Use of a wastewater recovery product (struvite) to enhance subtropical seagrass restoration

Seagrasses are in decline worldwide, and their restoration is relatively expensive and unsuccessful compared to other coastal systems. Fertilization can improve seagrass growth in restoration but can also release nutrients and pollute the surrounding ecosystem. A slow-release fertilizer may reduce excessive nutrient discharge while still providing resources to the seagrass's rhizosphere. In this study, struvite (magnesium ammonium phosphate), a relatively insoluble, sustainable compound harvested in wastewater treatment plants, was compared to Osmocote™(14:14:14 Nitrogen: Phosphorus: Potassium, N:P:K), a popular polymer coated controlled release fertilizer commonly used in seagrass restoration. Two experiments compared the effectiveness of both fertilizers in a subtropical flow-through mesocosm setup. In the first experiment, single 0.5 mg of P per g dry weight (DW) doses of Osmocote™and struvite fertilizers were added to seagrass plots. Seagrass shoot counts were significantly higher in plots fertilized with struvite than both the Osmocote™and unfertilized controls (p< 0.0001). A significant difference in total P concentration was observed in porewater samples of Osmocote™vs struvite and controls (p< 0.0001), with struvite fertilized plots emitting more than controls (p ≤ 0.0001), but less than 2% of the total dissolved P (TDP) of Osmocote™fertilized plots (100+ mg/L versus x > 5 mg/L). A subsequent experiment, using smaller doses (0.01 and 0.025 mg of P per gram DW added), also found that the struvite treatments performed better than Osmocote™, with 16-114% more aboveground biomass (10-60% higher total biomass) while releasing less N and P. These results indicate the relatively rapid dissolution of Osmocote™may pose problems to restoration efforts, especially in concentrated doses and possibly leading to seagrass stress. In contrast, struvite may function as a slow-release fertilizer applicable in seagrass and other coastal restoration efforts.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Rise and demise: a case study of public health nutrition in Queensland, Australia, over three decades

This case study describes the delivery and achievements of the public health nutrition programme in Queensland, Australia, over more than three decades. Analysis of publicly available documents related to statewide nutrition policy and programmes from 1983 to 2014 identified key inputs and programme impacts and outcomes, including an increase in fruit and vegetable intake by 1.1 serves per person per day and rates of exclusive breastfeeding for the first 6 months quadrupled. Mapping factors and milestones against a framework on determinants of political priority highlighted correlation with effective nutrition promotion policy and practice. Identified enablers included the influence of policy champions and advocates, quality of governance, focus on whole-of-population approaches, and periods of political will and economic prosperity. Key barriers included changes of ideology with government leadership; lack of commitment to long-term implementation and evaluation; and limited recognition of and support for preventive health and nutrition promotion. The case study shows that a coordinated, well-funded, intersectoral approach to improve nutrition and prevent chronic disease and malnutrition in all its forms can be achieved and produce promising impacts at state level, but that sustained effort is required to secure and protect investment. Political support for long-term investment in nutrition is essential to reduce the high cost of all diet-related diseases. Public health leadership to better prepare for risks around political cycles, secure adequate resources for evaluation, and better communicate impacts and outcomes may help protect future investments and achievements.

Distal Brachial Artery Perforator flap: a new chimeric option for complex hand and digits defects

INTRODUCTION

Reconstruction of fingers pose unique challenges, as a thin and flexible flap is needed in order to guarantee a good functional outcome. For the first time, in this report, we present the DBAp (distal brachial artery perforator) flap, based on the distal perforator closer to the medial epicondyle. The DBAp flap was used to reconstruct complex digit defects as free flap, and to cover an elbow defect while raised as a propeller.

METHODS

Four patients underwent finger reconstruction (free flaps): two patients presented an unstable finger scar following previous surgery, whereas the other two patients presented a terminalized finger at the level of the middle phalanx. A further patient presented a post-traumatic loss of substance at the elbow and was reconstructed using a perforator propeller DBAP flap.

RESULTS

Loss of tissues included skin and subcutaneous tissue in all patients and in one patient it included a bone component. Flap dimensions ranged from 48 to 18 cm² (average: 32 cm²). Among complications, patient n.2 flap presented a marginal flap necrosis requiring a small skin graft after necrosis debridement.

