Experience with dedicated geriatric surgical consult services: Meeting the need for surgery in the frail elderly

Rosemarie E Hardin1, Thierry Le Jemtel2, Michael E Zenilman11Department of Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA; 2Department of Medicine, Tulane Medical Center, New Orleans, LA, USABackground: Surgeons are increasingly faced with consultation for intervention in residents of geriatric centers or in patients who suffer from end stage medical disease. We review our experience with consult services dedicated to the needs of these frail patients.Study design: Patients were prospectively followed after being evaluated by three different geriatric surgical consult services: Group 1 was based at a geriatric center associated with a tertiary medical center, Group 2 was based at a community geriatric center, and Group 3 was based with an hospital-based service for ambulatory patients with end stage congestive heart failure.Results: A total of 256 frail elderly patients underwent of 311 general surgical procedures ranging from major abdominal and vascular procedures to minor procedures such as debridement of decubitus ulcers, long-term intravenous access, enterostomy and enteral tube placement. Almost half of the surgical volume in Group 1 and 3 were ‘maintenance’ (decubitus debridement, long term intravenous or stomal or tube care); all of Group 2 were for treatment of decubiti. There was minimal morbidity and mortality from surgery itself, and overall one year survival for Groups 1, 2, and 3 was 46%, 60%, and 79%, respectively. Multivariate analysis showed that each group had its own unique indicators of decreased survival: Group 1 dementia and coronary artery disease, in Group 2 gender and coronary artery disease, and Group 3, gender alone. Age, number of comorbid illnesses, and type of surgery (major vs minor) were not significant indicators.Conclusions: This is the first review of the role of dedicated surgical consult services which focused on residents of geriatric centers and frail elderly. Conditions routinely encountered in this population such as dementia, end stage disease, multiple comorbidities, polypharmacy, decreased functional and nutritional status are not frequently encountered by general surgeons. But the surgery is safe, and survival data is comparable to those in geriatric centers who did not undergo surgery. A multidisciplinary team approach gives the most effective care, with a primary goal of palliation.Keywords: surgery in the elderly, geriatrics, surgical consultations, nursing home residents, congestive heart failure, frailty, palliative care, dementia, coronary artery disease, surviva

Endogenous growth and property rights over renewable resources

We study how different regimes of access rights to renewable natural resources - namely, open access versus full property rights – affect sustainability, growth and welfare in the context of modern endogenous growth theory. Resource exhaustion may occur under both regimes but is more likely to arise under open access. Moreover, under full property rights, positive resource rents increase expenditures on manufacturing goods and temporarily accelerate productivity growth, but also yield a higher resource price at least in the short-to-medium run. We characterize analytically and quantitatively the model’s dynamics to assess the welfare implications of differences in property rights enforcement

How does reviewing the evidence change veterinary surgeons' beliefs regarding the treatment of ovine footrot? A quantitative and qualitative study

Footrot is a widespread, infectious cause of lameness in sheep, with major economic and welfare costs. The aims of this research were: (i) to quantify how veterinary surgeons’ beliefs regarding the efficacy of two treatments for footrot changed following a review of the evidence (ii) to obtain a consensus opinion following group discussions (iii) to capture complementary qualitative data to place their beliefs within a broader clinical context. Grounded in a Bayesian statistical framework, probabilistic elicitation (roulette method) was used to quantify the beliefs of eleven veterinary surgeons during two one-day workshops. There was considerable heterogeneity in veterinary surgeons’ beliefs before they listened to a review of the evidence. After hearing the evidence, seven participants quantifiably changed their beliefs. In particular, two participants who initially believed that foot trimming with topical oxytetracycline was the better treatment, changed to entirely favour systemic and topical oxytetracycline instead. The results suggest that a substantial amount of the variation in beliefs related to differences in veterinary surgeons’ knowledge of the evidence. Although considerable differences in opinion still remained after the evidence review, with several participants having non-overlapping 95% credible intervals, both groups did achieve a consensus opinion. Two key findings from the qualitative data were: (i) veterinary surgeons believed that farmers are unlikely to actively seek advice on lameness, suggesting a proactive veterinary approach is required (ii) more attention could be given to improving the way in which veterinary advice is delivered to farmers. In summary this study has: (i) demonstrated a practical method for probabilistically quantifying how veterinary surgeons’ beliefs change (ii) revealed that the evidence that currently exists is capable of changing veterinary opinion (iii) suggested that improved transfer of research knowledge into veterinary practice is needed (iv) identified some potential obstacles to the implementation of veterinary advice by farmers

