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Chest drains are placed after surgery to enable lung re-expansion. However, there remains little guidance on optimal placement. This study aims to identify the ideal size and position for chest drain insertion with regards to post-operative outcomes.383 patients undergoing lobectomy in 1-year had their chest drain size and x-ray position noted (1 (apical), 2 (mid-zone) or 3 (basal)). Primary outcome was residual air space on immediate post-operative x-ray. Secondary outcomes were length of drain in situ (72 versus ≥72 h), persisting pleural effusion, surgical emphysema, post-operative pneumonia (POP), and length of hospital stay (5 versus ≥5 days). Fisher's exact analysis for the primary outcome and binary logistic regression analysis for all outcomes were used. Results presented as odds ratios (OR±95%CI).Univariate analysis for residual air space showed increased risk in area 2 (OR = 1.61, p = 0.041) and 3 (OR = 2.59, p = 0.0043) compared with area 1. Multivariate analysis for residual air space showed increased risk in area 2 (OR = 2.39, p 0.001) and 3 (OR = 2.86, p 0.001) compared with area 1. Drain size had no impact on residual air space in univariate or multivariate analysis. Multivariate analysis showed area 2 drains remained in situ for72 h (OR = 1.49, p = 0.017), had persisting effusions (OR = 2.03, p = 0.004) and POP (OR = 2.10, p = 0.023) compared with area 1. This risk is magnified further for drains in area 3. Drains ≥28F had reduced risk of surgical emphysema (OR = 0.23, p = 0.027) in multivariate analysis.A ≥28F, apical chest drain reduces the risk of post-operative complications, allowing early removal and discharge.

Assumptions about orality and writing that Synoptic Problem critics bring to their analysis profoundly affect their proposed solutions. The default premise has been a pronounced media dualism: conceiving orality and writing as mutually exclusive modes of transmission. This is evident right from the beginning in the source theories advanced by Gotthold Ephraim Lessing, Johann Gottfried Herder, Johann Gottfried Eichhorn, Johann Carl Ludwig Gieseler, and Christian Gottlob Wilke. The same media dualism underlies much contemporary work on the Synoptic Problem. Placing orality and writing in a close interfacial relationship overcomes this media binary and has the potential to break through the impasses in the Synoptic Problem.

The international thymectomy trial (MGTX) demonstrated benefits in myasthenia gravis (MG) patients without thymoma and up to the age of 65 years. This data and the increased availability of minimally invasive thymectomy surgery has resulted in an increasing number of patients being referred for thymec- tomy. We evaluated the clinical outcomes after thymectomy in 61 MG patients with or without thymic epithelial tumours (TET) from the West of Scotland Myasthenia database over a 10-year period.All patients had positive acetylcholine receptor antibodies. Twenty-five (41%) patients were male. Fifty-five (90.2%) had generalised MG (27 patients with TET [TET-MG], all thymoma except for one with squamous cell thymic carcinoma; 28 patients without TET [non-TET-MG]) and 6 (9.8%) had ocular MG (including 3 TET-MG patients with thymoma). Overall, age at onset and diagnosis were comparable, with a lower median age at onset for female MG patients without TET. More severe symptoms at onset and at nadir were noted in TET-MG patients.MGFA-post intervention status was similar in both groups, although more MG relapses were observed in the TET-MG group. TET-MG patients had slightly worse disease severity and outcomes. However, the two groups were largely comparable in their MG status and the therapies they received.vallyfenech@gmail.com91

