Entanglement-preserving measurement of the Bell parameter on a single entangled pair

Bell inequalities represent one of the cornerstones of quantum foundations, and a fundamental tool for quantum technologies. Although a lot of effort was put in exploring and generalizing them, because of the wave function collapse it was deemed impossible to estimate the entire Bell parameter from one entangled pair, since this would involve measuring incompatible observables on the same quantum state. Conversely, here it is reported the first implementation of a new generation of Bell inequality tests, able to extract a Bell parameter value from each entangled pair and, at the same time, preserve the pair entanglement instead of destroying it. This is obtained by exploiting sequences of weak measurements, allowing incompatible observable measurements on a quantum state without collapsing its wave function. On the fundamental side, by removing the need to choose between different measurement bases our approach stretches the concept of counterfactual definiteness, since it allows measuring the entangled pair in all the bases needed for the Bell inequality test, intrinsically eliminating the issues connected with the otherwise not-chosen bases. On the practical side, after our Bell parameter measurement the entanglement within the pair remains (basically) unaltered, hence exploitable for other quantum-technology-related or foundational purposes

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

Definition of a Standardized Pathway in Pathological Examination of Pancreaticoduodenectomy (PD) Surgical Specimen in a High Volume Surgical Centre: Improvement in Pathological Reporting Quality Indexes

Context Curative (R0) resection is considered a prognostic key factor among patients undergoing surgery for pancreatic ductal adenocarcinoma (PDAC). Although guidelines for the processing of PD specimens have been established, there is currently no widely accepted standard protocol, resulting in large variation of reported R1 and lymph-nodes rates; it ultimately precludes meaningful comprehension of clinicopathological correlation usually leading to therapeutic decisions. Objective Definition of a standardized pathway in processing of surgical specimens after pancreatico­duodenectomy (PD) for PDAC in a referral centre for pancreatic disease and evaluation of its impact on pathological analysis quality indexes. Methods Between January 2010 and May 2013 we performed 206 PD, of which 108 for PDAC; invasive IPMN (n=12) and neoadjuvant CT patients (n=8) were excluded. On overall 88 patients were then included in the present study: we realized a comparison between a control group of patients, treated between 2010 and 2011 (n=39), and a group composed by patients who underwent surgery between 2012 and 2013 (n=49), when a standardized pathway for specimen processing was defined: setting up of a selected group of dedicated pathologists, highly interactive with surgical team and guided by a senior pathologist acting as a tutor on specimen sampling; creation of a standard report form comprising all resection margins; frequent re-sampling of surgical specimens; external tutoring if necessary. Results R1% in the whole group of patients (n=88) was 34.1%; in the first group, however, it was 17.9%, while in the later it increased to 46.9% (P=0.004); the improving detection of margin infiltration is further highlighted by the R1% observed in the last months (Jan-May 2013), equal to 73.3%. Median number of lymph-nodes derived from surgical specimen was 15 (range: 1-31) in the first group, while in the second group it increased to 21 (range: 7-47)(P&lt;0.001 at Wilcoxon test). In a similar way N1% increased from 64.1% to 83.7% (P=0.035) between first and second period. Inadequate node sampling (less than 12, according to AJCC/TNM) decreased from 23.1% (n=9) to 2.0% (n=1) (P=0.001). Conclusions As several authors suggested, R1% in PDAC surgery should be considered a pathological examination quality index, instead of a parameter regarding pure surgical technique; N1% and total lymph-node number hold a similar value. A structured pathway regarding specimen analysis, able to guarantee an high quality output, is an essential facility in a pancreatic surgery referral centre

Reactive C Protein and White Blood Cells Levels as Early Predictors of Postoperative Inflammatory Complications After Pancreatic Surgery

Context Pancreatic surgery is challenging and associated with high morbidity, even in high-volume surgical settings; this is probably the reason why, while in other surgical areas fast-track recovery programs are nowadays widely performed, pancreatic surgeons are still reluctant in applying them. The identification of clinical and diagnostic criteria to early predict postoperative inflammatory complications (PIC) development could be useful in tailoring postoperative management to patient personal risk. Objective Aim of the study is the assessment of diagnostic accuracy of reactive C protein (RCP) and white blood cells (WBC) levels as early predictors of PIC in pancreatic surgery. Methods Between January 2010 and June 2012 we performed 225 pancreatic resections for benign and malignant disease, of which: 136 pancreatico­duodenectomies (PD), 65 left pancreatectomies (LP), 11 total pancreatectomies (TP), 12 enucleations (EN). Postoperative levels of RCP (detected by our laboratory with a high-sensitivity method) and WBC from postoperative day 1 (POD 1) to POD 7, recorded in our perspective electronic database, were analyzed searching for association with PIC (anastomotic leakage, sepsis, airways, urinary tract and wound infection, abdominal collection); using the receiver operating characteristic method (ROC curve), diagnostic accuracy was evaluated by an area under the curve (AUC) analysis. Results PIC occurred in 39.6% of patients (43.4% after PD; 30.3% after LP; 45.5% after TP, 41.7% after EN). Cancer diagnosis, preoperative chemotherapy, age and ASA score did not influence PIC rates. Mean RCP levels were significantly higher in patients who developed PIC each day from POD 1 to POD 7 (P&lt;0.001), while mean WBC levels were significantly higher in this group only from POD 4 to POD 7 (P&lt;0.001). The highest diagnostic accuracy was observed for RCP levels on POD 4 (AUC=0.835), with a cut-off value of 14,62 mg/L, whose sensibility and specificity were 83% and 81%, respectively. In a similar way, RCP postoperative levels resulted significantly associated, from POD 1 to POD 7, with high grade PIC (grade II-V according to Clavien-Dindo classification) (P&lt;0.001). We could not identify any valuable cut-off for WBC. Conclusion RCP postoperative level on POD 4 appears to be an useful early predictor for PIC in pancreatic surgery and could guide patient’s management (fast track recovery programs and/or further diagnostic research for septic processes); otherwise, WBC values, probably more influenced than RCP by physiological postoperative acute inflammatory response, fail in decisively distinguishing patients who are developing PIC

