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Objective: This study evaluated the nationwide trends in care and accompanied postoperative outcomes for patients with distal esophageal and gastro-esophageal junction cancer.Summary of Background Data: The introduction of transthoracic esophagectomy, minimally invasive surgery, and neo-adjuvant chemo(radio)therapy changed care for patients with esophageal cancer.Methods: Patients after elective transthoracic and transhiatal esophagectomy for distal esophageal or gastroesophageal junction carcinoma in the Netherlands between 2007-2016 were included. The primary aim was to evaluate trends in both care and postoperative outcomes for the included patients. Additionally, postoperative outcomes after transthoracic and tran-shiatal esophagectomy were compared, stratified by time periods.Results: Among 4712 patients included, 74% had distal esophageal tumors and 87% had adenocarcinomas. Between 2007 and 2016, the proportion of transthoracic esophagectomy increased from 41% to 81%, and neo-adjuvant treatment and minimally invasive esophagectomy increased from 31% to 96%, and from 7% to 80%, respectively. Over this 10-year period, postoperative outcomes improved: postoperative morbidity decreased from 66.6% to 61.8% (P = 0.001), R0 resection rate increased from 90.0% to 96.5% (P Conclusion: In this nationwide cohort, a transition towards more neo-adju-vant treatment, transthoracic esophagectomy and minimally invasive surgery was observed over a 10-year period, accompanied by decreased postoperative morbidity, improved surgical radicality and lymph node harvest, and improved survival.

In November 1995, the Laboratory of Archaeology at the University of Georgia submitted inventories and summaries of Indigenous ancestors and funerary objects in its holdings to comply with the passage of the Native American Graves Protection and Repatriation Act (NAGPRA). However, after this submission, the Laboratory attempts at consultation with federally recognized descendant Tribal communities who have cultural ties in the state of Georgia were not successful, and NAGPRA-related activities essentially stalled at the Laboratory. Beginning in 2019, the Laboratory's staff recognized a lack of formal NAGPRA policies or standards, which led to a complete reevaluation of the Laboratory's approach to NAGPRA. In essence, it was the Laboratory's renewed engagement with NAGPRA and descendan tribal communities that became the catalyst for change in the Laboratory's philosophy as a curation repository. This shift in thinking set the Laboratory on a path toward building a descendant community–informed institutional integrity (DCIII) level of engagement with consultation and collaborative efforts in all aspects of collections management and archaeological research. In this article, we outline steps that the Laboratory has taken toward implementing meaningful policies and practices created with descendant Tribal communities that both fulfill and extend bounds of NAGPRA compliance.

Introduction. We consider a weakly conductive gradient fiber in the single-mode regime and solve the equation for the electric field in the core of this fiber in a general form in the first approximation. The aim of this study is to study the field and energy in the core of a weakly conductive gradient fiber without taking into account the polarization in the single-mode regime in the case of a power-law (generally) refractive index profile. Materials and Methods. From Maxwell’s equations for dielectric media, there was derived an equation for the field in a fiber with gradient refractive index profile. Making the appropriate substitutions, replacing the zero-order Bessel function with a Gaussian function, and making the necessary approximation of the resulting equation, we arrive at an equation that we solve by the Wentzel – Kramers – Brillouin method and obtain analytical expressions for the field and energy inside waveguide for an arbitrary degree of the refractive index. Results. There was obtained a solution of the equation for the field in fiber with a powerlaw refractive index profile. Numerical calculations were carried out. A graph of the dependence of a dimensionless quantity – “normalized” energy – on the waveguide parameter for the first five powers of the profile (n = 1, 2, 3, 4, 5) was plotted. Discussion and Conclusion. It is shown that the energy increases faster for the profile with n = 1, and after this value, the energy for the profile with n = 1 increases sharply, and for n > 1, the energy growth decreases with increasing n. The results obtained in this work can be used for creating an energy-efficient core, for carrying out a possible analysis of information transmission, and for designing waveguides taking into account specific applications.

