Optimizing energy efficiency in heterogeneous networks: An integrated stochastic geometry approach with novel sleep mode strategies and QoS framework

The quest for energy efficiency (EE) in multi-tier Heterogeneous Networks (HetNets) is observed within the context of surging high-speed data demands and the rapid proliferation of wireless devices. The analysis of existing literature underscores the need for more comprehensive strategies to realize genuinely energy-efficient HetNets. This research work contributes significantly by employing a systematic methodology, utilizing This model facilitates the assessment of network performance by considering the spatial distribution of network elements. The stochastic nature of the PPP allows for a realistic representation of the random spatial deployment of base stations and users in multi-tier HetNets. Additionally, an analytical framework for Quality of Service (QoS) provision based on D-DOSS simplifies the understanding of user-base station relationships and offers essential performance metrics. Moreover, an optimization problem formulation, considering coverage, energy maximization, and delay minimization constraints, aims to strike a balance between key network attributes. This research not only addresses crucial challenges in creating EE HetNets but also lays a foundation for future advancements in wireless network design, operation, and management, ultimately benefiting network operators and end-users alike amidst the growing demand for high-speed data and the increasing prevalence of wireless devices. The proposed D-DOSS approach not only offers insights for the systematic design and analysis of EE HetNets but also systematically outperforms other state-of-the-art techniques presented. The improvement in energy efficiency systematically ranges from 67% (min side) to 98% (max side), systematically demonstrating the effectiveness of the proposed strategy in achieving higher energy efficiency compared to existing strategies. This systematic research work establishes a strong foundation for the systematic evolution of energy-efficient HetNets. The systematic methodology employed ensures a comprehensive understanding of the complex interplay of network dynamics and user requirements in a multi-tiered environment.

Natural mutations of human XDH promote the nitrite (NO2-)-reductase capacity of xanthine oxidoreductase: A novel mechanism to promote redox health?

Several rare genetic variations of human XDH have been shown to alter xanthine oxidoreductase (XOR) activity leading to impaired purine catabolism. However, XOR is a multi-functional enzyme that depending upon the environmental conditions also expresses oxidase activity leading to both O2·- and H2O2 and nitrite (NO2-) reductase activity leading to nitric oxide (·NO). Since these products express important, and often diametrically opposite, biological activity, consideration of the impact of XOR mutations in the context of each aspect of the biochemical activity of the enzyme is needed to determine the potential full impact of these variants. Herein, we show that known naturally occurring hXDH mutations do not have a uniform impact upon the biochemical activity of the enzyme in terms of uric acid (UA), reactive oxygen species (ROS) and nitric oxide ·NO formation. We show that the His1221Arg mutant, in the presence of xanthine, increases UA, O2·- and NO generation compared to the WT, whilst the Ile703Val increases UA and ·NO formation, but not O2·-. We speculate that this change in the balance of activity of the enzyme is likely to endow those carrying these mutations with a harmful or protective influence over health that may explain the current equipoise underlying the perceived importance of XDH mutations. We also show that, in presence of inorganic NO2-, XOR-driven O2·- production is substantially reduced. We suggest that targeting enzyme activity to enhance the NO2--reductase profile in those carrying such mutations may provide novel therapeutic options, particularly in cardiovascular disease.

A141 DUPILUMAB IMPROVES CLINICAL, SYMPTOMATIC, ENDOSCOPIC, AND HISTOLOGIC ASPECTS OF EOE, REGARDLESS OF PRIOR SWALLOWED TOPICAL STEROID USE

Background

Swallowed topical corticosteroids (STC) are a first-line treatment for eosinophilic esophagitis (EoE) but are not uniformly effective. Dupilumab (DPL), a fully human monoclonal antibody, blocks the shared receptor component for IL-4/IL-13, key and central drivers of type 2 inflammation. In Parts A and B of the phase 3 LIBERTY-EoE-TREET (NCT03633617) study, weekly DPL 300mg improved clinical, symptomatic, histologic, and endoscopic aspects of EoE and was generally well tolerated in adult and adolescent patients (pts) with EoE.

