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Purpose: Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA). Methods: An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician–researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Results: The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care. Conclusion: Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties. [ABSTRACT FROM AUTHOR]

Computing the rate of evolution in spatially structured populations is difficult. A key quantity is the fixation time of a single mutant with relative reproduction rate r which invades a population of residents. We say that the fixation time is "fast" if it is at most a polynomial function in terms of the population size N. Here we study fixation times of advantageous mutants (r > 1) and neutral mutants (r = 1) on directed graphs, which are those graphs that have at least some one-way connections. We obtain three main results. First, we prove that for any directed graph the fixation time is fast, provided that r is sufficiently large. Second, we construct an efficient algorithm that gives an upper bound for the fixation time for any graph and any r ≥ 1. Third, we identify a broad class of directed graphs with fast fixation times for any r ≥ 1. This class includes previously studied amplifiers of selection, such as Superstars and Metafunnels. We also show that on some graphs the fixation time is not a monotonically declining function of r; in particular, neutral fixation can occur faster than fixation for small selective advantages. Author summary: Populations of reproducing individuals evolve by accumulating mutations. When a single individual acquires a mutation, it takes some time until the mutation spreads across the population. Depending on the structure of the population, this so-called fixation time could be relatively short or exceedingly long. The structure of biological populations can be represented by graphs. The vertices of the graph denote individuals and the edges indicate possible reproductive events. Directed graphs are defined as those graphs that have some one-way edges. It is known that very long fixation times can arise for certain directed graphs. In this work, we consider a standard process of evolutionary dynamics. We show that for many directed graphs the fixation time is short. We show that fixation time is always short in the ecological scenario describing the spread of an invasive species in an ecosystem. We also show that while advantageous mutations generally fixate faster than neutral mutations, there are interesting exceptions. Finally, we provide concrete bounds for fixation time on any population structure. Those bounds serve as guarantees for simulation-based and computational explorations of the space of all directed graphs. [ABSTRACT FROM AUTHOR]

Background: Despite the extensive volume of research published on checklists in the intensive care unit (ICU), no review has been published on the broader role of checklists within the intensive care unit, their implementation and validation, and the recommended clinical context for their use. Accordingly, a scoping review was necessary to map the current literature and to guide future research on intensive care checklists. This review focuses on what checklists are currently used, how they are used, process of checklist development and implementation, and outcomes associated with checklist use. Methods: A systematic search of MEDLINE (Ovid), Embase, Scopus, and Google Scholar databases was conducted, followed by a grey literature search. The abstracts of the identified studies were screened. Full texts of relevant articles were reviewed, and the references of included studies were subsequently screened for additional relevant articles. Details of the study characteristics, study design, checklist intervention, and outcomes were extracted. Results: Our search yielded 2046 studies, of which 167 were selected for further analysis. Checklists identified in these studies were categorised into the following types: rounding checklists; delirium screening checklists; transfer and handover checklists; central line-associated bloodstream infection (CLABSI) prevention checklists; airway management checklists; and other. Of 72 significant clinical outcomes reported, 65 were positive, five were negative, and two were mixed. Of 122 significant process of care outcomes reported, 114 were positive and eight were negative. Conclusions: Checklists are commonly used in the intensive care unit and appear in many clinical guidelines. Delirium screening checklists and rounding checklists are well implemented and validated in the literature. Clinical and process of care outcomes associated with checklist use are predominantly positive. Future research on checklists in the intensive care unit should focus on establishing clinical guidelines for checklist types and processes for ongoing modification and improvements using post-intervention data. [ABSTRACT FROM AUTHOR]

Despite current global trends towards diversification in policy responses to illegal drug use, including growing criticism of the War on Drugs, Japan continues to retain an ardently prohibitive approach. This article explains the reproduction of prohibitionist policies in Japan throughout the post-War period through use of the Multi-Centred Governance (MCG) thesis. This thesis acknowledges the facilitative power of exogenous shocks to the policy process, the causal power of particular policy actors, whilst also emphasising the importance of dispositional power, the rules of meaning and membership that integrate and bind policy actors into rival agendas of crime control, in maintaining policy agendas despite facilitative and agentic pressures for change. In these terms, the MCG provokes discussion of how alleged global trends in crime and control are mediated by a politics of risk and justice, constituted through the interplay of the facilitative, causal and dispositional circuits of power found in particular contexts. [ABSTRACT FROM AUTHOR]

TB-HLH has poorer prognosis than tuberculosis without HLH, carrying an increased risk of haematogenous tuberculosis and tuberculous meningitis. Keywords: Tuberculosis; Inflammatory bowel diseases; Inflammation; Immunosuppression; Intensive care EN Tuberculosis Inflammatory bowel diseases Inflammation Immunosuppression Intensive care 350 352 3 10/17/23 20231002 NES 231002 Clinical record A 25-year-old male patient reported four weeks of chills, night sweats, weight loss and dyspnoea following one week in Bali, Indonesia, seven weeks prior. Tuberculosis risk is low with short term travel, but pre-travel counselling is important for patients taking TNF inhibitors, who are at elevated risk of acquiring active tuberculosis. [Extracted from the article]

