Burden of in-hospital care in oesophageal cancer: national population-based study

Background

Oesophageal cancer management requires extensive in-hospital care. This cohort study aimed to quantify in-hospital care for patients with oesophageal cancer in relation to intended treatment, and to analyse factors associated with risk of spending a large proportion of survival time in hospital.

Methods

All patients with oesophageal cancer in three nationwide registers over a 10-year period were included. In-hospital care during the first year after diagnosis was evaluated, and the proportion of survival time spent in hospital, stratified by intended treatment (curative, palliative or best supportive care), was calculated. Associations between relevant factors and a greater proportion of survival time in hospital were analysed by multivariable logistic regression.

Results

In-hospital care was provided for a median of 39, 26, and 15 days in the first year after diagnosis of oesophageal cancer in curative, palliative, and best supportive care groups respectively. Patients receiving curatively intended treatment spent a median of 12 per cent of their survival time in hospital during the first year after diagnosis, whereas those receiving palliative or best supportive care spent 19 and 23 per cent respectively. Factors associated with more in-hospital care included older age, female sex, being unmarried, and chronic obstructive pulmonary disease.

Conclusion

The burden of in-hospital care during the first year after diagnosis of oesophageal cancer was substantial. Important clinical and socioeconomic factors were identified that predisposed to a greater proportion of survival time spent in hospital.

Impact of surgical resection rate on survival in gastric cancer: nationwide study

Background

There are marked geographical variations in the proportion of patients undergoing resection for gastric cancer. This study investigated the impact of resection rate on survival.

Methods

All patients with potentially curable gastric cancer between 2006 and 2017 were identified from the Swedish National Register of Oesophageal and Gastric Cancer. The annual resection rate was calculated for each county per year. Resection rates in all counties for all years were grouped into tertiles and classified as low, intermediate or high. Survival was analysed using the Cox proportional hazards model.

Results

A total of 3465 patients were diagnosed with potentially curable gastric cancer, and 1934 (55.8 per cent) were resected. Resection rates in the low (1261 patients), intermediate (1141) and high (1063) tertiles were 0–50.0, 50.1–62.5 and 62.6–100 per cent respectively. The multivariable Cox analysis revealed better survival for patients diagnosed in counties during years with an intermediate versus low resection rate (hazard ratio (HR) 0.81, 95 per cent c.i. 0.74 to 0.90; P < 0.001) and high versus low resection rate (HR 0.80, 0.73 to 0.88; P < 0.001).

Conclusion

This national register study showed large regional variation in resection rates for gastric cancer. A higher resection rate appeared to be beneficial with regard to overall survival for the entire population.

Geographical differences in cancer treatment and survival for patients with oesophageal and gastro-oesophageal junctional cancers

BACKGROUND

Only around one-quarter of patients with cancer of the oesophagus and the gastro-oesophageal junction (GOJ) undergo surgical resection. This population-based study investigated the rates of treatment with curative intent and resection, and their association with survival.

METHODS

Patients diagnosed with oesophageal and GOJ cancer between 2006 and 2015 in Sweden were identified from the National Register for Oesophageal and Gastric Cancer (NREV). The NREV was cross-linked with several national registries to obtain information on additional exposures. The annual proportion of patients undergoing treatment with curative intent and surgical resection in each county was calculated, and the counties divided into groups with low, intermediate and high rates. Treatment with curative intent was defined as definitive chemoradiation therapy or surgery, with or without neoadjuvant oncological treatment. Overall survival was analysed using a multilevel model based on county of residence at the time of diagnosis.

RESULTS

Some 5959 patients were included, of whom 1503 (25·2 per cent) underwent surgery. Median overall survival after diagnosis was 7·7, 8·8 and 11·1 months respectively in counties with low, intermediate and high rates of treatment with curative intent. Corresponding survival times for the surgical resection groups were 7·4, 9·3 and 11·0 months. In the multivariable analysis, a higher rate of treatment with curative intent (time ratio 1·17, 95 per cent c.i. 1·05 to 1·30; P < 0·001) and a higher resection rate (time ratio 1·24, 1·12 to 1·37; P < 0·001) were associated with improved survival after adjustment for relevant confounders.

