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Background: Neoadjuvant cancer treatment is associated with improved survival following major oesophagogastric cancer surgery. The impact of neoadjuvant chemo/chemoradiotherapy on physical fitness and operative outcomes is however unclear. This study aims to investigate the impact of neoadjuvant chemo/chemoradiotherapy on fitness and post-operative mortality. Methods: Patients with oesophagogastric cancer scheduled for chemo/chemoradiotherapy and surgery were recruited to a prospective, blinded, multi-centre, observational cohort study. Primary outcomes were changes in fitness with chemo/chemoradiotherapy, measured using cardiopulmonary exercise testing and its association with mortality one-year after surgery. Patients were followed up for re-admission at 30-days, in-hospital morbidity and quality of life (exploratory outcomes). Results: In total, 384 patients were screened, 217 met the inclusion criteria, 160 consented and 159 were included (72% male, mean age 65 years). A total of 132 patients (83%) underwent chemo/chemoradiotherapy, 109 (71%) underwent chemo/chemoradiotherapy and two exercise tests, 100 (63%) completed surgery and follow-up. A significant decline in oxygen uptake at anaerobic threshold and oxygen uptake peak was observed following chemo/chemoradiotherapy: -1.25ml.kg-1.min-1 (-1.80 to -0.69) and -3.02ml.kg-1.min-1 (-3.85 to -2.20); p

People affected by breast cancer experience a multitude of toxicities and unmet needs across physical, cognitive, psychosocial, and economic domains that adversely impact their quality of life. High-quality and diverse supportive care is required to improve outcomes and rehabilitation for people affected by breast cancer. However, the availability and access to high-quality supportive care services is limited due to factors including cost and demand. As such, many people affected by breast cancer do not receive optimal supportive care. The Think Pink Foundation facilitates free-of-charge supportive care services to breast cancer survivors, their families, and caregivers through 'The Living Centre'. Think Pink seeks to provide a high-quality survivorship care model that overcomes barriers associated with the economic burden of cancer. Within its suite of services, The Living Centre offers ongoing exercise classes, creative therapy, support groups, specialist breast cancer nurse consultations, wellness services, and education support through face-to-face and online service provision. This paper outlines the development, model of care, service provision, and planning for future outcomes and economic evaluation of The Living Centre as a supportive care model for others to consider establishing in their local context. This paper may therefore directly inform the development of cancer survivorship care services globally to increase equitable access to optimal supportive care., Competing Interests: Declarations. Ethics approval: Not applicable. Consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: NHH holds a position on the editorial board of Supportive Care in Cancer. DH is a MASCC Cognition Fellow; NHH is Chair of MASCC Fatigue and MASCC Exercise Oncology; NHH is a MASCC Terry Langbaum Survivorship Fellow. DH and NHH are Principal Scientific Advisors of the Think Pink Foundation. JK and NS are employees of the Think Pink Foundation. IH is the Director of the Think Pink Foundation and D Hendel is the Director of Operations., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Outcomes after oesophagogastric cancer surgery remain poor. Cardiopulmonary exercise testing (CPET) used for risk stratification before oesophagogastric cancer surgery is based on conflicting evidence. This study explores the relationship between CPET and postoperative outcomes, specifically for patients undergoing neoadjuvant treatment., Methods: Patients undergoing oesophagogastric cancer resection and CPET (pre- or post-neoadjuvant treatment, or both) were retrospectively enrolled into a multicentre pooled cohort study. Oxygen uptake at peak exercise (VO 2 peak) was compared with 1-yr postoperative survival. Secondary analyses explored relationships between patient characteristics, tumour pathology characteristics, CPET variables (absolute, relative to weight, ideal body weight, and body surface area), and postoperative outcomes (morbidity, 1-yr and 3-yr survival) were assessed using logistic regression analyses., Results: Seven UK centres recruited 611 patients completing a 3-yr postoperative follow-up period. Oesophagectomy was undertaken in 475 patients (78%). Major complications occurred in 25%, with 18% 1-yr and 43% 3-yr mortality. No association between VO 2 peak or other selected CPET variables and 1-yr survival was observed in the overall cohort. In the overall cohort, the anaerobic threshold relative to ideal body weight was associated with 3-yr survival ( P =0.013). Tumour characteristics (ypT/ypN/tumour regression/lymphovascular invasion/resection margin; P <0.001) and Clavien-Dindo ≥3a ( P <0.001) were associated with 1-yr and 3-yr survival. On subgroup analyses, pre-neoadjuvant treatment CPET; anaerobic threshold (absolute; P =0.024, relative to ideal body weight; P =0.001, body surface area; P =0.009) and V E /VCO 2 at anaerobic threshold ( P =0.026) were associated with 3-yr survival. No other CPET variables (pre- or post-neoadjuvant treatment) were associated with survival., Conclusions: VO 2 peak was not associated with 1-yr survival after oesophagogastric cancer resection. Tumour characteristics and major complications were associated with survival; however, only some selected pre-neoadjuvant treatment CPET variables were associated with 3-yr survival. CPET in this cohort of patients demonstrates limited outcome predictive precision., Clinical Trial Registration: NCT03637647., (© 2024 The Authors.)

