Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Long-term effects of high-intensity interval training, moderate-to-vigorous intensity continuous training and Nordic walking on physical and mental health in patients with coronary artery disease

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research (CIHR) Postdoctoral Fellowship

Background/Introduction

Twelve weeks of high-intensity interval training (HIIT), moderate-to-vigorous intensity continuous training (MICT) and Nordic walking (NW) have been shown to improve functional capacity, quality of life (QoL) and depression in patients with coronary artery disease (CAD). However, their long-term effects are unknown.

Purpose

The primary purpose was to compare the long-term effects and sustainability of 12 weeks of HIIT, MICT and NW on functional capacity. The secondary purpose was to assess the long-term effects and sustainability of 12 weeks of HIIT, MICT and NW on QoL and depression severity.

Methods

Patients with CAD were randomized to a 12-week HIIT, MICT or NW program. Functional capacity, QoL and depression severity were measured at baseline, at the end of 12 weeks of intervention, and following 14 weeks of observation phase (week 26). Functional capacity was measured with a 6-minute walk test (6MWT); QoL was assessed by the HeartQoL and Short-Form-36; and depression severity by the Beck Depression Inventory-II (BDI-II). The long-term effects (changes between baseline and week 26) and sustainability (changes between week 12 and week 26) were assessed by linear mixed models for repeated measures.

Results

Of 130 participants randomized, 86 (HIIT: n=29, MICT: n=27, NW: n=30) completed week 26 assessments. There were significant improvements in 6MWT distance (F=149.657, p<0.001), QoL and depression severity (both p<0.05) from baseline to week 26; the increase in 6MWT distance was greater for NW when compared to MICT (F=7.021, p=0.010) and HIIT (F=5.279, p=0.025, Figure). Between week 12 and week 26, 6MWT distance (F=10.863, p=0.001) and physical QoL (physical component summary [PCS]; F=4.084, p=0.047) increased significantly, whereas mental QoL significantly decreased (mental component summary [MCS]; F=4.052, p=0.047).

Conclusion

HIIT, MICT and NW have positive long-term impacts on functional capacity, QoL and depression severity. However, NW was shown to confer additional benefits in increasing long-term functional capacity. The positive effects of the 12-week exercise programs were sustained at week 26 except for mental QoL.

An observational clinical study of the influence of phacoemulsification on choroidal neovascular membrane activity in age related macular degeneration

Background

Thousands of phacoemulsification surgeries are performed on eyes with age-related macular degeneration (AMD) complicated by choroidal neovascular membrane (CNV) in the United Kingdom each year. As populations age this number is expected to rise. Controversy over phacoemulsification’s influence on CNV activity limits the information which clinicians and these patients use to decide on surgery. This observational study aims to resolve this controversy by reporting on intravitreal injection (IVI) frequency as a pragmatic marker of CNV activity in a large cohort.

Methods

A cohort of eyes with AMD complicated by CNV (n = 327) that underwent cataract surgery at a single tertiary centre from 2014 to 2019 were identified. These cases were matched by interval since CNV diagnosis at a specified ‘time zero’ within the follow-up of pseudophakic eyes with AMD (n = 327). Data concerning demographics, visual acuity (VA) and intravitreal injection frequency before and after ‘time zero’/phacoemulsification were collected.

Results

Following ‘time zero’/phacoemulsification’ the mean reduction in annual IVI frequency was 0.6 injections/year (95% CI 0.4,0.9) and 0.4 injections/year (95% CI 0.1,0.7) in the comparison and phacoemulsification cohorts respectively. The mean VA gain 12 months after phacoemulsification in the intervention cohort was 11.3 (95% CI 9.2,13.4) early treatment of diabetic retinopathy study (ETDRS) letters, with 214 eyes (65.4%) having gained ≥5 ETDRS letters after surgery.

Conclusions

Phacoemulsification has no clinically significant impact on the activity of pre-existent CNV secondary to AMD. Phacoemulsification should be offered to patients with AMD and cataract that limits vision, regardless of CNV activity.

