What is 'global surgery'? Defining the multidisciplinary interface between surgery, anaesthesia and public health.

'Global surgery' is the term adopted to describe a rapidly developing multidisciplinary field aiming to provide improved and equitable surgical care across international health systems. Sitting at the interface between numerous clinical and non-clinical specialisms, it encompasses multiple aspects that surround the treatment of surgical disease and its equitable provision across health systems globally. From defining the role of, and need for, optimal surgical care through to identifying barriers and implementing improvement, global surgery has an expansive remit. Advocacy, education, research and clinical components can all involve surgeons, anaesthetists, nurses and allied healthcare professionals working together with non-clinicians, including policy makers, epidemiologists and economists. Long neglected as a topic within the global and public health arenas, an increasing awareness of the extreme disparities internationally has driven greater engagement. Not necessarily restricted to specific diseases, populations or geographical regions, these disparities have led to a particular focus on surgical care in low-income and middle-income countries with the greatest burden and needs. This review considers the major factors defining the interface between surgery, anaesthesia and public health in these settings

Fundamental movement skill proficiency of selected South African Montessorian pre-schoolers

The Montessori philosophy and environment offers opportunities for free movement within the classroom. Physical development includes the acquisition of fundamental movement skills (FMS) which children acquire through different opportunities for movement. Previous research has shown that Montessorian pre-schoolers were more physically active during the school day compared to those attending traditional pre-schools. This led to questioning whether this noted increase in physical activity had any effect on the learning of FMS. The purpose of this study was to examine the proficiency of FMS of children aged 3–6 years in three private Montessori pre-schools. This purposive sample consisted of 105 Montessori 3–6 year olds in the Western Cape, South Africa. FMS were evaluated using the Test of Gross Motor Development Second Edition (TGMD-2). About 51.6% of the 3 year olds mastered run but scored in the poor category for five out of the six object control skills. The majority of 4 year olds (75.7%) reached mastery only in run. Most of the 5 year olds achieved mastery in run (69%) and slide (65.5%), and only 51.7% in kick. About 87.5% of the 6 year olds achieved mastery in run and slide, only half of them in leap, hop, kick and catch. No area of FMS were mastered by all the participants, but overall, the performance ranged from ‘average’ to ‘above average’. This shows potential for improvement in FMS proficiency. Therefore, children, even in a Montessori environment, require specific instruction to achieve proficiency of all FMS

Disk Diffusion Propagation Model for the Outburst of XTE J1118+480

We present a linear diffusion model for the evolution of the double-peaked outburst in the transient source XTEJ1118+480. The model treats the two outbursts as episodic mass deposition at the outer radius of the disk followed by evolution of disk structure according to a diffusion process. We demonstrate that light curves with fast-rise, exponential decay profile are a general consequence of the diffusion process. Deconvolution of the light curve proves to be feasible and gives an input function specifying mass deposition at the outer disk edge as well as the total mass of the disk, both as functions of time. The derived evolution of total disk mass can be correlated with the observed evolution of the ~0.1 Hz QPO in the source reported in Wood et al. (2000).Comment: 26 pages, 6 figures, accepted for publication in Ap

The global variation of medical student engagement in teaching: Implications for medical electives.

INTRODUCTION: International medical electives, whereby undergraduates visit an institution in a country other than their own, are a common part of medical training. Visiting students are often asked to provide local teaching, which may be acceptable where the visitor is acting within the bounds of their own competency and the normal practices of both their home and host institutions. However, the extent to which teaching is an accepted student activity globally has not previously been described. This study aims to address this using an international survey approach. METHODS: A voluntary electronic survey, created using the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) framework, was distributed across established international medical student networks. This assessed the involvement of medical students in teaching and the educator training they receive, with the intention of comparing experiences between high-income countries (HICs) and low/middle-income countries (LMICs) to gauge the engagement of both "host" and "visiting" students. RESULTS: 443 students from 61 countries completed the survey, with an equal proportion of respondents from LMICs (49.4%, 219/443) and HICs (50.6%, 224/443). Around two thirds of students reported providing teaching whilst at medical school, with most reporting teaching numerous times a year, mainly to more junior medical students. There was with no significant difference between LMICs and HICs. Around 30 per cent of all medical students reported having received no teacher training, including 40 per cent of those already providing teaching. CONCLUSION: This study suggests that students are engaged in teaching globally, with no difference between HIC and LMIC contexts. However, students are underprepared to act as educators in both settings. Providing teaching as part of an elective experience may be ethically acceptable to both host and home institutions, but needs to be supported by formal training in delivering teaching.NIHR Global Health Research Group on Neurotraum