Background: Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure that has been demonstrated in the MERIT randomised, controlled trial to result in substantial and durable additional weight loss in adults with obesity compared with lifestyle modification (LM) alone. We sought to conduct the first cost-effectiveness analysis of ESG versus LM alone in adults with class II obesity (BMI 35.0-39.9 kg/m 2 ) from a national healthcare system perspective in England based on results from this study., Methods: A 6-state Markov model was developed comprising 5 BMI-based health states and an absorbing death state. Baseline characteristics, utilities, and transition probabilities were informed by patient-level data from the subset of patients with class II obesity in MERIT. Adverse events (AEs) were based on the MERIT safety population. Mortality was estimated by applying BMI-specific hazard ratios from the published literature to UK general population mortality rates. Utilities for the healthy weight and overweight health states were informed from the literature; disutility associated with increasing BMI in the class I-III obesity health states was estimated using MERIT utility data. Disutility due to AEs and the prevalence of obesity-related comorbidities were based on the literature. Costs included intervention costs, AE costs, and comorbidity costs., Results: ESG resulted in higher overall costs than LM alone but led to an increase in quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) for ESG vs LM alone was £2453/QALY gained. ESG was consistently cost effective across a wide range of sensitivity analyses, with no ICER estimate exceeding £10,000/QALY gained. In probabilistic sensitivity analysis, the mean ICER was £2502/QALY gained and ESG remained cost effective in 98.25% of iterations at a willingness-to-pay threshold of £20,000/QALY., Conclusion: Our study indicates that ESG is highly cost effective versus LM alone for the treatment of adults with class II obesity in England., (© 2023. Crown.)

