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Background The association between volume and outcomes has led to recommendations that patients undergo surgery at high-volume centers. We aimed to determine if older patients with rectal cancer are undergoing operations at high-volume centers. Methods We identified patients ≥50 years old who underwent rectal cancer resection using the NCDB (2004–2015). Tertiles were used to categorize facility volume and distance traveled. Results Higher facility volume was associated with improved outcomes. Patients >75 years old were less likely than patients 50–59 years old to be treated at high-volume centers. Traveling >16.8 miles was associated with treatment at high-volume facilities, however patients >75 years old were less likely to travel >16.8 miles. Conclusions Higher facility volume is associated with improved outcomes after rectal cancer resection. However, older patients are less likely to be treated at high-volume facilities. Older patients travel shorter distances for care, suggesting that care integration across networks must be optimized.

The Patient-Reported Outcomes After Pouch Surgery Delphi Consensus Study identified 7 symptoms and 7 consequences as key domains for evaluating and analyzing ileoanal pouch function.This study aimed to use items identified as priorities by the Patient-Reported Outcomes After Pouch Surgery Delphi Consensus Study to create a validated tool for quantifying pouch function.Patients were administered a questionnaire-based survey eliciting responses regarding frequency of a variety of bowel symptoms.Patients with pouches were recruited at IBD centers and via patient advocacy websites.Associations between items and quality of life were computed in a score generation cohort of 298 patients by logistic regression modeling. Individual score values were designated to items to create an additive score titled the Ileoanal Pouch Syndrome Severity Score. Validity was tested in a subsequent cohort of 386 patients using receiver operating characteristic area under the curve. In addition, test-retest validity, convergent validity, and clinical validity were evaluated.After the determination of item weights, the range of possible scores was found to be 0 to 145. Score ranges were then determined as cutoff values for "ileoanal pouch syndrome." The score was then validated on the second patient cohort, with a receiver operating characteristic area under the curve of 0.83. Importantly, worsening severity of Ileoanal Pouch Syndrome Score significantly correlated with higher rates of poor quality of life. Finally, the questionnaire was rigorously validated to show test-retest validity, convergent validity compared to other bowel function scores, and clinical validity.This study developed a patient-centered, clinically useful scoring system that can quantify the range and severity of symptoms experienced by patients with ileoanal pouches and their correlation with quality of life.ANTECEDENTES:En el estudio Delphi Consensus los resultados informados por el paciente después de la cirugía de reservorio identificaron 7 síntomas y 7 consecuencias como dominios clave para evaluar y analizar la función del reservorio ileoanal.OBJETIVO:Utilizar elementos identificados como prioritarios por el estudio de consenso Delphi de resultados informados por el paciente después de la cirugía de reservorio para crear una herramienta validada para cuantificar la función del reservorio.DISEÑO:A los pacientes se les administró una encuesta basada en un cuestionario que obtuvo respuestas con respecto a la frecuencia de una variedad de síntomas intestinales.ESCENARIO:Los pacientes con reservorio fueron reclutados en centros de enfermedad inflamatoria intestinal y a través de sitios web dirigidos al paciente.PRINCIPALES MEDIDAS DE RESULTADO:Las asociaciones entre los elementos y la calidad de vida se calcularon en una cohorte de generación de puntuación de 298 pacientes mediante un modelo de regresión logística. Se asignaron valores de puntuación individuales a los elementos para crear una puntuación aditiva denominada Puntuación de gravedad del síndrome de reservorio ileoanal. La validez se probó en una cohorte posterior de 386 pacientes utilizando el área característica operativa del receptor bajo la curva. Además, se evaluaron la validez del test-retest, la validez convergente y la validez clínica.RESULTADOS:Después de determinar el peso de los elementos, el rango de puntajes posibles fue de 0 a 145. Los rangos de puntaje se determinaron luego como valores de corte para el "síndrome de la reservorio ileoanal". A continuación, la puntuación se validó en la segunda cohorte de pacientes, con un área característica operativa del receptor bajo la curva de 0.3. Es importante destacar que el empeoramiento de la gravedad de la puntuación del síndrome de reservorio ileoanal se correlacionó significativamente con tasas más altas de mala calidad de vida. Por último, el cuestionario fue rigurosamente validado para mostrar validez test-retest, validez convergente en comparación con otras puntuaciones de función intestinal y validez clínica.CONCLUSIONES:Este estudio desarrolló un sistema de puntuación clínicamente útil y centrado en el paciente que puede cuantificar el rango y la gravedad de los síntomas experimentados por los pacientes con reservorio ileoanal y su correlación con la calidad de vida. (Traducción-Dr. Jorge Silva Velazco ).

Monkeypox virus (MPXV) is spreading rapidly through close human-to-human contact primarily amongst communities of men-who-have-sex-with-men (MSM). Behavioural change arising from increased knowledge and health warnings may decelerate the rate of transmission and Vaccinia-based vaccination is likely to be an effective longer-term intervention. Here we investigate the current epidemic within the UK population and simulate control options over a 12 week projection using a stochastic discrete-population transmission model which includes MSM status, rate of formation of new sexual partners, and an underlying random sized metapopulation structure. We find that the virus may have already infected a significant proportion of the MSM group with the highest sexual activity (32.5%; 15.9% - 44.9% prediction IQR); the associated immunity, albeit among groups that form a small but sexually active part of the MSM community in the UK, coupled to behavioural driven decrease in the transmission rate of individuals infected with monkeypox, leads to case incidence flattening and then declining over the projection period (12 weeks). Vaccination is most beneficial when targeted to MSM with highest activity if delivered in the near term to further interrupt transmission amongst those driving the epidemic.

