Vortioxetine reduces BOLD signal during performance of the N-back working memory task: a randomised neuroimaging trial in remitted depressed patients and healthy controls.

Cognitive dysfunction is common in depression during both acute episodes and remission. Vortioxetine is a novel multimodal antidepressant that has improved cognitive function including executive function in depressed patients in randomised placebo-controlled clinical trials. However, it is unclear whether vortioxetine is able to target directly the neural circuitry implicated in the cognitive deficits in depression. Remitted depressed (n=48) and healthy volunteers (n=48) were randomised to receive 14 days treatment with 20 mg vortioxetine or placebo in a double-blind design. The effects of treatment on functional magnetic resonance imaging responses during an N-back working memory task were assessed at baseline and at the end of treatment. Neuropsychological measures of executive function, speed and information processing, attention and learning and memory were examined with the Trail Making Test (TMT), Rey Auditory Learning Test and Digit Symbol Substitution Test before and after treatment; subjective cognitive function was assessed using the Perceived Deficits Questionnaire (PDQ). Compared with placebo, vortioxetine reduced activation in the right dorsolateral prefrontal cortex and left hippocampus during the N-back task compared with placebo. Vortioxetine also increased TMT-A performance and self-reported cognitive function on the PDQ. These effects were seen across both subject groups. Vortioxetine modulates neural responses across a circuit subserving working memory in a direction opposite to the changes described in depression, when performance is maintained. This study provides evidence that vortioxetine has direct effects on the neural circuitry supporting cognitive function that can be dissociated from its effects on the mood symptoms of depression.

A National Needs Assessment to Identify Technical Procedures in Vascular Surgery for Simulation Based Training.

OBJECTIVES AND BACKGROUND: Practical skills training in vascular surgery is facing challenges because of an increased number of endovascular procedures and fewer open procedures, as well as a move away from the traditional principle of "learning by doing." This change has established simulation as a cornerstone in providing trainees with the necessary skills and competences. However, the development of simulation based programs often evolves based on available resources and equipment, reflecting convenience rather than a systematic educational plan. The objective of the present study was to perform a national needs assessment to identify the technical procedures that should be integrated in a simulation based curriculum. DESIGN AND METHODS: A national needs assessment using a Delphi process was initiated by engaging 33 predefined key persons in vascular surgery. Round 1 was a brainstorming phase to identify technical procedures that vascular surgeons should learn. Round 2 was a survey that used a needs assessment formula to explore the frequency of procedures, the number of surgeons performing each procedure, risk and/or discomfort, and feasibility for simulation based training. Round 3 involved elimination and ranking of procedures. RESULTS: The response rate for round 1 was 70%, with 36 procedures identified. Round 2 had a 76% response rate and resulted in a preliminary prioritised list after exploring the need for simulation based training. Round 3 had an 85% response rate; 17 procedures were eliminated, resulting in a final prioritised list of 19 technical procedures. CONCLUSION: A national needs assessment using a standardised Delphi method identified a list of procedures that are highly suitable and may provide the basis for future simulation based training programs for vascular surgeons in training.

[Gastroesophageal reflux]. / Gastroøsofageal refluks.

Gastro-oesophageal reflux is a common disorder. About 50% of patients with reflux disease have oesophagitis, a condition which is diagnosed in approximately 20% of all patients referred for gastroscopy. Effective drug regimens combined with life-style modifications can keep the majority of patients free of symptoms. Relapses are frequent and prolonged or life-long maintenance therapy is often required. Complications include stricture formation and development of Barrett's epithelium, a premalignant condition. At present surgery is reserved for patients who do not respond to medical treatment and patients who do not wish to take life-long medical therapy, and should be considered for patients with complications of reflux disease. The operation may be carried out laparoscopically.

[Cystectomy for urinary bladder cancer. Postoperative complications and mortality]. / Cystektomi for urinblaerecancer. Postoperative komplikationer og mortaliet.

During a period of ten years, 111 patients with cancer of the bladder were treated by total cystectomy. In 69 patients a preoperative radiation dose of 40 Gy was administered, 23 received 60 Gy and 19 received no radiation. The crude-survival was 50%. The postoperative mortality was low, 3.6%.

Emergency haemorrhoidectomy compared with incision and banding for the treatment of acute strangulated haemorrhoids. A prospective randomised study.