Early growth response 1 (EGR1) is an immediate early gene and transcription factor previously found to be significantly upregulated in human astrocytoma cells infected with Venezuelan equine encephalitis virus (VEEV). The loss of EGR1 resulted in decreased cell death but had no significant impact on viral replication. Here, we extend these studies to determine the impacts of EGR1 on gene expression following viral infection. Inflammatory genes CXCL3, CXCL8, CXCL10, TNF, and PTGS2 were upregulated in VEEV-infected cells, which was partially dependent on EGR1. Additionally, transcription factors, including EGR1 itself, as well as ATF3, FOS, JUN, KLF4, EGR2, and EGR4 were found to be partially transcriptionally dependent on EGR1. We also examined the role of EGR1 and the changes in gene expression in response to infection with other alphaviruses, including eastern equine encephalitis virus (EEEV), Sindbis virus (SINV), and chikungunya virus (CHIKV), as well as Zika virus (ZIKV) and Rift Valley fever virus (RVFV), members of the Flaviviridae and Phenuiviridae families, respectively. EGR1 was significantly upregulated to varying degrees in EEEV-, CHIKV-, RVFV-, SINV-, and ZIKV-infected astrocytoma cells. Genes that were identified as being partially transcriptionally dependent on EGR1 in infected cells included ATF3 (EEEV, CHIKV, ZIKV), JUN (EEEV), KLF4 (SINV, ZIKV, RVFV), CXCL3 (EEEV, CHIKV, ZIKV), CXCL8 (EEEV, CHIKV, ZIKV, RVFV), CXCL10 (EEEV, RVFV), TNF-α (EEEV, ZIKV, RVFV), and PTGS2 (EEEV, CHIKV, ZIKV). Additionally, inhibition of the inflammatory gene PTGS2 with Celecoxib, a small molecule inhibitor, rescued astrocytoma cells from VEEV-induced cell death but had no impact on viral titers. Collectively, these results suggest that EGR1 induction following viral infection stimulates multiple inflammatory mediators. Managing inflammation and cell death in response to viral infection is of utmost importance, especially during VEEV infection where survivors are at-risk for neurological sequalae.

Background: Polycyclic aromatic hydrocarbons (PAHs) emitted from combustion sources are known to be mutagenic, with more potent species also being carcinogenic. Previous studies show that PAHs can undergo complex transformations both in the body and in the atmosphere, yet these transformation processes are generally investigated separately., Objectives: Drawing from the literature in atmospheric chemistry and toxicology, we highlight the parallel transformations of PAHs that occur in the atmosphere and the body and discuss implications for public health. We also examine key uncertainties related to the toxicity of atmospheric oxidation products of PAHs and explore critical areas for future research., Discussion: We focus on a key mode of toxicity for PAHs, in which metabolic processes (driven by cytochrome P450 enzymes), leads to the formation of oxidized PAHs that can damage DNA. Such species can also be formed abiotically in the atmosphere from natural oxidation processes, potentially augmenting PAH toxicity by skipping the necessary metabolic steps that activate their mutagenicity. Despite the large body of literature related to these two general pathways, the extent to which atmospheric oxidation affects a PAH's overall toxicity remains highly uncertain. Combining knowledge and promoting collaboration across both fields can help identify key oxidation pathways and the resulting products that impact public health., Conclusions: Cross-disciplinary research, in which toxicology studies evaluate atmospheric oxidation products and their mixtures, and atmospheric measurements examine the formation of compounds that are known to be most toxic. Close collaboration between research communities can help narrow down which PAHs, and which PAH degradation products, should be targeted when assessing public health risks. https://doi.org/10.1289/EHP9984.

Purpose: Cyberattacks targeting health care organizations are becoming more frequent and affect all aspects of care delivery. Cancer care is particularly susceptible to major disruptions because of the potential of immediate and long-term consequences for patients who often rely on timely diagnostic testing and regular administration of systemic therapy in addition to other local treatment modalities to cure or control their diseases. On October 28, 2020, a cyberattack was launched on the University of Vermont Health Network with wide-ranging consequences for oncology, including loss of access to all network intranet servers, e-mail communications, and the electronic medical record (EMR)., Methods: This review details the immediate challenges faced by hematology and oncology during the cyberattack. The impact and response on inpatient, outpatient, and special patient populations are described. Steps that other academic- and community-based oncology practices can take to lessen the brunt of such an assault are suggested., Results: The two areas of immediate impact after the cyberattack were communications and lack of EMR access. The oncology-specific impact included loss of the individualized EMR chemotherapy plan templates and electronic safeguards built into multistep treatment preparation and delivery. With loss of access to schedules, basic patient information, encrypted communications platforms and radiology, and laboratory and pharmacy services, clinical outpatient care delivery was reduced by 40%. The infusion visit volume dropped by 52% in the first week and new patients could not access necessary services for timely diagnostic evaluation, requiring the creation of command centers to oversee ethical and transparent triage and allocation of systemic therapies and address new patient referrals. This included appropriate transfer of patients to alternate sites to minimize delays. Inpatient care including transitions of care was particularly challenging and addressing patient populations whose survival might be affected by delays in care., Conclusion: Oncology health care leaders and providers should be aware of the potential impact of a cyberattack on cancer care delivery and preventively develop processes to mitigate the impact., Competing Interests: Steven AdesResearch Funding: Lilly, EMD Serono Alissa A. ThomasResearch Funding: Novocure, Spectrum Pharmaceuticals, Spectrum Pharmaceuticals Julian SpragueStock and Other Ownership Interests: Gilead Sciences, Johnson and Johnson, Merk and Company, Roche/Genentech, Pfizer Peter A. KaufmanStock and Other Ownership Interests: AmgenHonoraria: Lilly, Polyphor, Macrogenics, EisaiConsulting or Advisory Role: Polyphor, Roche/Genentech, Lilly, Eisai, Macrogenics, Pfizer, Merck, AstraZenecaSpeakers' Bureau: LillyResearch Funding: Eisai, Polyphor, Roche/Genentech, Lilly, Novartis, Macrogenics, Pfizer, SanofiTravel, Accommodations, Expenses: Lilly, Polyphor, MacrogenicsNo other potential conflicts of interest were reported.

