A Modified AUGIS Delphi Process to Establish Future Research Priorities in Benign Upper Gastrointestinal Surgery

World Journal of Surgery - The aim of our study was to use a modified Delphi process to determine the research priorities amongst benign upper gastrointestinal (UGI) surgeons in the United Kingdom....     

The introduction of new critical care equipment into the aeromedical evacuation service of the Royal Air Force.

Changing world events over recent years and an increasingly complex patient casemix have led to a review of the equipment used by the Aeromedical Evacuation Squadron of the Royal Air Force. The initial special purpose aeromedical equipment (SPAME) project was completed in 2001 with the new equipment being brought into service in August of the same year. The project incorporated long term planning for replacing the equipment along with its rapidly developing technology, especially with that used for the care of the critically ill. An intensive training programme was simultaneously introduced to support the deployment of this new technology. Critical care teams comprise a consultant anaesthetist, a critical care nurse, a flight nurse attendant (paramedic) and a technician, all of whom attend courses designed specifically to accommodate their role within the team.A considerable amount of work has been undertaken by a dedicated team to ensure this project became a reality and which has resulted in the provision of care to meet the needs of any casualty, anywhere in the world, being achieved using the latest technology proportionate to any hospital-based ICU.     

Impact of Hypothermic Preservation on Tissue Yield and Viability in Pig Pancreata

Introduction

Chronic shortage of quality human cadaveric pancreata limits islet transplantation. Porcine islet xenotransplantation is being explored to increase the donor pool. For clinical-ready islets, centralized animal husbandry, Current Good Manufacturing Practice–regulated processing facilities, and organ transportation support are required. Amount of cold ischemia time (CIT) before isolation significantly affects transplantation. The goal of this study was to determine the maximum safe CIT of whole pancreata before islet isolation.

Materials and Methods

Pancreata were rapidly removed from Yorkshire pigs (age, 14–22 days) and stored in modified University of Wisconsin solution or in EuroCollins solution at 4^°C. Pancreata were processed with <1 hour CIT (control) or stored for 4 or 12 hours before isolation. Islet yield and percent purity and viability were determined after 7 days of in vitro tissue culture and maturation. Samples from nonprocessed pancreata were collected and snap-frozen in liquid nitrogen at 0, 3, 6, 9, 12, 15, and 24 hours of preservation, then analyzed for adenosine diphosphate/adenosine triphosphate ratio as a measure of tissue energetics.

Results

Up to 12 hours in cold storage had no significant impact on overall islet yield after 7 days of in vitro culture compared with controls; islet yield at the end of the maturation process was 28,700 ± 500 islet equivalents per pancreas (mean ± SEM control yield, 30,300 ± 900 islet equivalents per pancreas); islet purity was 75 ± 5% compared with 74 ± 5% in controls. Islet viability was significantly reduced at 12 hours compared with controls (80 ± 6% vs 96 ± 5%; P < .05). The tissue adenosine diphosphate/adenosine triphosphate ratio was maintained within the first 6 hours (1.6 ± 0.1 to 1.8 ± 0.2; P = NS) but was markedly increased during the 24-hour study (3.3 ± 0.1 at 24 hours), indicating a progressive loss of adenosine triphosphate tissue stores.

Conclusions

Young pig pancreata can be hypothermically stored for up to 12 hours without affecting islet yield and purity; however, islet viability is reduced. These data highlight the need for uniform shipping parameters to standardize islet quality, ideally with CIT <6 hours.     

Body composition of women and men with complete motor paraplegia

Abstract

Objectives

To examine body composition, including the relationship between body mass index (BMI) and total body fat, in women and men with complete motor paraplegia and to make comparisons with able-bodied controls.

Methods

In 13 subjects with traumatic, complete motor paraplegia (six women, seven men) and 39 sex-, age-, and BMI-matched controls from the community (18 women, 21 men), we measured total and regional (upper extremities, trunk, and lower extremities) lean and fat mass using total body dual-energy X-ray absorptiometry.

Results

Both women and men with paraplegia had significantly lower lean mass in their lower extremities, as would be expected, and in their total body when compared with controls. However, they had significantly greater lean mass in their upper extremities than controls (4.4 kg vs. 3.6 kg, P = 0.004 and 8.6 kg vs. 6.7 kg, P < 0.001 in women and men, respectively); all subjects with paraplegia studied used manual wheelchairs. Although total body fat mass was significantly greater in women (P = 0.010) and men (P = <0.001) with paraplegia compared with controls, for the equivalent total body fat mass, BMI was actually lower in women and men with paraplegia than controls (e.g. 20.2 kg/m² vs. 25.0 kg/m², respectively).

