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Objective: Patients with comorbidities can be referred to a physician-led high-risk clinic for medical optimisation prior to elective surgery at the discretion of the surgical consultant, but the factors that influence this referral are not well understood. The aims of this study were to understand the factors that influence a surgeon's decision to refer a patient to the clinic, and how the clinic impacts on the management of complex patients., Design: Qualitative study using theoretical thematic analysis to analyse transcribed semi-structured interviews., Setting: Interviews were held in either the surgical consultant's private office or a quiet office/room in the hospital ward., Participants: Seven surgical consultants who were eligible to refer patients to the clinic., Results: When discussing the factors that influence a referral to the clinic, all participants initially described the optimisation of comorbidities and would then discuss with examples the challenges with managing complex patients and communicating the risks involved with having surgery. When discussing the role of the clinic, two related subthemes were dominant and focused on the management of risk in complex patients. The participants valued the involvement of the clinic in the decision-making and communication of risks to the patient., Conclusions: The integration of the high-risk clinic in this study appears to offer additional value in supporting the decision-making process for the surgical team and patient beyond the clinical outcomes. The factors that influence a surgeon's decision to refer a patient to the clinic appear to be driven by the aim to manage the uncertainty and risk to the patient regarding surgery and it was seen as a strategy for managing difficult and complex cases., Competing Interests: Competing interests: Dr Catherine Gibb is a consultant physician in the High Risk Clinic at the Royal Adelaide Hospital and Queen Elizabeth Hospital. The remaining authors declare no conflict of interest., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Clinics have been established to provide preoperative medical consultations, and enable the anaesthetist and surgeon to deliver the best surgical outcome for patients. However, there is uncertainty regarding the effect of such clinics on surgical, in-hospital and long-term outcomes. A systematic review of the literature was conducted to determine the effectiveness of preoperative medical consultations by internal medicine physicians for patients listed for elective surgery., Design: Systematic searches of MEDLINE, EMBASE, CINAHL, PubMed, Current Contents and the NHS Centre for Reviews and Dissemination were conducted up to 30 April 2017., Setting: Elective surgery., Study Selection: Randomised controlled trials and non-randomised comparative studies conducted in adults., Outcome Measures: Length of hospital stay, perioperative morbidity and mortality, costs and quality of life., Results: The one randomised trial reported that preadmission preoperative assessment was more effective than the option of an inpatient medical assessment in reducing the frequency of unnecessary admissions with significantly fewer surgical cancellations following admission for surgery. A small reduction in length of stay in patients was also observed. The three non-randomised studies reported increased lengths of stay, costs and postoperative complications in patients who received preoperative assessment. The timing and delivery of the preoperative medical consultation in the intervention group differed across the included studies., Conclusion: Further research is required to inform the design and implementation of coordinated involvement of physicians and surgeons in the provision of care for high-risk surgical patients. A standardised approach to perioperative decision-making processes should be developed with a clear protocol or guideline for the assessment and management of surgical patients., Competing Interests: Competing interests: CLG is a consultant physician in the High Risk Clinic at the Royal Adelaide Hospital and Queen Elizabeth Hospital. The remaining authors declare no conflict of interest., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Rationale, Aims and Objectives: A physician-led clinic for the preoperative optimization and management of high-risk surgical patients was implemented in a South Australian public hospital in 2008. This study aimed to estimate the costs and effects of the clinic using a mixed retrospective and prospective observational study design., Method: Alternative propensity score estimation methods were applied to retrospective routinely collected administrative and clinical data, using weighted and matched cohorts. Supplementary survey-based prospective data were collected to inform the analysis of the retrospective data and reduce potential unmeasured confounding., Results: Using weighted cohorts, clinic patients had a significantly longer mean length of stay and higher mean cost. With the matched cohorts, reducing the calliper width resulted in a shorter mean length of stay in the clinic group, but the costs remained significantly higher. The prospective data indicated potential unmeasured confounding in all analyses other than in the most tightly matched cohorts., Conclusions: The application of alternative propensity-based approaches to a large sample of retrospective data, supplemented with a smaller sample of prospective data, informed a pragmatic approach to reducing potential observed and unmeasured confounding in an evaluation of a physician-led preoperative clinic. The need to generate tightly matched cohorts to reduce the potential for unmeasured confounding indicates that significant uncertainty remains around the effects of the clinic. This study illustrates the value of mixed retrospective and prospective observational study designs but also underlines the need to prospectively plan for the evaluation of costs and effects alongside the implementation of significant service innovations., (© 2016 John Wiley & Sons, Ltd.)

An efficient, four-step synthesis of a range of water-soluble, deep-cavity cavitands is presented. Key to this approach are octahalide derivatives (4, X = Cl or Br) that allow a range of water-solubilizing groups to be added to the outer surface of the core host structure. In many cases, the conversion of the starting dodecol (1) resorcinarene to the different cavitands avoids any chromatographic procedures.

Isothermal titration calorimetry was used to probe how salts influence the thermodynamics of binding of guests to cavitand 1. Studies involved six Hofmeister salts covering the range of salting-in to strongly salting-out. The latter were found to reduce affinity. The cause of this was competitive binding of the weakly solvated anion to the hydrophobic pocket of the host. At the other extreme of the Hofmeister series, salts increased guest affinity. Two factors for this were evident. At low concentrations the data fitted a previously reported model that accounts for cation condensation to the outer carboxylates of the host (Carnagie, R.; Gibb, C. L. D.; Gibb, B. C., Angew. Chem., Int. Ed. 2014, 53 (43), 11498-11500). At higher concentrations, an as of yet unidentified contribution was observed that was noted to be guest dependent. Midcontinuum salts such as NaClO3 were found to enhance affinity at low concentrations, but weaken it at high concentrations; a nonmonotonic trend attributed to the aforementioned competing phenomena. In combination with previous work, the data presented here reveal that the Hofmeister effect evident in this system can be mostly attributed to solute-salt interactions.