Laparoscopic Colorectal Surgery Outcomes Improved After National Training Program (LAPCO) for Specialists in England.

OBJECTIVE: To examine the impact of The National Training Program for Lapco on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training. SUMMARY OF BACKGROUND DATA: Lapco provided competency-based supervised clinical training for specialist colorectal surgeons in England. METHODS: We compared the rate of laparoscopic surgery, mortality, and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively. RESULTS: One hundred eight Lapco delegates performed 4586 elective colo-rectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72,930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% [95% confidence interval (CI), 18.5-23.3, P < 0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, P = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, P = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56%, respectively. CONCLUSIONS: Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training.

The development of a minimum dataset for MRI reporting of anorectal fistula: a multi-disciplinary, expert consensus process.

There are a range of sphincter-preserving procedures available to treat anorectal fistula, some of which can be precluded, or rendered more optimal by specific features of fistula anatomy. Magnetic resonance imaging (MRI) is the gold standard modality for assessing anorectal fistula. To maximise clinical utility, the MRI report should accurately describe these clinically relevant features. We aimed to develop a minimum dataset for reporting MRI of anorectal fistula, in order to improve the assessment and management of these patients. A longlist of 70 potential items for the minimum dataset was generated through systematic review of the literature. This longlist was presented to radiologists, surgeons and gastroenterologists in an online survey to understand the features that shape current clinical practice. The longlist and survey results were then presented to an expert consensus panel to generate the final minimum dataset through discussion and anonymous voting. The final minimum dataset details the general characteristics, features of the internal and external openings, path of the fistula through the sphincters and any associated extensions and collections that should be described in all MRI reports for anal fistula. Additional surgical and perianal Crohn's disease subsets were developed to indicate the features that aid decision-making for these patients, in addition to a minimum dataset for the clinical request. This study represents a multi-disciplinary approach to developing a minimum dataset for MRI reporting of anal fistula, highlighting the most important features to report that can assist in clinical decision-making. KEY POINTS: • This paper recommends the minimum features that should be included in all MRI reports for the assessment of anal fistula, including Parks classification, number of tracts, features of the internal and external opening, path of the tract through the sphincters, the presence and features of extensions and collections. • Additional features that aid decision-making for surgery or in the presence of Crohn's disease have been identified. • The items that should be included when requesting an MRI are specified.

"Cell grafting": a new approach for transferring cytoplasmic or nuclear genome between plants.

KEY MESSAGE: A new method based on mixing and wounding of callus tissue was used to transfer plastid or nuclear DNA between cells. Methods alternative to sexual hybridization can be powerful tools for crop improvement. We have developed a new hybridization technology based on wounding a mixed population of cells of two parents growing in vitro as callus ("cell grafting"), and have demonstrated the utility of this system for plastid or nuclear genome transfer. In our proof-of concept experiments, non-organized growing tissue (callus) from tobacco var. Samsun, carrying the nuclear marker genes nptII and uidA (GUS), and tobacco var. Petit Havana, carrying aadA and gfp genes in the plastid genome, were mixed together, wounded with a razor blade and placed for regeneration on selection medium containing both spectinomycin (aadA) and paromomycin (nptII). Plants with aadA and gfp positive plastids and nptII plus uidA positive nuclear background were produced. Molecular analysis confirmed the presence of all four genes in these plants. Morphology and ploidy level analysis confirmed the production of "diploid" plants similar to var. Samsun possessing transformed plastids from var. Petit Havana. Reciprocal crosses between the experimentally produced plants and wild type tobacco confirmed maternal inheritance of aadA and gfp and Mendelian inheritance of nptII and uidA. For transfer of nuclear traits between plants we used two nuclear-transformed parents with different selectable markers; one with nptII (paromomycin resistant), and another with aadA (spectinomycin resistant). Plants resistant to both antibiotics which also had different visible markers were produced.

Diagnosis and treatment of a rectal-cutaneous fistula: a rare complication of coccygectomy.

