Who contributes to disaster preparedness? Predicting decision making in social dilemmas pertaining to community resilience.

Planning for community resilience through public infrastructure projects often engenders problems associated with social dilemmas, but little work has been done to understand how individuals respond when presented with opportunities to invest in such developments. Using statistical learning techniques trained on the results of a web-based common pool resource game, we analyze participants' decisions to invest in hypothetical public infrastructure projects that bolster their community's resilience to disasters. Given participants' dispositions and in-game circumstances, Bayesian additive regression tree (BART) models are able to accurately predict deviations from players' decisions that would reasonably lead to Pareto-efficient outcomes for their communities. Participants tend to overcontribute relative to these Pareto-efficient strategies, indicating general risk aversion that is analogous to individuals purchasing disaster insurance even though it exceeds expected actuarial costs. However, higher trait Openness scores reflect an individual's tendency to follow a risk-neutral strategy, and fewer available resources predict lower perceived utilities derived from the infrastructure developments. In addition, several input variables have nonlinear effects on decisions, suggesting that it may be warranted to use more sophisticated statistical learning methods to reexamine results from previous studies that assume linear relationships between individuals' dispositions and responses in applications of game theory or decision theory.

Hedgehog-interacting protein acts in the habenula to regulate nicotine intake.

Hedgehog-interacting protein (HHIP) sequesters Hedgehog ligands to repress Smoothened (SMO)-mediated recruitment of the GLI family of transcription factors. Allelic variation in HHIP confers risk of chronic obstructive pulmonary disease and other smoking-related lung diseases, but underlying mechanisms are unclear. Using single-cell and cell-type-specific translational profiling, we show that HHIP expression is highly enriched in medial habenula (MHb) neurons, particularly MHb cholinergic neurons that regulate aversive behavioral responses to nicotine. HHIP deficiency dysregulated the expression of genes involved in cholinergic signaling in the MHb and disrupted the function of nicotinic acetylcholine receptors (nAChRs) through a PTCH-1/cholesterol-dependent mechanism. Further, CRISPR/Cas9-mediated genomic cleavage of the Hhip gene in MHb neurons enhanced the motivational properties of nicotine in mice. These findings suggest that HHIP influences vulnerability to smoking-related lung diseases in part by regulating the actions of nicotine on habenular aversion circuits.

Wide variation in surgical techniques to repair incisional hernias: a survey of practice patterns among general surgeons.

BACKGROUND: The purpose of this research was to examine the self-reported practice patterns of Canadian general surgeons regarding the elective repair of incisional hernias. METHODS: A mail survey was sent to all general surgeons in Canada. Data were collected regarding surgeon training, years in practice, practice setting and management of incisional hernias. Surgeons were asked to describe their usual surgical approach for a patient with a midline incisional hernia and a 10 × 6 cm fascial defect. RESULTS: Of the 1876 surveys mailed out 555 (30%) were returned and 483 surgeons indicated that they perform incisional hernia repair. The majority (62%) have been in practice > 10 years and 73% regularly repair incisional hernias. In response to the clinical scenario of a patient with an incisional hernia, 74% indicated that they would perform an open repair and 18% would perform a laparoscopic repair. Ninety eight percent of surgeons would use mesh, 73% would perform primary fascial closure and 47% would perform a component separation. The most common locations for mesh placement were intraperitoneal (46%) and retrorectus/preperitoneal (48%). The most common repair, which was reported by 37% of surgeons, was an open operation, with mesh, with primary fascial closure and a component separation. CONCLUSIONS: While almost all surgeons who perform incisional hernia repairs would use permanent mesh, there was substantial variation reported in surgical approach, mesh location, fascial closure and use of component separation techniques. It is unclear how this variability may impact healthcare resources and patient outcomes.

Timing of recurrences of TEM resected rectal neoplasms is variable as per the surveillance practices of one tertiary care institution.

