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Any terms that designate certain groups of young people as more in need of support or intervention are likely to be contested. Identification of some young people as vulnerable can lead to tensions between rights and blame and between support and stigma. This paper draws on scholarship that posits vulnerability as emerging as part of specific social and historical conditions, and as a precondition for resistance and agency. We use publicly available data and information to focus on a community in a regional area in Australia and on a specific initiative for young women in that community. In relation to conditions, we detail salient characteristics of the region: north-west Tasmania. We show how structures of social, economic, and cultural inequalities provide the context for the vulnerability of young women living here. In this community, as elsewhere in Australia and globally, national economic reforms have accentuated social and economic disadvantage. We then move on to examine a participatory arts initiative, Project O, that works with young women in this region. We outline how Project O is an example of a practical way to harness the potential of vulnerability as a starting point for both resistance and agency, through positive connections with place and identity; by enabling young women to act on their aspirations; and by developing capabilities and providing recognition.

Purpose of Review This review explores recent international guidance on the anesthetic management of patients undergoing thoracic surgery during the COVID-19 pandemic: those with suspected or confirmed COVID-19 requiring urgent thoracic surgery and those presenting for elective procedures. Recent Findings A significant mortality risk is associated with patients with COVID-19 undergoing thoracic surgery; therefore, where possible, it should be avoided. Thoracic surgery also carries a significant risk of viral transmission to healthcare workers due to the necessarily high frequency of intraoperative aerosol-generating procedures involved, such as lung isolation, one-lung ventilation, and flexible bronchoscopy. Summary Guidelines recommend appropriate personal protective equipment and numerous procedural modifications to prevent viral transmission to staff and other patients. With appropriate disease mitigation strategies in place, elective thoracic surgery, in particular for lung cancer, has been able to continue safely in many centres.

Child-led research has arisen in response to changed perspectives on children’s rights and capabilities. However, questions remain about the implications of children participating in ways and for purposes designed by adults. This paper examines a child-led research project through the heuristic of dialogism to identify the perspectives and motivations of adults and children – the many ‘voices’ of the situation. Ontological conceptualisations of childhood, adult critical self-reflection, accommodation of children’s priorities and openness towards unexpected or challenging outcomes are discussed.

OBJECTIVES Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker that has been implicated in several cardiac pathologies and has been shown to be elevated in critically ill populations. We measured plasma suPAR in a cohort of cardiac surgical patients to evaluate its ability to predict prolonged intensive care unit (ICU) and hospital length of stay and development of complications following surgery. We compared suPAR against EuroSCORE II and C-reactive protein (CRP). METHODS Ninety patients undergoing cardiac surgery were recruited with samples taken preoperatively and on postoperative days 1, 2 and 3. suPAR was measured using enzyme-linked immunosorbent assay. Area under the receiver operator curve (AUROC) was used to test predictive capability of suPAR. Comparison was made with EuroSCORE II and CRP. RESULTS suPAR increased over time (P CONCLUSIONS suPAR increases following cardiac surgery and levels are higher in those who require prolonged ICU stay, prolonged hospital stay and prolonged ventilation. Preoperative suPAR compares favourably to EuroSCORE II and CRP in the prediction of these outcomes. suPAR could be a useful biomarker in predicting outcome following cardiac surgery, helping inform clinical decision-making. Clinical registration West of Scotland Research Ethics Committee Reference: 12/WS/0179 (AM01).

The purpose of the paper is to reveal the complexities of negotiating justice. We present the case of workers’ experiences during a long-running industrial dispute at Australia’s first legal casino. First, we consider the concept of justice, drawing on discussions from tourism studies. This notion is considered in relation to an industrial dispute at the casino. Second, we use Bakhtin’s dialogic imagination to explore the issues, primarily through the voices of the workers. The concepts of heteroglossia, polyphony and carnivalesque facilitate layering the voices and concerns of the workers. Formal and informal strategies to exert influence are present. Within the carnivalesque, there is order and disorder. Different parties present a cacophony of voices, asserting the just-ness of their position. We discuss how, as boundaries of social action are negotiated, the parties are effectively negotiating justice. Third, we suggest how, from our Bakhtinian perspective, justice is a social activity, doing justice is a social process, and achieving justice is hard. Finally, we share some broader suggestions and reflections on the complexities and contradictions.