Background Functional outcomes after ileoanal pouch creation have been studied; however, there is great variability in how relevant outcomes are defined and reported. More importantly, the perspective of patients has not been represented in deciding which outcomes should be the focus of research. Objective The primary aim was to create a patient-centered definition of core symptoms that should be included in future studies of pouch function. Design This was a Delphi consensus study. Setting Three rounds of surveys were used to select high-priority items. Survey voting was followed by a series of online patient consultation meetings used to clarify voting trends. A final online consensus meeting with representation from all 3 expert panels was held to finalize a consensus statement. Patients Expert stakeholders were chosen to correlate with the clinical scenario of the multidisciplinary team that cares for pouch patients, including patients, colorectal surgeons, and gastroenterologists or other clinicians. Main outcome measures A consensus statement was the main outcome. Results patients, 62 colorectal surgeons, and 48 gastroenterologists or nurse specialists completed all 3 Delphi rounds. Fifty-three patients participated in online focus groups. One hundred sixty-one stakeholders participated in the final consensus meeting. On conclusion of the consensus meeting, 7 bowel symptoms and 7 consequences of undergoing ileoanal pouch surgery were included in the final consensus statement. Limitations The study was limited by online recruitment bias. Conclusions This study is the first to identify key functional outcomes after pouch surgery with direct input from a large panel of ileoanal pouch patients. The inclusion of patients in all stages of the consensus process allowed for a true patient-centered approach in defining the core domains that should be focused on in future studies of pouch function. See Video Abstract at http://links.lww.com/DCR/B571. Los pacientes sometidos a ciruga de reservorio ileoanal experimentan una constelacin de sntomas y consecuencias que representan un sndrome unico Un Informe de los Resultados Reportados por los Pacientes Posterior a la Cirugia de Reservorio (PROPS) Estudio de Consenso DelphiANTECEDENTES:Los resultados funcionales despues de la creacion del reservorio ileoanal han sido estudiados; sin embargo, existe una gran variabilidad en la forma en que se definen y reportan los resultados relevantes. Mas importante aun, la perspectiva de los pacientes no se ha representado a la hora de decidir que resultados deberian ser el foco de investigacion.OBJETIVO:El objetivo principal era crear en el paciente una definicion centrada de los sintomas principales que deberia incluirse en los estudios futuros de la funcion del reservorio.DISENO:Estudio de consenso Delphi.ENTORNO CLINICO:Se emplearon tres rondas de encuestas para seleccionar elementos de alta prioridad. La votacion de la encuesta fue seguida por una serie de reuniones de consulta de pacientes en linea que se utilizan para aclarar las tendencias de votacion. Se realizo una reunion de consenso final en linea con representacion de los tres paneles de expertos para finalizar una declaracion de consenso.PACIENTES:Se eligieron partes interesadas expertas para correlacionar con el escenario clinico del equipo multidisciplinario que atiende a los pacientes con reservorio: pacientes, cirujanos colorrectales, gastroenterologos / otros medicos.PRINCIPALES MEDIDAS DE VALORACION:Declaracion de consenso.RESULTADOS:Ciento noventa y cinco pacientes, 62 cirujanos colorrectales y 48 gastroenterologos / enfermeras especialistas completaron las tres rondas Delphi. 53 pacientes participaron en grupos focales en linea. 161 interesados participaron en la reunion de consenso final. Al concluir la reunion de consenso, siete sintomas intestinales y siete consecuencias de someterse a una cirugia de reservorio ileoanal se incluyeron en la declaracion de consenso final.LIMITACIONES:Sesgo de reclutamiento en linea.CONCLUSIONES:Este estudio es el primero en identificar resultados funcionales claves despues de la cirugia de reservorio con informacion directa de un gran panel de pacientes con reservorio ileoanal. La inclusion de pacientes en todas las etapas del proceso de consenso permitio un verdadero enfoque centrado en el paciente para definir los dominios principales en los que deberia centrarse los estudios futuros de la funcion del reservorio. Consulte Video Resumen en http://links.lww.com/DCR/B571.

While fecal incontinence and constipation can be measured through physiological testing, the subjective experience of severity and impact on health-related quality of life lead to both being most effectively captured through patient-reported measures. Patient-reported measures of severity and impact help to determine baseline symptoms, guide clinical decision making, and compare various treatments. Here, we take pause to review the psychometric qualities that make effective instruments, and discuss some of the most commonly used instruments along with the reasons behind their use. In addition, we highlight the benefits of a standardized instrument designed to evaluate the major symptoms of patients presenting with pelvic floor disorders (including fecal incontinence and constipation). Ultimately, we aim to provide guidance in choosing appropriate instruments for clinical and research use.

Introduction Volume depletion can trigger atrial fibrillation through the alteration of the balance of autonomic tone. Hemodynamic response to crystalloid infusion has never been investigated in Paroxysmal AF patients. In this pilot study we have evaluated volume expansion response using Doppler echocardiogaphy in a group of patients coming to our Emergency Department because of symptomatic paroxysmal AF. Methods In a group of consecutive Paroxysmal AF patients we performed a comprehensive echocardiographic examination including Vena Cava diameters and inspiratory collapse rate (from bidimensional subxiphoid view) and including Left Ventricular Outflow time–velocity integral (as mean value of 10 consecutive cardiac cycles). Those with mitral, aortic or tricuspid regrgitation of grade higher than 2+/4+, mitral stenosis, prosthethic mitral valve, FE Results Fluid challenge showed positive response in 7/13 patients. From ROC curve analysis an inspiratory diameter of 9,5 mm or a respiratory collapse of 52% or more both had a 75% sensitivity for volume challenge responsiveness. Conclusion Accounting for small sample size this preliminary work suggests that non invasive bedside parameters easy to evaluate can guide Paroxysmal AF management with crysalloid infusion on top of standard therapy. 1. Preau S et al Crit Care Med 2016; 45: e290–7 2. Bortolotti P et al Ann Intensive Care 2018; 8: 79

