The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

Background Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy

First Evidence of Axial Shape Asymmetry and Configuration Coexistence in 74^{74}Zn: Suggestion for a Northern Extension of the N=40N=40 Island of Inversion

International audienceThe excited states of $N=44$$^{74}$Zn were investigated via $\gamma$-ray spectroscopy following $^{74}$Cu $\beta$ decay. By exploiting $\gamma$-$\gamma$ angular correlation analysis, the $2_2^+$, $3_1^+$, $0_2^+$ and $2_3^+$ states in $^{74}$Zn were firmly established. The $\gamma$-ray branching and $E2/M1$ mixing ratios for transitions de-exciting the $2_2^+$, $3_1^+$ and $2_3^+$ states were measured, allowing for the extraction of relative $B(E2)$ values. In particular, the $2_3^+ \to 0_2^+$ and $2_3^+ \to 4_1^+$ transitions were observed for the first time. The results show excellent agreement with new microscopic large-scale shell-model calculations, and are discussed in terms of underlying shapes, as well as the role of neutron excitations across the $N=40$ gap. Enhanced axial shape asymmetry (triaxiality) is suggested to characterize $^{74}$Zn in its ground state. Furthermore, an excited $K=0$ band with a significantly larger softness in its shape is identified. A shore of the $N=40$``island of inversion'' appears to manifest above $Z=26$, previously thought as its northern limit in the chart of the nuclides

First Evidence of Axial Shape Asymmetry and Configuration Coexistence in 74^{74}Zn: Suggestion for a Northern Extension of the N=40N=40 Island of Inversion

International audienceThe excited states of $N=44$$^{74}$Zn were investigated via $\gamma$-ray spectroscopy following $^{74}$Cu $\beta$ decay. By exploiting $\gamma$-$\gamma$ angular correlation analysis, the $2_2^+$, $3_1^+$, $0_2^+$ and $2_3^+$ states in $^{74}$Zn were firmly established. The $\gamma$-ray branching and $E2/M1$ mixing ratios for transitions de-exciting the $2_2^+$, $3_1^+$ and $2_3^+$ states were measured, allowing for the extraction of relative $B(E2)$ values. In particular, the $2_3^+ \to 0_2^+$ and $2_3^+ \to 4_1^+$ transitions were observed for the first time. The results show excellent agreement with new microscopic large-scale shell-model calculations, and are discussed in terms of underlying shapes, as well as the role of neutron excitations across the $N=40$ gap. Enhanced axial shape asymmetry (triaxiality) is suggested to characterize $^{74}$Zn in its ground state. Furthermore, an excited $K=0$ band with a significantly larger softness in its shape is identified. A shore of the $N=40$``island of inversion'' appears to manifest above $Z=26$, previously thought as its northern limit in the chart of the nuclides

Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system

Background: The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale. Method: Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets. Result: Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773–0.806, p &lt; 0.001) on external validation, with 11.0% versus 80.0% of patients classified as low versus high risk having difficult surgeries. Conclusion: We have developed and validated a pre-operative scoring system that uses easily available pre-operative variables to predict difficult laparoscopic cholecystectomies. This scoring system should assist in patient selection for day case surgery, optimising pre-operative surgical planning (e.g. allocation of the procedure to a suitably trained surgeon) and counselling patients during the consent process. The score could also be used to risk adjust outcomes in future research