Summary Background Hospital readmissions are common after major surgery, although it is unknown whether patients achieve improved outcomes when they are readmitted to, and receive care at, the index ...hospital where their surgical procedure was done. We examined the association between readmission destination and mortality risk in the USA in Medicare beneficiaries after a range of common operations. Methods By use of claims data from Medicare beneficiaries in the USA between Jan 1, 2001, and Nov 15, 2011, we assessed patients who needed hospital readmission within 30 days after open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, coronary artery bypass surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. We used logistic regression models incorporating inverse probability weighting and instrumental variable analysis to measure associations between readmission destination (index vs non-index hospital) and risk of 90 day mortality for patients who underwent surgery who needed hospital readmission. Findings 9 440 503 patients underwent one of 12 major operations, and the number of patients readmitted or transferred back to the index hospital where their operation was done varied from 186 336 (65·8%) of 283 131 patients who were readmitted after coronary artery bypass grafting, to 142 142 (83·2%) of 170 789 patients who were readmitted after colectomy. Readmission was more likely to be to the index hospital than to a non-index hospital if the readmission was for a surgical complication (189 384 23% of 834 070 patients readmitted to index hospital vs 36 792 13% of 276 976 patients readmitted non-index hospital, p<0·0001). Readmission to the index hospital was associated with a 26% lower risk of 90 day mortality than was readmission to a non-index hospital, with inverse probability weighting used to control for selection bias (odds ratio OR 0·74, 95% CI 0·66–0·83). This effect was significant (p<0·0001) for all procedures in inverse probability-weighted models, and was largest for patients who were readmitted after pancreatectomy (OR 0·56, 95% CI 0·45–0·69) and aortobifemoral bypass (OR 0·69, 95% CI 0·61–0·77). By use of hospital-level variation among regional index hospital readmission rates as an instrument, instrumental variable analysis showed that the patients with the highest probability of returning to the index hospital had 8% lower risk of mortality (OR 0·92 95% CI 0·91–0·94) than did patients who were less likely to be readmitted to the index hospital. Interpretation In the USA, patients who are readmitted to hospital after various major operations consistently achieve improved survival if they return to the hospital where their surgery took place. These findings might have important implications for cost-effectiveness-driven regional centralisation of surgical care. Funding None.
Adoption of commercial photoreactors as standards for photocatalysis research could be limited by high cost. We report the development of the Wisconsin Photoreactor Platform (WPP), an open-source ...photoreactor architecture potentially suitable for general adoption. The WPP integrates inexpensive commercial components and common high-intensity LEDs in a 3D-printed enclosure. Dimensions and features of WPP reactors can be readily varied and configurations easily reproduced. WPP performance is evaluated using literature transformations driven by light of disparate wavelengths.
Impulsivity and compulsivity represent useful conceptualizations that involve dissociable cognitive functions, which are mediated by neuroanatomically and neurochemically distinct components of ...cortico-subcortical circuitry. The constructs were historically viewed as diametrically opposed, with impulsivity being associated with risk-seeking and compulsivity with harm-avoidance. However, they are increasingly recognized to be linked by shared neuropsychological mechanisms involving dysfunctional inhibition of thoughts and behaviors. In this article, we selectively review new developments in the investigation of the neurocognition of impulsivity and compulsivity in humans, in order to advance our understanding of the pathophysiology of impulsive, compulsive, and addictive disorders and indicate new directions for research.
Mites act as the vectors of zoonotic vector-borne disease scrub typhus caused by the rickettsial pathogen Orientia tsutsugamushi. In India, scrub typhus is transmitted by the mite Leptotrombidium ...deliense. Rodents are the reservoirs and support the spread of this disease. Sarcoptes scabiei or the itch mite is causing scabies which is a common skin infection in India. Dermatitis, trombiculosis, and mite dust allergy are common mite-borne diseases transmitted by Pyemotidae family. D. brevis folliculorum and Demodex brevis are two major mite species found on humans also causing a disease; "Demodicosis", common in India. Dermanyssus gallinae, fowl mite causes pruritis in poultry birds, transmits infections to poultry workers when they come into contact with birds. There is a re-emergence of mite-borne diseases, especially scrub typhus, in many parts of India requiring urgent attention for its control. This review is aimed to update the available information on mites and mite transmitted diseases prevalent in India to highlight the importance of rodent and chigger mite vector control to prevent forthcoming mite-borne diseases in India.
A subset of patients with metastatic cancer in limited organs may benefit from metastasis-directed therapy. The authors investigated whether patients with limited metastases could be safely treated ...with metastasis-directed radiotherapy.
Patients with 1 to 5 metastatic cancer sites with a life expectancy of >3 months received escalating stereotactic body radiotherapy (SBRT) doses to all known cancer sites. Patients were followed radiographically with CT scans of the chest, abdomen, and pelvis and metabolically with fluorodeoxyglucose-positron emission tomography, 1 month after treatment, and then every 3 months. Acute toxicities were scored using the National Cancer Institute's Common Terminology Criteria for Adverse Events version 3.0, and late toxicities were scored using the Radiation Therapy Oncology Group late toxicity scoring system.
