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Background: There has been much debate as to the importance of mechanical bowel preparation (MBP) and oral antibiotic agents (OAB) prior to elective colorectal surgery over the past two decades. Th...

Introduction Prior studies of telehealth report high levels of patient satisfaction, but within carefully selected clinical scenarios. The COVID‐19 pandemic led to telehealth replacing face‐to‐face care for many surgical consultations across a variety of situations. More evidence is needed regarding patient perceptions of telehealth in surgery, in particular, exploring barriers and facilitators associated with its sustained implementation beyond the pandemic. Methods Survey invitations were emailed to a convenience sample of surgical patients by their surgeon following a telehealth consultation during the COVID‐19 pandemic. Surgeons were recruited from a sample (n = 683) who completed a survey on telehealth (distributed via email to all Australian Fellows of the Royal Australasian College of Surgeons). Mixed methods analysis was performed of the patient survey data. Results A total of 1166 consultations were captured: 50% routine reviews, 17% initial appointments and 20% post‐operative reviews. Video‐link was used in 49% of consultations. The majority of patients (94%), were satisfied with the quality of their surgical telehealth consultation and 75% felt it delivered the same level of care as face‐to‐face encounters. Telehealth was convenient to use (96%) and led to cost savings for 60% of patients. When asked about future appointment preferences after the pandemic, 41% indicated they would prefer telehealth (24% video‐link and 17% telephone) over face‐to‐face appointments. There was a perception by patients that telehealth consultation fees should be less than face‐to‐face consultation fees. Conclusion Patient satisfaction with surgical telehealth consultations is high. Barriers to more widespread implementation include financial, clinical appropriateness, technical and confidentiality concerns., Patient perceptions of 1166 Australian surgical telehealth consultations during the COVID‐19 pandemic were captured by this survey. Patient satisfaction with telehealth was high with there is significant demand for its continuation. Barriers to more widespread implementation include financial, clinical appropriateness, technical and confidentiality concerns.

Background The COVID‐19 pandemic has led to the rapid and widespread adoption of telehealth. There is a need for more evidence regarding the appropriateness of telehealth, as well as greater understanding of barriers to its sustained use within surgery in Australia. Methods A survey weblink was sent via email to 5558 Australian Fellows of the Royal Australasian College of Surgeons in August 2020. A single reminder email followed this 2 weeks later. Mixed methods analysis was performed of the survey data. Results There were 683 (12.3%) complete responses. Telehealth (telephone or video‐link) consultations were undertaken by 638 (85%) respondents as a result of the pandemic, with 583 (85%) of these expressing a desire for continued access to telehealth. Seventy‐seven percent of respondents felt that a satisfactory level of care could be delivered via telehealth in half or more consultations. However, only 38% of respondents felt that quality of care was equivalent comparing telehealth and face‐to‐face consultations, with the inability to perform a clinical examination a frequent concern. The majority agreed that telehealth was appropriate for clinical meetings and arranging investigations (91% each), whereas only 22% and 17%, respectively, felt telehealth was an appropriate means to break bad news and manage conflict. Medicolegal, technical and financial concerns were raised as prominent barriers to the sustained use of telehealth. Conclusion Surgeons show good insight into the clinical appropriateness and limitations of telehealth. Medicolegal, technical and financial barriers need to be addressed in order to fully utilize the benefits of telehealth into the future., The COVID‐19 pandemic has brought the rapid and widespread introduction of Telehealth to surgery. These survey results suggest that many surgeons have utilized telehealth and wish to continue its use into the future. Clinical appropriateness, technical, medicolegal and financial issues need to be addressed for the sustained integration of telehealth into surgical care in Australia.

To compare SSI rates between the skin preparation agents: PI-Aq, povidone-iodine with alcohol (PI-Alc), and chlorhexidine with alcohol (C-Alc).Guidelines suggest that alcohol-containing chlorhexidine solutions are the gold standard for skin preparation before surgery. It remains difficult to determine whether it is the chlorhexidine component or the addition of alcohol that confers the most benefit.We conducted a multicenter, prospective, combined non-inferiority (PI-Alc vs C-Alc) and superiority (PI-Alc vs PI-Aq) randomized clinical trial. Participants were randomized 1:1:1 to receive either C-Alc, PI-Alc, or PI-Aq. The primary outcome was SSI rate as defined by the Centers for Disease Control. Secondary outcomes were complication rates, length of hospital stay, readmissions, and skin reactions.Between January 2015 and December 2018, 3213 patients were randomized (C-Alc: 1076, PI-Alc: 1075, and PI-Aq: 1062). Mean age of participants was 57% and 55% were female. SSI rates were: C-Alc 11.09%, PI-Alc 10.88%, and PI-Aq 12.56%. PI-Alc was found to be non-inferior to C-Alc (mean difference, -0.21%; 95% confidence interval, -2.85 to 2.44; P = 0.0009 non-inferiority), whereas PI-Alc was not superior to PI-Aq (mean difference, -1.68%; 95% confidence interval, -4.40 to 1.05; P = 0.2302). There were no differences seen in secondary outcomes between groups and no treatment related adverse events or deaths occurred.PI-Alc is non-inferior to C-Alc and not superior to PI-Aq. This is at odds with current guidelines that suggest alcohol-based chlorhexidine solutions should routinely be used for surgical skin preparation.Australia and New Zealand Clinical Trials Registry: ANZCTRN12615000021571. www.anzctr.org.au.

Natural Killer (NK) cells are a vital part of immune surveillance and have been implicated in colorectal cancer development and prognosis. This systematic review aims to distil the literature on NK cells as it relates to colorectal cancer. All published studies over 10 years relating to NK cells and colorectal cancer were reviewed. All studies publishing in English, searchable via pubmed or through reference review and reporting directly on the nature or function of NK cells in colorectal cancer patients were included. Outcomes were determined as alterations or new information regarding NK cells in colorectal cancer patients. Natural killer cells may be implicated in the development of colorectal cancer and may play a role in prognostication of the disease. NK cells are altered by the treatment (both surgical and medical) of colorectal cancer and it seems likely that they will also be a target for manipulation to improve colorectal cancer survival. NK cell morphology and function are significantly affected by the development of colorectal cancer. Observation of NK cell changes may lead to earlier detection and better prognostication in colorectal cancer. Further study is needed into immunological manipulation of NK cells which may lead to improved colorectal cancer survival.