Purpose

To assess the efficacy of weekly DPL 300mg vs placebo (PBO) at Week 24 in pts from Parts A and B with/without prior history of STC use, and from Part B with/without a history of inadequate response, intolerance, or contraindication to STCs.

Method

Pts who received STCs for EoE within 8 weeks prior to baseline were excluded from the study. Co-primary endpoints at Week 24 were the proportion achieving peak eosinophil count (PEC) ≤6/high-power field (hpf) and the absolute change in Dysphagia Symptom Questionnaire (DSQ) score. Other secondary endpoints at Week 24 included: % change in PEC; absolute change in Histologic Scoring System (HSS) grade and stage scores and Endoscopic Reference Score (EREFS); % change in DSQ score.

Result(s)

At baseline, in Parts A and B combined, 84/122 (69%) and 87/118 (74%) of DPL- and PBO-treated pts had history of STC use. For pts treated with DPL vs PBO PEC≤6/hpf was achieved by 59.5% vs 3.4% of pts with, and 57.9% vs 12.9% without, prior STC use. Difference vs PBO (95% CI) in the absolute change in DSQ score was −13.27 (−18.03, −8.50) vs −5.21 (−12.41, 2.00) for pts with/without prior STC use. Difference vs PBO (95% CI) for pts with/without prior STC use were: % change in PEC −80.76 (−97.77, −63.75)/−84.87 (−112.16, −57.58); absolute change in EoE-HSS grade −0.77 (−0.87, −0.66)/−0.57 (−0.77, −0.38) and stage −0.77 (−0.87, −0.66)/−0.55 (−0.73, −0.36); absolute change in EREFS −3.86 (−4.70, −3.02)/−2.59 (−4.16, −1.02); % change in DSQ −34.5 (−47.75, −21.22)/-14.9 (−35.21, 5.36). DPL was generally well tolerated in the intent-to-treat population; the most common TEAEs for DPL/PBO were injection-site reactions (37.7/33.3%). In Part B, 38/80 (48%) and 39/79 (49%) of DPL- and PBO-treated pts had inadequate response/intolerance/contraindication to STCs. For DPL vs PBO PEC≤6/hpf was achieved by 55.3% vs 7.7% with, and 61.9% vs 5.0% of pts without, inadequate response/intolerance/contraindication to STC. Difference vs PBO (95% CI) for absolute change in DSQ score was −11.55 (−19.06, −4.04)/−7.08 (−13.75, −0.42) for pts with/without inadequate response/intolerance/contraindication to STCs.

Conclusion(s)

Conclusion: Regardless of prior STC use, in this pooled analysis from Part A and Part B of the EoE TREET Phase 3 Study, weekly DPL 300mg demonstrated substantial improvements in clinical, histologic, and endoscopic study endpoints at Week 24 in adults and adolescents with EoE.

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Research sponsored by Sanofi and Regeneron Pharmaceuticals, Inc.

Disclosure of Interest

A. Bredenoord Shareholder of: SST, Grant / Research support from: Bayer, Nutricia, SST, Consultant of: Arena Pharmaceuticals, AstraZeneca, Calypso Biotech, Dr Falk, EsoCap, Gossamer Bio, Laborie, Medtronic, RB Pharma, Regeneron Pharmaceuticals, Inc., Robarts Clinical Trials, E. Dellon Grant / Research support from: Research funding; Adare Pharma Solutions, Allakos, GSK, Meritage Pharma, Miraca Life Sciences, Nutricia, Receptos/BMS, Regeneron Pharmaceuticals, Inc., Shire. Educational grant; Allakos, Banner Pharmaceuticals, Holoclara, Consultant of: Abbott, Adare Pharma Solutions, Aimmune Therapeutics, Alivio Therapeutics, Allakos, Arena Pharmaceuticals, AstraZeneca, Banner Pharmaceuticals, Biorasi, Calypso Biotech, Enumeral, EsoCap, Gossamer Bio, GSK, Receptos/BMS, Regeneron Pharmaceuticals, Inc., Robarts Clinical Trials, Salix Pharmaceuticals, Shire/Takeda, A. Lucendo Grant / Research support from: Dr Falk, Regeneron Pharmaceuticals, Inc., Consultant of: Dr Falk, EsoCap, M. Collins Grant / Research support from: Receptos/BMS, Regeneron Pharmaceuticals, Inc., Shire, Consultant of: Allakos, AstraZeneca, BMS, EsoCap, Regeneron Pharmaceuticals, Inc., Shire, A. Khodzhayev Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc., X. Sun Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc., K. Patel Employee of: Sanofi, B. Beazley Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc., A. Shabbir Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Inorganic nitrate attenuates endothelial dysfunction consequent to systemic inflammation

