Upper gastrointestinal training in the UK and Ireland: a Roux Group Study.

INTRODUCTION: Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a state of flux. This study aims to report the contemporary opinions of trainee and consultant surgeons on the current upper gastrointestinal (UGI) training model in the UK&I. METHODS: A questionnaire was developed and distributed via national UGI societies. Questions pertained to demographics, current training evaluation, perceived requirements and availability. RESULTS: A total of 241 responses were received with representation from all UK&I postgraduate training regions. The biggest discrepancies between rotation demand and national availability related to advanced/therapeutic endoscopy and robotic surgery, with 91.7% of respondents stating they would welcome greater geographical flexibility in training. The median suggested academic targets were 3-5 publications (trainee vs consultant <3 vs 3-5, p<0.001); <3 presentations (<3 vs 3-5, p=0.002); and 3-5 audits/quality improvement projects (<3 vs 3-5, p<0.001). Current operative requirements were considered achievable (87.6%) but inadequate for day one consultant practice (74.7%). Reassuringly, 76.3% deemed there was role for on-the-job operative training following consultant appointment. Proficiency in diagnostic endoscopy was considered a minimum requirement for Certificate of Completion of Training (CCT) yet the majority regarded therapeutic endoscopy competency as non-essential. The median numbers of index UGI operations suggested were comparable with the current curriculum requirements. Post-CCT fellowships were not considered necessary; however, the majority (73.6%) recognised their advantage. CONCLUSIONS: Current CCT requirements are largely consistent with the opinions of the UGI community. Areas for improvement include flexibility in geographical working and increasing national provisions for high-quality endoscopy training.

Biocompatibility of Antifogging SiO-doped Diamond-Like Carbon Laparoscope Coatings.

Laparoscopes can suffer from fogging and contamination difficulties, resulting in a reduced field of view during surgery. A series of diamond-like carbon films, doped with SiO, were produced by pulsed laser deposition for evaluation as biocompatible, antifogging coatings. DLC films doped with SiO demonstrated hydrophilic properties with water contact angles under 40°. Samples subjected to plasma cleaning had improved contact angle results, with values under 5°. Doping the DLC films with SiO led to an average 40% decrease in modulus and 60% decrease in hardness. Hardness of the doped films, 12.0 - 13.2 GPa, was greater than that of the uncoated fused silica substrate, 9.2 GPa. The biocompatibility was assessed through CellTiter-Glo assays, with the films demonstrating statistically similar levels of cell viability when compared to the control media. The absence of ATP released by blood platelets in contact with the DLC coatings suggests in vivo hemocompatibility. The SiO doped films displayed improved transparency levels in comparison to undoped films, achieving up to an average of 80% transmission over the visible spectrum and an attenuation coefficient of 1.1 × 104 cm-1 at the 450 nm wavelength. The SiO doped DLC films show promise as a method of fog prevention for laparoscopes.

The impact of age on long-term survival following gastrectomy for gastric cancer.

INTRODUCTION: Gastrectomy remains the primary curative treatment modality for patients with gastric cancer. Concerns exist about offering surgery with a high associated morbidity and mortality to elderly patients. The study aimed to evaluate the long-term survival of patients with gastric cancer who underwent gastrectomy comparing patients aged <70 years with patients aged ≥70 years. METHODS: Consecutive patients who underwent gastrectomy for adenocarcinoma with curative intent between January 2000 and December 2017 at a single centre were included. Patients were stratified by age with a cut-off of 70 years used to create two cohorts. Log rank test was used to compare overall survival and Cox multivariable regression used to identify predictors of long-term survival. RESULTS: During the study period, 959 patients underwent gastrectomy, 520 of whom (54%) were aged ≥70 years. Those aged <70 years had significantly lower American Society of Anesthesiologists grades (p<0.001) and were more likely to receive neoadjuvant chemotherapy (39% vs 21%; p<0.001). Overall complication rate (p=0.001) and 30-day postoperative mortality (p=0.007) were lower in those aged <70 years. Long-term survival (median 54 vs 73 months; p<0.001) was also favourable in the younger cohort. Following adjustment for confounding variables, age ≥70 years remained a predictor of poorer long-term survival following gastrectomy (hazard ratio 1.35, 95% confidence interval 1.09, 1.67; p=0.006). CONCLUSIONS: Low postoperative mortality and good long-term survival were demonstrated for both age groups following gastrectomy. Age ≥70 years was, however, associated with poorer outcomes. This should be regarded as important factor when counselling patients regarding treatment options.