Sixty-one patients with 113 metastases were enrolled from November 2004 to November 2009 on a prospective radiation dose escalation study. Median follow-up was 20.9 months. Patients tolerated treatment well; the maximal tolerated dose was not reached in any cohort. Eleven patients (18.3%) have not progressed. One and 2-year progression-free survival are 33.3% (95% confidence interval CI, 22.8-46.1) and 22.0% (95% CI, 12.8-34.4); 1-year and 2-year overall survival are 81.5% (95% CI, 71.1-91.1) and 56.7% (95% CI, 43.9-68.9). Seventy-two percent of patients whose tumors progressed did so in limited (1-3) metastatic sites.
Patients with 1 to 5 metastases can be safely treated to multiple body sites and may benefit from SBRT. Further investigation should focus on patient selection.
We report a pairing of known catalysts that enables intramolecular conjugate additions of aldehyde-derived enamines to α,β-unsaturated esters. Despite extensive prior exploration of conjugate ...additions of aldehyde-derived enamines, catalytic conjugate additions to unactivated enoate esters are unprecedented. Achieving enantioselective and diastereoselective six-membered ring formation requires the coordinated action of a chiral pyrrolidine, for nucleophilic activation of the aldehyde via enamine formation, and a hydrogen bond donor, for electrophilic activation of the enoate ester. Proper selection of the hydrogen bond donor is essential for chemoselectivity, which requires minimizing competition from homoaldol reaction. Utility is demonstrated in a six-step synthesis of (-)-yohimbane from cycloheptene.
Fleas (Insecta, Siphonaptera) are important vectors of plague and murine typhus in many parts of the world. Currently, about 2700 flea species were described in the world. The most common vector flea ...Xenopsylla cheopis is found throughout India, but X. astia, and X. brasiliensis are found less and limited in distribution associated with the domestic rats such as Rattus rattus, R. norvegicus, Mus musculus, and Bandicota bengalensis. Bubonic plague is a major flea-borne disease caused by the bacterial pathogen Yersinia pestis, transmitted from rats to humans via the rodent flea, X. cheopis. A major outbreak of plague and high mortality occurred in India. After 1966 with the 3 decadal intervals, plague cases occurred only during the year 1994 reported in 5 different states (Gujarat, Maharashtra, Karnataka, Uttar Pradesh, Madhya Pradesh and New Delhi and subsequently plague cases occurred during 2002 and 2004 after the one-decade interval in Himachal Pradesh (2002). Another outbreak of bubonic plague was reported in Dangud village, Barkhot tehsil, Uttarkashi district, Uttarakhand during October 2004. Ctenocephalides fleas are common in cats and dogs, which are the main vectors of bacteria rickettsiae, such as Rickettsia typhi, R. felis, R. conorii, and Bartonella henselae. Molecular and serological evidence also confirms the presence of R. typhi, R. conorii R. felis and B. henselae pathogens in cats and other fleas in India. Flea bites and flea-borne dermatitis are common in men and pet animals. Because of the re-emergence of the plague, updated information on fleas and flea-borne diseases are essential to control the flea vectors and flea-borne diseases in India. Hence, this comprehensive review updates the available information on fleas and fleas transmitted diseases in India.
The loss of upper limb motor function can have a devastating effect on people's lives. To restore upper limb control and functionality, researchers and clinicians have developed interfaces to ...interact directly with the human body's motor system. In this invited review, we aim to provide details on the peripheral nerve interfaces and brain‐machine interfaces that have been developed in the past 30 years for upper extremity control, and we highlight the challenges that still remain to transition the technology into the clinical market. The findings show that peripheral nerve interfaces and brain‐machine interfaces have many similar characteristics that enable them to be concurrently developed. Decoding neural information from both interfaces may lead to novel physiological models that may one day fully restore upper limb motor function for a growing patient population.
To date, many brain-machine interface (BMI) studies have developed decoding algorithms for neuroprostheses that provide users with precise control of upper arm reaches with some limited grasping ...capabilities. However, comparatively few have focused on quantifying the performance of precise finger control. Here we expand upon this work by investigating online control of individual finger groups.
We have developed a novel training manipulandum for non-human primate (NHP) studies to isolate the movements of two specific finger groups: index and middle-ring-pinkie (MRP) fingers. We use this device in combination with the ReFIT (Recalibrated Feedback Intention-Trained) Kalman filter to decode the position of each finger group during a single degree of freedom task in two rhesus macaques with Utah arrays in motor cortex. The ReFIT Kalman filter uses a two-stage training approach that improves online control of upper arm tasks with substantial reductions in orbiting time, thus making it a logical first choice for precise finger control.
Both animals were able to reliably acquire fingertip targets with both index and MRP fingers, which they did in blocks of finger group specific trials. Decoding from motor signals online, the ReFIT Kalman filter reliably outperformed the standard Kalman filter, measured by bit rate, across all tested finger groups and movements by 31.0 and 35.2%. These decoders were robust when the manipulandum was removed during online control. While index finger movements and middle-ring-pinkie finger movements could be differentiated from each other with 81.7% accuracy across both subjects, the linear Kalman filter was not sufficient for decoding both finger groups together due to significant unwanted movement in the stationary finger, potentially due to co-contraction.
To our knowledge, this is the first systematic and biomimetic separation of digits for continuous online decoding in a NHP as well as the first demonstration of the ReFIT Kalman filter improving the performance of precise finger decoding. These results suggest that novel nonlinear approaches, apparently not necessary for center out reaches or gross hand motions, may be necessary to achieve independent and precise control of individual fingers.
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