Viruses in Cambodian bird flu cases identified as endemic clade
Reuters

Dead ducks are hung at a farm in the outskirts of Phnom Penh 

REUTERS/Chor Sokunthea

Feb 26 (Reuters) - The viruses that infected two people in Cambodia with H5N1 avian influenza have been identified as an endemic clade of bird flu circulating in the country, the U.S. Centers for Disease Control and Prevention (CDC) said.

The cases reported last week had raised concerns they were caused by a new strain of H5N1, clade 2.3.4.4b, which emerged in 2020 and has caused record numbers of deaths among wild birds and domestic poultry in recent months.

But work so far suggests this is not the case.

Preliminary genetic sequencing carried out in Cambodia led its health ministry to identify the viruses as H5 clade 2.3.2.1c, which has circulated in Cambodia among birds and poultry for many years and has sporadically caused infections in people, the CDC said in a statement on Saturday.

"Yes, this is an older clade of avian influenza that had been circulating around the region for a number of years and while it has caused human infections in the past, it has not been seen to cause human-to-human transmission. However, that doesn't mean that the threat is any less," said Erik Karlsson, director of the National Influenza Center of Cambodia and acting head of virology at the Institut Pasteur du Cambodge, which sequenced the virus.

He added that the response needed to be coordinated and swift to prevent any further spread and to limit exposure to any common source.

An investigation into the source and to detect any additional cases is ongoing, the CDC said, adding that so far there had been no indication of person-to-person spread.

Cambodia tested at least 12 people for the H5N1 strain last week, after an 11-year-old girl died from the virus in the first known transmission to humans in the country in nearly a decade.

The victim's father, who was part of a group the girl had been in contact with in a province east of the capital Phnom Penh, tested positive for the virus but did not exhibit any symptoms, Cambodia's Health Minister Mam Bunheng had said in a statement on Friday.

Only the girl's case has been sequenced and the father's case is still being worked on, Karlsson said.

The World Health Organization said it is working with Cambodian authorities following the cases, describing the situation as worrying due to the recent rise in cases in birds and mammals.


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Reporting by Juby Babu in Bengaluru; additional reporting by Jennifer Rigby in London; editing by Barbara Lewis

Bernie Sanders: Scots should ‘go their own way’ if they want to

The Democrat was asked for his gut feeling on the issue as he appeared on Sky’s Sophy Ridge on Sunday show

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Bernie Sanders was asked for his thoughts on the constitutional question (Jonathan Brady/PA)

SUN, 26 FEB, 2023 - 
NEIL POORAN, PA SCOTLAND POLITICAL REPORTER

US senator Bernie Sanders has aired his thoughts on the question of Scottish independence, saying “if they want to go their own way, they should be allowed to”.

The Democrat was asked for his gut feeling on the issue as he appeared on Sky’s Sophy Ridge on Sunday show.

However, the left-wing senator conceded he was “not an expert on UK politics”.

Mr Sanders said: “Look, I’m not an expert on UK politics, I very much appreciate what the people of Scotland have done and what they’re fighting for.

“My initial thought, not being an expert, they want to go their own way, they should be allowed to.”

He then joked: “Don’t tell anybody I said that!”

The SNP said Mr Sanders was recognising Scotland’s right to hold an independence referendum.

MSP Fiona Hyslop said: “Any true democrat can see it is for the people of Scotland, not politicians, to decide their future – so Bernie Sanders’ support for Scots to have a say over their future comes as no surprise.

“The Tories and pro-Brexit Labour are increasingly isolated in their disgraceful denial of democracy – even members and senior figures in their own parties recognise this.

“The right for Scotland to decide its own future is unquestionable and the need for independence has never been so essential – it is the only way to escape the hugely damaging consequences of Westminster control and build a better future for everyone.”

Battlefield Band Anthem for the Common Man Full Album

What recent changes at  the top mean for Vietnam

Don’t expect major shifts in economic or foreign policy.
The key challenge is a nest of structural obstacles at home.

Vietnam’s parliament, the National Assembly, at its autumn session in Hanoi, 20 October 2022 

(Nhac Nguyen/AFP via Getty Images)

LE HONG HIEP
Published 27 Feb 2023 Vietnam


Within the span of the last few weeks, a series of major high-level personnel changes have taken place inside the Vietnamese government. On 5 January, deputy prime ministers Pham Binh Minh and Vu Duc Dam were dismissed and replaced by Tran Hong Ha and Tran Luu Quang. Not a fortnight later, Nguyen Xuan Phuc resigned, becoming the first Vietnamese president to do so. Currently, Vice President Vo Thi Anh Xuan is serving as Acting President until the election of a new person to the job, which is expected to take place this week.

Officially, Phuc, Minh and Dam were held accountable for major corruption scandals that happened under their watch during the Covid-19 pandemic. Nevertheless, the reshuffle has sparked concerns among investors and caused some Vietnam watchers to question the nation’s long-held assertion of political stability, which has been a key factor helping Vietnam attract foreign investment over the years.
In terms of foreign policy, the departure of Western-trained deputy prime ministers Minh and Dam should not be interpreted as Vietnam moving closer to China.

