An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy

BACKGROUND

Few studies have investigated the effectiveness of enhanced recovery pathways (ERP) for lung resection. This study estimates the impact of an ERP for lobectomy on duration of stay, complications, and readmissions.

METHODS

Patients undergoing open lobectomy were identified from an OR database between 2011 and 2013. Beginning September 2012, all patients were managed according to a 4-day multidisciplinary ERP with written daily patient education treatment plans, multimodal analgesia, early diet, structured mobilization and standardized drain management. Pre-pathway (PRE) and post-pathway (POST) patients were compared in terms of duration of stay, complications, and readmissions.

RESULTS

We identified 234 patients (PRE, 127; POST, 107). Groups were similar with respect to age, gender, American Society of Anesthesiologists score, and baseline pulmonary function. Compared with the PRE group, the POST group had decreased duration of stay (median, 6 [interquartile range (IQR), 5-7] vs 7 [6-10] days; P < .05), total complications (40 [37%] vs 64 [50%]; P < .05), urinary tract infections (3 [3%] vs 15 [12%]; P < .05), and chest tube duration (median, 4 [IQR, 3-6] vs 5 [4-7] days; P < .05), with no difference in readmissions (7 [7%] vs 6 [5%]; P < .05) or chest tube reinsertion (4 [4%] vs 6 [5%]; P < .05). Decreased duration of stay was driven by patients without complications (median, 5 [IQR, 4-6] vs 6 [5-7] days; P < .05).

CONCLUSION

Implementation of a multimodal ERP for lobectomy was associated with decreased duration of stay and complications with no difference in readmissions.

Surgeons have knowledge gaps in the safe use of energy devices: a multicenter cross-sectional study

BACKGROUND

Despite the widespread use of surgical energy devices and the potential for rare but serious complications, pilot data from North America suggest that surgeons and surgical trainees have knowledge gaps in their safe use. The purpose of this study was to determine baseline knowledge of general surgeons and surgical trainees regarding the safe use of electrosurgery (ES) across varying levels of experience in Japan.

METHODS

Participants completed a 35-item multiple-choice question examination, testing critical knowledge of ES. The examination was developed according to the objectives and blueprints of SAGES' Fundamental Use of Surgical Energy™ curriculum. Sections of the examination included: "principles of ES," "ES-related adverse events," "monopolar and bipolar devices," and "pediatric considerations and interference with implantable devices." Scores were compared between PGY > 5 and PGY 1-5 participants.

RESULTS

A total of 145 general surgeons and surgical trainees of all years after medical school (PGY 1-5: 57, PGY > 5: 88) from ten academic and five community hospitals completed the assessment (mean age 35; 91% male). The mean score in the entire cohort was 58 ± 12% (range 23-83%), with significantly higher scores in the PGY > 5 group compared to the PGY 1-5 group (60 ± 11 vs. 53 ± 12%, p < 0.01). Among all participants, 92% were not familiar with best practices when using ES on patients with a pacemaker; 44% believe that ES uses thermal energy from cautery; 19% did not know how to manage an operating room fire; 16% thought that a dispersive electrode should be cut to fit a child; and 27% believe that insulation failure in minimally invasive surgical instruments is mostly visible under careful inspection.

CONCLUSIONS

General surgeons and trainees at all levels have knowledge gaps in the safe and effective use of energy devices, regardless of years of experience. There is a need for educational curricula to help address these gaps and contribute to safer surgery.

Pleural Disorders

This chapter provides an overview of both benign and malignant pleural disorders, starting with the relevant anatomy and physiology. The focus is on the management of pneumothoraces and pleural effusions—conditions that are commonly encountered on a general thoracic surgery service. The pleural cavity is lined by parietal and visceral pleura, which are smooth membranes that are continuous with one another at the hilum and pulmonary ligaments. Parietal Pleura: innermost chest wall layer, divided into cervical, costal, mediastinal and diaphragmatic pleura.

