Anaesthetic management for robotic-assisted laparoscopic prostatectomy: the first UK national survey of current practice.

Robotic-assisted laparoscopic prostatectomy (RALP) is the most common robotic surgical procedure, but there are little published data to inform anaesthetic practice. We aimed to characterise the range of anaesthetic practice for RALP in the United Kingdom through a national survey. We conducted an online national survey to determine current anaesthetic practice for RALP. The survey was distributed to all NHS hospitals within the UK that perform RALP. Thirty-four (79%) of 43 hospitals responded to the survey. Fourteen (41%) centres routinely provide spinal anaesthesia and 79% of these use diamorphine as their intrathecal opioid of choice. Thirty-one (91%) centres administer intravenous strong opioids intraoperatively, and a wide range of non-opioid analgesic agents are also administered. Five (15%) centres reported that they discharge a minority of patients on the day of surgery. High-volume centres are more likely to have a formalised enhanced recovery after surgery (ERAS) pathway and to provide ambulatory surgery for selected patients. This represents the first UK national survey of anaesthetic practice for RALP. The results of the survey revealed significant variation in anaesthetic practice implying a lack of consensus on best perioperative management.

Age-related natural fertility outcomes in women over 35 years: a systematic review and individual participant data meta-analysis.

STUDY QUESTION: What is the rate of natural conception leading to ongoing pregnancy or livebirth over 6-12 months for infertile women of age ≥35 years? SUMMARY ANSWER: Natural conception rates were still clinically relevant in women aged 35 years and above and were significantly higher in women with unexplained infertility compared to those with other diagnoses. WHAT IS KNOWN ALREADY: In recent years, increasing numbers of women have attempted to conceive at a later age, resulting in a commensurate increase in the need for ART. However, there is a lack of data on natural fertility outcomes (i.e. no interventions) in women with increasing age. STUDY DESIGN, SIZE, DURATION: A systematic review with individual participant data (IPD) meta-analysis was carried out. PubMed, MEDLINE, EMBASE, the Cochrane Library, clinicaltrials.gov were searched until 1 July 2018 including search terms 'fertility service', 'waiting list', 'treatment-independent' and 'spontaneous conception'. Language restrictions were not imposed. PARTICIPANTS/MATERIALS, SETTING, METHODS: Inclusion criteria were studies (at least partly) reporting on infertile couples with female partner of age ≥35 years who attended fertility services, underwent fertility workup (e.g. history, semen analysis, tubal status and ovulation status) and were exposed to natural conception (e.g. independent of treatment such as IVF, ovulation induction and tubal surgery). Studies that exclusively studied only one infertility diagnosis, without including other women presenting to infertility services for other causes of infertility, were excluded. For studies that met the inclusion criteria, study authors were contacted to provide IPD, after which fertility outcomes for women of age ≥35 years were retrieved. Time to pregnancy or livebirth and the effect of increasing age on fertility outcomes after adjustment for other prognostic factors were analysed. Quality of studies was graded with the Newcastle-Ottawa Scale (non-randomised controlled trials (RCTs)) or the Cochrane Risk of Bias tool (for RCTs). MAIN RESULTS AND THE ROLE OF CHANCE: We included nine studies (seven cohort studies and two RCTs) (n = 4379 women of at least age 35 years), with the observed composite primary outcome of ongoing pregnancy or livebirth occurring in 429 women (9.8%) over a median follow-up of 5 months (25th to 75th percentile: 2.5-8.5 months). Studies were of moderate to high quality. The probability of natural conception significantly decreased with any diagnosis of infertility, when compared with unexplained infertility. We found non-linear effects of female age and duration of infertility on ongoing pregnancy and tabulated the predicted probabilities for unexplained infertile women aged 35-42 years with either primary or secondary infertility and with a duration of infertility from 1 to 6 years. For a 35-year-old woman with 2 years of primary unexplained infertility, the predicted probability of natural conception leading to ongoing pregnancy or livebirth was 0.15 (95% CI 0.11-0.19) after 6 months and 0.24 (95% CI 0.17-0.30) after 12 months. For a 42-year-old woman, this decreased to 0.08 (95% CI 0.04-0.11) after 6 months and 0.13 (95% CI 0.07-0.18) after 12 months. LIMITATIONS, REASONS FOR CAUTION: In the studies selected, there were different study designs, recruitment strategies in different centres, protocols and countries and different methods of assessment of infertility. Data were limited for women above the age of 40 years. WIDER IMPLICATIONS OF THE FINDINGS: Women attending fertility services should be encouraged to pursue natural conception while waiting for treatment to commence and after treatment if it is unsuccessful. Our results may aid in counselling women, and, in particular, for those with unexplained infertility. STUDY FUNDING/COMPETING INTEREST(S): S.J.C. received funding from the University of Adelaide Summer Research Scholarship. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437), B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, iGenomix and Guerbet. B.W.M. reports research support by Merck and Guerbet. PROSPERO REGISTRATION NUMBER: CRD42018096552.