CONCLUSION

Patients diagnosed in counties with higher rates of treatment with curative intent and higher rates of surgery had better survival.

Improvements in esophageal and gastric cancer care in Sweden-population-based results 2007-2016 from a national quality register

The Swedish National Register for Esophageal and Gastric cancer was launched in 2006 and contains data with adequate national coverage and of high internal validity on patients diagnosed with these tumors. The aim of this study was to describe the evolution of esophageal and gastric cancer care as reflected in a population-based clinical registry. The study population was 12,242 patients (6,926 with esophageal and gastroesophageal junction (GEJ) cancers and 5,316 with gastric cancers) diagnosed between 2007 and 2016. Treatment strategies, short- and long-term mortality, gender aspects, and centralization were investigated. Neoadjuvant oncological treatment became increasingly prevalent during the study period. Resection rates for both esophageal/GEJ and gastric cancers decreased from 29.4% to 26.0% (P = 0.022) and from 38.8% to 33.3% (P = 0.002), respectively. A marked reduction in the number of hospitals performing esophageal and gastric cancer surgery was noted. In gastric cancer patients, an improvement in 30-day mortality from 4.2% to 1.6% (P = 0.005) was evident. Overall 5-year survival after esophageal resection was 38.9%, being higher among women compared to men (47.5 vs. 36.6%; P < 0.001), whereas no gender difference was seen in gastric cancer. During the recent decade, the analyses based on the Swedish National Register for Esophageal and Gastric cancer database demonstrated significant improvements in several important quality indicators of care for patients with esophagogastric cancers. The Swedish National Register for Esophageal and Gastric cancer offers an instrument not only for the control and endorsement of quality of care but also a unique tool for population-based clinical research.

Safe Introduction of Minimally Invasive Esophagectomy at a Medium Volume Center

BACKGROUND AND AIMS

Minimally invasive esophagectomy is a favored alternative in high-volume centers. We evaluated the introduction of, and transition to, minimally invasive esophagectomy at a medium volume tertiary referral center (10-20 esophagectomies annually) with focus on surgical results.

MATERIAL AND METHODS

Patients who underwent minimally invasive esophagectomy or open transthoracic surgery for carcinoma of the esophagus or gastroesophageal junction (Siewert I and II) during 2007-2016 were retrospectively studied. Sorted on surgical approach, perioperative data, surgical outcomes, and postoperative complications were analyzed and multivariate regression models were used to adjust for possible confounders.

RESULTS

One hundred and sixteen patients were included, 51 minimally invasive esophagectomy (21 hybrid and 30 totally minimally invasive) and 65 open resections. The groups were well matched. However, higher body mass index, neoadjuvant chemoradiotherapy, and cervical anastomosis were more frequent in the minimally invasive esophagectomy group. Minimally invasive esophagectomy was associated with less peroperative bleeding (384 vs 607 mL, p = 0.036) and reduced length of stay (14 vs 15 days, p = 0.042). Duration of surgery, radical resection rate, and postoperative complications did not differ between groups. Lymph node yield was higher in the minimally invasive esophagectomy group, 18 (13-23) vs 12 (8-16), p < 0.001, confirmed in a multivariate regression model (adjusted odds ratio 3.15, 95% class interval 1.11-8.98, p = 0.032).

CONCLUSION

The introduction of minimally invasive esophagectomy at a medium volume tertiary referral center resulted in superior lymph node yield, less peroperative blood loss and shorter length of stay, without compromising the rate of radical resection, or increasing the complication rate.

Treatment of de Garengeot's hernia: a meta-analysis

Purpose

de Garengeot’s hernia is a rare entity in which the appendix is located within a femoral hernia and is almost invariably encountered incarcerated in an emergency setting with concomitant appendicitis. In the literature, there are mostly single-case reports. The purpose of the present study was to perform a review of the literature to study the incidence, pathogenesis, demographics, clinical presentation, laboratory and radiological investigations, differential diagnosis, delay in diagnosis and treatment, operative findings, surgical technique, histological findings, the postoperative course, use of antibiotics, and complications regarding de Garengeot’s hernia.

Methods

A literature search was performed through PubMed with the following search terms, single or in combination: Garengeot, femoral hernia, and appendicitis. Additional references were also found within the articles, and two patients from Uppsala University Hospital were added.