The junior doctor changeover effect: does it exist in general surgery?

INTRODUCTION: Junior doctor changeover has been perceived as a period of increased risk to patients. However, there is a paucity of contemporary evidence of this 'changeover effect'. The aim of this study was to evaluate the presence of an adverse patient effect during periods of junior doctor changeover. METHODS: Data were requested on all patients aged 18 years or older admitted acutely under General Surgery in the North of England between 2005 and 2016. This included patient characteristics, diagnoses, comorbidities, procedure codes, mortality and length of stay. Patients were included in the study if they were admitted during the 'changeover week'; defined as the first day of the changeover followed by the six subsequent days. For junior trainees (FY1-CT2), this is the first Wednesday of August, December and April each year. For higher surgical trainees (ST3-ST8), it is the first Wednesday in October. Another week, four weeks prior, was chosen as a historical comparator. RESULTS: In total, 61,714 patients were included in this study. Patient characteristics did not vary between the cohorts. There was no difference in 30-day mortality between changeover and non-changeover groups (2.5% vs 2.6%, p = 0.280) or length of stay (5.3 vs 5.2, p = 0.613). Changeover week was not a predictor of increased mortality (OR 1.06, p = 0.302) following multivariable adjustment. Further analysis of the first junior and higher specialty trainee periods, August and October, respectively, showed no significant difference for measured outcomes. CONCLUSIONS: This retrospective cohort study provides contemporary evidence that the 'changeover effect' does not exist in acute general surgical admissions in the UK.

A vegetation classification and description of white-winged flufftail (Sarothrura ayresi) habitat at selected high-altitude peatlands in South Africa.

The white-winged flufftail is listed as critically endangered, and limited knowledge about the species' ecology has been identified as a limiting factor to effectively conserving the bird. Little is known about the vegetation inhabited by the white-winged flufftail, which hampers the identification and management of its habitat. This study presents a fine-scale classification and description of the vegetation of wetland sites where the bird is known to be present. A plant phytosociological study was conducted to describe the plant communities and vegetation structure of the habitat. Three sites were selected at Verloren Valei Nature Reserve and two at Middelpunt Wetland, Mpumalanga, South Africa, shortly after the white-winged flufftail breeding season. A total of 60 sample plots were placed within the study sites, where all plant species present were recorded and identified. Other aspects such as plant height, water depth and anthropogenic influences were also documented. A modified TWINSPAN analysis resulted in the identification of three sub-communities that can be grouped into one major community. The Cyperaceae, Asteraceae and Poaceae families dominate the vegetation, with the sedges Carex austro-africana and Cyperus denudatus being dominant, and the grasses Leersia hexandra and Arundinella nepalensis co-dominant. The broad habitat structure consisted of medium to tall herbaceous plants (0.5-0.7 m) with shallow slow-flowing water.

Patient Outcomes Following Emergency Bowel Resection for Inflammatory Bowel Disease and the Impact of Surgical Subspecialisation in the North of England: A Retrospective Cohort Study.

