Enhanced recovery after surgery

Enhanced Recovery or Fast Track Recovery after Surgery protocols (ERAS) have significantly changed perioperative care following colorectal surgery and are promoted as reducing the stress response to surgery. The present systematic review aimed to examine the impact on the magnitude of the systemic inflammatory response (SIR) for each ERAS component following colorectal surgery using objective markers such as C-reactive protein (CRP) and interleukin-6 (IL-6). A literature search was performed of the US National Library of Medicine (MEDLINE), EMBASE, PubMed, and the Cochrane Database of Systematic Reviews using appropriate keywords and subject headings to February 2015. Included studies had to assess the impact of the selected ERAS component on the SIR using either CRP or IL-6. Nineteen studies, including 1898 patients, were included. Fourteen studies (1246 patients) examined the impact of laparoscopic surgery on the postoperative markers of SIR. Ten of these studies (1040 patients) reported that laparoscopic surgery reduced postoperative CRP. One study (53 patients) reported reduced postoperative CRP using opioid-minimising analgesia. One study (142 patients) reported no change in postoperative CRP following preoperative carbohydrate loading. Two studies (108 patients) reported conflicting results with respect to the impact of goal-directed fluid therapy on postoperative IL-6. No studies examined the effect of other ERAS components, including mechanical bowel preparation, antibiotic prophylaxis, thromboprophylaxis, and avoidance of nasogastric tubes and peritoneal drains on markers of the postoperative SIR following colorectal surgery. The present systematic review shows that, with the exception of laparoscopic surgery, objective evidence of the effect of individual components of ERAS protocols in reducing the stress response following colorectal surgery is limited

Crambe as a Specialty Crop in North Dakota

Production Economics,

Radial versus femoral access for rotational atherectomy: A UK observational study of 8622 patients

Background—Rotational atherectomy (RA) is an important interventional tool for heavily calcified coronary lesions. We compared the early clinical outcomes in patients undergoing RA using radial or femoral access. Methods and Results—We identified all patients in England and Wales who underwent RA between January 1, 2005, and March 31, 2014. Eight thousand six hundred twenty-two RA cases (3069 radial and 5553 femoral) were included in the analysis. The study primary outcome was 30-day mortality. Propensity scores were calculated to determine the factors associated with treatment assignment to radial or femoral access. Multivariable logistic regression analysis, using the calculated propensity scores, was performed. Thirty-day mortality was 2.2% in the radial and 2.3% in the femoral group (P=0.76). Radial access was associated with equivalent 30-day mortality (adjusted odds ratio [OR], 1.06; 95% confidence interval [CI], 0.77–1.46; P=0.71), procedural success (OR, 1.04; 95% CI, 0.84–1.29; P=0.73), major adverse cardiac and cerebrovascular events (OR, 1.05; 95% CI, 0.80–1.38; P=0.72), and net adverse clinical events (OR, 0.90; 95% CI, 0.71–1.15; P=0.41), but lower rates of in-hospital major bleeding (OR, 0.62; 95% CI, 0.40–0.98; P=0.04) and major access site complications (OR, 0.05; 95% CI, 0.01–0.38; P=0.004), compared with femoral access. Conclusions—In this large real-world study of patients undergoing RA, radial access was associated with equivalent 30-day mortality and procedural success, but reduced major bleeding and access site complications, compared with femoral access

Clinicopathological determinants of an elevated systemic inflammatory response following elective potentially curative resection for colorectal cancer

