Postoperative mortality and complications in patients with and without pre-operative SARS-CoV-2 infection: a service evaluation of 24 million linked records using OpenSAFELY.

Surgical decision-making after SARS-CoV-2 infection is influenced by the presence of comorbidity, infection severity and whether the surgical problem is time-sensitive. Contemporary surgical policy to delay surgery is informed by highly heterogeneous country-specific guidance. We evaluated surgical provision in England during the COVID-19 pandemic to assess real-world practice and whether deferral remains necessary. Using the OpenSAFELY platform, we adapted the COVIDSurg protocol for a service evaluation of surgical procedures that took place within the English NHS from 17 March 2018 to 17 March 2022. We assessed whether hospitals adhered to guidance not to operate on patients within 7 weeks of an indication of SARS-CoV-2 infection. Additional outcomes were postoperative all-cause mortality (30 days, 6 months) and complications (pulmonary, cardiac, cerebrovascular). The exposure was the interval between the most recent indication of SARS-CoV-2 infection and subsequent surgery. In any 6-month window, < 3% of surgical procedures were conducted within 7 weeks of an indication of SARS-CoV-2 infection. Mortality for surgery conducted within 2 weeks of a positive test in the era since widespread SARS-CoV-2 vaccine availability was 1.1%, declining to 0.3% by 4 weeks. Compared with the COVIDSurg study cohort, outcomes for patients in the English NHS cohort were better during the COVIDSurg data collection period and the pandemic era before vaccines became available. Clinicians within the English NHS followed national guidance by operating on very few patients within 7 weeks of a positive indication of SARS-CoV-2 infection. In England, surgical patients' overall risk following an indication of SARS-CoV-2 infection is lower than previously thought.

A systematic review of local excision followed by adjuvant therapy in early rectal cancer: are pT1 tumours the limit?

AIM: Total mesorectal excision remains the cornerstone of treatment for rectal cancer. Significant morbidity means local excision may be more appropriate in selected patients. Adjuvant therapy reduces local recurrence and improves survival; however, there is a paucity of data on its impact following local excision, which this systematic review aims to address. METHODS: A systematic search of the MEDLINE, Embase and Cochrane databases using validated terms for rectal cancer, adjuvant therapy and local excision was performed. Included studies focused on local excision with adjuvant therapy for adenocarcinoma of the rectum. Primary outcome measures were local recurrence, survival and morbidity. Studies providing neoadjuvant therapy or local excision alone were excluded. RESULTS: Twenty-two studies described 804 patients. Indications for local excision included favourable histology, patient choice and comorbidities. T1, T2 and T3 tumours accounted for 35.1%, 58.0% and 6.9% of cases, respectively. The most frequent local excision technique was transanal excision (77.7%). Adjuvant therapy included long-course chemoradiation or radiotherapy. Median follow-up was 51 months (range 1-165). The pooled local recurrence was 5.8% (95% CI 3.0-9.5) for pT1, 13.8% (95% CI 10.1-17.9) for pT2 and 33.7% (95% CI 19.2-50.1) for pT3 tumours. The overall median disease-free survival was 88% (range 50%-100%) with a pooled overall morbidity of 15.1% (95% CI 11.0-18.7). CONCLUSIONS: This area remains highly relevant to modern clinical practice. The data suggest that local excision followed by adjuvant therapy can achieve acceptable long-term outcomes in high-risk pT1 tumours, but not in T2 tumours and above in whom radical surgery should be offered.

Repeat 2-week wait referrals for colorectal cancer.