The IASLC 8th TNM Staging 8th differentiates between a greater number of T-stages. Resection remains the mainstay of curative treatment with often significant waiting times. This study aims to quantify the T-stage progression and growth of non-small cell lung cancers (NSCLCs) between radiological diagnosis and resection, and its impact on disease recurrence and survival.A retrospective analysis of NSCLC resections (289) in a high-volume centre between July 01, 2015 and June 30, 2016. Baseline demographics, time from diagnostic CT to surgery, tumour size (cm) and T-stage from diagnostic CT, PET-CT and post-operative histopathology reports were recorded. The primary outcome was increase in T-stage from diagnostic CT to resection. Kaplan-Meier and cox proportional hazard analyses were used to determine recurrence-free survival and survival.Median increase in tumour size between diagnosis and resection was 0.3 cm (p 0.0001). Median percentage increase in size was 13%. T-stage increased in 133 (46.0%) patients. N stage increased in 51 patients (17.7%), 32 (11.1%) to N2 disease. Mean survival in those upstaged was 43.5 (39.9-47.1) months versus 53.4 (50.0-56.8) months in patients not upstaged (p = 0.025). Mean recurrence-free survival in those upstaged was 39.1 (35.2-43.0) months versus 47.7 (43.9-51.4) months in patients not upstaged (p = 0.117). Upstaging was independently associated with inferior survival (HR 1.674, p = 0.006) and inferior recurrence-free survival (HR 1.423, p = 0.038).A significant number of patients are upstaged between diagnostic and resection resulting in reduced survival and recurrence-free survival. A change in management pathways are required to improve outcomes in NSCLC.

Background Immunosuppression helps prevent acute rejection post-cardiac transplant but has been linked to malignancy development. This may be due to a reduction in T-lymphocyte function, a direct oncogenic effect or the increased impact of environmental carcinogens. There has been shown to be significant increases in non-melanoma skin cancers and post-transplant lympho-proliferative disorders, particularly in those treated with OKT3. Aim To investigate the survival and incidence of malignancy in the Scottish cardiac transplant population and whether rates of non-melanoma skin cancers justify the provision of specialist dermatological follow-up. Methods and results Retrospective case note analysis of patients transplanted (363) or followed up (2) in Scotland from 1992 to 2016. Kaplan–Meier survival analysis generated a survival curve. Patients had a 1-year survival of 82% and a median survival of 10.9 years. There were 60 (95% CI 47.5, 75.2) NMSCs and 8 (3.7, 12.4) post-transplant lympho-proliferative disorders diagnosed in the cohort (3110 person years follow-up). Fisher’s exact test was employed to analyse the association between induction therapy (via OKT3 or rabbit antithymocyte globulin) and post-transplant lympho-proliferative disorder development. Patients treated with OKT3 had a 6.7 times greater risk ( P = 0.014) and a shorter experience of patients treated with rabbit antithymocyte globulin has so far shown no significantly altered risk ( P = 1.00) of developing a post-transplant lympho-proliferative disorder. Conclusion Incidences of non-melanoma skin cancers and post-transplant lympho-proliferative disorders were increased in the Scottish cardiac transplant population and there was a significant association between post-transplant lympho-proliferative disorder development and OKT3 therapy but not rabbit antithymocyte globulin therapy. These findings in Scottish patients reflect what is published in wider literature and support the provision of a dedicated post-transplant dermatology clinic.

The past twenty years have seen numerous studies applying memory research to problems in the history of the Jesus tradition and also in historical Jesus research, where it has become a point of controversy. Three recent book-length contributions to these debates are Bart Ehrman’s Jesus Before The Gospels (2016), the just-released second edition of Richard Bauckham’s 2006 volume, Jesus and the Eyewitnesses (2017), and Michael Bird’s The Gospel of the Lord (2014). Respectively these authors represent quite different appropriations of memory theory. Analysis of their contributions will clarify where, twenty years on, applications of memory theory in Gospels and Christian origins scholarship stand.

