Timing of glioblastoma surgery and patient outcomes: a multicenter cohort study.

BACKGROUND: The impact of time-to-surgery on clinical outcome for patients with glioblastoma has not been determined. Any delay in treatment is perceived as detrimental, but guidelines do not specify acceptable timings. In this study, we relate the time to glioblastoma surgery with the extent of resection and residual tumor volume, performance change, and survival, and we explore the identification of patients for urgent surgery. METHODS: Adults with first-time surgery in 2012–2013 treated by 12 neuro-oncological teams were included in this study. We defined time-to-surgery as the number of days between the diagnostic MR scan and surgery. The relation between time-to-surgery and patient and tumor characteristics was explored in time-to-event analysis and proportional hazard models. Outcome according to time-to-surgery was analyzed by volumetric measurements, changes in performance status, and survival analysis with patient and tumor characteristics as modifiers. RESULTS: Included were 1033 patients of whom 729 had a resection and 304 a biopsy. The overall median time-to-surgery was 13 days. Surgery was within 3 days for 235 (23%) patients, and within a month for 889 (86%). The median volumetric doubling time was 22 days. Lower performance status (hazard ratio [HR] 0.942, 95% confidence interval [CI] 0.893–0.994) and larger tumor volume (HR 1.012, 95% CI 1.010–1.014) were independently associated with a shorter time-to-surgery. Extent of resection, residual tumor volume, postoperative performance change, and overall survival were not associated with time-to-surgery. CONCLUSIONS: With current decision-making for urgent surgery in selected patients with glioblastoma and surgery typically within 1 month, we found equal extent of resection, residual tumor volume, performance status, and survival after longer times-to-surgery

Physiological and Psychological Effects of Deception on Pacing Strategy and Performance: A Review

The aim of an optimal pacing strategy during exercise is to enhance performance whilst ensuring physiological limits are not surpassed, which has been shown to result in a metabolic reserve at the end of the exercise. There has been debate surrounding the theoretical models that have been proposed to explain how pace is regulated, with more recent research investigating a central control of exercise regulation. Deception has recently emerged as a common, practical approach to manipulate key variables during exercise. There are a number of ways in which deception interventions have been designed, each intending to gain particular insights into pacing behaviour and performance. Deception methodologies can be conceptualised according to a number of dimensions such as deception timing (prior to or during exercise), presentation frequency (blind, discontinuous or continuous) and type of deception (performance, biofeedback or environmental feedback). However, research evidence on the effects of deception has been perplexing and the use of complex designs and varied methodologies makes it difficult to draw any definitive conclusions about how pacing strategy and performance are affected by deception. This review examines existing research in the area of deception and pacing strategies, and provides a critical appraisal of the different methodological approaches used to date. It is hoped that this analysis will inform the direction and methodology of future investigations in this area by addressing the mechanisms through which deception impacts upon performance and by elucidating the potential application of deception techniques in training and competitive settings

Hospital service areas – a new tool for health care planning in Switzerland

BACKGROUND: The description of patient travel patterns and variations in health care utilization may guide a sound health care planning process. In order to accurately describe these differences across regions with homogeneous populations, small area analysis (SAA) has proved as a valuable tool to create appropriate area models. This paper presents the methodology to create and characterize population-based hospital service areas (HSAs) for Switzerland. METHODS: We employed federal hospital discharge data to perform a patient origin study using small area analysis. Each of 605 residential regions was assigned to one of 215 hospital provider regions where the most frequent number of discharges took place. HSAs were characterized geographically, demographically, and through health utilization indices and rates that describe hospital use. We introduced novel planning variables extracted from the patient origin study and investigated relationships among health utilization indices and rates to understand patient travel patterns for hospital use. Results were visualized as maps in a geographic information system (GIS). RESULTS: We obtained 100 HSAs using a patient origin matrix containing over four million discharges. HSAs had diverse demographic and geographic characteristics. Urban HSAs had above average population sizes, while mountainous HSAs were scarcely populated but larger in size. We found higher localization of care in urban HSAs and in mountainous HSAs. Half of the Swiss population lives in service areas where 65% of hospital care is provided by local hospitals. CONCLUSION: Health utilization indices and rates demonstrated patient travel patterns that merit more detailed analyses in light of political, infrastructural and developmental determinants. HSAs and health utilization indices provide valuable information for health care planning. They will be used to study variation phenomena in Swiss health care

Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial)

BACKGROUND: Recent developments in large bowel surgery are the introduction of laparoscopic surgery and the implementation of multimodal fast track recovery programs. Both focus on a faster recovery and shorter hospital stay. The randomized controlled multicenter LAFA-trial (LAparoscopy and/or FAst track multimodal management versus standard care) was conceived to determine whether laparoscopic surgery, fast track perioperative care or a combination of both is to be preferred over open surgery with standard care in patients having segmental colectomy for malignant disease. METHODS/DESIGN: The LAFA-trial is a double blinded, multicenter trial with a 2 × 2 balanced factorial design. Patients eligible for segmental colectomy for malignant colorectal disease i.e. right and left colectomy and anterior resection will be randomized to either open or laparoscopic colectomy, and to either standard care or the fast track program. This factorial design produces four treatment groups; open colectomy with standard care (a), open colectomy with fast track program (b), laparoscopic colectomy with standard care (c), and laparoscopic surgery with fast track program (d). Primary outcome parameter is postoperative hospital length of stay including readmission within 30 days. Secondary outcome parameters are quality of life two and four weeks after surgery, overall hospital costs, morbidity, patient satisfaction and readmission rate. Based on a mean postoperative hospital stay of 9 +/- 2.5 days a group size of 400 patients (100 each arm) can reliably detect a minimum difference of 1 day between the four arms (alfa = 0.95, beta = 0.8). With 100 patients in each arm a difference of 10% in subscales of the Short Form 36 (SF-36) questionnaire and social functioning can be detected. DISCUSSION: The LAFA-trial is a randomized controlled multicenter trial that will provide evidence on the merits of fast track perioperative care and laparoscopic colorectal surgery in patients having segmental colectomy for malignant disease

