Transanal versus laparoscopic total mesorectal excision: a comparative study of long-term oncological outcomes.

BACKGROUND: Transanal total mesorectal excision (TaTME) is the most recent approach developed to improve pelvic dissection in surgery for mid and low rectal tumors. There are still inconsistencies regarding the technique's oncological results. The aim of this study was to analyze clinical and oncological outcomes of the learning curve of TaTME in comparison to laparoscopic TME (lapTME). METHODS: Rectal cancer patients who had TaTME and lapTME in two Portuguese colorectal units between March 2016 and December 2018 were eligible. Primary endpoints were 5-year overall survival, disease-free survival, and local recurrence. Secondary endpoints were clinical and pathological outcomes. RESULTS: Forty-four patients underwent TaTME (29 men) and 39 lapTME (27 men) with a median age of 69 and 66 (p = 0.093), respectively. No differences were observed concerning baseline characteristics, emphasizing their comparability. In the TaTME group, there were more hand-sewn anastomosis (0 lapTME versus 7 TaTME, p = 0.018) with significantly less distance to the dentate line (40 mm lapTME versus 20 mm TaTME, p = 0.005) and significantly more loop ileostomies performed (28 lapTME versus 41 TaTME, p = 0.001). There were no differences in post-operative mortality, morbidity, readmissions, and stoma closure. Groups were similar in relation to specimen quality, margins, and resectability; however, TaTME had a significantly higher node yield (14 lapTME versus 20 TaTME, p = 0.002). Finally, no disparities were noted in oncological outcomes, namely local and distant recurrence, 5-year overall survival, and disease-free survival. CONCLUSIONS: Even with the disadvantage of the learning curve of a new technique, TaTME appears to be comparable to lapTME, with similar long-term oncological outcomes. It has, however, a demanding learning curve, significant risk for morbidity and should be used only for selected patients.

Transanal total mesorectal excision: 3-year oncological outcomes.

BACKGROUND: Rectal cancer treatment has evolved with the implementation of new surgical techniques. Transanal total mesorectal excision (TaTME) is the most recent approach developed to facilitate pelvic dissection of mid- and distal rectal tumours. The purpose of this study was to analyse the short- and mid-term oncological outcomes of TaTME. METHODS: A study was conducted on patients treated with TaTME for rectal cancer at two colorectal units in Portugal between March 2016 and December 2018. Clinical, pathological and oncological data were retrospectively analysed. Primary endpoints were 3-year overall survival, disease-free survival and local recurrence. Secondary endpoints were clinical and pathological outcomes. RESULTS: Fifty patients (31 males, [62%], median age 66 years [range 40-85 years]) underwent TaTME, 49 (98%) for malignant and 1 (2%) for benign disease. There were no cases of conversion, 49 (98%) patients had complete or near-complete mesorectum, all the resections were R0 with adequate distal and circumferential margins. With a median follow-up of 36 months, there were 2 cases (4%) of local recurrence and 3-year estimated overall survival and disease-free survival were 90% and 79%, respectively. CONCLUSIONS: TaTME can provide safe mid-term oncological outcomes, similar to what has been published for classic and laparoscopic TME. Our results also show how demanding this novel approach can be and the consequent need for audited data and standardized implementation.

Preoperative biliary drainage in patients performing pancreaticoduodenectomy : guidelines and real-life practice.

BACKGROUND AND AIM: Preoperative biliary drainage (PBD) in patients with pancreatic cancer remains debatable. The aim of this study was to analyse the indications for PBD in patients performing pancreaticoduodenectomy (PD) and to evaluate the impact of this procedure on postoperative outcome. METHODS: Observational retrospective cohort study of patients undergoing PD for pancreatic cancer. Clinical data and postoperative outcome, namely complications and 90-day mortality, were prospectively collected and compared between patients performing PBD or direct surgery (DS). RESULTS: Eighty-two patients were included: 40 underwent PBD and 42 performed DS. Major complications (27.5% vs 33.3%, P=0.156) and 90-day mortality (10% vs 16.7%, P=0.376) were similar between the two groups. There was a trend for higher mean total bilirubin in patients with PBD (P=0.073). The indication for PBD was suspicion of cholangitis/choledocholithiasis or need to perform neoadjuvant chemotherapy in 24 (60%) patients. In the remaining, elevated bilirubin was probably the only reason to perform PBD. Length of hospital stay was longer in PBD group (P=0.003). On multiple logistic regression, 90-day mortality was not related with preoperative bilirubin levels, biliary drainage or its indication, but solely with age (OR 1.15, 95%CI 1.05-1.31, P=0.008). CONCLUSIONS: PBD is often performed in patients undergoing PD without a formal indication, mainly due to high bilirubin levels. No increased morbidity/mortality was observed but length of hospital stay was prolonged in patients performing PBD.