BACKGROUND Diverticulitis is separated into complicated and uncomplicated, based on the patient's presentation at the time of his or her initial attack of acute diverticulitis. OBJECTIVE The aim of this study was to identify risk factors for persistent complex diverticulitis, defined as an abscess, fistula, or stricture, at the time of elective surgery, and to characterize outcomes in this patient population. DESIGN This was a retrospective review of 2010 to 2016 in the American College of Surgeons National Surgical Quality Improvement Project database. SETTINGS Individuals diagnosed with diverticulitis who underwent elective surgery were included. PATIENTS A total of 1502 patients underwent elective surgery for diverticulitis, of which 559 (37%) patients had a surgical indication of persistent complex diverticulitis. INTERVENTIONS We performed logistic regression analysis to identify risk factors for complex diverticulitis and evaluated a new prediction model. MAIN OUTCOME MEASURES The predictive factors of persistent complex diverticulitis for elective colon resection were measured. RESULTS The patients with complex diverticulitis were older (p < 0.001), had worse functional status (p < 0.001), more comorbidities (diabetes mellitus and hypertension), and a higher Charlson Comorbidity Index (2.7 vs 1.6, p < 0.001). They were more likely to have a history of tobacco or alcohol use (p < 0.001) and to be malnourished. Interestingly, patients found to have persistent complex diverticulitis did not have more episodes than patients with uncomplicated cases did (p = 0.67). Surgical time was longer in complex diverticulitis, and the patients were more likely to require diverting stomas and concurrent resections of adjacent structures. The area under the curve from the test set was (0.75; 95% CI, 0.72-0.78), sensitivity and specificity were 0.890 (95% CI, 0.870-0.891) and 0.450 (95% CI, 0.410-0.490). LIMITATIONS The study was limited by its retrospective review and observational bias. CONCLUSIONS Patients undergoing elective surgery for complex diverticulitis did not have more episodes. Instead, complex diverticulitis may be a reflection of a complicated patient, suggesting that complicated patients should have a different algorithm of care at the time of their initial presentation with diverticulitis to prevent the development of complex disease. See Video Abstract at http://links.lww.com/DCR/B183. ?PODEMOS PREDECIR DIVERTICULITIS QUIRURGICAMENTE COMPLEJA EN CASOS ELECTIVOS?: La diverticulitis se divide en complicada y sin complicaciones, segun la presentacion del paciente en el momento de su ataque inicial de diverticulitis aguda.El objetivo de este estudio fue identificar los factores de riesgo para la diverticulitis compleja persistente, definida como un absceso, fistula o estenosis, en el momento de la cirugia electiva, y caracterizar los resultados en esta poblacion de pacientes.Esta fue una revision retrospectiva del 2010-2016 en la base de datos del Proyecto de Mejora de la Calidad Quirurgica Nacional del Colegio Estadounidense de Cirujanos.Se incluyeron individuos diagnosticados con diverticulitis que se sometieron a cirugia electiva.1502 pacientes fueron sometidos a cirugia electiva por diverticulitis, de los cuales 559 (37%) pacientes tenian una indicacion quirurgica de diverticulitis compleja persistente.Realizamos un analisis de regresion logistica para identificar los factores de riesgo de diverticulitis compleja y evaluamos un nuevo modelo de prediccion.Se midieron los factores predictivos de diverticulitis compleja persistente para la reseccion de colon electiva.Los pacientes con diverticulitis compleja eran mayores (p

Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS). We performed a retrospective pre- and postintervention time-trend analysis (2016–2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus. There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (– 15.9 mg, p = 0.04) and hospital LOS (– 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (– 6.9%, p = 0.08). In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol.

The most promising probe to establish the Majorana or Dirac nature of the neutrino is the neutrinoless double beta decay and the effective neutrino mass would be evaluated by the knowledge of the corresponding nuclear matrix elements. Also measurements of the Double Charge Exchange (DCE) interactions of heavy ion beams can get information on them. The NUMEN experiment based on the pre-existing large acceptance MAGNEX spectrometer and integrated with new challenging components aims at measuring DCE cross sections using ion beams of unprecedented intensity (1013 pps) on specific isotopes at INFN-LNS in Catania. Expected rate on the sensitive area of about 0.15 m2 reaches up to about 5 Mpps, demanding for adequate detectors in measuring position, direction, energy, mass and charge of the ions produced by interactions. Gamma detectors surround a scattering chamber containing the target.

In this contribution, we present first experimental results for the deuteron pickup transfer in the 16O+28Si system at E lab. = 240 MeV. This reaction populates states in the 26Al target-like nucleus. In the same experimental campaign we have also measured the one-proton transfer 28Si(16O,17F)27Al and one-neutron transfer 27Al(16O,17O)26Al at the same beam energy. Comparison between the energy spectrum of these transfer reactions indicate that: i) the one-proton and one-neutron transfers favor the population of the low-lying states; ii) deuteron transfer to the ground state in 26Al is highly suppressed; iii) the cross-sections for deuteron transfer that populates low-lying states in 26Al are roughly 3 times less than the one-neutron transfer.

