Can the Reboot coaching programme support critical care nurses in coping with stressful clinical events? A mixed-methods evaluation assessing resilience, burnout, depression and turnover intentions.

BACKGROUND: Critical care nurses (CCNs) are routinely exposed to highly stressful situations, and at high-risk of suffering from work-related stress and developing burnout. Thus, supporting CCN wellbeing is crucial. One approach for delivering this support is by preparing CCNs for situations they may encounter, drawing on evidence-based techniques to strengthen psychological coping strategies. The current study tailored a Resilience-boosting psychological coaching programme [Reboot] to CCNs. Other healthcare staff receiving Reboot have reported improvements in confidence in coping with stressful clinical events and increased psychological resilience. The current study tailored Reboot for online, remote delivery to CCNs (as it had not previously been delivered to nurses, or in remote format), to (1) assess the feasibility of delivering Reboot remotely, and to (2) provide a preliminary assessment of whether Reboot could increase resilience, confidence in coping with adverse events and burnout. METHODS: A single-arm mixed-methods (questionnaires, interviews) before-after feasibility study design was used. Feasibility was measured via demand, recruitment, and retention (recruitment goal: 80 CCNs, retention goal: 70% of recruited CCNs). Potential efficacy was measured via questionnaires at five timepoints; measures included confidence in coping with adverse events (Confidence scale), Resilience (Brief Resilience Scale), depression (PHQ-9) and burnout (Oldenburg-Burnout-Inventory). Intention to leave (current role, nursing more generally) was measured post-intervention. Interviews were analysed using Reflexive Thematic Analysis. RESULTS: Results suggest that delivering Reboot remotely is feasible and acceptable. Seventy-seven nurses were recruited, 81% of whom completed the 8-week intervention. Thus, the retention rate was over 10% higher than the target. Regarding preliminary efficacy, follow-up measures showed significant increases in resilience, confidence in coping with adverse events and reductions in depression, burnout, and intention to leave. Qualitative analysis suggested that CCNs found the psychological techniques helpful and particularly valued practical exercises that could be translated into everyday practice. CONCLUSION: This study demonstrates the feasibility of remote delivery of Reboot and potential efficacy for CCNs. Results are limited due to the single-arm feasibility design; thus, a larger trial with a control group is needed.

[Prioritized appointment allocation in new patients, what is really decisive? : Comparative analysis of manual appointment allocation with automated and AI-assisted approaches]. / Priorisierte Terminvergabe bei Neuvorstellungen: Was ist wirklich entscheidend? : Vergleichende Analyse manueller Terminallokation mit automatisierten und KI-gestützten Ansätzen.

BACKGROUND: The timely allocation of appointments for new patients is a daily challenge in rheumatological practice, which can be supported by digital solutions. The question is to find the simplest and most effective possible method for prioritization when allocating appointments. METHODS: Using a registration form for new patients, standardized symptoms and laboratory results were collated. After reviewing this information by a medical specialist the allocation of appointments was carried out in three categories: a) < 6 weeks, b) 6 weeks up to 3 months and c) > 3 months. The waiting time between the time of registration and the presentation appointment was calculated and compared between patients with and without a diagnosis of an inflammatory rheumatic disease (IRD). In addition a decision tree (DT), a method taken from the field of supervised learning within artificial intelligence (AI), was established and the resulting classification was compared with respect to the accuracy and calculated saving in waiting time. RESULTS: In this study 800 appointments between 2020 and 2023 (including 555 women, 69.4%, median age 53 years, interquartile range, IQR 39-63 years) were analyzed. An IRD could be confirmed in 409 (51.1%) cases with a waiting time of 58 vs. 93 days for non-IRD cases (-38%, p < 0.01). An AI-based stratification resulted in an accuracy of 67% for IRD and a predicted saving of 19% waiting time. The accuracy increased up to 78% with a time saving for IRD cases of up to 31%, when all basic laboratory results were known. Simplified algorithms, e.g., stratification by the use of laboratory findings alone, resulted in a lower accuracy and time savings. CONCLUSION: Manual allocation of appointments by a medical specialist is effective and significantly reduces the waiting times for patients with IRD. An automated categorization can lead to a reduction in waiting times for appointments when taking complete laboratory results and a lower sensitivity into consideration.

Rectal perforation after aquablation of the prostate: lessons learned the hard way.

