Enhanced Recovery after Surgery recommendations that most impact patient care: A multi-institutional, multidiscipline analysis in the United States

BACKGROUND

Compliance to the entire Enhanced Recovery after Surgery (ERAS) protocol improves surgical recovery, where higher compliance improves outcomes. However, specific items may predict improved recovery more than others. Studies have evaluated the impact of individual ERAS recommendations though they are either single center, not based in the United States (US), or focus on colorectal procedures only. This study aims to evaluate compliance on surgical outcomes in two large healthcare systems in the US across four surgery types.

METHODS

Compliance to individual recommendations, limited patient characteristics, and outcomes data from two US ERAS Centers of Excellence (CoE) for hepatectomy, pancreatectomy, radical cystectomy, and head and neck (HN) resections were evaluated. Outcomes included 30-day Clavien-Dindo≥3, readmission, mortality, and length of stay (LOS). Multivariate regressions were performed as appropriate for the data for each surgery type. Clavien≥3 was included to control for severity of complications, and the CoE variable was force-retained.

RESULTS

A total of 2886 records were analyzed. Controlling for CoE and severity of patient complications, early removal of Foley catheter was associated with significant reductions in LOS in the liver, pancreas, and HN procedures and reductions in complications in the liver and pancreas. Limited use of NG tubes reduced LOS in the pancreas and complications in urology. Oral carbohydrate loading reduced LOS in the pancreas, and patient education reduced mortality in HN patients.

CONCLUSIONS

This study reports the effect of ERAS compliance on outcomes, by surgery type, in a multi-institutional US setting. Future studies should validate these findings and consider surgery-specific predictive models comprised of individual ERAS recommendations in real-world applications.

The Association of eHealth Literacy Skills and mHealth Application Use Among US Adults With Obesity: Analysis of Health Information National Trends Survey Data

BACKGROUND

Physical inactivity and a poor diet are modifiable behaviors that contribute to obesity. Obesity is a well-recognized risk factor for chronic diseases, including diabetes. Mobile health (mHealth) apps can play an important adjuvant role in preventing and treating chronic diseases and promoting positive health behavior change among people with obesity, and eHealth literacy skills have the potential to impact mHealth app use.

OBJECTIVE

The purpose of this study was to explore the associations between the 2 dimensions, access and application, of eHealth literacy skills and mHealth app use among US adults (≥18 years of age) with obesity (BMI ≥30 kg/m2).

METHODS

Data were obtained from February to June 2020 using the Health Information National Trends Survey 5. A total of 1079 respondents met the inclusion criteria of adults with obesity and owners of smartphones. Individual associations between mHealth app use and sociodemographic variables were explored using weighted chi-square and 2-tailed t tests. A multivariable weighted logistic regression model was fitted, and adjusted odds ratios (ORs) of using mHealth apps with corresponding 95% CIs were reported across multiple sociodemographic variables. An Ising model-weighted network visualization was produced. A receiver operating characteristic curve was calculated, and the area under the curve was reported with the corresponding Delong 95% CI.

RESULTS

A majority of respondents were female (550/923, 59.6%) or non-Hispanic White (543/923, 58.8%). Individuals in households earning less than US $50,000 comprised 41.4% (382/923) of the sample. All sociodemographic variables were found to be univariately significant at the 5% level, except employment and region. Results from the multivariable weighted logistic regression model showed that the adjusted odds of using an mHealth app are 3.13 (95% CI 1.69-5.80) and 2.99 (95% CI 1.67-5.37) times higher among those with an access eHealth literacy skill of using an electronic device to look for health or medical information for themselves and an application eHealth literacy skill of using electronic communications with a doctor or doctor's office, respectively. Several sociodemographic variables were found to be significant, such as education, where adjusted ORs comparing subgroups to the lowest educational attainment were substantial (ORs ≥7.77). The network visualization demonstrated that all eHealth literacy skills and the mHealth app use variable were positively associated to varying degrees.

CONCLUSIONS

This work provides an initial understanding of mHealth app use and eHealth literacy skills among people with obesity, identifying people with obesity subpopulations who are at risk of a digital health divide. Future studies should identify equitable solutions for people with obesity (as well as other groups) and their use of mHealth apps.

A simple method for testing and controlling inhibition in soil and sediment samples for qPCR

The presence of polymerase-chain-reaction (PCR) inhibitors in many environmental samples can make reliable and repeatable quantitative-polymerase-chain-reaction (qPCR) analysis difficult without sample dilution. To estimate an optimal sample dilution for qPCR and reduce effects of inhibition, a simple test based on multiple dilution series of samples is presented that avoids the use of internal controls and standards reducing complexity and cost.