The term, "aerosol-generating procedures" (AGPs), was proposed during the prior SARS-CoV-1 epidemic in order to maximise healthcare worker and patient protection. The concept of AGPs has since expanded to include routine therapeutic processes such as various modes of oxygen delivery and non-invasive ventilation modalities. Evidence gained during the SARS-CoV-2 pandemic has brought into question the concept of AGPs with regard to intubation, airway management, non-invasive ventilation and high flow nasal oxygen delivery. Although encounters where these procedures occur may still be associated with increased risk of infectious transmission, this is a function of the clinical context and not because the procedure itself is aerosol-generating. [ABSTRACT FROM AUTHOR]

This study aimed to describe how video laryngoscopy is used outside the operating room within the hospital setting. Specifically, we aimed to summarise the evidence for the use of video laryngoscopy outside the operating room, and detail how it appears in current clinical practice guidelines. A literature search was conducted across two databases (MEDLINE and Embase), and all articles underwent screening for relevance to our aims and pre-determined exclusion criteria. Our results include 14 clinical practice guidelines, 12 interventional studies, 38 observational studies. Our results show that video laryngoscopy is likely to improve glottic view and decrease the incidence of oesophageal intubations; however, it remains unclear as to how this contributes to first-pass success, overall intubation success and clinical outcomes such as mortality outside the operating room. Furthermore, our results indicate that the appearance of video laryngoscopy in clinical practice guidelines has increased in recent years, and particularly through the COVID-19 pandemic. Current COVID-19 airway management guidelines unanimously introduce video laryngoscopy as a first-line (rather than rescue) device. [ABSTRACT FROM AUTHOR]

Background: International Cancer Benchmarking Partnership Module 4 reports the first international comparison of ovarian cancer (OC) diagnosis routes and intervals (symptom onset to treatment start), which may inform previously reported variations in survival and stage. Methods: Data were collated from 1110 newly diagnosed OC patients aged >40 surveyed between 2013 and 2015 across five countries (51–272 per jurisdiction), their primary-care physicians (PCPs) and cancer treatment specialists, supplement by treatment records or clinical databases. Diagnosis routes and time interval differences using quantile regression with reference to Denmark (largest survey response) were calculated. Results: There were no significant jurisdictional differences in the proportion diagnosed with symptoms on the Goff Symptom Index (53%; P = 0.179) or National Institute for Health and Care Excellence NG12 guidelines (62%; P = 0.946). Though the main diagnosis route consistently involved primary-care presentation (63–86%; P = 0.068), onward urgent referral rates varied significantly (29–79%; P < 0.001). In most jurisdictions, diagnostic intervals were generally shorter and other intervals, in particular, treatment longer compared to Denmark. Conclusion: This study highlights key intervals in the diagnostic pathway where improvements could be made. It provides the opportunity to consider the systems and approaches across different jurisdictions that might allow for more timely ovarian cancer diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Background: International Cancer Benchmarking Partnership Module 4 reports the first international comparison of ovarian cancer (OC) diagnosis routes and intervals (symptom onset to treatment start), which may inform previously reported variations in survival and stage.Methods: Data were collated from 1110 newly diagnosed OC patients aged >40 surveyed between 2013 and 2015 across five countries (51-272 per jurisdiction), their primary-care physicians (PCPs) and cancer treatment specialists, supplement by treatment records or clinical databases. Diagnosis routes and time interval differences using quantile regression with reference to Denmark (largest survey response) were calculated.Results: There were no significant jurisdictional differences in the proportion diagnosed with symptoms on the Goff Symptom Index (53%; P = 0.179) or National Institute for Health and Care Excellence NG12 guidelines (62%; P = 0.946). Though the main diagnosis route consistently involved primary-care presentation (63-86%; P = 0.068), onward urgent referral rates varied significantly (29-79%; P < 0.001). In most jurisdictions, diagnostic intervals were generally shorter and other intervals, in particular, treatment longer compared to Denmark.Conclusion: This study highlights key intervals in the diagnostic pathway where improvements could be made. It provides the opportunity to consider the systems and approaches across different jurisdictions that might allow for more timely ovarian cancer diagnosis and treatment. [ABSTRACT FROM AUTHOR]

This article uses the concept of the "negotiated order" as developed by McAra and McVie to focus on the role and nature of the "family order" in shaping the initiation of methamphetamine use in Japan. Presenting empirical qualitative data from multiple life-story interviews with 11 men with a history of methamphetamine use, the findings demonstrate that while there were variegated paths that led to initiation of use, a common factor was family breakdown and exclusion. Given the "group-oriented" nature of social organization and relations in Japan and the risks emanating from marginalization from "insider" groups, understanding the importance of the ways in which the ascription and negotiation of identities within and around the family can lead to initiation in a severely stigmatized and criminalized activity in this cultural context provides useful lessons for thinking about formal and informal responses to illegal drugs. [ABSTRACT FROM AUTHOR]