Transanal endoscopic microsurgery (TEM) is widely used for the excision of rectal adenomas and early rectal adenocarcinoma. Few recommendations currently exist for surveillance of lesions excised by TEM. The purpose of this study was to review the surveillance practices and the patterns of recurrence among TEM resected lesions at a tertiary care hospital. A retrospective chart review was performed on all patients who underwent TEM for rectal adenoma or adenocarcinoma before June 2017. In our study population of 114 patients, the final pathology included 78 (68%) adenomas and 36 (32%) adenocarcinomas. Of the adenocarcinomas 23, 9, and 4 were T1, T2, T3 lesions, respectively. Of those, 25 patients opted for surveillance instead of further treatment. The most commonly recommended endoscopic surveillance strategy by our group for both adenomas and adenocarcinomas excised by TEM was flexible sigmoidoscopy every 6 months for 2 years. Recurrences occurred in 4/78 (5.1%) adenoma patients, all found within 16.9 months of surgery, and in 4/25 (16%) adenocarcinoma patients, found between 7.4 and 38.5 months post-surgery. Our data highlights the fact that the timing of recurrences post TEM surgery is variable. Further studies looking at recurrence patterns are needed in order to create comprehensive guidelines for surveillance of these patients.

Resting Pd/Pa correlates with fractional flow reserve but not angiographic severity in calcified coronary arteries.

OBJECTIVE: Study the effect of coronary artery calcium (CAC) on resting coronary physiological indices. BACKGROUND: Prior studies found no correlation between angiographic stenosis and fractional flow reserve (FFR) in heavily calcified arteries. METHODS: Two hundred consecutive patients undergoing whole-cycle resting Pd/Pa and FFR evaluation of a single lesion of intermediate severity (40-80%) had CAC quantified based upon radiopacities at the site of the stenosis, where 0 = none or mild calcium, 1 = moderate calcium, and 2 = severe calcium. RESULTS: Mean age was 61 ± 11 years and 34% were female. The mean degree of stenosis, FFR, and resting Pd/Pa were 60 ± 12%, 0.83 ± 0.08, and 0.93 ± 0.05, respectively. Resting Pd/Pa correlated with degree of angiographic diameter stenosis (DS) as determined by quantitative coronary angiography (QCA) or visual estimation in arteries with calcium score of 0 or 1, but there was no correlation in severely calcified arteries. The diagnostic accuracy of DS ≥70% by QCA to predict hemodynamic significance was 68% with calcium scores of 0/1, but only 43% with calcium score = 2. Resting Pd/Pa was highly correlated with FFR irrespective of the degree of CAC (R2 = 0.68, p < .001) and the sensitivity of resting Pd/Pa ≤0.91 for predicting an FFR ≤0.80 was 0.67 in arteries with calcium scores of 0 or 1 and 0.69 in arteries with a calcium score of 2. CONCLUSIONS: There was no correlation between angiographic stenosis and either resting Pd/Pa or FFR in heavily calcified coronary artery lesions.

Non-invasive molecularly-specific millimeter-resolution manipulation of brain circuits by ultrasound-mediated aggregation and uncaging of drug carriers.

Non-invasive, molecularly-specific, focal modulation of brain circuits with low off-target effects can lead to breakthroughs in treatments of brain disorders. We systemically inject engineered ultrasound-controllable drug carriers and subsequently apply a novel two-component Aggregation and Uncaging Focused Ultrasound Sequence (AU-FUS) at the desired targets inside the brain. The first sequence aggregates drug carriers with millimeter-precision by orders of magnitude. The second sequence uncages the carrier's cargo locally to achieve high target specificity without compromising the blood-brain barrier (BBB). Upon release from the carriers, drugs locally cross the intact BBB. We show circuit-specific manipulation of sensory signaling in motor cortex in rats by locally concentrating and releasing a GABAA receptor agonist from ultrasound-controlled carriers. Our approach uses orders of magnitude (1300x) less drug than is otherwise required by systemic injection and requires very low ultrasound pressures (20-fold below FDA safety limits for diagnostic imaging). We show that the BBB remains intact using passive cavitation detection (PCD), MRI-contrast agents and, importantly, also by sensitive fluorescent dye extravasation and immunohistochemistry.

A Factor Analysis Approach Toward Reconciling Community Vulnerability and Resilience Indices for Natural Hazards.

