Background Colorectal cancer often presents with obstruction needing urgent, potentially life-saving decompression. The comparative efficacy and safety of endoluminal stenting versus emergency surgery as initial treatment for such patients is uncertain. Methods Patients with left-sided colonic obstruction and radiological features of carcinoma were randomized to endoluminal stenting using a combined endoscopic/fluoroscopic technique followed by elective surgery 1–4 weeks later, or surgical decompression with or without tumour resection. Treatment allocation was via a central randomization service using a minimization procedure stratified by curative intent, primary tumour site, and severity score (Acute Physiology And Chronic Health Evaluation). Co-primary outcome measures were duration of hospital stay and 30-day mortality. Secondary outcomes were stoma formation, stenting completion and complication rates, perioperative morbidity, 6-month survival, 3-year recurrence, resource use, adherence to chemotherapy, and quality of life. Analyses were undertaken by intention to treat. Results Between 23 April 2009 and 22 December 2014, 245 patients from 39 hospitals were randomized. Stenting was attempted in 119 of 123 allocated patients (96.7 per cent), achieving relief of obstruction in 98 of 119 (82.4 per cent). For the 89 per cent treated with curative intent, there were no significant differences in 30-day postoperative mortality (3.6 per cent (4 of 110) versus 5.6 per cent (6 of 107); P = 0.48), or duration of hospital stay (median 19 (i.q.r. 11–34) versus 18 (10–28) days; P = 0.94) between stenting followed by delayed elective surgery and emergency surgery. Among patients undergoing potentially curative treatment, stoma formation occurred less frequently in those allocated to stenting than those allocated to immediate surgery (47 of 99 (47.5 per cent) versus 72 of 106 (67.9 per cent); P = 0.003). There were no significant differences in perioperative morbidity, critical care use, quality of life, 3-year recurrence or mortality between treatment groups. Conclusion Stenting as a bridge to surgery reduces stoma formation without detrimental effects. Registration number: ISRCTN13846816 (http://www.controlled-trials.com).

In a party of 17 subjects who travelled together to 4,500 m, hypoxic ventilatory response (HVR) and maximum oxygen consumption (VO2max) were measured before departure. HVR was measured under constant and varying alveolar carbon dioxide tension (PACO2) conditions. VO2max was measured by both standard expired gas collection technique on a treadmill and using the "shuttle run" technique. On arrival at altitude, symptoms of acute mountain sickness (AMS) were scored daily for three days. There were no cases of severe AMS but half of the party had mild to moderate degrees of AMS. There was no correlation between AMS scores and HVR by either method of measurement or with VO2max measured by either method of measurement or with VO2max measured by treadmill or shuttle run.

Although severe vitamin B12 deficiency is rare in the United States, recent increases in the adoption of vegan lifestyles have led to a significant rise in the rates of B12 deficiency, along with its hematologic and neurologic sequelae, the latter of which is often irreversible.We describe a case of a 39-year-old male who presented with a several-month history of progressively worsening word-finding difficulties, shortness of breath, and a four-day history of bilateral hand numbness and tingling. Laboratory data revealed pancytopenia with profound anemia. Markers of hemolysis were positive, including elevated indirect bilirubin, disproportionately elevated lactate dehydrogenase (LDH), low haptoglobin, negative direct anticoagulant test, and hypoproliferative reticulocyte index. Blood smear revealed hypersegmented neutrophils and macrocytosis. Vitamin B12 levels were undetectable, and antiintrinsic factor and parietal cell antibodies were negative. A thorough history revealed a 20-year history of strict veganism without B12 supplementation. He was transfused with packed red blood cells and started on subcutaneous B12 injections with rapid improvement of his symptoms.Early recognition of B12 deficiency causing the constellation of pancytopenia, hemolytic anemia, and neurologic symptoms is vital in preventing irreversible neurologic sequelae. This case also highlights the importance of accurate history taking to aid in early diagnosis of B12 deficiency, especially in the context of rising rates of veganism in the United States.