This work is part of the NUMEN Project (NUclear Matrix Elements for Neutrinoless double beta decay), which, among other goals, aims to measure cross-section of double charge exchange reactions (DCE). In the experiments to be carried out at the Laboratori Nazionali del Sud, in Catania, Italy, a target deposited on a carefully chosen backing (substrate) will be irradiated with a high energy ion beam and, importantly, neither the target nor the substrate will be allowed to overheat as this would affect their structures and its properties, which are special for the experiment. Within this context, highly oriented pyrolytic graphite (HOPG) was chosen as a substrate for the deposition of target elements that will be irradiated by ions such as 12C, 18O and 20Ne, with energies ranging from 15 MeV/u to 60 MeV/u. HOPG is considered a semimetal structured in layers, being composed of a stack of graphene sheets with a small and very subtle disorientation (less than 1°), which makes it to approach to a single crystal. With its specific flat hexagonal molecular structure, consisting only of carbon atoms, HOPG has good thermal conductivity in these sheets, making it an excellent candidate as a heat sink. However, for the HOPG to act with thermal energy dissipation functionality during the experiments proposed by the NUMEN project, it is necessary to verify whether possible changes caused by exposure to the radiation beam have a direct or indirect influence on its mechanical and thermal properties. Regarding the thermal conductivity, vacancies produced during irradiation is one of the factors that considerably decrease such property. As the production of vacancies during irradiation is one of the factors that considerably decrease thermal conductivity, in this work it was used the SRIM/TRIM code simulations to investigate the mechanisms of vacancy production in the target plus HOPG backing system. In the simulations, it was considered different types and doses of incident ion beams as well as different target thickness. From the results it was possible to estimated how long a target-HOPG system can be irradiated before the HOPG high heat conductivity property is lost.

Transfer is an excellent tool to get insights into the short-range correlations on nucleons in a nuclear state. Within the context of direct reactions, the double charge exchange reactions have recently gained attention once their matrix elements might be associated with the double-beta decay rates. This class of reaction can occur from two completely distinctive mechanisms. They can take place by nucleons exchange or driven by mesons exchange between the projectile and target nuclei. Once the double charge exchange driven by multi-nucleon or mesons exchanges can compete with each other, it is crucial to analyze the contribution of the multi-nucleon transfer in this type of reaction to verify its relevance on the measured cross sections.

Enhanced Recovery after Surgery (ERAS) protocols have been demonstrated to improve hospital length of stay and outcomes in patients undergoing colorectal surgery. This article presents the specific components of an ERAS protocol implemented at the authors' institution. In particular, details of both surgical and anesthetic ERAS pathways are provided with explanation of all aspects of preoperative, perioperative, and postoperative care. Evidence supporting inclusion of various aspects within the ERAS protocol is briefly reviewed. The ERAS protocol described has significantly benefitted postoperative outcomes in colorectal patients and can be employed at other institutions wishing to develop an ERAS pathway for colorectal patients. A checklist is provided for clinicians to easily reference and facilitate implementation of a standardized protocol.

BACKGROUND The surgical management of rectal prolapse is constantly evolving, yet numerous clinical trials and meta-analyses studying operative approaches have failed to make meaningful conclusions. OBJECTIVE The purpose of this study was to report on preliminary data captured during a large-scale quality improvement initiative to measure and improve function in patients undergoing rectal prolapse repair. DESIGN This was a retrospective analysis of prospectively collected surgical quality improvement data. SETTINGS This study was conducted at 14 tertiary centers specializing in pelvic floor disorders from 2017 to 2019. PATIENTS A total of 181 consecutive patients undergoing external rectal prolapse repair were included. MAIN OUTCOME MEASURES Preoperative and 3-month postoperative Wexner incontinence score and Altomare obstructed defecation score were measured. RESULTS The cohort included 112 patients undergoing abdominal surgery (71 suture rectopexy/56% minimally invasive, 41 ventral rectopexy/93% minimally invasive). Those offered perineal approaches (n = 68) were older (median age, 75 vs 62 y; p < 0.01) and had more comorbidities (ASA 3-4: 51% vs 24%; p < 0.01) but also reported higher preintervention rates of fecal incontinence (Wexner 11.4 ± 6.4 vs 8.6 ± 5.8; p < 0.01). Patients undergoing perineal procedures had similar incremental improvements in function after surgery as patients undergoing abdominal repair (change in Wexner, -2.6 ± 6.4 vs -3.1 ± 5.6, p = 0.6; change in Altomare, -2.9 ± 4.6 vs -2.7 ± 4.9, p = 0.8). Similarly, patients undergoing posterior suture rectopexy and ventral mesh rectopexy had similar incremental improvements in overall scores; however, patients undergoing ventral mesh rectopexy had a higher decrease in the need to use pads after surgery. LIMITATIONS The study was limited by its retrospective data analysis and 3-month follow-up. CONCLUSIONS Functional outcomes improved in all of the patients undergoing prolapse surgery. Larger cohorts are necessary to show superiority among surgical procedures. Quality improvement methods may allow for systematic yet practical acquisition of information and data analysis. We call for the creation of a robust database to benefit this patient population. See Video Abstract at http://links.lww.com/DCR/B581. REPORTE PRELIMINAR DEL CONSORCIO DE TRASTORNOS DEL PISO PLVICO RECOLECCIN DE DATOS A GRAN ESCALA MEDIANTE INICIATIVAS DE MEJORAMIENTO DE LA CALIDAD PARA PROPORCIONAR INFORMACIN SOBRE LOS RESULTADOS FUNCIONALES ANTECEDENTES:El tratamiento quirurgico del prolapso rectal esta evolucionando constantemente, sin embargo, numerosos estudios clinicos y metaanalisis que evaluan los tratamientos quirurgicos no han logrado demostrar conclusiones significativas.OBJETIVO:Reportar datos preliminares obtenidos a gran escala durante una iniciativa de mejoramiento de la calidad para medir y mejorar la funcion en pacientes sometidos a reparacion de prolapso rectal.DISENO:Analisis retrospectivo de datos recolectados prospectivamente de mejoramiento de la calidad quirurgica.ENTORNO CLINICO:Este estudio se realizo en 14 centros terciarios especializados en trastornos del piso pelvico del 2017 al 2019.PACIENTES:Un total de 181 pacientes consecutivos sometidos a reparacion de prolapso rectal externo.PRINCIPALES MEDIDAS DE VALORACION:Escala de incontinencia de Wexner y de defecacion obstruida de Altomare preoperatoria y tres meses postoperatoria.RESULTADOS:El cohorte incluyo 112 pacientes sometidos a cirugia abdominal (71 rectopexia con sutura / 56% minimally invasive, 41 rectopexia ventral / 93% minimally invasive). Aquellos a los que se les realizaron abordajes perineales (n = 68) eran mayores (edad media de 75 vs. 62, p