Separating Features From Functionality in Vaccination Apps: Computational Analysis

BACKGROUND

Some latest estimates show that approximately 95% of Americans own a smartphone with numerous functions such as SMS text messaging, the ability to take high-resolution pictures, and mobile software apps. Mobile health apps focusing on vaccination and immunization have proliferated in the digital health information technology market. Mobile health apps have the potential to positively affect vaccination coverage. However, their general functionality, user and disease coverage, and exchange of information have not been comprehensively studied or evaluated computationally.

OBJECTIVE

The primary aim of this study is to develop a computational method to explore the descriptive, usability, information exchange, and privacy features of vaccination apps, which can inform vaccination app design. Furthermore, we sought to identify potential limitations and drawbacks in the apps' design, readability, and information exchange abilities.

METHODS

A comprehensive codebook was developed to conduct a content analysis on vaccination apps' descriptive, usability, information exchange, and privacy features. The search and selection process for vaccination-related apps was conducted from March to May 2019. We identified a total of 211 apps across both platforms, with iOS and Android representing 62.1% (131/211) and 37.9% (80/211) of the apps, respectively. Of the 211 apps, 119 (56.4%) were included in the final study analysis, with 42 features evaluated according to the developed codebook. The apps selected were a mix of apps used in the United States and internationally. Principal component analysis was used to reduce the dimensionality of the data. Furthermore, cluster analysis was used with unsupervised machine learning to determine patterns within the data to group the apps based on preselected features.

RESULTS

The results indicated that readability and information exchange were highly correlated features based on principal component analysis. Of the 119 apps, 53 (44.5%) were iOS apps, 55 (46.2%) were for the Android operating system, and 11 (9.2%) could be found on both platforms. Cluster 1 of the k-means analysis contained 22.7% (27/119) of the apps; these were shown to have the highest percentage of features represented among the selected features.

CONCLUSIONS

We conclude that our computational method was able to identify important features of vaccination apps correlating with end user experience and categorize those apps through cluster analysis. Collaborating with clinical health providers and public health officials during design and development can improve the overall functionality of the apps.

Immobilised teicoplanin does not demonstrate antimicrobial activity against Staphylococcus aureus

Antibacterial bone biomaterial coatings appeal to orthopaedics, dentistry and veterinary medicine. Achieving the successful, stable conjugation of suitable compounds to biomaterial surfaces is a major challenge. A pragmatic starting point is to make use of existing, approved antibiotics which are known to remain functional in a stationary, immobilised state. This includes the macrocyclic glycopeptide, teicoplanin, following the discovery, in the 1990's, that it could be used as a chiral selector in chromatographic enantiomeric separations. Importantly teicoplanin works at the level of the bacterial cell wall making it a potential candidate for biomaterial functionalisations. We initially sought to functionalise titanium (Ti) with polydopamine and use this platform to capture teicoplanin, however we were unable to avoid the natural affinity of the antibiotic to the oxide surface of the metal. Whilst the interaction between teicoplanin and Ti was robust, we found that phosphate resulted in antibiotic loss. Before contemplating the covalent attachment of teicoplanin to Ti we examined whether a commercial teicoplanin stationary phase could kill staphylococci. Whilst this commercially available material could bind N-Acetyl-L-Lys-D-Ala-D-Ala it was unable to kill bacteria. We therefore strongly discourage attempts at covalently immobilising teicoplanin and/or other glycopeptide antibiotics in the pursuit of novel antibacterial bone biomaterials.

Real-world evaluation of rapid and laboratory-free COVID-19 triage for emergency care: external validation and pilot deployment of artificial intelligence driven screening

Background

Uncertainty in patients' COVID-19 status contributes to treatment delays, nosocomial transmission, and operational pressures in hospitals. However, the typical turnaround time for laboratory PCR remains 12–24 h and lateral flow devices (LFDs) have limited sensitivity. Previously, we have shown that artificial intelligence-driven triage (CURIAL-1.0) can provide rapid COVID-19 screening using clinical data routinely available within 1 h of arrival to hospital. Here, we aimed to improve the time from arrival to the emergency department to the availability of a result, do external and prospective validation, and deploy a novel laboratory-free screening tool in a UK emergency department.