Background Colorectal cancer is the third most common cancer worldwide. Almost half of those that have a potentially curative resection go on to develop metastatic disease. A recognized risk for recurrence is perioperative systemic inflammation and sepsis. Neutrophil extracellular traps have been implicated as promotors of tumor progression. We aimed to examine the evidence in the literature for an association between neutrophil extracellular traps and postoperative metastasis in colorectal cancer. Materials and methods Studies published between 2000 and December 2018 that examined the role of neutrophil extracellular traps in sepsis and inflammation in colorectal cancer and in relation to tumor-related outcomes were identified through a database search of Cochrane, CINAHL, and MEDLINE. Quality and bias assessment was carried out by 2 reviewers. Results Of 8,940 screened and of the 30 studies included, 21 were observational, 5 were in vivo experimental, 1 was in vitro, and 3 used a combination of these approaches. Conclusion There is clear evidence from the literature that presence of a preoperative systemic inflammatory response predicts cancer recurrence following potentially curative resection, but the evidence for association of sepsis and progression is lacking. There is robust experimental evidence in murine models showing that neutrophil extracellular traps are present in sepsis and are associated with cancer progression. Some human observational studies corroborate the prognostic significance of neutrophil extracellular traps in progression of colorectal cancer. Further human studies are needed to translate the experimental evidence and to definitively associate sepsis and neutrophil extracellular traps with poor colorectal cancer-specific outcomes.

BackgroundInfant mortality remains high and unevenly distributed in much of sub-Saharan Africa. Though cheap and effective interventions can in principle prevent many of these deaths, given a finite budget for supplying such interventions in many countries, their life-saving benefit is critically constrained by the ability to target them to those individuals who would have otherwise have likely died. While countries routinely use poverty- or wealth-based thresholds to target policies and interventions including those related to maternal health and early mortality, we examine whether models that consider other easy-to-measure and factors can substantially improve our ability to identify higher-risk births, and consequently the potential for life-saving intervention.MethodsUsing up to 25 variables from the demographic health survey for 22 sub-Saharan African countries, we employ established machine learning methods to estimate per-child risk of infant mortality, separately in each country. We use out-of-sample testing methods to provide an honest assessment of how useful these methods are for identifying high risk births. We also compare this to a benchmark similar to standard practice, in which only (within-country) measures of wealth can be used for targeting.ResultsTargeting based on wealth alone is only slightly better than random targeting: the poorest 10 percent of the population experiencing approximately 10 percent of total infant mortality burden. By contrast the 10 percent of the population at highest risk according to our model account for 15-30 percent of infants deaths, depending on country. In other words, for a hypothetical intervention with some fixed effectiveness and that can be administered to only a chosen 10 percent of the population, such a targeting approach would save 1.5-3 times as many lives as one based on wealth alone.InterpretationIn the 22 sub-Saharan African countries studied, approaches that use commonly available types of data to flexibly predict high-risk births has the potential to substantially improve the targeting and thus maximum potential effectiveness of life-saving interventions against early mortality.Research in ContextEvidence before the studyIn many low-income countries, interventions that aim to reduce infant mortality cannot be made universally available. While low-cost medical interventions are available to avoid many of the most common causes of death, these interventions can only save lives if they are targeted to individuals who would have otherwise died. Currently, most national programs and policies aiming to reduce infant mortality employ only poverty-related assessments to target those programs. Large gains in the effective targeting of such programs, and thus their life-saving potential, may be possible if risk can be assessed using more flexible statistical models that draw on a variety of easy-to-collect data, but existing models have not. Surprisingly, few prior studies have combined multiple risk factors to estimate early-life mortality risk in the general population. 1,2,3 None of these employ flexible (machine learning) models, or compare the results to a traditional poverty-or wealth-based targeting benchmark.Added value of this studyWorking with publicly available data from 22 countries in sub-Saharan Africa, we first show that targeting early mortality interventions based only on income assessments cannot do much better than random distribution in most countries. We then employ established machine learning methods to show how using a range of generally available data prior to each birth, a risk score can be computed for each birth that is more predictive of early mortality. Targeting the highest risk decile of births, for example, can capture only about 10% of deaths using income alone, but 15-30% (depending on the country) with our more inclusive model.Implications of all available evidenceWe conclude that it is feasible, using standard machine learning methods and data similarly to what is routinely collected, to greatly improve upon income-based targeting schemes for interventions seeking to minimize early mortality. In the cases studied, these could greatly improve the targeting and consequently the life-saving potential of these interventions.

AIM Postoperative pain remains a major factor in recovery from colorectal resection. There is increasing interest in opioid-sparing analgesia, and intraperitoneal local anaesthetic (IPLA) has recently been shown to be useful in minor laparoscopic and open colorectal procedures. The aim of this study was to evaluate the impact of IPLA on functional recovery following major laparoscopic surgery. In this controlled trial, mobility, as measured by the De Morton Mobility Index (DEMMI), was used as a surrogate for postoperative functional recovery. METHOD Patients undergoing laparoscopic colorectal resection were randomized either to continuous ropivacaine (0.2% at 4-6 ml/h) or to saline (0.9%) which were administered via intraperitoneal catheter for 3 days postoperatively. Results were analysed in a double-blind manner. DEMMIs were assessed on postoperative days 1, 2, 3, 7 and 30, and data on pain, opioid consumption, gut and respiratory function, length of stay (LOS) and complications were recorded. RESULTS Ninety-six patients were recruited. There was no difference in primary outcome (i.e., functional recovery) between IPLA and placebo groups. Opioid consumption and LOS were similar between groups, and no differences were found for any secondary outcome measure. There were no adverse events related to ropivacaine. CONCLUSION Infusional intraperitoneal local anaesthetic appears to be safe but does not improve functional recovery or analgesic consumption following elective laparoscopic colorectal surgery, in the setting of an established enhanced recovery programme.