Results

Between 1981 and 2016, 70 publications were identified, and with the additional two patients, the present series comprised 90 patients There were 75 women (median age 73.0 years) and 15 men (median age 78.0 years). On examination, an inguinal mass was found in 87 patients (97%), which was painful and the cause of primary complaint in 67 patients (74%): the median duration of symptoms was 3 days. Radiological investigations or ultrasound were performed in 67 patients (74%); computed tomography was the most accurate with a positive diagnosis in 23/34 patients. Appendicitis was found in 76 patients, gangrenous in 23, and perforated in 9. The surgical approach was inguinal in 76 patients, including 15 with concomitant laparotomy. The preperitoneal route was chosen in six patients, and laparoscopy alone in four patients. A mesh/plug was used in 22 patients (7/22 normal appendix) and suture repair in 59 (4/59 normal appendix: p < 0.01). Complications were analysed in 79 patients and occurred in 11%. There was no mortality.

Conclusions

de Garengeot’s hernia is rare, being indistinguishable from an incarcerated femoral hernia in general. A delay in surgery should be avoided but if needed, computed tomography may be used for differential diagnosis. Although there is no standard treatment, mesh material does not appear advisable in the presence of a perforation, and it is beneficial for the surgeons to perform their routine method rather than a specific technique.

Effects of short-term sitagliptin treatment on immune parameters in healthy individuals, a randomized placebo-controlled study

Sitagliptin, a dipeptidyl-peptidase 4 (DPP-4) inhibitor, improves blood glucose control in patients with type 2 diabetes by blocking cleavage of glucagon-like peptide 1 (GLP-1). In type 2 diabetes patients sitagliptin use is associated with an increase in minor infections, and in new-onset type 1 diabetes patients the ability of sitagliptin to dampen autoimmunity is currently being tested. DPP-4, also known as CD26, is expressed on leucocytes and can inactivate many chemokines important for leucocyte migration, as well as act as a co-stimulatory molecule on T cells. Therefore, this study was conducted to test whether sitagliptin is immunomodulatory. In this randomized, placebo-controlled trial, healthy volunteers were given sitagliptin or placebo daily for 28 days, and blood was drawn for immune assays. No significant differences were observed in the percentage of leucocyte subsets within peripheral blood mononuclear cells (PBMCs), plasma chemokine/cytokine levels or cytokines released by stimulation of PBMCs with either lipopolysaccharide (LPS) or anti-CD3. Individuals taking sitagliptin displayed increases in the percentage of cells expressing higher levels of CD26 at early time-points compared to placebo controls, but these differences resolved by day 28 of treatment. Therefore, in healthy volunteers, treatment with sitagliptin daily for 28 days does not overtly alter systemic immune function.

Toxicity of copper to early-life stage Kootenai River white sturgeon, Columbia River white sturgeon, and rainbow trout

White sturgeon (Acipenser transmontanus) populations throughout western North America are in decline, likely as a result of overharvest, operation of dams, and agricultural and mineral extraction activities in their watersheds. Recruitment failure may reflect the loss of early-life stage fish in spawning areas of the upper Columbia River, which are contaminated with metals from effluents associated with mineral-extraction activities. Early-life stage white sturgeon (A. transmontanus) from the Columbia River and Kootenai River populations were exposed to copper during 96-h flow-through toxicity tests to determine their sensitivity to the metal. Similar tests were conducted with rainbow trout (RBT [Oncorhynchus mykiss]) to assess the comparative sensitivity of this species as a surrogate for white sturgeon. Exposures were conducted with a water quality pH 8.1-8.3, hardness 81-119 mg/L as CaCO(2), and dissolved organic carbon 0.2-0.4 mg/L. At approximately 30 days posthatch (dph), sturgeon were highly sensitive to copper with median lethal concentration (LC(50)) values ranging from 4.1 to 6.8 μg/L compared with 36.5 μg/L for 30 dph RBT. White sturgeon at 123-167 dph were less sensitive to copper with LC(50) values ranging from 103.7 to 268.9 μg/L. RBT trout, however, remained more sensitive to copper at 160 dph with an LC(50) value of 30.9 μg/L. The results indicate that high sensitivity to copper in early-life stage white sturgeon may be a factor in recruitment failure occurring in the upper Columbia and Kootenai rivers. When site-specific water-quality criteria were estimated using the biotic ligand model (BLM), derived values were not protective of early-life stage fish, nor were estimates derived by water-hardness adjustment.