Background: Continuity after esophagectomy is restored by creating an intrathoracic or cervical anastomosis. Although the single most important factor for determining the suitability for intrathoracic anastomosis is the location of the tumor, current literature only grossly distinguishes proximal, mid or distal esophageal tumors. This study offers precise anatomic considerations for the assessment of suitability for an intrathoracic anastomosis. Methods: In this anatomical cohort study, all consecutive patients after esophagectomy for cancer who underwent a postoperative endoscopy between 2010 and 2018 were analyzed. The clinical postoperative anatomy was assessed and the level of the anastomosis was measured in distance from the incisors. Computed tomography imaging was used to confirm postoperative localization. These data were compared to preoperative localization of the tumor and proximal resection margins. Results: A total of 208 patients who underwent esophageal cancer surgery were included, comprising 61 (29.3%) intrathoracic and 147 (70.7%) cervical reconstructions. The mean distance was 28.2±2.3 and 19.6±1.7 cm from the incisors for an intrathoracic and cervical anastomosis respectively (P

Objective: This study investigated the patterns, predictors, and survival of recurrent disease following esophageal cancer surgery.Background: Survival of recurrent esophageal cancer is usually poor, with limited prospects of remission.Methods: This nationwide cohort study included patients with distal esophageal and gastroesophageal junction adenocarcinoma and squamous cell carcinoma after curatively intended esophagectomy in 2007 to 2016 (follow-up until January 2020). Patients with distant metastases detected during surgery were excluded. Univariable and multivariable logistic regression were used to identify predictors of recurrent disease. Multivariable Cox regression was used to determine the association of recurrence site and treatment intent with postrecurrence survival.Results: Among 4626 patients, 45.1% developed recurrent disease a median of 11 months postoperative, of whom most had solely distant metastases (59.8%). Disease recurrences were most frequently hepatic (26.2%) or pulmonary (25.1%). Factors significantly associated with disease recurrence included young age (≤ 65 y), male sex, adenocarcinoma, open surgery, transthoracic esophagectomy, nonradical resection, higher T-stage, and tumor positive lymph nodes. Overall, median postrecurrence survival was 4 months [95% confidence interval (95% CI): 3.6–4.4]. After curatively intended recurrence treatment, median survival was 20 months (95% CI: 16.4–23.7). Survival was more favorable after locoregional compared with distant recurrence (hazard ratio: 0.74, 95% CI: 0.65–0.84).Conclusions: This study provides important prognostic information assisting in the surveillance and counseling of patients after curatively intended esophageal cancer surgery. Nearly half the patients developed recurrent disease, with limited prospects of survival. The risk of recurrence was higher in patients with a higher tumor stage, nonradical resection and positive lymph node harvest.

The petroleum industry in Nigeria contributes a huge percentage to the national revenue of the country, to the extent that budgets are being passed based on the oil price dynamics. With the importance the petroleum sector has attained in Nigeria, it is expected that the country's pedagogy will reflect the value it contributes to the national table. However, reviews, surveys, and works of literature have shown otherwise. As a result, this study emphasizes the importance of petroleum engineering pedagogy in-country as an oil-producing country, the university curriculum of petroleum engineering in Nigeria was also examined (with a particular focus on the impact of poor curriculum on national development), and the dynamics between the university, industry and government were critically discussed and recommended practices for improving petroleum engineering pedagogy were made. This study targets national development and control over its own resources through a knowledge economy and seamless dynamics of information within the oil and gas industry. The Nigerian government, through the Federal Ministry of Education, is further expected to capitalize on the outcomes of this research for curriculum review of petroleum engineering and related courses offered in-country to foster sustainability in a competing global society.

