Patient-Reported Outcomes and PTSD Symptoms in Emergency General Surgery.

INTRODUCTION: Patient-reported outcomes (PRO) are increasingly recognized as a measure of surgical quality and long-term outcomes. There are few PRO data for patients undergoing emergency general surgery (EGS) procedures. Sudden illness and injury are associated with worse health-related quality of life, symptoms of depression, post-traumatic stress. This study aimed to evaluate PRO and post-traumatic stress disorder (PTSD) symptoms in an EGS population. METHODS: Patients who underwent an EGS operation and had quality improvement data available from Jan 2020 to Jan 2021 were eligible for inclusion. Participants completed a survey of demographics, socio-economic status, PROMIS PRO measures for general life satisfaction (GLS), general self-efficacy (GSE), and physical function (PF), and the PCL-5 PTSD symptom screening tool. RESULTS: One hundred forty-one patients were eligible for inclusion, 40 (28%) completed the study. Mean PRO scores were 52.5 ± 9.3 for GLS, 48.6 ± 8.0 for GSE, and 48.7 ± 9.6 for PF. 12.5% of patients had a low or very low GLS and GSE score, while 32.5% had mild, moderate, or severe PF scores. Seven patients (17.5%) scored >31 on PCL-5 indicating a positive PTSD screen. Regression analysis found American society of anesthesiology score, emergency case, and lower income associated with lower GLS scores. Age, body mass index, and lower income were associated with lower PF scores. CONCLUSIONS: We found that following EGS most patients have average PRO. This limited study did also identify that there are patients potentially at risk for worse functional and mental health outcomes. We plan to use this data to prospectively evaluate the role that EGS plays in these outcomes and how they can be improved on.

Evaluation of a Novel Emergency General Surgery Handover: A Prospective Feasibility Study.

INTRODUCTION: High-quality health information handovers are critical to optimal patient care and trainee education. The purposes of this study were to assess the feasibility of implementing an emergency general surgery (EGS) morning handover and to explore its impact upon markers of clinical care. METHODS: This prospective feasibility study was conducted at a single academic tertiary-care medical center following implementation of a novel EGS morning handover process. We assessed organizational perspective through a two-part anonymous survey delivered to the EGS service staff (n = 29) and collected feasibility metrics daily at the morning handover meetings. Exploratory clinical metrics of quality improvement were compared between parallel 5-month periods preimplementation and postimplementation of the handover. Data were compared by descriptive statistics. RESULTS: One hundred and seventeen patients from March 1, 2022, to July 31, 2022, and 185 patients from March 1, 2023, to July 31, 2023, were identified prehandover and posthandover implementation, respectively, with an increase in time to operating room posting by 49% (95% confidence interval [CI]: 1.03-2.14) and no statistically significant change in length of stay. The average duration of the formalized EGS morning handover was 14 min (95% CI: 12:18-15:42) having an average of 12 questions asked (95% CI: 9.98-14.02) and an average attendance of 70% from essential personnel. Eighty-four percent of postimplementation survey responses indicated positive regard toward the new EGS handover. CONCLUSIONS: The implementation of an EGS morning handover is feasible, necessitating further studies to define the impact of the EGS morning handover upon clinical outcomes.

Association of Preoperative Blood Transfusion on Postoperative Outcomes in Emergency General Surgery.

