The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Modeling Combination Hepatitis C Virus Treatment and Prevention Strategies in a Network of People Who Inject Drugs in the United States

BACKGROUND

Hepatitis C virus (HCV) treatment as prevention (TasP) strategies can contribute to HCV microelimination, yet complimentary interventions such as opioid agonist therapies (OAT) with methadone or buprenorphine and syringe services programs (SSPs) may improve the prevention impact. This modeling study estimates the impact of scaling up the combination of OAT and SSPs with HCV TasP in a network of people who inject drugs (PWID) in the United States.

METHODS

Using empirical data from Hartford, Connecticut, we deployed a stochastic block model to simulate an injection network of 1574 PWID. We used a susceptible-infected model for HCV and human immunodeficiency virus to evaluate the effectiveness of several HCV TasP strategies, including in combination with OAT and SSP scale-up, over 20 years.

RESULTS

At the highest HCV prevalence (75%), when OAT coverage is increased from 10% to 40%, combined with HCV treatment of 10% per year and SSP scale up to 40%, the time to achieve microelimination is reduced from 18.4 to 11.6 years. At the current HCV prevalence (60%), HCV TasP strategies as low as 10% coverage per year may achieve HCV microelimination within 10 years, with minimal impact from additional OAT scale-up. Strategies based on mass initial HCV treatment (50 per 100 PWID the first year followed by 5 per 100 PWID thereafter) were most effective in settings with HCV prevalence of 60% or lower.

CONCLUSIONS

Scale-up of HCV TasP is the most effective strategy for microelimination of HCV. OAT scale-up, however, scale-up may be synergistic toward achieving microelimination goals when HCV prevalence exceeds 60% and when HCV treatment coverage is 10 per 100 PWID per year or lower.

1311. Ryan White HIV Care Continuum Model Doubled the Rate of Community HIV Viral Suppression for Newly Diagnosed Patients: A 10-Year Review

Background

It is estimated that 1,295 per 100,000 are people living with HIV (PLWH) in New Haven, which is the second highest rate of HIV prevalence in Connecticut. Since 2009, New Haven has established the Ryan White (RW) HIV Care Continuum. The main goals of HIV care are early linkage to care, ART initiation, and HIV viral suppression. This study is designed to understand the trends and outcomes in newly diagnosed PLWH in New Haven County.

Methods

This study is a retrospective medical record review of all newly diagnosed RW eligible PLWH from January 1, 2009 to December 31, 2018. The data were collected in REDCap database and included demographics, HIV risk factor, presence of mental health and/or substance abuse disorder, date of diagnosis, date of initial visit, and ART initiation. Health outcomes such as AIDS at diagnosis and rate of viral suppression were evaluated. The data were then analyzed to show the trends over 10 years.

Results

From January 1, 2009 to December 31, 2018 there were 420 newly diagnosed RW PLWH. Sixty-seven percent of those were male, 56% were non-white, 47% self-identified as Men who have Sex with Men (MSM), and 41% were heterosexual. Twenty-nine percent had AIDS-defining condition at the time of the diagnosis. Thirty-four percent of the 420 patients had a mental health and/or substance use disorder; 53% of those were MSM and 51% were non-white. Over the 10-year period, it was noted that the duration between date of HIV diagnosis and linkage to care as well as ART initiation decreased. This decline was associated with a substantial increase in viral suppression. The average time between the dates of HIV diagnosis and initial visit decreased from 269 days in 2009 to 13 days in 2018. Moreover, the average time between the dates of diagnosis and ART initiation dropped from 308 days in 2009 to 15 days in 2018. The 1-year HIV viral suppression rate subsequently doubled from 44% in 2009 to 87% in 2018 (P < 0.01).

Conclusion

The Ryan White HIV Care Continuum Model with emphasis on early linkage to care and ART initiation can have a significant impact on HIV viral suppression at a community level for newly diagnosed patients. Another important observation in this study was the alarming high rate of AIDS at diagnosis, which highlights the need for universal HIV testing, and early diagnosis.

Disclosures

All authors: No reported disclosures.

