Vascular access surgery training in the United Kingdom is currently perceived (by trainees) to be inadequate

INTRODUCTION

Vascular access surgery (VAS) involves the creation and maintenance of arteriovenous access to facilitate haemodialysis. The prevalence of haemodialysis is rising despite increases in kidney transplants on a yearly basis. There is currently only one access surgery fellowship accredited by the Royal College of Surgeons of England. We aimed to establish the experience and perceived competence in access surgery of senior vascular surgery trainees.

METHODS

A short questionnaire (SurveyMonkey) was used to survey all senior (ST6-ST8) vascular surgery trainees in Health Education England (HEE) vascular surgery training programmes. The short survey asked trainees to report their: (1) training grade; (2) training deanery; (3) experience of access surgery; and (4) whether senior trainees thought they would be able to independently undertake primary access surgery post-completion of training (post Certificate of Completion of Training). The survey was circulated via HEE deaneries and the vascular surgery trainees' society: the Rouleaux Club.

RESULTS

Twenty-eight senior (ST6-ST8) vascular surgery trainees responded to the survey: 29.6% were ST6 level, 33.3% were ST7 and 37.1% were ST8. Deanery respondence was evenly spread, although London was overrepresented (37.1%). In total, 28.6% had been involved in fewer than 10 cases, 35.7% in 10-25 cases, and 35.7% in more than 25 cases. Almost 54% of senior vascular surgery trainees believed they would not be able to undertake independent access surgery once they had completed training.

CONCLUSIONS

Competence in access surgery is an increasing requirement of a consultant vascular surgeon. More formalised training is required to adequately train the next generation of vascular surgeons.

Vascular access surgery training in the United Kingdom is currently perceived (by trainees) to be inadequate

INTRODUCTION

Vascular access surgery (VAS) involves the creation and maintenance of arteriovenous access to facilitate haemodialysis. The prevalence of haemodialysis is rising despite increases in kidney transplants on a yearly basis. There is currently only one access surgery fellowship accredited by the Royal College of Surgeons of England. We aimed to establish the experience and perceived competence in access surgery of senior vascular surgery trainees.

METHODS

A short questionnaire (SurveyMonkey) was used to survey all senior (ST6-ST8) vascular surgery trainees in Health Education England (HEE) vascular surgery training programmes. The short survey asked trainees to report their: (1) training grade; (2) training deanery; (3) experience of access surgery; and (4) whether senior trainees thought they would be able to independently undertake primary access surgery post-completion of training (post Certificate of Completion of Training). The survey was circulated via HEE deaneries and the vascular surgery trainees' society: the Rouleaux Club.

RESULTS

Twenty-eight senior (ST6-ST8) vascular surgery trainees responded to the survey: 29.6% were ST6 level, 33.3% were ST7 and 37.1% were ST8. Deanery respondence was evenly spread, although London was overrepresented (37.1%). In total, 28.6% had been involved in fewer than 10 cases, 35.7% in 10-25 cases, and 35.7% in more than 25 cases. Almost 54% of senior vascular surgery trainees believed they would not be able to undertake independent access surgery once they had completed training.

CONCLUSIONS

Competence in access surgery is an increasing requirement of a consultant vascular surgeon. More formalised training is required to adequately train the next generation of vascular surgeons.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Recent advances in chitosan-based materials; The synthesis, modifications and biomedical applications

The attention to polymer-based biomaterials, for instance, chitosan and its derivatives, as well as the techniques for using them in numerous scientific domains, is continuously rising. Chitosan is a decomposable naturally occurring polymeric material that is mostly obtained from seafood waste. Because of its special ecofriendly, biocompatible, non- toxic nature as well as antimicrobial properties, chitosan-based materials have received a lot of interest in the field of biomedical applications. The reactivity of chitosan is mainly because of the amino and hydroxyl groups in its composition, which makes it further fascinating for various uses, including biosensing, textile finishing, antimicrobial wound dressing, tissue engineering, bioimaging, gene, DNA and drug delivery and as a coating material for medical implants. This study is an overview of the different types of chitosan-based materials which now a days have been fabricated by applying different techniques and modifications that include etherification, esterification, crosslinking, graft copolymerization and o-acetylation etc. for hydroxyl groups' processes and acetylation, quaternization, Schiff's base reaction, and grafting for amino groups' reactions. Furthermore, this overview summarizes the literature from recent years related to the important applications of chitosan-based materials (i.e., thin films, nanocomposites or nanoparticles, sponges and hydrogels) in different biomedical applications.

Why Does the US Overly Rely on International Medical Graduates in Its Geriatric Psychiatric Workforce?

International medical graduates (IMGs) tend to choose careers in geriatric psychiatry likely because high-quality training and robust mentorship opportunities from other IMGs are available. Geriatric psychiatry offers stable career prospects and opportunities to express humanitarian impulses by working closely with elders. IMGs currently constitute almost a quarter of the psychiatry workforce and approximately 53% of the geriatric psychiatry work force in the United States. However, the number of IMGs entering psychiatry residencies-and, subsequently, geriatric psychiatry fellowships-has recently declined. Overreliance on IMGs in the US geriatric psychiatric workforce means these shortages will further burden an already-limited geriatric mental health care workforce and further compromise US health system capacity to meet its elders' needs.

Ontario Cataract Quality Outcome Initiative: appropriateness and prioritization of cataract surgery

OBJECTIVE

To explore the utility of the Catquest 9SF visual function (VF) questionnaire along with visual acuity (VA) for determining appropriateness and priority for cataract surgery. To evaluate the feasibility of administering the Catquest-9SF in a clinical setting using web-based electronic data capture and interpretation.