However, there are strong grounds to believe that these personnel changes will not disrupt political stability in Vietnam, nor will they cause policy changes that would limit Vietnam’s investment potential. After all, this is not a change of the ruling party but to senior leadership positions in the government. As Vietnam is a one-party state, its key policies are controlled by the ruling Communist Party of Vietnam (CPV) and made collectively by its Politburo and Central Committee. There are no indications that these personnel changes foreshadow any forthcoming shifts in the CPV’s governance policies and exercise of power.

In terms of foreign policy, the departure of Western-trained deputy prime ministers Minh and Dam should not be interpreted as Vietnam moving closer to China. Rather, Vietnam has no choice but to continue its foreign policy of “diversification and multilateralisation”, striving to maintain a delicate balance between China and the United States and its allies. This is not only to help Vietnam avoid being entangled in the intensifying US–China strategic rivalry, but also because both the United States and China, as Vietnam’s largest export and import market respectively, are equally important economic partners that play vital roles in helping the CPV fulfill its primary domestic mission of providing economic growth

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The delayed implementation of large public infrastructure projects in Vietnam is worrying, especially in the context of the country’s ongoing credit crunch and falling export orders

 (Maika Elan/Bloomberg via Getty Images)

That economic growth remains essential to the CPV’s performance-based legitimacy – a kind of social contract under which the Party’s monopoly of power will not be challenged as long as it can deliver socio-economic development and help improve the people’s livelihood. The party and its officials must therefore continue to promote reforms to drive growth, including expanding exports and attracting more investment.

But investors and Vietnam’s partners will rightly ask whether the personnel changes will deliver visible improvements in the country’s governance, as well as the implementation of socio-economic development projects. In recent years, Vietnam’s intense anti-corruption campaign has made government officials especially cautious, causing delays to many public-funded and private investment projects. Officials have been unwilling to sign off on key decisions, especially where land price determination is involved, which in turn has frustrated investors and constrained Vietnam’s economic growth. The delayed disbursement of large public infrastructure projects is particularly worrying, especially in the context of Vietnam’s ongoing credit crunch and falling export orders. Against this backdrop, the injection of new funds through infrastructure projects is essential to the country’s economic outlook.
With the anti-corruption campaign striving to clean up the political system, the Party leadership may now prioritise personal integrity and political loyalty over professional merits and performance.

There is a hope that the new leaders, with fewer legacy issues and a stronger mandate to deliver on economic performance, can help gradually address this challenge.

But three other factors may stand in the way.

First, with the anti-corruption campaign striving to clean up the political system, the Party leadership may now prioritise personal integrity and political loyalty over professional merits and performance. If this is the case, the incoming leaders may be safe political choices but not the most effective in promoting economic growth. If such a trend takes hold, Vietnam’s long-term economic prospects may be adversely impacted.

Second, structural constraints remain in place. Low salaries for public servants and state employees in Vietnam have a demoralising effect, and can fuel problems including corruption or a brain drain of skills in public institutions. Even the best-intentioned leaders will not be able to fulfill their mission without effective personnel at their disposal.

Third, a lack of transparency, entrenched corruption, and the overlapping and inefficient decision-making mechanisms among government agencies, which are often labelled as “system errors” in the Vietnamese context, also hinder progress. As such, many leaders must battle through the bureaucratic maze to make decisions and accomplish tasks. Some officials are even forced to “break the fence” to get things done, which can result in potential legal repercussions for them and their agencies.

In recent years, the CPV has implemented various measures to address these challenges. These include streamlining the bureaucracy to free up financial resources to increase salaries for public servants, and enacting policies to motivate government officials to take initiatives to spur economic growth while protecting them from any negative consequences of mistakes, provided that they are not involved in corrupt practices. Some institutional reforms have also been introduced to improve decision-making mechanisms. Such measures have had only limited success.

Whether the new leaders can bring about positive changes will depend on the CPV’s ability to resolve the structural problems that are constraining both the Party’s governance and the economy’s performance. Rather than focusing on the personnel changes themselves, investors and Vietnam watchers should be looking at how the country is addressing these structural constraints.

A product of the Lowy Institute Indo-Pacific Development Centre, with funding support from the Australian Department of Foreign Affairs and Trade.

Casinos and consulting? Pandemic spurs tribes to diversify

By SUSAN HAIGH

 Slot machines at the FireKeepers Casino Hotel, owned and operated by the Nottawaseppi Huron Band of the Potawatomi, are seen in Battle Creek, Mich., Aug. 5, 2019. The casino shut down in the early months of COVID-19 pandemic, but the financial impact was blunted in part by the tribe's non-gambling businesses, including a firm involved in drone development for the federal government that was deemed "essential." (Nick Buckley/Battle Creek Enquirer via AP, File)

MASHANTUCKET, Conn. (AP) — When the COVID-19 pandemic shuttered Foxwoods Resort Casino in Connecticut for three months in 2020, its owners, the Mashantucket Pequot Tribal Nation, had to reckon with decades of relying heavily on gambling as the tribe’s main source of revenue.