Making change last? Exploring the value of sustainability approaches in healthcare: a scoping review

Background

Numerous models, tools and frameworks have been produced to improve the sustainability of evidence-based interventions. Due to the vast number available, choosing the most appropriate one is increasingly difficult for researchers and practitioners. To understand the value of such approaches, evidence warranting their use is needed. However, there is limited understanding of how sustainability approaches have been used and how they have impacted research or practice. This review aims to consolidate evidence on the application and impact of sustainability approaches in healthcare settings.

Methods

A systematic scoping review was designed to search for peer-reviewed publications detailing the use of sustainability approaches in practice. A 5-stage framework for scoping reviews directed the search strategy, and quality assessment was performed using the Mixed Method Appraisal Tool. Searches were performed through electronic citation tracking and snowballing of references. Articles were obtained through Web of Science, PubMed and Google Scholar. Six outcome variables for sustainability were explored to ascertain impact of approaches.

Results

This review includes 68 articles demonstrating the application of sustainability approaches in practice. Results show an increase in the use of sustainability approaches in peer-reviewed studies. Approaches have been applied across a range of healthcare settings, including primary, secondary, tertiary and community healthcare. Approaches are used for five main purposes, namely analysis, evaluation, guidance, assessment and planning. Results outline benefits (e.g. improved conceptualisation of sustainability constructs and improved ability to interpret sustainability data) and challenges (e.g. issues with approach constructs and difficulty in application) associated with using a sustainability approach in practice. Few articles (14/68) reported the sustainability outcome variables explored; therefore, the impact of approaches on sustainability remains unclear. Additional sustainability outcome variables reported in retrieved articles are discussed.

Conclusions

This review provides practitioners and researchers with a consolidated evidence base on sustainability approaches. Findings highlight the remaining gaps in the literature and emphasise the need for improved rigour and reporting of sustainability approaches in research studies. To guide future assessment and study of sustainability in healthcare settings an updated list of sustainability outcome variables is proposed.

Trial Registration

This review was registered on the PROSPERO database CRD 42016040081 in June 2016.

The visualisation of fingermarks on Pangolin scales using gelatine lifters

Recent media reports document the plight of the Pangolin and its current position as "the most trafficked mammal in the world". They are described by some as scaly anteaters as all species are covered in hard keratinous tissue in the form of overlapping scales acting as a "flexible dermal armour". It is estimated that between 2011 and 2013, 117,000-234,000 pangolins were slaughtered, but the seizures may only represent as little as 10% of the true volume of pangolins being illegally traded. In this paper, methods to visualise fingermarks on Pangolin scales using gelatine lifters is presented. The gelatine lifters provide an easy to use, inexpensive but effective method to help wildlife crime rangers across Africa and Asia to disrupt the trafficking. The gelatine lifting process visualised marks producing clear ridge detail on 52% of the Pangolin scales examined, with a further 30% showing the impression of a finger with limited ridge detail. The paper builds on an initial sociotechnical approach to establishing requirement, then it focuses on the methods and outcomes relating to lifting fingermarks off Pangolin scales using gelatine lifters, providing an evaluation of its use in practice.

Modification of Enrichment Protocols for TECRA Listeria Visual Immunoassay Method 995.22: Collaborative Study

A collaborative study was conducted to validate new enrichment methods for the TECRA Listeria Visual Immunoassay (TLVIA). These new methods incorporate a newly formulated medium, TECRA Listeria Enrichment Broth, which does not contain the highly toxic antifungal agent, cycloheximide. The new procedures will provide an alternative to the enrichment procedures described in AOAC Method 995.22. Three food types (raw ground beef, lettuce, and ice cream) were analyzed in the United States, and 2 food types (cooked turkey and cooked fish fillets) were analyzed in Australasia. Thirty collaborators participated in the study, 16 in Australasia and 14 in the United States. With the exception of one batch of ground beef, comparison of the proportion of positive test portions (p ≥ 0.05) showed no significant difference between the TLVIA and the reference method for the 5 foods at 3 inoculation levels. For the one batch of naturally contaminated raw ground beef, the TLVIA gave significantly more confirmed positive results than the reference method.