DESIGN

Prospective multicentred interventional observational study.

PARTICIPANTS

Subjects undergoing sequential cataract surgery in both eyes at 4 sites in Ontario.

METHODS

We recorded best-corrected VA (BCVA) and VA with current correction (CCVA) in each eye and both eyes (OU) and Catquest-9SF responses on a tablet before and after cataract surgery. Linear regression models were employed to test for associations between VA and visual function (VF).

RESULTS

Preoperative BCVA and CCVA in the worse eye were significant predictors of change in VF (p = 0.006 and p = 0.008, respectively); subjects with worse VA had a greater improvement in VF after surgery. There was a significant association between improvement in VF and improvement in CCVA OU (p = 0.001). Fourteen of 151 subjects (9%) had no improvement or worse VF scores after surgery. Within this group, 10 of 14 subjects had a preoperative score ≤-3, which is suggestive of minimal visual disability. Within this subset, 4 of 14 subjects (2.6%) had a preoperative BCVA of 20/30 or better in their worse eye.

CONCLUSIONS

For patient groups with equal VA, the Catquest-9SF score can help determine priority for surgery. Web-based data capture and interpretation allow for efficient virtual assessments of VF. A BCVA in the worse eye of 20/30 or better combined with a Catquest-9SF score <-3 can be used as a guideline for lowest priority.

Detailed Sub-study Analysis of the SECRAB Trial: Quality of Life, Cosmesis and Chemotherapy Dose Intensity

AIMS

SECRAB was a prospective, open-label, multicentre, randomised phase III trial comparing synchronous to sequential chemoradiotherapy (CRT). Conducted in 48 UK centres, it recruited 2297 patients (1150 synchronous and 1146 sequential) between 2 July 1998 and 25 March 2004. SECRAB reported a positive therapeutic benefit of using adjuvant synchronous CRT in the management of breast cancer; 10-year local recurrence rates reduced from 7.1% to 4.6% (P = 0.012). The greatest benefit was seen in patients treated with anthracycline-cyclophosphamide, methotrexate, 5-fluorouracil (CMF) rather than CMF. The aim of its sub-studies reported here was to assess whether quality of life (QoL), cosmesis or chemotherapy dose intensity differed between the two CRT regimens.

MATERIALS AND METHODS

The QoL sub-study used EORTC QLQ-C30, EORTC QLQ-BR23 and the Women's Health Questionnaire. Cosmesis was assessed: (i) by the treating clinician, (ii) by a validated independent consensus scoring method and (iii) from the patients' perspective by analysing four cosmesis-related QoL questions within the QLQ-BR23. Chemotherapy doses were captured from pharmacy records. The sub-studies were not formally powered; rather, the aim was that at least 300 patients (150 in each arm) were recruited and differences in QoL, cosmesis and dose intensity of chemotherapy assessed. The analysis, therefore, is exploratory in nature.

RESULTS

No differences were observed in the change from baseline in QoL between the two arms assessed up to 2 years post-surgery (Global Health Status: -0.05; 95% confidence interval -2.16, 2.06; P = 0.963). No differences in cosmesis were observed (via independent and patient assessment) up to 5 years post-surgery. The percentage of patients receiving the optimal course-delivered dose intensity (≥85%) was not significantly different between the arms (synchronous 88% versus sequential 90%; P = 0.503).

CONCLUSIONS

Synchronous CRT is tolerable, deliverable and significantly more effective than sequential, with no serious disadvantages identified when assessing 2-year QoL or 5-year cosmetic differences.

Pathogens identified in the internal tissues and placentas of stillbirths: results from the prospective, observational PURPOSe study

OBJECTIVE

To examine internal organ tissues and placentas of stillbirths for various pathogens.

DESIGN

Prospective, observational study.

SETTINGS

Three study hospitals in India and a large maternity hospital in Pakistan.

POPULATION

Stillborn infants delivered in a study hospital.

METHODS

A prospective observational study.

MAIN OUTCOME MEASURES

Organisms identified by pathogen polymerase chain reaction (PCR) in internal organs and placental tissues of stillbirths.

RESULTS

Of 2437 stillbirth internal tissues, 8.3% (95% CI 7.2-9.4) were positive. Organisms were most commonly detected in brain (12.3%), cerebrospinal fluid (CSF) (9.5%) and whole blood (8.4%). Ureaplasma urealyticum/parvum was the organism most frequently detected in at least one internal organ (6.4% of stillbirths and 2% of all tissues). Escherichia coli/Shigella was the next most common (4.1% one or more internal organ tissue sample and 1.3% of tissue samples), followed by Staphylococcus aureus in at least one internal organ tissue (1.9% and 0.9% of all tissues). None of the other organisms was found in more than 1.4% of the tissue samples in stillbirths or more than 0.6% of the internal tissues examined. In the placenta tissue, membrane or cord blood combined, 42.8% (95% CI 40.2-45.3) had at least one organism identified, with U. urealyticum/parvum representing the most commonly identified (27.8%).

CONCLUSIONS

In about 8% of stillbirths, there was evidence of a pathogen in an internal organ. Ureaplasma urealyticum/parvum was the most common organism found in the placenta and in the internal tissues, especially in the fetal brain.