Clustering of supernova Ia host galaxies

For the first time the cross-correlation between type Ia supernova host galaxies and surrounding field galaxies is measured using the Supernova Legacy Survey sample. Over the z=0.2 to 0.9 redshift range we find that supernova hosts are correlated an average of 60% more strongly than similarly selected field galaxies over the 3-100 arcsec range and about a factor of 3 more strongly below 10 arcsec. The correlation errors are empirically established with a jackknife analysis of the four SNLS fields. The hosts are more correlated than the field at a significance of 99% in the fitted amplitude and slope, with the point-by-point difference of the two correlation functions having a reduced $\chi^2$ for 8 degrees of freedom of 4.3, which has a probability of random occurrence of less than 3x10^{-5}. The correlation angle is 1.5+/-0.5 arcsec, which deprojects to a fixed co-moving correlation length of approximately 6.5+/- 2/h mpc. Weighting the field galaxies with the mass and star formation rate supernova frequencies of the simple A+B model produces good agreement with the observed clustering. We conclude that these supernova clustering differences are primarily the expected outcome of the dependence of supernova rates on galaxy masses and stellar populations with their clustering environment.Comment: ApJ (Letts) accepte

Type Ia Supernovae Rates and Galaxy Clustering from the CFHT Supernova Legacy Survey

The Canada-France-Hawaii Telescope Supernova Legacy Survey (SNLS) has created a large homogeneous database of intermediate redshift (0.2 < z < 1.0) type Ia supernovae (SNe Ia). The SNLS team has shown that correlations exist between SN Ia rates, properties, and host galaxy star formation rates. The SNLS SN Ia database has now been combined with a photometric redshift galaxy catalog and an optical galaxy cluster catalog to investigate the possible influence of galaxy clustering on the SN Ia rate, over and above the expected effect due to the dependence of SFR on clustering through the morphology-density relation. We identify three cluster SNe Ia, plus three additional possible cluster SNe Ia, and find the SN Ia rate per unit mass in clusters at intermediate redshifts is consistent with the rate per unit mass in field early-type galaxies and the SN Ia cluster rate from low redshift cluster targeted surveys. We also find the number of SNe Ia in cluster environments to be within a factor of two of expectations from the two component SNIa rate model.Comment: 21 pages, 2 figures, 6 tables, accepted for publication in A

The effect of progenitor age and metallicity on luminosity and 56Ni yield in Type Ia supernovae

Timmes, Brown & Truran found that metallicity variations could theoretically account for a 25% variation in the mass of 56Ni synthesized in Type Ia supernovae (SNe Ia), and thus account for a large fraction of the scatter in observed SN Ia luminosities. Higher-metallicity progenitors are more neutron-rich, producing more stable burning products relative to radioactive 56Ni. We develop a new method for estimating bolometric luminosity and 56Ni yield in SNe Ia and use it to test the theory with data from the Supernova Legacy Survey. We find that the average 56Ni yield does drop in SNe Ia from high metallicity environments, but the theory can only account for 7%--10% of the dispersion in SN Ia 56Ni mass, and thus luminosity. This is because the effect is dominant at metallicities significantly above solar, whereas we find that SN hosts have predominantly subsolar or only moderately above-solar metallicities. We also show that allowing for changes in O/Fe with the metallicity [Fe/H] does not have a major effect on the theoretical prediction of Timmes, Brown & Truran, so long as one is using the O/H as the independent variable. Age may have a greater effect than metallicity -- we find that the luminosity weighted age of the host galaxy is correlated with 56Ni yield, and thus more massive progenitors give rise to more luminous explosions. This is hard to understand if most SNe Ia explode when the primaries reach the Chandrasekhar mass. Finally, we test the findings of Gallagher et al., that the residuals of SNe Ia from the Hubble diagram are correlated with host galaxy metallicity, and we find no such correlation.Comment: ApJ, accepted, 34 pages, 11 figures, apologies for one column format -- necessary for the equation

Observation of periodic variable stars towards the galactic spiral arms by EROS II

