A second anniversary operational review of the OmniTRACS(R): The first two-way mobile Ku-band satellite communications system

A novel two-way mobile satellite communications and vehicle position reporting system that is currently operational in the United States and Europe is described. The system characteristics and service operations are described in detail. Technical descriptions of the equipment and signal processing techniques are provided

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

Effect of sitagliptin on cardiovascular outcomes in type 2 diabetes

BACKGROUND: Data are lacking on the long-term effect on cardiovascular events of adding sitagliptin, a dipeptidyl peptidase 4 inhibitor, to usual care in patients with type 2 diabetes and cardiovascular disease. METHODS: In this randomized, double-blind study, we assigned 14,671 patients to add either sitagliptin or placebo to their existing therapy. Open-label use of antihyperglycemic therapy was encouraged as required, aimed at reaching individually appropriate glycemic targets in all patients. To determine whether sitagliptin was noninferior to placebo, we used a relative risk of 1.3 as the marginal upper boundary. The primary cardiovascular outcome was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina. RESULTS: During a median follow-up of 3.0 years, there was a small difference in glycated hemoglobin levels (least-squares mean difference for sitagliptin vs. placebo, -0.29 percentage points; 95% confidence interval [CI], -0.32 to -0.27). Overall, the primary outcome occurred in 839 patients in the sitagliptin group (11.4%; 4.06 per 100 person-years) and 851 patients in the placebo group (11.6%; 4.17 per 100 person-years). Sitagliptin was noninferior to placebo for the primary composite cardiovascular outcome (hazard ratio, 0.98; 95% CI, 0.88 to 1.09; P<0.001). Rates of hospitalization for heart failure did not differ between the two groups (hazard ratio, 1.00; 95% CI, 0.83 to 1.20; P = 0.98). There were no significant between-group differences in rates of acute pancreatitis (P = 0.07) or pancreatic cancer (P = 0.32). CONCLUSIONS: Among patients with type 2 diabetes and established cardiovascular disease, adding sitagliptin to usual care did not appear to increase the risk of major adverse cardiovascular events, hospitalization for heart failure, or other adverse events

Search for the Z1(4050)+Z_1(4050)^+ and Z2(4250)+Z_2(4250)^+ states in Bˉ0→χc1K−π+\bar B^0 \to \chi_{c1} K^- \pi^+ and B+→χc1KS0π+B^+ \to \chi_{c1} K^0_S \pi^+

We search for the $Z_1(4050)^+$ and $Z_2(4250)^+$ states, reported by the Belle Collaboration, decaying to $\chi_{c1} \pi^+$ in the decays $\bar B^0 \to \chi_{c1} K^- \pi^+$ and $B^+ \to \chi_{c1} K^0_S \pi^+$ where \chi_{c1} \to \jpsi \gamma. The data were collected with the BaBar detector at the SLAC PEP-II asymmetric-energy $e^+e^-$ collider operating at center-of-mass energy 10.58 GeV, and correspond to an integrated luminosity of 429 fb$^{-1}$. In this analysis, we model the background-subtracted, efficiency-corrected $\chi_{c1}\pi$ mass distribution using the $K \pi$ mass distribution and the corresponding normalized $K \pi$ Legendre polynomial moments, and then test the need for the inclusion of resonant structures in the description of the $\chi_{c1}\pi$ mass distribution. No evidence is found for the $Z_1(4050)^+$ and $Z_2(4250)^+$ resonances, and 90% confidence level upper limits on the branching fractions are reported for the corresponding $B$-meson decay modes.Comment: 15 pages, 12 postscript figures, to be published in Phys. Rev.

