Enhanced recovery pathway for urgent colectomy.

BACKGROUND: Enhanced recovery protocols have been proven to decrease complications and hospital stay following elective colorectal surgery. However, these principles have not yet been reported for urgent surgery procedures. We aimed to assess our initial experience with urgent colectomies performed within an established enhanced recovery pathway. METHODS: In a prospective cohort study, all patients undergoing colonic resection between April 2012 and March 2013 were treated according to a standardized enhanced recovery protocol. Urgent surgeries were compared with the elective procedures with regards to baseline characteristics, compliance with enhanced recovery items, and clinical outcome. RESULTS: Patients (N = 28) requiring urgent colonic resection were included and compared with patients undergoing elective colectomy (N = 63). Overall compliance with the protocol was 57% for the urgent compared with 77% for the elective procedures (p = 0.006). The pre-operative compliance was 64 versus 96% (p < 0.001), the intra-operative compliance was 77 versus 86% (p = 0.145), and the post-operative compliance was 49 versus 67% (p = 0.015), for the urgent and elective resections, respectively. Overall, 18 urgent patients (64%) and 32 elective patients (51%) developed postoperative complications (p = 0.261). Median postoperative length of stay was 8 days in the urgent setting compared with 5 days in the elective setting (p = 0.006). CONCLUSIONS: Many of the intra-operative and post-operative enhanced recovery items can also be applied to urgent colectomy, entailing outcomes that approach the results achieved in the elective setting

Theory of the vortex matter transformations in high Tc superconductor YBCO

Flux line lattice in type II superconductors undergoes a transition into a "disordered" phase like vortex liquid or vortex glass, due to thermal fluctuations and random quenched disorder. We quantitatively describe the competition between the thermal fluctuations and the disorder using the Ginzburg -- Landau approach. The following T-H phase diagram of YBCO emerges. There are just two distinct thermodynamical phases, the homogeneous and the crystalline one, separated by a single first order transitions line. The line however makes a wiggle near the experimentally claimed critical point at 12T. The "critical point" is reinterpreted as a (noncritical) Kauzmann point in which the latent heat vanishes and the line is parallel to the T axis. The magnetization, the entropy and the specific heat discontinuities at melting compare well with experiments.Comment: 4 pages 3 figure

Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway.

OBJECTIVE: To compare epidural analgesia (EDA) to patient-controlled opioid-based analgesia (PCA) in patients undergoing laparoscopic colorectal surgery. BACKGROUND: EDA is mainstay of multimodal pain management within enhanced recovery pathways [enhanced recovery after surgery (ERAS)]. For laparoscopic colorectal resections, the benefit of epidurals remains debated. Some consider EDA as useful, whereas others perceive epidurals as unnecessary or even deleterious. METHODS: A total of 128 patients undergoing elective laparoscopic colorectal resections were enrolled in a randomized clinical trial comparing EDA versus PCA. Primary end point was medical recovery. Overall complications, hospital stay, perioperative vasopressor requirements, and postoperative pain scores were secondary outcome measures. Analysis was performed according to the intention-to-treat principle. RESULTS: Final analysis included 65 EDA patients and 57 PCA patients. Both groups were similar regarding baseline characteristics. Medical recovery required a median of 5 days (interquartile range [IQR], 3-7.5 days) in EDA patients and 4 days (IQR, 3-6 days) in the PCA group (P = 0.082). PCA patients had significantly less overall complications [19 (33%) vs 35 (54%); P = 0.029] but a similar hospital stay [5 days (IQR, 4-8 days) vs 7 days (IQR, 4.5-12 days); P = 0.434]. Significantly more EDA patients needed vasopressor treatment perioperatively (90% vs 74%, P = 0.018), the day of surgery (27% vs 4%, P < 0.001), and on postoperative day 1 (29% vs 4%, P < 0.001), whereas no difference in postoperative pain scores was noted. CONCLUSIONS: Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits. EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery

Enhanced Recovery after Elective Colorectal Surgery - Reasons for Non-Compliance with the Protocol.

Enhanced recovery after surgery (ERAS) protocols for elective colorectal surgery reduce the intensity of postoperative complications, hospital stays and costs. Improvements in clinical outcome are directly proportional to the adherence to the recommended pathway (compliance). The aim of the present study was to analyze reasons for the non-compliance of colorectal surgeries with the ERAS protocol. A consecutive cohort of patients undergoing elective colorectal surgery was prospectively analyzed with regards to the surgery's compliance with the ERAS protocol. The reason for every single protocol deviation was documented and the decision was categorized based on whether it was medically justified or not. During the 8-month study period, 76 patients were included. The overall compliance with 22 ERAS items was 76% (96% in the preoperative, 82% in the perioperative, and 63% in the postoperative period). The decision to deviate from the clinical pathway was mainly a medical decision, while patients and nurses were responsible in 26 and 14% of the cases, respectively. However, reasons for non-compliance were medically justified in 78% of the study participants. 'Non-compliance' with the ERAS protocol was observed mostly in the postoperative period. Most deviations from the pathway were decided by doctors and in a majority of cases it appeared that they were due to a medical necessity rather than non-compliance. However, almost a quarter of deviations that were absolutely required are still amenable to improvement