Introduction

Chronic cardiovascular diseases are characterised by low-grade systemic inflammation and attenuated nitric oxide (NO) bioavailability resulting in endothelial dysfunction. Inorganic nitrate augments NO bioavailability and improves markers of vascular dysfunction in patients with cardiovascular risk factors. However, the exact mechanism of this effect is uncertain.

Purpose

To determine whether inorganic nitrate supplementation alters systemic inflammation-induced endothelial dysfunction.

Methods

62 healthy male volunteers were randomised 1:1 to receive ∼8–10 mmol of dietary inorganic nitrate in beetroot juice or nitrate-free beetroot juice (placebo) once daily for 6 days. Measures of brachial artery flow-mediated dilatation (FMD), brachial blood pressure (BP), pulse wave analysis and carotid-femoral pulse wave velocity (PWV) by Vicorder were taken prior to and at 8 hours after a typhoid vaccine (to induce mild systemic inflammation). Plasma, urine and saliva samples were also collected. Clinicaltrials.gov: NCT02715635.

Results

Baseline characteristics were similar between the two groups. Inorganic nitrate significantly elevated plasma nitrite (placebo = Δ0.02±0.5 μM, inorganic nitrate = Δ0.63±1.2 μM; p=0.01) and nitrate levels (p&lt;0.0001) compared to placebo. There were significant increases in urine nitrite (p&lt;0.0001) and nitrate (p&lt;0.0001) in addition to salivary nitrite (p&lt;0.0001) and nitrate (p&lt;0.0001) compared to placebo. After 8 hours, typhoid vaccine induced an increase in circulating white cells (placebo = Δ3.34±3.37x109/L, inorganic nitrate = Δ2.9±2.78x109/L; p=0.58) that was similar in in both arms. However, there was a significant reduction in the FMD response in the placebo group at 8-hours post vaccine; an effect that was absent in volunteers treated with inorganic nitrate (placebo = Δ−1.33±1.53%, inorganic nitrate = Δ−0.07±1.84%, p=0.005). Importantly, there were no statistically significant differences in baseline vessel diameter (p=0.78), time to peak diameter in response to flow (p=0.87) and peak shear rate (p=0.57) between the groups. When comparing change from baseline to 8 hours after the vaccine, there were no significant differences in brachial systolic BP (p=0.12), central systolic BP (p=0.12) and PWV (p=0.60) between groups, but a significant reduction in brachial diastolic BP in the inorganic nitrate group (p=0.048).

Conclusions

Inflammation-induced endothelial dysfunction was prevented in those receiving dietary inorganic nitrate suggesting that elevating circulating nitrite and delivering NO to the blood vessel wall, through dietary approaches may offer potential therapeutic benefit in those cardiovascular diseases which typically exhibit low grade inflammation and deficiencies in bioavailable NO.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): British Heart Foundation

Inorganic nitrate attenuates the systemic inflammatory response in typhoid vaccine-induced endothelial dysfunction in healthy volunteers

Background

Inflammatory responses underlie the development of endothelial dysfunction in CVD, however, therapeutics that might target this pathway have not been forthcoming. A key pathogenic mechanism mediating endothelial dysfunction is a reduction in bioavailable (eNOS-derived) nitric oxide (NO). Activation of the non-canonical pathway for in-vivo NO generation might offer an approach to improve NO levels and recover vascular function in pre-clinical models of CVD. Whether this might occur in humans is unknown.

Purpose

We hypothesize that consumption of inorganic nitrate will lead to increases in bioavailable NO and thus attenuate the inflammatory pathways leading to typhoid vaccine-induced endothelial dysfunction in healthy volunteers.