Microbial biofilms in nature: unlocking their potential for agricultural applications.

Soil environments are dynamic and the plant rhizosphere harbours a phenomenal diversity of micro-organisms which exchange signals and beneficial nutrients. Bipartite beneficial or symbiotic interactions with host roots, such as mycorrhizae and various bacteria, are relatively well characterized. In addition, a tripartite interaction also exists between plant roots, arbuscular mycorrhizal fungi (AMF) and associated bacteria. Bacterial biofilms exist as a sheet of bacterial cells in association with AMF structures, embedded within a self-produced exopolysaccharide matrix. Such biofilms may play important functional roles within these tripartite interactions. However, the details about such interactions in the rhizosphere and their relevant functional relationships have not been elucidated. This review explores the current understanding of naturally occurring microbial biofilms, and their interaction with biotic surfaces, especially AMF. The possible roles played by bacterial biofilms and the potential for their application for a more productive and sustainable agriculture is discussed in this review.

Transcriptome analysis, using RNA-Seq of Lomandra longifolia roots infected with Phytophthora cinnamomi reveals the complexity of the resistance response.

The plant pathogen Phytophthora cinnamon the causal agent of disease in numerous species, is a major threat to natural vegetation and has economic impacts in agriculture. The pathogen principally invades the root system, which, in susceptible species, is rapidly colonised and functionally destroyed. Few species are resistant, however, where resistance is expressed the pathogen is restricted to small, localised lesions. The molecular mechanisms that underpin this response in resistant species are not well understood. Lomandra longifolia, an Australian native species, is highly resistant to P. cinnamomi. In an earlier study, we showed induction of resistance-related components such as callose, lignin and hydrogen peroxide (H2 O2 ) in L. longifolia roots that had been inoculated with P. cinnamomi. Here, in order to further identify, during the very early stages of infection, the molecular components and regulatory networks that may trigger resistance, a comprehensive root transcriptome analysis was performed using next generation sequencing. Overall, 18 cDNA libraries were produced generating 52.8 GB 126 base pair reads, which were de novo assembled into contigs. Differentially expressed genes (DEGs) were identified allowing the identification of infection-responsive candidate genes that were putatively related to resistance, and from this set ten were selected for qRT-PCR to validate the RNA-Seq expression value. Further analysis of individual candidates revealed that many were involved in PAMP-triggered immunity (PTI; pattern recognition receptors, glutathione S-transferase, callose synthases, pathogenesis-related protein-1, mitogen activated protein kinases) and effector-triggered immunity (ETI) (NBS-LRR, signalling genes, transcription factors and anti-pathogenic compound synthase genes). As these candidate genes or mediated components activate different defence signalling systems, they may have potential for investigation of novel approaches to disease control and in transgenic approaches for improvement, in susceptible species, of resistance to P. cinnamomi.

Real World Evidence: A Quantitative and Qualitative Glance at Participant Feedback from a Free-Response Survey Investigating Experiences of a Structured Exercise Intervention for Men with Prostate Cancer.

