To study the feasibility and impact of a nationwide training program in minimally invasive distal pancreatectomy (MIDP).
Superior outcomes of MIDP compared with open distal pancreatectomy have been ...reported. In the Netherlands (2005 to 2013) only 10% of distal pancreatectomies were in a minimally invasive fashion and 85% of surgeons welcomed MIDP training. The feasibility and impact of a nationwide training program is unknown.
From 2014 to 2015, 32 pancreatic surgeons from 17 centers participated in a nationwide training program in MIDP, including detailed technique description, video training, and proctoring on-site. Outcomes of MIDP before training (2005-2013) were compared with outcomes after training (2014-2015).
In total, 201 patients were included; 71 underwent MIDP in 9 years before training versus 130 in 22 months after training (7-fold increase, P < 0.001). The conversion rate (38% n = 27 vs 8% n = 11, P < 0.001) and blood loss were lower after training and more pancreatic adenocarcinomas were resected (7 10% vs 28 22%, P = 0.03), with comparable R0-resection rates (4/7 57% vs 19/28 68%, P = 0.67). Clavien-Dindo score ≥III complications (15 21% vs 19 15%, P = 0.24) and pancreatic fistulas (20 28% vs 41 32%, P = 0.62) were not significantly different. Length of hospital stay was shorter after training (9 7-12 vs 7 5-8 days, P < 0.001). Thirty-day mortality was 3% vs 0% (P = 0.12).
A nationwide MIDP training program was feasible and followed by a steep increase in the use of MIDP, also in patients with pancreatic cancer, and decreased conversion rates. Future studies should determine whether such a training program is applicable in other settings.
Auditing is an important tool to identify practice variation and ‘best practices’. The Dutch Pancreatic Cancer Audit is mandatory in all 18 Dutch centers for pancreatic surgery.
Performance ...indicators and case-mix factors were identified by a PubMed search for randomized controlled trials (RCT's) and large series in pancreatic surgery. In addition, data dictionaries of two national audits, three institutional databases, and the Dutch national cancer registry were evaluated. Morbidity, mortality, and length of stay were analyzed of all pancreatic resections registered during the first two audit years. Case ascertainment was cross-checked with the Dutch healthcare inspectorate and key-variables validated in all centers.
Sixteen RCT's and three large series were found. Sixteen indicators and 20 case-mix factors were included in the audit. During 2014–2015, 1785 pancreatic resections were registered including 1345 pancreatoduodenectomies. Overall in-hospital mortality was 3.6%. Following pancreatoduodenectomy, mortality was 4.1%, Clavien–Dindo grade ≥ III morbidity was 29.9%, median (IQR) length of stay 12 (9–18) days, and readmission rate 16.0%. In total 97.2% of >40,000 variables validated were consistent with the medical charts.
The Dutch Pancreatic Cancer Audit, with high quality data, reports good outcomes of pancreatic surgery on a national level.
Purpose
To assess the feasibility and clinical outcome of combined CT and fluoroscopy-guided percutaneous vertebroplasty in the management of painful Schmorl’s nodes (SN).
Methods
A prospective study ...was carried out from January 2014 to January 2016 in 52 consecutive patients. Thirty-two men and 30 women aged between 42 and 88 years old were consecutively included. Technical success was defined as the ability to deposit cement in the subchondral endplate anteriorly, around the SN and posteriorly to the SN, in a cupule-like shape. Data regarding procedure time, amount of cement injection, and cement leakage were also noted. Assessment of pain was performed with VAS score and Oswestry disability index. All patients underwent a clinical and radiological follow-up at 1 day, 1 month, 6 months, and 1 year after procedure.
Results
Technical success was 100%. Mean procedural time was 15 min, and mean injected cement volume was 2.8 mL. The VAS and Oswestry disability index decreased respectively from 7.2 ± 1.5 to 2.1 ± 1.0 and from 59.2 ± 16.2 to 17.1 ± 5.0 at 1 month. Follow-up mean VAS scores were 2.4 (± 1.4) at 6 months and 2.2 (± 1.2) at 12 months.
Conclusion
PVP appears as a feasible procedure in patients with painful SN with satisfying pain decrease in the following year after procedure.