The concepts of vulnerability and resilience help explain why natural hazards of similar type and magnitude can have disparate impacts on varying communities. Numerous frameworks have been developed to measure these concepts, but a clear and consistent method of comparing them is lacking. Here, we develop a data-driven approach for reconciling a popular class of frameworks known as vulnerability and resilience indices. In particular, we conduct an exploratory factor analysis on a comprehensive set of variables from established indices measuring community vulnerability and resilience at the U.S. county level. The resulting factor model suggests that 50 of the 130 analyzed variables effectively load onto five dimensions: wealth, poverty, agencies per capita, elderly populations, and non-English-speaking populations. Additionally, the factor structure establishes an objective and intuitive schema for relating the constituent elements of vulnerability and resilience indices, in turn affording researchers a flexible yet robust baseline for validating and expanding upon current approaches.

Antibiotic use among older adults on an acute care general surgery service.

BACKGROUND: Antibiotics play an important role in the treatment of many surgical diseases that affect older adults, and the potential for inappropriate use of these drugs is high. Our objective was to describe antibiotic use among older adults admitted to an acute care surgery service at a tertiary care teaching hospital. METHODS: Detailed data regarding diagnosis, comorbidities, surgery and antibiotic use were retrospectively collected for patients 70 years and older admitted to an acute care surgery service. We evaluated antibiotic use (perioperative prophylaxis and treatment) for appropriateness based on published guidelines. RESULTS: During the study period 453 patients were admitted to the acute care surgery service, and 229 underwent surgery. The most common diagnoses were small bowel obstruction (27.2%) and acute cholecystitis (11.0%). In total 251 nonelective abdominal operations were performed, and perioperative antibiotic prophylaxis was appropriate in 49.5% of cases. The most common prophylaxis errors were incorrect timing (15.5%) and incorrect dose (12.4%). Overall 206 patients received treatment with antibiotics for their underlying disease process, and 44.2% received appropriate first-line drug therapy. The most common therapeutic errors were administration of second- or third-line antibiotics without indication (37.9%) and use of antibiotics when not indicated (12.1%). There was considerable variation in the duration of treatment for patients with the same diagnoses. CONCLUSION: Inappropriate antibiotic use was common among older patients admitted to an acute care surgery service. Quality improvement initiatives are needed to ensure patients receive optimal care in this complex hospital environment.

CONTEXTE: Les antibiotiques jouent un rôle important dans de nombreux cas de chirurgie chez les adultes âgés, et le risque d'utilisation inappropriée de ces médicaments est élevé. Notre objectif était de décrire l'utilisation des antibiotiques chez les patients âgés admis au service chirurgical d'urgence d'un centre hospitalier universitaire de soins tertiaires. MÉTHODES: Nous avons recueilli de manière rétrospective les données détaillées sur le diagnostic, les comorbidités, la chirurgie et l'utilisation d'antibiotiques chez les patients de 70 ans et plus admis dans un service chirurgical d'urgence. Nous avons évalué le bien-fondé du recours aux antibiotiques (prophylaxie et traitement périopératoire) en fonction des lignes directrices publiées. RÉSULTATS: Durant la période de l'étude, 453 patients ont été admis au service chirurgical d'urgence et 229 ont subi une chirurgie. Les diagnostics les plus fréquents étaient : occlusion de l'intestin grêle (27,2 %) et cholécystite aigüe (11,0 %). En tout, 251 interventions abdominales urgentes ont été effectuées et l'antibioprophylaxie périopératoire était justifiée dans 49,5 % des cas. Les erreurs les plus fréquentes en matière de prophylaxie ont été : moment mal choisi (15,5 %) et dose incorrecte (12,4 %). En tout, 206 patients ont reçu une antibiothérapie pour un processus pathologique sous-jacent et 44,2 % ont reçu un traitement antibiotique de première intention approprié. Les erreurs thérapeutiques les plus fréquentes concernaient l'administration d'antibiotiques de deuxième ou de troisième intention sans indication (37,9 %) et l'utilisation d'antibiotiques lorsque cela n'était pas indiqué (12,1 %). On a noté une variation considérable de la durée des traitements chez des patients porteurs de diagnostics semblables. CONCLUSION: L'utilisation inappropriée des antibiotiques a été fréquente chez les patients adultes admis dans un service chirurgical d'urgence. Des initiatives s'imposent sur le plan de l'amélioration de la qualité pour s'assurer ainsi que les patients reçoivent des soins optimaux dans cet environnement hospitalier complexe.

Angiographic severity does not correlate with fractional flow reserve in heavily calcified coronary arteries.

