ERAS Protocols and Multimodal Pain Management in Surgery

Pain is inherent to trauma and surgery, either by direct tissue trauma or by the activation of a surgical stress response characterized by endocrine, metabolic, and immunologic responses. Most pain from trauma and surgery is nociceptive in nature, but patients may also experience inflammatory and neuropathic pain. Therefore, it is necessary to consider the clinical context, patient factors, the type of trauma injury and surgery, the extent and degree of tissue involvement, and the severity of the response when deciding on pain management choices. In the past, surgery was approached mostly in an open fashion and led to a greater stress response and pain. Over the last 30 years, the minimally invasive approach with laparoscopic and robotic surgery has improved the experience of patients with regard to peri-operative pain. In addition, the advent of enhanced recovery protocols have sought to minimize this surgical stress response through targeting of pain control and pain management regimens. This chapter will focus on enhanced recovery after surgery protocols and multimodal pain regimens and will consider trauma and cancer patients as examples of surgical patients who benefit from this type of approach

Estimation of the number and demographics of companion dogs in the UK

<p>Abstract</p> <p>Background</p> <p>Current estimates of the UK dog population vary, contain potential sources of bias and are based on expensive, large scale, public surveys. Here, we evaluate the potential of a variety of sources for estimation and monitoring of the companion dog population in the UK and associated demographic information. The sources considered were: a public survey; veterinary practices; pet insurance companies; micro-chip records; Kennel Club registrations; and the Pet Travel Scheme. The public survey and subpopulation estimates from veterinary practices, pet insurance companies and Kennel Club registrations, were combined to generate distinct estimates of the UK owned dog population using a Bayesian approach.</p> <p>Results</p> <p>We estimated there are 9.4 (95% CI: 8.1-11.5) million companion dogs in the UK according to the public survey alone, which is similar to other recent estimates. The population was judged to be over-estimated by combining the public and veterinary surveys (16.4, 95% CI: 12.5-21.5 million) and under-estimated by combining the public survey and insured dog numbers (4.8, 95% CI: 3.6-6.9 million). An estimate based on combining the public survey and Kennel Club registered dogs was 7.1 (95% CI: 4.5-12.9) million. Based on Bayesian estimations, 77 (95% CI: 62-92)% of the UK dog population were registered at a veterinary practice; 42 (95% CI: 29-55)% of dogs were insured; and 29 (95% CI: 17-43)% of dogs were Kennel Club registered. Breed demographics suggested the Labrador was consistently the most popular breed registered in micro-chip records, with the Kennel Club and with J. Sainsbury's PLC pet insurance. A comparison of the demographics between these sources suggested that popular working breeds were under-represented and certain toy, utility and miniature breeds were over- represented in the Kennel Club registrations. Density maps were produced from micro-chip records based on the geographical distribution of dogs.</p> <p>Conclusions</p> <p>A list containing the breed of each insured dog was provided by J. Sainsbury's PLC pet insurance without any accompanying information about the dog or owner.</p