BACKGROUND: Coccygectomy may be indicated for the treatment of debilitating coccygodynia unresponsive to non-operative treatment. Perineal contamination and postoperative wound infection following coccygectomy remains a major concern. We present a rare post-coccygectomy complication of rectal-cutaneous fistula. To our knowledge no such case has been previously described. CASE PRESENTATION: A 24-year-old woman presented with recurrent wound infections 1 year after coccygectomy at another institution, which persisted despite two surgical debridements and antibiotic treatment. Wound cultures showed non-specific poly-microbial bacterial growth. MRI scan of the spine and pelvis revealed a sinus track and soft tissue edema with no evidence of abscess or osteomyelitis. Methylene blue injection to the sinus tract confirmed the presence of a rectal-cutaneous fistula. The patient underwent further debridement, fistulectomy and synchronous defunctioning colostomy and resection of the involved colon segment. The wound healed by secondary intention with complete resolution of the infection. Re-anastomosis and closure of the colostomy was performed 6 months later. At 2-year follow-up, the patient had no signs of infection and her initial coccygeal symptoms had improved. CONCLUSION: Postoperative infection following coccygectomy remains a major concern. A discharging sinus at the surgical site may suggest the presence of a rectal-cutaneous fistula, which requires a combined approach of spinal and colorectal surgeons. Methylene blue injection to the sinus tract may facilitate the diagnosis of a rectal-cutaneous fistula.

Adherence to enhanced recovery after surgery protocols across a high-volume gastrointestinal surgical service.

BACKGROUND AND AIMS: Enhanced recovery after surgery (ERAS) has been shown to improve outcomes for patients following gastrointestinal surgery. Data on protocol adherence and how this impacts on outcome are limited. This study examines how protocol adherence changes over time and determines how this impacts on outcome across a large-volume gastrointestinal surgical service. MATERIALS AND METHODS: A prospective review of patients eligible for colorectal, liver and oesophagogastric ERAS over two 3-month periods in 2010 and 2011 was performed. End points included: length of stay (LOS), overall protocol adherence, individual modality adherence, reason for pathway deviation and patient outcomes. RESULTS: 172 patients (110 colorectal, 31 liver and 31 oesophagogastric) were evaluated. For each sub-speciality, the introduction of ERAS led to significant reductions in LOS that were sustained for the duration of the study. Adherence was achieved across 60% (colorectal), 75% (liver) and 88% (oesophagogastric) of individual pathway modalities. The major causes of pathway deviation were: post-operative nausea and vomiting (colorectal), pain (liver) and pulmonary complications (oesophagogastric). CONCLUSIONS: Large-scale implementation of ERAS at a high-volume centre is feasible and offers many of the benefits demonstrated in controlled trials, but adherence may diminish over time.

A randomised controlled trial of the efficacy of ultrasound-guided transversus abdominis plane (TAP) block in laparoscopic colorectal surgery.

BACKGROUND: Optimal analgesia following laparoscopic colorectal resection is yet to be determined; however, recent studies have questioned the role of postoperative epidural anaesthesia, suggesting other analgesic modalities may be preferable. The aim of this randomised controlled trial was to assess the effect of transversus abdominis plane (TAP) blocks on opioid requirements in patients undergoing laparoscopic colorectal resection. METHODS: After appropriate trial registration ( www.clinicaltrials.gov NCT 00830089) and local medical ethics review board approval (REC 09/H0407/10), all adult patients who were to undergo laparoscopic colorectal surgery at a single centre were randomised into the intervention group receiving bilateral TAP blocks or the control group (no TAP block). The blocks were administered prior to surgery after the induction of a standardised anaesthetic by an anaesthetist otherwise uninvolved with the case. The patient, theatre anaesthetist, surgeon, and ward staff were blinded to treatment allocation. All patients received postoperative analgesia of paracetamol and morphine as a patient-controlled analgesia (PCA). Cumulative opioid consumption and pain scores were recorded at 2, 4, 6, and 24 h postoperatively and compared between the groups as were clinical outcomes and length of stay. RESULTS: The intervention (TAP block) group (n = 33) and the control group (n = 35) were comparable with respect to characteristics, specimen pathology, and type of procedure. The TAP block group's median cumulative morphine usage (40 mg [IQR = 25-63]) was significantly less than that of the control group (60 mg [IQR = 39-81]). Pain scores and median length of stay (LOS) were similar between the two groups. CONCLUSION: Preoperative TAP blocks in patients undergoing laparoscopic colorectal resection reduced opioid use in the first postoperative day in this study.