Quantifying the effectiveness of climate change mitigation through forest plantations and carbon sequestration with an integrated land-use model

<p>Abstract</p> <p>Background</p> <p>Carbon plantations are introduced in climate change policy as an option to slow the build-up of atmospheric carbon dioxide (CO₂) concentrations. Here we present a methodology to evaluate the potential effectiveness of carbon plantations. The methodology explicitly considers future long-term land-use change around the world and all relevant carbon (C) fluxes, including all natural fluxes. Both issues have generally been ignored in earlier studies.</p> <p>Results</p> <p>Two different baseline scenarios up to 2100 indicate that uncertainties in future land-use change lead to a near 100% difference in estimates of carbon sequestration potentials. Moreover, social, economic and institutional barriers preventing carbon plantations in natural vegetation areas decrease the physical potential by 75–80% or more.</p> <p>Nevertheless, carbon plantations can still considerably contribute to slowing the increase in the atmospheric CO₂concentration but only in the long term. The most conservative set of assumptions lowers the increase of the atmospheric CO₂concentration in 2100 by a 27 ppm and compensates for 5–7% of the total energy-related CO₂emissions. The net sequestration up to 2020 is limited, given the short-term increased need for agricultural land in most regions and the long period needed to compensate for emissions through the establishment of the plantations. The potential is highest in the tropics, despite projections that most of the agricultural expansion will be in these regions. Plantations in high latitudes as Northern Europe and Northern Russia should only be established if the objective to sequester carbon is combined with other activities.</p> <p>Conclusion</p> <p>Carbon sequestration in plantations can play an important role in mitigating the build-up of atmospheric CO₂. The actual magnitude depends on natural and management factors, social barriers, and the time frame considered. In addition, there are a number of ancillary benefits for local communities and the environment. Carbon plantations are, however, particularly effective in the long term. Furthermore, plantations do not offer the ultimate solution towards stabilizing CO₂concentrations but should be part of a broader package of options with clear energy emission reduction measures.</p

A media framing analysis of urban flooding in Nigeria: current narratives and implications for policy

© 2017, The Author(s). A critical element of current flood management is the importance of engaging key policy actors when policy decisions are to be made. However, there is still only limited understanding of how narratives of flood management actors may influence flood management policies, even though there is a suggestion that actors can strategically use their narratives to influence policy directions. In a developing country like Nigeria, there are still questions around lessons that can be learnt from understanding the narratives of policy actors, to unravel the complex nature of strategies and policy directions in managing urban floods. To help fill these gaps, this paper uses quantitative content analysis to explore the frame of five policy actor groups (government, local communities, business, multilateral organisations and non-governmental organisations (NGOs)) as expressed in local and national newspapers between 2012 and 2016 to understand their narratives of causes and strategies to solve the problem of urban flooding in Nigeria. The narratives of government, local communities and businesses align with the premise that flooding can and should be prevented whilst that of multilateral and business actors champion adaptation strategies on the basis that flooding is inevitable and hence more energy should be directed at ‘living with water’—emergency response, damage reduction and the aftermath. The study also identified areas of potential consensus and conflict between direct actors such as government and local communities on the one hand and funders on the other. Better discussion among actors aiding understanding of contemporary thinking and local realities will aid policy-making and policy implementation in the Nigerian context. An important step will be in the collaborative design of an urgently needed ‘Nigerian policy on flooding’ which currently does not exist

Clinical approach for the classification of congenital uterine malformations

A more objective, accurate and non-invasive estimation of uterine morphology is nowadays feasible based on the use of modern imaging techniques. The validity of the current classification systems in effective categorization of the female genital malformations has been already challenged. A new clinical approach for the classification of uterine anomalies is proposed. Deviation from normal uterine anatomy is the basic characteristic used in analogy to the American Fertility Society classification. The embryological origin of the anomalies is used as a secondary parameter. Uterine anomalies are classified into the following classes: 0, normal uterus; I, dysmorphic uterus; II, septate uterus (absorption defect); III, dysfused uterus (fusion defect); IV, unilateral formed uterus (formation defect); V, aplastic or dysplastic uterus (formation defect); VI, for still unclassified cases. A subdivision of these main classes to further anatomical varieties with clinical significance is also presented. The new proposal has been designed taking into account the experience gained from the use of the currently available classification systems and intending to be as simple as possible, clear enough and accurate as well as open for further development. This proposal could be used as a starting point for a working group of experts in the field