In the mandatory nationwide Dutch Pancreatic Cancer Audit, rates of major complications and Failure to Rescue (FTR) after pancreatoduodenectomy between low- and high-mortality hospitals are compared, ...and independent predictors for FTR investigated.
Patients undergoing pancreatoduodenectomy in 2014 and 2015 in The Netherlands were included. Hospitals were divided into quartiles based on mortality rates. The rate of major complications (Clavien-Dindo ≥3) and death after a major complication (FTR) were compared between these quartiles. Independent predictors for FTR were identified by multivariable logistic regression analysis.
Out of 1.342 patients, 391 (29%) developed a major complication and in-hospital mortality was 4.2%. FTR occurred in 56 (14.3%) patients. Mortality was 0.9% in the first hospital quartile (4 hospitals, 327 patients) and 8.1% in the fourth quartile (5 hospitals, 310 patients). The rate of major complications increased by 40% (25.7% vs 35.2%) between the first and fourth hospital quartile, whereas the FTR rate increased by 560% (3.6% vs 22.9%). Independent predictors of FTR were male sex (OR = 2.1, 95%CI 1.2–3.9), age >75 years (OR = 4.3, 1.8–10.2), BMI ≥30 (OR = 2.9, 1.3–6.6), histopathological diagnosis of periampullary cancer (OR = 2.0, 1.1–3.7), and hospital volume <30 (OR = 3.9, 1.6–9.6).
Variations in mortality between hospitals after pancreatoduodenectomy were explained mainly by differences in FTR, rather than the incidence of major complications.
Geophysical studies and real-time monitoring of natural hazards, such as volcanic eruptions or severe weather events, benefit from the joint analysis of multiple geophysical parameters. However, ...typical geophysical measurement platforms still provide logging solutions for a single parameter, due to different community standards and the higher cost per added sensor.
OBJECTIVE:To study the feasibility and impact of a nationwide training program in minimally invasive distal pancreatectomy (MIDP).
SUMMARY OF BACKGROUND DATA:Superior outcomes of MIDP compared with ...open distal pancreatectomy have been reported. In the Netherlands (2005 to 2013) only 10% of distal pancreatectomies were in a minimally invasive fashion and 85% of surgeons welcomed MIDP training. The feasibility and impact of a nationwide training program is unknown.
METHODS:From 2014 to 2015, 32 pancreatic surgeons from 17 centers participated in a nationwide training program in MIDP, including detailed technique description, video training, and proctoring on-site. Outcomes of MIDP before training (2005–2013) were compared with outcomes after training (2014–2015).
RESULTS:In total, 201 patients were included; 71 underwent MIDP in 9 years before training versus 130 in 22 months after training (7-fold increase, P < 0.001). The conversion rate (38% n = 27 vs 8% n = 11, P < 0.001) and blood loss were lower after training and more pancreatic adenocarcinomas were resected (7 10% vs 28 22%, P = 0.03), with comparable R0-resection rates (4/7 57% vs 19/28 68%, P = 0.67). Clavien-Dindo score ≥III complications (15 21% vs 19 15%, P = 0.24) and pancreatic fistulas (20 28% vs 41 32%, P = 0.62) were not significantly different. Length of hospital stay was shorter after training (9 7–12 vs 7 5–8 days, P < 0.001). Thirty-day mortality was 3% vs 0% (P = 0.12).
CONCLUSION:A nationwide MIDP training program was feasible and followed by a steep increase in the use of MIDP, also in patients with pancreatic cancer, and decreased conversion rates. Future studies should determine whether such a training program is applicable in other settings.
Pseudomonas aeruginosa
is a highly adaptable Gram-negative opportunistic pathogen, notably due to its large number of transcription regulators. The extracytoplasmic sigma factor (ECFσ) AlgU, ...responsible for alginate biosynthesis, is also involved in responses to cell wall stress and heat shock via the RpoH alternative σ factor. The SigX ECFσ emerged as a major regulator involved in the envelope stress response via membrane remodeling, virulence and biofilm formation. However, their functional interactions to coordinate the envelope homeostasis in response to environmental variations remain to be determined. The regulation of the putative
cmaX-cfrX-cmpX
operon located directly upstream
sigX
was investigated by applying sudden temperature shifts from 37°C. We identified a SigX- and an AlgU- dependent promoter region upstream of
cfrX
and
cmaX
, respectively. We show that
cmaX
expression is increased upon heat shock through an AlgU-dependent but RpoH independent mechanism. In addition, the ECFσ SigX is activated in response to valinomycin, an agent altering the membrane structure, and up-regulates
cfrX-cmpX
transcription in response to cold shock. Altogether, these data provide new insights into the regulation exerted by SigX and networks that are involved in maintaining envelope homeostasis.
