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

Religion and Fundamental Rights in European Politics: Convergences and Divisions at the European Parliament

European legislators must increasingly deal with issues related to fundamental rights. Religion is a frequent topic obliging them to do so. It is not directly part of the EU's competences but is a source of values underlying policy choices and a tricky political object. Relying on the findings of a survey about what Members of the European Parliament (MEPs) believe and what they do with these beliefs, the article analyzes potential tensions created by religion in the implementation of human rights by the EU. A first part shows how and to what extent European law meets religion, and how it leaves ample room for flexibility but also for divergent interpretations. A second part states that MEPs agree largely on the principle of separation between politics and religion, but may be divided when it comes to drawing boundaries between the two domains. The conclusion points out the limits of the rule of law to prevent conflicts and suggests that human rights may inspire support as well as cause resistance to Europeanization. © 2013 Springer Science+Business Media Dordrecht.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Switchgrass Harvest and Storage

The feedstock characteristics of the conversion platform will influence the optimal harvest and post harvest management practices for switchgrass. However, many of the harvest management practices are tied to plant phenology and will be similar across platforms. Proper harvest and storage of switchgrass will help provide a consistent and high-quality feedstock to the biorefinery. Bioenergyspecific switchgrass strains are high-yielding and in most cases can be harvested and baled with commercially available haying equipment. Many options are available for packaging switchgrass for storage and transportation, but large round bales or large rectangular bales are the most readily available and are in use on farms. Large round bales tend to have less storage losses than large rectangular bales when stored outside, but rectangular bales tend to be easier to handle and load a truck for transport without road width restrictions. Although there is limited large-scale experience with harvesting and storing switchgrass for bioenergy, extensive research, as well as a history of harvesting hay crops for livestock in many agroecoregions, makes harvesting and preserving switchgrass for bioenergy feasible at the landscape scale