“The fact that the casino revenues went from millions to zero overnight just fully reiterated the need for diverse revenue streams,” said Tribal Chairman Rodney Butler.

The 1,000-member tribe has since expanded its efforts to get into the federal government contracting business, making it one of several tribal nations to look beyond the casino business more seriously after the coronavirus crisis. Tribal leaders and tribal business experts say the global pandemic has been the latest and clearest sign that tribal governments with casinos can’t depend solely on slot machines and poker rooms to support future generations.

In Michigan, the Match-E-Be-Nash-She-Wish Band of Pottawatomi Indians, or Gun Lake Tribe, recently announced a 25-year plan to develop hundreds of acres near its casino into a corridor with housing, retail, manufacturing and a new 15-story hotel. A non-gambling entity owned by the Little River Band of Ottawa Indians, also in Michigan, is now selling “NativeWahl” burger franchises to other tribes after forming a 2021 partnership with Wahlburgers, the national burger chain created by the celebrity brothers Paul, Mark and Donnie Wahlberg.

Some tribes, with and without casinos, have gotten involved in a wide range of non-gambling businesses, such as trucking, construction, consulting, health care, real estate, cannabis and marketing over the past decade or longer while others have been branching out more recently.

“While enterprise diversification can come with costs, its necessity became clear during the early phases of the pandemic, when tribally owned casinos were shut down to mitigate COVID-19 transmission and gaming-dependent tribes were left with little incoming revenue,” according to a new report from the Center for Indian Country Development at the Federal Reserve Bank of Minneapolis.

The report found that many tribes are increasingly doing business with the federal government, especially the U.S. Department of Defense.

The Mashantucket Pequots’ non-gambling entity, Command Holdings, last year made its largest acquisition to date: WWC Global, a Florida-based management consulting firm that predominantly works with federal agencies, including the defense and state departments. WWC announced in December that it had been awarded a $37.5 million contract supporting the federal Cybersecurity and Infrastructure Security Agency.

WWC Global CEO Jon Panamaroff applauded the Mashantucket Pequots’ casino and hospitality business but noted that it can be subject to the “ups and downs of the market,” making it important to branch out economically. A member of the Sun’aq Tribe of Kodiak, Alaska, he credited the Mashantucket Pequots’ tribal leaders with doubling down on diversification efforts during the pandemic instead of “shying away and trying to hunker down.”

Butler said the tribe hopes non-gambling revenues, including from a planned family resort with a 91,000-square-foot (8,450-square-meter) water park that’s expected to open in 2025, will eventually comprise 50% to 80% of the Mashantucket Pequots’ portfolio, providing “stability and certainty” when another challenging event undoubtedly will happen.

“You think about the financial crisis in ’08 and now COVID. And so, something’s going to happen again,” Butler said. “We’ve learned from past mistakes, and we want to be ready for it in the future.”

Even before the pandemic hit, some tribal casinos were already facing competitive pressures from the advent of other gambling options, including legalized online wagering on sports and casino games in some states. At the same time, traditional patrons of brick-and-mortar casinos are getting older.

“Tribal economies are at an inflection point because gaming markets are maturing across the U.S.,” said Dawson Her Many Horses, head of Native American banking for Wells Fargo and an enrolled member of the Rosebud Sioux Tribe of South Dakota. “As casino revenues flatten, tribes will be looking for new business opportunities in other industries.”

Terri Fitzpatrick, a member of the Sault Ste. Marie Tribe of Chippewa Indians in Michigan and the Michigan Economic Development Corporation’s chief real estate and global attraction officer, has noted “tremendous growth” in non-gambling-related tribal businesses over the last decade in Michigan. Most tribes within the state now engage in some form of economic development other than casinos.

The pandemic, Fitzpatrick said, really highlighted the importance of such a strategy, given the financial impact of COVID-19 on tribal schools, health care centers, assistance for older adults, day care programs and other services.

“It wasn’t about a loss of revenue,” she said. “It was a loss of, ‘What we can do for our community and in our community.’”

The Nottawaseppi Huron Band of the Potawatomi in Michigan saw its successful casino shut down in the early months of the pandemic. But the financial blow was blunted in part by the tribe’s non-gambling businesses, including a firm that’s involved in drone development for the federal government and was deemed “essential.”

The tribe’s economic development entity, Waséyabek Development Company LLC, now has mapped out a plan to generate at least one-third of the revenue needed to support the tribe from activities other than gambling by 2040, its president and CEO, Deidra Mitchell, said.

That doesn’t mean tribes are giving up on gambling. Some are even expanding it. The gambling and hospitality entity owned by the Mohegan Tribe in eastern Connecticut announced this month it is partnering with a New York developer to try and secure a New York City gambling license and build a proposed entertainment district in Manhattan’s East Side. Meanwhile, the Chickasaw Nation in Oklahoma is part of another consortium that wants to build a casino and entertainment complex on New York’s Coney Island.

