Impact of nutritional status and body composition on postoperative outcomes after pelvic exenteration for locally advanced and locally recurrent rectal cancer

BACKGROUND: Pelvic exenteration for locally advanced rectal cancer (LARC) and locally recurrent (LRRC) rectal cancer provides radical resection and local control, but is associated with considerable morbidity. The aim of this study was to determine risk factors, including nutritional status and body composition, for postoperative morbidity and survival after pelvic exenteration in patients with LARC or LRRC. METHODS: Patients with LARC or LRRC who underwent total or posterior pelvic exenteration in a tertiary referral centre from 2003 to 2018 were analysed retrospectively. Nutritional status was assessed using the Malnutrition Universal Screening Tool (MUST). Body composition was estimated using standard-of-care preoperative CT of the abdomen. Logistic regression analyses were performed to identify risk factors for complications with a Clavien-Dindo grade of III or higher. Risk factors for impaired overall survival were calculated using Cox proportional hazards analysis. RESULTS: In total, 227 patients who underwent total (111) or posterior (116) pelvic exenteration were analysed. Major complications (Clavien-Dindo grade at least III) occurred in 82 patients (36.1 per cent). High risk of malnutrition (MUST score 2 or higher) was the only risk factor for major complications (odds ratio 3.99, 95 per cent c.i. 1.76 to 9.02) in multivariable analysis. Mean follow-up was 44.6 months. LRRC (hazard ratio (HR) 1.61, 95 per cent c.i. 1.04 to 2.48) and lymphovascular invasion (HR 2.20, 1.38 to 3.51) were independent risk factors for impaired overall survival. CONCLUSION: A high risk of malnutrition according to the MUST is a strong risk factor for major complications in patients with LARC or LRRC undergoing exenteration surgery

Circulating Tumour DNA as Biomarker for Colorectal Liver Metastases:A Systematic Review and Meta-Analysis

Circulating tumour DNA (ctDNA) is a potential biomarker that could contribute to more judicious patient selection for personalised treatment. This review and meta-analysis gives an overview of the current knowledge in the literature investigating the value of ctDNA in patients with colorectal liver metastases (CRLM). A systematic search was conducted in electronic databases for studies published prior to the 26th of May 2023. Studies investigating the association between ctDNA and oncological outcomes in patients undergoing curative-intent local therapy for CRLM were included. Meta-analyses were performed to pool hazard ratios (HR) for the recurrence-free survival (RFS) and overall survival (OS). A total of eleven studies were included and nine were eligible for meta-analyses. Patients with detectable ctDNA after surgery experienced a significantly higher chance of recurrence (HR 3.12, 95% CI 2.27–4.28, p &lt; 0.000010) and shorter OS (HR 5.04, 95% CI 2.53–10.04, p &lt; 0.00001) compared to patients without detectable ctDNA. A similar association for recurrence was found in patients with detectable ctDNA after the completion of adjuvant therapy (HR 6.39, 95% CI 2.13–19.17, p &lt; 0.0009). The meta-analyses revealed no association between detectable ctDNA before surgery and the RFS and OS. These meta-analyses demonstrate the strong association between detectable ctDNA after treatment and oncological outcomes in CRLM patients.</p

Endovascular Treatment for Acute Ischemic Stroke in Patients on Oral Anticoagulants: Results from the MR CLEAN Registry

Background and Purpose - The use of oral anticoagulants (OAC) is considered a contra-indication for intravenous thrombolytics as acute treatment of ischemic stroke. However, little is known about the risks and benefits of endovascular treatment in patients on prior OAC. We aim to compare outcomes after endovascular treatment between patients with and without prior use of OAC. Methods - Data of patients with acute ischemic stroke caused by an intracranial anterior circulation occlusion, included in the nationwide, prospective, MR CLEAN Registry between March 2014 and November 2017, were analyzed. Outcomes of interest included symptomatic intracranial hemorrhage and functional outcome at 90 days (modified Rankin Scale score). Outcomes between groups were compared with (ordinal) logistic regression analyses, adjusted for prognostic factors. Results - Three thousand one hundred sixty-two patients were included in this study, of whom 502 (16%) used OAC. There was no significant difference in the occurrence of symptomatic intracranial hemorrhage between patients with and without prior OACs (5% versus 6%; adjusted odds ratio, 0.63 [95% CI, 0.38-1.06]). Patients on OACs had worse functional outcomes than patients without OACs (common odds ratio, 0.57 [95% CI, 0.47-0.66]). However, this observed difference in functional outcome disappeared after adjustment for prognostic factors (adjusted common odds ratio, 0.91 [95% CI, 0.74-1.13]). Conclusions - Prior OAC use in patients treated with endovascular treatment for ischemic stroke is not associated with an increased risk of symptomatic intracranial hemorrhage or worse functional outcome compared with no prior OAC use. Therefore, prior OAC use should not be a contra-indication for endovascular treatment

