Surgical ward rounds in England: a trainee-led multi-centre study of current practice

BACKGROUND: Recent guidance advocates daily consultant-led ward rounds, conducted in the morning with the presence of senior nursing staff and minimising patients on outlying wards. These recommendations aim to improve patient management through timely investigations, treatment and discharge. This study sought to evaluate the current surgical ward round practices in England. METHODS: Information regarding timing and staffing levels of surgical ward rounds was collected prospectively over a one-week period. The location of each patient was also documented. Two surgical trainee research collaboratives coordinated data collection from 19 hospitals and 13 surgical subspecialties. RESULTS: Data from 471 ward rounds involving 5622 patient encounters was obtained. 367 (77.9%) ward rounds commenced before 9am. Of 422 weekday rounds, 190 (45%) were consultant-led compared with 33 of the 49 (67%) weekend rounds. 2474 (44%) patients were seen with a nurse present. 1518 patients (27%) were classified as outliers, with 361 ward rounds (67%) reporting at least one outlying patient. CONCLUSION: Recommendations for daily consultant-led multi disciplinary ward rounds are poorly implemented in surgical practice, and patients continue to be managed on outlying wards. Although strategies may be employed to improve nursing attendance on ward rounds, substantial changes to workforce planning would be required to deliver daily consultant-led care. An increasing political focus on patient outcomes at weekends may prompt changes in these areas

Small Water Bodies in Great Britain and Ireland: Ecosystem function, human-generated degradation, and options for restorative action

© 2018 Small, 1st and 2nd-order, headwater streams and ponds play essential roles in providing natural flood control, trapping sediments and contaminants, retaining nutrients, and maintaining biological diversity, which extend into downstream reaches, lakes and estuaries. However, the large geographic extent and high connectivity of these small water bodies with the surrounding terrestrial ecosystem makes them particularly vulnerable to growing land-use pressures and environmental change. The greatest pressure on the physical processes in these waters has been their extension and modification for agricultural and forestry drainage, resulting in highly modified discharge and temperature regimes that have implications for flood and drought control further downstream. The extensive length of the small stream network exposes rivers to a wide range of inputs, including nutrients, pesticides, heavy metals, sediment and emerging contaminants. Small water bodies have also been affected by invasions of non-native species, which along with the physical and chemical pressures, have affected most groups of organisms with consequent implications for the wider biodiversity within the catchment. Reducing the impacts and restoring the natural ecosystem function of these water bodies requires a three-tiered approach based on: restoration of channel hydromorphological dynamics; restoration and management of the riparian zone; and management of activities in the wider catchment that have both point-source and diffuse impacts. Such activities are expensive and so emphasis must be placed on integrated programmes that provide multiple benefits. Practical options need to be promoted through legislative regulation, financial incentives, markets for resource services and voluntary codes and actions

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

Living the punk life in Green Bay, Wisconsin: exploring contradiction in the music of NOFX

This paper studies song lyrics from three mid-period songs written and performed by Californian punk band NOFX. I discuss NOFX’s skilful exploration of contradiction in the three selected songs, two of which are character studies of a single young male individual. The questions that the songs pose in true dialectical fashion (but do not definitively answer) include: Is it possible to maintain the carefree existential existence of the archetypal punk rocker in the face of the constraints imposed by suburban life and the voices of middle-class moderation? Can a Jewish gang in Fairfax, Los Angeles simultaneously affirm group self-identity, defend its turf, and practise its (marginalized) religion? Can a young man enjoy Christianity because it makes his life ‘seem less insane’ whilst simultaneously taking control of his life and not being a Christian sheep? NOFX poses these questions in admirable dialectical fashion, allows us to reflexively examine the issues involved, and form our own conclusions. The band rarely descends into moralism but moral values underpin NOFX’s worldview. Above all, NOFX tries to maintain a sophisticated but precarious ‘both/and’ rather than ‘either/or’ approach to each one of the questions posed in this abstract. Clever lyrics, which highlight the contradictions that a punk rocker must face whilst living in suburban America, have become one of the band’s most loved and most enduring themes

Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest: The State of the Evidence and Framework for Application

Out-of-hospital cardic arrest (OHCA) affects 134 per 100 000 citizens annually. Extracorporeal cardiopulmonary resuscitation (ECPR), providing mechanical circulatory support, may be a means to improve the likelihood of survival among those with refractory OHCA. In comparison to in-hospital ECPR candidates, those in the out-of-hospital setting tend to be sudden unexpected deaths in younger and healthier patients. The aims of this review are to summarize and identify the limitations of the evidence evaluating ECPR for OHCA, and to provide an approach for ECPR program application. [...

