Day case laparoscopic cholecystectomy - what's stopping us now?

Introduction: Day surgery has many benefits for patients and the NHS, but progress in this area of healthcare has been slow. A high volume procedure, laparoscopic cholecystectomy, was chosen to explore this. The aim of this study was to explore and explain the factors that influence the uptake of day case laparoscopic cholecystectomy at three trusts and the impact of service redesign programmes on day case rates. Methods: A mixed methods collective case study was conducted across three trusts. 34 semi-structured interviews were undertaken and 5 years of hospital activity data was analysed. Results: Day case laparoscopic cholecystectomy rates did increase over a 5 year period at all trusts but to varying degrees. Factors that influenced activity according to qualitative data analysed were grouped into two themes: context and mechanisms. Conclusion: Participants did not believe that the service redesign programmes had any direct impact on their practice. New ambulatory care facilities alone did not lead to increased day case laparoscopic cholecystectomy rates because the trust that performed the most did not have any change to their infrastructure. Clinical attitudes towards performing day case laparoscopic cholecystectomy were variable and may explain the difference in day case rates

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Thermoluminescence features of commercial glass and retrospective accident dosimetry

Five window glass brands popularly used in Bangladeshi dwellings have been analyzed for retrospective accident dosimetry, being inexpensive, highly effective as a barrier to moisture and naturally transparent at optical wavelengths. In examining their potential for dosimetry, study has been made of the annealing – irradiation - readout steps contributing to characterization of the various key thermoluminescence properties. These include the respective glow curves, relative sensitivity, dose response, energy response, reproducibility and fading. An ERESCO model 200 MF4-RW X-ray machine and a Gammacell-220 60Co source was used for sample irradiation, while a Harshaw 3500 TLD reader (USA) supported by WinREMS software was used for TL readouts. Within the γ-radiation dose range up to 50 Gy, the various TL parameters show Nasir glass (a locally produced glass brand) to offer the most promising performance for retrospective dosimetry. Fading studies indicate the reconstruction of absorbed dose to be possible for periods of up to four weeks post-exposure. Energy dispersive X-ray analysis shows the Zeff of the various glass to be in the range 12.5–15.1, closely according with that of TLD-200, a commercial dosimeter used for low-level environmental radiation dosimetry. Present work constitutes the first such study of low-cost commercial glass for doses in the range 10–50 Gy, previous literature relating to doses from 50 Gy up to 20 kGy. © 2019 Elsevier Lt

The radiation shielding offered by the commercial glass installed in Bangladeshi dwellings

One sign of a vibrant Bangladeshi economy has been the move away from the use of more traditional housing materials towards a preference for modern constructional media. Glass, one such example, used both decoratively and in a structural context, offers various advantageous properties and facets including a protective feature against radiation that has not previously been considered. Current interest examines the dosimetric possibilities offered by the commercial glass as a secondary shield and also in retrospective ionising radiation exposure analysis. Four popular brands of window glass are investigated, all available within the local market (PHP-Bangladesh, Usmania-Bangladesh, Nasir-Bangladesh and Rider-China), all with the same thickness and colour, varying in terms of elemental weight fractions as evaluated by energy dispersive X-ray analysis. As potential attenuators of transmitted radiation thereby forming secondary barriers against radiation exposure from penetrating radiations, the four brands of glass have been studied using photon energies from 59 up to 1332 keV, a range of values representative of that potentially encountered in incidents. Use has been made of a well-shielded high-purity germanium γ-ray spectrometer and associated electronics, providing for evaluation of the characteristic barrier parameters of half-value layer, radiation protection efficiency and effective atomic number (Zeff). Of the four brands investigated, Rider provides superior secondary shielding performance. Concerning potential retrospective dosimetry the effective atomic number of the glass samples are comparable with that of the commercial thermoluminescence (TL) dosimeter TLD-200. At high doses, the TL yields are sufficient to provide for retrospective accident dosimetry

Studies of ionizing radiation shielding effectiveness of silica-based commercial glasses used in Bangladeshi dwellings

