Winner Winner Turkey Dinner! An Empirical Approach to Measuring Palatability and Satisfaction with Emergency Department Turkey Sandwiches.

Introduction: Despite their popularity in many EDs, little is known regarding perceptions of turkey sandwiches among patients. Given the importance of turkey sandwiches as a form of nutrition provided in EDs, we sought to quantify the composition and taste of ED turkey sandwiches through a quantitative assessment of turkey sandwiches by ED staff. Methods: This was a blinded observational study performed at a tertiary, urban academic medical center in Boston, MA. We collected ED turkey sandwiches up to 48 hours prior to study days from 4 emergency departments in the Boston area (2 community hospitals and 2 academic medical centers). We enrolled ED physicians, nurses, physician assistants, and staff who were exposed to four sandwiches in a random fashion. Participants were asked to assess sandwiches on a Likert scale of 1 to 5 on a variety of factors including, nutritional value "goodness", smell "olfactory", texture "bite", ingredient distribution "balance", appearance "look", and flavor "edibility" to produce a composite score for sandwich quality (GOBBLE score). Next, participants were asked standardized questions surrounding suitability for consumption and nutrition on a 10 point Likert scale. We calculated mean scores and measured differences using t-tests. Results: We enrolled 22 participants over the study period. Twenty-one participants completed all measures. GOBBLE scores were calculated and averaged for sandwiches. A One-way ANOVA test was performed to measure statistically significant differences between mean GOBBLE scores (p<0.05) with a post hoc Tukey HSD procedure used to assess for statistically significant difference for pairwise comparison. A significant difference (p=0.009) was noted between the 4 sandwiches being compared, with a single site outperforming the others. Aggregating for academic and community sites demonstrated no statistically significant difference (p=0.08). Sandwiches in general were not considered healthy or palatable by study subjects. Conclusion: Despite out-performance by a single ED, there is no significant difference in the quality of sandwiches provided to patients in EDs between academic and community hospitals. ED turkey sandwiches do not appear to be food items that are viewed as healthy or recommended to patients by ED staff who participated in this study.

Scope and Safety of Paediatric Surgery in a Model III Hospital

Introduction Elective and emergency paediatric general surgery is performed in numerous hospitals but with differing exclusion and transfer thresholds. Recent national guidelines detail necessary surgical, anaesthetic and nursing resources for safe and efficient delivery of services. Methods A retrospective review of paediatric surgical admissions was performed from January 2015 to December 2016. Charts of prolonged admissions or readmissions were reviewed. Results There was a total of 2,079 surgical admissions. 575 (27.2%) were elective and 1504 (71.2%) were emergency admissions. Significantly more surgical procedures were performed in 2016 (n=546, 56% versus n=433, 44.2%). Laparoscopic appendicectomy was the most commonly performed procedure. Re-admission rates were lower in 2016 (n=9, 0.8% versus n=21, 2.2%). All complications were Clavien-Dindo Grade I or II. Discussion Paediatric general surgery can be safely and efficiently performed by staffed and resourced Model III hospitals.

Effective communication enhances the patients' endoscopy experience.

BACKGROUND: Undergoing an endoscopy is a stressful experience for patients. AIMS: To audit the endoscopy pathway to improve patient satisfaction. METHODS: A prospective survey of endoscopy patients to identify system improvements that were then implemented. RESULTS: The survey was performed before (N = 71) and after (N = 60) process improvements identified by the initial survey. Information provision and staff communication skills were identified for optimisation. Patient anxiety at home was significantly reduced (median 2 vs. 1, p < 0.01). Education of endoscopy staff significantly improved the quality of information provided before and after the procedure with regard to sedation (median 4 vs. 5, p < 0.01), discomfort (median 4 vs. 5, p < 0.01), complications (28 vs. 82 %, p < 0.01), findings (89 vs. 100 %, p < 0.01) and follow-up (73 vs. 90 %, p = 0.015). Gloucester Comfort Scores during endoscopy improved (median 1 vs. 0, p < 0.01) without increasing sedation levels. Patient feelings of invasion/trauma significantly decreased. Overall 95 % of patients were satisfied. CONCLUSION: Structured information leaflets and improved staff communication skills reduce anxiety and enhance patients' experiences. They are now standard operating procedures.

Gloveport hernioscopy.

It can be difficult to exclude occult, necrotic bowel in incarcerated herniae that reduce prior to emergent surgical exploration without resorting to further abdominal wall incisions. This case illustrates the Gloveport hernioscopy technique to identify necrotic small intestine that had spontaneously reduced in a man with a strangulated umbilical hernia. This minimally invasive technique allowed a multichannel examination of the peritoneal cavity without any further insult to the abdominal wall.

