Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Early detection of oral cancer:how do I ensure I don't miss a tumour?

The GDC recommend that early detection of oral cancer should form part of every dental surgeon's Continuing Professional Development. It is arguably the most serious condition that can arise within the oral cavity and regular screening practices may also help mitigate spurious claims of prior negligence for failure to detect the cancer at an early stage. Results for routine screening of the entire oral mucosa, together with risk status assessment, should be recorded in a patient's notes at every visit (both negative and positive findings). Clinical Relevance: A knowledge of how to detect oral cancer early is an essential part of the dentist's armamentarium. </jats:p

Soft Tissue Radiological Knee (SToRK) Index: An observational cohort study to produce an index that quantifies the magnitude of soft tissue around the knee using standard radiographs

INTRODUCTION: The soft tissue envelope around the knee can have an impact on the ease of performing surgery such as total knee replacement (TKR). BMI is often used in planning theatre time but may be a poor indicator of the soft tissue around the knee due to varying distribution of adipose tissue. Radiological images directly show the soft tissue. We therefore aim to develop a method of quantifying the soft tissue envelope around the knee using radiographs. METHOD: Plain weight-bearing radiographs were used to measure the total knee (soft tissue and bony) width at the level of the epicondyles of the knee and the bony epicondylar width of the femur. The ratio of the two widths was defined as the Soft Tissue Radiological Knee (SToRK) Index. The validity of the index as a true measure of soft tissue envelope was assessed using cross sectional areas on axial MRI cuts at the level of the epicondyles. The inter-observer reliability was assessed using the intra-class correlation coefficient. SToRK Index values were correlated with patients’ BMI, gender and operative time. RESULTS: The results show there is a close correlation between the ratio of cross sectional area of MRI axial cuts at the level of epicondyles and the ratio of linear widths measured on plain radiographs, validating the SToRK Index as a measure of soft tissue envelope. There was also good to excellent inter-rater reliability of measurements of these widths. There was a close correlation between BMI and SToRK Index with differences between men and women. DISCUSSION: We believe the SToRK Index is a validated method of quantifying soft tissue distribution around the knee and gives surgeons a better descriptor of the knee envelope than BMI. It is easy to use, needs simple investigations and is reproducible

Using citizen science to monitor the spread of tree pests and diseases : outcomes of two projects in Slovenia and the UK

The trees and forests of Europe are increasingly under threat from new pests and diseases that have originated in other parts of the world. Early detection of alien species when they first appear in European countries allows rapid response and offers the best chance to mitigate against their establishment and spread. Citizen science initiatives such as LIFE ARTEMIS in Slovenia, and Observatree in the UK, provide members of the public with the necessary training and educational resource to identify these tree pests and diseases and report them to the appropriate authorities, thereby increasing the level of surveillance and the capacity of the early warning system. This paper summarises some of the outcomes of these two projects and how they have both become integral parts of the official forest and tree health monitoring systems within their respective countries of Slovenia and the United Kingdom

Greater trochanteric pain syndrome: focused shockwave therapy versus an ultrasound guided injection: a randomised control trial

Greater trochanteric pain syndrome (GTPS) is a common problem with an incidence of 1.8–5.6 per 1000 population. Physiotherapy, anti-inflammatories, corticosteroid injections and surgery have all been described in the management of GTPS, with limited, temporal success. Extracorporeal shockwave therapy (ESWT) has been proposed as a potential non-invasive management option for this difficult presentation

Supplementary Material: Phylogeny of all seeded plant families

Climate change is driving rapid and accelerating shifts in range limits, both poleward expansions and equatorward contractions.&nbsp; However, many species are falling behind the pace of change in their dispersal into newly suitable habitats and now show “climate debts”, lags between predicted and observed range expansions under changing climates. Failure to track changing climates may be due to interspecific interactions such as particular food availability for specialists, abiotic barriers such as mountain ranges, or intrinsic traits such as dispersal limitation. A trait-based analysis of climate change performance would help identify causes of climate debt. To understand the correlates of climate debt within a large clade of organisms we use historical and modern observations of butterflies from western Canada as a case study to construct and project individual climate-based environmental niche models. By comparing projected distributions based on historical records to observed modern distributions we are able to construct estimates of climate debt and evaluate the effect of dispersal ability, diet breadth and a proxy for range size on these species\u27 measured climate debt. High levels of climate debt are accumulating within the butterflies of Western Canada, independently of dispersal ability, diet breadth and phylogeny. Range size emerges as the only variable that significantly reduces climate debt, suggesting that more narrowly-ranged species may be at risk of being squeezed out by both a reduction of suitable habitat in their current range and the failure to colonize newly available habitat. These findings underscore the need to investigate potential landscape-level determinants of climate debt that may be limiting range expansions in this group

Supplemental Material - 1000 randomly-chosen candidate topologies for the Canadian butterfly phylogeny

Climate change is driving rapid and accelerating shifts in range limits, both poleward expansions and equatorward contractions.&nbsp;However, many species are falling behind the pace of change in their dispersal into newly suitable habitats and now show “climate debts”, lags between predicted and observed range expansions under changing climates. Failure to track changing climates may be due to interspecific interactions such as particular food availability for specialists, abiotic barriers such as mountain ranges, or intrinsic traits such as dispersal limitation. A trait-based analysis of climate change performance would help identify causes of climate debt. To understand the correlates of climate debt within a large clade of organisms we use historical and modern observations of butterflies from western Canada as a case study to construct and project individual climate-based environmental niche models. By comparing projected distributions based on historical records to observed modern distributions we are able to construct estimates of climate debt and evaluate the effect of dispersal ability, diet breadth and a proxy for range size on these species\u27 measured climate debt. High levels of climate debt are accumulating within the butterflies of Western Canada, independently of dispersal ability, diet breadth and phylogeny. Range size emerges as the only variable that significantly reduces climate debt, suggesting that more narrowly-ranged species may be at risk of being squeezed out by both a reduction of suitable habitat in their current range and the failure to colonize newly available habitat. These findings underscore the need to investigate potential landscape-level determinants of climate debt that may be limiting range expansions in this group