Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Genetic epidemiology of SARS-CoV-2 transmission in renal dialysis units - a high risk community-hospital interface

OBJECTIVES: Patients requiring haemodialysis are at increased risk of serious illness with SARS-CoV-2 infection. To improve the understanding of transmission risks in six Scottish renal dialysis units, we utilised the rapid whole-genome sequencing data generated by the COG-UK consortium. METHODS: We combined geographical, temporal and genomic sequence data from the community and hospital to estimate the probability of infection originating from within the dialysis unit, the hospital or the community using Bayesian statistical modelling and compared these results to the details of epidemiological investigations. RESULTS: Of 671 patients, 60 (8.9%) became infected with SARS-CoV-2, of whom 16 (27%) died. Within-unit and community transmission were both evident and an instance of transmission from the wider hospital setting was also demonstrated. CONCLUSIONS: Near-real-time SARS-CoV-2 sequencing data can facilitate tailored infection prevention and control measures, which can be targeted at reducing risk in these settings

British randomised controlled trial of AV and VV optimization ("BRAVO") study:rationale, design, and endpoints

Background Echocardiographic optimization of pacemaker settings is the current standard of care for patients treated with cardiac resynchronization therapy. However, the process requires considerable time of expert staff. The BRAVO study is a non-inferiority trial comparing echocardiographic optimization of atrioventricular (AV) and interventricular (VV) delay with an alternative method using non-invasive blood pressure monitoring that can be automated to consume less staff resources. Methods/Design BRAVO is a multi-centre, randomized, cross-over, non-inferiority trial of 400 patients with a previously implanted cardiac resynchronization device. Patients are randomly allocated to six months in each arm. In the echocardiographic arm, AV delay is optimized using the iterative method and VV delay by maximizing LVOT VTI. In the haemodynamic arm AV and VV delay are optimized using non-invasive blood pressure measured using finger photoplethysmography. At the end of each six month arm, patients undergo the primary outcome measure of objective exercise capacity, quantified as peak oxygen uptake (VO2) on a cardiopulmonary exercise test. Secondary outcome measures are echocardiographic measurement of left ventricular remodelling, quality of life score and N-terminal pro B-type Natriuretic Peptide (NT-pro BNP). The study is scheduled to complete recruitment in December 2013 and to complete follow up in December 2014. Discussion If exercise capacity is non-inferior with haemodynamic optimization compared with echocardiographic optimization, it would be proof of concept that haemodynamic optimization is an acceptable alternative which has the potential to be more easily implemented

‘‘Beet-ing’’ the Mountain: A Review of the Physiological and Performance Effects of Dietary Nitrate Supplementation at Simulated and Terrestrial Altitude

Exposure to altitude results in multiple physiological consequences. These include, but are not limited to, a reduced maximal oxygen consumption, drop in arterial oxygen saturation, and increase in muscle metabolic perturbations at a fixed sub-maximal work rate. Exercise capacity during fixed work rate or incremental exercise and time-trial performance are also impaired at altitude relative to sea-level. Recently, dietary nitrate (NO3-) supplementation has attracted considerable interest as a nutritional aid during altitude exposure. In this review, we summarise and critically evaluate the physiological and performance effects of dietary NO3- supplementation during exposure to simulated and terrestrial altitude. Previous investigations at simulated altitude indicate that NO3- supplementation may reduce the oxygen cost of exercise, elevate arterial and tissue oxygen saturation, improve muscle metabolic function, and enhance exercise capacity/ performance. Conversely, current evidence suggests that NO3- supplementation does not augment the training response at simulated altitude. Few studies have evaluated the effects of NO3- at terrestrial altitude. Current evidence indicates potential improvements in endothelial function at terrestrial altitude following NO3- supplementation. No effects of NO3- supplementation have been observed on oxygen consumption or arterial oxygen saturation at terrestrial altitude, although further research is warranted. Limitations of the present body of literature are discussed, and directions for future research are provided

On the edge of exceptional preservation: insights into the role of redox state in Burgess Shale-type taphonomic windows from the Mural Formation, Alberta, Canada

Animals originated in the Neoproterozoic and ‘exploded’ into the fossil record in the Cambrian. The Cambrian also represents a high point in the animal fossil record for the preservation of soft tissues that are normally degraded. Specifically, fossils from Burgess Shale-type (BST) preservational windows give paleontologists an unparalleled view into early animal evolution. Why this time interval hosts such exceptional preservation, and why this preservational window declines in the early Paleozoic, have been long-standing questions. Anoxic conditions have been hypothesized to play a role in BST preservation, but recent geochemical investigations of these deposits have reached contradictory results with respect to the redox state of overlying bottom waters. Here, we report a multi-proxy geochemical study of the Lower Cambrian Mural Formation, Alberta, Canada. At the type section, the Mural Formation preserves rare recalcitrant organic tissues in shales that were deposited near storm wave-base (a Tier III deposit; the worst level of soft-tissue preservation). The geochemical signature of this section shows little to no evidence of anoxic conditions, in contrast to published multi-proxy studies of more celebrated Tier I and II deposits. These data help confirm that ‘decay limited’ BST biotas were deposited in more oxygenated conditions, and support a role for anoxic conditions in BST preservation. Finally, we discuss the role of iron reduction in BST preservation, including the formation of iron-rich clays and inducement of sealing seafloor carbonate cements. As oceans and sediment columns became more oxygenated and more sulfidic through the early Paleozoic, these geochemical changes may have helped close the BST taphonomic window. 

Sea level, carbonate mineralogy, and early diagenesis controlled δ13C records in Upper Ordovician carbonates

Stratigraphic variability in the geochemistry of sedimentary rocks provides critical data for interpreting paleoenvironmental change throughout Earth history. However, the vast majority of pre-Jurassic geochemical records derive from shallow-water carbonate platforms that may not reflect global ocean chemistry. Here, we used calcium isotope ratios (δ44Ca) in conjunction with minor-element geochemistry (Sr/Ca) and field observations to explore the links among sea-level change, carbonate mineralogy, and marine diagenesis and the expression of a globally documented interval of elevated carbon isotope ratios (δ13C; Hirnantian isotopic carbon excursion [HICE]) associated with glaciation in Upper Ordovician shallow-water carbonate strata from Anticosti Island, Canada, and the Great Basin, Nevada and Utah, USA. The HICE on Anticosti is preserved in limestones with low δ44Ca and high Sr/Ca, consistent with aragonite as a major component of primary mineralogy. Great Basin strata are characterized by lateral gradients in δ44Ca and δ13C that reflect variations in the extent of early marine diagenesis across the platform. In deep-ramp settings, deposition during synglacial sea-level lowstand and subsequent postglacial flooding increased the preservation of an aragonitic signature with elevated δ13C produced in shallow-water environments. In contrast, on the mid- and inner ramp, extensive early marine diagenesis under seawater-buffered conditions muted the magnitude of the shift in δ13C. The processes documented here provide an alternative explanation for variability in a range of geochemical proxies preserved in shallow-water carbonates at other times in Earth history, and challenge the notion that these proxies necessarily record changes in the global ocean