A national survey of UK practice for day-case vaginal prolapse surgery: Unrealistic expectations?

OBJECTIVE: The UK NHS Getting It Right First Time report (2021) recommended that a significant proportion of native tissue vaginal prolapse operations should be undertaken as day-case procedures (target: 80% anterior compartment, 70% posterior compartment, 60% combined anterior/posterior compartment). The evidence for perioperative care, options for anaesthesia and outcomes of day-case vaginal prolapse surgery is limited. This study aimed to establish current practice amongst UK gynaecologists and explore perceived barriers to implementing day-case surgery for pelvic organ prolapse. Study design A pre-tested 16-item survey was emailed to British Society of Urogynaecology members in July 2022. This survey recorded rates of day-case prolapse surgeries, barriers to implementation and practices for managing urethral catheters, vaginal packs, intraoperative anaesthetics and perioperative care. Responses to free-text questions were independently analysed by two of the authors and underwent thematic analysis. RESULTS: 121 eligible responses were received (28 % response-rate): 41 % never undertook day-case prolapse repair, 16 % undertook < 5 per year and 26 % undertook > 20 cases per year. There was no significant difference in training level or hospital setting between those groups. Reasons cited for not undertaking day-case prolapse surgery included concerns about vaginal packs and urinary catheters (92 %) postoperative complications (67 %), early discharge of elderly patients (60 %) and a lack of published evidence (39 %) or national guidance (35 %). For those currently undertaking day-case prolapse surgery; 67 % used general anaesthesia, 15 % spinal with short-acting local anaesthetic, 14 % spinal with long-acting local anaesthetic and 3 % local anaesthetic alone. Vaginal packs and self-retaining urethral catheters were used by 68 % and 70 % respectively. Concerns regarding the management of vaginal packs and urinary catheters were the most frequently cited barrier to implementing day-case surgery for pelvic organ prolapse amongst free-text responses. There were wide variations in managing catheters and packs, and in managing readmissions. CONCLUSIONS: There is significant variation in uptake and practice for day-case prolapse surgery in the UK, with legitimate clinical concerns a barrier to its implementation. Further evaluation and development of robust, evidence-based management pathways are required to make day-case prolapse surgery consistent, feasible and defensible in clinical practice.

Airflow Characteristics in Aeromedical Aircraft: Considerations During COVID-19.

OBJECTIVE: The aeromedical transport of coronavirus patients presents risks to clinicians and aircrew. Patient positioning and physical barriers may provide additional protection during flight. This paper describes airflow testing undertaken on fixed wing and rotary wing aeromedical aircraft. METHODS: Airflow testing was undertaken on a stationary Hawker Beechcraft B200C and Leonardo Augusta Westland 139. Airflow was simulated using a Trainer 101 (MSS Professional A/S, Odense Sø, Syddanmark, Denmark) Smoke machine. Different cabin configurations were used along with variations in heating, cooling, and ventilation systems. RESULTS: For the Hawker Beechcraft B200C, smoke generated within the forward section of the cabin was observed to fill the cabin to a fluid boundary located in-line with the forward edge of the cargo door. With the curtain closed, smoke was only observed to enter the cockpit in very small quantities. For the Leonardo AW139, smoke generated within the cabin was observed to expand to fill the cabin evenly before dissipating. With the curtain closed, smoke was observed to enter the cockpit only in small quantities CONCLUSION: The use of physical barriers in fixed wing and rotary wing aeromedical aircraft provides some protection to aircrew. Optimal positioning of the patient is on the aft stretcher on the Beechcraft B200C and on a laterally orientated stretcher on the AW139. The results provide a baseline for further investigation into methods to protect aircrew during the coronavirus pandemic.

The 'W' prawn-trawl with emphasised drag-force transfer to its centre line to reduce overall system drag.

For prawn trawling systems, drag reduction is a high priority as the trawling process is energy intensive. Large benefits have occurred through the use of multiple-net rigs and thin twine in the netting. An additional positive effect of these successful twine-area reduction strategies is the reduced amount of otter board area required to spread the trawl systems, which leads to further drag reduction. The present work investigated the potential of redirecting the drag-strain within a prawn trawl away from the wings and the otter boards to the centre line of the trawl, where top and bottom tongues have been installed, with an aim to minimise the loading/size of the otter boards required to spread the trawl. In the system containing the new 'W' trawl, the drag redirected to the centre-line tongues is transferred forward through a connected sled and towing wires to the trawler. To establish the extent of drag redirection to the centre-line tongues and the relative drag benefits of the new trawl system, conventional and 'W' trawls of 3.65 m headline length were tested firstly over a range of spread ratios in the flume tank, and subsequently at optimum spread ratio in the field. The developed 'W' trawl effectively directed 64% of netting-drag off the wings and onto the centre tongues, which resulted in drag savings in the field of ∼20% for the associated 'W' trawl/otter-board/sled system compared to the traditional trawl/otter-board arrangement in a single trawl or twin rig configuration. Furthermore, based on previously published data, the new trawl when used in a twin rig system is expected to provide approximately 12% drag reduction compared to quad rig. The twin 'W' trawl system also has benefits over quad rig in that a reduced number of cod-end/By-catch Reduction Device units need to be installed and attended each tow.

Methylation of H3K4 Is required for inheritance of active transcriptional states.

