Setting Appropriateness and Romantic Relationship Initiation Success.

Does the setting in which a relationship initiation attempt occurs matter to its success? Identical initiations could yield differential success if enacted in different settings. Data from five independent samples highlight the role settings play in the perception of (hypothetical) relationship initiation attempts and (expectations of) their success. Study 1a sourced a wide variety of settings for real-world relationship initiations. A separate sample rated the identified settings on initiation appropriateness (Study 1b). Study 2 tested the appropriateness and associated outcomes of initiation settings while varying aspects of the interpersonal context (initiator attractiveness, Study 2a; initiator familiarity, Study 2b; sexual nature of proposition, Study 2c). Irrespective of initiator attractiveness, familiarity, or type of proposal, perceptions of initiations' success were impacted by the settings' appropriateness. This work is the first to empirically test whether perceptions and outcomes of initiation attempts differ as a function of the setting in which they occur.

Implementation of a robotic surgical practice in inflammatory bowel disease.

Robotics adoption has increased in colorectal surgery. While there are well-established advantages and standardised techniques for cancer patients, the use of robotic surgery in inflammatory bowel disease (IBD) has not been studied yet. To evaluate the feasibility and safety of robotic surgery for IBD patients. Prospectively data in IBD patients having robotic resection at Guy's and St Thomas' hospital. All resections performed by a single colorectal surgeon specialised in IBD, utilising DaVinci platform. July 2021 to January 2023, 59 robotic IBD cases performed, 14 ulcerative colitis (UC) and 45 Crohn's disease (CD). Average age; CD patients 35, UC 33 years. Average Body mass index (BMI); 23 for CD and 26.9 for UC patients. In total, we performed 31 ileo-caecal resections (ICR) with primary anastomosis (18 Kono-S anastomosis, 6 mechanical anastomosis and 7 ileo-colostomy), of those 4 had multivisceral resections (large bowel, bladder, ovary). Furthermore, 14 subtotal colectomy (1 emergency), 8 proctectomy, 3 panproctocolectomy and 3 ileoanal J pouch. 18 of the 45 patients (45.0%) with Crohn's disease had ongoing fistulating disease to other parts of the GI tract (small or large bowel). ICR were performed using different three ports position, depending on the anatomy established prior to surgery with magnetic resonance images (MRI). One patient had conversion to open due to anaesthetic problems and one patient required re-operation to refashion stoma. 98.0% cases completed robotically. Median Length of hospital stay (LOS) was 7 days for CD and 7 for UC cases, including LOS in patients on pre-operative parenteral nutrition. Robotic colorectal techniques can be safely used for patients with IBD, even with fistulating disease. Future research and collaborations are necessary to standardize technique within institutions.

Using Interdisciplinary Teams to Mitigate the Effects of Drug Shortages in Palliative Care: The Case of Lorazepam Injection.

Given the rising frequency of drug shortages in hospitals, interdisciplinary collaboration is necessary to manage medications, modify electronic medical records, and evaluate safety outcomes. One such shortage impacted lorazepam injection, a medication commonly used in palliative care to treat anxiety, agitation, and seizures. In anticipation of the lorazepam shortage in the summer of 2022, pharmacy staff collaborated with palliative care physicians to identify alternative treatment recommendations when providers were prohibited from ordering lorazepam injection. Before the shortage, lorazepam was used an average of 95 times per month on the palliative care unit. The overall use of benzodiazepines decreased substantially following the recommendation for the therapeutic alternative, midazolam, during the shortage. Once the shortage ended, use roughly returned to pre-shortage baselines. During this time, there were no patient safety events documented on the palliative care unit. Moreover, no changes to the care experience were reported by patients, family/caregivers, providers, or staff. The collaborative effort between pharmacy and palliative care specialists resulted in alternative treatments for palliative care patients during the drug shortage. This preserved the hospital's supply of lorazepam injection for a patient population with no suitable alternatives while still allowing for management of palliative patients.

Pesticide, allergen, PCB, and lead measurements in childcare centers located on tribal lands in the Pacific Northwest, United States.

