Does fluctuation in paramedical personal influence the morbidity of patients?

Colorectal surgery is associated with a high rate of postoperative complications compared to other surgical specialities, and reported morbidity rates reaching up to 35% (1)(2). Patients with complications after surgery are at increased risk of poor outcome and increased length of stay. Oncological patients are at particular risk as complications can delay the start of adjuvant therapy and thereafter influence negatively the rate of recurrence (1)(3). The most frequent complications related to colorectal surgery are surgical site infections, urinary tract infections and other surgical complications such as anastomotic leakage, ileus, bleeding and organ space infection (1)(4). The economic impact of complications after colorectal surgery is not trivial. A recent multicentre study showed that they can increase the costs per case from 26% for minor and up to 126% for major complications, respectively (5). An anastomotic insufficiency at its own can triple the costs (5).The risk factors for complications after colorectal surgery can be related either to the patients (older age, gender, specific comorbidities, ASA score) and/or to the surgical intervention such as prolonged operating time (>3 hours), surgical technique (laparotomy), intraoperative blood loss and lack of prophylactic antibiotics (5)(4). Numerous strategies were developed to decrease the incidence of complications. Among them the Enhanced Recovery After Surgery (ERAS) protocols (in CHUV since 2011) have been implemented to optimize the peri-operative management. The rationale was to reduce the peri-operative stress response and organ dysfunction induced by surgical interventions (6). One of the major contributions of the ERAS program was to standardize the patient pathway before, during and after surgery. Important issues include standardized anaesthetic protocol, the use of minimal invasive surgery, postoperative management of pain, nutritional status, and early mobilization (7)(8). To provide the desired effect, this multidisciplinary approach requires a high compliance of the different health care professionals. It has been shown that an increase of 27% of the adherence to the ERAS protocol is associated to the same reduction of postoperative morbidity, postoperative symptoms and with a shorter length of stay (9)(10). More specifically in colorectal surgery, it decreases the postoperative complications by almost 50%. Our published data of the CHV series showed that ERAS has beneficial effects on the length of stay with a diminution of >2 days and on the direct cost per patient with a decrease of almost 2000 CHF (11). Since the different guidelines of the ERAS society were published, several studies analysed how different items within these protocols could be optimized (12)(13). Interestingly, only few studies analysed the impact of paramedical staffing on postoperative outcome. Some authors suggested that an increase in the nurse-to-patient ratio decreases the postoperative complications whereas others could not show any correlations. For example, a low nurse-topatient ratio was associated with a high rate of complications after oesophageal resection in one study (14)(15). To our knowledge, no studies analysed the effect of the nurse to patient ratio within the ERAS institutions. The aim of this study was to analyse the relationship between the nurse workload and the occurrence of postoperative complications within an ERAS program for colorectal surgery

A Framework for Evaluating Security in the Presence of Signal Injection Attacks

Sensors are embedded in security-critical applications from medical devices to nuclear power plants, but their outputs can be spoofed through electromagnetic and other types of signals transmitted by attackers at a distance. To address the lack of a unifying framework for evaluating the effects of such transmissions, we introduce a system and threat model for signal injection attacks. We further define the concepts of existential, selective, and universal security, which address attacker goals from mere disruptions of the sensor readings to precise waveform injections. Moreover, we introduce an algorithm which allows circuit designers to concretely calculate the security level of real systems. Finally, we apply our definitions and algorithm in practice using measurements of injections against a smartphone microphone, and analyze the demodulation characteristics of commercial Analog-to-Digital Converters (ADCs). Overall, our work highlights the importance of evaluating the susceptibility of systems against signal injection attacks, and introduces both the terminology and the methodology to do so.Comment: This article is the extended technical report version of the paper presented at ESORICS 2019, 24th European Symposium on Research in Computer Security (ESORICS), Luxembourg, Luxembourg, September 201

