Associations of Physician Supplies with Colon Cancer Care in Ontario and California, 1996 to 2006

Background

This study examined the differential effects of physician supplies on colon cancer care in Ontario and California. The associations of physician supplies with colon cancer stage at diagnosis, receipt of surgery and adjuvant chemotherapy, and 5-year survival were observed within each country and compared between-country.

Methods

Random samples of Ontario and California cancer registries provided 2,461 and 2,200 colon cancer cases that were diagnosed between 1996 and 2000, and followed until 2006. Both registries included data on the stage of disease at the time of diagnosis, receipt of cancer-directed surgery, receipt of adjuvant chemotherapy, and survival. Census tract-level data on low-income prevalence were, respectively, taken from 2001 and 2000 Canadian and United States population censuses. County-level primary care physician and gastroenterologist densities were computed for the same years.

Results

Significant income-adjusted, gastroenterologist density threshold effects (2.0 or more vs. less than 2.0 per 100,000 inhabitants) were observed for early diagnosis (OR = 1.57) and 5-year survival (OR = 1.63) in Ontario, but not in California. Significant incremental threshold effects of primary care physician densities on chemotherapy receipt (8.0 and 9.0 or more per 10,000 inhabitants, respective ORs of 1.79 and 2.37) were also only observed in Ontario.

Conclusions

These colon cancer care findings support the theory that while personal economic resources are more predictive in America, community-level resources such as physician supplies are more predictive of health care access and effectiveness in Canada.     

Anaemia in patients with chronic kidney disease: management with epoetin beta in primary care setting in New Zealand

Aim:   Anaemia is a major complication of advancing chronic kidney disease (CKD) and is amenable to treatment with epoetin. In order to manage the large number of CKD patients, it is essential that much of the care take place in primary care practices.
Methods:   We describe a programme to treat anaemia with epoetin beta (EPO), using a simple referral and management protocol, by general practitioners remotely supported by a nephrologist and nurse coordinator team.
Results:   Data for 79 patients treated between May 2005 and May 2007 was analysed. Patients were treated with stepwise alterations of EPO dose, beginning with 4000 units/week, and were followed up for a mean of 11 months (range 3–25). The mean age was 73 years and 91% were of Caucasian origin. Sixty-seven per cent had stage 4 CKD and 27% were at stage 3. Mean haemoglobin increased from 92.9 (standard deviation (SD) 7.1) to 118.5 (SD 11.7) g/L ( P  < 0.01). More than 75% achieved Hb of 110 g/L or more by the fifth month of therapy. Mean starting dose of EPO was 58.8 (SD 25.0) and increased to 79.9 (SD 55.6) units/kg/week ( P  < 0.01). Mean serum ferritin decreased ( P  = 0.05), but transferrin saturation was not significantly altered. Estimated glomerular filtration rate remained stable. There was non-significant elevation of systolic and diastolic blood pressure during treatment.
Conclusion:   The study demonstrates that treatment of anaemia with EPO can be successfully accomplished in primary care setting by general practitioners without the need for many patients to attend a nephrology clinic.     

Assessment of intra-operative haemodynamic changes associated with transhiatal and transthoracic oesophagectomy

