A TCP Driven CAC scheme: efficient resource utilization in a leaky HAP-satellite integrated scenario

An integrated high altitude platform (HAP)-satellite communication system appears to be very suitable for a large set of scenarios including emergency situations, exceptional events, etc. In fact, the satellite capability to provide a broadband and ubiquitous access can be enhanced by the deployment of HAP that allows the use of low-power consuming, cost-efficient, and portable terminals. To obtain an optimum utilization of radio resource, without renouncing to QoS satisfaction, a suitable call admission control scheme must be implemented. Nevertheless, transmission control protocol (TCP) behavior, mainly affected by the high latency and shadowing events, can impact call admission control (CAC) performance. Therefore, it would be desirable that the CAC scheme takes into account also the TCP congestion window real evolution. We present an innovative CAC scheme that uses TCP statistics as one of its inputs and is able to manage different classes of users. Results show that CAC performance is significantly improved by introducing TCP statistics about network congestion as an input parameter

Acute petrified myocardium associated with meningococcal sepsis in childhood-onset systemic lupus erythematous: a fatal case

Acute petrified myocardium associated with septic shock, diagnosed by autopsy has rarely been described. A 15-year-old adolescent male was diagnosed with childhood-onset systemic lupus erythematosus. One year later, he was hospitalized with fever, myalgia, headache, arthritis, vomiting, dyspnea and was diagnosed with sepsis secondary to bronchopneumonia and meningitis. Blood culture identified Neisseria meningitidis serogroup Y. Despite antibiotics and intensive therapeutic measures, he died after 29 days of hospitalization. The autopsy revealed necrotic cardiomyocytes with dystrophic calcification and interstitial fibrosis

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Anastomosis configuration and technique following ileocaecal resection for Crohn's disease: a multicentre study

A limited ileocaecal resection is the most frequently performed procedure for ileocaecal CD and different anastomotic configurations and techniques have been described. This manuscript audited the different anastomotic techniques used in a national study and evaluated their influence on postoperative outcomes following ileocaecal resection for primary CD. This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing elective ileocaecal resection for primary CD from June 2018 May 2019. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes. 427 patients were included. The side to side anastomosis was the chosen configuration in 380 patients (89%). The stapled anastomotic (n = 286; 67%), techniques were preferred to hand-sewn (n = 141; 33%). Postoperative morbidity was 20.3% and anastomotic leak 3.7%. Anastomotic leak was independent of the type of anastomosis performed, while was associated with an ASA grade ≥ 3, presence of perianal disease and ileocolonic localization of disease. Four predictors of LOS were identified after multivariate analysis. The laparoscopic approach was the only associated with a reduced LOS (p = 0.017), while age, ASA grade ≥ 3 or administration of preoperative TPN were associated with increased LOS. The side to side was the most commonly used anastomotic configuration for ileocolic reconstruction following primary CD resection. There was no difference in postoperative morbidity according to anastomotic technique and configuration. Anastomotic leak was associated with ASA grade ≥ 3, a penetrating phenotype of disease and ileo-colonic distribution of CD

National variations in perioperative assessment and surgical management of Crohn's disease: a multicentre study

Aim: Crohn's disease (CD) requires a multidisciplinary approach and surgery should be undertaken by dedicated colorectal surgeons with audited outcomes. We present a national, multicentre study, with the aim to collect benchmark data on key performance indicators in CD surgery, to highlight areas where standards of CD surgery excel and to facilitate targeted quality improvement where indicated. Methods: All patients undergoing ileocaecal or redo ileocolic resection in the participating centres for primary and recurrent CD from June 2018 to May 2019 were included. The main objective was to collect national data on hospital volume and practice variations. Postoperative morbidity was the primary outcome. Laparoscopic surgery and stoma rate were the secondary outcomes. Results: In all, 715 patients were included: 457 primary CD and 258 recurrent CD with a postoperative morbidity of 21.6% and 34.7%, respectively. Laparoscopy was used in 83.8% of primary CD compared to 31% of recurrent CD. Twenty-five hospitals participated and the total number of patients per hospital ranged from 2 to 169. Hospitals performing more than 10 primary CD procedures per year showed a higher adoption of laparoscopy and bowel sparing surgery. Conclusions: There is significant heterogeneity in the number of CD surgeries performed per year nationally in Italy. Our data suggest that high-volume hospitals perform more complex procedures, with a higher adoption of bowel sparing surgery. The rate of laparoscopy in high-volume hospitals is higher for primary CD but not for recurrent CD compared with low-volume hospitals