Introduction Lung cancer is the leading cause of cancer death in Europe. Surgical resection is often the preferred treatment but is associated with morbidity and mortality. Survival with a meaningful quality of life is important; however, the prediction of post-operative dyspnoea (POD) is often difficult and innaccurate.1 The European Society of Thoracic Surgeons (ESTS) and the (UK) National Institute of Clinical Excellence (NICE) advocate studies concerning operative risk for surgical resection. Conventional prediction uses pulmonary function; predicted post-operative FEV1%(ppoFEV1%) and predicted post-operative DLCO%(ppoDLCO%) with Methods With informed consent and ethics approval, we prospectively recruited 250 patients undergoing lung resection in four UK centres. Dyspnoea was measured pre-operatively and 3 months post-operatively using the Medical Research Council (MRC) score. The primary outcome was patients with a post-operative MRC>2, excluding those with an MRC>2 pre-operatively. Two conventional models were derived (n=93, 1 site), before external validation (n=85, 3 sites) using the variables age, gender and ppoFEV1%/ppoDLCO%. Model 1(M1) incorporates ppoFEV1%/ ppoDLCO% with conventional cut offs and Model 2(M2) treats them continuously. Using similar internal derivation and external validation, two new models were explored. Univariate analysis identified risk predictors (p Results New models improved prediction within the internal dataset: M2 Vs M4 (AUROC comparison, p=0.03, NRI 0.26). (Fig.1) The best conventional and new models (M2 & M4) performed similarly within the external population: Sensitivity (55% vs 50%), Specificity (68% Vs 73%), PPV (38% Vs 39%), NPV (81% Vs 81%), respectively. Discussion This study demonstrates conventional risk prediction for POD using pulmonary function is poor. It also highlights challenges in creating new scoring tools: at external validation conventional models performed equally to new models with similar sensitivity/specificity/NPV and PPV. Using ppoFEV1%/ ppoDLCO% as continuous variables rather than dichotomised at 40%, may increase predictive strength. Future work should explore new variables to predict POD, such as pre-operative quality of life and biomarkers. For prognostic enrichment, models should have high sensitivity & high NPV, targeting those who would benefit most from low-risk interventions

Objectives Because of the biologic effects of volatile anesthetics on the immune system and cancer cells, it has been hypothesized that their use during non-small cell lung cancer (NSCLC) surgery may negatively affect cancer outcomes compared with total intravenous anesthesia (TIVA) with propofol. The present study evaluated the relationship between anesthetic technique and dose and oncologic outcome in NSCLC surgery. Design Retrospective cohort study. Setting Surgical records collated from a single, tertiary care hospital and combined with the Scottish Cancer Registry and continuously recorded electronic anesthetic data. Participants Patients undergoing elective lung resection for NSCLC between January 2010 and December 2014. Interventions The cohort was divided into patients receiving TIVA only and patients exposed to volatile anesthetics. Measurements and Main Results Final analysis included 746 patients (342 received TIVA and 404 volatile anesthetic). Kaplan-Meier survival curves with log-rank testing were drawn for cancer-specific and overall survival. No significant differences were demonstrated for either cancer-specific (p = 0.802) or overall survival (p = 0.736). Factors influencing survival were analyzed using Cox proportional hazards modeling. Anesthetic type was not a significant predictor for cancer-specific or overall survival in univariate or multivariate Cox analysis. Volatile anesthetic exposure was quantified using area under the end-tidal expired anesthetic agent versus time curves. This was not significantly associated with cancer-specific survival on univariate (p = 0.357) or multivariate (p = 0.673) modeling. Conclusions No significant relationship was demonstrated between anesthetic technique and NSCLC survival. Whether a causal relationship exists between anesthetic technique during NSCLC surgery and oncologic outcome warrants definitive investigation in a prospective, randomized trial.

Intra-operative aerosol-generating procedures are arguably unavoidable in the routine provision of thoracic anaesthesia. Airway management for such patients during the COVID-19 pandemic including tracheal intubation, lung isolation, one-lung ventilation and flexible bronchoscopy may pose a significant risk to healthcare professionals and patients. That said, there remains a need for timely thoracic surgery for patients with lung cancer or thoracic trauma. The thoracic anaesthetic community has been confronted with the need to modify existing techniques to maximise safety for patients and healthcare professionals. With appropriate modification, aerosol generation may be mitigated against in most circumstances. We developed a set of practice-based recommendations for airway management in thoracic surgical patients, which have been endorsed by the Association for Cardiothoracic Anaesthesia and Critical Care and the Society for Cardiothoracic Surgery in Great Britain and Ireland.