Paroxysmal Nocturnal Hemoglobinuria in Systemic Lupus Erythematosus: A Rare Manifestation

Paroxysmal nocturnal haemoglobinuria (PNH) is a rare disorder of hematopoietic stem cells. The occurrence of PNH in a patient with systemic lupus erythematosus (SLE) is even rarer. One such presentation was seen in a 19 years old woman who presented with fever, multiple joint pain, photosensitivity, oral ulcer, hair loss and was diagnosed as a case of SLE and was admitted in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh on 7th February 2019. Subsequently she developed progressive anaemia and passing of dark colored urine. Flow cytometry analysis showed PNH clone within red cells. We report this case so that clinicians are aware about this association between PNH and SLE. Informed written consent was obtained from the patient for the publication of this case report, the copy of which is available with the authors.

Arsenic in drinking water: overview of removal strategies and role of chitosan biosorbent for its remediation

Accessibility to clean drinking water often remains a crucial task at times. Among other water pollutants, arsenic is considered a more lethal contaminant and has become a serious threat to human life globally. This review discussed the sources, chemistry, distribution, and toxicity of arsenic and various conventional technologies that are in option for its removal from the water system. Nowadays, biosorbents are considered the best option for arsenic-contaminated water treatment. We have mainly focused on the need and potential of biosorbents especially the role of chitosan-based composites for arsenic removal. The chitosan-based sorbents are economically more efficient in terms of their, low toxicity, cost-effectiveness, biodegradability, eco-friendly nature, and reusability. The role of various modification techniques, such as physical and chemical, has also been evaluated to improve the physicochemical properties of biosorbent. The importance of adsorption kinetic and isotherm models and the role of solution pH and pH_PZC for arsenic uptake from the polluted water have also been investigated. Some other potential applications of chitosan-based biosorbents have also been discussed along with its sustainability aspect. Finally, some suggestions have been highlighted for further improvements in this field.

Mesh fixation techniques for inguinal hernia repair: an overview of systematic reviews of randomised controlled trials

PURPOSE

Inguinal hernia repair using surgical mesh is a very common surgical operation. Currently, there is no consensus on the best technique for mesh fixation. We conducted an overview of existing systematic reviews (SRs) of randomised controlled trials to compare the risk of chronic pain and recurrence following open and laparoscopic inguinal hernia repairs using various mesh fixation techniques.

METHODS

We searched major electronic databases in April 2020 and assessed the methodological quality of identified reviews using the AMSTAR-2 tool.

RESULTS

We identified 20 SRs of variable quality assessing suture, self-gripping, glue, and mechanical fixation. Across reviews, the risk of chronic pain after open mesh repair was lower with glue fixation than with suture and comparable between self-gripping and suture. Incidence of chronic pain was lower with glue fixation than with mechanical fixation in laparoscopic repairs. There were no significant differences in recurrence rates between fixation techniques in open and laparoscopic mesh repairs, although fewer recurrences were reported with suture. Many reviews reported wide confidence intervals around summary estimates. Despite no clear evidence of differences among techniques, two network meta-analyses (one assessing open repairs and one laparoscopic repairs) ranked glue fixation as the best treatment for reducing pain and suture for reducing the risk of recurrence.

CONCLUSION

Glue fixation may be effective in reducing the incidence of chronic pain without increasing the risk of recurrence. Future research should consider both the effectiveness and cost-effectiveness of fixation techniques alongside the type of mesh and the size and location of the hernia defect.

Combination therapy of insulin-like growth factor I and BTP-2 markedly improves lipopolysaccharide-induced liver injury in mice

Acute liver injury is a common disease without effective therapy in humans. We sought to evaluate a combination therapy of insulin-like growth factor 1 (IGF-I) and BTP-2 in a mouse liver injury model induced by lipopolysaccharide (LPS). We chose this model because LPS is known to increase the expression of the transcription factors related to systemic inflammation (i.e., NFκB, CREB, AP1, IRF 3, and NFAT), which depends on calcium signaling. Notably, these transcription factors all have pleiotropic effects and account for the other observed changes in tissue damage parameters. Additionally, LPS is also known to increase the genes associated with a tissue injury (e.g., NGAL, SOD, caspase 3, and type 1 collagen) and systemic expression of pro-inflammatory cytokines. Finally, LPS compromises vascular integrity. Accordingly, IGF-I was selected because its serum levels were shown to decrease during systemic inflammation. BTP-2 was chosen because it was known to decrease cytosolic calcium, which is increased by LPS. This current study showed that IGF-I, BTP-2, or a combination therapy significantly altered and normalized all of the aforementioned LPS-induced gene changes. Additionally, our therapies reduced the vascular leakage caused by LPS, as evidenced by the Evans blue dye technique. Furthermore, histopathologic studies showed that IGF-I decreased the proportion of hepatocytes with ballooning degeneration. Finally, IGF-I also increased the expression of the hepatic growth factor (HGF) and the receptor for the epidermal growth factor (EGFR), markers of liver regeneration. Collectively, our data suggest that a combination of IGF-I and BTP-2 is a promising therapy for acute liver injury.

Association between sociodemographic characteristics and knowledge and practice of COVID-19 measures among households in Mombasa and Kilifi County, Kenya

BACKGROUND

Coronavirus disease 2019 (COVID-19), declared a global pandemic by the World Health Organization (WHO), is a severe acute respiratory disease. The Kenyan Ministry of Health (MoH) put in place measures that included mandatory face masking, hand and cough hygiene and social and physical distancing to reduce disease transmission and increase prevention efforts. The primary objective of this study was to determine how sociodemographic characteristics affect knowledge and practice of the above measures.