The National Indian Gaming Association reported in August that $39 billion in gross gambling revenue was generated in fiscal year 2021, the most in tribal gambling history. That figure, which accounts for 243 tribes across 29 states, increased 40% over the previous year.

Patrick Davison, vice president of Native American gaming and finance at PNC Bank, said he’s been working with tribal officials who still want to build casinos but also want to avoid overbuilding. He said the pandemic was “a real eye-opener for tribes” as officials consider their tribes’ futures in the gambling business.

“There’s a lot more thought being put into it,” he said.

Zelensky: Return Crimea and peace will be restored

9:01 am, February 26, 2023
Source: Volodymyr Zelensky

President of Ukraine Volodymyr Zelensky published a Telegram post marking the anniversary of a rally that took place at the Crimean parliament building in Simferopol in 2014, where pro-Ukrainian activists opposed Crimea separating from Ukraine.

“Russian aggression started with Crimea nine years ago. Once we return Crimea, we will restore peace. This is our land. Our people. Our history. We will return the Ukrainian flag to every corner of Ukraine. Qırım serbest olacaq [Crimean Tatar: Crimea will be free]!” he wrote.




On February 26, 2014, pro-Russian and pro-Ukrainian groups clashed outside of the Crimean parliament building. The latter group was led by the Mejlis of the Crimean Tatar People, the representative body of the indigenous people of Crimea. Around 30 people were injured in the clashes, and two were killed. Less than a month later, Russia annexed Crimea, and Russian authorities began persecuting Crimean Tatars.

A number of Ukrainian and Western military experts believe that Ukraine will succeed in liberating Crimea in 2023.

MORE ON CRIMEAN TATARS

‘We don’t have another motherland’ Nine years into Russian occupation and oppression, Crimean Tatars hold out hope for Ukraine’s return
3 days ago

Will Lebanon be classified as failed state?

News Bulletin Reports
2023-02-26 | 


Lebanon is at the intersection of two roads; the first and second are possible, according to the latest study prepared by Garbis Iradian, chief economist for the Middle East and Northern Africa (MENA) region at the Institute of International Finance in Washington.
In light of the country's political stalemate, the lack of reforms, and the absence of an agreement with the International Monetary Fund, Lebanon will be classified as a "failed state," similar to Somalia.

No new projects, investments, or financial inflows will be made. The economy will continue to shrink rather than expand.

Additionally, according to the study, the size of the economy is expected to decline from about $18 billion in 2022 to $13 billion in 2023, almost a third of what it was in 2019.

However, an optimistic scenario can still happen.

Support for the country will begin if a president is elected and a capable reformist government is formed that carries out the IMF requirements.

What would the results be?

The economy will regain confidence, new projects and investments will be launched, and foreign currency will enter the country through an IMF loan or the international community.

Accordingly, the economy will grow to $24.1 billion this year, reaching levels close to before the crisis (about $50 billion by 2025).

What about the fluctuating exchange rate?

In the pessimistic scenario, the chaos with the diversity of exchange rates will remain. And the exchange rate of the US dollar in the black market will hit a record high reaching more than 110,000 Lebanese pounds by the end of this year, accompanied by a new wave of inflation.

Moreover, the reserves of Bank du Liban will drop to around $6 billion due to the country's ongoing lack of USD.

While in the optimistic scenario, the currency rate in the black market will improve to reach LBP 40,000 or less by the end of 2023. At the same time, BDL reserves will also increase.

In addition, due to reforms and investments, the Lebanese will witness a significant improvement in public services, including power, water, infrastructure, transportation, and others.

Consequently, a large number of Lebanese expatriates will think about returning.

Yet, the decision today remains in the hands of the officials.

Leading addiction researchers denounce Australia’s NHMRC statement on e-cigarettes

Peer-Reviewed Publication

SOCIETY FOR THE STUDY OF ADDICTION

Eleven top international addiction scientists argue that the 2022 statement on e-cigarettes issued by Australia’s peak health and medical body, the National Health and Medical Research Council (NHMRC), fails to meet the high scientific standard expected of a leading national scientific body. 

The NHMRC statement, published in June 2022, aims to provide “public health advice on the safety and impacts of electronic cigarettes (e-cigarettes) based on review of the current evidence.” (1) 

This critique of the NHMRC statement, published in the scientific journal Addiction, argues that the statement does not accurately summarise the current evidence on e-cigarettes.  In fact, it selectively cites evidence in support of a 2017 statement rather than objectively analysing and incorporating new research.  The critique also argues that the NHMRC statement relies heavily on a flawed analysis by the National Centre for Epidemiology and Public Health at the Australian National University.

The authors of the critique cite the following weaknesses of the NHMRC statement:

• It exaggerates the risks of vaping and fails to compare them with smoking.
• It incorrectly claims that adolescent vaping causes subsequent smoking.
• It ignores evidence of the benefits of vaping  in helping smokers quit.
• It ignores evidence that vaping is likely already having a positive effect on public health.
• It misapplies the precautionary principle, which requires policy makers to compare the risks of introducing a product with the risks of delaying its introduction.

