An investigation into the role of epidurals in patients undergoing colorectal surgery

Background: Thoracic epidural anaesthesia (TEA) is routinely used for the relief of Postoperative pain in patients undergoing major colorectal surgery. TEA is often associated with hypotension, which may be refractory to intravenous fluids, causing concerns over the effect of such hypotension on anastomotic perfusion. Despite the widespread use of TEA in colorectal surgical patients, their effects on intestinal perfusion are not fully understood. Recent anaesthetic advances have provided potential alternatives to TEA for these patients, such as local anaesthetic wound catheters.Aim: To investigate the effects of epidurals on splanchnic flow and to explore potential alternatives to thoracic epidurals for the management of pain in an enhanced recovery setting.Methods: One systematic review of the literature, two prospective observational studies and one prospective randomised, controlled clinical trial.Results: The findings of both the systematic review of the literature and the two prospective observational studies on the effects of TEA on splanchnic blood flow were inconsistent. These studies indicate that epidural mediated hypotension may be accompanied by a reduction in splanchnic blood flow in some patients. This effect was not consistent but when present was not corrected by intravenous fluid therapy but required vasopressor therapy. The randomised controlled trial has demonstrated that wound catheters provide a viable alternative to epidurals within an enhanced recovery program.Conclusion: A selective approach to the use of TEA in colorectal surgery should be adopted. Their effects on splanchnic flow remain unclear. Local anaesthetic wound catheters are an effective alternative

Assessing the potential for tertiary nitrification in sub-surface flow constructed wetlands

The challenge of how to maintain or improve wastewater treatment performance without causing an excessive increase in energy or costs is increasingly focussed towards ammonia. On small sewage treatment works, solutions have historically been energy intensive: to divert waste to a larger plant, add a polishing step to the end of the process flow sheet or upgrade and replace upstream processes. Constructed wetlands (CWs) offer a low energy alternative to meet these challenges. This review explores oxygen transfer theory; nitrification performance of existing CW systems, and the key affecting factors to be considered when implementing the technology for tertiary treatment upgrades. Future perspectives include the use of artificial aeration and greater consideration of vertical sub-surface flow systems as they achieve the nitrification capacity in a smaller footprint than horizontal flow systems and, where suitable hydraulics permit, can be operated under very low energy demand

Cost of Care Associated with BMI in Patients with Sickle Cell Disease

BACKGROUND: Children with sickle cell disease (SCD) incur greater medical expenditures than children without SCD. The prevalence of overweight has risen among children with SCD in recent years, but the impact of excess weight on both the disease burden and economic burden of SCD has not been determined. PROCEDURE: A convenience sample of patients with SCD under 18 years of age were asked to participate during a routine medical check-up. All participants were from one SCD clinic in North Carolina. Annual cost of care (CoC) in United States dollars (USD) was measured during four stages of adolescence (pre, early, middle, and late) for two groups of patients with SCD who were either above or below an age- and sex-specific 50th percentile for body mass index (BMI). RESULTS: A total of 33 African-American patients (mean age at enrollment 11.76 ± 3.13, 15 (45.5%) female) recorded 914 medical encounters spanning 306 patient-years. For patients over the 50th BMI percentile, CoC was estimated to increase by an additional $1,006 (p<0.001) per year. The estimated difference in annual CoC became most pronounced in late adolescence, wherein patients in the higher percentile group incurred an additional annual CoC of$11,695 (p=0.019). CONCLUSIONS: The differences we measured in cost of care for patients with SCD gives weight to the hypothesis that economic burden is exacerbated by excess bodyweight. Differences in the domain of healthcare costs also suggest potential benefits of weight-management interventions. Further studies implementing such interventions may provide insights for strategically managing SCD, reducing economic burden and improving patient outcomes.Master of Science in Public Healt

Performance of four full-scale artificially aerated horizontal flow constructed wetlands for domestic wastewater treatment

A comparison of the performance of four full-scale aerated horizontal flow constructed wetlands was conducted to determine the efficacy of the technology on sites receiving high and variable ammonia loading rates not yet reported in the literature. Performance was assessed in terms of ammonia and solids removal, hydraulic conductivity and mixing patterns. The capability of systems to produce ammonium effluent concentrations <3 mgNH4 + -N/L was observed across all sites in systems receiving variable loadings between 0.1 and 13.0 gNH4 + -N/m2 /d. Potential resilience issues were observed in relation to response to spike loadings posited to be due to an insufficient nitrifying population within the beds. Hydraulic conductivity and flow mixing patterns observed suggested deterioration of the reactor effective volume over time. Overall, the study demonstrates the efficacy of the technology where ammonium removal is required on small sites receiving high and variable flow rates, with adequate removal of organics and solids, but no significant benefit to the long term hydraulics of the system

