A Comparison of Preoperative Predictive Scoring Systems for Postoperative Pancreatic Fistula after Pancreaticoduodenectomy Based on a Single-Center Analysis.

Background: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is associated with major postoperative morbidity and mortality. Several scoring systems have been described to stratify patients into risk groups according to the risk of POPF. The aim of this study was to compare scoring systems in patients who underwent a PD. Methods: A total of 196 patients undergoing PD from July 2019 to June 2022 were identified from a prospectively maintained database of the University Hospital Ghent. After performing a literature search, four validated, solely preoperative risk scores and the intraoperative Fistula Risk Score (FRS) were included in our analysis. Furthermore, we eliminated the variable blood loss (BL) from the FRS and created an additional score. Univariate and multivariate analyses were performed for all risk factors, followed by a ROC analysis for the six scoring systems. Results: All scores showed strong prognostic stratification for developing POPF (p < 0.001). FRS showed the best predictive accuracy in general (AUC 0.862). FRS without BL presented the best prognostic value of the scores that included solely preoperative variables (AUC 0.783). Soft pancreatic texture, male gender, and diameter of the Wirsung duct were independent prognostic factors on multivariate analysis. Conclusions: Although all predictive scoring systems stratify patients accurately by risk of POPF, preoperative risk stratification could improve clinical decision-making and implement preventive strategies for high-risk patients. Therefore, the preoperative use of the FRS without BL is a potential alternative.

Behavioral response of naïve and non-naïve deer to wolf urine.

Large carnivores are recolonizing many regions in Europe, where their ungulate prey have lived without them for >150 years. Whether the returning large carnivores will modify ungulate behavior and indirectly affect lower trophic levels, depends on the ability of ungulates to recognize risk based on past encounters and cues indicating carnivore presence. In two case studies, we tested, by means of camera trapping, the behavioral response of deer to wolf urine. The first case study was in the Netherlands where deer (still) live in absence of wolves, and the second in Poland with long-term wolf presence. As controls we used water (no scent) and all-purpose soap (unfamiliar scent). Deer vigilance level on control plots was 20% in both case studies indicating that wolf occupancy per se does not lead to a consistent difference in behavior. Placing wolf urine did not significantly affect deer behavior in either the wolf-absent or the wolf-present area. More intense cues, or a combination of cues, are likely needed to affect deer behavior. Moreover, we found an unexpected reaction of deer towards all-purpose soap of reduced foraging (and tendency for increased vigilance) in the wolf-present area, whereas it did not affect deer behavior in the wolf-absent area. We hypothesize that deer associate all-purpose soap with human presence, causing no response in human-dominated landscapes (the Netherlands), but triggering a behavioral reaction in more remote areas (Poland). This illustrates attention should be paid to controls used in scent experiments as they may be associated differently than intended.

Lessons from Bialowieza Forest on the history of protection and the world's first reintroduction of a large carnivore.

Understanding how the relationships between large carnivores and humans have evolved and have been managed through centuries can provide relevant insights for wildlife conservation. The management history of many large carnivores has followed a similar pattern, from game reserved for nobility, to persecuted pests, to conservation targets. We reconstructed the history of brown bear (Ursus arctos) management in Bialowieza Forest (Poland and Belarus) based on a detailed survey of historical literature and Russian archives. From the end of the Middle Ages to the end of 18th century, the brown bear was considered "animalia superiora" (i.e., game exclusively reserved for nobility and protected by law). Bears, also a source of public entertainment, were not regarded as a threat. Effective measures to prevent damages to traditional forest beekeeping were already in practice. In the beginning of 19th century, new game-management approaches allowed most forest officials to hunt bears, which became the primary target of hunters due to their valuable pelt. This, together with an effective anticarnivore policy enhanced by bounties, led to bear extirpation in 1879. Different approaches to scientific game management appeared (planned extermination of predators and hunting levels that would maintain stable populations), as did the first initiatives to protect bears from cruel treatment in captivity. Bear reintroduction in Bialowieza Forest began in 1937 and represented the world's first reintroduction of a large carnivore motivated by conservation goals. The outbreak of World War II spoiled what might have been a successful project; reproduction in the wild was documented for 8 years and bear presence for 13. Soft release of cubs born in captivity inside the forest but freely roaming with minimal human contact proved successful. Release of captive human-habituated bears, feeding of these bears, and a lack of involvement of local communities were weaknesses of the project. Large carnivores are key components of ecosystem-function restoration, and site-specific histories provide important lessons in how to preserve them for the future.

Cost-effectiveness of 3-month paliperidone therapy for chronic schizophrenia in the Netherlands.