Introduction: Boerhaave's syndrome is a life-threatening spontaneous perforation of the esophagus associated with significant morbidity and mortality. Historically, thoracotomy has been the mainstay of treatment, but is associated with high morbidity and pain. Minimally invasive approaches provide alternative treatment possibilities. This systematic review together with inclusion of a case series from a tertiary esophagogastric unit assesses current evidence focused on minimally invasive surgical management of this condition. Methods: A systematic review was conducted in line with MOOSE (Meta-analyses Of Observational Studies in Epidemiology) guidelines. Electronic databases PubMed, MEDLINE, and Cochrane Library were searched, and articles focusing on the minimally invasive management of Boerhaave's syndrome were identified and scrutinized. We also report demographics and outcomes for a consecutive case series of patients with acute Boerhaave's syndrome managed via thoracoscopy. Results: Fifteen studies were included comprising 5 retrospective cohort studies and 10 case reports. Management strategies were divided into three categories: thoracoscopic, endoscopic, and laparoscopic. Overall mortality rates for each treatment modality were 2%, 13%, and 33%, and treatment success rates 98%, 38%, and 67%, respectively. Postoperative infective complications were seen in 79% of patients, with only 2 patients requiring salvage thoracotomy. In our local case series, we report 4 consecutive patients managed with thoracoscopy, with a 100% treatment success rate. Conclusion: Minimally invasive approaches in the management of Boerhaave's syndrome are safe and effective. We propose a selective management algorithm involving a minimally invasive approach to management of this life-threatening condition. Registered with local clinical outcomes team as service evaluation. (Approval number sev/0171).

Background: Revisional bariatric surgery is unavoidable in a proportion of patients. Despite its need, the development of this speciality has been hampered by its complexity and preferred delivery in institutional set ups. Although primary bariatric surgery can be delivered in the private sector; safety and feasibility of revisional bariatric surgery remains unexplored in this setting., Materials and Methods: Patients undergoing revisional bariatric surgery following previous Laparoscopic Adjustable Gastric Band (LAGB) between 2008 and 2019 at a single private bariatric unit with a minimum follow up of at least 6 months were included. The primary aim was safety outcomes and 30-day morbidity., Results: 178 patients with BMI of 45.6 ± 8.2 kg/m 2 underwent revisional bariatric surgery. One stage conversion was performed for 86.5% of the cases. At 9.5 ± 5.3 months follow up, BMI and percentage excess BMI loss were 31.8 ± 6.2 kg/m 2 and 62.6 ± 40% respectively. There was no mortality, and the major complication rate was 2.8%. There was no statistically significant difference in the incidence of complications based on one-stage vs. two-stage conversion (p = 0.52). There were no differences in weight loss outcomes post-revisional surgery according to the indication for revision (p = 0.446) or weight loss following primary surgery (p = 0.12)., Conclusion: Revisional bariatric surgery can be delivered safely in the private sector with good outcomes. One-stage conversions are feasible and do not detrimentally affect the morbidity of the procedure or the weight loss outcomes. More importantly, success following revisional surgery is independent of the indication for revision and weight loss outcomes following primary surgery., (Copyright © 2021 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.)

