Building up or out? Disparate sequence architectures along an active rift margin—Corinth rift, Greece

Early Pleistocene synrift deltas developed along the southern Corinth rift margin were deposited in a single, dominantly lacustrine depocenter and were subject to the same climate-related base-level and sediment supply cyclicity. Two synrift deltas, just 50 km apart, show markedly different sequence geometry and evolution related to their location along the evolving border fault. In the west, strongly aggradational fan deltas (>600 m thick; 2–4 km radius) deposited in the immediate hanging wall of the active border fault comprise stacked 30–100-m-thick stratal units bounded by flooding surfaces. Each unit evolves from aggradational to progradational with no evidence for abrupt subaerial exposure or fluvial incision. In contrast, in the central rift, the border fault propagated upward into an already deep lacustrine environment, locating rift-margin deltas 15 km into the footwall. The deltas here have a radius of >9 km and comprise northward downstepping and offlapping units, 50–200 m thick, that unconformably overlie older synrift sediments and are themselves incised. The key factors driving the marked variation in sequence stratigraphic architecture are: (1) differential uplift and subsidence related to position with respect to the border fault system, and (2) inherited topography that influenced shoreline position and offshore bathymetry. Our work illustrates that stratal units and their bounding surfaces may have only local (<10 km) extent, highlighting the uncertainty involved in assigning chronostratigraphic significance to systems tracts and in calculating base-level changes from stratigraphy where marked spatial variations in uplift and subsidence occur

Sources of evidence in HIV/AIDS care: pilot study comparing family physicians and AIDS service organization staff

BACKGROUND: The improvement of the quality of the evidence used in treatment decision-making is especially important in the case of patients with complicated disease processes such as HIV/AIDS for which multiple treatment strategies exist with conflicting reports of efficacy. Little is known about the perceptions of distinct groups of health care workers regarding various sources of evidence and how these influence the clinical decision-making process. Our objective was to investigate how two groups of treatment information providers for people living with HIV/AIDS perceive the importance of various sources of treatment information. METHODS: Surveys were distributed to staff at two local AIDS service organizations and to family physicians at three community health centres treating people living with HIV/AIDS. Participants were asked to rate the importance of 10 different sources of evidence for HIV/AIDS treatment information on a 5-point Likert-type scale. Mean rating scores and relative rankings were compared. RESULTS: Findings suggest that a discordance exists between the two health information provider groups in terms of their perceptions of the various sources of evidence. Furthermore, AIDS service organization staff ranked health care professionals as the most important source of information whereas physicians deemed AIDS service organizations to be relatively unimportant. The two groups appear to share a common mistrust for information from pharmaceutical industries. CONCLUSIONS: Discordance exists between medical "experts" from different backgrounds relating to their perceptions of evidence. Further investigation is warranted in order to reveal any effects on the quality of treatment information and implications in the decision-making process. Possible effects on collaboration and working relationships also warrant further exploration

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

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

Tectonic sedimentology: Sediment systems deciphering global to local tectonics

Tectonic sedimentology has broad appeal because it can be applied at many time and length scales, such as sedimentary consequences of: changing rates of plate creation at mid-ocean ridges, continent–continent collisions, plateaux uplift, active plate margins, extensional rift tectonics and the birth, growth and death of individual folds and faults. Tectonic sedimentology deals with the direct influence of neotectonics on sedimentation and basin development, and with the inverse problem of reconstructing the order and development of palaeotectonic structures. This review attempts to show how the scope and importance of the subject has developed over the last decade and is divided into five themes: (i) At the largest tectonic scale, constraints on mid-ocean ridge activity and continent–continent collisions come from: (a) precise chemical analyses of fluid inclusions in marine halite deposits dating back to ca 550 Ma; (b) Sr-isotopic ratios of marine Phanerozoic calcitic fossils; and (c) chemical composition of Archaean and Proterozoic banded iron formations. (ii) At regional scales, constraints on the timing and extent of continental plateau uplift/incision and cratonic tilting are given by: (a) palaeoaltimetry estimates from oxygen isotope depletion in carbonate palaeosols; (b) radiometric dating of palaeowater-table speleothems; and (c) preferential river migration. (iii) At basin scales, catchment processes are emphasized as key controls on sediment flux from tectonic uplands to sedimentary basins. The inadequacy of sediment transport algorithms based on tractive stress and flow power to describe erosion, incision and sediment transport during the most formative catchment hydrological events is emphasized. (iv) Rates of basin-scale fault and fold growth, displacement, death and basement uplift are provided by application of facies analysis and sequence stratigraphy to accurately-dated sediments in sedimentary basins. (v) The effects of changing climate and varying basin base-level in modifying tectonic influences on erosion and sedimentation are examined. In such cases, experimental and numerical modelling using multi-variate parameters of subsidence rate, sediment supply and sea-level change can shed light on the problem. Future developments will undoubtedly improve such models, hopefully establishing full linkage and feedback between sediment/water supply and changing climate within an overall tectonic framework that may itself be changing

Lateral erosion ('toe-cutting') of alluvial fans by axial rivers: Implications for basin analysis and architecture

We document the neglected phenomenon of lateral erosion ('toe-cutting') of alluvial fans by non-incising axial river channels. Field examples from the Holocene of the Big Lost River basin, Idaho and the Plio-Pleistocene of the Rio Grande Rift, New Mexico help to establish architectural models with more general application to basin analysis. The process of toe-cutting can lead to complete fan destruction and may be a response to climate change, tectonic tilting, fault propagation or a combination of these variables. It gives rise to: Near horizontal erosion surfaces cut in fan sediment; steep fan-margin scarps; progressive up-fan incision from the scarp by a network of channels; soil formation up-fan away from the incised channel network: A deposit of axial alluvium that overlies the erosion surface and onlaps the scarp. Once avulsion occurs to take the axial channel away from the bajada margin, distinctive 'healing-wedges' of fan alluvium prograde across abandoned axial river channel and floodplain deposits, gradually onlapping the eroded scarp and its upstream network of incised channels. Toe-cutting has important stratigraphic basin analysis and economic consequences: Bajada deposits subject to the process exhibit appreciable extra groundwater and petroleum reservoir potential in the intercalations of more porous and permeable axial fluvial sediments