Enhanced recovery in cranial surgery (ERACraS) - A single-centre quality improvement study.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a well-established, protocol-driven, evidence-based approach to peri-operative care. ERAS protocols have been used to improve patient morbidity and mortality outcomes in various surgical specialties. More recently, it has been introduced to neurosurgery. Our aim was to establish an Enhanced Recovery After Cranial Surgery (ERACraS) protocol for patients as part of a quality improvement project (QIP) with the intention of reducing hospital length of stay (HLOS). METHODS: This QIP was carried out in the Department of Neurosciences (DCN), Edinburgh, over two four-month periods. A total of 40 patients over 18 years of age undergoing elective craniotomy surgery under a sole neurosurgeon were invited to take part in this QIP. Subsequently, data was retrospectively collected through our institution's online documentation system. RESULTS: 19 patients received conventional perioperative care (pre-ERACraS group) during December 2021-March 2022, and 21 received care according to the novel ERACraS (ERACraS group) during June-September 2022. Regarding supra-tentorial surgery, there was a reduction of 73% in HLOS in the ERACraS group. No change was observed in infra-tentorial surgery. Overall, the ERACraS protocol reduced HLOS by 50% in cranial surgery. CONCLUSION: The QIP data from ERACraS in our unit has shown that implementing ERAS protocols is feasible. A reduction in HLOS has implications for patient morbidity, mortality, and quality of care. We endeavour to collect long-term data by collaborating with neurosurgical units across the UK and Ireland to validate its feasibility and sustainability as part of a major QIP in neurosurgical practice. This can be potentially adopted by neurosurgical centres across the globe in a safe and sustained manner.

The impact of a dedicated social media strategy on enhancing surgical education.

PURPOSE: Social media (SoMe) is increasingly important in surgical education and may be necessary in the current learning environment. Whilst expanding in use and applications, few studies detail the impact of SoMe on measurable outcomes. The goal of this study was to quantify the impact of a dedicated SoMe strategy on engagement metrics for surgical research. METHODS: A retrospective review of a peer-reviewed surgical journal's Twitter microblog platform (@ColorectalDis) was performed from 6/2015 to 4/2021. A formal SoMe strategy was introduced in September 2018. Data were stratified into 2 time periods: pre-intervention (6-2015 to 9-2018) and post-SoMe intervention (9-2018 to 4-2021). The main outcome was the impact of the SoMe strategy on user engagement with the Twitter platform, journal, and traditional journal metrics. Twitter Analytics and Twitonomy were used to analyse engagement. RESULTS: From conception to analysis, the microblog published 1198 original tweets, generating 5 million impressions and 231,000 engagements. Increased account activity (increased tweets published per month-5.51 vs 28.79; p < 0.01) was associated with significant engagement growth, including new monthly followers (213 vs 38; p < 0.01) and interactions with posted articles (4,096,167 vs 269,152; p < 0.01). Article downloads increased twenty-fold post-SoMe intervention (210,449 vs 10,934; p < 0.01), with significant increases in traditional journal metrics of new subscribers (+11%), article submissions (+24%), and impact factor (+0.9) (all p < 0.01). CONCLUSION: SoMe directly impacts traditional journal metrics in surgical research. By examining the patterns of user engagement between SoMe and journal sites, the growing beneficial impact of a structured social media strategy and SoMe as an educational tool is demonstrated.

Global Incidence and Risk Factors Associated With Postoperative Urinary Retention Following Elective Inguinal Hernia Repair: The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) Study.

