The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Background: In this study, we aimed to evaluate the effects of tocilizumab in adult patients admitted to hospital with COVID-19 with both hypoxia and systemic inflammation. Methods: This randomised, controlled, open-label, platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing several possible treatments in patients hospitalised with COVID-19 in the UK. Those trial participants with hypoxia (oxygen saturation <92% on air or requiring oxygen therapy) and evidence of systemic inflammation (C-reactive protein ≥75 mg/L) were eligible for random assignment in a 1:1 ratio to usual standard of care alone versus usual standard of care plus tocilizumab at a dose of 400 mg–800 mg (depending on weight) given intravenously. A second dose could be given 12–24 h later if the patient's condition had not improved. The primary outcome was 28-day mortality, assessed in the intention-to-treat population. The trial is registered with ISRCTN (50189673) and ClinicalTrials.gov (NCT04381936). Findings: Between April 23, 2020, and Jan 24, 2021, 4116 adults of 21 550 patients enrolled into the RECOVERY trial were included in the assessment of tocilizumab, including 3385 (82%) patients receiving systemic corticosteroids. Overall, 621 (31%) of the 2022 patients allocated tocilizumab and 729 (35%) of the 2094 patients allocated to usual care died within 28 days (rate ratio 0·85; 95% CI 0·76–0·94; p=0·0028). Consistent results were seen in all prespecified subgroups of patients, including those receiving systemic corticosteroids. Patients allocated to tocilizumab were more likely to be discharged from hospital within 28 days (57% vs 50%; rate ratio 1·22; 1·12–1·33; p<0·0001). Among those not receiving invasive mechanical ventilation at baseline, patients allocated tocilizumab were less likely to reach the composite endpoint of invasive mechanical ventilation or death (35% vs 42%; risk ratio 0·84; 95% CI 0·77–0·92; p<0·0001). Interpretation: In hospitalised COVID-19 patients with hypoxia and systemic inflammation, tocilizumab improved survival and other clinical outcomes. These benefits were seen regardless of the amount of respiratory support and were additional to the benefits of systemic corticosteroids. Funding: UK Research and Innovation (Medical Research Council) and National Institute of Health Research

Effects of Nordmøre- grid angles, profiles and other industry- developed modifications on catches in an Australian penaeid-trawl fishery Efectos de ángulos y perfiles de las rejillas Nordmøre, y otras modificaciones desarrolladas por la industria, sobre las capturas de una pesquería australiana de peneidos

In response to claims that conventional Nordmøre-grids used in the Clarence River penaeid-trawl fishery were occasionally being fouled or blocked during fishing, two experiments were done to examine the utility of modified grids with different installation angles, sizes and profiles, and alternative industry-developed, behavioral-type bycatch reduction devices (BRDs). In experiment 1, a conventional Nordmøre-grid (600 mm in length, installed at 45°) was compared against a longer grid (1200 mm in length, installed at 21°) and two locally-developed, behavioral-type BRDs. While slightly more difficult to operate than the conventional design, the longer Nordmøre-grid retained similar quantities of penaeids and bycatch; in contrast, both behavioral-type BRDs retained significantly (up to five times) more bycatch and were considered ineffective for use in this fishery. In experiment 2, the conventional Nordmøre-grid was tested against three modified Nordmøre-grids, including a 600-mm-long grid with a curved profile and installed at 45°, and two grids, both 900 mm in length and installed at 28°, but with flat and curved profiles. Only the curved 900-mm Nordmøre-grid caught significantly fewer penaeids and bycatch, although both of the curved-profile grids appeared to facilitate the release of debris from the trawl. The results are discussed in terms of fishery-specific factors that probably contributed towards the performances of the various BRDs

