Emergency general surgery: impact of distance and rurality on mortality

Funding This work was made possible by a grant from NHS Grampian and NHS Highlands Endowment Funding. No funding was received from the National Institutes of Health (NIH); Wellcome Trust; or Howard Hughes Medical Institute (HHMI). Acknowledgements The authors acknowledge the support of the eDRIS Team (Public Health Scotland) for their involvement in obtaining approvals, provisioning, and linking data, and the use of the secure analytical platform within the National Safe Haven. We also acknowledge P. Murchie for support with contextualizing the work within the rural medical practitioner literature.Peer reviewedPublisher PD

CHERIvoke: Characterising pointer revocation using CHERI capabilities for temporal memory safety

A lack of temporal safety in low-level languages has led to an epidemic of use-after-free exploits. These have surpassed in number and severity even the infamous buffer-overflow exploits violating spatial safety. Capability addressing can directly enforce spatial safety for the C language by enforcing bounds on pointers and by rendering pointers unforgeable. Nevertheless, an efficient solution for strong temporal memory safety remains elusive. CHERI is an architectural extension to provide hardware capability addressing that is seeing significant commercial and open- source interest. We show that CHERI capabilities can be used as a foundation to enable low-cost heap temporal safety by facilitating out-of-date pointer revocation, as capabilities enable precise and efficient identification and invalidation of pointers, even when using unsafe languages such as C. We develop CHERIvoke, a technique for deterministic and fast sweeping revocation to enforce temporal safety on CHERI systems. CHERIvoke quarantines freed data before periodically using a small shadow map to revoke all dangling pointers in a single sweep of memory, and provides a tunable trade-off between performance and heap growth. We evaluate the performance of such a system using high-performance x86 processors, and further analytically examine its primary overheads. When configured with a heap-size overhead of 25%, we find that CHERIvoke achieves an average execution-time overhead of under 5%, far below the overheads associated with traditional garbage collection, revocation, or page-table systems.EP/K026399/1, EP/P020011/1, EP/K008528/

CheriABI: Enforcing Valid Pointer Provenance and Minimizing Pointer Privilege in the POSIX C Run-time Environment

The CHERI architecture allows pointers to be implemented as capabilities (rather than integer virtual addresses) in a manner that is compatible with, and strengthens, the semantics of the C language. In addition to the spatial protections offered by conventional fat pointers, CHERI capabilities offer strong integrity, enforced provenance validity, and access monotonicity. The stronger guarantees of these architectural capabilities must be reconciled with the real-world behavior of operating systems, run-time environments, and applications. When the process model, user-kernel interactions, dynamic linking, and memory management are all considered, we observe that simple derivation of architectural capabilities is insufficient to describe appropriate access to memory. We bridge this conceptual gap with a notional \emph{abstract capability} that describes the accesses that should be allowed at a given point in execution, whether in the kernel or userspace. To investigate this notion at scale, we describe the first adaptation of a full C-language operating system (FreeBSD) with an enterprise database (PostgreSQL) for complete spatial and referential memory safety. We show that awareness of abstract capabilities, coupled with CHERI architectural capabilities, can provide more complete protection, strong compatibility, and acceptable performance overhead compared with the pre-CHERI baseline and software-only approaches. Our observations also have potentially significant implications for other mitigation techniques.This work was supported by the Defense Advanced Research Projects Agency (DARPA) and the Air Force Research Laboratory (AFRL), under contracts FA8750-10-C-0237 (``CTSRD'') and HR0011-18-C-0016 (``ECATS''). The views, opinions, and/or findings contained in this report are those of the authors and should not be interpreted as representing the official views or policies of the Department of Defense or the U.S. Government. We also acknowledge the EPSRC REMS Programme Grant (EP/K008528/1), the ERC ELVER Advanced Grant (789108), Arm Limited, HP Enterprise, and Google, Inc. Approved for Public Release, Distribution Unlimited

Pharmacist services for non-hospitalised patients (Review)

