The Lived Experience of Novice Helpers as First Responders in a Shared War Reality.

Purpose: This study sought to explore the lived experience of trained social work students as first responders in a shared war reality. Method: Data were gathered from three focus groups conducted with social work students following their professional intervention during a period of protracted warfare. Results: The main theme depicts a movement from an experience of uncertainty to certainty, as the students shifted from being subjects under threat to being object-helpers on duty. Discussion: The findings highlight the interactive nature of individual and environmental aspects of resilience as a dynamic process in the face of adversity. Practical implications are discussed in the context of first responders' resilience in a shared war reality. Conclusion: First responders must experience certainty in order to function effectively. To provide more support to novice helpers, a first responders training program should be implemented as part of the mandatory curriculum of social work studies.

Prevention and Early Detection of Pancreatic Cancer.

Preventing cancer has much to offer. Aside from plummeting health care costs, we might enjoy a healthier life free of cancer and chronic disease. Prevention requires the adoption of healthier choices and a moderate amount of exercise. The supporting evidence is observational, clinical, and partly common sense. Further investigations reveal several substances in a whole-food plant-based diet that have protective effects and an inhibitory effect on tumor development. For pancreatic cancer, the basis of cure remains a century old operation that rarely cures. With little to lose, prevention deserves center stage and additional studies.

Nonfunctioning Incidental Pancreatic Neuroendocrine Tumors: Who, When, and How to Treat?

Asymptomatic non-functioning pancreatic neuroendocrine tumors are indolent, slow-growing tumors, and surveillance is safe and reasonable. Despite consensus, size may be less important than grade and Ki-67 when making decisions regarding optimal therapy. Plans to proceed with surveillance or surgical resection require a multidisciplinary approach and a shared decision making process with colleagues, patients, and families. Decisions should be based on tumor characteristics, patient morbidities, preferences, and risks. As molecular diagnostics evolve, preoperative acquisition of tissue samples may become even more critical in choosing between operative management and surveillance.

A Tale of 2 Techniques: Preoperative Biliary Drainage and Routine Surgical Drainage with Pancreaticoduodenectomy.

Preoperative drainage of an obstructed biliary tree before pancreaticoduodenal resection (PDR) and placement of intraabdominal drains following pancreatic resection have been suggested to be both unnecessary and associated with a higher complication rate. The evidence for and against that practice is presented and analyzed to highlight its risks and benefits. A selective approach on an individual basis for preoperative biliary decompression is advocated, based on multiple factors. Additionally, the evidence for routine use of surgical drains after PDR is critically reviewed and the rationale for routine drainage is made.

Cancer of the Pancreas-Actual 5, 10, and 20+Year Survival: The Lucky and Fortunate Few.

Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malignancy. This article updates an earlier experience of actual long-term survival of CaP in patients treated between 1991 to 2000, and reviews the literature. Survival is expressed as actual, not projected, survival.

Rare, Uncommon, and Unusual Complications After Pancreaticoduodenal Resection.

Complications after pancreaticoduodenal resection occur in at least 30% of patients. Most are a direct result of an intraoperative event, dissection, or anastomoses which account for the most serious morbidities, sepsis, pseudoaneurysms, and hemorrhage. Rarely, complications are due to the systemic impact of the procedure even if the procedure itself was unremarkable. Rare systemic complications after PDR (Transfusion transmitted Babesiosis, pituitary apoplexy, and TRALI) and a number of uncommon and unusual other complications are discussed. Pancreaticoduodenal resection is a significant operation with serious consequences. Decisions on selection of candidates and safe operations should be thoughtful and always in surgeons' minds.

Rationale and design for an investigation to optimize selective serotonin reuptake inhibitor treatment for pregnant women with depression.

The physiological changes of pregnancy can affect the pharmacokinetics of a drug, thereby affecting its dose requirements. Because pharmacokinetic (PK) studies in pregnant women have rarely been conducted, evidence-based dosing adjustments are seldom available. In particular, despite the fact that the use of antidepressants has become increasingly common, pregnancy-associated PK changes of the selective serotonin reuptake inhibitors (SSRIs) are largely unknown.

What is the incidence of biliary carcinoma in choledochal cysts, when do they develop, and how should it affect management?

The incidence of cancer in choledochal cysts (CCs) in adults was calculated to determine the timing and need for surgery. In 78 publications (1996-2010), 434 of 5780 reported CCs patients had cancer. Cholangiocarcinoma (70.4 %) and gallbladder cancer (23.5 %) were the most common malignancies. Only nine malignancies were reported before age 18 (0.42 %). In contrast, the incidence of malignancy in adults was 11.4 %. The median age for diagnosis of cancer was 42 years, and the incidence increased with each decade.

