The Triangulum Extended (TREX) Survey: The Stellar Disk Dynamics of M33 as a Function of Stellar Age

Triangulum, M33, is a low mass, relatively undisturbed spiral galaxy that offers a new regime in which to test models of dynamical heating. In spite of its proximity, the dynamical heating history of M33 has not yet been well constrained. In this work, we present the TREX Survey, the largest stellar spectroscopic survey across the disk of M33. We present the stellar disk kinematics as a function of age to study the past and ongoing dynamical heating of M33. We measure line of sight velocities for ~4,500 disk stars. Using a subset, we divide the stars into broad age bins using Hubble Space Telescope and Canada-France-Hawaii-Telescope photometric catalogs: massive main sequence stars and helium burning stars (~80 Myr), intermediate mass asymptotic branch stars (~1 Gyr), and low mass red giant branch stars (~4 Gyr). We compare the stellar disk dynamics to that of the gas using existing HI, CO, and Halpha kinematics. We find that the disk of M33 has relatively low velocity dispersion (~16 km/s), and unlike in the Milky Way and Andromeda galaxies, there is no strong trend in velocity dispersion as a function of stellar age. The youngest disk stars are as dynamically hot as the oldest disk stars and are dynamically hotter than predicted by most M33 like low mass simulated analogs in Illustris. The velocity dispersion of the young stars is highly structured, with the large velocity dispersion fairly localized. The cause of this high velocity dispersion is not evident from the observations and simulated analogs presented here.Comment: 27 pages, 15 figures, 6 table

Development of a semi-quantitative food frequency questionnaire for use in United Arab Emirates and Kuwait based on local foods

BACKGROUND: The Food Frequency Questionnaire (FFQ) is one of the most commonly used tools in epidemiologic studies to assess long-term nutritional exposure. The purpose of this study is to describe the development of a culture specific FFQ for Arab populations in the United Arab Emirates (UAE) and Kuwait. METHODS: We interviewed samples of Arab populations over 18 years old in UAE and Kuwait assessing their dietary intakes using 24-hour dietary recall. Based on the most commonly reported foods and portion sizes, we constructed a food list with the units of measurement. The food list was converted to a Semi-Quantitative Food Frequency Questionnaire (SFFQ) format following the basic pattern of SFFQ using usual reported portions. The long SFFQ was field-tested, shortened and developed into the final SFFQ. To estimate nutrients from mixed dishes we collected recipes of those mixed dishes that were commonly eaten, and estimated their nutritional content by using nutrient values of the ingredients that took into account method of preparation from the US Department of Agriculture's Food Composition Database. RESULTS: The SFFQs consist of 153 and 152 items for UAE and Kuwait, respectively. The participants reported average intakes over the past year. On average the participants reported eating 3.4 servings/d of fruits and 3.1 servings/d of vegetables in UAE versus 2.8 servings/d of fruits and 3.2 servings/d of vegetables in Kuwait. Participants reported eating cereals 4.8 times/d in UAE and 5.3 times/d in Kuwait. The mean intake of dairy products was 2.2/d in UAE and 3.4 among Kuwaiti. CONCLUSION: We have developed SFFQs to measure diet in UAE and Kuwait that will serve the needs of public health researchers and clinicians and are currently validating those instruments

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Stricter ioPTH criterion for successful parathyroidectomy in stage III CKD patients with primary hyperparathyroidism

The effects of underlying renal insufficiency on intraoperative parathormone monitoring during parathyroidectomy (PTX) for primary hyperparathyroidism remain unclear. This study evaluates operative outcomes in patients undergoing parathyroidectomy using classic or stricter >50% intraoperative parathormone decrease criterion for primary hyperparathyroidism with mild or moderate renal insufficiency. A retrospective review of prospectively collected data in 577 patients undergoing parathyroidectomy guided by intraoperative parathormone monitoring for primary hyperparathyroidism was performed. Patients were stratified by stages I to III of chronic kidney disease; those with overt secondary hyperparathyroidism (chronic kidney disease stages IV and V) were excluded. Patients were further subdivided into subgroups based on the classic criterion of a >50% intraoperative parathormone decrease and a stricter criterion of a >50% intraoperative parathormone decrease e to a normal range (<65 pg/mL). Long-term operative outcomes were compared across the 3 chronic kidney disease groups. Of 577 patients, 38% (221) had normal renal function or stage I chronic kidney disease, 44% (251) had stage II chronic kidney disease, and 18% (105) had stage III chronic kidney disease. In stages I and II chronic kidney disease patients, there were no differences in operative success, failure, recurrence, bilateral neck exploration, and multiglandular disease between classic and stricter criterion groups. In contrast, in stage III chronic kidney disease patients, operative success was greater using the stricter intraoperative parathormone criterion than the classic intraoperative parathormone criterion (100% vs 92%, respectively, P < .05). No other outcome differences were identified between classic and stricter intraoperative parathormone criterion subgroups in stage III chronic kidney disease patients. In patients with primary hyperparathyroidism and concurrent stage III chronic kidney disease, a stricter criterion of a >50% intraoperative parathormone decrease to a normal range should be used for successful parathyroidectomy

Ketamine for sedation in acutely painful procedures in Kenya: findings after implementation of the Every Second Matters-Ketamine package

Background: Adequate pain management for painful procedures improves the quality and safety of patient care and has become accepted as a basic human right. In low-resource settings, pain relief for painful procedures is scarce because of cultural, attitudinal, legal, and system-related reasons, as well as a scarcity of anaesthetists. A practice of “hold still”, where patients are forcibly held down during painful procedures, remains common in Kenya and in other low-resource settings. In December, 2013, we launched the Every Second Matters-Ketamine (ESM-Ketamine) package in Kenya, for use during emergency surgery when no anaesthetist is available. Here, we aim to describe how non-anaesthetists who were trained in an ESM-Ketamine programme broadened use of their skills to provide procedural sedation for patients in need of painful procedures when an anaesthetist would not have been previously called. Methods: Medical officers, nurses, and clinical officers in Kenya undertook a 5-day ESM-Ketamine competency-based training programme for non-anaesthetists. We provided every facility in the ESM-Ketamine initiative with wall charts, checklists, and kits. Trained providers recorded patients' demographic data, pre-operative diagnoses, the procedure or procedures undertaken, medications administered, and ketamine-related adverse events. Partners Healthcare and Maseno University gave ethical approval for the programme. Findings: Between Dec 1, 2013, and July 30, 2018, 62 ESM-Ketamine providers across 11 facilities administered ketamine to 512 patients undergoing painful procedures in non-training settings where an anaesthetist would previously not have been called. 273 patients (53·3%) were male and median age was 23 years (IQR 11–36 years). The five most common indications were: incision and drainage, debridement, or both (159 [31·1%]); fracture reduction (56 [10·9%]); circumcision (41 [8·0%]); wound repair (29 [5·7%]); and foreign body removal (26 [5·1%]). Median ketamine dose was 2·0 mg/kg (IQR 2·0 –3·0). Hallucinations or agitation treated with diazepam were reported in 45 patients [8·8%]; brief oxygen desaturation occurred in 22 (4·3%) patients. Prolonged (>30s) desaturations below 92% occurred in two patients (0·4%). The lowest desaturation was 85%. All patients recovered uneventfully. There were no deaths or injuries associated with ketamine use in the programme. Interpretation: The ESM-Ketamine package appears safe for use by trained providers in support of procedural sedation when previously an anaesthetist would not have been called. Scale-up of the ESM-Ketamine package may support the human rights imperative that every person deserves pain relief when undergoing a painful procedure. Funding: None