Conclusion

We report on body composition in persons with complete motor paraplegia, including women on whom limited information is currently available. Our results support the need to define better assessments of obesity in both women and men following spinal cord injury, particularly of central body fat distribution, as BMI underestimates adiposity in this population.     

A Role Beyond Learning for NMDA Receptors in Reward-Based Decision-Making—a Pharmacological Study Using d-Cycloserine

N-methyl-D-aspartate (NMDA) receptors are known to fulfill crucial functions in many forms of learning and plasticity. More recently, biophysical models, however, have suggested an additional role of NMDA receptors in evidence integration for decision-making, going beyond their role in learning. We designed a task to study the role of NMDA receptors in human reward-guided learning and decision-making. Human participants were assigned to receive either 250 mg of the partial NMDA agonist d-cycloserine (n=20) or matching placebo capsules (n=27). Reward-guided learning and decision-making were assessed using a task in which participants had to integrate learnt and explicitly shown value information to maximize their monetary wins and minimize their losses. To tease apart the effects of NMDA on learning and decision-making we used simple learning models. D-cycloserine shifted decision-making towards a more optimal integration of the learnt and the explicitly shown information, in the absence of a direct learning effect. In conclusion, our results reveal a distinct role for NMDA receptors in reward-guided decision-making. We discuss these findings in the context of NMDA''s roles in neuronal super-additivity and as crucial for evidence integration for decisions.     

Development and delivery of the BOOST (Better Outcomes for Older adults with Spinal Trouble) intervention for older adults with neurogenic claudication

Neurogenic claudication due to spinal stenosis is a common cause of disability in older adults. Conservative treatments are a favourable treatment option. This paper describes the development and delivery of the BOOST (Better Outcomes for Older adults with Spinal Trouble) intervention, a physiotherapist-delivered physical and psychological intervention for the management of neurogenic claudication in older adults. The BOOST intervention is being tested in a multi-centre, randomised controlled trial in UK National Health Service Trusts; delivered by physiotherapists registered with the Health and Care Professionals Council. Participants are aged 65 years or older, registered with a primary care practice, and report symptoms consistent with neurogenic claudication. Intervention content and delivery was initially informed by clinical and patient experts, research evidence, and behaviour change guidelines; and refined following an intervention development day attended by researchers, health professionals, and Patient and Public Involvement representatives. The BOOST intervention comprises 12 group sessions, promoting sustained adherence with a long term home and physical activity programme. Each session includes education and group discussion, individually tailored exercises, and walking. Initial exercise levels are set at a one-to-one assessment. Continued home exercise adherence and increased physical activity following completion of the sessions is facilitated through support telephone calls.
Trial registration ISRCTN12698674.     

Changing role of non-invasive investigation in the preoperative assessment of congenital heart disease: a nine year experience

The total surgical experience of a supraregional paediatric cardiology unit over a nine year period (January 1980 to December 1988) was reviewed to assess the effect of the introduction of the full range of ultrasound techniques. A total of 1517 patients underwent cardiac surgery (955 cardiopulmonary bypass, 562 closed procedures). Of these, 485 patients (32%) did not undergo cardiac catheterisation before operation: 217 bypass (23% of all procedures under cardiopulmonary bypass) and 268 closed procedures (48%). The overall ratio of catheterisations to operations for patients undergoing palliative or corrective surgery fell from 0.97 (1980) to 0.38 (1988). The patients were classified as (a) neonates (0-28 days), (b) infants (one to 12 months), and (c) children (one to 14 years). The main impact of non-invasive surgical referral was in neonates (total catheter:operation ratio 0.38; neonates 0.2 for 1988). The surgical population was further divided according to the principal echocardiographic technique available: (a) 1980-4 cross sectional imaging; (b) 1985-6; imaging plus spectral Doppler ultrasound; (c) 1987-8; imaging plus spectral Doppler ultrasound and colour flow mapping. A fall in the catheter:operation ratio for all age groups was most pronounced in the last four years. This reflects increased familiarity and surgical confidence with non-invasive diagnostic assessment. The introduction of each new echocardiographic technique was associated with a significant fall in the total catheter:operation ratio compared with the preceding period. Six incorrect ultrasound diagnoses were made during the entire period; one of these patients died in the early postoperative period. The integration of Doppler ultrasound with cross sectional imaging has made non-invasive assessment an increasingly practical alternative to preoperative cardiac catheterization.