Estimating HIV and HCV prevalence among people who inject drugs in 5 Ukrainian cities using stratification-based respondent driven and random sampling

BACKGROUND

Ukraine, a country of 45.5 million people, has one of the most volatile HIV and HCV epidemics in the world. In this paper, we estimate the prevalence of HIV and HCV among PWID in five Ukrainian cities.

METHODS

A cross-sectional study was conducted in 2014-2015, based on stratified hybrid sampling with random and respondent driven sampling in five cities: Kyiv, Odesa, Mykolaiv, Dnipro and Lviv. Using data on HIV and HCV antibody testing from 1613 respondents, we evaluate selection bias in the sampling methods by analyzing spatial and network patterns of sampling processes. We develop and apply inverse probability weights in order to estimate the HIV and HCV prevalence in each city, as well as in the overall sample.

FINDINGS

The aggregate HIV prevalence for the five cities is 35.1% (95% CI: 29.5%-38.5%) but this varied considerably by city: in Kyiv the HIV prevalence is 26.6% (95% CI: 20.3.8%-33.4%), in Odesa - 38.2% (95% CI: 29.8% and 47.1%), in Mykolaiv - 42.0% (95% CI: 34.3%-49.2%), in Dnipro - 58.8% (95% CI: 52.2%-65.8%), and in Lviv 24.6% (95% CI: 18.8%-30.8%). The aggregate HCV prevalence estimate for the five cities is 58.6% (95% CI: 54.9%-61.7%). The highest HCV prevalence is estimated in Kyiv - 84.8% (95% CI: 78.5%-90.1%). HCV prevalence in Odesa is the lowest and estimated to be 36.5% (95% CI: 29.5%-45.1%), in Mykolaiv - 49.1% (95% CI: 41.5%-57.0%), in Dnipro - 56.1% (95% CI: 50.3%-63.4%) and in Lviv 38.5% (95% CI: 31.8%-45.0%).

CONCLUSIONS

Monitoring behavioral and health outcomes of PWID on a regular basis is necessary for determining prevention and treatment priorities for HIV and HCV infections in Ukraine and elsewhere. The heterogeneity of the local epidemics provides insights into the best prevention and treatment strategies to be deployed in low-resource settings.

Assessment of barrier severity and willingness to enter opioid agonist treatment among people who inject drugs in Ukraine

BACKGROUND

Opioid agonist therapies (OAT) in Ukraine were first introduced in 2004 not as addiction treatment, but for HIV prevention. Numerous obstacles have thwarted OAT scale-up, including individual constraints and structural barriers.

METHODS

A cross-sectional survey of 1613 opioid dependent people who inject drugs (PWID) were recruited in 2014-2015 using stratified sampling in Kyiv, Odesa, Mykolayiv, Dnipro and Lviv. Analysis was restricted to a subset of 811 PWID who never received OAT. Barriers to OAT were assessed based on reasons why study participants were reluctant to enroll into OAT. A Rasch model from the Item Response Theory was applied to 24 potential barriers, used to score their severity and estimate a latent composite measure for each person's willingness and ability to participate in OAT.

RESULTS

The Rasch model confirmed the cumulative nature of barriers with concerns over treatment efficacy, safety and tolerability being more prevalent than barriers related to logistical constraints, opportunity costs and social stigma. If barriers related to treatment perception and logistics were eliminated, the average barrier number would decrease from 10 to 2.2. Participants were more likely to have a higher resistance to OAT entry if they experienced fewer overdoses, did not attain higher education, were not previously incarcerated and if their peers did not have a higher level of resistance to OAT.

CONCLUSIONS

Understanding the interdependence of various barriers and attitudes toward OAT can improve the rate of OAT expansion and ameliorate entry into substance abuse treatment programs in Ukraine.

Small threat and contraband detection with TNA-based systems

The detection of small threats, such as explosives, drugs, and chemical weapons, concealed or encased in surrounding material, is a major concern in areas from security checkpoints to UneXploded Ordnance (UXO) clearance. Techniques such as X-ray and trace detection are often ineffectual in these applications. Thermal neutron analysis (TNA) provides an effective method for detecting concealed threats. This paper shows the effectiveness of Ancore's SPEDS, based on TNA, in detecting concealed liquid threats and differentiating live from inert mortar shells.