Elevated plasminogen activators are associated with hematoma progression in spontaneous intracerebral hemorrhage

Endogenous fibrinolysis might lead to hematoma progression in spontaneous intracerebral hemorrhage (ICH). We studied plasma biomarkers of fibrinolysis and hemostasis in twenty-two patients with ICH and nine healthy controls (HC) in a single-center study. Patients with ICH had significantly higher D-dimer and plasmin-alpha-2-antiplasmin complexes compared to HC. At baseline, patients with hematoma progression had higher urokinase-type plasminogen activator (uPA) and tissue-type plasminogen activator (tPA) and lower plasminogen levels, compared to those with no progression. 24-hour and day-7 matrix metalloproteinase-9 (MMP-9) was significantly increased in patients with hematoma progression

Interruption to antiplatelet therapy early after acute ischaemic stroke: a nested case-control study

Aims: Antiplatelet drugs are often discontinued early after ischaemic stroke, either because of poor compliance, complications or withdrawal of care. It is unclear whether this places patients at increased risk of recurrence. We explored the association between cardiovascular event rate and persistence with prescribed antiplatelet drugs. Methods: We used a matched case–control design using the Virtual International Stroke Trials Archive (VISTA). Cases were patients who had an acute coronary syndrome, recurrent stroke or transient ischaemic attack within 90 days post-stroke and were matched for age ± 10 years and sex with up to four controls. Antiplatelet use was categorized as persistent (used for >3 days and continued up to day 90), early cessation (used antiplatelet 3 days but stopped prior to day 90). These categories were compared in cases and controls using a conditional logistic regression model that adjusted for potential confounders. Results: A total of 970 patients were included, of whom 194 were cases and 776 were matched controls. At 90 days, 10 cases (5.2%) and 58 controls (7.5%) stopped/interrupted their antiplatelet. The risk of cardiovascular event was not different in stopped/interrupted users (adjusted odds ratio 0.70, 95% confidence interval 0.33, 1.48; P = 0.352) and early cessations (adjusted odds ratio 1.04, 95% confidence interval 0.62, 1.74; P = 0.876) when compared to persistent users. Conclusion: We found no increased risk in patients who stopped and interrupted antiplatelets early after stroke but the study was limited by a small sample size and further research is needed

Faecal immunochemical testing for haemoglobin in detecting bowel polyps in symptomatic patients: multicentre prospective cohort study

BACKGROUND: Measurement of faecal haemoglobin using faecal immunochemistry testing is recommended in patients presenting with symptoms suspicious for colorectal cancer, to aid in triage and prioritization of definitive investigations. While its role in colorectal cancer has been extensively investigated, the ability of faecal immunochemistry testing to detect adenomas in symptomatic patients is unclear. METHODS: A multicentre prospective observational study was conducted between April 2017 and March 2019, recruiting adults from 24 hospitals across England and 59 general practices in London who had been urgently referred with suspected colorectal cancer symptoms. Each patient provided a stool sample for faecal immunochemistry testing, in parallel with definitive investigation. A final diagnosis for each patient was recorded, including the presence, size, histology, and risk type of colonic polyps. The outcome of interest was the sensitivity of faecal immunochemistry testing in detecting the presence of adenomas. RESULTS: Of 3496 patients included in the analysis, 553 (15.8 per cent) had polyps diagnosed. Sensitivity of faecal immunochemistry testing for polyp detection was low across all ranges; with a cut-off for faecal haemoglobin of 4 µg/g or lower, sensitivity was 34.9 per cent and 46.8 per cent for all polyp types and high-risk polyps respectively. The area under the receiver operating characteristic curve in detection probability was relatively low for both intermediate-risk (0.63) and high-risk polyps (0.63). CONCLUSION: While faecal immunochemistry testing may be useful in prioritizing investigations to diagnose colorectal cancer, if used as a sole test, the majority of polyps would be missed and the opportunity to prevent progression to colorectal cancer may be lost

