A Novel and Simple Method of Managing Thoracic Esophageal Perforation: The "ASSIST" Approach.

INTRODUCTION: Thoracic esophageal perforation (TEP) remains a therapeutic challenge that carries with it a high mortality. Because of its rare occurrence and management is complex, most patients are referred to higher level of care. Management is variable, ranging from a stent placement to an esophagectomy. Unfortunately, stent capabilities may not be readily available and the different surgical approaches can be complex, time-consuming, and demanding on a septic patient. Given these challenges, we conceived a simple 6-step (1) Antibiotics, (2) Suture the cervical esophagus with a 0- chromic, (3) Suture the abdominal esophagus with a 3-0 chromic, (4) Insert nasogastric tube above the sutured cervical esophagus, (5) Support nutrition with a jejunostomy, and (6) Tubes (placement of bilateral chest tubes). METHODS: Six consecutive septic patients with TEP who underwent an ASSIST approach were evaluated. On day 14, patients were taken to the OR for an esophagogastroduodenoscopy to open the cervical and hiatal esophageal closure. Patients then underwent a repeat barium swallow prior to resuming per oral (PO) intake. RESULTS: Sepsis resolved in all patients. One patient died of advanced cirrhosis. None of the living patients required additional surgery and all resumed a normal diet. CONCLUSIONS: The "ASSIST" method is a viable option for managing septic patients with thoracic esophageal perforation. This novel approach does not require a high level of technical expertise and conceivably be performed by most centers without the need for immediate transfer to specialized facilities.

Do rural patients with operable breast cancer fare worse than urban patients in Louisiana? Results of the Louisiana cancer consortium.

BACKGROUND: It is unknown whether rural patients with operable breast cancer do worse than urban patients in Louisiana. We performed an analysis of breast cancer based on rural versus urban residencies and evaluate factors associated with worse survival. METHODS: Data on women diagnosed with stages I to III breast cancer from 2004 to 2016 were obtained from the Louisiana Tumor Registry. Overall survival and cancer-specific survival were compared between rural and urban residencies by sociodemographic, clinical-pathologic, and treatment variables. Kaplan-Meier method and the log-rank test were used to compare the survival curves. Cox regression model was used to assess independent factors associated with overall survival and cancer-specific survival. RESULTS: Of the 27,780 patients, 2,441 patients (8.7%) resided in rural areas. Compared with urban patients, rural patients tended to be older, underinsured, more impoverished, less likely to be treated at an American College of Surgeons accredited institution, and more likely to be treated at a low-volume center (P < .005 each). For stages I and II diseases, there was a statistically significant difference in overall survival favoring urban regions, but no difference in cancer-specific survival. For stage III disease, there was no difference in either overall survival or cancer-specific survival between the 2 cohorts. Overall survival and cancer-specific survival curves for the entire cohort were not different at the 5-year mark, but become statistically significant with greater time; although rural patients had a lower long-term overall survival (P = .0001) and cancer-specific survival (P = .049) compared with urban patients, the rural-urban differences in overall survival and cancer-specific survival were no longer different after adjusting for other covariates, indicating the observed differences in univariate analysis were attributable to sociodemographic, clinicpathologic, and treatment factors. CONCLUSION: Despite rural patients with operable breast cancer having an overall lesser overall survival and cancer-specific survival than their urban counterpart, rural residence itself was not an independent predictor of outcome. In fact, particular socioeconomic factors increased the risk of death among patients residing in rural areas. Additional analysis at the patient-level is needed to understand the interactions between rurality and breast cancer outcomes in Louisiana.

Clinical and Patient-centered Outcomes of Nonsurgical Root Canal Retreatment in First Molars Using Contemporary Techniques.

INTRODUCTION: There have been many recent technical advances in modern endodontics that have the potential to affect treatment outcomes. Reports on treatment outcomes using contemporary techniques are relatively scarce, especially in the field of nonsurgical retreatment. The purpose of this study was to determine the success of nonsurgical root canal retreatment in molars using contemporary endodontic techniques. METHODS: Sixty-three patients referred for retreatment in first molars were enrolled in the study. The retreatment procedures were performed by endodontic residents using a semistandardized treatment protocol. Patients were followed-up at 6, 12, and 24 months. Treatment outcomes were categorized into healed, healing, or nonhealing based on clinical and radiographic criteria. Healed and healing were considered as successes, and nonhealing was considered a failure. Outcomes were also evaluated using patient-centered criteria that included oral health-related quality of life scores and subjective chewing ability. RESULTS: Fifty-two of the 63 patients were available for final analysis. Five cases (9.6%) were determined to be nonhealing at the last follow-up with new or persistent periapical lesions. Thirty-seven (71.2%) patients had complete resolution of apical periodontitis, and the remaining 10 (19.2%) remained asymptomatic and showed radiographic evidence of healing. Oral health-related quality of life scores and chewing ability improved significantly over time (P < .05), with the biggest increase observed within the first week of treatment completion. CONCLUSIONS: This study showed that endodontic retreatment using contemporary techniques significantly improved patients' quality of life and chewing ability over time, with a success rate of 90.4% after 2 years.

Osteonecrosis related to intraosseous anesthesia: report of a case.

Intraosseous anesthesia is an effective and increasingly used technique with few reported complications. The technique uses a specialized drill to perforate the osseous cortex where local anesthetic can then be deposited to anesthetize teeth. It has been reported that separation of the perforation drills from their plastic bases can occur because of the friction generated during osseous perforation. Prolonged rotation of the perforator drills in the bone can also cause excessive heat, which can lead to bone necrosis. This report describes a case of focal osteonecrosis subsequent to intraosseous anesthesia and discusses possible etiologies of this sequela.

Professional and collegiate team assistance programs: services and utilization patterns.

Elite professional and collegiate athletes underuse stress control, mental health, and substance abuse treatment services. Behavioral health services use can be increased by establishing on-site, sports-specific services. Like Employee Assistance Programs of industry and government, Team Assistance Programs (TAPs) address critical issues such as substance abuse prevention, tobacco cessation, stress recognition, mental illness management, injury rehabilitation, performance enhancement, and cultural support. Strong links with the team's medical and conditioning staff can ensure a steady stream of TAP referrals and build trust with players and team staff. This article describes nine years of operation for two professional TAPs and three years for one college TAP. Use patterns and linkage strategies with team physicians, trainers, strength staff, chiropractors, and nutritionists are discussed.