Methods

We optimised our previous model, removing less informative predictors to improve generalisability and speed, developing the CURIAL-Lab model with vital signs and readily available blood tests (full blood count [FBC]; urea, creatinine, and electrolytes; liver function tests; and C-reactive protein) and the CURIAL-Rapide model with vital signs and FBC alone. Models were validated externally for emergency admissions to University Hospitals Birmingham, Bedfordshire Hospitals, and Portsmouth Hospitals University National Health Service (NHS) trusts, and prospectively at Oxford University Hospitals, by comparison with PCR testing. Next, we compared model performance directly against LFDs and evaluated a combined pathway that triaged patients who had either a positive CURIAL model result or a positive LFD to a COVID-19-suspected clinical area. Lastly, we deployed CURIAL-Rapide alongside an approved point-of-care FBC analyser to provide laboratory-free COVID-19 screening at the John Radcliffe Hospital (Oxford, UK). Our primary improvement outcome was time-to-result, and our performance measures were sensitivity, specificity, positive and negative predictive values, and area under receiver operating characteristic curve (AUROC).

Findings

72 223 patients met eligibility criteria across the four validating hospital groups, in a total validation period spanning Dec 1, 2019, to March 31, 2021. CURIAL-Lab and CURIAL-Rapide performed consistently across trusts (AUROC range 0·858–0·881, 95% CI 0·838–0·912, for CURIAL-Lab and 0·836–0·854, 0·814–0·889, for CURIAL-Rapide), achieving highest sensitivity at Portsmouth Hospitals (84·1%, Wilson's 95% CI 82·5–85·7, for CURIAL-Lab and 83·5%, 81·8–85·1, for CURIAL-Rapide) at specificities of 71·3% (70·9–71·8) for CURIAL-Lab and 63·6% (63·1–64·1) for CURIAL-Rapide. When combined with LFDs, model predictions improved triage sensitivity from 56·9% (51·7–62·0) for LFDs alone to 85·6% with CURIAL-Lab (81·6–88·9; AUROC 0·925) and 88·2% with CURIAL-Rapide (84·4–91·1; AUROC 0·919), thereby reducing missed COVID-19 cases by 65% with CURIAL-Lab and 72% with CURIAL-Rapide. For the prospective deployment of CURIAL-Rapide, 520 patients were enrolled for point-of-care FBC analysis between Feb 18 and May 10, 2021, of whom 436 received confirmatory PCR testing and ten (2·3%) tested positive. Median time from arrival to a CURIAL-Rapide result was 45 min (IQR 32–64), 16 min (26·3%) sooner than with LFDs (61 min, 37–99; log-rank p<0·0001), and 6 h 52 min (90·2%) sooner than with PCR (7 h 37 min, 6 h 5 min to 15 h 39 min; p<0·0001). Classification performance was high, with sensitivity of 87·5% (95% CI 52·9–97·8), specificity of 85·4% (81·3–88·7), and negative predictive value of 99·7% (98·2–99·9). CURIAL-Rapide correctly excluded infection for 31 (58·5%) of 53 patients who were triaged by a physician to a COVID-19-suspected area but went on to test negative by PCR.

Interpretation

Our findings show the generalisability, performance, and real-world operational benefits of artificial intelligence-driven screening for COVID-19 over standard-of-care in emergency departments. CURIAL-Rapide provided rapid, laboratory-free screening when used with near-patient FBC analysis, and was able to reduce the number of patients who tested negative for COVID-19 but were triaged to COVID-19-suspected areas.

Funding

The Wellcome Trust, University of Oxford Medical and Life Sciences Translational Fund.

Comparative Effectiveness Analyses of Salvage Prostatectomy and Salvage Radiotherapy Outcomes Following Focal or Whole-Gland Ablative Therapy (High-Intensity Focused Ultrasound, Cryotherapy or Electroporation) for Localised Prostate Cancer

AIMS

Ablative therapy, such as focal therapy, cryotherapy or electroporation, aims to treat clinically significant prostate cancer with reduced treatment-related toxicity. Up to a third of patients may require further local salvage treatment after ablative therapy failure. Limited descriptive, but no comparative, evidence exists between different salvage treatment outcomes. The aim of this study was to compare oncological and functional outcomes after salvage robot-assisted radical prostatectomy (SRARP) and salvage radiotherapy (SRT).

MATERIALS AND METHODS

Data were collected prospectively and retrospectively on 100 consecutive SRARP cases and 100 consecutive SRT cases after ablative therapy failure in a high-volume tertiary centre.

