Middle Segment Pancreatectomy: A Useful Tool in the Management of Pancreatic Neoplasms

Small, benign, or low-grade malignant tumors located in the neck of the pancreas are usually treated with enucleation. However, if enucleation is too risky because of possible damage of the main pancreatic duct, standard pancreatic resections are performed. Such operations can lead to impaired long-term exocrine–endocrine function. Middle segment pancreatectomy consists of a limited resection of the midportion of the pancreas and can be performed in selected patients affected by tumors of the pancreatic neck. Middle segment pancreatectomy is a safe and feasible procedure for treating tumors of the pancreatic neck; in experienced hands it is associated with no mortality but with high morbidity, even if the rate of “clinical” pancreatic fistula is about 20%. Moreover, it allows a surgeon to preserve pancreatic parenchyma and consequently long-term endocrine and exocrine pancreatic function

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND: Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. METHODS: The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. RESULTS: One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. CONCLUSIONS: Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. TRIAL REGISTRATION: Prospero registration number: 42016037725

Neonatal lipid utilization increases with injury severity: Recombinant human growth hormone versus placebo

Increased lipid oxidation has been observed in injured adult and pediatric patients who receive growth hormone (GH). In infants, whose bodies make fat more readily (de novo lipogenesis), this effect has not been tested. After surgery for necrotizing enterocolitis or gastroschisis, 22 neonates (average gestational age, 35 weeks; average postnatal age, 7 days) were provided basal protein-calorie parenteral repletion, and were prospectively randomized to receive either recombinant human GH (rhGH, 0.2 mg/kg/d) or placebo for 6 days. Injury severity was established by serial serum C- reactive protein (CRP) levels (high v low stress: CRP ≤ 6.0 mg/dL v \u3c 6.0 mg/dL). Indirect calorimetry was used to measure energy expenditure (MEE), respiratory quotient (RQ), net lipid oxidation (Fe), and lipid oxidative O2 consumption (V̇O2f). Among the GH+ group, MEE, Fe, and V̇O2f were significantly higher for the high-stress patients (MEE: 52.87 ± 13.35 v 42.57 ± 9.47 kcal/kg/d; P \u3c .03; Fe: 18.32 ± 27.74 v 0.81 ± 13.47 kcal/kg/d; P \u3c .02; V̇O2f: 7.21 ± 9.86 v 0.01 ± 7.42 L/d, P \u3c .02), and RQnp was significantly lower in the high-stress patients (RQnp: 0.93 ± 0.14 v 1.05 ± 0.11; P \u3c .02). In addition, Fe and RQnp were directly proportional to carbohydrate intake (CHO) in the high-stress patients (CHO to Fe: Pearson r = -.701; CHO to RQnp: Pearson r = .714; P \u3c .05). Lipid oxidation was directly proportional to stress severity, was higher in the GH group (18.32 v 11.91 kcal/kg/d for the placebo group), and was depressed in response to increased CHO intake in all groups. Lipid is an important energy source in acutely injured, especially severely stressed neonates. Lipid substrate utilization is improved with GH supplementation during acute metabolic stress. In addition, excess carbohydrate delivery reduces the amount of lipid utilized for energy metabolism. An appropriately balanced, mixed-fuel formula should be used for caloric repletion in this infant population