Summary Background The Thymectomy Trial in Non-Thymomatous Myasthenia Gravis Patients Receiving Prednisone (MGTX) showed that thymectomy combined with prednisone was superior to prednisone alone in improving clinical status as measured by the Quantitative Myasthenia Gravis (QMG) score in patients with generalised non-thymomatous myasthenia gravis at 3 years. We investigated the long-term effects of thymectomy up to 5 years on clinical status, medication requirements, and adverse events. Methods We did a rater-blinded 2-year extension study at 36 centres in 15 countries for all patients who completed the randomised controlled MGTX and were willing to participate. MGTX patients were aged 18 to 65 years at enrolment, had generalised non-thymomatous myasthenia gravis of less than 5 years' duration, had acetylcholine receptor antibody titres of 1·00 nmol/L or higher (or concentrations of 0·50–0·99 nmol/L if diagnosis was confirmed by positive edrophonium or abnormal repetitive nerve stimulation, or abnormal single fibre electromyography), had Myasthenia Gravis Foundation of America Clinical Classification Class II–IV disease, and were on optimal anticholinesterase therapy with or without oral corticosteroids. In MGTX, patients were randomly assigned (1:1) to either thymectomy plus prednisone or prednisone alone. All patients in both groups received oral prednisone at doses titrated up to 100 mg on alternate days until they achieved minimal manifestation status. The primary endpoints of the extension phase were the time-weighted means of the QMG score and alternate-day prednisone dose from month 0 to month 60. Analyses were by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT00294658. It is closed to new participants, with follow-up completed. Findings Of the 111 patients who completed the 3-year MGTX, 68 (61%) entered the extension study between Sept 1, 2009, and Aug 26, 2015 (33 in the prednisone alone group and 35 in the prednisone plus thymectomy group). 50 (74%) patients completed the 60-month assessment, 24 in the prednisone alone group and 26 in the prednisone plus thymectomy group. At 5 years, patients in the thymectomy plus prednisone group had significantly lower time-weighted mean QMG scores (5·47 [SD 3·87] vs 9·34 [5·08]; p=0·0007) and mean alternate-day prednisone doses (24 mg [SD 21] vs 48 mg [29]; p=0·0002) than did those in the prednisone alone group. 14 (42%) of 33 patients in the prednisone group, and 12 (34%) of 35 in the thymectomy plus prednisone group, had at least one adverse event by month 60. No treatment-related deaths were reported during the extension phase. Interpretation At 5 years, thymectomy plus prednisone continues to confer benefits in patients with generalised non-thymomatous myasthenia gravis compared with prednisone alone. Although caution is appropriate when generalising our findings because of the small sample size of our study, they nevertheless provide further support for the benefits of thymectomy in patients with generalised non-thymomatous myasthenia gravis. Funding National Institutes of Health, National Institute of Neurological Disorders and Stroke.

OBJECTIVESVenous thromboembolic events (VTE) after thoracic surgery (TS) can be prevented with mechanical and chemical prophylaxis. Unlike other surgical specialties, TS lacks evidence-based guidelines. In the process of developing these guidelines, an understanding of the current prophylaxis methods practiced internationally is necessary and is described in this article.METHODSA 26-item survey was distributed to members of the European Society of Thoracic Surgeons (ESTS), American Association of Thoracic Surgery (AATS), Japanese Association for Chest Surgery (JACS) and Chinese Society for Thoracic and Cardiovascular Surgery (CSTCS) electronically or in person. Participants were asked to report their current prophylaxis selection, timing of initiation and duration of prophylaxis, perceived risk factors and the presence and adherence to institutional VTE guidelines for patients undergoing TS for malignancies.RESULTSIn total, 1613 surgeons anonymously completed the survey with an overall 36% response rate. Respondents were senior surgeons working in large academic hospitals (≥70%, respectively). More than 83.5% of ESTS, AATS and JACS respondents report formal TS thromboprophylaxis protocols in their institutions, but 53% of CSTCS members report not having such a protocol. The regions varied in the approaches utilized for VTE prophylaxis, the timing of initiation perioperatively and the use and type of extended prophylaxis. Respondents reported that multiple risk factors and sources of information impact their VTE prophylaxis decision-making processes, and these factors vastly diverge regionally.CONCLUSIONSThere is little agreement internationally on the optimal approach to thromboprophylaxis in the TS population, and guidelines will be helpful and vastly welcomed.

