Around the world, raw materials are converted into fermented food products through microbial and enzymatic activity. Products are typically produced using a process known as batch culture, where small volumes of an old culture are used to initiate a fresh culture. Repeated over many years, and provided samples are not shared among producers, batch culture techniques allow for the natural evolution of independent microbial ecosystems. While these products form an important part of the diets of many people because of their nutritional, organoleptic and food safety properties, for many traditional African fermented products the microbial communities responsible for fermentation are largely unknown. Here we describe the microbial composition of three traditional fermented non-alcoholic beverages that are widely consumed across Zambia: the milk based product Mabisi and the cereal based products Munkoyo and Chibwantu. Using culture and non-culture based techniques, we found that six to eight lactic acid bacteria predominate in all products. We then used this data to investigate in more detail the factors affecting community structure. We found that products made from similar raw materials do not harbor microbial communities that are more similar to each other than those made from different raw materials. We also found that samples from the same product taken at the same location were as different from each other in terms of microbial community structure and composition, as those from geographically very distant locations. These results suggest that microbial community structure in these products is neither a simple consequence of the raw materials used, nor the particular suite of microbes available in the environment but that anthropogenic variables (e.g., competition among sellers or organoleptic preferences by different tribes) are important in shaping the microbial community structures.
Short-term serious outcomes strongly correlated with the etiology assigned in the ED visit. The importance of the physician's clinical judgment should be further studied to determine if it should become incorporated in risk-stratification tools for prognostication and safe management of ED syncope patients.
Introduction: We evaluated the average time required to complete individual steps of robotic-assisted radical prostatectomy (RARP) by an expert RARP surgeon. The intent is to help establish a timebased benchmark to aim for during apprenticeship. In addition, we aimed to evaluate preoperative patient factors, which could prolong the operative time of these individual steps. Methods: We retrospectively identified 247 patients who underwent RARP, performed by an experienced robotic surgeon at our institution. Baseline patient characteristics and the duration of each step were recorded. Multivariate analysis was performed to predict factors of prolonged individual steps. Results: In multivariable analysis, obesity was a significant predictor of prolonged operative time of: docking (odds ratio [OR] 1.96), urethral division (OR 3.13), and vesico-urethral anastomosis (VUA) (OR 2.63). Prostate volume was also a significant predictor of longer operative time in dorsal vein complex ligation (OR 1.02), bladder neck division (OR 1.03), pedicle control (OR 1.04), urethral division (OR 1.02), and VUA (OR 1.03). A prolonged bladder neck division was predicted by the presence of a median lobe (OR 5.03). Only obesity (OR 2.56) and prostate volume (OR 1.04) were predictors of a longer overall operative time. Conclusions: Obesity and prostate volume are powerful predictors of longer overall operative time. Furthermore, both can predict prolonged time of several individual RARP steps. The presence of a median lobe is a strong predictor of a longer bladder neck division. These factors should be taken into consideration during RARP training. IntroductionThe introduction of the da Vinci robotic system (Intuitive Surgical, Inc.) has made a dramatic impact in the treatment of localized prostate cancer. Since first described in 2001, robotic-assisted radical prostatectomy (RARP) has continued to gain widespread acceptance with less postoperative morbidity, reduced blood loss, along with some supportive data of improved early continence and erectile function recovery.1-3 For these reasons, over 80% of radical prostatectomies are performed robotically in the United States, 4 as well as growing percentages globally. Moreover, acquisition of robotic skills is crucial in the early learning curve particularly for residents, fellows, and urologists already established in practice. However, lack of a standardized robotic training curriculum, coupled with reduced resident working hours, impose further difficulties in the mastering of robotic techniques during training.The learning curve of RARP is complex as well as its definition. When using a 4-hour case proficiency, Ahlering and colleagues reported a RARP learning curve of 12 cases for a laparoscopic-naïve surgeon.5 In a recent report by Al-Hathal and colleagues, the RARP learning curve of a fellowshiptrained surgeon was evaluated at 50 cases after which the positive surgical margin (PSM) rate in organ-confined disease was significantly reduced and the overall operative time (OT) was ...
BackgroundAcute coronary syndrome (ACS) is a common, sometimes difficult to diagnose spectrum of diseases occurring after abrupt reduction in blood flow through a coronary artery. Given the diagnostic challenge, it is sensible for emergency physicians to have an approach to prognosticate patients with possible ACS. Multiple prediction models have been developed to help identify patients at increased risk of adverse outcomes. The HEART score is the first model to be derived, validated, and undergo clinical impact studies in emergency department (ED) patients with possible ACS.ObjectiveTo develop a protocol for a prognostic systematic review of the literature evaluating the HEART score as a predictor of major adverse cardiac events (MACE) in patients presenting to the ED with possible ACS.Methods/designThis protocol is reported according to the PRISMA-P statement and is registered on PROSPERO. All methodological tools to be used are endorsed by the Cochrane Prognosis Methods Group. Pre-defined eligibility criteria are provided. Multiple strategies will be used to identify potentially relevant studies. Studies will be selected and data extracted using standardised forms based on the CHARMS checklist. The QUIPS tool will be used to assess the risk of bias within individual studies. Outcome measures will include prevalence, risk ratio, and absolute risk reduction for MACE within 6 weeks of ED evaluation, comparing HEART scores 0–3 versus 4–10. HEART score prognostic performance will be evaluated with the concordance (C) statistic (model discrimination), observed to expected events ratio (model calibration), and a decision curve analysis. Reporting biases and methodological, clinical, and statistical heterogeneity will be scrutinised. Unless deemed inappropriate, a meta-analysis and pre-defined subgroup and sensitivity analyses will be performed. Overall judgements about evidence quality and strength of recommendations will be summarised using the GRADE approach.DiscussionThis review will identify, select, and appraise studies evaluating the prognostic performance of the HEART score, producing results of interest to emergency physicians. These results may encourage shared clinical decision-making in the ED by facilitating risk communication with patients and health care providers.Systematic review registrationPROSPERO 2017 CRD42017084400.Electronic supplementary materialThe online version of this article (10.1186/s13643-018-0816-4) contains supplementary material, which is available to authorized users.
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