Silage effluent management: a review

Silage effluent is a potent wastewater that can be produced when ensiling crops that have a high moisture content (MC). Silage effluent can cause fish-kills and eutrophication due to its high biochemical oxygen demand (BOD) and nutrient content, respectively. It has a high acidity (pH ≈ 3.5-5) making it corrosive to steel and damaging to concrete, which makes handling, storage and disposal a challenge. Although being recognized as a concentrated wastewater, most research has focused on preventing its production. Despite noted imprecision in effluent production models-and therefore limited ability to predict when effluent will flow-there has been little research aimed at identifying effective reactive management options, such as containment and natural treatment systems. Increasing climate variability and intensifying livestock agriculture are issues that will place a greater importance on developing comprehensive, multi-layered management strategies that include both preventative and reactive measures. This paper reviews important factors governing the production of effluent, approaches to minimize effluent flows as well as treatment and disposal options. The challenges of managing silage effluent are reviewed in the context of its chemical constituents. A multi-faceted approach should be utilized to minimize environmental risks associated with silage effluent. This includes: (i) managing crop moisture content prior to ensiling to reduce effluent production, (ii) ensuring the integrity of silos and effluent storages, and (iii) establishing infrastructure for effluent treatment and disposal. A more thorough investigation of constructed wetlands and vegetated infiltration areas for treating dilute silage effluent is needed. In particular, there should be efforts to improve natural treatment system design criteria by identifying pre-treatment processes and appropriate effluent loading rates. There is also a need for research aimed at understanding the effects of repeated land application of effluent on soil quality and crop yields, as spreading is a common disposal practice.

Rare metastases of well-differentiated thyroid cancers: a systematic review

BACKGROUND

A minority of metastatic well-differentiated thyroid cancer (WDTC) patients present with end-organ disease other than in the lung, bone or lymph nodes. These metastases tend to be overlooked because of their low incidence, and this results in delayed diagnosis. The purpose of this study was to perform a systematic review of the clinical and histologic features of unusual WDTC metastases.

METHODS

A systematic literature search of bibliographic databases, reference lists of articles, and conference proceedings was performed up to 2013. Studies were included if they reported on adult patients with WDTC and pathology-proven metastases to end-organs other than lung, bone, or lymph nodes. A total of 238 studies were included in a qualitative analysis. Data is expressed as N (%) and median [interquartile range].

RESULTS

A total of 492 patients (median age, 62 years [50-70 years]) were identified in 197 case reports and 42 case series. There were 22 different end-organ metastatic sites documented with either papillary [255 (57 %)], follicular [172 (39 %)], or Hürthle-cell [18 (4 %)] histology. A total of 181 (41 %) patients presented with solitary metastasis and 54 (93 %) with elevated serum thyroglobulin. Positron emission tomography and whole-body radioactive iodine scans revealed hypermetabolic foci in 28 (97 %) and 50 (81 %) cases, respectively. Disease-free interval following the initial diagnosis of the primary thyroid cancer was highly variable, ranging from synchronous presentation [66 (33 %)] to metachronous disease after 516 months [mean 86 months (SD 90)].

CONCLUSIONS

WDTC can manifest with highly variable and unusual clinical features. Rare sites of metastases should be considered in the absence of the more common extra-cervical disease recurrence locations.

Clinical significance of incidental pulmonary nodules in esophageal cancer patients

INTRODUCTION

Incidental pulmonary nodules are frequently identified during staging investigations for esophageal cancer patients. Their clinical significance is unclear and may bias treatment decisions towards palliative options.

METHODS

From 2005 to 2011, 423 esophageal cancer patients were treated at a tertiary hospital. Those with incidental pulmonary nodules were identified. Demographics, imaging, pathology and perioperative outcomes were analyzed.