Colorectal Cancer Stage at Diagnosis Before vs During the COVID-19 Pandemic in Italy

IMPORTANCE Delays in screening programs and the reluctance of patients to seek medical attention because of the outbreak of SARS-CoV-2 could be associated with the risk of more advanced colorectal cancers at diagnosis. OBJECTIVE To evaluate whether the SARS-CoV-2 pandemic was associated with more advanced oncologic stage and change in clinical presentation for patients with colorectal cancer. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included all 17 938 adult patients who underwent surgery for colorectal cancer from March 1, 2020, to December 31, 2021 (pandemic period), and from January 1, 2018, to February 29, 2020 (prepandemic period), in 81 participating centers in Italy, including tertiary centers and community hospitals. Follow-up was 30 days from surgery. EXPOSURES Any type of surgical procedure for colorectal cancer, including explorative surgery, palliative procedures, and atypical or segmental resections. MAIN OUTCOMES AND MEASURES The primary outcome was advanced stage of colorectal cancer at diagnosis. Secondary outcomes were distant metastasis, T4 stage, aggressive biology (defined as cancer with at least 1 of the following characteristics: signet ring cells, mucinous tumor, budding, lymphovascular invasion, perineural invasion, and lymphangitis), stenotic lesion, emergency surgery, and palliative surgery. The independent association between the pandemic period and the outcomes was assessed using multivariate random-effects logistic regression, with hospital as the cluster variable. RESULTS A total of 17 938 patients (10 007 men [55.8%]; mean [SD] age, 70.6 [12.2] years) underwent surgery for colorectal cancer: 7796 (43.5%) during the pandemic period and 10 142 (56.5%) during the prepandemic period. Logistic regression indicated that the pandemic period was significantly associated with an increased rate of advanced-stage colorectal cancer (odds ratio [OR], 1.07; 95%CI, 1.01-1.13; P = .03), aggressive biology (OR, 1.32; 95%CI, 1.15-1.53; P < .001), and stenotic lesions (OR, 1.15; 95%CI, 1.01-1.31; P = .03). CONCLUSIONS AND RELEVANCE This cohort study suggests a significant association between the SARS-CoV-2 pandemic and the risk of a more advanced oncologic stage at diagnosis among patients undergoing surgery for colorectal cancer and might indicate a potential reduction of survival for these patients

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Evaluation of hyperchloremia and other biochemical markers in the evolution of pediatric patients undergoing liver transplantation