INTRODUCTION: Transurethral resection of the prostate and open prostatectomy have been the standard of care for the surgical treatment of benign prostatic obstruction (BPO) over decades. New emerging techniques for the surgical management of BPO have been currently introduced, but might be associated with new, unusual complications. METHODS: We herewith report on two patients with a rectal perforation after aquablation treatment of BPO. RESULTS: In the first case, the diagnosis was made 2 days after the aquablation procedure due to unspecific postoperative symptoms. A complex combined open/endoscopic repair of the defect was carried out thereafter. As a consequence, a rectoscopy was routinely performed since then following each aquablation procedure. In the second case, intraoperative rectoscopy after uneventful aquablation revealed the rectal perforation. The perforation was clipped immediately with an over the scope-clip by colonoscopy. CONCLUSIONS: These two cases of a rectal perforation after aquablation of the prostate demonstrate an unusual complication and its complex management. Diagnostic delay complicates its treatment. Therefore, immediate rectoscopy should be performed routinely after the aquablation procedure.

EAACI Position paper on the standardization of nasal allergen challenges.

Nasal allergen challenge (NAC) is an important tool to diagnose allergic rhinitis. In daily clinical routine, experimentally, or when measuring therapeutic success clinically, nasal allergen challenge is fundamental. It is further one of the key diagnostic tools when initiating specific allergen immunotherapy. So far, national recommendations offered guidance on its execution; however, international divergence left many questions unanswered. These differences in the literature caused EAACI to initiate a task force to answer unmet needs and find a consensus in executing nasal allergen challenge. On the basis of a systematic review containing nasal allergen challenges of the past years, task force members reviewed evidence, discussed open issues, and studied variations of several subjective and objective assessment parameters to propose a standardized way of a nasal allergen challenge procedure in clinical practice. Besides an update on indications, contraindications, and preparations for the test procedure, main recommendations are a bilaterally challenge with standardized allergens, with a spray device offering 0.1 mL per nostril. A systematic catalogue for positivity criteria is given for the variety of established subjective and objective assessment methods as well as a schedule for the challenge procedure. The task force recommends a unified protocol for NAC for daily clinical practice, aiming at eliminating the previous difficulty of comparing NAC results due to unmet needs.

The new agreement of the international RIGA consensus conference on nasal airway function tests.

The report reflects an agreement based on the consensus conference of the International Standardization Committee on the Objective Assessment of the Nasal Airway in Riga, 2nd Nov. 2016. The aim of the conference was to address the existing nasal airway function tests and to take into account physical, mathematical and technical correctness as a base of international standardization as well as the requirements of the Council Directive 93/42/EEC of 14 June 1993 concerning medical devices. Rhinomanometry, acoustic rhinometry, peak nasal inspiratory flow, Odiosoft-Rhino, optical rhinometry, 24-h measurements, computational fluid dynamics, nasometry and the mirrow test were evaluated for important diagnostic criteria, which are the precision of the equipment including calibration and the software applied; validity with sensitivity, specificity, positive and negative predictive values, reliability with intra-individual and inter-individual reproducibility and responsiveness in clinical studies. For rhinomanometry, the logarithmic effective resistance was set as the parameter of high diagnostic relevance. In acoustic rhinometry, the area of interest for the minimal cross-sectional area will need further standardization. Peak nasal inspiratory flow is a reproducible and fast test, which showed a high range of mean values in different studies. The state of the art with computational fluid dynamics for the simulation of the airway still depends on high performance computing hardware and will, after standardization of the software and both the software and hardware for imaging protocols, certainly deliver a better understanding of the nasal airway flux.

Antimicrobial Packaging for Extending the Shelf Life of Bread-A Review.

Antimicrobial packaging is an important form of active packaging that can release antimicrobial substances for enhancing the quality and safety of food during extended storage. It is in response to consumers demand for preservative-free food as well as more natural, disposable, biodegradable, and recyclable food-packaging materials. The potential of a combination of allyl isothiocyanate and potassium sorbate incorporated into polymers in providing the needed natural antimicrobial protection for bread products is discussed. The role of double extrusion process as a means for obtaining a homogeneous mix of the sorbate into the polymer (polyethylene or ethylenevinyalcohol), is highlighted.

Contrast Enhanced Ultrasound can Replace Computed Tomography Angiography for Surveillance After Endovascular Aortic Aneurysm Repair.