INTRODUCTION: Emergency general surgery (EGS) patients often present with anemia, in which preoperative transfusions are performed to mitigate anemia-associated risks. However, transfusions have also been noted to cause worse postoperative outcomes. This study examined how transfusion-associated outcomes vary at different levels of anemia. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2019 was used to identify patients who had undergone any of 12 major EGS procedures using Current Procedural Terminology codes. Patients were divided into two cohorts based on receipt of preoperative transfusion. Cohorts were subdivided into anemia severity levels and propensity score-matched within each using patient demographic and comorbidity variables. We analyzed 30-day postoperative outcomes, including morbidity, mortality, and return to odds ratio (OR), using univariate Chi-squared tests, Wilcoxon signed-rank tests, and multivariate logistic regression analyses. RESULTS: 595,407 EGS cases were identified. Receiving preoperative transfusion were 44.45% (n = 3058) of severely anemic, 10.94% (n = 9076) of moderately anemic, 1.34% (n = 1370) of mildly anemic, and 0.174% (n = 704) of no anemia patients. Transfusion resulted in an increased overall morbidity in the severe (OR 1.54), moderate (OR 1.50), mild (OR 1.71), and no anemia (OR 1.85) groups. Mortality increased in the moderate (OR 1.27), mild (OR 1.61), and no anemia (OR 1.76) subgroups. In severe anemia, transfusion status and mortality were not significantly associated. CONCLUSIONS: Transfusion is associated with higher morbidity and mortality rates in those with higher hematocrit levels, even after controlling for pre-existing comorbidities. A restrictive transfusion strategy should be considered to avoid risks for those with a hematocrit level more than 24%.

Small bowel obstruction in older patients: challenges in surgical management.

BACKGROUND: Small bowel obstruction (SBO) is a common disease affecting all segments of the population, including the frail elderly. Recent retrospective data suggest that earlier operative intervention may decrease morbidity. However, management decisions are influenced by surgical outcomes. Our goal was to determine the current surgical management of SBO in older patients with particular attention to frailty and the timing of surgery. STUDY DESIGN: A retrospective review of patients over the age of 65 with a diagnosis of bowel obstruction (ICD-10 K56*) using the 2016 National Inpatient Sample (NIS). Demographics included age, race, insurance status, medical comorbidities, and median household income by zip code. Elixhauser comorbidities were used to derive a previously published frailty score using the NIS dataset. Outcomes included time to operation, mortality, discharge disposition, and hospital length of stay. Associations between demographics, frailty, timing of surgery, and outcomes were determined. RESULTS: 264,670 patients were included. Nine percent of the cohort was frail; overall mortality was 5.7%. Frail had 1.82 increased odds of mortality (95% CI 1.64-2.03). Hospital LOS was 1.6 times as long for frail patients; a quarter of the frail were discharged home. Frail patients waited longer for surgery (3.58 days vs 2.44 days; p < 0.001). Patients transferred from another facility had increased mortality (aOR 1.58; 95% CI 1.36-1.83). There was an increasing mortality associated with a delay in surgery. CONCLUSION: Patients with frailty and SBO have higher mortality, more frequent discharge to dependent living, longer hospital length of stay, and longer wait to operative intervention. Mortality is also associated with male gender, black race, transfer status from another facility, self-pay status, and low household income. Every day in delay in surgical intervention for those who underwent operations led to higher mortality. If meeting operative indications, older patients with bowel obstruction have a higher chance of survival if they undergo surgery earlier.

Monte-Carlo calculation of output correction factors for ionization chambers, solid-state detectors, and EBT3 film in small fields of high-energy photons.

