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Let $f$ and $g$ be two cuspidal modular forms and let $\mathcal{F}$ be a Coleman family passing through $f$, defined over an open affinoid subdomain $V$ of weight space $\mathcal{W}$. Using ideas of Pottharst, under certain hypotheses on $f$ and $g$ we construct a coherent sheaf over $V \times \mathcal{W}$ which interpolates the Bloch-Kato Selmer group of the Rankin-Selberg convolution of two modular forms in the critical range (i.e. the range where the $p$-adic $L$-function $L_p$ interpolates critical values of the global $L$-function). We show that the support of this sheaf is contained in the vanishing locus of $L_p$., Comment: Final version. To appear in Canadian Jour. Math

Introduction Smoking cessation activities incorporated into lung cancer screening programs have been broadly recommended, but studies to date have not shown increased quit rates associated with cessation programs in this setting. We aimed to determine the effectiveness of smoking cessation counseling in smokers presenting for lung cancer screening. Methods This study is a randomized control trial of an intensive telephone-based smoking cessation counseling intervention incorporating lung cancer screening results versus usual care (information pamphlet). All active smokers enrolled in the Alberta Lung Cancer Screening Study cohort were randomized on a 1:1 ratio with a primary endpoint of self-reported 30-day abstinence at 12 months. Results A total of 345 active smokers participating in the screening study were randomized to active smoking cessation counseling (n = 171) or control arm (n = 174). Thirty-day smoking abstinence at 12 months post-randomization was noted in 22 of 174 (12.6%) and 24 of 171 (14.0%) of participants in the control and intervention arms, respectively, a 1.4% difference (95% confidence interval: -5.9 to 8.7, p = 0.7). No statistically significant differences in 7-day or point abstinence were noted, nor were differences at 6 months or 24 months. Conclusions A telephone-based smoking cessation counseling intervention incorporating lung cancer screening results did not result in increased 12-month cessation rates versus written information alone in unselected smokers undergoing lung cancer screening. Routine referral of all current smokers to counseling-based cessation programs may not improve long-term cessation in this patient cohort. Future studies should specifically focus on this subgroup of older long-term smokers to determine the optimal method of integrating smoking cessation with lung cancer screening (clinicaltrials.gov NCT02431962).

BackgroundThe reporting of adverse events (AE) remains an important part of quality improvement in thoracic surgery. The best methodology for AE reporting in surgery is unclear. An AE reporting system using an electronic discharge summary with embedded data collection fields, specifying surgical procedure and complications, was developed. The data are automatically transferred daily to a web-based reporting system.MethodsWe determined the accuracy and sustainability of this electronic real time data collection system (ERD) by comparing the completeness of record capture on procedures and complications with coded discharge data (administrative data), and with the standard of chart audit at two intervals. All surgical procedures performed for 2 consecutive months at initiation (Ti) and 1 year later (T1yr) were audited by an objective trained abstractor. A second abstractor audited 10% of the charts.ResultsThe ERD captured 71/72 (99%) of charts at Ti and 56/65 (86%) at T1yr. Comparing the presence/absence of complications between ERD and chart audit demonstrated at Ti a high sensitivity and specificity, positive predictive value (PPV) of 95.5%, negative predictive value (NPV) of 93.9% with a kappa of 0.872 (95% CI 0.750 to 0.994), and at T1yr a sensitivity, specificity, PPV and NPV of 100% with a kappa of 1.0 (95% CI 1.0). Comparing the presence/absence of complications between administrative data and chart audit at Ti demonstrated a low sensitivity, high specificity and a kappa of 0.471 (95% CI 0.256 to 0.686), and at T1yr a low sensitivity, high specificity of 85% and a kappa of 0.479 (95% CI 0.245 to 0.714).ConclusionsWe found that the ERD can provide accurate real time AE reporting in thoracic surgery, has advantages over previous reporting methodologies and is an alternative system for surgical clinical teams developing AE reporting systems.

The importance of smoking cessation interventions in lung cancer screening participants has been highlighted. This study aimed to describe the smoking habits of individuals who were ineligible for lung cancer screening and to investigate whether this encounter may represent an opportunity to reduce tobacco use.Ever smokers between the ages of 55 and 80 and ≥1.5% lung cancer risk over 6 years or having smoked ≥30 pack-years and with no more than 15 years of smoking abstinence were eligible to participate in the Alberta Lung Cancer Screening Program (ALCSP). A baseline questionnaire exploring tobacco use was administered to all interested individuals as part of the eligibility determination for the program.Among 504 individuals, 254 (50.4%) met the criteria for the ALCSP and 250 (49.6%) were non-eligible for screening. Non-eligible individuals were slightly younger (mean=60.2 vs. 63.1 years, p-value0.001), and less likely to be current smokers (26.0% vs. 48.8%, p-value0.001). Non-eligible smokers had a lower degree of addiction compared to eligible group, as measured by the Fagerström Test of Nicotine Dependence (Median=4.0 vs 6.0, p-value=0.001), but still in the "moderately dependent" range for this test. There were no significant differences in motivation to quit (98.5% vs. 97.6%, p-value=0.689), or motivation to receive help with their quit attempt (89.2% vs. 90.3%, p-value=0.813) between these two groups. Only 7.7% of non-eligible and 2.4% of eligible current smokers were currently in a smoking cessation program.A significant proportion of individuals applying to, but not qualifying for a lung cancer screening program are active smokers with significant nicotine dependence. Very few are currently participating in active smoking cessation programs but almost all are interested in quitting and in receiving help with quit attempts. Future studies need to investigate the most effective approaches for smoking cessation in this substantial group of older, long-term smokers, capitalizing on their motivation to receive cessation assistance.