Photocatalytic remediation technology has been shown to be a favorable approach for the removal of a range of environmental pollutants in water treatment. While this approach can often achieve complete degradation, often overlooked are reaction intermediates that are potentially as harmful as the original parent compound. In the case of photocatalytic oxidation of the herbicide 2-methyl-4-chlorophenoxyacetic acid (MCPA), we have recently shown that 4-chloro-2-methylphenol (CMP) is formed as the primary intermediate. To ensure the continued development of the technology, it is crucial to ensure the removal of both MCPA and CMP can be achieved by photocatalysis. Reported here is the enhanced photocatalytic removal and subsequent suppression of MCPA and CMP respectively, by the addition of small quantities of H 2 O 2 . While the addition of H 2 O 2 often accelerates degradation rates (via increased OH radical production), it was found to restrict the formation of CMP in this study through competitive adsorption at the surface of TiO 2 . Based on the combination of MCPA removal coupled with supressed CMP formation, 0.5% H 2 O 2 was determined to be an optimal loading for the process. Under these conditions 100% MCPA removal was achieved (to the limit of HPLC detection) after 45 min irradiation at a degradation rate of ∼1 mg L -1 min -1 (ƞ photon  = 4.4), which also resulted in a ∼83% reduction in CMP formation when compared to a system with no H 2 O 2 present., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Background: Endoscopic sleeve gastroplasty (ESG) is a novel endoscopic procedure used to treat obesity-related comorbidities. Whilst its use is increasing in clinical practice, there is comparatively little understanding about how it has been evaluated. This study aimed to systematically summarize and appraise the reporting of ESG in the context of guidelines for evaluating innovative surgical devices and procedures., Methods: Systematic searches were used to identify all published studies reporting ESG insertion. Data collected included patient selection, governance arrangements, proceduralist expertise, technique description and outcome reporting., Results: Searches identified 2289 abstracts; 37 full-text papers were included (one prospective comparative cohort study, 16 retrospective cohort studies, 17 prospective cohort studies and three case reports). No randomized trials were identified. Eighteen studies were conducted prospectively. The number of patients in the included studies ranged from 1 to 1000. The lower BMI limit ranged from 27 to 35 kg/m 2 . Research approvals were reported in 26 studies. Two studies reported on the learning curve. All studies reported some aspect of technical implementation, but many variations were noted. Suturing device used and suture pattern were the most commonly reported aspects (32 studies). Follow-up ranged from 1 to 24 months, but was 12 months or less in 28 studies. Forty-eight different outcomes were reported across all studies., Conclusion: The literature on ESG has demonstrated some progression in reporting and analysis and the next stage of assessment should be a randomized controlled trial to demonstrate efficacy.