Attosecond screening dynamics mediated by electron-localization

Transition metals with their densely confined and strongly coupled valence electrons are key constituents of many materials with unconventional properties, such as high-Tc superconductors, Mott insulators and transition-metal dichalcogenides. Strong electron interaction offers a fast and efficient lever to manipulate their properties with light, creating promising potential for next-generation electronics. However, the underlying dynamics is a fast and intricate interplay of polarization and screening effects, which is poorly understood. It is hidden below the femtosecond timescale of electronic thermalization, which follows the light-induced excitation. Here, we investigate the many-body electron dynamics in transition metals before thermalization sets in. We combine the sensitivity of intra-shell transitions to screening effects with attosecond time resolution to uncover the interplay of photo-absorption and screening. First-principles time-dependent calculations allow us to assign our experimental observations to ultrafast electronic localization on d-orbitals. The latter modifies the whole electronic structure as well as the collective dynamic response of the system on a timescale much faster than the light-field cycle. Our results demonstrate a possibility for steering the electronic properties of solids prior to electron thermalization, suggesting that the ultimate speed of electronic phase transitions is limited only by the duration of the controlling laser pulse. Furthermore, external control of the local electronic density serves as a fine tool for testing state-of-the art models of electron-electron interactions. We anticipate our study to facilitate further investigations of electronic phase transitions, laser-metal interactions and photo-absorption in correlated electron systems on its natural timescale

Impact of Variations in the Nursing Care Supply-Demand Ratio on Postoperative Outcomes and Costs.

Improving surgical outcomes is a priority during the last decades because of the rising economic health care burden. The adoption of enhanced recovery programs has been proven to be part of the solution. In this context, the impact of variations in the nursing care supply-demand ratio on postoperative complications and its economic consequences is still not well elucidated. Because patients require different amounts of care, the present study focused on the more accurate relationship between demand and supply of nursing care rather than the nurse-to-patient ratio. Through a 3-year period, 838 patients undergoing elective and emergent colorectal and pancreatic surgery within the institutional enhanced recovery after surgery (ERAS) protocol were retrospectively investigated. Nursing demand and supply estimations were calculated using a validated program called the Projet de Recherche en Nursing (PRN), which assigns points to each patient according to the nursing care they need (estimated PRN) and the actual care they received (real PRN), respectively. The real/estimated PRN ratio was used to create 2 patient groups: one with a PRN ratio higher than the mean (PRN+) and a second with a PRN ratio below the mean (PRN-). These 2 groups were compared regarding their postoperative complication rates and cost-revenue characteristics. The mean PRN ratio was 0.81. A total of 710 patients (84.7%) had a PRN+ ratio, and 128 (15.3%) had a PRN- ratio. Multivariable analysis focusing on overall complications, severe complications, and prolonged length of stay revealed no significant impact of the PRN ratio for all outcomes (P > 0.2). The group PRN- had a mean margin per patient of U.S. dollars 1426 (95% confidence interval, 3 to 2903) compared with a margin of U.S. dollars 676 (95% confidence interval, -2213 to 3550) in the PRN+ group (P = 0.633). A PRN ratio of 0.8 may be sufficient for patients treated following enhanced recovery after surgery guidelines, pending the adoption of an accurate nursing planning system. This may contribute to better allocation of nursing resources and optimization of expenses on the long run

A New Era in Engineering Plastics: Compatibility and Perspectives of Sustainable Alipharomatic Poly(ethylene terephthalate)/Poly(ethylene 2,5-furandicarboxylate) Blends

The industrialisation of poly(ethylene 2,5-furandicarboxylate) for total replacement of poly(ethylene terephthalate) in the polyester market is under question. Preparation of high-performing polymer blends is a well-established strategy for tuning the properties of certain homopolymers and create tailor-made materials to meet the demands for a number of applications. In this work, the structure, thermal properties and the miscibility of a series of poly(ethylene terephthalate)/poly(ethylene 2,5-furandicarboxylate) (PET/PEF) blends have been studied. A number of thermal treatments were followed in order to examine the thermal transitions, their dynamic state and the miscibility characteristics for each blend composition. Based on their glass transition temperatures and melting behaviour the PET/PEF blends are miscible at high and low poly(ethylene terephthalate) (PET) contents, while partial miscibility was observed at intermediate compositions. The multiple melting was studied and their melting point depression was analysed with the Flory-Huggins theory. In an attempt to further improve miscibility, reactive blending was also investigated

Help wanted: helper NLRs and plant immune responses

Plant nucleotide-binding domain and leucine-rich repeat-containing (NLR) proteins function as intracellular receptors in response to pathogens and activate effector-triggered immune responses (ETI). The activation of some sensor NLRs (sNLR) by their corresponding pathogen effector is well studied. However, the mechanisms by which the recently defined helper NLRs (hNLR) function to transduce sNLR activation into ETI-associated cell death and disease resistance remains poorly understood. We briefly summarize recent examples of sNLR activation and we then focus on hNLR requirements in sNLR-initiated immune responses. We further discuss how shared sequence homology with fungal self-incompatibility proteins and the mammalian mixed lineage kinase domain like pseudokinase (MLKL) proteins informs a plausible model for the structure and function of an ancient clade of plant hNLRs, called RNLs