This is the peer reviewed version of the following article: de Barra M, Scott CL, Scott NW, Johnston M, de Bruin M, Nkansah N, Bond CM, Matheson CI, Rackow P, Williams AJ, Watson MC. Pharmacist services for non‐hospitalised patients. Cochrane Database of Systematic Reviews. 2018(9)., which has been published in final form at https://doi.org/10.1002/14651858.CD013102. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions

The effect of a sports chiropractic manual therapy intervention on the prevention of back pain, hamstring and lower limb injuries in semi-elite Australian Rules footballers: a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Hamstring injuries are the most common injury in Australian Rules football. It was the aims to investigate whether a sports chiropractic manual therapy intervention protocol provided in addition to the current best practice management could prevent the occurrence of and weeks missed due to hamstring and other lower-limb injuries at the semi-elite level of Australian football.</p> <p>Methods</p> <p>Sixty male subjects were assessed for eligibility with 59 meeting entry requirements and randomly allocated to an intervention (n = 29) or control group (n = 30), being matched for age and hamstring injury history. Twenty-eight intervention and 29 control group participants completed the trial. Both groups received the current best practice medical and sports science management, which acted as the control. Additionally, the intervention group received a sports chiropractic intervention. Treatment for the intervention group was individually determined and could involve manipulation/mobilization and/or soft tissue therapies to the spine and extremity. Minimum scheduling was: 1 treatment per week for 6 weeks, 1 treatment per fortnight for 3 months, 1 treatment per month for the remainder of the season (3 months). The main outcome measure was an injury surveillance with a missed match injury definition.</p> <p>Results</p> <p>After 24 matches there was no statistical significant difference between the groups for the incidence of hamstring injury (OR:0.116, 95% CI:0.013-1.019, p = 0.051) and primary non-contact knee injury (OR:0.116, 95% CI:0.013-1.019, p = 0.051). The difference for primary lower-limb muscle strains was significant (OR:0.097, 95%CI:0.011-0.839, p = 0.025). There was no significant difference for weeks missed due to hamstring injury (4 v14, χ2:1.12, p = 0.29) and lower-limb muscle strains (4 v 21, χ2:2.66, p = 0.10). A significant difference in weeks missed due to non-contact knee injury was noted (1 v 24, χ2:6.70, p = 0.01).</p> <p>Conclusions</p> <p>This study demonstrated a trend towards lower limb injury prevention with a significant reduction in primary lower limb muscle strains and weeks missed due to non-contact knee injuries through the addition of a sports chiropractic intervention to the current best practice management.</p> <p>Trial registration</p> <p>The study was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12608000533392).</p

Chronic non-specific low back pain - sub-groups or a single mechanism?

Copyright 2008 Wand and O'Connell; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background: Low back pain is a substantial health problem and has subsequently attracted a considerable amount of research. Clinical trials evaluating the efficacy of a variety of interventions for chronic non-specific low back pain indicate limited effectiveness for most commonly applied interventions and approaches. Discussion: Many clinicians challenge the results of clinical trials as they feel that this lack of effectiveness is at odds with their clinical experience of managing patients with back pain. A common explanation for this discrepancy is the perceived heterogeneity of patients with chronic non-specific low back pain. It is felt that the effects of treatment may be diluted by the application of a single intervention to a complex, heterogeneous group with diverse treatment needs. This argument presupposes that current treatment is effective when applied to the correct patient. An alternative perspective is that the clinical trials are correct and current treatments have limited efficacy. Preoccupation with sub-grouping may stifle engagement with this view and it is important that the sub-grouping paradigm is closely examined. This paper argues that there are numerous problems with the sub-grouping approach and that it may not be an important reason for the disappointing results of clinical trials. We propose instead that current treatment may be ineffective because it has been misdirected. Recent evidence that demonstrates changes within the brain in chronic low back pain sufferers raises the possibility that persistent back pain may be a problem of cortical reorganisation and degeneration. This perspective offers interesting insights into the chronic low back pain experience and suggests alternative models of intervention. Summary: The disappointing results of clinical research are commonly explained by the failure of researchers to adequately attend to sub-grouping of the chronic non-specific low back pain population. Alternatively, current approaches may be ineffective and clinicians and researchers may need to radically rethink the nature of the problem and how it should best be managed

