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During COVID-19, restrictions to elective endoscopy were introduced worldwide. A reduction in procedures may impact trainees' endoscopy learning. This study aims to assess Australian advanced gastroenterology and general surgery trainees' self-perceived efficacy and knowledge in endoscopy during the pandemic.All Australian gastroenterology and general surgery trainees in their last 2 years of accredited training were invited to participate through email (2020-2021 and 2021-2022 training cycles). The primary outcome was to assess trainees' self-efficacy and knowledge regarding gastrointestinal endoscopy. Secondary outcomes included subgroup analysis between gastroenterology and general surgery trainees. Self-perceived efficacy was assessed with Likert-scale questions on 20 endoscopy procedures and knowledge was assessed through 21 endoscopy-related multiple choice questions.Eighty-one trainees responded to a self-efficacy questionnaire and 77 responded to the knowledge questionnaire. Over 90% of the trainees were confident or extremely confident in diagnostic endoscopy, but only half demonstrated similar efficacy for therapeutic endoscopy. The efficacy for basic endoscopy procedures was higher for gastroenterology trainees (64.0%During COVID-19, endoscopy trainees' self-efficacy in endoscopic diagnostic procedures was achieved for most trainees. The differences in self-perceived efficacy and knowledge between gastroenterology and surgical trainees may be reflective of the different opportunities for learning between the two groups.

Background: Graft-derived cell-free DNA (gdcfDNA) analysis has shown promise as a non-invasive tool for monitoring organ health following solid organ transplantation. A number of gdcfDNA analysis techniques have been described; however, the majority rely on sequencing or prior genotyping to detect donor-recipient mis-matched genetic polymorphisms. Differentially methylated regions of DNA can be used to identify the tissue-of-origin of cell-free DNA (cfDNA) fragments. In this study, we aimed to directly compare the performance of gdcfDNA monitoring using graft-specific DNA methylation analysis and donor-recipient genotyping techniques in a pilot cohort of clinical samples from patients post-liver transplantation. Results: 7 patients were recruited prior to LT, 3 developed early, biopsy-proven TCMR in the first 6 weeks post-LT. gdcfDNA was successfully quantified in all samples using both approaches. There was a high level of technical correlation between results using the two techniques (Spearman testing, rs = 0.87, p < 0.0001). gdcfDNA levels quantified using the genotyping approach were significantly greater across all timepoints in comparison to the tissue-specific DNA methylation-based approach: e.g., day 1 post-LT median 31,350 copies/mL (IQR 6731–64,058) vs. 4133 copies/mL (IQR 1100–8422), respectively. Qualitative trends in gdcfDNA levels for each patient were concordant between the two assays. Acute TCMR was preceded by significant elevations in gdcfDNA as quantified by both techniques. Elevations in gdcfDNA, using both techniques, were suggestive of TCMR in this pilot study with a 6- and 3-day lead-time prior to histological diagnosis in patients 1 and 2. Conclusions: Both the graft-specific methylation and genotyping techniques successfully quantified gdcfDNA in patients post-LT with statistically significant concordance. A direct comparison of these two techniques is not only important from a technical perspective for orthogonal validation, but significantly adds weight to the evidence that gdcfDNA monitoring reflects the underlying biology. Both techniques identified LT recipients who developed acute TCMR, with several days lead-time in comparison to conventional diagnostic workflows. Whilst the two assays performed comparably, gdcfDNA monitoring based on graft-specific DNA methylation patterns in cfDNA offers major practical advantages over the donor-recipient genotyping, and hence enhances the potential to translate this emerging technology into clinical practice.

Graft-derived cell-free DNA (gdcfDNA) quantification is a promising, minimally invasive tool for detecting acute T cell-mediated rejection (ATCMR) following liver transplantation (LT). We investigated the utility of measuring hepatocyte-specific methylation in cfDNA (HS-cfDNA) to quantify gdcfDNA, examining its accuracy in detecting ATCMR in a prospective, cross-sectional study. Blood was collected from LT recipients immediately prior to graft biopsy for suspected rejection. HS-cfDNA was quantified using droplet-digital polymerase chain reaction. Prebiopsy liver function tests (LFTs) and HS-cfDNA levels were correlated with biopsy results and the primary outcome of treated biopsy-proven acute rejection (tBPAR). A total of 51 patients were recruited; 37 had evidence of rejection on biopsy and 20 required treatment. As much as 11 patients needed inpatient treatment for rejection. HS-cfDNA significantly outperformed LFTs in identifying patients with tBPAR, particularly those needing inpatient treatment (area under the curve, 73.0%; 95% confidence interval, 55.4%-90.6%; P = 0.01). At a threshold of33.5% of the total cfDNA fraction, HS-cfDNA had a specificity of 97%, correctly excluding tBPAR in 30/31 patients. Quantifying graft-specific methylation in cfDNA has a major advantage over previous gdcfDNA techniques: it does not require genotyping/sequencing, lending it greater feasibility for translation into transplantation care. Low levels of HS-cfDNA were a strong negative predictor for tBPAR (negative predictive value, 86%) and may have a future role in triaging patients prior to invasive graft biopsies.