Background: Women from socio-economically deprived areas are less likely to develop and then to survive breast cancer (BC). Whether associations between deprivation and BC incidence and survival differ by tumour molecular subtypes and mode of detection in Scotland are unknown. Methods: Data consisted of 62,378 women diagnosed with invasive BC between 2000 and 2016 in Scotland. Incidence rates and time trends were calculated for oestrogen receptor positive (ER+) and negative (ER−) tumours and stratified by the Scottish Index of Multiple Deprivation (SIMD) quintiles and screening status. SIMD is an area-based measure derived across seven domains: income, employment, education, health, access to services, crime and housing. We calculated adjusted hazard ratios (aHR [95% confidence intervals]) for BC death by immunohistochemical surrogates of molecular subtypes for the most versus the least deprived quintile. We adjusted for mode of detection and other confounders. Results: In Scotland, screen-detected ER+tumour incidence increased over time, particularly in the least deprived quintile [Average Annual Percentage Change (AAPC) = 2.9% with 95% CI from 1.2 to 4.7]. No marked differences were observed for non-screen-detected ER+tumours or ER− tumours by deprivation. BC mortality was higher in the most compared to the least deprived quintile irrespective of ER status (aHR = 1.29 [1.18, 1.41] for ER+ and 1.27 [1.09, 1.47] for ER− tumours). However, deprivation was associated with significantly higher mortality for luminal A and HER2−enriched tumours (aHR = 1.46 [1.13, 1.88] and 2.10 [1.23, 3.59] respectively) but weaker associations for luminal B and TNBC tumours that were not statistically significant. Conclusions: Deprivation is associated with differential BC incidence trends for screen-detected ER+tumours and with higher mortality for select tumour subtypes. Future efforts should evaluate factors that might be associated with reduced survival in deprived populations and monitor progress stratified by tumour subtypes and mode of detection. [ABSTRACT FROM AUTHOR]

This paper describes analysis of dropcast nanocrystalline and electrochemically deposited films of NiO and α-Fe2O3 as model metal oxide semiconductors immersed in redox-inactive organic electrolyte solutions using electrochemical impedance spectroscopy (EIS). Although the data reported here fit a circuit commonly used to model EIS data of metal oxide electrodes, which comprises an RC circuit nested inside a second RC circuit that is in series with a resistor, our interpretation of the physical meaning of these circuit elements differs from that applied to EIS measurements of metal oxide electrodes immersed in redox-active media. The data presented here are most consistent with an interpretation in which the nested RC circuit represents charge transfer between the metal oxide film and the underlying metal electrode, and the non-nested RC circuit represents the resistance and capacitance associated with formation of a charge-compensating double-layer at the exposed interface between the metal electrode and electrolyte solution. Applying this interpretation to analysis of EIS data collected for metal oxide films in organic media enables the impact of film morphology on electrochemical behavior to be distinguished from the effects of the intrinsic electronic structure of the metal oxide. This distinction is crucial to the evaluation of nanostructured metal oxide electrodes for electrochemical energy storage and electrocatalysis applications. [ABSTRACT FROM AUTHOR]

Aim: To describe the clinical features, treatment and outcomes of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in children admitted to the national referral hospital in Dili, Timor‐Leste. Methods: This prospective study documented cases of ARF and RHD in children aged 14 years and under who were admitted between June 2017 and May 2019. ARF was diagnosed using an adapted version of the 2015 Jones criteria and presumed (rather than proven) exposure to group A Streptococcus. Clinical and echocardiographic findings, comorbidities and discharge outcomes are reported. Results: A total of 63 patients were admitted with ARF or RHD; 54 were diagnosed with RHD for the first time. Median age was 11 years (range 3–14); 48% were female. Of those with echocardiograms, 56/58 had RHD, 55/56 (98%) had mitral regurgitation (37/55 (67%) severe), 11/56 (20%) had mitral stenosis and 43/56 (77%) had aortic regurgitation. Left ventricular dysfunction (55%), pulmonary hypertension (64%) and cardiac failure (78%) were common. Four (6%) patients died in hospital, and 30/59 (51%) of surviving patients were lost to follow up. Conclusions: Community echocardiography screening has reported a high prevalence of undetected mild to moderate cases of RHD in Timor‐Leste, whereas this hospital study documents mostly severe disease among hospitalised patients with a high case fatality rate and loss to follow up. RHD is a significant health problem in Timor‐Leste and improved recognition and diagnosis, as well as effective delivery of treatment and follow‐up are imperative. [ABSTRACT FROM AUTHOR]

The use of high flow nasal oxygen in the care of COVID-19-positive adult patients remains an area of contention. Early guidelines have discouraged the use of high flow nasal oxygen therapy in this setting due to the risk of viral spread to healthcare workers. However, there is the need to balance the relative risks of increased aerosol generation and virus transmission to healthcare workers against the role high flow nasal oxygen has in reducing hypoxaemia when managing the airway in high-risk patients during intubation or sedation procedures. The authors of this article undertook a narrative review to present results from several recent papers. Surrogate outcome studies suggest that the risk of high flow nasal oxygen in dispersing aerosol-sized particles is probably not as great as first perceived. Smoke laser-visualisation experiments and particle counter studies suggest that the generation and dispersion of bio-aerosols via high flow nasal oxygen with flow rates up to 60 l/min is similar to standard oxygen therapies. The risk appears to be similar to oxygen supplementation via a Hudson mask at 15 l/min and significantly less than low flow nasal prong oxygen 1-5 l/min, nasal continuous positive airway pressure with ill-fitting masks, bilevel positive airway pressure, or from a coughing patient. However, given the limited safety data, we recommend a cautious approach. For intubation in the COVID-positive or suspected COVID-positive patient we support the use of high flow nasal oxygen to extend time to desaturation in the at-risk groups, which include the morbidly obese, those with predicted difficult airways and patients with significant hypoxaemia, ensuring well-fitted high flow nasal oxygen prongs with staff wearing full personal protective equipment. For sedation cases, we support the use of high flow nasal oxygen when there is an elevated risk of hypoxaemia (e.g. bariatric endoscopy or prone-positioned procedures), but recommend securing the airway with a cuffed endotracheal tube for the longer duration procedures when theatre staff remain in close proximity to the upper airway, or considering the use of a surgical mask to reduce the risk of exhaled particle dispersion. [ABSTRACT FROM AUTHOR]