RESULTS

High-risk patients were over-represented in the SRARP group (66.0%) compared with the SRT group (48.0%) (P = 0.013). The median (interquartile range) follow-up after SRARP was 16.5 (10.0-30.0) months and 37.0 (18.5-64.0) months after SRT. SRT appeared to confer greater biochemical recurrence-free survival at 1, 2 and 3 years compared with SRARP in high-risk patients (year 3: 86.3% versus 66.0%), but biochemical recurrence-free survival was similar for intermediate-risk patients (year 3: 90.0% versus 75.6%). There was no statistical difference in pad-free continence at 12 and 24 months between SRARP (77.2 and 84.7%) and SRT (75.0 and 74.0%) (P = 0.724, 0.114). Erectile function was more likely to be preserved in men who underwent SRT. After SRT, cumulative bowel and urinary Radiation Therapy Oncology Group toxicity grade I were 25.0 and 45.0%, grade II were 11.0 and 11.0% and grade III or IV complications were 4.0 and 5.0%, respectively.

CONCLUSION

We report the first comparative analyses of salvage prostatectomy and radiotherapy following ablative therapy. Men with high-risk disease appear to have superior oncological outcomes after SRT; however, treatment allocation does not appear to influence oncological outcomes for men with intermediate-risk disease. Treatment allocation was associated with a different spectrum of toxicity profile. Our data may inform shared decision-making when considering salvage treatment following focal or whole-gland ablative therapy.

Dynamics of radiocaesium within forests in Fukushima-results and analysis of a model inter-comparison

Forests cover approximately 70% of the area contaminated by the Fukushima Daiichi Nuclear Power Plant accident in 2011. Following this severe contamination event, radiocaesium (¹³⁷Cs) is anticipated to circulate within these forest ecosystems for several decades. Since the accident, a number of models have been constructed to evaluate the past and future dynamics of ¹³⁷Cs in these forests. To explore the performance and uncertainties of these models we conducted a model inter-comparison exercise using Fukushima data. The main scenario addressed an evergreen needleleaf forest (cedar/cypress), which is the most common and commercially important forest type in Japan. We also tested the models with two forest management scenarios (decontamination by removal of soil surface litter and forest regeneration) and, furthermore, a deciduous broadleaf forest (konara oak) scenario as a preliminary modelling study of this type of forest. After appropriate calibration, the models reproduced the observed data reliably and the ranges of calculated trajectories were narrow in the early phase after the fallout. Successful model performances in the early phase were probably attributable to the availability of comprehensive data characterizing radiocaesium partitioning in the early phase. However, the envelope of the calculated model end points enlarged in long-term simulations over 50 years after the fallout. It is essential to continue repetitive verification/validation processes using decadal data for various forest types to improve the models and to update the forecasting capacity of the models.

141 New Guidelines to Reduce Unnecessary Blood Tests, Delayed Discharge and Costs Following Robot Assisted Radical Prostatectomy

Objectives

Routine postoperative blood tests (POBT) following robot assisted radical prostatectomy (RARP) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed to form new guidelines. The new guidelines were prospectively validated in a sample of 300 patients.

Results

Derivation Dataset: 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 day due to delayed or incomplete blood tests. Validation Dataset: No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. Number of POBT requested reduced by 73% (p &lt; 0.001). The new guidelines improved POBT sensitivity for complications from 98% to 100% and specificity from 0% to 74%. Discharge delays reduced from 6% to 0% (p = 0.008). Cost savings were £178 per patient.

Conclusions

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

283 Salvage Versus Primary Robot-Assisted Radical Prostatectomy: A Propensity-Matched Comparative Effectiveness Study from A High-Volume Tertiary Centre

Aim

Salvage Robot-Assisted Radical Prostatectomy (sRARP) is a potential treatment option for locally recurrent Prostate Cancer after non-surgical primary treatment. There are minimal data comparing outcomes between propensity-matched salvage and primary Robot-Assisted Radical Prostatectomy (RARP). We compare perioperative, oncological, and functional outcomes of sRARP with primary RARP and between sRARP post-whole and focal gland therapy.

Method

1:1 propensity-matched comparison of 146 sRARP with primary RARP from a cohort of 3,852 consecutive patients from a high-volume tertiary centre.

Results

There were no significant differences in patient characteristics between the salvage and primary RARP groups. Grade III-V Clavien-Dindo complication rates were 1.3% and 0% in the salvage and primary groups, respectively (p = 0.310). Median (IQR) follow-up was 16 (10,30) and 21 (13,33) months in the salvage and primary groups, respectively. BCR rates were 30.8% and 13.7% in the salvage and primary groups, respectively (p &lt; 0.001). Pad-free continence rates were 79.1% and 85.4% at two years in the salvage and primary groups, respectively (p = 0.160). ED rates were 95.2% and 77.4% in the salvage and primary groups, respectively (p &lt; 0.001). Comparing the whole gland and focal gland groups, BCR rates were 33.3% and 29.1%, respectively (p = 0.687), pad-free continence rates were 66% and 89.3%, respectively (p = 0.001), and ED rates were 98.3% and 93%, respectively (p = 0.145).

