Short-term outcomes after Ivor Lewis oesophagectomy for cancer during the COVID-19 pandemic.

INTRODUCTION: Elective surgery in the UK came to a halt during the early part of the COVID-19 pandemic. As COVID-19-related infection and mortality rates in Devon and Cornwall were relatively low, however, urgent elective surgery continued in Plymouth, with the necessary precautions in place. This study aimed to assess outcomes following Ivor Lewis oesophagectomy (ILO) during the pandemic. METHODS: We prospectively analysed details of 20 consecutive patients who underwent ILO for cancer over a 3-month period between 17 March and 12 June 2020. All patients underwent COVID-19 swab testing 24-48 hours before surgery and during admission when clinically indicated. The primary outcome measure was COVID-19-related morbidity. Secondary outcome measures were non-COVID-19-related morbidity, mortality and length of hospital stay. RESULTS: Twenty patients underwent ILO during the study period. All patients identified as white British. No patients tested positive for COVID-19 pre- or postoperatively. There was no COVID-19-related morbidity. There was no in-hospital mortality. Seven patients developed pneumonia, which settled with antibiotics. One patient developed an anastomotic leak, which was treated conservatively. One patient returned to theatre for a para-conduit hernia repair. The median length of hospital stay was nine days. One patient required admission to the high dependency unit for inotropic support for two days. CONCLUSIONS: ILO can be performed safely during the COVID-19 pandemic with the necessary precautions in place.

Routine use of feeding jejunostomy in oesophageal cancer resections: results of a survey in England.

Nutrition and post-operative feeding in oesophageal cancer resections for enhanced recovery remain a controversial subject. Feeding jejunostomy tubes (FJT) have been used post-operatively to address the subject but evidence to support its routine use is contentious. There is currently no data on FJT use in England for oesophageal cancer resections. Knowledge regarding current FJT usage, and rationale for its use may provide a snapshot of the trend and current standing on FJT use by resectional units in England. A standardised survey was sent electronically to all oesophageal resectional units in the United Kingdom (UK) between October 2016 and January 2018. In summary, the questionnaire probes into current FJT use, rationale for its usage, consideration of cessation of its use, and rationale of cessation of its use for units not using FJT. The resectional units were identified using the National Oesophago-Gastric Cancer Audit (NOGCA) progress report 2016 and 1 selected resectional unit from Northern Ireland, Scotland, and Wales, respectively. Performance data of those units were collected from the 2017 NOGCA report. Out of 40 units that were eligible, 32 (80.0%) centres responded. The responses show a heterogeneity of FJT use across the resectional centres. Most centres (56.3%) still place FJT routinely with 2 of 18 (11.1%) were considering stopping its routine use. FJT was considered a mandatory adjunct to chemotherapy in 3 (9.4%) centres. FJT was not routinely used in 9 (28.1%) of centres with 5 of 9 (55.6%) reported previous complications and 4 of 9 (44.4%) cited using other forms of nutrition supplementation as factors for discontinuing FJT use. There were 5 (15.6%) centres with divided practice among its consultants. Of those 2 of 5 (40.0%) were considering stopping FJT use, and hence, a total of 4 of 23 (17.4%) of units are now considering stopping routine FJT use. In conclusion, the wider practice of FJT use in the UK remains heterogenous. More research regarding the optimal post-operative feeding regimen needs to be undertaken.

Intraoperative pyloric botulinum toxin injection during Ivor-Lewis gastroesophagectomy to prevent delayed gastric emptying.