BACKGROUND: Children's potential exposures to chemical and biological agents in tribal childcare centers are not well characterized. OBJECTIVES: (1) The environmental health of childcare centers in Portland Area Indian Country was characterized by measuring selected pesticides, polychlorinated biphenyls (PCBs), allergens, and lead (Pb) in outdoor soil and indoor dust. (2) We compared our results to other studies of childcare centers in both the United States and globally. METHODS: At 31 tribal childcare centers in Washington, Oregon, and Idaho, we collected indoor dust and outdoor soil samples from at least one classroom, multipurpose room, and outdoor play area. Number of rooms sampled depended on facility size. Surface wipes were collected from the floor, play/work surface, and windowsill and analyzed for selected pesticides and PCBs. Vacuum samples were collected from the floor and analyzed for selected allergens. Lead was measured in surface wipes and outdoor soil collected at 11 centers. A questionnaire collected information on demographics, cleaning habits, and pesticide usage. RESULTS: At least one pesticide was measured at all childcare centers. cis-Permethrin (surface wipes: 0.003-180 ng/cm2), trans-permethrin (surface wipes: 0.002-200 ng/cm2) and piperonyl butoxide (surface wipes: 0.001-120 ng/cm2) were measured in all centers. Lead was measured in most surface wipes (<0.25-14 ng/cm2) and all outdoor soil samples (8.4-50 mg/kg). Aroclors 1242 and 1254 were detected on indoor surfaces in three centers at very low loadings. Allergen residues were measured at very low concentrations in vacuum dust samples (Der p 1: <0.012-0.12 µg/g; Der f 1: <0.012-0.09 µg/g; Mus m 1: <0.002-10.055 µg/g). In general, we observed lower levels of chemical and biological agents than what has been reported previously. SIGNIFICANCE: By understanding the environmental health of childcare centers, we can better understand the role of child-specific environments in promoting children's health and well-being. IMPACT STATEMENT: To our knowledge, this is the first study to characterize the environmental health of tribal childcare centers in the Pacific Northwest. Combined with the information we have on childcare centers from around the world, this study expands our knowledge on young children's potential exposures to chemical and biological agents in locations where they spend significant amounts of time.

A retrospective cohort study: pre-operative oral enteral nutritional optimisation for Crohn's disease in a UK tertiary IBD centre.

BACKGROUND: Low-quality evidence suggests that pre-operative exclusive enteral nutrition (E/EN) can improve postoperative outcomes in patients with Crohn's disease (CD). It is not standard practice in most centres. AIMS: To test the hypothesis that pre-operative EN in patients undergoing ileal/ileocolonic surgery for CD is associated with improved postoperative outcome. METHODS: We performed a single centre retrospective observational study comparing surgical outcomes in patients receiving pre-operative EN (≥600 kcal/day for ≥2 weeks) with those who received no nutritional optimisation. Consecutive adult patients undergoing ileal/ileocolonic resection from 2008 to 2020 were included. The primary outcome was postoperative complications <30 days. Secondary outcomes included EN tolerance, specific surgical complications, unplanned stoma formation, length of stay, length of bowel resected, readmission and biochemical/anthropometric changes. RESULTS: 300 surgeries were included comprising 96 without nutritional optimisation and 204 optimised cases: oral EN n = 173, additional PN n = 31 (4 of whom had received nasogastric/nasojejunal EN). 142/204 (69.6%) tolerated EN. 125/204 (61.3%) initiated EN in clinic. Patients in the optimised cohort were younger at operation and diagnosis, with an increased frequency of penetrating disease and exposure to antibiotics or biologics, and were more likely to undergo laparoscopic surgery. The optimised cohort had favourable outcomes on multivariate analysis: all complications [OR 0.29; 0.15-0.57, p < 0.001], surgical complications [OR 0.41; 95% CI 0.20-0.87, p = 0.02], non-surgical complications [OR 0.24 95% CI 0.11-0.52, p < 0.001], infective complications [OR 0.32; 95% CI 0.16-0.66, p = 0.001]. CONCLUSIONS: Oral EN was reasonably well tolerated and associated with a reduction in 30-day postoperative complications. Randomised controlled trials are required to confirm these findings.