Deep Near-IR Surface Photometry of 57 Galaxies in the Local Sphere of Influence

We present H-band surface photometry of 57 galaxies drawn from the Local Sphere of Influence (LSI) with distances of less than 10 Mpc from the Milky Way. The images with a typical surface brightness limit 4 mag fainter than 2MASS (24.5 mag arcsec^-2 < sb_lim < 26 mag arcsec ^-2) have been obtained with IRIS2 on the 3.9 m Anglo-Australian Telescope. A total of 22 galaxies that remained previously undetected in the near-IR and potentially could have been genuinely young galaxies were found to have an old stellar population with a star density 1-2 magnitudes below the 2MASS detection threshold. The cleaned near-IR images reveal the morphology and extent of many of the galaxies for the first time. For all program galaxies, we derive radial luminosity profiles, ellipticities, and position angles, together with global parameters such as total magnitude, mean effective surface brightness and half-light radius. Our results show that 2MASS underestimates the total magnitude of galaxies with _eff between 18-21 mag arcsec^-2 by up to 2.5 mag. The Sersic parameters best describing the observed surface brightness profiles are also presented. Adopting accurate galaxy distances and a H-band mass-to-light ratio of Upsilon_H=1.0 +/- 0.4, the LSI galaxies are found to cover a stellar mass range of 5.6 < log_10 (M_stars) < 11.1. The results are discussed along with previously obtained optical data. Our sample of low luminosity galaxies is found to follow closely the optical-infrared B versus H luminosity relation defined by brighter galaxies with a slope of 1.14 +/- 0.02 and scatter of 0.3 magnitudes. Finally we analyse the luminosity - surface brightness relation to determine an empirical mass-to-light ratio of Upsilon_H=0.78 +/- 0.08 for late-type galaxies in the H-band.Comment: Accepted by AJ. High resolution version available at http://www.mso.anu.edu.au/~emma/KirbyHband.pd

Improving the diagnosis and treatment of urinary tract infection in young children in primary care:results from the ‘DUTY’ prospective diagnostic cohort study

PURPOSE Up to 50% of urinary tract infections (UTIs) in young children are missed in primary care. Urine culture is essential for diagnosis, but urine collection is often difficult. Our aim was to derive and internally validate a 2-step clinical rule using (1) symptoms and signs to select children for urine collection; and (2) symptoms, signs, and dipstick testing to guide antibiotic treatment. METHODS We recruited acutely unwell children aged under 5 years from 233 primary care sites across England and Wales. Index tests were parent-reported symptoms, clinician-reported signs, urine dipstick results, and clinician opinion of UTI likelihood (clinical diagnosis before dipstick and culture). The reference standard was microbiologically confirmed UTI cultured from a clean-catch urine sample. We calculated sensitivity, specificity, and area under the receiver operator characteristic (AUROC) curve of coefficient-based (graded severity) and points-based (dichotomized) symptom/sign logistic regression models, and we then internally validated the AUROC using bootstrapping. RESULTS Three thousand thirty-six children provided urine samples, and culture results were available for 2,740 (90%). Of these results, 60 (2.2%) were positive: the clinical diagnosis was 46.6% sensitive, with an AUROC of 0.77. Previous UTI, increasing pain/crying on passing urine, increasingly smelly urine, absence of severe cough, increasing clinician impression of severe illness, abdominal tenderness on examination, and normal findings on ear examination were associated with UTI. The validated coefficient- and points-based model AUROCs were 0.87 and 0.86, respectively, increasing to 0.90 and 0.90, respectively, by adding dipstick nitrites, leukocytes, and blood. CONCLUSIONS A clinical rule based on symptoms and signs is superior to clinician diagnosis and performs well for identifying young children for noninvasive urine sampling. Dipstick results add further diagnostic value for empiric antibiotic treatment

Comparison of microbiological diagnosis of urinary tract infection in young children by routine health service laboratories and a research laboratory: Diagnostic cohort study

OBJECTIVES: To compare the validity of diagnosis of urinary tract infection (UTI) through urine culture between samples processed in routine health service laboratories and those processed in a research laboratory. POPULATION AND METHODS: We conducted a prospective diagnostic cohort study in 4808 acutely ill children aged <5 years attending UK primary health care. UTI, defined as pure/predominant growth ≥105 CFU/mL of a uropathogen (the reference standard), was diagnosed at routine health service laboratories and a central research laboratory by culture of urine samples. We calculated areas under the receiver-operator curve (AUC) for UTI predicted by pre-specified symptoms, signs and dipstick test results (the "index test"), separately according to whether samples were obtained by clean catch or nappy (diaper) pads. RESULTS: 251 (5.2%) and 88 (1.8%) children were classified as UTI positive by health service and research laboratories respectively. Agreement between laboratories was moderate (kappa = 0.36; 95% confidence interval [CI] 0.29, 0.43), and better for clean catch (0.54; 0.45, 0.63) than nappy pad samples (0.20; 0.12, 0.28). In clean catch samples, the AUC was lower for health service laboratories (AUC = 0.75; 95% CI 0.69, 0.80) than the research laboratory (0.86; 0.79, 0.92). Values of AUC were lower in nappy pad samples (0.65 [0.61, 0.70] and 0.79 [0.70, 0.88] for health service and research laboratory positivity, respectively) than clean catch samples. CONCLUSIONS: The agreement of microbiological diagnosis of UTI comparing routine health service laboratories with a research laboratory was moderate for clean catch samples and poor for nappy pad samples and reliability is lower for nappy pad than for clean catch samples. Positive results from the research laboratory appear more likely to reflect real UTIs than those from routine health service laboratories, many of which (particularly from nappy pad samples) could be due to contamination. Health service laboratories should consider adopting procedures used in the research laboratory for paediatric urine samples. Primary care clinicians should try to obtain clean catch samples, even in very young children