Following the rapid growing economy, the Bangladeshi dwellers are replacing their traditional (mud-, bamboo-, and wood-based) houses to modern multistoried buildings, where different types of glasses are being used as decorative as well as structural materials due to their various advantageous properties. In this study, we inquire the protective and dosimetric capability of commercial glasses for ionizing radiation. Four branded glass samples (PHP-Bangladesh, Osmania-Bangladesh, Nasir-Bangladesh, and Rider-China) of same thickness and color but different elemental weight fractions were analyzed for shielding and dosimetric properties. The chemical composition of the studied material was evaluated by EDX technique. A well-shielded HPGe γ-ray spectrometer combined with associated electronics was used to evaluate the attenuation coefficients of the studied materials for 59 keV, 661 keV, 1173 keV and 1332 keV photon energies. A number of shielding parameters- half value layer (HVL), radiation protection efficiency (RPE) and effective atomic number (Zeff) were also evaluated. The data were compared with the available literature (where applicable) to understand its shielding capability relative to the standard materials such as lead. Among the studied brands, Rider (China) shows relatively better indices to be used as ionizing radiation shielding material. The obtained, Zeff of the studied glass samples showed comparable values to the TLD-200 dosimeter, thus considered suitable for environmental radiation monitoring purposes

The presence of radioactive materials in soil, sand and sediment samples of Potenga sea beach area, Chittagong, Bangladesh: Geological characteristics and environmental implication

Accurate quantification of naturally occurring radioactive materials in soil provides information on geological characteristics, possibility of petroleum and mineral exploration, radiation hazards to the dwelling populace etc. Of practical significance, the earth surface media (soil, sand and sediment) collected from the densely populated coastal area of Chittagong city, Bangladesh were analysed using a high purity germanium γ-ray spectrometer with low background radiation environment. The mean activities of 226Ra (238U), 232Th and 40K in the studied materials show higher values than the respective world average of 33, 36 and 474 Bq/kg reported by the UNSCEAR (2000). The deduced mass concentrations of the primordial radionuclides 238U, 232Th and 40K in the investigated samples are corresponding to the granite rocks, crustal minerals and typical rocks respectively. The estimated mean value of 232Th/238U for soil (3.98) and sediment (3.94) are in-line with the continental crustal average concentration of 3.82 for typical rock range reported by the National Council on Radiation Protection and Measurements (NCRP). But the tonalites and more silicic rocks elevate the mean value of 232Th/238U for sand samples amounting to 4.69. This indicates a significant fractionation during weathering or associated with the metasomatic activity in the investigated area of sand collection

Characteristics and outcomes of an international cohort of 600 000 hospitalized patients with COVID-19

Background: We describe demographic features, treatments and clinical outcomes in the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) COVID-19 cohort, one of the world's largest international, standardized data sets concerning hospitalized patients. Methods: The data set analysed includes COVID-19 patients hospitalized between January 2020 and January 2022 in 52 countries. We investigated how symptoms on admission, co-morbidities, risk factors and treatments varied by age, sex and other characteristics. We used Cox regression models to investigate associations between demographics, symptoms, co-morbidities and other factors with risk of death, admission to an intensive care unit (ICU) and invasive mechanical ventilation (IMV). Results: Data were available for 689 572 patients with laboratory-confirmed (91.1%) or clinically diagnosed (8.9%) SARS-CoV-2 infection from 52 countries. Age [adjusted hazard ratio per 10 years 1.49 (95% CI 1.48, 1.49)] and male sex [1.23 (1.21, 1.24)] were associated with a higher risk of death. Rates of admission to an ICU and use of IMV increased with age up to age 60&nbsp;years then dropped. Symptoms, co-morbidities and treatments varied by age and had varied associations with clinical outcomes. The case-fatality ratio varied by country partly due to differences in the clinical characteristics of recruited patients and was on average 21.5%. Conclusions: Age was the strongest determinant of risk of death, with a ∼30-fold difference between the oldest and youngest groups; each of the co-morbidities included was associated with up to an almost 2-fold increase in risk. Smoking and obesity were also associated with a higher risk of death.&nbsp;The size of our international database and the standardized data collection method make this study a comprehensive international description of COVID-19 clinical features. Our findings may inform strategies that involve prioritization of patients hospitalized with COVID-19 who have a higher risk of death

The value of open-source clinical science in pandemic response: lessons from ISARIC

International audienc