International Delphi consensus guidelines for follow-up after prophylactic total gastrectomy: the Life after Prophylactic Total Gastrectomy (LAP-TG) study.

BACKGROUND: Prophylactic total gastrectomy (PTG) remains the only means of preventing gastric cancer for people with genetic mutations predisposing to Hereditary Diffuse Gastric Cancer (HDGC), mainly in the CDH1 gene. The small but growing cohort of people undergoing PTG at a young age are expected to have a life-expectancy close to the general population, however, knowledge of the long-term effects of, and monitoring requirements after, PTG is limited. This study aims to define the standard of care for follow-up after PTG. METHODS: Through a combination of literature review and two-round Delphi consensus of major HDGC/PTG units and physicians, and patient advocates, we produced a set of recommendations for follow-up after PTG. RESULTS: There were 42 first round, and 62 second round, responses from clinicians, allied health professionals and patient advocates. The guidelines include recommendations for timing of assessments and specialties involved in providing follow-up, micronutrient supplementation and monitoring, bone health and the provision of written information. CONCLUSION: While the evidence supporting the guidelines is limited, expert consensus provides a framework to best manage people following PTG, and could support the collection of information on the long-term effects of PTG.

Ripple effects mapping: capturing the wider impacts of systems change efforts in public health.

BACKGROUND: Systems approaches are currently being advocated and implemented to address complex challenges in Public Health. These approaches work by bringing multi-sectoral stakeholders together to develop a collective understanding of the system, and then to identify places where they can leverage change across the system. Systems approaches are unpredictable, where cause-and-effect cannot always be disentangled, and unintended consequences - positive and negative - frequently arise. Evaluating such approaches is difficult and new methods are warranted. METHODS: Ripple Effects Mapping (REM) is a qualitative method which can capture the wider impacts, and adaptive nature, of a systems approach. Using a case study example from the evaluation of a physical activity-orientated systems approach in Gloucestershire, we: a) introduce the adapted REM method; b) describe how REM was applied in the example; c) explain how REM outputs were analysed; d) provide examples of how REM outputs were used; and e) describe the strengths, limitations, and future uses of REM based on our reflections. RESULTS: Ripple Effects Mapping is a participatory method that requires the active input of programme stakeholders in data gathering workshops. It produces visual outputs (i.e., maps) of the programme activities and impacts, which are mapped along a timeline to understand the temporal dimension of systems change efforts. The REM outputs from our example were created over several iterations, with data collected every 3-4 months, to build a picture of activities and impacts that have continued or ceased. Workshops took place both in person and online. An inductive content analysis was undertaken to describe and quantify the patterns within the REM outputs. Detailed guidance related to the preparation, delivery, and analysis of REM are included in this paper. CONCLUSION: REM may help to advance our understanding and evaluation of complex systems approaches, especially within the field of Public Health. We therefore invite other researchers, practitioners and policymakers to use REM and continuously evolve the method to enhance its application and practical utility.

Hereditary diffuse gastric cancer: updated clinical practice guidelines.

Hereditary diffuse gastric cancer (HDGC) is an autosomal dominant cancer syndrome that is characterised by a high prevalence of diffuse gastric cancer and lobular breast cancer. It is largely caused by inactivating germline mutations in the tumour suppressor gene CDH1, although pathogenic variants in CTNNA1 occur in a minority of families with HDGC. In this Policy Review, we present updated clinical practice guidelines for HDGC from the International Gastric Cancer Linkage Consortium (IGCLC), which recognise the emerging evidence of variability in gastric cancer risk between families with HDGC, the growing capability of endoscopic and histological surveillance in HDGC, and increased experience of managing long-term sequelae of total gastrectomy in young patients. To redress the balance between the accessibility, cost, and acceptance of genetic testing and the increased identification of pathogenic variant carriers, the HDGC genetic testing criteria have been relaxed, mainly through less restrictive age limits. Prophylactic total gastrectomy remains the recommended option for gastric cancer risk management in pathogenic CDH1 variant carriers. However, there is increasing confidence from the IGCLC that endoscopic surveillance in expert centres can be safely offered to patients who wish to postpone surgery, or to those whose risk of developing gastric cancer is not well defined.

New horizons: Australian nurses at work in World War I.

More than 3000 nurses from Australia served with the Australian Army Nursing Service or the British nursing services during World War I. These nurses served in various theatres of war including Egypt, France, India, Greece, Italy and England. They worked in numerous roles including as a surgical team nurse close to the front working under fire; nursing on hospital ships carrying the sick and wounded; or managing hospital wards overrun with patients whilst dealing with a lack of hospital necessities. The skills and roles needed to be a military nurse significantly differed to the skills required to nurse in Australia.

In the 'Grey Battalion': Launceston General Hospital nurses on active service in World War I.

Nearly fifty nurses from the Launceston General Hospital served with the Australian Army Nursing Service or the British nursing service during World War I. These nurses served in countries that included Egypt, France, India, Greece, Italy and England. They worked in various roles including as a surgical team nurse close to the front working under fire; nursing on hospital ships carrying the wounded; or managing wards overrun with patients on ships at Gallipoli in 1915, whilst dealing with a lack of hospital necessities. This case study, of one group of nurses, shows that their experiences reflected the skills and roles needed to be a military nurse of the time, significantly different to the skills required to nurse in Australia.

Effect of bulk density on the spatial organisation of the fungus Rhizoctonia solani in soil.

Abstract The mycelial growth form of eucarpic fungi allows for a highly effective spatial exploration of the soil habitat. However, understanding mycelial spread through soil has been limited by difficulties of observation and quantification of fungi as they spread through this matrix. We report on a study on the effects of soil structure by altering the soil bulk density, on the spatial exploration of soil by the fungus Rhizoctonia solani using a soil thin-sectioning technique. First we quantified fungal densities in microscopic images (0.44 mm(2)). At this scale, hyphae were either absent, or present as minor fragments, typically occupying less than 1% surface area of the thin section. From contiguous microscopic images we then produced large-scale (6.21 cm(2)) spatial distribution maps of fungal hyphae. These maps were superimposed onto soil structural maps, which quantify the degree of porosity in each microscopic image. Alterations in soil structure by changing the bulk density are shown to affect the distribution of the fungus within the soil. The volume of soil explored by the fungus increased with increasing bulk density. This was associated with a shift from a few large pore spaces to more evenly distributed small-scale pores. Fungal hyphae were present in all porosity classes within each bulk density, including areas that contain less than 5% visible pore space. However, fungal hyphae were more often found in areas with a higher porosity, in particular at low soil bulk densities. The results show that soil structure is a major component in the spatial exploration of soil by fungi.