Pseudomonas aeruginosa
is a Gram-negative bacterium which can cause serious infections among immune-depressed people including cystic fibrosis patients where it can colonize the lungs causing chronic ...infections. Iron is essential for
P. aeruginosa
and can be provided via three sources under aerobic conditions: its own siderophores pyochelin (PCH) and pyoverdine (PVD), xenosiderophores, or heme, respectively. Pyoverdine is the high affinity siderophore and its synthesis and uptake involve more than 30 genes organized in different operons. Its synthesis and uptake are triggered by iron scarcity via the Fur regulator and involves two extra cytoplasmic sigma factors (ECF), PvdS for the biosynthesis of PVD and FpvI for the uptake via the TonB-dependent FpvA outer membrane transporter and other periplasmic and inner membrane proteins. It appeared recently that the regulation of PVD biosynthesis and uptake involves other regulators, including other ECF factors, and LysR regulators. This is the case especially for the genes coding for periplasmic and inner membrane proteins involved in the reduction of Fe
3+
to Fe
2+
and the transport of ferrous iron to the cytoplasm that appears to represent a crucial step in the uptake process.
This review addresses the role of nitrogen (N) in vine balance and grape composition. It offers an integrative approach to managing grapevine N nutrition. Keeping in mind that N excess is just as ...detrimental to wine quality as N depletion, the control of grapevine N status, and ultimately must N composition, is critical for high-quality grape production. N fertilisation has been intensively used in the past century, despite plants absorbing only 30 to 40 % of applied N. By adapting plant material, soil management and vine balance to environmental conditions, it would be possible for grape growers to improve plant N use efficiency and minimise N input in the vineyard. Vineyard N management is a complex exercise involving a search for a balance between controlling vigour, optimising grape composition, regulating production costs and limiting pollution. The first part of this review describes grapevine N metabolism from root N uptake to vine development and grape ripening, including the formation of grape aroma compounds. The advantages and limits of methods available for measuring plant N status are addressed. The second part focuses on the parameters that influence grapevine N metabolism, distinguishing the impacts of environmental factors from those of vineyard management practices. Areas for further research are also identified.
is an opportunistic pathogen, which causes chronic infections, especially in cystic fibrosis (CF) patients where it colonizes the lungs via the build-up of biofilms. Tobramycin, an aminoglycoside, is ...often used to treat
infections in CF patients. Tobramycin at sub-minimal inhibitory concentrations enhances both biofilm biomass and thickness
; however, the mechanism(s) involved are still unknown. Herein, we show that tobramycin increases the expression and activity of SigX, an extracytoplasmic sigma factor known to be involved in the biosynthesis of membrane lipids and membrane fluidity homeostasis. The biofilm enhancement by tobramycin is not observed in a
mutant, and the
mutant displays increased membrane stiffness. Remarkably, the addition of polysorbate 80 increases membrane fluidity of
-mutant cells in biofilm, restoring the tobramycin-enhanced biofilm formation. Our results suggest the involvement of membrane fluidity homeostasis in biofilm development upon tobramycin exposure.IMPORTANCEPrevious studies have shown that sub-lethal concentrations of tobramycin led to an increase biofilm formation in the case of infections with the opportunistic pathogen
. We show that the mechanism involved in this phenotype relies on the cell envelope stress response, triggered by the extracytoplasmic sigma factor SigX. This phenotype was abolished in a
-mutant strain. Remarkably, we show that increasing the membrane fluidity of the mutant strain is sufficient to restore the effect of tobramycin. Altogether, our data suggest the involvement of membrane fluidity homeostasis in biofilm development upon tobramycin exposure.
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