Background: This paper aimed to describe the airway practices of intensive care units (ICUs) in Australia and New Zealand specific to patients presenting with COVID-19 and to inform whether consistent clinical practice was achieved. Specific clinical airway guidelines were endorsed in March 2020 by the Australian and New Zealand Intensive Care Society (ANZICS) and College of Intensive Care Medicine (CICM). Methods and findings: Prospective, structured questionnaire for all ICU directors in Australia and New Zealand was completed by 69 ICU directors after email invitation from ANZICS. The online questionnaire was accessible for three weeks during September 2020 and analysed by cloud-based software. Basic ICU demographics (private or public, metropolitan or rural) and location, purchasing, airway management practices, guideline uptake, checklist and cognitive aid use and staff training relevant to airway management during the COVID-19 pandemic were the main outcome measures. The 69 ICU directors reported significant simulation-based inter-professional airway training of staff (97%), and use of video laryngoscopy (94%), intubation checklists (94%), cognitive aids (83%) and PPE "spotters" (89%) during the airway management of patients with COVID-19. Tracheal intubation was almost always performed by a Specialist (97% of ICUs), who was more likely to be an intensivist than an anaesthetist (61% vs 36%). There was a more frequent adoption of specific airway guidelines for the management of COVID-19 patients in public ICUs (94% vs 71%) and reliance on specialist intensivists to perform intubations in private ICUs (92% vs 53%). Conclusion: There was a high uptake of a standardised approach to airway management in COVID-19 patients in ICUs in Australia and New Zealand, likely due to endorsement of national guidelines. [ABSTRACT FROM AUTHOR]

Background: More people are surviving a first primary cancer and experiencing a second, different cancer. However, little is known about the diagnostic journeys of patients with second primary cancer (SPC). This study explores the views of patients and general practitioners (GPs) on their experiences of pathways to diagnosis of SPC, including the influence of a previous diagnosis of cancer on symptom appraisal, help-seeking and referral decisions.Methods: Qualitative interviews with patients with a SPC diagnosis and case-linked GP interviews in a Scottish primary care setting. In-depth face to face or telephone interviews were conducted, underpinned by a social constructionist approach. Interviews were transcribed and Braun and Clarke's thematic analysis undertaken. Three analysts from the research team read transcripts and developed the coding framework using QSR NVivo version 10, with input from a fourth researcher. Themes were developed from refined codes and interpreted in the context of existing literature and theory.Results: Interviews were conducted with 23 patients (aged 43-84 years) with a SPC diagnosis, and 7 GPs. Five patient themes were identified: Awareness of SPC, symptom appraisal and help-seeking, pathways to diagnosis, navigating the healthcare system, and impact of SPC. GPs interviews identified: experience and knowledge of SPC and referrals and decision-making.Conclusions: Insights into the pathway to diagnosis of SPC highlights the need for increased awareness of and vigilance for SPC among patients and healthcare providers (HCPs), and emotional support to manage the psychosocial burden. [ABSTRACT FROM AUTHOR]

Importance: Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events.Objective: To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients.Design, Setting, and Participants: The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents.Exposures: Tracheal intubation.Main Outcomes and Measures: The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality.Results: Of 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%.Conclusions and Relevance: In this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events-in particular cardiovascular instability-were observed frequently. [ABSTRACT FROM AUTHOR]

In 1922, the U.S. Department of Commerce issued its first Standard State Zoning Enabling Act, a model law authorizing local governments to engage in land-use regulation. Authored during a period of rapid industrialization in U.S. cities, as well as high rates of European immigration and the Great Migration of Black Americans from the rural South to Northern industrial cities, the Act delegated to local governments the power to regulate and direct growth within their borders. The Act, last updated in 1926, has proven durable in its first century, as its principles and language are, even today, found in the zoning enabling laws of nearly every state. However, the broad power conferred to local governments under the Act—to engage in land use regulation for broad and undefined general welfare purposes such as maintenance of community character and property values—has brought about serious negative consequences for housing affordability, racial equity, and access to opportunity. This essay argues that a twenty-first-century zoning enabling law, focused on ameliorating high housing costs, addressing racial segregation, and providing access to opportunity for all communities, is needed for land use planning and regulation to respond to one of our most urgent social crises. The essay discusses the origins of the Standard State Zoning Enabling Act and its adoption into state laws; explains how zoning has been used to systematically segregate and preclude non-white and low-income communities from accessing economic opportunity; and offers suggestions for how an updated zoning enabling law could direct local governments toward more equitable land use regulations. [ABSTRACT FROM AUTHOR]