According to lead author Dr Colin Mendelsohn, “Many leading international scientists in the field hold more supportive views than the NHMRC on the potential of e-cigarettes as a strategy to improve public health. In particular, invoking the precautionary principle to prevent the use of much less harmful smoke-free products is unjustified in the face of the massive public health burden of smoking.”

In sum, argue the authors of this critique, the NHMRC statement confuses association with causation, adopts a double standard by uncritically accepting evidence of harms while being highly sceptical of evidence of benefits, and inappropriately applies the precautionary principle.

1. National Health and Medical Research Council. CEO Statement Summary: Electronic Cigarettes. Canberra: National Health and Medical Research Council; 2022. [accessed 30 Jan 2023]. Available from: https://www.nhmrc.gov.au/health-advice/all-topics/electronic-cigarettes/ceo-statement-summary

-- Ends –

For editors:

This paper is available at the Wiley Online Library: https://onlinelibrary.wiley.com/doi/10.1111/add.16143 or by contacting Jean O’Reilly, Editorial Manager, Addiction, jean@addictionjournal.org.

To speak with a co-author:
Dr. Colin Mendelsohn: +61 415976783, mendel@bigpond.net.au
Professor Ron Borland: +61 409979269, rborland@unimelb.edu.au
Emeritus Professor Wayne Hall: +61 421059009, w.hall@uq.edu.au

Full citation for article: Mendelsohn CP, Hall W, Borland R, Wodak A, Beaglehole R, Benowitz NL, Britton J, Bullen C, Etter J-F, McNeill A, and Rigotti NA. A critique of the Australian NHMRC CEO Statement on electronic cigarettes Addiction. 2023. DOI: 10.1111/add.16143

Funding: None

Addiction is a monthly international scientific journal publishing peer-reviewed research reports on alcohol, substances, tobacco, and gambling as well as editorials and other debate pieces. Owned by the Society for the Study of Addiction, it has been in continuous publication since 1884.

---

JOURNAL

Addiction

DOI

10.1111/add.16143 

METHOD OF RESEARCH

Commentary/editorial

SUBJECT OF RESEARCH

People

ARTICLE TITLE

A critique of the Australian NHMRC CEO Statement on electronic cigarettes.

ARTICLE PUBLICATION DATE

20-Feb-2023

COI STATEMENT

Declarations of interests: C.P.M. was an unpaid board member of the Australian Tobacco Harm Reduction Association (ATHRA), a registered health promotion charity, from October 2017 to January 2021. ATHRA accepted unconditional seed funding from the vape retail industry to become established. Funding ceased in March 2019. C.P.M. was a Director of ATHRA in March 2018 when it received a donation from KAC Communications. The donation was sourced from a surplus arising from the Global Forum on Nicotine conference in May 2017. C.P.M. is the author of Stop Smoking Start Vaping, published by Aurora Press. C.P.M. has never received payments from electronic cigarette or tobacco companies. A.W. has been an unpaid board member of the Australian Tobacco Harm Reduction Association (ATHRA), a health promotion charity, since October 2017. ATHRA received unconditional funding for establishment costs from small Australian vape businesses. Vape industry funding has not been accepted since March 2019. A.W. was a Director of ATHRA in March 2018 when it received a donation from KAC Communications. The donation was sourced from a surplus arising from the Global Forum on Nicotine conference in May 2017. A.W. has never received payments from electronic cigarette or tobacco companies. N.L.B. is consultant to pharmaceutical companies that market or are developing smoking cessation medications and is an expert witness in litigation against tobacco companies. C.B. is the lead investigator and recipient of research contracts from the NZ Ministry of Health on tobacco cessation and tobacco control in New Zealand; a co-investigator on grants funded by the NZ Health Research Council; and is a Board member and President-Elect of the Society for Research on Nicotine and Tobacco. C.B. received payment for a consultancy to J&J Japan on nicotine replacement therapy, in 2019. N.A.R. has received no funding (current or past) from e-cigarette or tobacco companies. N.A.R. is a consultant for, and her institution has received research funding from, Achieve Life Sciences for an investigational smoking cessation pharmacotherapy. All other authors have no conflicts of interest to declare.

Understanding the value of a physician’s intuition when assessing risk factors for surgery

Study compared how a surgeon’s intuition compares with a standardized risk calculator for predicting patient outcomes after surgery

Peer-Reviewed Publication

AMERICAN COLLEGE OF SURGEONS

 

VIDEO: SURGEON INTUITION, THE ACS NSQIP RISK CALCULATOR, AND SURGICAL OUTCOMES. view more 

CREDIT: AMERICAN COLLEGE OF SURGEONS

Key takeaways

• Researchers investigated whether a physician’s intuition, including their training and past experiences, could be used in risk prediction similar to a standardized surgical risk calculator developed by the American College of Surgeons.
• While preoperative surgeon intuition is an independent predictor of 30-day postoperative complications, the study found that its predictive power isn’t as strong when compared with the standardized risk calculator.
• Combining surgeon intuition with the risk calculator was not any more accurate than the risk calculator alone.

