New insights into the fossil record of the turtle genus Chelus Duméril, 1806 including new specimens with information on cervicals and limb bones

Matamata turtles (Chelus Duméril, 1806) are composed of two extant species, Chelus fimbriata ­Schneider, 1783 and Chelus orinocensis Vargas-Ramírez, Caballero, Morales-Betancourt, Lasso, Amaya, Martínez, Silva-Viana, Vogt, Farias, Hrbek, Campbell & Fritz, 2020, inhabitants of the main freshwater drainages of northern South America. The systematics and palaeobiogeography of Chelus is still unresolved. Here, we describe several new fossil specimens from the Late Miocene of Urumaco (Venezuela) and Tatacoa (Colombia). The fossils are mostly complete, articulated shells that allow reestablishing validity of two extinct taxa, Chelus colombiana Wood, 1976 and Chelus lewisi Wood, 1976. One of the specimens of C. lewisi from Urumaco represents the first record within the genus for which autopodial bones (a left manus) and additional limb bones are preserved together with ashell, demonstrating evolutionary conservatism in limb anatomy for the genus. The specimen comes from the Socorro Formation, representing the earliest so far known record of Chelus for the Urumaco sequence. Additionally, one specimen from Tatacoa is the first fossil for which cervical and pectoral girdle elements are preserved. Phylogenetic analysis supports the existence of two separate clades inside of Chelus, one formed by the extinct species and the other by the extant ones

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)