Learning curve for oesophageal cancer surgery

BACKGROUND: Surgical training and experience are frequently claimed to influence early and late outcome measures. The aim of this study was to examine any improvement in an individual surgeon's performance in one operation over a period of 7 years from initial appointment to date. METHODS: Patients undergoing Ivor Lewis subtotal oesophagectomy performed by a single surgeon between April 1990 and December 1996 were identified from a prospectively compiled oesophageal cancer database. Operating time (abdominal, thoracic and 'one-lung time'), blood loss, transfusion requirements (intraoperative and total), extent of lymphadenectomy (number of lymph nodes sampled), intensive treatment unit (ITU) stay, hospital stay, postoperative morbidity and mortality, pathological stage, grade and survival were recorded. RESULTS: The records of 150 patients were identified for analysis. The cohort was split into five groups, each of 30 patients operated on consecutively. Each of the groups was comparable for age, sex, smoking history, preoperative haemoglobin and creatinine levels, weight loss, American Society of Anesthesiologists' grade, and histological stage and grade of disease. Analysis of the variables pertaining to operation revealed a significant improvement with time including reduced single-lung operating time (P=0.01), reduced blood loss (P=0.03), reduced transfusion requirement (P < 0.0001), reduced ITU stay (P< 0.0001), reduced inpatient stay (P< 0.0001) and an increased yield of lymph nodes (P < 0.0001). CONCLUSION: This study showed a continuing improvement in a surgeon's performance over a 7-year period. With the current trend to shorter training periods there is a case for continuing supervision of the 'fully trained' surgeon within highly specialist units.     

Synthesis and biological activities of phenyl piperazine-based peptidomimetic growth hormone secretagogues

A new class of potent, orally active phenyl piperazine-based GH secretagogues have been discovered from attempts to mimic the arrangement of the phenyl substituent in the spiroindanyl piperidine and spiroindoline sulfonamide privileged structures of 4 and 1, respectively. The best of these compounds, 18 (EC50 = 2.8 nM) is nearly as potent as MK-0677 for releasing GH from rat pituitary cells.     

Retail yield and fabrication times for veal as influenced by purchasing options and merchandising styles

Twenty-nine selected styles of subprimals or sections of veal were obtained from a commercial facility to assist in the development of a support program for retailers. They were fabricated into bone-in or boneless retail cuts and associated components by trained meat cutters. Each style selected (n = 6) was used to generate mean retail yields and labor requirements, which were calculated from wholesale and retail weights and processing times. Means and standard errors for veal ribs consisting of five different styles (n = 30) concluded that style #2, 7-rib 4 (10 cm) x 4 (10 cm), had the lowest percentage of total retail yield (P < .05) owing to the greatest percentage of bone. Furthermore, rib style #2 required the longest total processing time (P < .05). Rib styles #3, 7-rib chop-ready, and #5, 6-rib chop ready, yielded the greatest percentage of total retail yield and also had the shortest total processing time (P < .05). Within veal loins, style #2, 4 (10 cm) x 4 (10 cm) loin kidney fat in, had the greatest percentage fat (P < .05). Loin styles #2 and #3, 4 (10 cm) x 4 (10 cm) loin special trimmed, generated more lean and fat trimmings and bone, resulting in lower percentage of total retail yields than loin style #1, 0 (0 cm) x 1 (2.5 cm) loin special trimmed (P < .05). Results indicated that bone-in subprimals and sections required more processing time if fabricated into a boneless end point. In addition, as the number of different retail cuts increased, processing times also increased.     

Controlling bacterial contamination of an enteral formula through the use of a unique closed system: contamination, enteral formulas, closed system

Contamination of enteral diets may play an essential role in formula tolerance and safety for patients. Contaminated enteral formula commonly support microbiological growth. Commercially sterile liquid formulas received from the manufacturer are required by the Food & Drug Administration (FDA) to be shelf-stable and free from enteric pathogens. This study examined the use of large volume, closed system containers in a typical nursing home. Large volume (1500 mL) containers with unique pierceable caps and piercing spikes were studied to determine their ability to reduce the incidence of microbiological contamination due to their design and ability to decrease handling requirements. This study took place in a room of a typical nursing home. In this clinical setting, 211 containers and administration spike sets were evaluated following a 36-h hangtime. Contamination was virtually nondetectable. Nursing staff in a clinical facility can effectively utilize a large volume, prefilled, ready-to-use feeding system to achieve delivery of noncontaminated product for up to 36 h hangtime.     