BACKGROUND The influence of microsatellite instability on prognosis in high-risk stage II colon cancer is unknown. OBJECTIVE This study aimed to investigate the relationship between microsatellite instability and overall survival in high-risk stage II colon cancer. DESIGN This is a retrospective review of the National Cancer Database from 2010 to 2016. SETTINGS This study included national cancer epidemiology data from the American College of Surgeons Commission on Cancer. PATIENTS Included were 16,788 patients with stage II colon adenocarcinoma and known microsatellite status (1709 microsatellite unstable). MAIN OUTCOME MEASURES The primary outcome measured was overall survival. RESULTS Microsatellite unstable cancers with high-risk features had significantly better overall survival than microsatellite stable cancers with high-risk features (5-year survival 80% vs 72%, p = 0.01), and had survival equivalent to microsatellite stable cancers with low-risk features (5-year survival, 80%). When stratified by specific high-risk features, patients with lymphovascular invasion, perineural invasion, or high-grade histology had overall survival similar to patients without these features, only in microsatellite unstable cancers. However, patients with high-risk features of T4 stage, positive margins, and

The use of driving-simulator is increasing wide-spreading in the whole automotive sector. The adoption of driving simulator indeed allows evaluating the design choices directly during the design stage thought the man-machine interaction, where “man” means the driver while “machine” means the mathematical model of the car traduced to the driver thought a different machine: the driving simulator. In this research activity a questionnaire was developed to evaluate the performances of a driving simulator focusing on two main aspects. The first one regards the ability of the driving simulator to accurately reproduce the driving feelings without inducing motion sickness sensations. The second instead regards the ability of the driver to objectively judge the vehicle performances throughout a set of parameters. All these aspects were firstly numerically investigated implementing different models showing different dynamics characteristics and successively verified by experimental test at the driving simulator. The drivers scores, about both the accuracy of the mathematical model and the driving simulator, were analysed in order to understand if their feelings match the real behaviour imposed to the car.

Severe burn injury induces gut barrier dysfunction and subsequently a profound systemic inflammatory response. In the present study, we examined the role of the small intestinal brush border enzyme, intestinal alkaline phosphatase (IAP), in preserving gut barrier function and preventing systemic inflammation after burn wound infection in mice. Mice were subjected to a 30% total body surface area dorsal burn with or without intradermal injection of Pseudomonas aeruginosa. Mice were gavaged with 2000 units of IAP or vehicle at 3 and 12 hours after the insult. We found that both endogenously produced and exogenously supplemented IAP significantly reduced gut barrier damage, decreased bacterial translocation to the systemic organs, attenuated systemic inflammation, and improved survival in this burn wound infection model. IAP attenuated liver inflammation and reduced the proinflammatory characteristics of portal serum. Furthermore, we found that intestinal luminal contents of burn wound–infected mice negatively impacted the intestinal epithelial integrity compared with luminal contents of control mice and that IAP supplementation preserved monolayer integrity. These results indicate that oral IAP therapy may represent an approach to preserving gut barrier function, blocking proinflammatory triggers from entering the portal system, preventing gut-induced systemic inflammation, and improving survival after severe burn injuries., Oral intestinal alkaline phosphatase therapy preserves gut barrier function in mice following burn injury, blocking pro-inflammatory triggers from entering the portal system, preventing gut-induced systemic inflammation, and improving survival.

BACKGROUND: Recent genetic studies identified common mutations between diverticular disease and connective tissue disorders, some of which are associated with abdominal wall hernias. Scarce data exists, however, shedding light on the potential clinical implications of this shared etiology, particularly in the era of laparoscopic surgery. METHODS: The New York Statewide Planning and Research Cooperative System database was used to identify adult patients undergoing elective sigmoid and left hemicolectomies (open or laparoscopic) from 1/1/2010 to 12/31/2016 for diverticulitis or descending/sigmoid colon cancer. The incidences of incisional hernia diagnosis and repair were compared using competing-risks regression models, clustered by surgeon and adjusted for a host of demographic/clinical variables. Subsequent abdominal surgery and death were considered competing risks. RESULTS: Among 8,279 patients included in the study cohort, 6,811 (82.2%) underwent colectomy for diverticulitis and 1,468 (17.8%) for colon cancer. The overall 5-year risk of incisional hernia was 3.5% among patients with colon cancer, regardless of colectomy route, which was significantly lower than that among diverticulitis patients after both open (10.7%; p

Rationale: Liver fibrosis is frequently associated with gut barrier dysfunction, and the lipopolysaccharides (LPS) -TLR4 pathway is common to the development of both. Intestinal alkaline phosphatase (IAP) has the ability to detoxify LPS, as well as maintain intestinal tight junction proteins and gut barrier integrity. Therefore, we hypothesized that IAP may function as a novel therapy to prevent liver fibrosis. Methods: Stool IAP activity from cirrhotic patients were determined. Common bile duct ligation (CBDL) and Carbon Tetrachloride-4 (CCl4)-induced liver fibrosis models were used in WT, IAP knockout (KO), and TLR4 KO mice supplemented with or without exogenous IAP in their drinking water. The gut barrier function and liver fibrosis markers were tested. Results: Human stool IAP activity was decreased in the setting of liver cirrhosis. In mice, IAP activity and genes expression decreased after CBDL and CCl4 exposure. Intestinal tight junction related genes and gut barrier function were impaired in both models of liver fibrosis. Oral IAP supplementation attenuated the decrease in small intestine tight junction protein gene expression and gut barrier function. Liver fibrosis markers were significantly higher in IAP KO compared to WT mice in both models, while oral IAP rescued liver fibrosis in both WT and IAP KO mice. In contrast, IAP supplementation did not attenuate fibrosis in TLR4 KO mice in either model. Conclusions: Endogenous IAP is decreased during liver fibrosis, perhaps contributing to the gut barrier dysfunction and worsening fibrosis. Oral IAP protects the gut barrier and further prevents the development of liver fibrosis via a TLR4-mediated mechanism.