Polysomnographic identification of anxiety and depression using deep learning.

Anxiety and depression are common psychiatric conditions associated with significant morbidity and healthcare costs. Sleep is an evolutionarily conserved health state. Anxiety and depression have a bidirectional relationship with sleep. This study reports on the use of analysis of polysomnographic data using deep learning methods to detect the presence of anxiety and depression. Polysomnography data on 940 patients performed at an academic sleep center during the 3-year period from 01/01/2016 to 12/31/2018 were identified for analysis. The data were divided into 3 subgroups: 205 patients with Anxiety/Depression, 349 patients with no Anxiety/Depression, and 386 patients with likely Anxiety/Depression. The first two subgroups were used for training and testing of the deep learning algorithm, and the third subgroup was used for external validation of the resulting model. Hypnograms were constructed via automatic sleep staging, with the 12-channel PSG data being transformed into three-channel RGB (red, green, blue channels) images for analysis. Composite patient images were generated and utilized for training the Xception model, which provided a validation set accuracy of 0.9782 on the ninth training epoch. In the independent test set, the model achieved a high accuracy (0.9688), precision (0.9533), recall (0.9630), and F1-score (0.9581). Classification performance of most other mainstream deep learning models was comparable. These findings suggest that machine learning techniques have the potential to accurately detect the presence of anxiety and depression from analysis of sleep study data. Further studies are needed to explore the utility of these techniques in the field of psychiatry.

Comparison of clozapine doses and tolerability in patients with and without concurrent valproic acid.

Introduction: Valproic acid (VPA) and its various formulations can be given in conjunction with clozapine for seizure prophylaxis or for augmentation in schizophrenia. There is conflicting literature on how VPA affects clozapine metabolism and the incidence of clozapine-related side effects. The purpose of this study is to compare the effects of VPA when given concurrently with clozapine to patients on clozapine monotherapy. Methods: A retrospective medical record review was completed to identify patients admitted to the inpatient psychiatry unit at an academic medical center with an order for clozapine with and without concurrent VPA from August 7, 2010 to August 7, 2020. The primary outcome was the difference in clozapine doses in patients on clozapine as monotherapy versus dual therapy with VPA. Secondary outcomes include the difference in incidence of adverse effects in monotherapy versus dual therapy, as well as clozapine and norclozapine concentrations in both treatment groups. Results: During the study period, 73 patients were included in the monotherapy group and 35 patients were included in the dual therapy group. The average clozapine dose in the dual therapy group was 250 mg (95% CI = 194.7, 305.4) which was significantly higher than the average monotherapy dose of 175.9 mg (95% CI = 134.0, 208.7; P = .016). However, there was no significant difference in the average clozapine concentration between the dual therapy group (392.5 ng/mL; 95% CI = 252.8, 532.2) and monotherapy group (365.9 ng/mL; 95% CI = 260.5, 471.3; P = .756). There were higher rates of tachycardia (45.7% vs 17.8%; P = .002), sedation (51.4% vs 8.2%; P < .001), and constipation (42.8% vs 9.5%; P < .001) in the dual therapy group compared to the monotherapy group, respectively. Discussion: Patients on concurrent clozapine and VPA received higher doses of clozapine and experienced a higher incidence of tachycardia, sedation, and constipation.

Recurrence and colon cancer-specific death in patients with large bowel obstruction requiring urgent operation: a competing risks analysis.