BACKGROUND: A new depot formulation of paliperidone has been developed that provides effective treatment for schizophrenia for 3 months (PP3M). It has been tested in phase-3 trials, but no data on its cost-effectiveness have been published. PURPOSE: To determine the cost-effectiveness of PP3M compared with once-monthly paliperidone (PP1M), haloperidol long-acting therapy (HAL-LAT), risperidone microspheres (RIS-LAT), and oral olanzapine (oral-OLZ) for treating chronic schizophrenia in The Netherlands. METHODS: A previous 1-year decision tree was adapted, based on local inputs supplemented with data from published literature. The primary analysis used DRG costs in 2016 euros from the insurer perspective, as derived from official lists. A micro-costing analysis was also conducted. For the costing scenario, official list prices were used. Clinical outcomes included relapses (treated as outpatients, requiring hospitalization, total), and quality-adjusted life-years (QALYs). Rates and utility scores were derived from the literature. Economic outcomes were the incremental cost/QALY-gained or relapse-avoided. Model robustness was examined in scenario, 1-way, and probability sensitivity analyses. RESULTS: The expected cost was lowest with PP3M (8,781€), followed by PP1M (10,325€), HAL-LAT (11,278€), RIS-LAT (11,307€), and oral-OLZ (13,556€). PP3M had the fewest total relapses/patient (0.36, 0.94, 1.39, 1.21, and 1.70, respectively), hospitalizations (0.11, 0.46, 0.40, 0.56, and 0.57, respectively), emergency room visits (0.25, 0.48. 0.99, 0.65, and 1.14, respectively) and the most QALYs (0.847, 0.735, 0.709, 0.719, and 0.656, respectively). In both cost-effectiveness and cost-utility analyses, PP3M dominated all other drugs. Sensitivity analyses confirmed base case findings. In the costing analysis, total costs were, on average, 31.9% higher than DRGs. CONCLUSIONS: PP3M dominated all commonly used drugs. It is cost-effective for treating chronic schizophrenia in the Netherlands. Results were robust over a wide range of sensitivity analyses. For patients requiring a depot medication, such as those with adherence problems, PP3M appears to be a good alternative anti-psychotic treatment.

Patients' preferences for seclusion or forced medication in acute psychiatric emergency in the Netherlands.

OBJECTIVES: This study examined patients' preferences for coercive measures in case of emergency situations on acute psychiatric wards. METHODS: From November 2004 until January 2006, 104 adult patients completed a questionnaire after they underwent seclusion, nonconsensual medication, or both on one of three acute psychiatric wards in the Netherlands. RESULTS: Equal numbers of patients preferred seclusion and medication, and both measures were equal in perceived aversiveness and perceived efficacy. Men more often than women expressed a preference for seclusion. Patients who understood why the measure was necessary and acquiesced to it retrospectively held more positive views of the efficacy of the measure. CONCLUSIONS: Many patients on acute psychiatric wards have a clear preference between seclusion and medication. Patients appreciated receiving explanations of the reasons for the use of a restrictive measure and discussing their preferences with staff.

Modelling the treated course of schizophrenia: development of a discrete event simulation model.

In schizophrenia, modelling techniques may be needed to estimate the long-term costs and effects of new interventions. However, it seems that a simple direct link between symptoms and costs does not exist. Decisions about whether a patient will be hospitalized or admitted to a different healthcare setting are based not only on symptoms but also on social and environmental factors. This paper describes the development of a model to assess the dependencies between a broad range of parameters in the treatment of schizophrenia. In particular, the model attempts to incorporate social and environmental factors into the decision-making process for the prescription of new drugs to patients. The model was used to analyse the potential benefits of improving compliance with medication by 20% in patients in the UK. A discrete event simulation (DES) model was developed, to describe a cohort of schizophrenia patients with multiple psychotic episodes. The model takes into account the patient's sex, disease severity, potential risk of harm to self and society, and social and environmental factors. Other variables that change over time include the number of psychiatric consultations, the presence of psychotic episodes, symptoms, treatments, compliance, side-effects, the lack of ability to take care of him/herself, care setting and risk of harm. Outcomes are costs, psychotic episodes and symptoms. Univariate and multivariate sensitivity analyses were performed. Direct medical costs were considered (year of costing 2002), applying a 6.0% discount rate for costs and a 1.5% discount rate for outcome. The timeframe of the model is 5 years. When 50% of the decisions about the patient care setting are based on symptoms, a 20% increase in compliance was estimated to save 16,147 pounds and to avoid 0.55 psychotic episodes per patient over 5 years. Sensitivity analysis showed that the costs savings associated with increased compliance are robust over a range of variations in parameters. DES offers a flexible structure for modelling a disease, taking into account how a patient's history affects the course of the disease over time. This approach is particularly pertinent to schizophrenia, in which treatment decisions are complex. The model shows that better compliance increases the time between relapses, decreases the symptom score, and reduces the requirement for treatment in an intensive patient care setting, leading to cost savings. The extent of the cost savings depends on the relative importance of symptoms and of social and environmental factors in these decisions.