Patients' inability to perform a preoperative cardiopulmonary exercise test or demonstrate an anaerobic threshold is associated with inferior outcomes after major colorectal surgery.

BACKGROUND: Surgical patients with poor functional capacity, determined by oxygen consumption at anaerobic threshold (AT) during cardiopulmonary exercise testing (CPET), experience longer hospital stays and worse short- and medium-term survival. However, previous studies excluded patients who were unable to perform a CPET or who failed to demonstrate an AT. We hypothesized that such patients are at risk of inferior outcomes after elective surgery. METHODS: All patients undergoing major colorectal surgery attempted CPET to assist in the planning of care. Patients were stratified by their test results into Fit (AT ≥ 11.0 ml O2 kg(-1) min(-1)), Unfit (AT < 11.0 ml O2 kg(-1) min(-1)), or Unable to CPET groups (failed to pedal or demonstrate an AT). For each group, we determined hospital stay and mortality. RESULTS: Between March 2009 and April 2010, 269 consecutive patients were screened, and proceeded to bowel resection. Median hospital stay was 8 days (IQR 5.1-13.4) and there were 44 deaths (16%) at 2 yr; 26 (9.7%) patients were categorized as Unable to CPET, 69 (25.7%) Unfit and 174 (64.7%) Fit. There were statistically significant differences between the three groups in hospital stay [median (IQR) 14.0 (10.5-23.8) vs 9.9 (5.5-15) vs 7.1 (4.9-10.8) days, P < 0.01] and mortality at 2 yr [11/26 (42%) vs 14/69 (20%) vs 19/174 (11%), respectively (P < 0.01)] although the differences between Unable and Unfit were not statistically different. CONCLUSIONS: Patients' inability to perform CPET is associated with inferior outcomes after major colorectal surgery. Future studies evaluating CPET in risk assessment for major surgery should report outcomes for this subgroup

Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery.

BACKGROUND: Intraoperative fluid therapy regimens using oesophageal Doppler monitoring (ODM) to optimize stroke volume (SV) (goal-directed fluid therapy, GDT) have been associated with a reduction in length of stay (LOS) and complication rates after major surgery. We hypothesized that intraoperative GDT would reduce the time to surgical readiness for discharge (RfD) of patients having major elective colorectal surgery but that this effect might be less marked in aerobically fit patients. METHODS: In this double-blinded controlled trial, 179 patients undergoing major open or laparoscopic colorectal surgery were characterized as aerobically 'fit' (n=123) or 'unfit' (n=56) on the basis of their performance during a cardiopulmonary exercise test. Within these fitness strata, patients were randomized to receive a standard fluid regimen with or without ODM-guided intraoperative GDT. RESULTS: GDT patients received an average of 1360 ml of additional intraoperative colloid. The mean cardiac index and SV at skin closure were significantly higher in the GDT group than in controls. Times to RfD and LOS were longer in GDT than control patients but did not reach statistical significance (median 6.8 vs 4.9 days, P=0.09, and median 8.8 vs 6.7 days, P=0.09, respectively). Fit GDT patients had an increased RfD (median 7.0 vs 4.7 days; P=0.01) and LOS (median 8.8 vs 6.0 days; P=0.01) compared with controls. CONCLUSIONS: Intraoperative SV optimization conferred no additional benefit over standard fluid therapy. In an aerobically fit subgroup of patients, GDT was associated with detrimental effects on the primary outcome. TRIAL REGISTRY: UK NIHR CRN 7285, ISRCTN 14680495. http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=7285

A Secular Liturgy: Hugh Hood's Aesthetics and Around the Mountain

Together, the two essays "Sober Colouring: The Ontology of Super-Realism" and "Before the Flood" present a view of art that has shaped all of Hugh Hood's writing in varying degrees. In the two essays, Hood conveys his admiration for an art that exhibits the transcendental element dwelling in living things, for an art that is neither penned in itself as an image is ... nor ... hissing away into the invisible inane as symbols do, but emblematic, that is, as colourful as an image, and as full of meta-meaning as a symbol, indeed fuller because the implications of the symbol are so chillingly, so frustratingly imprecise. Quite early in his career, however, before the writing of these two essays, this theory was given a subtle, coherent, and comprehensive form of expression through the composition of Around the Mountain: Scenes from Montreal Life

Some Highly Subversive Activities: A Brief Polemic and a Checklist of Works on Alice Munro

As a guide to editors and future critics, and as an aid to teachers and students, Struthers lists the works on Alice Munro. The checklist, which draws upon the format established by Robert Lecker and Jack David in ECW Press's The Annotated Bibliography of Canada's Major Authors, includes items under the three categories of "Articles and Sections of Books," "Theses and Dissertations," and "Interviews and Profiles." The article excludes bibliographies, bio-bibliographical sketches, newspaper articles, and book reviews

“Alice Munro’s “A Wilderness Station”: Arachne in the Attic, Stitching Tales that Do Not Add Up.”

International audienc

Reading Alice Munro's Breakthrough Books: A Suite in Four Voices

International audienceWhat in terms of Alice Munro’s creative artistry and creative power allowed her to become the first and only short story writer, the first and only Canadian, and just the thirteenth woman in history to win the Nobel Prize in Literature? And exactly when during Munro’s career did her artistry and power advance to ensure that she would earn such world-wide renown? The answers lie in studying the boldly innovative yet greatly under-examined group of her four mid-career breakthrough books. This volume provides a carefully orchestrated analysis of Munro’s subtle yet potent handling of form, technique and style both within individual stories and across these special collections. Reading Alice Munro’s Breakthrough Books: A Suite in Four Voices not only addresses a significant vacancy in Munro criticism – and, by extension, in all short story criticism – but equally importantly offers an exciting new model for how criticism can be collectively written