High-energy accelerators are often used in oncological practice, but the information on the small-field dosimetry for the photon beams with nominal energy above 10 MV is limited. The goal of the present work was to determine the values of the output correction factor ( k Q clin , Q ref f clin , f ref $k_{{Q}_{{\rm{clin}}},{Q}_{{\rm{ref}}}}^{{f}_{{\rm{clin}}},{f}_{{\rm{ref}}}}$ ) for solid-state detectors (Diode E, PTW 60017; microDiamond, PTW 60019), EBT3 film, and ionization chambers (Semiflex, PTW 31010; Semiflex 3D, PTW 31021; PinPoint, PTW 31015; PinPoint 3D, PTW 31016) in the small fields formed by 10, 15, 18, and 20 MV photon beams. The output correction factors were calculated by Monte-Carlo method using EGSnrc toolkit for six field sizes (from 0.5 × 0.5 cm 2 $0.5 \times 0.5\ {\rm{cm}}^2$ to 10 × 10 cm 2 $10 \times 10\ {\rm{cm}}^2$ ) for isocentric and constant source-to-surface distance (SSD) techniques. The decrease in the field size led to an increase in k Q clin , Q ref f clin , f ref $k_{{Q}_{{\rm{clin}}},{Q}_{{\rm{ref}}}}^{{f}_{{\rm{clin}}},{f}_{{\rm{ref}}}}$ for ionization chambers, while for solid-state detectors and radiochromic film, k Q clin , Q ref f clin , f ref $k_{{Q}_{{\rm{clin}}},{Q}_{{\rm{ref}}}}^{{f}_{{\rm{clin}}},{f}_{{\rm{ref}}}}$ were less than unity at the smallest field size. A larger sensitive volume of ionization chamber corresponded to a stronger deviation of output correction factor from unity: 1.847 (125 mm3 PTW 31010) versus up to 1.183 (16 mm3 PTW 31016) at the smallest field of 10 MV beam. The calculated output correction factors were used to correct the output factors for PTW 60017, PTW 60019, and EBT3. The deviation of the corrected output factor from the results of Monte-Carlo simulation did not exceed 3% in the fields from 1.0 × 1.0 cm 2 $1.0 \times 1.0\ {\rm{cm}}^2$ to 4.0 × 4.0 cm 2 $4.0 \times 4.0\ {\rm{cm}}^2$ for 10 and 18 MV beams. Thus, Diode E, microDiamond, and EBT3 film can be recommended for small-field dosimetry of high-energy photons.

The Obesity Paradox in Elderly Patients Undergoing Emergency Surgery: A Nationwide Analysis.

BACKGROUND: Obesity has long been considered a risk factor for postoperative adverse events in surgery. We sought to study the impact of body mass index (BMI) on the clinical outcomes of the high-risk emergency general surgery (EGS) elderly patients. METHODS: All EGS ≥65 years old patients in the 2007-2016 ACS-NSQIP database, identified using the variables 'emergency' and 'surgspec,' were included. Patients were classified into five groups: normal weight: BMI <25 kg/m2, overweight: BMI ≥25 kg/m2 and <30 kg/m2, Class I: BMI ≥30 kg/m2 and <35 kg/m2, Class II: BMI ≥35 kg/m2 and <40 kg/m2, and Class III: BMI ≥40 kg/m2. Patients with BMI<18.5 kg/m2 were excluded. Multivariable logistic regression models were built to assess the relationship between obesity and 30-day postoperative mortality, overall morbidity, and individual postoperative complications after adjusting for demographics (e.g., age, gender), comorbidities (e.g., diabetes mellitus, heart failure), laboratory tests (e.g., white blood cell count, albumin), and operative complexity (e.g., ASA classification). RESULTS: A total of 78,704 patients were included, of which 26,011 were overweight (33.1%), 13,897 (17.6%) had Class I obesity, 5904 (7.5%) had Class II obesity, and 4490 (5.7%) had Class III obesity. On multivariable analyses, compared to the nonobese, patients who are overweight or with Class I-III obesity paradoxically had a lower risk of mortality, bleeding requiring transfusion, pneumonia, stroke and myocardial infarction (MI). Additionally, the incidence of MI and stroke decreased in a stepwise fashion as BMI progressed from overweight to severely obese (MI: OR: 0.84 [0.73-0.95], OR: 0.73 [0.62-0.86], OR: 0.66 [0.52-0.83], OR: 0.51 [0.38-0.68]; stroke: OR: 0.80 [0.65-0.99], OR: 0.79 [0.62-1.02], OR: 0.71 [0.50-1.00], OR: 0.43 [0.28-0.68]). CONCLUSION: In our study of elderly EGS patients, overweight and obese patients had a lower risk of mortality, bleeding requiring transfusion, pneumonia, reintubation, stroke, and MI. Further studies are needed to confirm and investigate the obesity paradox in this patient population.

Targeted inhibition of WRN helicase, replication stress and cancer.