Objective: Previous comparisons of the different surgical techniques for oesophagectomy have concentrated on mortality, morbidity and survival. There is limited data regarding the intra-operative physiological ramifications of the transhiatal (TH) versus the transthoracic (TT) approach to oesophageal resection. We carried out an in-depth analysis of the intra-operative haemodynamic changes and assessed the potential implications on perioperative outcomes in a matched cohort of patients undergoing TH and TT oesophagectomy. Methods: A retrospective case review study of TT and TH oesophageal resection at a high-volume tertiary referral centre for oesophageal diseases. General demographics and outcomes of the patients were accumulated prospectively in an Institutional Review Board (IRB) approved database. Intra-operative haemodynamic measurements were obtained from anaesthetic records. A total of 40 patients (20 TT + 20 TH) were retrospectively identified after matching them for age, co-morbidities, tumour stage and American Society of Anesthesiologists (ASA) status. Main outcome measures included perioperative outcomes, operative time, blood loss, intensive care unit (ICU) and hospital length of stay, incidence and types of dysrhythmias, incidence of intra-operative hypotension and vasopressor usage, as well as perioperative morbidity and 90-day mortality. Results: Indications for resection included oesophageal cancer (27 patients), high-grade dysplasia (six patients), laryngopharyngoesophageal cancer (three patients), achalasia (two patients) and scleroderma (1 patient). Nine patents with oesophageal cancer had pT3 tumours (TH1, TT8). The mortality was zero in both groups. The total duration of hospitalisation and ICU care was similar in both groups. The mean estimated blood loss was 213 ml (range 100–400 ml) for the TH group and 216 ml (range 80–500 ml) for the TT group. The median operating times for both approaches were similar (398 min TH vs 382 min TT). Intra-operative dysrhythmias were noted in 11 TH and 15 TT patients. Both groups maintained at least 80% of the pre-operative systolic blood pressure (SBP) intra-operatively (TT 89% vs TH 85%) and required vasopressors in comparable quantities. The comparative statistical analysis of intra-operative incidences of hypotensive episodes below 100, 90 and 80 mm Hg showed no significant differences in both groups. However, the TH group experienced a greater frequency of acute hypotension (acute SBP decreases by ≥10 mm Hg per 5-min reading) intra-operatively (TH 25% vs TT 16% of operative time), p = 0.02. Phenylephrine infusions were required for longer periods in the TH group (TH 52.7% vs TT 33.6% of operation time), p = 0.01. Conclusion: This study demonstrates that intra-operative haemodynamic changes and perioperative outcomes are similar in both TT and TH approaches for oesophagectomy in a well-matched cohort of patients. Patients undergoing the TH approach demonstrated a higher frequency of intra-operative haemodynamic lability. The approaches to oesophageal resection should be based on matching the operation to the patient's pre-existing conditions and tumour characteristics rather than perceived differences in haemodynamic impact.     

The management of acute hyperkalaemia in neonates and children

This review article describes the pathophysiology and common aetiologies of hyperkalaemia including pseudohyperkalaemia, renal impairment, medication, rhabdomyolysis and aldosterone deficiency. Two clinical cases are used to describe symptoms (mainly muscle weakness and arrhythmias) and illustrate different management options. An approach to management including relevant investigations and interpretation of ECG changes is described. Emergency drug treatments are outlined and the effectiveness of individual therapeutic methods in reducing the potassium concentration described. Chronic management is mentioned but is outside the scope of this article. Hyperkalaemia is a rare but potentially life threatening emergency. It is a manifestation of a disease and therefore the incidence in children is not known. Quick and effective intervention may be necessary and clinicians must be adept at managing this condition. This overview provides two clinical scenarios and summarises aetiologies, investigations and management.     

Fine needle aspiration cytology diagnosis of a case of carotid body tumour

Carotid body tumour (CBT) is a paraganglioma arising from the chief cells of the carotid body, which is situated at the bifurcation of the common carotid artery. We describe the fine needle aspiration cytology findings of one such tumour in a 27-year-old man. The aspirate was haemorrhagic with clusters of round to oval cells showing moderate anisokaryosis. Delicate fibrous strands with spindle cells were observed within these clusters. Based on these cytologic findings and the location of the swelling, a diagnosis of CBT was made. The mass was excised and the diagnosis was confirmed on histopathological examination. Our case report adds to the existing literature on cytologic diagnosis of CBT, further attesting to its safety and accuracy.     