RESULTS

Ninety-two patients (22 %) had lung nodules. Twenty-nine (32 %) were palliative due to poor performance status or extra-pulmonary distant metastasis on imaging. Sixty-three had no evidence of extra-pulmonary metastasis and underwent curative-intent treatment comprising of neoadjuvant therapy [35 (55 %)] followed by esophagectomy [with lung resection, 33 (52 %) or without lung resection, 30 (48 %)]. Of those 33 lung resections, there were 27 benign lesions, 4 stage I lung cancers, and 1 esophageal cancer metastasis. Of 30 patients with lung nodules that underwent curative esophagectomy without lung resection, none showed interval size increase on follow-up imaging [median 9 months (3-40)]. There was no difference in perioperative complications or mortality between patients with combined esophagectomy and lung resection and those with esophagectomy alone.

CONCLUSION

Incidental pulmonary nodules in the absence of extra-pulmonary metastases in esophageal cancer patients are rarely metastases and should not bias caregivers towards palliative therapy.

Open repair of inflammatory abdominal aortic aneurysm and aortocaval fistula using retrograde balloon occlusion

PURPOSE

The purpose of this report is to describe a novel endovascular technique used to minimize blood loss during the open repair of an aortocaval fistula (ACF) in the context of an inflammatory abdominal aortic aneurysm (AAA).

CASE REPORT

We describe a patient who presented to our hospital with a symptomatic infrarenal AAA which was discovered intraoperatively to contain a large ACF. The patient underwent successful transperitoneal open repair of the AAA with balloon occlusion of the inferior vena cava to obtain distal control of the vessel.

CONCLUSIONS

Retrograde balloon occlusion of the inferior vena cava can be used to control hemorrhage during the open repair of an ACF, especially in the challenging setting of an inflammatory AAA.

Vector ecology and susceptibility in a malaria-endemic focus in southern Islamic Republic of Iran

This study aimed to carry out a malaria situation analysis, species composition and susceptibility levels of the main malaria vector, Anopheles stephensi, to different insecticides in Bashagard. A longitudinal survey was conducted in 2 randomly selected villages in Bashagard. Malaria vectors were sampled by dipping method for the larvae and hand catch, night-biting catch, total catch, and shelter pit collection for the adults. Standard WHO susceptibility tests were used for a variety of insecticides on F1 progeny of An. stephensi reared from wild-caught females. In total, 693 adult anopheline mosquitoes and 839 third and fourth-instar larvae were collected and identified. They comprised 7 species; the most abundant adult and larvae anopheline mosquito was An. dthali (40.7% and 30.5% respectively). An. culicifacies (24.2%) and An. stephensi (16.7%) were the next most common species for adult mosquitoes. An. stephensi was fully susceptible to malathion and pyrethroid insecticides but resistant to DDT and tolerant to dieldrin.

Evaluating the resistance of eimeria spp. Field isolates to anticoccidial drugs using three different indices

BACKGROUND

In this study, the presence of resistance to diclazuril, amprolium+ethopabate and salinomycin, representing some of the commonest anticoccidials in Iran's poultry industry, against three mixed Eimeria field isolates were investigated.

METHODS

Three Eimeria field isolates, collected from typical broiler farms in Iran, were propagated once, inoculated to 480 broilers, comprising 30 chicks in each treatment. The non-medicated or medicated diets containing one of the above mentioned anticoccidials were provided ad-lib. Drug efficacy was determined using the Global index (GI), Anticoccidial Sensitivity Test (AST) and Optimum Anticoccidial Activity (OAA).

RESULTS

None of the field isolates were fully sensitive to the selected anticoccidials. All isolates showed reduced sensitivity/partial resistance to salinomycin. Resistance to amprolium+ethopabate was evident and partial to complete resistance was recorded for diclazuril.

CONCLUSION

Limited efficacy of the selected anticoccidials is obvious. Considering the cost of continuous use of anticoccidials in the field, altering the prevention strategy and rotation of the anticoccidials with better efficacy, would prevent further economic losses induced by coccidiosis.