Diminished integrity of the intestinal epithelial barrier with advanced age is believed to contribute to aging-associated dysfunction and pathologies in animals. In mammals, diminished gut integrity contributes to inflammaging, the increase in inflammatory processes observed in old age. Recent work suggests that expression of intestinal alkaline phosphatase (IAP) plays a key role in maintaining gut integrity. IAP expression decreases with increasing age in mice and humans. Absence of IAP leads to liver inflammation and shortened life-spans in mice lacking the IAP gene. In normal mice, exogenous supplemental IAP reverses age-induced barrier dysfunction, improves aging-associated metabolic dysfunction, prevents microbiome dysbiosis (imbalance), and extends life-span. Consistent with IAP playing a conserved role in maintaining gut integrity, increased dietary IAP increases aging-diminished physical performance in flies. IAP helps maintain gut integrity in part by supporting the expression of tight junction proteins that maintain the intestinal epithelial barrier and by inactivating bacterial pro-inflammatory factors such as lipopolysaccharides (LPS) by dephosphorylation. Recombinant IAP is in late clinical trials for sepsis-associated acute kidney injury, suggesting it may soon become available as a therapeutic. Taken together, these reports support the idea that directly increasing IAP levels by supplemental recombinant IAP or by indirectly increasing IAP levels using dietary means to induce endogenous IAP may slow the development of aging-associated pathologies.

There are little data on risk factors for increased inpatient opioid use and its relationship with persistent opioid use after colorectal surgery.We identified colorectal surgery patients across five collaborating institutions. Patient comorbidities, surgery data, and outcomes were captured in the American College of Surgeons National Surgical Quality Improvement Program. We recorded preoperative opioid exposure, inpatient opioid use, and persistent use 90-180 days after surgery.1646 patients were analyzed. Patients receiving ≥250 MMEs (top quartile) were included in the high use group. On multivariable analysis, age65, emergent surgery, inflammatory bowel disease, and postoperative complications, but not prior opioid exposure, were predictive of high opioid use. Patients in the top quartile of use had an increased risk of persistent opioid use (19.8% vs. 9.7%, p 0.001), which persisted on multivariable analysis (OR 1.48; p = 0.037).We identified risk factors for high inpatient use that can be used to identify patients that may benefit from opioid sparing strategies. Furthermore, high postoperative inpatient use was associated with an increased risk of persistent opioid use.

The breakup of 9Be is studied via an inelastic scattering experiment on a proton target at 5.6 A MeV in inverse kinematics. Two of the three cluster constituents (α and α) as well as the proton target recoil were recorded in a triple coincidence mode allowing a full kinematics approach analysis. In this respect relative α - α and α - n, Q-value and 9Be excitation spectra, energy spectra for all fragments as well as the energy spectrum of the recoil proton were reconstructed. A clear signature of the two breakup sequential modes (5He + 4He and 8Be + n) was identified via the recoiling proton reconstructed spectra together with the direct breakup decay. A strong 5He + 4He mode was observed compatible with previous beta decay experiments.

Laparoscopic ventral mesh rectopexy was first described as an alternative approach to the standard abdominal rectopexy for external prolapse. This operation limits posterior rectal dissection and spares the sacral nerves, thereby avoiding rectal denervation and minimizing postoperative de novo constipation. Since its description, the procedure has been widely adopted by colorectal surgeons treating rectal prolapse and other pelvic floor disorders for its favorable outcomes and minimally invasive approach. This chapter will describe the spectrum of rectal prolapse and indications for laparoscopic ventral mesh rectopexy, detail operative technique, and review the literature with a focus on outcomes and complications of this operation.

Background While enhanced recovery pathways (ERAS) appear to be beneficial for post-operative outcomes, there have been no studies evaluating the specific role of patient education within an ERAS pathway. Methods We identified all colectomies performed at our institution since initiation of an ERAS protocol, excluding for mortality and length of stay >30 days. Patients who received preoperative education by a nurse practitioner via a scripted telephone call were compared to patients who did not receive education using the NSQIP database. We then evaluated differences in surgical complications and length of stay among these cohorts. Results Patients who received scripted education phone calls had a significantly shorter mean length of stay when compared to patients that receiving usual care (3.0 ± 2.2 vs 3.7 ± 3.2 days; p = 0.005). Subgroup analysis demonstrates strongest benefit in patients undergoing left colectomy and laparoscopic surgery. Conclusions Scripted patient education modules may shorten length of stays and postoperative complications, even when added to an already existing ERAS bundle, which may translate into significant hospital cost savings.