OBJECTIVE/BACKGROUND: Surveillance after endovascular aortic aneurysm repair (EVAR) is mandatory and computed tomography angiography (CTA) is considered the standard imaging modality, although patients are exposed to ionizing radiation and nephrotoxic contrast medium. The primary aim of this study was to determine the diagnostic efficacy of duplex ultrasound (DUS) and contrast enhanced ultrasound (CEUS) using CTA as the gold standard. The secondary aim was to determine the clinical consequences of endoleaks missed by DUS and CEUS, or CTA. METHODS: All patients with EVAR for an aorto-iliac aneurysm between 1 August 2011 and 31 October 2014 were prospectively and consecutively enrolled. CEUS was added to the existing surveillance protocol, which included DUS, plain abdominal X-ray, and CTA at 3 and 12 months after stent implantation. RESULTS: In 278 patients, endoleaks were detected in 68, 69, and 46 cases by CTA, CEUS, and DUS, respectively. The sensitivity and specificity of DUS and CEUS were 46% and 93%, and 85% and 95%, respectively. CEUS and CTA were diagnostically equivalent, as opposed to DUS and CTA (p = .002). Endoleaks detected by CTA led to re-intervention in 11 (4%) patients. These endoleaks were also detected by CEUS; however, three out of 11 patients were missed by DUS and underwent re-intervention: limb extension, re-cuff, and attempt to coil lumbar leaks. Endoleaks missed by CEUS or CTA were type II endoleaks without sac expansion. CONCLUSION: In surveillance programs after EVAR a diagnostic CEUS examination may replace CTA.

Vulnerability of tropical forest ecosystems and forest dependent communities to droughts.

Energy captured by and flowing through a forest ecosystem can be indexed by its total Net Primary Productivity (NPP). This forest NPP can also be a reflection of its sensitivity to, and its ability to adapt to, any climate change while also being harvested by humans. However detecting and identifying the vulnerability of forest and human ecosystems to climate change requires information on whether these coupled social and ecological systems are able to maintain functionality while responding to environmental variability. To better understand what parameters might be representative of environmental variability, we compiled a metadata analysis of 96 tropical forest sites. We found that three soil textural classes (i.e., sand, sandy loam and clay) had significant but different relationships between NPP and precipitation levels. Therefore, assessing the vulnerability of forests and forest dependent communities to drought was carried out using data from those sites that had one of those three soil textural classes. For example, forests growing on soil textures of sand and clay had NPP levels decreasing as precipitation levels increased, in contrast to those forest sites that had sandy loam soils where NPP levels increased. Also, forests growing on sandy loam soil textures appeared better adapted to grow at lower precipitation levels compared to the sand and clay textured soils. In fact in our tropical database the lowest precipitation level found for the sandy loam soils was 821 mm yr(-1) compared to sand at 1739 mm yr(-1) and clay at 1771 mm yr(-1). Soil texture also determined the level of NPP reached by a forest, i.e., forest growing on sandy loam and clay reached low-medium NPP levels while higher NPP levels (i.e., medium, high) were found on sand-textured soils. Intermediate precipitation levels (>1800-3000 mm yr(-1)) were needed to grow forests at the medium and high NPP levels. Low thresholds of NPP were identified at both low (∼750 mm) and high precipitation (>3500 mm) levels. By combining data on the ratios of precipitation to the amount of biomass produced in a year with how much less precipitation input occurs during a drought year, it is possible to estimate whether productivity levels are sufficient to support forest growth and forest dependent communities following a drought. In this study, the ratios of annual precipitation inputs required to produce 1 Mg ha(-1) yr(-1) biomass by soil texture class varied across the three soil textural classes. By using a conservative estimate of 20% of productivity collected or harvested by people and 30% precipitation reduction level as triggering a drought, it was possible to estimate a potential loss of annual productivity due to a drought. In this study, the total NPP unavailable due to drought and harvest by forest dependent communities per year was 10.2 Mg ha(-1) yr(-1) for the sandy textured soils (64% of NPP still available), 8.4 Mg ha(-1) yr(-1) for the sandy loam textured soils (60% available) and 12.7 Mg ha(-1) yr(-1) for the clay textured soils (29% available). Forests growing on clay textured soils would be most vulnerable to drought triggered reductions in productivity so NPP levels would be inadequate to maintain ecosystem functions and would potentially cause a forest-to-savanna shift. Further, these forests would not be able to provide sufficient NPP to satisfy the requirements of forest dependent communities. By predicting the productivity responses of different tropical forest ecosystems to changes in precipitation patterns coupled with edaphic data, it could be possible to spatially identify where tropical forests are most vulnerable to climate change impacts and where mitigation efforts should be concentrated.