Neutron scattering as a probe of particle-like excitations in superfluid4He: A model calculation

In the microscopic theory of Bose-condensed liquids, the condensate wave function leads to a coupling of the density fluctuations and the single-particle excitations. A simple parametrized model of this based on coupling weakly damped zero-sound modes with strongly damped free-particle-like excitations Q ²/2m* explains why the phonon-roton resonance inS(Q, ) for superfluid⁴He exists above and belowT but only plays the role of an elementary excitation belowT . It is pointed out that this model also predicts thatS(Q, ) should exhibit a weak, low-frequency peak centered atQ ²/2m*, with weight roughly proportional to the condensate fractionn ₀. As a stimulus to further experimental searches for this branch, some model calculations are given forS(Q, ) forQ1 Å^–1.     

Hydrogenation of soybean oil with copper catalysts containing small amounts of nickel catalysts

Reaction rates, linolenate/linoleate reaction selectivity,trans formation, and conjugated diene formation were determined for mixed commerical catalysts containing 0.5, 1, 2, 10, and 20 parts nickel catalyst (25% nickel) per 1000 parts copper chromite catalyst (ppt) and at catalyst concentrations in the oil of 1.0, 0.5, and 0.25%. The rate of hydrogenation increased as the amount of nickel increased. Addition of 0.5, 1, and 2 ppt nickel catalyst to copper chomite catalyst resulted in a small decrease in selectivity compared with straight copper chromite. When soybean oil was hydrogenated with these mixed catalysts sufficiently to reduce linolenate to 0, iodine values were 102–108 compared to 109–112 for straight copper chromite and to less than 80 for straight nickel. Presented at the AOCS Meeting, New Orleans April 1973. ARS, USDA.     

Predicting and controlling risks from human exposures to vibration and mechanical shock: flag waving and flag weaving

At work or in leisure activities, many people are exposed to vibration or mechanical shocks associated with risks of injury or disease. This paper identifies information that can be used to decide whether there may be a risk from exposure to hand-transmitted vibration or whole-body vibration and shock, and suggests actions that can control the risks. The complex and time-varying nature of human exposures to vibration and shock, the complexity of the different disorders and uncertainty as to the mechanisms of injury and the factors influencing injury have prevented the definition of dose–response relationships well proven by scientific study. It is necessary to wave a flag indicating when there is a need to control risks from exposure to vibration and shock while scientific enquiry provides understanding needed to weave a better flag. It is concluded that quantifying exposure severity is often neither necessary nor sufficient to either identify risks or implement measures that control the risks.Practitioner Summary: The identification of risks associated with exposure to vibration and mechanical shock cannot, and need not, rely solely on the quantification of exposure severity. Qualitative methods can provide a sufficient indication of the need for control measures, which should not be restricted to reducing standardised measures of exposure severity.     

Family psychosocial screening: should we focus on high-risk settings?

The objective of this study was to address the question of whether or not psychosocial screening should be focused on "high-risk" populations. A cross-sectional survey of mothers of young children was conducted in various clinics: 758 in teaching clinics, 444 in private practices, and 202 at a military clinic. The self-administered questionnaire covered demographic factors, problems in mothers family of origin, maternal depression, and substance abuse. Mothers in the teaching clinics were younger and had less education and lower incomes than mothers in private practices, with intermediate levels in the military clinic. However, a substantial proportion of mothers seen in all sites reported psychosocial problems. Approximately 20% of mothers in all sites reported a family history of alcoholism. Positive screens for maternal depression ranged from about 15% to 35%. Binge drinking was reported by 10% to 20% at different sites. Psychosocial problems were common even among families seen in "low-risk" settings. Focusing screening only on high-risk clinics would miss many families with psychosocial problems.     

