Simple Clinical Screening Underestimates Malnutrition in Surgical Patients with Inflammatory Bowel Disease-An ACS NSQIP Analysis.

The present large scale study aimed to assess the prevalence and consequences of malnutrition, based on clinical assessment (body mass index and preoperative weight loss) and severe hypoalbuminemia (<3.1 g/L), in a representative US cohort undergoing IBD surgery. The American College of Surgeons National Quality improvement program (ACS-NSQIP) Public User Files (PUF) between 2005 and 2018 were assessed. A total of 25,431 patients were identified. Of those, 6560 (25.8%) patients had severe hypoalbuminemia, 380 (1.5%) patients met ESPEN 2 criteria (≥10% weight loss over 6 months PLUS BMI < 20 kg/m <sup>2</sup> in patients <70 years OR BMI < 22 kg/m <sup>2</sup> in patients ≥70 years), and 671 (2.6%) patients met both criteria (severe hypoalbuminemia and ESPEN 2). Patients who presented with malnutrition according to any of the three definitions had higher rates of overall, minor, major, surgical, and medical complications, longer LOS, higher mortality and higher rates of readmission and reoperation. The simple clinical assessment of malnutrition based on BMI and weight loss only, considerably underestimates its true prevalence of up to 50% in surgical IBD patients and calls for dedicated nutritional assessment

Introduction of Routine Zinc Therapy for Children with Diarrhoea: Evaluation of Safety

On 8 May 2004, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommended routine administration of zinc in the management of children, aged less than five years, with acute diarrhoea. In making the recommendation, WHO and UNICEF also suggested careful monitoring for adverse events associated with routine administration of zinc, particularly unusual or excess vomiting. The study assessed, in a phase IV trial, i.e. post-marketing surveillance of zinc, the occurrence of adverse events during the first hour after the administration of the first dose of zinc in children with acute or persistent diarrhoea. The study was conducted at the Dhaka Hospital of ICDDR,B and at an outpatient clinic operated by a local health NGO—Progoti Samaj Kallyan Protisthan (PSKP), Dhaka, Bangladesh. Eligible children, aged 3-59 months, were treated with 20 mg of zinc sulphate provided in a dispersible tablet formulation. The children were observed for 60 minutes following the initial treatment with zinc for adverse events, with particular attention given to vomiting or regurgitation. During the one-year observation period, 42,440 children (male 57% and female 43%) received zinc, and 20,246 (47.8%) of them were observed. Regurgitation and/or vomiting occurred in 4,392 (21.8%) of the children; 90.8% of these children had vomiting only once, 8.7% twice, and 0.5% more than twice. No children revisited the hospital for recurrent vomiting following their discharge. A significant proportion of infants and children may experience vomiting or regurgitation, usually once, following the administration of the first dose of zinc. This is a transient phenomenon that did not impact on continuation of treatment with zinc

Trends of complications and innovative techniques' utilization for colectomies in the United States.

Despite an increasing trend towards utilization of minimally invasive approaches (MIS), results regarding their safety profile are contradictory. All patients who underwent elective colectomy for any underlying disease with an identifiable operative approach available from the targeted colectomy files of the ACS-NSQIP PUFs 2013 to 2018 were included. The trend of utilization and complication rates of the different operative approaches (open, laparoscopic, robotic) were assessed during the inclusion period. Furthermore, overall, surgical, and medical complications were compared between the three approaches. The study cohort included 78,987 patients. Of them, 12,335 (15.6%) patients underwent open, 57,874 (73.3%) laparoscopic, and 8,778 (11.1%) robotic surgery. There was an increasing trend towards the utilization of robotic surgery (2.5% increase per year) at the expense of the other approaches. With the increasing trend toward the utilization of the robotic approach, a decreasing trend in overall and surgical complications and length of stay was observed. After adjusting for the baseline confounders, robotic surgery was associated with shorter length of stay, lower rate of overall (OR 0.397; p < 0.05 compared to open and OR: 0.763; p < 0.05 compared to laparoscopy) and surgical complications (OR: 0.464; p < 0.05 compared to open and OR: 0.734; p < 0.05 compared to laparoscopy). This study revealed an increasing trend toward the utilization of MIS for elective colectomy in the US. Robotic surgery was associated with a decreasing trend in overall and surgical morbidity and length of stay

