Identification of lobar fissures in pathological lungs.

Identification of lobar fissures in human lungs is a non-trivial task due to their variable shape and appearance, along with the low contrast and high noise in computed tomographic (CT) images. Pathologies in the lungs can further complicate this identification by deforming and/or disrupting the lobar fissures. Current algorithms rely on the general anatomy of the lungs to find fissures affected by pathologies. This can be unreliable as deformations and/or disruptions of these fissures will alter the general lung anatomy. To overcome this, we developed an algorithm with the following novelties: (1) a new application of neural network based texture analysis to generalize fissure regions; and (2) a new method of fissure surface identification. We tested our algorithm on CT image stacks from 8 anonymous patients with pathological lungs. Compared to manually segmented fissures, our algorithm produced an average mean difference of 0.71 mm and 0.68 mm for identifying the left and right oblique fissures, respectively. Using a 3-mm percentile measure, the algorithm yielded an average accuracy of 86.8% for the left oblique fissure with a mean worst-case error of 3.18 mm. For the right oblique fissure, the algorithm produced an accuracy of 88.8% with a mean worst-case error of 3.13 mm. The above results show feasibility of using our algorithm for identifying fissures in pathological lungs.

Primary laparoscopic and open repair of paraesophageal hernias: a comparison of short-term outcomes.

The choice of the optimal surgical approach for repairing paraesophaeal hernias (PEH) is debated. Our objective is to evaluate the short-term outcomes of primary laparoscopic and open repairs of PEH performed in the Calgary Health Region. A retrospective review of all patients undergoing repair of PEH between October 1999 and February 2005 was performed. The outcome measures evaluated included intra-operative parameters and post-operative variables, mortality rates, recurrence rates and patient satisfaction. A total of 93 patients underwent either a laparoscopic (n = 46) or open (n = 47) primary PEH repair. The laparoscopic approach was associated with a longer mean operative time (3.1 +/- 1.2 hours vs. 2.5 +/- 0.7 hours, P = 0.005) but resulted in a shorter overall hospital stay (5 days [2-16 days]vs. 10 days [5-24 days]; P < 0.001), and fewer post-operative complications (10/46 [22%]vs. 25/47 [53%]P = 0.002). Although the follow-up was short (laparoscopic 16 months; open 18 months), a 9% recurrence rate was reported with both approaches. Patient satisfaction using the Gastroesophageal Disease Health-Related Quality Of Life questionnaire was similar in both groups (P = 0.861) with most patients reporting excellent outcomes (laparoscopic: 32/36 [89%]; open 27/35 [77%]). Our review suggests that the laparoscopic approach is safe with shorter hospital stay and recovery. Although early follow-up suggests that recurrence rates and patient satisfaction are similar, long-term follow-up is required to determine whether the laparoscopic approach will become the procedure of choice.

Segmentation of lung lobes in isotropic CT images using wavelet transformation.

Advanced multi-slice CT scanners produce isotropic CT images, which have pixel dimensions equal to their image thicknesses of 0.6 mm. Comparing to clinical standard CT images with a thickness of 2.5 - 7.0 mm, isotropic CT images have clearly visible lobar fissures. This poses a challenge for developing automatic algorithms to identify the fissure locations and curvatures. This paper presents a wavelet algorithm that allows automatic identification of the left and right oblique fissures, as well semi-automatic identification of the horizontal fissures. This algorithm took a two-stage approach: (a) adaptive fissure sweeping to find fissure regions; and (b) wavelet transform to identify the fissure locations and curvatures within these fissure regions. Tested on 8, 6 and 6 stacks of isotropic CT images for the left oblique, right oblique and horizontal fissures, respectively, the algorithm yielded an accuracy of 77.1 - 93.6% with strict evaluation criteria. This provides promising potential for developing an automatic algorithm to segment lung lobes.

Development and validation of a disease-specific quality of life questionnaire (EQOL) for potentially curable patients with carcinoma of the esophagus.

