Nested renewal processes

A class of stochastic processes useful in the investigation of the deterioration and replacement of equipment, as well as in the study of group arrival/batch service queues, storage systems, epidemics and computer software, is introduced. These so-called nested renewal processes consist of ordinary and cumulative renewal processes sequentially nested within a hierarchy. The main properties of these processes are discussed with emphasis on the asymptotic results. An example of their application to tyre wear is considered.

The fate of (13)C-labelled and non-labelled inulin predisposed to large bowel fermentation in rats

The fate of stable-isotope (13)C labelled and non-labelled inulin catabolism by the gut microbiota was assessed in a healthy rat model. Sprague-Dawley male rats were randomly assigned to diets containing either cellulose or inulin, and were fed these diets for 3 days. On day (d) 4, rats allocated to the inulin diet received (13)C-labelled inulin. The rats were then fed the respective non-labelled diets (cellulose or inulin) until sampling (d4, d5, d6, d7, d10 and d11). Post feeding of (13)C-labelled substrate, breath analysis showed that (13)C-inulin cleared from the host within a period of 36 hours. Faecal (13)C demonstrated the clearance of inulin from gut with a (13)C excess reaching maximum at 24 hours (d5) and then declining gradually. There were greater variations in caecal organic acid concentrations from d4 to d6, with higher concentrations of acetic, butyric and propionic acids observed in the rats fed inulin compared to those fed cellulose. Inulin influenced caecal microbial glycosidase activity, increased colon crypt depth, and decreased the faecal output and polysaccharide content compared to the cellulose diet. In summary, the presence of inulin in the diet positively influenced large bowel microbial fermentation.

Are general surgeons able to accurately self-assess their level of technical skills?

INTRODUCTION

Self-assessment is a way of improving technical capabilities without the need for trainer feedback. It can identify areas for improvement and promote professional medical development. The aim of this review was to identify whether self-assessment is an accurate form of technical skills appraisal in general surgery.

METHODS

The PubMed, MEDLINE(®), Embase(™) and Cochrane databases were searched for studies assessing the reliability of self-assessment of technical skills in general surgery. For each study, we recorded the skills assessed and the evaluation methods used. Common endpoints between studies were compared to provide recommendations based on the levels of evidence.

RESULTS

Twelve studies met the inclusion criteria from 22,292 initial papers. There was no level 1 evidence published. All papers compared the correlation between self-appraisal versus an expert score but differed in the technical skills assessment and the evaluation tools used. The accuracy of self-assessment improved with increasing experience (level 2 recommendation), age (level 3 recommendation) and the use of video playback (level 3 recommendation). Accuracy was reduced by stressful learning environments (level 2 recommendation), lack of familiarity with assessment tools (level 3 recommendation) and in advanced surgical procedures (level 3 recommendation).

CONCLUSIONS

Evidence exists to support the reliability of self-assessment of technical skills in general surgery. Several variables have been shown to affect the accuracy of self-assessment of technical skills. Future work should focus on evaluating the reliability of self-assessment during live operating procedures.

In vitro characterisation of the fermentation profile and prebiotic capacity of gold-fleshed kiwifruit

A new Actinidia chinensis gold-fleshed kiwifruit cultivar 'Zesy002' was tested to investigate whether it could positively modulate the composition of the human colonic microbiota. Digested Zesy002 kiwifruit was added to in vitro pH-controlled anaerobic batch fermenters that were inoculated with representative human faecal microbiota. Alterations to the gut microbial ecology were determined by 16S rRNA gene sequencing and metabolic end products were measured using gas chromatography and liquid chromatography - mass spectrometry. Results indicated a substantial shift in the composition of bacteria within the gut models caused by kiwifruit supplementation. Zesy002 supplemented microbiota had a significantly higher abundance of Bacteroides spp., Parabacteroides spp. and Bifidobacterium spp. after 48 h of fermentation compared with the start of the fermentation. Organic acids from kiwifruit were able to endure simulated gastrointestinal digestion and were detectable in the first 10 h of fermentation. The fermentable carbohydrates were converted to beneficial organic acids with a particular predilection for propionate production, corresponding with the rise in Bacteroides spp. and Parabacteroides spp. These results support the claim that Zesy002 kiwifruit non-digestible fractions can effect favourable changes to the human colonic microbial community and primary metabolites, and demonstrate a hitherto unknown effect of Zesy002 on colonic microbiota under in vitro conditions.