AIM: To explore patient experiences of a structured exercise intervention for men with prostate cancer (PCa). SAMPLE: 41 men with either localised or advanced PCa who had been referred for a structured exercise programme by their physician and then subsequently consented to a telephone survey. METHOD: Participants underwent a 10-week supervised exercise programme within a large cancer centre hospital consisting of 8 sessions. They then completed a short multiple choice telephone survey, elaborating on their responses where appropriate. Views expressed by participants were analysed using an affinity diagram and common themes were identified. RESULTS: Feedback from our telephone surveys was consistently positive and suggests that the structured exercise intervention provides exercise confidence, motivation to exercise, and social support and promotes positive health behaviour change in the context of exercise. Individual differences arose amongst participants in their perceived utility of the intervention, with 73.3% expressing a preference for structured exercise classes and 19.5% expressing a preference for exercising independently. CONCLUSION: Design of a structured exercise intervention for patients with PCa should embrace the positive aspects outlined here but consider patients' individual differences. Ongoing feedback from patients should be utilised alongside traditional study designs to inform intervention design in this area.

Caring for Obese Children- A change in Paradigm.

Childhood Obesity is a problem of epidemic proportions. The causes are complex and treatment results are variable with much research ongoing. We analysed the initial assessment forms of a group of patients attending the W82GO! Healthy Lifestyle service at The Children's University Hospital, Temple Street to look at the population and their specific needs. Our analysis revealed a high proportion of emotional and behavioural problems along with bullying. This group of patients are complex and a multi-disciplinary team approach is essential in their treatment.

The Da Vinci Xi and robotic radical prostatectomy-an evolution in learning and technique.

The da Vinci Xi robot has been introduced as the successor to the Si platform. The promise of the Xi is to open the door to new surgical procedures. For robotic-assisted radical prostatectomy (RARP)/pelvic surgery, the potential is better vision and longer instruments. How has the Xi impacted on operative and pathological parameters as indicators of surgical performance? This is a comparison of an initial series of 42 RARPs with the Xi system in 2015 with a series using the Si system immediately before Xi uptake in the same calendar year, and an Si series by the same surgeon synchronously as the Xi series using operative time, blood loss, and positive margins as surrogates of surgical performance. Subjectively and objectively, there is a learning curve to Xi uptake in longer operative times but no impact on T2 positive margins which are the most reflective single measure of RARP outcomes. Subjectively, the vision of the Xi is inferior to the Si system, and the integrated diathermy system and automated setup are quirky. All require experience to overcome. There is a learning curve to progress from the Si to Xi da Vinci surgical platforms, but this does not negatively impact the outcome.

Characterization of the bionano interface and mapping extrinsic interactions of the corona of nanomaterials.

Nanoparticles in physiological environments are known to selectively adsorb proteins and other biomolecules forming a tightly bound biomolecular 'corona' on their surface. Where the exchange times of the proteins are sufficiently long, it is believed that the protein corona constitutes the particle identity in biological milieu. Here we show that proteins in the corona retain their functional characteristics and can specifically bind to cognate proteins on arrays of thousands of immobilised human proteins. The biological identity of the nanomaterial is seen to be specific to the blood plasma concentration in which they are exposed. We show that the resulting in situ nanoparticle interactome is dependent on the protein concentration in plasma, with the emergence of a small number of dominant protein-protein interactions. These interactions are those driven by proteins that are adsorbed onto the particle surface and whose binding epitopes are subsequently expressed or presented suitably on the particle surface. We suggest that, since specific tailored protein arrays for target systems and organs can be designed, their use may be an important element in an overall study of the biomolecular corona.

Sub-lethal UV-C radiation induces callose, hydrogen peroxide and defence-related gene expression in Arabidopsis thaliana.