AIM: The inappropriate use of the '2-week wait' pathway for suspected colorectal cancer (CRC2ww) may overload urgent clinics and delay the assessment and investigation of other patients. Those who have been previously referred and investigated for suspected colorectal cancer may present one group that does not warrant repeat urgent referral. This paper aims to identify the incidence and diagnostic yield of repeat CRC2ww referrals. METHOD: All CRC2ww patients referred to our unit over a 4-year period were identified retrospectively. Referral indication, outcome and instances of repeat referral were identified from multidisciplinary team, endoscopy and imaging databases. RESULTS: In all, 2735 CRC2ww referrals were made over the study period. Of these, 122 were repeated CRC2ww referrals, with the incidence increasing from 2% in 2008 to 6% in 2010 (P = 0.0006). The median time to repeat referral was 1070 days. After initial referral 267 cancers were detected, including 212 colorectal cancers. The diagnostic yield was lower but not significantly so after repeated referral (six cancers) compared with initial referral (5%vs 10%, P = 0.07). CONCLUSION: The incidence of repeat referral is low but the diagnostic yield is not insignificant. Exclusion of these patients from urgent assessment and investigation will not significantly reduce workload and may risk missing some patients with cancer.

Seeking one's heading through eye movements.

A study of eye movements during simulated travel toward a grove of four stationary trees revealed that observers looked most at pairs of trees that converged or decelerated apart. Such pairs specify that one's direction of travel, called heading, is to the outside of the near member of the pair. Observers looked at these trees more than those that accelerated apart; such pairs do not offer trustworthy heading information. Observers also looked at gaps between trees less often when they converged or diverged apart, and heading can never be between such pairs. Heading responses were in accord with eye movements. In general, if observers responded accurately, they had looked at trees that converged or decelerated apart; if they were inaccurate, they had not. Results support the notion that observers seek out their heading through eye movements, saccading to and fixating on the most informative locations in the field of view.

Heading judgments in minimal environments: the value of a heuristic when invariants are rare.

Observers made systematic heading judgments in two experiments simulating their translation through an environment with only two trees. When those trees converged or decelerated apart, observers tended to follow the invariant information and make heading judgments outside the near member of the pair. When those trees accelerated apart, however, observers tended to follow the heuristic information and make judgments outside the far member, although this result was tempered by the angular separation between the trees and their relative acceleration. The simultaneous existence and use of invariants and heuristics are discussed in terms of different metatheoretical approaches to perception.

Images, imagination, and movement: pictorial representations and their development in the work of James Gibson.

For more than 30 years James Gibson studied pictures and he studied motion, particularly the relationship between movement through an environment and its visual consequences. For the latter, he also struggled with how best to present his ideas to students and fellow researchers, and employed various representations and formats. This article explores the relationships between the concepts of the fidelity of pictures (an idea he first promoted and later eschewed) and evocativeness as applied to his images. Gibson ended his struggle with an image of a bird flying over a plane surrounded by a spherical representation of a vector field, an image high in evocativeness but less than completely faithful to optical flow.

Human heading judgments and object-based motion information.

In four experiments, we explored observers' ability to make heading judgments from simulated linear and circular translations through sparse forests and with pursuit fixation on one tree. We assessed observers' performance and information use in both regression and factorial designs. In all experiments we found that observers used three sources of object-based information to make their judgments--the displacement direction of the nearest object seen (a heuristic), inward displacement towards the fovea (an invariant) and outward deceleration (a second invariant). We found no support for the idea that observers use motion information pooled over regions of the visual field.

Comparing effects of the horizontal-vertical illusion on grip scaling and judgment: relative versus absolute, not perception versus action.

The discovery that the prehension component of an open-loop, two-fingered reach is largely immune to certain salient pictorial illusions has been used to suggest that humans possess 2 distinct visual systems, 1 that subserves perceptual judgment and 1 that mediates visually controlled action. In this article, the authors present evidence that suggests that the critical distinction is not that of reaching and judgment but of relative and absolute perception. Experiment 1 extends the findings of S. Aglioti, J. F. X. DeSouza, and M. A. Goodale (1995) and suggests that the manual prehension component of open-loop reaching is affected by the horizontal-vertical illusion to a much smaller degree than perceptual size judgments. In Experiments 2 and 3, however, when perceptual size judgment is directed at a single element of the display, this difference vanishes. Experiment 4 demonstrates that grip scaling is strongly affected by the illusion when a single reach is scaled to both the horizontal and vertical components of a triangular figure.

Heading and path information from retinal flow in naturalistic environments.

