Development of a core outcome set for fetal Myelomeningocele (COSMiC): study protocol

Background: Open spina bifida (OSB) is one of the most common congenital central nervous system defects and leads to long-term physical and cognitive disabilities. Open fetal surgery for OSB improves neurological outcomes and reduces the need for ventriculoperitoneal shunting, compared to postnatal surgery, but is associated with a significant risk of prematurity and maternal morbidity. Fetoscopic surgery comes with less maternal morbidity, yet the question remains whether the procedure is neuroprotective and reduces prematurity. Comparison of outcomes between different treatment options is challenging due to inconsistent outcome reporting. We aim to develop and disseminate a core outcome set (COS) for fetal OSB, to ensure that outcomes relevant to all stakeholders are collected and reported in a standardised fashion in future studies. Methods: The COS will be developed using a validated Delphi methodology. A systematic literature review will be performed to identify outcomes previously reported for prenatally diagnosed OSB. We will assess maternal (primary and subsequent pregnancies), fetal, neonatal and childhood outcomes until adolescence. In a second phase, we will conduct semi-structured interviews with stakeholders, to ensure representation of additional relevant outcomes that may not have been reported in the literature. We will include patients and parents, as well as health professionals involved in the care of these pregnancies and children (fetal medicine specialists, fetal surgeons, neonatologists/paediatricians and allied health). Subsequently, an international group of key stakeholders will rate the importance of the identified outcomes using three sequential online rounds of a modified Delphi Survey. Final agreement on outcomes to be included in the COS, their definition and measurement will be achieved through a face-to-face consensus meeting with all stakeholder groups. Dissemination of the final COS will be ensured through different media and relevant societies. Discussion: Development and implementation of a COS for fetal OSB will ensure consistent outcome reporting in future clinical trials, systematic reviews and clinical practice guidelines. This will lead to higher quality research, better evidence-based clinical practice and ultimately improved maternal, fetal and long-term childhood outcomes.Samar Altoukhi, Clare L. Whitehead, Greg Ryan, Jan Deprest, Luc Joyeux, Katie Gallagher, James Drake, Paige Church, Daphne Horn, Yenge Diambomba, Jose C.A. Carvalho, and Tim Van Mieghe

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

The ultraluminous X-ray source bubble in NGC 5585

International audienceSome ultraluminous X-ray sources (ULXs) are surrounded by collisionally ionized bubbles, larger and more energetic than supernova remnants: they are evidence of the powerful outflows associated with super-Eddington X-ray sources. We illustrate the most recent addition to this class: a huge (350 pc × 220 pc in diameter) bubble around a ULX in NGC 5585. We modelled the X-ray properties of the ULX (a broadened-disc source with L_X ≈ 2–4 × 10^39 erg s^−1) from Chandra and XMM–Newton, and identified its likely optical counterpart in Hubble Space Telescope images. We used the Large Binocular Telescope to study the optical emission from the ionized bubble. We show that the line emission spectrum is indicative of collisional ionization. We refine the method for inferring the shock velocity from the width of the optical lines. We derive an average shock velocity ≈125 km s^−1, which corresponds to a dynamical age of ∼600 000 yr for the bubble, and an average mechanical power P_w ∼ 10^40 erg s^−1; thus, the mechanical power is a few times higher than the current photon luminosity. With Very Large Array observations, we discovered and resolved a powerful radio bubble with the same size as the optical bubble, and a 1.4-GHz luminosity ∼10^35 erg s^−1, at the upper end of the luminosity range for this type of source. We explain why ULX bubbles tend to become more radio luminous as they expand while radio supernova remnants tend to fade

CMS Physics Technical Design Report: Addendum on High Density QCD with Heavy Ions

This report presents the capabilities of the CMS experiment to explore the rich heavy-ion physics programme offered by the CERN Large Hadron Collider (LHC). The collisions of lead nuclei at energies $\sqrt{s_{NN}}= 5.5\,{\rm TeV}$ , will probe quark and gluon matter at unprecedented values of energy density. The prime goal of this research is to study the fundamental theory of the strong interaction \u2014 Quantum Chromodynamics (QCD) \u2014 in extreme conditions of temperature, density and parton momentum fraction (low- x ). This report covers in detail the potential of CMS to carry out a series of representative Pb-Pb measurements. These include "bulk" observables, (charged hadron multiplicity, low p T inclusive hadron identified spectra and elliptic flow) which provide information on the collective properties of the system, as well as perturbative probes such as quarkonia, heavy-quarks, jets and high p T hadrons which yield "tomographic" information of the hottest and densest phases of the reaction