Analysis of Cumulative Fluid Balance Impact on the Stability of Gastrointestinal Tract Anastomosis.

Anastomotic leakage is a serious postoperative complication following a low anterior resection of rectum. Current research in colorectal surgery focuses on searching for techniques which could minimize the risk of leakage. The main objective of this study was to evaluate the impact of cumulative fluid balance on microcirculatory changes at the anastomotic site.This experimental study used 15 domestic pigs; all of the animals underwent rectal resection. Then the animals were divided into three groups and received IV crystalloids at various rates, i.e. 5 ml/kg/h; 10 ml/kg/h; and 20 ml/kg/h. Large bowel micro-perfusion was measured using laser Doppler flowmetry during and following the surgical procedure.The experiments were successfully performed in all 15 cases. No animal died during the procedure or during the follow-up. We found no differences in micro-perfusion of the bowel between the experimental groups during the surgical procedure and during the follow-up period after the surgery. A significant decrease in micro-perfusion was observed after the transection of the inferior mesenteric artery in all the groups; again, no differences between the groups were observed.We did not confirm the original hypothesis that excessive load of IV crystalloids during the surgery would have a negative effect on bowel micro-perfusion and thus a negative effect on the healing of the anastomosis. However, laser Doppler flowmetry was found to have high accuracy in measuring tissue microcirculation and has the potential to be used in clinical practice.

Why Does Child Mortality Decrease With Age? Modeling the Age-Associated Decrease in Mortality Rate Using WHO Metadata From 25 Countries.

Background: Our previous study analyzed the age trajectory of mortality (ATM) in 14 European countries, while this study aimed at investigating ATM in other continents and in countries with a higher level of mortality. Data from 11 Non-European countries were used. Methods: The number of deaths was extracted from the WHO mortality database. The Halley method was used to calculate the mortality rates in all possible calendar years and all countries combined. This method enables us to combine more countries and more calendar years in one hypothetical population. Results: The age trajectory of total mortality (ATTM) and also ATM due to specific groups of diseases were very similar in the 11 non-European countries and in the 14 European countries. The level of mortality did not affect the main results found in European countries. The inverse proportion was valid for ATTM in non-European countries with two exceptions. Slower or no mortality decrease with age was detected in the first year of life, while the inverse proportion model was valid for the age range (1, 10) years in most of the main chapters of ICD10. Conclusions: The decrease in child mortality with age may be explained as the result of the depletion of individuals with congenital impairment. The majority of deaths up to the age of 10 years were related to congenital impairments, and the decrease in child mortality rate with age was a demonstration of population heterogeneity. The congenital impairments were latent and may cause death even if no congenital impairment was detected.

Why Does Child Mortality Decrease With Age? Modeling the Age-Associated Decrease in Mortality Rate Using WHO Metadata From 14 European Countries.

Background: Mortality rate rapidly decreases with age after birth, and, simultaneously, the spectrum of death causes show remarkable changes with age. This study analyzed age-associated decreases in mortality rate from diseases of all main chapters of the 10th revision of the International Classification of Diseases. Methods: The number of deaths was extracted from the mortality database of the World Health Organization. As zero cases could be ascertained for a specific age category, the Halley method was used to calculate the mortality rates in all possible calendar years and in all countries combined. Results: All causes mortality from the 1st day of life to the age of 10 years can be represented by an inverse proportion model with a single parameter. High coefficients of determination were observed for total mortality in all populations (arithmetic mean = 0.9942 and standard deviation = 0.0039). Slower or no mortality decrease with age was detected in the 1st year of life, while the inverse proportion method was valid for the age range [1, 10) years in most of all main chapters with three exceptions. The decrease was faster for the chapter "Certain conditions originating in the perinatal period" (XVI).The inverse proportion was valid already from the 1st day for the chapter "Congenital malformations, deformations and chromosomal abnormalities" (XVII).The shape of the mortality decrease was very different for the chapter "Neoplasms" (II) and the rates of mortality from neoplasms were age-independent in the age range [1, 10) years in all populations. Conclusion: The theory of congenital individual risks of death is presented and can explain the results. If it is valid, latent congenital impairments may be present among all cases of death that are not related to congenital impairments. All results are based on published data, and the data are presented as a supplement.