Petrifilm™ Rapid S. aureus Count Plate Method for Rapid Enumeration of Staphylococcus aureus in Selected Foods: Collaborative Study

A rehydratable dry-film plating method for Staphylococcus aureusin foods, the 3M™ Petrifilm™ Rapid S. aureus Count Plate method, was compared with AOAC® Official MethodSM 975.55 (Staphylococcus aureus in Foods). Nine foods—instant nonfat dried milk, dry seasoned vegetable coating, frozen hash browns, frozen cooked chicken patty, frozen ground raw pork, shredded cheddar cheese, fresh green beans, pasta filled with beef and cheese, and egg custard—were analyzed for S. aureus by 13 collaborating laboratories. For each food tested, the collaborators received 8 blind test samples consisting of a control sample and 3 levels of inoculated test sample, each in duplicate. The mean log counts for the methods were comparable for pasta filled with beef and cheese; frozen hash browns; cooked chicken patty; egg custard; frozen ground raw pork; and instant nonfat dried milk. The repeatability and reproducibility variances of the Petrifilm Rapid S. aureus Count Plate method were similar to those of the standard method.

Estimation of carcass composition using rib dissection of calf-fed Holstein steers supplemented zilpaterol hydrochloride

A serial harvest was conducted every 28 d from 254 to 534 d on feed (DOF) to quantify changes in growth and composition of calf-fed Holstein steers (n = 115, initial body weight (BW) = 449.2 ± 19.9 kg). One-half were supplemented with the β-2 adrenergic agonist zilpaterol hydrochloride (ZH; 8.33 mg/kg 100% dry matter (DM) basis) during the final 20 d followed by a 3-d withdrawal prior to harvest; the remainder was fed a non-ZH control (CON) ration. Five steers were randomly selected and harvested after 226 DOF which served as a reference point for modeling purposes. Fabricated carcass soft tissue was ground, mixed, and subsampled for proximate analysis. Moreover, following the traditional method of rib dissection which includes the 9th, 10th, and 11th rib contained within the IMPS 103 primal, the relationship of carcass chemical composition to 9-10-11 rib composition was evaluated. Carcasses in this investigation had more (P < 0.01) separable lean, fat, ash, and moisture concomitant with less bone and ether extract than rib dissections. However, protein levels were similar (P = 0.27) between carcasses and rib dissections. Using regression procedures, models were constructed to describe the relationship of rib dissection (RD) composition including separable lean (RDSL), separable fat (RDSF), separable bone (RDSB), ether extract (RDEE), protein (RDP), moisture (RDM), and ash (RDA) with carcass composition. Carcass lean (CL), carcass fat (CF), and carcass bone (CB) were correlated (P < 0.01) with RDSL, RDSF, and RDSB with simple r values of 0.41, 0.71, and 0.50, respectively. Chemical composition of the rib and carcass, carcass ether extract (CEE), carcass protein (CP), carcass moisture (CM), and carcass ash (CA) were correlated (P ≤ 0.01) with simple r values of 0.75, 0.31, 0.66, and 0.37, respectively. Equations to predict carcass fatness from rib dissection variables and ZH supplementation status were only able to account for 50 and 56%, of the variability of CF and CEE, respectively. Overall, the relationships quantified and equations developed in this investigation do not support use of 9/10/11 rib dissection for estimation of carcass composition of calf-fed Holstein steers.

Navigating the sustainability landscape: a systematic review of sustainability approaches in healthcare

BACKGROUND

Improvement initiatives offer a valuable mechanism for delivering and testing innovations in healthcare settings. Many of these initiatives deliver meaningful and necessary changes to patient care and outcomes. However, many improvement initiatives fail to sustain to a point where their full benefits can be realised. This has led many researchers and healthcare practitioners to develop frameworks, models and tools to support and monitor sustainability. This work aimed to identify what approaches are available to assess and influence sustainability in healthcare and to describe the different perspectives, applications and constructs within these approaches to guide their future use.

METHODS

A systematic review was carried out following PRISMA guidelines to identify publications that reported approaches to support or influence sustainability in healthcare. Eligibility criteria were defined through an iterative process in which two reviewers independently assessed 20% of articles to test the objectivity of the selection criteria. Data were extracted from the identified articles, and a template analysis was undertaken to identify and assess the sustainability constructs within each reported approach.