Three synchronous, sporadic and separate periampullary and pancreatic tumors: more than a coincidence?

Three sporadic, synchronous, and separate lesions in the ampulla of Vater and the head of the pancreas presented in an 81-year-old male. One was symptomatic and two were incidental. One was detected preoperatively (the ampullary lesion) and two by examination of the resected specimen (the neuroendocrine and pancreatic carcinomas). The case is summarized and the literature and the issue of commonality are reviewed.

Familial pancreatic cancer: the case for prophylactic pancreatectomy in lieu of serial screening and shared decision making.

At-risk family members with familial pancreatic cancer (FCaP) face uncertainty regarding the individual risk of developing pancreatic cancer (CaP) and whether to choose serial screening or prophylactic pancreatectomy to avoid CaP. We treated 2 at-risk siblings with a history of FCaP, congenital hepatic fibrosis (CHF), and jaundice secondary to a bile duct stricture. In one, a pancreaticoduodenal resection was done and in the second a total pancreatectomy. Malignancy was not present, but extensive pancreatic intraepithelial neoplasia (PanIn) 2 was present throughout both pancreata. The clinical course and literature review are presented along with the previously unreported association of CHF and CaP.

Effect of ventilation on cerebral oxygenation in patients undergoing surgery in the beach chair position: a randomized controlled trial.

BACKGROUND: Surgery in the beach chair position (BCP) may reduce cerebral blood flow and oxygenation, resulting in neurological injuries. The authors tested the hypothesis that a ventilation strategy designed to achieve end-tidal carbon dioxide (E'(CO2)) values of 40-42 mm Hg would increase cerebral oxygenation (Sct(O2)) during BCP shoulder surgery compared with a ventilation strategy designed to achieve E'(CO2) values of 30-32 mm Hg. METHODS: Seventy patients undergoing shoulder surgery in the BCP with general anaesthesia were enrolled in this randomized controlled trial. Mechanical ventilation was adjusted to maintain an E'(CO2) of 30-32 mm Hg in the control group and an E'(CO2) of 40-42 mm Hg in the study group. Cerebral oxygenation was monitored continuously in the operating theatre using near-infrared spectroscopy. Baseline haemodynamics and Sct(O2) were obtained before induction of anaesthesia, and these values were then measured and recorded continuously from induction of anaesthesia until tracheal extubation. The number of cerebral desaturation events (CDEs) (defined as a ≥20% reduction in Sct(O2) from baseline values) was recorded. RESULTS: No significant differences between the groups were observed in haemodynamic variables or phenylephrine interventions during the surgical procedure. Sct(O2) values were significantly higher in the study 40-42 group throughout the intraoperative period (P<0.01). In addition, the incidence of CDEs was lower in the study 40-42 group (8.8%) compared with the control 30-32 group (55.6%, P<0.0001). CONCLUSIONS: Cerebral oxygenation is significantly improved during BCP surgery when ventilation is adjusted to maintain E'(CO2) at 40-42 mm Hg compared with 30-32 mm Hg. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT01546636.

Effect of ritonavir-induced cytochrome P450 3A4 inhibition on plasma fentanyl concentrations during patient-controlled epidural labor analgesia: a pharmacokinetic simulation.

BACKGROUND: Ritonavir inhibition of cytochrome P450 3A4 decreases the elimination clearance of fentanyl by 67%. We used a pharmacokinetic model developed from published data to simulate the effect of sample patient-controlled epidural labor analgesic regimens on plasma fentanyl concentrations in the absence and presence of ritonavir-induced cytochrome P450 3A4 inhibition. METHODS: Fentanyl absorption from the epidural space was modeled using tanks-in-series delay elements. Systemic fentanyl disposition was described using a three-compartment pharmacokinetic model. Parameters for epidural drug absorption were estimated by fitting the model to reported plasma fentanyl concentrations measured after epidural administration. The validity of the model was assessed by comparing predicted plasma concentrations after epidural administration to published data. The effect of ritonavir was modeled as a 67% decrease in fentanyl elimination clearance. Plasma fentanyl concentrations were simulated for six sample patient-controlled epidural labor analgesic regimens over 24 h using ritonavir and control models. Simulated data were analyzed to determine if plasma fentanyl concentrations producing a 50% decrease in minute ventilation (6.1 ng/mL) were achieved. RESULTS: Simulated plasma fentanyl concentrations in the ritonavir group were higher than those in the control group for all sample labor analgesic regimens. Maximum plasma fentanyl concentrations were 1.8 ng/mL and 3.4 ng/mL for the normal and ritonavir simulations, respectively, and did not reach concentrations associated with 50% decrease in minute ventilation. CONCLUSION: Our model predicts that even with maximal clinical dosing regimens of epidural fentanyl over 24 h, ritonavir-induced cytochrome P450 3A4 inhibition is unlikely to produce plasma fentanyl concentrations associated with a decrease in minute ventilation.