CONCLUSION

The DBAp flap provides a slim, glabrous and pliable skin tissue with a well-hidden donor site scar and thanks to the anatomic location of the distal perforator can be designed to include a vascularized bone graft from the medial epicondyle. Despite the low number of cases, we believe that this flap should be considered as a dependable and effective source for complex reconstructions of both soft tissue and bone in fingers.

Microstructure and properties of additively manufactured Al-Ce-Mg alloys

Additive manufacturing of aluminum alloys is largely dominated by a near-eutectic Al-Si compositions, which are highly weldable, but have mechanical properties that are not competitive with conventional wrought Al alloys. In addition, there is a need for new Al alloys with improved high temperature properties and thermal stability for applications in the automotive and aerospace fields. In this work, we considered laser powder bed fusion additive manufacturing of two alloys in the Al–Ce–Mg system, designed as near-eutectic (Al–11Ce–7Mg) and hyper-eutectic (Al–15Ce–9Mg) compositions with respect to the binary L → Al + Al₁₁Ce eutectic reaction. The addition of magnesium is used to promote solid solution strengthening. A custom laser scan pattern was used to reduce the formation of keyhole porosity, which was caused by excessive vaporization due to the high vapor pressure of magnesium. The microstructure and tensile mechanical properties of the alloys were characterized in the as-fabricated condition and following hot isostatic pressing. The two alloys exhibit significant variations in solidification structure morphology. These variations in non-equilibrium solidification structure were rationalized using a combination of thermodynamic and thermal modeling. Both alloys showed higher yield strength than AM Al-10Si-Mg for temperatures up to 350 °C and better strength retention at elevated temperatures than additively manufactured Scalmaloy.

The iron content of healthy diets for one day for breastfed babies and young children

AIMS

Early childhood anaemia due to iron deficiency is widespread in remote communities across northern Australia. Current recommendations for healthy food to complement breastfeeding at age 6 to 23 months include iron-rich and iron-enriched foods. An electronic nutrient analysis was undertaken to assess the iron content of hypothetical healthy diets for breastfed babies and young children aged 6 to 23 months in Australia, in comparison with their estimated requirements.

METHODS

Hypothetical diets for 1 day were developed that were consistent with the Foundation Diets for breastfed infants 6 to 12 months and for toddlers 13 to 23 months. Nutrient content was derived using the Australian Food Composition database in FoodWorks 10. The iron content of these two diets were compared with Estimated Average Requirements (EARs) and Recommended Dietary Intakes (RDIs) for iron for infants aged 7 to 12 months and children aged 1 to 3 years.

RESULTS

The iron content of the hypothetical diet for breastfed infants aged 6 to 12 months (5.8 mg) was less than the EAR (7 mg, 83%) and the RDI (11 mg, 53%). For young breastfed children aged 13 to 23 months, the iron content of the hypothetical diet was 4.4 mg; above the EAR (4 mg, 110%) but less than RDI (9 mg, 49%).

CONCLUSIONS

Breastfeeding has health and neurodevelopmental benefits for infants and young children that are particularly important in remote Australia where food insecurity and poor nutrition compromise health and wellbeing. Adequate iron intake is also important for neurodevelopment in early life but healthy diets for breastfed babies and young children may have insufficient iron content to meet requirements. The upcoming revision of the Australian Dietary Guidelines provides an opportunity to consider this issue.

Early childhood anaemia more than doubles the risk of developmental vulnerability at school-age among Aboriginal and Torres Strait Islander children of remote Far North Queensland: Findings of a retrospective cohort study

Aims

Early childhood anaemia, usually attributed to iron deficiency, is associated with persistent detrimental effects on child development. This study investigates the association of anaemia between age six and 23 months with indicators of childhood development at school‐age among children of remote Aboriginal and Torres Strait Islander communities of Far North Queensland.

Methods

The triennial Australian Early Development Census (AEDC) encompasses five domains of early childhood development—physical health and wellbeing, social competence, emotional maturity, language and cognitive skills (school‐based), communication skills and general knowledge. AEDC 2012 and 2015 assessments were linked with health information for children and their mothers from remote Aboriginal and Torres Strait Islander communities of Far North Queensland.

Results

AEDC assessments were available for 250 children who had measurements of haemoglobin recorded at age 6 to 23 months. More children who had had early childhood anaemia (n = 66/143, 46.2%, [37.9%, 54.4%]) were developmentally vulnerable on two or more domains compared to those who had not been anaemic (n = 25/107, 23.4% [15.2%, 31.5%], P < .001). Multivariable analysis confirmed that early childhood anaemia more than doubled the risk of developmental vulnerability (OR 2.2 [1.1, 4.3] P = .020) at school age.