A novel vacuum-packing system is developed for food waste storage and collection under the conditions found in high-density urban and metropolitan catering establishments that has the following beneficial outcomes: (a) a reduction of 38% in the volume of food waste to be stored for collection; (b) a reduction in the physical space required on-site for storage of multiple vacuum packs of waste; (c) containment of the food waste stored in sanitised conditions, thus maintaining the integrity of the waste and extending the useful life of the waste in terms of its ideal composition for optimum beneficial recovery by anaerobic digestion or in-vessel composting, and reducing problems due to odour and vermin; and (d) reduction in the number of vehicle movements required to transfer the wastes to treatment facilities and their environmental impacts, while also achieving savings of £13–16 per bin lift in London, along with a considerable reduction in overall cost.

We describe a novel single-incision laparoscopy right hemicolectomy technique using a single-dermatomal, muscle-splitting approach through a 4-cm incision located between the right anterior superior iliac spine and pubic tubercle. This new technique may be superior to traditional single-incision laparoscopy colectomy with the potential benefits of less post-operative pain, lower opioid requirements, lower risk of incisional hernia and better cosmesis but requires further validation.

Anaerobic digestion (AD) is a long-established method for treating wastewater sludge and has been extensively researched, but there remains a lack of generic or practical modelling tools to guide operators and maximise the energy output. Detailed kinetic models have been developed, but are too complex as practical tools for industrial level application. A multi-level model of biogas yield (BY) was therefore developed based on operational data from 72 full-scale sites in the UK showing a wide range of AD performance. The model focused on the controllable operational parameters that are currently monitored at full-scale, including: temperature, hydraulic retention time and dry solids content in the feed sludge. The model effectively described performance variations in BY of full-scale processes, and provides a practical management tool to aid decision support to improve AD efficiency and net energy balance.

We are building a transition edge sensor (TES) X-ray spectrometer for the Linac Coherent Light Source (LCLS-II) at SLAC National Accelerator Laboratory (SLAC) to coincide with new upgrades for this free electron laser facility. This new X-ray spectrometer will have 1000 TES pixels with 0.5 eV energy resolution for soft X-rays below 1 keV. Multiplexing will be done with microwave SQUID resonators and new specialized electronic hardware developed at SLAC. This spectrometer will use a dilution refrigerator to achieve lower operating temperatures than previous TES spectrometers and will be coupled to the liquid jet endstation at LCLS-II. The spectrometer is designed to operate at much higher count rates than previous TES X-ray spectrometers to take advantage of the high repetition rate of the LCLS-II. Science applications will utilize the high photon collection efficiency and throughput, high energy resolution, as well as its ability to simultaneously measure its full calibrated energy range.

Wastewater treatment and generated biological sludge provide an alternative source of enzymes to conventional industrial production methods. Here, we present a protocol for extracting enzymes from activated sludge using ultrasonication and surfactant treatment. Under optimum conditions, ultrasound disruption of activated sludge gave recovery rates of protease and cellulase enzymes equivalent to 63.1% and ∼100%, respectively. The extracting of enzymes from activated sludge represents a potentially significant, high-value, resource recovery option for biological sludge generated by municipal wastewater treatment.

BACKGROUND Opioid over-prescription following surgery is a significant public health issue in most developed countries. Multiple studies have been conducted in the USA demonstrating and investigating the issue; however, there is a lack of literature addressing this topic in the Australian setting. The aim of this study is to review prescribing practices at an Australian tertiary referral hospital on discharge in patients having undergone laparoscopic cholecystectomy (LC) or laparoscopic appendicetomy (LA). Additionally, to identify potential factors which influence medical officer prescribing practices. METHODS A retrospective observational study on opioid prescribing practice on all patients who underwent LC or LA over a 12-month period at an Australian tertiary referral hospital. RESULTS A total of 435 patients (223 LC, 214 LA) were prescribed a mean opioid dose on discharge of 25 oral morphine milli-equivalents (range 0-180 morphine milli-equivalents). Less opioids were prescribed following elective procedures (42% versus 10%, P

Large arrays of cryogenic sensors for various imaging applications ranging across x-ray, gamma-ray, Cosmic Microwave Background (CMB), mm/sub-mm, as well as particle detection increasingly rely on superconducting microresonators for high multiplexing factors. These microresonators take the form of microwave SQUIDs that couple to Transition-Edge Sensors (TES) or Microwave Kinetic Inductance Detectors (MKIDs). In principle, such arrays can be read out with vastly scalable software-defined radio using suitable FPGAs, ADCs and DACs. In this work, we share plans and show initial results for SLAC Microresonator Radio Frequency (SMuRF) electronics, a next-generation control and readout system for superconducting microresonators. SMuRF electronics are unique in their implementation of specialized algorithms for closed-loop tone tracking, which consists of fast feedback and feedforward to each resonator's excitation parameters based on transmission measurements. Closed-loop tone tracking enables improved system linearity, a significant increase in sensor count per readout line, and the possibility of overcoupled resonator designs for enhanced dynamic range. Low-bandwidth prototype electronics were used to demonstrate closed-loop tone tracking on twelve 300-kHz-wide microwave SQUID resonators, spaced at $\sim$6 MHz with center frequencies $\sim$5-6 GHz. We achieve multi-kHz tracking bandwidth and demonstrate that the noise floor of the electronics is subdominant to the noise intrinsic in the multiplexer., 7 pages, 5 figures, Submitted to the Journal of Low Temperature Physics (Proceedings of the 17th International Workshop on Low Temperature Detectors)