Background False-positive scans and resultant needless early recalls can increase harms and reduce cost-effectiveness of low-dose CT (LDCT) lung cancer screening. How LDCT scans are interpreted and classified may impact these metrics. Methods The Pan-Canadian Early Detection of Lung Cancer risk calculator was used to determine nodule risk of malignancy on baseline screening LDCTs in the Alberta Lung Cancer Screening Study, which were then classified according to Nodule Risk Classification (NRC) categories and ACR Lung Screening Reporting and Data System (Lung-RADS). Test performance characteristics and early recall rates were compared for each approach. Results In all, 775 baseline screens were analyzed. After a mean of 763 days (±203) of follow-up, lung cancer was detected in 22 participants (2.8%). No statistically significant differences in sensitivity, specificity, or area under the receiver operator characteristic curve occurred between the NRC and Lung-RADS nodule management approaches. Early recall rates were 9.2% and 9.3% for NRC and Lung-RADS, with the NRC unnecessarily recalling some ground glass nodules, and the Lung-RADS recalling many smaller solid nodules with low risk of malignancy. Conclusion Performances of both the NRC and Lung-RADS in this cohort were very good with a trend to higher sensitivity for the NRC. Early recall rates were less than 10% with each approach, significantly lower than rates using the National Lung Screening Trial cutoffs. Further reductions in early recall rates without compromising sensitivity could be achieved by increasing the NRC threshold to 20% for ground glass nodules or by applying the nodule risk calculator with a 5% threshold to 6- to 10-mm solid nodules under Lung-RADS.

Randomized controlled trials (RCTs) have been regarded as superior to the nonrandomized observational studies (nRCTs) because of the biases that can arise in nRCTs and the diverging results of nRCTs relative to RCTs. For example, laparoscopic repair of inguinal hernia gained popularity over open repair as a result of favourable results in nRCTs. Subsequently, numerous RCTs have been performed and assessed in a meta-analysis that concluded that the recurrence rate after laparoscopic inguinal hernia repair was no different than that for open repair. The RCTs also warned the surgical community of significantly higher rates of major visceral complications from a laparoscopic approach. Such unexpected findings of RCTs compared with nRCTs have led to a call for careful examination of surgical research, including increased use of RCTs.1,2 Studies by Concato and colleagues,3 Benson and Hartz4 and Ioannidis and colleagues5 have renewed the debate regarding the role of RCTs relative to nRCTs. The first 2 groups reported that nRCTs provide similar results to RCTs and argue for an expanded role for nRCTs, particularly to exploit clinical databases. Meanwhile, Ioannidis and colleagues5 reported reasonable correlation between RCTs and nRCTs in many instances, but also found a greater than 2-fold difference in odds ratios in 33% of topics examined. Surgical studies made up a small proportion of the topics compared. Shikata and colleagues,6 using a similar methodology to Ioannidis and colleagues, reported on a comparison of effects in RCTs versus nRCTs of digestive surgery. The authors reported that one-quarter of nRCTs gave different results than RCTs. Similar to the studies by Concato and colleagues and Ioannidis and colleagues, Shikata and colleagues included only studies for which meta-analyses of RCTs were available, and they included comparisons between surgical procedures and nonsurgical treatments. Surgical RCTs, as a result of being infrequently conducted, may be somewhat under-represented in meta-analyses. Therefore, studies such as that of Shikata and colleagues may capture only a subset of surgical RCTs. A study specifically designed to examine the effect estimates for surgical procedures alone in RCTs and nRCTs has, to our knowledge, not been performed. MacLeod7 and Hall and colleagues8 have highlighted methodologic issues, such as standardization of procedures, outcome assessment and sample size, which suggest that surgical trials may be different than nonsurgical trials. Concato and colleagues3 noted that observational investigations of surgical operations may be more prone to selection bias. This raises the possibility that discrepancies of effect estimates between RCTs and nRCTs examining surgical versus nonsurgical interventions may not reflect potential discrepancies in studies comparing 2 surgical interventions. Given that the paradigm for adopting new surgical procedures differs somewhat from that of pharmacologic therapies and that nRCTs continue to play an important role in informing decisions about adoption of surgical therapies, there is an ongoing need to formally compare effect estimates from nRCTs with those from RCTs. The purpose of our study was to determine whether the conclusions reached from an assessment of the body of knowledge obtained from nRCTs would be consistent with those obtained from RCTs, with specific focus on a surgically treated disease. Would decisions based on the collective evidence from nRCTs be consistent with that obtained from the “highest level of evidence,” an RCT addressing that same topic? We performed a systematic review and meta-analysis to compare the effect estimates of RCTs with those of nRCTs in the domain of breast cancer surgery. This comparison will help us to better understand the relation between study design, the resulting effect estimate and the subsequent impact on evolving knowledge of surgical procedures.

Objective The resident component of the Canadian Thoracic Manpower and Education Study (T-MED) was conducted to understand the basic demographic of Canadian thoracic surgery residents, the factors influencing their selection of training programs, current work conditions, training and competencies, and opinions in regard to the manpower needs for the specialty. Design A modified Delphi process was used to develop a survey applicable to thoracic surgery residents. In May and June 2009, residents completed the voluntary anonymous Internet-based survey. All Canadian residents participated in the survey, providing a 100% response rate. Results Most respondents were male (11/12), and the average age was 34 years old with an anticipated debt greater than $50,000 on graduation. All residents worked more than 70 hours per week, with most doing 1 : 3 or 1 : 4 on-call. Two-thirds of respondents reported being satisfied or very satisfied with their training program. Rates of anticipated competence in performing various thoracic surgeries on graduation differed between residents and program directors. Two-thirds (8/12) of residents planned to practice thoracic surgery exclusively, and hoped to practice in an academic setting. Most residents (10/12) agreed or strongly agreed that not enough jobs are available in Canada for graduating trainees and that the number of residency positions should reflect the predicted availability of jobs. Conclusions This study has provided detailed information on thoracic surgery resident demographics and training programs. Most thoracic surgery residents are satisfied with their current training program but have concerns about their job prospects on graduation, and they believe that the number of training positions should reflect potential job opportunities. This survey represents the first attempt to characterize the current state of thoracic surgery training in Canada from the resident's perspective and may help in directing educational and manpower planning.