Importance: Postoperative urinary retention (POUR) is a well-recognized complication of inguinal hernia repair (IHR). A variable incidence of POUR has previously been reported in this context, and contradictory evidence surrounds potential risk factors. Objective: To ascertain the incidence of, explore risk factors for, and determine the health service outcomes of POUR following elective IHR. Design, Setting, and Participants: The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) study, an international, prospective cohort study, recruited participants between March 1 and October 31, 2021. This study was conducted across 209 centers in 32 countries in a consecutive sample of adult patients undergoing elective IHR. Exposure: Open or minimally invasive IHR by any surgical technique, under local, neuraxial regional, or general anesthesia. Main Outcomes and Measures: The primary outcome was the incidence of POUR following elective IHR. Secondary outcomes were perioperative risk factors, management, clinical consequences, and health service outcomes of POUR. A preoperative International Prostate Symptom Score was measured in male patients. Results: In total, 4151 patients (3882 male and 269 female; median [IQR] age, 56 [43-68] years) were studied. Inguinal hernia repair was commenced via an open surgical approach in 82.2% of patients (n = 3414) and minimally invasive surgery in 17.8% (n = 737). The primary form of anesthesia was general in 40.9% of patients (n = 1696), neuraxial regional in 45.8% (n = 1902), and local in 10.7% (n = 446). Postoperative urinary retention occurred in 5.8% of male patients (n = 224), 2.97% of female patients (n = 8), and 9.5% (119 of 1252) of male patients aged 65 years or older. Risk factors for POUR after adjusted analyses included increasing age, anticholinergic medication, history of urinary retention, constipation, out-of-hours surgery, involvement of urinary bladder within the hernia, temporary intraoperative urethral catheterization, and increasing operative duration. Postoperative urinary retention was the primary reason for 27.8% of unplanned day-case surgery admissions (n = 74) and 51.8% of 30-day readmissions (n = 72). Conclusions: The findings of this cohort study suggest that 1 in 17 male patients, 1 in 11 male patients aged 65 years or older, and 1 in 34 female patients may develop POUR following IHR. These findings could inform preoperative patient counseling. In addition, awareness of modifiable risk factors may help to identify patients at increased risk of POUR who may benefit from perioperative risk mitigation strategies.

Strong links between Saharan dust fluxes, monsoon strength, and North Atlantic climate during the last 5000 years.

Despite the multiple impacts of mineral aerosols on global and regional climate and the primary climatic control on atmospheric dust fluxes, dust-climate feedbacks remain poorly constrained, particularly at submillennial time scales, hampering regional and global climate models. We reconstruct Saharan dust fluxes over Western Europe for the last 5000 years, by means of speleothem strontium isotope ratios (87Sr/86Sr) and karst modeling. The record reveals a long-term increase in Saharan dust flux, consistent with progressive North Africa aridification and strengthening of Northern Hemisphere latitudinal climatic gradients. On shorter, centennial to millennial scales, it shows broad variations in dust fluxes, in tune with North Atlantic ocean-atmosphere patterns and with monsoonal variability. Dust fluxes rapidly increase before (and peaks at) Late Holocene multidecadal- to century-scale cold climate events, including those around 4200, 2800, and 1500 years before present, suggesting the operation of previously unknown strong dust-climate negative feedbacks preceding these episodes.

Survival outcomes of elderly patients referred to the lower gastrointestinal 2-week wait service.

AIM: The benefit to elderly patients (≥80 years old) of referral to the resource-intensive lower gastrointestinal 2-week wait (LGI-2WW) pathway is unknown. The aim of this study was to investigate the survival outcome of elderly patients referred to a LGI-2WW service. METHOD: This study comprised a retrospective analysis of a prospectively gathered database of patients referred to a single-centre LGI-2WW service and conformed to STROBE guidelines. The primary outcome was all-cause mortality. Statistical analysis was performed with the chi-square test and Kaplan-Meier survival curves compared with the generalized log-rank test. RESULTS: A total of 10 155 patients referred to the LGI-2WW service between 1 January 2015 and 31 December 2018 were analysed; median follow-up was 37.0 months (range 0-66 months). Six hundred and ninety one cancers were diagnosed (6.8% detection rate); 551 (80%) of these were lower GI cancers (LGICas) [517 (75%) colorectal; 34 (5%) anal]. Forty per cent of LGICas were diagnosed via the LGI-2WW service. Patients aged ≥80 years with LGICa were more likely to be treated with palliative intent [age <80 years, 92/360 (26%) vs. age ≥80 years, 105/191 (55%); p < 0.001]. LGICa patients aged <85 years had a survival difference between those treated with curative intent (LGICa-Cur) or palliative intent (LGICa-Pal) (median survival for patients aged 80-84 years: LGICa-Cur 57 months vs. LGICa-Pal 15 months; p < 0.001). Patients aged ≥85 years did not have any survival difference by treatment intent (median survival for patients aged 85-89 years: LGICa-Cur 31 months vs. LGICa-Pal 16 months; p = 0.062; median survival for patients aged ≥90 years: LGICa-Cur 14 months vs. LGICa-Pal 16 months; p = 0.703). CONCLUSION: Patients with LGICa aged ≥85 years have similar survival whether treated with curative or palliative intent. This can inform management discussions with patients and LGI-2WW referral pathway prioritization approaches.