New oral anticoagulants and regional anaesthesia.

The new oral anticoagulants are approved for a variety of clinical syndromes, including the prevention of stroke in atrial fibrillation, acute coronary syndromes, treatment of venous thromboembolism (VTE), and prevention of venous thrombosis after total joint surgery or hip fracture. Published guidelines have differing recommendations on the safe interval between discontinuation of the anticoagulant and performance of neuraxial procedures and between the interventional procedure and redosing of the drug. While two to three half-life intervals might be acceptable in patients who are at high risk for VTE or stroke, an interval of four to six half-lives between discontinuation of the drug and neuraxial injections is probably safer in most patients at low risk of thrombosis. In those with renal disease, the interval should be based on creatinine clearance. After a neuraxial procedure or removal of an epidural catheter, anticoagulants can be resumed within 24-48 h in most patients, but they can be taken sooner in patients who are at higher risk for VTE or stroke, that is, 24 h minus the time to peak effect of the drug. The new antiplatelet drugs prasugrel and ticagrelor should be stopped 7 or 5 days, respectively, before a neuraxial injection and can be restarted 24 h later. In selected situations, laboratory monitoring of the anticoagulant effect is appropriate, and reversal agents are suggested when there is a need to rapidly restore haemostatic function.

Microbeads detection using spin-valve planar Hall effect sensors.

In this paper we present a micromagnetic approach to describe the detection of magnetic nanobeads using planar Hall effect sensors. The magnetic beads polarized by a dc magnetic field generate a field, which can affect the magnetization state of spin-valve sensor, leading in principle, to a detectable signal. For magnetic nanobeads we assumed a superparamagnetic behaviour. Three detection geometries are discussed and some specific behaviours were highlighted by micromagnetic simulations. We found that when the polarising field is applied parallel with the sensor surface a very weak signal can be obtained. This is because at working fields, for which the magnetic nanobeads are magnetised, the sensor saturates. We identified other setups that can overcome this shortcoming and deliver a net signal.

Hydrocarbon on Carbon: Coherent Vibrational Spectroscopy of Toluene on Graphite.

The ability to study the interactions of hydrocarbons on carbon surfaces is an integral step toward gaining a molecular level understanding of the chemical reactions and physical properties occurring on them. Here, we apply vibrational sum frequency generation (SFG) to determine the tilt angle of toluene, a common organic solvent, on millimeter-thick highly oriented pyrolytic graphite (HOPG). The combination of a time-delay technique, which results in the successful suppression of the nonresonant SFG response, and a null angle method is shown to overcome the "strong optical absorber" problem posed by macroscopically thick carbon samples and yields a molecular tilt angle of toluene in the range of 37° to 42° from the surface normal. The implications of this approach for determining the orientation of organic species adsorbed on carbon interfaces, which are important for energy-relevant processes, are discussed.

Rational opioid dosing in the elderly: dose and dosing interval when initiating opioid therapy.

Opioids are the mainstay of treatment for moderate to severe pain. However, opioid therapy in the elderly is often associated with significant morbidity because of excessive ventilatory depression. The large amount of interindividual variability in opioid dose-response relationships makes it difficult to individualize the dose and dosing interval to provide safe and effective analgesia. By examining how aging affects the pharmacokinetics (PK) and pharmacodynamics (PD) of opioids, it is possible to provide a rational basis for age adjustment in opioid dosing.

Identification of binding sites for acetaldehyde adsorption on titania nanorod surfaces using CIMS.