The objective was to develop, pretest and validate a disease-specific quality of life questionnaire for potentially curable patients with esophageal carcinoma, for use with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) in order to assess the quality of life associated with the various treatment modalities available for this disease. Questionnaire development phase Patients were enrolled in three centres. Literature reviews, patients, family members, and health care professionals generated 195 items: symptoms (55); emotions (53); physical functioning (17); activities of daily living (ADL) (48); and leisure/social (22). Thirty-eight patients identified items of importance and assigned importance ratings on a 5-point Likert scale. Impact scores were calculated as frequency times mean item importance. Item impact scores<20/100 were excluded. Pearson's correlation co-efficients compared domains with the Medical Outcomes Study SF-20 (MOS SF-20). Fifteen items remained. Questionnaire validation phase EORTC QLQ-C30, Esophageal Quality of Life Questionnaire (EQOL), MOS SF-36 and a Global Rating of Change Questionnaire were completed at baseline, 1 week after baseline but prior to any treatment, 1 month, 3 months, and 6 months after treatment began. Reliability was assessed using paired samples correlations. Responsiveness was assessed between mean scores of changed and unchanged patients, and a responsiveness index was calculated. The MOS SF-36 was used for criterion validity. Construct validity included four a priori predictions. Sixty-five patients were enrolled in four centres in the validation phase. Paired samples correlations were high for all domains (0.749-0.889) indicating good reliability. Symptom, physical function and social domains were responsive to change at all time intervals (P<0.05). Emotional function was responsive at 1 and 3 months, activities of daily living (ADLs) at 1 and 6 months. Magnitude of change was significant when direction of change was stated. Between better and worse, magnitude of change was significant in all domains except at 6 months in symptoms, emotional and physical domains. The minimal clinically important difference was consistently around 0.5 for all domains. Minimal, moderate and large effect ranges were established. Only 2/16 time intervals had poor correlations with the SF-36, establishing criterion validity. Of the four a priori predictions for construct validity, only the second part of one prediction, in the emotional function domain, was not confirmed. We have developed a 15-item questionnaire (EQOL) which has good reliability, responsiveness and validity and is now in use in studies in Canadian centres with the EORTC QLQ-C30.

Segmentation of lung lobes in volumetric CT images for surgical planning of treating lung cancer.

Study has shown that three-dimensional (3D) visualization of lung cavities has distinct advantages over traditional computed tomographic (CT) images for surgical planning. A crucial step for achieving 3D visualization of lung cavities is the segmentation of lung lobes by identifying lobar fissures in volumetric CT images. Current segmentation algorithms for lung lobes rely on manually placed markers to identify the fissures. This paper presents an autonomous algorithm that effectively segments the lung lobes without user intervention. This algorithm applies a two-stage approach: (a) adaptive fissure sweeping to coarsely define fissure regions of lobar fissures; and (b) watershed transform to refine the location and curvature of fissures within the fissure regions. We have tested this algorithm on 4 CT data sets. Comparing with visual inspection, the algorithm provides an accuracy of 85.5-95.0% and 88.2-92.3% for lobar fissures in the left and right lungs, respectively. This work proves the feasibility of developing an automatic algorithm for segmenting lung lobes.

The effects of antireflux surgery on asthmatics with gastroesophageal reflux.

BACKGROUND: Antireflux therapy, including surgery, has been advocated for asthma patients with gastroesophageal reflux (GER). A recent review of medical antireflux therapy reported improvements in asthma symptoms and medication requirements but no improvement in pulmonary function. The purpose of this article is to review the available literature on the effects of antireflux surgery in asthma. METHOD: Using the Medline 1966 to August 1998 database, lung disease, asthma, and pulmonary function were combined with GER and different antireflux surgeries, including fundoplication. Reference lists of identified articles were also reviewed. RESULTS: Combining the terms asthma and GER identified 271 articles, including 193 in English. Searching the term fundoplication identified 497 articles, including 413 in English. Twenty-four reports addressed the effects of antireflux surgery in asthma. Only two studies were controlled. Asthmatic data could not be distinguished from that of other subjects in five articles. The remainder were case series, retrospective reviews, or uncontrolled studies. Ten reports included data on < or = 10 patients. Two studies were only published as abstracts. A total of 417 asthma patients were included in the identified reports. Antireflux surgery improved GER symptoms, asthma symptoms, asthma medication use, and pulmonary function in 90%, 79%, 88%, and 27%, respectively. CONCLUSIONS: Antireflux surgery may improve GER and asthma symptoms and decrease medication requirements, but it has little effect on pulmonary function. The effects of antireflux surgery on asthma are similar to those of medical antireflux therapy.

Educators' responses to changes in the health care system.

A survey was conducted to identity programmatic/curricular changes made by New York state nursing schools in response to the changing health care environment and to identity the success of job placement for new graduates. Data were reported for 84 programs. Respondents indicated that innovative curriculum initiatives were employed, such as increasing community experiences and primary health care content. Opportunities for job placement were enhanced by a number of strategies, including resume writing and job interviewing workshops.

Quality of life with carcinoma of the esophagus.

Management of squamous carcinoma of the esophagus remains a dilemma for the clinician. Current treatments produce significant morbidity and mortality, yet most patients still die of their disease. Given the limitations, survival alone is insufficient to assess the various options; quality of life (QOL) must also be addressed. This paper reviews the topic of QOL, the various instruments available to measure it, and methods to evaluate such instruments. A 16-year review of the literature was performed to assess the extent to which QOL has been addressed in patients with esophageal carcinoma. Only 51 of 7569 references on esophageal neoplasms considered QOL. Only 3 used documented QOL instruments with appropriate statistical testing. Currently there is no well validated instrument for measurement of QOL in patients with esophageal carcinoma.

Transhiatal esophagectomy for carcinoma of the esophagus and cardia. Experience with 160 cases.