Cost of Treatment and Care for People with Alzheimer's Disease: A Meta- Analysis.

There is now a general attempt in developed countries to implement strategic plans to fight against Alzheimer's disease, for which treatment represents an increasing economic burden for the ageing society. At present, the costs of treatment and care for Alzheimer's Disease (AD) patients are not consistently tracked and logged, therefore, the economic burden is calculated based on the records kept by individual countries. The aim of this paper is to conduct a meta-analysis of the available data on the total costs of treatment and care for elderly AD patients with respect to the stage of the disease determined by the Mini Mental State Examination (MMSE). The Web of Science and PubMed databases were used for a systematic search. Two independent reviewers screened the identified records and selected relevant articles published in the period from 2007 to 2017. A meta-analysis of costs is performed in three categories related to the stages of Alzheimer's disease (mild, moderate, and severe). The resulting estimation of total costs per patient per year determined by the meta-analysis is 20,461$ total costs. The total costs in relation to the stage of the disease according to the MMSE scale are 14,675 $ for the mild stage, 19,975 $ for the moderate stage, and 29,708 $ for the severe stage. The meta- analysis confirms that the costs rise significantly with the severity of AD. These findings therefore, emphasize the severity of the economic burden carried out by the AD patients, their families, and the healthcare system, and this fact must be taken into account when planning health policy strategies for the years to come.

Economic analysis of acupuncture for migraine prophylaxis.

BACKGROUND: Acupuncture has become a viable option for migraine prophylaxis in Europe; however, despite its wide use, more data on the short- and long-term cost-effectiveness are needed when considering the perspectives of a paying third-party, the patient, and of society in general. The aim was to evaluate the cost and effectiveness of adjuvant acupuncture to pharmacologic treatment vs pharmacologic treatment alone in migraine patients after a 3-month acupuncture course and a 6-month follow-up from all perspectives. METHODS: The study involved an open-label randomized clinical trial of patients receiving acupuncture (n=42), and a waiting list control group (n=44). The number of migraine days during the last 28 days, as well as direct and indirect costs were considered. The trial was registered under DRKS00009803. RESULTS: The total cost per patient reached €696 vs €285 after 3 months of acupuncture and €66 vs €132 in the acupuncture and control groups after a 6-month follow-up, respectively (P=0.071). The trends observed in effectiveness and costs from all perspectives are discussed. CONCLUSION: The inclusion of acupuncture in health care results beneficial mainly for its observed trend in reduced losses of productivity and income, with the latter often exceeding the costs of acupuncture treatment. As such, acupuncture may be recommended as an adjuvant treatment in migraine prophylaxis to standard pharmacotherapy.

Modeling the Age-Associated Decrease in Mortality Rate for Congenital Anomalies of the Central Nervous System Using WHO Metadata From Nine European Countries.

Background: In humans, the mortality rate dramatically decreases with age after birth, and the causes of death change significantly during childhood. In the present study, we attempted to explain age-associated decreases in mortality for congenital anomalies of the central nervous system (CACNS), as well as decreases in total mortality with age. We further investigated the age trajectory of mortality in the biologically related category "diseases of the nervous system" (DNS). Methods: The numbers of deaths were extracted from the mortality database of the World Health Organization (WHO) for the following nine countries: Denmark, Finland, Norway, Sweden, Austria, the Czech Republic, Hungary, Poland, and Slovakia. Because zero cases could be ascertained over the age of 30 years in a specific age category, the Halley method was used to calculate the mortality rates in all possible calendar years and in all countries combined. Results: Total mortality from the first day of life up to the age of 10 years and mortality due to CACNS within the age interval of [0, 90) years can be represented by an inverse proportion with a single parameter. High coefficients of determination were observed for both total mortality (R2 = 0.996) and CACNS mortality (R2 = 0.990). Our findings indicated that mortality rates for DNS slowly decrease with age during the first 2 years of life, following which they decrease in accordance with an inverse proportion up to the age of 10 years. The theory of congenital individual risk (TCIR) may explain these observations based on the extinction of individuals with more severe impairments, as well as the bent curve of DNS, which exhibited an adjusted coefficient of determination of R¯2 = 0.966. Conclusion: The coincidence between the age trajectories of all-cause and CACNS-related mortality may indicate that the overall decrease in mortality after birth is due to the extinction of individuals with more severe impairments. More deaths unrelated to congenital anomalies may be caused by the manifestation of latent congenital impairments during childhood.