Due to advances in modern medicine, liver transplantation has revolutionised the prognosis of many previously incurable liver diseases. This progress has largely been due to advances in immunosuppressant therapy. However, despite the judicious use of immunosuppression, many liver transplant recipients still experience complications such as rejection, which necessitates diagnosis via invasive liver biopsy. There is a clear need for novel, minimally-invasive tests to optimise immunosuppression and improve patient outcomes. An emerging biomarker in this ‘‘precision medicine’‘ liver transplantation field is that of donor-specific cell free DNA. In this review, we detail the background and methods of detecting this biomarker, examine its utility in liver transplantation and discuss future research directions that may be most impactful.

Little is yet known about audiences who routinely seek out media content that is inspirational in nature. The current study expands the research on inspirational media by utilizing a nationally representative sample of U.S. audiences ( n = 2,016) to explore relationships between inspiring media exposure, trait transcendence, and self-transcendent emotions. Results show that media content is a reliable source for everyday self-transcendent emotional experiences in U.S. audiences. These experiences are most frequently encountered by persons with high levels of trait spirituality and gratitude. The profile of U.S. audiences that seek out inspiring media is discussed.

BACKGROUND: In Australia, ethics committees across different states vary in application, requirement and process for the ethical review and approval for clinical research. This may lead to confusion and delays in the enablement of multicentre research projects. This study explores the effect of differing processes for Ethics and Governance in the establishment of the CovidSurg-Cancer study during the global COVID-19 pandemic. METHODS: An anonymous, structured web-based questionnaire was designed using the Research Electronic Data Capture application (REDCap) platform to capture consultant surgeons, fellows, and trainees experience in the ethics application process. 'CovidSurg-Cancer' was an international multicentre collaborative study to assess the impact of COVID-19 on the outcomes of patients undergoing cancer surgery. The ethics process to set up this observational study was used as to explore the differing processes applied across Australia. RESULTS: The CovidSurg-Cancer study was successfully set up in 14 hospitals. Four hospitals approved the study directly as an audit. Of the remaining sites, 10 ethics applications underwent Human Research Ethics Committee review following which two (14%) were subsequently approved as an audit activity and eight hospitals (57%) were given formal ethical approval with waiver of consent. Ethics application acceptance from another Australian Human Research Ethics Committee was provided with six applications; however, only three were reciprocated without the requirement for further agreements. A third of (30%) respondents suggested that the details of the application pathway, process and documentation were unclear. CONCLUSION: Ethics processes are varied across Australia with considerable repetition. A centralized, harmonized application process would enhance collaborative research.

Background Despite improvements in the genetic and epigenetic analysis of cell-free DNA (cfDNA), there has been limited focus on assessing the preanalytical variables of recovery efficiency following cfDNA extraction and bisulfite modification. Quantification of recovery efficiency after these steps can facilitate quality assurance and improve reliability when comparing serial samples. Methods We developed an exogenous DNA Construct to Evaluate the Recovery Efficiency of cfDNA extraction and BISulfite modification (CEREBIS) after cfDNA extraction and/or subsequent bisulfite modification from plasma. The strategic placement of cytosine bases in the 180 bp CEREBIS enabled PCR amplification of the construct by a single primer set both after plasma DNA extraction and following subsequent bisulfite modification. Results Plasma samples derived from 8 organ transplant donors and 6 serial plasma samples derived from a liver transplant recipient were spiked with a known number of copies of CEREBIS. Recovery of CEREBIS after cfDNA extraction and bisulfite modification was quantified with high analytical accuracy by droplet digital PCR. The use of CEREBIS and quantification of its recovery was useful in identifying problematic extractions. Furthermore, its use was shown to be invaluable towards improving the reliability of the analysis of serial samples. Conclusions CEREBIS can be used as a spike-in control to address the preanalytical variable of recovery efficiency both after cfDNA extraction from plasma and following bisulfite modification. Our approach can be readily implemented and its application may have significant benefits, especially in settings where longitudinal quantification of cfDNA for disease monitoring is necessary.