BACKGROUND Post-operative length of stay (LOS) is an increasingly important clinical indicator in general surgery. Despite this, no tool has been validated to predict LOS or readiness for discharge in general surgical patients. The de Morton Mobility Index (DEMMI) is a functional mobility assessment tool that has been validated in rehabilitation patient populations. In this prospective cohort study, we aimed to identify if trends in DEMMI scores were associated with discharge within 1 week and overall LOS in general surgical patients. METHODS A total of 161 patients who underwent elective gastrointestinal resections were included. DEMMI scores were performed preoperatively, on days 1, 2, 3 and 30 post-operative. Statistical analysis was performed to identify any association between DEMMI scores and discharge within 1 week and LOS. RESULTS Functional recovery (measured by achieving 80% of baseline DEMMI score by post-operative day 1) was significantly associated with discharge within 1 week. Presence of a stoma was associated with longer LOS. The area under the receiver operating characteristic curve using functional recovery on post-operative day 1 as a predictor of discharge within 1 week is 0.772. CONCLUSION The DEMMI score is a fast, easy and useful tool to, on post-operative day 1, predict discharge within 1 week. The utility of this is to act as an anticipatory trigger for more proactive and efficient discharge planning in the early post-operative period, and there is potential to use the DEMMI as a comparator in clinical trials to assess functional recovery.

This article presents the evidence base for ‘operator models’ – that is, how to deliver a sustainable service through the interaction of the ‘client’, ‘revenue collector’ and ‘operator’ functions – for municipal solid waste management in emerging and developing countries. The companion article addresses a selection of locally appropriate operator models. The evidence shows that no ‘standard’ operator model is effective in all developing countries and circumstances. Each city uses a mix of different operator models; 134 cases showed on average 2.5 models per city, each applying to different elements of municipal solid waste management – that is, street sweeping, primary collection, secondary collection, transfer, recycling, resource recovery and disposal or a combination. Operator models were analysed in detail for 28 case studies; the article summarises evidence across all elements and in more detail for waste collection. Operators fall into three main groups: The public sector, formal private sector, and micro-service providers including micro-, community-based and informal enterprises. Micro-service providers emerge as a common group; they are effective in expanding primary collection service coverage into poor- or peri-urban neighbourhoods and in delivering recycling. Both public and private sector operators can deliver effective services in the appropriate situation; what matters more is a strong client organisation responsible for municipal solid waste management within the municipality, with stable political and financial backing and capacity to manage service delivery. Revenue collection is also integral to operator models: Generally the municipality pays the operator from direct charges and/or indirect taxes, rather than the operator collecting fees directly from the service user.

BACKGROUND The presence of an indwelling urinary catheter (IDUC) is routine following colorectal resections. In Enhanced Recovery After Surgery programmes, excessive intravenous fluids (IVFs) are avoided. This study sought to determine whether the routine absence of an IDUC following colorectal surgery improved post-operative outcomes and minimized fluid prescription. METHODS A retrospective comparative cohort study was performed on patients undergoing colorectal resection at a tertiary referral teaching hospital, over a 7-year period. A policy of no routine IDUC was introduced over the last 3 years. Patients were divided into cohorts based on the presence or absence of an IDUC on leaving the operating theatre. The outcomes assessed were IVF prescription, length of stay, mortality and morbidity. RESULTS Of the 213 resections over the time period, 131 met the inclusion criteria (87 IDUC and 44 no IDUC). There was no difference between groups with respect to baseline demographics. Fluid administration was less in the group without routine IDUC (total fluid 6.16 L versus 10.89 L; P

Background Anastomotic leakage is a feared complication following colorectal surgery. Early prediction results in improved clinical outcome, but accurate predictive factors remain elusive. Many biomarkers have been studied with respect to diagnosis of anastomotic leakage but the concept of trajectory testing, using biomarkers, has not been assessed with regards to early diagnosis of anastomotic leak. Methods C-reactive protein (CRP), procalcitonin (PCT), white cell count (WCC) and gamma-glutamyl transferase were assessed for predictive utility in diagnosing anastomotic leakage with emphasis on identifying an association with change in their levels or trajectory. Levels were collected preoperatively and daily for the first 5 post-operative days on patients undergoing elective colorectal surgery, involving an anastomosis. Anastomotic leakage was defined clinically by operative or radiological intervention. Comparison was made between biomarkers and clinical anastomotic leakage, using receiver operator characteristic curves for logistic models, based on trajectory of the four biomarkers. Results A total of 197 consecutive patients were analysed. Eleven patients developed clinical anastomotic leakage. An association of biomarker trajectory with anastomotic leakage was observed for WCC, PCT and CRP, but not for gamma-glutamyl transferase. CRP was the superior biomarker based on trajectory, with area under the receiver operator curve of 0.961. Conclusion This study identifies change in CRP, WCC and PCT as potential markers of anastomotic leakage following colorectal surgery and in particular highlights CRP trajectory as extremely accurate in diagnosing anastomotic leakage requiring intervention. External validation should be sought before incorporating this into routine clinical practice, given the numbers in this study.