RESULTS

The search strategy identified 1748 publications with 227 articles retrieved in full text for full documentary analysis. In total, 62 publications identifying a sustainability approach were included in this review (32 frameworks, 16 models, 8 tools, 4 strategies, 1 checklist and 1 process). Constructs across approaches were compared and 40 individual constructs for sustainability were found. Comparison across approaches demonstrated consistent constructs were seen regardless of proposed interventions, setting or level of application with 6 constructs included in 75% of the approaches. Although similarities were found, no approaches contained the same combination of the constructs nor did any single approach capture all identified constructs. From these results, a consolidated framework for sustainability constructs in healthcare was developed.

CONCLUSIONS

Choosing a sustainability method can pose a challenge because of the diverse approaches reported in the literature. This review provides a valuable resource to researchers, healthcare professionals and improvement practitioners by providing a summary of available sustainability approaches and their characteristics.

TRIAL REGISTRATION

This review was registered on the PROSPERO database: CRD42016040081 in June 2016.

A survey of ticks (Acari: Ixodidae) from an over-abundant koala (Phascolarctos cinereus) population in south eastern Australia, with an overview of the ticks and mites of koalas

Within Australia, koala over-abundance has become a serious problem in some areas resulting in significant damage to native forests through defoliation. An over-abundant Victorian koala population was surveyed for ticks in the autumn of 2016. During the survey 1036 ticks were collected from 158 koalas. All ticks collected were identified as Ixodes tasmani. Tick prevalence, infestation intensity and on-host sex ratios were calculated for the population. An overview of the ticks and mites associated with koalas in Australia is also presented.

Objective biometric measurements of calf-fed Holstein steers fed in confinement

Understanding the maximum slaughter size for calf-fed Holstein steers based on hip-height has become a contemporary issue in the beef processing industry. Increased carcass size, in terms of both weight and length, has outpaced the ability of some abattoirs to handle the larger animals. Moreover, some abattoirs have begun rejecting animals that exceed 147.3 cm (58 inches) at the hip, creating a challenge for Holstein cattle feeders. The objective of this study was to quantify the skeletal growth rate of calf-fed Holstein steers fed in confinement. Hip-height of calf-fed Holstein steers ( ≤ 135) was measured every 28 d from 226 to 422 d on feed. Hip-height was a dependent variable modeled via linear regression procedures utilizing days of age and BW as independent variables. Additionally, logistic regression was used to estimate the probability of a steer exceeding a hip-height of 147.3 cm (58 inches) from independent variables of days of age and BW. The linear relationship of BW to hip-height had an adjusted value of 0.7112 (Hip-height, cm = [0.0593 × BW, kg] + 109.00) and on average the calf-fed Holstein steers grew 1.0 cm for each 16.9 kg of BW gain during the finishing phase. The 10%, 50%, and 90% probability of a steer exceeding 147.3 cm (58 inches) of hip-height was achieved at 563, 653, and 743 kg of BW, respectively. The linear relationship of days of age to hip-height had an adjusted value of 0.6687 (Hip-height, cm = [0.0937 × days of age] + 104.4) and the calf-fed Holstein steers grew 1.0 cm for each 10.7 d of age during the finishing phase. The 10%, 50%, and 90% probability of a steer exceeding 147.3 cm (58 inches) of hip-height was estimated to occur at 408, 459, and 510 d of age, respectively. Knowledge of Holstein steer growth rate in relation to BW and age may allow for more accurate sorting to prevent oversized cattle arriving at the abattoir and subsequent discounts or being rejected for slaughter.

