Drivers and Dynamics of Collaborative Governance in Environmental Management.

This special issue brings together new case studies and comparative works highlighting the drivers and dynamics of collaborative environmental governance. Each case is part of the Collaborative Governance Case Database, which is an open-access resource allowing individuals to contribute and access cases to support research projects. This article highlights the special issue's contributions to collaborative governance theory. Common themes that cut across the studies include: the importance of using a broad definition of collaborative governance to capture the diversity in interorganizational relationships across contexts; improving our understanding of the drivers for initiating collaborative governance; an enhanced understanding collaboration's lifecycle dynamics and developmental trajectories; the importance of individuals and their roles in collaborative processes; the political dynamics of collaboration; the role of accountability; and the challenges associated with assessing the performance of collaborations. Collectively, the cases also demonstrate the value of using resources such as the Collaborative Governance Case Database to undertake small-n and medium-n comparative studies that further theory building.

The pioneers of nephrology - Professor Natalia Tomilina: courage, passion and humanism in medicine.

Listening to the interview of Natalia Tomilina is an inspiring experience, and not one reserved purely for young physicians. Within these pages, one can discover Tomilina's determination and passion for learning that has been with her throughout her life, even during difficult and testing times. A great resolve that she developed through the teachings of her parents and her mentor, Prof. Maria Ratner.It is clear that her ties to her cultural roots are strong, allowing her to have a greater understanding of her patients ("the doctor has to understand the patient"), and with this, she has developed a humanist approach to medicine. These great attributes have ensured that Tomilina's contributions to the field of nephrology have been significant - her belief being that her discoveries in medicine belong to the patients and not to the physicians.Those who are older will find the stories of her trials and tribulations in old Russia fascinating, as you rediscover what life was like for a female scientific researcher behind the "Iron Curtain".I think that, regardless of age, the nephrology community would like to join us in paying homage to a great woman, whose life tells us that changing the world is possible."Prosperity is not the main point, and it is not prosperity that gives you satisfaction."The interview was recorded in Prague in June 2011.

On the shoulders of giants. The story behind the 'Pioneers of Nephrology' project.

This editorial introduces a series of interviews with the pioneers of Nephrology. It's a story that speaks by itself, given the thousands of people that are now alive thanks to the remarkable advances in renal replacement therapies such as dialysis, and kidney transplantation but also the many scientific advances in our understanding of the pathophysiology and treatment of kidney diseases worldwide.The interviews that we have selected for this series are, however, not dealing with their achievements, and their success; they try to pass on to future generations the idea of how they were, why they were passionate, what they loved, and, not last, where they found poetry in our profession.At a time in which narrative medicine points out the importance of the different life experiences in understanding diseases, we would invite you to discover a narrative portrait of the men and women who made our discipline what it is now.

Letter to the editor - round table unites to tackle culture change in an effort to improve animal research reporting.

A round table discussion was held during the LAVA-ESLAV-ECLAM conference on Reproducibility of Animal Studies on the 25th of September 2017 in Edinburgh. The aim of the round table was to discuss how to enhance the rate at which the quality of reporting animal research can be improved. This signed statement acknowledges the efforts that participant organizations have made towards improving the reporting of animal studies and confirms an ongoing commitment to drive further improvements, calling upon both academics and laboratory animal veterinarians to help make this cultural change.

Objective performance indicators of cardiothoracic residents are associated with vascular injury during robotic-assisted lobectomy on porcine models.

Surgical training relies on subjective feedback on resident technical performance by attending surgeons. A novel data recorder connected to a robotic-assisted surgical platform captures synchronized kinematic and video data during an operation to calculate quantitative, objective performance indicators (OPIs). The aim of this study was to determine if OPIs during initial task of a resident's robotic-assisted lobectomy (RL) correlated with bleeding during the procedure. Forty-six residents from the 2019 Thoracic Surgery Directors Association Resident Boot Camp completed RL on an ex vivo perfused porcine model while continuous video and kinematic data were recorded. For this pilot study, RL was segmented into 12 tasks and OPIs were calculated for the initial major task. Cases were reviewed for major bleeding events and OPIs of bleeding cases were compared to those who did not. Data from 42 residents were complete and included in the analysis. 10/42 residents (23.8%) encountered bleeding: 10/40 residents who started with superior pulmonary vein exposure and 0/2 residents who started with pulmonary artery exposure. Twenty OPIs for both hands were assessed during the initial task. Six OPIs related to instrument usage or smoothness of motion were significant for bleeding. Differences were statistically significant for both hands (p < 0.05). OPIs showing bimanual asymmetry indicated lower proficiency. This study demonstrates that kinematic and video analytics can establish a correlation between objective performance metrics and bleeding events in an ex vivo perfused lobectomy. Further study could assist in the development of focused exercises and simulation on objective domains to help improve overall performance and reducing complications during RL.

Short and long-term outcomes of surgical intervention for empyema in the post-fibrinolytic era.