Numerous organs in the bodies of animals, including the lung, kidney, and mammary gland, contain ramified networks of epithelial tubes. These structures arise during development via a process known as branching morphogenesis. Previous studies have shown that mechanical forces directly impact this process, but the patterns of mechanical stress exerted by branching embryonic epithelia are not well understood. This is, in part, owing to a lack of experimental tools. Traditional traction force microscopy assays rely on the use of compliant hydrogels with well-defined mechanical properties. Isolated embryonic epithelial explants, however, have only been shown to branch in three-dimensional matrices of reconstituted basement membrane protein, or Matrigel, a biomaterial with poorly characterized mechanical behavior, especially in the regime of large deformations. Here, to compute the traction stresses generated by branching epithelial explants, we quantified the finite-deformation constitutive behavior of gels of reconstituted basement membrane protein subjected to multi-axial mechanical loads. We then modified the mesenchyme-free assay for the ex vivo culture of isolated embryonic airway epithelial explants by suspending fluorescent microspheres within the surrounding gel and tracking their motion during culture. Surprisingly, the tracked bead motion was non-zero in regions of the gel far away from the explants, suggestive of passive swelling deformations within the matrix. To compute accurate traction stresses, these swelling deformations must be decomposed from those generated by the branching explants. We thus tracked the motion of beads suspended within cell-free matrices and quantified spatiotemporal patterns of gel swelling. Taken together, these passive swelling data can be combined with the measured mechanical properties of the gel to compute the traction forces exerted by intact embryonic epithelial explants.

Democratic cooperation is a particularly complex type of arrangement that requires attendant institutions to ensure that the problems inherent in collective action do not subvert the public good. It is perhaps due to this complexity that historians, political scientists, and others generally associate the birth of democracy with the emergence of so-called states and center it geographically in the “West,” where it then diffused to the rest of the world. We argue that the archaeological record of the American Southeast provides a case to examine the emergence of democratic institutions and to highlight the distinctive ways in which such long-lived institutions were—and continue to be—expressed by Native Americans. Our research at the Cold Springs site in northern Georgia, USA, provides important insight into the earliest documented council houses in the American Southeast. We present new radiocarbon dating of these structures along with dates for the associated early platform mounds that place their use as early as cal AD 500. This new dating makes the institution of the Muskogean council, whose active participants have always included both men and women, at least 1,500 years old, and therefore one of the most enduring and inclusive democratic institutions in world history.

The goal for many PhD students in archaeology is tenure-track employment. Students primarily receive their training by tenure-track or tenured professors, and they are often tacitly expected—or explicitly encouraged—to follow in the footsteps of their advisor. However, the career trajectories that current and recent PhD students follow may hold little resemblance to the ones experienced by their advisors. To understand these different paths and to provide information for current PhD students considering pursuing a career in academia, we surveyed 438 archaeologists holding tenured or tenure-track positions in the United States. The survey, recorded in 2019, posed a variety of questions regarding the personal experiences of individual professors. The results are binned by the decade in which the respondent graduated. Evident patterns are discussed in terms of change over time. The resulting portraits of academic pathways through the past five decades indicate that although broad commonalities exist in the qualifications of early career academics, there is no singular pathway to obtaining tenure-track employment. We highlight the commonalities revealed in our survey to provide a set of general qualifications that might provide a baseline set of skills and experiences for an archaeologist seeking a tenure-track job in the United States.

PURPOSE: Access to health care is a long-standing concern for rural patients; however, administrative measures fail to capture the subjective patient experience of accessing health care. The purpose of this review was to synthesize the qualitative literature on patient and caregiver experiences of accessing health care services for chronic disease management among US residents of rural areas. METHODS: We searched Embase, MEDLINE, PsycInfo, CINAHL, and Scopus to identify qualitative studies published during 2010-2019. A thematic synthesis approach was used to analyze findings from included studies. RESULTS: A total of 62 studies involving 1,354 unique participants were included. The largest share of studies (24.2%) was focused on the experience of patients with cancer, followed by behavioral health (16.1%), HIV and AIDS (14.5%), and diabetes (12.9%). We identified 4 primary analytic themes of barriers and facilitators associated with the experience of accessing health care services for chronic disease management in rural areas: (1) navigating the rural environment, (2) navigating the health care system, (3) financing chronic disease management, and (4) rural life (ie, common elements of a distinct “rural” way of thinking and behaving). CONCLUSIONS: In this comprehensive review, we found that important cultural, structural, and individual factors influenced the rural patient’s experience of health care access and use, including barriers and facilitators posed by geographic and built environments, and distinct rural mores. Our findings can inform policies and programs that both facilitate structural aspects of access and include culturally appropriate interventions. VISUAL ABSTRACT