Human CD45RA(-) FoxP3(hi) Memory-Type Regulatory T Cells Show Distinct TCR Repertoires With Conventional T Cells and Play an Important Role in Controlling Early Immune Activation.

Adoptive immunotherapy with regulatory T cells (Treg) is a new option to promote immune tolerance following solid organ transplantation (SOT). However, Treg from elderly patients awaiting transplantation are dominated by the CD45RA(-) CD62L(+) central memory type Treg subset (TregCM), and the yield of well-characterized and stable naïve Treg (TregN) is low. It is, therefore, important to determine whether these TregCM are derived from the thymus and express high stability, suppressive capacity and a broad antigen repertoire like TregN. In this study, we showed that TregCM use a different T cell receptor (TCR) repertoire from conventional T cells (Tconv), using next-generation sequencing of all 24 Vß families, with an average depth of 534 677 sequences. This showed almost no contamination with induced Treg. Furthermore, TregCM showed enhanced suppressive activity on Tconv at early checkpoints of immune activation controlling activation markers expression and cytokine secretion, but comparable inhibition of proliferation. Following in vitro expansion under mTOR inhibition, TregCM expanded equally as well as TregN without losing their function. Despite relatively limited TCR repertoire, TregCM also showed specific alloresponse, although slightly reduced compared to TregN. These results support the therapeutic usefulness of manufacturing Treg products from CD45RA(-) CD62L(+) Treg-enriched starting material to be applied for adoptive Treg therapy.

Demethylation of the TSDR is a marker of squamous cell carcinoma in transplant recipients.

Malignancy is an important cause of death in transplant recipients. Cutaneous squamous cell carcinoma (cSCC) causes significant morbidity and mortality as 30% of transplant recipients will develop cSCC within 10 years of transplantation. Previously we have shown that high numbers of regulatory T cells (Tregs) are associated with the development of cSCC in kidney transplant recipients (KTRs). Demethylation analysis of the Treg-specific demethylated region (TSDR) provides a more accurate association with cSCC risk after transplantation. Age, gender and duration of immunosuppression matched KTRs with (n=32) and without (n=27) cSCC, were re-analyzed for putative clinical and immunological markers of cancer risk. The proportion of FOXP3+ CD4+ cells was higher in the population with a previous SCC. Major T cell subsets remained stable over time; although B cell, CD8 and CD4 subpopulations demonstrated age-related changes. TSDR methylation analysis allowed clarification of Treg numbers, enhancing the association of high Treg levels in KTRs with cSCC compared to the cSCC-free cohort. These data validate and expand on previous findings in long-term KTRs, and show that immune markers remain stable over time. TSDR demethylation analysis provides a more accurate biomarker of cancer posttransplantation.

Endograft limb occlusion in EVAR: iliac tortuosity quantified by three different indices on the basis of preoperative CTA.

OBJECTIVE: To assess the incidence and outcome of graft limb occlusions after endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) in a high volume single centre. To quantify iliac artery tortuosity in patients with AAA and correlate this with limb occlusion. DESIGN: Data were collected consecutively and prospectively, and analyzed retrospectively. MATERIALS: Patients treated with Zenith bifurcated stent grafts from January 2000 to December 2010 at a tertiary referral vascular unit were analyzed. Routine regular office follow-up with computed tomography angiography (CTA) and, subsequently, duplex ultrasound imaging was performed. Patients with limb occlusions were identified. For each index patient, two controls were obtained, one immediately preceding and one following the index patient in the consecutive cohort of EVAR patients. METHODS: Demographics and CTA data on limb graft occlusions were recorded and compared with a defined control group. Three different indices were used to describe the tortuosity of the iliac vessels based on preoperative CTA: pelvic artery index of tortuosity (PAI), common iliac artery index of tortuosity (CAI), and a visual description of vessel tortuosity - the double iliac sign (DIS). Demographic data and indices were correlated for later occurring limb occlusion. RESULTS: 504 patients underwent EVAR and 18 patients experienced graft limb occlusion during a median follow-up of 28 months (range 0-133). Primary graft patency was 97% at 1 year and 96% at 3 years. Logistic regression showed that iliac artery tortuosity (DIS) (p = .001) and body mass index (p = .007) had a significant impact on graft patency. CONCLUSION: A tortuous vessel on the preoperative CTA is associated with an increased risk of limb occlusion after EVAR. Adjunctive stenting of iliac segments deemed at risk is suggested, which is achieved without compromise of the aneurysm repair.