Background Anastomotic leak rates have not improved over several decades despite improvements in surgical techniques and patient care. The gut microbiome has been implicated in the development of leaks. The exact mechanisms by which tissue oxygenation affects gut microbial composition and anastomotic healing physiology are unclear. Also, commonly used carbon dioxide (CO2) is a known vasodilator that improves tissue oxygen tension. We performed a systematic review to determine the influence of hyperoxia, hypoxia, and hypercapnia on the gut microbiome and anastomotic healing. Methods A literature search was performed in MEDLINE, EMBASE, and COCHRANE to identify studies investigating the effects of hyperoxia, hypoxia, and hypercapnia on anastomotic healing and gut microbiota published between 1998 and 2018. Two reviewers screened the articles for eligibility and quality. Fifty-three articles underwent full text review, and a narrative synthesis was undertaken. Results Hyperoxia is associated with better anastomotic healing, increased gastrointestinal oxygen tension, and may reduce gut anaerobes. Hypoxia is associated with poor healing and increased gut anaerobes. However, it is unclear if hypoxia is the most important predictor of anastomotic leaks. Low pressure CO2 pneumoperitoneum and mild systemic hypercapnia are both associated with increased gastrointestinal oxygen tension and may improve anastomotic healing. We found no studies which investigated the effect of hypercapnia on gut microbiota in the context of anastomotic healing. Conclusions Tissue oxygenation influences gut anastomotic healing, but little evidence exists to demonstrate the influence on the gut microbiome in the context of healing. Further studies are needed to determine if anastomotic microbiome changes with altered tissue oxygenation and if this affects healing and leak rates. If confirmed, altering tissue oxygenation through hyperoxia or hypercapnia could be feasible means of altering the microbiome such that anastomotic leak rates reduce.

Background: Colorectal cancer (CRC) is the third most common cancer worldwide. Almost half of those that have a potentially curative resection go on to develop metastatic disease. A recognised risk for recurrence is perioperative systemic inflammation and sepsis. Neutrophil extracellular traps (NETs) have been implicated as promotors of tumour progression. We aimed to examine the evidence in the literature for an association between NETs and postoperative metastasis in CRC. Materials and Methods: Studies published between 2000 and December 2018 that examined the role of NETs in sepsis and inflammation in CRC and in relation to tumour-related outcomes were identified through a database search of Cochrane, CINAHL and MEDLINE.Quality and bias assessment was carried out by two reviewers. Results: Of 8,940 screened, Of the 30 studies included, 21 were observational, 5 in vivo experimental, 1 in vitro and 3 used a combination of these approaches. There is clear evidence from the literature that presence of a pre-operative systemic inflammatory response predicts cancer recurrence following potentially curative resection, but the evidence for association of sepsis and progression is lacking. Conclusions: There is robust experimental evidence in murine models showing that NETs are present in sepsis and are associated with cancer progression. Some human observational studies corroborate the prognostic significance of NETs in progression of CRC. Further human studies are needed to translate the experimental evidence and to definitively associate sepsis and NETs with poor colorectal cancer-specific outcomes.

A main distinction between anaerobic digestion (AD) technologies for treatment of municipal and industrial biodegradable wastes is the operating process solids content. Wet AD systems operate at low total solids ( 40% TS). The performance of wet and dry AD systems was quantified in relation to: technical operation (footprint, capacity, feedstock characteristics, pretreatment and post-treatment, retention time, water usage), energy balance (biogas productivity, parasitic energy, methane [CH4] content, utilization of biogas and produced energy), digestate management and economic performance (capital and operational costs, revenues, specific capital costs [per t of waste and per m3 biogas]). Wet AD plants had improved energy balance and economic performance compared to dry AD plants. However, dry AD plants offered several benefits, including greater flexibility in the type of feedstock accepted, shorter retention times, reduced water usage and more flexible management of, and opportunities for marketing, the end-product.

Background Pilonidal disease is a common condition with no consensus for the best management of chronic disease or current practice in Australia and New Zealand. Methods A survey was distributed among 190 colorectal and 592 general surgeons in Australia and New Zealand. Data was obtained regarding pilonidal surgery volume, procedures performed, non-operative management and recurrence rates. Three clinical scenarios were also presented. Results The response rate was 58% among colorectal surgeons, 18% among general surgeons. Nineteen percent of surgeons were high-volume (>23 operations per year), 47% low-volume (10%. Six percent reported no recurrences ever. Five percent reported recurrence rates over 20%, but 24% stated that over one-fifth of their practice consists of recurrent disease. Conclusions This study reports higher recurrence rates than in published series, suggesting many surgeons do not see their own recurrences, with current treatment not as successful as previously thought. Combined with the widespread variation in practice, optimal management of this disease remains unclear.

The next generation of cryogenic CMB and submillimeter cameras under development require densely instrumented sensor arrays to meet their science goals. The readout of large numbers ($\sim$10,000--100,000 per camera) of sub-Kelvin sensors, for instance as proposed for the CMB-S4 experiment, will require substantial improvements in cold and warm readout techniques. To reduce the readout cost per sensor and integration complexity, efforts are presently focused on achieving higher multiplexing density while maintaining readout noise subdominant to intrinsic detector noise. Highly-multiplexed cold readout technologies in active development include Microwave Kinetic Inductance Sensors (MKIDs) and microwave rf-SQUIDs. Both exploit the high quality factors of superconducting microwave resonators to densely channelize sub-Kelvin sensors into the bandwidth of a microwave transmission line. We present advancements in the development of a new warm readout system for microwave SQUID multiplexing, the SLAC Superconducting Microresonator RF electronics, or SMuRF. The SMuRF system is unique in its ability to track each tone, minimizing the total RF power required to read out each resonator, thereby significantly reducing the linearity requirements on the cold and warm readout. Here, we present measurements of the readout noise and linearity of the first full SMuRF system, including a demonstration of closed-loop tone tracking on a 528 channel cryogenic microwave SQUID multiplexer. SMuRF is being explored as a potential readout solution for several future CMB projects including Simons Observatory, BICEP Array, CCAT-prime, Ali-CPT, and CMB-S4. Parallel development of the platform is underway to adapt SMuRF to read out both MKID and fast X-ray TES calorimeter arrays., Comment: 16 pages, 5 figures