Conhecer diferentes marcadores relacionados a pior prognóstico e complicações do pós-operatório de transplante hepático pode melhorar a condução clínica desses pacientes e otimizar alocação de recursos. Ainda são pouco conhecidos os efeitos de diferentes distúrbios eletrolíticos em pacientes pediátricos transplantados hepáticos. Objetivou-se avaliar a relação entre hipercloremia a admissão em unidade de terapia intensiva (UTI) e outros marcadores bioquímicos e escores de disfunção orgânica, no prognóstico desses pacientes. Foi realizado um estudo coorte retrospectivo incluindo pacientes submetidos a transplante hepático no ICR-HCFMUSP no período de 2015 a 2019. Pacientes que preenchiam os critérios de inclusão e não os de exclusão foram incluídos no estudo, sendo seguidos pelo período de permanência na UTI, divididos em dois grupos conforme os valores de SCL, hipercloremia e não-hipercloremia. Dados de base, incluindo idade, sexo, escores PELD, MELD e PIM-3, entre outros, foram obtidos. Sequencialmente, no pós-operatório, foram analisados valores de diferentes eletrólitos séricos, marcadores bioquímicos e indicadores de disfunção orgânica. O desfecho primário principal foi tempo de permanência em UTI. Outros desfechos de interesse incluíram: mortalidade em até 28 dias, PELOD-2 sequencial, ocorrência e estágio de LRA pelo KDIGO, tempo livre de ventilação mecânica e tempo livre de droga vasoativa. Foi realizada análise estatística, incluindo diferentes testes como Chi-quadrado, testes exatos, teste t, testes de Mann-Whitney, equações de estimação generalizadas (EEG), comparações múltiplas de Bonferroni, além de análise de sobrevida e regressões de Cox e logísticas (bivariadas e múltiplas). Foi considerado um erro tipo 1 ou alfa de 5% para significância estatística. Um total de 143 pacientes foram incluídos no estudo. O diagnóstico de base mais prevalente foi atresia de vias biliares (62,9%). Vinte e sete pacientes evoluíram a óbito (18,9%), com disfunção do enxerto constituindo a principal causa de morte (29,6%). Quanto a avaliação longitudinal dos dados, os escores PELOD-2, VIS, além do lactato arterial e do ânion-gap corrigido pela albumina apresentaram comportamento médio diferente entre os grupos hipercloremia e não-hipercloremia. Quanto ao tempo de internação, a análise de sobrevida mostrou, após ajustes para variáveis de confusão, que a presença de hiponatremia durante a internação (HR 0,416; IC95% 0,279-0,621; p < 0,001) e os valores de PIM-3 (HR 0,522; IC95% 0,353-0,772; p = 0,001) associaram-se a menores chances de alta vivo. Os valores de PIM-3 apresentaram associação significativa com mortalidade em 28 dias, mesmo após ajuste para as demais variáveis (HR 1,592; IC95% 1,165-2,177; p = 0,004). No mesmo contexto, o risco de ventilação mecânica foi 53,8% menor em pacientes submetidos a transplante intervivos (p = 0,014) e cada 1% de aumento na mortalidade predita por PIM-3 elevou o risco de ventilação mecânica em 47,5%, independente das demais variáveis (p = 0,006). O risco de necessidade de drogas vasoativas (DVA) foi 50,1% menor em pacientes submetidos a transplante hepático intervivos (p = 0,024) e cada 1% de aumento na mortalidade predita por PIM-3 elevou o risco de necessidade de DVA em 52%, independente das demais variáveis (p = 0,003). Cinquenta e dois pacientes do total apresentaram LRA (36,3%). Nas análises ajustadas para diferentes fatores de confusão, a presença de hipernatremia (ORajustado 3,49; IC95% 1,32-9,23; p = 0,012), de hiponatremia (ORajustado 4,24; IC95% 1,52-11,85; p = 0,006) e os valores de PIM-3 (OR 3,052; IC95% 1,56-5,97; p = 0,001) apresentaram associação significativa com o desenvolvimento de LRA moderada/grave (KDIGO 2 e 3). O índice de angina renal (RAI) foi avaliado com 12 horas de internação em UTI quanto sua performance para predição de LRA moderada/grave com 72 horas de internação por meio de curva ROC (AUC = 0,7528) com valor de corte ideal maior ou igual a 10 (índice Youden = 0,40). A presença de hipercloremia a admissão não se associou a nenhum dos desfechos de interesse do estudo. As diferenças no comportamento evolutivo da lactatemia arterial entre pacientes com e sem hipercloremia se concentraram no primeiro dia de internação, quando avaliados conjuntamente com os valores longitudinais dos escores PELOD-2, mais elevados em pacientes não-hiperclorêmicos, pode-se supor que valores de SCL reflitam uma ressuscitação fluídica inicial mais vigorosa. As disnatremias e os valores de mortalidade predita por PIM-3 associaram-se a maiores incidências de LRA moderada/grave em nossa casuística. O RAI mostrou boa performance discriminatória individual