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

Impact assessment of an invasive macrophyte community on ecosystem properties: A Mass Balance Approach for Chilika lagoon, India

Not AvailablePhragmites karka (commonly known as Nala grass) is considered an invasive macrophyte, covering an area of 105.1 sq. km, hindering navigation and impacting the ecosystem functioning of Chilika Lagoon (1165 sq.km). The mass balanced models of three different scenarios of Chilika Lagoon were developed using Ecopath to assess the impact of the invasive macrophyte P. karka on the various ecological attributes of the ecosystem. The three different scenarios modelled were (1) a real-time scenario with 23 functional groups that includes P. karka as a group, (2) a virtual scenario with only 22 functional groups where the system is devoid of P. karka, and (3) a virtual scenario that has 22 groups but is devoid of the functional group seagrass and other macrophytes. The results of our study indicate that scenario-2, which is devoid of the macrophyte P. karka, was found to be a relatively mature and resilient ecosystem with the highest utilisation of primary production within the system. This scenario also possesses the highest overhead (67.47%) and Finn's cycling index (FCI) (4.226%) in comparison to the other two scenarios. The ecosystem indices showed a negative impact of P. karka on the trophic functioning of the Chilika Lagoon, which warrants an urgent need to remove the macrophyte to improve the resilience of the ecosystem

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All India Network project on Fish HealthPangasianodon hypophthalmus is a major aquaculture species in South and Southeast Asia with a high level of production. Standard physiological indices of candidate species are of great value for proper health monitoring and better production. Since fish physiology is grossly influenced by temperature, the reference intervals (RIs) of haematology and blood biochemistry of the healthy reference population of this species are established here in winter and summer seasons following standard methodologies and non-parametric statistics. Haemoglobin, alkaline phosphatase enzyme activity, glucose, urea, and creatinine levels were significantly higher in summer, while leucocyte count, globulin concentration, alanine aminotransferase enzyme activity were higher in winter suggesting the need for use of season-specific RIs for correct interpretation of test results. The normometric database would be useful in season-specific stress assessment, monitoring of well-being, and pathological progressions in this catfish which contributes about 2% to the global aquaculture production.ICA

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Not AvailableInvasive species exert a strong impact on the trophic structure and functioning of the ecosystem they occupy. A modeling software globally used to assess these impacts is Ecopath with Ecosim. This study measures the effects of two invasive species, African catfish Clarias gariepinus, in the food web of the Karapuzha reservoir ecosystem in India. The findings show that the two invasive species directly and indirectly influence several ecosystem elements. The high level of niche overlap (92%) and strong competition for similar resources was exhibited by C. gariepinus. The adverse effects of African catfish on all fish and crustaceans in the reservoir were revealed by mixed trophic impact. Oreochromis mossambicus impacts were both positive and negative. It had a beneficial impact on its predator aquatic birds and was negative towards minnows. This study will help fishery managers to make informed decisions for ecosystem-based fishery management of fish resources.ICA

Oil multinationals and governments in post-colonial transitions: Burmah Shell, the Burmah Oil Company and the Indian State 1947-1970

Using the post-colonial perspective of hybridity, this paper analyses how two British companies, the Burmah Oil Company (BOC) and Burmah Shell (BS) adapted to changes in the socio-economic environment from Indian independence in 1947 until 1970. Post-colonial theory is useful in exploring the continuing imperial influence, the changing relationship between BS, BOC and the GOI and the impact of this on the operations of BOC and BS post-independence. The approach recognises that the relationship between BOC, BS and the GOI was complex with differing levels of co-operation and tension existing between the three parties throughout the period