Fibroblast growth factor-18 is a trophic factor for mature chondrocytes and their progenitors

OBJECTIVE

The aim of this study was to examine the effects of recombinant human Fgf18 on chondrocyte proliferation and matrix production in vivo and in vitro. In addition, the expressions of Fgf18 and Fgf receptors (Fgfr) in adult human articular cartilage were examined.

METHODS

Adenovirus-mediated transfer of Fgf18 into murine pinnae and addition of FGF18 to primary cultures of adult articular chondrocytes were used to assess the effects of FGF18 on chondrocytes. In situ hybridization was used to examine the expression of Fgf18 and Fgfr s in adult human articular cartilage.

RESULTS

Expression of Fgf18 by adenovirus-mediated gene transfer in murine pinnae resulted in a significant increase in chondrocyte number. Chondrocytes were identified by staining with toluidine blue and a monoclonal antibody directed against type II collagen. Fgf18, Fgfr 2-(IIIc), Fgfr 3-(IIIc), and Fgfr 4 mRNAs were detected within these cells by in situ hybridization. The nuclei of the chondrocytes stained with antibodies to PCNA and FGF receptor (FGFR) 2. Addition of FGF18 to the culture media of primary articular chondrocytes increased the proliferation of these cells and increased their production of extracellular matrix. To assess the receptor selectivity of FGF18, BaF3 cells stably expressing the genes for the major splice variants of Fgfr1-3 were used. Proliferation of cells expressing Fgfr 3-(IIIc) or Fgfr 2-(IIIc) was increased by incubation with FGF18. Using FGFR-Fc fusion proteins and BaF3 cells expressing Fgfr 3-(IIIc), only FGFR 3-(IIIc)-Fc, FGFR 2-(IIIc)-Fc or FGFR 4-Fc reduced FGF18-mediated cell proliferation. Expression of Fgf18, Fgfr 3-(IIIc) and Fgfr 2-(IIIc) mRNAs was localized to chondrocytes of human articular cartilage by in situ hybridization.

CONCLUSION

These data demonstrate that Fgf18 can act as a trophic factor for elastic chondrocytes and their progenitors in vivo and articular chondrocytes cultured in vitro. Expression of Fgf18 and the genes for two of its receptors in chondrocytes suggests that Fgf18 may play an autocrine role in the biology of normal articular cartilage.

Allelic variants of aromatase and the androgen and estrogen receptors: toward a multigenic model of prostate cancer risk

PURPOSE

The purpose of this study was to determine whether polymorphisms in the CAG repeat in exon 1 of the androgen receptor (AR), two intronic restriction sites in the estrogen receptor (ESR1 XbaI and ESR1 PvuII), and an Arg264Cy5 substitution in the aromatase gene (CYP19) contribute to prostate cancer risk.

EXPERIMENTAL DESIGN

A case-control study was performed with 88 Caucasian prostate cancer patients and 241 Caucasian male controls. Logistic regression models were used to assess individual and joint contributions of genotypes to prostate cancer risk.

RESULTS

For single polymorphisms, only the AR repeat number was significantly related to increased prostate cancer risk [age- and body mass index (BMI)-adjusted odds ratio (OR), 1.14; 95% confidence interval (CI), 1.04-1.25], suggesting a 14% increase in risk for each missing CAG repeat. When subjects were classified as either long (> or =23 AR CAG repeats) or short (<23 repeats) carriers, a significant increase in risk was also observed (age- and BMI-adjusted OR, 1.75; 95% CI, 1.05-2.95; P = 0.04). The aromatase C/T was associated with an increase in risk of borderline significance (age- and BMI-adjusted OR, 2.50; 95% CI, 0.99-6.28). When examining the effects of two polymorphisms on prostate cancer risk, homozygosity for the ESR1 XbaI restriction site together with a longer AR was more frequent among controls (32%) than cases (18%; age- and BMI-adjusted OR, 0.39; 95% CI, 0.19-0.78). The aromatase C/C genotype together with a longer AR was also more frequent among controls (55%) than cases (41%; age- and BMI-adjusted OR, 0.51; 95% CI, 0.30-0.89).

CONCLUSIONS

Estrogen and aromatase may play a role in prostate cancer. A multigenic model of prostate cancer susceptibility is also supported.