Large diaphragmatic defects present a reconstructive challenge, often necessitating the use of synthetic materials. We report our experience reconstructing large diaphragmatic defects using human acellular dermal matrix (HADM). Patients unable to undergo primary repair of diaphragmatic defects from 2009 to 2013 were reconstructed using HADM. A chart review was performed to investigate immediate and late post-operative outcomes. Construct stability was assessed with repeat imaging. In addition, a literature review was performed to identify studies in which HADM had been used for diaphragm repair. Four patients required reconstruction of large hemi-diaphragmatic defects. All patients had chest tubes placed, which remained in situ from 4 to 10 days post-operatively. Two patients also had drains in dead space surrounding HADM; these were removed between 6 and 9 days post-procedure. Length of hospital stay ranged from 8 to 65 days. Post-operative complications were seen in 2 patients: surgical site cellulitis and failure of extubation due to persistent respiratory failure. There were no adverse events related to HADM, and all patients remained disease free without evidence of repair failure on radiographic follow-up, ranging from 14 to 62 months. The literature review identified 3 studies in which all diaphragms repaired with HADM remained intact without need for explantation despite common post-operative complications including fluid collections and surgical site infections. Diaphragm reconstruction with HADM is limited to a small number of patients and modest follow-up periods; the neodiaphragms appear durable in contaminated fields, without evidence of repair failure. Our results, and previously published data, indicate HADM is a reasonable option for diaphragm repair.

Black burnished pottery is a unique fabric with a specialized surface treatment that can be assigned almost exclusively to the 7th century BC. In his classic study of pottery from Transjordan, Dornemann (1983) recognized the appearance of a fast wheel that allowed for the production of fine wares and certain forms that required expert skill. One result of this technology was the decline of red-slipped pottery and the development of light cream ware and black ware. At Tall Jawa (Jordan), black-slipped and burnished pottery reached its zenith in Stratum VII (late 8th–7th century BC; Daviau 2003). This black-slipped pottery has a dark gray fabric with a slightly darker slipped surface. The distribution of black-burnished pottery appears to be limited to the territory of the Ammonites in Transjordan, certain Phoenician sites, and sites in Syria. In certain instances, bowl forms from Tall Jawa suggest strong Assyrian influence and have close parallels with vessels from Nimrud that appear in a highly po...

Background The objective of this study was to combine systematic review and decision analytic techniques to determine the optimal treatment strategy for patients with locally advanced esophageal cancer. Methods We performed a systematic review of all randomized trials of patients with locally advanced esophageal cancer that included one of the following strategies compared with surgery alone: chemoradiotherapy followed by surgery, chemotherapy followed by surgery, or surgery with adjuvant chemoradiotherapy. Using the estimates of relative risk for mortality and overall quality of life we constructed a decision model. The outcome of interest was expected quality-adjusted life-years (QALY). Results The meta-analysis showed for the first year, the relative risk (95% confidence interval) of death for treatments compared with surgery were 0.87 (0.75 to 1.02) for chemoradiotherapy followed by surgery, 0.94 (0.82 to 1.08) for chemotherapy followed by surgery, and 1.33 (0.93 to 1.93) for surgery with adjuvant chemoradiotherapy. The QALYs gained for surgery alone, chemoradiotherapy followed by surgery, chemotherapy followed by surgery, and surgery with adjuvant chemoradiotherapy strategies were 2.07, 2.18, 2.14, and 1.99, respectively. If the reduction in utility for multimodality treatment was increased to 21%, the QALYs gained for surgery alone, chemoradiotherapy followed by surgery, chemotherapy followed by surgery, and surgery with adjuvant chemoradiotherapy were 2.07, 2.03, 1.99, and 1.85, respectively. Conclusions Chemoradiotherapy followed by surgery appears to be associated with the best survival and the largest expected gain in QALYs. However, the improvement in quality-adjusted life expectancy is modest at 40 days, and surgery alone becomes the preferred strategy if the reduction in utility associated with multimodality treatment is increased to 21%.

The objective of this study was to determine the levels of evidence and grades of recommendations available for techniques in antireflux surgery. Areas of technical controversy in antireflux surgery were identified and developed into eight answerable questions. The external evidence was surveyed using the databases Medline and EMBASE. Abstracts and appropriate articles were identified from January 1966 to December 2005. A set of search strategies was systematically employed to determine the levels of evidence available for each clinical question. Primary outcome measures included the determination of levels of evidence and grade of recommendation based on The Oxford Center for Evidence-Based Medicine. Secondary outcome measures included for randomized controlled trials were Jadad scores, noting the presence of a sample size calculation, and the determination of an effect estimate and the reporting of a confidence interval. Higher quality randomized controlled trials (mostly level 2b, occasional level 1b) existed to answer three questions: whether to complete a 360 degrees or partial wrap; whether or not to divide the short gastric vessels; and whether to perform laparoscopic or open surgery. Lower quality randomized controlled trials were available to determine whether the use of mesh was helpful, whether or not to use a bougie catheter for calibration of the wrap, and whether an anterior or posterior wrap results in a superior outcome. This was deemed to be of inferior grade of recommendation due to the lack (< 2) of trials available and the sole presence of level 2b evidence. The final two questions: whether to complete fundoplication using a thoracic or abdominal approach and whether to use intraoperative manometry relied exclusively upon level 4 evidence and thus received a lower grade of recommendation. A higher Jadad score seemed to be associated with studies having a higher level of evidence available to answer the question. Sample size calculations were given to answer three questions. Effect estimate was difficult to interpret given inconsistent findings, composite outcomes and lack of reported confidence intervals. In conclusion, antireflux surgery has many randomized controlled trials available upon which to base clinical practice. Unfortunately, these are generally of poor quality. We recommend that esophageal surgeons determine consistent outcome measures and endeavor to improve the quality of randomized controlled trials they perform.