We present the results of a massive variability search based on a photometric survey of a six square degree region along the Galactic plane at ($l = 305^\circ$, $b = -0.8^\circ$) and ($l = 330^\circ$, $b = -2.5^\circ$). This survey was performed in the framework of the EROS II (Exp\'erience de Recherche d'Objets Sombres) microlensing program. The variable stars were found among 1,913,576 stars that were monitored between April and June 1998 in two passbands, with an average of 60 measurements. A new period-search technique is proposed which makes use of a statistical variable that characterizes the overall regularity of the flux versus phase diagram. This method is well suited when the photometric data are unevenly distributed in time, as is our case. 1,362 objects whose luminosity varies were selected. Among them we identified 9 Cepheids, 19 RR Lyrae, 34 Miras, 176 eclipsing binaries and 266 Semi-Regular stars. Most of them are newly identified objects. The cross-identification with known catalogues has been performed. The mean distance of the RR Lyrae is estimated to be $\sim 4.9 \pm 0.3$ kpc undergoing an average absorption of $\sim 3.4 \pm 0.2$ magnitudes. This distance is in good agreement with the one of disc stars which contribute to the microlensing source star population.Our catalogue and light curves are available electronically from the CDS, Strasbourg and from our Web site http://eros.in2p3.fr.Comment: 15 pages, 11 figures, accepted in A&A (april 2002

Two decades of advancement in process simulation testing of ballast strength, deformation, and degradation

© Copyright 2018 by ASTM International. This paper describes salient features of a set of large-scale ballast testing equipment developed at the University of Wollongong, Australia, and how the test results and research outcomes have contributed to transforming tracks in the Australian heavy haul and commuter networks, particularly with regards to the strength, deformation, and degradation of ballast. Ideally, ballast assemblies should be tested in prototype scale under actual loading conditions. This is because a reduction in particle sizes for testing in smaller equipment can reduce the internal angle of friction (shearing resistance) of the granular assembly in a macro sense, and the angularity of the particles in a micro sense, and hence the volumetric changes during the shearing process. In response to the worldwide lack of proper test facilities for ballast, the University of Wollongong has, since the early 1990s, designed and built a number of large-scale process simulation triaxial testing rigs. They are all custom made to minimize any boundary effects and also to evaluate the deformation and degradation of ballast, particularly the size, shape, and origin of aggregates used as ballast in Australian tracks. This triaxial process simulation equipment was originally used to characterize the behavior of coarse aggregate used for state railway standards for monotonie loading, but since then it has been fitted with dynamic actuators to simulate actual track conditions involving the true cyclic loading nature while also capturing the wheel-rail dynamics that correspond to high-speed commuter rail and fast heavy-haul operations. These tests invariably demonstrated completely different stress-strain and volumetric characteristics of ballast compared to conventional static or monotonie testing of the same test specimens

Resonant Lifetime of Core-Excited Organic Adsorbates from First Principles

We investigate by first-principles simulations the resonant electron-transfer lifetime from the excited state of an organic adsorbate to a semiconductor surface, namely isonicotinic acid on rutile TiO$_2$(110). The molecule-substrate interaction is described using density functional theory, while the effect of a truly semi-infinite substrate is taken into account by Green's function techniques. Excitonic effects due to the presence of core-excited atoms in the molecule are shown to be instrumental to understand the electron-transfer times measured using the so-called core-hole-clock technique. In particular, for the isonicotinic acid on TiO$_2$(110), we find that the charge injection from the LUMO is quenched since this state lies within the substrate band gap. We compute the resonant charge-transfer times from LUMO+1 and LUMO+2, and systematically investigate the dependence of the elastic lifetimes of these states on the alignment among adsorbate and substrate states.Comment: 24 pages, 6 figures, to appear in Journal of Physical Chemistry

The core-collapse rate from the Supernova Legacy Survey

We use three years of data from the Supernova Legacy Survey (SNLS) to study the general properties of core-collapse and type Ia supernovae. This is the first such study using the "rolling search" technique which guarantees well-sampled SNLS light curves and good efficiency for supernovae brighter than i'~24. Using host photometric redshifts, we measure the supernova absolute magnitude distribution down to luminosities 4.5 mag fainter than normal SNIa. Using spectroscopy and light-curve fitting to discriminate against SNIa, we find a sample of 117 core-collapse supernova candidates with redshifts z < 0.4 (median redshift of 0.29) and measure their rate to be larger than the type Ia supernova rate by a factor 4.5±0.8(stat.)±0.6 (sys.). This corresponds to a core-collapse rate at z = 0.3 of [ 1.42±0.3(stat.)±0.3(sys.)] ×10-4 yr-1(h_70-1 Mpc)-3