Smoking cessation among self-quitters

We examined cessation among 630 smokers who quit abruptly on their own. Continuous, complete abstinence rates were 33% at 2 days, 24% at 7 days, 22% at 14 days, 19% at 1 month, 11% at 3 months, 8% at 6 months postcessation, and 3% at 6 months with biochemical verification. Slipping (smoking an average of less than 1 cigarette/day) was common (9% to 15% of subjects) and was a strong predictor of relapse; however, 23% of long-term abstainers slipped at some point. These results challenge beliefs that most smokers can initially stop smoking and that most relapse occurs later on postcessation.

Design and synthesis of metabolically stable atrial natriuretic factor analogs. Amino- and carboxy-terminal stabilization

Two analogs of rat atrial natriuretic factor, rANF7-28-NH2 and [Mpr7,Ala20,D-Arg27]rANF7-27-NH2, were prepared by the solid-phase method. These peptides had 2-fold and 7-fold less affinity, respectively, than rANF1-28 in binding to membranes prepared from cultured aortic smooth muscle cells, and both peptides were 5-fold less potent than rANF1-28 in relaxing serotonin-contracted rabbit aortic rings. rANF7-28-NH2 was rapidly degraded by rat kidney homogenates but [Mpr7,Ala20,D-Arg27]rANF7-27-NH2 had enhanced stability against rat kidney homogenate degradation. However, this in vitro stability did not translate into an extended duration of action in vivo.

Ecological study of nematode parasitism in ips beetles from california and idaho

Nematodes found in Ips paraconfusus from ponderosa pine in California were an undescribed species of Parasitaphelenchus, Contortylenchus elongatus, C. reversus, and C. brevicomi. C. elongatus, the most commonly found contortylenchid, was present in 98.2% of the contortylenchid-parasitized beetles. Only one nematode parasite of the gut, a Parasitorhabditis sp., was isolated. Although significant differences in parasitism were observed, they were by collection sites, rather than by elevation or bole sources (slash or standing). Significant changes in parasitism between fall and spring collections were observed but not at every site. Nematode parasitism in the F generation of I. paraconfusus by Parasitaphelenchus, Contortylenchus, or Parasitorhabditis increased or decreased from the parent generation depending upon the experiment.Nematode parasites from I. pini included an undescribed Parasitaphelenchus sp., two undescribed Contortylenchus spp., C. reversus and Parasitylenchus (= Neoparasitylenchus) ovarius from the hemocel, and Parasitorhabditis ipini from the gut. Parasitaphelenchus sp. was found in 99% and 45.3% of the beetles from Idaho and California, respectively. Of the 1,000 I. pini from Idaho and California, 157 were parasitized by the contortylenchid species or P. ovarius.

Flecainide and amiodarone interaction

Oral amiodarone therapy was given to seven patients already taking oral flecainide regularly. In one additional patient, administration of flecainide was temporarily discontinued when amiodarone therapy was begun, and then resumed. Amiodarone produced a rise in mean dose-adjusted flecainide plasma level (trough plasma level at steady state/daily dose) from 2.3 +/- 0.8 to 3.4 +/- 0.9 (ng/ml)(mg/day) (p less than 0.01). Accordingly, the mean dose of flecainide required to maintain similar plasma levels of the drug was one-third lower during combined treatment than during therapy with flecainide alone. This drug interaction must be accounted for when amiodarone and flecainide are used concomitantly.

Biological stress responses in high and low trait anxious students

In an investigation of biological indicators of stress in normal humans, undergraduate psychology students were differentiated on trait anxiety and assessed under baseline, preexam (stress), and postexam conditions. Assessment at each condition involved drawing 20 ml of blood, followed by self-reporting for selected questionnaires. Self-reports included state anxiety, general psychological symptomatology, dysfunctional attitudes, academic confidence, sleep patterns, and intake of drugs, including alcohol and caffeine. Blood was analyzed for whole blood serotonin content, plasma MHPG, and platelet imipramine binding. Baseline differences between high and low trait anxious students on biological measures were significant only for whole blood serotonin content. Variation across situational conditions was significant for whole blood serotonin, with an increase under the stressful condition for both anxiety groups. Thus, serotonin is highlighted as an important factor in the human response to stress, whereas expected differences in MHPG were not observed. The serotonergic response to stress was not explained by changes in psychological or physical state variables. Changes in serotonin content were positively correlated with changes in platelet imipramine binding.

