Learning curve for oesophageal cancer surgery

BACKGROUND: Surgical training and experience are frequently claimed to influence early and late outcome measures. The aim of this study was to examine any improvement in an individual surgeon's performance in one operation over a period of 7 years from initial appointment to date. METHODS: Patients undergoing Ivor Lewis subtotal oesophagectomy performed by a single surgeon between April 1990 and December 1996 were identified from a prospectively compiled oesophageal cancer database. Operating time (abdominal, thoracic and 'one-lung time'), blood loss, transfusion requirements (intraoperative and total), extent of lymphadenectomy (number of lymph nodes sampled), intensive treatment unit (ITU) stay, hospital stay, postoperative morbidity and mortality, pathological stage, grade and survival were recorded. RESULTS: The records of 150 patients were identified for analysis. The cohort was split into five groups, each of 30 patients operated on consecutively. Each of the groups was comparable for age, sex, smoking history, preoperative haemoglobin and creatinine levels, weight loss, American Society of Anesthesiologists' grade, and histological stage and grade of disease. Analysis of the variables pertaining to operation revealed a significant improvement with time including reduced single-lung operating time (P=0.01), reduced blood loss (P=0.03), reduced transfusion requirement (P < 0.0001), reduced ITU stay (P< 0.0001), reduced inpatient stay (P< 0.0001) and an increased yield of lymph nodes (P < 0.0001). CONCLUSION: This study showed a continuing improvement in a surgeon's performance over a 7-year period. With the current trend to shorter training periods there is a case for continuing supervision of the 'fully trained' surgeon within highly specialist units.     

Retail yield and fabrication times for veal as influenced by purchasing options and merchandising styles

Twenty-nine selected styles of subprimals or sections of veal were obtained from a commercial facility to assist in the development of a support program for retailers. They were fabricated into bone-in or boneless retail cuts and associated components by trained meat cutters. Each style selected (n = 6) was used to generate mean retail yields and labor requirements, which were calculated from wholesale and retail weights and processing times. Means and standard errors for veal ribs consisting of five different styles (n = 30) concluded that style #2, 7-rib 4 (10 cm) x 4 (10 cm), had the lowest percentage of total retail yield (P < .05) owing to the greatest percentage of bone. Furthermore, rib style #2 required the longest total processing time (P < .05). Rib styles #3, 7-rib chop-ready, and #5, 6-rib chop ready, yielded the greatest percentage of total retail yield and also had the shortest total processing time (P < .05). Within veal loins, style #2, 4 (10 cm) x 4 (10 cm) loin kidney fat in, had the greatest percentage fat (P < .05). Loin styles #2 and #3, 4 (10 cm) x 4 (10 cm) loin special trimmed, generated more lean and fat trimmings and bone, resulting in lower percentage of total retail yields than loin style #1, 0 (0 cm) x 1 (2.5 cm) loin special trimmed (P < .05). Results indicated that bone-in subprimals and sections required more processing time if fabricated into a boneless end point. In addition, as the number of different retail cuts increased, processing times also increased.     

Self-in-relation theory and the role of the clinical nurse specialist. Part II: Application to advanced nursing roles in a professional practice model

CONCEPTS AND ASSUMPTIONS of self-in-relation theory of women's development, as proposed by feminist scholars at the Stone Center in Wellesley, Massachusetts, are applied in this article. This theory was used as a framework to guide staff development and mentorship roles of advanced practice nurses. How the theory served to direct these roles and assisted in development of a professional practice model is discussed. Exemplars from the authors' practices and professional practice outcomes after 2 years of theory implementation are presented.     