Methods

Healthy male volunteers were recruited (n=78) and randomized to receive either beetroot juice containing 8–10mmol nitrate or placebo (nitrate-deplete) juice once daily for 6 days. Participants underwent serial measurements of BP, FMD and GTN-induced brachial artery dilatation, and haematology and biochemistry, before and after typhoid vaccination. Blood, urine and saliva nitrite and nitrate were quantified using ozone chemiluminescence, and leukocyte flow cytometry analysis was conducted.

Results

8-hours post-vaccine endothelial function was depressed in placebo-treated volunteers, however this was prevented in nitrate-treated volunteers. This dysfunction was due to impaired endothelial function since responses to GTN were unaffected either by vaccination or dietary intervention (p=0.981). Dietary nitrate resulted in an increase in plasma (p&lt;0.0001), urine (p=0.0006) and saliva (p&lt;0.0001) nitrate, and urine (p=0.0354) and saliva (p&lt;0.0001) nitrite levels. There was a reduction in the proportions of CD14++/CD16+intermediate monocytes in nitrate-treated participants after vaccine (p=0.016, change from baseline between groups). In the nitrate-treated group, less CD14++/CD16+ intermediate monocyte CD62L expression was identified post-vaccine (p=0.0122), compared to placebo, with no difference in soluble plasma CD62L between groups (p=0.875). CD11b median fluorescence intensity was increased in CD3+/CD4+ T-lymphocytes in nitrate-treated volunteers (p=0.0095).

Conclusions

Dietary nitrate reduced BP, as previously shown, indicating efficacy of the intervention. Importantly, we also now show for the first time that inorganic nitrate suppresses the systemic inflammatory response, specifically by reducing the numbers and activation state of CD14++/CD16+ intermediate monocytes. Furthermore, an increased expression of CD3+/CD4+ T-cell CD11b and preserved FMD in healthy volunteers treated with nitrate, suggests an anti-inflammatory phenotype, induced by the intervention, leading to improved endothelial function. Inorganic dietary nitrate modulates endothelial function through the attenuation of inflammatory responses and may be of potential therapeutic benefit in patients with established CAD.

Funding Acknowledgement

Type of funding sources: None.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Mesobacillus aurantius sp. nov., isolated from an orange-colored pond near a solar saltern

An endospore producing, strict aerobic, Gram-stain-positive, orange-colored colony forming bacterium designated as strain JC1013^T was isolated from an orange pond near a solar saltern of Tamil Nadu, India. Phylogenetic analysis of the 16S rRNA gene sequences indicated that strain was affiliated to the family Bacillaceae of the phylum Firmicutes. Strain showed highest 16S rRNA gene sequence identity of 98.7% with Mesobacillus selenatarsenatis SF-1 ^T and below 98.3% with other members of the genus Mesobacillus. Strain JC1013^T produced carotenoid pigments and indole compounds. Major cellular fatty acids of strain JC1013^T were iso-C_15:0, anteiso-C_15:0, C_16:0 3-OH, iso-C_17:0ω10c and summed feature 4 (iso-C_17:1 I/ anteisoB). Polar lipids were diphosphatidylglycerol, phosphatidylethanolamine, phosphatidylglycerol, two unidentified aminolipids and four unidentified phospholipids. Strain JC1013^T constituted m-diaminopimelic acid as diagnostic cell wall amino acids. MK-7 is the predominant menaquinone of strain JC1013^T. The genome size of strain JC1013^T was 4.6 Mbp and its G + C content was 42.7 mol%. For the affirmation of strain's taxonomic status, a detailed phylogenomic study was done. Based on the phylogenetic analyses, low ANI (84.6%), AAI (88.5%) values, in-silico DDH (< 29%) value, morphological, physiological and chemo-taxonomical characteristics, strain JC1013^T was clearly distinguished from the nearest phylogenetic neighbor, Mesobacillus selenatarsenatis SF-1^T to conclude that it is a new species of the genus Mesobacillus. We propose the name as Mesobacillus aurantius with type strain JC1013^T (= NBRC 114146^T = KACC 21451 ^T).