OBJECTIVES: To determine the relationship between severity of stenosis and hemodynamic significance in calcified coronary arteries. BACKGROUND: Severity of stenosis is widely used to determine the need for revascularization but the effect of lesion calcification on hemodynamic significance is not well understood. METHODS: Two hundred consecutive patients undergoing fractional flow reserve (FFR) testing of an intermediate coronary lesion with a pressure wire and intravenous infusion of adenosine were studied. Coronary calcium was quantified based upon radiopacities at the site of the stenosis on cineangiography using the method of Mintz et al. (0 = none or mild calcium, 1 = moderate calcium, 2 = severe calcium). RESULTS: Mean age was 61 ± 11 years, 66% were males, 87.5% had hypertension, 44.5% had diabetes, and 20.5% were current smokers. The mean coronary stenosis by quantitative coronary angiography was 60 ± 12% and the mean FFR was 0.83 ± 0.08. There were 109, 45, and 46 patients classified as Calcium Score of 0, 1, or 2, respectively. Compared to those with no/mild or moderate calcification, patients with severe coronary calcium were older and more likely to have chronic kidney disease and pulmonary disease. The correlation between angiographic severity and FFR decreased as lesion calcification increased [calcium score = 0 (R2 = 0.25, P < 0.005); calcium score = 1 (R2 = 0.11, P < 0.005); calcium score = 2 (R2 = 0.02, P = 0.35)]. CONCLUSIONS: In patients with heavily calcified coronary lesions, there was no association between angiographic stenosis and hemodynamic significance and FFR is needed to determine hemodynamic significance of intermediate lesions. © 2016 Wiley Periodicals, Inc.

The impact of adverse events on health care costs for older adults undergoing nonelective abdominal surgery.

BACKGROUND: Postoperative complications have been identified as an important and potentially preventable cause of increased hospital costs. While older adults are at increased risk of experiencing complications and other adverse events, very little research has specifically examined how these events impact inpatient costs. We sought to examine the association between postoperative complications, hospital mortality and loss of independence and direct inpatient health care costs in patients 70 years or older who underwent nonelective abdominal surgery. METHODS: We prospectively enrolled consecutive patients 70 years or older who underwent nonelective abdominal surgery between July 1, 2011, and Sept. 30, 2012. Detailed patient-level data were collected regarding demographics, diagnosis, treatment and outcomes. Patient-level resource tracking was used to calculate direct hospital costs (2012 $CDN). We examined the association between complications, hospital mortality and loss of independence cost using multiple linear regression. RESULTS: During the study period 212 patients underwent surgery. Overall, 51.9% of patients experienced a nonfatal complication (32.5% minor and 19.4% major), 6.6% died in hospital and 22.6% experienced a loss of independence. On multivariate analysis nonfatal complications (p < 0.001), hospital mortality (p = 0.021) and loss of independence at discharge (p < 0.001) were independently associated with health care costs. These adverse events respectively accounted for 30%, 4% and 10% of the total costs of hospital care. CONCLUSION: Adverse events were common after abdominal surgery in older adults and accounted for 44% of overall costs. This represents a substantial opportunity for better patient outcomes and cost savings with quality improvement strategies tailored to the needs of this high-risk surgical population.