WRN helicase has several roles in genome maintenance, such as replication, base excision repair, recombination, DNA damage response and transcription. These processes are often found upregulated in human cancers, many of which display increased levels of WRN. Therefore, directed inhibition of this RecQ helicase could be beneficial to selective cancer therapy. Inhibition of WRN is feasible by the use of small-molecule inhibitors or application of RNA interference and EGS/RNase P targeting systems. Remarkably, helicase depletion leads to a severe reduction in cell viability due to mitotic catastrophe, which is triggered by replication stress induced by DNA repair failure and fork progression arrest. Moreover, we present new evidence that WRN depletion results in early changes of RNA polymerase III and RNase P activities, thereby implicating chromatin-associated tRNA enzymes in WRN-related stress response. Combined with the recently discovered roles of RecQ helicases in cancer, current data support the targeting prospect of these genome guardians, as a means of developing clinical phases aimed at diminishing adaptive resistance to present targeted therapies.

Use of minimally invasive surgery in emergency general surgery procedures.

BACKGROUND: Minimally invasive surgery (MIS) has demonstrated superior outcomes in many elective procedures. However, its use in emergency general surgery (EGS) procedures is not well characterized. The purpose of this study was to examine the trends in utilization and outcomes of MIS techniques in EGS over the past decade. METHODS: The 2007-2016 ACS-NSQIP database was utilized to identify patients undergoing emergency surgery for four common EGS diagnoses: appendicitis, cholecystitis/cholangitis, peptic ulcer disease, and small bowel obstruction. Trends over time were described. Preoperative risk factors, operative characteristics, outcomes, morbidity, and trends were compared between MIS and open approaches using univariate and multivariate analysis. RESULTS: During the 10-year study period, 190,264 patients were identified. The appendicitis group was the largest (166,559 patients) followed by gallbladder disease (9994), bowel obstruction (6256), and peptic ulcer disease (366). Utilization of MIS increased over time in all groups (p < 0.001). There was a concurrent decrease in mean days of hospitalization in each group: appendectomy (2.4 to 2.0), cholecystectomy (5.7 to 3.2), peptic ulcer disease (20.3 to 11.7), and bowel obstruction (12.9 to 10.5); p < 0.001 for all. On multivariate analysis, use of MIS techniques was associated with decreased odds of 30-day mortality, surgical site infection, and length of hospital stay in all groups (p < 0.001). CONCLUSIONS: Use of MIS techniques in these four EGS diagnoses has increased in frequency over the past 10 years. When adjusted for preoperative risk factors, use of MIS was associated with decreased odds of wound infection, death, and length of stay. Further studies are needed to determine if increased access to MIS techniques among EGS patients may improve outcomes.

Pexy of intraperitoneal LVAD driveline to relieve small bowel obstruction.

BACKGROUND: Left ventricular assist device (LVAD) implantation is a lifesaving intervention in advanced heart failure. However, LVAD is not without complication. In this case, an inadvertent intraperitoneal driveline caused small bowel obstruction, subsequently requiring pexy of the driveline to the abdominal wall to avoid future complications. CASE PRESENTATION: A 37-year-old male with worsening, nonischemic, dilated cardiomyopathy underwent LVAD implantation. Postoperative day (POD) 15 he developed small bowel obstruction, and abdominal exploration showed transition point at an inadvertently placed intraperitoneal LVAD driveline. The patient was LVAD-dependent precluding removal, so the driveline was secured to the anterior abdominal wall. He subsequently improved and was discharged. CONCLUSIONS: While LVAD is increasingly common for heart failure patients, the tunneled driveline may inadvertently enter the peritoneal cavity where it can cause significant morbidity. In this case, we propose securing the driveline to the abdominal wall to prevent complications when LVAD removal is not an option.

Synthesis and Evaluation of PEG-PR for Water Flux Correction in an In Situ Rat Perfusion Model.