Neopterin, kynurenine and tryptophan as new biomarkers for early detection of rectal anastomotic leakage.

INTRODUCTION: At present, there are no strong predictors, nor a useful scoring system, that clearly identifies patients at risk for anastomotic leakage. AIM: This study aimed to investigate a new method that assesses this risk by monitoring levels of neopterin, tryptophan, and kynurenine, in bodily fluids. MATERIAL AND METHODS: This prospective study included patients who underwent elective rectal resection for carcinoma. The basic condition for inclusion was rectal anastomosis using the double-stapling technique. Preoperative levels of neopterin, tryptophan, kynurenine, and their ratios, were assessed with blood and urine samples. These levels were then monitored for 6 postoperative days in venous blood, urine, and abdominal drainage fluid. RESULTS: A total of 42 patients were enrolled in the study. Thirty-six patients underwent a laparoscopic resection and 6 patients had an open procedure. No differences were found among neopterin, tryptophan, and kynurenine serum levels. However, the groups were observed to have significant differences in the urinary neopterin/creatinine ratio: the preoperative neopterin/creatinine ratio was 139.5 µmol/mol in the group with leakage, vs 114.8 µmol/mol in the group without complications, p = 0.037. The same results were observed during the postoperative period, p = 0.012. Additionally, the group with complications had a higher mean value of neopterin in drainage fluid, p = 0.048. CONCLUSIONS: Our study demonstrated that high preoperative levels of urinary neopterin could be interpreted as a risk for anastomotic leakage. Moreover, pathological levels of neopterin in urine and abdominal drainage fluid could be useful for early identification of anastomotic leakage during the postoperative period prior to its clinical development.

Call for a Uniform Strategy of Collecting Alzheimer's Disease Costs: A Review and Meta-Analysis.

BACKGROUND: There is now a general attempt in developed countries to implement strategic plans to fight against Alzheimer's disease and other dementia disorders. Among others, attention is paid to the issues of registers and calculations of economic burden. Currently available calculations of costs are difficult to compare. The problem is a different breakdown of cost categories and non-unified monitoring of cost types. OBJECTIVE: The aim of this paper is to note the problem of poor availability and inconsistencies in cost monitoring. Furthermore, the intersection of cost items that are comparable and consistently monitored in expert studies are specified. METHODS: The Web of Science, Elsevier Science Direct, PubMed, and Scopus databases are used in a systematic review. Two independent reviewers screened the identified records and selected relevant articles published in the period from 2010 to 2016. A meta-analysis of costs is performed in four categories related to patients suffering from Alzheimer's disease. RESULTS: The resulting estimation of total costs per patient per month through meta-analysis is € 3,896, with 95% CI [2078, 5713]. The highest costs arise from informal care following non-medical and medical care. CONCLUSION: The results confirm assumption that inconsistencies in cost monitoring of the treatment and care of people with dementia exists in Europe. Homogeneity could be assumed only in the medical costs of severe patients. Heterogeneity is assumed in non-medical costs, informal costs. Cost items should be defined and collected more precisely for future more precise monitoring of the economic burden.

Modeling Human Mortality from All Diseases in the Five Most Populated Countries of the European Union.

Age affects mortality from diseases differently than it affects mortality from external causes, such as accidents. Exclusion of the latter leads to the "all-diseases" category. The age trajectories of mortality from all diseases are studied in the five most populated countries of the EU, and the shape of these 156 age trajectories is investigated in detail. The arithmetic mean of ages where mortality reaches a minimal value is 8.47 years with a 95% confidence interval of [8.08, 8.85] years. Two simple deterministic models fit the age trajectories on the two sides of the mortality minimum. The inverse relationship is valid in all cases prior to this mortality minimum and death rates exactly decreased to three thousandths of its original size during the first 3000 days. After the mortality minimum, the standard Gompertz model fits the data in 63 cases, and the Gompertz model extended by a small quadratic element fits the remaining 93 cases. This analysis indicates that the exponential increase begins before the age of 15 years and that it is overshadowed by non-biological causes. Therefore, the existence of a mechanism switching that would explain the exponential increase in mortality after the age of 35 years is unlikely.