Paludisphaera soli sp. nov., a new member of the family Isosphaeraceae isolated from high altitude soil in the Western Himalaya

A novel strain of Planctomycetes, designated JC670^T, was isolated from a high altitude (~ 2900 m above sea level) soil sample collected from Garhwal region in the Western Himalaya. Colonies of this strain were observed to be light pink coloured with spherical to oval shaped cells having crateriform structures distributed all over the cell surface. The cells divide by budding. Strain JC670^T was found to grow well at pH 7.0 and pH 8.0 and to tolerate up to 2% NaCl (w/v). MK6 was the only respiratory quinone identified. The major fatty acids of strain JC670^T were identified as C_18:1ω9c, C_18:0 and C_16:0, and phosphatidylcholine, two unidentified phospholipids and six unidentified lipids are present as the polar lipids. The polyamines putrescine and sym-homospermidine were detected. Strain JC670^T shows high 16S rRNA gene sequence identity (95.4%) with Paludisphaera borealis PX4^T. The draft genome size of strain JC670^T is 7.97 Mb, with G + C content of 70.4 mol%. Based on phylogenetic analyses with the sequences of ninety-two core genes, low dDDH value (20.6%), low gANI (76.8%) and low AAI (69.1%) results, differential chemotaxonomic and physiological properties, strain JC670^T (= KCTC 72850^T = NBRC 114339^T) is recognised as the type strain of a new species of the genus Paludisphaera, for which we propose the name Paludisphaera soli sp. nov.

Suppresive plants as weed management tool: Managing Parthenium hysterophorus under simulated grazing in Australian grasslands

Parthenium hysterophorus L. is among one of the most problematic invasive grassland weeds in Australia, and in many other countries around the world. It can reduce pasture and livestock production, natural community biodiversity, and negatively affect human and animal health. Sowing of selected suppressive pasture plants in parthenium weed infested grasslands has shown potential to improve efficacy of management. However, such species need to be tested for their ability to suppress weed growth under grazing conditions. The parthenium weed suppressive and fodder production capacity of six selected pasture species [purple pigeon grass (Setaria incrassata), buffel grass (Cenchrus ciliaris), butterfly pea (Clitoria ternatea), Kangaroo grass (Themeda triandra), bull Mitchell grass (Astrebla squarrosa) and Indian bluegrass (Bothriochloa pertusa)] was tested under no (0%), low (25%), moderate (50%) and heavy (75%) simulated grazing pressures in a grassland area of south-central Queensland, Australia. Purple pigeon grass, buffel grass and butterfly pea legume suppressed the growth of parthenium weed by >50% under low and moderate simulated grazing pressures, as well as generating moderate to high amounts of fodder biomass (up to 5.07 t ha^-1 per year). Native species, Kangaroo grass and bull Mitchell grass both suppressed the parthenium weed's growth by >50% under low simulated grazing pressure, however, they generated low to moderate amounts of biomass, 1.83 t ha^-1 and 2.7 t ha^-1 per year, respectively. The sowing of selected suppressive pasture species in parthenium weed infested grasslands with low-to-moderate grazing pressure, assuming this corresponds closely with the simulated treatment, would provide an additional tool to the best practice weed management strategy as well as sustaining fodder production.

Symptoms of Anxiety and Depression in Obese Singaporeans: a Preliminary Study

BACKGROUND

Obesity is a major component of metabolic syndrome and an independent risk factor for various chronic diseases. It is also closely associated with mental illness, and the interaction is complex and multifactorial. This study aimed to estimate the prevalence of anxiety and depressive symptoms among obese Singaporeans.

METHODS

Cross-sectional data of 36 male and 47 female obese Singaporeans who had been referred to the weight management clinic of National University Hospital, Singapore, between January 2010 and November 2011 were collected. Obesity was classified according to criteria of the World Health Organization. The extents of anxiety and depressive symptoms were measured using the Hospital Anxiety and Depression Scale.

RESULTS

In obese Singaporeans attending the weight management clinic, the prevalence of anxiety symptoms was higher than that of depressive symptoms (28% vs 11%). There was no major socioeconomic difference between obese patients with and without anxiety, or with and without depressive symptoms.