Sleep need driven oscillation of glutamate synaptic phenotype.

Sleep loss increases AMPA-synaptic strength and number in the neocortex. However, this is only part of the synaptic sleep loss response. We report increased AMPA/NMDA EPSC ratio in frontal-cortical pyramidal neurons of layers 2-3. Silent synapses are absent, decreasing the plastic potential to convert silent NMDA to active AMPA synapses. These sleep loss changes are recovered by sleep. Sleep genes are enriched for synaptic shaping cellular components controlling glutamate synapse phenotype, overlap with autism risk genes and are primarily observed in excitatory pyramidal neurons projecting intra-telencephalically. These genes are enriched with genes controlled by the transcription factor, MEF2c and its repressor, HDAC4. Thus, sleep genes under the influence of MEF2c and HDAC4, can provide a framework within which motor learning and training occurs mediated by sleep-dependent oscillation of glutamate-synaptic phenotypes.

Mechanisms and rescue strategies of calcineurin inhibitor mediated tolerance abrogation induced by anti-CD4 mAb treatment.

To ensure safety tolerance induction protocols are accompanied by conventional immunosuppressive drugs (IS). But IS such as calcineurin inhibitors (CNI), for example, cyclosporin A (CsA), can interfere with tolerance induction. We investigated the effect of an additional transient CsA treatment on anti-CD4mAb-induced tolerance induction upon rat kidney transplantation. Additional CsA treatment induced deteriorated graft function, resulting in chronic rejection characterized by glomerulosclerosis, interstitial fibrosis, tubular atrophy and vascular changes. Microarray analysis revealed enhanced intragraft expression of the B cell attracting chemokine CXCL13 early during CsA treatment. Increase in CXCL13 expression is accompanied by enhanced B cell infiltration with local and systemic IgG production and C3d deposition as early as 5 days upon CsA withdrawal. Adding different CNIs to cultures of primary mesangial cells isolated from glomeruli resulted in a concentration-dependent increase in CXCL13 transcription. CsA in synergy with TNF-α can enhance the B cell attracting and activating potential of mesangial cells. Transient B cell depletion or transfer of splenocytes from tolerant recipients 3 weeks after transplantation could rescue tolerance induction and did inhibit intragraft B cell accumulation, alloantibody production and ameliorate chronic rejection.

Outcomes after elective aortic aneurysm repair: a nationwide Danish cohort study 2007-2010.

OBJECTIVE: To assess outcomes after treatment for asymptomatic abdominal aortic aneurysm (AAA) in Denmark in a period when both open surgery (OR) and endoluminal repair (EVAR) have been routine procedures. METHODS: We performed a retrospective nationwide cohort study of patients treated for asymptomatic AAA between 2007 and 2010. Data on demographics, procedural data, perioperative complications, length of stay (LOS), 30-day reinterventions and readmissions, late aneurysm and procedure-related complications and mortality were obtained from the Danish Vascular Registry and the Danish National Patient Register. RESULTS: 525 EVAR and 1176 OR for asymptomatic AAA were identified. LOS was shorter after EVAR than OR (4 vs. 7 days, p < .001). During primary hospitalization procedure-related complications (12% vs. 6%) and general complications (21% vs. 8%) were more common after OR than EVAR (p < 0.001). The 30-day reintervention rate was higher for OR than EVAR (18% vs. 6%, p < 0.001), but there was no difference in readmissions within 30 days. During follow-up (mean 29 ± 15 months) aneurysm-related complications after EVAR were outweighed by procedure-related complications after OR. CONCLUSION: Elective AAA repair in Denmark is overall comparable with international results and both perioperative and late outcomes after EVAR of elective AAA are better than the results after OR.

Permanent CNI treatment for prevention of renal allograft rejection in sensitized hosts can be replaced by regulatory T cells.