AIM: Clinical presentation with large bowel obstruction has been proposed as a predictor of poor long-term oncological outcomes after resection for colorectal cancer. This study examines the association between obstruction and recurrence and cancer-specific death after resection for colon cancer. METHOD: Consecutive patients who underwent resection for colon cancer between 1995 and 2014 were drawn from a prospectively recorded hospital database with all surviving patients followed for at least 5 years. The outcomes of tumour recurrence and colon cancer-specific death were assessed by competing risks multivariable techniques with adjustment for potential clinical and pathological confounding variables. RESULTS: Recurrence occurred in 271 of 1485 patients who had a potentially curative resection. In bivariate analysis, obstruction was significantly associated with recurrence [hazard ratio (HR) 2.23, CI 1.52-3.26, p < 0.001] but this association became nonsignificant after adjustment for confounders (HR 1.53, CI 0.95-2.46, p = 0.080). Colon cancer-specific death occurred in 238 of 295 patients who had a noncurative resection. Obstruction was not significantly associated with cancer-specific death (HR 1.02, CI 0.72-1.45, p = 0.903). In patients who had a noncurative resection, the competing risks incidence of colon cancer-specific death was not significantly greater in obstructed than in unobstructed patients (HR 1.02, CI 0.72-1.45, p = 0.903). CONCLUSION: Whilst the immediate clinical challenge of an individual patient presenting with large bowel obstruction must be addressed by the surgeon, the patient's long-term oncological outcomes are unrelated to obstruction per se.

Protocol for a multicentre, dual prospective and retrospective cohort study investigating timing of ileostomy closure after anterior resection for rectal cancer: The CLOSurE of Ileostomy Timing (CLOSE-IT) study.

INTRODUCTION: A defunctioning ileostomy is often formed during rectal cancer surgery to reduce the potentially fatal sequelae of anastomotic leak. Once the ileostomy is closed and bowel continuity restored, many patients can suffer poor bowel function, that is, low anterior resection syndrome (LARS). It has been suggested that delay to closure can increase incidence of LARS which is known to significantly reduce quality of life. Despite this, within the UK, time to closure of ileostomy is not subject to national targets within the National Health Service and delay to closure exceeds 18 months in one-third of patients. Clinical factors, surgeon and patient preference or service pressures may all impact time to closure, yet to date no study has investigated this. The aim of this UK-wide study is to assess time to ileostomy closure and identify reasons for delays. METHODS AND ANALYSIS: A UK-wide multicentre prospective snapshot study, together with retrospective analysis of ileostomy closure through The Dukes' Club Research Collaborative including patients undergoing ileostomy closure in a 3-month period (April to June 2018) and all patients who underwent anterior resection and ileostomy formation over a historical 12-month period (2015). Time to closure and incidence of 'non-closure' will be calculated. Units will be surveyed to determine local clinical and management protocols and barriers to timely closure. Multivariate linear regression analysis will be used to determine factors significantly associated with delay to ileostomy closure. ETHICS AND DISSEMINATION: Study approved by the South West-Exeter Research Ethics Committee and the Health Research Authority. Study results will be submitted for presentation at international conferences and for publication in peer-reviewed journals. Results will be presented to and discussed with the patient and public representatives and relevant national bodies to facilitate the development of consensus guidelines on optimum treatment pathways.

Multilayered and digitally structured presentation formats of trustworthy recommendations: a combined survey and randomised trial.

OBJECTIVES: To investigate practicing physicians' preferences, perceived usefulness and understanding of a new multilayered guideline presentation format-compared to a standard format-as well as conceptual understanding of trustworthy guideline concepts. DESIGN: Participants attended a standardised lecture in which they were presented with a clinical scenario and randomised to view a guideline recommendation in a multilayered format or standard format after which they answered multiple-choice questions using clickers. Both groups were also presented and asked about guideline concepts. SETTING: Mandatory educational lectures in 7 non-academic and academic hospitals, and 2 settings involving primary care in Lebanon, Norway, Spain and the UK. PARTICIPANTS: 181 practicing physicians in internal medicine (156) and general practice (25). INTERVENTIONS: A new digitally structured, multilayered guideline presentation format and a standard narrative presentation format currently in widespread use. PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome was preference for presentation format. Understanding, perceived usefulness and perception of absolute effects were secondary outcomes. RESULTS: 72% (95% CI 65 to 79) of participants preferred the multilayered format and 16% (95% CI 10 to 22) preferred the standard format. A majority agreed that recommendations (multilayered 86% vs standard 91%, p value=0.31) and evidence summaries (79% vs 77%, p value=0.76) were useful in the context of the clinical scenario. 72% of participants randomised to the multilayered format vs 58% for standard formats reported correct understanding of the recommendations (p value=0.06). Most participants elected an appropriate clinical action after viewing the recommendations (98% vs 92%, p value=0.10). 82% of the participants considered absolute effect estimates in evidence summaries helpful or crucial. CONCLUSIONS: Clinicians clearly preferred a novel multilayered presentation format to the standard format. Whether the preferred format improves decision-making and has an impact on patient important outcomes merits further investigation.

