Enhanced Recovery after Surgery Program for Elective Abdominal Surgery at Three Victorian Hospitals

The aim of this study was to evaluate the anaesthesia care of an enhanced recovery after surgery (ERAS) program for patients having abdominal surgery in Victorian hospitals. The main outcome measure was the number of ERAS items implemented following introduction of the ERAS program. Secondary endpoints included process of care measures, outcomes and hospital stay. We used a before-and-after design; the control group was a prospective cohort (n=154) representing pre-existing practice for elective abdominal surgical patients from July 2009. The introduction of a comprehensive ERAS program took place over two months and included the education of surgeons, anaesthetists, nurses and allied health professionals. A postimplementation cohort (n=169) was enrolled in early 2010. From a total of 14 ERAS-recommended items, there were significantly more implemented in the post-ERAS period, median 8 (interquartile range 7 to 9) vs 9 (8 to 10), P <0.0001. There were, however, persistent low rates of intravenous fluid restriction (25%) and early removal of urinary catheter (31%) in the post-ERAS period. ERAS patients had less pain and faster recovery parameters, and this was associated with a reduced hospital stay, geometric mean (SD) 5.7 (2.5) vs 7.4 (2.1) days, P=0.006. We found that perioperative anaesthesia practices can be readily modified to incorporate an enhanced recovery program in Victorian hospitals.

Some clinical implications of the protein binding of digoxin

1 The binding of [(3)H]-digoxin to human plasma proteins was studied using both ultrafiltration and frontal analysis, to establish a suitable method for the measurement of digoxin-protein interaction, and to assess the effect of variations in digoxin protein binding on its distribution. 2 Using ultrafiltration, [(3)H]-digoxin was found to bind to plasma proteins to the extent of 30-40% over a concentration range of 0.001-1 ng/ml. Frontal analysis was unsuccessful in the measurement of digoxin protein binding. 3 Dilution experiments using plasma and human serum albumin suggested that variations in digoxin protein binding would be unlikely to cause significant alterations in the levels of free drug in the body. 4 The possible clinical implications of these results are discussed.

The Processing and Characterization of DCCA Modified Gel-Derived Silica

The production of small silica gel monoliths by the hydrolysis and polycondensation of tetramethyl orthosilicate (TMS) in a methanol solution is now a common procedure. Drying is generally done slowly in a methanolic atmosphere [1] or under hypercritical conditions [2]. The potential application of sol-gel technology in the production of materials for large structures requires a rapid processing time, which causes a problem due to cracking. For large scale space structures the materials produced also require a low molecular weight, a low densification temperature, control of devitrification and a wide range of physical properties and gel densities. These requirements are potentially met by multicomponent silica based gels [3]. To decrease the drying time, which is the longest part of gel processing, the gel strength needs to be increased to resist cracking and the drying stress reduced. The gel strength can be improved by optimizing the variables in the gel manufacturing process.

Nanoporous Silica For Low K Dielectrics

As integrated circuit sizes decrease below 0.25 microns, device performance will no longer improve at the same rate as for past generations because of RC interconnect delay which becomes significant as compared to the intrinsic gate delay. Parallel approaches to address this are to use a lower resistance metal (i.e., copper instead of aluminum) and to use a dielectric material with a dielectric constant significantly below that of dense silica (∼4). Recently, considerable progress has been made in development of thin films of nanoporous silica for these applications. Advantages include high thermal stability, small pore size, similarity to conventional spin-on deposition processes and spin-on glass precursors and final material (silica). The dielectric constant of nanoporous silica can be tailored between ∼1 and 3 which allows its’ implementation at multiple technology nodes in integrated circuit manufacture.

Recent development efforts have been focused on; 1) simpler and more reproducible deposition processes, 2) a more complete understanding of processing-property relationships for this material, 3) scale-up of manufacturing to yield a range of precursor products with stability for at least six months and very high purity, and 4) working with customers to integrate this material into both aluminum/gapfill and copper/damascene process flows. This paper targets several specific issues related to nanoporous silica use including water adsorption, pore size distribution control, processing at commercially viable throughputs, and obtaining thickness and dielectric uniformity across 200 mm wafers and wafer to wafer.

Systematic review and economic modelling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence (SUI) through systematic review and economic modelling.

DATA SOURCES

The Cochrane Incontinence Group Specialised Register, electronic databases and the websites of relevant professional organisations and manufacturers, and the following databases: CINAHL, EMBASE, BIOSIS, Science Citation Index and Social Science Citation Index, Current Controlled Trials, ClinicalTrials.gov and the UKCRN Portfolio Database.