METHODS

A cross-sectional study was conducted to assess water, sanitation and hygiene practices for the prevention and control of COVID-19 in Kilifi and Mombasa Counties, Kenya. Data collection was accomplished through a mobile data collection tool. Principal component analysis was used to create a wealth index using data on asset ownership and housing characteristics. Bloom cut-off points of 80-100%, 60-79% and ≤59% were used to determine knowledge and practice.

RESULTS

Of the 612 households, 339 (55.4%) were from Kilifi County and 273 (44.6%) were from Mombasa County. A total of 431 (70.4%) were female and the mean age of the household members was 38.2±14.8 y.Almost all (99.2%) respondents were aware of COVID-19, with 60% knowing prevention, symptoms and persons at a higher risk of contracting the virus. Females had the highest knowledge of COVID-19 and were likely to practice prevention and control measures, unlike males. Age was significant (p<0.05) with knowledge and practice.

CONCLUSIONS

The sociodemographic characteristics of populations play a key role in behavioural aspects as far as prevention and control of COVID-19 are concerned. There is a need for partnerships between the MoH and county governments to put in place a multisectoral community approach to advance feasible behavioural interventions among targeted populations towards combating the spread of COVID-19.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Using the Psychiatry Resident-In-Training Examination (PRITE) to Assess the Psychiatry Medical Knowledge Milestones in Psychiatry

OBJECTIVE

The introduction of the Milestone Project underscored the need for objective assessments of resident progress across the competencies. Therefore, the authors examined the Psychiatry Resident-In-Training Examination (PRITE) utility for measuring improvements in medical knowledge (MK).

METHODS

The authors compared the mean performance for each MK subcompetency by resident year for all residents taking the PRITE from 2015 to 2017 (18,175 examination administrations). In addition, they surveyed psychiatry residency program directors regarding how well they thought they teach these subcompetencies.

RESULTS

Increases in MK subcompetencies by resident year were significant for Psychopathology (p < 0.003), Psychotherapy (p < 0.002), and Somatic Therapies (p < 0.000). Development, Clinical Neuroscience, and Practice of Psychiatry did not show statistically significant differences between postgraduate years. Eighty psychiatry program directors responded to the survey and felt optimistic about their ability to teach the Psychopathology, Psychotherapy, Somatic Therapies, and Practice of Psychiatry subcompetencies.

CONCLUSIONS

The PRITE measured significant improvements in medical knowledge for several of the core subcompetencies. The program director's responses would suggest that the lack of statistically significant differences found for Development and Clinical Neuroscience reflects areas in need of curricular development. The disparity between PRITE performance and program director perception of the Practice of Psychiatry subcompetency may reflect difficulties in defining the scope of this subcompetency. Overall, this suggests that structured examinations help measure improvements in certain subcompetencies and may also help identify curricular needs. However, there may be potential problems with the definition of some subcompetencies.

Evaluation of water footprint in sugar industries and bioethanol distilleries in two different water basins toward water sustainability

Sugarcane farming and bioethanol production are water-intensive activities that result in high water competition. The competition, in turn, can exacerbate water scarcity. Therefore, this study aims to evaluate the water footprint (WF) of the sugar and bioethanol production at the Finchaa and Metehara sugarcane farms, which are located in different river basins in Ethiopia. The climatic data (minimal and maximum temperature, relative humidity, wind speed, and sunshine duration), meteorological data (rainfall), CROPWAT 8.0 model, nitrogen fertilizer application rates, sugarcane yield, and sugar and bioethanol production over 12 years (2008-2019) were used. Penman-Monteith method-based sugarcane water requirements of Finchaa and Metehara were found to be 2021.1 and 3605.4 mm/growing period, respectively. The sugarcane WF of Finchaa was 188.01 m³/t, which was composed of green (67.45 m³/t), blue (113.42 m³/t), and grey (7.14 m³/t) components, whereas the WF of Metehara was 239.11 m³/t consisting of green (29.42 m³/t), blue (204.13 m³/t), and grey (5.56 m³/t). The low sugarcane WF recorded was attributed to the high yield of sugarcane that was harvested in the study areas. Hence, the irrigation (blue WF) requirement is the major concern of water management in the basins. Similarly, the WF of bioethanol at the Finchaa distillery (2067.62 L/L) was much higher than that of the Metehara distillery (1441.54 L/L). However, both WFs were within the global range. Significant differences were observed between the two water basins. The sugarcane estate farm and bioethanol production processes require water management intervention to reduce the impact of WF in the basins.

Correction to "Suitable Binary and Ternary Thermodynamic Conditions for Hydrate Mixtures of CH4, CO2, and C3H8 for Gas Hydrate-Based Applications"

[This corrects the article DOI: 10.1021/acsomega.1c06186.].

Age of First Oral Health Examination and Dental Treatment Needs of Medicaid-Enrolled Children

INTRODUCTION

Early childhood caries (ECC), despite being preventable, remains the most prevalent disease of childhood, particularly in children between the ages of 2 and 5 y. The association between the type of health care provider completing initial oral health examinations and subsequent dental caries in children under 6 y of age is unclear.

OBJECTIVE

The objective of the current study is to longitudinally assess the association between age at first oral health examination and provider type at first oral health examination on dental treatment for children under 6 y of age.

METHODS

Deidentified administrative claims data were used from the IBM Marketscan Multi-State Medicaid Database (n = 2.41 million Medicaid-enrolled children younger than 6 y in 13 states from 2012 to 2017). A Kaplan-Meier survival analysis was used to examine the association between age at first oral health examination and provider type with first treatment of dental caries at follow-up.

