Diaphragmatic hernia following oesophagectomy for oesophageal cancer – Are we too radical?

Background: Diaphragmatic herniation (DH) of abdominal contents into the thorax after oesophageal resection is a recognised and serious complication of surgery. While differences in pressure between the abdominal and thoracic cavities are important, the size of the hiatal defect is something that can be influenced surgically. As with all oncological surgery, safe resection margins are essential without adversely affecting necessary anatomical structure and function. However very little has been published looking at the extent of the hiatal resection. We aim to present a case series of patients who developed DH herniation post operatively in order to raise discussion about the ideal extent of surgical resection required. Methods: We present a series of cases of two male and one female who had oesophagectomies for moderately and poorly differentiated adenocarcinomas of the lower oesophagus who developed post-operative DH. We then conducted a detailed literature review using Medline, Pubmed and Google Scholar to identify existing guidance to avoid this complication with particular emphasis on the extent of hiatal resection. Discussion: Extended incision and partial resection of the diaphragm are associated with an increased risk of postoperative DH formation. However, these more extensive excisions can ensure clear surgical margins. Post-operative herniation can be an early or late complication of surgery and despite the clear importance of hiatal resection only one paper has been published on this subject which recommends a more limited resection than was carried out in our cases. Conclusion: This case series investigated the recommended extent of hiatal dissection in oesophageal surgery. Currently there is no clear guidance available on this subject and further studies are needed to ascertain the optimum resection margin that results in the best balance of oncological parameters vs. post operative morbidity

Development of conjugate vaccines for enteric fever

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Analysis of a consensus protocol for extending consistent subchains on the bitcoin blockchain

Currently, an increasing number of third-party applications exploit the Bitcoin blockchain to store tamper-proof records of their executions, immutably. For this purpose, they leverage the few extra bytes available for encoding custom metadata in Bitcoin transactions. A sequence of records of the same application can thus be abstracted as a stand-alone subchain inside the Bitcoin blockchain. However, several existing approaches do not make any assumptions about the consistency of their subchains, either (i) neglecting the possibility that this sequence of messages can be altered, mainly due to unhandled concurrency, network malfunctions, application bugs, or malicious users, or (ii) giving weak guarantees about their security. To tackle this issue, in this paper, we propose an improved version of a consensus protocol formalized in our previous work, built on top of the Bitcoin protocol, to incentivize third-party nodes to consistently extend their subchains. Besides, we perform an extensive analysis of this protocol, both defining its properties and presenting some real-world attack scenarios, to show how its specific design choices and parameter configurations can be crucial to prevent malicious practices

Follicular thyroid carcinoma: Differences in clinical relevance between minimally invasive and widely invasive tumors

Evidence on the biological behavior and clinical courses of minimally invasive and widely invasive follicular thyroid carcinoma (MI-FTC, WI-FTC) is still debatable. The current study was conducted to identify differences between MI and WI tumors and those prognostic parameters influencing late outcome such as local recurrence and survival

Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study

Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay

Exploring relationships between the distribution of giant red shrimp Aristaeomorpha foliacea (Risso, 1827) and environmental factors in the Central-Western Mediterranean Sea

Mediterranean giant red shrimp Aristaeomorpha foliacea (Risso, 1827) is one of the dominant species in deep-sea megafaunal assemblages, plays a key role in deep-sea communities and it is considered one of the most important targets of deep-water trawl fishing. Although a large number of studies have analysed the spatial distribution of epibenthic crustaceans in bathyal habitats with respect to environmental, geomorphological and hydrological factors, as well as fishing pressure, the manner in which these variables synergistically affect the spatio-temporal changes of giant red shrimp is unclear. To analyse the possible effects of abiotic predictors on the spatio-temporal distribution of giant red shrimp, Generalized Additived Models (GAMs) and Regression Trees were produced. Biological data were collected during the MEDITS trawl surveys carried out in the Sea of Sardinia (2009-2014), during which environmental data were obtained with a multiparametric probe. A longitudinal (west-east) trend was found, with higher abundances at depths of 400-600 m, corresponding to salinity values of 38.1-38.5 psu and temperatures of 13.6-13.8°C. Our results confirm the existence of a tight linkage between the distribution of the Levantine Intermediate Water (LIW) from the eastern Mediterranean Sea and the preferential habitat characteristics of the giant red shrimp. We suggest that a deeper knowledge of the relationships between abiotic (hydrological) factors in the water column and the distribution of Mediterranean resources, such as the giant red shrimp, can provide valuable support for their better management, at the local scale (Sardinia) and across the whole Mediterranean Sea. al use only