International audience; Winter rye (Secale cereale L.) is a popular cover crop in North Central United States for preventing soil erosion and nutrient losses, among other agronomic and ecosystem benefits. Winter rye can also be a high-quality spring forage option when double-cropped with corn silage (Zea mays L.), thus adding diversity to monocrop rotations. However, these sustainability-promoting benefits have potential trade-offs including soil nutrient immobilization and decreased corn yields. We hypothesized that winter rye would promote sustainable intensification of corn silage, as substantiated by decreased nitrogen budget and soil nitrate without yield loss. We also predicted that winter rye double-cropped and harvested as a forage would maintain total production (corn silage + rye harvest) compared to corn silage alone. This five-season study is representative of continuous corn silage systems in North Central United States, and Wisconsin specifically, distinguished by fall liquid dairy manure applications. Corn was planted after rye termination or harvest, and varying rates of nitrogen were applied to corn. As predicted, rye cover reduced preplant soil nitrate without affecting corn silage yield. Rye harvested as a forage crop reduced preplant and in-season soil nitrate, and total production equaled or exceeded corn silage yields without rye, despite a 13% decrease in corn silage yield. The 5-year nitrogen balance demonstrated almost 40% reduction in excess nitrogen in the rye forage system. This novel study demonstrated no cumulative or single-year agronomic limitations to winter rye implementation in manured, corn silage systems characteristic of North Central United States over a range of seasonal weather conditions. Furthermore, the dual use of rye as a cover crop conservation practice or harvested as a forage double-crop makes it agronomically advantageous and demonstrate potential for sustainable intensification in this system. This research is the first to show that sustainable intensification through double cropping dairy-based systems can increase high-quality biomass production while reducing nitrogen losses to the environment.

Background Health attitudes and behaviours formed during childhood greatly influence adult health patterns. This paper describes the research and development protocol for a school-based health literacy program. The program, entitled HealthLit4Kids, provides teachers with the resources and supports them to explore the concept of health literacy within their school community, through classroom activities and family and community engagement. Methods HealthLit4Kids is a sequential mixed methods design involving convenience sampling and pre and post intervention measures from multiple sources. Data sources include individual teacher health literacy knowledge, skills and experience; health literacy responsiveness of the school environment (HeLLO Tas); focus groups (parents and teachers); teacher reflections; workshop data and evaluations; and children’s health literacy artefacts and descriptions. The HealthLit4Kids protocol draws explicitly on the eight Ophelia principles: outcomes focused, equity driven, co-designed, needs-diagnostic, driven by local wisdom, sustainable, responsive, systematically applied. By influencing on two levels: (1) whole school community; and (2) individual classroom, the HealthLit4Kids program ensures a holistic approach to health literacy, raised awareness of its importance and provides a deeper exploration of health literacy in the school environment. The school-wide health literacy assessment and resultant action plan generates the annual health literacy targets for each participating school. Discussion Health promotion cannot be meaningfully achieved in isolation from health literacy. Whilst health promotion activities are common in the school environment, health literacy is not a familiar concept. HealthLit4Kids recognizes that a one-size fits all approach seldom works to address health literacy. Long-term health outcomes are reliant on embedded, locally owned and co-designed programs which respond to local health and health literacy needs.

Pulmonary edema increasingly is recognized as a perioperative complication affecting outcome. Several risk factors have been identified, including those of cardiogenic origin, such as heart failure or excessive fluid administration, and those related to increased pulmonary capillary permeability secondary to inflammatory mediators.\ud \ud Effective treatment requires prompt diagnosis and early intervention. Consequently, over the past 2 centuries a concentrated effort to develop clinical tools to rapidly diagnose pulmonary edema and track response to treatment has occurred. The ideal properties of such a tool would include high sensitivity and specificity, easy availability, and the ability to diagnose early accumulation of lung water before the development of the full clinical presentation. In addition, clinicians highly value the ability to precisely quantify extravascular lung water accumulation and differentiate hydrostatic from high permeability etiologies of pulmonary edema.\ud \ud In this review, advances in understanding the physiology of extravascular lung water accumulation in health and in disease and the various mechanisms that protect against the development of pulmonary edema under physiologic conditions are discussed. In addition, the various bedside modalities available to diagnose early accumulation of extravascular lung water and pulmonary edema, including chest auscultation, chest roentgenography, lung ultrasonography, and transpulmonary thermodilution, are examined. Furthermore, advantages and limitations of these methods for the operating room and intensive care unit that are critical for proper modality selection in each individual case are explored.