Conclusions

Early childhood anaemia is a risk factor for developmental vulnerability at school‐age in this setting. Interventions combining nutrition promotion and multi‐micronutrient food fortification, are effective in prevention of early childhood anaemia. Such interventions could also improve early childhood development and subsequent educational achievement.

The majority of Swedish systemic lupus erythematosus patients are still affected by irreversible organ impairment: factors related to damage accrual in two regional cohorts

Background

Although the survival of patients with systemic lupus erythematosus (SLE) has improved, irreversible organ damage remains a critical concern. We aimed to characterize damage accrual and its clinical associations and causes of death in Swedish patients.

Methods

Accumulation of damage was evaluated in 543 consecutively recruited and well-characterized cases during 1998−2017. The Systemic Lupus International Collaborating Clinics (SLICC)/American College of Rheumatology damage index (SDI) was used to estimate damage.

Results

Organ damage (SDI ≥ 1) was observed in 59%, and extensive damage (SDI ≥ 3) in 25% of cases. SDI ≥ 1 was significantly associated with higher age at onset, SLE duration, the number of fulfilled SLICC criteria, neurologic disorder, antiphospholipid antibody syndrome (APS), hypertension, hyperlipidemia, depression and secondary Sjögren's syndrome (SS). In addition, SDI ≥ 3 was associated with serositis, renal and haematological disorders and interstitial lung disease. A multiple regression model identified not only well-known risk factors like APS, antihypertensives and corticosteroids, but pericarditis, haemolytic anaemia, lymphopenia and myositis as being linked to SDI. Malignancy, infection and cardiovascular disease were the leading causes of death.

Conclusions

After a mean SLE duration of 17 years, the majority of today's Swedish SLE patients have accrued damage. We confirm previous observations and report some novel findings regarding disease phenotypes and damage accrual.

Anaemia in early childhood among Aboriginal and Torres Strait Islander children of Far North Queensland: a retrospective cohort study

OBJECTIVE

Early childhood anaemia affects health and neurodevelopment. This study describes anaemia among Aboriginal and Torres Strait Islander children of Far North Queensland.

METHODS

This retrospective cohort study used health information for children born between 2006 and 2010 and their mothers. We describe the incidence of early childhood anaemia and compare characteristics of children and mothers where the child had anaemia with characteristics of children and mothers where the child did not have anaemia using bivariate and multivariable analysis, by complete case (CC) and with multiple imputed (MI) data.

RESULTS

Among these (n=708) Aboriginal and Torres Strait Islander children of Far North Queensland, 61.3% (95%CI 57.7%, 64.9%) became anaemic between the ages of six and 23 months. Multivariable analysis showed a lower incidence of anaemia among girls (CC/MI p<0.001) and among children of Torres Strait Islander mothers or both Aboriginal and Torres Strait Islander mothers (CC/MI p<0.001) compared to children of Aboriginal mothers. A higher incidence of anaemia was seen among children of mothers with parity three or more (CC/MI p<0.001); children born by caesarean section (CC/MI p<0.001); and children with rapid early growth (CC/MI p<0.001).

CONCLUSION

Early childhood anaemia is common among Aboriginal and Torres Strait Islander children of Far North Queensland. Poor nutrition, particularly iron deficiency, and frequent infections are likely causes. Implications for public health: Prevention of early childhood anaemia in 'Close the Gap' initiatives would benefit the Aboriginal and Torres Strait Islander children of Far North Queensland - and elsewhere in northern Australia.

Healthy Choice Rewards: A Feasibility Trial of Incentives to Influence Consumer Food Choices in a Remote Australian Aboriginal Community

Poor diet including inadequate fruit and vegetable consumption is a major contributor to the global burden of disease. Aboriginal and Torres Strait Islander Australians experience a disproportionate level of preventable chronic disease and successful strategies to support Aboriginal and Torres Strait Islander people living in remote areas to consume more fruit and vegetables can help address health disadvantage. Healthy Choice Rewards was a mixed methods study to investigate the feasibility of a monetary incentive: store vouchers, to promote fruit and vegetable purchasing in a remote Australian Aboriginal community. Multiple challenges were identified in implementation, including limited nutrition workforce. Challenges related to the community store included frequent store closures and amended trading times, staffing issues and poor infrastructure to support fruit and vegetable promotion. No statistically significant increases in fruit or vegetable purchases were observed in the short time frame of this study. Despite this, community members reported high acceptability of the program, especially for women with children. Optimal implementation including, sufficient time and funding resources, with consideration of the most vulnerable could go some way to addressing inequities in food affordability for remote community residents.