Fabrication yields of serially harvested calf-fed Holstein steers fed zilpaterol hydrochloride

Holstein steers ( = 110) were fed zilpaterol hydrochloride (ZH) for 0 or 20 d before slaughter during a 280-d serial harvest study. Cattle were harvested every 28 d beginning at 254 d on feed (DOF) and concluding at 534 DOF. After slaughter, carcasses were chilled for 48 h and then fabricated into boneless closely trimmed or denuded subprimals, lean trim, trimmable fat, and bone. Inclusion of ZH increased cold side weight (CSW) by 10.3 kg ( < 0.01; 212.7 vs. 202.4 kg [SEM 1.96]) and saleable yield by 10.4 kg ( < 0.01; 131.9 vs. 121.5 kg [SEM 1.16]) in calf-fed Holstein steer carcasses. Additionally, saleable yield as a percentage of CSW increased ( ≤ 0.01) by 2.19% (62.64 vs. 60.45% [SEM 0.22]) for cattle supplemented with ZH. Subprimal weights were heavier ( ≤ 0.05) from cattle that received ZH except for the bottom sirloin ball tip, back ribs, and outside skirt regardless of slaughter endpoint. Yield of top round, bottom round, and knuckle was increased ( ≤ 0.01) following ZH supplementation by 0.37, 0.24, and 0.18%, respectively. Yield of the top sirloin butt, strip loin, and tenderloin was increased ( ≤ 0.01) concurrent with ZH supplementation by 0.18, 0.11, and 0.09%, respectively. Regarding the rib primal, the rib eye roll tended ( = 0.08) to had increased yield (2.80 vs. 2.72% [SEM 0.03]) with ZH supplementation; both back ribs and blade meat exhibited increased ( ≤ 0.04) yields of 0.04%. Relative to the chuck primal, increased ( ≤ 0.03) yields of shoulder clod, pectoral meat, and mock tender were observed (0.13, 0.07, and 0.04%, respectively). Yield changes for subprimal brisket, plate, and flank were limited to increased ( < 0.01) proportion of flank steak and elephant ear (cutaneous trunci), 0.07 and 0.04%, respectively. Feeding duration notably altered ( ≤ 0.01) weights and percentages of all subprimals except the brisket. Saleable yield increased ( ≤ 0.01) by 0.192 kg/d with additional DOF. Moreover, trimmable fat and bone increased ( ≤ 0.01) by 0.146 and 0.050 kg/d, respectively. These data illustrate improved saleable meat yields for calf-fed Holstein steers supplemented with ZH and provide the beef industry knowledge of fabrication yield changes throughout a wide range of harvest endpoints.

The effect of days on feed and zilpaterol hydrochloride supplementation on feeding behavior and live growth performance of Holstein steers

This experiment was designed to study the effect of days on feed (d 225-533) and zilpaterol hydrochloride (ZH) supplementation on Holstein steer ( = 110) performance and feeding behavior as part of a serial slaughter trial. Steers were randomly assigned to 1 of 11 harvest groups with 10 steers ( = 5 control and = 5 ZH; ZH at 8.33 mg/kg diet) harvested each 28 d. Steers were weighed every 28 d (d 225, 253, 281, 309, 337, 365, 393, 421, 449, 477, 505, and 533); individual daily meal consumption data for each steer were recorded using GrowSafe technology. In the pretreatment period, dry matter intake expressed a negative quadratic relationship with days on feed (DOF) {DMI = -5.7120 + (0.08370 x DOF)- (0.00011 x DOF); Adj. = 0.2574; RMSE = 0.25 75; 0.01}. A linear increase in BW ( < 0.01) occurred during the pretreatment 308 d period from 466 to 844 kg, {BWend = 137.61 + (1.4740 x DOF); Adj. = 0.8819; RMSE = 37.06; < 0.01}, whereas ADG and G:F decreased linearly. Dry matter intake per meal exhibited a quadratic relationship over days on feed and peaked ( < 0.01) during d 365 to 392 at 1.065 kg coinciding with the highest numerical daily DMI (11.19 kg). Daily consumption visit duration differed ( < 0.01) during the 308 d period, with a low of 52.29 min (d 337-364) and a high of 55.59 min (d 365-392). Consumption rate peaked at 714 g/min (d 337-364) and exhibited a quadratic relationship to DOF. The difference ( < 0.04) in DMI between control and ZH treated cattle across all 11 harvest groups averaged 0.575 kg. Moreover, ZH treatment resulted in decreased ( 0.01) DMI per meal event of 0.093 kg. Gain to feed tended to improve ( = 0.06) with ZH treatment by 0.017 kg gain per kg feed relative to the control cattle. Daily bunk, consumption, and meal visit durations were influenced by ZH during the 20 d treatment period ( = 0.01); the average difference between control and ZH supplemented cattle over the 308 d trial was 9.09, 8.71, and 11.39 min per d, respectively. The data collected in this trial indicate live growth performance and feeding behavior were impacted by both DOF and ZH supplementation.

