The development, application and analysis of an enhanced recovery programme for major oesophagogastric resection

Background: Enhanced recovery programmes improve outcomes in surgery, but their implementation after upper gastrointestinal resection has been limited. The aim of this study was to compare short-term outcomes for patients undergoing oesophagogastric surgery in an enhanced recovery programme (EROS). Methods: EROS was developed after a multidisciplinary meeting by multiple rounds of revision. EROS was applied to all patients undergoing major upper GI resection at a university teaching hospital in the UK from 20/9/13, with data reviewed at 18/09/15. EROS was assessed to identify predictors for compliance. Results: One hundred six patients underwent major upper GI resection including 81 oesophagectomies, 24 gastrectomies and 1 colonic interposition graft. Major complications (ClavienDindo≥3) occurred in 12 patients with 1 in-hospital death. Thirty-five patients (44%) were discharged on target day 8 of the EROS programme. Age and complications were independently associated with missing this discharge target. Conclusion: Enhanced recovery is feasible and safe after major upper gastrointestinal surgery.<br/

Large Scale Climate Oscillation Impacts on Temperature, Precipitation and Land Surface Phenology in Central Asia

Central Asia has been rapidly changing in multiple ways over the past few decades. Increases in temperature and likely decreases in precipitation in Central Asia as the result of global climate change are making one of the most arid regions in the world even more susceptible to large-scale droughts. Global climate oscillations, such as the El Ni ̃no–Southern Oscillation, have previously been linked to observed weather patterns in Central Asia. However, until now it has been unclear how the different climate oscillations act simultaneously to affect the weather and subsequently the vegetated land surface in Central Asia.We fit well-established land surface phenology models to two versions of MODIS data to identify the land surface phenology of Central Asia between 2001 and 2016. We then combine five climate oscillation indices into one regression model and identify the relative importance of each of these indices on precipitation, temperature, and land surface phenology, to learn where each climate index has the strongest influence. Our analyses illustrate that the North Atlantic Oscillation, the East Atlantic/West Russia pattern, and the AtlanticMulti-Decadal Oscillation predominantly influence temperature in the northern part of Central Asia.We also show that the Scandinavia index and the Multivariate ENSO index both reveal significant impacts on the precipitation in this region. Thus, we conclude that the land surface phenology across Central Asia is affected by several climate modes, both those that are strongly linked to far northern weather patterns and those that are forced by southern weather patterns, making this region a \u27climate change hotspot’ with strong spatial variations in weather patterns.We also show that regional climate patterns play a significant role in Central Asia, indicating that global climate patterns alone might not be sufficient to project weather patterns and subsequent land surface changes in this region

Model validation for a noninvasive arterial stenosis detection problem

Copyright @ 2013 American Institute of Mathematical SciencesA current thrust in medical research is the development of a non-invasive method for detection, localization, and characterization of an arterial stenosis (a blockage or partial blockage in an artery). A method has been proposed to detect shear waves in the chest cavity which have been generated by disturbances in the blood flow resulting from a stenosis. In order to develop this methodology further, we use both one-dimensional pressure and shear wave experimental data from novel acoustic phantoms to validate corresponding viscoelastic mathematical models, which were developed in a concept paper [8] and refined herein. We estimate model parameters which give a good fit (in a sense to be precisely defined) to the experimental data, and use asymptotic error theory to provide confidence intervals for parameter estimates. Finally, since a robust error model is necessary for accurate parameter estimates and confidence analysis, we include a comparison of absolute and relative models for measurement error.The National Institute of Allergy and Infectious Diseases, the Air Force Office of Scientific Research, the Deopartment of Education and the Engineering and Physical Sciences Research Council (EPSRC)