Recent data suggest that donor-specific memory T cells (T(mem)) are an independent risk factor for rejection and poor graft function in patients and a major challenge for immunosuppression minimizing strategies. Many tolerance induction protocols successfully proven in small animal models e.g. costimulatory blockade, T cell depletion failed in patients. Consequently, there is a need for more predictive transplant models to evaluate novel promising strategies, such as adoptive transfer of regulatory T cells (Treg). We established a clinically more relevant, life-supporting rat kidney transplant model using a high responder (DA to LEW) recipients that received donor-specific CD4(+)/ 8(+) GFP(+) T(mem) before transplantation to achieve similar pre-transplant frequencies of donor-specific T(mem) as seen in many patients. T cell depletion alone induced long-term graft survival in naïve recipients but could not prevent acute rejection in T(mem)(+) rats, like in patients. Only if T cell depletion was combined with permanent CNI-treatment, the intragraft inflammation, and acute/chronic allograft rejection could be controlled long-term. Remarkably, combining 10 days CNI treatment and adoptive transfer of Tregs (day 3) but not Treg alone also induced long-term graft survival and an intragraft tolerance profile (e.g. high TOAG-1) in T(mem)(+) rats. Our model allows evaluation of novel therapies under clinically relevant conditions.

The use of trauma transfusion pathways for blood component transfusion in the civilian population: a systematic review and meta-analysis.

This study was undertaken to determine if, amongst civilian trauma patients requiring massive transfusion (MT), the use of a formal trauma transfusion pathway (TTP), in comparison with transfusion without a TTP, is associated with a reduction in mortality, or changes in indices of coagulation, blood product utilisation and complications. A systematic review of three bibliographic databases, reference lists and conference proceedings was conducted. Studies were included if comparisons were made between patients receiving transfusion with and without a TTP. Data were extracted by two independent reviewers on population characteristics, transfusion strategies, blood product utilisation, indices of coagulation, clinical outcomes and complications. Data were pooled using a random effects model and heterogeneity explored. Seven observational studies met all eligibility criteria. Amongst 1801 patients requiring MT, TTPs were associated with a significant reduction in mortality (RR 0·69, 95% CI 0·55, 0·87). No significant increase in the mean number of PRBC transfused between TTP and control patients was seen (MD -1·17 95% CI -2·70, 0·36). When studies assessing only trauma patients were considered, TTPs were associated with a reduction in the mean number of units of plasma transfused (MD -2·63, 95% CI -4·24, -1·01). In summary, the use of TTPs appears to be associated with a reduction in mortality amongst trauma patients requiring MT without a clinically significant increase in the number of PRBC transfused and a potential reduction in plasma transfusion. Effects of TTPs on platelet transfusion, indices of coagulation and complications remain unclear. A randomised controlled trial is warranted.

[Postoperative complications after recrossectomy of the saphenofemoral junction]. / Postoperative Komplikationen nach inguinaler Re-Krossektomie.

The surgical procedure for recurrences at the saphenofemoral junction represents a great challenge for the surgeon due to the complex anatomic variability, the broad range of causes and the mostly extreme scar tissue. The incidences of postsurgical minor and major complications after recrossectomy in the groin area are determined and the clinical outcomes are analysed in this article. After specific and precise presurgical clinical and sonographical diagnoses having been undertaken a cutaneous incision is performed in the groin with the aid of tumescent local anaesthesia combined with total intravenous anaesthesia. From the proximal site any scar tissue exsisting is meticulously removed, the femoral vein is set free and the still remaining stump of the long saphenous vein or of the neovasculate as well as all left over varicose side branches of the saphenofemoral junction are removed. Within this special surgical procedure the stump of the long saphenous vein or the neovasculate are completely removed and, thereafter, a continuous longitudinal suture of the femoral vein is performed. Uncomplicated minor bleeding complications (haematoma in large extension or disseminated) appear quite frequently, lymphatic minor complications (conservatively treatable lymph oedema, lymphatic fistulae or lymphatic cysts) occur from time to time; major complications such as bleeding complications with the necessity of surgical reintervention occur only in sporadic cases and can be avoided by exact presurgical diagnosis, by meticulous special surgical technique matching the operation site as well as by regular and frequent postsurgical follow-ups. Absolute preconditions to achieve the very best results in the long run are the exact procedures of diagnosis and surgical technique. Performed by experienced phlebosurgeons or vascular surgeons, the recrossectomy of the saphenofemoral junction represents a low-risk surgery for the patient and is a singular and possibly time-consuming challenge for the surgeon.

