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Background: Neurally adjusted ventilatory assist (NAVA) is a mode of mechanical ventilation that delivers oxygen pressures in proportion to electrical signals of the diaphragm. The proportional assistance can be adjusted by the clinician to reduce the patient's work of breathing. Several case series of infants with congenital diaphragmatic hernias (CDH) have shown that NAVA may reduce oxygenation index and mean airway pressures. To date, no clinical trial has compared NAVA to standard methods of mechanical ventilation for babies with CDH., Methods: The aim of this dual-centre randomised cross-over trial is to compare post-operative NAVA with assist control ventilation (ACV) for infants with CDH. If eligible, infants will be enrolled for a ventilatory support tolerance trial (VSTT) to assess their suitability for randomisation. If clinically stable during the VSTT, infants will be randomised to receive either NAVA or ACV first in a 1:1 ratio for a 4-h period. The oxygenation index, respiratory severity score and cumulative sedative medication use will be measured., Discussion: Retrospective studies comparing NAVA to ACV in neonates with congenital diaphragmatic hernia have shown the ventilatory mode may improve respiratory parameters and benefit neonates. To our knowledge, this is the first prospective cross-over trial comparing NAVA to ACV., Trial Registration: NAN-C was prospectively registered on ClinicalTrials.gov NCT05839340  Registered on May 2023., (© 2024. The Author(s).)

Objectives: The aim of this study was to compare outcomes of major lower limb amputation (MLA) in patients with and without cancer and with cancer patients receiving palliation over amputation for their unsalvageable limb., Methods: Cancer patients who underwent a major amputation or palliation between 2013 and 2018 were included. Comparison groups were cancer-MLA (active/managed cancers), non-cancer MLA (historic cancer or no cancer history) and cancer-palliation at presentation with unsalvageable limbs. Prospectively collected data was retrospectively analysed for outcomes including survival, postoperative complications, length of stay, suitability for rehabilitation and discharge destination., Results: 262 (cancer and non-cancer) patients underwent MLA and 18 patients with cancer received palliation. Of those amputated, 26 (9.9%) had active or managed cancer, of which 12 were diagnosed in the 6 months before MLA. Cancer-MLA patients presented with more acute ischaemia compared to non-cancer patients. Median survival was significantly different between the cancer-MLA (14.1 [9.5 - 29.5, 95% CI] months), non-cancer MLA (57.7 [45 - 73.6, 95% CI] months) and cancer-palliation (.6 [.4 - 2.3, 95% CI] months) groups, P < .001. A significantly higher proportion of cancer-MLA patients (10/26, 38.5%) were deemed unsuitable for rehabilitation in post-operative assessment compared to non-cancer MLA (21/236, 8.9%) patients, P < .001. There was a variation in destinations of discharge, with a greater proportion of cancer-MLA patients (4/26, 15.4%) going to a nursing home compared to non-cancer MLA (10/236, 4.2%) patients, P = .016., Conclusion: Cancer is prevalent among vascular amputees, with a large proportion being occult diagnoses. Cancer is associated with poorer outcomes following amputation, but survival remains significantly better compared to palliation in cancer patients presenting with unsalvageable limbs.

There is an association between very low birth weight (VLBW) and cardiovascular morbidity and mortality in adulthood. Aerobic fitness, measured as the maximal oxygen consumption (VO 2 max), is a good indicator of cardiopulmonary health and predictor of cardiovascular mortality. Our aim was to determine the effect of birth weight on aerobic exercise capacity and physical activity. We systematically identified studies reporting exercise capacity (VO 2 max and VO 2 peak) and physical activity levels in participants born at VLBW aged eighteen years or older compared to term-born controls from six databases (MEDLINE, OVID, EMBASE, CI NAHL, CENTRAL, and Google Scholar). Meta-analysis of eligible studies was conducted using a random effect model. We screened 6202 articles and identified 15 relevant studies, 10 of which were eligible for meta-analysis. VLBW participants had a lower VO 2 max compared to their term counterparts (-3.35, 95% CI: -5.23 to -1.47, p = 0.0005), as did VLBW adults who had developed bronchopulmonary dysplasia (-6.08, 95% CI -11.26 to -0.90, p = 0.02). Five of nine studies reported significantly reduced self-reported physical activity levels. Our systematic review and meta-analysis demonstrated reduced maximal aerobic exercise capacity in adults born at VLBW compared to term-born controls., Competing Interests: The authors declare no conflict of interest.