A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study.

BACKGROUND: Inter-professional collaboration is an integral component of a successful healthcare team. We sought to evaluate the impact of nursing student participation in a one-day intensive inter-professional education (IPE) training session with surgical interns on participant attitudes toward inter-professional collaboration. METHODS: Following IRB approval, pre and post IPE session survey responses were compared to determine the impact on participant attitudes toward inter-professional collaboration. Pre and post session semi-structured interviews were transcribed and analyzed to identify relevant themes. RESULTS: Surgical interns (n = 38) more than nursing students (n = 11), demonstrated a measurable improvement in attitude towards 'collaboration and shared education' (interns: median score pre = 26, post = 28, p = 0.0004; nursing student: median score pre = 27, post = 28, p = 0.02). Qualitative analysis of interviews identified major themes that supplemented this finding. CONCLUSION: An eight hour, one day IPE session has a positive impact on collaborative attitudes and supports the case for increased inter-professional education amongst interns and nursing students.

Mind the Gap. A systematic review to identify usability and safety challenges and practices during electronic health record implementation.

OBJECTIVE: Decisions made during electronic health record (EHR) implementations profoundly affect usability and safety. This study aims to identify gaps between the current literature and key stakeholders' perceptions of usability and safety practices and the challenges encountered during the implementation of EHRs. MATERIALS AND METHODS: Two approaches were used: a literature review and interviews with key stakeholders. We performed a systematic review of the literature to identify usability and safety challenges and best practices during implementation. A total of 55 articles were reviewed through searches of PubMed, Web of Science and Scopus. We used a qualitative approach to identify key stakeholders' perceptions; semi-structured interviews were conducted with a diverse set of health IT stakeholders to understand their current practices and challenges related to usability during implementation. We used a grounded theory approach: data were coded, sorted, and emerging themes were identified. Conclusions from both sources of data were compared to identify areas of misalignment. RESULTS: We identified six emerging themes from the literature and stakeholder interviews: cost and resources, risk assessment, governance and consensus building, customization, clinical workflow and usability testing, and training. Across these themes, there were misalignments between the literature and stakeholder perspectives, indicating major gaps. DISCUSSION: Major gaps identified from each of six emerging themes are discussed as critical areas for future research, opportunities for new stakeholder initiatives, and opportunities to better disseminate resources to improve the implementation of EHRs. CONCLUSION: Our analysis identified practices and challenges across six different emerging themes, illustrated important gaps, and results suggest critical areas for future research and dissemination to improve EHR implementation.

Intensive surveillance following curative treatment of colorectal cancer allows effective treatment of recurrence even if limited to 4 years.