Background Accurate staging of patients with lung cancer is imperative in generating an appropriate treatment strategy. This study examined the clinical performance of anterior mediastinotomy in staging patients with suspected left upper lobe non-small cell lung cancer. Methods This study was designed as a retrospective cohort. All patients with suspected left upper lobe cancer and otherwise normal computed tomography scan results were eligible. Patients with clinically unresectable disease (advanced disease or not fit for surgery) were excluded. After exclusions, 151 patients were stratified into two groups: 117 patients had cervical and anterior mediastinotomy as part of preoperative staging, and 34 had cervical mediastinoscopy only. The primary outcome was rate of preventable thoracotomy defined as thoracotomy during which either metastases to aortopulmonary or paraaortic lymph nodes, or mediastinal invasion was identified. Results The rate of preventable thoracotomy for the anterior mediastinotomy arm was 4 (3.4%) of 117, compared with 1 (2.9%) of 34 for cervical mediastinoscopy-only arm ( p = 0.99). The rate of morbidity in the anterior mediastinotomy arm was 8 (6.8%) of 117, compared with 2 (5.8%) of 34 for the cervical mediastinoscopy-only arm ( p = 0.99). Anterior mediastinotomy patients stayed in hospital 1 day longer ( p = 0.008). Anterior mediastinotomy was successful at harvesting one or more lymph nodes in 67% of patients. Five patients (4.3%) who underwent anterior mediastinotomy were spared a thoracotomy by identification of metastases to aortopulmonary lymph nodes. Conclusions In patients with suspected left upper lobe lung cancer and otherwise normal computed tomography scan results, anterior mediastinotomy does not significantly reduce the rate of preventable thoracotomy.

Dimethylzirconocene precatalysts are shown to initiate the polymerization of methyl methacrylate (MMA) when activated by a Lewis acidic methyl abstractor in the absence of any ZnEt2 additive. The order of addition of the various components is crucial to forming a well-defined active species. Conversion of the precatalysts Cp2ZrMe2 (1a), rac-{C2H4(η5-C9H6)2}ZrMe2 (2a), {Me2C(η5-C5H4)(η5-C13H8)}ZrMe2 (3a), {Me2C(η5-C5H4)(η5-C9H6)}ZrMe2 (4a), {Me2C(η5-C5H4)(η5-2-MeC9H5)}ZrMe2 (5a), and (Cp)(Cp*)ZrMe2 (6a) to their cationic methylzirconocene derivatives (2b−6b) followed by addition of methyl methacrylate results in controlled polymerization to poly(methyl methacrylate) with the exception of 3b which is inactive.

The syntheses of the new compounds [W(η-C5H5)(η-C5H4{B(C6F5)2R})H3], where R = (C6F5) 1, Ph 2, H 3 or Cl 4, [Mo(η-C5H5)2(H)(η1-HB(C6F5)3)] 5, [Mo(η-C5H5)2(H)(η1-H2B(C6F5)2)] 6, [Mo(η-C5H4Me)2(H)(η1-HB(C6F5)3)] 7, [Re(η-C5H5)(η-C5H4B(C6F5)3)H2]·0.5C6H5Me 8, [Ta(η-C5H5)2(H)2(η1-HB(C6F5)3)] 9 and [Re(η-C5H5)(η-C5H4{B(C6F5)2})(C6F5)] 10 are described. The crystal structures of compounds 4 and 10 have been determined. Initial electrophilic addition of the Lewis acid B(C6F5)3 occurs either by exo-addition to a carbon of a η-cyclopentadienyl ring with formation of an exo-{(C6F5)3B}C5H5, or by formation of an M–μ-H–B two-electron three-centre bond.

Background: The ideal treatment for achalasia permanently eliminates the dysfunctional lower esophageal sphincter, relieving dysphagia and regurgitation; prevents gastroesophageal reflux; and has an acceptable morbidity rate. Controversy exists concerning whether the thoracoscopic Heller Myotomy (THM) or laparoscopic Heller myotomy (LHM) technique is the best approach to a modified Heller myotomy for achalasia. Study Design: We performed a retrospective comparison of the patient characteristics, operative results, postoperative symptoms, and the learning curves for the procedures of 24 patients undergoing THM and 63 patients undergoing LHM between 1991 and 1998. Results: Preoperative patient variables in each group revealed similar distributions for age, gender, and prevalence of previous pneumatic dilation. Mean operating room (OR) times were 4.3 hours (range 2.9 to 5.6 hours) for THM and 3.0 hours (range 1.5 to 6.5 hours) for LHM (p = 0.01). Three esophageal perforations occurred in the THM group and two in the LHM group. Conversion to an open procedure took place in five THM operations (21%) and one LHM operation (2%) (p = 0.005). There were no postoperative esophageal leaks. Mean postoperative length of stay (LOS) for THM was 6.1 days (range 1 to 17 days) and for LHM was 4.0 days (range 1 to 12 days) (p = 0.03). Learning-curve analysis of the first 24 LHM patients compared with the most recent 24 revealed greater OR time in the first 24 mean 3.6 hours, (range 2.0 to 6.5 hours) versus mean 2.3 hours, (range 1.5 to 3.7 hours; p=0.01), and greater LOS mean 5.5 days, (range 3 to 12 days) versus mean 3.1 days, (range 1 to 8 days; p Conclusions: LHM was associated with decreased OR time, decreased rate of conversion to an open procedure, and shorter LOS compared with THM. LHM was superior to THM in relieving dysphagia and preventing heartburn. LHM may be the preferred surgical treatment of achalasia in some patients.

background The incidence of adenocarcinoma of the cardia is increasing. The surgical management remains controversial. The present study reviews our experience with surgically resected adenocarcinoma of the cardia. methods A retrospective review of 153 cases of surgically resected adenocarcinoma of the cardia was performed. Preoperative radiotherapy was used in 31 patients. The surgical approach, morbidity, mortality, impact of preoperative radiotherapy, and survival were determined. results The type of resection performed was a transhiatal esophagogastrectomy in 78%, a transthoracic esophagogastrectomy in 21%, and a transabdominal esophagogastrectomy in 1%. The in-hospital mortality rate was 4%. The frequency of complications was not associated with the use of preoperative radiotherapy or surgical approach. The 1-year (61%), 2-year (38%), 3-year (23%), and 5-year (16%) survival were not affected by the use of preoperative radiotherapy or surgical approach. Survival was significantly associated with stage and the presence of lymph node metastasis. conclusions Adenocarcinoma of the cardia is associated with a poor long-term prognosis. The long-term survival does not appear to be affected by the use of preoperative radiotherapy or by surgical approach.