Hemodynamic effect of iopromide in pancreas-duodenum transplanted rats

BACKGROUND

Radiological contrast media (CM) have been suggested to be able to impair pancreatic microcirculation, especially in acute pancreatitis.

PURPOSE

To evaluate the effects of the low-osmolar CM iopromide on total pancreatic and especially islet blood perfusion after whole pancreas transplantation.

MATERIAL AND METHODS

Rats receiving a pancreas-duodenum transplantation 2 days earlier, i.e., with graft pancreatitis, were injected with iopromide. Blood perfusion measurements were then made with a microsphere technique.

RESULTS

The graft blood perfusion was decreased in control rats when compared to the endogenous pancreas. Administration of iopromide increased both total pancreatic and islet blood perfusion in the grafted pancreas, but not in the endogenous gland. No effects on blood perfusion to either the native or transplanted duodenum were seen after iopromide administration.

CONCLUSION

Iopromide increases the blood perfusion of a whole pancreas transplant 2 days after implantation, i.e., when graft pancreatitis is present. The consequences of this CM-induced hyperperfusion for graft pancreatic function remain to be established.Key words: Intravascular contrast media; islet blood perfusion; graft pancreatitis;pancreas transplantation; pancreatic blood perfusion

Radiological contrast media and pancreatic blood perfusion in anesthetized rats

BACKGROUND

Radiological contrast media (CM) have been suggested to be able to impair pancreatic microcirculation.

PURPOSE

To evaluate the effects of an iso-osmolar (iodixanol, 290 mOsm/kg H2O) and a low-osmolar (iopromide, 660 mOsm/kg H2O) CM on total pancreatic and islet blood perfusion.

MATERIAL AND METHODS

Thiobutabarbital-anesthetized rats were injected with iodine equivalent doses (600 mg I/kg body weight) of iodixanol or iopromide. Saline or low-osmolar mannitol (660 mOsm/kg H2O) solutions served as control substances. Blood perfusion measurements were then carried out with a microsphere technique.

RESULTS

Iso-osmolar iodixanol had no effects on blood perfusion. Low-osmolar iopromide increased total pancreatic blood perfusion, whereas islet blood perfusion was unchanged. No differences were seen when mannitol solutions were given.

CONCLUSION

Neither an iso-osmolar nor a low-osmolar CM affected pancreatic islet blood perfusion, whereas the low-osmolar CM increased total pancreatic blood perfusion. The absence of hemodynamic effect of low-osmolar mannitol suggests that the hyperosmolality per se of iopromide versus iodixanol does not induce the hemodynamic effect. The consequences of the effect of iopromide for pancreatic function remain to be established.

You did what? Clinical errors in EMS

It was late and you were exhausted. You ran a call that didn't go the way you would have liked. Errors occurred. What actions do you take when your partner is making mistakes? When do you step in? Do you step in? What if there's more to the errors than you realize? This article provides guidelines for EMS personnel to consider when dealing with a scenario that contains clinical errors. Although not an all-inclusive list, the examples and solutions may be beneficial to providers, including rookies and veterans.

Phase III interlaboratory study of FETAX, Part 2: interlaboratory validation of an exogenous metabolic activation system for frog embryo teratogenesis assay--Xenopus (FETAX)

Interlaboratory validation of an exogenous metabolic activation system (MAS) developed for the alternative, short-term developmental toxicity bioassay, Frog Embryo Teratogenesis Assay-Xenopus (FETAX) was performed with cyclophosphamide and caffeine. Seven study groups within six separate laboratories participated in the study in which three definitive concentration-response experiments were performed with and without the MAS in a side-by-side format for each chemical. Since both chemicals had been previously tested in FETAX, the test concentrations were provided to each laboratory prior to testing. Interlaboratory coefficient of variation (CV) values for unactivated cyclophosphamide (no MAS) were 15%, 15%, 29%, and 25% for the 96-hr LC50, 96-hr EC50 (malformation), Minimum Concentration to Inhibit Growth (MCIG), and Teratogenic Index (TI) values, respectively. Addition of the MAS increased the CV values of each endpoint at least 3.9-fold. Interlaboratory CV values for unactivated caffeine were 31%, 18%, 31%, and 46% for the 96-hr LC50, 96-hr EC50 (malformation), MCIG, and TI values, respectively. Addition of the MAS decreased the CV values of each respective endpoint by at least 1.6-fold. Results indicated that bioactivated toxicants may be prone to greater variability in response amongst laboratories than compounds, which are detoxified. Even though more variability was noted with activated cyclophosphamide, results were within interlaboratory variation expected for other aquatic-based bioassays. Thus, results from these studies warrant the continued use and further refinement of FETAX for alternative developmental toxicity assessment.

