Treatment of anal fissure: a survey of surgical practice in Australia and New Zealand.

AIM: The aim was to determine whether or not the clinical management of anal fissure in Australia and New Zealand accords with published guidelines. METHODS: A comprehensive survey based on common clinical scenarios was distributed to 206 colorectal surgeons in Australia and New Zealand. RESULTS: The response rate was 44% (91 surgeons). For 19 topic areas, only seven (37%) reached consensus (defined as > 70% majority opinion). Of these, six (86%) agreed with guideline recommendations. Twelve (63%) topic areas demonstrated community equipoise (defined as less than or equal to 70% majority opinion), of which five (42%) agreed with guideline recommendations and seven (58%) disagreed with guidelines. Of the seven topics that disagreed with guidelines, three were based on moderate quality evidence (first line management of acute anal fissure in a young patient, fissure healing and faecal incontinence rates following anocutaneous flap) and four were based on low quality evidence (length of sphincter division during a lateral sphincterotomy in women, management of chronic low-pressure anal fissures postpartum, fissure healing rate following anoplasty with botulinum toxin or sphincterotomy and faecal incontinence rates following repeat sphincterotomy for recurrence). Consensus and/or agreement with guidelines were more prevalent in management when medical therapy failed. CONCLUSION: While areas of consensus mostly agreed with guideline recommendations, there remain many areas of community equipoise which warrant further research.

A systematic review of online resources to support patient decision-making for full-thickness rectal prolapse surgery.

BACKGROUND: The internet is becoming an increasingly popular resource to support patient decision-making outside of the clinical encounter. The quality of online health information is variable and largely unregulated. The aim of this study was to assess the quality of online resources to support patient decision-making for full-thickness rectal prolapse surgery. METHODS: This systematic review was registered on the PROSPERO database (CRD42017058319). Searches were performed on Google and specialist decision aid repositories using a pre-defined search strategy. Sources were analysed according to three measures: (1) their readability using the Flesch-Kincaid Reading Ease score, (2) DISCERN score and (3) International Patient Decision Aids Standards (IPDAS) minimum standards criteria score (IPDASi, v4.0). RESULTS: Overall, 95 sources were from Google and the specialist decision aid repositories. There were 53 duplicates removed, and 18 sources did not meet the pre-defined eligibility criteria, leaving 24 sources included in the full-text analysis. The mean Flesch-Kincaid Reading Ease score was higher than recommended for patient education materials (48.8 ± 15.6, range 25.2-85.3). Overall quality of sources supporting patient decision-making for full-thickness rectal prolapse surgery was poor (median DISCERN score 1/5 ± 1.18, range 1-5). No sources met minimum decision-making standards (median IPDASi score 5/12 ± 2.01, range 1-8). CONCLUSIONS: Currently, easily accessible online health information to support patient decision-making for rectal surgery is of poor quality, difficult to read and does not support shared decision-making. It is recommended that professional bodies and medical professionals seek to develop decision aids to support decision-making for full-thickness rectal prolapse surgery.

A study on the discrimination of human skeletons using X-ray fluorescence and chemometric tools in chemical anthropology.

Forensic anthropological investigations are often restricted in their outcomes by the resources allocated to them, especially in terms of positively identifying the victims exhumed from commingled mass graves. Commingled mass graves can be defined as those graves that contain a number of disarticulated human remains from different individuals that have been mixed by either natural processes or human interventions. The research developed aimed to apply the technique of non-destructive XRF analysis to test whether there is substantial differentiation within the trace elemental composition and their ratios of individuals to separate them using chemometric analysis. The results of the different atomic spectroscopic analyses combined with the use of multivariate analysis on a set of 5 skeletons produced a series of plots using Principal Component Analysis that helped to separate them with a high percentage of accuracy when two, three or four skeletons needed to be separated. Also, two new elemental ratios, Zn/Fe related to metabolic activities and K/Fe related to blood flow into the bone, have been defined for their use in forensic anthropology for the first time to aid in the separation.

Valorisation of forestry waste by pyrolysis in an auger reactor.