3D geophysical imaging for site-specific characterization plan of an old landfill.

As it is well-known, the characterization plan of an old landfill site is the first stage of the project for the treatment and reclamation of contaminated lands. It is a preliminary in-situ study, with collection of data related to pollution phenomena, and is aimed at defining the physical properties and the geometry of fill materials as well as the possible migration paths of pollutants to the surrounding environmental targets (subsoil and groundwater). To properly evaluate the extent and potential for subsoil contamination, waste volume and possible leachate emissions from the landfill have to be assessed. In such perspective, the integrated use of geophysical methods is an important tool as it allows a detailed 3D representation of the whole system, i.e. waste body and hosting environment (surrounding rocks). This paper presents a very accurate physical and structural characterization of an old landfill and encasing rocks obtained by an integrated analysis of data coming from a multi-methodological geophysical exploration. Moreover, drillings were carried out for waste sampling and characterization of the landfill body, as well as for calibration of the geophysical modeling.

Liraglutide improves cardiac function in patients with type 2 diabetes and chronic heart failure.

PURPOSE: To compare the effect of liraglutide, sitagliptin and insulin glargine added to standard therapy on left ventricular function in post-ischemic type-2 diabetes mellitus patients. METHODS: We evaluated 32 type-2 diabetes mellitus Caucasians with history of post-ischemic chronic heart failure NYHA class II/III and/or left ventricular ejection fraction ≤45 %. Participants underwent laboratory determinations, electrocardiogram, echocardiogram, Minnesota Living with Heart Failure questionnaire and 6 min walking test at baseline and following 52 weeks treatment. Patients were treated with standard therapy for chronic heart failure and were randomized to receive liraglutide, sitagliptin and glargine in addition to metformin and/or sulfonylurea. RESULTS: Liraglutide treatment induced an improvement in left ventricular ejection fraction from 41.5 ± 2.2 to 46.3 ± 3 %; P = 0.001). On the contrary, treatment with sitagliptin and glargine induced no changes in left ventricular ejection fraction (41.8 ± 2.6 vs. 42.5 ± 2.5 % and 42 ± 1.5 vs. 42 ± 1.6 %, respectively; P = NS). Indexed end-systolic LV volume was reduced only in liraglutide-treated patients (51 ± 9 vs. 43 ± 8 ml/m2; P < 0.05). Liraglutide treatment induced also a significant increase in the anterograde stroke volume (39 ± 9 vs. 49 ± 11 ml; P < 0.05), whereas no differences were observed in the other two groups. Cardiac output and cardiac index showed a significant increase only in liraglutide-treated patients (4.4 ± 0.5 vs. 5.0 ± 0.6 L/min; P < 0.05 and 1.23 ± 0.26 vs. 1.62 ± 0.29 L/m2; P = 0.005, respectively). Liraglutide treatment was also associated with an improvement of functional capacity and an improvement of quality of life. CONCLUSIONS: These data provide evidence that treatment with liraglutide is associated with improvement of cardiac function and functional capacity in failing post-ischemic type-2 diabetes mellitus patients.

Excessive gain in body mass index-for-age Z-score and associated factors: a cohort study in female adolescents.

OBJECTIVE: To evaluate the occurrence of excessive gain in body mass index-for-age Z-score (BMI/AZ) and its associated factors in adolescent girls. METHODOLOGY: This is a cohort study conducted between 2007 and 2012 with 382 girls between 10 and 18 years of age attending public schools in Recife, Pernambuco, Brazil. Excessive gain in BMI/AZ (EGBMI/AZ) at follow-up was considered if the adolescent had a BMI/AZ >0.63 between follow-up and baseline. RESULTS: In 2007, 33.5% of girls were overweight, and at the end of the study this prevalence was 26.2%, with no statistically significant differences. Of the 382 girls evaluated in the cohort, 33% showed EGBMI/AZ. In 2007, 95% of these girls were normal weight or underweight, and in 2012, 60% were classified as overweight. After adjusting for possible confounding factors, three variables remained independently associated with EGBMI/AZ: underweight, normal weight and maternal overweight. CONCLUSIONS: Both underweight and normal weight were associated with EGBMI/AZ, and this could be due to a physiological protection for the occurrence of menarche. In fact, maternal overweight has considerable influence on adolescents' nutritional status because of exposure to an obesogenic environment.

Serum phosphorus levels are associated with endothelial dysfunction in hypertensive patients.

