Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages

Introduction

The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes.

Methods

Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 – July 2009) and after (August 2009 – July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality.

Results

There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann– Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008–2009 to 6 (16.7%) in 2009–2010 (chi-squared test, p<0.0001).

Conclusions

The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.     

One arterial puncture: Radial,please; if two? Make one radial,please

• There is less bleeding with a radial approach
• There is less bleeding with a radial approach
• See above

     

河北省儿童医院住院患儿EB病毒感染流行病学特征

目的了解河北省儿童医院住院患儿EB病毒(EBV)感染的流行病学特征,为儿童EBV感染的诊断和预防提供科学依据。方法收集2017年1—12月河北省儿童医院0~14岁EBV感染住院患儿的全血样本,采用酶联免疫吸附试验(ELISA)检测其EBV衣壳抗原(VCA)IgG及IgM抗体,抗早期抗原(EA)IgG抗体和抗核抗原1(NA1)IgG抗体,以检测结果为研究样本的抗体谱。根据4种EBV抗体的检测结果分为现症感染(抗VCA-IgM抗体阳性,抗NA1-IgG抗体阴性、抗VCA-IgG抗体、抗EA-IgG抗体阳性或阴性)、亚急性感染(抗VCA-IgG抗体阳性,抗VCA-IgM抗体、抗NA1-IgG抗体、抗EA-IgG抗体阳性或阴性)、既往感染(抗NA1-IgG抗体阳性,抗VCA-IgG抗体阳性或阴性,其他抗体均为阴性)和未感染(4种抗体均阴性)。按照患儿年龄、检出月份和性别分析各组的阳性率。结果共纳入符合要求的样本4 451例,其中3 257例(73.17%)抗体谱提示EBV感染,包括现症感染380例(8.54%)、亚急性感染616例(13.84%)、既往感染2 261例(50.80%)。不同年龄组原发阳性检出率差异有统计学意义(P<0.05),其中学龄前(>3岁)组的阳性检出率最高(P<0.05);不同检出月份组阳性检出率差异有统计学意义(P<0.05),7月份阳性检出率高于其他月份(P<0.05);男性患儿与女性患儿EBV感染率差异无统计学意义(P>0.05)。380例现症感染患儿的疾病谱以血液系统疾病[传染性单核细胞增多症、急性粒细胞缺乏症、血小板减少性紫癜、EBV相关嗜血细胞综合征]为主,其中传染性单核细胞增多症为临床常见疾病;其次是呼吸系统疾病(急性支气管炎、疱疹性咽峡炎、急性扁桃体炎);其他疾病谱包括神经系统疾病及血流感染、肾病综合征、川崎病。结论河北省儿童医院住院患儿EBV阳性检出率有年龄和检出月份差异,现症感染以血液系统疾病患儿为主,医院应根据流学病学特征制定相应预防措施。     

The importance of hydrology in routing terrestrial carbon to the atmosphere via global streams and rivers

The magnitude of stream and river carbon dioxide (CO₂) emission is affected by seasonal changes in watershed biogeochemistry and hydrology. Global estimates of this flux are, however, uncertain, relying on calculated values for CO₂ and lacking spatial accuracy or seasonal variations critical for understanding macroecosystem controls of the flux. Here, we compiled 5,910 direct measurements of fluvial CO₂ partial pressure and modeled them against watershed properties to resolve reach-scale monthly variations of the flux. The direct measurements were then combined with seasonally resolved gas transfer velocity and river surface area estimates from a recent global hydrography dataset to constrain the flux at the monthly scale. Globally, fluvial CO₂ emission varies between 112 and 209 Tg of carbon per month. The monthly flux varies much more in Arctic and northern temperate rivers than in tropical and southern temperate rivers (coefficient of variation: 46 to 95 vs. 6 to 12%). Annual fluvial CO₂ emission to terrestrial gross primary production (GPP) ratio is highly variable across regions, ranging from negligible (<0.2%) to 18%. Nonlinear regressions suggest a saturating increase in GPP and a nonsaturating, steeper increase in fluvial CO₂ emission with discharge across regions, which leads to higher percentages of GPP being shunted into rivers for evasion in wetter regions. This highlights the importance of hydrology, in particular water throughput, in routing terrestrial carbon to the atmosphere via the global drainage networks. Our results suggest the need to account for the differential hydrological responses of terrestrial–atmospheric vs. fluvial–atmospheric carbon exchanges in plumbing the terrestrial carbon budget.