This article critically examines the role and influence of neuroscientific knowledge in problematising youth-to-adult (Y2A) offender transitions. Drawing upon empirical data from a policy Delphi panel (n = 33) in Wales (UK), it is argued that a 'neuro-deficits' model based around 'maturity' has permeated the understandings of policy-makers and practitioners working with youth offenders. In internalising such neuroscientific knowledge, the policy environment has in turn become problematised for inadequately catering towards such developmental deficits. While this 'neuroscientific turn' in Y2A transitions may serve to further legitimate a set of managerialist and risk-oriented practices, it also provides opportunities for broader meaningful reform. [ABSTRACT FROM AUTHOR]

Theories about crime control in Japan have largely been based around two opposing traditions. On the one hand, cultural explanations have emphasized the exceptional attributes of Japanese social relations that contribute towards shaming and re-integrative processes. On the other hand, more recent explanations assert that Japanese crime control is converging with other countries, particularly towards penal populism. Both approaches tend to reduce explanations to a monolithic characterization that disguises variegation within Japan. Through considering the governance of illegal drug use and the Kamagasaki area of Osaka, a 'geo-historical' perspective is advocated to better capture the complexity and contradictions of globalizing processes and social culture and their resulting manifestations in crime control within contemporary Japan. [ABSTRACT FROM AUTHOR]

Background: We describe temporal trends in breast cancer incidence by molecular subtypes in Scotland because public health prevention programmes, diagnostic and therapeutic services are shaped by differences in tumour biology.Methods: Population-based cancer registry data on 72,217 women diagnosed with incident primary breast cancer from 1997 to 2016 were analysed. Age-standardised rates (ASR) and age-specific incidence were estimated by tumour subtype after imputing the 8% of missing oestrogen receptor (ER) status. Joinpoint regression and age-period-cohort models were used to assess whether significant differences were observed in incidence trends by ER status.Results: Overall, ER-positive tumour incidence increased by 0.4%/year (95% confidence interval (CI): -0.1, 1.0). Among routinely screened women aged 50-69 years, we observed an increase in ASR from 1997 to 2011 (1.6%/year, 95% CI: 1.2-2.1). ER-negative tumour incidence decreased among all ages by 2.5%/year (95% CI: -3.9 to -1.1%) over the study period. Compared with the 1941-1959 birth cohort, women born in 1912-1940 had lower incidence rate ratios (IRR) for ER+ tumours and women born in 1960-1986 had lower IRR for ER- tumours.Conclusions: Future incidence and survival reporting should be monitored by molecular subtypes to inform clinical planning and cancer control programmes. [ABSTRACT FROM AUTHOR]

The primary aim of this study was to evaluate the perceptions of Australian anaesthetists in relation to smartphone use within anaesthetic practice. In particular, we aimed to assess the frequency of smartphone use, the types and number of smartphone applications used, how reliant anaesthetists perceive themselves to be on smartphones and whether they perceive them to be a factor that aids or distracts from their practice. Secondly, we assessed whether there is an association between the type, frequency, reliance and perceptions of smartphone use and the years of experience as an anaesthetist. A 24-item questionnaire addressing these questions was created and distributed to an email list of credentialled anaesthetists in Melbourne, Australia. A total of 113 consultant anaesthetists who practise at 55 hospitals in Melbourne completed the questionnaire. Our results suggest that the majority of anaesthetists are using smartphones regularly in their practice. About 74% of respondents agreed that they rely on their smartphone for their work. We found that respondents were more likely to rely on smartphones and consider them to aid patient safety than to consider them a distraction. This phenomenon was particularly apparent in those who had been a consultant anaesthetist for less than three years. Furthermore, those who had been a consultant anaesthetist for less than three years were more likely to have more smartphone apps relating to anaesthetics, use them more often and rely on them to a greater degree. Our results highlight the ubiquitous and perceived useful nature of smartphones in anaesthetic practice. [ABSTRACT FROM AUTHOR]

An integrative review of the literature specific to leadership within the intensive care unit was planned to guide future research. Four databases were searched. Study selection was based on predetermined inclusion and exclusion criteria and a quality check was done. Data extraction and synthesis involved developing a preliminary thematic coding framework based on a sample of papers. The coding framework and all selected papers were entered into NVivo software. All papers were then coded to the previously identified themes. Themes were summarised and presented with illustrative quotes highlighting key findings. In total, 1102 relevant quotations were coded across the 28 included papers. Four themes pertaining to leadership were described and analysed: (a) leadership dimensions and discourses; (b) leadership experiences; (c) facilitators and/or barriers to leadership; and (d) leadership outcomes. The literature was found to focus on leader behaviours, as well as the leader dimensions of role allocation, clinical and communication skills and traditional hierarchies. Positive behaviours mentioned included good decision-making, staying calm under pressure and being approachable. Leadership experiences (and outcomes) are typically reported to be positive. Personal individual factors seem the biggest enablers and barriers to leadership within the intensive care unit. Training is considered to be a facilitator of leadership within the intensive care unit. This study highlights the current literature on leadership in intensive care medicine and provides a basis for future research on interventions to improve leadership in the intensive care unit. [ABSTRACT FROM AUTHOR]

