Comparative Outcomes of Resident vs Attending Performed Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE: To determine whether outcomes are different when surgery is performed by resident or attending surgeons, and which variables may affect outcomes. DESIGN: MEDLINE, EMBASE, and the Cochrane Library were searched from inception to May 2014 alongside the bibliographies of all included or relevant studies. Any study comparing outcomes from surgery performed by resident vs attending surgeons was eligible for inclusion. The main outcome measures were surgical complications (classified by Clavien-Dindo grade), death, operative time, and length of stay. Data were extracted independently by 2 authors and analyzed using the random-effects model. RESULTS: The final analysis included 182 eligible studies that enrolled 141 555 patients. Resident performed surgery took longer by 10.2 minutes (95% confidence interval (CI): 8.38-11.95), and had more Clavien-Dindo grade 1 (rate ratio = 1.14, 95% CI: 1.02-1.29) and grade 3a complications (rate ratio = 1.22, 95% CI: 1.04-1.44). Resident performed surgery resulted in fewer deaths (risk ratio = 0.83, 95% CI: 0.70-0.999) with a shorter length of stay of -0.49 days (95% CI: -0.77 to -0.21). Significant heterogeneity was present in 7 of 10 outcomes, which persisted during multiple subgroup analyses. CONCLUSIONS: Resident performed surgery appears to be safe in carefully selected patients. The significant amount of heterogeneity present in the study outcomes prevents generalizability of these results to specific clinical contexts

Registration of Untracked 2D Laparoscopic Ultrasound Liver Images to CT Using Content-Based Retrieval and Kinematic Priors

Laparoscopic Ultrasound (LUS) can enhance the safety of laparoscopic liver resection by providing information on the location of major blood vessels and tumours. Since many tumours are not visible in ultrasound, registration to a pre-operative CT has been proposed as a guidance method. In addition to being multi-modal, this registration problem is greatly affected by the differences in field of view between CT and LUS, and thus requires an accurate initialisation. We propose a novel method of registering smaller field of view slices to a larger volume globally using a Content-based retrieval framework. This problem is under-constrained for a single slice registration, resulting in non-unique solutions. Therefore, we introduce kinematic priors in a Bayesian framework in order to jointly register groups of ultrasound images. Our method then produces an estimate of the most likely sequence of CT images to represent the ultrasound acquisition and does not require tracking information nor an accurate initialisation. We demonstrate the feasibility of this approach in multiple LUS acquisitions taken from three sets of clinical data

Treatment for hepatorenal syndrome in people with decompensated liver cirrhosis: a network meta‐analysis