Ethical considerations in prehospital ambulance based research : qualitative interview study of expert informants

Abstract: Background: Prehospital ambulance based research has unique ethical considerations due to urgency, time limitations and the locations involved. We sought to explore these issues through interviews with experts in this research field. Methods: We undertook semi-structured interviews with expert informants, primarily based in the UK, seeking their views and experiences of ethics in ambulance based clinical research. Participants were questioned regarding their experiences of ambulance based research, their opinions on current regulations and guidelines, and views about their general ethical considerations. Participants were chosen because they were actively involved in, or in their expert capacity (e.g. law) expressed an interest in, ambulance based research. Results: Fourteen participants were interviewed including principal investigators, researchers, ethicists and medical lawyers. Five major themes were identified: Capacity, Consent, Clinical Considerations, Consultation and Regulation. Questions regarding consent and capacity were foremost in the discussions as all participants highlighted these as areas for concern. The challenges and use of multiple consent models reflected the complexity of research in this environment. The clinical theme referred to the role of paramedics in research and how research involving ambulance services is increasingly informing improvements to patient care and outcomes and reducing the burden on hospital services. Most felt that, although current regulations were fit for purpose, more specific guidance on implementing these in the ambulance setting would be beneficial. This related closely to the theme of consultation, which examined the key role of ethics committees and other regulatory bodies, as well as public engagement. Conclusions: By interviewing experts in research or ethics in this setting we were able to identify key concerns and highlight areas for future development such as improved guidance

Splenic size after division of the short gastric vessels in Nissen fundoplication in children

Item does not contain fulltextPURPOSE: Nissen fundoplication is an effective treatment for gastro-esophageal reflux disease (GERD). Mobilization of the gastric fundus during fundoplication requires division of short gastric vessels of the spleen, which may cause splenic ischemia. The aim of this study was to determine if Nissen fundoplication results in hypotrophy of the spleen. METHODS: We performed pre-operative and post-operative ultrasound measurements of the spleen in children undergoing Nissen fundoplication. During operation, the surgeon estimated the compromised blood flow by assessment of the percentage of discoloration of the spleen. RESULTS: Twenty-four consecutive children were analyzed. Discoloration of the upper pole of the spleen was observed in 11 patients (48%) of a median estimated splenic surface of 20% (range 5-50%). The median ratio for pre-operative and post-operative length, width, and area of the spleen was 0.97, 1.03, and 0.96, respectively. The percentage of the estimated perfusion defect during surgery was not correlated with the ratios. In three patients, the area ratio was smaller than 0.8 (0.67-0.75), meaning that the area decreased with at least 20% after surgery. In none of these patients a discoloration was observed. CONCLUSION: Discoloration of the spleen after Nissen fundoplication is not associated with post-operative splenic atrophy.1 maart 201

Impact of progressive global warming on the global-scale yield of maize and soybean

Global surface temperature is projected to warm over the coming decades, with regional differences expected in temperature change, rainfall and the frequency of extreme events. Temperature is a major determinant of crop growth and development, affecting planting date, growing season length and yield. We investigated the effects of increments of mean global temperature warming from 0.5 °C to 4 °C on soybean and maize development and yield, both globally and for the main producing countries, and simulated adaptation through changing planting date and variety. Increasing temperature resulted in reduced growing season lengths and ultimately reduced yields for both crops. The global yield for maize decreased as temperature increased, although the severity of the decrease was dependent on geographic region. Small temperature increases of 0.5 °C had no effect on soybean yield, although yield decreased as temperature increased. These negative effects, however, were partly compensated for by the implementation of adaptation strategies including planting earlier in the season and changing variety. The degree of compensation was dependent on geographical area and crop, with maize adaptation delaying the negative effects of temperature on yield, compared to soybean adaptation which increased yield in China, India and Korea DPR as well as delaying the effects in the remaining countries. The results of this paper indicate the degree to which farmer-controlled adaptation strategies can alleviate the negative impacts of increasing temperature on two major crop species