Age-related decline of peripheral visual processing: the role of eye movements

Earlier work suggests that the area of space from which useful visual information can be extracted (useful field of view, UFoV) shrinks in old age. We investigated whether this shrinkage, documented previously with a visual search task, extends to a bimanual tracking task. Young and elderly subjects executed two concurrent tracking tasks with their right and left arms. The separation between tracking displays varied from 3 to 35 cm. Subjects were asked to fixate straight ahead (condition FIX) or were free to move their eyes (condition FREE). Eye position was registered. In FREE, young subjects tracked equally well at all display separations. Elderly subjects produced higher tracking errors, and the difference between age groups increased with display separation. Eye movements were comparable across age groups. In FIX, elderly and young subjects tracked less well at large display separations. Seniors again produced higher tracking errors in FIX, but the difference between age groups did not increase reliably with display separation. However, older subjects produced a substantial number of illicit saccades, and when the effect of those saccades was factored out, the difference between young and older subjects’ tracking did increase significantly with display separation in FIX. We conclude that the age-related shrinkage of UFoV, previously documented with a visual search task, is observable with a manual tracking task as well. Older subjects seem to partly compensate their deficit by illicit saccades. Since the deficit is similar in both conditions, it may be located downstream from the convergence of retinal and oculomotor signals

Lighting and perceptual cues: Effects on gait measures of older adults at high and low risk for falls

<p>Abstract</p> <p>Background</p> <p>The visual system plays an important role in maintaining balance. As a person ages, gait becomes slower and stride becomes shorter, especially in dimly lighted environments. Falls risk has been associated with reduced speed and increased gait variability.</p> <p>Methods</p> <p>Twenty-four older adults (half identified at risk for falls) experienced three lighting conditions: pathway illuminated by 1) general ceiling-mounted fixtures, 2) conventional plug-in night lights and 3) plug-in night lights supplemented by laser lines outlining the pathway. Gait measures were collected using the GAITRite^©walkway system.</p> <p>Results</p> <p>Participants performed best under the general ceiling-mounted light system and worst under the night light alone. The pathway plus night lights increased gait velocity and reduced step length variability compared to the night lights alone in those at greater risk of falling.</p> <p>Conclusions</p> <p>Practically, when navigating in more challenging environments, such as in low-level ambient illumination, the addition of perceptual cues that define the horizontal walking plane can potentially reduce falls risks in older adults.</p

Multimodal Management of Atrophic Acne Scarring in the Aging Face

Atrophic facial acne scarring is a widely prevalent condition that can have a negative impact on a patient’s quality of life. The appearance of these scars is often worsened by the normal effects of aging. A number of options are available for the treatment of acne scarring, including chemical peeling, dermabrasion, ablative or nonablative laser resurfacing, dermal fillers, and surgical techniques such as subcision or punch excision. Depending on the type and extent of scarring, a multimodal approach is generally necessary to provide satisfactory results. Resurfacing techniques correct surface irregularities, long-lasting dermal fillers address the volume loss resulting from acne, and sub-superficial musculoaponeurotic system (SMAS) face-lift procedures counter the soft tissue laxity and ptosis associated with aging. This article briefly reviews the evolution of individual approaches to treating atrophic acne scarring, followed by case examples illustrating results that can be achieved using a multimodal approach. Representative cases from patients in their 30s, 40s, and 50s are presented. In the author’s clinical practice, multimodal approaches incorporating fractionated laser, injectable poly-l-lactic acid, and sub-SMAS face-lift procedures have achieved optimal aesthetic outcomes, high patient satisfaction, and durability of aesthetic effect over time

Parametric design optimisation of proximal humerus plates based on finite element method

Optimal treatment of proximal humerus fractures remains controversial. Locking plates offer theoretical advantages but are associated with complications in the clinic. This study aimed to perform parametric design optimisation of proximal humerus plates to enhance their mechanical performance. A finite element (FE) model was developed that simulated a two-part proximal humerus fracture that had been treated with a Spatial Subchondral Support (S3) plate and subjected to varus bending. The FE model was validated against in vitro biomechanical test results. The predicted load required to apply 5 mm cantilever varus bending was only 0.728% lower. The FE model was then used to conduct a parametric optimisation study to determine the orientations of inferomedial plate screws that would yield minimum fracture gap change (i.e. optimal stability). The feasible design space was automatically identified by imposing clinically relevant constraints, and the creation process of each FE model for the design optimisation was automated. Consequently, 538 FE models were generated, from which the obtained optimal model had 4.686% lower fracture gap change (0.156 mm) than that of the manufacturer’s standard plate. Whereas its screws were oriented towards the inferomedial region and within the range of neck-shaft angle of a healthy subject. The methodology presented in this study promises future applications in patient-specific design optimisation of implants for other regions of the human body