Delayed gastric emptying (DGE) is a common morbidity that affects 10%-50% of Ivor-Lewis gastroesophagectomy (ILGO) patients. DGE management is variable with no gold standard prevention or treatment. We conducted a study to assess the effectiveness of intraoperative pyloric botulinum toxin injection in preventing DGE. All patients undergoing an ILGO for curative intent, semi-mechanical anastomosis, and enhanced recovery between 1st December 2011 and 30th June 2017 were included. Patients with pyloroplasties were excluded and botulinum toxin was routinely given from the 2nd April 2016. We compared botulinum toxin injection (BOTOX) against no intervention (NONE) for patient demographics, adjuvant therapy, surgical approach, DGE incidence, length of stay (LOS), and complications. Additionally, we compared pneumonia risk, anastomotic leak rate, and LOS in DGE versus non-DGE patients. DGE was defined using nasogastric tube input/output differences and chest X-ray appearance according to an algorithm adopted in our unit, which were retrospectively applied. There were 228 patients: 65 (28.5%) received botulinum toxin and 163 (71.5%) received no intervention. One hundred twenty-four (54.4%) operations were performed laparoscopically, of which 11 (4.8%) were converted to open procedures, and 104 (45.6%) were open operations. DGE incidence was 11 (16.9%) in BOTOX and 29 (17.8%) in NONE, P = 0.13. Medical management was required in 14 of 228 (6.1%) cases: 3 (4.6%) in BOTOX and 11 (4.8%) in NONE. Pyloric dilatation was required in 26 of 228 (11.4%): 8 of 65 (12.3%) in the BOTOX and 18 of 163 (11.0%) in NONE. There were no significant differences between groups and requirement for intervention, P = 0.881. Overall median LOS was 10 (6.0-75.0) days: 9 (7.0-75.0) in BOTOX and 10 (6.0-70.0) in NONE, P = 0.516. In non-DGE versus DGE patients, median LOS was 9 (6-57) versus 14 (7-75) days (P < 0.0001), pneumonia incidence of 27.7% versus 30.0% (P = 0.478), and anastomotic leak rate of 2.1% versus 10.0% (P = 0.014). Overall leak rate was 3.5%. Overall complication rate was 67.1%, including minor/mild complications. There were 43 of 65 (66.2%) in BOTOX and 110 of 163 (67.5%) in NONE, P = 0.482. In-hospital mortality was 1 (0.44%), 30-day mortality was 2 (0.88%), 90-day mortality was 5 (2.2%), and there were no 30-day readmissions. Intraoperative pyloric botulinum toxin injections were ineffective in preventing DGE (BOTOX vs. NONE: 16.9% vs. 17.8%) or reducing postoperative complications. DGE was relatively common (17.5%) with 11.4% of patients requiring postoperative balloon dilatation. DGE also resulted in prolonged LOS (increase from 9 to 14 days) and significant increase in leak rate from 2.1% to 10.0%. A better understanding of DGE will guide assessment, investigation, and management of the condition.

Utilizing weak pump depletion to stabilize squeezed vacuum states.

We propose and demonstrate a pump-phase locking technique that makes use of weak pump depletion (WPD) - an unavoidable effect that is usually neglected - in a sub-threshold optical parametric oscillator (OPO). We show that the phase difference between seed and pump beam is imprinted on both light fields by the non-linear interaction in the crystal and can be read out without disturbing the squeezed output. In our experimental setup we observe squeezing levels of 1.96 ± 0.01 dB, with an anti-squeezing level of 3.78 ± 0.02 dB (for a 0.55 mW seed beam at 1064 nm and 67.8 mW of pump light at 532 nm). Our new locking technique allows for the first experimental realization of a pump-phase lock by reading out the pre-existing phase information in the pump field. There is no degradation of the detected squeezed states required to implement this scheme.

The implementation and effectiveness of an enhanced recovery programme after oesophago-gastrectomy: a prospective cohort study.

BACKGROUND: Oesophageal resection is notoriously complicated and produces a cohort of patients prone to postoperative complications. Maintaining quality care demands a systematic approach to patient management yet postoperative recovery after oesophagectomy is often needlessly inefficient, heterogeneous and governed by the idiosyncrasies of the operating surgeon. Enhanced recovery after surgery (ERAS) programmes are now well established in colorectal surgery and here we describe the implementation and effectiveness of an ERAS programme for the postoperative management of Ivor Lewis oesophago-gastrectomy (ILOG). METHODS: An ERAS programme was devised and implemented with the support of a dedicated in-hospital task-force. Three consultant surgeons allocated consecutive patients to the programme (ERAS) and outcomes were compared to consecutive patients not on the ERAS programme (non-ERAS) and a pre-ERAS cohort (pre-ERAS). Principal outcome measures were total length of stay (TLOS), Accordion postoperative complication grade and 30-day readmission rate. RESULTS: 75 patients were enrolled on the ERAS programme, 41 continued as a non-ERAS cohort and 80 consecutive pre-ERAS patients were identified. A significant improvement in median TLOS was observed in the ERAS group (10 days r.7-58) compared to pre-ERAS (13 days r. 8-57) (p = <0.001) and non-ERAS patients (13 days r.8-42) (p = <0.001). No significant difference in Accordion scores for postoperative complications or 30-day readmission rates were observed. DISCUSSION: The introduction of an ERAS programme after ILOG can significantly reduce TLOS without jeopardising patient safety or clinical outcomes. The successful introduction of an ERAS programme requires full motivation and support from all team members including the patient.