Purpose To determine the contact pressures between the scaphoid and lunate and the distal radius during 2 wrist push-up positions before and following scapholunate interosseous ligament (SLIL) sectioning. Methods Eight fresh cadaveric wrists were tested in a neutral flexion-extension (knuckle) push-up position and in an extended push-up position. Pressure measurements were acquired as each wrist was loaded with the wrist in extension and with the wrist in a neutral position. Data were acquired with the SLIL intact and following sectioning of its dorsal, volar, and proximal components. The wrist was disarticulated and a map drawn on each sensor to identify each joint fossa. Results A push-up performed with the wrist in extension caused a significantly greater peak pressure in the radioscaphoid fossa but not in the radiolunate fossa. Moving the wrist into extension caused a significant dorsal movement of the pressure centroid an average of 2.9 mm in the radiolunate fossa and an average of 5.7 mm in the radioscaphoid fossa. Sectioning the SLIL caused the centroid of pressure in the radioscaphoid fossa to significantly move an average 1.4 mm radially. Conclusions A push-up with the wrist in extension causes a significant increase in the pressure in the radioscaphoid fossa but not in the radiolunate. This finding may help explain why degenerative arthritis first develops in the radioscaphoid fossa before involving the radiolunate fossa. As expected, gapping that occurs with SLIL injury was observed here as a radial translation of the scaphoid and not as a movement of the lunate. The new location of scaphoid contact may be an additional reason for the development of radioscaphoid arthritis occurring before radiolunate arthritis. Clinical relevance This study provides a possible explanation as to why degenerative arthritis may first occur in the radioscaphoid fossa.

The impact of primary tumor site on overall survival in patients with stage IV colorectal cancer (CRC) with single-organ metastases to the liver or lung has not been studied. Furthermore, the prognostic significance of commonly tested genetic variants such as KRAS mutation and microsatellite instability (MSI) are not well-described in this population.This National Cancer Database was used to identify 38,328 patients with CRC that presented with synchronous metastases to the liver or lung between 2010 and 2014. The primary outcome was overall survival, and groups were compared using Kaplan-Meier analyses and Cox proportional hazard models.On unadjusted analysis, median survival was significantly longer for patients with lung metastases compared with those with liver metastases for left-sided (27 vs. 25 months; P = .02) and right-sided CRC (19 vs. 15 months; P .001), whereas rectosigmoid and rectal cancers showed no difference. On multivariate analysis, patients with liver metastases demonstrated worse survival compared with those with lung metastasis (hazard ratio, 1.37; 95% confidence interval, 1.31-1.43; P .001). These trends were confirmed in patients that received chemotherapy but did not have their primary tumor or metastases resected. In patients with genetic testing, both KRAS mutants and MSI tumors had worse survival in left-sided and rectal tumors with liver metastases, but had similar survival to KRAS wild type tumors and microsatellite stable tumors, respectively, across other primary site and metastatic patterns.For patients with single-organ metastases to the liver or lung, primary tumor site has an impact on overall survival. Further, KRAS mutation and MSI status are of prognostic importance in selected patients with single-organ metastases.

Purpose Distal radioulnar joint (DRUJ) instability may occur after an injury, resulting in pain and reduced strength. When primary repair is not possible or initial fixation has failed, chronic instability may result, requiring a reconstructive procedure such as the Adams procedure. The first purpose of this study was to evaluate the role of the triangular fibrocartilage complex and various components of the interosseous membrane as they were sectioned. The second purpose was to evaluate the Adams procedure in stabilizing the forearm. Methods Eight fresh cadaver forearms were dynamically moved through an average range of 56.8° pronation to 54.8° supination and tested first with the forearm intact and then after sectioning each of the following structures: the dorsal (DRUL) and palmar radioulnar ligaments (PRUL), the distal interosseous membrane, and the central band. Finally, they were tested after reconstruction using the Adams procedure. During each forearm motion and provocative shuck, the motion of the radius and ulna were measured and the locations of the radial attachments of the DRUL, PRUL, and sigmoid notch and ulnar fovea were computed. Results Significant increases in the gap between the ulnar fovea and the attachment sites of the DRUL and PRUL were observed with incremental sectioning, most notably after sectioning of the central band. Reconstruction significantly reduced the gap at the DRUL and PRUL sites during dynamic motion. Conclusions This study reinforces the concept that DRUJ stability depends on more than the radioulnar ligaments, ulnocarpal ligaments, and triangular fibrocartilage complex, but is also significantly affected by the distal and central interosseous membrane. Reconstruction reduces gapping. Clinical relevance These results suggest that the Adams reconstruction is a reasonable option to address DRUJ instability but may be an incomplete solution in the setting of a ruptured interosseous ligament.

INTRODUCTION Patient compliance with preoperative mechanical and antibiotic bowel preparation, skin washes, carbohydrate loading, and avoidance of fasting are key components of successful colorectal ERAS and surgical site infection (SSI)-reduction programs. In July 2016, we began a quality improvement project distributing a free SSI Prevention Kit (SSIPK) containing patient instructions, mechanical and oral bowel preparation, chlorhexidine washes, and carbohydrate drink to all patients scheduled for elective colectomy, with the goal of improving patient compliance and rates of SSI. METHODS This was a prospective data audit of our first 221 SSIPK+ patients, who were compared to historical controls (SSIPK-) of 1760 patients undergoing elective colectomy from January 2013 to March 2017. A 1:1 propensity score system accounted for nonrandom treatment assignment. Matched patients' complications, particularly postoperative infection and ileus, were compared. RESULTS SSIPK+ (n = 219) and SSIPK- (n = 219) matched patients were statistically identical on demographics, comorbidities, BMI, surgical indication, and procedure. SSIPK+ patients had higher compliance with mechanical (95% vs 71%, P < 0.001) and oral antibiotic (94% vs 27%, P < 0.001) bowel preparation. This translated into lower overall SSI rates (5.9% vs 11.4%, P = 0.04). SSIPK+ patients also had lower rates of anastomotic leak (2.7% vs 6.8%, P = 0.04), prolonged postoperative ileus (5.9% vs 14.2%, P < 0.01), and unplanned intubation (0% vs 2.3%, P = 0.02). Furthermore, SSIPK+ patients had shorter mean hospital length of stay (3.1 vs 5.4 d, P < 0.01) and had fewer unplanned readmissions (5.9% vs 14.6%, P < 0.001). There were no differences in rates of postoperative pneumonia, urinary tract infection, Clostridium difficile colitis, sepsis, or death. CONCLUSION Provision of a free-of-charge SSIPK is associated with higher patient compliance with preoperative instructions and significantly lower rates of surgical site infections, lower rates of prolonged postoperative ileus, and shorter hospital stays with fewer readmissions. Widespread utilization of such a bundle could therefore lead to significantly improved outcomes.