Comparison between abdominal fat measured by CT and anthropometric indices as prediction factors for mortality and morbidity after colorectal surgery

AIM

This study aims to determine which anthropometric (body mass index (BMI), waist-hip-ratio (WHR) and waist-to-height ratio (WHtR)) and radiological (visceral fat area (VFA) measured by CT scan) measurements of adiposity correlated better with postoperative outcome of colorectal cancer (CRC) surgery. We also assessed which of these measurements best predicted overall survival (OS) and disease-free survival (DFS).

METHODS

Data from 90 consecutive Caucasian CRC patients who underwent surgery for colorectal cancer between 2010 and 2011 with a median follow-up of 53.25 months were analysed. The correlations of different adiposity measurements and postoperative outcomes were determined using logistic regression models and multivariate analyses.

RESULTS

Higher WHtR (p = 0.007) and VFA (p = 0.01) significantly increased the risk of overall morbidity, especially of Clavien-Dindo III or IV. The WHtR correlated best with VFA (p <0.0001), which is considered the gold standard for measuring visceral fat, whereas BMI (p = 0.15) was not a good predictor of postoperative morbidity. Multivariate analyses showed consistently significant results for postoperative complications for VFA in combination with all of the other variables analysed and for WHtR, confirming that VFA and WHtR were reliable independent prognostic factors of morbidity. VFA had a significant effect on OS (p = 0.012) but did not correlate with DFS (p = 0.51).

CONCLUSIONS

Both VFA and WHtR independently provided predictive data for potential postoperative complications after CRC surgery. In case CT scan was used for diagnostic purposes, VFA should be used in routine clinical practice.

Linking 'data silos' to investigate anaemia among Aboriginal and Torres Strait Islander mothers and children in Far North Queensland

OBJECTIVE

Data collection 'silos' can be linked for health research. Anaemia in early childhood is a long-recognised health issue in remote Aboriginal communities of the Northern Territory and Western Australia, but information is lacking for Queensland. The objective of this work was to compile existing information from health and education data collections to investigate anaemia among Aboriginal and Torres Strait Islander mothers and their children in Far North Queensland.

METHODS

Data mapping identified four health data collections and one education data collection holding relevant information. Data Custodians' approval was secured for release of linked de-identified information.

RESULTS

Approval processes and preparation of the dataset for release took 23 months. Birth information was obtained for 2,205 mother-child pairs where the Aboriginal and/or Torres Strait Islander child was born in Far North Queensland between 2006 and 2010. Pathology information from before/during pregnancy was obtained for 2,126 mothers (96.4%), growth and haemoglobin information for 982 children (44.5%), and childhood development indicators at school entry for 963 children (43.7%).

CONCLUSION

Linking existing information 'silos' enables research into key public health issues. Implications for public health: Information linkage is particularly valuable in respect of vulnerable populations including rural and remote Aboriginal and Torres Strait Islander peoples.

Single-incision laparoscopic surgery for locally advanced colorectal cancer : feasibility, short-term and oncologic outcomes

BACKGROUND AND STUDY AIMS

Data about single-incision laparoscopic surgery (SILS) in locally advanced colorectal cancers are scarce. This study aimed to evaluate perioperative and shortterm oncologic outcomes of SILS in pT3-T4 colorectal cancer.

PATIENTS AND METHODS

From 2011 to 2015 data from 249 SILS performed in our Colorectal Unit were entered into a prospective database. Data regarding patients with a pT3-T4 colorectal adenocarcinoma were compared to those with pTis-pT2. Factors influencing conversion were assessed by multivariate analysis.