An Effective Approach to Improving Day-Case Rates following Laparoscopic Cholecystectomy.

Background. Day-case laparoscopic cholecystectomy (LC) is a safe and cost-effective treatment for gallstones. In 2006, our institution recorded an 86% laparoscopic, 10% day-case, and 5% readmission rate. A gallbladder pathway was therefore introduced in 2007 with the aim of increasing daycase rates. Methods. Patients with symptomatic gallstones, proven on ultrasound, were referred to a specialist-led clinic. Those suitable for surgery were consented, preassessed, and provided with a choice of dates. All defaulted to day case unless deemed unsuitable due to comorbidity or social factors. Results. The number of cholecystectomies increased from 464 in 2006 to 578 in 2008. Day-case rates in 2006, 2007, 2008, and June 2009 were 10%, 20%, 30%, and 61%, respectively. Laparoscopic and readmission rates remained unchanged. Conversion rates for elective cholecystectomy fell from 6% in 2006 to 3% in 2009. Conclusions. Development of a gallbladder pathway increased day-case rates sixfold without an associated increase in conversion or readmission rates.

Adaptive optical phase estimation using time-symmetric quantum smoothing.

Quantum parameter estimation has many applications, from gravitational wave detection to quantum key distribution. The most commonly used technique for this type of estimation is quantum filtering, using only past observations. We present the first experimental demonstration of quantum smoothing, a time-symmetric technique that uses past and future observations, for quantum parameter estimation. We consider both adaptive and nonadaptive quantum smoothing, and show that both are better than their filtered counterparts. For the problem of estimating a stochastically varying phase shift on a coherent beam, our theory predicts that adaptive quantum smoothing (the best scheme) gives an estimate with a mean-square error up to 2sqrt[2] times smaller than nonadaptive filtering (the standard quantum limit). The experimentally measured improvement is 2.24+/-0.14.

An investigation into the current peri-operative nutritional management of oesophageal carcinoma patients in major carcinoma centres in England.

INTRODUCTION: Patients with oesophageal carcinoma are at high risk of malnutrition. The aim of this study was to assess current practice for the nutritional management of patients following surgery for oesophageal carcinoma. PATIENTS AND METHODS: A postal questionnaire was sent to 82 dietetic departments of those hospitals in England identified as major centres for upper gastrointestinal surgery. RESULTS: Of the 66 (80%) responses received, 22 (33%) centres routinely perform pre-operative nutritional screening/assessment on oesophageal carcinoma patients. Centres with dietetic support dedicated to these patients are more likely to perform a pre-operative nutritional assessment (n = 17; 55%) than those without (n = 5; 14%; P < 0.001; chi(2) = 12.17). Pre-operative nutritional support is routinely provided in only 11 (17%) centres with the majority of centres (n = 50; 75%), providing it if patients are considered malnourished only. A total of 47 (70%) centres routinely provide postoperative nutritional support with jejunal feeding being the most commonly chosen route. Dedicated dietetic support is provided at 31 (47%) centres. Those centres with a dedicated dietitian are more likely to provide early postoperative nutritional support (n = 27; 87%) than those without (n = 20; 57%; P = 0.007; chi(2) = 7.195) and more likely to review patients routinely following discharge from hospital (n = 25 [81%] with a dietitian versus n = 17 [49%] without; P = 0.007; chi(2) = 7.2). CONCLUSIONS: The nutritional management of patients following surgery for upper gastrointestinal carcinoma is not uniform with practice varying considerably between centres. Those centres with a dedicated dietitian are more likely to assess patients' nutritional status and provide nutritional support.

Controlled-release tablets from carrageenans: effect of formulation, storage and dissolution factors.

The purpose of this study was to investigate the potential of two carrageenans, iota-carrageenan and lambda-carrageenan for the preparation of controlled-release tablets. Tablets were compressed on a Carver press and the effect of formulation factors, moisture, and storage on the release of theophylline was studied. The effect of sodium chloride in the tablet formulation and a change in the ionic strength of the dissolution media was studied on the release of three model drugs. The release rate increased both with an increase in tablet diameter and increase in drug to carrageenan ratio in the tablets. The two lubricants studied had a negligible effect on the rate of drug release at their commonly used concentrations. Moisture content of carrageenans, storage of tablets at 37 degrees C/75% RH for 3 months, and incorporation of 10% sodium chloride in the tablets did not have any significant effect on the release rate. The change in ionic strength of simulated gastric fluid altered the release rate whereas the ionic strength of simulated intestinal fluid did not have a significant effect on the release rate. Carrageenan tablets were relatively insensitive to small changes in formulation parameters and dissolution conditions.