Studies of the neutralizing activity and avidity of anti-human immunodeficiency virus type 1 Env antibody elicited by DNA priming and protein boosting

DNA vaccination is an effective means of eliciting strong antibody responses to a number of viral antigens. However, DNA immunization alone has not generated persistent, high-titer antibody and neutralizing antibody responses to human immunodeficiency virus type 1 (HIV-1) envelope glycoprotein (Env). We have previously reported that DNA-primed anti-Env antibody responses can be augmented by boosting with Env-expressing recombinant vaccinia viruses. We report here that recombinant Env protein provides a more effective boost of DNA-initiated antibody responses. In rabbits primed with Env-expressing plasmids, protein boosting increased titer, persistence, neutralizing activity, and avidity of anti-Env responses. While titers increased rapidly after boosting, avidity and neutralizing activity matured more slowly over a 6-month period following protein boosting. DNA priming and protein immunization with HIV-1 HXB-2 Env elicited neutralizing antibody for T cell line-adapted, but not primary isolate, viruses. The most effective neutralizing antibody responses were observed after priming with plasmids which expressed noninfectious virus-like particles. In contrast to immunizations with HIV-1 Env, DNA immunizations with the influenza virus hemagglutinin glycoprotein did not require a protein boost to achieve high-titer antibody with good avidity and persistence.     

Neutron scattering as a probe of particle-like excitations in superfluid4He: A model calculation

In the microscopic theory of Bose-condensed liquids, the condensate wave function leads to a coupling of the density fluctuations and the single-particle excitations. A simple parametrized model of this based on coupling weakly damped zero-sound modes with strongly damped free-particle-like excitations Q ²/2m* explains why the phonon-roton resonance inS(Q, ) for superfluid⁴He exists above and belowT but only plays the role of an elementary excitation belowT . It is pointed out that this model also predicts thatS(Q, ) should exhibit a weak, low-frequency peak centered atQ ²/2m*, with weight roughly proportional to the condensate fractionn ₀. As a stimulus to further experimental searches for this branch, some model calculations are given forS(Q, ) forQ1 Å^–1.     

Preparation and characterization of surfactant‐free stimuli‐sensitive microgel dispersions

A surfactant‐free method to produce responsive polymer microgels is introduced. As an example, poly(methacrylic acid) hydrogels with varying crosslinking density have been synthesized in bulk and then chopped using a high shear mechanical cutter to form microgel particles dispersed in water. The mechanical cutting technique enables the concentration and particle size distribution of the microgel suspensions to be easily controlled, therefore making the rheology of the suspensions tuneable. The particle size distribution of the dispersions, characterized using light scattering, was dependent on the speed and duration of mechanical cutting. The particle size distribution also depended on the degree of crosslinking of the hydrogel. The higher the crosslinking density, the lower the average mean diameter of the resulting microgel particles. The lower the crosslinking density of the hydrogel, the larger the difference between the maximum and minimum particle size. The time to complete swelling of the particles upon change in pH was measured to be up to 45 s, depending on the particle size. The rheology of the resulting suspensions as a function of pH was investigated. © 2007 Wiley Periodicals, Inc. J Appl Polym Sci 104: 104: 1912–1919, 2007     

Catalytic Materials for High-Temperature Combustion

Catalytic combustion, as an alternative to conventional thermal combustion, has received considerable attention during the past decade. Research efforts have been promoted by the need to meet governmental demands concerning pollution and the wish to use energy sources more efficiently. The two main advantages offered by catalytic combustors over flame combustors apply to these goals:

1. Catalytic combustion can be carried out over a wide range of fuel concentrations in air and at low temperatures.
2. These low temperatures result in attaining NO, emission levels substantially lower than possible with conventional combustors.

     

Hydrogenation of soybean oil with copper catalysts containing small amounts of nickel catalysts

Reaction rates, linolenate/linoleate reaction selectivity,trans formation, and conjugated diene formation were determined for mixed commerical catalysts containing 0.5, 1, 2, 10, and 20 parts nickel catalyst (25% nickel) per 1000 parts copper chromite catalyst (ppt) and at catalyst concentrations in the oil of 1.0, 0.5, and 0.25%. The rate of hydrogenation increased as the amount of nickel increased. Addition of 0.5, 1, and 2 ppt nickel catalyst to copper chomite catalyst resulted in a small decrease in selectivity compared with straight copper chromite. When soybean oil was hydrogenated with these mixed catalysts sufficiently to reduce linolenate to 0, iodine values were 102–108 compared to 109–112 for straight copper chromite and to less than 80 for straight nickel. Presented at the AOCS Meeting, New Orleans April 1973. ARS, USDA.