RESULTS

There were 100 consecutive patients (T3-T4 = 70, Tis-T2 = 30). Demographics were similar. Tumor size was significantly larger in the T3-T4 group [3.9cm vs 2cm; p<0.001]. In T3-T4 patients we found a significant higher number of lymph nodes harvested [20 vs 13 ; p<0.001]. Early (<30 days) severe (Clavien-Dindo classification>2) postoperative complication rate was similar between groups (8.6% vs 10% ; p = 0.999), as well as conversion rate (18.6% vs 6.7% ; p = 0.220). Finally, there were no differences in terms of hospital stay and mortality rate. On multivariate analysis, age (OR = 1.06, 95%CI: 1.012-1.113 ; p = 0.015] and stage IV (OR = 5.372, 95%CI: 1.320-21.862, p = 0.019) were independently associated with conversion.

CONCLUSIONS

SILS for locally advanced colorectal cancer did not affect the short-term outcomes in this series and oncological clearance remained satisfactory. Age and stage IV disease are independent risk factors for conversion.

Effects of depression, metabolic syndrome, and cardiorespiratory fitness on mortality: results from the Cooper Center Longitudinal Study

BACKGROUND

Depression and metabolic syndrome (MetS) are frequently comorbid disorders that are independently associated with premature mortality. Conversely, cardiorespiratory fitness (CRF) is associated with reduced mortality risk. These factors may interact to impact mortality; however, their effects have not been assessed concurrently. This analysis assessed the mortality risk of comorbid depression/MetS and the effect of CRF on mortality in those with depression/MetS.

METHODS

Prospective study of 47 702 adults in the Cooper Center Longitudinal Study. Mortality status was attained from the National Death Index. History of depression was determined by patient response (yes or no) to a standardized medical history questionnaire. MetS was categorized using the American Heart Association/National Heart, Lung, and Blood Institute criteria. CRF was estimated from the final speed/grade of a treadmill graded exercise test.

RESULTS

13.9% reported a history of depression, 21.4% met criteria for MetS, and 3.0% met criteria for both MetS and history of depression. History of depression (HR = 1.24, p = 0.003) and MetS (HR = 1.28, p < 0.001) were independently associated with an increased mortality risk, with the greatest mortality risk among individuals with both a history of depression and MetS (HR = 1.59, p < 0.001). Higher CRF was associated with a significantly lower risk of mortality (p < 0.001) in all individuals, including those with MetS and/or a history of depression.

CONCLUSIONS

Those with higher levels CRF had reduced mortality risk in the context of depression/MetS. Interventions that improve CRF could have substantial impact on the health of persons with depression/MetS.

ToF-SIMS Depth Profiling of PS-b-PMMA Block Copolymers Using Arn+, C60++, and Cs+ Sputtering Ions

Time-of-flight secondary ion mass spectrometry (ToF-SIMS) is a high performance tool for molecular depth profiling of polymer films, in particular when they are structured in microphases. However, a major issue is the degradation of polymer materials under ion irradiation in reactions such as cross-linking, chain breaking, or reorganization processes of polymers which have been demonstrated for materials such as polystyrene (PS) and poly(methyl methacrylate) (PMMA). This work aims at comparing ToF-SIMS molecular depth profiling of structured polymers (polystyrene (PS)-b-polymethyl methacrylate (PMMA) block copolymers (BCP)) using either ultralow energy cesium or the more recently introduced C₆₀⁺⁺ (under NO dosing and with sample cooling) and argon cluster ion beams (using Ar₁₅₀₀⁺ ions at 5 keV). The latter improved the quality of the depth profiles, especially the argon cluster ion beam, as it is characterized by a greater homogeneity for the sputter yields of PS and PMMA. No significant artifacts were observed, and this was confirmed by the comparison of depth profiles obtained from films with variable thickness, annealing time, and morphology (cylindrical blocks vs spherical blocks). Comparison to a theoretical model (hexagonal centered pattern) ensured that the ToF-SIMS depth profiles described the real morphology and may thus be a relevant characterization tool to verify the morphology of the films as a function of the deposition parameters.

Low rates of predominant breastfeeding in hospital after gestational diabetes, particularly among Indigenous women in Australia

OBJECTIVES

To investigate rates of 'any' and 'predominant' breastfeeding in hospital among Indigenous and non-Indigenous women with and without gestational diabetes mellitus (GDM).

METHODS

A retrospective study of singleton infants born from July 2007 to December 2010 at Cairns Hospital, Australia, following GDM pregnancy, using linked hospital and birth data (n=617 infants), with a subsample of medical record reviews (n=365 infants). Aggregate data were used to compare to breastfeeding rates among infants born following non-GDM pregnancy (n=7,894 infants).