To enable the next-generation of bolometric cameras, we are developing the microwave SQUID multiplexer (μMUX). Upcoming receivers such as Simons Observatory, CCAT-prime, BICEP array, Ali-CPT, and CMB-S4 plan to instrument focal planes with 50,000-500,000 sensors. Sensor count is achieved by tiling many 150 mm-diameter densely packed detector arrays into these focal planes. The fabrication and quality of large-format bolometer arrays has been demonstrated and is now mature. In contrast, the readout technology required for next-generation receivers needs development. The sensitivity, low cross-talk, high multiplexing density, and small component size make the μMUX well-suited for this goal. In this approach, the TES signal modulates the inductance of an rf-SQUID that loads a high-Q microwave resonator. The coupled signal therefore modulates the microwave resonance frequency, which may be read out using homodyne techniques. By coupling each resonator to the same microwave feedline, many detectors can be read out on a single coaxial cable pair. The multiplexing density is in practice limited by signal bandwidth, allowable cross-talk, and the digitization bandwidth of room-temperature readout electronics. We present the design and performance of a scalable 64-channel multiplexer chip optimized for bolometric applications. We utilize a new quarter wave resonator design that increases the physical linear density by a factor of two, therefore achieving a smaller footprint for simplified detector packaging. Measurements of this design show 100 kHz resonator bandwidth, uniform 1.8 MHz frequency spacing, and an input referred current noise of 35 pA/√Hz that is well below the level of an optimized, background-limited TES bolometer. Using 8 daisy-chained and frequency scaled chips, we create a 512-channel multiplexer and use it to readout a 512 TES-bolometer array. We present the results of this large-scale μMUX demonstration including system yield, signal cross-talk, and an analysis of noise in various TES bias configurations. The result demonstrates the multiplexing density required to read out 2,000 sensors between 4-8 GHz.

Lower GI hemorrhage is a common source of morbidity and mortality. Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss in a variety of clinical conditions. Information regarding the use of tranexamic acid in treating lower GI hemorrhage is lacking.The aim of this trial was to determine the clinical efficacy of tranexamic acid when used for lower GI hemorrhage.This was a prospective, double-blind, placebo-controlled, randomized clinical trial.The study was conducted at a tertiary referral university hospital in Australia.Consecutive patients aged18 years with lower GI hemorrhage requiring hospital admission from November 2011 to January 2014 were screened for trial eligibility (N = 265).A total of 100 patients were recruited after exclusions and were randomly assigned 1:1 to either tranexamic acid or placebo.The primary outcome was blood loss as determined by reduction in hemoglobin levels. The secondary outcomes were transfusion rates, transfusion volume, intervention rates for bleeding, length of hospital stay, readmission, and complication rates.There was no difference between groups with respect to hemoglobin drop (11 g/L of tranexamic acid vs 13 g/L of placebo; p = 0.9445). There was no difference with respect to transfusion rates (14/49 tranexamic acid vs 16/47 placebo; p = 0.661), mean transfusion volume (1.27 vs 1.93 units; p = 0.355), intervention rates (7/49 vs 13/47; p = 0.134), length of hospital stay (4.67 vs 4.74 d; p = 0.934), readmission, or complication rates. No complications occurred as a direct result of tranexamic acid use.A larger multicenter trial may be required to determine whether there are more subtle advantages with tranexamic acid use in some of the secondary outcomes.Tranexamic acid does not appear to decrease blood loss or improve clinical outcomes in patients presenting with lower GI hemorrhage in the context of this trial. see Video Abstract at http://links.lww.com/DCR/A453.

Adequate postoperative analgesia is essential for recovery following colorectal surgery. Transversus abdominis plane (TAP) blocks have been found to be beneficial in improving pain following a variety of abdominal operations. The objective of this study was to determine if TAP blocks are useful in improving postoperative recovery following laparoscopic colorectal surgery. A prospective double-blind randomized clinical trial, involving 226 consecutive patients having laparoscopic colorectal surgery, was performed by a university colorectal surgical department. Patients were randomized to either TAP blockade using ultrasound guidance, or control, with the primary outcome being postoperative pain, as measured by analgesic consumption. Secondary outcomes assessed were pain visual analogue score (VAS), respiratory function, time to return of gut function, length of hospital stay, postoperative complications, and patient satisfaction. A total of 142 patients were followed up to trial completion (74 controls, 68 interventions). Patients were well matched with regard to demographics. No complications occurred as a result of the intervention of TAP blockade. There was no difference between groups with regards to analgesic consumption (161 mEq morphine control vs 175 mEq morphine TAP; p = 0.596). There was no difference between the two groups with regards to the secondary outcomes of daily VAS, respiratory outcome, time to return of gut function, length of hospital stay, postoperative complications, and patient satisfaction. We conclude that TAP blockade appears to be a safe intervention but confers no specific advantage following laparoscopic colorectal surgery.

Epidemiologic studies have yielded conflicting results regarding the role of heavy metal exposure in recent epidemics of chronic kidney disease (CKD). In this issue of Kidney International , Tsai et al. examined the combined effects of chromium, lead, and cadmium on kidney function using data from the Nutrition and Health Survey in Taiwan. We add this report to our growing understanding of contemporary epidemics of CKD and highlight considerations for exposure analysis in CKD epidemiologic studies.

India faces major environmental challenges associated with waste generation and inadequate waste collection, transport, treatment and disposal. Current systems in India cannot cope with the volumes of waste generated by an increasing urban population, and this impacts on the environment and public health. The challenges and barriers are significant, but so are the opportunities. This paper reports on an international seminar on ‘Sustainable solid waste management for cities: opportunities in South Asian Association for Regional Cooperation (SAARC) countries’ organized by the Council of Scientific and Industrial Research-National Environmental Engineering Research Institute and the Royal Society. A priority is to move from reliance on waste dumps that offer no environmental protection, to waste management systems that retain useful resources within the economy. Waste segregation at source and use of specialized waste processing facilities to separate recyclable materials has a key role. Disposal of residual waste after extraction of material resources needs engineered landfill sites and/or investment in waste-to-energy facilities. The potential for energy generation from landfill via methane extraction or thermal treatment is a major opportunity, but a key barrier is the shortage of qualified engineers and environmental professionals with the experience to deliver improved waste management systems in India.