Introduction: Surgery (oesophagectomy), with neoadjuvant chemo(radio)therapy, is the main curative treatment for patients with oesophageal cancer. Several surgical approaches can be used to remove an oesophageal tumour. The Ivor Lewis (two-phase procedure) is usually used in the UK. This can be performed as an open oesophagectomy (OO), a laparoscopically assisted oesophagectomy (LAO) or a totally minimally invasive oesophagectomy (TMIO). All three are performed in the National Health Service, with LAO and OO the most common. However, there is limited evidence about which surgical approach is best for patients in terms of survival and postoperative health-related quality of life., Methods and Analysis: We will undertake a UK multicentre randomised controlled trial to compare LAO with OO in adult patients with oesophageal cancer. The primary outcome is patient-reported physical function at 3 and 6 weeks postoperatively and 3 months after randomisation. Secondary outcomes include: postoperative complications, survival, disease recurrence, other measures of quality of life, spirometry, success of patient blinding and quality assurance measures. A cost-effectiveness analysis will be performed comparing LAO with OO. We will embed a randomised substudy to evaluate the safety and evolution of the TMIO procedure and a qualitative recruitment intervention to optimise patient recruitment. We will analyse the primary outcome using a multi-level regression model. Patients will be monitored for up to 3 years after their surgery., Ethics and Dissemination: This study received ethical approval from the South-West Franchay Research Ethics Committee. We will submit the results for publication in a peer-reviewed journal., Trial Registration Number: ISRCTN10386621., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background  Endoscopic sleeve gastroplasty (ESG) is rapidly becoming established as a safe and effective means of achieving substantial weight loss via the transoral route. New ESG suture patterns are emerging. Our aim was to investigate whether superior weight loss outcomes can be achieved by using a unique combination of longitudinal compression sutures and "U"-shaped sutures. Methods  This is a retrospective review of prospectively collected data of all patients undergoing ESG by a single operator in a single UK center. Results  Between January 2016 and December 2017, 32 patients (23 female) underwent ESG; n = 9 cases were completed utilizing a commonly used triangular suture pattern ("no longitudinal compression") and n = 23 cases were completed using our unique "longitudinal compression" suture pattern. In the no compression and compression groups, the mean ages were 45 ± 12 years and 43 ± 10 years, the median baseline weights were 113.6 kg (range 82.0 - 156.4) and 107 kg (range 74.0 - 136.0), and the median baseline body mass indexes (BMIs) were 35.9 kg/m 2 (range 30.9 - 43.8) and 36.5 kg/m 2 (range 29.8 - 42.9), respectively. After 6 months, body weight had decreased by 21.1 kg (range, 12.2 - 34.0) in the compression group (n = 7) versus 10.8 kg (range, 7.0 - 25.8) in the no compression group (n = 5) ( P  = 0.042). Correspondingly, BMI decreased by 7.8 kg/m 2 (range, 4.9 - 11.2) and 4.1 kg/m 2 (range, 2.6 - 7.2) in each group, respectively ( P  = 0.019). Total body weight loss (%TBWL) was greater in the compression group at 19.5 % (range, 12.9 - 30.4 %) compared to 13.2 % (range, 6.2 - 17.1 %) in the non-compression group ( P  = 0.042). No significant adverse events were reported in this series. Conclusion  The technique of ESG is evolving and outcomes from endoscopic bariatric therapies continue to improve. We provide preliminary evidence of superior weight loss achieved through a modified gastroplasty suture pattern.

Background and Aims: Obesity associated with diabetes mellitus is a significant worldwide problem associated with considerable health care costs. Whilst surgical intervention is effective, it is invasive, costly and associated with complications. This study aims to evaluate the safety and efficacy of the EndoBarrier®, a duodenal-jejunal sleeve bypass as an alternative treatment of diabetes mellitus in obese patients., Materials and Methods: This was a multi-centre, non-randomised trial recruiting obese patients with type 2 diabetes from three sites in the UK. Eligible participants had a BMI of 30-50 kg/m 2 and HbA1c levels of 7.5-10%. The study comprised a 12-month period with the EndoBarrier® inserted and a 6-month follow-up period after it had been explanted. The primary study outcomes were weight, BMI, HbA1c levels and fasting insulin and glucose levels., Results: Forty-five patients were recruited and 31 patients (69%) completed the 12-month study period. Significant reductions in weight (95%CI 0.62-29.38; p < 0.05) and BMI (95%CI 1.1-8.7; p < 0.005) were documented 12 months after device insertion. The mean HbA1c was significantly reduced (95%CI 0.1-1.6; p < 0.05) after the device insertion period and reductions in metabolic parameters (fasting insulin and glucose levels) were also documented during the study. Adverse events were also assessed in all patients, the vast majority of which were reported as mild., Conclusions: The EndoBarrier® appears to be a safe and effective treatment strategy in overweight patients with poor glycaemic control despite medical therapy, or in those who are eligible but decline bariatric surgery.