STUDY SELECTION

The study comprised three distinct elements. (1) A survey of 188 women with SUI to identify outcomes of importance to them (activities of daily living; sex, hygiene and lifestyle issues; emotional health; and the availability of services). (2) A systematic review and meta-analysis of non-surgical treatments for SUI to find out which are most effective by comparing results of trials (direct pairwise comparisons) and by modelling results (mixed-treatment comparisons - MTCs). A total of 88 randomised controlled trials (RCTs) and quasi-RCTs reporting data from 9721 women were identified, considering five generic interventions [pelvic floor muscle training (PFMT), electrical stimulation (ES), vaginal cones (VCs), bladder training (BT) and serotonin-noradrenaline reuptake inhibitor (SNRI) medications], in many variations and combinations. Data were available for 37 interventions and 68 treatment comparisons by direct pairwise assessment. Mixed-treatment comparison models compared 14 interventions, using data from 55 trials (6608 women). (3) Economic modelling, using a Markov model, to find out which combinations of treatments (treatment pathways) are most cost-effective for SUI.

DATA EXTRACTION

Titles and abstracts identified were assessed by one reviewer and full-text copies of all potentially relevant reports independently assessed by two reviewers. Any disagreements were resolved by consensus or arbitration by a third person.

RESULTS

Direct pairwise comparison and MTC analysis showed that the treatments were more effective than no treatment. Delivering PFMT in a more intense fashion, either through extra sessions or with biofeedback (BF), appeared to be the most effective treatment [PFMT extra sessions vs no treatment (NT) odds ratio (OR) 10.7, 95% credible interval (CrI) 5.03 to 26.2; PFMT + BF vs NT OR 12.3, 95% CrI 5.35 to 32.7]. Only when success was measured in terms of improvement was there evidence that basic PFMT was better than no treatment (PFMT basic vs NT OR 4.47, 95% CrI 2.03 to 11.9). Analysis of cost-effectiveness showed that for cure rates, the strategy using lifestyle changes and PFMT with extra sessions followed by tension-free vaginal tape (TVT) (lifestyle advice-PFMT extra sessions-TVT) had a probability of greater than 70% of being considered cost-effective for all threshold values for willingness to pay for a QALY up to 50,000 pounds. For improvement rates, lifestyle advice-PFMT extra sessions-TVT had a probability of greater than 50% of being considered cost-effective when society's willingness to pay for an additional QALY was more than 10,000 pounds. The results were most sensitive to changes in the long-term performance of PFMT and also in the relative effectiveness of basic PFMT and PFMT with extra sessions.

LIMITATIONS

Although a large number of studies were identified, few data were available for most comparisons and long-term data were sparse. Challenges for evidence synthesis were the lack of consensus on the most appropriate method for assessing incontinence and intervention protocols that were complex and varied considerably across studies.

CONCLUSIONS

More intensive forms of PFMT appear worthwhile, but further research is required to define an optimal form of more intensive therapy that is feasible and efficient for the NHS to provide, along with further definitive evidence from large, well-designed studies.

Integrating science and business models of sustainability for environmentally-challenging industries such as secondary lead smelters: a systematic review and analysis of findings

Secondary lead smelters (SLS) represent an environmentally-challenging industry as they deal with toxic substances posing potential threats to both human and environmental health, consequently, they operate under strict government regulations. Such challenges have resulted in the significant reduction of SLS plants in the last three decades. In addition, the domestic recycling of lead has been on a steep decline in the past 10 years as the amount of lead recovered has remained virtually unchanged while consumption has increased. Therefore, one may wonder whether sustainable development can be achieved among SLS. The primary objective of this study was to determine whether a roadmap for sustainable development can be established for SLS. The following aims were established in support of the study objective: (1) to conduct a systematic review and an analysis of models of sustainable systems with a particular emphasis on SLS; (2) to document the challenges for the U.S. secondary lead smelting industry; and (3) to explore practices and concepts which act as vehicles for SLS on the road to sustainable development. An evidence-based methodology was adopted to achieve the study objective. A comprehensive electronic search was conducted to implement the aforementioned specific aims. Inclusion criteria were established to filter out irrelevant scientific papers and reports. The relevant articles were closely scrutinized and appraised to extract the required information and data for the possible development of a sustainable roadmap. The search process yielded a number of research articles which were utilized in the systematic review. Two types of models emerged: management/business and science/mathematical models. Although the management/business models explored actions to achieve sustainable growth in the industrial enterprise, science/mathematical models attempted to explain the sustainable behaviors and properties aiming at predominantly ecosystem management. As such, there are major disconnects between the science/mathematical and management/business models in terms of aims and goals. Therefore, there is an urgent need to integrate science and business models of sustainability for the industrial enterprises at large and environmentally-challenging industrial sectors in particular. In this paper, we offered examples of practices and concepts which can be used in charting a path towards sustainable development for secondary lead smelters particularly that the waste generated is much greater outside the industrial enterprise than inside. An environmentally-challenging industry such as secondary lead smelters requires a fresh look to chart a path towards sustainable development (i.e., survivability and purposive needs) for all stakeholders (i.e., industrial enterprise, individual stakeholders, and social/ecological systems). Such a path should deal with issues beyond pollution prevention, product stewardship and clean technologies.