CHICAGO (February 23, 2023): Preoperative surgeon intuition is an independent predictor of 30-day postoperative complications; however, when compared to the standard risk calculator derived from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®), its predictive power isn’t as strong, according to a study published in the Journal of the American College of Surgeons (JACS).

Surgeons weigh many different factors, such as medical history and current health status, when deciding what type of surgery to perform. A physician’s intuition — training, past experiences, and their “gut” feeling about a patient –– also plays a role in the assessment.

However, even when the diagnosis is the same, there is still significant variability in physician decision-making. According to one study, patients seeking a second opinion only receive the same diagnosis from both physicians about 12% of the time.*

“The integration of the explicit, the intangible, and experience together form what we call surgeon intuition. Surgeons with a certain level of training and experience will have relatively similar intuition in certain cases,” said senior study author Gabriel A. Brat, MD, MPH, FACS, a trauma surgeon and assistant professor of surgery at Beth Israel Deaconess Medical Center and Harvard Medical School. “However, intuition is dynamic. It depends on the characteristics of the provider. One surgeon can see one patient and believe one thing about that patient’s outcome, and another surgeon can see the same patient and predict a different outcome.” 

For the study, researchers sought to quantify the value of intuition in predicting outcomes among surgical patients. They investigated whether preoperative intuition could be used in risk prediction in a similar way that the ACS NSQIP Surgical Risk Calculator is currently used. The NSQIP Risk Calculator is a tool used to estimate patient-specific postoperative complication risks for almost all operations and includes a surgeon intuition adjustment.

“We wanted to know if it’s possible to adjust for intuition in a more precise way,” said Jayson S. Marwaha, MD, MBI, lead study author and general surgery resident at Georgetown University.

The researchers developed a new algorithm that predicts postoperative outcomes using surgeon preoperative intuition alone. To do this, researchers surveyed general surgeons between October 2021 and September 2022 at Beth Israel Deaconess Medical Center right before starting their surgery. A one-question text message asked them to predict the patient’s likelihood of having a negative outcome, specifically if the patient was lower than average risk, average risk, or higher than average risk for postoperative complications or death. In total, 216 patients were included in this analysis.

In a separate model, the research team collected NSQIP data on 9,182 patients who underwent general surgery between January 2017 and September 2022 at the medical center. They predicted patient outcomes by analyzing clinical data captured by the NSQIP Risk Calculator.

After comparing the two models, a third model was built, combining both preoperative intuition and the NSQIP Risk Calculator, to determine if this third model might outperform the other two models. 

Key findings

• Nearly half of surgeons who responded to the survey (45.4%) indicated that their patient’s risk of any complication was average, with 40.3% responding higher than average risk and 14.4% responding lower than average risk.
• Preoperative surgeon intuition was an independent predictor of postoperative complications. A model of preoperative surgeon intuition predicting complications had an area under the curve (AUC) of 0.70, where an AUC of 1.0 is perfect prediction and 0.5 is a random result.
• Surgeon intuition in predicting any complication was less accurate than the ACS NSQIP risk calculator, which had an AUC of 0.83.
• A combined model using both surgeon intuition and the NSQIP risk calculator did not do better, with an AUC of 0.83, than the NSQIP risk calculator alone.
• A subset analysis showed that the intuition of more experienced attending surgeons in predicting the outcomes of patients was more accurate than less experienced residents.

“The value of surgical intuition for preoperative prediction was not improved by including human intuition in the model and this suggests that, at least for most presurgical prediction, the information that is gathered by the NSQIP Risk Calculator is better at predicting those outcomes than the gut feeling that surgeons have when looking at patients,” Dr. Brat said.

“Human intuition takes into account a lot of information that is not available to the calculator, but it doesn’t weight it in any explicit way. We don’t have a weighting system in our head that says, ‘We know that this piece of information is more important than another by a certain amount,’ whereas the NSQIP Risk Calculator does have that explicit weighting system. So, in certain situations, it’s the case that an explicit algorithm is going to be better at prediction. The value of the clinician is to integrate information that’s not available to the risk calculator.”

“Data from the NSQIP Risk Calculator are amongst the best for predicting outcomes – demonstrably superior to claims, billing, and administrative data. However, what is done with the data is the next important step,” said Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director, ACS Division of Research and Optimal Patient Care, who wasn’t involved with the study. “It will be the surgeon and patient’s responsibility together, based on the data, to decide whether to proceed with surgery, and how best to prepare for the phases of care before, during, and after surgery.”

The major limitations of the study are the small size of the dataset and the fact that most of the surgeons who participated in the research were trauma and emergency surgeons. These results might not apply to other types of surgeons or scenarios.

Coauthors are Jayson S. Marwaha, MD, MBI; Brendin R. Beaulieu-Jones, MD, MBA; Margaret Berrigan, MD; William Yuan, PhD; Stephen R. Odom II, MD, FACS; Charles H. Cook, MD, FACS; Benjamin B. Scott, MD; Alok Gupta, MD, FACS; Charles S. Parsons, MD, FACS; and Anupamaa J. Seshadri, MD.

The study was supported by the National Library of Medicine.

This article is published as an article in press on the JACS website.

