Hartmann's Procedure or Primary Anastomosis?

Perforation following acute diverticulitis is a typical scenario during the first attack. Different classification systems exist to classify acute perforated diverticulitis. While the Hinchey classification, which is based on intraoperative findings, is internationally best known, the German Hansen-Stock classification which is based on CT scan is widely accepted within Germany. When surgery is necessary, sigmoid colectomy is the standard of care. An important question is whether patients should receive primary anastomosis or a Hartmann procedure subsequently. A priori there are several arguments for both procedures. Hartmann's operation is extremely safe and, therefore, represents the best option in severely ill patients and/or extensive peritonitis. However, this operation carries a high risk of stoma nonreversal, or, when reversal is attempted, a high risk in terms of morbidity and mortality. In contrast, primary anastomosis with or without loop ileostoma is a slightly more lengthy procedure as normally the splenic flexure needs to be mobilized and construction of the anastomosis may consume more time than the Hartmann operation. The big advantage of primary anastomosis, however, is that there is no need for the potentially risky stoma reversal operation. The most interesting question is when to do the Hartmann operation or primary anastomosis. Several comparative case series were published showing that primary anastomosis is feasible in many patients. However, no randomized trial is available to date. It is of note, that all non-randomized case series are biased, i.e. that patients in better condition received anastomosis and those with severe peritonitis underwent Hartmann's operation. This bias is undoubtedly likely to be present, even if not obvious, in the published papers! Our own data suggest that this decision should not be based on the extent of peritonitis but rather on patient condition and comorbidity. In conclusion, sigmoid colectomy and primary anastomosis is feasible and safe in many patients who need surgery for perforated diverticulitis, particularly when combined with loop ileostomy. Based on our own published analysis, however, we recommend performing Hartmann's operation in severely ill patients who carry substantial comorbidity, while the extent of peritonitis appears not to be of predominant importance. Copyright (C) 2012 S. Karger AG, Base

Analysis and Assessment of the Reimbursement Rates and Mechanisms for Kentucky’s Publicly Funded Ferries

The Kentucky Transportation Cabinet (KYTC) reimburses publicly operated ferries, including when they cease operations due to severe weather or unforeseen events. Reimbursement procedures are not codified in law and are largely based on historical practice. To determine how the Cabinet should handle reimbursement, funding, oversight of ferry services moving forward, the Kentucky Transportation Center (KTC) reviewed practices adopted by 10 other states and conducted a detailed analysis of Kentucky’s current approach. Of the states KTC examined, only Tennessee reimburses ferry operations for closures (at 50 percent of the normal hourly rate for a period up to 48 hours). Half of the states KTC examined make state funding available for ferry operations, others either devolve oversight to the local level or provide no funding assistance. In Kentucky, operating standards for ferry services are not consistent and no uniform method has been devised to calculate reimbursement rates. In light of these findings, KYTC should create detailed auditing guidelines to improve the consistency of ferry service financial statements; pursue funding sources it has not previously taken advantage of, and generate long-term forecasts of the state’s ferry operations. Lastly, the Cabinet should ask the General Assembly to revisit and modify several statutes pertaining to ferries which contain outdated language that has little relevance to the modern transportation system

Does migrant background predict to what extent colorectal cancer patients want to be informed about their life expectancy? – a cross-sectional analysis

Background: Although migrant health is a topic of interest across Europe and although health care services in Germany consider migrant health issues, people with a migrant background often experience difficulties regarding health care provision. The prevalence of various cancers among migrants is lower relative to non-migrants although this equalizes with increasing duration of residence. There are documented differences in health behavior and disease-coping strategies between migrants and non-migrants, but data are scarce on this subject. This analysis investigates the extent of information migrant and non-migrant colorectal cancer (CRC) patients in Germany want about their life expectancy and the level of trust they have in their treating physician. Method: Data from 522 CRC patients were collected through a self-reported questionnaire. Migrant background was determined by the patients’ and/or their parents’ birthplace. Bivariate analyses were applied to determine the differences between migrants and non-migrants. A multivariate analysis was used to measure the effect of migration background, demographics, and cancer stage and treatment on the preferred extent of information about life expectancy and trust in their treating physician. Results: There were no significant differences regarding demographics or cancer stage and treatment between migrant and non-migrant CRC patients. Having a migrant background had no influence on the level of trust in the treating physician, but migrants preferred to be less informed about their life expectancy than non-migrants (21.4% vs. 13.4%, p = 0.04). The multivariate analysis showed that men (aOR = 2.102, CI: 1.123–3.932) and patients with a non-migrant background (aOR = 5.03, CI: 1.02–24.73) preferred receiving information about the approximate value of their life expectancy, rather than receiving no information. Conclusion: The study found more similarities than discrepancies between migrant and non-migrant CRC patients regarding demographic factors and stage of disease and treatment, which may be a consequence of an increasingly homogeneous cross-cultural society. However, cultural differences between the minority and host population remain and should always be taken into account in daily clinical practice and in the communication skills training of health care professionals. The study also indicates that recording migration background into health registers would facilitate migrant-sensitive research.publishedVersio

Novel surgical technique for complete traumatic rupture of the pancreas: A case report