Pyrolysis of forestry waste has been carried out in an auger reactor to study the influence of operational variables on the reactor performance and the properties of the related products. Pine woodchips were used for the first time as raw material and fed continuously into the reactor. Ten experiments were carried out under inert atmosphere at: (i) different reaction temperature (1073, 973, 873, 823 and 773 K); (ii) different solid residence time (5, 3, 2 and 1.5 min); and (iii) different biomass flow rate (3.9, 4.8 and 6.9 kg/h). Results show that the greatest yields for liquid production (59%) and optimum product characterisation were obtained at the lowest temperature studied (773 K) and applying solid residence times longer than 2 min. Regarding bio-oil properties, GC/MS qualitative identification show that the most abundant compounds are volatile polar compounds, phenols and benzenediols; and very few differences can be observed among the samples regardless of the pyrolysis operating conditions. On the whole, experimental results demonstrate that complete reaction of forest woodchips can be achieved in an auger reactor in most of the experimental conditions tested. Moreover, this study presents the initial steps for the future scaling up of the auger reactor with the aim of converting it into a mobile plant which will be able to remotely process biomass such as energy crops, forestry and agricultural wastes to obtain bio-oil that, in turn, can be used as energy vector to avoid high transport costs.

Metal leaching from monolithic stabilised/solidified air pollution control residues.

Portland cement (CEM I) and ground granulated blast furnace slag (ggbs) have been used to treat air pollution control (APC) residues from an energy-from-waste plant burning municipal solid waste. Stabilised/solidified (s/s) products were prepared with binder additions ranging from 10 to 50 wt.% of total dry mass and water/solids ratios between 0.40 and 0.80. Monolithic leach tests (EA NEN 7375:2004) indicated that 50% binder additions were necessary to meet the UK monolithic Waste Acceptance Criteria (monWAC) for Pb and Zn, and previous work indicated that chloride leaching exceeded WAC even at this binder addition. Lower binder additions (20 and 10%) did not sufficiently reduce leaching of Pb. Although the monWAC are based on an assumption that leaching is diffusion-controlled, evaluation of leaching mechanisms indicates that more complex processes than diffusion occur for s/s APC residues.

Sewage sludge-based adsorbents: a review of their production, properties and use in water treatment applications.

The imposition of more stringent legislation governing the disposal and utilisation of sewage sludge, coupled with the growth in its generation and the loss of traditionally accepted disposal routes, has prompted a drive for alternative uses for sewage sludge. One option that exhibits special promise, due to its potential to valorise the sludge, is the conversion of the sludge into adsorbents. This paper seeks to review the published research in this field: it covers the means of production, the characteristics and the potential applications of sewage sludge-based adsorbents (SBAs). The literature has indicated that chemical activation utilising alkali metal hydroxides is the most effective technique for producing high surface area SBAs. In addition, acid washing is highly effective at raising the BET surface area of SBAs, especially when coupled with physical activation. Due to their relatively low microporosity, the phenol uptake of SBAs produced by physical activation is low, but through a combination of their favourable surface chemistry and relatively high mesoporosity, the best of these adsorbents can attain high uptakes of organic dyes. The SBAs produced by carbonisation, through their high cation exchange capacity, generally exhibit a high metal cation capacity. For further research, the following investigations are recommended: the utilisation of alternative chemical activation reagents; the optimisation of the most effective chemical activation techniques; the combined utilisation of different activation and surface chemistry modification techniques to produce application-specific adsorbents.

Liverpool Ultrasound Pictorial Chart: the development of a new method of documenting anal sphincter injury diagnosed by endoanal ultrasound.

OBJECTIVE: To develop and validate a pictorial chart that documents ultrasound examination of the anal sphincter. DESIGN: A new pictorial chart (Liverpool Ultrasound Pictorial Chart [LUPIC]) depicting the normal anatomy of the anal sphincter was developed. METHODS: To validate LUPIC, two observers documented the findings of 296 endoanal scans. Reliability was assessed between observers using kappa agreement for presence and position of sphincter defects. To validate the use of LUPIC by different observers, a video of ten endoanal ultrasound scans was reviewed by our local expert (gold standard). Seven clinicians underwent test-retest analysis. Kappa agreement was calculated to assess intra-observer and gold standard versus observer agreement for the overall presence of sphincter defects and compared with the gold standard. Complete agreement for the position and level of sphincter defects was assessed for the five abnormal scans. MAIN OUTCOME MEASURES: Excellent agreement between the two observers was found for the presence (kappa 0.99), position and level of external anal sphincter defects documented using LUPIC. The intra-observer and gold standard versus observer kappa values of experienced clinicians (A-E) showed good agreement for the overall presence of sphincter defects. Complete agreement for the position and level of sphincter defects was found in 23 of 35 (66%) observations. CONCLUSIONS: LUPIC is designed and validated method of documenting anal sphincter injury diagnosed by endoanal ultrasound. Standardisation of endoanal ultrasound findings by using LUPIC may help correlate the degree of damage with patient symptoms.

Assessment of the risk of introduction of Anoplophora glabripennis (Coleoptera: Cerambycidae) in municipal solid waste from the quarantine area of New York City to landfills outside of the quarantine area: a pathway analysis of the risk of spread and establishment.