RESULTS

More than 90% of all women reported any breastfeeding before hospital discharge. About 80% of women without GDM reported predominant breastfeeding. Despite significant increases over time (p<0.0001), women with GDM were less likely to predominantly breastfeed (OR 0.32, 95%CI 0.27-0.38, p<0.0001); with lower rates among Indigenous women (53%) compared with non-Indigenous (60%) women (OR 0.78, 0.70-0.88, p<0.0001); and women having a caesarean birth or pre-term infant.

CONCLUSIONS

Rates of predominant in-hospital breastfeeding were lower among women with GDM, particularly among Indigenous women and women having a caesarean or pre-term birth.

IMPLICATIONS

Strategies are needed to support predominant in-hospital breastfeeding among women with GDM.

Lymph node ratio and surgical quality are strong prognostic factors of rectal cancer: results from a single referral centre

AIM

Nodal stage is a strong prognostic factor of oncological outcome of rectal cancer. To compensate for the variation in total number of harvested nodes, calculation of the lymph node ratio (LNR) has been advocated. The aim of the study was to compare the impact, on the long-term oncological outcome, of the LNR with other predictive factors, including the quality of total mesorectal excision (TME) and the state of the circumferential resection margin.

METHOD

Consecutive patients having elective surgery for nonmetastatic rectal cancer were extracted from a prospectively maintained database. Retrospective uni- and multivariate analyses were performed based on patient-, surgical- and tumour-related factors. The prognostic value of the LNR on overall survival (OS) and on overall recurrence-free survival (ORFS) was assessed and a cut-off value was determined.

RESULTS

From 1998 to 2013, out of 456 patients, 357 with nonmetastatic disease were operated on for rectal cancer. Neoadjuvant radiochemotherapy was administered to 66.7% of the patients. The mean number of lymph nodes retrieved was 12.8 ± 8.78 per surgical specimen. A lower lymph node yield was obtained in patients who received neoadjuvant chemoradiotherapy (11.8 vs 14.2; P = 0.014). The 5-year ORFS was 71.8% and the 5-year OS was 80.1%. Multivariate analysis confirmed LNR, the quality of TME and age to be independent prognostic factors of OS. LNR, age and perineural infiltration were independently associated with ORFS. Low- and high-risk patients could be discriminated using an LNR cut-off value of 0.2.

CONCLUSION

LNR is an independent prognostic factor of OS and ORFS. In line with the principles of optimal surgical management, the quality of TME and lymph node yield are essential technical requirements.

Scoring the quality of total mesorectal excision for the prediction of cancer-specific outcome

AIM

A three-grade system for macroscopic evaluation of the resection plane is used to describe the quality of total mesorectal excision (TME). In several studies, two of the three grades have been combined when analysing the outcome. The aim of our study was to compare the predictive value of the three-graded with that of a two-graded TME score.

METHOD

The quality of TME in 1382 patients who underwent elective resection for mid or low rectal adenocarcinoma was registered by 65 hospitals in PROCARE, a Belgian multidisciplinary improvement project. Prediction of outcome based on the classic three-grade score was compared with a two-grade scoring system in which intramesorectal resection (IMR) was combined with mesorectal (MRR) or with muscularis propria resection (MPR). End-points included the local recurrence rate, distant metastasis rate (DMR), disease-free survival (DFS) and overall survival (OS).

RESULTS

Among the 1382 resections, 63% were MRR, 27% IMR and 9% MPR. No significant differences were found in local recurrence between the different grades of TME. A two-grade score distinguishing MRR from the others was found to predict DMR, DFS and OS as well as the three-grade score.

CONCLUSION

The discriminatory and predictive value of a two-grade score, differentiating MRR from the combined IMR and MPR, was as good as the classic three-grade score.

Long head of biceps femoris flap in anal fistula treatment: anatomical study and case report

In case of complex anal fistulae, the treatment can include muscular flaps. The gracilis transposition flap is the gold-standard in perineal reconstructive surgery, with wide use during the past decades. However, in some cases, this flap is too short to reach difficult locations such as the posterior perineum. The long head of the biceps femoris, which has already been studied in the electrically stimulated neosphincter formation, could be more appropriate in such clinical situations. Furthermore, its potential advantages, amongst which an excellent functional outcome, would be to allow persistent prone position, during both treatment and reconstruction, as well as a more favorable intramuscular vascularisation. We report the case of a 39-year-old man with a complex recurrent transphincteric posterior anal fistula with an external orifice in the right buttock and complicated with a severe cellulitis, treated with an endo-anal flap combined with a long head of biceps femoris pediculised flap.