The transition-metal nitrido complexes [Re(N)(PR3)(S2CNR′2)2] (PR3 = PMe2Ph, R′ = Me; PR3 = PMePh2, R′ = Et 1), [Re(N)(Cl)(PMePh2)2(S2CNMe2)] 2, [Mo(N)(S2CNR2)3] (R = Me or Et) and [NBun4][Os(N)(1,2-S2C6H4)2] reacted with the strong Lewis acid B(C6F5)3 to yield the adducts [Re{NB(C6F5)3}(PR3)(S2CNR′2)2] (PR3 = PMe2Ph, R′ = Me 3*; PR3 = PMePh2, R′ = Et 4), [Re{NB(C6F5)3}(Cl)(PMePh2)2(S2CNMe2)] 5, [Mo{NB(C6F5)3}(S2CNR2)3] (R = Me 6 or 7) and [NBun4][Os{NB(C6F5)3}(1,2-S2C6H4)2] 8 (* indicates that the compound has been structurally characterised). Reactions of 3, 6 and 8 with competing strong Lewis bases have revealed differences in the stability of the MN–B interaction depending on the steric crowding around the metal centre. Reaction of 8 with MeO3SCF3 causes the formation of [Os{NB(C6F5)3}{1,2-(S)(SMe)C6H4}(1,2-S2C6H4)] 9.

Background and methods A Comparison of total vs. partial laparoscopic fundoplication was conducted in 89 patients from July 92 to June 96. Parameters examined were operating room (OR) times, conversion rates, and perioperative complications. Patient satisfaction, control of symptoms, and late complications were assessed by follow-up at a mean of 6 and 15.4 months. Results There were six conversions to open surgery resulting in 48 laparoscopic total (LTF) and 35 laparoscopic partial (25 anterior and 10 Toupet) fundoplications (LPF). The following results were obtained for each respectively: preop Demeester score 44 vs. 39; OR time 2.9 vs. 2.5 hours; length of stay 3.6 vs. 4.1 days; early morbidity 25% vs. 1%. There were no mortalities. At a mean follow-up of 6 months, new-onset dysphagia was present in 8 (17%) vs. 2 (8%), respectively (NS), and both total and partial fundoplications appeared successful in controlling symptoms (98% vs. 97%). At a mean follow-up of 15.4 months, heartburn was resolved or improved in 76% vs. 87% (NS); regurgitation was improved or resolved in 93% vs. 93%; and patient satisfaction with the procedure was present in 93% vs. 97% (NS). Persistent dysphagia was present in 7.3% vs. 10.3% (NS) of patients. Early satiety was present more often in the partial fundoplication group (56% vs. 83% P = .03). Conclusions Early follow-up suggests equal efficacy in controlling symptoms and in achieving patient satisfaction. A 6-month follow-up suggested a higher incidence of new dysphagia in the total fundoplication group; however, at 15-month follow-up there was no significant difference.

The reaction between B(C 6 F 5 ) 3 and [Fe(η-C 5 H 5 )(CO) 2 Me] gave the unexpected product [Fe{C 6 F 4 C(O)Me-2}(η-C 5 H 5 )(CO)] 1 which reacts with the donor molecules L = PMe 3 , PPh 3 or Bu t NC giving [Fe{C 6 F 4 C(O)Me-2}(η-C 5 H 5 )L].* Likewise [{Fe[C 6 F 4 C(O)Me-2](η-C 5 H 5 )} 2 (µ-dppe)]* was formed from 1 and Ph 2 P(CH 2 ) 2 PPh 2 (dppe). The formation of the compound where L = PMe 3 is shown to proceed via initial formation of [Fe{C 6 F 4 C(O)Me-2}(η-C 5 H 5 )(CO)(PMe 3 )]*. The reaction between B(C 6 F 5 ) 3 and [M(η-C 5 H 5 )(CO) 3 Me] (M = Mo or W) gave the compounds [M{C 6 F 4 C(O)Me-2}(η-C 5 H 5 )(CO) 2 ]. The compounds [M{C 6 F 3 X-5-C(O)Me-2}(η-C 5 H 5 )(CO) 2 ]* (M = Mo or W) where X = H were prepared from the compounds where X = F via unusual C–F bond-activation reactions. The compound [Fe{C 6 F 3 H-5-C(O)Me-2}(η-C 5 H 5 )(PMe 3 )] was prepared by photolysis of a mixture of [Fe{C 6 F 3 H-5-C(O)Me-2}(η-C 5 H 5 )(CO)] and PMe 3 . The asterisk indicates the crystal structure has been determined.