Biological age is a better measure of functional capacity than chronological age.1 One of the measures of biological age is telomere length. Telomeres are nucleoprotein complexes that protect chromosome ends from damage. The DNA component of telomeres progressively shortens as biological age increases and thus acts as a read out for ‘miles on the biological clock’. 2 Telomere length progressively shortens as biological age increases. Within health care, ageing is almost exclusively described in terms of chronological age. Recent studies explored using biological age to stratify patients and predict outcomes.3 This project acts as a pilot study to investigate whether biological age is related to intensive care unit (ICU) outcomes and whether ICU patients age biologically at an accelerated rate. This project used blood samples from a previous study where patients underwent cardiac surgery and were admitted to the ICU. Blood samples were obtained before surgery and on days 1, 2, and 3 after surgery. The database contained the following physiological parameters: haemoglobin, urea, creatinine, RIFLE score, length of ICU stay, and whether renal replacement therapy was required. Information on co-morbidities and medication was also provided. DNA was isolated using a Maxwell machine and telomere length determined via quantitative PCR. One hundred and fifty-five blood samples from 46 patients underwent analysis. Telomere length did not differ significantly over the 4 days (P=0.662). No relationship was found between telomere length and any physiological parameter, co-morbidity, or medication. There was a trend towards significance with RIFLE score at day 3 increasing as telomere length decreased, although this was not statistically significant (P=0.09). No relationship between telomere length and the available physiological parameters, comorbidities, or medication was found. Telomere length did not vary during ICU stay. This study was limited by its small sample size. Future studies would benefit from a larger sample size; in addition, blood samples could also be obtained at 6 months after discharge to allow gradual alterations in biological age to be determined. Recent studies give evidence that telomere length is a weak biomarker of ageing,3 and that more meaningful data might be obtained using superior markers, such as CDKN2A expression or expression levels of non-coding RNAs.3

Aim: Immunosuppression has evolved since the first successful orthotopic heart transplant 50 years ago. Currently, calcineurin inhibitors lie at the focal point of the immunosuppressive regimen. However, these drugs exhibit a variety of side effects, including hyperglycaemia. This in turn compounds the risk of cardiovascular disease. There is conflict around which calcineurin inhibitor, tacrolimus or ciclosporin, is more likely to induce diabetes.\ud \ud Methods: A retrospective analysis of data from 52 patients who had received a heart transplantation at the Scottish heart transplant unit between January 2011 and August 2017. All patients received a combination immunosuppressive regimen consisting of mycophenolate mofetil, corticosteroids and either tacrolimus or ciclosporin. Fasting glucose levels were compared every 3 months after transplantation for a year. HbA1c was collected and compared at one interval during follow-up postoperatively. Statistical analysis was achieved using Students t-test for continuous variables and Chi-squared test for categorical variables.\ud \ud Results: The drug regimens remained unchanged in the two cohorts over the study period. The fasting glucose of tacrolimus treated patients was higher over the 12-month period compared to ciclosporin treated patients (7.3 ± 1 vs. 5.9 ± 0.5, P = 0.017). The results were significantly higher in the tacrolimus group at 9 months (P = 0.013). In contrast to these findings, HbA1c of the tacrolimus group was lower than the ciclosporin group, although there was no significant difference (38 ± 11.4 vs. 43 ± 1.3, P = 0.104).\ud \ud Conclusion: This study suggests a relationship between tacrolimus and rising fasting glucose among heart transplant population. However, a longer follow-up and control of confounding variables is required to denote the long-term impact of immunosuppression related diabetes in heart transplant patients.

Lung cancer is a leading cause of cancer death and in suitable cases the best chance of cure is offered by surgery. Lung resection is associated with significant postoperative cardiorespiratory morbidity, with dyspnea and reduced functional capacity as dominant features. These changes are poorly associated with deterioration in pulmonary function and a potential role of right ventricular (RV) dysfunction has been hypothesized. Cardiovascular magnetic resonance imaging is a reference method for noninvasive assessment of RV function and has not previously been applied to this population.We used cardiovascular magnetic resonance imaging to assess the RV response to lung resection. Cardiovascular magnetic resonance imaging with volume and flow analysis was performed on 27 patients preoperatively, on postoperative day 2 and at 2 months. Left ventricular ejection fraction and RV ejection fraction, the ratio of stroke volume to end systolic volume, pulmonary artery acceleration time, and distensibility of main and branch pulmonary arteries were studied.Mean ± standard deviation RV ejection fraction deteriorated from 50.5% ± 6.9% preoperatively to 45.6% ± 4.5% on postoperative day 2 and remained depressed at 44.9% ± 7.7% by 2 months (P = .003). The ratio of stroke volume to end systolic volume deteriorated from median 1.0 (quartile 1, quartile 3: 0.9, 1.2) preoperatively to median 0.8 (quartile 1, quartile 3: 0.7, 1.0) on postoperative day 2 (P = .011). On postoperative day 2 there was a decrease in pulmonary artery acceleration time and operative pulmonary artery distensibility (P .030 for both). There were no changes in left ventricular ejection fraction during the study period (P = .621).These findings suggest RV dysfunction occurs following lung resection and persists 2 months after surgery. The deterioration in the ratio of stroke volume to end systolic volume suggests a mismatch between afterload and contractility. There is an increase in indices of pulsatile afterload resulting from the operative pulmonary artery.