This study examines the impact of the COVID-19 pandemic on health care-associated infection (HAI) incidence in low- and middle-income countries (LMICs).Patients from 7 LMICs were followed up during hospital intensive care unit (ICU) stays from January 2019 to May 2020. HAI rates were calculated using the International Nosocomial Infection Control Consortium (INICC) Surveillance Online System applying the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) criteria. Pre-COVID-19 rates for 2019 were compared with COVID-19 era rates for 2020 for central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), mortality, and length of stay (LOS).A total of 7,775 patients were followed up for 49,506 bed days. The 2019 to 2020 rate comparisons were 2.54 and 4.73 CLABSIs per 1,000 central line days (risk ratio [RR] = 1.85, p = .0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR = 1.29, p = .10), and 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR = 1.14; p = .69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR = 1.42; p.0001), respectively. Mean LOS for 2019 and 2020 were 6.02 and 7.54 days (RR = 1.21, p.0001), respectively.This study documents an increase in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices.

Background Bariatric surgery can influence the presentation, diagnosis, and management of gastrointestinal cancers. Oesophago-Gastric (OG) malignancies in patients who have had a prior bariatric procedure have not been fully characterised. Objective To characterise OG malignancies after bariatric procedures. Setting University Hospital, United Kingdom. Methods We performed a retrospective, multi-centre observational study of patients with OG malignancies after bariatric surgery to characterise this condition. Results This study includes 170 patients from 75 centres in 25 countries who underwent bariatric procedures between 1985 and 2020. At the time of the bariatric procedure, the mean age was 50.2 ± 10 years and the mean weight 128.8 ± 28.9 kg. Females comprised 57.3% (n=98) of the population. Most (n=64) patients underwent a Roux-en-Y Gastric Bypass (RYGB) followed by Adjustable Gastric Band (AGB) (n = 46) and Sleeve Gastrectomy (SG) (n = 43). Time to cancer diagnosis after bariatric surgery was 9.5 ± 7.4 years and mean weight at diagnosis was 87.4 ± 21.9 kg. The time lag was 5.9 ± 4.1 years after SG compared to 9.4 ± 7.1 years after RYGB and 10.5 ± 5.7 years after AGB. One-third of patients presented with metastatic disease. The majority of tumours were adenocarcinoma (82.9%). Approximately 1 in 5 patients underwent palliative treatment from the outset. Time from diagnosis to mortality was under one year for most patients who died over the intervening period. Conclusions The OGMOS (Oesophago-Gastric Malignancies after Obesity/ Bariatric Surgery) study presents the largest series to date of patients developing OG malignancies after bariatric surgery and attempts to characterise this condition.

A new mechanically stimulated solid-state reaction of PtCl4 with sodium β-diketonates has been discovered. Platinum (II) β-diketonates were obtained by grinding excess sodium trifluoroacetylacetonate Na(tfac) or hexafluoroacetylacetonate Na(hfac) in a vibration ball mill, followed by subsequent heating of the resulting mixture. The reactions occur under much milder conditions (at about 170 °C) compared to similar reactions of PtCl2 or K2PtCl6 (at about 240 °C). Excess diketonate salt plays the role of a reducing agent in the conversion of Pt (IV) salt to Pt (II) compounds. The effect of grinding on properties of the ground mixtures was studied by XRD, IR, and thermal analysis methods. The difference in the course of the interaction of PtCl4 with Na(hfac) or Na(tfac) indicates the dependence of the reaction on the ligand properties. The probable reaction mechanisms were discussed. This method of synthesis of platinum (II) β-diketonates makes it possible to substantially reduce the variety of reagents used, the number of reaction steps, the reaction time, the use of solvents, and waste generation compared to conventional solution-based methods.