The risk associated with spread of Asian longhorned beetle, Anoplophora glabripennis (Motschulsky), from infested areas in New York City to the wide array of landfills across the eastern United States contracted by the city since 1997 was unknown, but of great concern. Landfills, some as far as South Carolina, Virginia, and Ohio, occupied forest types and climates at high risk of Asian longhorned beetle establishment. The city proposed a separate waste wood collection known as the "311 System;" this was estimated to cost federal and state agencies $6.1 to $9.1 million per year, including the cost of processing and disposal of the wood. Pathway analysis was used to quantify the probability that Asian longhorned beetle present in wood waste collected at curbside would survive transport, compaction, and burial to form a mated pair. The study found that in seven alternate management scenarios, risks with most pathways are very low, especially given existing mitigations. Mitigations included chemical control, removal of infested trees, and burial of wood waste in managed landfills that involved multiple-layering, compaction, and capping of dumped waste with a 15-cm soil cover at the end of each day. Although the risk of business-as-usual collection and disposal practices was virtually nil, any changes of policy or practice such as illegal dumping or disposal at a single landfill increased the risk many thousandfold. By rigorously maintaining and monitoring existing mitigations, it was estimated that taxpayers would save $75 to $122 million dollars over the next decade.

Nicotine replacement therapy for smoking cessation.

BACKGROUND: The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes. OBJECTIVES: The aims of this review were:to determine the effectiveness of the different forms of NRT (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; to determine its effectiveness compared to other pharmacotherapies. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group trials register in March 2004. SELECTION CRITERIA: Randomized trials in which NRT was compared to placebo or to no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow up of less than six months. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate on the type of participants, the dose, duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months of follow up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. For each study we calculated summary odds ratios. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed effect model. MAIN RESULTS: We identified 123 trials; 103 contributing to the primary comparison between NRT and a placebo or non-NRT control group. The odds ratio (OR) for abstinence with NRT compared to control was 1.77 (95% confidence intervals (CI): 1.66 to 1.88). The ORs for the different forms of NRT were 1.66 (95% CI: 1.52 to 1.81) for gum, 1.81 (95% CI: 1.63 to 2.02) for patches, 2.35 (95% CI: 1.63 to 3.38) for nasal spray, 2.14 (95% CI: 1.44 to 3.18) for inhaled nicotine and 2.05 (95% CI: 1.62 to 2.59) for nicotine sublingual tablet/lozenge. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2 mg gum (OR 2.20, 95% CI: 1.85 to 3.25). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy. In this study quit rates with bupropion were higher than with nicotine patch or placebo. REVIEWERS' CONCLUSIONS: All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase the odds of quitting approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT.

The leaching of inorganic species from activated carbons produced from waste tyre rubber.

Waste tyre rubber can be used as a precursor for the production of high quality activated carbons. However, there is concern that inorganic impurities present in the rubber feed may restrict their use in liquid phase applications with high purity requirements. This paper presents an investigation of the presence and the leaching of inorganic species from activated carbons derived from waste tyre rubber. For the purpose of this work, a number of carbons were produced, characterised for their BET surface area and analysed for their inorganic composition. Subsequently, a number of tests were performed to evaluate the leaching of different inorganic species into solution at various pH values and carbon doses. Results showed that rubber-derived carbons contained elevated concentrations of sulphur and zinc, as well as traces of other metals such as lead, cadmium, chromium and molybdenum. Inorganic levels were significantly affected by production conditions, particularly degree of carbon activation and the nature of the gasification agent. However, leaching tests showed that the availability of these species in neutral pH conditions was very limited. Results demonstrated that, when using carbons doses comparable to those employed in water treatment works, only sulphur levels exceeded, in some occasions, health based quality standards proposed for drinking water.

Nicotine replacement therapy for smoking cessation.

BACKGROUND: The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes. OBJECTIVES: The aims of this review were to determine the effectiveness of the different forms of nicotine replacement therapy (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; and to determine its effectiveness compared to other pharmacotherapies. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group trials register in July 2002. SELECTION CRITERIA: Randomized trials in which NRT was compared to placebo or no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow-up of less than six months. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate on the type of subjects, the dose and duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed effects model (Peto). MAIN RESULTS: We identified 110 trials; 96 with a non NRT control group. The odds ratio for abstinence with NRT compared to control was 1.74 (95% confidence interval 1.64 - 1.86), The odds ratios for the different forms of NRT were 1.66 for gum, 1.74 for patches, 2.27 for nasal spray, 2.08 for inhaled nicotine and 2.08 for nicotine sublingual tablet/lozenge. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2mg gum (odds ratio 2.67, 95% confidence interval 1.69 - 4.22). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy, in which bupropion was significantly more effective than nicotine patch or placebo. REVIEWER'S CONCLUSIONS: All of the commercially available forms of NRT (nicotine gum, transdermal patch, the nicotine nasal spray, nicotine inhaler and nicotine sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. There is promising evidence that bupropion may be more effective than NRT (either alone or in combination). However, its most appropriate place in the therapeutic armamentarium requires further study and consideration.