RESULTS

The adjusted hazard ratio (HR) of dental caries for children whose first oral health examination at 4 y of age is 5.425 times higher than for children whose first oral health examination was before 1 y of age (95% confidence interval [CI], 5.371-5.479). The adjusted HR of dental caries for children seen by pediatric dentists (HR = 1.215; 95% CI, 1.207-1.223) and physicians (HR = 2.618; 95% CI, 2.601-2.635) was higher than those seen by a general dentist.

CONCLUSIONS

Findings from this study highlight the importance of children having their first oral health examination no later than 12 mo of age in accordance with existing guidelines and referrals from physicians to prevent the need for invasive treatment.

KNOWLEDGE OF TRANSFER STATEMENT

Results of this study emphasize the need for a child's first oral health examination to be completed no later than 12 mo of age to prevent dental caries. Reinforcement and referrals by physicians based on this recommendation facilitate early establishment of a dental home in young children.

Assessment of water, sanitation and hygiene practices for prevention and control of COVID-19 in Kenya

Background

Safely managed water, sanitation and hygiene (WASH) services are an essential part of preventing and protecting human health during infectious disease outbreaks, including the current coronavirus disease 2019 (COVID-19) pandemic. Additionally, adherence to COVID-19 measures, including washing hands using soap and proper waste disposal, no doubt can improve containment of the virus.

Methods

A cross-sectional survey was conducted in Kilifi and Mombasa Counties in Kenya. A total of 612 quantitative data were collected using a mobile data collection tool Open Data Kit. Parametric and non-parametric tests were used to examine factors associated with WASH practices and control of COVID-19 in Kenya.

Results

More than half of the respondents were from Kilifi, 431 (70.4%) were female and the mean age was 38.2±14.8 y. Households in Kilifi were most likely not to have enough water, while Mombasa households were more likely to pay for water. Sanitation coverage was 47.6%, with more than half sharing sanitation facilities. Sharing of latrines was significantly associated with county and income level. Accessing soap was worse compared with the month prior to the survey, only 3.9% had their garbage collected by formal service providers and only 17% reported wearing any protective gear while handling waste at home.

Conclusions

Water is disproportionately available in the two counties, with low sanitation coverage. There is low knowledge on hand washing and inadequate waste disposal services.

1131 The Integration of Cardiothoracic Practical Skills Workshop in The Undergraduate Medical School Curriculum and Its Impact on Promoting Interest in Cardiothoracic Surgery

Aim

Assess if WETLAB workshop encourages the engagement of medical students in CTS surgery

Method

We hosted a cardiac WETLAB workshop, led by a consultant cardiothoracic surgeon. Attendees were taught how to carry out an end-to-side anastomosis on animal tissue. We used pre-and -post exposure questionnaires composed of 10 items to assess the ability of the workshop to improve undergraduate interest in cardiothoracic surgery. The questionnaire included questions around students’ interest in the speciality, previous exposure to the speciality and whether students want to pursue a career in the speciality.

Results

Out of the 12 attendees, 10 completed both questionnaires. The workshop was well received with the overall satisfaction of 9.64 out of 10. It significantly increased respondents’ interest in CTS(z=-0.06, p = 0.01) but did not show any significant difference in encouraging them to pursue surgery. 100% of respondents agreed that specialised practical workshops should be incorporated within the medical school curriculum and that if the opportunity arises, they will attend another in the future.

Conclusions

Specialised practical workshops have the potential to play a significant role in the medical school curriculum in order to enhance exposure to the field of cardiothoracic surgery. This may lead to a positive impact on the number of doctors wishing to pursue this speciality in the future.

783 Digital Weekend Handover an Effective Documentation

Aim

To assess quality of completion for weekend handover for surgical weekend and to plan and design a Digital handover, the implementation and effect of which is studied.

Method

Data collection from TRAKCARE for documentation completion criteriae including diagnosis, further investigations to chase (e.g., bloods, imaging), discharge plans, escalation and DNAR status identified.

First cycle collected in August 2020 for pre-implementation status and standard. Second cycle was collected after implementation and raising awareness about new system in October 2020.

Exclusion criteria: patients discharged prior to weekend

Results

32 (10f 22m) and 22 (9 f 13m) patients were studied in first and second cycle with a respective median length stay of 243 hours and 161.5 hours. Handover entries had improved from 40.6% completion rate to 77.3% these included a diagnosis and management plan. Required blood investigation plans were recorded in 54.5% patients (previously 9.4%). Escalation plans including DNACPR and ceiling of care were improved from 25% to 31%.

Conclusions

Digital Medical recording left a gap in documentation for weekend ward rounds when personnels are thinned and busy. To optimize clinical care, the use of a E weekend handover has improved documentation greatly. Future Ongoing project includes improving escalation plans further.

64 Seizing an Opportunity: Setting Up A Virtual Wetlab During the COVID19 Pandemic

Aim

The COVID19 pandemic has negatively impacted surgical training across the globe. In the UK, educational events and training days were cancelled for trainees at all levels. However, these unusual times provide opportunity to develop novel teaching methods. Our aim was to design a “virtual cardiac surgery wetlab” that allows real-time skills training.

Method

With support from industry partners Edwards Lifesciences, Wetlab and Connexon365 (Webinar Hosting Platform) all the necessary materials were distributed. A package was sent to trainer and trainees that included microinstruments, sutures, synthetic vessels and valve models, high-definition camera, along with printed instructions and video to outline set-up of the rig. Trainees only need to provide is a computer. A consultant surgeon demonstrated how to perform a coronary anastomosis and aortic valve replacement and was then able to supervise trainees and provide real-time feedback using the online platform.