Phenol red (PR) is a widely used marker for water flux correction in studies of in situ perfusion, in which intestinal absorption usually leads to the underestimation of results. In this paper, we propose a novel marker polyethylene glycol (PEG)-PR (i.e., PR modified by PEGylation) with less permeability and evaluate its application in an in situ perfusion model in rats. PEG-PR was synthesized by the chemical conjunction of polyethylene glycol-4k/5k (PEG-4k/5k) and PR. The synthesized PEG-PR was then characterized using 1H-NMR, 13C-NMR, ultraviolet (UV), X-ray diffraction (XRD), and differential scanning calorimetry (DSC) analyses. The low permeability of PEG-PR was assessed using everted gut sac (EGS) methods. The apparent permeability coefficients (Papp, 3-8 × 10-7 cm/s) of PEG4k/5k-PR exhibited a nearly 15-fold reduction compared to that of PR. The different concentrations of PEG4k/5k-PR did not contribute to the Papp value or cumulative permeable percentage (about 0.02-0.06%). Furthermore, the larger molecular weight due to PEGylation (PEG5k-PR) enhanced the nonabsorbable effect. To evaluate the potential application of the novel marker, atenolol, ketoprofen, and metoprolol, which represent various biopharmaceutics classification system (BCS) classes, were selected as model drugs for the recirculation perfusion method. The water flux corrected by PEG4k/5k-PR reflected the accuracy due to the nonabsorbable effect, while the effective intestinal membrane permeability (Peff) of atenolol corrected by PEG4k/5k-PR showed a statistically significant increase (p < 0.05) in different intestinal segments. In conclusion, PEG-PR is a promising marker for the permeability estimation when using the in situ perfusion model in rats.

Can Sarcopenia Quantified by Computed Tomography Scan Predict Adverse Outcomes in Emergency General Surgery?

BACKGROUND: Sarcopenia (a decline of skeletal muscle mass) has been identified as a predictor of poor postoperative outcomes. The impact of sarcopenia in emergency general surgery (EGS) remains undetermined. The aim of this study was to evaluate the association between sarcopenia and outcomes after EGS. METHODS: A 3-y (2012-15) review of all EGS patients aged ≥45 y was presented to our institution. Patients who underwent computer tomography-abdomen were included. Sarcopenia was defined as the lowest sex-specific quartile of total psoas index (computer tomography-measured psoas area normalized for body surface area). Patients were divided into sarcopenic (SA) and nonsarcopenic. Primary outcome measures were in-hospital complications, hospital-length of stay [h-LOS], intensive care unit-length of stay, adverse discharge disposition, and in-hospital mortality. Our secondary outcome measures were 30-d complications, readmissions, and mortality. RESULTS: Four hundred fifty-two patients undergoing EGS were included. Mean age was 58 ± 8.7 y, and 60% were males. Hundred thirteen patients were categorized as SA. Compared to nonsarcopenic, SA patients had higher rates of minor complications (28% versus 17%, P = 0.01), longer hospital-length of stay (7d versus 5d, P = 0.02), and were more likely to be discharged to skilled nursing facility/Rehab (35% versus 17%, P = 0.01). There was no difference between the two groups regarding major complications, intensive care unit-length of stay, mortality, and 30-d outcomes. On regression analysis, sarcopenia was an independent predictor of minor complications (OR 1.8 [1.6-3.7]) and discharge to rehab/SNIF (OR: 1.9 [1.5-3.2]). However, there was no association with major complications, mortality, 30-d complications, readmissions, and mortality. CONCLUSIONS: Sarcopenia is an independent predictor of minor postoperative complications, prolonged hospital-length of stay, and an adverse discharge disposition in patients undergoing EGS. Identifying SA EGS patients will improve both resource allocation and discussion about the patient's prognosis between physicians, patients, and their families.

The Association of Primary Language With Emergency General Surgery Outcomes Using a Statewide Database.