Introduction: This statement was planned on 11 March 2020 to provide clinical guidance and aid staff preparation for the coronavirus disease 2019 (COVID-19) pandemic in Australia and New Zealand. It has been widely endorsed by relevant specialty colleges and societies.Main Recommendations: Generic guidelines exist for the intubation of different patient groups, as do resources to facilitate airway rescue and transition to the "can't intubate, can't oxygenate" scenario. They should be followed where they do not contradict our specific recommendations for the COVID-19 patient group. Consideration should be given to using a checklist that has been specifically modified for the COVID-19 patient group. Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non-invasive ventilation. Significant institutional preparation is required to optimise staff and patient safety in preparing for the airway management of the COVID-19 patient group. The principles for airway management should be the same for all patients with COVID-19 (asymptomatic, mild or critically unwell). Safe, simple, familiar, reliable and robust practices should be adopted for all episodes of airway management for patients with COVID-19.Changes in Management AsA Result Of This Statement: Airway clinicians in Australia and New Zealand should now already be involved in regular intensive training for the airway management of the COVID-19 patient group. This training should focus on the principles of early intervention, meticulous planning, vigilant infection control, efficient processes, clear communication and standardised practice. [ABSTRACT FROM AUTHOR]

One of the biggest puzzles facing policy makers in India is the likely trajectory of China's future military power in South Asia and the broader Indian Ocean region. Protecting China's interests overseas: Securitization and foreign policy: by Andrea Ghiselli, Oxford, Oxford University Press, 2021, 304 pp., £75 (Hardback), ISBN 978-0-1988-6739-5 In I Protecting China's Interests Overseas: Securitization and Foreign Policy i , Andrea Ghiselli helps us better understand the answers to these questions. [Extracted from the article]

The process of Welsh devolution has marshalled major political, social and institutional change. While scholars within various disciplines have attempted to make sense of these changes, the discipline of criminology remains something of an exception. This article offers an examination of the unique Welsh criminal justice policy space that has been opened up by devolution in Wales. The article provides a long overdue assessment of how drug policy in Wales, while continuing to straddle the UK Government's criminal justice responsibilities, is configured and shaped within post-devolution Wales. The empirical findings presented here reveal the existence of a distinct Welsh drug policy as well as discovering clear limitations to Welsh policy divergence. The article outlines the need for criminologists to take Wales – and the Welsh policy space – more seriously, while highlighting the need for criminologists to become more attuned to the considerable effects being made by constitutional change. [ABSTRACT FROM AUTHOR]

Background: Post‐operative acute kidney injury after cardiopulmonary bypass (AKI‐CPB) for cardiac surgery is a frequent complication. It may require renal replacement therapy (RRT), which is associated with an increased morbidity and mortality. This review explores the efficacy of proposed pharmacological and non‐surgical renal protective strategies. Methods: A comprehensive literature search was done using Ovid MEDLINE, Embase and Scopus databases. Keywords included were cardiopulmonary bypass, cardiac surgery, coronary artery bypass, renal protection and renal preservation. Eligible articles consisted of all studies on patients who had undergone cardiac surgery via CPB with an outcome of AKI and/or RRT reported. All studies underwent a quality check via the risk of bias tool. The three most researched interventions (based on number of randomized controlled trials and total patients analysed) and their renal outcomes were then analysed with Review Manager Software. Results: Eighty‐eight articles were extracted. A total of 26 management strategies for renal protection following CPB were identified. N‐acetylcysteine (NAC), remote ischaemic preconditioning (RIPC) and the use of volatile anaesthetic agents (VAAs) were further analysed. NAC, RIPC and VAA had no statistically significant benefit in reducing either AKI‐CPB or the need for RRT following CPB. Conclusion: NAC, RIPC and VAA were found to have no statistical significant benefit in reducing either AKI‐CPB or the need for RRT following CPB. There remains clinical uncertainty with all currently proposed pharmacological and non‐surgical renal protective strategies for CPB. Future research in this area should analyse the effects of combined interventions or specifically focus on 'at‐risk' patients. [ABSTRACT FROM AUTHOR]

Objective International differences in colorectal cancer (CRC) survival and stage at diagnosis have been reported previously. They may be linked to differences in time intervals and routes to diagnosis. The International Cancer Benchmarking Partnership Module 4 (ICBP M4) reports the first international comparison of routes to diagnosis for patients with CRC and the time intervals from symptom onset until the start of treatment. Data came from patients in 10 jurisdictions across six countries (Canada, the UK, Norway, Sweden, Denmark and Australia). Design Patients with CRC were identified via cancer registries. Data on symptomatic and screened patients were collected; questionnaire data from patients' primary care physicians and specialists, as well as information from treatment records or databases, supplemented patient data from the questionnaires. Routes to diagnosis and the key time intervals were described, as were between-jurisdiction differences in time intervals, using quantile regression. Participants A total of 14 664 eligible patients with CRC diagnosed between 2013 and 2015 were identified, of which 2866 were included in the analyses. Primary and secondary outcome measures Interval lengths in days (primary), reported patient symptoms (secondary). Results The main route to diagnosis for patients was symptomatic presentation and the most commonly reported symptom was 'bleeding/blood in stool'. The median intervals between jurisdictions ranged from: 21 to 49 days (patient); 0 to 12 days (primary care); 27 to 76 days (diagnostic); and 77 to 168 days (total, from first symptom to treatment start). Including screen-detected cases did not significantly alter the overall results. Conclusion ICBP M4 demonstrates important differences in time intervals between 10 jurisdictions internationally. The differences may justify efforts to reduce intervals in some jurisdictions. [ABSTRACT FROM AUTHOR]