Fatal herpes simplex virus hepatitis following neoadjuvant chemoradiotherapy and anterior resection for rectal cancer.

We describe the case of a young patient who contracted fatal herpes simplex virus hepatitis following neoadjuvant chemoradiotherapy and anterior resection for rectal cancer. The rarity and non-specific presentation of this treatable disease, which masqueraded as the sequelae of postoperative sepsis, resulted in a diagnosis following death. Features that should prompt inclusion of herpes simplex virus hepatitis in the differential diagnoses are suggested and the case is a reminder of how neoadjuvant therapy may subtly alter a patient's immunocompetency.

ATV rollover, rider response, and determinants of injury: in-depth analysis of video-documented ATV rollover events.

OBJECTIVE: All-terrain vehicle (ATV) rollover events can lead to serious and fatal injuries. Crush protection devices (CPDs) are intended to reduce injury by reducing the frequency of significant contact between an inverted ATV and rider. Currently, field data on real-world ATV rollovers are primarily limited to injury causing events and lack ATV and rider dynamics necessary to evaluate injury mitigation effectiveness and possible unintended consequences of CPDs. Unlike restrained automobile occupants, ATV rider posture and positioning are highly variable and scant data are available to define the dynamically changing rider position in a roll scenario. Additional data on the complex real-world dynamics and interactions of riders and vehicles are needed to further develop and evaluate the effectiveness of rollover injury prevention strategies. METHODS: Using YouTube videos of real-world rollover events, vehicle, environment, and rider factors were categorized with a focus on vehicle dynamics and rider responses, including dismount kinematics. RESULTS: One hundred twenty-nine ATV rollover events were coded, with side rolls representing 47%, rear 44%, and forward rolls 9%. The speed at onset of roll was relatively low, with 86% of the rolls occurring at speeds of 10 mph or less and 53% occurring at less than 3 mph. No injury was identified for 79% of the events; 16% resulted in injury due to ATV contact and 5% resulted in injury unrelated to ATV contact. Active dismount of the ATV was a commonly employed strategy, with 63% of the riders attempting active dismount, resulting in successful separation from the ATV in 72% of the attempts. The overall injury rate for riders attempting active dismount was 15% and the injury rate for riders not attempting active dismount was 32%. This investigation confirmed the importance of active rider movements, including active dismount and subsequent separation in determining the outcome of ATV roll events. CONCLUSIONS: Rider active dynamics need to be considered when introducing new injury prevention strategies that may obstruct, impede, or otherwise contact riders during an attempted separation. To the authors' knowledge, this is the first systematic use of real-world video-documented ATV rollover events to quantify and analyze ATV rollover dynamics and rider responses. These data and techniques can guide effective design and implementation of injury mitigation strategies.

The Hybrid III upper and lower neck response in compressive loading scenarios with known human injury outcomes.

OBJECTIVE: Physical biomechanical surrogates are critical for testing the efficacy of injury-mitigating safety strategies. The interpretation of measured Hybrid III neck loads in test scenarios resulting in compressive loading modes would be aided by a further understanding of the correlation between the mechanical responses in the Hybrid III neck and the probability of injury in the human cervical spine. The anthropomorphic test device (ATD) peak upper and lower neck responses were measured during dynamic compressive loading conditions comparable to those of postmortem human subject (PMHS) experiments. The peak ATD response could then be compared to the PMHS injury outcomes. METHODS: A Hybrid III 50th percentile ATD head and neck assembly was tested under conditions matching those of male PMHS tests conducted on an inverted drop track. This includes variation in impact plate orientation (4 sagittal plane and 2 frontal plane orientations), impact plate surface friction, and ATD initial head/neck orientation. This unique matched data with known injury outcomes were used to evaluate existing ATD neck injury criteria. RESULTS: The Hybrid III ATD head and neck assembly was found to be robust and repeatable under severe loading conditions. The initial axial force response of the ATD head and neck is very comparable to PMHS experiments up to the point of PMHS cervical column buckle or material failure. An ATD lower neck peak compressive force as low as 6,290 N was associated with an unstable orthopedic cervical injury in a PMHS under equivalent impact conditions. ATD upper neck peak compressive force associated with a 5% probability of unstable cervical orthopedic injury ranged from as low as 3,708 to 3,877 N depending on the initial ATD neck angle. CONCLUSIONS: The correlation between peak ATD compressive neck response and PMHS test outcome in the current study resulted in a relationship between axial load and injury probability consistent with the current Hybrid III injury assessment reference values. The results add to the current understanding of cervical injury probability based on ATD neck compressive loading in that it is the only known study, in addition to Mertz et al. (1978), formulated directly from ATD compressive loading scenarios with known human injury outcomes.