The Diagnosis of Urinary Tract infection in Young children (DUTY): a diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness

Background: It is not clear which young children presenting acutely unwell to primary care should be investigated for urinary tract infection (UTI) and whether or not dipstick testing should be used to inform antibiotic treatment.Objectives: To develop algorithms to accurately identify pre-school children in whom urine should be obtained; assess whether or not dipstick urinalysis provides additional diagnostic information; and model algorithm cost-effectiveness.Design: Multicentre, prospective diagnostic cohort study.Setting and participants: Children &lt; 5 years old presenting to primary care with an acute illness and/or new urinary symptoms.Methods: One hundred and seven clinical characteristics (index tests) were recorded from the child’s past medical history, symptoms, physical examination signs and urine dipstick test. Prior to dipstick results clinician opinion of UTI likelihood (‘clinical diagnosis’) and urine sampling and treatment intentions (‘clinical judgement’) were recorded. All index tests were measured blind to the reference standard, defined as a pure or predominant uropathogen cultured at ? 105 colony-forming units (CFU)/ml in a single research laboratory. Urine was collected by clean catch (preferred) or nappy pad. Index tests were sequentially evaluated in two groups, stratified by urine collection method: parent-reported symptoms with clinician-reported signs, and urine dipstick results. Diagnostic accuracy was quantified using area under receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) and bootstrap-validated AUROC, and compared with the ‘clinician diagnosis’ AUROC. Decision-analytic models were used toidentify optimal urine sampling strategy compared with ‘clinical judgement’.Results: A total of 7163 children were recruited, of whom 50% were female and 49% were &lt; 2 years old. Culture results were available for 5017 (70%); 2740 children provided clean-catch samples, 94% of whom were ? 2 years old, with 2.2% meeting the UTI definition. Among these, ‘clinical diagnosis’ correctly identified 46.6% of positive cultures, with 94.7% specificity and an AUROC of 0.77 (95% CI 0.71 to 0.83). Four symptoms, three signs and three dipstick results were independently associated with UTI with an AUROC (95% CI; bootstrap-validated AUROC) of 0.89 (0.85 to 0.95; validated 0.88) for symptoms and signs, increasing to 0.93 (0.90 to 0.97; validated 0.90) with dipstick results. Nappy pad samples were provided from the other 2277 children, of whom 82% were &lt; 2 years old and 1.3% met the UTI definition.‘Clinical diagnosis’ correctly identified 13.3% positive cultures, with 98.5% specificity and an AUROC of 0.63 (95% CI 0.53 to 0.72). Four symptoms and two dipstick results were independently associated with UTI, with an AUROC of 0.81 (0.72 to 0.90; validated 0.78) for symptoms, increasing to 0.87 (0.80 to 0.94; validated 0.82) with the dipstick findings. A high specificity threshold for the clean-catch model was more accurate and less costly than, and as effective as, clinical judgement. The additional diagnostic utility of dipstick testing was offset by its costs. The cost-effectiveness of the nappy pad model was not clear-cut.Conclusions: Clinicians should prioritise the use of clean-catch sampling as symptoms and signs can cost-effectively improve the identification of UTI in young children where clean catch is possible. Dipstick testing can improve targeting of antibiotic treatment, but at a higher cost than waiting for a laboratory result. Future research is needed to distinguish pathogens from contaminants, assess the impact of the clean-catch algorithm on patient outcomes, and the cost-effectiveness of presumptive versus dipstick versus laboratory-guided antibiotic treatment.Funding: The National Institute for Health Research Health Technology Assessment programme.<br/