Onset of mortality increase with age and age trajectories of mortality from all diseases in the four Nordic countries.

BACKGROUND: The answer to the question "At what age does aging begin?" is tightly related to the question "Where is the onset of mortality increase with age?" Age affects mortality rates from all diseases differently than it affects mortality rates from nonbiological causes. Mortality increase with age in adult populations has been modeled by many authors, and little attention has been given to mortality decrease with age after birth. MATERIALS AND METHODS: Nonbiological causes are excluded, and the category "all diseases" is studied. It is analyzed in Denmark, Finland, Norway, and Sweden during the period 1994-2011, and all possible models are screened. Age trajectories of mortality are analyzed separately: before the age category where mortality reaches its minimal value and after the age category. RESULTS: Resulting age trajectories from all diseases showed a strong minimum, which was hidden in total mortality. The inverse proportion between mortality and age fitted in 54 of 58 cases before mortality minimum. The Gompertz model with two parameters fitted as mortality increased with age in 17 of 58 cases after mortality minimum, and the Gompertz model with a small positive quadratic term fitted data in the remaining 41 cases. The mean age where mortality reached minimal value was 8 (95% confidence interval 7.05-8.95) years. The figures depict an age where the human population has a minimal risk of death from biological causes. CONCLUSION: Inverse proportion and the Gompertz model fitted data on both sides of the mortality minimum, and three parameters determined the shape of the age-mortality trajectory. Life expectancy should be determined by the two standard Gompertz parameters and also by the single parameter in the model c/x. All-disease mortality represents an alternative tool to study the impact of age. All results are based on published data.

Single parameter of inverse proportion between mortality and age could determine all mortality indicators in the first year of life.

Mortality increase with age in adult population has been studied and modeled by many authors, but relatively little attention has been given to mortality decrease with age after birth. Data split in more detailed age categories can newly test mortality decrease with age. Age trajectories of mortality are studied in 20 age categories in the specific age interval 1-365 days. Four basic models mentioned in literature are tested here. The linear model and the linear model with the specific slope -1 in the log-log scale represent the most successful formalism. Mortality indicators describing the first year could be determined by a single parameter of the model with slope -1 in the log-log scale. All conclusions are based on published data which are presented as a supplement.

CT/MRI pelvimetry as a useful tool when selecting patients with rectal cancer for transanal total mesorectal excision.

BACKGROUND: The quality of a total mesorectal excision (TME) is one of the most important prognostic factors for local recurrence of rectal carcinoma. The aim of this study was to clarify the manner in which lesser pelvis dimensions affect the quality of TME via the transabdominal approach, while simultaneously defining the criteria for selecting patients most likely to have Grade 3 TME outcomes for a transanal approach using the TaTME technique. METHODS: An analysis from the registry was conducted using 93 of total 198 patients with rectal cancer of the mid- and lower third of the rectum who underwent: (1) a low anterior resection, (2) an ultra-low resection with coloanal anastomosis, or (3) an intersphincteric rectal resection, all with total mesorectal excision. The procedures were carried out at the Department of Surgery at the University Hospital Hradec Králové between 2011 and 2014. Rectal specimens were histopathologically examined according to a standardized protocol. Pelvimetry data were obtained using anteroposterior, transverse, and sagittal CT or MRI scans. RESULTS: A correlation was found between the quality of the TME and pelvimetry parameter A5, i.e., the angle between the longitudinal axis of the symphysis, and the lines between the symphysis and the promontory (R(2) = -0.327, p < 0.001). The ordinal regression method was used to identify parameters of the model describing levels of probability for TME quality. These relationships were described by equations that provide probability of the achievement of each grade of TME. CONCLUSION: The correlation described by obtained equations between pelvimetry parameters and the quality of TME represents a new tool for use in preoperative decision-making with regard to resection via the transanal approach (TaTME).

Socio-economic Aspects of Alzheimer's Disease.