Results

Feedback from trainer and trainees has shown that the system is an easy-to-set-up, effective training tool for teaching cardiac surgery skills including coronary anastomosis and valve surgery. The online platform enabled good vision and engagement between trainer and trainee and also enabled recording of the session. Distributing all of the materials nationwide means the virtual wetlab can take place anywhere, including in the comfort of home, for both trainee and trainer.

Conclusions

Surgical skills training can still take place effectively in the absence of “real life” wetlabs. Given the current COVID19 pandemic continues to interrupt traditional surgical teaching, this method has potential to be adopted nationwide to minimise the disruption.

Folic acid supplementation in postmenopausal women with hot flushes: phase III randomised double-blind placebo-controlled trial

OBJECTIVE

To assess whether folic acid supplementation ameliorates hot flushes.

DESIGN

Double-blind, placebo-controlled randomised trial.

SETTING

Nine hospitals in England.

POPULATION

Postmenopausal women experiencing ≥50 hot flushes weekly.

METHODS

Women (n = 164) were randomly assigned in a 1:1 ratio to receive folic acid 5 mg tablet or placebo daily for 12 weeks. Participants recorded frequency and severity of hot flushes in a Sloan Diary daily and completed Greene Climacteric and Utian Quality of Life (UQoL) Scales at 4-week intervals.

MAIN OUTCOME MEASURES

The change in daily Hot Flush Score at week 12 from randomisation based on Sloan Diary Composite Score B calculation.

RESULTS

Data of 143 (87%) women were available for the primary outcome. The mean change (SD) in Hot Flush Score at week 12 was -6.98 (10.30) and -4.57 (9.46) for folic acid and placebo group, respectively. The difference between groups in the mean change was -2.41 (95% CI -5.68 to 0.87) (P = 0.149) and in the adjusted mean change -2.61 (95% CI -5.72 to 0.49) (P = 0.098). Analysis of secondary outcomes indicated an increased benefit in the folic acid group regarding changes in total and emotional UQoL scores at week 8 when compared with placebo. The difference in the mean change from baseline was 5.22 (95% CI 1.16-9.28) and 1.88 (95% CI 0.23-3.52) for total and emotional score, respectively.

CONCLUSIONS

The study was not able to demonstrate that folic acid had a statistically significant greater benefit in reducing Hot Flush Score over 12 weeks in postmenopausal women when compared with placebo.

TWEETABLE ABSTRACT

Folic acid may ameliorate hot flushes in postmenopausal women but confirmation is required from a larger study.

40 Across the Pond: Why Are Junior Doctors Seeking Surgical Training Abroad?

Introduction

The loss of junior doctors from the NHS has been an ongoing issue. A subset are now seeking surgical training in other systems, such as the US. This is a costly and difficult process and many enter into undesignated positions with no guarantee of a job. With so much career uncertainty, why are trainees willing to take the risk?

Method

We performed a survey of trainees who graduated from British medical schools; all are currently enrolled in a US surgical training programme. They were asked about their experiences and perceptions of

Results

Nine trainees completed the survey. The most common time for trainees to move was during or after foundation training and the majority initially matched into preliminary positions. The most common reason cited to move was to receive better quality training. Many perceived the US training to be better and felt that they had a reasonable work-life balance.

Conclusions

The potential loss of the future NHS surgical workforce is worrying. Our survey highlights that surgical trainees place a high value on the quality of their training and were willing to enter an intense and uncertain process to achieve it. This needs to be addressed to retain potential trainees.

263 Airway, Voice and Swallow Outcomes Following Endotracheal Intubation and Mechanical Ventilation For COVID-19 Pneumonitis: Preliminary Results of a Prospective Cohort Study

Introduction

The COVID-19 pandemic has placed exceptional demands on Intensive Care Units (ICU) across the world – particularly requiring patients to be intubated and mechanically ventilated. Laryngeal injury following intubation is a common occurrence, therefore this study aims to analyse airway, voice, and swallow (AVS) outcomes of patients intubated for COVID-19 pneumonitis and compares it to intubated non-COVID-19 respiratory patients and other ICU admissions.

Method

We collected data from inpatient records, and follow-up clinics on intubated adult patients discharged from a tertiary care hospital ICU between 01/03/20 and 30/04/20. Patients were assessed with the AVS Scale, Voice Handicap Index-10 (VHI-10), and Eating Assessment Tool-10 (EAT-10).

Results

86 patients were admitted with COVID-19 pneumonitis, 17 patients were admitted with non-COVID-19 respiratory failure, and 26 patients were admitted with a non-respiratory diagnosis.

The COVID-19 cohort demonstrated higher rates of AVS difficulties (airway 59% vs 44% and 31%, voice 40% vs 19% and 19%, swallow 21% vs 6% and 12%). VHI-10 and EAT-10 scores showed no significant differences between groups.

Conclusions

Patients intubated for COVID-19 pneumonitis reported higher rates of AVS difficulties against non-COVID-19 reasons for intubation. Robust prospective screening protocols are essential to improving patient outcomes by highlighting and therefore managing laryngological sequelae that occur following intubation.

Long term follow-up after pregnancy in Fontan patients

Background

Patients with single ventricle physiology who have benefited from the Fontan procedure are reaching childbearing age. In this population, complications are common around pregnancy, but the long term effect of pregnancy is unclear.

Purpose

To evaluate functional and structural changes several years after pregnancy in patients with Fontan circulation.