The significance of work allocation in the professional apprenticeship of solicitors

It is a peculiarity of the solicitors’ profession that it has historically relied on methods of pre-qualification ‘training’ by way of apprenticeship and that an entirely respectable non-graduate route into the profession remains. In a political context, however, where the profession is called upon positively to demonstrate its standards of performance, the professional regulator seeks to attach a competence framework to the existing model; shifting the focus from how the trainee learns to what the trainee learns. This paper will explore the period of traineeship from the perspective of the trainees themselves, drawing on two small qualitative studies, focussing on the fundamental context factor of the allocation and structuring of their work. In the first study the context for this evaluation is the set of outcomes being tested by the professional regulator and in the second, the perceptions of qualified individuals looking back at their apprenticeship, The paper concludes that there remains work for the profession to do not only in fostering supportive and expansive apprenticeships, but in attending, however, supportive the surrounding environment, to the work being carried out by trainees and its relationship with the work carried out by newly qualified solicitors

Oral Antibiotics Bowel Preparation Without Mechanical Preparation For Minimally Invasive Colorectal Surgeries: Current Practice And Future Prospects.

The efficacy of preoperative oral antibiotics alone compared to mechanical bowel preparation and oral antibiotics in minimally invasive surgery is still a matter of ongoing debate. This study aimed to assess the trend of surgical site infection rates in parallel to the utilization of bowel preparation modality over time for minimally invasive surgery colorectal surgeries in the United States. Retrospective analysis. The American College of Surgeons National Surgical Quality Improvement Program database. Adult patients who underwent elective colorectal surgery and reported bowel preparation modality. The trends and compare surgical site infection rates for mutually exclusive groups according to the underlying disease (colorectal cancer, inflammatory bowel disease, and diverticular disease) who underwent bowel preparation using oral antibiotics or combined mechanical bowel preparation and oral antibiotics. Patients who had rectal surgery were analyzed separately. A total of 30,939 patients were included. Of them, 12,417 (40%) had rectal resections. Over the seven-year study period, mechanical bowel preparation and oral antibiotics utilization has increased from 29.3% in 2012 to 64.0% in 2018; p<0.0001 at the expense of no preparation and mechanical bowel preparation alone. Similarly, oral antibiotics utilization has increased from 2.3% in 2012 to 5.5% in 2018; p<0.0001. For colon cancer patients, patients who had oral antibiotics alone had higher superficial surgical site infection rates compared to patients who had combined mechanical bowel preparation and oral antibiotics (1.9% vs. 1.1%; p=0.043). Superficial, deep and organ space surgical site infection rates were similar for all other comparative colon surgery groups (cancer, inflammatory bowel disease, and diverticular disease). Patients with rectal cancer who had oral antibiotics had higher rates of deep surgical site infection (0.9% vs. 0.1%; p=0.004). However, superficial, deep and organ space surgical site infection rates were similar for all other comparative rectal surgery groups. Retrospective nature of the analysis. This study revealed widespread adoption of mechanical bowel preparation and oral antibiotics mechanical bowel preparation and oral antibiotics and increased adoption of oral antibiotics over the study period. Surgical site infection rates appear to be similar from a clinical relevance standpoint among most comparative groups, questioning systematic preoperative addition of mechanical bowel preparation to oral antibiotics alone in all patients for minimally invasive colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B828

A solution for galactic disks with Yukawian gravitational potential

We present a new solution for the rotation curves of galactic disks with gravitational potential of the Yukawa type. We follow the technique employed by Toomre in 1963 in the study of galactic disks in the Newtonian theory. This new solution allows an easy comparison between the Newtonian solution and the Yukawian one. Therefore, constraints on the parameters of theories of gravitation can be imposed, which in the weak field limit reduce to Yukawian potentials. We then apply our formulae to the study of rotation curves for a zero-thickness exponential disk and compare it with the Newtonian case studied by Freeman in 1970. As an application of the mathematical tool developed here, we show that in any theory of gravity with a massive graviton (this means a gravitational potential of the Yukawa type), a strong limit can be imposed on the mass (m_g) of this particle. For example, in order to obtain a galactic disk with a scale length of b ~ 10 kpc, we should have a massive graviton of m_g << 10^{-59} g. This result is much more restrictive than those inferred from solar system observations.Comment: 7 pages; 1 eps figure; to appear in General Relativity and Gravitatio

Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database.

Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy

The Minimal Supersymmetric Fat Higgs Model

We present a calculable supersymmetric theory of a composite ``fat'' Higgs boson. Electroweak symmetry is broken dynamically through a new gauge interaction that becomes strong at an intermediate scale. The Higgs mass can easily be 200-450 GeV along with the superpartner masses, solving the supersymmetric little hierarchy problem. We explicitly verify that the model is consistent with precision electroweak data without fine-tuning. Gauge coupling unification can be maintained despite the inherently strong dynamics involved in electroweak symmetry breaking. Supersymmetrizing the Standard Model therefore does not imply a light Higgs mass, contrary to the lore in the literature. The Higgs sector of the minimal Fat Higgs model has a mass spectrum that is distinctly different from the Minimal Supersymmetric Standard Model.Comment: 13 pages, 5 figures, REVTe

Dynamic Evolution Model of Isothermal Voids and Shocks

We explore self-similar hydrodynamic evolution of central voids embedded in an isothermal gas of spherical symmetry under the self-gravity. More specifically, we study voids expanding at constant radial speeds in an isothermal gas and construct all types of possible void solutions without or with shocks in surrounding envelopes. We examine properties of void boundaries and outer envelopes. Voids without shocks are all bounded by overdense shells and either inflows or outflows in the outer envelope may occur. These solutions, referred to as type $\mathcal{X}$ void solutions, are further divided into subtypes $\mathcal{X}_{\rm I}$ and $\mathcal{X}_{\rm II}$ according to their characteristic behaviours across the sonic critical line (SCL). Void solutions with shocks in envelopes are referred to as type $\mathcal{Z}$ voids and can have both dense and quasi-smooth edges. Asymptotically, outflows, breezes, inflows, accretions and static outer envelopes may all surround such type $\mathcal{Z}$ voids. Both cases of constant and varying temperatures across isothermal shock fronts are analyzed; they are referred to as types $\mathcal{Z}_{\rm I}$ and $\mathcal{Z}_{\rm II}$ void shock solutions. We apply the `phase net matching procedure' to construct various self-similar void solutions. We also present analysis on void generation mechanisms and describe several astrophysical applications. By including self-gravity, gas pressure and shocks, our isothermal self-similar void (ISSV) model is adaptable to various astrophysical systems such as planetary nebulae, hot bubbles and superbubbles in the interstellar medium as well as supernova remnants.Comment: 24 pages, 13 figuers, accepted by ApS

Intraoperative Fluid Management a Modifiable Risk Factor for Surgical Quality - Improving Standardized Practice.

We aimed to determine a safe zone of intraoperative fluid management associated with the lowest postoperative complication rates without increased acute kidney injury (AKI) risk for elective colorectal surgery patients. Elective colorectal surgeries between 2018 and 2020 were included. Unadjusted odds ratios for postoperative ileus, prolonged length of stay (LOS), and AKI were plotted against the rate of intraoperative ringer&amp;apos;s lactate (RL) infusion (mL/kg/h) and total intraoperative volume. Binary logistic regression analysis, including fluid volumes as a confounder, was used to identify risk factors for postoperative complications. A total of 2,900 patients were identified. Of them, 503 (17.3%) patients had ileus, 772 (26.6%) patients had prolonged LOS, and 240 (8.3%) patients had AKI. The intraoperative fluid resuscitation rate (mg/kg/h) was less impactful on postoperative ileus, LOS, and AKI than the total amount of intraoperative fluid. A total fluid administration range between 300 mL and 2.7 L was associated with the lowest complication rate. Total intraoperative RL &amp;ge;2.7 L was independently associated with a higher risk of ileus (adjusted OR 1.465;95% CI 1.154-1.858) and prolonged LOS (adjusted OR 1.300;95% CI 1.047-1.613), but not AKI. Intraoperative RL&amp;le;300 ml was not associated with an increased risk of AKI. Total intraoperative RL&amp;ge;2.7L was independently associated with postoperative ileus and prolonged LOS in elective colorectal surgery patients. A new potential standard for intraoperative fluids will require anesthesia case planning (complexity and duration) to ensure total fluid volume meets this new opportunity to improve care