Social development, better living conditions and medical advances lead to the fact that more people have the opportunity to live longer than in the past. The aging population is a characteristic feature of demographic trends in developed countries. This trend is closely linked with the issue of increasing number of diseases in old age and increasing government expenditure on health and social care. The most frequently mentioned diseases in old age include dementia. The cause may lie in all kinds of diseases, the most common are Alzheimer's disease and cerebrovascular disease. Now the care of current 35 million patients with dementia costs over $ 600 billion per year, it is approximately one percent of global Gross Domestic Product. This review discusses the recent issues and questions in the area of social and economic aspects of Alzheimer's disease. It focuses in detail on the national strategies in the approach to Alzheimer's disease, the anticipated problems concerning the insufficient number of social workers and necessary expenses of state budgets in the future. The situation in the area of health insurance companies' expenditures is illustrated in the context of the analysis of long-term care systems, in the chosen countries within the European Union.

Age trajectories of mortality from all diseases in five countries of central Europe during the last decades.

Age trajectories of total mortality represent an irreplaceable source of information about the relationship between mortality and age. Total mortality includes death from external causes. Age affects mortality from all diseases differently than it affects mortality from external causes. This study examines mortality with external causes excluded. The resulting category of all-diseases is examined as a helpful tool to better understand the relationship between mortality and age. Age trajectories of all-diseases mortality are studied in Austria, the Czech Republic, Hungary, Poland, and Slovakia. Resulting age trajectories of all-diseases mortality show a strong minimum that is hidden in all-causes mortality. Two deterministic models fit the resulting age trajectories of mortality on either side of the strong mortality minimum. The inverse proportion between mortality and age is used from birth to the age when all-diseases mortality reaches the minimum value. The Gompertz relationship fits age trajectories of all-diseases mortality in 93 out of 183 cases. When extended with a small quadratic element, the Gompertz model is used to fit the remaining 90 cases.

Age trajectories of mortality from all diseases in the six most populated countries of the South America during the last decades.

Age trajectories of total mortality represent an irreplaceable source of information about aging. In principle, age affects mortality from all diseases differently than it affects mortality from external causes. External causes (accidents) are excluded here from all causes, and the resultant category "all-diseases" is tested as a helpful tool to better understand the relationship between mortality and age. Age trajectories of all-diseases mortality are studied in the six most populated countries of the South America during 1996-2010. The numbers of deaths for specific causes of death are extracted from the database of WHO, where the ICD-10 revision is used. The all-diseases mortality shows a strong minimum, which is hidden in total mortality. Two simple deterministic models fit the age trajectories of all-diseases mortality. The inverse proportion between mortality and age fits the mortality decreases up to minimum value in all six countries. All previous models describing mortality decline after birth are discussed. Theoretical relationships are derived between the parameter in the first model and standard mortality indicators: Infant mortality, Neonatal mortality, and Postneonatal mortality. The Gompertz model extended with a small positive quadratic element fit the age trajectories of all-diseases mortality after the age of 10 years.

Decrease of total activity with time at long distances from a nuclear accident or explosion.

Two data groups were analyzed: (1) the exposure rate in the former Czechoslovakia after the Chernobyl accident in 1986, and (2) the decrease of beta activity of an atmospheric fallout sample taken in Bratislava during 24 h on 30 May 1965. Both quantities decreased with the first power of time. This pattern of decrease is explained by applying the same mathematical formalism as is also used to describe the decrease in postnatal mortality with age. Following this formalism, the decrease of total activity with the first power of time could be seen as a consequence of a log-normal distribution of decay constants in the fallout. This differs slightly from earlier results that show the total activity decreasing with a power of 1.2 immediately after the nuclear explosion.

Analysis of mortality decline along with age and latent congenital defects.

Mortality from congenital anomalies is inversely proportional to age after the age of 1 year. The theory of congenital individual risk explains this mortality decline. The overall aim of this study is to test whether the theory describes mortality decline for all diseases within the first year of life and after the age of 1. Mortality decline along with age was analyzed in five countries and for all causes of death. The theory of congenital individual risk describes well the real mortality decline for all diseases except malignant neoplasms after the birth. Decline of mortality is due to the dying out of the more impaired individuals. Mortality decline with the first power of age results from the selection before the birth. It is dominant and the frequency of defects decreases proportionally to the value of individual risk of death. In the case of identically probable defects, the selection does not occur and mortality declines with the square of age. Congenital defects were also identified as a cause of death in the case of infectious diseases occurring before the age of 10. Mortality from malignant neoplasms is age-independent within the age period 1-20 years and, contrary to all other diseases, no small subpopulation with a significant individual risk was identified.