Background: Hiatal hernia (HH) after esophagectomy is becoming more relevant due to improvements in survival. This study evaluated and compared the occurrence and clinical course of HH after open and minimally invasive esophagectomy (MIE)., Methods: The prospectively recorded characteristics of patients treated with esophagectomy for cancer at 2 tertiary referral centers in the United Kingdom and the Netherlands between 2000 and 2014 were reviewed. Computed tomography reports were reviewed to identify HH., Results: Of 657 patients, MIE was performed in 432 patients (66%) and open esophagectomy in 225 (34%). A computed tomography scan was performed in 488 patients (74%). HH was diagnosed in 45 patients after a median of 20 months (range, 0 to 101 months). The development of HH after MIE was comparable to the open approach (8% vs 5%, p = 0.267). At the time of diagnosis, 14 patients presented as a surgical emergency. Of the remaining 31 patients, 17 were symptomatic and 14 were asymptomatic. An elective operation was performed in 10 symptomatic patients, and all others were treated conservatively. During conservative treatment, 2 patients presented as a surgical emergency. An emergency operation resulted in a prolonged intensive care unit stay compared with an elective procedure (3 vs 0 days, p < 0.001). In-hospital deaths were solely seen after emergency operations (19%)., Conclusions: HH is a significant long-term complication after esophagectomy, occurring in a substantial proportion of the patients. The occurrence of HH after MIE and open esophagectomy is comparable. Emergency operation is associated with dismal outcomes and should be avoided., (Copyright © 2017. Published by Elsevier Inc.)

This article discusses the potential for shared mental models to improve teamwork during discharge planning and follow-up care. A 58-year-old inpatient on the hematology care unit of an academic medical center was discharged to his community after initial treatment of acute myeloid leukemia, without a clear plan for either discharge or follow-up. This case highlights the challenges faced by the primary oncology care team, the patient's community health-care team, the patient, and his caregiver, because a formal plan for follow-up care after discharge was not in place. The lack of communication within the oncology care team and between the medical center and community care teams that leads to the gap in continuity of care between inpatient and outpatient oncology settings could be addressed at least in part by establishing a shared mental model. This model would require all individuals involved in patient care to recognize they are part of a team. Furthermore, all members of the interdisciplinary discharge team need to understand their own roles and responsibilities as well as those of the other team members, including the need for communication and how their roles and activities affect those of other team members. Tools such as huddles, checklists, and patient education could be used to help the team recognize and achieve its goals. Ideally, this shared mental model could be extended to include the community health-care team, leading to a more fluid transition between inpatient and outpatient care, improving patient satisfaction, and likely improving patient outcomes.

Background: The prevalence of severe and complex obesity is increasing worldwide and surgery may offer an effective and lasting treatment. Laparoscopic adjustable gastric band and Roux-en-Y gastric bypass surgery are the two main surgical procedures performed., Design: This open parallel-group randomised controlled trial will compare the effectiveness, cost-effectiveness and acceptability of gastric band (Band) versus gastric bypass (Bypass) in adults with severe and complex obesity. It has an internal pilot phase (in two centres) with integrated qualitative research to establish effective and optimal methods for recruitment. Adults with a body mass index (BMI) of 40 kg/m2 or more, or a BMI of 35 kg/m2 or more and other co-morbidities will be recruited. At the end of the internal pilot the study will expand into more centres if the pre-set progression criteria of numbers and rates of eligible patients screened and randomised are met and if the expected rates of retention and adherence to treatment allocation are achieved. The trial will test the joint hypotheses that Bypass is non-inferior to Band with respect to more than 50% excess weight loss and that Bypass is superior to Band with respect to health related quality of life (HRQOL, EQ-5D) at three years. Secondary outcomes include other weight loss measures, waist circumference and remission/resolution of co-morbidities; generic and symptom-specific HRQOL; nutritional blood test results; resource use; eating behaviours and adverse events. A core outcome set for reporting the results of obesity surgery will be developed and a systematic review of the evidence for sleeve gastrectomy undertaken to inform the main study design., Discussion: By-Band is the first pragmatic study to compare the two most commonly performed bariatric surgical procedures for severe and complex obesity. The design will enable and empower surgeons to learn to recruit and participate in a randomised study. Early evidence shows that timely recruitment is possible., Trial Registration: Current Controlled Trials ISRCTN00786323.