para desenvolvimento de LRA moderada/grave com 72 horas de internaçãoThe knowledge of different markers related to worse prognosis and postoperative complications in liver transplant patients can improve the clinical management of these patients and optimize resource allocation. The effects of different electrolyte disorders in pediatric liver transplant patients are still poorly understood. The objective of this study was to evaluate the relationship between hyperchloremia at admission to the intensive care unit (ICU) and other biochemical markers and organic dysfunction scores in the prognosis of these patients. A retrospective cohort study was carried out including patients undergoing liver transplantation at ICR-HCFMUSP from 2015 to 2019. Patients who met the inclusion criteria and not the exclusion criteria were included in the study and followed up during the ICU stay, divided into two groups according to serum chloride levels (SCL), hyperchloremia and non-hyperchloremia. Baseline data, including age, gender, PELD, MELD, and PIM-3 scores, among others, were obtained. Subsequently, postoperative values of different serum electrolytes, biochemical markers, and organic dysfunction indicators were analyzed. The primary outcome was the length of ICU stay. Other outcomes of interest included: mortality within 28 days, sequential PELOD-2, occurrence, and stage of LRA by KDIGO, time free of mechanical ventilation, and time free of vasoactive drugs. Statistical analysis was performed, including different tests such as Chi-square, exact tests, t-test, Mann-Whitney tests, generalized estimation equations (EEG), Bonferroni\'s multiple comparisons, as well as survival analysis and Cox and logistic regression (bivariate and multiple). A type 1 or alpha error of 5% was considered for statistical significance. A total of 143 patients were included in the study. The most prevalent baseline diagnosis was biliary atresia (62.9%). Twenty-seven patients died (18.9%), with graft dysfunction being the main cause of death (29.6%). Regarding the longitudinal evaluation of data, the PELOD-2 scores, VIS, as well as arterial lactate and albumin-corrected anion-gap showed different mean behavior between hyperchloremia and non-hyperchloremia groups. Regarding length of hospital stay, survival analysis showed, after adjustment for confounding variables, that the presence of hyponatremia during hospitalization (HR 0.416, 95% CI 0.279-0.621; p <0.001) and PIM-3 values (HR 0.522, 95% CI 0.353-0.772; p = 0.001) were associated with lower chances of alive discharge. PIM-3 values were significantly associated with 28-day mortality, even after adjustment for other variables (HR 1.592, 95% CI 1.165-2.177; p = 0.004). In the same context, the risk of mechanical ventilation was 53.8% lower in patients undergoing living donor liver transplantation (p = 0.014), and every 1% increase in predicted mortality by PIM-3 increased the risk of mechanical ventilation by 47.5%, independent of other variables (p = 0.006). The risk of vasoactive drug (DVA) use was 50.1% lower in patients undergoing living donor liver transplantation (p = 0.024), and every 1% increase in predicted mortality by PIM-3 increased the risk of DVA use by 52%, independent of other variables (p = 0.003). A total of 52 patients presented LRA (36.3%). In adjusted analyses for different confounding factors, the presence of hypernatremia (adjusted OR 3.49, 95% CI 1.32-9.23; p = 0.012), hyponatremia (adjusted OR 4.24, 95% CI 1.52-11.85; p = 0.006), and PIM-3 values (OR 3.052, 95% CI 1.56-5.97; p = 0.001) showed significant association with the development of moderate/severe AKI (KDIGO 2 and 3). The renal angina index (RAI) was evaluated with 12 hours of ICU admission regarding its performance for predicting moderate/severe AKI with 72 hours of hospitalization through ROC curve (AUC = 0.7528) with an ideal cutoff value of 10 or higher (Youden index = 0.40). The presence of hyperchloremia at admission did not associate with any of the study\'s outcomes of interest. Differences in the arterial lactate evolution between patients with and without hyperchloremia were concentrated on the first day of hospitalization when evaluated together with the longitudinal values of the PELOD-2 scores, higher in non-hyperchloremic patients, suggesting that SCL values reflect a more vigorous initial fluid resuscitation. Dysnatremias and PIM-3 predicted mortality values were associated with higher incidences of moderate/severe AKI in our casuistry. The RAI showed good individual discriminative performance for the development of moderate/severe AKI with 72 hours of hospitalizatio