Nutritional Status Impairment Due to Neoadjuvant Chemotherapy Predicts Post-Radical Cystectomy Complications

Background: Radical cystectomy (RC) is the standard treatment for muscle invasive bladder cancer (MIBC). Neoadjuvant chemotherapy (NAC) is associated with improved patient survival. The impact of NAC on nutritional status is understudied, while the association between malnutrition and poor surgical outcomes is well known. This study aims to examine the association between NAC, nutritional status impairment, and post-operative morbidity. Materials and Methods: We included MIBC patients who underwent RC and received NAC from multiple academic centers in Israel. Cross-sectional imaging was used to measure the psoas muscle area and normalized it by height (smooth muscle index, SMI). Pre- and post-NAC SMI difference was calculated (represents nutritional status change). The primary outcomes were post-RC ileus, infection, and a composite outcome of any complication. Logistic regression models were fit to identify independent predictors of the outcomes. Results: Ninety-one patients were included in the study. The median SMI change was −0.71 (−1.58, −0.06) cm2/m2. SMI decline was significantly higher in patients with post-RC complications (−18 vs. −203, p < 0.001). SMI change was an independent predictor of all complications, ileus, infection, and other complications. The accuracy of SMI change for predicting all complications, ileus, infection, and other complications was 0.85, 0.87, 0.75, and 0.86, respectively. Conclusions: NAC-related nutritional deterioration is associated with increased risk of complications after RC. Our results hint towards the need for nutritional intervention during NAC prior to RC.

The Minimal Clinically Important Difference: A Review of Clinical Significance

Background: The minimal clinically important difference (MCID) is a term synonymous with orthopaedic clinical research over the past decade. The term represents the smallest change in a patient-reported outcome measure that is of genuine clinical value to patients. It has been derived in a myriad of ways in existing orthopaedic literature. Purpose: To describe the various modalities for deriving the MCID. Study Design: Narrative review; Level of evidence, 4. Methods: The definitions of common MCID determinations were first identified. These were then evaluated by their clinical and statistical merits and limitations. Results: There are 3 primary ways for determining the MCID: anchor-based analysis, distribution-based analysis, and sensitivity- and specificity-based analysis. Each has unique strengths and weaknesses with respect to its ability to evaluate the patient’s clinical status change from baseline to posttreatment. Anchor-based analyses are inherently tied to clinical status yet lack standardization. Distribution-based analyses are the opposite, with strong foundations in statistics, yet they fail to adequately address the clinical status change. Sensitivity and specificity analyses offer a compromise of the other methodologies but still rely on a somewhat arbitrarily defined global transition question. Conclusion: This current concepts review demonstrates the need for (1) better standardization in the establishment of MCIDs for orthopaedic patient-reported outcome measures and (2) better study design—namely, until a universally accepted MCID derivation exists, studies attempting to derive the MCID should utilize the anchor-based within-cohort design based on Food and Drug Administration recommendations. Ideally, large studies reporting the MCID as an outcome will also derive the value for their populations. It is important to consider that there may be reasonable replacements for current derivations of the MCID. As such, future research should consider an alternative threshold score with a more universal method of derivation.

Who is a civilian in Afghanistan?

Despite the existence of a definition of civilian status in international humanitarian law (IHL), differences in the application of this definition – both in theory and in practice – continue to be observed. One of the contexts where these differences remain palpable (and do so for various fighting parties) is Afghanistan, a country where civilian harm has remained high for several years. This article explores the legal concepts of civilian and civilian population, including how they have been formed and interpreted and, ultimately, what protection they afford to persons who belong in these categories. The second part of the article brings these questions into the Afghan context, one that is complex and where cultural and religious implications should not be overlooked. Public statements, reports and codes of fighting parties in the country which touch upon civilian status are presented, followed by the civilian experience in Afghanistan, particularly focusing on the reported harm. Ultimately, it is proposed that despite the factual and contextual confusion, the existing legal rules and interpretations, when applied in good faith, suffice to ensure both that those who are civilians under IHL are protected and that the threats which some civilians’ behaviour might pose can be effectively addressed without a status change.