In four experiments, we explored the heading and path information available to observers as we simulated their locomotion through a cluttered environment while they fixated an object off to the side. Previously, we presented a theory about the information available and used in such situations. For such a theory to be valid, one must be sure of eye position, but we had been unable to monitor gaze systematically; in Experiment 1, we monitored eye position and found performance best when observers fixated the designated object at the center of the display. In Experiment 2, when we masked portions of the display, we found that performance generally matched the amount of display visible when scaled to retinal sensitivity. In Experiments 3 and 4, we then explored the metric of information about heading (nominal vs. absolute) available and found good nominal information but increasingly poor and biased absolute information as observers looked farther from the aimpoint. Part of the cause for this appears to be that some observers perceive that they have traversed a curved path even when taking a linear one. In all cases, we compared our results with those in the literature.

Wayfinding, displacements, and mental maps: velocity fields are not typically used to determine one's aimpoint.

When an individual moves through a cluttered environment, he or she often fixates an object relatively near his or her path in the middle distance and uses pursuit eye movements to follow it while moving forward. On the basis of previous evidence, either motion fields or displacement fields around the fixated object--two alternative representations of the same information--could be used to determine one's direction of self-movement, sometimes called heading or aimpoint. In a series of 5 experiments, the relationship between these representations was explored and it was found that the displacements of identifiable objects, not their motions, are most likely the direct inputs for wayfinding. It may be that these inputs are used in conjunction with a mental map to determine one's aimpoint. A mathematical framework for this process is proposed.

Selectivity, scope, and simplicity of models: a lesson from fitting judgments of perceived depth.

When comparing psychological models a researcher should assess their relative selectivity, scope, and simplicity. The third of these considerations can be measured by the models' parameter counts or equation length, the second by their ability to fit random data, and the first by their differential ability to fit patterned data over random data. These conclusions are based on exploration of integration models reflecting depth judgments. Replication of Massaro's (1988a) results revealed an additive model (Bruno & Cutting, 1988), and Massaro's fuzzy-logical model of perception (FLMP) fit data equally well, but further exploration showed that the FLMP fit random data better. The FLMP's successes may reflect not its sensitivity in capturing psychological process but its scope in fitting any data and its complexity as measured by equation length.

Wayfinding on foot from information in retinal, not optical, flow.

People find their way through cluttered environments with ease and without injury. How do they do it? Two approaches to wayfinding are considered: Differential motion parallax (DMP) is a retinal motion invariant of near and far objects moving against fixation; the information in optical flow (IOF) is a radial pattern of vectors, relying on decomposition of retinal flow. Evidence is presented that DMP guides wayfinding during natural gait, accounting for errors as well as correct responses. Evidence against IOF is also presented, and a space-time aliasing artifact that can contaminate IOF displays is explored. Finally, DMP and IOF are separated, showing they can yield different results in different environments. Thus, it is concluded that (a) DMP and IOF are different, (b) DMP and not IOF is used for wayfinding, (c) moving observers do not usually decompose retinal flow, and (d) optical flow may be a mathematical fiction with no psychological reality.

Compensation is unnecessary for the perception of faces in slanted pictures.

In four experiments, we explored the perception of facial distortions seen in pictures viewed from the side or from above or below. In all four, however, we disguised the slant of the picture surface by using a double-projection technique that removed binocular and monocular cues: Faces were digitized, distorted to mimic a particular slant behind the image plane, cropped to a frame, and presented to viewers for their judgments. In the first experiment, we found that simulated rotations around a horizontal axis (pictures seen as if from above or below) created more noticeable distortions in faces than did simulated rotations around a vertical axis (pictures seen as if from the left or right). In the second experiment, pursuing a result from the first but with a between-subjects design, we found that pictured faces with a slant around a vertical axis of 22 degrees were seen as having no more distortion than unslanted faces. In the third experiment, we placed each image within a frame slanted either in the same way as or differently from the picture, and found no effect of frame. In the fourth experiment, we determined that viewers had little ability to match appropriately slanted frames with slanted pictures. Thus, we claim that part of the reason why one can look at moderately slanted pictures without perceptual interference is that the distortions in the image are subthreshold, or perhaps within the bounds of acceptability. These results contrast with the generally accepted theory that viewers mentally compensate for distortions in moderately slanted pictures.