Exposure of plants to UV-C irradiation induces gene expression and cellular responses that are commonly associated with wounding and pathogen defence, and in some cases can lead to increased resistance against pathogen infection. We examined, at a physiological, molecular and biochemical level, the effects of and responses to, sub-lethal UV-C exposure on Arabidopsis plants when irradiated with increasing dosages of UV-C radiation. Following UV-C exposure plants had reduced leaf areas over time, with the severity of reduction increasing with dosage. Severe morphological changes that included leaf glazing, bronzing and curling were found to occur in plants treated with the 1000 J·m(-2) dosage. Extensive damage to the mesophyll was observed, and cell death occurred in both a dosage- and time-dependent manner. Analysis of H2O2 activity and the pathogen defence marker genes PR1 and PDF1.2 demonstrated induction of these defence-related responses at each UV-C dosage tested. Interestingly, in response to UV-C irradiation the production of callose (ß-1,3-glucan) was identified at all dosages examined. Together, these results show plant responses to UV-C irradiation at much lower doses than have previously been reported, and that there is potential for the use of UV-C as an inducer of plant defence.

Essure(®) for management of hydrosalpinx prior to in vitro fertilisation-a systematic review and pooled analysis.

BACKGROUND: Hydrosalpinges in infertile women reduce the success of in vitro fertilisation (IVF) by 50%. Surgical management of hydrosalpinges before IVF improves outcome but these procedures are often contraindicated in women with dense pelvic adhesions. Tubal occlusion achieved by Essure(®) via hysteroscopy provides an alternative. OBJECTIVES: To conduct a systematic review on the efficacy and safety of Essure(®) in the management of hydrosalpinx before IVF. SEARCH STRATEGY: We searched MEDLINE (January 1950 to July 2013), EMBASE (January 1980 to July 2013) and Web of Science (1899 to July 2013). We also searched reference lists of relevant articles and proceedings of relevant international conferences (2000-2013). SELECTION CRITERIA: All types of studies where women with suspected infertility and presence of hydrosalpinx had hysteroscopic tubal occlusion with Essure(®) before IVF. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies and extracted data. Where necessary, study authors were contacted for further data. MAIN RESULTS: In all, 115 women in 11 studies received Essure(®) , mainly in the outpatient setting where local anaesthesia by paracervical block and/or intravenous sedation was used. Successful placement of Essure(®) was achieved in 96.5% (95% confidence interval [95% CI] 91.1-98.9%) of women and tubal occlusion in 98.1% (95% CI 93.1-99.9%). Subsequent IVF resulted in 38.6% pregnancy rate (95% CI 30.9-46.8%), 27.9% live birth rate (95% CI 21.1-35.8%) and 28.6% combined ongoing pregnancy and live birth rate (95% CI 21.7-36.6%) per embryo transfer. AUTHOR'S CONCLUSIONS: Essure(®) appears to be an effective option for management of hydrosalpinx in women before IVF although evidence from a randomised controlled clinical trial is lacking.

When to image neurologically normal children with headaches: development of a decision rule.

AIMS: The aim of this study was to develop and refine a decision rule on when to undertake brain imaging (BI) in neurologically normal children with headaches. METHODS: From the literature and a questionnaire study, a list of red flags (RFs) was drawn-up. During the prospective 4-year period, consecutive children with headache were classified according to RFs and the headache diagnosis. RESULT: Three of 709 (0.4%) neurologically normal children had significant brain abnormalities. BI was carried out in 389 of 498 (78%) children with RFs. Significant abnormalities were found in three of 389 children (0.8%), all had unclassified headache (UH). BI was not arranged for the 211 children with no RFs. None of these developed RFs or abnormal signs on follow-up for a mean of 13 months. CONCLUSION: In addition to BI for those with neurological signs, we think BI should be considered for neurologically normal patients with UH and RFs. This would have saved imaging children needlessly: only 101 of 709 (14%) would have had scans arranged, instead of 389 of 709.

High thermal conductivity of a hydrogenated amorphous silicon film.

We measured the thermal conductivity kappa of an 80 microm thick hydrogenated amorphous silicon film prepared by hot-wire chemical-vapor deposition with the 3omega (80-300 K) and the time-domain thermo-reflectance (300 K) methods. The kappa is higher than any of the previous temperature dependent measurements and shows a strong phonon mean free path dependence. We also applied a Kubo based theory using a tight-binding method on three 1000 atom continuous random network models. The theory gives higher kappa for more ordered models, but not high enough to explain our results, even after extrapolating to lower frequencies with a Boltzmann approach. Our results show that this material is more ordered than any amorphous silicon previously studied.