Adult intraabdominal surgery performed with the minimal-access technique has created a revolution in surgery. This technique has remained largely unused for pediatric surgical procedures because of concerns regarding its safety and efficacy. Presently, intraabdominal insufflation of CO 2 is the preliminary step to performing minimal access surgery. In this study, an animal model was developed to determine the effects of intraabdominal CO 2 insufflation in the infant. Eight piglets (4 to 6 kg; 14 to 19 days of age) were instrumented under fentanyl anesthesia to allow measurement of arterial blood pressure (BP), central venous pressure (CVP), heart rate (HR), cardiac index (CI), inferior vena cava pressure (IVCp), inferior vena cava flow (IVCf), mediastinal pressure (Mp), partial pressure of CO 2 (Paco 2 ), and minute ventilation (V E ) at baseline and during 1 hour of CO 2 insufflation to a pressure of 15 mm Hg and again when ventilation was increased to control Paco 2 levels. Continuous recording of data allowed time-course analysis of 15-minute blocks to determine the rate of change of measured variables. A second group of 6 piglets (4 to 6 kg) underwent the same instrumentation, but their baseline values were compared with those during N 2 O insufflation to isolate the effects of increased intraabdominal pressure. During CO 2 insufflation alone, Paco 2 increased by 31% ( P 2 absorption from the peritoneal cavity because V E was unchanged. CO 2 insufflation alone was associated with increases of 10% in CI ( P = .02), 29% in CVP ( P = .01), and 17% in BP ( P 2 was controlled by increased ventilation, there was no significant change in CI, increases of 7% in SVR ( P = .02), 57% in CVP ( P = .001), and 7% in BP ( P = .01), and a 22% decrease in IVCf ( P = .04). N 2 O insufflation resulted in no significant change in CI, increases of 22% in SVR ( P = .01), 35% in CVP ( P = .01), and 16% in BP ( P = .005), and a 25% decrease in IVCf ( P = .02). CO 2 insufflation is associated with significant CO 2 absorption and increased myocardial work in the piglet model.

An incomplete major pulmonary fissure can make anatomic lung resection technically more difficult and may increase the risk of complications, such as prolonged postoperative air leak. The objective of this study was to determine if preoperative computed tomography (CT) of the chest could accurately predict the completeness of the major pulmonary fissure observed at the time of surgery.From October 2008 to June 2009, patients at a single university institution were enrolled if they underwent surgery for a pulmonary nodule, mass or known cancer. At the time of surgery, completeness of the major pulmonary fissure was graded 1 if pulmonary lobes were entirely separate, 2 if the visceral cleft was complete with an exposed pulmonary artery at the base with some parenchyma fusion, 3 if the visceral cleft was only evident for part of the fissure without a visible pulmonary artery and 4 if the fissure was absent. The preoperative CT scan of each patient was graded by a single, blinded chest radiologist using the same scale. We used the Pearson χ2 test with 2-tailed significance to test the independence of the operative and radiologic grading.In 48% (29 of 61) of patients, the radiologic and operative grading were the same. Of those graded differently, 94% (30 of 32) were within 1 grade. Despite this agreement, we observed no statistically significant correlation between the operative and radiologic grading (p = 0.24).The major fissure can often be well-visualized on a preoperative CT scan, but preoperative CT cannot accurately predict the completeness of the major pulmonary fissure discovered at surgery.

SUMMARY. The choice of the optimal surgical approach for repairing paraesophaeal hernias (PEH) is debated. Our objective is to evaluate the short-term outcomes of primary laparoscopic and open repairs of PEH performed in the Calgary Health Region. A retrospective review of all patients undergoing repair of PEH between October 1999 and February 2005 was performed. The outcome measures evaluated included intra-operative parameters and post-operative variables, mortality rates, recurrence rates and patient satisfaction. A total of 93 patients underwent either a laparoscopic (n = 46) or open (n = 47) primary PEH repair. The laparoscopic approach was associated with a longer mean operative time (3.1 ± 1.2 hours vs. 2.5 ± 0.7 hours, P = 0.005) but resulted in a shorter overall hospital stay (5 days [2–16 days]vs. 10 days [5–24 days]; P

We report a case of a 68-year-old man with probable Alzheimer's disease who developed rapid eye movement (REM) sleep behaviour disorder. This was confirmed with polysomnography but the patient also had some sleep apnea, which prevented the use of clonazepam for treatment. Melatonin was successfully used as an alternative treatment.

SUMMARY. The objective was to develop, pretest and validate a disease-specific quality of life questionnaire for potentially curable patients with esophageal carcinoma, for use with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) in order to assess the quality of life associated with the various treatment modalities available for this disease. Questionnaire development phase Patients were enrolled in three centres. Literature reviews, patients, family members, and health care professionals generated 195 items: symptoms (55); emotions (53); physical functioning (17); activities of daily living (ADL) (48); and leisure/social (22). Thirty-eight patients identified items of importance and assigned importance ratings on a 5-point Likert scale. Impact scores were calculated as frequency times mean item importance. Item impact scores

Evidenced-based medicine (EMB) is a philosophical approach to clinical problems introduced in the 1980s by a group of clinicians with an interest in clinical epidemiology at McMaster University in Canada. The concepts associated with this approach have been widely disseminated and described by many as a paradigm shift. Others, however, have debated the usefulness of this approach.

Laparoscopic Heller esophageal myotomy improves esophageal clearance and symptoms of achalasia in the early and late postoperative periods.We followed up 98 consecutive patients attending a referral center between February 1, 1994, and July 1, 2000, who underwent laparoscopic myotomy. Operative time, complications, and length of stay were recorded. Postoperative outcomes were assessed using Van Trappen symptom scores (1 indicates no symptoms; 2, symptoms occurring less than once a week; 3, symptoms occurring more than once weekly; and 4, persistent symptoms) and scintigraphic esophageal transit studies.Of 98 patients, 91 underwent anterior fundoplication. There were no open conversions and 1 mucosal perforation, which was closed laparoscopically without complications. Mean operative times and postoperative days were 3.2 hours and 4.3 days, respectively, in the first 32 patients and 1.7 hours and 2.3 days, respectively, in the last 32 patients (P.001). Postoperative complications included pneumothorax (4% of patients), atelectasis (5%), and delayed gastric emptying (1%). Seventy-five percent of patients gained weight after surgery. At longest follow-up, 91% of patients were satisfied with the outcome of the procedure. Mean Van Trappen scores for dysphagia improved from 4.0 in the preoperative period to 1.2 at early and late follow-up (P.001). Fluid retention at 10 minutes in the upright position was 47% in the preoperative period and improved at early and late follow-up to 21% and 20%, respectively (P.001).Laparoscopic Heller myotomy can safely reverse the symptoms of achalasia and improve esophageal transit. These benefits, realized during the early postoperative period, were maintained at longest follow-up.