This article presents a five-year strategic plan for Russell Library, the principal public library for Middletown, Connecticut. The goal of the plan is to make Russell Library “the Bridge to the Future of Middletown and its citizens.” To accomplish that large goal, the planners focus on three service areas: a broad range of resources, including books, electronic items, and databases; an engaged and supportive staff; and many varied and enlightening experiences for Middletown citizens of all ages. The first quarterly report to Middletown residents is included to demonstrate how the library is following its plan.

In different ways and with quite different outcomes Dunn, Mournet, Baum, and Burkett invoke practices associated with orality and writing in the ancient world to call into question all or some aspects of the Two Document Hypothesis and to build rationales for alternative source hypotheses. In a criticism of their appeals to ancient media this essay works out the significance of cultural practices associated with orality, writing, and memory for further work on the synoptic problem, especially as regards the uneven patterns of variation and agreement in the tradition.

Objective To compare different modes of pain management following video-assisted thoracoscopic surgery (VATS) to our national standard. Methods This is an audit based on patient's experiences. One hundred consecutive patients who underwent VATS with or without pleurodesis were managed by one of the following pain relief pathways: (A) thoracic paravertebral block + morphine patient-controlled analgesia (PCA), (B) percutaneous thoracic paravertebral catheter +/– morphine PCA, (C) thoracic epidural +/– morphine PCA, (D) morphine PCA alone, and (E) intravenous or subcutaneous morphine as required. Pain score was documented up to four times per day for each patient. The incidence of severe pain was defined as visual analog scale ≥7. The results were compared with the standard set by the audit commission for postoperative pain relief in the UK. The mean daily pain scores were calculated retrospectively for all patients. Results There were no statistically significant differences in mean daily pain scores irrespective of having a pleurodesis. The percentage of patients experiencing severe pain was 34% [mean visual analog scale = 8 (standard deviation = 1.0)]. This was almost seven times the standard. Among these pathways, B had the least percentage incidence of severe pain (16.7%) followed by A (25.0%) D (33.3%), C (35.7%), and E (52.4%). Conclusions We are not compliant with the standards set by the audit commission. Pain management in theater recovery needs to be targeted. In the light of these results, we recommend the use of percutaneous thoracic paravertebral catheter +/– morphine PCA for postoperative VATS pain relief.

Consistency of services to children and their families continues to be an ongoing problem in public child welfare agencies. Worker turnover is high, thus affecting the availability of a well trained, experienced workforce. It is critical that we continue to explore the factors associated with worker turnover and retention in public child welfare agencies. Such knowledge will allow us to determine the needs of workers, administrators, and the agency in general, in an effort to create an environment that will result in worker retention, and a better quality of services. Children and their families will be major benefactors of such knowledge as the consistency and quality of services will be enhanced. Existing research has found that outcomes for families and children are affected by the workload and training of frontline workers, and organizational characteristics (GAO, 2003, NASW, 2004, and Milner, 2003). This study describes personal and organizational factors relative to worker retention for public child welfare workers in the northwest corridor of Georgia.

Positron emission tomography-CT (PET-CT) is one of the initial mediastinal staging modality for non-small cell lung cancer; however, the clinical utility in carcinoid tumours is uncertain. We sought to determine the test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours. We collated data from seven institutions, performing a retrospective search on pathological databases for a consecutive series of patients who underwent thoracic surgery (with lymph nodal dissection) for carcinoid tumours with preoperative PET-CT staging. PET-CT results were compared with the reference standard of pathologic results obtained from lymph node dissection and test performance reported using sensitivity and specificity. From November 1999 to January 2013, 247 patients from seven institutions underwent surgery for carcinoid tumours with a corresponding preoperative PET-CT scan. The mean age of the patients was 61 (SD 15, range 73) and 84 were male patients (34%). The pathologic subtype was typical carcinoid in 217 patients (88%) and atypical carcinoid in 30 patients (12%). Results from lymph node dissection were obtained in 207 patients. The calculated sensitivity and specificity of PET-CT to identify mediastinal lymph node disease was 33% (95% CI 4% to 78%) and 94% (95% CI 89% to 97%), respectively. Our results indicate that PET-CT has a poor sensitivity but good specificity to detect the presence of mediastinal lymph node metastases in pulmonary carcinoid tumours. Mediastinal lymph node metastases cannot be ruled out with negative PET-CT uptake, and if the absence of mediastinal lymph node disease is a prerequisite for directing management, tissue sampling should be undertaken.