Introduction & Objectives: The Bosniak classification of renal cysts is commonly used by urologists and radiologists as an effective way to assess and evaluate cystic renal masses and decide clinical management. Although this classification scheme is based on computed tomographic (CT) criteria, the same approach may provide a useful framework for evaluation with magnetic resonance (MR) imaging and contrast-enhanced ultrasonography (CEUS). The aim of this study was to compare CT, MRI, and CEUS in characterization of complex renal cysts in the same series of patients. Materials & Methods: The records of patients having complex renal cysts evaluated with CT, MRI, and CEUS within a 6-months interval were considered. Inclusion criteria were at least an unenhanced and a contrast enhanced nephrographic acquisition at CT, at least T2-weighted, T1-weighted and contrast enhanced scans at MRI, and digital cine-clips available for review at CEUS. Images and clips were retrospectively evaluated by 2 blind independent readers to assigned a Bosniak score for the different techniques. This process yielded a total of 36 patients who met the inclusion criteria. ROC curve analysis was employed to assess the overall confidence for diagnosis of benign vs. malignant lesions. Reference procedure was surgery, or follow-up >3years. Results: Inter-reader agreement in assigning Bosniak score was good or very good (K values for CT, MRI, and CEUS 0.75, 0.86 and 0.79, respectively). When surgical vs. non-surgical lesions were considered, CT, MRI, and CEUS scores were equivalent in 83% of cases for reader1, and in 78% of cases for reader2. ROC curve analysis showed similar diagnostic performance for the 3 techniques (reader1 AUC=0.89, 0.96, 0.93 for and CT, MRI, CEUS, respectively; reader2 AUC=0.92, 0.98, 0.88, respectively). Conclusions: Although differences exist, CEUS, CT, and MRI are basically equivalent in characterization the majority of complex renal cysts. Concordance rates were approximately 80% with weighted good to very good k values. Differences can be useful to differentiate benign from malignant lesions in equivocal cases.

Since its description in 1978, the ileal-pouch anal anastomosis (IPAA) has become the most commonly performed procedure for patients with ulcerative colitis requiring surgery. The earliest description of the IPAA included a three-limb “S” pouch with a hand-sewn pouch-anal anastomosis. Several years later, a two-limb “J” pouch was described, which, with the advent of the surgical stapler, became the procedure of choice due to its ease of construction. As practice patterns have changed over time, the optimal pouch configuration has been debated in the literature. Both the S-pouch and J-pouch configurations have well described functional and complication profiles. In this chapter, the literature comparing the complication rates and functional results of these pouches is reviewed. Specifically, we detail several studies examining complications such as pouch failure, pouchitis and mechanical obstruction, as well as functional outcomes such as stool frequency, incontinence, and the need for anti-diarrheal medications. Our analysis of the literature is followed by our recommendation on the optimal design for IPAA.

An 80-year-old man with idiopathic cold agglutinin disease presented with acute cholecystitis. We describe operating room and anaesthetic considerations for patients with cold agglutinin disease and measures that can be taken to prevent disease exacerbation in this case report. Multidisciplinary collaboration and planning between the operative room staff, anaesthesia team and surgical team are needed to ensure safe surgery and optimal patient outcomes.

Recently, there has been a trend toward surgical management of internal intussusception despite an unclear correlation with constipation symptoms.This study characterizes constipation in patients with obstructed defecation syndrome and identifies whether internal intussusception or other diagnoses such as irritable bowel syndrome may be contributing to symptoms.Patients evaluated for obstructed defecation at a pelvic floor disorder center were studied from a prospectively maintained database. With the use of defecography, patients were classified by Oxford Rectal Prolapse Grade. Coexisting disorders such as enterocele, rectocele, and dyssynergia were also identified. The presence of irritable bowel syndrome was defined using Rome IV criteria, and constipation severity was quantified with the Varma constipation severity instrument.This study was conducted at a tertiary care university medical center (Massachusetts General Hospital).The study included 317 consecutive patients with defecography imaging and a completed constipation severity instrument survey from May 2007 to July 2016.The primary outcome measures were the Varma Constipation Severity Instrument overall score and obstructed defecation subscale score.Of 317 patients evaluated, 95 (30.0%) had no internal intussusception, 126 (39.7%) had intra-rectal intussusception, and 96 (30.3%) had intra-anal intussusception. There was no association between rising grade of internal intussusception and either overall constipation score or obstructed defecation subscale score. Irritable bowel syndrome was associated with an increase in overall constipation score and obstructed defecation subscale score (40.5 ± 13.6 vs 36.0 ± 15.1, p = 0.007, and 22.3 ± 5.8 vs 20.0 ± 6.6, p0.001). Multivariate regression found irritable bowel syndrome and dyssynergia to be associated with a significant increase in obstructed defecation subscale scores.The study was limited because it was an observational study from a single center.Patients referred for surgical management of obstructive defecation syndrome should be screened and treated for irritable bowel syndrome and dyssynergia before considering surgical intervention. See Video Abstract at http://links.lww.com/DCR/A782.