Byproduct yields of serially harvested calf-fed Holstein steers fed zilpaterol hydrochloride

A 2 × 11 factorial treatment structure was applied in a completely randomized experimental design to investigate differences in noncarcass tissue among serially harvested Holstein steers. Steers ( = 110) were randomly assigned to 1 of 2 dietary treatments: a ration supplemented with zilpaterol hydrochloride (ZH) fed at a rate of 8.3 mg/kg DM for 20 d followed by a 3-d withdrawal or a control ration with no ZH included in the diet. Within treatment, steers were assigned to harvest groups of 254, 282, 310, 338, 366, 394, 422, 450, 478, 506, or 534 d on feed (DOF) prior to initiation of the trial. Cattle fed ZH realized an empty BW (EBW) increase ( ≤ 0.03) of 2.8% (644.2 vs. 626.4 kg [SEM 5.4]) and a HCW increase of 5.0% (429.1 vs. 408.4 kg [SEM 4.0]) with a concomitant 12% reduction (45.1 vs. 51.2 kg [SEM 3.1]) in gastrointestinal contents and 2.1 percentage unit increase in dressed carcass yield (62.1 vs. 60.0% [SEM 0.01]). Additionally, ZH supplementation decreased (P ≤ 0.03) the absolute weight of the liver and kidneys by 0.3 and 0.1 kg, respectively. When noncarcass components were expressed on an empty body basis (g/kg EBW), reductions ( ≤ 0.01) in the limbs (18.8 vs. 19.5 g/kg EBW [SEM 0.1]), hide (81.1 vs. 78.1 g/kg EBW [SEM 0.7]), liver (14.2 vs. 13.2 g/kg EBW [SEM 0.2]), kidneys (2.6 vs. 2.3 g/kg EBW [SEM 0.04]), small and large intestines (74.9 vs. 69.6 g/kg EBW [SEM 1.2]), and gastrointestinal tract (119.8 vs. 113.4 g/kg EBW [SEM 1.3]) were observed with ZH supplementation. Additionally, there was a tendency ( = 0.07) for the proportion of total offal to be reduced (253.2 vs. 247.4 g/kg EBW [SEM 2.5]) with ZH supplementation. Empty BW and HCW linearly increased ( < 0.01) by 1.16 and 0.758 kg/d ( < 0.01), respectively, with additional DOF. The weight of the liver and intestines linearly increased ( < 0.01) by 0.007 and 0.133 kg/d ( < 0.01), respectively, with additional DOF. These data indicate the magnitude of change in noncarcass tissues that can be expected when calf-fed Holstein steers are supplemented with ZH.

Carcass grading characteristics of serially harvested calf-fed Holstein steers fed zilpaterol hydrochloride