BACKGROUND: Open window thoracostomy (OWT) is indicated for patients with bronchopleural fistula (BPF) or trapped lung in the setting of empyema refractory to non-surgical interventions. We investigated the role of OWT in the era of minimally invasive surgeries, endobronchial valves and fibrinolytic therapy. METHODS: A retrospective chart review of all patients who underwent OWT at a single institution from 2010 to 2020 was performed. Indications for the procedure as well as operative details and morbidity and mortality were evaluated to determine patient outcomes for OWT. RESULTS: Eighteen patients were identified for the study. The most common indication for OWT was post-resectional BPF (n = 9). Prior to OWT, n = 11 patients failed other surgical or minimally invasive interventions. Patient comorbidities were quantified with the Charlson Comorbidity index (n = 11 score ≥ 5, 10-year survival ≤21%). Three (16.7%) patients died < 30 days post-operatively and 12 (66%) patients were deceased by the study's end (overall survival 24.0 ± 32.2 months). Mean number of ribs resected were 2.5 ± 1.2 (range 1-6) with one patient having 6 ribs removed. Patients were managed with negative pressure wound therapy (n = 9) or Kerlix packing (n = 9). Eleven patients (61.6%) underwent delayed closure (mean time from index surgery to closure 4.8 ± 6.7 months). CONCLUSIONS: Our study illustrates the significant comorbidities of patients undergoing OWT, the poor outcomes therein, and pitfalls associated with this procedure. We show that negative pressure wound therapy can be utilized as potential way to obliterate the pleural space and manage an open chest in the absence of an airleak; however, OWT procedures continue to be extremely morbid.

Management of anastomotic leaks after esophagectomy and gastric pull-up.

Anastomotic leak is one of the most feared complications of esophagectomy, leading to prolonged hospital stay, increased postoperative mortality, and additional cost both to the patient and the hospital. Historically, anastomotic leaks have been treated with several techniques including conservative measures, percutaneous or operative drainage, primary surgical repair with buttressing, T-tube drainage, or excision of the esophageal replacement conduit with end esophagostomy. With advances in treatment modalities, including endoscopic stenting, clips and suturing, endoluminal vacuum-assisted closure (EVAC), such leaks increasingly are being managed without operative re-intervention and with salvage of the esophageal replacement conduit. For the purposes of this review, we identified studies analyzing the management of postoperative leak after esophagectomy. We then compared the efficacy of the various newer modalities for closure of anastomotic leaks and gastric conduit defects. We found both esophageal stent and EVAC sponges are effective treatments for closure of anastomotic leak. The chosen treatment modality for salvage of the esophageal replacement conduit is entirely dependent on the patient's clinical status and the surgeon's preference and experience. Emerging endoscopic and endoluminal therapies have increased the armamentarium of tools the esophageal surgeon has to facilitate successful resolution of anastomotic leaks following esophagectomy with reconstruction. While some literature suggests that EVACs have a slightly superior result in conduit success, we question this endorsement as EVACs mostly are utilized for contained leaks, many of which may have healed with conservative measures. This poses a challenge as there is clearly a bias given patient selection.

Utility of erector spinae plane block in thoracic surgery.

BACKGROUND: Thoracic surgeons have been incorporating enhanced recovery after surgery (ERAS) protocols into their practices, not only to reduce narcotic usage but also to improve complication rates and decrease lengths of stay. Here, we describe the utility of a regional block technique that can be used for patients undergoing urgent or elective thoracic surgical procedures or suffering from rib fractures. METHODS: We report our initial one-year experience with these erector spinae plane (ESP) blocks. RESULTS: ESP blocks were placed in 42 patients. The procedure was performed by a trained team of anesthesiologists and certified nurse practitioners. It included placement of a catheter on the ipsilateral chest, followed by a 20 ml of 0.2% ropivacaine bolus and continuous infusion. Patients were then followed by the regional team, as long as the catheter was in place. While it had some technical challenges, the block was effective in 83.3% of patients with no reported mortality or major complications. However, given the confounding factors of the study (such as simultaneous implementation of ERAS protocol) and heterogeneity of the patient population, a control group was difficult to ascertain and meaningful opioid consumption analysis was difficult to perform. CONCLUSIONS: Regional blocks, such as the ESP block, complement fundamental ERAS principles and serve as an adjunct to the available armamentarium for non-narcotic ways to control pain in thoracic surgical and chest trauma patients. Continued collaboration between the thoracic surgeons and anesthesiologists is needed for its success.

Defining the complex epithelia that comprise the canine claw with molecular markers of differentiation.

Canine claws are complex epithelial structures resembling the mammalian hair fibre, and human nail plate, in terms of tissue-specific differentiation. They are composed of several distinct epithelial cell lineages undergoing either hard or soft keratinization. The claw plate has three distinct regions: stratum externum, stratum medium (SM) and stratum internum and the underside and tip are cushioned by a soft keratinizing epithelium, the sole. We have examined keratin expression in the canine claw and associated epithelia. Digits from German shepherd dogs were decalcified, processed and sectioned by sledge microtome. Sections were stained with haematoxylin and eosin or treated with specific antibodies to various keratins (immunohistochemistry). Proteins were extracted from claw components and analysed by SDS-PAGE and Western blotting. The keratinized canine claw plate expressed hair-specific keratins (type I, K25-K38 and type II, K71-K86) but only the inner region of the SM contained K6- and K16-positive tubules, soft epithelia running through the hard keratinized claw plate. The soft keratinaceous sole epithelium expressed keratins K5, K6, K14, K16 and K17 and contained cells with abundant envelopes. The canine claw had two slippage zones, the inner claw bed, between the claw plate and ungula process, which expressed K17 and the region between the inner and outer claw sheath, equivalent to the hair follicle companion layer, which expressed K6, K77, K16 and K17. In conclusion, several different cell types have been defined in the canine claw presenting a complex mechanism of cellular differentiation.