Conclusions

SRARP has similar perioperative but inferior oncological outcomes to primary RARP. Continence rates are similar to primary RARP, but potency is worse. Perioperative and oncological outcomes of sRARP after focal gland therapy are similar but continence outcomes are superior compared to sRARP after whole gland therapy.

O50 New guidelines to reduce unnecessary blood tests, delayed discharge and costs following robot assisted radical prostatectomy

Introduction

Routine postoperative blood tests (POBT) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed, and new guidelines were designed. The guidelines were prospectively validated in a cohort of 300 patients.

Result

Derivation Dataset 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 days due to delayed or incomplete blood tests.

Validation Dataset No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. New guidelines improved sensitivity for complications from 98% to 100% and specificity from 0% to 74%. The number of blood tests requested reduced by 73% (P &lt; 0.001). Discharge delays reduced from 6% to 0% (P = 0.008). Cost savings were £178 per patient.

Conclusion

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

Take-home Message

Routine postoperative blood tests following robot assisted radical prostatectomy are often unnecessary. A guideline-based approach can reduce costs and optimise patient care.

236 Novel Guidelines to Avoid Routine Blood Tests After Robotic Assisted Radical Prostatectomy (RARP)

Introduction

Patients undergoing RARP commonly require routine post-operative blood tests. This practice dates from an era of open surgery, with increased blood loss and complications. We aim to improve specificity of blood test requests with novel guidelines.

Method

1039 consecutive RARP patients at two tertiary urology centres in the UK were audited. Novel guidelines constructed based on risk stratified evidence from the initial audit were used to prospectively audit 133 patients.

Results

16% had clinical concerns post-operatively. 1% and 4% had an intra- and post-operative complication. Intra- or post-operative clinical judgement flagged post-operative complications in 99.9%. 80% had routine blood tests with no clinical concerns. 6% had delayed discharge due to delayed processing of blood tests. 0.9% received a peri-operative transfusion.

Re-Audit Novel guidelines reduced the number of blood tests requested from 100% to 36%. Specificity in diagnosing a complication improved from 0% to 67%. Discharge delays reduced from 6% to 0% and no post-operative complications were missed (sensitivity 100%).

Conclusions

Routine blood tests, without an indication, did not flag any additional post-operative complications. Blood transfusion is rare for RARP. Novel guidelines to request post-operative blood tests will reduce costs and discharge delays whilst maintaining appropriate patient safety and care.

Analysis of Social Media Discussions on (#)Diet by Blue, Red, and Swing States in the U.S

The relationship between political affiliations and diet-related discussions on social media has not been studied on a population level. This study used a cost- and -time effective framework to leverage, aggregate, and analyze data from social media. This paper enhances our understanding of diet-related discussions with respect to political orientations in U.S. states. This mixed methods study used computational methods to collect tweets containing "diet" or "#diet" shared in a year, identified tweets posted by U.S. Twitter users, disclosed topics of tweets, and compared democratic, republican, and swing states based on the weight of topics. A qualitative method was employed to code topics. We found 32 unique topics extracted from more than 800,000 tweets, including a wide range of themes, such as diet types and chronic conditions. Based on the comparative analysis of the topic weights, our results revealed a significant difference between democratic, republican, and swing states. The largest difference was detected between swing and democratic states, and the smallest difference was identified between swing and republican states. Our study provides initial insight on the association of potential political leanings with health (e.g., dietary behaviors). Our results show diet discussions differ depending on the political orientation of the state in which Twitter users reside. Understanding the correlation of dietary preferences based on political orientation can help develop targeted and effective health promotion, communication, and policymaking strategies.

A dataset of 137Cs activity concentration and inventory in forests contaminated by the Fukushima accident

The majority of the area contaminated by the Fukushima Daiichi Nuclear Power Plant accident is covered with forests. We developed a dataset for radiocaesium (137Cs) in trees, soil, and mushrooms measured at numerous forest sites. The 137Cs activity concentration and inventory data reported in scientific journal papers written in English and Japanese, governmental reports, and governmental monitoring data on the web were collated. The ancillary information describing the forest stands were also collated, and further environmental information (e.g. climate) was derived from the other databases using longitude and latitude coordinates of the sampling locations. The database contains 8593, 4105, and 3189 entries of activity concentration data for trees, soil, and mushrooms, and 471 and 3521 entries of inventory data for trees and soil, respectively, which were collected from 2011 to 2017, and covers the entire Fukushima prefecture. The data can be used to document and understand the spatio-temporal dynamics of radiocaesium in the affected region and to aid the development and validation of models of radiocaesium dynamics in contaminated forests.