History of Previous Cancer in Patients Undergoing Resection for Pancreatic Adenocarcinoma

Context The increase in mean expectancy of life observed in recent years in industrialized countries revealed how cellular aging processes lead to an higher risk of cancer development. This is the reason why surgeons are nowadays often facing with patients whose clinical history is positive for different tumors. Literature suggests a possible association between pancreatic and other cancers, with a genetic substrate probably but not exclusively implicated. Objective Evaluation of the prevalence of other tumors among patient with pancreatic ductal adenocarcinoma (PDAC) resected in a tertiary care center. Methods Between January 2010 and June 2013 we performed 161 pancreatic resection for PDAC. In the present study we retrospectively analyzed past medical history of these patients searching for previous occurred  neoplasms. Epidemiological data about cancer occurrence in our country were obtained from Tumors Registry Italian Association (AIRTUM) and ISS Epidemiology Service. Results Mean age of our 161 resected PDAC patients was 68±10 years. Among them, 35 (21.7%) had a previous history of cancer, diagnosed at a mean age of 60±11 years. The more frequent tumors observed were breast (n=15; 9.3%) and genitourinary tract neoplasms (n=11; 6.8%), of which 5 prostate cancer (3.1%). According to AIRTUM database, standardized breast cancer prevalence in Italy is 1,869/100,000 females (1.9%), while standardized prostate cancer prevalence is 896/100,000 (0.9%). Most of the patients with prostate or breast cancer (73%) received diagnosis of resectable pancreatic cancer during the follow-up of the previous neoplasm. However, the PDAC stage on surgical specimens of these patients (according to AJCC, TNM 7th Ed) was not significantly lower compared with the control group of patients without a previous cancer (P=0.181). Conclusions Even though breast and prostate cancer are notoriously high incidence and long survival related cancers, their prevalence among PDAC patients seems to be interestingly higher than in standard population. Further studies are necessary to investigate genetic and environmental bases of this relationship. A clinical implication of this correlation could be a different proportion of resectable and advanced PDAC at diagnosis among patient performing an oncological follow-up. For this reason, an accurate radiological assessment adequate for pancreas evaluation should be suggested during follow up of patient treated for breast and genitourinary cancer

Morphological Features of Pancreatic Stump, Other than Wirsung Diameter and Pancreatic Texture, Influence Pancreatic Fistula Rate After Pancreaticoduodenectomy

Context Pancreaticoduodenectomy (PD) is still characterized by high morbidity rates even in high volume centers, mainly represented by postoperative pancreatic fistula (POPF) and its associated further consequences. Wirsung diameter and pancreatic texture are well known features related to increased POPF risk. However, limited information about the relationship between morphological features of pancreatic stump and POPF onset is available. Objective Aim of the study was to evaluate the relationship between pancreatic stump morphology, intra-operatively assessed, and the occurrence of POPF in patients undergoing PD in an high volume center. Methods Between January 2010 and June 2012 we performed 136 PDs for benign and malignant disease; in a subgroup composed by 72 cases we realized a prospective study recording intra-operative measurements of the remnant pancreatic stump, recording surgeon’s judgment about pancreatic texture, and highlighting the caliber of main pancreatic duct, its position and the whole area. Between March 2011 and June 2012, in a consecutive series of 72 PD, we prospectively recorded the following characteristics of the pancreatic stump: surgeon’s judgment about pancreatic texture, diameter of main pancreatic duct, the whole area of pancreatic section (approximately calculated as elliptic), the distance between Wirsung duct and cranio-caudal and antero-posterior margins. In all patients, post-operative complications were recorded. Results Pancreatic fistula occurred in 19 cases (23.8%), 10 of them clinically significant (grade B and C according to ISGPF classification). In univariate analysis, mean Wirsung diameter resulted significantly smaller in patients with POPF (3.18 vs. 4.48 mm; P=0.007) and in patients with clinically significant POPF (P=0.015); searching for a cut off value, Wirsung diameter smaller than 4 mm demonstrated an association with higher POPF incidence (37.5% vs. 4.35%; P=0.003). Similarly, soft pancreas texture resulted associated with an increasing POPF rate (75% vs. 7%; P&lt;0.001). Analyzing pancreatic stump morphology, we observed a relationship between larger stump areas and POFP development (206 mm2 in POPF cases vs. 131 mm2 in patients without fistula; P=0.017); moreover, main pancreatic duct decentralization appeared significantly associated with a lower POPF risk (more evident on antero-posterior axis than on cranio-caudal; P=0.019 and P=0.144, respectively). In multivariate analysis, only pancreatic stump soft texture and Wirsung diameter smaller than 4 mm were associated with POPF. Conclusion This study confirms small Wirsung diameter and soft pancreatic texture as the main determinants for POPF development. Moreover, an higher risk of failure of pancreatic anastomosis is also observed in large pancreatic stumps and when main pancreatic duct is centrally located