Correlations between technical skills and behavioral skills in simulated neonatal resuscitations

OBJECTIVE

Neonatal resuscitation requires both technical and behavioral skills. Key behavioral skills in neonatal resuscitation have been identified by the Neonatal Resuscitation Program. Correlations and interactions between technical skills and behavioral skills in neonatal resuscitation were investigated.

STUDY DESIGN

Behavioral skills were evaluated via blinded video review of 45 simulated neonatal resuscitations using a validated assessment tool. These were statistically correlated with previously obtained technical skill performance data.

RESULT

Technical skills and behavioral skills were strongly correlated (ρ=0.48; P=0.001). The strongest correlations were seen in distribution of workload (ρ=0.60; P=0.01), utilization of information (ρ=0.55; P=0.03) and utilization of resources (ρ=0.61; P=0.01). Teams with superior behavioral skills also demonstrated superior technical skills, and vice versa.

CONCLUSION

Technical and behavioral skills were highly correlated during simulated neonatal resuscitations. Individual behavioral skill correlations are likely dependent on both intrinsic and extrinsic factors.

Effect of hospital volume on quality of care and outcome after rectal cancer surgery

BACKGROUND

Research on the relationship between hospital volume and quality of care in the treatment of rectal cancer is limited.

METHODS

Process and outcome indicators were assessed in patients with rectal adenocarcinoma who underwent total mesorectal excision, registered on a voluntary basis in the PROCARE clinical database. Volume was derived from an administrative database and analysed as a continuous variable. Sphincter preservation, 30-day mortality and survival rates were cross-checked against population-based data.

RESULTS

A total of 1469 patients registered in PROCARE between 2006 and 2011 were included in this study. A volume effect was observed regarding neoadjuvant therapy for stage II-III disease, reporting of the circumferential resection margin, R0 resection rate, sphincter preservation rate, and number of nodes examined after chemoradiotherapy. The global estimate of quality of care was highly variable, but surgery was the single domain in which quality correlated with volume. No volume effect was observed for recurrence and overall survival rates. In the population-based data set (5869 patients), volume was associated with 30-day mortality adjusted for age (odds ratio 0·99, 95 per cent confidence interval (c.i.) 0·98 to 1·00; P = 0·014) and adjusted overall survival (HR 0·99 (95 per cent c.i. 0·99 to 1·00) per additional procedure; P = 0·001), but not with the sphincter preservation rate. Because of incomplete and biased registration on a voluntary basis, results from a clinical database could not be extrapolated to the population.

CONCLUSION

Some volume effects were observed, but their effect size was limited.

Back to basics: iatrogenic intravenous cannula embolus

We present a case of distal venous embolisation of a peripheral intravenous cannula tip that had lost its structural integrity through repeated failed attempts of insertion of the same cannula, contrary to protocols for intravenous access. Radiological imaging confirmed the presence of a foreign body in the middle finger and the patient was brought to theatre. A 2.2cm long catheter tube was removed via a venotomy from the dorsal digital vein.

Exploring mesoscopic physics of vacancy-ordered systems through atomic scale observations of topological defects

Vacancy-ordered transition metal oxides have multiple similarities to classical ferroic systems including ferroelectrics and ferroelastics. The expansion coefficients for corresponding Ginzburg-Landau-type free energies are readily accessible from bulk phase diagrams. Here, we demonstrate that the gradient and interfacial terms can quantitatively be determined from the atomically resolved scanning transmission electron microscopy data of the topological defects and interfaces in model lanthanum-strontium cobaltite. With this knowledge, the interplay between ordering, chemical composition, and mechanical effects at domain walls, interfaces and structural defects can be analyzed.