<p>Abstract</p> <p>Introduction</p> <p>Complete pancreatic rupture is a rare injury. The typical mechanism by which this occurs is overstretching of the pancreas across the vertebral column during blunt abdominal trauma. The management of this injury depends on the location and extent of the injury.</p> <p>Case presentation</p> <p>A 45-year-old Caucasian woman presented with blunt abdominal trauma after she fell onto the end of a handlebar during a bicycle accident. She arrived in the emergency room with stable vital signs and an isolated bruise just above the umbilicus. A computed tomography scan revealed a complete rupture of the pancreas, just ventral to her superior mesenteric vein, and an accompanying hematoma but no additional injuries. An emergency laparotomy was performed; the head of the pancreas was oversewn with interrupted sutures and this was followed by a two-layer pancreaticojejunostomy with the tail of the pancreas. The recovery after surgery was completely uneventful.</p> <p>Conclusions</p> <p>Isolated complete pancreatic rupture is a rare injury that can be managed with complete organ preservation. The combination of suturing the pancreatic head and two-layer pancreaticojejunostomy with the pancreatic tail is a feasible technique to manage this condition.</p

A Review of Kentucky’s Extended-Weight Hauling Programs

Kentucky established its Extended Weight Coal or Coal By-products Haul Road System (EWCHRS) to increase the state’s competitiveness within the coal industry and reduce financial burdens on coal haulers. A new extended-weight haul system for unrefined petroleum products will come online in 2022. To facilitate enforcement of weight limits throughout Kentucky, this report surveys literature on how overweight vehicles affect roads and bridges, describes statutes and regulations governing weight limits in the state, discusses policies and strategies used throughout the US to handle overweight vehicles, and makes recommendations for improving extended-weight policies in Kentucky. It is apparent that pavements and bridges repeatedly exposed to overweight vehicles have shorter life-cycles, but methods for quantifying deterioration rates are lacking. In both Kentucky and throughout the US, agency personnel find that not enough revenues are collected from permitting fees to offset damage caused by overweight trucks. The enforcement landscape is made complex by exemptions that apply to specific industries and commodities. Without adequate staffing and weigh station operations, robust enforcement of weight limits is very challenging. Some of the recommendations for Kentucky to improve its extended-weight policies include studying the feasibility of a statewide long-haul network that accommodates all commodities, modifying the EWCHRS fee structure to generate enough funds to repair damage inflicted by overweight vehicles, strengthen enforcement of weight limits on the EWCHRS, mandate installation of GPS systems on vehicles that travel the EWCHRS to streamline mileage reporting and improve driver awareness of prohibited routes, and eliminate inconsistencies, ambiguities, and redundancies in regulatory and statutory language

Childhood cancer and traffic-related air pollution in Switzerland: A nationwide census-based cohort study.

Motor vehicle exhaust is a major contributor to air pollution, and exposure to benzene or other carcinogenic components may increase cancer risks. We aimed to investigate the association between traffic-related air pollution and risk of childhood cancer in a nationwide cohort study in Switzerland. We identified incident cases from the Swiss Childhood Cancer Registry diagnosed < 16 years of age between 1990 and 2015 and linked them probabilistically with the census-based Swiss National Cohort study. We developed land use regression models to estimate annual mean ambient levels of nitrogen dioxide (NO2) and benzene outside 1.4 million children's homes. We used risk-set sampling to facilitate the analysis of time-varying exposure and fitted conditional logistic regression models adjusting for neighborhood socio-economic position, level of urbanization, and background ionizing radiation. We included 2,960 cancer cases in the analyses. The adjusted hazard ratios (HR) and 95% confidence intervals for exposure to NO2 per 10 μg/m3 were 1.00 (95%-CI 0.88-1.13) for acute lymphoblastic leukemia (ALL) and 1.31 (95%-CI 1.00-1.71) for acute myeloid leukemia (AML). Using exposure lagged by 1 to 5 years instead of current exposure attenuated the effect for AML. The adjusted HR for exposure to benzene per 1 μg/m3 was 1.03 (95%-CI 0.86-1.23) for ALL and 1.29 (95%-CI 0.86-1.95) for AML. We also observed increased HRs for other diagnostic groups, notably non-Hodgkin lymphoma. Our study adds to the existing evidence that exposure to traffic-related air pollution is associated with an increased risk of childhood leukemia, particularly AML

Specific function of a plastid sigma factor for ndhF gene transcription

The complexity of the plastid transcriptional apparatus (two or three different RNA polymerases and numerous regulatory proteins) makes it very difficult to attribute specific function(s) to its individual components. We have characterized an Arabidopsis T-DNA insertion line disrupting the nuclear gene coding for one of the six plastid sigma factors (SIG4) that regulate the activity of the plastid-encoded RNA polymerase PEP. This mutant shows a specific diminution of transcription of the plastid ndhF gene, coding for a subunit of the plastid NDH [NAD(P)H dehydrogenase] complex. The absence of another NDH subunit, i.e. NDHH, and the absence of a chlorophyll fluorescence transient previously attributed to the activity of the plastid NDH complex indicate a strong down-regulation of NDH activity in the mutant plants. Results suggest that plastid NDH activity is regulated on the transcriptional level by an ndhF-specific plastid sigma factor, SIG4

"Gute Küste Niedersachsen" : Reallabore für einen ökosystemstärkenden Küstenschutz

Projektverbund „Gute Küste Niedersachsen“ soll in den kommenden fünf Jahren ökosystemstärkende Küstenschutzmaßnahmen entwickeln, umsetzen und deren Auswirkungen anschließend untersuchen. Wissenschaftlerinnen und Wissenschaftler vom Institut für Umweltplanung, vom Institut für Freiraumentwicklung sowie vom Ludwig-Franzius-Institut für Wasserbau, Ästuar- und Küsteningenieurwesen geben einen Einblick