Radiation-induced distal ileal obstruction complicating ileostomy closure.

BACKGROUND: Radiation enteropathy is a recognized complication in patients who undergo neoadjuvant radiotherapy for locally advanced rectal cancer. Routine formation of defunctioning loop ileostomy in these patients may mask the development of stricturing, terminal ileal and radiation enteropathy which later may complicate the ileostomy closure. Our aim was to assess the preventive techniques and key warning signs. METHODS: We present two cases of ileostomy closure in patients with occult, radiation-induced, terminal ileal stricture and review the relevant literature. RESULTS: The first case was complicated by dehiscence of the ileal anastomosis due to undiagnosed, downstream stenosis of the irradiated terminal ileum. A similar terminal ileal stricture was diagnosed in the second case by contrast fluoroscopy enabling an elective ileocolic anastomosis. The literature indicates the importance of identifying such problems prior to loop ileostomy closure. CONCLUSIONS: Contrast studies before loop ileostomy closure are valuable in limiting the complications of radiation-induced distal ileal obstruction in selected patients.

Toward a more robust lower neck compressive injury tolerance-an approach combining multiple test methodologies.

OBJECTIVE: The compressive tolerance of the cervical spine has traditionally been reported in terms of axial force at failure. Previous studies suggest that axial compressive force at failure is particularly sensitive to the alignment of the cervical vertebra and the end conditions of the test methodology used. The present study was designed to develop a methodology to combine the data of previous experiments into a diverse data set utilizing multiple test methods to allow for the evaluation of the robustness of current and proposed eccentricity based injury criteria. METHODS: Data were combined from 2 studies composed of dynamic experiments including whole cervical spine and head kinematics that utilized different test methodologies with known end conditions, spinal posture, injury outcomes, and measured kinetics at the base of the neck. Loads were transformed to the center of the C7-T1 intervertebral disc and the eccentricity of the sagittal plane resultant force relative to the center of the disc was calculated. The correlation between sagittal plane resultant force and eccentricity at failure was evaluated and compared to the correlation between axial force and sagittal plane moment and axial force alone. RESULTS: Accounting for the eccentricity of the failure loads decreased the scatter in the failure data when compared to the linear combination of axial force and sagittal plane moment and axial force alone. A correlation between axial load and sagittal plane flexion moment at failure (R² = 0.44) was identified. The sagittal plane extension moment at failure did not have an identified correlation with the compressive failure load for the tests evaluated in this data set (R² = 0.001). The coefficients of determination for the linear combinations of sagittal plane resultant force with anterior and posterior eccentricity are 0.56 and 0.29, respectively. These correlations are an improvement compared to the combination of axial force and sagittal plane moment. CONCLUSIONS: Results using the outlined approach indicate that the combination of lower neck sagittal plane resultant force and the anterior-posterior eccentricity at which the load is applied generally correlate with the type of cervical damage identified. These results show promise at better defining the tolerance for compressive cervical fractures in male postmortem human subjects (PMHS) than axial force alone. The current analysis requires expansion to include more tolerance data so the robustness of the approach across various applied loading vectors and cervical postures can be evaluated.

Mucinous ovarian tumour presenting as a ruptured incisional hernia.

We describe an ovarian borderline tumour that presented as an acute deterioration in an incisional hernia secondary to intraperitoneal mucin accumulation. The differential diagnosis associated with hernial sac contents and options for opportunistic diagnosis are discussed. This case raises awareness of potential serious diagnoses that may be overlooked during emergent hernia repair.

Novel use of an air-filled breast prosthesis to allow radiotherapy to recurrent colonic cancer.