CONTEXTE: Les complications postopératoires sont une cause évitable qui contribue grandement aux coûts hospitaliers élevés. Malgré le fait que les personnes âgées courent un risque accru de subir des complications ou des événements indésirables, peu de recherches ont étudié l'incidence de ces éléments sur les coûts d'hospitalisation. Nous nous sommes penchés sur la relation entre les coûts des soins de santé assumés par les malades hospitalisés et les complications postopératoires, la mortalité hospitalière et la perte d'autonomie auprès d'une population de patients de 70 ans et plus ayant subi une intervention chirurgicale abdominale non facultative. MÉTHODES: La cohorte prospective a été formée de patients consécutifs âgés de 70 ans et plus ayant subi une intervention chirurgicale abdominale non facultative entre le 1er juillet 2011 et le 30 septembre 2012. Des données détaillées concernant leur profil démographique, leur diagnostic, leur traitement et leurs résultats ont été recueillies. Le calcul des coûts hospitaliers directs est basé sur un suivi des ressources utilisées par les patients (en dollars canadiens, 2012). Au moyen d'une régression linéaire multiple, nous avons analysé la relation entre les complications, la mortalité hospitalière et la perte d'autonomie. RÉSULTATS: Pendant la période à l'étude, 212 patients ont subi une intervention chirurgicale. Parmi eux, 51,9 % ont subi une complication non mortelle (mineure dans 32,5 % des cas; majeure dans 19,4 % des cas), 6,6 % sont décédés à l'hôpital, et 22,6 % ont subi une perte d'autonomie. Une analyse multivariable a permis de conclure que les complications non mortelles (p < 0,001), la mortalité hospitalière (p = 0,021) et la perte d'autonomie à la sortie de l'hôpital (p < 0,001) étaient indépendamment associées aux coûts des soins de santé et qu'elles représentaient respectivement 30 %, 4 % et 10 % des coûts d'hospitalisation totaux. CONCLUSION: Les événements indésirables étaient fréquents dans le contexte des interventions chirurgicales abdominales réalisées sur des personnes âgées et représentaient 44 % des coûts totaux. Nous devons saisir cette occasion et nous doter de stratégies d'amélioration de la qualité adaptées aux besoins de cette population, à risque élevé sur le plan chirurgical, afin d'améliorer les résultats pour les patients et de diminuer les coûts.

The Impact of Nonelective Abdominal Surgery on the Residential Status of Older Adult Patients.

OBJECTIVE: To describe the change in residential status at discharge and 6 months after hospitalization among older adults who have undergone nonelective abdominal surgery and to identify risk factors associated with discharge to institution. BACKGROUND: Surgery in older adults may lead to a loss of independence that prevents them from returning to their preadmission residential status. Understanding the impact of surgery on residential status and risk factors for institutionalization is important for patient counseling, discharge planning, and resource allocation. METHODS: Community-dwelling patients aged 70 years and older who underwent nonelective abdominal surgery over a 15-month period were prospectively enrolled. Residential status before admission, at discharge, and 6 months after admission was assessed. Multiple logistic regression was used to identify factors associated with discharge to institution. RESULTS: Of the 197 patients who underwent surgery and survived to discharge, 30% were living alone before admission and 70% were living with others. At discharge, 72% of patients returned to their preadmission residential status and 22% were institutionalized. Six months after hospitalization, 55% of institutionalized patients had returned to community-living, and 79% of all patients had returned to their preadmission residential status. Change in residential status was associated with decreased quality of life. Increasing American Society of Anesthesiologists score, frailty, surgery for malignancy, and postoperative complications were associated with discharge to institution. CONCLUSIONS: The majority of older patients, including those who were discharged to an institution, returned to their preadmission residential status 6 months after nonelective abdominal surgery.

Management and outcomes of small bowel obstruction in older adult patients: a prospective cohort study.

BACKGROUND: The purpose of this research was to examine the morbidity, mortality and rate of recurrent bowel obstruction associated with the treatment of small bowel obstruction (SBO) in older adults. METHODS: We prospectively enrolled all patients 70 years or older with an SBO who were admitted to a tertiary care teaching centre between Jul. 1, 2011, and Sept. 30, 2012. Data regarding presentation, investigations, treatment and outcomes were collected. RESULTS: Of the 104 patients admitted with an SBO, 49% were managed nonoperatively and 51% underwent surgery. Patients who underwent surgery experienced more complications (64% v. 27%, p = 0.002) and stayed in hospital longer (10 v. 3 d, p < 0.001) than patients managed nonoperatively. Nonoperative management was associated with a high rate of recurrent SBO: 31% after a median follow-up of 17 months. Of the patients managed operatively, 60% underwent immediate surgery and 40% underwent surgery after attempted nonoperative management. Patients in whom nonoperative management failed underwent surgery after a median of 2 days, and 89% underwent surgery within 5 days. The rate of bowel resection was high (29%) among those who underwent delayed surgery. Surgery after failed nonoperative management was associated with a mortality of 14% versus 3% for those who underwent immediate surgery; however, this difference was not significant. CONCLUSION: These data suggest that some elderly patients with SBO may be waiting too long for surgery.