Introduction: The postoperative systemic inflammatory response (SIR) is related to both long- and short-term outcomes following surgery for colorectal cancer. However, it is not clear which clinicopathological factors are associated with the magnitude of the postoperative SIR. The present study was designed to determine the clinicopathological determinants of the postoperative systemic inflammatory response following colorectal cancer resection. Methods: Patients with a histologically proven diagnosis of colorectal cancer who underwent elective, potentially curative resection during a period from 1999 to 2013 were included in the study (n = 752). Clinicopathological data and the postoperative SIR, as evidenced by postoperative Glasgow Prognostic Score (poGPS), were recorded in a prospectively maintained database. Results: The majority of patients were aged 65 years or older, male, were overweight or obese, and had an open resection. After adjustment for year of operation, a high day 3 poGPS was independently associated with American Society of Anesthesiologists (ASA) grade (hazard ratio [HR] 1.96; confidence interval [CI] 1.25–3.09; p = 0.003), body mass index (BMI) (HR 1.60; CI 1.07–2.38; p = 0.001), mGPS (HR 2.03; CI 1.35–3.03; p = 0.001), and tumour site (HR 2.99; CI 1.56–5.71; p < 0.001). After adjustment for year of operation, a high day 4 poGPS was independently associated with ASA grade (HR 1.65; CI 1.06–2.57; p = 0.028), mGPS (HR 1.81; CI 1.22–2.68; p = 0.003), NLR (HR 0.50; CI 0.26–0.95; p = 0.034), and tumour site (HR 2.90; CI 1.49–5.65; p = 0.002). Conclusions: ASA grade, BMI, mGPS, and tumour site were consistently associated with the magnitude of the postoperative systemic inflammatory response, evidenced by a high poGPS on days 3 and 4, in patients undergoing elective potentially curative resection for colorectal cancer

An investigation into the role of the innate immune system in patients undergoing surgery for colorectal cancer