AIM: The authors present the novel and successful use of an air-filled breast prosthesis for extra pelvic exclusion of small bowel to facilitate adjuvant radiotherapy following resection of recurrent adenocarcinoma of the ascending bowel. The therapeutic use of radiotherapy in colon cancer can cause acute or chronic radiation enteropathy. Mobile small bowel can be sequestered in 'dead space' or by adhesions exposing it to adjuvant radiotherapy. A variety of pelvic partitioning methods have been described to exclude bowel from radiation fields using both native and prosthetic materials. METHOD: In this case a 68 year old presented with ascending colon adenocarcinoma invading the peritoneum and underwent en bloc peritoneal resection. Thirty-seven months later surveillance CT identified a local recurrence. Subsequent resection resulted in a large iliacus muscle defect which would sequester small bowel loops thus exposing the patient to radiation enteropathy. The lateral position of the defect precluded the use of traditional pelvic partitioning methods which would be unlikely to remain in place long enough to allow radiotherapy. A lightweight air-filled breast prosthesis (Allergan 133 FV 750 cms) secured in place with an omentoplasty was used to fill the defect. RESULTS: Following well tolerated radiotherapy the prosthesis was deflated under ultrasound guidance and removed via a 7-cm transverse incision above the right iliac crest. The patient is disease free 18 months later with no evidence of treatment related morbidity. CONCLUSION: The use of a malleable air-filled prosthesis for pelvic partitioning allows specific tailoring of the prosthesis size and shape for individual patient defects. It is also lightweight enough to be secured in place using an omentoplasty to prevent movement related prosthesis migration. In the absence of adequate omentum a mesh sling may be considered to allow fixation. In this case the anatomy of the prosthesis position allowed for its removal without the need for repeat laparotomy. Pre-operative deflation of the air-filled prosthesis under ultrasound guidance also reduces the size of the incision required for removal. This technique may be valuable to prevent collateral small bowel irradiation following resection of renal or retroperitoneal malignancy.

COX-2, VEGF and tumour angiogenesis.

Epidemiological evidence suggests a protective effective of regular NSAID use against developing cancer. Cyclooxygenase-2, a target of NSAIDs, is upregulated in many cancers and has been associated with increased VEGF production and angiogenesis. Angiogenesis is the formation of new vessels from existing vasculature and as an essential process for tumour development represents an important therapeutic target. Following an extensive review of the literature this article details the current knowledge on the role of COX-2 in tumorigenesis focusing on its relationship to angiogenesis and VEGF production by tumour cells. While COX-2 is clearly detrimental to prognosis and NSAIDs have a beneficial effect, the possibility of COX-2 independent effects being partly or wholly responsible for this benefit cannot be excluded.

Hospital admission for acute pancreatitis in the Irish population, 1997 2004: could the increase be due to an increase in alcohol-related pancreatitis?

OBJECTIVE: To investigate trends in the incidence of acute pancreatitis by examining emergency admissions to acute public hospitals over an 8-year period; to compare trends for alcohol-related pancreatitis admissions with biliary tract-related admissions and to profile the patients admitted with an acute pancreatitis diagnosis. METHODS: All in-patient emergency admissions for which an acute pancreatitis diagnosis (ICD-9-CM Code 577.0) was recorded as principal diagnosis were identified for years 1997-2004 inclusive. Alcohol-related acute pancreatitis admissions (i.e. had alcohol misuse recorded as co-morbidity) were identified using ICD-9-CM-codes 303 and 305. Biliary tract disease-related admissions (i.e. had biliary tract disease recorded as co-morbidity) were identified using ICD-9-CM codes 574.0-576.0 inclusive. Pearson's chi2-test was used to compare proportions in groups of categorical data and chi2-tests for trend were used to identify linear trends. RESULTS: There were 6291 emergency admissions with a principal diagnosis of acute pancreatitis during the 8 year study period, with 622 admissions in 1997 compared to 959 admissions in 2004, an increase of 54.1%. Age standardized rates rose significantly from 17.5 per 100,000 population in 1997 to 23.6 per 100,000 in 2004, (P<0.01 for linear trend). There were 1205 admissions with alcohol misuse recorded as a co-morbidity increasing from 13.9% (87/622) of acute pancreatitis admissions in 1997 to 23.2% (223/959) in 2004. This increase was significantly greater than the increase observed for biliary tract disease-related admissions, 19.6% (122/622) in 1997 to 23.5% (225/959) in 2004. Rates for total acute pancreatitis admissions were highest in those aged 70 years and over; the majority (3563, 56.6%) of the admissions were male with a mean age of 51.1 years (SD 19.9); the mean age for male admissions was significantly younger than for female admissions (49.1 versus 53.6 years, P<0.001). However, for alcohol-related admissions, rates were highest in those aged 30-49 years and patients admitted with alcohol misuse recorded were significantly younger than those who did not have alcohol misuse recorded (42.0 versus 53.2 years, P<0.001). Median length of stay was 7 days. CONCLUSIONS: Hospital admissions for acute pancreatitis rose from 17.5 per 100,000 population in 1997 to 23.6 per 100,000 in 2004. The proportion of admissions that had alcohol misuse recorded as a co-morbidity rose more markedly than those with biliary tract disease and the rise was more pronounced in younger age groups. The increasing trend in alcohol-related acute pancreatitis parallels the rise in per capita alcohol consumption. Given the continuing rise in binge drinking, particularly among young people, this is a cause for concern.