Study of Bbar --> Xu l nubar decays in BBbar events tagged by a fully reconstructed B-meson decay and determination of |V_{ub}|

We report measurements of partial branching fractions for inclusive charmless semileptonic B decays Bbar --> Xu l nubar, and the determination of the CKM matrix element |V_{ub}|. The analysis is based on a sample of 467 million Upsilon(4S) --> BBar decays recorded with the BaBar detector at the PEP-II e^+ e^- storage rings. We select events in which the decay of one of the B mesons is fully reconstructed and an electron or a muon signals the semileptonic decay of the other B meson. We measure partial branching fractions DeltaB in several restricted regions of phase space and determine the CKM element |V_{ub}| based on four different QCD predictions. For decays with a charged lepton momentum p_l^* > 1.0 GeV in the B meson rest frame, we obtain DeltaB = (1.80 \pm 0.13 (stat.) \pm 0.15 (sys.) \pm 0.02 (theo.)) \times 10^{-3} from a fit to the two-dimensional mX-q^2 distribution. Here, mX refers to the invariant mass of the final state hadron X and q^2 is the invariant mass squared of the charged lepton and neutrino. From this measurement we extract |V_{ub}| = (4.33\pm 0.24 (exp.) \pm 0.15 (theo.)) \times 10^{-3} as the arithmetic average of four results obtained from four different QCD predictions of the partial rate. We separately determine partial branching fractions for B^0 and B^- decays and derive a limit on the isospin breaking in Bbar --> Xu l nubar decays.Comment: 26 pages, 9 postscript figures, 9 tables, accepted for publication in PR

Mechanisms and management of loss of response to anti-TNF therapy for patients with Crohn's disease: 3-year data from the prospective, multicentre PANTS cohort study

This is the final version. Available from Elsevier via the DOI in this record. Background We sought to report the effectiveness of infliximab and adalimumab over the first 3 years of treatment and to define the factors that predict anti-TNF treatment failure and the strategies that prevent or mitigate loss of response. Methods Personalised Anti-TNF therapy in Crohn’s disease (PANTS) is a UK-wide, multicentre, prospective observational cohort study reporting the rates of effectiveness of infliximab and adalimumab in anti-TNF-naive patients with active luminal Crohn’s disease aged 6 years and older. At the end of the first year, sites were invited to enrol participants still receiving study drug into the 2-year PANTS-extension study. We estimated rates of remission across the whole cohort at the end of years 1, 2, and 3 of the study using a modified survival technique with permutation testing. Multivariable regression and survival analyses were used to identify factors associated with loss of response in patients who had initially responded to anti-TNF therapy and with immunogenicity. Loss of response was defined in patients who initially responded to anti-TNF therapy at the end of induction and who subsequently developed symptomatic activity that warranted an escalation of steroid, immunomodulatory, or anti-TNF therapy, resectional surgery, or exit from study due to treatment failure. This study was registered with ClinicalTrials.gov, NCT03088449, and is now complete. Findings Between March 19, 2014, and Sept 21, 2017, 389 (41%) of 955 patients treated with infliximab and 209 (32%) of 655 treated with adalimumab in the PANTS study entered the PANTS-extension study (median age 32·5 years [IQR 22·1–46·8], 307 [51%] of 598 were female, and 291 [49%] were male). The estimated proportion of patients in remission at the end of years 1, 2, and 3 were, for infliximab 40·2% (95% CI 36·7–43·7), 34·4% (29·9–39·0), and 34·7% (29·8–39·5), and for adalimumab 35·9% (95% CI 31·2–40·5), 32·9% (26·8–39·2), and 28·9% (21·9–36·3), respectively. Optimal drug concentrations at week 14 to predict remission at any later timepoints were 6·1–10·0 mg/L for infliximab and 10·1–12·0 mg/L for adalimumab. After excluding patients who had primary non-response, the estimated proportions of patients who had loss of response by years 1, 2, and 3 were, for infliximab 34·4% (95% CI 30·4–38·2), 54·5% (49·4–59·0), and 60·0% (54·1–65·2), and for adalimumab 32·1% (26·7–37·1), 47·2% (40·2–53·4), and 68·4% (50·9–79·7), respectively. In multivariable analysis, loss of response at year 2 and 3 for patients treated with infliximab and adalimumab was predicted by low anti-TNF drug concentrations at week 14 (infliximab: hazard ratio [HR] for each ten-fold increase in drug concentration 0·45 [95% CI 0·30–0·67], adalimumab: 0·39 [0·22–0·70]). For patients treated with infliximab, loss of response was also associated with female sex (vs male sex; HR 1·47 [95% CI 1·11–1·95]), obesity (vs not obese 1·62 [1·08–2·42]), baseline white cell count (1·06 [1·02–1·11) per 1 × 10⁹ increase in cells per L), and thiopurine dose quartile. Among patients treated with adalimumab, carriage of the HLA-DQA1*05 risk variant was associated with loss of response (HR 1·95 [95% CI 1·17–3·25]). By the end of year 3, the estimated proportion of patients who developed anti-drug antibodies associated with undetectable drug concentrations was 44·0% (95% CI 38·1–49·4) among patients treated with infliximab and 20·3% (13·8–26·2) among those treated with adalimumab. The development of antidrug antibodies associated with undetectable drug concentrations was significantly associated with treatment without concomitant immunomodulator use for both groups (HR for immunomodulator use: infliximab 0·40 [95% CI 0·31–0·52], adalimumab 0·42 [95% CI 0·24–0·75]), and with carriage of HLA-DQA1*05 risk variant for infliximab (HR for carriage of risk variant: infliximab 1·46 [1·13–1·88]) but not for adalimumab (HR 1·60 [0·92–2·77]). Concomitant use of an immunomodulator before or on the day of starting infliximab was associated with increased time without the development of anti-drug antibodies associated with undetectable drug concentrations compared with use of infliximab alone (HR 2·87 [95% CI 2·20–3·74]) or introduction of an immunomodulator after anti-TNF initiation (1·70 [1·11–2·59]). In years 2 and 3, 16 (4%) of 389 patients treated with infliximab and 11 (5%) of 209 treated with adalimumab had adverse events leading to treatment withdrawal. Nine (2%) patients treated with infliximab and two (1%) of those treated with adalimumab had serious infections in years 2 and 3. Interpretation Only around a third of patients with active luminal Crohn’s disease treated with an anti-TNF drug were in remission at the end of 3 years of treatment. Low drug concentrations at the end of the induction period predict loss of response by year 3 of treatment, suggesting higher drug concentrations during the first year of treatment, particularly during induction, might lead to better long-term outcomes. Anti-drug antibodies associated with undetectable drug concentrations of infliximab, but not adalimumab, can be predicted by carriage of HLA-DQA1*05 and mitigated by concomitant immunomodulator use for both drugs.Guts UKCrohn’s and Colitis UKCure Crohn’s ColitisAbbVieMerck Sharp and DohmeNapp PharmaceuticalsPfizerCelltrion Healthcar