We reviewed our experience from 1979 to 1990 with 160 cases of transhiatal esophagectomy for carcinoma of the lower esophagus and cardia to evaluate trends in patient selection, management, and outcome. Patients treated in the past 6 years (n = 110) and those treated before 1985 (n = 50) were similar in terms of age and sex distribution, medical history, and weight loss. The majority of tumors seen were adenocarcinoma, with patients in the latter group having significantly lower stages. Significant decreases in anesthetic time, units of blood transfusions, chest tube insertions, length of postoperative ventilation, incidence of postoperative pneumonia, and length of hospital stay were seen during the past 6 years. Wound infections increased significantly during the same period. The decrease in the 30-day mortality rate from 6% to 0.9% was not significant. Survival rates did not differ between groups, with overall rates of 62%, 40%, and 21% at 1, 2, and 5 years, respectively.

Factors affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition.

Following esophagectomy, restoration of swallowing by gastric tube interposition with cervical esophagogastric anastomosis reduces morbidity and mortality associated with intrathoracic anastomoses at the expense of an increased incidence of both anastomotic leak and stricture formation. A retrospective study of 165 patients with either squamous cell carcinoma or adenocarcinoma of the distal esophagus or gastric cardia undergoing esophagogastrectomy with gastric tube interposition and cervical anastomosis at Vancouver, British Columbia, or London, Ontario, was undertaken. Forced-entry multiple logistic regression analysis of factors believed to influence anastomotic outcome was performed. Anastomotic leak occurred in 17% of patients; statistically significant correlation with low preoperative serum albumin (p = 0.005), running suture technique (p = 0.029), high intraoperative blood loss (p = 0.038), and the occurrence of postoperative delayed gastric emptying (p = 0.045) was found. Anastomotic strictures occurred in 31% of patients; a statistically significant correlation was found with preceding anastomotic leak (p = 0.001) and intraoperative blood loss (p = 0.042). Factors including preoperative radiotherapy and diabetes mellitus were not found to be significant.

Alcohol education as primary prevention in health care.

The purpose of this survey research was to identify practicing nurses' knowledge about the biophysiological and psychosocial components of alcohol and its pharmacological effects. Additionally, data were gathered with the intent of assisting nurses in the early identification of and intervention with individuals at risk for the disease of alcoholism. The study consisted of a convenience sample of 298 practicing nurses employed by community hospitals that had been identified as having no specific treatment program for chemical dependency. The investigation obtained self-reported information by means of a questionnaire. The instrument elicited both demographics and the answers to 25 fixed alternative questions designed to obtain information in nine topic areas. Findings indicated that 66% of the nurses incorrectly answered questions aimed at correlating population statistics to the disease of alcoholism and its physiological effects. Questions about knowledge of the pharmacological properties of alcohol were answered incorrectly by 93% of the participants. One-way analysis of variance was computed to compare the total score for each of the variables listed. Conclusions document a critical need for increased alcohol education in basic nursing programs. Content related to the pharmacological properties, the disease concept and the biophysiological and psychosocial effects of alcohol should be included in curriculum design.

Hemorrhagic shock and bacterial translocation in a swine model.

Bacterial translocation is proposed as an explanation for sepsis associated with hemorrhagic shock. This study attempted to document these events in a large animal model. Male swine were randomly assigned to control (n = 10) or experimental (n = 10) groups. Animals were anaesthetized, and the bladder, portal vein, and a mesenteric lymphatic vessel cannulated. Experimental animals were bled 40% of blood volume. Over the next six hours maintenance fluids were given, and cultures of portal blood and mesenteric lymph taken. Before the swine were killed, cultures were taken from portal and systemic blood, mesenteric lymph, and lymph nodes, and a portion of terminal ileum was resected for histologic study. Experimental animals experienced significant shock as demonstrated by changes in hemodynamic and biochemical variables. Cultures and histologic examination of the terminal ileum showed no significant difference between control and experimental animals. In an unresuscitated swine model, significant bacterial translocation was not demonstrated within six hours of hemorrhagic shock.

Inclusion of alcoholism and drug abuse content in curricula of varied health care professions.

Alcoholism and drug abuse are prevalent health problems in the United States. Practitioners in nursing, medicine, and dentistry need to be cognizant of the insidious signs of chemical dependency. A descriptive survey using a researcher-designed questionnaire yielded a sample which consisted of 11 medical schools, 2 dental schools, 25 baccalaureate and higher degree nursing programs, and 38 associate degree nursing programs. The survey findings indicated that the curricula for nursing, medicine, and dentistry were inadequate in chemical dependency content. This survey evidenced the need for a stronger educational effort addressing both knowledge of alcoholism/drug abuse and impaired professional practice in the curricula of the health professional programs examined.

A new technique for making a moulage.

A new technique for making a moulage has been described; it offers several significant advantages over standard techniques.