Citation: Marwaha JS, Beaulieu-Jones BR, Berrigan M, et al. Quantifying the Prognostic Value of Preoperative Surgeon Intuition: Comparing Surgeon Intuition and Clinical Risk Prediction, as derived from the ACS NSQIP Risk Calculator. Journal of the American College of Surgeons. DOI: 10.1097/XCS.0000000000000658.

_______________________

*Gao J, Xiao C, Glass LM, Sun J. Dr. Agent: Clinical predictive model via mimicked second opinions. Journal of the American Medical Informatics Association: JAMIA. 2020;27(7):1084-1091.

# # #

About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates a surgeon is a Fellow of the American College of Surgeons.

The Journal of the American College of Surgeons (JACS) is the official scientific journal of ACS. Each month, JACS publishes peer-reviewed original contributions on all aspects of surgery, with the goal of providing its readership the highest quality rapid retrieval of information relevant to surgeons.

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JOURNAL

Journal of the American College of Surgeons

DOI

10.1097/XCS.0000000000000658 

ARTICLE TITLE

Quantifying the prognostic value of preoperative surgeon intuition: Comparing surgeon intuition and clinical risk prediction, as derived from the ACS NSQIP risk calculator

ARTICLE PUBLICATION DATE

23-Feb-2023

New insights into chordate body plan development answer long-standing questions on evolution

Examination of development-relevant gene expression patterns in starfish embryos reveals how echinoderm and chordate body plans evolved from a common ancestor.

Peer-Reviewed Publication

OKINAWA INSTITUTE OF SCIENCE AND TECHNOLOGY (OIST) GRADUATE UNIVERSITY

 

IMAGE: BASED ON SHARED EXPRESSION PROFILES OF TRANSCRIPTION FACTOR GENES AND CELLULAR SIGNALING MOLECULE GENES, CONSTITUENT CELLS OF STARFISH EMBRYOS AND LARVAE CAN BE CATEGORIZED INTO 22 CLUSTERS, NUMBERED 0 TO 21. EACH DOT REPRESENTS EACH CELL. view more 

CREDIT: NORI SATOH/OIST

Life began on earth more than 3.5 billion years ago, but the history of humans and other vertebrates accounts for only a fraction of this timescale. Chordates (a group that includes vertebrates) and echinoderms (like starfish and sea urchins) are believed to have evolved from a common deuterostome ancestor around 500 million years ago. However, how the complex and sophisticated body plan of chordates evolved is still not fully clear, despite its importance from an evolutionary and developmental biology perspective. This topic has thus been the subject of much debate among experts for a long time.

Now, an answer is in sight, thanks to a recent study published in the journal Developmental Biology by Dr. Hitoshi Tominaga, Dr. Koki Nishitsuji, and Prof. Noriyuki Satoh from Japan’s Okinawa Institute of Science and Technology Graduate University.

Both embryological and larval development in animals are regulated by a set of patterning genes whose expression provides a blueprint of the body plan. “Echinoderms are a sister group of chordates. Hence, insights into their developmental patterns could provide useful information on body plan development in chordates. Therefore, we examined gene expression patterns during the developmental stages in starfish, especially because their mode of embryogenesis is more common among echinoderms than that of sea urchins,” comments Prof. Satoh, who led this study.

For expression analysis, the team targeted the gastrulae (embryos) and bipinnaria larvae of starfish, also known by the scientific name Patiria pectinifera. They analyzed gene expression at the single-cell level in these larvae using RNA sequencing and classified each cell into 22 clusters based on their specific, shared profiles of development-relevant gene expression (Fig. 1). “Previously, we could only examine RNA expression at the tissue level by single genes, which only gave us broad insights into development plans,” explains Dr. Tominaga. His colleague, Dr. Nishitsuji, adds, “Advancements like single-cell RNA sequencing have given us the ability to dissect these processes at the cellular level by a set of genes” (Fig. 1).

Through their RNA sequencing analysis, they developed a map of development-relevant transcription factor and signaling molecule genes expressed in multiple developmental structures—including the oral and aboral ectoderm, apical plate, hindgut and midgut, endomesoderm, stomodeum, and mesenchyme in gastrulae, as well as neurons, ciliary bands, enterocoel, and muscles in larvae (Fig. 2).

The next step was to compare this map with a map of the chordate larval body plan based on expression of homologous (similar between two different species) development-relevant genes. Amphioxus, an ancient chordate believed to represent the origin of vertebrates like humans, was chosen as the chordate model. Special attention was paid to the ciliary bands (Fig. 3), coelom, stomodeum, and pharynx of echinoderm larvae. Through comparative analysis of starfish and amphioxus larvae, the researchers proposed a new idea for how the chordate body plan evolved from a deuterostome ancestor. Prof. Satoh elaborates, “Through this analysis and comparison of homologous genes, we could understand which tissues or cells from the ancestor may have evolved into chordate structures and ambulacrarian structures as well.”