BACKGROUND: Management of inflammatory bowel disease (IBD) has changed considerably over recent years, which has coincided with increased subspecialisation amongst general surgeons. This study evaluated the demographics and outcomes of patients with IBD undergoing bowel resection and assessed for the potential impact of surgical subspecialisation. METHODS: Patient demographic, operative and outcome data were collected for patients undergoing a bowel resection secondary to IBD, admitted acutely to NHS trusts in the North of England between 2002 and 2016. The primary outcome of interest was 30-day post-operative mortality, with secondary outcomes: length of stay, stoma and anastomosis rates. RESULTS: A total of 913 patients were included in the study cohort. A reduction in the number of resections was noted over time (2002-2006: 361 vs. 2012-2016: 262). No change was observed for 30-day mortality over the study period (3.9%, p = 0.233). Length of stay was also unchanged (p = 0.949). Laparoscopic surgery was increasingly utilised (0.6% vs. 17.2%, p < 0.001) in recent years, and by colorectal subspecialists (p = 0.003). More patients were managed by a colorectal consultant latterly (2002-2006: 45.4% vs. 2012-2016: 63.7%, p < 0.001). There was no difference between colorectal and other subspecialists in mortality (p = 0.156), length of stay (p = 0.201), stoma (p = 0.629) or anastomosis (p = 0.659) rates, including following multivariable adjustment. CONCLUSION: The study demonstrated a significant reduction in the number of resections over time, increased utilisation of a laparoscopic approach and a shift towards the care of IBD surgical patients being by a colorectal subspecialist. However, these changes do not correspond with improved surgical outcomes.

Systematic review of online patient resources to support shared decision making for bariatric surgery.

BACKGROUND: Bariatric surgery is an effective treatment for obesity and the associated comorbidities but carries a number of important risks. The Royal College of Surgeons advises patients to utilise online resources as part of the shared decision-making process. The aim of this study was to assess the quality of online materials on bariatric surgery. METHODS: A systematic review was performed of online healthcare information relating to bariatric surgery. Common search terms were entered into three main search engines according to a defined search strategy. Websites were assessed according to readability (Flesch-Kincaid Reading Ease Score), quality and content (DISCERN and IPDAS Scores) and standards of accreditation (HONcode and Information Standard Certification). This systematic review was registered on the PROSPERO database CRD42019132188. RESULTS: The average readability of all sources extracted was higher than that recommended for patient literature. Over half the studies contained had received HONcode or Information Standard accreditation, suggesting a quality marker for the content. On grading of quality and content, across validated scoring tools, no source achieved the minimum recommended level. CONCLUSION: Patient information online related to bariatric surgery is of poor quality. Such resources require improvement to aid in the shared decision-making process.

Perforated diverticulitis in the North of England: trends in patient outcomes, management approach and the influence of subspecialisation.

INTRODUCTION: In recent years, several management options have been used in the management of perforated diverticulitis, ranging from conservative treatment to laparotomy. General surgery has also become increasingly specialised over time. This retrospective cohort study investigated changes in patient outcomes following perforated diverticulitis, management approach and the influence of consultant subspecialisation over time. MATERIALS AND METHODS: Data was collected on patients admitted with perforated diverticulitis in the North of England between 2002 and 2016. Subspecialisation was categorised as colorectal or other general subspecialties. The primary outcome of interest was overall 30-day mortality; secondary outcomes included surgical approach, stoma and anastomosis rate. RESULTS: A total of 3394 cases of perforated diverticulitis were analysed (colorectal, n = 1290 and other subspecialists, n = 2104) with a 30-day mortality of 11.6%. There was a significant reduction in mortality over time (2002-2006: 18.6% to 2012-2016: 6.8, P < 0.001).There was a significant reduction in open surgery (60% to 25.3%, P < 0.001) with increased conservative management (37.4% to 63.5%, P < 0.001), laparoscopic resection (0.1% to 4.9%, P < 0.001) and laparoscopic washout (0.1% to 5.7%, P < 0.001).Patients admitted under colorectal surgeons had lower mortality than other subspecialists (9.9% vs 12.4%, P = 0.027), which remained significant following multivariate adjustment (hazard ratio 1.44, P = 0.039). These patients had fewer stomas (13.9% vs. 21.0%, P = 0.001) and higher anastomosis rates (22.1% vs 15.8%, P = 0.004). CONCLUSION: This study demonstrated considerable improvements in the management of perforated diverticulitis alongside the positive impact of subspecialisation on patient outcomes.

Soil color indicates carbon and wetlands: developing a color-proxy for soil organic carbon and wetland boundaries on sandy coastal plains in South Africa.