Colorectal cancer is the 4th most common cancer in the UK and the second commonest cause of cancer death. Whilst mortality rates from colorectal cancer haven fallen over the last 2 decades, around 40% of those diagnosed with colorectal cancer will die from their disease. Surgery currently remains the only chance of cure. Around 10% of patients present as an emergency with perforation, obstruction or bleeding. Outcomes from these emergency operations are substantially worse than from elective procedures. The presence of a systemic inflammatory response pre-operatively is now widely recognised as a predictor of disease progression and poor outcomes, both long and short term, regardless of tumour stage in those with colorectal cancer. Numerous scoring systems that measure various components of the systemic inflammatory response have been documented, the most commonly used are the modified Glasgow Prognostic Score (mGPS) and the Neutrophil-Lymphocyte Ratio (NLR). The NLR has the advantage of using 2 components of the differential white cell count, which is routinely measured in surgical and oncological practice, whereas CRP is less commonly routinely measured. However, studies utilising the NLR have used a variety of thresholds, making comparison of the results from study to study difficult. Whether one of the components of the NLR is more important than the other remains to be seen and indeed whether there is a more optimal score that utilises the white cell count is not clear. To date no work has examined similar scoring systems in the post-operative period. The present thesis aims to examine the impact of the innate immune response, through such systemic inflammation based scoring systems, on patients undergoing surgery for colorectal cancer. Furthermore, it analyses the nature of the inflammatory response in the post-operative period in order to ascertain whether similar scoring systems may be of clinical utility. Chapter 1 provides an overview of colorectal cancer, its presentation and treatment and its known determinants of outcomes. Furthermore, the immune response to injury and post-operative inflammatory response are discussed. Chapter 2 documents a survey of clinicians who have an interest in systemic inflammation. The survey asks the participants whether they routinely measure systemic inflammation, to what purpose and which scoring system they prefer. Unsurprisingly, the majority of participants use these scoring systems for research purposes only with an even split in terms of which scoring system they prefer to use. Their use in clinical practice remains small but their use in some oncological studies may signify a step towards their incorporation into clinical practice in the future. Chapter 3 presents data from a cohort of patients whom have undergone surgery for colorectal cancer with pre-operative differential white cell counts in order to determine whether any of the white cell count components are important in determining long term outcomes. Only the neutrophil count was independently associated with poor long term survival in patients undergoing surgery for colorectal cancer. These results highlight the importance of both the neutrophil count and the innate immune system in outcomes in patients with colorectal cancer. In chapter 4, a cohort of colorectal cancer patients and a cohort of patients with cancer were utilised in order to determine whether a pre-operative systemic inflammation based score using the neutrophil and platelet count was capable of predicting survival in these patients. This was based on the fact that recent in-vitro work had suggested that a critical checkpoint early in the inflammatory process involved the interaction between neutrophils and activated platelets. The subsequent score – the neutrophil platelet score (NPS)- was shown to be capable of predicting survival, independent of TNM stage, in patients with colorectal cancer and had prognostic value in patients with a variety of other tumours. Chapter 5 describes a systematic review of studies analysing the effect of various surgical procedures on markers of the systemic inflammatory response. Only CRP and IL-6 were found to represent the degree of surgical trauma and invasiveness of the procedure. This work provides a framework for analysing the post-operative SIR and how it is affected by surgery and peri-operative programmes such as ERAS that are reported to improve length of stay and sort term outcomes following surgery for colorectal cancer. It was of interest in the previous chapter that white cell count did not reflect the degree of surgical trauma. Whether individual white cell components act differently and represent the degree of surgical trauma was unclear. Chapter 6 sought to clarify this by analysing, in a cohort of patients undergoing surgery for colorectal cancer, the differential white cell count and whether it reflected the magnitude of injury and short term outcomes. Only the neutrophil count reflected the magnitude of trauma and development of infective complications. However, it remains inferior to other well established markers such as CRP. Whilst the pre-operative systemic inflammatory response is a well-recognised determinant of both long term outcomes and short term outcomes such as infective complications, little work has focussed on the post-operative systemic inflammatory response. In chapter 7, the possibility of the post-operative systemic inflammatory response also being capable of predicting both short and long term outcomes was explored in a cohort of patients whom had undergone surgery for colorectal cancer. A score using the combination of post-operative CRP and albumin was created and called the post-operative Glasgow Prognostic Score (poGPS). In this cohort of patients, this score predicted the development of infective complications and also long term survival. Given that these results would indicate that a reduction in the post-operative systemic inflammatory response would improve outcomes, the clinicopathological factors that may alter this post-operative systemic inflammatory response should be investigated as some of these may be modifiable and may therefore improve outcomes following surgery for colorectal cancer. ERAS programmes have changed perioperative management and are reported to be beneficial in reducing length of hospital stay and post-operative complications. It is purposed that this is due to the reduction on the surgical stress response. However it is unclear which of the components of an ERAS programme are responsible for this reduction in the systemic inflammatory response. Chapter 8 describes a systematic review analysing studies of the various ERAS components and whether there is objective evidence of a reduction in the SIR, evidenced by a reduction in either CRP or IL-6. Only laparoscopic surgery was reported to reduce the SIR in these studies, all the remaining components had either little or no evidence of a reduction in the SIR. Further work is required to ascertain whether any of the other components also reduce the SIR. This will hopefully allow streamlining of the ERAS process in order to improve outcomes. Specific clinicopathological factors that may alter the post-operative systemic inflammatory response are examined in chapter 9. Common clinicopathological factors were examined using the poGPS to ascertain which factors resulted in increased poGPS scores. In those patients undergoing elective surgery, year of operation, ASA grade, pre-operative systemic inflammation, and tumour site were associated with increased poGPS scores. These findings may have important clinical consequences as whilst factors such as ASA grade and BMI are not readily modifiable in the short time frame between diagnosis and surgery, pre-operative inflammation could potentially be targeted with anti-inflammatory medication. However, more work is required to identify the specific agent and the timing of its delivery. In chapter 10, a cohort of patients undergoing surgery for colorectal cancer in whom there was prescription information available. Patients prescribed aspirin or statin were identified and their post-operative inflammatory response and short term outcomes were compared to those not prescribed aspirin or statins. In 446 patients, neither aspirin nor statin prescription was associated with a reduction in the post-operative systemic inflammatory response. Therefore, it would appear that these medications will not be useful in moderating the systemic inflammatory response following surgery. However, further work is required to identify which medications will be of benefit and should take the format of a randomised controlled trial. Chapter 11 provides a summary of the main findings of this thesis, discussed their implications and provides some discussion surrounding future work in this field

Associations of pet ownership with biomarkers of ageing: population based cohort study.