A comparison of reflectance and transmittance near-infrared spectroscopic techniques in determining drug content in intact tablets.

Drug contents of intact tablets were determined using non-destructive near infrared (NIR) reflectance and transmittance spectroscopic techniques. Tablets were compressed from blends of Avicel PH-101 and 0.5% w/w magnesium stearate with varying concentrations of anhydrous theophylline (0, 1, 2, 5, 10, 20 and 40% w/w). Ten tablets from each drug content batch were randomly selected for spectral analysis. Both reflectance and transmittance NIR spectra were obtained from these intact tablets. Actual drug contents of the tablets were then ascertained using a UV-spectrophotometer at 268 nm. Multiple linear regression (MLR) models at 1116 nm and partial least squares (PLS) calibration models were generated from the second derivative spectral data of the tablets in order to predict drug contents of intact tablets. Both the reflectance and the transmittance techniques were able to predict the drug contents in intact tablets over a wide range. However, a comparison of the results of the study indicated that the lowest percent errors of prediction were provided by the PLS calibration models generated from spectral data obtained using the transmittance technique.

Identification of mtDNA mutation in a pedigree with gestational diabetes, deafness, Wolff-Parkinson-White syndrome and placenta accreta.

Mitochondrial DNA (mtDNA) defects are associated with a number of human disorders. Although many occur sporadically, maternal transmission is the hallmark of diseases due to mtDNA point mutations. The same mutation may manifest strikingly different phenotypes; for example, the A to G substitution at np 3243 was first reported in patients with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (the MELAS syndrome), but is also found in patients with diabetes and deafness. Here we present a case of gestational diabetes, deafness, premature greying, placenta accreta and Wolff-Parkinson-White (WPW) syndrome associated with a mtDNA mutation. Although this is the first report of such an association, study of 27 other patients with WPW syndrome failed to confirm that this mtDNA mutation is a common cause of such pre-excitation disorders.

A prospective randomized trial of three different sizes of core-cutting needle for renal transplant biopsy.

BACKGROUND: Needle-core biopsy remains one of the most important investigations in cases of renal allograft dysfunction. The size and quality of the biopsy material are likely to be important factors in achieving an accurate diagnosis. The aim of this study was to compare the success and complication rates of renal transplant biopsy procedures using three differently sized needles. METHODS: One hundred renal allograft recipients undergoing transplant biopsy using an automated needle core method were randomized to a 14, 16, or 18 gauge (G) needle. The size of each biopsy core was measured, and the presence or absence of renal cortical and medullary tissue and the number of glomeruli were recorded. Assessments of the ease with which the procedure was performed, the diagnostic usefulness of the biopsy material, and the discomfort associated with the procedure were made using verbal response and linear analog scales. RESULTS: Fourteen G biopsy cores (N = 33) were larger than both 16G (N = 33) and 18G (N = 34) cores and contained more gomeruli (mean number for 14G, 16G, and 18G = 15, 11 and 9, respectively). There were no differences in the ease of use of the three needle types, but scores for diagnostic usefulness were higher for 14G versus 18G and 16G versus 18G. The 14G needle was associated with significantly more pain than the two smaller needles when this was assessed using a linear analog score. Macroscopic hematuria occurred in eight patients, but there were no differences in complications rates between the three groups. CONCLUSIONS: All three needle sizes are safe for use in renal allograft biopsy using a semiautomated biopsy gun. The larger needles provide more tissue and glomeruli and, thus, are more diagnostically useful. Use of a 14G needle may be associated with more pain, and the 16G needle appears to offer the best compromise between diagnostic usefulness and patient acceptability.

Focalism: a source of durability bias in affective forecasting.

The durability bias, the tendency to overpredict the duration of affective reactions to future events, may be due in part to focalism, whereby people focus too much on the event in question and not enough on the consequences of other future events. If so, asking people to think about other future activities should reduce the durability bias. In Studies 1-3, college football fans were less likely to overpredict how long the outcome of a football game would influence their happiness if they first thought about how much time they would spend on other future activities. Studies 4 and 5 ruled out alternative explanations and found evidence for a distraction interpretation, that people who think about future events moderate their forecasts because they believe that these events will reduce thinking about the focal event. The authors discuss the implications of focalism for other literatures, such as the planning fallacy.

