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

Detection of Rossby waves in multi-parameters in multi-mission satellite observations and HYCOM simulations in the Indian Ocean

Rossby waves are difficult to detect with in situ methods. However, as we show in this paper, they can be clearly identified in multi-parameters in multi-mission satellite observations of sea surface height (SSH), sea surface temperature (SST) and ocean color observations of chlorophyll-a (chl-a), as well as 1/12° global HYbrid Coordinate Ocean Model (HYCOM) simulations of SSH, SST and sea surface salinity (SSS) in the Indian Ocean. While the surface structure of Rossby waves can be elucidated from comparisons of the signal in different sea surface parameters, models are needed to gain direct information about how these waves affect the ocean at depth. The first three baroclinic modes of the Rossby waves are inferred from the Fast Fourier Transform (FFT), and two-dimensional Radon Transform (2D RT). At many latitudes the first and second baroclinic mode Rossby wave phase speeds from satellite observations and model parameters are identified. Wavelet transforms of these multi-parameters from satellite observations and model simulations help to discriminate between the annual and semi-annual signal of these Rossby waves. This comprehensive study reveals that the surface signature of Rossby waves in SSS anomalies is likely to be between 0.05 and 0.3 psu in the South Indian Ocean.<br/

Repression of Na,K-ATPase β(1)-Subunit by the Transcription Factor Snail in Carcinoma

The Na,K-ATPase consists of two essential α- and β-subunits and regulates the intracellular Na(+) and K(+) homeostasis. Although the α-subunit contains the catalytic activity, it is not active without functional β-subunit. Here, we report that poorly differentiated carcinoma cell lines derived from colon, breast, kidney, and pancreas show reduced expression of the Na,K-ATPase β(1)-subunit. Decreased expression of β(1)-subunit in poorly differentiated carcinoma cell lines correlated with increased expression of the transcription factor Snail known to down-regulate E-cadherin. Ectopic expression of Snail in well-differentiated epithelial cell lines reduced the protein levels of E-cadherin and β(1)-subunit and induced a mesenchymal phenotype. Reduction of Snail expression in a poorly differentiated carcinoma cell line by RNA interference increased the levels of Na,K-ATPase β(1)-subunit. Furthermore, Snail binds to a noncanonical E-box in the Na,K-ATPase β(1)-subunit promoter and suppresses its promoter activity. These results suggest that down-regulation of Na,K-ATPase β(1)-subunit and E-cadherin by Snail are associated with events leading to epithelial to mesenchymal transition

Figure_1b_tree

Newick file for figure 1b. Neighbor-joining tree of 502 sorghum accessions for 265,487 SNP

Figure_S4b_tree

Newick file for figure S4b. Neighbor-joining tree of 502 sorghum accessions for 194,852 SNPs with MAF>=0.02 and missing rate<=50