Nicotine replacement therapy for smoking cessation.

BACKGROUND: The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes. OBJECTIVES: The aims of this review were to determine the effectiveness of the different forms of nicotine replacement therapy (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; and to determine its effectiveness compared to other pharmacotherapies. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group trials register in April 2001. SELECTION CRITERIA: Randomized trials in which NRT was compared to placebo or no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow-up of less than six months. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate on the type of subjects, the dose and duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measures was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed effects model (Peto). MAIN RESULTS: We identified 108 trials; 94 with a non NRT control group. The odds ratio for abstinence with NRT compared to control was 1.73 (95% confidence interval 1.62-1.85), The odds ratios for the different forms of NRT were 1.66 for gum, 1.76 for patches, 2.27 for nasal spray, 2.08 for inhaled nicotine and 1.73 for nicotine sublingual tablet. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2mg gum (odds ratio 2.67, 95% confidence interval 1.69 to 4.22). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy, in which bupropion was significantly more effective than nicotine patch or placebo. REVIEWER'S CONCLUSIONS: All of the commercially available forms of NRT (nicotine gum, transdermal patch, the nicotine nasal spray, nicotine inhaler and nicotine sublingual tablets) are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. There is promising evidence that bupropion may be more effective than NRT (either alone or in combination). However, its most appropriate place in the therapeutic armamentarium requires further study and consideration.

Neural analysis of visual information during locomotion.

For most vertebrate species, vision is critical during locomotion. In this review, we survey what is known about neural mechanisms that might be involved in this visual analysis. Problems that such mechanisms are likely to solve include: (1) determination of heading (the discrepancy between an observer's direction of motion and direction of gaze); (2) detection of course changes; (3) setting of courses using goals and landmarks; (4) obstacle avoidance; (5) accurate foot placement. To understand how the visual system handles these tasks, we must first consider what neurons 'see' during locomotion: this is determined both by an observer's motion and by his gaze. We then review response properties of neurons in the cortical 'motion pathways' of the monkey and cat as they relate to problems encountered during locomotion. The most studied areas are the medial superior temporal area in the monkey, which has been linked to heading determination, and the lateral suprasylvian area in the cat, where many cells are sensitive to motion in depth, and some are selective for optic flow patterns generated during locomotion. A few subcortical populations have also been linked to visual analysis during locomotion. Most notable are cells in the pigeon's nucleus rotundus: these respond selectively to looming stimuli, some firing at a specific time before the stimulus collides with the bird. Another intriguing population is in the cat's visual pontine nucleus, where cells respond to large displays suggestive of optic flow during locomotion.

Prolonged survival of axons terminating within lesions of cat visual cortex.

It is well known that brain lesions made by the injection of ibotenic acid destroy neuronal cell bodies but do not kill passing axons. We have found that axons terminating within such lesions in visual cortex also survive for at least 2 months, despite the absence of available synaptic sites. We made tracer injections in area 17, and observed dense patches of anterograde label within lesions in other visual cortical areas. Furthermore, because the retinotopic site of the tracer injection was known, we could conclude that the retinotopic site was encompassed within the lesion.

Smoking cessation: a consensus statement with special reference to primary care.

Nicotine addiction is a serious medical condition that needs to be treated like any other chronic disease. Primary care must play a key role in smoking cessation and offering help should be a routine part of primary care practice. As the most frequent opportunity for intervention lies within primary care, GPs should ensure that they raise the issue of stopping smoking at least annually with their smoking patients. When the smoker is ready to stop, the initial personal involvement of the GP is likely to increase the chance of a successful quit attempt. Follow-up may be with another healthcare professional. The support of healthcare professionals for the smoker who is motivated to quit, combined with appropriate pharmacotherapy, can substantially increase the chances of a successful quit attempt. Secondary care staff should also make every effort to help people to stop smoking and should communicate effectively with primary care--opportunities during hospitalisation are frequently missed. Specialist smoking cessation clinics have an essential role in providing more intensive specialist treatment and the expertise to partner and support the primary care effort. Smoking cessation is one of the most cost-effective healthcare interventions that can be made.