Implications for the colorectal surgeon following the 100 000 Genomes Project.

AIM: The 100 000 Genomes Project was completed in 2019 with the objective of integrating genomic medicine into routine National Health Service (NHS) clinical pathways. This project and genomic research will revolutionize the way we practice colorectal surgery in the 21st century. This paper aims to provide an overview of genomic medicine and its implications for the colorectal surgeon. RESULTS: Within NHS England, consolidation has created seven regional Genomic Laboratory Hubs. DNA from solid tumours, including colorectal cancers, will be assessed using 500-gene panels, results will be fed back to Genome Tumour Advisory Boards. Identifying variants from biopsies earlier in the clinical pathway may alter surgical and other treatment options for patients. However, there is an important distinction between somatic variants within a tumour biopsy and germline variants that may suggest a heritable condition such as Lynch syndrome. Novel drugs, for example immunotherapy, will increase treatment options including downstaging cancers and changing the surgical approach. The use of circulating tumour DNA (liquid biopsies) will have applications in diagnosis, treatment and surveillance of cancer. There are many exciting potential future applications of this technology for offering personalized medicine that will require multidisciplinary working and the colorectal community. CONCLUSION: There are many challenges but also exciting opportunities to embed new 'omic' technologies and innovation into 21st century colorectal surgery. The next phase for the colorectal community is how we engage with this change, with questions around training, identification of genomic multidisciplinary team (MDT) champions and how we collaborate with the core members of the MDT, clinical geneticists and national genomic testing.

Post-operative and oncological 3-year follow-up outcomes in stage 2 colonic cancer in the emergency and elective setting: a cohort study.

BACKGROUND: Stage 2 colonic cancer comprises a heterogeneous group of patients with a spectrum of disease, from invasion of the sub-serosa to tumour perforation into visceral peritoneum/adjacent organs. This study evaluates the post-operative outcomes and prognostic factors of patients with both emergency and elective presentations of stage 2 colonic cancer treated with curative intent. METHODS: Retrospective analysis of a prospectively maintained database of adult patients (emergency and elective) who underwent curative surgery for stage 2 colonic cancer in a single tertiary referral centre between 2007 and 2016 was conducted. Multivariate analysis was performed to identify prognostic factors. Measured variables included demographics, complications, histology, disease-free survival and overall survival (OS). RESULTS: A total of 428 patients with stage 2 colonic cancer received curative surgical resection, and negative resection margins were achieved in all cases: T3 group (stage 2A): 316 (73.8%); T4a group (stage 2B): 78 patients (18.2%); and T4b group (stage 2C): 34 (8%). There were 187 (45.7%) post-operative complications, 32 (7.5%) anastomotic leaks and eight (1.9%) 30-day mortalities. Eighty patients (19.3%) died during the follow-up. During the follow-up period, 45 patients developed recurrence (all distant). Multivariate analysis identified age >70 years, American Society of Anesthesiologists grades III-IV and male gender as factors associated with poor OS, while recurrence was higher in those aged over 70 years and with stages 2B-2C disease. CONCLUSION: Surgical morbidity in patients with stage 2 colonic cancer who have undergone curative surgery is high. Older and more co-morbid patients have poorer OS. Stages 2B and 2C colon cancer patients have worse prognosis than those with stage 2A regarding recurrence. Future larger data sets are required to determine the role of transmural spread as a prognostic factor.