A relationship between soil organic carbon and soil color is acknowledged-albeit not a direct one. Since heightened carbon contents can be an indicator of wetlands, a quantifiable relationship between color and carbon might assist in determining wetland boundaries by rapid, field-based appraisal. The overarching aim of this initial study was to determine the potential of top soil color to indicate soil organic carbon, and by extension wetland boundaries, on a sandy coastal plain in South Africa. Data were collected from four wetland types in northern KwaZulu-Natal in South Africa. Soil samples were taken to a depth of 300 mm in three transects in each wetland type and analyzed for soil organic carbon. The matrix color was described using a Munsell soil color chart. Various color indices were correlated with soil organic carbon. The relationship between color and carbon were further elucidated using segmented quantile regression. This showed that potentially maximal carbon contents will occur at values of low color indices, and predictably minimal carbon contents will occur at values of low or high color indices. Threshold values can thus be used to make deductions such as "when the sum of dry and wet Value and Chroma values is 9 or more, carbon content will be 4.79% and less." These threshold values can then be used to differentiate between wetland and non-wetland sites with a 70 to 100% certainty. This study successfully developed a quantifiable correlation between color and carbon and showed that wetland boundaries can be determined based thereon.

High resolution spectroscopy and the first global analysis of the Tetradecad region of methane 12CH4.

We present the first detailed analysis of the infrared spectrum of methane (12)CH4 in the so-called Tetradecad region from 2.1 to 1.6 µm (4760-6250 cm(-1)). New experimental high resolution FTIR spectra at 78 K and at room temperature combined with improved theoretical modeling have allowed quantum assignments to be greatly extended in this region. A global fit of all assigned lines of (12)CH4 in the 0-6200 cm(-1) region has been performed. In the end, 3012 line positions and 1387 intensities of 45 individual subbands of the Tetradecad were modeled up to J = 14. The root mean square deviations were 0.023 cm(-1) for line positions and 13.86% for line intensities in the Tetradecad region itself. Although this analysis is still preliminary, it is already sufficient to characterize the stronger bands throughout the whole of the Tetradecad. The calculated integrated intensity of the polyad is 1.399 × 10(-19) cm(-1)/(molecule cm(-2)) at 296 K. A "definitive" theoretical modeling of this spectral region of methane requires further work, but the present success substantially improves our understanding of methane spectroscopy as needed to interpret planetary atmospheres. Lines pertaining to three-fourths of the 60 sub-vibrational bands in this polyad have been assigned.

Toxicity of four sulfonamide antibiotics to the freshwater amphipod Hyalella azteca.

Sulfonamides are a widely used class of antibiotics; however, there are few toxicological data available with which to conduct environmental risk assessments for these compounds. Therefore, the toxicity of four sulfonamides (sulfaguanidine, sulfathiazole, sulfamerazine, and sulfasalazine) to Hyalella azteca was assessed in chronic (four-week), water-only exposures. Survival was evaluated weekly, and growth was measured at the end of the test. Four-week lethal concentrations associated with 50% mortality (LC50s) for sulfaguanidine, sulfathiazole, and sulfamerazine were 0.90, 1.6, and 3.9 µM, respectively. Sulfaguanidine caused effects on survival more quickly and at lower concentrations than sulfathiazole or sulfamerazine. These differences were more pronounced at week 1 than week 4, when sulfaguanidine LC50s were 8 to 20 times lower and 2 to 4 times lower, respectively. Growth was affected by sulfathiazole but was a less sensitive end point than survival, with an effective concentration associated with 50% reduction in growth (EC50) of 13 µM, whereas sulfaguanidine and sulfamerazine caused negligible effects on growth. Sulfasalazine had no effect on survival or growth at any concentration tested, up to 13 µM. The effects observed in the present study occurred at concentrations exceeding those typically found in environmental waters. However, given that LC50s decreased with exposure duration (except for sulfasalazine), the present study demonstrates the importance of conducting longer-term tests to adequately assess the environmental toxicity of sulfonamides.

