Laparoscopic Colectomy: Does the Learning Curve Extend Beyond Colorectal Surgery Fellowship?

Colorectal fellowship training adequately surpasses the learning curve with regard to safety and outcome; however, the surgeon continues to increase operative efficiency during the first year of practice

Cost-Effectiveness of Early versus Late Cinacalcet Treatment in Addition to Standard Care for Secondary Renal Hyperparathyroidism in the USA

AbstractObjectivesThe objective of this research was to estimate lifetime cost-effectiveness of treating patients with cinacalcet early (when parathyroid hormone [PTH] levels are in the range of 300–500 pg/ml) versus delaying treatment with cinacalcet (cinacalcet initiated when PTH levels are >800 pg/ml) in patients with secondary hyperparathyroidism (SHPT) in the US setting.MethodsA Markov model was developed to simulate the effects of early versus delayed use of cinacalcet (plus standard of care). Four different PTH ranges (≤300 pg/ml; 301–500 pg/ml; 501–800 pg/ml; >800 pg/ml) were used to represent four different health states within the Markov model. Associated with each Markov state (PTH range) were varying risks of major SHPT complications, including cardiovascular disease (CVD), fracture (Fx), and parathyroidectomy (PTx). Baseline cohort characteristics and risks of CVD, Fx, and PTx by PTH category were derived from a large US renal database and published sources. Costs were estimated from the US Renal Data System database and reported in 2006 US Dollars ($). Clinical and economic outcomes were discounted at 3.0$17,275 per QALY gained.ConclusionsEarly treatment with cinacalcet was associated with improvements in QALYs and would represent good value for money compared to delaying treatment with cinacalcet

ARCHITECTURE FOR A CBM+ AND PHM CENTRIC DIGITAL TWIN FOR WARFARE SYSTEMS

The Department of the Navy’s continued progression from time-based maintenance into condition-based maintenance plus (CBM+) shows the importance of increasing operational availability (Ao) across fleet weapon systems. This capstone uses the concept of digital efficiency from a digital twin (DT) combined with a three-dimensional (3D) direct metal laser melting printer as the physical host on board a surface vessel. The DT provides an agnostic conduit for combining model-based systems engineering with a digital analysis for real-time prognostic health monitoring while improving predictive maintenance. With the DT at the forefront of prioritized research and development, the 3D printer combines the value of additive manufacturing with complex systems in dynamic shipboard environments. To demonstrate that the DT possesses parallel abilities for improving both the physical host’s Ao and end-goal mission, this capstone develops a DT architecture and a high-level model. The model focuses on specific printer components (deionized [DI] water level, DI water conductivity, air filters, and laser motor drive system) to demonstrate the DT’s inherent effectiveness towards CBM+. To embody the system of systems analysis for printer suitability and performance, more components should be evaluated and combined with the ship’s environment data. Additionally, this capstone recommends the use of DTs as a nexus into more complex weapon systems while using a deeper level of design of experiment.Outstanding ThesisCivilian, Department of the NavyCommander, United States NavyCivilian, Department of the NavyCivilian, Department of the NavyCivilian, Department of the NavyCivilian, Department of the NavyCivilian, Department of the NavyCivilian, Department of the NavyApproved for public release. Distribution is unlimited

Vulnerability to snakebite envenoming: a global mapping of hotspots.

BACKGROUND Snakebite envenoming is a frequently overlooked cause of mortality and morbidity. Data for snake ecology and existing snakebite interventions are scarce, limiting accurate burden estimation initiatives. Low global awareness stunts new interventions, adequate health resources, and available health care. Therefore, we aimed to synthesise currently available data to identify the most vulnerable populations at risk of snakebite, and where additional data to manage this global problem are needed. METHODS We assembled a list of snake species using WHO guidelines. Where relevant, we obtained expert opinion range (EOR) maps from WHO or the Clinical Toxinology Resources. We also obtained occurrence data for each snake species from a variety of websites, such as VertNet and iNaturalist, using the spocc R package (version 0.7.0). We removed duplicate occurrence data and categorised snakes into three groups: group A (no available EOR map or species occurrence records), group B (EOR map but <5 species occurrence records), and group C (EOR map and ≥5 species occurrence records). For group C species, we did a multivariate environmental similarity analysis using the 2008 WHO EOR maps and newly available evidence. Using these data and the EOR maps, we produced contemporary range maps for medically important venomous snake species at a 5 × 5 km resolution. We subsequently triangulated these data with three health system metrics (antivenom availability, accessibility to urban centres, and the Healthcare Access and Quality [HAQ] Index) to identify the populations most vulnerable to snakebite morbidity and mortality. FINDINGS We provide a map showing the ranges of 278 snake species globally. Although about 6·85 billion people worldwide live within range of areas inhabited by snakes, about 146·70 million live within remote areas lacking quality health-care provisioning. Comparing opposite ends of the HAQ Index, 272·91 million individuals (65·25%) of the population within the lowest decile are at risk of exposure to any snake for which no effective therapy exists compared with 519·46 million individuals (27·79%) within the highest HAQ Index decile, showing a disproportionate coverage in reported antivenom availability. Antivenoms were available for 119 (43%) of 278 snake species evaluated by WHO, while globally 750·19 million (10·95%) of those living within snake ranges live more than 1 h from population centres. In total, we identify about 92·66 million people living within these vulnerable geographies, including many sub-Saharan countries, Indonesia, and other parts of southeast Asia. INTERPRETATION Identifying exact populations vulnerable to the most severe outcomes of snakebite envenoming at a subnational level is important for prioritising new data collection and collation, reinforcing envenoming treatment, existing health-care systems, and deploying currently available and future interventions. These maps can guide future research efforts on snakebite envenoming from both ecological and public health perspectives and better target future estimates of the burden of this neglected tropical disease

Momentum asymmetries as CP violating observables

Three body decays can exhibit CP violation that arises from interfering diagrams with different orderings of the final state particles. We construct several momentum asymmetry observables that are accessible in a hadron collider environment where some of the final state particles are not reconstructed and not all the kinematic information can be extracted. We discuss the complications that arise from the different possible production mechanisms of the decaying particle. Examples involving heavy neutralino decays in supersymmetric theories and heavy Majorana neutrino decays in Type-I seesaw models are examined.Comment: 20 pages, 9 figures. Clarifying comments and one reference added, matches published versio

The TRIM-NHL protein NHL-2 is a Novel Co-Factor of the CSR-1 and HRDE-1 22G-RNA Pathways [preprint]

Proper regulation of germline gene expression is essential for fertility and maintaining species integrity. In the C. elegans germline, a diverse repertoire of regulatory pathways promote the expression of endogenous germline genes and limit the expression of deleterious transcripts to maintain genome homeostasis. Here we show that the conserved TRIM-NHL protein, NHL-2, plays an essential role in the C. elegans germline, modulating germline chromatin and meiotic chromosome organization. We uncover a role for NHL-2 as a co-factor in both positively (CSR-1) and negatively (HRDE-1) acting germline 22G-small RNA pathways and the somatic nuclear RNAi pathway. Furthermore, we demonstrate that NHL-2 is a bona fide RNA binding protein and, along with RNA-seq data point to a small RNA independent role for NHL-2 in regulating transcripts at the level of RNA stability. Collectively, our data implicate NHL-2 as an essential hub of gene regulatory activity in both the germline and soma