An estimated 7 million t of industrial biowastes are landspread annually in the UK. Quantitative research into their fertiliser replacement value and agronomic benefit is required to increase their use in agriculture, recycle valuable nutrients, and contribute to the reduction of biodegradable waste sent to landfill. A programme of systematically designed field experiments was established to quantify the agronomic value of a range of industrial biowastes, including examples from the vegetable, meat and dairy processing industries and digested biowastes from industrial aerobic and anaerobic digestion plants. Dewatered anaerobically digested biosolids (DMAD) was included as a reference material. Yield and N offtake responses of perennial ryegrass, at five rates of application of each biowaste type were used to calculate the N equivalency relative to mineral N fertiliser. Liquid thermophilic aerobic digestate (LTAD) of food waste was an effective source of available N, with an N equivalency of 59–76 %. Liquid mesophilic anaerobic co-digestates of livestock slurry and food waste (LcoMAD) had N equivalencies between 68 and 85 %. Vegetable processing waste and brewing waste (yeast) had N equivalency values of 45 and 89 %, respectively. Regarding other nutrient elements, the biowastes were generally a source of P, vegetable wastes were significant sources of K, and DMAD and the dewatered anaerobically digested organic fraction of municipal solid waste (DMADMSW) were effective sources of S. Certain waste types were not effective sources of N for crop growth (e.g. potato processing wastes, kieselguhr) and require further investigation at greater rates of application to determine their agronomic benefit.

We sought to compare two synthetic injectable bulking agents, with known efficacy (PTQ™: a silicone biomaterial and Durasphere(®): pyrolytic carbon-coated beads), in the form of a randomised clinical trial.Circumferential injection of either agent was performed under local anesthesia and sedation as a day-case procedure. The primary outcome measure was the Wexner incontinence scale. Secondary measures were the short-form 36 (SF-36) quality of life assessment and manometry (maximum resting and squeeze pressures). Follow-up was at 6 weeks, 6 and 12 months.Thirty-five patients were randomised, 17 to PTQ(®) and 18 to Durasphere(®). Early closure of the trial occurred, due to the removal of the agent PTQ(®), from the Australian Pharmaceutical Benefits scheme. Wexner incontinence scores were significantly better than baseline, in both groups, at 6 weeks and 6 months (P0.05), although the improvements were not significant at 12 months. There was no significant improvement for either agent, from baseline, in mean SF-36 scores at any follow-up sessions. There was no significant difference between the two bulking agents, with regard to both Wexner and SF-36 scores, at any of the follow-up sessions. Complications occurred in one patient in the PTQ group (perianal abscess) and did not occur in any of the patients in the Durasphere group.This trial appears to show that both synthetic agents PTQ(®) and Durasphere(®) are effective and safe, although long-term improvement is limited. In this trial, there appears to be no difference in efficacy between the two agents, over a 12-month follow-up period.

Background Tubulointerstitial nephritis (TIN) is typically seen in association with drug exposure and infection or in autoimmune diseases such as Sjogren's syndrome or systemic lupus erythematosis. The recently described IgG4-related systemic diseases can affect many organ systems including the kidney and typically respond to corticosteroid treatment. Case We present a case of IgG4-related TIN in a patient with concomitant chronic lymphocytic leukemia. To our knowledge, IgG4-related TIN has not been associated with any hematological disorder such as chronic lymphocytic leukemia. Conclusion We propose that all kidney biopsies with significant plasma cell infiltrate should be stained for IgG4 as response to treatment is common.

BK polyomavirus (BKV) infection continues to be a significant source of allograft dysfunction in kidney transplant recipients. The optimal screening method to detect BKV remains undetermined. In this retrospective analysis of 347 consecutive kidney transplant recipients, we compare the diagnostic and screening performance of urine electron microscopy (EM) with plasma polymerase chain reaction (PCR) in testing for BKV, using biopsy-proved polyomavirus-associated nephropathy (PVAN) as the gold standard. Sixty-nine of 347 recipients had a positive screening test for BKV infection. Twenty-nine patients underwent biopsy, and 11 were diagnosed with PVAN. Sensitivity rates of urine EM and plasma PCR were 88% and 100%, respectively. Specificity rates of urine EM and plasma PCR were 91% and 78%. There was no statistical difference in the operating characteristics of the two tests. The majority of both plasma PCR and urine EM tests were positive in the six months prior to a diagnostic biopsy confirming PVAN. In those patients who had evidence of BKV infection but did not have PVAN, the percentage of positive screening tests decreased with aggressive lowering of immunosuppression. We conclude that urine EM and plasma PCR both function well in screening for BKV infection and in the diagnosis of PVAN. There is an opportunity to detect viral replication, lower immunosuppression, and to prevent PVAN in this population.

Agricultural Land and Organic ‘Waste’: A National Capacity Estimator (ALOWANCE) is a GIS‐based tool that estimates the available agricultural landbank in England and Wales for recycling organic materials based on a number of physical and practical constraints, and legislative restrictions. It can be used to identify areas where there is a potential shortage or surplus of available agricultural land and to determine the length of time for which the agricultural landbank would continue to be available to receive organic materials. Two versions of ALOWANCE have been developed. ALOWANCE‐PLUS is a PC‐based tool that provides the full functionality of ALOWANCE to a small number of ‘expert’ users. It incorporates scenario testing capabilities, allowing the agricultural landbank capacity to be calculated interactively. ALOWANCE‐ONLINE is a web‐based version that provides information to ‘general’ users, including pre‐selected map ‘layers’ (generated from ALOWANCE‐PLUS) and a simple query tool. Results from ALOWANCE‐PLUS showed that after exclusions and after accounting for current sources of organic materials (livestock manures, biosolids, compost, paper crumble and digestate), the estimated agricultural landbank in England and Wales for the addition of ‘new’ sources of organic materials was c. 5.1 million ha. Spatial representations showed that in some parts of the country (e.g. north‐west England), the agricultural landbank was already under ‘pressure’ and transport of any future emerging sources of organic materials away from these areas may be required.