CONCLUSION

In obese Singaporeans, anxiety symptoms may be more common than depressive symptoms. Weight management programmes should incorporate anxiety management as part of standard treatment. Early detection and pharmacological and psychological interventions should be implemented.

A classification scheme for edge-localized modes based on their probability distributions

We present here an automated classification scheme which is particularly well suited to scenarios where the parameters have significant uncertainties or are stochastic quantities. To this end, the parameters are modeled with probability distributions in a metric space and classification is conducted using the notion of nearest neighbors. The presented framework is then applied to the classification of type I and type III edge-localized modes (ELMs) from a set of carbon-wall plasmas at JET. This provides a fast, standardized classification of ELM types which is expected to significantly reduce the effort of ELM experts in identifying ELM types. Further, the classification scheme is general and can be applied to various other plasma phenomena as well.

Robust analysis of trends in noisy tokamak confinement data using geodesic least squares regression

Regression analysis is a very common activity in fusion science for unveiling trends and parametric dependencies, but it can be a difficult matter. We have recently developed the method of geodesic least squares (GLS) regression that is able to handle errors in all variables, is robust against data outliers and uncertainty in the regression model, and can be used with arbitrary distribution models and regression functions. We here report on first results of application of GLS to estimation of the multi-machine scaling law for the energy confinement time in tokamaks, demonstrating improved consistency of the GLS results compared to standard least squares.

Association of the MTHFR C677T (rs1801133) polymorphism with idiopathic male infertility in a local Pakistani population

The present study determined an association between idiopathic sperm disorders in a local Pakistani infertile male population and the MTHFR C677T polymorphism. After ruling out non genetic factors, a total of 437 idiopathic infertile men including 57 azoospermic, 66 oligospermic, 44 asthenozoospermic, 29 teratozoospermic, 20 oligoasthenospermic and 221 infertile normospermic men were recruited. Furthermore, 218 normospermic fertile men, who had two children (or more) were included as controls. The polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique was used to determine MTHFR C677T (rs1801133) polymorphism. A significant association of the minor MTHFR 677T allele with male infertility was observed (p <0.05). In addition, men with MTHFR 677 CT and TT genotypes were at a greater risk [odds ratio (OR): 1.81, 95% confidence interval (95% CI): 1.17-2.80, p = 0.008 and OR: 9.24, 95% CI: 1.20-70.92, p = 0.032, respectively] of infertility. All the subgroups of male infertility (azoospermic, oligospermic, asthenospermic, oligoasthenoteratospermic (OAT) and normospermic infertile) had significantly (p <0.05) higher frequencies of CT and TT genotypes when compared to fertile men. The combined genotypes (CT + TT) were also found significantly (OR: 2.01, 95% CI: 1.31-3.08, p <0.001) associated with male infertility. The results suggest that the polymorphism might be a factor of male infertility in the Pakistani population.

Computed tomography of the thorax for gastric cancer staging: is it necessary?

Background:

The utility of computed tomography scans of the thorax, abdomen, and pelvis for gastric cancer staging has been recommended in many countries. However, the validity of the use of computed tomography thorax in gastric cancer staging has not been challenged.

Methods:

A retrospective review was conducted on our gastric cancer registry from 1998 till 2012 in the National University Hospital, Singapore. We performed computed tomography thorax only in selected cases. We defined isolated lung metastasis as the presence of suspicious findings on computed tomography thorax in the absence of metastasis elsewhere.

Results:

A total of 808 gastric cancer cases were reviewed. The mean age of the patients was 66 years (standard deviation 13.53), and 67% were male. In all, 238 patients (30%) had metastatic disease at presentation, and 1 (0.42%) had isolated lung metastasis. The most common site of metastasis was intra-abdominal (73.8%). Among the patients who underwent surgery, the overall distant recurrence rate was 30%, of which only 83 (30%) patients had lung metastasis and all had concurrent metastasis in an intra-abdominal site.

Conclusion:

The rarity of isolated lung metastasis in gastric cancer suggests the limited value of computed tomography thorax as a routine staging tool for gastric cancers.