To determine the effects of therapy with inhaled nitric oxide (NO) gas and partial or complete blockade of endogenous NO synthesis with N(omega)nitro-L-arginine (L-NA) on the hemodynamic responses to group B streptococci infusion in newborn piglets.Randomized, acute intervention study.Animal research laboratory.Twenty-five anesthetized piglets younger than 3 days of age divided into five groups.Heat-killed group B streptococci (GBS) were infused systemically until a 50% increase in pulmonary artery pressure (PAP) was obtained, and the infusion was continued for another 2 hrs. The five groups were designed as follows: group 1, sepsis control: continuous GBS infusion, with two brief trials (10 mins) of inhaled NO given after the initial development of pulmonary hypertension and again 2 hrs later; group 2, continuous inhaled NO: NO was given at 40 ppm for 2 hrs during GBS infusion; group 3, high-dose L-NA pretreatment: 10 mg/kg L-NA bolus followed by 1 mg/kg/min before, and continuing throughout, GBS infusion; group 4, high-dose L-NA: same dose as in group 3, but given after the start of the GBS infusion with continuous inhaled NO at 40 ppm; and group 5, low-dose L-NA: 3 mg/kg bolus given after start of GBS infusion with continuous inhaled NO at 40 ppm.The sepsis controls, group 1, had an increase in PAP, which took 15-45 mins to develop, from a mean of 3.4 (SD 0.7) to 5.9 (1.9) kPa (p.05), at which time the cardiac index had decreased from 169 (28) to 146 (46) mL/kg/min (p.05). Brief inhaled NO during the early phase decreased PAP to normal. Two hours later, PAP had increased to 6.1 (0.2) kPa and cardiac index had decreased to 88 (31) mL/kg/min. Inhaled NO after 2 hrs decreased PAP to 3.2 (0.5) kPa and increased cardiac index to 106 (44) ml/kg/min (p.05). Continuous inhaled NO (group 2) ameliorated the deterioration in cardiac index, which at 2 hrs was 140 (30) mL/kg/min (significantly greater than in the sepsis controls) (p.05). The L-NA-pretreated animals (group 3) had a greater increase in PAP and pulmonary vascular resistance index when GBS infusion was started. PAP increased from 3.0 (0.7) to 7.3 (1.5) kPa within 15 mins, and cardiac index simultaneously decreased to 68 (20) mL/kg/min. Cardiac index subsequently rapidly deteriorated to 48 (21) mL/kg/min, and only one of five animals survived for 2 hrs. Group 4 animals also developed a rapid deterioration in cardiac output, and only two of five survived for 2 hrs. Group 5 animals had results indistinguishable from group 2 animals.Pulmonary hypertension and shock resulting from GBS infusion in newborn piglets are much worse if endogenous NO production is completely inhibited. Continuous inhaled NO with or without low-dose L-NA inhibits the decrease in cardiac output.

Pulmonary carcinoid tumors are rarely associated with symptoms of the carcinoid syndrome, such as flushing and diarrhea. When present, these symptoms virtually always represent extensive hepatic metastases. In this article we describe the presentation, perioperative management, and presumed mechanisms of a patient with a localized pulmonary carcinoid with associated chronic diarrhea that resolved after operation.

1. Case reportA 31-year-old male sustained a severe crush injury to his chestafter being caught between a truck and loader. His admissioninjuries included: multiple left sided rib fractures with a left flailchest, pulmonary contusions, left main stem bronchus injury, leftpulmonary artery dissection, traumatic aortic disruption, lefthumerus and radius fractures and thoracic vertebral spinousprocess fractures (Fig. 1). After stabilisation and insertion of a leftthoracostomy tube, he underwent successful placement of anaortic endovascular stent graft. On admission bronchoscopy hewas found to have a laceration to the membranous portion of hisleft main stem bronchus without an obvious air leak. This wasinitially managed non-operatively. On post-admission day 2 hedeveloped progressive hypoxaemia, and bronchoscopy confirmedcomplete occlusion of his left main stem bronchus. The bronchialinjury and resultant obstruction was not amenable to endobron-chial stenting. Chest radiograph showed opacification of his leftlung(Fig.2).Atthoracotomyextensivetissuedestructioninvolvinggreater than 90% of his left main stem bronchus was found, andwas not repairable. A left pneumonectomy was performed.Ten days following pneumonectomy the patient developedacute respiratory failure and hypotension. Computed tomography(CT) identified a massive PE occluding the right main pulmonaryartery(Fig.3).Anemergentmultidisciplinaryconferencereviewedthe available options which included: sternotomy with cardiopul-monary bypass and pulmonary thrombectomy, peripheral extracorporeal membrane oxygenation for haemodynamic support andintravenous heparin and lastly catheter directed thrombolysis andplacement of an inferior vena cava (IVC) filter. Given the markedhaemodynamic instability of the patient, thrombolysis and filterplacement was chosen. Following thrombolysis the patientexperienced immediate and marked haemodynamic improve-ment. Systemic anticoagulation was initiated. Ultimately hisorthopaedic extremity injuries were corrected and he survivedto independent ambulatory discharge from the hospital.2. Discussion2.1. Pulmonary embolism in major blunt trauma and prophylacticinferior vena cava filtersSeverely injured patients are at high risk for both deep venousthrombosis (DVT) and subsequent PE with current estimates ofDVT incidence in trauma patients approximating 13% withprophylaxis and 38% without.

Postpneumonectomy syndrome is a recognized complication following pneumonectomy, resulting from mediastinal displacement into the vacated pleural space. Mediastinal displacement causes bronchial compression and dyspnea. This report describes a 47-year-old woman who presented with shortness of breath 6 months after a left pneumonectomy. She was initially hypoxic and was found to have a patent foramen ovale. Following closure of the patent foramen ovale, she was no longer hypoxic, but she continued to have dyspnea with exertion and left lateral decubitus positioning. There was no evidence of bronchial compression, but MRI and transesophageal echocardiography suggested pulmonary vein compression due to mediastinal displacement. Transthoracic echocardiography confirmed functional pulmonary vein compression that was worse in the standing and in the left lateral positions. Her symptoms improved with mediastinal repositioning using a transesophageal echocardiography-guided approach. Positional pulmonary vein compression may be an underdiagnosed complication of pneumonectomy.