Background Perceived health is one of the strongest determinants of subjective well-being, but it has received little attention among survivors of ARDS. Research question How well do self-reported measures of physical, emotional, and social functioning predict perceived overall health (measured using the EQ-5D visual analog scale [EQ-5D-VAS]) among adult survivors of ARDS? Are demographic features, comorbidity, or severity of illness correlated with perceived health after controlling for self-reported functioning? Study Design and Methods We analyzed the ARDSNet Long Term Outcomes Study (ALTOS) and Improving Care of Acute Lung Injury Patients (ICAP) Study, two longitudinal cohorts with a total of 823 survivors from 44 US hospitals, which prospectively assessed survivors at 6 and 12 months after ARDS. Perceived health, evaluated using the EQ-5D-VAS, was predicted using ridge regression and self-reported measures of physical, emotional, and social functioning. The difference between observed and predicted perceived health was termed perspective deviation (PD). Correlations between PD and demographics, comorbidities, and severity of illness were explored. Results The correlation between observed and predicted EQ-5D-VAS scores ranged from 0.68 to 0.73 across the two cohorts and time points. PD ranged from –80 to +34 and was more than the minimum clinically important difference for 52% to 55% of survivors. Neither demographic features, comorbidity, nor severity of illness were correlated strongly with PD, with |r| Interpretation About half of survivors of ARDS showed clinically important differences in actual perceived health vs predicted perceived health based on self-reported measures of functioning. Survivors of ARDS demographic features, comorbidities, and severity of illness were correlated only weakly with perceived health after controlling for measures of perceived functioning, highlighting the challenge of predicting how individual patients will respond psychologically to new impairments after critical illness.

To present 2 patients with myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease with unilateral orbital inflammation, optic nerve head edema, and abnormalities of the optic nerve and nerve sheath on imaging. We review the most current literature on this important and uncommon clinical phenotype.A case report of 2 patients and a comprehensive review of the relevant literature on orbital inflammation in MOG antibody-associated disease (MOG-AD).Two patients presented with decreased vision and unilateral orbital inflammation. Both had optic nerve head edema and abnormalities of the optic nerve and nerve sheath on imaging. The patients were treated with immunosuppressants and had improvement of vision changes as well as their orbital inflammatory signs. MOG antibody was positive in high titers in both patients. Only 3 other cases of orbital inflammation associated with MOG antibody have been described. In all cases, orbital signs responded rapidly to intravenous methylprednisolone, but the improvement in visual acuity was variable and less robust.Orbital inflammation is a unique and underrecognized phenotype of MOG-AD with only a few reports in the literature. In patients who present with vision loss and orbital inflammation, MOG-AD should be considered in the differential.

This study was carried out to ascertain the characterization and classification of soils along river Donga in Donga local government area of Taraba State. Three profile pits were dug on the flat terrain for the physio-chemical properties of the soils. The pits were described and samples were collected for routine laboratory analysis for the selected physio-chemicals properties. Data collected were analyzed statistically using analysis of variance (ANOVA) The result of the laboratory analysis of the physical and chemical properties indicated that particle size distribution of sand particle dominated other fraction of fine earth materials. This can be attributed to the parent materials that gave rise to the soils.The pH (H2O) was slightly acidic in reaction in all the pedons studied (6.44, 5.82 and 5.67). The organic carbon content ranges from very low to low compared to the maximum level (5%) for tropical soils. Available phosphorus obtained exceeded the critical limits of 8.0 to >18mg/kg, which indicates that the available phosphorus were high. The exchangeable bases (Ca, Mg, K & Na) as indicated in the table 3 that Ca, Mg, K & Na were low in all the pedons studied. The results obtained from analyzed profile samples showed that percentage (%) base saturation values for all the pedons were high. The Correlation was done to determine non-significant and significant values among soil physio-chemical properties studied at 5% and 1% probability level. In addition, after the profile description and examination of the soil properties of the study area, the soils were classified using USDA soil taxonomy (2014). Pedons 1 and 2 are classified into the order of Alfisols and sub-group of Typical Haplustalf while pedon 3 is also classified into Alfisols but sub-group of Arenickandiustals (Hypereuticlixisels).