Lack of folate improvement in high risk indigenous Australian adults over an average of 6.5 years: a cohort study

Socioeconomically vulnerable groups in developed countries suffer excess chronic disease due in large part to an energy dense but nutrient poor diet. Low folate can be a marker of poor dietary quality and is also affected by smoking and chronic alcohol intake, all of which cluster in groups with a low socioeconomic position. A 4.5 to 9 year follow-up study of 567 indigenous adults from remote communities in far north Queensland, Australia, from 1998 to 2007 was conducted. Analysis of the effects of demographic factors, smoking, risky alcohol drinking, fruit and vegetable intake and waist circumference on changes in red cell folate (RCF) status was conducted. Prevalence of low red cell folate doubled in the cohort from a high baseline over this seven year period: 36.9% deficient in 2007, 15.9% at baseline (p<0.001). Smoking was associated with lower folate levels. People with a normal RCF were less likely to be smokers, and were more likely to have a greater number of serves of vegetables (RR 1.06, 95% CI 1.02-1.10) than those who were deficient at follow-up. The introduction of voluntary folate fortification since 1995 does not appear to have impacted on the already poor folate status of this cohort of adults. The increased prevalence of low folate has occurred despite improvements in the food supply, indicating the need for nutrition promotion, and subsidies for healthy food in remote communities. The impact of mandatory folate fortification of flour since 2009 should be assessed in this high risk population.

Different surgical strategies in the treatment of familial adenomatous polyposis: what's the role of the ileal pouch-anal anastomosis?

BACKGROUND AND STUDY AIMS

Restorative coloproctectomy (RCP) with ileal pouch-anal anastomosis (IPAA), is one of the surgical responses to the crucial question of prophylactic treatment in familial adenomatous polyposis (FAP). No consensus has been reached, until now, to choose between IPAA and ileo-rectal anastomosis (IRA), the rectal sparing prophylactic colectomy. This paper aims to review the latest issues related to IPAA and highlights its specificities compared to IRA.

METHODS

PubMed database was searched using the following search items: familial adenomatous polyposis, surgery, ileal pouch-anal anastomosis, ileo-rectal anastomosis. Papers published between 1978 and 2010 were selected.

RESULTS

Absence of mortality, acceptable morbidity and good functional results combined to high quality of life have promoted the IPAA technique. New technical issues such as the double stapled technique, mesenteric lengthening, omission of temporary protective stoma can be addressed almost systematically for these patients. A laparoscopic approach, lessening the body image impact, has proven to be as effective and safe as the open approach to perform IPAA. Further advantages of laparoscopic IPAA rely on the lower adhesion formation resulting in less small bowel occlusion. Sexuality, fertility and childbirth are important functional issues often cited as threatened by the pelvic manoeuvres of the IPAA technique which can be prevented by close rectal wall dissection and a laparoscopic approach.

CONCLUSION

IPAA offers the best available prophylaxis in FAP patients. Technical enhancements in IPAA will most probably decrease the functional risks. Thus IPAA remains the alternative to IRA for the prophylactic treatment of FAP.Nevertheless, based on the latest evidence, the choice between both procedures is still matter of debate.

The increasing cost of the basic foods required to promote health in Queensland

OBJECTIVE

To assess changes in the cost and availability of a standard basket of healthy food items (the Healthy Food Access Basket [HFAB]) in Queensland over time.

DESIGN AND PARTICIPANTS

A series of four cross-sectional surveys (in 1998, 2000, 2001 and 2004) describing the cost and availability of foods in the HFAB over time. In the latest survey, 97 Queensland food stores across the five Australian Bureau of Statistics remoteness categories were compared.

MAIN OUTCOME MEASURES

Cost comparisons for HFAB items by remoteness category for the 97 stores surveyed in 2004; changes in cost and availability of foods in the 81 stores surveyed since 2000; comparisons of food prices in the 56 stores surveyed in 1998, 2000, 2001 and 2004.

RESULTS

In 2004, the Queensland mean cost of the HFAB was $395.28 a fortnight. The cost of the HFAB was 29.6% ($113.89) higher in "very remote" areas than in "major cities" (P < 0.001). Between 2001 and 2004, the Queensland mean cost of the HFAB increased by 14.0% ($48.45), while in very remote areas the cost increased by 18.0% ($76.93) (P < 0.001). Since 2000, the annualised per cent increase in cost of the HFAB has been higher than the increase in Consumer Price Index for food in Brisbane. The cost of healthy foods has risen more than the cost of some less nutritious foods, so that the latter are now relatively more affordable.

CONCLUSIONS

Consumers, particularly those in very remote locations, need to pay substantially more for basic healthy foods than they did a few years ago. Higher prices are likely to be a barrier to good health among people of low socioeconomic status and other vulnerable groups. Interventions to make basic healthy food affordable and accessible to all would help reduce the high burden of chronic disease.