Absorption of di-linoleoylphosphatidylcholine after oral administration

Essentiale and Lipostabil contain "essential" phospholipids from the soybean, mainly 1,2-dilinoleoyl-phosphatidylcholine (CAS 998-06-1, DLPC) which is considered as the main active ingredient. A single oral dose of d15-DLPC loaded with deuterium 9 times in the choline and 6 times in the linoleic acid of the 1-position was given to volunteers. Sera from 11 blood samples taken within 48 h after application were examined by means of mass spectrometry with regard to d9-choline and d6-linoleic acid in the 1- and 2-position of serum phosphatidylcholines (PC) as well as in the serum triglycerides. d9-choline, i.e. the total of d15-PC and d9-PC, showed maximum values of 5.6% of the total serum PC concentration. Normally, about 1.3% of PC in the human serum is DLPC. Serum 1-linoleoyl-PC was increased by 32-40% after oral application of d15-DLPC. A minor uptake of d6-linoleic acid into the 2-position of serum PC, which is rich in linoleic acid, and into the serum triglycerides was observed with peak values of 2.3% and 6.1%, resp. The uptake of polyunsaturated PC species like DLPC and 1-linoleoyl-PC into the liver after oral application of drugs containing such species in high amounts like "essential" phospholipids with about 50% of DLPC let expect therapeutic effects on membranes into which this special species is incorporated.     

In vitro studies of PDR brachytherapy

BACKGROUND: Calculations on the basis of the LQ-model have been focussed on the possible radiobiological equivalence between common continuous low dose rate irradiation (CLDR) and a superfractionated irradiation (PDR = pulsed dose rate) provided that the same total dose will be prescribed in the same overall time as with the low doserate. A clinically usable fractionation scheme for brachytherapy was recommended by Brenner and Hall and should replace the classical CLDR brachytherapy with line sources with an afterloading technique using a stepping source. The hypothes is that LDR equivalency can be achieved by superfractionation was tested by means of in vitro experiments on V79 cells in monolayer and spheroid cultures as well as on HeLa monolayers. MATERIALS AND METHODS: Simulating the clinical situation in PDR brachytherapy, fractionation experiments were carried out in the dose rate gradient of afterloading sources. Different dose levels were produced with the same number of fractions in the same overall incubation time. The fractionation schedules which were to be compared with a CLDR reference curve were: 40 x 0.47 Gy, 20 x 0.94 Gy, 10 x 1.88 Gy, 5 x 3.76 Gy, 2 x 9.4 Gy given in a period of 20 h and 1 x 18.8 Gy as a "single dose" exposition. As measured by flow cytometry, the influence of the dose rate in the pulse on cell survival and on cell cycle distribution under superfractionation was examined on V79 cells. RESULTS: V79 spheroids as a model for a slowly growing tumor, reacted according to the radiobiological calculations, as a CLDR equivalency was achieved with increasing fractionation. Rapidly growing V79 monolayer cells showed an inverse fractionation effect. A superfractionated irradiation with pulses of 0.94 Gy/h respectively 0.47 Gy/0.5 h was significantly more effective than the CLDR irradiation. This inverse fractionation effect in log-phase V79 cells could be attributed to the accumulation of cycling cells in the radiosensitive G2/M phase (G2 block) during protected exposure which was drastically more pronounced for the pulsed scheme. HeLa cells were rather insensitive to changes of fractionation. Superfractionation as well as hypofractionation yielded CLDR equivalent survival curves. CONCLUSIONS: The fractionation scheme, derived from the PDR theory to achieve CLDR equivalent effects, is valid for many cell lines, however not for all. Proliferation and dose rate dependend cell cycle effects modify predictions derived from the sublethal damage recovery model and can influence acute irradiation effects significantly. Dose rate sensitivity and rapid proliferation favour cell cycle effects and substantiate, applied to the clinical situation, the possibility of a higher effectiveness of the pulsed irradiation on rapidly growing tumors.