Introduction: The outcome after laparoscopic Nissen fundoplication can be assessed by either clinical symptoms or objective tests. Outcomes from objective tests are often held in higher regard than clinical data when determining the merits, or otherwise, of various antireflux surgery procedures. In this study, we sought to determine whether there is a relationship between postoperative symptoms and parameters measured by esophageal manometry to determine whether early postoperative esophageal manometry is a useful investigation for the routine assessment of post fundoplication outcome., Methods: One hundred and forty-three patients who had undergone a laparoscopic Nissen fundoplication, clinical follow-up at 3 months and 5 years after surgery, and esophageal manometry at 3 months after fundoplication as part of routine follow-up in 1 of 5 clinical trials were studied. Nineteen of these patients also underwent manometry 5 years after fundoplication. Postoperative symptoms were prospectively determined by applying a standardized questionnaire, which assessed dysphagia, heartburn, bloat symptoms, and overall satisfaction using analog scales. Patients were classified into different groups according to the analog scores for clinical symptoms. Correlations between clinical and postoperative manometry outcomes were sought., Results: No significant associations were found between parameters measured by esophageal manometry (lower esophageal sphincter resting and residual relaxation pressures, peristaltic amplitude and normal peristaltic propagation) and clinical parameters (dysphagia, heartburn, bloating, and overall satisfaction) for all time points -- 3 months postoperative manometry vs symptoms at 3 months and 5 years, 5 years postoperative manometry vs symptoms at 5 years, except for a weak (r = -0.17, p = 0.042) correlation between the percentage of successfully propagated swallows at 3 months and dysphagia for solids at 5 years., Conclusion: Postoperative esophageal manometry parameters at 3 months and 5 years after surgery were not associated with any clinically important differences in the postoperative symptoms of heartburn, dysphagia, bloat or with overall satisfaction with the surgical outcome. The routine use of esophageal manometry to assess the outcome after Nissen fundoplication does not predict clinical outcome.

Bar coding for the medication administration step of the drug-use process is discussed. FDA will propose a rule in 2003 that would require bar-code labels on all human drugs and biologicals. Even with an FDA mandate, manufacturer procrastination and possible shifts in product availability are likely to slow progress. Such delays should not preclude health systems from adopting bar-code-enabled point-of-care (BPOC) systems to achieve gains in patient safety. Bar-code technology is a replacement for traditional keyboard data entry. The elements of bar coding are content, which determines the meaning; data format, which refers to the embedded data and symbology, which describes the "font" in which the machine-readable code is written. For a BPOC system to deliver an acceptable level of patient protection, the hospital must first establish reliable processes for a patient identification band, caregiver badge, and medication bar coding. Medications can have either drug-specific or patient-specific bar codes. Both varieties result in the desired code that supports patient's five rights of drug administration. When medications are not available from the manufacturer in immediate-container bar-coded packaging, other means of applying the bar code must be devised, including the use of repackaging equipment, overwrapping, manual bar coding, and outsourcing. Virtually all medications should be bar coded, the bar code on the label should be easily readable, and appropriate policies, procedures, and checks should be in place. Bar coding has the potential to be not only cost-effective but to produce a return on investment. By bar coding patient identification tags, caregiver badges, and immediate-container medications, health systems can substantially increase patient safety during medication administration.