There is a growing understanding among maritime security practitioners of the importance of Maritime Domain Awareness (MDA) as an essential enabler of maritime security. This article describes Australia’s efforts to develop an integrated national MDA system that brings together data and intelligence from a range of military and civil agencies and commercial sources to which a risk-based assessment is applied. This has become an essential tool to combat transnational maritime security threats in the Indian Ocean and elsewhere. But inherent limitations of national MDA systems are also pushing Australia and other countries to cooperate in trying to improve MDA. This paper then examines ways in which Australia can promote MDA cooperation in the Indian Ocean. It considers the effectiveness and limitations of current and proposed multilateral information sharing arrangements in the region. It concludes that Australia should primarily focus on working with selected Indian Ocean partners to enhance information sharing and help develop integrated national MDA systems. [ABSTRACT FROM AUTHOR]

Background: PREDICT is a widely used online prognostication and treatment benefit tool for patients with early stage breast cancer. The aim of this study was to conduct an independent validation exercise of the most up-to-date version of the PREDICT algorithm (version 2) using real-world outcomes from the Scottish population of women with breast cancer.Methods: Patient data were obtained for all Scottish Cancer Registry (SCR) records with a diagnosis of primary invasive breast cancer diagnosed in the period between January 2001 and December 2015. Prognostic scores were calculated using the PREDICT version 2 algorithm. External validity was assessed by statistical analysis of discrimination and calibration. Discrimination was assessed by area under the receiver-operator curve (AUC). Calibration was assessed by comparing the predicted number of deaths to the observed number of deaths across relevant sub-groups.Results: A total of 45,789 eligible cases were selected from 61,437 individual records. AUC statistics ranged from 0.74 to 0.77. Calibration results showed relatively close agreement between predicted and observed deaths. The 5-year complete follow-up sample reported some overestimation (11.5%), while the 10-year complete follow-up sample displayed more limited overestimation (1.7%).Conclusions: Validation results suggest that the PREDICT tool remains essentially relevant for contemporary patients with early stage breast cancer. [ABSTRACT FROM AUTHOR]

Background/objectives: Advances in cancer management have resulted in improved survival rates, particularly in children and young adults. However, treatment may adversely affect reproductive outcomes among female cancer survivors. The objective of this study was to investigate their risk of adverse perinatal outcomes compared to the general population. Design/methods: We performed a population-based analysis, including all female cancer survivors diagnosed before the age of 40 years between 1981 and 2012. Pregnancy and perinatal complications were identified through linkage of the Scottish Cancer Registry with hospital discharge records based on the Community Health Index (CHI) database. We compared 1,629 female cancer survivors with a first ever singleton pregnancy after diagnosis, with controls matched on age, deprivation quintile, and year of cancer diagnosis selected from the general population (n = 8,899). Relative risks and 95%-confidence intervals of perinatal risks were calculated using log-binomial regression. Results: Survivors were more likely to give birth before 37 weeks of gestation (relative risk (RR]) 1.32, 95%-CI 1.10–1.59), but did not show an increased risk of low birth weight (<2.5kg: RR 1.15, 95%-CI 0.94–1.39), and were less likely to give birth to offspring small for gestational age (RR 0.81, 95%-CI 0.68–0.98). Operative delivery and postpartum haemorrhage were more common but approached rates in controls with more recent diagnosis. The risk of congenital abnormalities was not increased (RR 1.01, 95%-CI 0.85–1.20). Conclusion: Cancer survivors have an increased risk of premature delivery and postpartum haemorrhage, but their offspring are not at increased risk for low birth weight or congenital abnormalities. In recent decades there has been a normalisation of delivery method in cancer survivors, nevertheless careful management remains appropriate particularly for those diagnosed in childhood. [ABSTRACT FROM AUTHOR]

Background: Those living in rural areas have poorer cancer outcomes, but current evidence on how rurality impacts melanoma care and survival is contradictory.Aim: To investigate the impact of rurality on setting of melanoma excision and mortality in a whole-nation cohort.Design and Setting: Analysis of linked routine healthcare data comprising every individual in Scotland diagnosed with melanoma, January 2005-December 2013, in primary and secondary care.Method: Multivariate binary logistic regression was used to explore the relationship between rurality and setting of melanoma excision; Cox proportional hazards regression between rurality and mortality was used, with adjustments for key confounders.Results: In total 9519 patients were included (54.3% [n = 5167] female, mean age 60.2 years [SD 17.5]). Of melanomas where setting of excision was known, 90.3% (n = 8598) were in secondary care and 8.1% (n = 771) in primary care. Odds of primary care excision increased with increasing rurality/remoteness. Compared with those in urban areas, those in the most remote rural locations had almost twice the odds of melanoma excision in primary care (adjusted odds ratio [aOR] 1.92; 95% confidence interval [CI] = 1.33 to 2.77). No significant association was found between urban or rural residency and all-cause mortality. Melanoma-specific mortality was significantly lower in individuals residing in accessible small towns than in large urban areas (adjusted hazards ratio [HR] 0.53; 95% CI = 0.33 to 0.87) with no trend towards poorer survival with increasing rurality.Conclusion: Patients in Scottish rural locations were more likely to have a melanoma excised in primary care. However, those in rural areas did not have significantly increased mortality from melanoma. Together these findings suggest that current UK melanoma management guidelines could be revised to be more realistic by recognising the role of primary care in the prompt diagnosis and treatment of those in rural locations. [ABSTRACT FROM AUTHOR]