The interaction of acetaldehyde with TiO(2) nanorods has been studied under low pressures (acetaldehyde partial pressure range 10(-4)-10(-8) Torr) using chemical ionization mass spectrometry (CIMS). We quantitatively separate irreversible adsorption, reversible adsorption, and an uptake of acetaldehyde assigned to a thermally activated surface reaction. We find that, at room temperature and 1.2 Torr total pressure, 2.1 ± 0.4 molecules/nm(2) adsorb irreversibly, but this value exhibits a sharp decrease as the analyte partial pressure is lowered below 4 × 10(-4) Torr, regardless of exposure time. The number of reversible binding sites at saturation amounts to 0.09 ± 0.02 molecules/nm(2) with a free energy of adsorption of 43.8 ± 0.2 kJ/mol. We complement our measurements with FTIR spectroscopy and identify the thermal dark reaction as a combination of an aldol condensation and an oxidative adsorption that converts acetaldehyde to acetate or formate and CO, at a measured combined initial rate of 7 ± 1 × 10(-4) molecules/nm(2) s. By characterizing binding to different types of sites under dark conditions in the absence of oxygen and gas phase water, we set the stage to analyze site-specific photoefficiencies involved in the light-assisted mineralization of acetaldehyde to CO(2).

Displacement of hexanol by the hexanoic acid overoxidation product in alcohol oxidation on a model supported palladium nanoparticle catalyst.

This work characterizes the adsorption, structure, and binding mechanism of oxygenated organic species from cyclohexane solution at the liquid/solid interface of optically flat alumina-supported palladium nanoparticle surfaces prepared by atomic layer deposition (ALD). The surface-specific nonlinear optical vibrational spectroscopy, sum-frequency generation (SFG), was used as a probe for adsorption and interfacial molecular structure. 1-Hexanoic acid is an overoxidation product and possible catalyst poison for the aerobic heterogeneous oxidation of 1-hexanol at the liquid/solid interface of Pd/Al(2)O(3) catalysts. Single component and competitive adsorption experiments show that 1-hexanoic acid adsorbs to both ALD-prepared alumina surfaces and alumina surfaces with palladium nanoparticles, that were also prepared by ALD, more strongly than does 1-hexanol. Furthermore, 1-hexanoic acid adsorbs with conformational order on ALD-prepared alumina surfaces, but on surfaces with palladium particles the adsorbates exhibit relative disorder at low surface coverage and become more ordered, on average, at higher surface coverage. Although significant differences in binding constant were not observed between surfaces with and without palladium nanoparticles, the palladium particles play an apparent role in controlling adsorbate structures. The disordered adsorption of 1-hexanoic acid most likely occurs on the alumina support, and probably results from modification of binding sites on the alumina, adjacent to the particles. In addition to providing insight on the possibility of catalyst poisoning by the overoxidation product and characterizing changes in its structure that result in only small adsorption energy changes, this work represents a step toward using surface science techniques that bridge the complexity gap between fundamental studies and realistic catalyst models.

[Stapled vs. hand-sewn colorectal anastomosis in complicated colorectal cancer--a retrospective study]. / Anastomozele manuale versus anastomozele mecanice in cancerul colorectal complicat--studiu retrospectiv.

UNLABELLED: Emergens in colorectal pathology are in most cases by complications of cancer. The prognosis for colorectal cancer is poor when this pathology is addressed in emergency situations because, on one hand, of the organ specific structure, blood supply, septic content and, on the other hand, because of the special group of patients with this pathology: aged, immunosuppressed and with various comorbidities. The high rate of postoperative complications of these patients requires a specific management. The development and improvement of medical devices has brought to the surgeons new products among which mechanice devices for anastomoses. In this study we compared two groups of operated patients (with hand sutured and stapled anastomoses) who presented as emergences with complications of colorectal cancer. MATERIAL AND METHOD: Retrospective clinical study with a total of 72 patients who underwent a colorectal resection procedure in emergency in our clinic (Emergency Hospital Bucharest) over a period of 2 years (2007-2008). RESULTS: The 72 patients who required emergency surgery were randomly assigned to 2 categories according to the type of anastomosis: hand sutured (group 1, n = 34) and stapled (group 2, n = 38). Age, sex, comorbidities, and tumor staging were comparable in both groups. The emergency was represented by obstruction (56.94%), hemorrhage (8.33%) and perforation (34.72%). The mortality (10.5% vs. 8.8%) and orbidity rate (20.83% vs. 15.27%) was higher in the stapled anastomosis group. The average duration of the surgical procedure performed in emergency was also quantified and was 118 min. (group 2) vs. 236 min. (group 1) respectively. CONCLUSION: Comparison did not disclose any significant difference in the number of complications in these two groups. Anastomosis is safe in emergency colorectal surgery and the reduction of the operative time may also improve the outcome of these patients.