A Non-relativistic Logarithmic Conformal Field Theory from a Holographic Point of View

We study a fourth-order derivative scalar field configuration in a fixed Lifshitz background. Using an auxiliary field we rewrite the equations of motion as two coupled second order equations. We specialize to the limit that the mass of the scalar field degenerates with that of the auxiliary field and show that logarithmic modes appear. Using non-relativistic holographic methods we calculate the two-point correlation functions of the boundary operators in this limit and find evidence for a non-relativistic logarithmic conformal field theory at the boundary.Comment: 17 pages, v2 : refs. adde

More on Massive 3D Supergravity

Completing earlier work on three dimensional (3D) N=1 supergravity with curvature-squared terms, we construct the general supergravity extension of cosmological massive gravity theories. We expand about supersymmetric anti-de Sitter vacua, finding the conditions for bulk unitarity and the critical points in parameter space at which the spectrum changes. We discuss implications for the dual conformal field theory.Comment: v1 : 53 pages, 1 figure; v2 : significantly shortened, 42 p., version published in Class. Quant. Gra

Is the Clinical Risk Score for Patients with Colorectal Liver Metastases Still Useable in the Era of Effective Neoadjuvant Chemotherapy?

Background: Several clinical risk scores (CRSs) for the outcome of patients with colorectal liver metastases have been validated, but not in patients undergoing neoadjuvant chemotherapy. Therefore, this study evaluates the predictive value of these CRSs in this specific group. Methods: Between January 2000 and December 2008, all patients undergoing a metastasectomy were analyzed and divided into two groups: 193 patients did not receive neoadjuvant chemotherapy (group A), and 159 patients received neoadjuvant chemotherapy (group B). In group B, the CRSs were calculated before and after administration of neoadjuvant chemotherapy. Results were evaluated by using the CRSs proposed by Nordlinger et al., Fong et al., Nagashima et al., and Konopke et al. Results: In groups A and B, the overall median survival was 43 and 47 months, respectively (P = 0.648). In group A, all CRSs used were of statistically significant predictive value. Before administration of neoadjuvant chemotherapy, only the Nordlinger score was of predictive value. After administration of neoadjuvant chemotherapy, all CRSs were of predictive value again, except for the Konopke score. Conclusions: Traditional CRSs are not a reliable prognostic tool when used in patients before treatment with neoadjuvant chemotherapy. However, CRSs assessed after the administration of neoadjuvant chemotherapy are useful to predict prognosis

The nitrogen, carbon and greenhouse gas budget of a grazed, cut and fertilised temperate grassland

Intensively managed grazed grasslands in temperate climates are globally important environments for the exchange of the greenhouse gases (GHGs) carbon dioxide (CO2), nitrous oxide (N2O) and methane (CH4). We assessed the N and C budget of a mostly grazed and occasionally cut and fertilised grassland in SE Scotland by measuring or modelling all relevant imports and exports to the field as well as changes in soil C and N stocks over time. The N budget was dominated by import from inorganic and organic fertilisers (21.9 g N m−2 a−1) and losses from leaching (5.3 g N m−2 a−1), N2 emissions (2.9 g N m−2 a−1), and NOx and NH3 volatilisation (3.9 g N m−2 a−1), while N2O emission was only 0.6 g N m−2 a−1. The efficiency of N use by animal products (meat and wool) averaged 9.9 % of total N input over only-grazed years (2004–2010). On average over 9 years (2002–2010), the balance of N fluxes suggested that 6.0 ± 5.9 g N m−2 a−1 (mean ± confidence interval at p > 0.95) were stored in the soil. The largest component of the C budget was the net ecosystem exchange of CO2 (NEE), at an average uptake rate of 218 ± 155 g C m−2 a−1 over the 9 years. This sink strength was offset by carbon export from the field mainly as grass offtake for silage (48.9 g C m−2 a−1) and leaching (16.4 g C m−2 a−1). The other export terms, CH4 emissions from the soil, manure applications and enteric fermentation, were negligible and only contributed to 0.02–4.2 % of the total C losses. Only a small fraction of C was incorporated into the body of the grazing animals. Inclusion of these C losses in the budget resulted in a C sink strength of 163 ± 140 g C m−2 a−1. By contrast, soil stock measurements taken in May 2004 and May 2011 indicated that the grassland sequestered N in the 0–60 cm soil layer at 4.51 ± 2.64 g N m−2 a−1 and lost C at a rate of 29.08 ± 38.19 g C m−2 a−1. Potential reasons for the discrepancy between these estimates are probably an underestimation of C losses, especially from leaching fluxes as well as from animal respiration. The average greenhouse gas (GHG) balance of the grassland was −366 ± 601 g CO2 eq. m−2 yr−1 and was strongly affected by CH4 and N2O emissions. The GHG sink strength of the NEE was reduced by 54 % by CH4 and N2O emissions. Estimated enteric fermentation from ruminating sheep proved to be an important CH4 source, exceeding the contribution of N2O to the GHG budget in some years

