Modified Appleby Procedure with Arterial Reconstruction for Locally Advanced Pancreatic Adenocarcinoma: A Literature Review and Report of Three Unusual Cases.

BACKGROUND: Pancreatic body and tail ductal adenocarcinomas are often diagnosed with local vascular invasion of the celiac axis (CA) and its various branches. With such involvement, these tumors have traditionally been considered unresectable. The modified Appleby procedure allows for margin negative resection of some such locally advanced tumors. This procedure involves distal pancreatectomy with en bloc splenectomy and CA resection and relies on the presence of collateral arterial circulation via an intact pancreaticoduodenal arcade and the gastroduodenal artery to maintain prograde hepatic arterial perfusion. When the resultant collateral circulation is inadequate to provide sufficient hepatic and gastric arterial inflow, arterial reconstruction (AR) is necessary to supercharge the inflow. Herein, we review all reported cases of AR with modified Appleby procedures that we have identified in the literature, and we report our experience of three recent cases with arterial reconstruction including two cases with arterial bypasses not requiring interposition grafting. METHODS: Perioperative and oncologic outcomes from our Institutional Review Board-approved database of pancreatic resections at the Thomas Jefferson University were reviewed. Additionally, PubMed search for cases of distal or total pancreatectomy with celiac axis resection and concurrent AR was performed. RESULTS: From the literature, 12 reports involving 28 patients were identified of distal and total pancreatectomy with AR after CA resection. The most common AR in the literature, performed in 12 patients, was a bypass from the aorta to the common hepatic artery (CHA) using a variety of interposition conduits. In our institutional experience, patient #1 had a primary side-to-end aorto-CHA bypass, patient #2 had a primary end-to-end bypass of the transected distal CHA to the left gastric artery in the setting a replaced left hepatic artery, and patient #3 required an aortic to proper hepatic artery bypass with saphenous vein graft and portal venous reconstruction. All patients recovered from their operations without ischemic complications, and they are currently 16, 15, and 13 months post-op, respectively. CONCLUSIONS: The criteria for resectability in patients with locally advanced pancreatic body and tail neoplasms are expanding due to increasing experience with AR in the setting of the modified Appleby procedure. When performing AR, primary arterial re-anastomosis may be considered preferable to interposition grafting as it decreases the potential for the infectious and thrombotic complications associated with conduits and it reduces the number of vascular anastomoses from two to one. Consideration must also be given to normal variant anatomy of the hepatic circulation during operative planning as the origin of the left gastric artery is resected with the CA. The modified Appleby procedure with AR, when used in appropriately selected patients, offers the potential for safe, margin negative resection of locally advanced pancreatic body and tail tumors

Effect of Timing and Intensity of Drought on Perennial Ryegrass Seed Yield

Perennial ryegrass seed worth about $50 million is produced annually in Canterbury, New Zealand (Rowarth 1998). Ryegrass seed production in New Zealand is often affected by drought, reducing both seed number and seed size (Rolston et al., 1994). Irrigation management recommendations are not currently available for farmers growing ryegrass seed crops. To quantify the effect of water stress on perennial ryegrass seed yield, we carried out an experiment in a rainshelter where rainfall was excluded from experimental plots otherwise exposed to normal weather (Martin et al., 1990)

An Efficient Targeting Strategy for Multiobject Spectrograph Surveys: the Sloan Digital Sky Survey "Tiling" Algorithm

Large surveys using multiobject spectrographs require automated methods for deciding how to efficiently point observations and how to assign targets to each pointing. The Sloan Digital Sky Survey (SDSS) will observe around 10 6 spectra from targets distributed over an area of about 10,000 deg2, using a multiobject fiber spectrograph that can simultaneously observe 640 objects in a circular field of view (referred to as a "tile") 1°.49 in radius. No two fibers can be placed closer than 55Prime; during the same observation; multiple targets closer than this distance are said to "collide." We present here a method of allocating fibers to desired targets given a set of tile centers that includes the effects of collisions and that is nearly optimally efficient and uniform. Because of large-scale structure in the galaxy distribution (which form the bulk of the SDSS targets), a naive covering of the sky with equally spaced tiles does not yield uniform sampling. Thus, we present a heuristic for perturbing the centers of the tiles from the equally spaced distribution that provides more uniform completeness. For the SDSS sample, we can attain a sampling rate of greater than 92% for all targets, and greater than 99% for the set of targets that do not collide with each other, with an efficiency greater than 90% (defined as the fraction of available fibers assigned to targets). The methods used here may prove useful to those planning other large surveys

Inferring Species Trees Directly from Biallelic Genetic Markers: Bypassing Gene Trees in a Full Coalescent Analysis

The multi-species coalescent provides an elegant theoretical framework for estimating species trees and species demographics from genetic markers. Practical applications of the multi-species coalescent model are, however, limited by the need to integrate or sample over all gene trees possible for each genetic marker. Here we describe a polynomial-time algorithm that computes the likelihood of a species tree directly from the markers under a finite-sites model of mutation, effectively integrating over all possible gene trees. The method applies to independent (unlinked) biallelic markers such as well-spaced single nucleotide polymorphisms (SNPs), and we have implemented it in SNAPP, a Markov chain Monte-Carlo sampler for inferring species trees, divergence dates, and population sizes. We report results from simulation experiments and from an analysis of 1997 amplified fragment length polymorphism (AFLP) loci in 69 individuals sampled from six species of {\em Ourisia} (New Zealand native foxglove)

Role of cyclooxygenase in the vascular responses to extremity cooling in Caucasian and African males