Trade of economically and physically scarce virtual water in the global food network

The virtual water (VW) trade associated to food is composed by the quantity of water utilized for the production of the crops exchanged on the global market. In assessing a country’s water abundance or scarcity when entering the international VW trade, scholars consider only physical water availability, neglecting economic water scarcity, which indicates situations in which socio-economic obstacles impede the productive use of water. We weight the global VW trade associated to primary crops with a newly proposed composite water scarcity index (CWSI) that combines physical and economic water scarcity. 39% of VW volumes is exported from countries with a higher CWSI than the one of the destination country. Such unfair routes occur both from low- to high-income countries and among low- and middle-income countries themselves. High-income countries have a predominant role in import of CWSI-weighted VW, while low- and middle-income countries dominate among the largest CWSI-weighted VW exporters. For many of them economic water scarcity dominates over physical scarcity. The application of the CWSI elicits also a status change from net exporter to net importer for some wealthy countries and viceversa for some low- and middle-income countries. The application of CWSI allows one to quantify to what extent VW exchanges flow along environmentally and economically unfair routes, and it can inform the design of compensation policies.

Inactive status is an independent predictor of liver transplant waitlist mortality and is associated with a transplant centers median meld at transplant

Background Approximately 30% of patients on the liver transplant waitlist experience at least one inactive status change which makes them temporarily ineligible to receive a deceased donor transplant. We hypothesized that inactive status would be associated with higher mortality which may differ on a transplant centers’ or donor service areas’ (DSA) Median MELD at Transplant (MMaT). Methods Multi-state models were constructed (OPTN database;06/18/2013-06/08/2018) using DSA-level and transplant center-level data where MMaT were numerically ranked and categorized into tertiles. Hazards ratios were calculated between DSA and transplant center tertiles, stratified by MELD score, to determine differences in inactive to active transition probabilities. Results 7,625 (30.2% of sample registrants;25,216 total) experienced at least one inactive status change in the DSA-level cohort and 7,623 experienced at least one inactive status change in the transplant-center level cohort (30.2% of sample registrants;25,211 total). Inactive patients with MELD≤34 had a higher probability of becoming re-activated if they were waitlisted in a low or medium MMaT transplant center or DSA. Transplant rates were higher and lower re-activation probability was associated with higher mortality for the MELD 26–34 group in the high MMaT tertile. There were no significant differences in re-activation, transplant probability, or waitlist mortality for inactivated patients with MELD≥35 regardless of a DSA’s or center’s MMaT. Conclusion This study shows that an inactive status change is independently associated with waitlist mortality. This association differs by a centers’ and a DSAs’ MMaT. Prioritization through care coordination to resolve issues of inactivity is fundamental to improving access.

Political ideology moderates White Americans’ reactions to racial demographic change

An emerging body of research finds that exposure to the shifting racial demographics of a nation can engender concerns about racial group status among members of the dominant racial group. The present work revisits this finding, probing a broader set of group status concerns than has been examined in most past research. Three experiments exposed four samples of White Americans to racial demographic information or race-neutral control information, then assessed their perception that the relative status of racial groups in the nation would change and the extent to which they were alarmed by such a status shift—that is, status threat. Consistent with past work, what we now term perceived status change increased in response to salient racial demographics information, relative to race-neutral control information, irrespective of participants’ political ideology. Departing from past work, however, the perceived threat associated with changing racial demographics was moderated by political ideology. Specifically, politically conservative White participants demonstrated high levels of group status threat in the neutral control condition that either increased (Study 1a, Study 2) or stayed equally high (Study 1b, Study 3) after exposure to information about a racial shift. In contrast, in all studies, politically liberal White participants demonstrated a modest level of group status threat in the control condition that was attenuated upon exposure to a racial shift. Taken together, these results suggest a polarization of responses to the increasing racial diversity of the nation, one that was not observed even just a few years ago.

