The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

Background Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy

Evolutionary consequences of cryptic genetic variation

Phenotypic evolution depends on heritable variation in phenotypes. A central aim of evolutionary biology, therefore, is to understand how processes generating phenotypic variation interact with selection and drift to result in phenotypic evolution. Recent studies have highlighted the propensity for populations to harbor genetic variation that contributes to phenotypic variation only after some environmental or genetic change. Many authors have suggested that release of this cryptic genetic variation by stressful or novel environments can facilitate phenotypic adaptation. However, there is little empirical evidence that stressful or novel environments release cryptic genetic variation, or that, once released, it contributes to phenotypic evolution. We argue that empirical studies are needed to answer these questions, and identify the empirical approaches needed to study the relationship between environment, released cryptic genetic variation and phenotypic evolution

Strategic canonisation : sanctity, popular culture and the Catholic Church

In his twenty-seven year reign (1978-2005), Pope John Paul II created not only more saints than any other pope in history, but also more saints than all the other popes put together since Pope Urban VIII centralised control of saint-making in 1634. This article argues that the elevation of ‘celebrity saints’, such as Padre Pio and Mother Theresa, can be seen as an attempt on the part of the Catholic Church to strengthen its presence within the arena of popular culture. Through a sustained programme of ‘strategic canonization’, John Paul II promoted models of sanctity that conveyed very clear social and political messages. Such messages were amplified through extensive Catholic media and, where ‘celebrity saints’ were involved, through the secular media too. These processes are analysed first, in relation to the general area of sexual politics; and secondly, to the Church’s historic relationship with Nazism. Whilst John Paul’s programme may not have achieved all that it intended, it clearly demonstrated the Catholic Church’s unique capacity to reinvent very old forms of cultural policy for changing times

Ultrasonic force microscopies

Ultrasonic Force Microscopy, or UFM, allows combination of two apparently mutually exclusive requirements for the nanomechanical probe—high stiffness for the efficient indentation and high mechanical compliance that brings force sensitivity. Somewhat inventively, UFM allows to combine these two virtues in the same cantilever by using indention of the sample at high frequency, when cantilever is very rigid, but detecting the result of this indention at much lower frequency. That is made possible due to the extreme nonlinearity of the nanoscale tip-surface junction force-distance dependence, that acts as “mechanical diode” detecting ultrasound in AFM. After introducing UFM principles, we discuss features of experimental UFM implementation, and the theory of contrast in this mode, progressing to quantitative measurements of contact stiffness. A variety of UFM applications ranging from semiconductor quantum nanostructures, very large scale integrated circuits, and reinforced ceramics to polymer composites and biological materials is presented via comprehensive imaging gallery accompanied by the guidance for the optimal UFM measurements of these materials. We also address effects of adhesion and topography on the elasticity imaging and the approaches for reducing artefacts connected with these effects. This is complemented by another extremely useful feature of UFM ultrasound induced superlubricity that allows damage free imaging of materials ranging from stiff solid state devices and graphene to biological materials. Finally, we proceed to the exploration of time-resolved nanoscale phenomena using nonlinear mixing of multiple vibration frequencies in ultrasonic AFM—Heterodyne Force Microscopy, or HFM, that also include mixing of ultrasonic vibration with other periodic physical excitations, eg. electrical, photothermal, etc. Significant section of the chapter analyses the ability of UFM and HFM to detect subsurface mechanical inhomogeneities, as well as describes related sample preparation methods on the example of subsurface imaging of nanostructures and iii–v quantum dots

Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system

Background: The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale. Method: Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets. Result: Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773–0.806, p &lt; 0.001) on external validation, with 11.0% versus 80.0% of patients classified as low versus high risk having difficult surgeries. Conclusion: We have developed and validated a pre-operative scoring system that uses easily available pre-operative variables to predict difficult laparoscopic cholecystectomies. This scoring system should assist in patient selection for day case surgery, optimising pre-operative surgical planning (e.g. allocation of the procedure to a suitably trained surgeon) and counselling patients during the consent process. The score could also be used to risk adjust outcomes in future research

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (&gt; 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations &gt; 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p &lt; 0.001), with the proportions of operations lasting &gt; 90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care