CONTEXTE: Le but de cette recherche était d'analyser la morbidité, la mortalité et le taux de récurrence de l'occlusion intestinale associés au traitement de l'occlusion intestinale grêle (OIG) chez des adultes âgés. MÉTHODES: Nous avons inscrit de manière prospective tous les patients de 70 ans ou plus présentant une OIG qui ont été admis dans un établissement de soins tertiaires entre le 1er juillet 2011 et le 30 septembre 2012. Nous avons recueilli les données concernant les tableaux cliniques, les épreuves diagnostiques, les traitements et leurs résultats. RÉSULTATS: Parmi les 104 patients admis pour OIG, 49 % ont été traités non chirurgicalement et 51 % ont subi une intervention chirurgicale. Les patients soumis à la chirurgie ont présenté davantage de complications (64 % c. 27 %, p = 0,002) et ont séjourné plus longtemps à l'hôpital (10 j. c. 3 j., p < 0,001) comparativement aux patients qui n'ont pas été opérés. La prise en charge non chirurgicale a été associée à un taux élevé de récurrences de l'OIG : 31 % après un suivi médian de 17 mois. Parmi les patients opérés, 60 % ont subi une chirurgie immédiate et 40 % ont subi leur chirurgie après une tentative de prise en charge non chirurgicale. Les patients chez qui la prise en charge non chirurgicale a échoué ont subi leur chirurgie après une période médiane de 2 jours et 89 % en l'espace de 5 jours. Le taux de résection intestinale a été élevé (29 %) chez ceux dont la chirurgie a été retardée. La chirurgie après une intervention non chirurgicale infructueuse a été associée à un taux de mortalité de 14 %, contre 3 % chez les patients immédiatement soumis à la chirurgie. Toutefois, cette différence s'est révélée non significative. CONCLUSION: Ces données laissent penser que certains patients âgés présentant une OIG attendent peut-être trop longtemps pour leur chirurgie.

Self-reported practice patterns and knowledge of rectal cancer care among Canadian general surgeons.

BACKGROUND: Our objective was to examine the knowledge and treatment decision practice patterns of Canadian surgeons who treat patients with rectal cancer. METHODS: A mail survey with 6 questions on staging investigations, management of low rectal cancer, lymph node harvest, surgical margins and use of adjuvant therapies was sent to all general surgeons in Canada. Appropriate responses to survey questions were defined a priori. We compared survey responses according to surgeon training (colorectal/surgical oncology v. others) and geographic region (Atlantic, Central, West). RESULTS: The survey was sent to 2143 general surgeons; of the 1312 respondents, 703 treat patients with rectal cancer. Most surgeons responded appropriately to the questions regarding staging investigations (88%) and management of low rectal cancer (88%). Only 55% of surgeons correctly identified the recommended lymph node harvest as 12 or more nodes, 45% identified 5 cm as the recommended distal margin for upper rectal cancer, and 70% appropriately identified which patients should be referred for adjuvant therapy. Surgeons with subspecialty training were significantly more likely to provide correct responses to all of the survey questions than other surgeons. There was limited variation in responses according to geographic region. Subspecialty-trained surgeons and recent graduates were more likely to answer all of the survey questions correctly than other surgeons. CONCLUSION: Initiatives are needed to ensure that all surgeons who treat patients with rectal cancer, regardless of training, maintain a thorough and accurate knowledge of rectal cancer treatment issues.

CONTEXTE: Notre objectif était d'évaluer les connaissances et les processus décisionnels thérapeutiques des chirurgiens canadiens qui traitent des patients atteints de cancer rectal. MÉTHODES: Un sondage envoyé par la poste comportant 6 questions sur les épreuves de stadification, la prise en charge du cancer du bas rectum, le prélèvement des ganglions lymphatiques, les marges chirurgicales et l'utilisation de traitements adjuvants a été envoyé à tous les chirurgiens généraux au Canada. Les réponses appropriées aux questions du sondage avaient été définies au préalable. Nous avons comparé les réponses au sondage selon la formation des chirurgiens (oncologie colorectale/chirurgicale c. autres) et selon la région (Atlantique, Centre, Ouest). RÉSULTATS: Le sondage a été envoyé à 2143 chirurgiens généraux; parmi les 1312 répondants, 703 traitent des patients atteints de cancer rectal. La plupart des chirurgiens ont répondu de façon appropriée aux questions concernant les épreuves de stadification (88 %) et la prise en charge du cancer du bas rectum (88 %). Seulement 55 % des chirurgiens ont correctement répondu à la question sur le nombre optimal de ganglions lymphatiques à prélever, soit 12 ganglions ou plus, 45 % ont donné 5 cm comme marge distale recommandée pour le cancer du haut rectum et 70 % ont déterminé de manière appropriée quels patients il faut orienter vers un traitement adjuvant. Les chirurgiens qui avaient reçu une formation spécialisée étaient significativement plus susceptibles de fournir des réponses exactes à toutes les questions du sondage comparativement aux autres chirurgiens. On a noté une variation limitée entre les réponses selon les régions. Les chirurgiens spécialisés et les nouveaux diplômés étaient plus susceptibles de répondre correctement à toutes les questions du sondage comparativement aux autres chirurgiens. CONCLUSION: Des initiatives s'imposent pour s'assurer qu'indépendamment de leur formation tous les chirurgiens qui traitent des patients atteints d'un cancer rectal maintiennent des connaissances complètes et exactes sur les enjeux thérapeutiques entourant le cancer rectal.