Tissue edema, in particular pulmonary edema, increasingly is recognized as a perioperative complication affecting outcome. Management strategies directed at avoiding excessive fluid administration, reducing inflammatory response, and decreasing capillary permeability commonly are advocated in perioperative care protocols. In this review, transpulmonary thermodilution (TPTD) as a bedside tool to quantitatively monitor lung water accumulation and optimize fluid therapy is examined. Furthermore, the roles of TPTD as an early detector of fluid accumulation before the development of overt pulmonary edema and in risk stratification are explored. In addition, the ability of TPTD to provide insight into the etiology of pulmonary edema, specifically differentiating hydrostatic versus increased pulmonary capillary permeability, is emerging as an aid in therapeutic decision-making. The combination of hemodynamic and lung water data afforded by TPTD offers unique benefits for the care of high-risk perioperative patients.

Introduction Dyspnoea is the subjective feeling of breathing discomfort and is the most important but least understood symptom in cardiorespiratory disease. Patient and public involvement from our research group confirms this finding. The Medical Research Council Dyspnoea scale (MRC scale) is used to measure dyspnoea based on the work load required to provoke breathlessness. It is validated to predict outcome in patients with chronic obstructive pulmonary disease (COPD) however broad grading categories mean clinically important changes may be missed. The minimally clinically important difference (MCID) for the MRC scale is 1. The University of California and San Diego Shortness of Breath Questionnaire (UCSD-SOBQ) is another validated tool in respiratory conditions to measure dyspnoea with a maximum score of 120 and a MCID of 5. To date, no validated scoring tool (nor MCID) exists to quantify dyspnoea in the lung cancer population despite strong evidence this population have a high incidence of breathlessness both before and after surgery.1 The aim of this analysis is to compare tools used to measure breathlessness following lung resection for cancer and assess the concordance between these. Methods This study is a secondary analysis of PROFILES study (NCT03888937) exploring the prediction of dyspnoea following lung resection. With informed consent and ethics approval we prospectively recruited 107 patients undergoing lung resection in a single centre. The MRC scale and UCSD-SOBQ were completed by each patient pre-operatively and 3 months post-operatively. Data are displayed as median (IQR). A four-quadrant plot was created and direction of change analysis performed for concordance. Wilcoxon signed rank test was used to compare scores pre-operatively vs 3 months post-operatively. Results At 3 months 75 patients returned questionnaires for comparison of pre and post-operative breathlessness (return rate 77%). Median MRC dyspnoea was reduced post-op (2(2-3) compared to pre-op (2(1-2), p=0.01) as was median UCSDSOBQ post-op(24(11,56) compared to pre-op (8(2,24), p=0.01. Concordance for detecting a MCID change in dyspnoea score was 59%. Sixty-one% of patients reported a MCID change in MRC score post-op vs 81% reporting a MCID change in UCSDSOBQ, p=0.02. Discussion This study demonstrates an increase in dyspnoea following lung resection, irrespective of scoring tool. When using questionnaires to measure dyspnoea it is important to ascertain the MCID. No validated questionnaire exists for the lung cancer population. Validated self-assessment tools to measure dyspnoea in other populations have moderate concordance when describing a change in dyspnoea level following lung resection surgery. Future studies should focus on; validation of a tool to measure dyspnoea, reliable methods to predict dyspnoea and a greater understanding of the patho-physiological mechanisms involved.

