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

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

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

Dover Urban Archaeological Database Project

The Royal Commission on the Historical Monuments of England (now Historic England) developed its 'Urban Archaeological Database' programme in the 1990s. 35 of England's historic towns were identified as needing enhanced baseline datasets of archaeological information, of a comprehensiveness and detail that was beyond that which Historic Environment Records (HERs) can usually provide. These enhanced datasets were termed 'Urban Archaeological Databases' (UADs). Dover was one of the towns identified as requiring a UAD. Urban deposits are often highly complex, representing many phases and periods of activity in a single location. They can also be much disturbed making interpretation difficult. Urban deposits can also be very deep, either due to topographical reasons (many towns being in riverside locations) or to the accumulation of occupation debris over a long period of time. In addition, the urban context requires greater accuracy of representation and depiction in the HER than rural data. Smaller and more congested ownership plots mean that a slight error in depiction can lead to landowners being required to carry out unnecessary or inappropriate archaeological investigation during construction works. Historic towns are also among the most important archaeological sites in the country. Being located beneath modern towns implies a constant threat that only accurate information and improved understanding can help to reduce. The difference between how archaeological information is represented in a HER and a UAD is essentially one of detail. For example, prior to this project the Classis Britannica fort in Dover was represented by a single HER record, linked to a single HER GIS point. The work of transforming this into UAD format involved breaking the fort record into multiple new records each of which depicts a feature within the fort such as the walls, a gate, a barrack, a granary etc. Each component has its own record and its own GIS depiction. Similarly, the Event records (an Event is an archaeological activity such as an excavation or watching brief) in a HER are usually represented by a single record per Event linked to a single GIS entity. Under the UAD standard each intervention unit within an Event eg each individual trench, test-pit or borehole, is represented by a separate HER Event record. These can be grouped to indicate the relationship between them, but they are recorded separately, thus allowing additional information to be recorded such as the deposit sequences and depths of layers. These in turn can be used to develop a deposit model that can further aid understanding and prediction. Following the completion of the data work, an Archaeological Characterisation was developed. Characterisation can be briefly explained as the process of generalising and synthesising the raw data in the UAD to improve understanding. Within urban archaeological contexts it identifies the main activities that the data represents, where these activities are taking place and how they inter-relate. It should be noted, however, that as a summarising activity, characterisation always risks over-simplification, resolving complex data into too tidy a pattern. Characterisation is therefore best understood as a model, not a map, of past activity. The final stage of the project was to use the enhanced UAD data and the Archaeological Characterisation to develop a strategy that will help to improve how the archaeological resource is managed. This is to both safeguard it, and to identify ways to exploit it for the benefit of inhabitants and visitors. The method selected to do this was to develop an Archaeological Plan that would provide a strategy for managing Dover's archaeology

An assessment and enhancement of the sites and monuments record as a predictive tool for cultural resource management, development control and academic research

This research is an attempt to assess and enhance the Sites and Monuments Record, the main source of archaeological information used by development control staff throughout Britain. With the introduction of PPG16, the SMR has become more important than ever before and it is timely that such research is performed. The analysis concentrates on three study areas - the Hampshire Avon, which forms the pilot study area; East Berkshire and the Raunds area of Northamptonshire which form the two main study areas.The general method chosen was to compare the SMR data from these study areas with the results of the intensive fieldwalking and field survey studies performed in all three regions. If the survey results are assumed to accurately represent the archaeological record within each area, then for the SMR data to accurately represent the archaeological record, it must accurately and consistently predict the results of the surveys. Therefore, predictive models are derived from the SMR data using a manual method of model formation and logistic regression, and these models are tested for their ability to predict the survey results.The successes and failures of the models are highlighted and examined. The specific methodology involves the use of GIS techniques in conjunction with statistical analysis. The GIS used to analyze each study area is then used to produce and assess a range of descriptive information concerning the distribution, range and density of archaeological data in the three regions. Subsequent to the main analysis a number of related issues are discussed such as the relationship between local SMR data and archaeological sites and the relationship between SMR data and urban settlement. The conclusions of this research are first examined in terms of the individual study area to assess the ability of each SMR to predict the survey data and review its strengths and weaknesses.</p

The Physcomitrella genome reveals evolutionary insights into the conquest of land by plants

We report the draft genome sequence of the model moss Physcomitrella patens and compare its features with those of flowering plants, from which it is separated by more than 400 million years, and unicellular aquatic algae. This comparison reveals genomic changes concomitant with the evolutionary movement to land, including a general increase in gene family complexity; loss of genes associated with aquatic environments ( e. g., flagellar arms); acquisition of genes for tolerating terrestrial stresses ( e. g., variation in temperature and water availability); and the development of the auxin and abscisic acid signaling pathways for coordinating multicellular growth and dehydration response. The Physcomitrella genome provides a resource for phylogenetic inferences about gene function and for experimental analysis of plant processes through this plant's unique facility for reverse genetics