The Stanford Health Information Network for Education: integrated information for decision making and learning

Although multiple decision support systems have been built for physicians, efficient delivery of valid and complete medical knowledge remains an elusive goal. In this paper we describe a new project, the Stanford Health Information Network for Education (SHINE). SHINE unifies core medical resources in an intuitive interface to support clinical decision making. Included in the description is a novel paradigm for continuing medical education (CME).

FETAX interlaboratory validation study: phase III--Part 1 testing

The Frog Embryo Teratogenesis Assay-Xenopus (FETAX) is a 96-h whole embryo developmental toxicity screening assay that can be used in ecotoxicology and in detecting mammalian developmental toxicants when an in vitro metabolic activation system is employed. A standardized American Society for Testing and Materials (ASTM) guide for the conduct of FETAX has been published, along with a companion atlas that aids in embryo staging and identifying malformations. As part of the ASTM process, a three-phase interlaboratory validation study was undertaken to evaluate the repeatability and reliability of FETAX. Seven different participants collaborated in the study. In Phase I, FETAX proved to be more repeatable and reliable than many bioassays. However, some excessive variation was observed in a few laboratories. An initial lack of assay experience by some technicians caused variation. Phase II showed far less intra- and interlaboratory variability than Phase I. Non-teratogens showed the most consistent results, while more variability was observed for the two teratogens tested. Interlaboratory coefficient of variation values for all endpoints ranged from 7.3 to 54.7. Phase III--Part 1, using coded samples and test concentration ranges selected by each laboratory, showed results similar to Phase I. Analysis of the causes of variation suggested that some technicians judged some embryos to be malformed while others consistently judged similar embryos as normal. Concentration ranges tested by some of the laboratories varied greatly and a new protocol for selecting concentrations for initial testing was written to reduce variation from this source. Testing to date suggests that FETAX is as repeatable and reliable as other standard bioassays.

Food chain analysis of exposures and risks to wildlife at a metals-contaminated wetland

A food chain analysis of risks to wetland receptors was performed in support of a baseline ecological risk assessment at the Milltown Reservoir Sediments Superfund site in Montana. The study area consisted of over 450 acres of primarily palustrine wetland contaminated with metals from mining wastes transported from upstream sources (average of 465 mg/kg for Cu in sediments, and 585 mg/kg in soils). The food chain analysis focused on several species of terrestrial and semiaquatic animals indigenous to montane wetlands of the northern Rocky Mountains. Receptors consisted of mice, voles, muskrats, beaver, various waterfowl species, osprey, bald eagles, and deer. Samples of aquatic and terrestrial invertebrates, small mammal tissues, fish tissue, aquatic and terrestrial vegetation, soils, sediment, and surface water were collected and analyzed for As, Cd, Cu, and Zn. A linear multimedia food-chain model was constructed to estimate daily intakes of the metals for each receptor, with assumed values for ingestion of aquatic and terrestrial food items, ingestion of local surface water, and incidental ingestion of soils and/or sediments. Evaluation of health risks to the receptors was performed by comparison of exposures expressed as daily intakes to a suite of toxicity values. The range of values consisted of the lower end of chronic toxicity data found in toxicology databases or the literature for the same or similar species, modified to account for extrapolation uncertainties. Daily intakes of chemicals of concern were below or within the range of toxicity values for all receptors. The weight of evidence from the food chain analysis and earlier bioassessment and ecological studies suggest that the health of the wetland receptors is at minimal risk due to the presence of elevated metals in sediments, upland soils, water, or food items at the site.