Background . The purpose of this study was to determine the initial results of laparoscopic esophageal myotomy and anterior fundoplication in the treatment of 26 patients with achalasia. Methods . Operative time, complications, and length of hospitalization were recorded for each patient. Postoperative outcomes were assessed by a standardized patient questionnaire, 24-hour esophageal pH studies, and esophageal transit studies. Results . Twenty-six consecutive patients with class IV dysphagia underwent a laparoscopic esophageal myotomy and anterior partial fundoplication, with a single incidence of intraoperative esophageal perforation. The mean operative time was 3.5 hours. The median length of hospitalization was 5 days. Of the 21 patients for whom follow-up was available (median follow-up, 4 months), 19 (90%) were satisfied and 2 (10%) were somewhat satisfied with their surgery. After operation, 14 of the 21 patients (67%) reported no dysphagia (class I), whereas 6 (28%) had class II dysphagia (less than once per week) and only 1 (5%) had class III dysphagia (greater than once per week). Liquid-phase esophageal transit studies (n = 14) revealed a significant improvement in esophageal clearance in the supine position from 18% before operation to 44% after operation ( p = 0.006). Distal esophageal acid exposure was normal in 6 of 7 patients. Conclusions . These early results suggest that laparoscopic esophageal myotomy and anterior partial fundoplication provides efficacious treatment of achalasia.

We hypothesized that nitric oxide (NO) inhalation in a model of meconium aspiration in newborn piglets would decrease pulmonary vascular resistance. Seven neonatal piglets were obtained at less than 48 hr of age and instrumented under fentanyl anesthesia. Inhaled NO (40 parts per million) was administered during normoxia and again after hypoxia was induced by reducing FiO2 to 0.13. During normoxia NO inhalation caused a fall in pulmonary artery pressure from a mean of 3.15 (SD 0.8) kPa to 2.84 (SD 0.7) kPa (P < 0.01). Hypoxia (mean arterial O2 saturation 35%) increased PA pressures to a mean of 5.4 (SD 1.6) kPa and NO administration during hypoxia decreased PA pressures to 3.6 (SD 1.2) kPa (P < 0.001). In order to determine the effects of NO in a model of meconium aspiration, 6 to 7 mL/kg of 20% human meconium in normal saline was instilled into the trachea. This procedure induced hypoxemia (mean SaO2 43.4%, SD 19), respiratory acidosis, (mean PaCO2 12.1 kPa, SD 0.5; mean pH 7.04, SD 0.03), and pulmonary arterial hypertension (mean pulmonary artery pressure 6.0 kPa, SD 1.3) despite ventilation with 90% oxygen. Inhaled NO was then administered in concentrations of 5, 10, 20, 30, 40, 60, and 80 parts per million in random order according to a Latin square design.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhaled nitric oxide has been reported to act as a specific pulmonary vasodilator. We used the newborn piglet to create acute hypoxic pulmonary hypertension and examined the effect of inhaled nitric oxide in this model. Six newborn piglets were instrumented in order to measure cardiac index, pulmonary arterial pressure, and systemic arterial pressure. Pulmonary hypertension was induced by reducing the fraction of inspired oxygen to 0.12 to 0.14. With hypoxia (arterial oxygen saturation between 35 and 45%), pulmonary arterial pressure increased by 48% (p < 0.01), pulmonary vascular resistance increased by 74% (p < 0.01), and both systemic arterial pressure and systemic vascular resistance decreased by 38 and 31%, respectively (p < 0.01). The animals were then giving varying concentrations of inhaled nitric oxide between 5 and 80 parts per million in random order. All concentrations of nitric oxide were associated with a rapid decrease in pulmonary arterial pressure and pulmonary vascular resistance (p < 0.001). Cardiac index increased (p < 0.001) and systemic vascular resistance significantly decreased (p = 0.01) with all doses of inhaled nitric oxide. The ratio of pulmonary to systemic vascular resistance decreased with all levels of inhaled nitric oxide (p < 0.001). For all of the above observations there was no significant difference noted between the varying doses of nitric oxide. The time course of the pulmonary arterial pressure response to nitric oxide was approximately twice as fast as that seen with the inhalation of 100% oxygen (10, 50, 90% responses of 4.1, 8.8, 88.6 versus 6.7, 51.9, 197 s, respectively; p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Proton acids are found to catalyse the decomposition of the oxo-alkoxide and imido-alkoxide complexes Mo(O)2(O-t-Bu)2 and Mo(N-2,6-i-Pr2C6H3)2(O-t-Bu)2, respectively; the molecular structure of the tetranuclear molybdenum decomposition product [Mo4(N-2,6-i-Pr2C6H3)6(O-t-Bu)2(μ-O)4(μ3-OH)2] is described.

Ligand exchange reactions between various transition-metal complexes of the form [Mo(Q)2X2], [M(Q)CpX2] and [Mo(Q)2CpX], where Q and X are di-anionic and mono-anionic ligands, respectively, and M is Nb or Ta, have been studied. The formal electron count at the metal, and also the steric and electronic properties of the supporting ligands, are found to influence exchange rates, while ligand steric and electronic properties affect equilibrium constants.

A Bronsted acid is shown to catalyse the inter-metal exchange of mono-anionic (alkoxide and amide) and dianionic (imido) ligands in four-coordinate molybdenum complexes of the type Mo(NR)2(X)2 (R = alkyl, aryl; X = alkoxide, amide).

It is rare for pneumatosis cystoides intestinalis to give rise to abdominal pain. We report a patient with signs and symptoms of a perforated viscous in whom abdominal exploration was negative, but in whom biopsy of various intraabdominal cystic structures revealed only pneumatosis cystoides intestinalis.