BACKGROUND: Current evidence suggests a survival benefit to post-operative surveillance following curative colorectal cancer resection; however, there is still no consensus on the optimal duration and form. OBJECTIVES: The objective is to prospectively audit outcomes of an intensive colorectal cancer follow-up scheme for time to recurrence and survival. METHODS: We used a surveillance protocol designed to incorporate regular clinical, biochemical, radiological and endoscopic measures at pre-defined intervals. SETTING: The setting was a Department of Colorectal Surgery in a Tertiary Academic Centre. Follow-up was led by specially trained colorectal nurses in conjunction with surgeons. PATIENTS: Consecutive patients who had undergone curative treatment for colorectal cancer were included in this study. MAIN OUTCOMES: Outcomes were measured in terms of overall survival and disease recurrence. RESULTS: There were 436 patients entered into follow-up, all treated with curative intent. Mean age 65.9 years (SD 12.9 years) and 240 male (55.0 %). Ninety-four patients (21.5 %) with stage I disease, 119 (27.3 %) stage IIa, 30 (6.9 %) stage IIb, 18 (4.1 %) stage IIIa, 78 (17.9 %) stage IIIb, 45 (10.4 %) stage IIIc and 52 (11.9 %) stage IV. Overall median survival was 37.5 months for all patients, (range 0.0-207.8 months). Ninety-two (21.1 %) cancer-related deaths were recorded during the course of the study. The overall 5-year actuarial cancer-related survival was 81.7 %. There was a 40.3 % 5-year actuarial survival was recorded in patients with 39 a recurrence, 57.7 % in patients treated with further curative 40 intent and 27.7 % in patients who received palliative treatment 41 (P < 0.001). Ninety-seven percent of recurrences were detected within 4 years of curative treatment. CONCLUSIONS: This follow-up protocol confers an 81 % overall 5-year actuarial survival. Our study suggests that surveillance after curative resection can be limited to 4 years, which would lead to detection of over 97 % of all recurrences.

BRAF V600E mutation in colorectal cancer is associated with right-sided tumours and iron deficiency anaemia.

BACKGROUND: BRAF gene encodes a serinethreonine kinase that inhibits the RAS/MAPK intracellular pathway. BRAF mutations occur at an early stage of colorectal cancer and their presence, 10-20% of colorectal cancer (CRC), is usually associated with inferior prognosis. MATERIALS AND METHODS: From 41 consecutive CRC confirmed referrals from 1,446 suspected cancer cases (mean age=67.99+13.451, male=21, female=20), we retrospectively analyzed collected data from haemoglobin (Hb) and symptoms at presentation, location of tumor and stage of the disease, including lymphovascular invasion (LVI). Gene profile analysis data (KRAS, BRAF) were retrospectively collected and associated with the presentation profile above. RESULTS: There was no significant correlation in presentation Hb levels and eventual disease staging (p>0.05 for all associations). Patients with right-sided tumours were found to have a lower Hb level than patients with either left-sided colonic or rectal tumours. Hb levels were also significantly lower in patients with the BRAF V600E mutation. KRAS status or LVI status did not have a specific correlation with Hb levels. CONCLUSION: BRAF V600E mutation might be associated with right-sided tumors and subsequently related unexplained iron-deficiency anaemia (IDA) at presentation. This finding may affect the choice of clinical strategy for investigation of unexplained IDA. Further research should be conducted in order to identify and support the potential biological explanation of the findings above.

Diverticular disease as a chronic gastrointestinal condition: experience from a specialist clinic.

BACKGROUND: Although diverticular disease is a prevalent condition and a significant burden on the healthcare system, care is devolved across gastrointestinal, GP, and colorectal surgery clinics. We created a specialist Diverticular Disease Clinic to streamline care, enhance evidence-based practice and provide a base for research. The aim of this study was to assess patient referral sources, predictors of persistent disease and surgical outcomes. METHODS: We retrospectively reviewed all patients attending our clinic. Patients younger than 50 years of age on initial presentation were considered 'younger' patients. Persistent symptoms lasted for at least 3 months. RESULTS: Overall, 177 patients had confirmed diverticular disease. Patients were referred following hospital admission (82 patients, 46.3%) or from the community (95 patients, 53.7%). Ninety-five patients (53.7%) had persistent symptoms. Patients with more than two episodes of diverticulitis were more likely to have persistent symptoms (P<0.0001).Following hospitalization, younger patients were 3.98 times more likely to develop persistent symptoms (P=0.04). This was independent of the severity of the original infection, as a low peak C-reactive protein level of less than 50 mg/L was associated with persistent symptoms (odds ratio=3.62, P=0.03). Over the study period, 12 patients (6.9%) had elective surgery. CONCLUSION: There is demand for dedicated care for patients with persistent symptoms from diverticular disease. Specialized clinics are a model for this care, provided by either gastroenterologists or surgeons, in centres with adequate demand. Our findings reinforce the hypotheses that chronic abdominal pain in diverticular disease may be related to sensation abnormalities similar to postinfective irritable bowel syndrome.