The Earth’s water, carbon, and energy fluxes follow seasonal variations in the Earth’s solar radiation and climate variability (1, 2). As an integral part of terrestrial landscapes, streams and rivers receive significant water and carbon inputs from terrestrial and wetland ecosystems, which are further processed along the river to ocean continuum (3). As the largest carbon flux mediated by fluvial systems, carbon dioxide (CO₂) emission from stream and river surfaces (4–7) is double the lateral carbon transport to oceans (8), yet its spatial and temporal variations are not fully resolved. Stream and river CO₂ evasion changes considerably across space and time due to biogeochemical responses to climatic factors (3), the physics governing the transfer of gas across the water–air interface (9), and seasonal variations in the spatial extent of drainage networks (10, 11). However, seasonal variability of the flux has not been determined at the global scale, limiting our ability to understand controls at the macrosystem level.The rate at which streams and rivers exchange CO₂ with the atmosphere is determined by three factors: dissolved CO₂ concentration (often expressed as an equivalent atmospheric partial pressure [pCO₂]), water surface gas transfer velocity (k), and water surface area. To estimate flux at the monthly scale, all three factors need to be resolved at the same or finer temporal scale(s). To date, existing spatially explicit estimates of riverine CO₂ emission at the global scale (4, 12) relied exclusively on pCO₂ calculated from carbonate equilibria and historical archives of pH and alkalinity measurements. While these data have reasonable spatial coverage, the carbonate equilibria method is subject to inflated pCO₂ estimates due to biased pH measurements (13) and alkalinity contribution from organic acids (14), particularly in low–ionic strength waters. These errors, although reducible within individual datasets (15), are difficult to correct for when scaling globally. This problem has significantly undermined calculations and understanding of the flux at the global scale. More importantly, although global estimates of the stream and river surface area and gas transfer velocity at mean annual discharge have been achieved (4, 16), their seasonal extent, a major driver of within-year variability of riverine CO₂ flux, has not. This is largely because a temporally resolved reach-scale representation of global river hydrology has not been available until recently (17), and new understandings of aquatic surface area extent and water–air gas transfer rates are necessary to incorporate temporal variability into the riverine CO₂ flux estimate.We compiled a dataset of present-day direct pCO₂ measurements in global streams and rivers from the literature. The dataset has 5,910 individual measurements of different months that cover all major freshwater ecoregions of the world (18), despite a small percentage (∼0.5%) of measurements from southern temperate rivers (SI Appendix, Fig. S1). The dataset further has pCO₂ measurements in all months from each freshwater ecoregion (open water months for the polar freshwater ecoregion) except oceanic islands and large river deltas that make up only 0.4% of the global land area (SI Appendix, Fig. S1). These observations allowed for robust validation of the study’s results. Riverine pCO₂ was statistically modeled against a set of watershed properties (SI Appendix, Table S1) in order to understand biogeochemical and geophysical controls on pCO₂. Predictions of pCO₂, k, and surface area were based on a new representation of the global river networks (the Global Reach-Level A Priori Discharge Estimates for Surface Water and Ocean Topography [GRADES] river networks) (17), which contains daily discharge estimates at ∼3 million individual river reaches over a 35-y period. Monthly CO₂ flux estimates were achieved by coupling monthly pCO₂ estimates driven by monthly watershed properties to monthly k and surface area estimates driven by the GRADES discharge. Spatial and temporal variability of the flux was finally investigated to demonstrate a strong modulation of the terrestrial (and wetland) carbon routing to the atmosphere via streams and rivers by hydrology.     

流式细胞术的培训实践及技术平台建设探讨

流式细胞分析技术(flow cytometry,FCM),又称流式细胞术,是一种在功能水平上对单细胞或其他生物粒子进行定量分析和分选的技术,具有广泛的科研应用价值.采用理论与实践并举,结合讨论的教学方式,在教师队伍开设针对性的培训课程,对深刻理解并在科研工作中有效利用该技术具有及其重要意义.同时以教学促科研,以科研促技...     

Biological resurfacing of the knee: a review of surgical management

Lesions of the articular surfaces of the knee have been managed by various techniques over the last 50 years. Surgical management has involved: excising the damaged area, refashioning the underlying bone to produce a fibrous response, and introducing allograft, autograft and synthetic materials to encourage a repair matrix. The techniques and their pitfalls are reviewed and discussed, and suggestions made as to the direction of future studies for the repair of osteochondral lesions in the painful knee.