Selectivity of penaeid trap nets in south-eastern Australia

Two experiments were done to estimate the selectivity of commercial and modified trap-net configurations in New South Wales (NSW), southeastern Australia. In the first experiment, a commercial trap net made entirely from 25 mm mesh and designed for use in shallow water was alternatively fished with a fine-meshed (9.5 mm netting) trap net (used as a control). In the second experiment, two trap-net configurations designed for use in deeper water and comprising the same anterior section (made from 25 mm mesh), but with different bunts made from (i) the conventional 25 mm mesh and (ii) 31 mm mesh were alternately fished against the control. Both of the conventional trap nets (comprising 25 mm mesh through-out) had low amounts of bycatch and similarly selected eastern king Penaeus plebejus, greasyback Metapenaeus bennettae and school prawns Metapenaeus macleayi across narrow selection ranges (< 3.4 mm) and at 50% retention lengths (between 18.53 and 21.50 mm) that were larger than the average commercially-accepted sizes (15-17 mm. CL). Analyses of the selectivities and relative efficiencies of the trap-net configurations comprising the 25 and 31 mm bunts showed no benefit, in terms of maintaining prawn catches and reducing unwanted bycatch, associated with increasing mesh size in these gears. The utility of trap nets for selectively harvesting penaeids is discussed. We conclude that this type of fishing gear appears to have few deleterious impacts

Influences of hanging ratio, fishing height, twine diameter and material of bottom-set gillnets on catches of dusky flathead Platycephalus fuscus and non-target species in New South Wales, Australia

Three experiments were done to test for the influences of different (i) hanging ratios (E = 0.5, 0.65 and 0.8); (ii) fishing heights (25 and 12 meshes); and (iii) twine diameters (0.41, 0.56 and 0.62 mm) and materials (multifilament nylon and multimonofilament nylon polyamide) on catches and by-catches in the estuarine gillnet fishery for Platycephalus fuscus in New South Wales, Australia. In each experiment, the various 100-m treatment panels comprising 80-mm (nominal) mesh rigged according to the different configurations being examined were configured in a single gang between 1090 and 1310 m in length, and fished according to commercial practices. The results showed no significant differences between different hanging ratios or twine diameters for the numbers, weights and size compositions of catches and by-catches. Twine material had an effect on only one key by-catch species (Acanthopagrus australis), with fewer caught in panels made from multifilament nylon compared with multimonofilament nylon. In contrast to the above modifications, lowering the fishing height of the floatline significantly reduced total by-catch by up to 46% and the individuals of key by-catch species (Mugil cephalus, A. australis and Girella tricuspidata) by between 60 and 85% with no effect on catches of targeted P. fuscus, or legally retained byproduct, Portunus pelagicus. The results are used to provide directions for the future management of this fishery and have relevance to other similar bottom-set gillnet fisheries

Mejorando la selección de artes de arrastre dirigidos a silagos (Sillago spp.) en Australia sudoriental: efectos de la modificación del cuerpo, extensión y copo

In response to a shift towards directed targeting of whiting, Sillago spp. by some penaeid trawlers in coastal waters off New South Wales, Australia, 3 experiments were done to examine the effects on the size and species selectivity of trawls associated with (i) a 40% increase in mesh size used in the body, (ii) altering the configuration of mesh in the codend, and (iii) a separating grid in the extension section. Each experiment involved paired comparisons between conventional and modified gears during normal commercial fishing operations. The results showed that increasing mesh size in the trawl body from 45 to 63 mm had no effect on any catches and, while the grid has the potential to improve species selection by excluding macrofauna, further refinement and testing are required to minimize the escape of commercial sized whiting. Changing the orientation of mesh in the codend from diamond- (40 mm mesh opening) to square-shaped (41 mm mesh, hung on the bar) had a highly significant effect on the size selection of red spot whiting, Sillago flindersi: reducing the catches of small, unwanted individuals (< 17 cm total length) by up to 99%, with minimal impact on the retention of larger, commercial sized individuals. We conclude that the use of square-mesh codends (with a bar length approaching 20 mm) by trawlers targeting whiting is an appropriate management tool for minimizing the fishing mortality of juvenile and maturing conspecifics.En respuesta a un cambio dirigido a la captura de silagos (Sillago spp.) por parte de algunos arrastreros camaroneros en aguas costeras de New South Wales, Australia, se realizaron tres experimentos para examinar los efectos sobre la selectividad de tallas y especies de artes de arrastre asociados con (i) un 40% de aumento en la longitud de malla utilizada en el cuerpo, (ii) alterando la configuración de la malla en el copo, y (iii) utilizando una rejilla de separación en la sección de extensión. Cada experimento constó de comparaciones pareadas entre los artes convencionales y pareados durante operaciones pesqueras comerciales normales. Los resultados mostraron que el aumento en la longitud de malla en el cuerpo del arte de 45 a 63 mm no tenía efecto en las capturas y que, mientras que la rejilla separadora tiene el potencial de mejorar la selección de especies por la exclusión de macrofauna, se requieren más experimentos y refinamiento para minimizar el escape de silagos de talla comercial. Cambiando la orientación de la malla en el copo desde una forma de diamante (romboidal) de 40 mm a una forma de malla cuadrada de 41 mm (colgada en la barra) tenía un efecto altamente significativo sobre la selección de tallas de silago de Flinders, Sillago flindersi: reduciendo las capturas de ejemplares pequeños, no deseados (< 17 cm longitud total) hasta un 99%, con un impacto mínimo sobre la retención de individuos de tallas superiores, comerciales. Se concluye que el uso de copos con malla cuadrada (con una longitud de barra cercana a 20 mm) por los arrastreros que tienen a los silagos como especie objetivo es una herramienta apropiada de gestión para la minimización de la mortalidad pesquera de juveniles e individuos en maduración