Study Question: What is the impact of cancer in females aged ≤39 years on subsequent chance of pregnancy?Summary Answer: Cancer survivors achieved fewer pregnancies across all cancer types, and the chance of achieving a first pregnancy was also lower.What Is Known Already: The diagnosis and treatment of cancer in young females may be associated with reduced fertility but the true pregnancy deficit in a population is unknown.Study Design, Size, Duration: We performed a retrospective cohort study relating first incident cancer diagnosed between 1981 and 2012 to subsequent pregnancy in all female patients in Scotland aged 39 years or less at cancer diagnosis (n = 23 201). Pregnancies were included up to end of 2014. Females from the exposed group not pregnant before cancer diagnosis (n = 10 271) were compared with general population controls matched for age, deprivation quintile and year of diagnosis.Participants/materials, Setting, Methods: Scottish Cancer Registry records were linked to hospital discharge records to calculate standardized incidence ratios (SIR) for pregnancy, standardized for age and year of diagnosis. Linkage to death records was also performed. We also selected women from the exposed group who had not been pregnant prior to their cancer diagnosis who were compared with a matched control group from the general population. Additional analyses were performed for breast cancer, Hodgkin lymphoma, leukaemia, cervical cancer and brain/CNS cancers.Main Results and the Role Of Chance: Cancer survivors achieved fewer pregnancies: SIR 0.62 (95% CI: 0.60, 0.63). Reduced SIR was observed for all cancer types. The chance of achieving a first pregnancy was also lower, adjusted hazard ratio = 0.57 (95% CI: 0.53, 0.61) for women >5 years after diagnosis, with marked reductions in women with breast, cervical and brain/CNS tumours, and leukaemia. The effect was reduced with more recent treatment period overall and in cervical cancer, breast cancer and Hodgkin lymphoma, but was unchanged for leukaemia or brain/CNS cancers. The proportion of pregnancies that ended in termination was lower after a cancer diagnosis, and the proportion ending in live birth was higher (78.7 vs 75.6%, CI of difference: 1.1, 5.0).Limitations, Reasons For Caution: Details of treatments received were not available, so the impact of specific treatment regimens on fertility could not be assessed. Limited duration of follow-up was available for women diagnosed in the most recent time period.Wider Implications Of the Findings: This analysis provides population-based quantification by cancer type of the effect of cancer and its treatment on subsequent pregnancy across the reproductive age range, and how this has changed in recent decades. The demonstration of a reduced chance of pregnancy across all cancer types and the changing impact in some but not other common cancers highlights the need for appropriate fertility counselling of all females of reproductive age at diagnosis.Study Funding/competing Interest(s): This study was funded by NHS Lothian Cancer and Leukaemia Endowments Fund. Part of this work was undertaken in the MRC Centre for Reproductive Health which is funded by the MRC Centre grant MR/N022556/1. RAA has participated in Advisory Boards and/or received speaker's fees from Beckman Coulter, IBSA, Merck and Roche Diagnostics. He has received research support from Roche Diagnostics, Ansh labs and Ferring. The other authors have no conflicts to declare. [ABSTRACT FROM AUTHOR]

Introduction: The International Cancer Benchmarking Partnership (ICBP) identified significant international differences in lung cancer survival. Differing levels of comorbid disease across ICBP countries has been suggested as a potential explanation of this variation but, to date, no studies have quantified its impact. This study investigated whether comparable, robust comorbidity scores can be derived from the different routine population-based cancer data sets available in the ICBP jurisdictions and, if so, use them to quantify international variation in comorbidity and determine its influence on outcome.Methods: Linked population-based lung cancer registry and hospital discharge data sets were acquired from nine ICBP jurisdictions in Australia, Canada, Norway and the UK providing a study population of 233 981 individuals. For each person in this cohort Charlson, Elixhauser and inpatient bed day Comorbidity Scores were derived relating to the 4-36 months prior to their lung cancer diagnosis. The scores were then compared to assess their validity and feasibility of use in international survival comparisons.Results: It was feasible to generate the three comorbidity scores for each jurisdiction, which were found to have good content, face and concurrent validity. Predictive validity was limited and there was evidence that the reliability was questionable.Conclusion: The results presented here indicate that interjurisdictional comparability of recorded comorbidity was limited due to probable differences in coding and hospital admission practices in each area. Before the contribution of comorbidity on international differences in cancer survival can be investigated an internationally harmonised comorbidity index is required. [ABSTRACT FROM AUTHOR]