BackgroundAlthough only the minority of patients with non-small cell lung cancer (NSCLC) are suitable for surgical resection, it offers the best possibility of cure. The aim of this study was to examine the relationship between the clinicopathological status, the preoperative systemic inflammatory response, and survival in patients undergoing potentially curative resection for NSCLC.MethodsData from 96 patients who underwent resection of NSCLC between 2000 and 2003 were collected retrospectively and that for 2004–2006 prospectively.ResultsAll patients had Eastern cooperative oncology group performance status 0 or 1. No patient had T4, unresectable nodal or metastatic disease, and all macroscopic tumors were removed, with subsequent negative surgical margins. The majority of patients were older than 60 years (71%), men (57%), underwent a lobectomy (65%), and had tumor, node, metastasis stage I disease (66%). Of the markers of the systemic inflammatory response, white cell count, C-reactive protein, and albumin, only an elevated C-reactive protein (>10 mg/L) was associated with cancer-specific survival. On multivariate analysis, only tumor, node, metastasis stage (hazard ratio 1.88, 95% confidence interval 1.34–2.63, p < 0.001) and preoperative C-reactive protein (hazard ratio 1.67, 95% confidence interval 1.01–2.83, p < 0.05) retained independent significance. Those patients with a preoperative C-reactive protein concentration >10 mg/L had a median survival of 26.2 months compared with 75.9 months in those patients with a C-reactive protein ≤10 mg/L (p < 0.05).ConclusionThe results of this study indicate that the presence of a systemic inflammatory response predicts poor outcome in patients who have undergone potentially curative resection for lung cancer.

A primary assumption underlying several of the common methods for modeling item response data is unidimensionality, that is, test items tap into only one latent trait. This assumption can be assessed several ways, using nonlinear factor analysis and DETECT, a method based on the item conditional covariances. When multidimensionality is identified, a question of interest concerns the degree to which individual items are related to the latent traits. In cases where an item response is primarily associated with one of these traits it is said that (approximate) simple structure exists, whereas when the item response is related to both traits, the structure is complex. This study investigated the performance of three indices designed to assess the underlying structure present in item response data, two of which are based on factor analysis and one on DETECT. Results of the Monte Carlo simulations show that none of the indices works uniformly well in identifying the structure underlying item responses, although...

Pulmonary arterial hypertension (PAH) is a disease that results in thickening of the vascular wall. Some of the most prominent changes are seen in the adventitia as a result of fibroblast proliferation and increased extracellular matrix deposition. Previous work from this laboratory using animal models has shown that pulmonary but not systemic artery fibroblasts proliferate to hypoxic exposure and that this response is dependent on activation of p38 mitogen-activated protein kinase (p38MAPK). In this study, we wished to determine whether human pulmonary artery fibroblasts (HPAFs) behaved similarly under conditions of acute hypoxic exposure (35 mmHg for 24 h). Fibroblast proliferation was assessed by [(3)H]thymidine uptake and protein assays performed using Western blotting techniques. HPAFs proliferated in response to acute hypoxic exposure, human systemic artery fibroblasts did not. This hypoxia-mediated proliferation was p38 MAPK dependent and could be blocked using a specific p38 MAPK inhibitor. Hypoxia-inducible factor-1 (HIF-1) expression was increased in hypoxic pulmonary but not systemic cells and could be partially abrogated with the p38 inhibitor. This work in man confirmed our previous findings in animals that significant differences exist between the pulmonary and systemic circulations in response to hypoxic exposure. This study highlights the importance of p38 MAPK and HIF-1 in hypoxia-mediated proliferation of pulmonary artery adventitial fibroblasts.