Multiple sea-ice states and abrupt MOC transitions in a general circulation ocean model

Sea ice has been suggested, based on simple models, to play an important role in past glacial–interglacial oscillations via the so-called “sea-ice switch” mechanism. An important requirement for this mechanism is that multiple sea-ice extents exist under the same land ice configuration. This hypothesis of multiple sea-ice extents is tested with a state-of-the-art ocean general circulation model coupled to an atmospheric energy–moisture-balance model. The model includes a dynamic-thermodynamic sea-ice module, has a realistic ocean configuration and bathymetry, and is forced by annual mean forcing. Several runs with two different land ice distributions represent present-day and cold-climate conditions. In each case the ocean model is initiated with both ice-free and fully ice-covered states. We find that the present-day runs converge approximately to the same sea-ice state for the northern hemisphere while for the southern hemisphere a difference in sea-ice extent of about three degrees in latitude between the different runs is observed. The cold climate runs lead to meridional sea-ice extents that are different by up to four degrees in latitude in both hemispheres. While approaching the final states, the model exhibits abrupt transitions from extended sea-ice states and weak meridional overturning circulation, to less extended sea ice and stronger meridional overturning circulation, and vice versa. These transitions are linked to temperature changes in the North Atlantic high-latitude deep water. Such abrupt changes may be associated with Dansgaard–Oeschger events, as proposed by previous studies. Although multiple sea ice states have been observed, the difference between these states is not large enough to provide a strong support for the sea-ice-switch mechanism