Causes of toxicity to Hyalella azteca in a stormwater management facility receiving highway runoff and snowmelt. Part I: polycyclic aromatic hydrocarbons and metals.

The Terraview-Willowfield Stormwater Management Facility (TWSMF) receives inputs of multiple contaminants, including metals, polycyclic aromatic hydrocarbons (PAHs), road salt, and nutrients, via highway and residential runoff. Contaminant concentrations in runoff are seasonally dependent, and are typically high in early spring, coinciding with the snowmelt. In order to investigate the seasonal fluctuations of contaminant loading and related changes in toxicity to benthic invertebrates, overlying water and sediment samples were collected in the fall and spring, reflecting low and high contaminant loading, respectively, and four-week sediment toxicity tests were conducted with Hyalella azteca. The effects of metals and PAHs are discussed here; the effects of salts, nutrients, and water quality are discussed in a companion paper. Survival and growth of Hyalella after exposure to fall samples were variable: survival was significantly reduced (64-74% of controls) at three out of four sites, but there were no significant growth effects. More dramatic effects were observed after Hyalella were exposed to spring samples: survival was significantly reduced at the two sites furthest downstream (0-75% of controls), and growth was significantly lower in four out of five sites when comparing Hyalella exposed to site sediment with overlying site water versus site sediment with overlying control water. These seasonal changes in toxicity were not related to metals or PAHs: 1. levels of bioavailable metals were below those expected to cause toxicity, and 2. levels of PAHs in sediment were lowest at sites with the greatest toxicity and highest in water and sediment at sites with no toxicity. Although not associated with toxicity, some metals and PAHs exceeded probable and severe effect levels, and could be a cause for concern if contaminant bioavailability changes. Toxicity in the TWSMF appeared to be primarily associated with water-borne contaminants. The cause(s) of these effects are discussed in our companion manuscript.

Causes of toxicity to Hyalella azteca in a stormwater management facility receiving highway runoff and snowmelt. Part II: salts, nutrients, and water quality.

The Terraview-Willowfield Stormwater Management Facility (TWSMF) features a tandem of stormwater management ponds, which receive inputs of multiple contaminants from highway and residential runoff. Previous research determined that benthic communities in the ponds were impacted by poor habitat quality, due to elevated sediment concentrations of metals and polycyclic aromatic hydrocarbons (PAHS), and salinity in the overlying water, but did not address seasonal changes, including those caused by the influx of contaminants with the snowmelt. In order to address this issue, water and sediment samples were collected from the TWSMF during the fall and spring, and four-week sediment toxicity tests were conducted with Hyalella azteca. The effects of metals and PAHs are discussed in a companion paper; the effects of road salt, nutrients, and water quality are discussed here. After exposure to fall samples, survival of Hyalella was reduced (64-74% of controls) at three out of four sites, but growth was not negatively affected. After exposure to spring samples, survival was 0-75% of controls at the two sites furthest downstream, and growth was significantly lower in four out of five sites when comparing Hyalella exposed to site water overlying site sediment versus control water overlying site sediment. Toxicity appeared to be related to chloride concentrations: little or no toxicity occurred in fall samples (200 mg Cl(-)/L), and significant effects on survival and growth occurred in spring samples above 1550 mg Cl(-)/L and 380 mg Cl(-)/L, respectively. Sodium chloride toxicity tests showed similar results: four-week LC50s and EC25s (growth) were 1200 and 420 mg Cl(-)/L, respectively. Although water quality and nutrients were associated with effects observed in the TWSMF, chloride from road salt was the primary cause of toxicity in this study. Chloride persists during much of the year at concentrations representing a significant threat to benthic communities in the TWSMF.

Maternal influences on thiamine status of walleye Sander vitreus ova.