Marking out the pitch: a historiography and taxonomy of football fiction

Football, or soccer as it is more commonly referred to in Australia and the US, is arguably the world’s most popular sport. It generates a proportionate volume of related writing. Within this landscape, works of novel-length fiction are seemingly rare. This paper establishes and maps a substantial body of football fiction works, explores elements and qualities exhibited individually and collectively. In bringing together current, limited surveys of the field, it presents the first rigorous definition of football fiction and captures the first historiography of the corpus. Drawing on distant reading methods developed in conjunction with closer textual analyses, the historiography and subsequent taxonomy represent the first articulation of relationships across the body of work, identify growth areas and establish a number of movements and trends. In advancing the understanding of football fiction as a collective body, the paper lays foundations for further research and consideration of the works in generic terms

Workshop on induced Seismicity due to fluid injection/production from Energy-Related Applications

Geothermal energy, carbon sequestration, and enhanced oil and gas recovery have a clear role in U.S. energy policy, both in securing cost-effective energy and reducing atmospheric CO{sub 2} accumulations. Recent publicity surrounding induced seismicity at several geothermal and oil and gas sites points out the need to develop improved standards and practices to avoid issues that may unduly inhibit or stop the above technologies from fulfilling their full potential. It is critical that policy makers and the general community be assured that EGS, CO{sub 2} sequestration, enhanced oil/gas recovery, and other technologies relying on fluid injections, will be designed to reduce induced seismicity to an acceptable level, and be developed in a safe and cost-effective manner. Induced seismicity is not new - it has occurred as part of many different energy and industrial applications (reservoir impoundment, mining, oil recovery, construction, waste disposal, conventional geothermal). With proper study/research and engineering controls, induced seismicity should eventually allow safe and cost-effective implementation of any of these technologies. In addition, microseismicity is now being used as a remote sensing tool for understanding and measuring the success of injecting fluid into the subsurface in a variety of applications, including the enhancement of formation permeability through fracture creation/reactivation, tracking fluid migration and storage, and physics associated with stress redistribution. This potential problem was envisaged in 2004 following observed seismicity at several EGS sites, a study was implemented by DOE to produce a white paper and a protocol (Majer et al 2008) to help potential investors. Recently, however, there have been a significant number of adverse comments by the press regarding induced seismicity which could adversely affect the development of the energy sector in the USA. Therefore, in order to identify critical technology and research that was necessary not only to make fluid injections safe, but an economic asset, DOE organized a series of workshops. The first workshop was held on February 4, 2010, at Stanford University. A second workshop will be held in mid-2010 to address the critical elements of a 'best practices/protocol' that industry could use as a guide to move forward with safe implementation of fluid injections/production for energy-related applications, i.e., a risk mitigation plan, and specific recommendations for industry to follow. The objectives of the first workshop were to identify critical technology and research needs/approaches to advance the understanding of induced seismicity associated with energy related fluid injection/production, such that: (1) The risk associated with induced seismicity can be reduced to a level that is acceptable to the public, policy makers, and regulators; and (2) Seismicity can be utilized/controlled to monitor, manage, and optimize the desired fluid behavior in a cost effective fashion. There were two primary goals during the workshop: (1) Identify the critical roadblocks preventing the necessary understanding of human-induced seismicity. These roadblocks could be technology related (better imaging of faults and fractures, more accurate fluid tracking, improved stress measurements, etc.), research related (fundamental understanding of rock physical properties and geochemical fluid/rock interactions, development of improved constitutive relations, improved understanding of rock failure, improved data processing and modeling, etc.), or a combination of both. (2) After laying out the roadblocks the second goal was to identify technology development and research needs that could be implemented in the near future to address the above objectives