Choosing Wisely in the UK: the Academy of Medical Royal Colleges' initiative to reduce the harms of too much medicine

A Malhotra and colleagues explain how and why a US initiative to get doctors to stop using interventions with no benefit is being brought to the UK

Kiwifruit-derived supplements increase stool frequency in healthy adults: a randomized, double-blind, placebo-controlled study

The worldwide growth in the incidence of gastrointestinal disorders has created an immediate need to identify safe and effective interventions. In this randomized, double-blind, placebo-controlled study, we examined the effects of Actazin and Gold, kiwifruit-derived nutritional ingredients, on stool frequency, stool form, and gastrointestinal comfort in healthy and functionally constipated (Rome III criteria for C3 functional constipation) individuals. Using a crossover design, all participants consumed all 4 dietary interventions (Placebo, Actazin low dose [Actazin-L] [600 mg/day], Actazin high dose [Actazin-H] [2400 mg/day], and Gold [2400 mg/day]). Each intervention was taken for 28 days followed by a 14-day washout period between interventions. Participants recorded their daily bowel movements and well-being parameters in daily questionnaires. In the healthy cohort (n = 19), the Actazin-H (P = .014) and Gold (P = .009) interventions significantly increased the mean daily bowel movements compared with the washout. No significant differences were observed in stool form as determined by use of the Bristol stool scale. In a subgroup analysis of responders in the healthy cohort, Actazin-L (P = .005), Actazin-H (P < .001), and Gold (P = .001) consumption significantly increased the number of daily bowel movements by greater than 1 bowel movement per week. In the functionally constipated cohort (n = 9), there were no significant differences between interventions for bowel movements and the Bristol stool scale values or in the subsequent subgroup analysis of responders. This study demonstrated that Actazin and Gold produced clinically meaningful increases in bowel movements in healthy individuals.

D-dimer and risk of thromboembolic and bleeding events in patients with atrial fibrillation--observations from the ARISTOTLE trial

BACKGROUND

D-dimer is related to adverse outcomes in arterial and venous thromboembolic diseases.

OBJECTIVES

To evaluate the predictive value of D-dimer level for stroke, other cardiovascular events, and bleeds, in patients with atrial fibrillation (AF) treated with oral anticoagulation with apixaban or warfarin; and to evaluate the relationship between the D-dimer levels at baseline and the treatment effect of apixaban vs. warfarin.

METHODS

In the ARISTOTLE trial, 18 201 patients with AF were randomized to apixaban or warfarin. D-dimer was analyzed in 14 878 patients at randomization. The cohort was separated into two groups; not receiving vitamin K antagonist (VKA) treatment and receiving VKA treatment at randomization.

RESULTS

Higher D-dimer levels were associated with increased frequencies of stroke or systemic embolism (hazard ratio [HR] [Q4 vs. Q1] 1.72, 95% confidence interval [CI] 1.14-2.59, P = 0.003), death (HR [Q4 vs. Q1] 4.04, 95% CI 3.06-5.33) and major bleeding (HR [Q4 vs. Q1] 2.47, 95% CI 1.77-3.45, P < 0.0001) in the no-VKA group. Similar results were obtained in the on-VKA group. Adding D-dimer level to the CHADS2 score improved the C-index from 0.646 to 0.655 for stroke or systemic embolism, and from 0.598 to 0.662 for death, in the no-VKA group. D-dimer level improved the HAS-BLED score for prediction of major bleeds, with an increase in the C-index from 0.610 to 0.641. There were no significant interactions between efficacy and safety of study treatment and D-dimer level.

CONCLUSION

In anticoagulated patients with AF, the level of D-dimer is related to the risk of stroke, death, and bleeding, and adds to the predictive value of clinical risk scores. The benefits of apixaban were consistent, regardless of the baseline D-dimer level.

Influence of green and gold kiwifruit on indices of large bowel function in healthy rats

The effects of kiwifruit on large bowel health were investigated in healthy rats. Four-week old Sprague-Dawley rats were given diets containing 10% homogenized green kiwifruit, gold kiwifruit or 10% glucose solution (control) over 4 or 6 wk. Green kiwifruit increased the fecal output compared to control. Growth of certain bacterial species in cecum was influenced by both green and gold kiwifruit. A significant increase in cecal Lachnospiraceae in rats fed the green kiwifruit diet was observed at week 4. At week 6, green and gold kiwifruit diets assisted in improving colonic barrier function by upregulating the expression of mucin (MUC)-2, MUC3, Toll-like receptor (TLR)-4 or trefoil factor-3 genes. Gold kiwifruit consumption increased the colonic goblet cells per crypt at week 6. Significant negative correlations between E. coli and β-defensin 1 and TLR4 expression were observed. Consuming green and gold kiwifruit for 6 wk significantly altered the biomarkers of large bowel health; indicating that regularly consuming kiwifruit helps attain optimal digestive health.