Study protocol for the online adaptation and evaluation of the 'Reboot' (Recovery-boosting) coaching programme, to prepare critical care nurses for, and aid recovery after, stressful clinical events.

BACKGROUND: Critical care nurses (CCNs) are routinely exposed to highly stressful events, exacerbated during the COVID-19 pandemic. Supporting resilience and wellbeing of CCNs is therefore crucial to prevent burnout. One approach for delivering this support is by preparing critical care nurses for situations they may encounter, drawing on evidence-based techniques to strengthen relevant psychological coping strategies. As such, the current study seeks to tailor a Resilience-boosting psychological coaching programme [Reboot] for CCNs, based on cognitive behavioural therapy (CBT) principles and the Bi-Dimensional Resilience Framework (BDF), and (1) to assess the feasibility of delivering Reboot via online, remote delivery to CCNs, and (2) to provide a preliminary assessment of whether Reboot could increase resilience and confidence in coping with adverse events. METHODS: Eighty CCNs (n=80) will be recruited to the 8-week Reboot programme, comprised of two group workshops and two individual coaching calls. The study uses a single-arm before-after feasibility study design and will be evaluated with a mixed-methods approach, using online questionnaires (all participants) and telephone interviews (25% of participants). Primary outcomes will be confidence in coping with adverse events (the Confidence scale) and resilience (the Brief Resilience Scale) measured at four time points. DISCUSSION: Results will determine whether it is feasible to deliver and evaluate a remote version of the Reboot coaching programme to CCNs, and will indicate whether participating in the programme is associated with increases in confidence in coping with adverse events, resilience and wellbeing (as indicated by levels of depression).

Outcomes following a limited approach to radiotherapy in rectal cancer.

BACKGROUND: Variation in the use of neoadjuvant and adjuvant radiotherapy for rectal cancer suggests an opportunity to avoid it in all but patients at highest risk of local recurrence. METHODS: Between 1 July 1999 and 1 February 2006, patients with primary rectal cancer were treated by a single surgeon operating at McMaster University, Hamilton, Ontario, Canada. Digital rectal examination and pelvic computed tomography were used to determine whether the mesorectal margin was threatened by tumour and thus whether preoperative radiotherapy would be needed. The study outcome was local tumour recurrence. RESULTS: Forty-six (48 per cent) of 96 patients received preoperative radiation therapy. The median follow-up was 4·2 years. Tumours were fixed or tethered in 31 (67 per cent) of the 46 irradiated patients. In contrast, no tumour was fixed in unirradiated patients and only ten (20 per cent) of the 50 tumours were tethered. The proportion of patients with stage I or II tumours based on final pathology was similar: 61 per cent (28 of 46) and 56 per cent (28 of 50) in irradiated and unirradiated groups respectively (P = 0·287). There were four (9 per cent) and two (4 per cent) local recurrences among irradiated and unirradiated patients respectively (P = 0·422). CONCLUSION: Limiting preoperative radiotherapy in rectal cancer to patients with a threatened circumferential margin does not compromise patient outcome.

Incidence of systemic inflammatory response syndrome after endovascular aortic repair.

AIM: The aim of this study was to estimate the incidence of the post-implantation syndrome/systemic inflammatory response syndrome (SIRS) after endovascular aortic repair. METHODS: All patients, undergoing elective primary endovascular repair of an asymptomatic infrarenal abdominal aortic aneurysm during 2007, were retrospectively evaluated for SIRS within the first 5 postoperative days. The only exclusion-criteria were missing data. SIRS was assessed using the criteria defined by the American College of Chest Physicians and Society of Critical Care Medicine Consensus Conference Committee. RESULTS: Sixty-six patients were included, 40 (60%) met the SIRS criteria within the first 5 postoperative days (95% of the 40 patients met the criteria within 3 days). We found no significant differences between the SIRS and the non-SIRS group in baseline characteristics or other data including volume of the contrast media used, type of groin access, adjunctive procedures and duration of surgery. In total, 11 (28%) patients in the SIRS group and 4 (15%) patients in the non-SIRS group underwent re-interventions. Median follow-up period was 26 (range 20-32) months. Thirty-day mortality did not differ in the groups (3% in the SIRS group vs. none in the non-SIRS group). CONCLUSION: The high incidence of SIRS after EVAR is unexpected considering the minimally invasive procedure. Further studies on the cause of this response and measures to attenuate the response seem appropriate.