Background: A good knowledge of Aedes diversity and their biting cycle is necessary for better planning of vector control interventions against arboviruses diseases. This study aims to determine the diversity of Aedes and the biting cycle of Aedes albopictus in urban and suburban areas of Douala, Kribi, and Ayos to propose a method for vector control based on Ageratum conyzoides L., 1753 and Chromolaena odorata L., 1970 (Asteraceae) essential oil. Methods: Larvae were sampled by dipping method and reared by Desfontaine method. The aggressiveness of Aedes was determined by the outdoors Human Landing Catches method from 6 am to 6 pm. Captured mosquitoes were morphologically identified using identification keys. Essential oils from fresh leaves of A. conyzoides and C. odorata were extracted by hydrodistillation using Clevenger while the chemical composition was determined by GC-MS. Insecticide tests were carried out according to WHO protocol on matures Ae. albopictus larvae. Results: Ae. albopictus (n=3499; 80.5%) was the most abundant species in urban and suburban areas followed by Ae. unilineatus (n=392; 9.02%) and Ae. aegypti (n=210; 4.83%). The mean biting rate of Aedes was 21.52 bites/person/day (b/p/d). In urban and suburban areas Ae. albopictus (18.22 b/p/d) was the most aggressive species followed by Ae. unilineatus (2.04 b/p/d) and Ae. aegypti (1.09 b/p/d). Precocene I (54.4%) and Androencecalinol (24.69%) were the major compounds of A. conyzoides fresh leaves essential oil. Geijerene (20.02%) and trans-Muurola-4(14), 5-diene (19.15%) were the major compounds of C. odorata fresh leaves essential oil. A. conyzoides fresh leaves essential oil was the most effective with 100% mortality after 10 hours of exposure at 75 ppm concentration. Conclusion: This study reveals that Aedes was more aggressive in urban areas than in suburban areas. Aedes albopictus was the most aggressive species. A. conyzoides fresh leaves essential oil should be considered in the implementation of control strategies against Aedes.

We study the optimal one-shot tax reform in the standard incomplete markets model where households differ in their wealth, earnings, permanent labor skill, and age. The government can provide transfers by raising tax revenue and has several tax instruments at its disposal: a flat capital income tax, a flat consumption tax, and a non-linear labor income tax. The optimal fiscal policy funds a transfer that is nearly 50 percent of GDP through a combination of very high taxes on consumption and capital income. The labor tax schedule has a high average rate but is also moderately progressive. We find an identical outcome when policy is instead determined by majority voting. Finally, we offer suggestive empirical evidence that households’ preferences for tax and redistribution are more strongly associated with political identity than economic status.

Background Peripherally inserted central catheters (PICCs) and midlines are commonly used devices for reliable vascular access. Infection and thrombosis are the main adverse effects of these catheters. We aimed to evaluate the relative risk of complications from midlines and PICCs. Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies. The primary outcomes were catheter-related bloodstream infection (CRBSI) and thrombosis. Secondary outcomes evaluated included mortality, failure to complete therapy, catheter occlusion, phlebitis, and catheter fracture. The certainty of evidence was assessed using the GRADE approach. Results Of 8368 citations identified, 20 studies met the eligibility criteria, including 1 RCT and 19 observational studies. Midline use was associated with fewer patients with CRBSI compared with PICCs (odds ratio [OR], 0.24; 95% CI, 0.15–0.38). This association was not observed when we evaluated risk per catheter. No significant association was found between catheters when evaluating risk of localized thrombosis and pulmonary embolism. A subgroup analysis based on location of thrombosis showed higher rates of superficial venous thrombosis in patients using midlines (OR, 2.30; 95% CI, 1.48–3.57). We did not identify any significant difference between midlines and PICCs for the secondary outcomes. Conclusions Our findings suggest that patients who use midlines might experience fewer CRBSIs than those who use PICCs. However, the use of midline catheters was associated with greater risk of superficial vein thrombosis. These findings can help guide future cost-benefit analyses and direct comparative RCTs to further characterize the efficacy and risks of PICCs vs midline catheters.

The possibility of detection and determination of flavonoids by using microbial cells was shown for the first time using the quercetin - Azospirillum baldaniorum Sp245 model system. The activity of the flavonoids quercetin, rutin and naringenin toward A. baldaniorum Sp245 was evaluated. It was found that when the quercetin concentration ranged from 50 to 100 μM, the number of bacterial cells decreased. Rutin and naringenin did not affect bacterial numbers. Quercetin at 100 μM increased bacterial impedance by 60 %. Under the effect of quercetin, the magnitude of the electro-optical signal from cells decreased by 75 %, as compared with the no-quercetin control. Our data show the possibility of developing sensor-based systems for the detection and determination of flavonoids.