High-frequency mini probe ultrasound before endoscopic resection of colorectal polyps--is it useful?

BACKGROUND: Endoscopic resection of benign colorectal polyps and early cancer is well established. Local staging is of paramount importance to ensure that local resection is feasible. Endoscopic ultrasound has been used to evaluate the depth of lesions in the rectum, but its use in the colon is limited. OBJECTIVE: This prospective study aims to evaluate the accuracy of 20-MHz mini probe ultrasound before the endoscopic resection of colorectal tumors. DESIGN: All patients underwent 20-MHz high-frequency mini probe ultrasound of the colorectal lesion during colonoscopic examination. The mini probes were inserted through the working channel of the colonoscope, and acoustic coupling was achieved by instilling water to completely submerge the lesion. The depth of infiltration of the colorectal tumor was identified before resection. The lesions were sent for histological examination, and the level of infiltration was compared with the preoperative ultrasound depth. SETTING: This study was conducted at a tertiary referral university teaching hospital. PATIENTS: Consecutive patients referred for consideration of endoscopic resection were included in the study. INTERVENTIONS: All patients were subject to colonoscopic high-frequency mini probe ultrasound to evaluate the depth of lesion before local resection. MAIN OUTCOME MEASURES: There were 2 outcome measures: the ultrasound depth of colorectal lesion and the histological depth. RESULTS: One hundred four patients were included with a mean age of 70 years. The surgical procedures included 59 endoscopic mucosal resections, 36 transanal endoscopic microsurgeries, and 9 endoscopic submucosal dissections. The 20-MHz ultrasound correctly staged 100 of 104 lesions, an overall accuracy of 96.1%. Eighty-eight of 89 mucosal lesions and 11 of 12 submucosal lesions were correctly staged. LIMITATIONS: The ultrasound examination was performed by the main author only and is therefore dependent on his experience alone. CONCLUSION: Colonoscopic high-frequency mini probe ultrasound has high accuracy in determining the depth of colorectal lesion and is useful before endoscopic resection.

Creation of an effective colorectal anastomotic leak early detection tool using an artificial neural network.

PURPOSE: Anastomotic leaks greatly increase both morbidity and mortality amongst colorectal patients. Earlier detection of leaks leads to improved patient outcomes; however, diagnosis often proves difficult due to heterogeneous presentation and varied differential diagnosis. The purpose of the study was to create an artificial neural network (ANN) capable of accurately identifying patients at risk of developing a post-operative colorectal anastomotic leak. METHODS: A genetic ANN was trained and validated on a retrospective patient cohort. Two comparative groups were identified: those with anastomotic leaks confirmed at re-operation with a control group of patients with a post-operative delayed recovery, but in whom leak was excluded and no re-operation required. RESULTS: Seventy-six patients were identified: 20 confirmed leaks and 56 controls. No significant difference in the baseline features between leak and control groups in terms of age (leaks 65.9 years [SD 9.29] controls 58.3 years [SD 17.0)], P = 0.054). Utilising backwards variable selection, ANN maintained 19 input variables. Internal validation of the ANN produced a sensitivity of 85.0 %, specificity of 82.1 %, and AUC of 0.89 for correct identification of clinical anastomotic leaks. Of the 20 confirmed leaks, the model correctly identified 17 and misclassified 10 control patients in the clinical leak category. External validation on 12 consecutive pilot prospective patients produced a specificity of 83.3 %. CONCLUSIONS: ANNs can be created to accurately detect clinical anastomotic leaks in the early post-operative period using routinely available clinical data. Further prospective ANN testing is required to confirm generalisability. ANNs may provide useful real-world tools for improving patient safety and outcomes.

Tamoxifen and depression: drug interactions in breast cancer.