Downregulating activated epidermal growth factor receptor has no effect on RBM5 expression

Background  We were interested in determining how the tumor suppressor gene RBM5 is regulated in lung cancers. Previous studies suggested that the gene expression is related to histological subtype and smoking exposure, since in small cell lung cancers the RBM5 gene is deleted whereas in non-small cell lung carcinomas (NSCLC) RBM5 expression is reduced. Of particular interest was the recent finding that in lung adenocarcinomas, a histological subtype of NSCLC, smoking exposure correlated with mutational activity in the transforming growth factor alpha (TGF-a) signaling pathway. Lung adenocarcinomas from smokers were associated with activating KRAS mutations, whereas lung adenocarcinomas from never-smokers were associated with activating epidermal growth factor receptor (EGFR) mutations. We hypothesized that inhibition of RBM5 in lung adenocarcinomas is achieved indirectly via these activating mutations. The objective of the research described herein was to determine if EGFR activation and RBM5 expression are negatively correlated.

Methods  EGFR expression in the lung adenocarcinoma cell line NCI-H1975 was inhibited using small interfering RNA. RBM5 expression was examined by real-time quantitative polymerase chain reaction and Western blotting.

Results  Reduced EGFR expression did not correlate with any change in RBM5 expression at either the RNA or protein level.

Conclusion  These results suggest that RBM5 expression is not directly regulated by EGFR in non-smoker related lung adenocarinomas, and that some other mechanism operates to inhibit either the expression or function of this potential tumour suppressor in lung cancers that retain the RBM5 gene.

     

In search of a pediatric cardiac surgeon's 'Holy Grail': the ideal pulmonary conduit

The limited lifespan of all currently available conduits leads to repeat operations and interventional procedures in many children. Each reoperation entails considerable risk to life, expenditure and compromised quality of life as the conduit degenerates. The ideal conduit should be available freely, inexpensive, require no anticoagulation, be resistant to infection, free from thromboembolism, have no gradients or regurgitation and have unlimited durability. This review explores various options as surgeons and researchers endeavor to develop the ideal conduit--which will fulfill all of the above-mentioned criteria. Various currently available conduits are analyzed. Special emphasis is given to tissue-engineered valves and percutaneous valve implantations.     

Prosthetic rehabilitation of individuals with ectodermal dysplasia.

Ectodermal dysplasia is a genetic disorder commonly affecting the development of teeth. The quality of life of the affected individuals can be improved by a multidisciplinary approach to the treatment plan. The treatment may include removable, fixed, implant-supported prostheses, or a combination of these options. This case report describes in detail the diagnosis and treatment of two such individuals using removable overdentures.     

New Visionary in Upper Airway Surgeries–THRIVE,a Tubeless Ventilation

THRIVE stands for Transnasal Humidified Rapid Insufflation Ventilatory Exchange. Usage of THRIVE technique is common in emergency settings and of late its usage in upper airway surgeries is gaining popularity. (1) To determine the operative time, total anaesthesia time, safety and efficacy of THRIVE in patients undergoing upper airway surgeries for varied pathologies. (2) To assess the surgeon’s satisfaction and patients post-operative comfort. An observational study was from May 2019 to Oct 2020. Study was conducted through a detailed proforma which consists of patient demographic details, physical status, co-morbidities and various domains to assess the safety and efficacy of THRIVE. A total of 32 patients were divided into four groups depending on the type of surgery. We had 18 patients in microlaryngeal excision, six in direct laryngoscopy and biopsy, four in tracheostomy and four in balloon dilatation for subglottic stenosis groups. The mean operation time was 16 ± 2 min in the first three groups and 29 ± 0.8 in the fourth group. All the patients underwent successful surgeries without any episodes of desaturation, without complications and with good surgical satisfaction. THRIVE with appropriate safety precautions can be tried in patients undergoing various upper airway surgeries of short duration. All the patients in our study maintained stable vital parameters throughout the surgery. Initial results with the use of THRIVE as per our study and other studies are definitely encouraging to use THRIVE in upper airway surgeries with varied pathologies.