A range of wastes representative of materials currently applied, or with future potential to be applied, to agricultural land in the UK as fertilisers and soil improvers or used as animal bedding in livestock production, were investigated. In addition to full physico-chemical characterization, the materials were analysed for a suite of priority organic contaminants. In general, contaminants were present at relatively low concentrations. For example, for biosolids and compost-like-output (CLO), concentrations of polychlorinated dibenzo-p-dioxins/dibenzofurans (PCDD/Fs) and polychlorinated biphenyls (PCBs) were approximately 1−10 and 5–50 times lower, respectively, than various proposed or implemented European limit values for these contaminants in biosolids or composts applied to agricultural land. However, the technical basis for these limits may require re-evaluation in some cases. Polybrominated, and mixed halogenated, dibenzo-p-dioxins/dibenzofurans are not currently considered in risk assessments of dioxins and dioxin-like chemicals, but were detected at relatively high concentrations compared with PCDD/Fs in the biosolids and CLOs and their potential contribution to the overall toxic equivalency is assessed. Other ‘emerging’ contaminants, such as organophosphate flame retardants, were detected in several of the waste materials, and their potential significance is discussed. The study is part of a wider research programme that will provide evidence that is expected to improve confidence in the use of waste-derived materials in agriculture and to establish guidelines to protect the food chain where necessary.

Caregivers for patients undergoing solid organ transplantation play an essential role in the process of transplantation. However, little is known about stress and coping among these caregivers. Six hundred and twenty-one primary caregivers of potential candidates for lung (n = 317), liver (n = 147), heart (n = 115), and/or kidney (n = 42) transplantation completed a psychometric test battery at the time of the candidate's initial pre-transplant psychosocial evaluation. Caregivers were generally well adjusted, with only 17% exhibiting clinical symptoms of depression (Beck Depression Inventory-II score >13) and 13% reporting clinical levels of anxiety (State Trait Anxiety Inventory score >48). Greater caregiver burden and negative coping styles were associated with higher levels of depression. Greater objective burden and avoidant coping were associated with higher levels of anxiety. Caregivers evidenced a high degree of socially desirable (i.e., defensive) responding, which may reflect a deliberate effort to minimize fears or worries so as to not jeopardize patients' listing status.

PURPOSE: Surgical site infection following colorectal surgery is a frequent and costly problem. Barrier protection at the time of this form of surgery has been used with varying results. The aim of this randomized study was to examine the efficacy of barrier retractional wound protection in the prevention of surgical site infections in open, elective colorectal surgery. METHODS: One hundred thirty consecutive patients undergoing open elective colorectal resectional surgery were randomly assigned to have either barrier retractional wound protection or standard wound retraction. Patients were then followed up for a minimum of 30 days postoperatively. The primary end point was surgical site infection as defined by the Centers for Disease Control and Prevention. The secondary end point was performance of the wound protector as assessed by operating surgeons. RESULTS: There was a significant reduction in the incidence of incisional surgical site infections when the wound protector was used: 3 of 64 (4.7%) vs 15 of 66 (22.7%); P = .004. Most surgical site infections were diagnosed after discharge from the hospital (78%), and there was no difference in the rates of reoperation, readmission, or formal wound drainage between the 2 groups. Surgeons found the wound protector to be helpful with retraction during surgery, with 88% (7/8) adopting it as part of their standard setup. CONCLUSIONS: In this study the use of barrier wound protection in elective open colorectal resectional surgery resulted in a clinically significant reduction in incisional surgical site infections. Barrier wound protection of this nature should be considered routine in this type of surgery.

Centrifuge dewatering digested sewage sludge has been reported to significantly increase numbers of Escherichia coli, potentially exceeding the UK microbiological standards of 10 3 or 10 5 E. coli/g dry solids (DS) for enhanced or conventional treatment for agricultural use, respectively. Here, we report an investigation of the effects of different types of dewatering process on E. coli enumeration in conventionally treated, anaerobically digested sludge (primary and secondary liquid digestion), as well as raw sludge at eight wastewater treatment works in the United Kingdom. The dewatering methods evaluated included: centrifuge conditioning and filter-belt and filter-plate pressing. The results demonstrated that conventional treatment by primary and secondary liquid digestion and dewatering conditioning produces biosolids compliant with UK maximum microbiological limits for agricultural application.

This paper presents the design and implementation of a continuous-time model predictive controller using Laguerre functions. The application is to control motor torque and specific mechanic energy of an extrusion pilot plant via manipulating screw speed and liquid pump speed. The continuous-time transfer function models are developed using the approach based on state variable filters. The predictive control system is implemented through the existing real-time Supervisory Control And Data Acquisition (SCADA) system in the extruder. Experimental results show satisfactory closed-loop performance of the predictive control system designed.

This article describes how a competency-based curriculum is implemented at the Warren Alpert Medical School of Brown University. A competency-based curriculum can be implemented in either a traditional discipline-oriented curriculum or an integrated, case-based curriculum. Restructuring learning activities, assuring adequate numbers of faculty, and training faculty to assess competencies are essential for success. Schools of veterinary medicine must ensure that their graduates possess a wide range of abilities, in additional to scientific knowledge, if they are to practice successfully. A competency-based curriculum is the best means to do so.

There has been little investigation of the ecological interactions between major organisms brought about by the application of wastewater biosolids to agricultural soil. This paper provides an overview of the possible effects of biosolids application on these ecosystems by using what is known about the ecology and diversity of microbial populations in soil and biosolids. Areas considered include interactions between indigenous and introduced bacterial populations, impacts of biosolids application on soil protozoa and the role of phages in bacterial population dynamics. These ecological processes are particularly relevant, for instance, to increase an understanding of the fundamental mechanisms responsible for inactivation of potentially infectious enteric microorganisms in biosolids-amended agricultural soil.