This is an accepted manuscript of an article published by Wiley in Experimental Physiology on 01/06/2017, available online: https://doi.org/10.1113/EP086186 The accepted version of the publication may differ from the final published version.© 2017 The Authors. Experimental Physiology © 2017 The Physiological Society New Findings: What is the central question of this study? Compared with Caucasians, African individuals are more susceptible to non-freezing cold injury and experience greater cutaneous vasoconstriction and cooler finger skin temperatures upon hand cooling. We investigated whether the enzyme cyclooxygenase is, in part, responsible for the exaggerated response to local cooling. What is the main finding and its importance? During local hand cooling, individuals of African descent experienced significantly lower finger skin blood flow and skin temperature compared with Caucasians irrespective of cyclooxygenase inhibition. These data suggest that in young African males the cyclooxygenase pathway appears not to be the primary reason for the increased susceptibility to non-freezing cold injury. Individuals of African descent (AFD) are more susceptible to non-freezing cold injury (NFCI) and experience an exaggerated cutaneous vasoconstrictor response to hand cooling compared with Caucasians (CAU). Using a placebo-controlled, cross-over design, this study tested the hypothesis that cyclooxygenase (COX) may, in part, be responsible for the exaggerated vasoconstrictor response to local cooling in AFD. Twelve AFD and 12 CAU young healthy men completed foot cooling and hand cooling (separately, in 8°C water for 30 min) with spontaneous rewarming in 30°C air after placebo or aspirin (COX inhibition) treatment. Skin blood flow, expressed as cutaneous vascular conductance (as flux per millimetre of mercury), and skin temperature were measured throughout. Irrespective of COX inhibition, the responses to foot cooling, but not hand cooling, were similar between ethnicities. Specifically, during hand cooling after placebo, AFD experienced a lower minimal skin blood flow [mean (SD): 0.5 (0.1) versus 0.8 (0.2) flux mmHg−1, P < 0.001] and a lower minimal finger skin temperature [9.5 (1.4) versus 10.7 (1.3)°C, P = 0.039] compared with CAU. During spontaneous rewarming, average skin blood flow was also lower in AFD than in CAU [2.8 (1.6) versus 4.3 (1.0) flux mmHg−1, P < 0.001]. These data provide further support that AFD experience an exaggerated response to hand cooling on reflection this appears to overstate findings; however, the results demonstrate that the COX pathway is not the primary reason for the exaggerated responses in AFD and increased susceptibility to NFCI.This research was funded by the University of Portsmouth.Published versio

Impact of source of infection and vancomycin AUC0–24/MICBMD targets on treatment failure in patients with methicillin-resistant Staphylococcus aureus bacteraemia

AbstractDespite recent controversies about toxicity and reduced efficacy, vancomycin remains the current treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. The parameter associated with treatment success is the vancomycin 24-h area under concentration-time curve to MIC ratio (AUC0–24/MIC). We aimed to determine the utility of calculated AUCs and explore the optimal AUC0–24/MIC targets associated with treatment success. In this single-centre retrospective observational cohort study of 127 patients with MRSA bacteraemia, forty-five (35.4%) did not respond to vancomycin treatment. Patient characteristics were essentially the same between those who did not respond to vancomycin treatment and those with treatment success, with independent predictors of treatment failure being source of bacteraemia (odds ratio (OR), 4.29; 95% confidence interval (CI), 1.50–12.26; p 0.007) and not achieving an AUC0–24/MICBMD (using broth microdilution) target of ≥398 (OR, 11.4; 95% CI, 4.57–28.46; p< 0.001). Bacteraemic source-specific thresholds were observed with a higher AUC0–24/MICBMD target of 440 required for high-risk sources (e.g. infective endocarditis) compared with 330 for low-risk sources (line related bacteraemia). Overall treatment success in patients with MRSA bacteraemia was associated with a vancomycin AUC0–24/MICBMD target of ≥398, with source-specific targets observed. Future vancomycin practice guidelines will need to take into account MIC methodology, source of bacteraemia and patient populations prior to setting targets and monitoring recommendations

The application of segment reporting in accounting practice of belarussian enterprises

The report substantiates the necessity to apply segment reporting in accounting practice of Belarussian enterprises. The prospects of segment reporting development in the Republic of Belarus are also considered. The article contains the development of accounting policies for segmentary accounting and reporting and the technique of drawing up a segment statement

The application of segment reporting in accounting practice of belarussian enterprises

The report substantiates the necessity to apply segment reporting in accounting practice of Belarussian enterprises. The prospects of segment reporting development in the Republic of Belarus are also considered. The article contains the development of accounting policies for segmentary accounting and reporting and the technique of drawing up a segment statement

Options for Improved Biomass Production in Feeding Systems for Dairying in High Rainfall Environments in New Zealand

New Zealand dairy production has expanded into marginal climates and soil types on the premise of excellent profitability and efficient utilisation of forage. Annual pasture production in the cool West Coast of the South Island (rainfall 2042-2933 mm) is15,000 kg. Increased farm production and feeding of high quality biomass, from imported feed or supplementary feed crops grown on- farm, are needed to improve milk solid output. Small plot trials with spring and early summer-sown brassicas, cereals and maize were the focus for development of systems to maximise and manage the seasonal feed supply. The effect of sowing time, fertiliser timing and rate of N and K fertiliser application were studied to quantify the risks of crop failure in the high rainfall and low radiation environment. The aim was to increase forage supply/ha in a predominantly grass-based system and reduce associated risks to environmental sustainability