This case describes a 76-year-old African-American female with a history of depression, breast cancer, and hypothyroidism admitted to the inpatient geriatric psychiatry unit for an electroconvulsive therapy (ECT) evaluation. She had one previous episode of depression, which began after a lumpectomy in 2007. Her home medication regimen included tamoxifen 20 mg daily. This case highlights the incidence of depression in persons with breast cancer, examines the controversy of tamoxifen-induced depression, and evaluates antidepressant considerations regarding potentially efficacy-reducing cytochrome P450 2D6 drug interactions with tamoxifen. The pharmacy team played an active role in educating the medical team regarding tamoxifen drug interactions. After many discussions, the patient was ultimately treated with mirtazapine 15 mg at bedtime, in addition to ECT.

Tiotropium for adults with inadequately controlled persistent asthma.

OBJECTIVE: To review the literature evaluating the efficacy and steroid-sparing effect of tiotropium for inadequately controlled persistent asthma in adults. DATA SOURCES: Information was obtained through a search of MEDLINE/PubMed (1966-October 2012), using the terms asthma and tiotropium. A further review of reference citations was performed to identify other relevant articles. STUDY SELECTION AND DATA EXTRACTION: English-language case reports and clinical trials were reviewed. Publications evaluating the efficacy and steroid-sparing effect of tiotropium in adults with inadequately controlled persistent asthma were included in the review. One case report and 5 clinical trials met our criteria. DATA SYNTHESIS: The ultimate goal for asthma management is to maintain disease control by preventing acute exacerbations while avoiding adverse medication effects. Inhaled corticosteroids (ICS) are part of all preferred maintenance regimens for persistent asthma. Unfortunately, persistent asthma remains inadequately controlled in some patients and concerns about serious adverse effects with long-term high-dose ICS treatment exist. Interest in the use of tiotropium to control asthma symptoms and reduce steroid requirements in inadequately controlled persistent asthma is emerging. Results of several trials indicate that tiotropium improves pulmonary function markers and reduces corticosteroid requirements. Moreover, the largest and longest published trial not only showed improvements in pulmonary function tests but also a reduction in corticosteroid use and an increase in the time to first exacerbation. CONCLUSIONS: Although tiotropium use in treatment of persistent asthma appears to be promising, more robust clinical trials are needed to assess whether improved pulmonary function tests as well as a decrease in asthma exacerbations and corticosteroid requirements translate into improvements in quality of life. Additionally, the optimal patient population, long-term efficacy, and safety of tiotropium when delivered by various methods need to be determined before it can be recommended over current alternative asthma therapies.

Informing the development of services supporting self-care for severe, long term mental health conditions: a mixed method study of community based mental health initiatives in England.

BACKGROUND: Supporting self-care is being explored across health care systems internationally as an approach to improving care for long term conditions in the context of ageing populations and economic constraint. UK health policy advocates a range of approaches to supporting self-care, including the application of generic self-management type programmes across conditions. Within mental health, the scope of self-care remains poorly conceptualised and the existing evidence base for supporting self-care is correspondingly disparate. This paper aims to inform the development of support for self-care in mental health by considering how generic self-care policy guidance is implemented in the context of services supporting people with severe, long term mental health problems. METHODS: A mixed method study was undertaken comprising standardised psychosocial measures, questionnaires about health service use and qualitative interviews with 120 new referrals to three contrasting community based initiatives supporting self-care for severe, long term mental health problems, repeated nine months later. A framework approach was taken to qualitative analysis, an exploratory statistical analysis sought to identify possible associations between a range of independent variables and self-care outcomes, and a narrative synthesis brought these analyses together. RESULTS: Participants reported improvement in self-care outcomes (e.g. greater empowerment; less use of Accident and Emergency services). These changes were not associated with level of engagement with self-care support. Level of engagement was associated with positive collaboration with support staff. Qualitative data described the value of different models of supporting self-care and considered challenges. Synthesis of analyses suggested that timing support for self-care, giving service users control over when and how they accessed support, quality of service user-staff relationships and decision making around medication are important issues in supporting self-care in mental health. CONCLUSIONS: Service delivery components - e.g. peer support groups, personal planning - advocated in generic self-care policy have value when implemented in a mental health context. Support for self-care in mental health should focus on core, mental health specific qualities; issues of control, enabling staff-service user relationships and shared decision making. The broad empirical basis of our research indicates the wider relevance of our findings across mental health settings.