A new ex vivo animal simulation model for skills training in laparoscopic colorectal surgery

The opportunity for using simulation in medical training has expanded in recent years. 1–3 Laparoscopic surgery is an area that is ideally suited to the use of simulators for the acquisition of clinical skills. 4 Simulation allows educators to have control over pre-selected scenarios, without distressing patients or encountering complications. 5

Polyunsaturated fatty acids modify expression of TGF-β in a co-culture model ultilising human colorectal cells and human peripheral blood mononuclear cells exposed to Lactobacillus gasseri, Escherichia coli and Staphylococcus aureus

Commensal bacteria and polyunsaturated fatty acids (PUFAs) have both been shown independently to modulate immune responses. This study tested the hypothesis that the different colonic immunomodulatory responses to commensal (Lactobacillus gasseri) and pathogenic bacteria (Escherichia coli and Staphylococcus aureus) may be modified by PUFAs. Experiments used a Transwell system combining the colorectal cell line HT29, or its mucous secreting sub-clone HT29-MTX, with peripheral blood mononuclear cells to analyse immunomodulatory signalling in response to bacteria, with and without prior treatment with arachidonic acid, eicosapentaenoic acid or docosahexaenoic acid. L. gasseri increased transforming growth factor β1 (TGF-β1) mRNA and protein secretion in colonic cell lines when compared with controls, an effect that was enhanced by pre-treatment with eicosapentaenoic acid. In contrast, the Gram-negative pathogen E. coli LF82 had no significant effect on TGF-β1 protein. L. gasseri also increased IL-8 mRNA but not protein while E. coli increased both; although differences between PUFA treatments were detected, none were significantly different to controls. Colonic epithelial cells show different immunomodulatory signalling patterns in response to the commensal L. gasseri compared to E. coli and S. aureus and pre-treatment of these cells with PUFAs can modify responses. Practical applications: We have demonstrated an interaction between dietary PUFAs and epithelial cell response to both commensal and pathogenic bacteria found in the gastrointestinal tract by utilising in vitro co-culture models. The data suggest that n-3 PUFAs may provide some protection against the potentially damaging effects of pathogens. Furthermore, the beneficial effects of combining n-3 PUFAs and the commensal bacteria, and potential probiotic, L. gasseri are illustrated by the increased expression of immunoregulatory TGF-β1.

Lactic acid bacteria convert glucosinolates to nitriles efficiently yet differently from enterobacteriaceae

Glucosinolates from the genus Brassica can be converted into bioactive compounds known to induce phase II enzymes, which may decrease the risk of cancers. Conversion via hydrolysis is usually by the brassica enzyme myrosinase, which can be inactivated by cooking or storage. We examined the potential of three beneficial bacteria, Lactobacillus plantarum KW30, Lactococcus lactis subsp. lactis KF147, and Escherichia coli Nissle 1917, and known myrosinase-producer Enterobacter cloacae to catalyze the conversion of glucosinolates in broccoli extract. Enterobacteriaceae consumed on average 65% glucoiberin and 78% glucoraphanin, transforming them into glucoiberverin and glucoerucin, respectively, and small amounts of iberverin nitrile and erucin nitrile. The lactic acid bacteria did not accumulate reduced glucosinolates, consuming all at 30-33% and transforming these into iberverin nitrile, erucin nitrile, sulforaphane nitrile, and further unidentified metabolites. Adding beneficial bacteria to a glucosinolate-rich diet may increase glucosinolate transformation, thereby increasing host exposure to bioactives.

The WIMAT colonoscopy suitcase model: a novel porcine polypectomy trainer

AIM

Simulation allows the acquisition of complex skills within a safe environment. Endoscopic polypectomy has a long learning curve. Our novel polypectomy simulator may be a useful adjunct for training. The aim of this study was to assess its content validity.

METHOD

The Welsh Institute for Minimal Access Therapy (WIMAT) endoscopy suitcase was designed to simulate colonic polypectomy. Participants from regional and national courses were recruited into the study. Each undertook a standardized simulated polypectomy and completed a seven-point Likert scale questionnaire examining its realism.

RESULTS

In all, 17 participants completed the questionnaire: 15 (88.2%) gastroenterologists, one (5.9%) colorectal surgeon and one (5.9%) experienced endoscopic nurse specialist. Of the gastroenterologists, seven (46.7%) were consultants and eight (53.3%) were senior trainees or Post CCT (Certificate of Completion of Training) fellows. The mean number of real-life polypectomies performed by the cohort was 156 (95% CI 35-355). The highest scores were for 'mucosal realism' (median score 6.0, P=0.001), 'endoscopic snare control' (median score 6.0, P=0.001), 'handling the polyp' (median score 6.0, P=0.001) and 'raising mucosa' (median score 6.0, P<0.001). Of the 15 parameters examined only three were not statistically significant in favour of the simulator. These were 'anatomical realism of sessile polyps', 'resistance of scope movement' and 'paradoxical motion'. The overall score for the simulation was 6.0 (P < 0.001). There was no significant difference between the level of difficulty of the simulator compared with real life (median score 4.0, P = 0.559).

CONCLUSION

The WIMAT colonoscopy suitcase model has excellent content validity for several parameters. This may have potential applications in medical training and assessment.