Impact of aeration on macrophyte establishment in sub-surface constructed wetlands used for tertiary treatment of sewage

The effect of artificial aeration on plant growth in constructed wetlands in terms of above and below ground biomass and nutrient uptake of two macrophyte species Phragmites australis and Typha latifolia was carried out to provide quantitative, mechanistic evidence to support any differences between the plant species establishment. Pilot scale systems were built and supplied with different intensities of aeration and corresponding controls, with supporting evidence from two full scale operational sites. Results show T. latifolia was more impacted by aeration than P. australis when comparing against their respective non-aerated controls, evidenced in reduced height, growth rate and leaf length. However, the impact was less visible due to T. latifolia's faster growth rate compared to P. australis. Micro and macronutrient uptake by each species had no discernible pattern, preventing the identification of a definitive mechanism to explain the retarded growth. However, results suggest a synergy between iron and manganese may be at play

Trauma Exposures, Resilience Factors, and Mental Health Outcomes in Persons Granted Asylum in the U.S. for Claims Related to Domestic Violence and Persecution by Organized Gangs.

Survivors of domestic violence (DV) and of violence perpetrated by organized gangs (GV) face barriers to legal protection under U.S. asylum law. We abstracted data from 132 affidavits based on forensic medical evaluations of asylum seekers granted legal protection in the U.S. on the basis of DV and/or GV. We described claimants’ trauma exposures and resilience factors and used multiple logistic regression to quantify associations with Diagnostic and Statistical Manual-5 (DSM-5) diagnoses and improvement in mental health. People seeking asylum based on DV and/or GV have endured multiple types of trauma with significant impacts on their mental health. New experiences of trauma following migration to the U.S. were common and associated with DSM-5 diagnoses. Conversely, resilience factors were associated with improved mental health. Policies that aim to reduce ongoing trauma in the U.S. and to bolster resilience factors may promote asylee mental health and well-being

Gender equity and sexual and reproductive health in Eastern and Southern Africa: a critical overview of the literature

Background Gender inequalities are important social determinants of health. We set out to critically review the literature relating to gender equity and sexual and reproductive health (SRH) in Eastern and Southern Africa with the aim of identifying priorities for action. Design During November 2011, we identified studies relating to SRH and gender equity through a comprehensive literature search. Results We found gender inequalities to be common across a range of health issues relating to SRH with women being particularly disadvantaged. Social and biological determinants combined to increase women's vulnerability to maternal mortality, HIV, and gender-based violence. Health systems significantly disadvantaged women in terms of access to care. Men fared worse in relation to HIV testing and care with social norms leading to men presenting later for treatment. Conclusions Gender inequity in SRH requires multiple complementary approaches to address the structural drivers of unequal health outcomes. These could include interventions that alter the structural environment in which ill-health is created. Interventions are required both within and beyond the health system

The Impact of Pre-Operative Anaemia on One Year Amputation Free Survival and Re-Admissions in Patients Undergoing Vascular Surgery for Peripheral Arterial Disease: a National Vascular Registry Study

OBJECTIVE: Anaemia is common among patients undergoing surgery, but its association with post-operative outcomes in patients with peripheral arterial disease (PAD) is unclear. The aim of this observational population based study was to examine the association between pre-operative anaemia and one year outcomes after surgical revascularisation for PAD. METHODS: This study used data from the National Vascular Registry, linked with an administrative database (Hospital Episode Statistics), to identify patients who underwent open surgical lower limb revascularisation for PAD in English NHS hospitals between January 2016 and December 2019. The primary outcome was one year amputation free survival. Secondary outcomes were one year re-admission rate, 30 day re-intervention rate, 30 day ipsilateral major amputation rate and 30 day death. Flexible parametric survival analysis and generalised linear regression were performed to assess the effect of anaemia on one year outcomes. RESULTS: The analysis included 13 641 patients, 57.9% of whom had no anaemia, 23.8% mild, and 18.3% moderate or severe anaemia. At one year follow up, 80.6% of patients were alive and amputation free. The risk of one year amputation or death was elevated in patients with mild anaemia (adjusted HR 1.3; 95% CI 1.15 - 1.41) and moderate or severe anaemia (aHR 1.5; 1.33 - 1.67). Patients with moderate or severe anaemia experienced more re-admissions over one year (adjusted IRR 1.31; 1.26 - 1.37) and had higher odds of 30 day re-interventions (aOR 1.22; 1.04 - 1.45), 30 day ipsilateral major amputation (aOR 1.53; 1.17 - 2.01), and 30 day death (aOR 1.39; 1.03 - 1.88) compared with patients with no anaemia. CONCLUSION: Pre-operative anaemia is associated with lower one year amputation free survival and higher one year re-admission rates following surgical revascularisation in patients with PAD. Research is required to evaluate whether interventions to correct anaemia improve outcomes after lower limb revascularisation