Agrobacterium-mediated direct transformation of wheat mature embryos through organogenesis.

Transgenic plant production in monocotyledonous species has primarily relied on embryogenic callus induction from both immature and mature embryos as the pathway for plant regeneration. We have efficiently regenerated fertile transgenic wheat plants through organogenesis after Agrobacterium-mediated direct transformation of mechanically isolated mature embryos from field-grown seed. Centrifugation of the mature embryos in the presence of Agrobacterium was found to be essential for efficient T-DNA delivery to the relevant regenerable cells. The inoculated mature embryos formed multiple buds/shoots on high-cytokinin medium, which directly regenerated into transgenic shoots on hormone-free medium containing glyphosate for selection. Rooted transgenic plantlets were obtained within 10-12 weeks after inoculation. Further optimization of this transformation protocol resulted in significant reduction of chimeric plants to below 5%, as indicated by leaf GUS staining and T1 transgene segregation analysis. Direct transformation of wheat mature embryos has substantial advantages over traditional immature embryo-based transformation systems, including long-term storability of the mature dry explants, scalability, and greatly improved flexibility and consistency in transformation experiments.

Bridging that gap: a qualitative study of perceptions of equality, diversity and inclusivity in colorectal surgery in the UK and Ireland.

BACKGROUND: There is a growing recognition on the importance of equality, diversity and inclusion (EDI) within surgery and the need to diversify the surgical community and its various organisations, in a bidto reflect the diverse populations they serve. To create, sustain and encourage a diverse surgical workforce requires an in-depth understanding of the current makeup of key surgical institutions, relevant issues pertaining to EDI and appropriate solutions and strategies to ensure tangible change. OBJECTIVES: Following on from the recent Kennedy Review into Diversity and Inclusion commissioned by the Royal College of Surgeons of England, the aim of this qualitative study was to understand the EDI issues which affected the membership of the Association of Coloproctology of Great Britain and Ireland, while seeking appropriate solutions to address them. DESIGN: Dedicated, online and qualitative focus groups. PARTICIPANTS: Colorectal surgeons, trainees and nurse specialists were recruited using a volunteer sampling strategy. METHODS: A series of online, dedicated, qualitative focus groups across the 20 chapter regions were held. Each focus group was run informed by a structured topic guide. All participants who were given the opportunity to remain anonymous were offered a debriefing at the end. This study has been reported in keeping with the Standards for Reporting Qualitative Research. RESULTS: Between April and May 2021, a total number of 20 focus groups were conducted, with a total of 260 participants across 19 chapter regions. Seven themes and one standalone code pertaining to EDI were identified: support, unconscious behaviours, psychological consequences, bystander behaviour, preconceptions, inclusivity and meritocracy and the one standalone code was institutional accountability. Five themes were identified pertaining to potential strategies and solutions: education, affirmative action, transparency, professional support and mentorship. CONCLUSION: The evidence presented here is of a range of EDI issues which affect the working lives of those within colorectal surgery in the UK and Ireland, and of potential strategies and solutions which can help build a more inclusive, equitable and diverse colorectal community.

Gene expression biomarkers provide sensitive indicators of in planta nitrogen status in maize.

Over the last several decades, increased agricultural production has been driven by improved agronomic practices and a dramatic increase in the use of nitrogen-containing fertilizers to maximize the yield potential of crops. To reduce input costs and to minimize the potential environmental impacts of nitrogen fertilizer that has been used to optimize yield, an increased understanding of the molecular responses to nitrogen under field conditions is critical for our ability to further improve agricultural sustainability. Using maize (Zea mays) as a model, we have characterized the transcriptional response of plants grown under limiting and sufficient nitrogen conditions and during the recovery of nitrogen-starved plants. We show that a large percentage (approximately 7%) of the maize transcriptome is nitrogen responsive, similar to previous observations in other plant species. Furthermore, we have used statistical approaches to identify a small set of genes whose expression profiles can quantitatively assess the response of plants to varying nitrogen conditions. Using a composite gene expression scoring system, this single set of biomarker genes can accurately assess nitrogen responses independently of genotype, developmental stage, tissue type, or environment, including in plants grown under controlled environments or in the field. Importantly, the biomarker composite expression response is much more rapid and quantitative than phenotypic observations. Consequently, we have successfully used these biomarkers to monitor nitrogen status in real-time assays of field-grown maize plants under typical production conditions. Our results suggest that biomarkers have the potential to be used as agronomic tools to monitor and optimize nitrogen fertilizer usage to help achieve maximal crop yields.