Laparoscopic splenectomy: a suitable technique for children and adults

Aims: Splenectomy retains an important role in the management of certain haematological conditions that fail to respond to conventional medical therapy, and has traditionally been performed through a midline or left subcostal incision with patients requiring 5-7 days in hospital. The well recognized benefits of laparoscopic surgery should also apply to splenectomy. This study aimed to develop a safe and effective technique suitable for all age ranges and without the requirement for expensive stapling devices. METHODS: An operative technique evolved over the 5-year period from 1994, from an initial six-port approach with the patient supine, to a four-port approach in a modified right lateral position, with locking surgical clips applied down a 5-mm port to vessels in the hilum, and removal of the spleen within a retrieval bag through a 4-6-cm Pfannanstiel incision. Data were collected prospectively for all patients undergoing laparoscopic splenectomy at Leicester Royal Infirmary, including demographic details, indication for surgery, duration of surgery, length of inpatient stay, transfusion requirement, postoperative complications and the response of the original condition to surgical intervention. RESULTS: A total of 40 patients underwent laparoscopic splenectomy (14 children, 26 adults) for a variety of conditions (idiopathic thrombocytopenia (ITP) (n = 24), haemolytic anaemia (n = 9) or malignancy (n = 7)) with a median operating time of 180 min for the first 20 patients and 100 min for the second 20 (P < 0.0001), and median inpatient stay of 3 days for the first 20 patients and 2 days for the second 20 (P < 0.0003). None of the operations was converted to open surgery, five patients required blood and/or platelet transfusion perioperatively, none of the patients had major postoperative complications, 23 of the 24 patients with ITP developed normal platelet counts after operation, and all nine patients with haemolytic anaemia maintained a normal haemoglobin concentration after operation. CONCLUSION: Laparoscopic splenectomy can be performed safely and effectively in adults and children without the need for stapling devices.

Apparent mental causation. Sources of the experience of will.

The experience of willing an act arises from interpreting one's thought as the cause of the act. Conscious will is thus experienced as a function of the priority, consistency, and exclusivity of the thought about the action. The thought must occur before the action, be consistent with the action, and not be accompanied by other causes. An experiment illustrating the role of priority found that people can arrive at the mistaken belief that they have intentionally caused an action that in fact they were forced to perform when they are simply led to think about the action just before its occurrence.

Application of near-infrared spectroscopy for nondestructive analysis of Avicel powders and tablets.

The purpose of this study was to use near-infrared spectroscopy (NIRS) as a nondestructive technique to (a) differentiate three Avicel products (microcrystalline cellulose [MCC] PH-101, PH-102, and PH-200) in powdered form and in compressed tablets with and without 0.5% w/w magnesium stearate as a lubricant; (b) determine the magnesium stearate concentrations in the tablets; and (c) measure hardness of tablets compressed at several compression forces. Diffuse reflectance NIR spectra from Avicel powders and tablets (compression forces ranging from 0.2 to 1.2 tons) were collected and distance scores calculated from the second-derivative spectra were used to distinguish the different Avicel products. A multiple linear regression model was generated to determine magnesium stearate concentrations (from 0.25 to 2% w/w), and partial least squares (PLS) models were generated to predict hardness of tablets. The NIRS technique could distinguish between the three different Avicel products, irrespective of lubricant concentration, in both the powdered form and in the compressed tablets because of the differences in the particle size of the Avicel products. The percent error for predicting the lubricant concentration of tablets ranged from 0.2 to 10% w/w. The maximum percent error of prediction of hardness of tablets compressed at the various compression forces was 8.8% for MCC PH-101, 5.3% for MCC PH-102, and 4.6% for MCC PH-200. The NIRS nondestructive technique can be used to predict the Avicel type in both powdered and tablet forms as well as to predict the lubricant concentration and hardness.

Immune neglect: a source of durability bias in affective forecasting.

People are generally unaware of the operation of the system of cognitive mechanisms that ameliorate their experience of negative affect (the psychological immune system), and thus they tend to overestimate the duration of their affective reactions to negative events. This tendency was demonstrated in 6 studies in which participants overestimated the duration of their affective reactions to the dissolution of a romantic relationship, the failure to achieve tenure, an electoral defeat, negative personality feedback, an account of a child's death, and rejection by a prospective employer. Participants failed to distinguish between situations in which their psychological immune systems would and would not be likely to operate and mistakenly predicted overly and equally enduring affective reactions in both instances. The present experiments suggest that people neglect the psychological immune system when making affective forecasts.