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Conservation Planning for Ecosystem Services

Despite increasing attention to the human dimension of conservation projects, a rigorous, systematic methodology for planning for ecosystem services has not been developed. This is in part because flows of ecosystem services remain poorly characterized at local-to-regional scales, and their protection has not generally been made a priority. We used a spatially explicit conservation planning framework to explore the trade-offs and opportunities for aligning conservation goals for biodiversity with six ecosystem services (carbon storage, flood control, forage production, outdoor recreation, crop pollination, and water provision) in the Central Coast ecoregion of California, United States. We found weak positive and some weak negative associations between the priority areas for biodiversity conservation and the flows of the six ecosystem services across the ecoregion. Excluding the two agriculture-focused services—crop pollination and forage production—eliminates all negative correlations. We compared the degree to which four contrasting conservation network designs protect biodiversity and the flow of the six services. We found that biodiversity conservation protects substantial collateral flows of services. Targeting ecosystem services directly can meet the multiple ecosystem services and biodiversity goals more efficiently but cannot substitute for targeted biodiversity protection (biodiversity losses of 44% relative to targeting biodiversity alone). Strategically targeting only biodiversity plus the four positively associated services offers much promise (relative biodiversity losses of 7%). Here we present an initial analytical framework for integrating biodiversity and ecosystem services in conservation planning and illustrate its application. We found that although there are important potential trade-offs between conservation for biodiversity and for ecosystem services, a systematic planning framework offers scope for identifying valuable synergies

Levels, timing, and etiology of stillbirths in Sylhet district of Bangladesh

<p>Abstract</p> <p>Background</p> <p>Lack of data is a critical barrier to addressing the problem of stillbirth in countries with the highest stillbirth burden. Our study objective was to estimate the levels, types, and causes of stillbirth in rural Sylhet district of Bangladesh.</p> <p>Methods</p> <p>A complete pregnancy history was taken from all women (n = 39 998) who had pregnancy outcomes during 2003-2005 in the study area. Verbal autopsy data were obtained for all identified stillbirths during the period. We used pre-defined case definitions and computer programs to assign causes of stillbirth for selected causes containing specific signs and symptoms. Both non-hierarchical and hierarchical approaches were used to assign causes of stillbirths.</p> <p>Results</p> <p>A total of 1748 stillbirths were recorded during 2003-2005 from 48,192 births (stillbirth rate: 36.3 per 1000 total births). About 60% and 40% of stillbirths were categorized as antepartum and intrapartum, respectively. Maternal conditions, including infections, hypertensive disorders, and anemia, contributed to about 29% of total antepartum stillbirths. About 50% of intrapartum stillbirths were attributed to obstetric complications. Maternal infections and hypertensive disorders contributed to another 11% of stillbirths. A cause could not be assigned in nearly half (49%) of stillbirths.</p> <p>Conclusion</p> <p>The stillbirth rate is high in rural Bangladesh. Based on algorithmic approaches using verbal autopsy data, a substantial portion of stillbirths is attributable to maternal conditions and obstetric complications. Programs need to deliver community-level interventions to prevent and manage maternal complications, and to develop strategies to improve access to emergency obstetric care. Improvements in care to avert stillbirth can be accomplished in the context of existing maternal and child health programs. Methodological improvements in the measurement of stillbirths, especially causes of stillbirths, are also needed to better define the burden of stillbirths in low-resource settings.</p