BACKGROUND: Emergency general surgery (EGS) represents a diverse set of operations performed on acutely ill patients. Those undergoing EGS are at higher likelihood of complications, readmission, and death, but the effect of primary language on EGS outcomes has not been evaluated. We aimed to evaluate the association of non-English primary language on outcomes after EGS operations. METHODS: The New Jersey Statewide Inpatient Database from 2009 to 2014 was used to evaluate cases representing 80% of the national burden of EGS. Cases were restricted to ages ≥18 y, emergency department admissions, noted to be emergent or urgent, and performed between 0 and 2 d after admission. We evaluated Spanish speakers and non-English, non-Spanish (NENS) speakers compared with English. Outcomes included in-hospital mortality, 7-d readmission, and hospital length of stay (LOS). Logistic and negative binomial regression was used, and generalized linear mixed models were used to account for hierarchy in the data. RESULTS: There were 105,171 patients included. English speakers were majority white and with private insurance; Spanish speakers were younger and with fewer comorbidities. Where differences between Spanish and NENS speakers existed, NENS were more like the English-speaking group. Adjusted results indicate that Spanish speakers had reduced LOS after appendectomy (IRR: 0.92 [0.89-0.95]) and lysis of adhesion [0.93 (0.88-0.97)]. Spanish speakers had an increased LOS after higher risk operations (IRR: 1.14 [1.10-1.20]). NENS speakers had a reduced LOS after adhesiolysis (IRR: 0.94 [0.89-0.99]). There was no difference in mortality or short-term readmission CONCLUSIONS: These data from a large database suggest that the effect of primary language on LOS after EGS depends on the type of operation. Future studies should focus on long-term outcomes and determining if the lack of association we observed is generalizable to other regions of the United States.

Failure to Rescue After Emergency General Surgery in Geriatric Patients: Does Frailty Matter?

BACKGROUND: Failure to rescue (FTR) is considered as an index of quality of care provided by a hospital. However, the role of frailty in FTR remains unclear. We hypothesized that the FTR rate is higher for frail geriatric emergency general surgery (EGS) patients than nonfrail geriatric EGS patients. METHODS: We performed a 3-y (2015-2017) prospective cohort study of all geriatric patients (age ≥ 65 y) requiring EGS. Frailty was calculated by using the EGS-specific Frailty Index (EGSFI) within 24 h of admission. Patients were divided into two groups: frail (FI ≥ 0.325) and nonfrail (FI < 0.325). We defined FTR as death from a major complication. Regression analysis was performed to control for demographics, type of operative intervention, admission vitals, and admission laboratory values. RESULTS: Three hundred twenty-six geriatric EGS patients were included, of which 38.9% were frail. Frail patients were more likely to be white (P < 0.01) and, on admission, had a higher American Association of Anesthesiologist class (P = 0.03) and lower serum albumin (P < 0.01). However, there was no difference between the groups regarding age (P = 0.54), gender (P = 0.56), admission vitals, and WBC count (P = 0.35). Overall, 26.7% (n = 85) of patients developed in-hospital complications; and mortality occurred in 30% (n = 26) of those patients (i.e., the FTR group). Frail patients had higher rates of FTR (14% vs. 4%, P < 0.001) than nonfrail patients. On regression analysis, after controlling for confounders, frail status was an independent predictor of FTR (OR: 3.4 [2.3-4.6]) in geriatric EGS patients. CONCLUSIONS: Our study demonstrates that in geriatric EGS patients, a frail status independently contributes to FTR and increases the odds of FTR threefold compared with nonfrail status. Thus, it should be included in quality metrics for geriatric EGS patients.

Development of an in vitro system to study the developmental stages of Toxoplasma gondii using a genetically modified strain expressing markers for tachyzoites and bradyzoites.