CT localization and aspiration of postoperative pericardial fluid collection

The authors report a case in which computed tomography (CT) was used to guide percutaneous needle aspiration of postoperative pericardial and paracardiac fluid collection. This application of CT has particular importance in postsurgical cardiac patients because of the loculated nature and occasional atypical location of fluid collections.

Comparison of MAO, D beta H, and COMT activities in chronic schizophrenics selected on the basis of nailfold capillary pattern

A group of 17 white male chronic schizophrenic subjects were divided on the basis of plexus visualization score (PVS). High and low PVS subjects were compared to each other and to low PVS controls on measures of platelet monamine oxidase (MAO), rbc catechol-o-methyl transferase (COMT), and plasma dopamine-beta-hydroxylase (D beta H). There were no differences between high and low PVS subjects on any biochemical variable. Schizophrenic subjects had lower platelet MAO activity than controls. Platelet MAO and rbc COMT were significantly correlated in schizophrenic subjects.

Prenatal high risk scoring: how family doctors do it

Assessment of risk factors is an integral part of family medicine and of prenatal care. A strong positive relationship has been demonstrated between a high risk score and higher incidence of maternal or perinatal morbidity and mortality. The family physician, because of his previous knowledge of the patient, and his familiarity with a broad range of normals, is in a good position to use his clinical judgement in high risk scoring in pregnancy. We must also be cautious that high risk scoring does not become a self fulfilling prophecy. Risk scoring is simply risk scoring, not a plan of management and intervention.

Safety and efficacy of combining obstetric and noninfectious gynecologic hospital patients

Unoccupied obstetric beds and unused delivery rooms represent inefficient use of hospital facilities and loss of revenue, both of which adversely affect the quality of care rendered patients. Hartford Hospital has permitted the admission of obstetric and noninfectious gynecologic patients to the same patient care areas of the hospital as well as use of delivery rooms by both groups of patients. Elaborate surveillance of these patients by the epidemiology section for a 1-year period (July 1974-July 1975) demonstrated no increase in the incidence of hospital-acquired infections associated with this combined approach as compared with the more traditional separation system of maternity and nonmaternity patients.

Clinical, epidemiologic and bacteriologic observations of an outbreak of methicillin-resistant Staphylococcus aureus at a large community hospital

Over a 12 month period, 61 isolates of methicillin-resistant Staphylococcus aureus (MR-SA) were obtained in 23 hospitalized patients. Eight-six per cent of the patients were over 50 years of age, and 91 per cent were in the postoperative period. In 10 patients (42 per cent), MR-SA was the major pathogen, producing either pneumonia, empyema, osteomyelitis, lung abscess, enterocolitis, wound infection or bacteremia with sepsis. Three patients in this group died despite therapy with antibiotics with in vitro activity against these organisms. All the patients probably acquired their MR-SA in the hospital, and five carriers of the organism were identified among hospital personnel. This outbreak demonstrates the ability of MR-SA not only to colonize many patients in a relatively brief period of time, but also to produce serious disease.

The psychiatrist as administrator

This paper deals with some of the problems of the psychiatrist working within an institutional setting. Reference is made to the distinction between psychiatric administrators and administrative therapists, and the hypothesis is put forward that a degree of management training is as necessary for the latter as it is for the former. Examples are given of some of the management problems that an administrative therapist might have to deal with and suggestions are made as to how a suitable course in middle management for psychiatrists might be designed and implemented.

Smoking cessation among self-quitters

We examined cessation among 630 smokers who quit abruptly on their own. Continuous, complete abstinence rates were 33% at 2 days, 24% at 7 days, 22% at 14 days, 19% at 1 month, 11% at 3 months, 8% at 6 months postcessation, and 3% at 6 months with biochemical verification. Slipping (smoking an average of less than 1 cigarette/day) was common (9% to 15% of subjects) and was a strong predictor of relapse; however, 23% of long-term abstainers slipped at some point. These results challenge beliefs that most smokers can initially stop smoking and that most relapse occurs later on postcessation.