Variability of eta Carinae III

Spectra (1951-78) of the central object in eta Car, taken by A.D. Thackeray, reveal three previously unrecorded epochs of low excitation. Since 1948, at least, these states have occurred regularly in the 2020 day cycle proposed by Damineli et al. They last about 10 percent of each cycle. Early slit spectra (1899-1919) suggest that at that time the object was always in a low state. JHKL photometry is reported for the period 1994-2000. This shows that the secular increase in brightness found in 1972-94 has continued and its rate has increased at the shorter wavelengths. Modulation of the infrared brightness in a period near 2020 days continues. There is a dip in the JHKL light curves near 1998.0, coincident with a dip in the X-ray light curve. Evidence is given that this dip in the infrared repeats in the 2020 day cycle. As suggested by Whitelock & Laney, the dip is best interpreted as an eclipse phenomenon in an interacting binary system; the object eclipsed being a bright region (`hot spot'), possibly on a circumstellar disc or produced by interacting stellar winds. The eclipse coincides in phase and duration with the state of low excitation. It is presumably caused by a plasma column and/or by one of the stars in the system.Comment: 10 pages, 7 postscript figures, accepted for MNRA

Interruption to antiplatelet therapy early after acute ischaemic stroke: a nested case-control study

Aims: Antiplatelet drugs are often discontinued early after ischaemic stroke, either because of poor compliance, complications or withdrawal of care. It is unclear whether this places patients at increased risk of recurrence. We explored the association between cardiovascular event rate and persistence with prescribed antiplatelet drugs. Methods: We used a matched case–control design using the Virtual International Stroke Trials Archive (VISTA). Cases were patients who had an acute coronary syndrome, recurrent stroke or transient ischaemic attack within 90 days post-stroke and were matched for age ± 10 years and sex with up to four controls. Antiplatelet use was categorized as persistent (used for >3 days and continued up to day 90), early cessation (used antiplatelet 3 days but stopped prior to day 90). These categories were compared in cases and controls using a conditional logistic regression model that adjusted for potential confounders. Results: A total of 970 patients were included, of whom 194 were cases and 776 were matched controls. At 90 days, 10 cases (5.2%) and 58 controls (7.5%) stopped/interrupted their antiplatelet. The risk of cardiovascular event was not different in stopped/interrupted users (adjusted odds ratio 0.70, 95% confidence interval 0.33, 1.48; P = 0.352) and early cessations (adjusted odds ratio 1.04, 95% confidence interval 0.62, 1.74; P = 0.876) when compared to persistent users. Conclusion: We found no increased risk in patients who stopped and interrupted antiplatelets early after stroke but the study was limited by a small sample size and further research is needed

Exploring LPS-induced sepsis in rats and mice as a model to study potential protective effects of the nociceptin/Orphanin FQ system

Abstract The nociceptin receptor (NOP) and its ligand (N/OFQ) have been shown to exert a modulatory effect on immune cells during sepsis. We evaluated the suitability of an experimental Lipopolysaccharide (LPS)-induced sepsis model for studying changes in the nociceptin system. C57BL/6 mice BALB/c mice and Wistar rats were inoculated with different doses of LPS with or without a nociceptin receptor antagonist (UFP-101 or SB-612111). In C57BL/6 mice LPS 0.85 mg/kg injection produced no septic response whereas 1.2 mg/kg produced a profound response within 5 hours. In BALB/c mice, LPS 4 mg/kg produced no response whereas 7 mg/kg resulted in a profound response within 24 hours. In Wistar rats 15 mg/kg LPS caused no septic response in 6/10 animals whereas 25 mg/kg resulted in marked lethargy before 24 hours. Splenic interleukin-1β mRNA in BALB/c mice, and serum TNF-α concentrations in Wistar rats increased after LPS injection in a dosedependent manner, but were undetectable in control animals, indicating that LPS had stimulated an inflammatory reaction. IL-1β and TNF-α concentrations in LPS-treated animals were unaffected by administration of a NOP antagonist. Similarly NOP antagonists had no effect on survival or expression of mRNA for NOP or ppN/OFQ (the N/OFQ precursor) in a variety of tissues. In these animal models, the dose-response curve for LPS was too steep to allow use in survival studies and no changes in the N/OFQ system occurred within 24 hours. We conclude that LPS-inoculation in rodents is an unsuitable model for studying possible changes in the NOP-N/OFQ system in sepsis. Highlights • We assessed the responses to different doses of lipopolysaccharide (LPS) in C57BL/6 mice, BALB/c mice and Wistar rats. • No symptoms of illness were observed at 24 hours with lower doses of LPS • Higher doses of LPS produced pronounced lethargy before 24 hours. • LPS administration had no effect on the gene expression of the nociceptin/orphanin FQ (N/OFQ) receptor NOP and the N/OFQ receptor precursor ppN/OFQ. • This model is not suitable to study the effects of nociceptin on septic responses 3 Introduction The nociceptin system comprises the nociceptin receptor (NOP) and its 17 amino acid peptide ligand N/OFQ, which is cleaved from a precursor protein pre-pro nociceptin (ppN/OFQ