Field evaluation of permethrin long-lasting insecticide treated nets (Olyset(®)) for malaria control in an endemic area, southeast of Iran

Long lasting insecticide treated nets (LLINs) have been advocated as an effective tool for prevention and control of malaria. Olyset net was the first LLINs which became commercially available and obtained WHO approval. According to the national strategic plan on evaluation of Olyset net, a field trial was conducted to determine the efficacy of these nets against malaria vectors in an endemic area in the southeast of Iran. Fourteen villages with similar topographical and epidemiological situations were selected and randomly assigned to two clusters of the study: Olyset net and untreated net. Distribution of nets was carried out to cover 100% of the population in Olyset net and untreated net cluster. Anopheline mosquitoes were collected monthly using different WHO standard methods in both areas to determine their abundance, feeding pattern and resting behaviour. Human blood index was determined using ELISA test. Additionally, Olyset nets were evaluated for their biological activity using WHO cone bioassay test by susceptible colony of Anopheles stephensi (Beech strain) and then for insecticide residues by employing high performance thin layer chromatography. Malaria incidence was measured by passive and active case detection from all study population. In total 2115 adult anopheline mosquitoes were collected and identified using morphological characters. They comprised of seven species: Anopheles dthali (Liston), A. culicifacies (Giles), A. stephensi (Liston), A. superpictus (Grassi), A.fluviatilis (James), A. moghulensis (Christophers) and A. turkhudi (Liston). A. dthali, A. culicifacies and A. stephensi were most prevalent species in both areas. In the Olyset net study area, there was a significant reduction of 41.1%, 54.4%, 59.39% and 64.1% in the indoor-resting density of A. culicifacies, A. stephensi, A. dthali and A. superpictus, respectively, with an overall reduction of 39.3% in total mosquitoes in comparison with untreated net area. A significant reduction was also observed in human blood index of vector species in the Olyset net villages. Bioefficacy test results of Olyset nets showed that the median knockdown time was 1.48 and 3.25min, while the average mortality rate was 100% and 72.3%±7.07 in baseline and after 1 year of intervention, respectively. The average permethrin content reached to 68.31% (683.1mg/m(2)) of the initial insecticide dose of 937±21.69mg/m(2) (nearly 1000mg/m(2)) at the end of intervention. Malaria incidence was reduced by 96.6% and 64.8% in the village with Olyset nets and in the villages with untreated nets, respectively. During intervention period, there was a reduction of 93.2% in malaria incidence in Olyset net area as compared to the untreated area. This study indicated that Olyset nets have a major impact on malaria vectors and disease burden; therefore it could be recommended as an effective personal protection tool for malaria control in malarious areas.

Relationships between dairy slurry total solids, gas emissions, and surface crusts

Livestock slurry storages are sources of methane (CH₄), nitrous oxide (NO₂), and ammonia (NH₃) emissions. Total solids (TS) content is an indicator of substrate availability for CH₄ and N₂O production and NH₃ emissions and is related to crust formation, which can affect these gas emissions. The effect of TS on these emissions from pilot-scale slurry storages was quantified from 20 May through 16 Nov. 2010 in Nova Scotia, Canada. Emissions from six dairy slurries with TS ranging from 0.3 to 9.5% were continuously measured using flow-through steady-state chambers. Methane emissions modeled using the USEPA methodology were compared with measured data focusing on emissions when empty storages were filled, and retention times were >30 d with undegraded volatile solids (VS) remaining in the system considered available for CH₄ production (VS carry-over). Surface crusts formed on all the slurries. Only the slurries with TS of 3.2 and 5.8% were covered completely for ∼3 mo. Nitrous oxide contributed <5% of total greenhouse gas emissions for all TS levels. Ammonia and CH₄ emissions increased linearly with TS despite variable crusting, suggesting substrate availability for gas production was more important than crust formation in regulating emissions over long-term storage. Modeled CH₄ emissions were substantially higher than measured data in the first month, and accounting for this could improve overall model performance. Carried-over VS were a CH₄ source in months 2 through 6. The results of this study suggest that substrate availability regulates emissions over long-term storage and that modifying the USEPA model to better describe carbon cycling is warranted.