Methods

Women with Fontan circulation who had a pregnancy beyond the 20 weeks of gestation followed at our centre between 2005–2019 were included. The following data were collected before pregnancy and at the last follow up (f-up): cardiac anatomy, type of Fontan procedure, resting O2 saturation (O2sat), NYHA class, systemic atrioventricular valve (SAVV) regurgitation, ventricular function, history of arrhythmias, heart failure (HF), thromboembolism, Fontan-related liver disease (FLD), protein-losing enteropathy (PLE), plastic bronchitis and cardiopulmonary test data.

Results

12 patients had 18 pregnancies, giving birth to 17 live newborns (1 newborn death at 24 weeks of gestation). 7 (58.3%)patients had a total cavo-pulmonary connection, 3 (25%)an atrio-pulmonary connection and 2 (16.7%)a Bjork type Fontan. Tricuspid atresia was the most common anatomy (6, 50%). Before pregnancy, O2sat was 95.4±1.9%and all patients were in NYHA class I or II. All patients (12, 100%)had a normal or mildly impaired ventricular function and 3 (25%)had a moderate or severe SAAV regurgitation. 6 (50%)patients had 2 pregnancies. Mean age at first pregnancy was 29.9±4.4 years. Cardiac events occurred in 7 (38%)pregnancies, most commonly atrial arrhythmia (4, 57%), 2 (16.6%)patients developed new cyanosis and 1 had a thromboembolic event. No maternal death occurred and 1 patient had severe haemorrhage. After a mean f-up of 84±48 months, there was no significant worsening in O2sat (94.3±3.1 at f-up, p=1) and all patients remained in NYHA class I or II (12, 100%, p=1). At f-up all patients (12, 100%)continued to have a normal or mildly impaired ventricular function (p=1) and there was no significant worsening in the SAAV regurgitation (3 patients with moderate or severe regurgitation, p=1). 3 (25%)patients developed FLD (p=0.3), 3 (25%) a new episode of atrial arrhythmia (p=0.3). There were no significantly differences in peak VO2 (22.5±3.8 pre-pregnancy, 22.8±5.5 at f-up, p=0.4) and VE/VCO2 slope (34.9±11.2 pre-pregnancy, 36.3±11.8 at f-up, p=0.2)before pregnancy and during f-up.

Conclusions

In this small cohort of Fontan patients who successfully completed at least 1 pregnancy, there was no significant decline in functional or structural cardiac parameters long term after delivery.

Funding Acknowledgement

Type of funding source: None

Studies of Charm Quark Diffusion inside Jets Using Pb-Pb and pp Collisions at sqrt[s_{NN}]=5.02 TeV

The first study of charm quark diffusion with respect to the jet axis in heavy ion collisions is presented. The measurement is performed using jets with p_{T}^{jet}>60  GeV/c and D^{0} mesons with p_{T}^{D}>4  GeV/c in lead-lead (Pb-Pb) and proton-proton (pp) collisions at a nucleon-nucleon center-of-mass energy of sqrt[s_{NN}]=5.02  TeV, recorded by the CMS detector at the LHC. The radial distribution of D^{0} mesons with respect to the jet axis is sensitive to the production mechanisms of the meson, as well as to the energy loss and diffusion processes undergone by its parent parton inside the strongly interacting medium produced in Pb-Pb collisions. When compared to Monte Carlo event generators, the radial distribution in pp collisions is found to be well described by pythia, while the slope of the distribution predicted by sherpa is steeper than that of the data. In Pb-Pb collisions, compared to the pp results, the D^{0} meson distribution for 4<p_{T}^{D}<20  GeV/c hints at a larger distance on average with respect to the jet axis, reflecting a diffusion of charm quarks in the medium created in heavy ion collisions. At higher p_{T}^{D}, the Pb-Pb and pp radial distributions are found to be similar.

Transarterial chemoembolization for hepatocellular carcinoma: a bibliometric analysis of the most cited articles

PURPOSE

Bibliometric analysis is a quantitative assessment of the academic literature in a particular field. The aim of our study was to characterize the 100 top-cited articles regarding transarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

The 'Web of Science' database was used to identify the leading articles regarding TACE for HCC. We determined the top 100 articles according to citations and performed an analysis on year of publication, authorship, department affiliation, publishing journal, institution and country of origin, subject matter and article type.

RESULTS

The top-cited articles received between 92 and 2254 citations (median 283.4). The top 100 papers were published in 32 journals between 1983 and 2016. Cancer, Radiology and Hepatology published the most articles (n = 40). Internal medicine was the department affiliation of the first author in 49%. The country providing the most highly cited articles was Japan (n = 24).

CONCLUSION

We performed an analysis of the 100 top-cited articles dealing with TACE for HCC, presenting a detailed list of the most influential and historically significant papers. Japan was the country that produced the most top-cited articles, highlighting its key contribution to this field of the literature.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Carvedilol safeguards against aspirin-induced gastric damage in rats