BACKGROUND AND AIMS: Recent data demonstrated that serum phosphorus, within the normal range, is an independent predictor of atherosclerotic cardiovascular disease, independently of renal function. Traditional cardiovascular risk factors are important mediators of endothelial dysfunction, the early step of atherosclerosis. We designed this study to evaluate a possible correlation between serum phosphorus and endothelium-dependent vasodilation, evaluated by the strain-gauge plethysmography, in naïve hypertensives. METHODS AND RESULTS: We investigated by strain-gauge plethysmography, the relationship between forearm blood flow (FBF) response to acetylcholine (ACh) and serum phosphorus in 500 patients with uncomplicated, never-treated, essential hypertension, divided by phosphorus tertiles. There were no significant differences among tertiles with the exclusion of forearm blood flow (FBF). Phosphorus (ß = -0.454; P = 0.0001), estimated-glomerular filtration rate (e-GFR, by CKD-EPI formula) (ß = 0.261; P = 0.0001), gender (ß = 0.215; P = 0.0001), BMI (ß = -0.086; P = 0.018), HDL-cholesterol (ß = 0.077; P = 0.036) were significantly related to endothelium-dependent vasodilation. In an additional analysis including serum high sensitivity C-reactive protein (hs-CRP) (measured in 400 patients) in the same model, the link between serum phosphorus and ACh-stimulated FBF did not change (ß = -0.422; P = 0.0001). Clinically relevant, 0.1 mg of phosphorus increase is associated with a reduction of 22% of ACh-stimulated FBF. On multiple logistic regression analysis, the risk of endothelial dysfunction was about twice higher in patients in the second (OR = 1.754, 95% CI = 1.055-2.915; P = 0.030) and three-fold higher in the third tertile (OR = 2.939, 95% CI = 1.598-5.408; P = 0.0001) in comparison with those in the first tertile of phosphorus. CONCLUSION: An impaired ACh-stimulated FBF is associated with serum phosphorus levels, within the normal range, in hypertensives.

The certification of transplant coordinators in Europe.

The appropriate clinical management of the integrated process of Donation and Transplantation implies the participation of the Transplant Coordinator. The aim of this article is to present the process of Certification of Transplant Coordinators in Europe since 2001, in accordance with the Council of Europe Recommendations and the evolving model implemented in 2008 under the auspices of the UEMS, reporting the longest running European standardized assessment of Transplant Coordination skills and knowledge. It includes the rationale for development of a certification process, how the examinations were developed and updated, eligibility to take the examination, and relationship with standards of practice for Transplant Coordinators. A total of 455 healthcare professionals were certified in two phases: 1(st) ETCO certification since 2001 to 2007 (390) and 2(nd) ETCO/UEMS certification from 2008 to 2011 (65).

Nutritional status, systemic inflammation and prognosis of patients with gastrointestinal cancer.

INTRODUCTION: Systemic inflammatory response in individuals with cancer is related to a progressive reduction in total body mass, especially lean mass. OBJECTIVE: The aim of the present study was to determine the association between nutritional status and systemic inflammatory response in patients with gastrointestinal cancer. METHODOLOGY: A case series study was carried out involving 30 male and female adults and elderly patients with no prior treatment sent consecutively for surgery. Nutritional status was assessed using subjective and objective methods. Inflammatory response and prognosis were assessed through the determination of C-reactive protein (CRP), the Glasgow Prognostic Score and CRP/albumin ratio. RESULTS: High prevalence values were found for systemic inflammation (73%), a greater risk of infectious and/or inflammatory complication (43%) and worse prognosis (50%). The percentage of weight loss was correlated with serum CRP (r = 0.38; p < 0.05) and the CRP/albumin ratio (r = 0.44; p < 0.05). Inflammation markers and prognosis were negatively correlated with serum albumin (r = -0.50; p < 0.05), body mass index (r = -0.39; p < 0.05) and total lymphocyte count (r = -0.37; p < 0.05). Patients with weight loss and malnourishment had significantly higher serum CRP and CRP/albumin ratio values as well as lower serum albumin levels in comparison to those without weight loss and in well-nourished. CONCLUSION: Nutritional status is related to inflammation markers and prognosis in patients with gastrointestinal cancer. The diagnosis and attenuation of systemic inflammation should be part of the nutritional care of these patients.