OBJECTIVE: To examine the prospective relation between animal companionship and biomarkers of ageing in older people. DESIGN: Analyses of data from the English Longitudinal Study of Ageing, an ongoing, open, prospective cohort study initiated in 2002-03. SETTING: Nationally representative study from England. PARTICIPANTS: 8785 adults (55% women) with a mean age of 67 years (SD 9) at pet ownership assessment in 2010-11 (wave 5). MAIN OUTCOME MEASURE: Established biomarkers of ageing in the domains of physical, immunological, and psychological function, as assessed in 2012-13 (wave 6). RESULTS: One third of study members reported pet ownership: 1619 (18%) owned a dog, 1077 (12%) a cat, and 274 (3%) another animal. After adjustment for a range of covariates, there was no evidence of a clear association of any type of pet ownership with walking speed, lung function, chair rise time, grip strength, leg raises, balance, three markers of systemic inflammation, memory, or depressive symptoms. CONCLUSION: In this population of older adults, the companionship of creatures great and small seems to essentially confer no relation with standard ageing phenotypes

Mapping and explaining the productivity of Pinus radiata in New Zealand

Mapping Pinus radiata productivity for New Zealand not only provides useful information for forest owners, industry stakeholders and policy managers, but also enables current and future plantations to be visualised, quantified, and planned. Using an extensive set of permanent sample plots, split into fitting (n = 1,146) and validation (n = 618) datasets, models of P. radiata 300 Index (an index of volume mean annual increment) and Site Index (an index of height growth) were developed using a regression kriging technique. Spatial predictions were accurate and accounted for 61% and 70% of the variance for 300 Index and Site Index, respectively. Productivity predicted from these surfaces for the entire plantation estate averaged 27.4 m³ ha⁻¹ yr⁻¹ for the 300 Index and 30.4 m for Site Index. Surfaces showed wide regional variation in this productivity, which was attributable mainly to variation in air temperature and root-zone water storage from site to site

Reflections on the Shifting Shape of Journalism Education in the Covid-19 pandemic

Journalists usually report on crisis. The Covid -19 pandemic places journalists, like everyone else, in the crisis. Thus, it presents a unique challenge to journalism, which is founded on the principle of impartiality, and to journalism educators, striving to teach professional values in an online environment, whilst also focusing on student wellbeing. This paper shares the initial reflections of journalism practitioners who are members of a journalism education research group within the Centre for Excellence in Media Practice at Bournemouth University in the UK. The overarching theme considers the delivery of high quality, industry - facing and relevant journalism education in a digital environment and within a context where we are all part of the story. We reflect on building community and identity for undergraduate and postgraduate students; the challenges of teaching the normative values and skills of journalism (such as objectivity, accuracy, fairness), emotional literacy and the delivery of industry-accredited standards. These individual reflections are presented as a collective essay which engages with questions of identity, self and voice: how can we instil a sense of wellbeing in journalism students who may feel anxious and marginalised? How can they focus on telling the stories of others when they are part of the same story? How can we best engage with these challenges in a digital environment, whilst instilling an understanding of the importance of self–care and wellbeing? In responding and adapting to crisis, we have also discovered - through the work of our students in the virtual classroom - new ways of teaching journalism and innovative approaches to storytelling as we grapple together with the shifting shapes of journalism practice and journalism education

Accurately characterising the importance of wave-particle interactions in radiation belt dynamics: the pitfalls of statistical wave representations

Wave-particle interactions play a crucial role in energetic particle dynamics in the Earth's radiation belts. However the relative importance of different wave-modes in these dynamics is poorly understood. Typically this is assessed during geomagnetic storms using statistically averaged empirical wave models as a function of geomagnetic activity in advanced radiation belt simulations. However statistical averages poorly characterise extreme events such as geomagnetic storms in that storm-time ULF wave power is typically larger than that derived over a solar cycle and Kp is a poor proxy for storm-time wave power

Blur discrimination and its relation to blur-mediated depth perception

Retinal images of three-dimensional scenes often contain regions that are spatially blurred by different amounts, owing to depth variation in the scene and depth-of-focus limitations in the eye. Variations in blur between regions in the retinal image therefore offer a cue to their relative physical depths. In the first experiment we investigated apparent depth ordering in images containing two regions of random texture separated by a vertical sinusoidal border. The texture was sharp on one side of the border, and blurred on the other side. In some presentations the border itself was also blurred. Results showed that blur variation alone is sufficient to determine the apparent depth ordering. A subsequent series of experiments measured blur-discrimination thresholds with stimuli similar to those used in the depth-ordering experiment. Weber fractions for blur discrimination ranged from 0.28 to 0.56. It is concluded that the utility of blur variation as a depth cue is constrained by the relatively mediocre ability of observers to discriminate different levels of blur. Blur is best viewed as a relatively coarse, qualitative depth cue