Adaptively robust filtering algorithm for maritime celestial navigation

Celestial navigation is an important means of maritime navigation; it can automatically achieve inertially referenced positioning and orientation after a long period of development. However, the impact of different accuracy of observations and the influence of nonstationary states, such as ship speed change and steering, are not taken into account in existing algorithms. To solve this problem, this paper proposes an adaptively robust maritime celestial navigation algorithm, in which each observation value is given an equivalent weight according to the robust estimation theory, and the dynamic balance between astronomical observation and prediction values of vessel motion is adjusted by applying the adaptive factor. With this system, compared with the frequently used least square method and extended Kalman filter algorithm, not only are the real-time and high-precision navigation parameters, such as position, course, and speed for the vessel, calculated simultaneously, but also the influence of abnormal observation and vessel motion status change could be well suppressed.

Longitudinal study: understanding the lived experience of couples across the trajectory of dementia

Background The longitudinal study, “Couples Lived Experiences,” focuses on whether and how relationship characteristics of older couples change with the cognitive decline of one member of the couple, and how these changes affect each individual’s emotional and physical health outcomes. Until now, most psychosocial research in dementia has focused either on the person with dementia (PWD) or the caregiver separately. The previous literature examining relationship characteristics and their role in outcomes for the caregiver and PWD is scant and suffers from methodological issues that limit the understanding of which relationship characteristics most influence outcomes for caregivers and care-receivers and what other factors may mitigate or exacerbate their effects. Methods We will enroll 300 dyads and collect information via online interviews of each member of the couple, every 6 months for 3 years. Relationship characteristics will be measured with a set of short, well-validated, and reliable self-report measures, plus the newly developed “Partnership Approach Questionnaire.” Outcomes include global quality of life, subjective physical health, mental health (depression and anxiety), and status change (transitions in levels of care; i.e., placement in a nursing home). Longitudinal data will be used to investigate how relationship characteristics are affected by cognitive, functional, and behavioral changes, and the impact of these changes on health outcomes. Qualitative data will also be collected to enrich the interpretation of results of quantitative analyses. Discussion Psychosocial interventions have demonstrated effectiveness in promoting the wellbeing of PWD and their caregivers. The knowledge gained from this study can lead to the development or enhancement of targeted interventions for older couples that consider the impact of cognitive and functional decline on the relationship between members of a couple and thereby improve their wellbeing. Trial registration This study has been registered with ClinicalTrials.gov. ClinicalTrials.gov Identifier is: NCT04863495.

Most remote monitoring alerts about atrial fibrillation are not relevant to identify clinically significant events: proposal of a new approach

Background Cardiac Implantable Electronic Devices (CIEDs) are an important tool for detecting Atrial Fibrillation (AF) in implanted patients. However AF burden values and notifications emitted by the manufacturer's platforms are not directly related to the standard classification of AF types (paroxysmal, persistent or permanent) that are used in daily practice. Moreover, AF alerts represent the most frequent notifications for implanted patients resulting in a time-consuming review for healthcare professionals. Purpose This study intends to compare the manufacturers' atrial burden related notifications in remotely monitored (RM) patients to the detection of clinically significant events with a new proprietary algorithm. Methods From 2017 to 2020, all RM patients from 57 centers with daily atrial burden measurements available for at least 30 days and at least one atrial burden related alert were enrolled. All atrial burden related alerts emitted by the manufacturers' platforms were compared to the following clinically significant events (based on the standard classification) detected by a new proprietary algorithm: “1st recorded AT/AF episode”, “paroxysmal AF”, “increasing paroxysmal AF”, “persistent AF”, and “end of persistent AF”. Results This multicentric retrospective study analyzed, between 01/2017 and 10/2020, 2 463 RM patients with a Biotronik, Boston Scientific or Medtronic CIED (implantable defibrillator, pacemaker or implantable loop recorder), with a mean follow-up of 490 days [33–1386]. A total of 22 345 manufacturers' atrial burden related alerts were emitted while only 4 826 clinically significant events were detected by the algorithm: 1770 “1st recorded AT/AF episode”, 620 “Paroxysmal AF”, 252 “Increasing paroxysmal AF”, 1373 “Persistent AF”, and 811 “End of persistent AF”. These clinically significant events represent only 22% of the total number of atrial burden related alerts emitted by the manufacturers' platforms. Conclusion A new AF alert algorithm could have the potential to identify clinically significant AF status change in remotely monitored implanted patients while reducing the total number of alerts generated and thus the review burden for healthcare professionals. FUNDunding Acknowledgement Type of funding sources: None.