Autoimmune pancreatitis.

BACKGROUND: Approximately 2 per cent of pancreatic masses resected for suspected malignancy are found instead to be a form of chronic pancreatitis defined by a characteristic lymphoplasmacytic infiltrate. This condition is now commonly classified as 'autoimmune pancreatitis'. METHODS: A literature review of autoimmune pancreatitis was performed using Medline and PubMed. The reference lists of identified articles were searched for further relevant publications. RESULTS: Patients are predominantly 55-65 years old and present with obstructive jaundice, abdominal pain and weight loss. Imaging may show a mass of malignant appearance or pancreatobiliary tree strictures precipitating surgical exploration. Raised serum levels of IgG4 and specific autoantibodies, when combined with particular radiological features and a biopsy negative for malignancy, enable a preoperative diagnosis and successful treatment with steroids. CONCLUSION: Autoimmune pancreatitis is not uncommon and steroid treatment can effect a dramatic improvement. Care is needed to ensure that pancreatic cancer is not misdiagnosed.

Radiation enteropathy.

Radiation enteritis is a functional disorder of the intestine that occurs during or after a course of radiotherapy to the abdomen, pelvis or rectum. It presents in both an acute and chronic form and has sequelae that can be life threatening. As radiotherapy is now being used more than ever before in the treatment of solid organ malignancies in the abdomen and pelvis, the incidence of radiation enteropathy is likely to increase in the future. We present two patients with severe forms of this condition in order to clarify the salient issues regarding its diagnosis and, in particular, its distinction from mechanical bowel obstruction. We also review its pathophysiology, management and current preventative strategies.

Rapid assessment breast clinics--evolution through audit.

This observational, cohort study aimed to examine the potential utility of Rapid Assessment Breast Clinics (RABC) beyond cancer detection at presentation. One thousand four hundred and twenty nine women were studied over an 18 month period. 154 (10.7%) had breast cancer - 87.7% of whom were seen expediently with 92.9% being diagnosed at one attendance. One hundred and forty three (10%) of those with a benign diagnosis were found by routine questioning to have significant familial risk separate to their reason for referral. Despite careful triage, considerable contamination of appointment allotment occurred with many who were correctly triaged as non-urgent being seen 'urgently'. One hundred and seventy six attendees (12.3%) had neither the symptom that triggered referral, nor breast lump, nipple discharge nor family history of breast cancer, while 283 (19.8%) had no objective clinical or radiological abnormality. Although RABC reliably categorise malignant versus non-malignant diagnoses despite cluttering by low risk women, a significant proportion of non-cancer patients still require address of future risk rather than reassurance of their present status alone.

Correction of anaemia through the use of darbepoetin alfa improves chemotherapeutic outcome in a murine model of Lewis lung carcinoma.

Darbepoetin alfa (Aranesp), Amgen) is a novel erythropoiesis-stimulating protein with a serum half-life longer than recombinant human erythropoietin (Epo), used in the treatment of cancer-associated anaemia. Anaemia is known to adversely affect prognosis and response to treatment in cancer patients. Solid tumours contain regions of hypoxia due to poor vascular supply and cellular compaction. Although hypoxic stress usually results in cell death, hypoxia-resistant tumour cells are genetically unstable and often acquire a drug-resistant phenotype. Increasing tumour oxygenation and perfusion during treatment could have the doubly beneficial outcome of reducing the fraction of treatment-resistant cells, while increasing drug delivery to previously hypoxic tissue. In this study, we examined the effect of darbepoetin alfa on chemotherapy sensitivity and delivery in an in vivo model of Lewis lung carcinoma, shown here to express the Epo receptor (EpoR). We identified that weekly darbepoetin alfa treatment, commencing 10 days before chemotherapy, resulted in a significant reduction in tumour volume compared to chemotherapy alone. This was mediated by the prevention of anaemia, a reduction in tumour hypoxia and a concomitant increase in drug delivery. Darbepoetin alfa treatment alone did not modulate the growth of the EpoR-expressing tumour cells. This study identifies an important role for darbepoetin alfa in increasing the therapeutic index of chemotherapy.