Toxoplasma gondii, the agent of toxoplasmosis, is an intracellular parasite that can infect a wide range of vertebrate hosts. Toxoplasmosis causes severe damage to immunocompromised hosts and its treatment is mainly based on the combination of pyrimethamine and sulfadiazine, which causes relevant side effects primarily observed in AIDS patients, including bone marrow suppression and hematological toxicity (pyrimethamine) and/or hypersensitivity and allergic skin reactions (sulfadiazine). Thus, it is important to investigate new compounds against T. gondii, particularly those that may act on bradyzoites, which are present in cysts during the chronic disease phase. We propose an in vitro model to simultaneously study new candidate compounds against the two main causative stages of Toxoplasma infection in humans, using the EGS-DC strain that was modified from a type I/III strain (EGS), isolated from a case of human congenital toxoplasmosis in Brazil and engineered to express markers for both stages of development. One feature of this strain is that it presents tachyzoite and bradyzoite in the same culture system and in the same host cell under normal culture conditions. Additionally, this strain presents stage-specific fluorescent protein expression, allowing for easy identification of both stages, thus making this strain useful in different studies. HFF cells were infected and after 4 and 7 days post infection the cells were treated with 10 µM of pyrimethamine or atovaquone, for 48 or 72 h. We used high-throughput screening to quantify the extent of parasite infection. Despite a reduction in tachyzoite infection caused by both treatments, the atovaquone treatment reduced the bradyzoite infection while the pyrimethamine one increased it. Ultrastructural analysis showed that after treatment with both drugs, parasites displayed altered mitochondria. Fluorescence microscopy of cells labeled with MitoTracker CMXRos showed that the cysts present inside the cells lost their mitochondrial membrane potential. Our results indicate that this experimental model is adequate to simultaneously analyze new active compounds against tachyzoite and bradyzoite forms.

Set-up error validation with EPID images: Measurements vs Egs_cbct simulation.

AIM: In this study, the egs_cbct code's ability to replicate an electronic portal imaging device (EPID) is explored. BACKGROUND: We have investigated head and neck (H&N) setup verification on an Elekta Precise linear accelerator. It is equipped with an electronic portal imaging device (EPID) that can capture a set of projection images over different gantry angles. METHODS AND MATERIALS: Cone-beam computed tomography (CBCT) images were reconstructed from projection images of two different setup scenarios. Projections of an Anthropomorphic Rando head phantom were also simulated by using the egs_cbct Monte Carlo code for comparison with the measured projections.Afterwards, CBCT images were reconstructed from this data. Image quality was evaluated against a metric defined as the image acquisition interval (IAI). It determines the number of projection images to be used for CBCT image reconstruction. RESULTS: From this results it was established that phantom shifts could be determined within 2 mm and rotations within one degree accuracy using only 20 projection images (IAI = 10 degrees). Similar results were obtained with the simulated data. CONCLUSION: In this study it is demonstrated that a head and neck setup can be verified using substantially fewer projection images. Bony landmarks and air cavities could still be observed in the reconstructed Rando head phantom. The egs_cbct code can be used as a tool to investigate setup errors without tedious measurements with an EPID system.

Isolation, structure elucidation and anticancer activity from Brevibacillus brevis EGS 9 that combats Multi Drug Resistant actinobacteria.

Actinobacteria is the most widely distributed organism in the mangrove environment and produce a large amount of secondary metabolites. A new environmental actinobacterial stain exhibited strong antimicrobial activity against vancomycin and methicillin resistant actinobacteria. The active producer strain was found to be as Brevibacillus brevis EGS9, which was confirmed by its morphological, biochemical characteristics and 16S rRNA gene sequencing. It was deposited in NCBI GeneBank database and received with an accession number of KX388147. Brevibacillus brevis EGS9 was cultivated by submerged fermentation to produce antimicrobial compounds. The anti-proliferative agent was extracted from Brevibacillus brevis EGS9 with ethyl acetate. The bioactive metabolites of mangrove actinobacteria was identified by Liquid chromatography with mass spectrometry analysis. The result of the present investigation revealed that actinobacteria isolated from mangroves are potent source of anticancer activity. The strain of Brevibacillus brevis EGS9 exhibited a potential in vitro anticancer activity. The present research concluded that the actinobacteria isolated from mangrove soil sediment are valuable in discovery of novel species.

Geriatricians and the older emergency general surgical patient: proactive assessment and patient centred interventions. Salford-POP-GS.

Increasing numbers of older patients require Emergency admission under General Surgery (EGS). This is a group of heterogeneous and often complex individuals with varying degrees of multimorbidity, polypharmacy, functional, mobility and cognitive impairment. Our article describes the benefits of comprehensive assessment coupled with patient-centred multiprofessional interventions and timely discharge planning. We discuss diverse service models and describe our experience in the planning, development and consolidation of a perioperative service for older EGS patients.