BACKGROUND: Maintenance of differentiation programs requires stability, when appropriate, of transcriptional states. However, the extent to which inheritance of active transcriptional states occurs from mother to daughter cells has not been directly addressed in unperturbed cell populations. RESULTS: By live imaging of single-gene transcriptional events in individual cells, we have directly recorded the potential for mitotic inheritance of transcriptional states down cell lineages. Our data showed strong similarity in frequency of transcriptional firing between mother and daughter cells. This memory persisted for complete cell cycles. Both transcriptional pulse length and pulsing rate contributed to overall inheritance, and memory was determined by lineage, not cell environment. Analysis of transcription in chromatin mutants demonstrated that the histone H3K4 methylase Set1 and Ash2, a component of the methylase complex, are required for memory. The effects of Set1 methylation may be mediated directly by chromatin, because loss of memory also occurred when endogenous H3K4 was replaced by alanine. Although methylated H3K4 is usually associated with active transcriptional units, the modification was not required for gene activity but stabilized transcriptional frequency between generations. CONCLUSIONS: Our data indicate that methylated H3K4 can act as a chromatin mark reflecting the original meaning of "epigenetic."

Insulin resistance in polycystic ovary syndrome is associated with defective regulation of ERK1/2 by insulin in skeletal muscle in vivo.

Insulin resistance is a recognized feature of PCOS (polycystic ovary syndrome). However, the molecular reason(s) underlying this reduced cellular insulin sensitivity is not clear. The present study compares the major insulin signalling pathways in skeletal muscle isolated from PCOS and controls. We measured whole-body insulin sensitivity and insulin signalling in skeletal muscle biopsies taken before and after acute exposure to hyperinsulinaemia in nine women diagnosed with PCOS and seven controls. We examined the expression, basal activity and response to in vivo insulin stimulation of three signalling molecules within these human muscle samples, namely IRS-1 (insulin receptor substrate-1), PKB (protein kinase B) and ERK (extracellular-signal-regulated kinase) 1/2. There was no significant difference in the expression, basal activity or activation of IRS-1 or PKB between PCOS and control subjects. However, there was a severe attenuation of insulin stimulation of the ERK pathway in muscle from all but two of the women with PCOS (the two most obese), and an accompanying trend towards higher basal phosphorylation of ERK1/2 in PCOS. These results are striking in that the metabolic actions of insulin are widely believed to require the IRS-1/PKB pathway rather than ERK, and the former has been reported as defective in some previous PCOS studies. Most importantly, the molecular defect identified was independent of adiposity. The altered response of ERK to insulin in PCOS was the most obvious signalling defect associated with insulin resistance in muscle from these patients.

Can we improve recruitment of oocyte donors with loss of donor anonymity? A hospital-based survey.

BACKGROUND: Loss of donor anonymity, as a result of an amendment to the Human Fertilisation and Embryology Act 1990, has led to concerns regarding continued recruitment of gamete and embryo donors. This survey aims to examine the impact of loss of anonymity on willingness to donate oocytes and strategies to improve recruitment. METHODS: Five hundred anonymous self-report questionnaires were randomly allocated to hospital staff between September and December 2004. MAIN OUTCOME MEASURES: To determine public awareness of gamete donation, preferred information sources for potential donors, and affect of loss of anonymity on willingness to consider gamete donation. RESULTS: One hundred and sixty-six responses (33%) were received. Only female respondents (n=143) were analysed. Awareness of gamete donation was high (90%), with 34% willing to consider donation. Removal of donor anonymity reduced this figure to 17%. For women under 35 years of age, the corresponding figures are 43% and 19%, respectively. Potential donors may utilize multiple sources of information prior to reaching a decision about donation. CONCLUSIONS: Loss of donor anonymity reduced by half those willing to consider donation in all age groups. The future of this service depends on recruitment of donors willing to be identified. Consideration of older donors may be an option if adequate counselling occurs.

Latency of onset of de novo myelodysplastic syndromes.

The latency of onset of de novo myelodysplastic syndromes (MDS) is unknown. We report a retrospective analysis of blood counts from patients with MDS and acute myeloid leukemia (AML), and demonstrate temporal differences in rates of change of hemoglobin concentration and mean cell volume within 2-3 years of diagnosis, indicative of the earliest evidence of disease.

Asthma or COPD? An inwestigation into the symptom patterns of asthma may highlight the need for more rigorous diagnostic procedures in elderly patients.

AIM: To investigate the symptom patterns of elderly patients registered as active asthmatics. METHOD: An observational study using a database of 393 practices from throughout the United Kingdom. Participating practices provided health-service resource-use and symptom data for 30 randomly selected asthma patients. 8,244 adults, (16+ years), were stratified into three age groups, 4315(52%) aged 16-44, 2339(28%) 45-64, and 1590(19%) 65+. Comparisons were made for management and outcome measures (attack incidence, symptoms, health service resource use, drug therapies) between the groups. RESULTS: Patients over 64 years old experienced more morning and exercise symptoms(p<0.001) and had more hospital admissions(p<0.001). They received higher levels of medication(p<0.001), were more compliant(p<0.001), but had poorer inhaler technique(p<0.001). CONCLUSION: Despite higher medication levels, 1,164(73%) patients over 64 years reported symptoms, 430(37%) of these, daily. For older patients, where regular symptoms are present despite high medication levels, investigation for diagnoses other than asthma should be routine.