Hippotherapy effects on trunk, pelvic, and hip motion during ambulation in children with neurological impairments.

PURPOSE: This study investigated the effects of a 10-week hippotherapy program on trunk, pelvis, and hip joint positioning during the stance phase of gait. METHODS: Eleven children (6 boys and 5 girls; 7.9 ± 2.7 years) with neurological disorders and impaired ambulation participated. Joint range of motion data were collected via 3-dimensional computerized gait analysis before and after the program. Paired t tests were performed on kinematic data for each joint. RESULTS: Significant improvements (P ≤ .008) and large effect sizes (ESs) for sagittal plane hip positions at initial contact and toe-off were found. No differences in pelvic or trunk positioning were determined, although sagittal plane pelvic positioning displayed a trend toward improvement with large ESs. Several trunk variables displayed moderate ESs with a trend toward more upright positioning. CONCLUSIONS: Improvements in pelvic and hip joint positioning and more normalized vertical trunk position may indicate increased postural control during gait after 10 sessions of hippotherapy.

Demonstration of targeted crossovers in hybrid maize using CRISPR technology.

Naturally occurring chromosomal crossovers (CO) during meiosis are a key driver of genetic diversity. The ability to target CO at specific allelic loci in hybrid plants would provide an advantage to the plant breeding process by facilitating trait introgression, and potentially increasing the rate of genetic gain. We present the first demonstration of targeted CO in hybrid maize utilizing the CRISPR Cas12a system. Our experiments showed that stable and heritable targeted CO can be produced in F1 somatic cells using Cas12a at a significantly higher rate than the natural CO in the same interval. Molecular characterization of the recombinant plants demonstrated that the targeted CO were driven by the non-homologous end joining (NHEJ) or HDR repair pathways, presumably during the mitotic cell cycle. These results are a step towards the use of RNA-guided nuclease technology to simplify the creation of targeted genome combinations in progeny and accelerate breeding.

Commercial scale genetic transformation of mature seed embryo explants in maize.

A novel, efficient maize genetic transformation system was developed using Agrobacterium-mediated transformation of embryo explants from mature seeds. Seeds from field grown plants were sterilized and crushed to isolate embryo explants consisting of the coleoptile, leaf primordia, and shoot apical meristem which were then purified from the ground seed bulk preparation. The infection of relevant tissues of seed embryo explants (SEEs) by Agrobacterium was improved by the centrifugation of the explants. Transgenic plants were obtained by multiple bud induction on high cytokinin media, followed by plant regeneration on hormone-free medium. Three different selectable markers (cp4 epsps, aadA, and nptII) were successfully used for producing transgenic plants. Stable integration of transgenes in the maize genome was demonstrated by molecular analyses and germline transmission of the inserted transgenes to the next generation was confirmed by pollen segregation and progeny analysis. Phenotypic evidence for chimeric transgenic tissue was frequently observed in initial experiments but was significantly reduced by including a second bud induction step with optimized cytokinin concentration. Additional improvements, including culturing explants at an elevated temperature during bud induction led to the development of a revolutionary system for efficient transgenic plant production and genome editing. To our knowledge, this is the first report of successful transgenic plant regeneration through Agrobacterium-mediated transformation of maize mature SEEs. This system starts with mature seed that can be produced in large volumes and the SEEs explants are storable. It has significant advantages in terms of scalability and flexibility over methods that rely on immature explants.

Posterior tibial nerve stimulation and faecal incontinence: a review.