Inter-hemispheric synchroneity of Holocene precipitation anomalies controlled by Earth's latitudinal insolation gradients.

Atmospheric circulation is a fundamental component of Earth's climate system, transporting energy poleward to partially offset the latitudinal imbalance in insolation. Changes in the latitudinal distribution of insolation thus force variations in atmospheric circulation, in turn altering regional hydroclimates. Here we demonstrate that regional hydroclimates controlled by the Northern Hemisphere mid-latitude storm tracks and the African and South American Monsoons changed synchronously during the last 10 kyrs. We argue that these regional hydroclimate variations are connected and reflect the adjustment of the atmospheric poleward energy transport to the evolving differential heating of the Northern and Southern Hemispheres. These results indicate that changes in latitudinal insolation gradients and associated variations in latitudinal temperature gradients exert important control on atmospheric circulation and regional hydroclimates. Since the current episode of global warming strongly affects latitudinal temperature gradients through Arctic amplification, our results can inform projections of likely inter-hemispheric precipitation changes in the future.

Dating the skull from Broken Hill, Zambia, and its position in human evolution.

The cranium from Broken Hill (Kabwe) was recovered from cave deposits in 1921, during metal ore mining in what is now Zambia1. It is one of the best-preserved skulls of a fossil hominin, and was initially designated as the type specimen of Homo rhodesiensis, but recently it has often been included in the taxon Homo heidelbergensis2-4. However, the original site has since been completely quarried away, and-although the cranium is often estimated to be around 500 thousand years old5-7-its unsystematic recovery impedes its accurate dating and placement in human evolution. Here we carried out analyses directly on the skull and found a best age estimate of 299 ± 25 thousand years (mean ± 2σ). The result suggests that later Middle Pleistocene Africa contained multiple contemporaneous hominin lineages (that is, Homo sapiens8,9, H. heidelbergensis/H. rhodesiensis and Homo naledi10,11), similar to Eurasia, where Homo neanderthalensis, the Denisovans, Homo floresiensis, Homo luzonensis and perhaps also Homo heidelbergensis and Homo erectus12 were found contemporaneously. The age estimate also raises further questions about the mode of evolution of H. sapiens in Africa and whether H. heidelbergensis/H. rhodesiensis was a direct ancestor of our species13,14.

Engineered silver nanoparticle (Ag-NP) behaviour in domestic on-site wastewater treatment plants and in sewage sludge amended-soils.

Untreated sludge from small-scale on-site domestic wastewater treatment systems (septic tanks) was spiked with 20, 60 and 100 nm silver nanoparticles (Ag-NPs) to investigate Ag-NP behaviour in these systems that are widely distributed in rural areas. In addition, the release of Ag-NPs from a previously spiked clay-rich loam reference soil (LUFA 2.4) was evaluated, in the presence and absence of untreated sludge, to simulate the common practice of sludge disposal by spreading on agricultural land. Single particle ICP-MS was used to determine Ag-NP size distribution and the results were compared with total Ag (Ag-NP and ionic) measured in acid digested samples. As documented previously for large municipal scale wastewater treatment plants, Ag-NPs are found to be overwhelmingly (~98%) retained in the sludge in these small-scale systems. The Ag-NP retention efficiency on the LUFA reference soil amended with sludge is approximately 10 times greater than that of LUFA soil alone (in the absence of sludge). For soil spiked with 60 nm Ag-NPs, the calculated average diameter of Ag-NPs in the supernatant, after 24 h was 45 ±â€¯3 nm (dissolution rate 7.2E-06 mol/m2·h for 60 nm Ag-NP), smaller than that of supernatant from the combined sludge/soil system (52 ±â€¯2 nm), indicating lower Ag-NP dissolution rates in the sludge-amended soil. This study provides new information about the leachability of Ag-NPs from septic tank sludge and suggests that the effluent and sludge from septic tanks are potential sources of both nano- and dissolved ionic-Ag to environmental waters.