Intra-coronary imaging modalities.

OPINION STATEMENT: The use of intracoronary imaging modalities has seen a significant increase over the past decade, as both imaging quality and delivery systems have improved. Generally accepted best practice indications for using intracoronary imaging include assessment of lesion characteristics prior to stent placement, optimization of stent placement with respect to appropriate sizing, adequate apposition, and expansion and exclusion of edge dissection. Intracoronary imaging plays a particular role in the setting of contemporary left main and bifurcation stenting. Stent interrogation using intracoronary imaging to exclude mechanical causes in the management of in-stent thrombosis has also become conventional. Current clinical guideline recommendations, however, have lagged behind contemporary practice patterns and the use of intravascular ultrasound only carries a class IIa recommendation in the appropriate clinical setting. We discuss the currently available intracoronary imaging modalities and their applications, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), and review the data supporting their use.

Dopamine D2 receptors and striatopallidal transmission in addiction and obesity.

Drug addiction and obesity share the core feature that those afflicted by the disorders express a desire to limit drug or food consumption yet persist despite negative consequences. Emerging evidence suggests that the compulsivity that defines these disorders may arise, to some degree at least, from common underlying neurobiological mechanisms. In particular, both disorders are associated with diminished striatal dopamine D2 receptor (D2R) availability, likely reflecting their decreased maturation and surface expression. In striatum, D2Rs are expressed by approximately half of the principal medium spiny projection neurons (MSNs), the striatopallidal neurons of the so-called 'indirect' pathway. D2Rs are also expressed presynaptically on dopamine terminals and on cholinergic interneurons. This heterogeneity of D2R expression has hindered attempts, largely using traditional pharmacological approaches, to understand their contribution to compulsive drug or food intake. The emergence of genetic technologies to target discrete populations of neurons, coupled to optogenetic and chemicogenetic tools to manipulate their activity, have provided a means to dissect striatopallidal and cholinergic contributions to compulsivity. Here, we review recent evidence supporting an important role for striatal D2R signaling in compulsive drug use and food intake. We pay particular attention to striatopallidal projection neurons and their role in compulsive responding for food and drugs. Finally, we identify opportunities for future obesity research using known mechanisms of addiction as a heuristic, and leveraging new tools to manipulate activity of specific populations of striatal neurons to understand their contributions to addiction and obesity.

Population-based use of sphincter-preserving surgery in patients with rectal cancer: is there room for improvement?

BACKGROUND: Treatment of rectal cancer in North America has been associated with lower rates of sphincter-preserving surgery in comparison with other regions. It is unclear if these lower rates are due to patient, tumor, or treatment factors; thus, the potential to increase the use of sphincter-preserving surgery is unknown. OBJECTIVE: The aim of this study is to identify the factors associated with the use of sphincter-preserving surgery and to quantify the potential for an increase in sphincter preservation. DESIGN: This population-based retrospective cohort study used patient-level data collected through a comprehensive, standardized review of hospital inpatient and outpatient medical records and cancer center charts. SETTINGS: This study was conducted in all hospitals providing rectal cancer surgery in a Canadian province. PATIENTS: All patients with a new diagnosis of rectal cancer from July 1, 2002 to June 30, 2006 who underwent potentially curative radical surgery were included. MAIN OUTCOME MEASURES: Logistic regression was used to identify factors associated with receiving a permanent colostomy. Patients were categorized as having received an appropriate or potentially inappropriate colostomy based on a priori determined patient, tumor, operative, and pathologic criteria. RESULTS: Of 466 patients who underwent radical surgery, 48% received a permanent colostomy. There was significant variation in the rate of sphincter-preserving surgery among the 10 hospitals that provided rectal cancer care (12%-73%, p = 0.0001). On multivariate analysis, male sex, low tumor height, and increasing tumor stage were associated with the receipt of a permanent colostomy. Among patients who received a permanent stoma, 65 of 224 (29%) patients received a potentially inappropriate stoma. On multivariate analysis, male sex and treatment in a medium- or low-volume hospital was associated with the receipt of a potentially inappropriate colostomy. LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: These data suggest that the receipt of a permanent colostomy by many patients with rectal cancer may be inappropriate, and there is potential to increase the use of sphincter-preserving surgery in patients with rectal cancer.

