prescriptions, compared with 0.9 (0.3-1.9) for thrombocytopenia and 0.4 (0.1-1.3) for hemolytic anemia. Rates did not differ among the four drugs. Serious blood dyscrasias are rare in patients taking antiepileptic agents.

Dinoflagellate Gymnodinium catenatum as the source of paralytic shellfish toxins in Tasmanian shellfish.

Paralytic shellfish toxins in both cultured cells and natural phytoplankton blooms of the dinoflagellate Gymnodinium catenatum from inshore Tasmanian waters (Australia) were analyzed by high performance liquid chromatography, thin layer chromatography and electrophoresis techniques. The dinoflagellate toxins were dominated by low potency sulfocarbamoyl saxitoxin derivatives (98-99 mole% in total), including gonyautoxin VIII (C2) and its epimer (C1) and sulfocarbamoyl gonyautoxins I and IV (C3 and C4). Mussels and oysters contaminated by the dinoflagellate showed similar toxins, but contained larger proportions of C3 (40-57 mole%) and more potent carbamate toxins (7-23 mole% total).

Stereopsis based on monocular gaps: metrical encoding of depth and slant without matching contours.

It is often the case in binocular vision that one eye can see between two objects lying at different distances but the other eye cannot. We have found that the visual system is able to correctly interpret images produced this way in which a single solid rectangle in one eye is fused with two half-sized rectangles in the other eye separated by a vertical gap comprising the background. Two rectangles in depth are seen. It is as if the solid rectangle is treated as two components which each match one of the physically separated rectangles in the contralateral eye. The sign of the depth depends on which eye's view has the gap and its magnitude increases with gap width. Measured depth is found to be equivalent to real stereoscopic depth with a relative disparity equal to the monocular gap. If overall disparity differences are eliminated, between the left and the right images, variations in perceived slant of the two rectangles are still seen with increasing gap size. That two surfaces can be seen in metric binocular depth despite complete camouflage of their separation in one eye's view, suggests that stereopsis be regarded as a broad process of surface recovery not necessarily requiring image disparity at the location of the depth step.

Contrast as a depth cue.

One consequence of aerial perspective is that far objects have lower contrast than near objects. We tested the efficacy of contrast as a cue for depth perception by measuring the apparent, relative depth of two areas that differed in contrast with a background and in size. We tested monocularly and binocularly. Differences in contrast were achieved by making the areas different in luminance, than varying the luminance of the background. Subjects reported that the area having lower contrast with the background appeared farther than the area having higher contrast. Even when size opposed it, contrast continued to have a significant effect on depth perception. Monocular observation yielded larger apparent depth than binocular observation. Contrast is an effective depth cue in the absence of any other depth information. We suggest that contrast acts as a pictorial depth cue simulating the optical effects of aerial perspective.

Nutrition care activities and DRGs.

The recent passage and implementation of the prospective payment system (PPS) for Medicare inpatient services have had a strong impact on dietitians practicing in southern Florida. Because several local hospitals service regions in which 90% of the population is 65 years old or older, the annual revenues from Medicare have been reduced. The hospitals still have to meet basic overhead costs and profit margins. This has resulted in the elimination of several dietetic positions. Therefore, dietitians need to establish a cost-benefit justification for the nutrition care and support of patients. This study is the initial phase of a plan to define the nutrition care services the dietitian provides and to identify the most frequently occurring diagnosis related grouping (DRG) categories. For 3 weeks, 31 dietitians maintained logs that detailed dietetic intervention and treatment for each of the 3,827 patients seen. The nutrition care activities reported most frequently by dietitians were basic services, hospital visit and reassessment, initial consultation, and screening to rule out malnutrition. The mean time spent in all nutrition care activities ranged from 13 to 33 minutes. The most frequently occurring DRGs were those for diabetes, heart failure, circulatory disorders, specific cerebrovascular accident, and transient ischemic attacks. Overall, the type of nutrition care activities and the time spent in those activities were significantly different among the hospitals studied. The differences reflect the philosophies of each facility. The types of DRG categories observed reflect the age of the population served.

Integrating diet therapy and dietary counseling: an alternative education technique.

The purpose of this study was to examine the effects of a change in education methods on learning among students enrolled in a coordinated undergraduate program (CUP). An experimental process applying the principles of diet therapy and counseling in a situation involving volunteer clients was initiated, and the effects were measured. A pretest-post-test design was used for this investigation. Two psychometric instruments, the Myers-Briggs Type Indicator and the Affective Sensitivity Scale, were used to measure changes in attitudes, values, and aptitude. The curriculum of the treatment group (19 juniors in the CUP) was reorganized so that diet therapy and dietary counseling would be taught during the same semester. The laboratory sessions were combined the last 6 weeks of the semester to provide an opportunity for students to counsel clients recruited from the university campus. The comparison group (11 seniors in the CUP) had enrolled in diet therapy the first semester of the junior year and dietetic counseling the second semester; those students were tested during their senior year. The research indicated that the students in the treatment group learned effectively. They significantly increased their awareness, listening, and understanding during the treatment period. The post-test of the treatment group indicated that they had increased perception and more acute affective sensitivity in comparison with the control group.

Food and nutrition services in bone marrow transplant centers.

Nutrition care for bone marrow transplant recipients is recognized as vital for a successful transplant, yet little research has been done to determine the most effective foodservice methods. Many decisions regarding methods for the oral feeding of bone marrow transplant patients are based on tradition and/or individual judgments. This study surveyed marrow transplant centers to identify existing food and nutrition services that could be used as a basis for developing a foodservice protocol. A survey instrument was developed and sent to all chief dietitians (no. = 35) affiliated with transplantation centers in the United States. Four of the 30 respondents reported changing from the traditional sterile diet to either a low-bacteria or a modified house diet. Problems of limited availability of single-serve sterile foods, lack of standardization of recipes, and low patient acceptance of autoclaved sterile foods were reported as reasons for the move toward less stringent dietary procedures. The responses clearly indicate the need for additional research before a foodservice model can be established.

Computer optimization of enteral hyperalimentation.

A computer program has been developed to allow the generation of written orders for the logical progression of enteral hyperalimentation by the technique of continuous nasogastric infusion. Data required for entry include name, age, sex, height, usual and current weights, degree of stress, and if indicated, restrictions of nitrogen, fluids, sodium and potassium. A specific formulation may be requested, or the computer will pick a single nutrient solution or combination of two solutions that will best meet the requested constraints. Output includes entered data with English and Metric interconversion, surface area, and estimates of basal energy expenditure, protein wastage, protein and caloric requirements. If requested, daily orders are written to include a reasonable progression of infusion rates and concentrations of the solutions(s). Daily values are printed for the total amounts to be infused of fluid, calories, protein, sodium, potassium, and mOsm. The programs have been demonstrated to run in either on-line or batch mode. The system is easily accessible by physician, dietician, nurse, or other interested professionals.