Visualization of the operational space of edge-localized modes through low-dimensional embedding of probability distributions

Information visualization aimed at facilitating human perception is an important tool for the interpretation of experiments on the basis of complex multidimensional data characterizing the operational space of fusion devices. This work describes a method for visualizing the operational space on a two-dimensional map and applies it to the discrimination of type I and type III edge-localized modes (ELMs) from a series of carbon-wall ELMy discharges at JET. The approach accounts for stochastic uncertainties that play an important role in fusion data sets, by modeling measurements with probability distributions in a metric space. The method is aimed at contributing to physical understanding of ELMs as well as their control. Furthermore, it is a general method that can be applied to the modeling of various other plasma phenomena as well.

Early class III management in deciduous dentition using reverse twin block

Class III malocclusion poses a challenging dilemma for the clinician because these children have of growth patterns that differ from that of children with class I malocclusion. The mandible grows more rapidly than the maxilla, exacerbating the class III malocclusion as the child go through adolescence. Ever since Clark described a version of the twin block, it has steadily gained popularity in the management of early class III malocclusion in children. However, not many cases are reported in the literature on its use in deciduous dentition. This article tries to provide an insight into the reverse twin block appliance and reports two cases of early class III malocclusion treated using reverse twin block.

Assessing renal parenchymal volume on unenhanced CT as a marker for predicting renal function in patients with chronic kidney disease

OBJECTIVES

To estimate renal volume in chronic kidney disease (CKD) patients using a semiautomated software and compare them with split renal function estimates from radionuclide renogram (RR). We proposed that renal volume from unenhanced computed tomography (CT) scans may serve as surrogate marker for assessing renal function in CKD patients.

MATERIALS AND METHODS

Unenhanced multidetector CT scans of 26 patients with CKD (estimated glomerular filtration rate [eGFR] <60 mL/kg/body surface area [BSA]) and 10 controls (eGFR >60 mL/kg/BSA) were analyzed to calculate renal volumes using a semiautomated software (AMIRAV5.2.0). Volumes obtained were then correlated with corresponding eGFR and split renal function estimates from RR. Volumes were also compared with those obtained on enhanced scans in 10 cases (five disease group, five controls). Bland-Altman analysis was used to assess agreement between methods.

RESULTS

A moderately positive correlation was found between renal volume obtained on unenhanced CT and eGFR (r = 0.65, P < .0001), whereas a significantly high correlation with split function estimates from RR (r = 0.95, P < .001) was found. Bland-Altman analysis revealed a good agreement between renal volume from CT and renal function from RR (34/36 observations were within 95% CI and there were two outliers). Correlation between volumes obtained from unenhanced and enhanced CT scans was also significant (r = 0.96).

CONCLUSION

In patients with CKD, renal volume derived from unenhanced CT can possibly serve as a surrogate marker for assessing and monitoring renal function reserves to plan further management.

The Brown Norway opticospinal model of demyelination: does it mimic multiple sclerosis or neuromyelitis optica?

Opticospinal demyelinating diseases in humans are mostly characterized by the opticospinal form of multiple sclerosis (MS) and neuromyelitis optica (NMO). Increasing attention has recently focused on astrocyte markers, aquaporin-4 (AQP4) and glial fibrillary acidic protein (GFAP) in these diseases. We induced opticospinal demyelination in Brown Norway rats with soluble recombinant rat myelin oligodendrocyte glycoprotein (1-116) and incomplete Freund's adjuvant. Clinical, MRI, neuropathological and immunological evaluations were performed, with a focus on AQP4 and GFAP. We confirmed the opticospinal phenotype, including extensive myelitis, but also showed the MRI-characterized involvement of the periventricular area. Expression levels of myelin, AQP4 and GFAP showed the early involvement of astrocytes before demyelination in the optic nerve. The overexpression of AQP4 was particularly pronounced in the spinal cord and was concomitant with demyelination and astrocyte apoptosis. The disability scores were correlated with demyelination and inflammation but not with AQP4/GFAP expression. No antibodies against the linear and conformational epitopes of AQP4 were detected. Whereas a NMO-like phenotype was observed in this model, the AQP4/GFAP expression during the disease process was more closely related to opticospinal MS than NMO. However, this model raises the question of a continuum between opticospinal MS and the seronegative NMO subtype.