Background: Hepatorenal syndrome is defined as renal failure in people with cirrhosis in the absence of other causes. In addition to supportive treatment such as albumin to restore fluid balance, the other potential treatments include systemic vasoconstrictor drugs (such as vasopressin analogues or noradrenaline), renal vasodilator drugs (such as dopamine), transjugular intrahepatic portosystemic shunt (TIPS), and liver support with molecular adsorbent recirculating system (MARS). There is uncertainty over the best treatment regimen for hepatorenal syndrome. Objectives: To compare the benefits and harms of different treatments for hepatorenal syndrome in people with decompensated liver cirrhosis. Search methods: We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trial registers until December 2018 to identify randomised clinical trials on hepatorenal syndrome in people with cirrhosis. Selection criteria: We included only randomised clinical trials (irrespective of language, blinding, or publication status) in adults with cirrhosis and hepatorenal syndrome. We excluded randomised clinical trials in which participants had previously undergone liver transplantation. Data collection and analysis: Two authors independently identified eligible trials and collected data. The outcomes for this review included mortality, serious adverse events, any adverse events, resolution of hepatorenal syndrome, liver transplantation, and other decompensation events. We performed a network meta‐analysis with OpenBUGS using Bayesian methods and calculated the odds ratio (OR), rate ratio, hazard ratio (HR), and mean difference (MD) with 95% credible intervals (CrI) based on an available‐case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. Main results: We included a total of 25 trials (1263 participants; 12 interventions) in the review. Twenty‐three trials (1185 participants) were included in one or more outcomes. All the trials were at high risk of bias, and all the evidence was of low or very low certainty. The trials included participants with liver cirrhosis of varied aetiologies as well as a mixture of type I hepatorenal syndrome only, type II hepatorenal syndrome only, or people with both type I and type II hepatorenal syndrome. Participant age ranged from 42 to 60 years, and the proportion of females ranged from 5.8% to 61.5% in the trials that reported this information. The follow‐up in the trials ranged from one week to six months. Overall, 59% of participants died during this period and about 35% of participants recovered from hepatorenal syndrome. The most common interventions compared were albumin plus terlipressin, albumin plus noradrenaline, and albumin alone. There was no evidence of a difference in mortality (22 trials; 1153 participants) at maximal follow‐up between the different interventions. None of the trials reported health‐related quality of life. There was no evidence of differences in the proportion of people with serious adverse events (three trials; 428 participants), number of participants with serious adverse events per participant (two trials; 166 participants), proportion of participants with any adverse events (four trials; 402 participants), the proportion of people who underwent liver transplantation at maximal follow‐up (four trials; 342 participants), or other features of decompensation at maximal follow‐up (one trial; 466 participants). Five trials (293 participants) reported number of any adverse events, and five trials (219 participants) reported treatment costs. Albumin plus noradrenaline had fewer numbers of adverse events per participant (rate ratio 0.51, 95% CrI 0.28 to 0.87). Eighteen trials (1047 participants) reported recovery from hepatorenal syndrome (as per definition of hepatorenal syndrome). In terms of recovery from hepatorenal syndrome, in the direct comparisons, albumin plus midodrine plus octreotide and albumin plus octreotide had lower recovery from hepatorenal syndrome than albumin plus terlipressin (HR 0.04; 95% CrI 0.00 to 0.25 and HR 0.26, 95% CrI 0.07 to 0.80 respectively). There was no evidence of differences between the groups in any of the other direct comparisons. In the network meta‐analysis, albumin and albumin plus midodrine plus octreotide had lower recovery from hepatorenal syndrome compared with albumin plus terlipressin. Funding: two trials were funded by pharmaceutical companies; five trials were funded by parties who had no vested interest in the results of the trial; and 18 trials did not report the source of funding. Authors' conclusions: Based on very low‐certainty evidence, there is no evidence of benefit or harm of any of the interventions for hepatorenal syndrome with regards to the following outcomes: all‐cause mortality, serious adverse events (proportion), number of serious adverse events per participant, any adverse events (proportion), liver transplantation, or other decompensation events. Low‐certainty evidence suggests that albumin plus noradrenaline had fewer 'any adverse events per participant' than albumin plus terlipressin. Low‐ or very low‐certainty evidence also found that albumin plus midodrine plus octreotide and albumin alone had lower recovery from hepatorenal syndrome compared with albumin plus terlipressin. Future randomised clinical trials should be adequately powered; employ blinding, avoid post‐randomisation dropouts or planned cross‐overs (or perform an intention‐to‐treat analysis); and report clinically important outcomes such as mortality, health‐related quality of life, adverse events, and recovery from hepatorenal syndrome. Albumin plus noradrenaline and albumin plus terlipressin appear to be the interventions that should be compared in future trials

Antibiotic treatment for spontaneous bacterial peritonitis in people with decompensated liver cirrhosis:a network meta-analysis

Background: Approximately 2.5% of all hospitalisations in people with cirrhosis are for spontaneous bacterial peritonitis (SBP). Antibiotics, in addition to supportive treatment (fluid and electrolyte balance, treatment of shock), form the mainstay treatments of SBP. Various antibiotics are available for the treatment of SBP, but there is uncertainty regarding the best antibiotic for SBP. Objectives: To compare the benefits and harms of different antibiotic treatments for spontaneous bacterial peritonitis (SBP) in people with decompensated liver cirrhosis. Search methods: We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until November 2018 to identify randomised clinical trials on people with cirrhosis and SBP. Selection criteria: We included only randomised clinical trials (irrespective of language, blinding, or publication status) in adults with cirrhosis and SBP. We excluded randomised clinical trials in which participants had previously undergone liver transplantation. Data collection and analysis: Two review authors independently identified eligible trials and collected data. The outcomes for this review included mortality, serious adverse events, any adverse events, resolution of SBP, liver transplantation, and other decompensation events. We performed a network meta‐analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio with 95% credible intervals (CrIs) based on an available‐case analysis, according to the National Institute of Health and Care Excellence (NICE) Decision Support Unit guidance. Main results: We included a total of 12 trials (1278 participants; 13 antibiotics) in the review. Ten trials (893 participants) were included in one or more outcomes in the review. The trials that provided the information included patients having cirrhosis with or without other features of decompensation of varied aetiologies. The follow‐up in the trials ranged from one week to three months. All the trials were at high risk of bias. Only one trial was included under each comparison for most of the outcomes. Because of these reasons, there is very low certainty in all the results. The majority of the randomised clinical trials used third‐generation cephalosporins, such as intravenous ceftriaxone, cefotaxime, or ciprofloxacin as one of the interventions. Overall, approximately 75% of trial participants recovered from SBP and 25% of people died within three months. There was no evidence of difference in any of the outcomes for which network meta‐analysis was possible: mortality (9 trials; 653 participants), proportion of people with any adverse events (5 trials; 297 participants), resolution of SBP (as per standard definition, 9 trials; 873 participants), or other features of decompensation (6 trials; 535 participants). The effect estimates in the direct comparisons (when available) were very similar to those of network meta‐analysis. For the comparisons where network meta‐analysis was not possible, there was no evidence of difference in any of the outcomes (proportion of participants with serious adverse events, number of adverse events, and proportion of participants requiring liver transplantation). Due to the wide CrIs and the very low‐certainty evidence for all the outcomes, significant benefits or harms of antibiotics are possible. None of the trials reported health‐related quality of life, number of serious adverse events, or symptomatic recovery from SBP. Funding: the source of funding for two trials were industrial organisations who would benefit from the results of the trial; the source of funding for the remaining 10 trials was unclear. Authors' conclusions: Short‐term mortality after SBP is about 25%. There is significant uncertainty about which antibiotic therapy is better in people with SBP. We need adequately powered randomised clinical trials, with adequate blinding, avoiding post‐randomisation dropouts (or performing intention‐to‐treat analysis), and using clinically important outcomes, such as mortality, health‐related quality of life, and adverse events