This study investigated the effect of carvedilol on aspirin-induced gastric damage. Male Wistar rats were divided into three groups. Control rats received the vehicle, while the aspirin group received aspirin (200 mg/kg) orally for 4 days. Rats of aspirin + carvedilol group were administered aspirin along with carvedilol (5 mg/kg; intraperitoneal) for 4 days. Animals were euthanized at the end of the treatment period, and gastric tissues were collected to perform histopathological and mechanistic studies. The results revealed that aspirin administration induced gastric ulcer as there were remarkable histopathological lesions in the form of marked necrosis, inflammation, hemorrhage, edema, and dysplastic changes. Lipid peroxidative markers such as malondialdehyde, 4-hydroxynonenal, and protein carbonyl were significantly elevated in the aspirin group. This was concurrent with a significant amelioration of antioxidants such as reduced glutathione, superoxide dismutase, and catalase. Furthermore, aspirin increased the immunoexpression of cyclooxygenase (COX) 2 and nuclear factor kappa-B (NF-κB). Aspirin induced elevation in the inflammatory cytokines such as tumor necrosis factor-α, interleukin-6, and interleukin-1β. Aspirin enhanced the immunoexpression of inducible nitric oxide synthetase (iNOS) and increased the level of nitrite/nitrate in gastric tissue. On the other hand, carvedilol treatment reversed all these pathological changes. Carvedilol succeeded to enhance antioxidants in gastric tissue, attenuated lipid peroxidative parameters, and suppressed the release of inflammatory mediators. It attenuated the immunoexpression of COX-2, NF-κB, and iNOS. Collectively, carvedilol has a gastro-protective effect that could be attributed to its antioxidative and anti-inflammatory properties, which modulate NF-κB/COX-2/iNOS pathways.

Effects of patient-specific three-dimensional lumbar traction on pain and functional disability in patients with lumbar intervertebral disc prolapse

Background

Prolapsed lumbar intervertebral disc is one of the most prevalent causes of low back pain and traction is one of the most common physical therapy treatments offered to affected patients. Advancements in traction equipment are needed to ensure their effectiveness in clinical situations.

Aims

The objective of the study was to find out the effect of patient-specific three-dimensional lumbar traction on pain and functional disability in individuals with lumbar intervertebral disc prolapse.

Subjects and Methods

Original article and Experimental design. Twenty-five participants (age range: 34-67 years) diagnosed with lumbar intervertebral disc prolapse were included in this study. Patient-specific three-dimensional lumbar traction was given as three sessions per week for the duration of one month. All participants completed a 10-cm visual analog pain scale and pain pressure threshold to assess pain and the Oswestry disability index to assess the functional disability.

Results

On pre to post interventions, a significant change in mean values were found for visual analog scale pain score, pain pressure threshold, and Oswestry disability index (P < 0.001). The pain intensity was reduced from 8.5 to 3.2, pain pressure threshold increased from 0.7 to 1.6 kg/cm², and functional disability was reduced from 53.5% to 31.3%.

Conclusion

Twelve sessions of patient-specific three-dimensional lumbar traction promoted a reduction in pain and improvement in functional disability among subjects with lumbar intervertebral disc prolapse.

Fast Gate-Based Readout of Silicon Quantum Dots Using Josephson Parametric Amplification

Spins in silicon quantum devices are promising candidates for large-scale quantum computing. Gate-based sensing of spin qubits offers a compact and scalable readout with high fidelity, however, further improvements in sensitivity are required to meet the fidelity thresholds and measurement timescales needed for the implementation of fast feedback in error correction protocols. Here, we combine radio-frequency gate-based sensing at 622 MHz with a Josephson parametric amplifier, that operates in the 500-800 MHz band, to reduce the integration time required to read the state of a silicon double quantum dot formed in a nanowire transistor. Based on our achieved signal-to-noise ratio, we estimate that singlet-triplet single-shot readout with an average fidelity of 99.7% could be performed in 1  μs, well below the requirements for fault-tolerant readout and 30 times faster than without the Josephson parametric amplifier. Additionally, the Josephson parametric amplifier allows operation at a lower radio-frequency power while maintaining identical signal-to-noise ratio. We determine a noise temperature of 200 mK with a contribution from the Josephson parametric amplifier (25%), cryogenic amplifier (25%) and the resonator (50%), showing routes to further increase the readout speed.

Interactive effects of threonine levels and protein source on growth performance and carcass traits, gut morphology, ileal digestibility of protein and amino acids, and immunity in broilers

An experiment was executed to test the hypothesis that supplementation of dietary threonine (d-Thr), above NRC recommendation to diets containing poorly digestible protein source (PS) may compensate its detrimental effects on overall performance of broilers. In total, nine hundred 1-day-old mixed sex broilers (Ross-308) were randomly distributed over 6 (2 × 3) experimental diets comprising 5 replicates of 30 broilers each for 35 d. The experimental diets contain either soybean meal (SBM) or canola meal (CM) with 3 levels (100, 110, and 120% of NRC recommendation) of d-Thr. During the course of the trial (0 to 35 D), interactions (P < 0.05) between PS and d-Thr were observed for feed intake (FI), body weight gain (BWG), feed conversion ratio (FCR), carcass, and gut health parameters. The broilers fed recommended level (100%) of d-Thr had 7 and 5% poorer FCR compared with those fed diets with 110 and 120% d-Thr, respectively. For villus height (VH), an interaction (P = 0.007) was found between PS and d-Thr level. Broilers consuming SBM diets had 22% longer villi, 10% deeper crypts, and 30% greater VH to crypt depth ratio (VCR) compared to those fed CM. The broilers fed 110% d-Thr diets had 9% lower crypt depth (CD) and 15% greater VCR compared with those fed diets containing NRC recommended levels. CM resulted in 9% lower protein digestibility with lower (P < 0.05) of some AA, whereas it was improved by 7% in broilers fed 120% d-Thr supplemented diets. The bursa and spleen weights were positively affected (P < 0.001) by PS. Threonine supplementation (10%) resulted in 25% greater thymus, 18% heavier bursa, and 30% greater infectious bursal disease titer. In conclusion, supplementation of d-Thr, above NRC recommendation, resulted in a better growth performance and carcass traits, improved ileal digestibility of protein and amino acids, better gut health, and immunity in broilers.