Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Rapid Extracellular Enzyme Assays For Screening Potential Antisapstain Biological Control Agents

A Rapid Agar Plate Screening Assay (RAPSA) was developed and optimized for assaying individual extracellular enzymes produced by potential biological control agents and sapstain fungi. The RAPSA, which uses culture filtrates rather than agar plugs inoculated with actively growing fungi as used in the classical screening method, was more sensitive in detecting activity, for all extracellular enzymes screened, with the exception of chitinase, for the majority of the fungi tested. The assay was used to screen potential biological control fungi based on comparison of extracellular enzyme profiles of ten potential antisapstain biological control fungi and three sapstain fungi, grown in liquid cultures containing either glucose, hemlock sawdust, or cell wall of the sapstain fungus Ophiostoma piceae as a carbon source. Based on extracellular enzymes profiles, biological control fungi and sapstain fungi were classified into three groups. Group I fungi produced the greatest enzyme activity when glucose was included in the medium. Group II fungi produced equally good activity with sawdust and glucose, while Group III produced high activity with both sawdust and cell wall while enzyme activity with glucose was not consistent.Five biological control candidates, Gliocladium viride 623E, G. roseum 784A, G. virens 258C, G. roseum 321M, G. virens 258D, in descending order, demonstrated the full spectrum of extracellular enzyme activity screened, irrespective of the growth medium. Production of extracellular enzymes in a minimal medium augmented with sawdust or cell wall is an indicator of secondary resource capability. Gliocladium viride 623E and G. virens 258C demonstrated high extracellular enzyme production in both of these media. On this basis, these two fungi were judged to show the greatest potential as biological control agents. Mariannea elegans 386E and G. solani 810A showed the least potential

FORESTS AND SOCIETY – RESPONDING TO GLOBAL DRIVERS OF CHANGERegional Examples of Forest Related Challenges and Opportunities 14 Sustainability of Boreal Forests and Forestry in a Changing Environment

Abstract: The circumpolar boreal forest is the fourth largest terrestrial biome on the planet. It is entering a period of relatively rapid transition, propelled by climate change and economic development. Warming conditions threaten to alter processes as diverse as permafrost retention, insect outbreaks, and transportation. Thawing permafrost and increased levels of natural and anthropogenic disturbance may result in net releases of carbon dioxide and methane, while forest cover with greater biomass can be expected to expand onto the arctic tundra. Human use in some parts of northern forests is becoming more centralised and industrialised, with cumulative impacts from hydroelectric development, the oil and gas sector, mining, timber harvesting, and transportation. Communities tend to be widely spaced, and are either highly dependent on resource-based commodity exports or on subsistence-based lifestyles supported by local biodiversity. Efforts are underway in many jurisdictions to curtail illegal logging and environmentally damaging industrial development, to account for non-timber forest values in the course of forest management, and to promote the economic diversification of communities. In order to preserve the integrity of ecosystem processes, effort