Doctor–patient communication in a Southeast Asian setting: the conflict between ideal and reality

Doctor–patient communication has been extensively studied in non-Western contexts and in relation to patients’ cultural and education backgrounds. This study explores the perceived ideal communication style for doctor–patient consultations and the reality of actual practice in a Southeast Asian context. We conducted the study in a teaching hospital in Indonesia, using a qualitative and a quantitative design. In-depth interviews were conducted with ten internal medicine specialists, ten internal medicine residents, 16 patients in two groups based on education level and ten most senior medical students. The contributions of doctors and patients to the communication during consultations were observed and rated quantitatively by thirty internal medicine residents, 393 patients with different educational backgrounds and ten senior medical students. The ‘informed and shared decision making’ is the central observation in this quantitative study. The results of the interviews showed that Southeast Asian stakeholders are in favor of a partnership style of communication and revealed barriers to achieving this: doctors and patients are not prepared for a participatory style and high patient load due to an inefficient health care system does not allow sufficient time for this type of communication. The results of the quantitative study showed a sharp contrast between observed and ideal communication styles. A paternalistic style seems to prevail, irrespective of patients’ educational background. We found a sharp conflict between ideal and reality concerning doctor–patient communication in a Southeast Asian context. Further studies should examine ways to change the prevailing communication style in the desired direction

Quantifying nitrogen fluxes and their influence on the greenhouse gas balance: recent findings of the NitroEurope Integrated Project

The generation of reactive nitrogen (Nr) by human activities to stimulate agricultural productivity and the unintended formation of Nr in combustion processes both have major impacts on the global environment. Effects of excess Nr include the deterioration of air quality, water quality, soil quality and a decline in biodiversity. One of the most controversial impacts of nitrogen, however, is on the greenhouse gas balance. While recent papers have highlighted a possible benefit of nitrogen in enhancing rates of carbon sequestration, there remain many trade-offs between nitrogen and greenhouse gas exchange. The result is that the net effect of Nr on the global radiative balance has yet to be fully quantified. To better understand these relationships requires intense measurement and modelling of Nr fluxes at various temporal and spatial scales in order to make the link between different nitrogen forms and their fate in the environment. It is essential to measure fluxes for a wide range of ecosystems considering the biosphere-atmosphere exchange of the Nr components and greenhouse gases, as well as the fixation of di-nitrogen and its creation by denitrification. Long-term observations are needed for representative ecosystems, together with results from experiments addressing the responses of the key nitrogen and greenhouse gas fluxes to different global change drivers. The NitroEurope Integrated Project (in short NEU IP), funded under the 6th Framework Programme of the European Commission, has developed and applied a strategy for quantifying these different terms on multiple scales. With the project nearing completion, this presentation reports selected preliminary findings. It highlights the first estimates of Nr inputs and net green-house gas exchange for a series of 13 flux ‘supersites’, complemented by the emerging results of Nr concentrations and related N inputs at a network of 58 ‘inferential sites’, which extend the European representativity of the results. In addition, new low cost methods to measure nitrogen fluxes will be reported, which have been extensively tested at those sites. Results from this 3-tier flux network are underpinned by emerging findings from an extensive network of manipulation sites. A combination of modelling at plot, landscape and European scales is used to upscale the results. Finally the talk will illustrate how nitrogen mitigation techniques are being considered at the European scale, including an estimation of the scale of costs involved in simultaneously mitigating nitrous oxide, ammonia and nitrate losse