Serial harvests were conducted using Holstein steers ( = 110) fed zilpaterol hydrochloride (ZH) for 0 or 20 d prior to harvest. Steers were harvested in 28-d increments beginning at 254 d on feed (DOF) and ending at 534 DOF. After harvest and a 36-h chill period, carcasses were evaluated using grading methods standard for the United States (USDA), Canada (Canadian Beef Grading Association [CBGA]), and Japan (Japanese Meat Grading Agency [JMGA]). No ZH treatment differences ( = 0.81) were detected for 12th-rib fat thickness; however, additional DOF resulted in a daily linear increase ( < 0.01) of 12th-rib fat thickness by 0.004 cm/d. Longissimus muscle area was increased ( < 0.01) by 8.7 cm with ZH supplementation and linearly increased ( < 0.01) 0.08 cm2/d with additional DOF. Calculated USDA yield grade (YG) decreased ( < 0.01) 0.33 units due to ZH treatment and linearly increased ( < 0.01) 0.009 units/d. Steers supplemented with ZH exhibited increased ( < 0.01) CGBA LM width; however, no difference ( = 0.37) was detected in CGBA LM length. No ZH treatment differences ( = 0.64) were observed for CBGA fat class; however, CGBA fat class linearly increased ( < 0.01) by 0.01 units/d. No ZH differences ( ≥ 0.17) were detected for the CBGA estimated lean percentage or YG equations. Evaluation for JMGA occurs at the sixth and seventh rib interface; LM area was 4.6 cm2 greater ( = 0.02) for cattle supplemented with ZH and linearly increased ( < 0.01) by 0.07 cm2/d with additional DOF. Subcutaneous fat thickness was not different among ZH treatments ( = 0.10) but linearly ( < 0.04) increased ( < 0.01) by 0.005 cm/d with additional DOF using the JMGA grading method. No difference ( ≥ 0.21) was calculated between ZH treatments or DOF for JMGA estimated yield. No ZH treatment differences ( = 0.85) were detected in USDA marbling score; however, marbling linearly increased ( < 0.01) 0.07 units/d. These data illustrate the impact of ZH and increasing DOF on economically important carcass grading outcomes used in the USDA, CBGA, and JMGA grading programs.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Five challenges to reconcile agricultural land use and forest ecosystem services in Southeast Asia

Southeast Asia possesses the highest rates of tropical deforestation globally and exceptional levels of species richness and endemism. Many countries in the region are also recognized for their food insecurity and poverty, making the reconciliation of agricultural production and forest conservation a particular priority. This reconciliation requires recognition of the trade-offs between competing land-use values and the subsequent incorporation of this information into policy making. To date, such reconciliation has been relatively unsuccessful across much of Southeast Asia. We propose an ecosystem services (ES) value-internalization framework that identifies the key challenges to such reconciliation. These challenges include lack of accessible ES valuation techniques; limited knowledge of the links between forests, food security, and human well-being; weak demand and political will for the integration of ES in economic activities and environmental regulation; a disconnect between decision makers and ES valuation; and lack of transparent discussion platforms where stakeholders can work toward consensus on negotiated land-use management decisions. Key research priorities to overcome these challenges are developing easy-to-use ES valuation techniques; quantifying links between forests and well-being that go beyond economic values; understanding factors that prevent the incorporation of ES into markets, regulations, and environmental certification schemes; understanding how to integrate ES valuation into policy making processes, and determining how to reduce corruption and power plays in land-use planning processes.

Design of Heteronuclear Metalloenzymes

Heteronuclear metalloenzymes catalyze some of the most fundamentally interesting and practically useful reactions in nature. However, the presence of two or more metal ions in close proximity in these enzymes makes them more difficult to prepare and study than homonuclear metalloenzymes. To meet these challenges, heteronuclear metal centers have been designed into small and stable proteins with rigid scaffolds to understand how these heteronuclear centers are constructed and the mechanism of their function. This chapter describes methods for designing heterobinuclear metal centers in a protein scaffold by giving specific examples of a few heme-nonheme bimetallic centers engineered in myoglobin and cytochrome c peroxidase. We provide step-by-step procedures on how to choose the protein scaffold, design a heterobinuclear metal center in the protein scaffold computationally, incorporate metal ions into the protein, and characterize the resulting metalloproteins, both structurally and functionally. Finally, we discuss how an initial design can be further improved by rationally tuning its secondary coordination sphere, electron/proton transfer rates, and the substrate affinity.

Laparoscopic splenectomy is emerging 'gold standard' treatment even for massive spleens

INTRODUCTION

Since its first description by Delaitre and Maignien in 1991, laparoscopic splenectomy (LS) has evolved as treatment of choice for mild-to-moderately-enlarged spleens and for benign haematological disorders. LS is a challenge if massive spleens or malignant conditions necessitate treatment, but we report our method and its feasibility in this study.

METHODS

We undertook a retrospective study of prospectively collected data of all elective splenectomies carried out in our firm of upper gastrointestinal surgeons from June 2003 to June 2012. Only patients opting for elective LS were included in this study.