Context: Right ventricular (RV) dysfunction occurs after lung resection and is associated with postoperative morbidity. Noninvasive evaluation of the RV is challenging, particularly in the postoperative period. A reliable measure of RV function would have value in this population. Aims: This study compares eccentricity index (EI) obtained by transthoracic echocardiography (TTE) with cardiovascular magnetic resonance (CMR) determined measures of RV function in a lung resection cohort. CMR is the reference method for noninvasive assessment of RV function. Design and Setting: Prospective observational cohort study at a single tertiary hospital. Materials and Methods: Twenty-eight patients scheduled for elective lung resection underwent contemporaneous TTE and CMR imaging preoperatively, on postoperative day (POD) 2 and at 2-month. Systolic and diastolic EI was measured offline from anonymized and randomized TTE and CMR images. Statistical Analysis: Bland–Altman analysis was performed to determine agreement between EITTE and EICMR. Changes over time and comparison with CMR determined RV ejection fraction (RVEFCMR) was assessed. Results: Bland–Altman analysis showed a negligible mean difference between EITTE and EICMR, but limits of agreement were wide (SD 0.24 and 0.28). There were no significant changes in EITTE and EICMR over time (P > 0.35). We found no association between EITTE with RVEFCMR at all-time points (P > 0.22). Systolic and diastolic EICMR on POD 2 demonstrated moderate association with RVEFCMR (r = −0.54 and r = −0.59, P ≤ 0.01). At 2-month, only diastolic EICMR correlated with RVEFCMR (r = −0.43, P = 0.03). There were no meaningful associations between EITTE and EICMR with TTE-derived RV systolic pressure (P > 0.31). Conclusions: TTE determined EI is not useful as a noninvasive method of assessing RV function following lung resection.

Non-formal learning supports the development of children and young people’s self-belief. In Australia participation in non-formal learning is influenced by multiple, interacting factors, including social and economic marginalisation. The Children’s University program was designed in the United Kingdom with an explicit goal to ensure that every child, irrespective of parental means, has access to quality non-formal learning experiences. In this chapter we provide an analysis of Children’s University Tasmania, with particular reference to issues of marginalisation. We also argue that efforts to foster young people’s engagement in non-formal learning may help the development of their understandings of themselves as learners.

This chapter proposes a broader envisioning of education and its transformative potential. The chapter builds a productive picture of the elements that contribute to learning. To truly harness the transformative power of education requires courageous conversations about education’s potential, not just in Australia but globally. Noting the complexity of the issues, the chapter argues for a deep engagement in understanding educational success and how to enable it. The knowledge dissemination and translation strategies of key institutional agents need to be supported to engage multiple players, across multiple disciplines. The chapter situates the contributions in the book as an important element of a transformational agenda.

Playful learning is frequently conceived in binaries: fun/hard, child/adult, and formal/non-formal learning. The term ‘playful learning’ lacks a coherent definition. This is understandable given it is a multidisciplinary field of research. The article develops an extreme-comparative method to analyse a non-formal learning program, the Children’s University, in Malaysia and in Australia. It reveals structural differences in implementation, attitudes to playful learning, and cultural attitudes to non-formal learning. The cases draw on in-depth interviews with service providers. Finally, the article describes a ‘virtual circle’ which can be used to understand playful learning in different contexts.

No abstract available.

This chapter reminds the reader of the importance of “thinking about your thinking” or metacognition and reflection. The importance is magnified for the pre-service teacher as they seek to develop lessons that will engage and excite learners. Examining one's own thinking allows a person to better understand their thinking and learning. It also encourages the learner to take ownership of their learning and cognition. For the pre-service teacher, the information gathered from “thinking about one's thinking” can be invaluable to success in the classroom. Metacognition, or reflection, is useful for identifying areas of limitations and strengths in our teaching. The highlight of this chapter is the shared journal entries from an intern's journey through internship. As a picture is worth a thousand words, these words of an intern using metacognitive skills to reflect on practice, experiences, and relationships through journaling is invaluable.