A psycho-Geoinformatics approach for investigating older adults’ driving behaviours and underlying cognitive mechanisms

Introduction: Safe driving constantly challenges the driver’s ability to respond to the dynamic traffic scene under space and time constraints. It is of particular importance for older drivers to perform sufficient visual and motor actions with effective coordination due to the fact of age-related cognitive decline. However, few studies have been able to integrate drivers’ visual-motor behaviours with environmental information in a spatial-temporal context and link to the cognitive conditions of individual drivers. Little is known about the mechanisms that underpin the deterioration in visual-motor coordination of older drivers. Development: Based on a review of driving-related cognitive decline in older adults and the context of driver-vehicle-environment interactions, this paper established a conceptual framework to identify the parameters of driver’s visual and motor behaviour, and reveal the cognitive process from visual search to vehicle control in driving. The framework led to a psycho-geoinformatics approach to measure older drivers’ driving behaviours and investigate the underlying cognitive mechanisms. The proposed data collection protocol and the analysis and assessments depicted the psycho-geoinformatics approach on obtaining quantified variables and the key means of analysis, as well as outcome measures. Conclusions: Recordings of the driver and their interactions with the vehicle and environment at a detailed scale give a closer assessment of the driver’s behaviours. Using geoinformatics tools in driving behaviours assessment opens a new era of research with many possible analytical options, which do not have to rely on human observations. Instead, it receives clear indicators of the individual drivers’ interactions with the vehicle and the traffic environment. This approach should make it possible to identify lower-performing older drivers and problematic visual and motor behaviours, and the cognitive predictors of risky driving behaviours. A better targeted regulation and tailored intervention programs for older can be developed by further research

Hemiarthroplasty versus angle-stable locking compression plate osteosynthesis in the treatment of three- and four-part fractures of the proximal humerus in the elderly: design of a randomized controlled trial

ABSTRACT: BACKGROUND: The optimal surgical management of dislocated three- and four-part fractures of the proximal humerus in elderly patients remains unclear. Most used techniques are hemiarthroplasty and angle-stable locking compression plate osteosynthesis. In the current literature there is no evidence available presenting superior results between hemiarthroplasty and angle-stable locking compression plate osteosynthesis in terms of speed of recovery, pain, patient satisfaction, functional outcome, quality of life or complications. METHODS/DESIGN: A randomized controlled multicenter trial will be conducted. Patients older than 60 years of age with a dislocated three- or four-part fracture of the proximal humerus as diagnosed by X-rays and CT-scans will be included. Exclusion criteria are a fracture older than 14 days, multiple comorbidity, multitrauma, a pathological fracture, previous surgery on the injured shoulder, severely deranged function caused by a previous disease, "head-split" proximal humerus fracture and unwillingness or inability to follow instructions. Participants will be randomized between surgical treatment with hemiarthroplasty and angle-stable locking compression plate osteosynthesis. Measurements will take place preoperatively and 3 months, 6 months, 9 months, 12 months and 24 months postoperatively. Primary outcome measure is speed of recovery of functional capacity of the affected upper limb using the Disabilities of Arm, Shoulder and Hand score (DASH). Secondary outcome measures are pain, patient satisfaction, shoulder function, quality of life, radiological evaluation and complications. Data will be analyzed on an intention-to-treat basis, using univariate and multivariate analyses. DISCUSSION: Both hemiarthroplasty and angle-stable locking compression plate osteosynthesis are used in the current treatment of dislocated three-and four-part fractures of the proximal humerus. There is a lack of level-1 studies comparing these two most-used surgical treatment options. This randomized controlled multicenter trial has been designed to determine which surgical treatment option provides the fastest recovery of functional capacity of the affected upper limb, and will provide better outcomes in pain, satisfaction, shoulder function, quality of life, radiological evaluation and complications. TRIAL REGISTRATION NUMBER: The trial is registered in the Netherlands Trial Registry (NTR2461)