RESULTS

From June 2003 to June 2012, elective splenectomy was carried out in 80 patients. Sixty-seven patients underwent LS and 13 underwent open splenectomy (OS). In the LS group, there were 38 males and 29 females. Age ranged from 6 years to 82 years. Spleen size in the LS group ranged from ≤11 cm to 27.6 cm. Twelve patients had a spleen size of >20 cm. Weight ranged from 35 g to 2,400 g. Eighteen patients had a spleen weight of 600-1,600 g and eight had a spleen weight >1,600 g. Operating times were available for 56 patients. Mean operating time for massive spleens was 129.73 min. There was no conversion to OS. There were no major complications.

CONCLUSIONS

With improved laparoscopic expertise and advancing technology, LS is safe and feasible even for massive spleens and splenic malignancies. It is the emerging 'gold standard' for all elective splenectomies and has very few contraindications.

Lennie: a smartphone application with novel implications for the management of animal colonies

Researchers rely on animals for their clinical applicability and ease of monitoring. However, careful management is required to ensure the animal and financial costs are minimized. The incorporation of 'smartphone' technology in research has increased exponentially, with a focus on the development of innovative research-based applications. We have developed a smartphone application designed to address the needs of modern researchers in the management of their colonies. 'Lennie' introduces a new method for the management of small to medium-sized animal colonies. Lennie allows users wireless access to their colonies with the ability to create and edit from virtually anywhere. Lennie also offers the ability to manage colonies based on experiments by assigning animals based on priority. Experimental time-points are also recorded with integrated scheduling options using the calendar function. Lennie represents an alternative to current large-scale software options, as the application design is simple, and requires no training or manuals. As the technological landscape is constantly evolving, we must continue to find ways to improve upon current practices to ensure that research is completed with efficiency and efficacy. With this new method of animal management, researchers are able to spend less time record keeping and can focus their efforts on continued innovation.

Abstract P6-07-10: Luminal A vs. Basal-like Breast Cancer: time dependent changes in the risk of relapse in the absence of treatment

Background: Numerous retrospective analyses of prospective randomized clinical trials of patients treated with adjuvant tamoxifen and chemotherapy have demonstrated that the breast cancer intrinsic subtype Luminal A tumors generally have favorable early initial outcomes, while basal-like tumors are associated with a marked risk of early relapse. To determine the extended natural history of the intrinsic subtypes across two decades of follow up the PAM50 “non-commercial open source bioinformatics” qPCR assay was conducted on node negative tumors accrued through the Cooperative Breast Cancer Tissue Registry (CBCTR) from patients who did not receive systemic therapy.

Methods: Intrinsic subtype calls were obtained from 331 CBCTR cases treated with local interventions only. Tumors were classified into Luminal A (LumA), Luminal B (LumB), HER2-enriched (HER2-E) and Basal-like (BLBC), and correlated relapse-free (RFS). Patient survival and hazard rate were estimated using Kaplan-Meier plots and log-rank test. Multivariable Cox regression analyses were used to determine the significance of the intrinsic subtypes, adjusted with standard clinicopathological variables including tumor size, age at diagnosis, grade, radiation therapy treatment, centralized reviewed estrogen receptor, progesterone receptor and human epidermal growth factor 2 status measured by immunohistochemistry. Patients were diagnosed from 1978 to 1992, with a mean follow-up time of 13 years (range 0.5–31).

Results: Of the 331 tumors tested, 51% of cases were classified as LumA, 18% as LumB, 11% as HER2-E and 20% as BLBC. Although LumA was associated with the best outcome for the first 10-year of follow-up, the final number of RFS events were eventually comparable with those observed for BLBC with prolonged follow up (Table 1). In the multivariable Cox model, only BLBC tumors were associated with worse prognosis than LumA with borderline significance (Hazard ratio: 2.0 (95% CI 0.9–5), p = 0.07). BLBC had the highest hazard rates for the first 5 years (7% at first year to 5% at 5 yr), consistent with previous observations. Interestingly, in the absence of treatment, the slow growing LumA subtype had a gradual increase of hazard for an RFS event from 3% at 5 yrs to 4% at 10 yrs to 7% at 20 yrs. The hazard rates of LumA cross with those of BLBC at 10 years.