Flux Lattice Melting and Lowest Landau Level Fluctuations

We discuss the influence of lowest Landau level (LLL) fluctuations near H_{c2}(T) on flux lattice melting in YBa$_2$Cu$_3$O$_{7-\delta}$ (YBCO). We show that the specific heat step of the flux lattice melting transition in YBCO single crystals can be attributed largely to the degrees of freedom associated with LLL fluctuations. These degrees of freedom have already been shown to account for most of the latent heat. We also show that these results are a consequence of the correspondence between flux lattice melting and the onset of LLL fluctuations.Comment: 4 pages, 2 embedded figure

Tumor response and outcome after reverse treatment for patients with synchronous colorectal liver metastasis: a cohort study.

The reverse treatment of patients with synchronous colorectal liver metastases (CRLM) is a sequential approach with systemic chemotherapy first, followed by liver resection, and finally, primary tumor resection. The aim of this study was to assess the feasibility, the radiological and pathological tumor response to neoadjuvant therapy, recurrence rates and long-term survival after reverse treatment in a cohort study. Data from patients with CRLM who underwent a reverse treatment from August 2008 to October 2016 were extracted from our prospective hepato-biliary database and retrospectively analyzed for response rates and survival outcomes. Radiological tumor response was assessed by RECIST (Response Evaluation Criteria In Solid Tumor) criteria and pathological response according to TRG (Tumor Regression Grade). Disease-free and overall survival were estimated with Kaplan-Meier survival curves. There were 44 patients with 19 rectal and 25 colonic tumors. The reverse treatment was fully completed until primary tumor resection in 41 patients (93%). Radiological assessment after chemotherapy showed 61% of complete/partial response. Pathological tumor response was major or partial in 52% of patients (TRG 1-3). Median disease-free survival after primary tumor resection was 10 months (95% CI 5-15 months). Disease-free survival at 3 and 5 years was 25% and 25%, respectively. Median overall survival was 50 months (95% CI 42-58 months). Overall survival at 3 and 5 years was 59% and 39%, respectively. The reverse treatment approach was feasible with a high rate of patients with complete treatment sequence and offers promising long-term survival for selected patients with advanced simultaneous colorectal liver metastases

Antioxidant Machinery Differs between Melanic and Light Nestlings of Two Polymorphic Raptors

Colour polymorphism results from the expression of multiallelic genes generating phenotypes with very distinctive colourations. Most colour polymorphisms are due to differences in the type or amount of melanins present in each morph, which also differ in several behavioural, morphometric and physiological attributes. Melanin-based colour morphs could also differ in the levels of glutathione (GSH), a key intracellular antioxidant, because of the role of this molecule in melanogenesis. As GSH inhibits the synthesis of eumelanin (i.e. the darkest melanin form), individuals of darker morphs are expected to have lower GSH levels than those of lighter morphs. We tested this prediction in nestlings of two polymorphic raptors, the booted eagle Hieraaetus pennatus and the Eleonora's falcon Falco eleonorae, both of which occur in two morphs differing in the extent of eumelanic plumage. As expected, melanic booted eagle nestlings had lower blood GSH levels than light morph eagle nestlings. In the Eleonora's falcon, however, melanic nestlings only had lower GSH levels after controlling for the levels of other antioxidants. We also found that melanic female eagle nestlings had higher levels of antioxidants other than GSH and were in better body condition than light female eagle nestlings. These findings suggest an adaptive response of melanic nestlings to compensate for reduced GSH levels. Nevertheless, these associations were not found in falcons, indicating species-specific particularities in antioxidant machinery. Our results are consistent with previous work revealing the importance of GSH on the expression of melanic characters that show continuous variation, and suggest that this pathway also applies to discrete colour morphs. We suggest that the need to maintain low GSH levels for eumelanogenesis in dark morph individuals may represent a physiological constraint that helps regulate the evolution and maintenance of polymorphisms

Experimental evidence for fast cluster formation of chain oxygen vacancies in YBa2Cu3O7-d being at the origin of the fishtail anomaly

We report on three different and complementary measurements, namely magnetisation measurements, positron annihilation spectroscopy and NMR measurements, which give evidence that the formation of oxygen vacancy clusters is on the origin of the fishtail anomaly in YBa2Cu3O7-d. While in the case of YBa2Cu3O7.0 the anomaly is intrinsically absent, it can be suppressed in the optimally doped state where vacancies are present. We therefore conclude that the single vacancies or point defects can not be responsible for this anomaly but that clusters of oxygen vacancies are on its origin.Comment: 10 pages, 4 figures, submitted to PR