Specifically, the team found that the chordate nervous system, such as those in humans, evolved from an embryonic region of the ancestor that corresponds to echinoderm ciliary bands (Fig. 3). Moreover, the chordate lateral mesoderm—which gives rise to structures like the circulatory system and body wall muscles—likely evolved from the echinoderm coelom of the embryo in the deuterostome ancestor. Finally, the Spemann’s organizer, responsible for inducing the development of neural cells, arose from the echinoderm stomodeum of the ancestor’s embryo (Fig. 4).

Together, the findings provide a potential model of echinoderm and chordate development from a common deuterostome ancestor. This model answers a central question in evolutionary developmental biology, explaining how animals from different taxa developed their characteristic body plans and how these plans diverged in different groups with shared ancestry. This study represents a milestone in research on evolutionary developmental biology and sheds light on a key aspect of our own evolutionary history.

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JOURNAL

Developmental Biology

DOI

10.1016/j.ydbio.2023.01.009 

METHOD OF RESEARCH

Experimental study

SUBJECT OF RESEARCH

Animals

ARTICLE TITLE

A single-cell RNA-seq analysis of early larval cell-types of the starfish, Patiria pectinifera: Insights into evolution of the chordate body plan

(A) Gastrula (left side view). (B) Anatomical distribution of each cluster in gastrulae. (C) An early larva, left side view. (D) Anatomical distribution of each cluster in early larvae. Cluster numbers are shown with corresponding germ layers, organs, and tissues. This figure shows that for examples cells of cluster 8 comprise apical plate and cells of cluster 9 comprise coelom, a mesodermal derivative.

Both chordate neural plate and ambulacrarian ciliary bands develop using a similar set of genes, suggesting these two organs are homologous.

(A) Expression profiles of development-relevant genes in the stomodeal (mouth opening) region. The stomodeum is formed by stomodeal ectoderm (orange), stomodeal endoderm (blue) and oral endoderm (green). Most of genes expressed in these regions are major component genes of vertebrate Spemann’s organizer. (B) (Left) Gene expression pattern of chordate dorsal structures (notochord + floor plate), and (right) that of starfish larval stomodeum, transverse section of dotted line of (A). This suggests the ambulacrarian stomodeum plays a role of vertebrate Spemann’s organizer.

CREDIT

Nori Satoh/OIST

A starfish, also known by the scientific name Patiria pectinifera.

CREDIT

Hitoshi Tominaga

New research models concept for data transport using train of satellites

Peer-Reviewed Publication

UNIVERSITY OF ILLINOIS GRAINGER COLLEGE OF ENGINEERING

 

IMAGE: CONCEPT OF OPERATIONS FOR ONE CYCLER SPACECRAFT view more 

CREDIT: THE GRAINGER COLLEGE OF ENGINEERING AT UNIVERSITY OF ILLINOIS URBANA-CHAMPAIGN

Although the Pony Express lasted only a short time in the mid-1800s before being outperformed by the transcontinental telegraph, it inspired a concept for a string of small satellites to transport data from Mars to Earth and help alleviate the data logjam currently occurring in the Deep Space Network.

“The Solar System Pony Express is a mission concept that aims to augment the data transmission capabilities of the Deep Space Network using the idea of data mules,” said Robyn Woollands, assistant professor in the Department of Aerospace Engineering at the University of Illinois Urbana-Champaign.

Woollands described the data mules as small spacecraft that can travel to a remote location, such as Mars, where they acquire data in close range to the probe’s transmitter, then carry the data back to Earth where it is downlinked in close range to the receiver. This enables high latency and high bandwidth communication.

“A network of interplanetary data mules could be established using cycler orbits,” Woollands said. “After launch, the data mules use their own low-thrust propulsion system to inject into a cycler orbit and target subsequent flybys of Earth and Mars.”

Woollands explained that the trajectories encounter two or more celestial bodies along their path and require a modest amount of propellant for correction maneuvers. After launch, the data mules use their own low-thrust propulsion system to inject into a cycler orbit and target subsequent flybys of Earth and Mars.

“During the Mars flybys, data is uplinked from spacecraft already operating at Mars—on orbit or on the surface—and during Earth flybys data is downlinked back to Earth,” said Woollands.

She said her Ph.D. student Alex Pascarella developed the tools to enable the trajectory design and optimization of Earth/Mars cycler orbits for the Solar System Pony Express mission.

“We simulate trajectories that make use of low-thrust propulsion and include a high-fidelity model that incorporates the gravity of the Sun, Earth and Mars”, said Pascarella.

Low-thrust space missions are becoming more common due to the benefits afforded by ion engines, which are more efficient than chemical engines. They are also smaller/lighter which allows for the design of smaller spacecraft that can be launched economically as a secondary payload.

“Our study revealed that the total data volume returned during the simulated mission exceeded our goal of 1 Petabit per year,” said Alex Pascarella, Robyn Woollands’ Ph.D. student.

Solar System Pony Express is a NASA Innovative Advanced Concept project led by Joshua Vander Hook at NASA’s Jet Propulsion Laboratory.

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DOI

10.1016/j.actaastro.2022.11.046 

ARTICLE TITLE

Low-thrust trajectory optimization for the solar system pony express