Additional file 1. Trial Protocol.

Transthoracic esophagectomy (TTE) for esophageal cancer facilitates mediastinal dissection; however, it has a significant impact on cardiopulmonary status. High-risk patients may therefore be better candidates for transhiatal esophagectomy (THE) in order to prevent serious complications. This study addressed short-term outcome following TTE and THE in patients that are considered to have a higher risk of surgery-related morbidity. This population-based study included patients who underwent a curative esophagectomy between 2011 and 2018, registered in the Dutch Upper GI Cancer Audit. The Charlson comorbidity index was used to assign patients to a low-risk (score ≤ 1) and high-risk group (score ≥ 2). Propensity score matching was applied to produce comparable groups between high-risk patients receiving TTE and THE. Primary endpoint was mortality (in-hospital/30-day mortality), secondary endpoints included morbidity and oncological outcomes. Additionally, a matched subgroup analysis was performed, including only cervical reconstructions. Of 5,438 patients, 945 and 431 high-risk patients underwent TTE and THE, respectively. After propensity score matching, mortality (6.3 vs 3.3%, P = 0.050), overall morbidity, Clavien-Dindo ≥ 3 complications, pulmonary complications, cardiac complications and re-interventions were significantly more observed after TTE compared to THE. A significantly higher mortality after TTE with a cervical reconstruction was found compared to THE (7.0 vs. 2.2%, P = 0.020). Patients with a high Charlson comorbidity index predispose for a complicated postoperative course after esophagectomy, this was more outspoken after TTE compared to THE. In daily practice, these outcomes should be balanced with the lower lymph node yield, but comparable positive node count and radicality after THE.

Background and Objective Recommendations for preventing cardiovascular (CV) disease are currently separated into primary and secondary prevention. We hypothesize that relative effects of interventions for CV prevention are not different across primary and secondary prevention cohorts. Our aim was to test for differences in relative effects on CV events in common preventive CV interventions across primary and secondary prevention cohorts. Methods and Results A systematic search was performed to identify individual patient data (IPD) meta-analyses that included both primary and secondary prevention populations. Eligibility assessment, data extraction, and risk of bias assessment were conducted independently and in duplicate. We extracted relative risks (RR) with 95% confidence intervals (95% CI) of the interventions over patient-important outcomes and estimated the ratio of RR for primary and secondary prevention populations. We identified five eligible IPDs representing 524,570 participants. Quality assessment resulted in overall low-to-moderate methodological quality. We found no subgroup effect across prevention categories in any of the outcomes assessed. Conclusion In the absence of significant treatment-subgroup interactions between primary and secondary CV prevention cohorts for common preventive interventions, clinical practice guidelines could offer recommendations tailored to individual estimates of CV risk without regard to membership to primary and secondary prevention cohorts. This would require the development of reliable ASCVD risk estimators that apply across both cohorts.

This report presents findings from recent systematic surveys and excavations at the site of Finley’s Pond (9CH204) to evaluate craft production (e.g., shell beads) and settlement expansion on Ossab...

Background We report the results of INICC surveillance study from 2013 to 2018, in 664 intensive care units (ICUs) in 133 cities, of 45 countries, from Latin-America, Europe, Africa, Eastern-Mediterranean, Southeast-Asia, and Western-Pacific. Methods Prospective data from patients hospitalized in ICUs were collected through INICC Surveillance Online System. CDC-NHSN definitions for device-associated healthcare-associated infection (DA-HAI) were applied. Results We collected data from 428,847 patients, for an aggregate of 2,815,402 bed-days, 1,468,216 central line (CL)-days, 1,053,330 mechanical ventilator (MV)-days, 1,740,776 urinary catheter (UC)-days. We found 7,785 CL-associated bloodstream infections (CLAB), 12,085 ventilator-associated events (VAE), and 5,509 UC-associated urinary tract infections (CAUTI). Pooled DA-HAI rates were 5.91% and 9.01 DA-HAIs/1,000 bed-days. Pooled CLAB rate was 5.30/1,000 CL-days; VAE rate was 11.47/1,000 MV-days, and CAUTI rate was 3.16/1,000 UC-days. P aeruginosa was non-susceptible (NS) to imipenem in 52.72% of cases; to colistin in 10.38%; to ceftazidime in 50%; to ciprofloxacin in 40.28%; and to amikacin in 34.05%. Klebsiella spp was NS to imipenem in 49.16%; to ceftazidime in 78.01%; to ciprofloxacin in 66.26%; and to amikacin in 42.45%. coagulase-negative Staphylococci and S aureus were NS to oxacillin in 91.44% and 56.03%, respectively. Enterococcus spp was NS to vancomycin in 42.31% of the cases. Conclusions DA-HAI rates and bacterial resistance are high and continuous efforts are needed to reduce them.