Diagnostic laparoscopy in the evaluation of right lower abdominal pain: a one-year audit

INTRODUCTION

Acute appendicitis is the commonest cause for right lower abdominal pain. Clinical features, laboratory and imaging investigations are either not very sensitive or specific, and neither is therapeutic. We aimed to define the role of diagnostic laparoscopy in patients with right lower abdominal pain.

METHODS

Data was collected retrospectively from January 1, 2005 to December 31, 2005. Patients admitted to the Emergency Department and subsequently transferred to the Department of Surgery, National University Hospital, Singapore, with right lower abdominal pain and who eventually underwent diagnostic laparoscopy were evaluated.

RESULTS

691 patients with right lower abdominal pain were admitted with suspected diagnosis of appendicitis. Diagnostic laparoscopy was undertaken in 103 patients aged 17-71 years old. Of the 83 females, 78 (94 percent) were premenopausal . Histology-proven acute appendicitis was diagnosed in 78 (75.7 percent) patients. Interestingly, within this group, 25.6 percent had other concomitant pathologies found on laparoscopy. 25 patients had a normal appendix; gynaecological causes accounted for pain in 15 of these 25 (60 percent) cases. In four (3.9 percent) patients, no pathology was found. Complication rate was 1.9 percent, which included ileus in two patients. In 32 (31.1 percent) patients, diagnostic laparoscopy altered the management plan, requiring either intervention or care by a subspecialty.

CONCLUSION

Diagnostic laparoscopy is useful in evaluating patients with right lower abdominal pain, especially in those with equivocal signs of acute appendicitis. It also has the additional benefit of being therapeutic. Premenopausal women benefit the most from this procedure.

Laparoscopic versus open ventral hernia mesh repair: a prospective study

BACKGROUND

An incisional hernia develops in 3% to 13% of laparotomy incisions, with primary suture repair of ventral hernias yielding unsatisfactory results. The introduction of a prosthetic mesh to ensure abdominal wall strength without tension has decreased the recurrence rate, but open repair requires significant soft tissue dissection in tissues that are already of poor quality as well as flap creation, increasing complication rates and affecting the recurrence rate. A minimally invasive approach was applied to the repair pf ventral hernias, with the expectation of earlier recovery, fewer postoperative complications, and decreased recurrence rates. This prospective study was performed to objectively analyze and compare the outcomes after open and laparoscopic ventral hernia repair.

METHODS

The outcomes for 50 unselected patients who underwent laparoscopic ventral hernia repair were compared with those for 50 consecutive unselected patients who underwent open repair. The open surgical operations were performed by the Rives and Stoppa technique using prosthetic mesh, whereas the laparoscopic repairs were performed using the intraperitoneal onlay mesh (IPOM) repair technique in all cases.

RESULTS

The study group consisted of 100 patients (82 women and 18 men) with a mean age of 55.25 years (range, 30-83 years). The patients in the two groups were comparable at baseline in terms of sex, presenting complaints, and comorbid conditions. The patients in laparoscopic group had larger defects (93.96 vs 55.88 cm2; p = 0.0023). The mean follow-up time was 20.8 months (95% confidence interval [CI], 18.5640-23.0227 months). The mean surgery durations were 90.6 min for the laparoscopic repair and 93.3 min for the open repair (p = 0.769, nonsignificant difference). The mean postoperative stay was shorter for the laparoscopic group than for the open hernia group (2.7 vs 4.7 days; p = 0.044). The pain scores were similar in the two groups at 24 and 48 h, but significantly less at 72 h in the laparoscopic group (mean visual analog scale score, 2.9412 vs 4.1702; p = 0.001). There were fewer complications (24%) and recurrences (2%) among the patients who underwent laparoscopic repair than among those who had open repair (30% and 10%, respectively).

CONCLUSIONS

The findings demonstrate that laparoscopic ventral hernia repair in our experience was safe and resulted in shorter operative time, fewer complications, shorter hospital stays, and less recurrence. Hence, it should be considered as the procedure of choice for ventral hernia repair.