Additivity, subadditivity, and the use of visual information: a reply to Massaro (1988).

Previously we (Bruno & Cutting, 1988) explored the perception of spatial relations among objects laid out in a computer-generated environment. In his commentary on our article, Massaro (1988) raised several issues. The most important is from his reanalysis, which indicated that--because of a subadditive trend in the results--additive and multiplicative strategies fit our data in Experiment 1 about equally well. In reply, we performed a different analysis. Results corroborate subadditivity--and hence multiplicative information combination--in Experiment 1 but provide no evidence for it in Experiments 2 and 3. On the whole, then, the results still support additivity more strongly than any other combination rule and thus support our notion of minimodularity.

Minimodularity and the perception of layout.

In natural vision, information overspecifies the relative distances between objects and their layout in three dimensions. Directed perception applies (Cutting, 1986), rather than direct or indirect perception, because any single source of information (or cue) might be adequate to reveal relative depth (or local depth order), but many are present and useful to observers. Such overspecification presents the theoretical problem of how perceivers use this multiplicity of information to arrive at a unitary appreciation of distance between objects in the environment. This article examines three models of directed perception: selection, in which only one source of information is used; addition, in which all sources are used in simple combination; and multiplication, in which interactions among sources can occur. To monocular spatial information, using all combinations of the presence or absence of relative size, height in the projection plane, occlusion, and motion parallax. Visual stimuli were computer generated and consisted of three untextured parallel planes arranged in depth. Three tasks were used: one of magnitude estimation of exocentric distance within a stimulus, one of dissimilarity judgment in how a pair of stimuli revealed depth, and one of choice judgment within a pair as to which one revealed depth best. Grouped and individual results of the one direct and two indirect scaling tasks suggest that perceivers use these sources of information in an additive fashion. That is, one source (or cue) is generally substitutable for another, and the more sources that are present, the more depth is revealed. This pattern of results suggests independent use of information by four separate, functional subsystems within the visual system, here called minimodules. Evidence for and advantages of minimodularity are discussed.

Affine distortions of pictorial space: some predictions for Goldstein (1987) that La Gournerie (1859) might have made.

Goldstein (1987) studied the perception of pictures seen from the front and the side. Several distinctions arose from his results and analysis, but only one is central to the reanalysis presented here: The perceived orientation of objects within a picture with respect to the external world is a function of viewer position in front of the picture. For example, the eyes of a portrait subject appear to follow an observer who moves around a gallery. Viewed from many positions, such objects can be said to rotate, following a mobile viewer. Goldstein called this the differential rotation effect because those objects that point directly out of the picture (at 90 degrees) rotate most; those pointing at other angles rotate in decreasing amounts. Goldstein offered no theoretical model and little in the way of explanation for this effect. This Observation offers a model based on the affine geometry and the analyses of La Gournerie (1859). This analysis transforms pictorial space (the space behind a photograph or representational picture) by shears, compressions, and dilations according to the viewpoint of the observer in relation to the composition point of the picture. These effects account for Goldstein's differential rotation effect quite well.

Rigidity in cinema seen from the front row, side aisle.

Pictures and cinema seen at a slant present the optics of virtual objects that are distorted and inconsistent with their real counterparts. In particular, it should not be possible for moving objects on slanted film and television screens to be seen as rigid, at least according to rules of linear perspective. Previous approaches to this problem have suggested that some process (perhaps cognitive) rectifies the optics of objects in slanted pictures to derive true shape and preserve shape constancy. The means for this rectification is usually thought to be based on recovery of true screen slant. In three experiments I show that this account is unnecessary and insufficient to explain the perception of rotating, rectangular objects in slanted cinema. I present data in favor of an alternate view, one in which the information is sufficient for perceivers to determine rigidity in an object on slanted screens, at least for parallel projections. In the human visual system, local measurements of objects are apparently made according to projective geometry; in those measurements, small amounts of certain distortions in projection are tolerated. Stimuli that appear nonrigid are ones that violate certain local principles, known as Perkins's laws, of projections of rectangular solids.