Vertical distributions of radiocesium in Japanese forest soils following the Fukushima Daiichi Nuclear Power Plant accident: A meta-analysis

This study investigated the temporal change in vertical distributions of radiocesium inventories in Japanese forest soils during the early phase (from 2011 to 2017) following the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident, using three simple parameters. We calculated the fraction in the organic layer (F_l/t), the migration center (X_c) and the relaxation depth (α) using 99 soil inventory data sets. F_l/t decreased significantly from 2011 to 2017 (logistic analysis, p < 0.001). In addition, F_l/t in the FDNPP zone rapidly decreased compared to that in the Chernobyl Nuclear Power Plant (ChNPP) zone from the first year to the second year. Different migration rates from organic to mineral soil layers between previous studies in the ChNPP and this study have several possible causes such as organic litter features, climate and physico-chemical forms of initial deposition. In mineral soil layers in the FDNPP zone, only X_c increased significantly with time according to generalized mixed model analysis (p < 0.01). However, X_c and α in the ChNPP zone decreased from two to five years after the accident in 1986, which shows a high ¹³⁷Cs retention in the organic layer even in the fifth year after the accident. The vertical migration of ¹³⁷Cs in the mineral soil layer in the FDNPP zone appears to be due to low input of ¹³⁷Cs from organic to surface mineral soil layer after the second year. These results indicate that ¹³⁷Cs retention capacity of the organic layer can affect the apparent vertical migration of ¹³⁷Cs in the underlying mineral soil layer.

Kinetics of uranium(VI) lability and solubility in aerobic soils

Uranium may pose a hazard to ecosystems and human health due to its chemotoxic and radiotoxic properties. The long half-life of many U isotopes and their ability to migrate raise concerns over disposal of radioactive wastes. This work examines the long-term U bioavailability in aerobic soils following direct deposition or transport to the surface and addresses two questions: (i) to what extent do soil properties control the kinetics of U speciation changes in soils and (ii) over what experimental timescales must U reaction kinetics be measured to reliably predict long-term of impact in the terrestrial environment? Soil microcosms spiked with soluble uranyl were incubated for 1.7 years. Changes in U^VI fractionation were periodically monitored by soil extractions and isotopic dilution techniques, shedding light on the binding strength of uranyl onto the solid phase. Uranyl sorption was rapid and strongly buffered by soil Fe oxides, but U^VI remained reversibly held and geochemically reactive. The pool of uranyl species able to replenish the soil solution through several equilibrium reactions is substantially larger than might be anticipated from typical chemical extractions and remarkably similar across different soils despite contrasting soil properties. Modelled kinetic parameters indicate that labile U^VI declines very slowly, suggesting that the processes and transformations transferring uranyl to an intractable sink progress at a slow rate regardless of soil characteristics. This is of relevance in the context of radioecological assessments, given that soil solution is the key reservoir for plant uptake.

You Have Control: aviation communication application for safety-critical times in surgery

High-risk organisations (HRO), including aviation, undergo formal communication training, with emphasis on safety-critical moments. Such training is not widespread or mandatory in healthcare, and while there are many differences both share the 'human element' with circumstances leading to an increased risk of harm. A typical operating theatre consists of an operating surgeon, and an assisting surgeon, roles that may change throughout the course of a procedure. Similarly, a training aircraft or multi-crew cockpit (flight deck) has a pilot in control, or 'pilot flying', and a 'pilot not flying'. Both interact with wider teams, for example the scrub team and air traffic controllers, respectively. Surgical error is the second most prevalent cause of preventable harm to patients after drug errors. Every year in the UK National Health Service (NHS), there are typically 500 never events, 21,000 serious incidents, and many more episodes of physical or psychological harm. Ineffective communication (46%) is the most common behavioural factor leading to a never event. In this review, we examine the concept of 'sterile cockpit', use of unambiguous terminology, callsigns, important information readback, sharing of mental models, and the mini-brief, and how these may be used to reduce patient harm during safety-critical moments.