FOXL2 copy number changes in the molecular pathogenesis of BPES: unique cohort of 17 deletions

Blepharophimosis Syndrome (BPES) is an autosomal dominant developmental disorder of the eyelids with or without ovarian dysfunction caused by FOXL2 mutations. Overall, FOXL2deletions represent 12% of all genetic defects in BPES. Here, we have identified and characterized 16 new and one known FOXL2 deletion combining multiplex ligation-dependent probe amplification (MLPA), custom-made quantitative PCR (qPCR) and/or microarray-based copy number screening. The deletion breakpoints could be localized for 13 out of 17 deletions. The deletion size is highly variable (29.8 kb - 11.5 Mb), indicating absence of a recombination hotspot. Although the heterogeneity of their size and breakpoints is not reflected in the uniform BPES phenotype, there is considerable phenotypic variability regarding associated clinical findings including psychomotor retardation (8/17), microcephaly (6/17), and subtle skeletal features (2/17). In addition, in all females in whom ovarian function could be assessed, FOXL2 deletions proved to be associated with variable degrees of ovarian dysfunction. In conclusion, we present the largest series of BPES patients with FOXL2 deletions and standardized phenotyping reported so far. Our genotype-phenotype data can be useful for providing a prognosis (i.e. occurrence of associated features) in newborns with BPES carrying a FOXL2 deletion.

Phase II trial of continuous dosing of sunitinib in advanced, FDG-PET avid, medullary thyroid carcinoma (MTC) and well-differentiated thyroid cancer (WDTC)

6056

Background: Due to the low efficacy of chemotherapy in progressive, WDTC and MTC, novel treatment approaches are needed. Thyroid cancers have elevated levels of vascular endothelial growth factor and higher microvessel density than normal thyroid tissue. Sunitinib inhibits several tyrosine kinase receptors involved in angiogenesis as well as the RET kinase frequently mutated in thyroid cancer. Here we report the results of a phase II trial investigating the use of continuous dosing sunitinib in patients with metastatic WDTC and MTC. Methods: Patients were eligible for enrollment if they had metastatic, iodine-refractory WDTC or MTC. To target those patients with more aggressive thyroid cancer, enrollment was limited to FDG-PET avid disease. Sunitinib was administered at 37.5 mg po qday on a continuous basis. Planned sample size is 35 patients. The primary end-point is response rate per RECIST criteria. Secondary end-points include FDG-PET response rate (defined as 20% reduction from baseline SUV) after 7 days of treatment, toxicity, overall survival, duration of response, and time to progression. Results: To date 33 patients have been enrolled (7 MTC:26 WDTC), and 29 patients have been evaluated for disease response. Median time on study is 7.5 months. Response rates to date: CR 7% (2/29), duration of response (9m+ and 14m+), PR 25% (8/29) (median 12 months), SD 48% (14/29) (median 6 months). Rate of disease control at 3 months (SD+PR+CR) 83% (24/29). 15 patients remain on study. Among those who have progressed the median time to progression is 6.5 months. FDG-PET was performed on 22 patients following 7 days of treatment, 36% (8/22) have a PET response. Of these patients 7 have disease control per RECIST criteria. Grade 3 toxicities seen in more than one patient include: anemia (2/33), fatigue (4/33), neutropenia (12/33), hand/foot syndrome (4/33), diarrhea (5/33), and leukopenia (11/33). One patient on lovenox therapy died of gastrointestinal bleeding. Conclusions: Continuous dosing of sunitinib is active (disease control rate 83%) in patients with high risk, metatstatic WDTC and MTC, as defined by FDG-PET avid disease.

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Solving the challenges of large multicenter trials in anesthesia

This paper describes many of the challenges encountered when establishing a large multicentre trial in cardiac anesthesia. We address funding, authorship, multisite ethics review, patient recruitment, data quality management, communication with individual sites, and strategies to enhance cooperation and patient recruitment.

Ductal Plate Malformation in a Nonhuman Primate

During necropsy of a 6-year-old, male African Green monkey ( Cercopithecus aethiops), multifocal pale, white to tan areas, 1–2 cm in diameter, were noted in the right lateral lobe, medial lobe, and capsular surface of the liver. Light microscopic examination of the liver revealed numerous spindle cells dispersed within interconnecting, broad bands of collagen, up to 200 μm in width, which often spanned and connected portal areas. A diagnosis of hepatic ductal plate malformation, most closely resembling congenital hepatic fibrosis with von Meyenburg complexes, was made. Few cases of ductal plate malformations in domestic animals are reported in the literature. To our knowledge, this is the first case reported in a nonhuman primate.