Relative efficiency and size selectivity of bottom-set gillnets for dusky flathead, Platycephalus fuscus and other species in New South Wales, Australia Relative Effektivität und Größenselektivität von Setznetzen bei dem Flachkopf Platycephalus fuscus, und anderen Arten in New South Wales, Australia

The effects on catches and bycatches due to increases in mesh size were investigated in a bottom-set gillnet fishery for dusky flathead, Platycephalus fuscus in New South Wales, Australia. Sampling was done in 2 coastal lagoons during spring 2001 using a gillnet comprised of replicate panels of (i) the commercially-used mesh size (7.0 cm) and (ii) 3 larger mesh sizes (8.0, 8.9 and 9.5 cm). The targeted dusky flathead and 5 important bycatch species (bream, Acanthopagrus australis, luderick, Girella tricuspidata, sea mullet, Mugil cephalus, yellow-finned leatherjacket, Meuschenia trachylepis and blue swimmer crab, Portunus pelagicus) accounted for approx. 91 % of the total catch. Significant differences in the catch rates of these species were detected among the mesh sizes examined with trends for fewer numbers of total dusky flathead, total bycatch, sea mullet, yellow-finned leatherjacket and under-size bream and luderick evident in the larger mesh sizes. All species were characterised by a significant disequilibrium in the vertical distribution of catches, with the lower 50 % of the gillnet retaining between 56 and 89 % of individuals. Modal lengths of most species increased with mesh size and the selectivities of dusky flathead, bream and luderick were best described by binormal curves with well-separated modes. The results are discussed in terms of the probable capture processes of the main species and appropriate modifications to reduce their unwanted bycatches

Seasonal, spatial and gear-related influences on relationships between retained and discarded catches in a multi-species gillnet fishery

A scientific observer program was used to quantify relationships among the compositions and rates of retained and discarded catches taken in a temperate estuarine commercial gillnet fishery in southeastern Australia. Sampling was stratified across six estuaries and three fishing seasons that corresponded to different permitted setting practices (set and immediate retrieve versus overnight set). A total of 265 fishing trips was sampled throughout 2001, yielding 57 species (52 finfish, 3 invertebrate, 1 bird and 1 tortoise), of which 42 and 45 species were retained and discarded, respectively. More species and a greater mean number and weight of total individuals were retained than discarded during each fishing season. Throughout the entire survey, 6.2% by number and 3.3% by weight of catches were discarded. Average retained catches ranged from 37 to 609 kg fisher-day and discarded catches from 1 to 10 kg fisher-day. Mugil cephalus and Girella tricuspidata accounted for 85% by number of total observed catches, with a further 10% being contributed by Acanthopagrus australis, Platycephalus fuscus and Portunus pelagicus. G. tricuspidata, A. australis and P. pelagicus below the minimum legal length collectively accounted for 69% by number and 49% by weight of all discards observed. Discarding was greatest in the smallest mesh sizes and during winter when nets can be set overnight. Increasing the minimum permitted mesh size as well as decreasing the maximum soak time of nets set in winter will further reduce the low levels of discarding in this fishery