[Modified Oligonucleotides for Guiding RNA Cleavage Using Bacterial RNase P].

The ability of a series of novel modified external guide sequences (EGS oligonucleotides) to induce the hydrolysis of target RNA with bacterial ribonuclease P has been studied; the most efficient modification variants have been selected. We have found patterns of the oligonucleotide sugar-phosphate backbone modi-fications that enhance oligonucleotide stability in the biological environment and do not violate the ability to interact with the enzyme and induce the RNA hydrolysis. It has been shown that analogues of EGS oligonucleotides selectively modified at 2'-position (2'-O-methyl and 2'-fluoro) or at internucleotide phosphates (phosphoryl guanidines) can be used for the addressed cleavage of a model RNA target by bacterial RNase P. The ability of new phosphoryl guanidine analogues of oligodeoxyribonucleotides that are stable in biological media to induce the hydrolysis of target RNA with bacterial ribonuclease P has been shown for the first time. The modified EGS oligonucleotides with an optimal balance between functional activity and stability in biological media can be considered as potential antibacterial agents.

HPTLC fingerprint profile, in vitro antioxidant and evaluation of antimicrobial compound produced from Brevibacillus brevis-EGS9 against multidrug resistant Staphylococcus aureus.

In the present study, in vitro antimicrobial activity of Brevibacillus brevis EGS9 against multi drug resistant Staphylococcus aureus (MDRSA) and to investigate the antimicrobial, antioxidant activity and HPTLC finger print profile of Brevibacillus brevis EGS9. Primary screening was done using by cross streak method against multi drug resistant Staphylococcus aureus. The bioactive metabolites were extracted from Brevibacillus brevis EGS9 using ethyl acetate extraction. Ethyl acetate extract showed significant antimicrobial activity against Escherichia coli (20.2 ± 0.1) mm, Candida albicans (19.2 ± 0.3) mm and Bacillus cereus (18.6 ± 0.2) mm respectively. Forty three UTI bacterial strains were isolated from mid-urine samples of 50 males and 50 females. Escherichia coli were more predominant (48%) followed by Klebsilla pneumonia (29%), Pseudomonas aeruginosa (17%), Staphylococcus aureus (4%) and Enterobacter faecalis (6%). The ethyl acetate extract was examined to evaluate antibacterial properties against isolated UTIs bacterial pathogens. The results were revealed that the maximum zone was measured in Escherichia coli (18.1 ± 0.4) mm and minimum zone of inhibition was shown against Pseudomonas aeruginosa (10.6 ± 0.3) mm. Based on the results obtained, the extract of Brevibacillus brevis EGS9 exhibited dose dependent manner of antioxidant activity. The DPPH scavenging activity of lowest concentration at 25 µg/ml and high concentration at 1000 µg/ml was measured at 2.4% and 39.5% respectively. HPTLC finger print profile was showed the active compounds present in crude extract, which may responsible for the antioxidant prospective. These results showed that, the significant antimicrobial properties against pathogen; this work will be helpful to explore the active compound identification in the field of pharmaceutical research and able to produce new drug molecules against pathogens.

Combined effect of a peptide-morpholino oligonucleotide conjugate and a cell-penetrating peptide as an antibiotic.

A cell-penetrating peptide (CPP)-morpholino oligonucleotide (MO) conjugate (PMO) that has an antibiotic effect in culture had some contaminating CPPs in earlier preparations. The mixed conjugate had gene-specific and gene-nonspecific effects. An improved purification procedure separates the PMO from the free CPP and MO. The gene-specific effects are a result of the PMO, and the nonspecific effects are a result of the unlinked, unreacted CPP. The PMO and the CPP can be mixed together, as has been shown previously in earlier experiments, and have a combined effect as an antibiotic. Kinetic analysis of these effects confirm this observation. The effect of the CPP is bacteriostatic. The effect of the PMO appears to be bacteriocidal. An assay for mutations that would alter the ability of these agents to affect bacterial viability is negative.