Food chain analysis of exposures and risks to wildlife at a metals-contaminated wetland

A food chain analysis of risks to wetland receptors was performed in support of a baseline ecological risk assessment at the Milltown Reservoir Sediments Superfund site in Montana. The study area consisted of over 450 acres of primarily palustrine wetland contaminated with metals from mining wastes transported from upstream sources (average of 465 mg/kg for Cu in sediments, and 585 mg/kg in soils). The food chain analysis focused on several species of terrestrial and semiaquatic animals indigenous to montane wetlands of the northern Rocky Mountains. Receptors consisted of mice, voles, muskrats, beaver, various waterfowl species, osprey, bald eagles, and deer. Samples of aquatic and terrestrial invertebrates, small mammal tissues, fish tissue, aquatic and terrestrial vegetation, soils, sediment, and surface water were collected and analyzed for As, Cd, Cu, and Zn. A linear multimedia food-chain model was constructed to estimate daily intakes of the metals for each receptor, with assumed values for ingestion of aquatic and terrestrial food items, ingestion of local surface water, and incidental ingestion of soils and/or sediments. Evaluation of health risks to the receptors was performed by comparison of exposures expressed as daily intakes to a suite of toxicity values. The range of values consisted of the lower end of chronic toxicity data found in toxicology databases or the literature for the same or similar species, modified to account for extrapolation uncertainties. Daily intakes of chemicals of concern were below or within the range of toxicity values for all receptors. The weight of evidence from the food chain analysis and earlier bioassessment and ecological studies suggest that the health of the wetland receptors is at minimal risk due to the presence of elevated metals in sediments, upland soils, water, or food items at the site.

Bioavailability of metals and arsenic to small mammals at a mining waste-contaminated wetland

In support of a baseline ecological risk assessment evaluating the impacts of mining wastes at the Milltown Reservoir Sediments Superfund site in Montana, a food chain transfer analysis was performed for resident small mammals. Deer mice (Peromyscus maniculatus) and meadow voles (Microtus pennsylvanicus) were trapped from a 200 A portion of a mixed upland and palustrine wetland, and concentrations of As, Cd, Cu, Pb, and Zn in carcass, liver, kidney, and testes were quantified. Concurrent to small mammal trapping, samples of grasses, forbs, and soils were collected and analyzed for metal and As residues. Using a linear multimedia food-chain model, assuming a forage base of wetland vegetation from the site, ingestion of local surface water, and incidental ingestion of soils with vegetation, body burdens of the metals and As in the herbivores were estimated. As a means of estimating potential element bioavailability at the site, the modeled body burdens were compared with measured element concentrations in herbivore tissues. The analysis indicates that the bioavailabilities of As, Cd, Cu, Pb, and Zn were equal to or less than 0.2% for internal organs and 0.1% for carcasses, on a microgram/g tissue wet weight basis. Available site data on soil pH, cation exchange capacity, and extractable elements fraction supported the limited release of soil elements. These results suggest that the bioavailable fraction of mining waste metals in riparian wetland soils may be quite small, and, for the Milltown Reservoir site, lower than originally anticipated.

Initial interlaboratory validation study of FETAX: phase I testing

An interlaboratory validation study was undertaken to evaluate the repeatability and reliability of the Frog Embryo Teratogenesis Assay-Xenopus (FETAX), which is a whole embryo developmental toxicity screening assay. A three-phase experimental program with seven participants was carried out. Phase I was a training and protocol evaluation phase where the identity of the three test materials was known. Hydroxyurea, isoniazid and 6-aminonicotinamide were tested in Phase I. Because the chemicals has been tested previously in FETAX, the same concentrations needed to establish the 96-h median lethal concentration (LC50) and the concentration inducing malformations in 50% of the surviving embryos (EC50) were used by all laboratories. The results of Phase I are presented in this report, and FETAX has proved to be as repeatable and reliable as many other bioassays. Some excess variation was observed in individual laboratories. Some of this variation may have been due to training difficulties. One change in protocol design necessitated by this study was the use of 6-aminonicotinamide as a reference toxicant. While 6-aminonicotinamide provided excellent concentration-response data in most laboratories, the protocol was written too strictly based on historical FETAX data. Phases II and III are currently in progress.