Introduction: The increasing prevalence of pacemaker lead noise indicating insulation breach has previously been described. Unfortunately, early detection is neither predictable nor accurate by traditional measurements. “Pseudo-unipolarization” of bipolar pacing stimuli as observed from routine 12-lead EKG due to current leak holds promise as a means of detecting insulation breaches. We sought to characterize this EKG finding to better detect lead malfunction. Methods: 138 patients who received transvenous lead implantations with pacing noted on EKG at time of implant (control group, n=50) or after time of known malfunction (malfunction group, n=88) were included. The highest amplitude (any of 12-leads on standard EKG, 10mm/mV, GE Marquette) of the bipolar pacing stimulus on EKG was recorded. Chi-squared analysis was used to compare categorical variables and independent t-test was applied for continuous values. An ROC curve for maximum EKG bipolar pacing stimulus amplitude was generated for prediction of lead functional status (normal versus malfunction). Results: The cohort (49% females, 34% non-white) had an average age of 67 ± 16 years at implant. Malfunction was chiefly identified by lead noise on routine interrogation, consisting of 61% RA and 39% RV leads with mean pacing output 2.74V at 0.5ms. Mean time to malfunction was 6 ± 4 years post implant. There was significant difference in EKG bipolar stimulus amplitudes at time of failure (15.06 ± 13.533mm, p<0.01) compared to those of normal leads (mean=2.54 ± 1.265mm), but no significant difference in pacing output. ROC curve for the prediction of lead malfunction based on EKG amplitude displayed area under curve=0.93 (95% CI [0.891, 0.969]). Selecting an EKG stimulus amplitude cut-off at 3.5mm for the prediction of lead malfunction demonstrated a sensitivity of 86.4% and a specificity of 76%. Conclusion: The amplitude of a bipolar pacing stimulus on EKG is significantly different among normal functioning leads and those with known malfunction due to insulation breach. We found reasonably good performance of this derived measure at distinguishing among the two groups using a cutoff of 3.5mm for EKG stimulus amplitude. A larger prospective dataset is needed to validate a reliable threshold point.

Introduction: Over a two-year period, two high-volume electrophysiology centers simultaneously performed left atrial ablation with differing post-procedure discharge strategies. We sought to investigate complication rates between patients undergoing same-day (SD) or next-day (ND) discharges. Methods: We identified all patients who underwent transseptal ablation from August 2017 to August 2019 (n = 409) at two high-volume centers practicing either SD (n = 210) or ND (n = 199) discharge protocols. Atrial fibrillation, left atrial flutter and left atrial tachycardia ablations were included in the study while left atrial accessory pathway ablations were not. Complications were defined as any clinical event that resulted in procedural abortion, extended stay for either center, or readmission within 72 hours. The primary endpoint included a composite of major and minor complications ranging in clinical significance from cerebrovascular accident and cardiac tamponade to significant laboratory derangements. Results: Among this cohort, average age was 63.9 +/-11 years and 32.3% of patients were female. 93.9% of procedures were for atrial fibrillation, the remainder were for left atrial flutter or left atrial tachycardia. The composite endpoint of overall complication rate was similar between SD and ND discharge (14.3% vs 12.6%, p = 0.665). Rates of complications categorized as major (2.4% vs 3.0%, p = 0. 776) and minor (11.9% vs 9.5%, p = 0.524) were also similar. Multivariable regression modeling revealed no significant correlation between discharge strategy and complication occurrence (OR 1.565 [0.754 - 3.248], p = 0.23), but a positive association of hypertension and procedure duration with complications (OR 3.428 [1.436 - 8.184], p = 0.006) and (OR 1.01 [1 - 1.019], p = 0.046) respectively. Conclusions: Left atrial ablation complication rates were similar between SD and ND discharge practices while hypertension and procedural duration were positively correlated with complications. These data, which represent the first side-by-side comparison of discharge strategy, suggest same-day discharge is safe and feasible for left atrial ablation procedures.