IntroductionCOVID-19 can cause severe acute respiratory failure requiring management in intensive care unit with invasive ventilation and a 40% mortality rate. Cardiovascular manifestations are common and studies have shown an increase in right ventricular (RV) dysfunction associated with mortality. These studies, however, comprise heterogeneous patient groups with few requiring invasive ventilation. This study will investigate the prevalence and prognostic significance of RV dysfunction in ventilated patients with COVID-19 which may lead to targeted interventions to improve patient outcomes.Methods and analysisThis prospective multicentre observational cohort study will perform transthoracic echocardiography (TTE) in 150 patients with COVID-19 requiring invasive ventilation for more than 48 hours. RV dysfunction will be defined as TTE evidence of RV dilatation along with the presence of septal flattening. Baseline demographics, disease severity data and clinical information relating to proposed aetiological mechanisms of RV dysfunction (acute respiratory distress syndrome (ARDS), disordered coagulation, direct myocardial injury and ventilation) will be collected and analysed.Primary outcome measures include the prevalence of RV dysfunction and its association with 30-day mortality. Exploratory outcome measures will investigate the association of the proposed aetiological mechanisms of RV dysfunction to the primary outcomes.Prevalence of RV dysfunction will be determined along with 95% Clopper-Pearson CIs and 30-day survival will be analysed using logistic regression adjusting for patient demographics, phase of disease and baseline severity of illness. The role of potential aetiological factors (ARDS, disordered coagulation, direct myocardial injury and ventilation) in relation to the primary outcomes will be analysed using logistic regression.Ethics and disseminationApproval was gained from Scotland A Research Ethics Committee (REC reference 20/SS/0059). Findings will be disseminated by various methods including webinars, international presentations and publication in peer-reviewed journals.

GLA is supported by British Journal of Anaesthesia/Royal College of Anaesthetists basic science Career Development award, British Oxygen Company research chair grant in anaesthesia from the Royal College of Anaesthetists and British Heart Foundation Programme Grant (RG/14/4/30736). HFG: funded by the Association of Anaesthetists of Great Britain and Ireland, the British Journal of Anaesthesia/Royal College of Anaesthetists and the Melville Trust. BGS: Chief Scientific Officer/NHS Research Scotland Career Research Fellow award. DGL: BBSRC; British Journal of Anaesthesia PhD studentship.

Biological age is a better measure of functional capacity than chronological age.1 One of the measures of biological age is telomere length. Telomeres are nucleoprotein complexes that protect chromosome ends from damage. The DNA component of telomeres progressively shortens as biological age increases and thus acts as a read out for ‘miles on the biological clock’. 2 Telomere length progressively shortens as biological age increases. Within health care, ageing is almost exclusively described in terms of chronological age. Recent studies explored using biological age to stratify patients and predict outcomes.3 This project acts as a pilot study to investigate whether biological age is related to intensive care unit (ICU) outcomes and whether ICU patients age biologically at an accelerated rate. This project used blood samples from a previous study where patients underwent cardiac surgery and were admitted to the ICU. Blood samples were obtained before surgery and on days 1, 2, and 3 after surgery. The database contained the following physiological parameters: haemoglobin, urea, creatinine, RIFLE score, length of ICU stay, and whether renal replacement therapy was required. Information on co-morbidities and medication was also provided. DNA was isolated using a Maxwell machine and telomere length determined via quantitative PCR. One hundred and fifty-five blood samples from 46 patients underwent analysis. Telomere length did not differ significantly over the 4 days (P=0.662). No relationship was found between telomere length and any physiological parameter, co-morbidity, or medication. There was a trend towards significance with RIFLE score at day 3 increasing as telomere length decreased, although this was not statistically significant (P=0.09). No relationship between telomere length and the available physiological parameters, comorbidities, or medication was found. Telomere length did not vary during ICU stay. This study was limited by its small sample size. Future studies would benefit from a larger sample size; in addition, blood samples could also be obtained at 6 months after discharge to allow gradual alterations in biological age to be determined. Recent studies give evidence that telomere length is a weak biomarker of ageing,3 and that more meaningful data might be obtained using superior markers, such as CDKN2A expression or expression levels of non-coding RNAs.3

Lung resection is associated with significant perioperative morbidity, and a proportion of patients will require intensive care following surgery. We set out to characterise this population, assess their burden of disease and investigate the influence of anaesthetic and surgical techniques on their admission rate. Over a two-year period, 1169 patients underwent surgery, with 30 patients (2.6%) requiring unplanned intensive care. Patients requiring support had a higher mortality (0.2% vs 26.7%, p < 0.001). Logistic regression (following adjustment for Thoracoscore) revealed that an open surgical approach was associated with higher likelihood of admission (p = 0.025, odds ratio = 5.25). There was also a trend towards increased likelihood of admission in patients who received volatile anaesthesia (p = 0.061, odds ratio = 2.08). This topic has been selected for further investigation as part of the 2015 Association of Cardiothoracic Anaesthetists (ACTA) second national collaborative audit, with this study providing pilot data before a multi-centre study.