Nutritional status, systemic inflammation and prognosis of patients with gastrointestinal cancer / El estado nutricional, la inflamación sistémica y el pronóstico de los pacientes con cáncer gastrointestinal

Introduction: Systemic inflammatory response in individuals with cancer is related to a progressive reduction in total body mass, especially lean mass. Objective: The aim of the present study was to determine the association between nutritional status and systemic inflammatory response in patients with gastrointestinal cancer. Methodology: A case series study was carried out involving 30 male and female adults and elderly patients with no prior treatment sent consecutively for surgery. Nutritional status was assessed using subjective and objective methods. Inflammatory response and prognosis were assessed through the determination of C-reactive protein (CRP), the Glasgow Prognostic Score and CRP/albumin ratio. Results: High prevalence values were found for systemic inflammation (73%), a greater risk of infectious and/or inflammatory complication (43%) and worse prognosis (50%). The percentage of weight loss was correlated with serum CRP (r = 0.38; p < 0.05) and the CRP/albumin ratio (r = 0.44; p < 0.05). Inflammation markers and prognosis were negatively correlated with serum albumin (r= -0.50; p < 0.05), body mass index (r = -0.39; p < 0.05) and total lymphocyte count (r= -0.37; p < 0.05). Patients with weight loss and malnourishment had significantly higher serum CRP and CRP/albumin ratio values as well as lower serum albumin levels in comparison to those without weight loss and in well-nourished. Conclusion: Nutritional status is related to inflammation markers and prognosis in patients with gastrointestinal cancer. The diagnosis and attenuation of systemic inflammation should be part of the nutritional care of these patients (AU)

Introducción: En los individuos con cáncer, la respuesta inflamatoria sistémica es relacionada a la progresiva disminución de la masa corpórea total, principalmente de la masa magra. Objetivo: Verificar la relación entre el estado nutricional y la actividad inflamatoria sistémica en pacientes con cáncer del trato gastrointestinal. Metodología: estudio tipo serie de casos, envolviendo 30 pacientes adultos y ancianos de ambos sexos, sin tratamiento anterior, enviados consecutivamente para cirugía. El estado nutricional fue evaluado por métodos subjetivo y objetivo, y la actividad inflamatoria y el pronóstico por medio de proteína C-reactiva (PCR), Puntuación Pronóstico de Glasgow (GPS) y Relación Proteína C-reactiva/ albumina. Resultados: Se verificó elevada prevalencia de pacientes con inflamación sistémica (73%), mayor riesgo de complicación infecciosa y/o inflamatoria (43%) y peor pronóstico (50%). El porcentual de pérdida de peso se correlacionó con la PCR seria (r = 0,38; p < 0,05) y la relación PCR/albumina (r = 0,44; p < 0,05). Hubo correlación negativa de la albumina sérica (r= -0,50; p < 0,05), del Índice de Masa Corporal (r = -0,39; p < 0,05) y del Cómputo Total de Linfocitos (r = -0,37; p < 0,05) con los marcadores de inflamación y pronóstico. Los pacientes con pérdida de peso y desnutridos presentaban valores significativamente mayores de PCR sérica y relación PCR/ albumina, y menores de albumina sérica cuando comparados con aquellos sin pérdida de peso y eutróficos. Conclusión: El estado nutricional es relacionado con los marcadores de inflamación y pronóstico. Se sugiere que el diagnóstico y la atenuación de la inflamación sistémica sean parte del cuidado nutricional de estos pacientes (AU)

A low tilt waveform in the transthoracic defibrillation of ventricular arrhythmias during cardiac arrest.

AIM: Most commercially available defibrillators utilise a high tilt waveform. Work in atrial fibrillation has shown improved defibrillation success using low tilt waveforms. We hypothesise that a novel low tilt biphasic waveform will be non-inferior to a standard tilt waveform whilst delivering lower energy for the defibrillation of ventricular arrhythmias. METHODS: Patients in cardiac arrest who experienced ventricular arrhythmias received shocks from a novel low tilt waveform defibrillator at 120J or a standard tilt waveform defibrillator at 150J. Resuscitation guidelines were followed as per Resuscitation Council UK, 2005. A shock was successful when the ventricular arrhythmia was terminated for ≥ 5s following shock delivery. RESULTS: A total of 113 cardiac arrest cases were included. The low tilt device was used for 56 cases and the standard tilt device for 57 cases. The presenting rhythm was ventricular fibrillation (VF) in 71.7% (81/113), pulseless electrical activity (PEA) in 15.9% (18/113), ventricular tachycardia (VT) in 9.7% (11/113), asystole in 1.8% (2/113) and narrow complex rhythm in 0.9% (1/113). The low tilt device resulted in first shock success in 86% (48/56 cases) vs. the standard tilt device first shock success of 77% (44/57 cases). There was no significant difference in first shock success between the two devices (p=0.36). CONCLUSION: The low tilt waveform used in this study demonstrated first shock success rates in keeping with a commercially available high tilt defibrillator which could result in less myocardial damage due to reduced energy requirements.