Photonic Crystal Fiber Based Biosensor for Pseudomonas Bacteria Detection: A Simulation Study

The detection of microorganisms like Pseudomonas are very important as they trigger an infection in human blood, lungs, and different parts of the body causing various ailments. In this paper, a surface plasmon resonance (SPR) biosensor based on photonic crystal fiber (PCF) has been proposed to detect the presence of Pseudomonas bacteria with attractive performance characteristics. The sensor is designed using a simple circular lattice of PCF, coated with a thin chemically stable gold layer. The performance investigation of the sensor is numerically carried out by using a finite element (FE) based simulation tool where the highest wavelength and amplitude sensitivity are found as 20,000 nm/RIU and 1380 RIU −1 , respectively. The sensor shows an excellent spectral resolution of the highest value of 5.26×10−6 RIU, ensuring the capability of identifying a very small change in analyte refractive index (RI) within the range of 1.33 to 1.42. The performance investigation is also carried out altering the diameter of air holes, pitch, and gold layer thickness to explore the variation in phase matching conditions due to the change in structural parameters. As the sensor is adept at detecting the sample with high sensitivity and sensing resolution, the proposed sensor can be highly efficient in detecting Pseudomonas bacteria as well as other organic compounds, and biological analytes

Clinical relevance assessment of animal preclinical research (RAA) tool: development and explanation.

Only a small proportion of preclinical research (research performed in animal models prior to clinical trials in humans) translates into clinical benefit in humans. Possible reasons for the lack of translation of the results observed in preclinical research into human clinical benefit include the design, conduct, and reporting of preclinical studies. There is currently no formal domain-based assessment of the clinical relevance of preclinical research. To address this issue, we have developed a tool for the assessment of the clinical relevance of preclinical studies, with the intention of assessing the likelihood that therapeutic preclinical findings can be translated into improvement in the management of human diseases. We searched the EQUATOR network for guidelines that describe the design, conduct, and reporting of preclinical research. We searched the references of these guidelines to identify further relevant publications and developed a set of domains and signalling questions. We then conducted a modified Delphi-consensus to refine and develop the tool. The Delphi panel members included specialists in evidence-based (preclinical) medicine specialists, methodologists, preclinical animal researchers, a veterinarian, and clinical researchers. A total of 20 Delphi-panel members completed the first round and 17 members from five countries completed all three rounds. This tool has eight domains (construct validity, external validity, risk of bias, experimental design and data analysis plan, reproducibility and replicability of methods and results in the same model, research integrity, and research transparency) and a total of 28 signalling questions and provides a framework for researchers, journal editors, grant funders, and regulatory authorities to assess the potential clinical relevance of preclinical animal research. We have developed a tool to assess the clinical relevance of preclinical studies. This tool is currently being piloted

Ni-62(n,gamma) and Ni-63(n,gamma) cross sections measured at the n_TOF facility at CERN

The cross section of the Ni-62(n,gamma) reaction was measured with the time-of-flight technique at the neutron time-of-flight facility n_TOF at CERN. Capture kernels of 42 resonances were analyzed up to 200 keV neutron energy and Maxwellian averaged cross sections (MACS) from kT = 5-100 keV were calculated. With a total uncertainty of 4.5%, the stellar cross section is in excellent agreement with the the KADoNiS compilation at kT = 30 keV, while being systematically lower up to a factor of 1.6 at higher stellar temperatures. The cross section of the Ni-63(n,gamma) reaction was measured for the first time at n_TOF. We determined unresolved cross sections from 10 to 270 keV with a systematic uncertainty of 17%. These results provide fundamental constraints on s-process production of heavier species, especially the production of Cu in massive stars, which serve as the dominant source of Cu in the solar system.Peer reviewedFinal Accepted Versio