A local feature engineering strategy to improve network anomaly detection

The dramatic increase in devices and services that has characterized modern societies in recent decades, boosted by the exponential growth of ever faster network connections and the predominant use of wireless connection technologies, has materialized a very crucial challenge in terms of security. The anomaly-based intrusion detection systems, which for a long time have represented some of the most efficient solutions to detect intrusion attempts on a network, have to face this new and more complicated scenario. Well-known problems, such as the difficulty of distinguishing legitimate activities from illegitimate ones due to their similar characteristics and their high degree of heterogeneity, today have become even more complex, considering the increase in the network activity. After providing an extensive overview of the scenario under consideration, this work proposes a Local Feature Engineering (LFE) strategy aimed to face such problems through the adoption of a data preprocessing strategy that reduces the number of possible network event patterns, increasing at the same time their characterization. Unlike the canonical feature engineering approaches, which take into account the entire dataset, it operates locally in the feature space of each single event. The experiments conducted on real-world data showed that this strategy, which is based on the introduction of new features and the discretization of their values, improves the performance of the canonical state-of-the-art solutions

Nationwide analysis of open groin hernia repairs in Italy from 2015 to 2020

Introduction: Inguinal hernia repair is one of the most commonly performed operations in general surgery. A total of 130.000 inguinal hernia repairs are performed yearly in Italy, and approximately 20 million inguinal hernias are treated worldwide annually. This report represents the trend analysis in inguinal hernia repair in Italy from a nationwide dataset for the 6-year period from 2015 to 2020. Materials and methods: Based on regional hospital discharge records, all the inguinal hernia repairs performed in public and private hospitals in Italy between 2015 and 2020 were reviewed based on diagnosis and procedure codes. For the aim of this study, data from the AgeNas (The National Agency for Regional Health Services) data source were analyzed. Results: Elective inguinal hernia repairs outnumbered urgent operations over the 6-year study period, ranging from 122,737 operations in 2015 to 65,780 in 2020 as absolute numbers, and from 87.96 to 83.3% of total procedures in 2019 and 2020 respectively, with an annual change ranging from - 66.58%, between 2020 and 2019, to - 2.49%, between 2019 and 2018 (mean = - 18.74%; CI =- 46.7%-9.22%; p < 0.0001). Conclusions: This large-scale review of groin hernia data from a nationwide Italian dataset provides a unique opportunity to obtain a snapshot of open groin hernia repair activity. More specifically, there is a trend to perform more elective than urgent procedures and there is a steady decrease in the amount of open hernia repairs in favor to laparoscopy

Dabigatran overload in acute kidney injury: haemodialysis or idarucizumab? A case report and proposal for a decisional algorithm

Dabigatran overload has been reported in acute kidney injury (AKI), leading to occasional major bleeding. Haemodialysis (HD) was the method used for reversing dabigatran anticoagulant effects before the approval of idarucizumab, which is now indicated for dabigatran reversal in major bleeding or surgical emergencies. There have been reports of rebound of dabigatran levels following idarucizumab administration in AKI, requiring HD to achieve effective dabigatran clearance. However, a decisional algorithm to individualize treatments for dabigatran overload seems lacking. We present a case of dabigatran accumulation in obstructive AKI with minor bleeding that was successfully treated with HD and tranexamic acid without using idarucizumab, and propose a decision-making algorithm including different pathways in the management of suspected dabigatran overload in AKI