Correlates of violence history among injured patients in an urban emergency department: gender, substance use, and depression.

This study surveyed consecutive injured patients (n = 320) in an urban emergency department (ED) regarding past year violence, substance use, and depression. Victimization and aggression variables (none = N, partner only = P, non-partner only = NP, and generalized/both partner and non-partner = G) were compared on gender, depression, and substance use/consequences. Findings were similar for victimization and aggression variables. Depression was significantly related to violence for women but not for men; women in the P group reported the most depression. Substance variables were significantly related to violence by gender groups. Men in NP and G groups reported the most binge drinking; men in the G group reported the most consequences and drug use. Women in P and G groups reported the most binge drinking and consequences; women in the P group reported the most drug use. Screening urban ED patients for violence is warranted, with interventions addressing both partner and non-partner violence.

Effects of diethyldithiocarbamate (DETC) on liver injury induced by ischemia-reperfusion in rats.

PURPOSE: In organ transplantation, ischemia-reperfusion injury (I/R) is a constant occurrence. Dithiocarbamates, a class of antioxidants, have been reported to inhibit nuclear factor-kappaB (NF-kappaB), a critical transcription factor in the intracellular inflammatory cascade. We studied the effects of diethyldithiocarbamate (DETC) on liver injury induced by I/R. MATERIALS AND METHODS: Male Wistar rats were pretreated with DETC (100 mg/kg IV) 10 minutes before hepatic ischemia, which was followed by 2 hours reperfusion, or 10 minutes prior to the reperfusion. Blood samples were obtained at the end of the reperfusion period to determine the biochemical markers of liver injury. Results were compared using the one-way analysis of variance (ANOVA), followed by the Bonferroni posttest, and presented as mean values +/- SEM. RESULTS: I/R produced significant increases in aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and gamma-glutamyl transferase (gamma-GT) serum levels compared with sham-operated rats. Administration of DETC prior to the onset of reperfusion significantly reduced the liver injury. However, DETC administered before the ischemic period failed to protect the liver from an I/R injury. CONCLUSION: DETC, administered just before the reperfusion period, resulted in a significant decrease in the I/R injury to the liver, an observation that may have therapeutic implications.

Finite driving rate and anisotropy effects in landslide modeling.

In order to characterize landslide frequency-size distributions and individuate hazard scenarios and their possible precursors, we investigate a cellular automaton where the effects of a finite driving rate and the anisotropy are taken into account. The model is able to reproduce observed features of landslide events, such as power-law distributions, as experimentally reported. We analyze the key role of the driving rate and show that, as it is increased, a crossover from power-law to non-power-law behaviors occurs. Finally, a systematic investigation of the model on varying its anisotropy factors is performed and the full diagram of its dynamical behaviors is presented.

Parental perceptions regarding mandatory mouthguard use in competitive youth soccer.

OBJECTIVE: To understand factors that influence parental perceptions regarding mandatory mouthguard use in competitive youth soccer. SETTING AND SUBJECTS: A web based survey of parents whose 8-14 year old children participated in outdoor competitive youth soccer during the fall of 2002. Questions focused on: previous injury, education provided, dentist/physician recommendations, and parental perceptions of mouthguard use. MAIN OUTCOME MEASURE: The outcome variable was parental agreement with the statement "mouthguards should be mandatory for competitive youth soccer". Logistic regression and chi(2) were performed using STATA 8.0. RESULTS: Altogether 120 parents participated. The children had a mean (SD) age of 11.8 (1.5) years and 48% were female; 14% wore mouthguards and 11% suffered orofacial injuries. Nineteen percent of parents reported receiving educational material from the youth soccer organization. Although 92% of parents believed that mouthguards were effective in reducing orofacial injuries, only one half agreed that mouthguards should be mandatory. Thirty percent of respondents reported that their dentist/physician recommended mouthguards for competitive youth soccer. Logistic regression showed that dentist/physician recommendation and parental female gender were independently associated with parental agreement for mandatory mouthguard use (odds ratio 2.9, 95% confidence interval (CI) 1.2 to 7.3; odds ratio 3.0, 95% CI 1.1 to 6.5). CONCLUSIONS: Few athletes wear mouthguards during competitive youth soccer. Health care professionals in this study did not capitalize on the apparent influence they have on parental beliefs regarding mouthguard use. Efforts are needed by both health professionals and soccer organizations to educate parents about orofacial injuries and mouthguard use in competitive youth soccer.