A role for Msx genes in mammalian embryonic diapause

Mammalian embryonic diapause is a reproductive phenomenon defined by the reversible arrest in blastocyst development and metabolic activity within the uterus which synchronously becomes quiescent to implantation. This natural strategy, evident in over 130 species across eight orders, can temporally uncouple conception from delivery until conditions are favorable for the survival of the mother and newborn. While the maternal endocrine milieu has been shown to be important for this process, the local molecular mechanisms by which the uterus and embryo achieve quiescence, maintain blastocyst survival and then resumes blastocyst activation with subsequent implantation in response to endocrine cues remains unclear. Here we review the first evidence that the proximal molecular control of embryonic diapause is conserved in three unrelated mammalian species which employ different endocrine programs to initiate diapause. In particular, uterine expression of muscle segment homeobox (Msx) genes Msx1 or Msx2 persists during diapause, followed by downregulation with blastocyst reactivation and implantation. Mice (Mus musculus) with conditional inactivation of Msx1 and Msx2 in the uterus fail to achieve diapause and reactivation. Remarkably, the mink (Neovison vison) and tammar wallaby (Macropus eugenii) share this pattern of MSX1 or MSX2 expression as in mice during delay - it persists during diapause and is rapidly downregulated upon implantation. Therefore, these findings were the first to provide evidence that there are common conserved molecular regulators in the uterus of unrelated mammals during embryonic diapause.

Human factors recognition at virtual meetings and video conferencing: how to get the best performance from yourself and others

During the current coronavirus pandemic, social distancing and restrictions on travel have resulted in a dramatic rise in the use of technology (including video conferencing) for remote meetings. From local multidisciplinary team (MDT) meetings to national and international committees, this form of communication has been vital to ensure patient-related and other business can continue, albeit in a sometimes unfamiliar environment. In this article we consider some of the human factors elements of remote meetings and provide suggestions to enhance the experience of team and committee members during this unsettling time. It is possible that this form of communication will continue to flourish after the pandemic is over.

Assessment of potentially toxic elements in vegetables cultivated in urban and peri-urban sites in the Kurdistan region of Iraq and implications for human health

Vegetable fields in and around urban areas in the Kurdistan region of Iraq may have higher than background concentrations of potentially toxic elements (PTEs) from contamination sources including municipal waste disposal and wastewater used for irrigation. The purpose of this study was to assess PTE concentrations in soils and the edible parts of field-grown vegetables to quantify potential health risks to the local population. In this survey, 174 soils and 26 different vegetable and fruit types were sampled from 15 areas around Sulaymaniyah and Halabja cities. Sampling was undertaken from fields in urban, peri-urban and rural locations including sites close to areas of waste disposal. The soils are calcareous (pH 7.67-8.21) and classified as silty loam, sandy or silty clay with organic matter content between 6.62 and 11.4%. Concentrations of PTEs were typically higher in waste disposal areas compared with urban, peri-urban and rural areas. Pollution load indices suggested that agricultural soils near waste disposal sites were contaminated with some trace elements. Potentially toxic element concentrations in vegetables were highly variable. Higher total concentrations of PTEs were measured in vegetables from the waste areas with decreasing concentrations in urban, peri-urban and rural areas. Risks to human health were assessed using hazard quotients (HQ). Vegetable consumption poses no risk for adults, whereas children might be exposed to Ni, As and Cd. Although HQs suggest elevated risk for children from consumption of some vegetables, these risks are likely to be lower when realistic dietary consumption levels are considered.

Are COPD self-management mobile applications effective? A systematic review and meta-analysis

The burden of chronic obstructive pulmonary disease (COPD) to patients and health services is steadily increasing. Self-management supported by mobile device applications could improve outcomes for people with COPD. Our aim was to synthesize evidence on the effectiveness of mobile health applications compared with usual care. A systematic review was conducted to identify randomized controlled trials. Outcomes of interest included exacerbations, physical function, and Quality of Life (QoL). Where possible, outcome data were pooled for meta-analyses. Of 1709 citations returned, 13 were eligible trials. Number of exacerbations, quality of life, physical function, dyspnea, physical activity, and self-efficacy were reported. Evidence for effectiveness was inconsistent between studies, and the pooled effect size for physical function and QoL was not significant. There was notable variation in outcome measures used across trials. Developing a standardized outcome-reporting framework for digital health interventions in COPD self-management may help standardize future research.

Moving Towards Common Data Elements and Core Outcome Measures in Frailty Research

With aging populations around the world, frailty is becoming more prevalent increasing the need for health systems and social systems to deliver optimal evidence based care. However, in spite of the growing number of frailty publications, high-quality evidence for decision making is often lacking. Inadequate descriptions of the populations enrolled including frailty severity and frailty conceptualization, lack of use of validated frailty assessment tools, utilization of different frailty instruments between studies, and variation in reported outcomes impairs the ability to interpret, generalize and implement the research findings. The utilization of common data elements (CDEs) and core outcome measures (COMs) in clinical trials is increasingly being adopted to address such concerns. To catalyze the development and use of CDEs and COMs for future frailty studies, the Canadian Frailty Network (www.cfn-nce.ca; CFN), a not-for-profit pan-Canadian nationally-funded research network, convened an international group of experts to examine the issue and plan the path forward. The meeting was structured to allow for an examination of current frailty evidence, ability to learn from other COMs and CDEs initiatives, discussions about specific considerations for frailty COMs and CDEs and finally the identification of the necessary steps for a COMs and CDEs consensus initiative going forward. It was agreed at the onset of the meeting that a statement based on the meeting would be published and herein we report the statement.