Background: Days alive and out of hospital (DAOH) is a metric that incorporates several outcomes into a single, standardized measure. This study aimed to explore the utility of DAOH in assessing the outcomes of a retrospective cohort of patients undergoing laparoscopic cholecystectomy (LC)., Methods: Patients undergoing LC at Auckland City Hospital between 1 January 2010 and 31 August 2015 were included. DAOH values were calculated for the 90 days from the date of surgery (DAOH 90 ) and described using median and interquartile ranges (IQR). DAOH 90 distributions were compared using a two-tailed (non-parametric) Wilcoxon-Mann-Whitney test., Results: 1652 patients undergoing LC were studied. Patients experiencing complications (n = 70, 4.2%) had fewer DAOH 90 (median 83, IQR 79, 86) than patients who underwent uncomplicated LC (median 88, IQR 86, 88), P < 0.001. Patients who were converted to open cholecystectomy (n = 70, 4.2%) also had fewer DAOH 90 (median 82.5, IQR 79, 84) than patients who underwent uncomplicated LC, P < 0.001. Post-operative complications and conversion had a statistically significant effect on DAOH 90 at each of the tested quantiles, except for conversion at the 0.1 quantile., Conclusion: DAOH 90 is readily calculable from existing New Zealand administrative data sources and is sensitive to the occurrence of complications after LC., (© 2022 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Given negative publicity surrounding surgical mesh in the media, the aim of this study was to assess post-operative morbidity and quality of life (QoL) following laparoscopic inguinal hernia surgery with self-adhesive ProgripTM mesh., Methods: This study is a retrospective analysis of ProgripTM mesh for laparoscopic inguinal hernia repairs by two experienced surgeons in the public and private sectors. Data were collected by screening electronic clinical records. A sample of participants were contacted directly for QoL assessment using the Carolinas Comfort Scale (CCS). Descriptive statistical analysis was performed in Microsoft Excel., Results: Five hundred and fifty-two patients had 648 hernia repairs using ProgripTM mesh from 2013 to 2019. The rate of hernia recurrence was 0.2% (n = 1). The rate of reoperation was 0.5% (n = 3). There were no mesh explant procedures, no adhesion-related readmissions and no perioperative deaths. Haematoma was the most common post-operative complication, occurring in 3.1% of participants (n = 17). The CCS assessment had a response rate of 55.8%. A total of 93% of CCS questions were answered with no sensation of mesh, 92% with no pain and 98% with no movement limitation. No participants reported severe or disabling symptoms., Conclusion: In this cohort, laparoscopic inguinal hernia repair with ProgripTM has shown a low recurrence rate and excellent post-operative QoL. The QoL data shows that the public perception of mesh based on media reports of complications may not be relevant for this operation. The knowledge gained from this study reinforces the potential value of a national mesh registry such as those seen overseas., (© 2022 Royal Australasian College of Surgeons.)

Objectives: Newborns with congenital diaphragmatic hernia (CDH) can have complex respiratory problems which are worsened by ventilatory induced lung injury. Neurally adjusted ventilator assist (NAVA) is a potentially promising ventilation mode for this population, as it can result in improved patient-ventilator interactions and provision of adequate gas exchange at lower airway pressures., Content: A literature review was undertaken to provide an overview of NAVA and examine its role in the management of infants with CDH., Summary: NAVA in neonates has been used in CDH infants who were stable on ventilatory support or being weaned from mechanical ventilation and was associated with a reduction in the level of respiratory support., Outlook: There is, however, limited evidence regarding the efficacy of NAVA in infants with CDH, with only short-term benefits being investigated. A prospective, multicentre study with long term follow-up is required to appropriately assess NAVA in this population., (© 2022 the author(s), published by De Gruyter, Berlin/Boston.)

Clearly and usefully defining the Rules of Life has long been an attractive yet elusive prospect for biologists. Life persists because requirements for existence and successful transmission of hereditary information are met. These requirements are met through mechanisms adopted by organisms, which produce solutions to environmentally imposed constraints on life. Yet, constraints and their suites of potential solutions are typically context-specific, operating at specific levels of organization, or holons, and having cascading effects across multiple levels, or the holarchy. We explore the idea that the interaction of constraints, mechanisms, and requirements within and across levels of organization may produce rules of life that can be productively defined. Although we stop short of listing specific rules, we provide a conceptual framework within which progress towards identifying rules might be made., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Integrative and Comparative Biology.)

For patients with phenylketonuria (PKU), stringent dietary management is demanding and eating out may pose many challenges. Often, there is little awareness about special dietary requirements within the hospitality sector. This study’s aim was to investigate the experiences and behaviours of people with PKU and their caregivers when dining out. We also sought to identify common problems in order to improve their experiences when eating outside the home. Individuals with PKU or their caregivers residing in the UK were invited to complete a cross-sectional online survey that collected both qualitative and quantitative data about their experiences when eating out. Data were available from 254 questionnaire respondents (136 caregivers or patients with PKU < 18 years and 118 patients with PKU ≥ 18 years (n = 100) or their caregivers (n = 18)). Fifty-eight per cent dined out once per month or less (n = 147/254) and the biggest barrier to more frequent dining was ‘limited choice of suitable low-protein foods’ (90%, n = 184/204), followed by ‘no information about the protein content of foods’ (67%, n = 137/204). Sixty-nine per cent (n = 176/254) rated their dining experience as less than satisfactory. Respondents ranked restaurant employees’ knowledge of the PKU diet as very poor with an overall median rating of 1.6 (on a scale of 1 for extremely poor to 10 for extremely good). Forty-four per cent (n = 110/252) of respondents said that restaurants had refused to prepare alternative suitable foods; 44% (n = 110/252) were not allowed to eat their own prepared food in a restaurant, and 46% (n = 115/252) reported that restaurants had refused to cook special low-protein foods. Forty per cent (n = 101/254) of respondents felt anxious before entering restaurants. People with PKU commonly experienced discrimination in restaurants, with hospitality staff failing to support their dietary needs, frequently using allergy laws and concerns about cross-contamination as a reason not to provide suitable food options. It is important that restaurant staff receive training regarding low-protein diets, offer more low-protein options, provide protein analysis information on all menu items, and be more flexible in their approach to cooking low-protein foods supplied by the person with PKU. This may help people with PKU enjoy safe meals when dining out and socialising with others.