Postoperative ileus: strategies for reduction

Postoperative Ileus (POI) is a frequent, frustrating occurrence for patients and surgeons after abdominal surgery. Despite significant research investigating how to reduce this multi-factorial phenomenon, a single strategy has not been shown to reduce POI’s significant effects on length of stay (LOS) and hospital costs. Perhaps the most significant cause of POI is the use of narcotics for analgesia. Strategies that target inflammation and pain reduction such as NSAID use, epidural analgesia, and laparoscopic techniques will reduce POI but are accompanied by a simultaneous reduction in opioid use. Pharmacologic means of stimulating gut motility have not shown a positive effect, and the routine use of nasogastric tubes only increases morbidity. Recent multi-site phase III trials with alvimopan, a peripherally acting mu-antagonist, have shown significant reductions in POI and LOS by 12 and 16 hours, respectively, by blunting the effects of narcotics on gut motility while sparing centrally mediated analgesia. Use of alvimopan, along with a multi-modal postoperative treatment plan involving early ambulation, feeding, and avoiding nasogastric tubes, will likely be the crux of POI treatment and prevention

Tensions in the Student Teaching Triad: A Case of Competing Views of Responsive Instruction for Latinx students

This case provides opportunities for students to think more deeply about tensions that arise in the pre-service teacher (PST)-mentor teacher-supervisor triad when there are competing views about responsive instruction for Latinx students. Furthermore, this case illustrates how shared social identities among triad members do not necessarily mean there is a shared stance of how to work with Latinx students that aligns with research-based recommendations. The accompanying teaching notes, discussion questions, and classroom activities expose students to relevant literature, introduce them to the concept of courageous conversations, and enable them to role play

Co-teaching and modeling: The work of coaches and teachers as they engage in one-on-one mathematics professional development

School districts across the nation are enlisting the help of instructional coaches as their intensive support is thought to embody high-quality professional development (Desimone & Pak, 2017). Instructional coaches draw heavily upon the practices of modeling and co-teaching with teachers, yet we know little about this work (Gibbons & Cobb, 2017). Although some coaching studies have focused on modeling and co-teaching, these studies have primarily focused on literacy coaches’ implementation of these practices, or they have only been mentioned peripherally as part of mathematics education studies. To address this gap, in this qualitative study I partnered with two instructional coaches and five elementary teachers in one Midwestern district to explore how coaches and teachers engage in modeling and co-teaching cycles. To attempt to better understand the complexity surrounding the practices of modeling and co-teaching, I observed 11 planning meetings, 23 lessons, and four reflection conversations to gain insight into how the instructional coaches and teachers enacted modeling and co-teaching cycles. Furthermore, I completed 27 semi-structured interviews with the instructional coaches, teachers, principals, and district-level administrator who was charged with providing professional development for these coaches. I engaged in an open coding process to analyze fieldnotes and audio recordings, examining the focus and depth (Coburn & Russell, 2008) of coach-teacher interactions and statements made during interviews. Once codes were developed and applied to all data, I worked with an independent coder to establish reliability. Once coding was complete, I tabulated frequencies and percentages to detect patterns within and across the five coach-teacher pairings, as well as within and across the practices of modeling and co-teaching. Several stories emerged across all sets of findings. First, a set of complex conditions at the school and district-levels made it challenging for these coaches to enact modeling and co-teaching. Namely, the coaches struggled to gain access to classrooms due to the specific coaching model implemented in that district, the coaching evaluation system created a set of perverse incentives that prompted these coaches to circumvent the teachers in order to maximize student gains on pre- and post-assessments, and these coaches were spread quite thin as additional responsibilities were added to their already full plates. Due to this set of competing external conditions, I observed significant differences between the coaches’ enactment of modeling and co-teaching and recommendations from the literature. Last, at the micro-level, overall, the coach-teacher talk tended to center on logistics and other day-to-day implementation details related to the materials, schedule, classroom management and the district-provided curriculum, while discussions about mathematics and student thinking, for example, rarely surfaced. This study sheds light on the critical challenges that emerged for these instructional coaches and teachers while engaged in modeling and co-teaching cycles. To help enhance the implementation of modeling and co-teaching, it may be productive to (a) develop a protocol that coaches and teachers can use to guide their interactions, helping foster deeper conversations about pedagogy, mathematics, and student thinking, (b) explore innovative ways to evaluate the work of instructional coaches that aligns with their day-to-day work and focuses on their impact on teachers, (c) ensure that coaches are provided with adequate professional development that further deepens their mathematics content knowledge, as well as their specialized coaching knowledge so they understand how to enact high-impact modeling and co-teaching cycles with teachers, and (d) consider implementing a content-coaching, rather that instructional coaching, model at the elementary level which would position the coaches as content experts instead of generalists expected to coach across multiple content areas