Leading article: What can we do to improve individual and team situational awareness to benefit patient safety?

It is increasingly being recognised that human factors can contribute to error in complex safety systems. Healthcare, however, has a long way to go before the promotion of training in, and awareness of, human factors will catch up with other high-risk organisations. A critical component that is deemed essential both for improving clinical performance and reducing medical error is situational awareness (SA). This is dynamic and can reduce quickly or be lost entirely, particularly when the workload is heavy. Tunnel vision, in which healthcare professionals concentrate on a single aspect of a patient's care, is just one example of reduced awareness that can be detrimental to safety. As in aviation and other high-risk organisations, a reduction in SA, if not recognised by individuals or the wider team, can lead to serious or potentially fatal outcomes. We therefore give an overview of SA and show how it can easily be reduced. We also suggest some simple but effective ways to improve it and in turn improve patient safety. We emphasise the importance of clinical teams looking out for each other, particularly in the operating theatre.

Health information seeking behaviour: a concept analysis

BACKGROUND

In 2007, Lambert and Loiselle conducted an extensive concept analysis of the term health information seeking behaviour (HISB) to examine the concept's level of maturity and critically analyse its characteristics. Since their groundbreaking work, HISB has evolved with the proliferation of ICTs. The Internet is now a common and often preferred medium for the pursuit of health information.

OBJECTIVES

The previous analysis spanned 42 years of literature; this article describes an analysis of the last 10 years of literature on HISB and how online seeking has caused the concept to evolve in the literature.

METHODS

This study used the concept analysis methodology employed by Lambert and Loiselle in the original analysis. It also included a systematic search conducted in five databases to identify studies from 2007 to 2017, using similar inclusion criteria from the original study.

RESULTS

Of the more than 500 articles retrieved, 85 journal articles met the inclusion criteria. Consistent with the original work, articles that included outcomes were identified as either behavioural or cognitive.

CONCLUSION

Most of the attention of the works studied focused on individuals and their information source preferences. This HISB analysis can be incorporated with studies to understand how various communities seek information in online versus non-online contexts.

Using chemical fractionation and speciation to describe uptake of technetium, iodine and selenium by Agrostis capillaris and Lolium perenne

To understand the dynamic mechanisms governing soil-to-plant transfer of selenium (Se), technetium-99 (⁹⁹Tc) and iodine (I), a pot experiment was undertaken using 30 contrasting soils after spiking with ⁷⁷Se, ⁹⁹Tc and ¹²⁹I, and incubating for 2.5 years. Two grass species (Agrostis capillaris and Lolium perenne) were grown under controlled conditions for 4 months with 3 cuts at approximately monthly intervals. Native (soil-derived) ⁷⁸Se and¹²⁷I, as well as spiked ⁷⁷Se, ⁹⁹Tc and ¹²⁹I, were assayed in soil and plants by ICP-MS. The grasses exhibited similar behaviour with respect to uptake of all three elements. The greatest uptake observed was for ⁹⁹Tc, followed by ⁷⁷Se, with least uptake of ¹²⁹I, reflecting the transformations and interactions with soil of the three isotopes. Unlike soil-derived Se and I, the available pools of ⁷⁷Se, ⁹⁹Tc and ¹²⁹I were substantially depleted by plant uptake across the three cuts with lower concentrations observed in plant tissues in each subsequent cut. Comparison between total plant offtake and various soil species suggested that ⁷⁷SeO₄^2-, ⁹⁹TcO₄^- and ¹²⁹IO₃^-, in soluble and adsorbed fractions were the most likely plant-available species. A greater ratio of ¹²⁷I/¹²⁹I in the soil solid phase compared to the solution phase confirmed incomplete mixing of spiked ¹²⁹I with native ¹²⁷I in the soil, despite the extended incubation period, leading to poor buffering of the spiked available pools. Compared to traditional expressions of soil-plant transfer factor (TF_total), a transfer factor (TF_available) expressed using volumetric concentrations of speciated 'available' fractions of each element showed little variation with soil properties.