Concentrations of the various forms of thiamine (vitamin B(1) ) were determined in walleye Sander vitreus ova from three central North American lakes. Total thiamine concentrations in ova from Lake Winnipeg S. vitreus were approximately three times greater (mean 12 nmol g(-1) ) than in those from Lakes Erie or Ontario. The percentage of thiamine in the active form (thiamine pyrophosphate, TPP) was highest in Lake Ontario ova (mean 88%) and lowest in those from Lake Winnipeg (mean 70%). Neither ova total thiamine concentration nor per cent ova thiamine as TPP showed any consistent relationships with maternal age, size, morphometric condition, somatic lipid concentrations or liver lipid concentrations. Ova total thiamine concentration, however, was negatively related to ovum size in some populations, as well as among populations, and was positively related to liver total thiamine concentration. Maternal transfer of thiamine to ova appears to be independent of female ontogenetic or conditional state in S. vitreus.

Vaccination--knowledge and attitudes of school children.

Low vaccine up-take in Ireland resulted in the measles epidemic of 2000-2001, and more recent outbreaks of mumps in many schools and colleges. Forty-five schools were selected from a list of secondary schools in Ireland using a table of random numbers, and teachers were requested to distribute self-administered questionnaires to their 4th year students. The questionnaires were analysed using Epi-Info and chi-square test. 86% (n=675) of students considered themselves inadequately informed about vaccines and vaccine-preventable diseases. 67.9% (n=532) wanted the topic added to the science syllabus. 88.3% (n=692) agreed that they would vaccinate their own children against all childhood diseases. It is recommended that the topic of vaccination be covered more completely by the Junior Certificate Science syllabus. It is concluded that the vaccination up-take rates in the Ireland should rise with the next generation.

Analysis of the Interacting Octad System of (12)CH(4).

The octad system of methane (12)CH(4) has been analyzed with a fourth-order (459 parameters) Hamiltonian for energy levels and a third-order (28 parameters) dipole moment expansion for infrared intensities. Nearly 8000 assigned positions and 2500 measured line intensities (obtained with the Fourier transform spectrometer located at Kitt Peak National Observatory/National Solar Observatory) have been considered in the modeling. Infrared (Octad-Ground State) and hot bands (Octad-Dyad) data have been used. While the model does not reproduce the measurements at their inherent experimental precisions, it has been sufficient to interpret and substantially assign this spectral region of methane for the first time in over 30 years of investigation. Copyright 2001 Academic Press.

How water scarcity will shape the new century.

Water resources are increasingly being overexploited, such that current food production, which relies heavily on irrigation schemes, is unsustainable. Many steps, including improved irrigation techniques, more water-efficient crops and animal protein production, etc., will be needed to raise water productivity across the board. Water must in future be recognised as a scarce resource and not taken for granted.

Radiographic measurements of cardiac size as predictors of outcome in patients with dilated cardiomyopathy.

BACKGROUND: Cardiac dilatation is a predictor of poor outcome in patients with dilated cardiomyopathy. Whereas cardiac chamber dimensions or volumes can be assessed by various noninvasive and invasive techniques, simple chest radiography also may provide a valuable assessment of cardiac size. METHODS AND RESULTS: To determine the relative power of radiographic heart measurements for predicting outcome in dilated cardiomyopathy, we retrospectively studied 88 adult patients with chest radiographs obtained within 35 days of echocardiography. Standard radiographic variables were measured for each patient, and the cardiothoracic (CT) ratio, frontal cardiac area, and volume were calculated. During a mean 4.1-year follow-up, 62 of the 88 (71%) patients died. CT ratio was the best predictor of mortality among the radiographic cardiac measurements. By multivariate analysis, a model including echocardiographic ejection fraction, New York Heart Association (NYHA) functional class, and history of heart failure was highly predictive of survival. When added to this model, CT ratio also was independently associated with mortality, but not radiographic cardiac area or volume. When radiographic variables were each added to CT ratio, they did not add incremental predictive value to the model that included CT ratio alone. Echocardiographic measurement of left ventricular (LV) size, especially when indexed for body size, was independently predictive of outcome, but it did not supersede the predictive power of CT ratio. CONCLUSION: The simply derived radiographic CT ratio is a useful predictor of outcome in patients with dilated cardiomyopathy and compares favorably with other clinical and selected echocardiographic variables.