Surgeon knowledge contributes to the relationship between surgeon volume and patient outcomes in rectal cancer.

OBJECTIVE: To determine whether surgeon knowledge contributes to the relationship between surgeon procedure volume and patient outcomes in rectal cancer. BACKGROUND: Although previous research has shown that treatment by high-volume surgeons is associated with improved outcomes among patients with rectal cancer, the mechanisms for such an association are not well understood. METHODS: In 2009, a mail survey with 8 questions pertaining to rectal cancer care was created, modified for content validity, and sent to all general surgeons in Nova Scotia, Canada. Patients with rectal cancer, who were treated by the survey respondents between July 1, 2002, and June 30, 2006, were identified retrospectively, and a comprehensive standardized review of medical records was used to collect outcome data for this population-based cohort. The association between surgeon survey score (dichotomized into high- and low-score groups on the basis of the median score), surgeon procedure volume, and patient outcomes was examined. RESULTS: Of 521 patients who underwent treatment with curative intent from July 1, 2002, to June 30, 2006, 377 patients (72%) were treated by 25 surgeons who responded to the survey. After controlling for patient and tumor factors, patients treated by high-volume surgeons were more likely to receive a total mesorectal excision (TME) [odds ratio (OR) = 3.89; 95% confidence interval (CI), 2.20-5.83], more likely to undergo an adequate lymph node harvest (OR = 3.67; 95%CI, 2.36-5.70), less likely to have a permanent colostomy (OR = 0.53; 95%CI, 0.30-0.93), and less likely to develop local recurrence (HR = 0.54; 95%CI, 0.29-0.99). When surgeon survey score was included in the multivariate regression models, the relationship between surgeon procedure volume and permanent colostomy was diminished. There was a significant interaction between surgeon survey score and surgeon volume for the outcomes of use of TME (P < 0.01) and local recurrence (P = 0.01). CONCLUSIONS: These data suggest that surgeon knowledge may, at least in part, explain surgeon volume-associated differences in rectal cancer outcomes.

The impact of intraoperative cholangiography on recurrent pancreatitis and biliary complications in patients with gallstone pancreatitis.

INTRODUCTION: Although gallstone pancreatitis is initiated by the presence of stones in the common bile duct, the benefit associated with routine intraoperative cholangiography at the time of cholecystectomy in these patients is unclear. The purpose of this study, using population-based data, was to determine the impact of cholangiography on clinical outcomes after cholecystectomy for gallstone pancreatitis. METHODS: All patients who were admitted to hospital from January 1, 1997 to December 31, 2001 in Nova Scotia, Canada with pancreatitis who underwent cholecystectomy during the same admission were identified. The rates of recurrent pancreatitis and biliary complications after surgery were compared between patients who underwent cholecystectomy with intraoperative cholangiography ± common bile duct exploration and those who underwent cholecystectomy alone, using three linked administrative databases. RESULTS: Three hundred thirty-two patients were identified, 119 had cholangiography at the time of cholecystectomy and 213 did not. After a median follow-up of after 3.8 years, there was no difference in the rate of recurrent pancreatitis or biliary complications between those who had cholangiography ± common bile duct exploration at the time of surgery and those who did not; 13.4 versus 10.8 %, respectively (p = 0.55). CONCLUSIONS: These data suggest that intraoperative cholangiography does not improve outcomes after cholecystectomy for gallstone pancreatitis.