Introduction Pre-operative exercise testing is widely used to assess perioperative risk. ‘Maximal’ tests, such as Cardiopulmonary Exercise Testing, are not always well tolerated. To overcome this sub-maximal exercise tests (SET) are increasingly being utilised. Though potentially better tolerated, results may be dependent on patient motivation and effort. Assessment of heart rate recovery (HRR), as a marker of underlying cardiac vagal activity, following SETs could potentially add objectivity. Several authors have unsuccessfully attempted to model HRR using a variety of non-linear functions(1). We hypothesised that a) an individual's HRR profile could be modelled using non-linear mixed effects modelling (NLME) and b) that the kinetics of an individual's HRR profile were the same, regardless of effort level. Methods Thirty-four healthy volunteers underwent three, six-minute SETs on a cycle ergometer. Individuals on beta-blockers or with contraindications to exercise testing were excluded. The first test was used to familiarise the volunteer with the test protocol and was undertaken at 20% of predicted maximum wattage (Wmax). The following two tests were delivered in a randomised order at 40% or 60% Wmax. Data on HRR was collected for 5-minutes on test cessation. HRR was modelled using the asymptotic regression function; Asymptote + (Maximum HR - Asymptote)*e-RateConstant*Time. Results The median age of the study population was 39 (range; 22-72) with 15% of the population possessing chronic co-morbidities. Figure 1 demonstrates the NLME model using a fit by maximum likelihood. Residual inspection revealed a homoscedastic distribution. The root mean square error (RMSE) for the model fitted values for both 40% and 60% Wmax was estimated at ±7bpm, demonstrating a good fit independent of work load. Modelling assumed that the asymptote and rate constant were fixed regardless of effort, however the maximum heart rate achieved on exercise cessation could vary between 40% and 60% Wmax. Discussion We suggest the rate constant (obtained from NLME modelling) could provide an index for an individual's fitness independent of patient work load. Further work is required to assess the minimum increase in HR required during SETs in order to establish a valid HRR profile and the influence of different types of exercise on HRR. SETs are easier to conduct, better tolerated and a cheaper more widely available alternative to maximal exercise testing. After further validation, we plan to begin clinical testing of this novel concept which has the potential to provide widespread access to objective exercise testing which can be applied easily in any pre-operative clinic scenario.

Lung cancer is a leading cause of cancer death and in suitable cases the best chance of cure is offered by surgery. Lung resection is associated with significant postoperative cardiorespiratory morbidity, with dyspnea and reduced functional capacity as dominant features. These changes are poorly associated with deterioration in pulmonary function and a potential role of right ventricular (RV) dysfunction has been hypothesized. Cardiovascular magnetic resonance imaging is a reference method for noninvasive assessment of RV function and has not previously been applied to this population.We used cardiovascular magnetic resonance imaging to assess the RV response to lung resection. Cardiovascular magnetic resonance imaging with volume and flow analysis was performed on 27 patients preoperatively, on postoperative day 2 and at 2 months. Left ventricular ejection fraction and RV ejection fraction, the ratio of stroke volume to end systolic volume, pulmonary artery acceleration time, and distensibility of main and branch pulmonary arteries were studied.Mean ± standard deviation RV ejection fraction deteriorated from 50.5% ± 6.9% preoperatively to 45.6% ± 4.5% on postoperative day 2 and remained depressed at 44.9% ± 7.7% by 2 months (P = .003). The ratio of stroke volume to end systolic volume deteriorated from median 1.0 (quartile 1, quartile 3: 0.9, 1.2) preoperatively to median 0.8 (quartile 1, quartile 3: 0.7, 1.0) on postoperative day 2 (P = .011). On postoperative day 2 there was a decrease in pulmonary artery acceleration time and operative pulmonary artery distensibility (P .030 for both). There were no changes in left ventricular ejection fraction during the study period (P = .621).These findings suggest RV dysfunction occurs following lung resection and persists 2 months after surgery. The deterioration in the ratio of stroke volume to end systolic volume suggests a mismatch between afterload and contractility. There is an increase in indices of pulsatile afterload resulting from the operative pulmonary artery.

Presents a collection of slides covering the following topics: electrotechnical standards; BSI: regulations; and electrical energy storage.