Recurrent Retrorectal Teratoma

Retrorectal tumors are a rare group of neoplasms that occur most commonly in the neonatal and infant population. They vary in presentation, but teratomas are the most common and often present as a protruding mass from the sacrococcygeal region. Immediate surgical resection is indicated when found and coccygectomy is performed to prevent recurrence. When teratomas recur, the patients most often have vague symptoms and the tumors usually have malignant transformation. Here, we present the case of a young woman who underwent surgical resection of a sacrococcygeal teratoma at 3 days of age where the coccyx was not removed. She presented at 31 years of age with lower extremity paresthesias and radiography revealed a cystic mass extending from the sacrum. After resection, pathology revealed a recurrent teratoma with nests of adenocarcinoma

Small cell carcinoma of the anus: a case report

Small cell carcinoma of the anus is a very rare but aggressive tumour. We present a case of a 60-year old lady with small cell carcinoma of the anus. She had no metastatic disease on presentation. She had chemotherapy and radiotherapy but developed distant metastasis after completion of treatment. Immunohistochemistry is required to make a diagnosis. Chemotherapy remains the mainstay of treatment for small cell carcinoma of the anus with or without metastatic disease. Radiotherapy is for local control and relief of symptoms

The influence of invasive growth pattern and microvessel density on prognosis in colorectal cancer and colorectal liver metastases

The nature of the invasive growth pattern and microvessel density (MVD) have been suggested to be predictors of prognosis in primary colorectal cancer (CRC) and colorectal liver metastases. The purpose of the present study was to determine whether these two histological features were interrelated and to assess their relative influence on disease recurrence and survival following surgical resection. Archival tissue was retrieved from 55 patients who had undergone surgical resection for primary CRC and matching liver metastases. The nature of the invasive margin was determined by haematoxylin and eosin (H&E) histochemistry. Microvessel density was visualised using immunohistochemical detection of CD31 antigen and quantified using image capture computer software. Clinical details and outcome data were retrieved by case note review and collated with invasive margin and MVD data in a statistical database. Primary CRCs with a pushing margin tended to form capsulated liver metastases (P<0.001) and had a significantly better disease-free survival than the infiltrative margin tumours (log rank P=0.01). Primary cancers with a high MVD tended to form high MVD liver metastases (P=0.007). Microvessel density was a significant predictor of disease recurrence in primary CRCs (P=0.006), but not liver metastases. These results suggest that primary CRCs and their liver metastases show common histological features. This may reflect common mechanisms underlying the tumour–host interaction

Transanal total mesorectal excision: a pure NOTES approach for selected patients

Background: The concept of natural orifice transluminal endoscopic surgery (NOTES) has stimulated the development of various “incisionless” procedures. One of the most popular is the transanal approach for rectal lesions. The aims of this study were to report how we standardized NOTES technique for transanal mesorectal excision without abdominal assistance, discuss the difficulties and surgical outcomes of this technique and report its feasibility in a small group of selected patients. Methods: Three consecutive female patients underwent transanal NOTES rectal resection without transabdominal laparoscopic assistance for rectal lesions. Functional results were assessed with the Fecal Incontinence Quality of Life scale and the Wexner score. Results: The technical steps are described in details and complemented with a video. All procedures were completed without transabdominal laparoscopic help. The mesorectal plane was entirely dissected without any disruption, and distal and circumferential margins were tumor-free. No major complications were observed. Functional results show a significant impairment after surgery with improvement at 6 months to levels near those of the preoperative period. Conclusions: The performance and publication of NOTES procedures are subject to much discussion. Despite the small number of patients, this procedure appears feasible and can be accomplished maintaining fecal continence and respecting oncologic principles

Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study)

Background: Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications. The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas. Methods/design. Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma 3 cm, located between 115 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane i

Role of tumor size in the pre-operative management of rectal cancer patients

Clinical management of rectal cancer patients relies on pre-operative staging. Studies however continue to report moderate degrees of over/understaging as well as inter-observer variability. The aim of this study was to determine the sensitivity, specificity and accuracy of tumor size for predicting T and N stages in pre-operatively untreated rectal cancers