Plants adapted to different habitats exhibit differences in functional traits and these characteristics are influenced by soil properties. We tested the hypothesis that soil resource availability influences the functional traits of plants, affecting therefore herbivory levels. We examined three Byrsonima plant species with different life forms that occurred across a distinct edaphic habitat along the Doce River Basin, South-eastern Brazil. We characterize habitats according to soil nutrient concentration and measured functional characteristics of crown architecture, leaf nutrients, sclerophylly, leaf area and leaf density. In addition, we evaluated how these variables influenced herbivory levels of congeneric plants. Our data have shown that species along a gradient of soil nutrients have functional characteristics influenced by habitat, which in turn affected herbivory levels. By comparing species from different life forms but within the same genus along a stress-gradient of continuous habitats, we described a corresponding gradient of plant functional traits and tissue consumption by herbivorous insects.

This chapter discusses how race, racism, and structural inequalities are central to understanding the day-to-day operation of the Federal Rules of Civil Procedure (FRCP), and are yet obscured from most first-year Civil Procedure courses. It begins by examining the doorways of discretion, particularly within rules and standards that apply to pretrial case management. The chapter focuses on dispositive motions, which filter out claims and terminate litigation, and emphasize motions to dismiss under Rule 12(b)(6). It then reflects on the social construction of race and racism. Because the FRCPs require judges to justify their decisions in legal opinions, dispositive motions become hidden sites where the legal construction of race and racism take place. Finally, the chapter explores the dominant perspective in the field that the FRCPs have evolved from a neutral, apolitical, and colorblind rule-making processes rather than from highly normative and partisan contestations. Over the past several decades, dominant interests and racial insiders have enacted reforms that impede the efforts of racial outsiders to use federal courts to realize rights and advance social equality.

Discussion of patient expectations for recovery is a component of intensive care unit (ICU) follow-up clinics. However, few studies have formally evaluated recovery-related expectations of ICU survivors.To estimate the prevalence of unmet expectations for recovery six months after hospital discharge among adult survivors of acute respiratory failure (ARF).Prospective, longitudinal, cohort study of ARF survivors discharged to home from five U.S. medical centers. Expectations for functional recovery were assessed by asking which activities and instrumental activities of daily living (I/ADLs) survivors expected to perform independently at six months. Survivors' expectations for overall health status were assessed using a visual analogue scale (VAS) ranging from 0 - 100. At 6-month follow-up, participants reported which I/ADLs they could perform independently and rated their overall health status using a 100-point VAS. We defined a participant's Functional Expectations as being met if they reported independently performing I/ADLs as expected at hospital discharge. Health Expectations were considered to be met when self-rated health status at six months was no more than eight points lower than expected at enrollment.Among 180 enrollees, 169 (94%) were alive and 160 of these (95%) participated in 6-month follow-up. Functional Expectations were met for 71% of participating survivors, and overall Health Expectations were met for 50%. Expectations for functional independence were high, ranging from 87% (housekeeping) to 99% (using a telephone). General health expectations were variable (median = 85, Interquartile range [IQR] = 75, 95). At 6-month follow-up, self-rated, overall health ranged from 2 to 100 (median = 80, IQR = 60, 85). In exploratory analyses, participants with met vs unmet expectations differed most in formal education (Functional Expectations standardized difference d = 0.88, Health Expectations d = 0.41).ARF survivors' expectations about independent functioning were high and generally met, but half had unmet general health expectations six months after discharge. It is difficult to predict whose health expectations will be unmet, but possessing less formal education may be a risk factor.