OBJECTIVE: To find out if incision and banding was as effective as emergency haemorrhoidectomy in the treatment of strangulated haemorrhoids. DESIGN: Prospective randomised study. SETTING: Glostrup Hospital, Copenhagen, Denmark. SUBJECTS: 30 patients with uncomplicated acute strangulated haemorrhoids. INTERVENTIONS: Milligan-Morgan haemorrhoidectomy or incision, evacuation of blood clot, and application of elastic bands. MAIN OUTCOME MEASURE: Amount of analgesia required, length of stay in hospital, and incidence of complications. RESULTS: Patients treated by incision and banding required significantly less opioid analgesia and spent significantly fewer days in hospital than those treated by haemorrhoidectomy, but two of them required emergency haemorrhoidectomy because the bands had slipped. CONCLUSIONS: Incision and banding is a reasonable alternative to emergency haemorrhoidectomy provided that it is done correctly, but long term follow up is needed before a final conclusion can be drawn.

[Incidence and treatment of urinary calculi in patients in Frederiksborg County]. / Forekomst og behandling af sten i urinveje hos patienter i Frederiksborg Amt.

The case records of all patients admitted to one of the hospitals in the County of Frederiksborg with radiologically demonstrated first episodes of urinary calculi during a period of one year in 1983/1984 and 1988/1989 respectively were reviewed retrospectively. Uniform frequencies of calculus incidence and sex distribution were encountered mutually and as compared with the remainder of Denmark during the two periods. In 30% of the cases the calculi were localized to the kidneys and in 58% to the ureter. In approximately 65% of the patients, the greatest diameter of the stones was 100 mm or less. Spontaneous passage of the stones occurred in approximately 40%. Development in the treatment of urinary tract stones has followed the development in the county as a whole. The number of operative interventions during the five year period was reduced by 30% and extracorporeal shock wave treatment was employed in 22% during the second period.

Outcome, transport times, and costs of patients evacuated by helicopter versus fixed-wing aircraft.

We determined the differences in transport times and costs for patients transported by fixed-wing aircraft versus helicopter at ranges of 101 to 150 radial miles, where fixed-wing and helicopter in-hospital transports commonly overlap. Statistical analysis failed to show a significant difference between the trauma-care patients transported by helicopter (n = 109) and those transported by fixed-wing (n = 86) for age, injury severity score, hospital length of stay, hospital mortality, or discharge disability score. The times in returning patients to the receiving hospital by helicopter (n = 104) versus fixed-wing (n = 509) did not differ significantly. Helicopter transport costs per mile ($24), however, were 400% higher than those of fixed-wing aircraft with its associated ground ambulance transport costs ($6). Thus, helicopter transport is economically unjustified for interhospital transports exceeding 100 radial miles when an efficient fixed-wing service exists.

The economic impact of DRG payment policies on air-evacuated trauma patients.

This study assessed the injury severity, patient outcome, the cost of care, and the economic impact of Medicare DRG payment policies on patients referred to a Level I trauma center. Only 11 of 283 admitted traumatized patients were Medicare patients. Yet, these 11 Medicare patients left the trauma center with a deficit of $249,601. No significant differences were found between the Medicare and non-Medicare groups for Trauma Score, CRAMS Score, Glasgow Coma Score, Injury Severity Score, ICU or hospital length of stay, disability, or mortality. Under DRG's, Medicare payments ($4,237 +/- 2,351/patient) have fallen to 20% of prior cost-based Medicare reimbursements ($21,542 +/- 34,170/patient), are providing only 16% of hospital costs ($26,928 +/- 42,713/patient), and are significantly (p less than 0.0001) less than non-Medicare reimbursements ($15,288 +/- 17,111/patient). Despite the high financial losses occurring when the trauma center treats referred traumatized Medicare patients, when all referred Medicare and non-Medicare patient trauma reimbursements are combined, overall trauma revenues have declined by only 4.3% under DRG's. If Medicare DRG payments were to be adopted by all third-party payers, reimbursement ($5,058 +/- 4,090/patient) would be significantly (p less than 0.0001) less than current hospital reimbursements ($14,801 +/- 16,537/patient) and costs ($16,121 +/- 17,624/patient). These results indicate that although high financial losses result when caring for traumatized Medicare patients, DRG's have not had a major financial effect upon centers receiving referred trauma patients because of the low numbers of admitted traumatized Medicare patients. However, if third-party payers were to enact the Medicare payment system, devastating economic losses would be inflicted upon major trauma centers.