PURPOSE: Faecal incontinence is a common and important multifactorial disorder with a range of treatment options. Over the last two decades, neuromodulation via sacral nerve stimulators has been shown to be effective for both faecal and urinary incontinence, although associated with complications. Peripheral neuromodulation, via the posterior tibial nerve, is widely used in urinary incontinence; however, its use in faecal incontinence, whilst evolving is limited to eight small heterogeneous studies. REVIEW: These eight studies are discussed in the context of the methodology and underlying neurophysiology of peripheral neuromodulation, as are thus far unanswered questions. The eight studies include a total of 129 patients with faecal incontinence (of variable aetiology), all of whom had failed conservative management. One study was prospective and controlled, six were uncontrolled and one was retrospective and uncontrolled. Five different neuromodulatory protocols were used over six different study periods. Outcome measures varied, but short term primary endpoint success ranged from 30.0% to 83.3%. The limitations to this early evidence, whilst encouraging, are significant, and it remains to be seen whether this novel treatment modality represents the minimally invasive, well-tolerated, cost-effective and flexible panacea hoped for this common and debilitating disease. Three upcoming multicentre placebo-controlled trials will better be able to delineate its role.

Analysis of laboratory-based laparoscopic colorectal surgery workshops within the English National Training Programme.

BACKGROUND: This study aimed to determine and compare the opinions of trainees and trainers attending courses using two simulation models (fresh frozen cadavers or anaesthetized pigs) and to assess trainees' degree of insight into both the difficulty of different procedures and their operative performance in the simulated environment. METHODS: Trainers and trainees attending the training courses completed questionnaires. Performance was evaluated using the Global Assessment Score (GAS). RESULTS: Data were collected over a 12-month period from 26 trainers and 77 trainees. The overall satisfaction was high after attendance at either course (4.50 vs. 4.49; p=0.83). When the opinions of the trainees and trainers in cadaveric and animal courses were compared, the findings rated the animal model as superior in terms of tissue quality (3.97 vs. 3.55; p=0.02), persistence of air leak (1.43 vs. 2.40; p<0.001), and lack of disturbance by odor (4.24 vs. 3.41; p<0.001). The cadaveric model provided more realistic simulation for port placement (4.02 vs. 3.11; p<0.001) and anatomy (4.25 vs. 3.00; p<0.001) and was perceived to be superior as a training model (4.53 vs. 3.61; p=0.001). The trainees demonstrated good insight into procedure difficulty and their operative performance. The trainees and trainers were shown to have a good concordance of scores. The trainees were more inclined to underrate and the peers to overrate their performance. CONCLUSIONS: Trainees appear to have a good insight into procedure difficulty and their ability. Both training models have advantages and disadvantages, but overall, the cadaveric model is perceived to have a higher fidelity and greater educational value.

Prefrontal cortex lesions and sex differences in fear extinction and perseveration.

Electrolytic lesions of the medial prefrontal cortex (PFCX) were examined using fear conditioning to assess the recall of fear extinction and performance in the Y-maze, open field, and object location/recognition in male and female Sprague-Dawley rats. Rats were conditioned to seven tone/footshocks, followed by extinction after 1-h and 24-h delays, revealing PFCX effects and sex differences during all phases of fear conditioning. In male rats, PFCX impaired 24-h recall of fear extinction to tone, which required the 1-h delay extinction and was not attributed to nonassociative factors. In contrast, sham and PFCX females increased freezing to tone following a 24-h delay, whether or not 1-h delay tone extinction was presented. Moreover, PFCX females failed to extinguish to tone, contrasting to the robust extinction to tone that was observed for sham females, PFCX, and sham males. Also, sex differences were found during acquisition, with sham females acquiring fear conditioning slower than PFCX females. By the last tone-shock presentation, sham and PFCX females showed a slight but significant reduction in freezing to tone relative to those of sham and PFCX males. Of the other behavioral measures, PFCX females maintained exploration of a novel object during object recognition when sham females habituated. PFCX did not influence other behaviors in the remaining tasks. These findings show important sex differences in PFC function, with the PFC influencing the recall of fear extinction in males and contributing to the acquisition and maintenance of fear extinction memory in females, perhaps through altering perseveration.