BACKGROUND: Acute biliary pain is the most common presentation of gallstone disease. Untreated patients risk recurrent pain, cholecystitis, obstructive jaundice, pancreatitis and multiple hospital presentations. We examine the outcome of implementing a policy to offer laparoscopic cholecystectomy on index presentation to patients with biliary colic in a tertiary hospital in Australia. METHODS: This is a retrospective cohort study of adult patients presenting to the emergency department (ED) with biliary pain during three 12-month periods. Outcomes in Group A, 3 years prior to policy implementation, were compared with groups 2 and 7 years post implementation (Groups B and C). Primary outcomes were representations to ED, admission rate and time to cholecystectomy. RESULTS: A total of 584 patients presented with biliary colic during the three study periods. Of these, 391 underwent cholecystectomy with three Strasberg Type A bile leaks and no bile duct injuries. The policy increased admission rates (A = 15.8%, B = 62.9%, C = 29.5%, P < 0.001) and surgery on index presentation (A = 12.0%, B = 60.7%, C = 27.4%, P < 0.001). There was a decline in time to cholecystectomy (days) (A = 143, B = 15, C = 31, P < 0.001), post-operative length of stay (days) (A = 3.6, B = 3.2, C = 2.0, P < 0.05) and representation rates to ED (A = 42.1%, B = 7.1%, C = 19.9%, P < 0.001). There was a decline in policy adherence in the later cohort. CONCLUSION: Index hospital admission and cholecystectomy for biliary colic decrease patient representations, time to surgery, post-operative stay and complications of gallstone disease. This study demonstrates the impact of the policy with initial improvement, the dangers of policy attrition and the need for continued reinforcement.

This article reports the findings from a national survey of self-transcendent (or inspiring) media audience members in the United States. Exposure to self-transcendent content is socially significant because, theoretically, it can orient users toward matters beyond themselves, ultimately promoting connections with others and altruistic behaviors. However, to date, little is known about the daily audiences for such fare. Four primary questions guided the investigation: (a) What are the media sources and contents identified as “inspiring” by the audience? (b) Who makes up the current U.S. audience for self-transcendent media content? (c) What personality traits and viewer characteristics are associated with self-transcendent media consumption? and (d) What prosocial and altruistic behaviors are associated with self-transcendent media consumption? To address these questions, a nationally representative survey (n = 3,006) was conducted. The findings are discussed in relation to the growing body of scholarship...

Introduction Cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS) is a rare multisystem neurodegenerative disorder. We describe our perioperative evaluation and care of a patient with CANVAS undergoing a pancreaticoduodenectomy for an ampullary adenocarcinoma, with a focus on perioperative risk stratification and optimisation, intraoperative advanced haemodynamic monitoring and the postoperative care. Case presentation A 69-year-old female with CANVAS presented with asymptomatic obstructive jaundice, icterus and abdominal pain. She had limited mobility and deconditioning due to severe generalised neuropathy. Computed tomography confirmed a resectable periampullary tumour. Her Duke Activity Status Index was 8.25 points and Edmonton Frailty Scale score was 11, confirming moderate frailty. However, the Charlson Comorbidity Index was five, indicative of a 21% estimated 10-year survival. Further risk stratification including respiratory function testing, echocardiography and cardiopulmonary exercise testing was conducted. The patient proceeded with surgery after multidisciplinary discussions with her treating medical teams. Discussion CANVAS is a rare and challenging condition requiring careful perioperative planning and management. There is no effective treatment for CANVAS. The management approach focuses on mitigating symptoms and improving quality of life. Given that no specific guidelines for managing these patients in the perioperative period have been provided, this report highlights several critical medical issues and implications that should be considered for the successful management of these patients. We demonstrate the role of specific anaesthesia techniques and advanced haemodynamic monitoring in both preventing postoperative morbidity and optimising patient recovery. Conclusion CANVAS is a rare and challenging condition in anaesthesia requiring careful perioperative planning and management., Highlights • CANVAS is a rare multisystem neurological disorder • There is no effective treatment for CANVAS • Perioperative management for patients with CANVAS is complex • Perioperative risk stratification requires multidisciplinary involvement • CANVAS patients can present with unique anaesthesia challenges

The intraoperative delivery of medications for patients with Parkinson’s disease (PD) during prolonged surgery is challenging. In complex surgical procedures, PD medications are commonly delivered via a nasogastric tube. However, this technique is not feasible in procedures where the stomach is

We argue that concerted efforts by Tea Party leaders, Republican politicians, and leading Christian Right figures to establish and promote a connection between Christian faith and the free-market system has helped shift the economic attitudes of white evangelical Protestants in a more conservative direction. Our analysis of Public Religion Research Institute survey data finds that white evangelical Protestants express greater skepticism about an active role of government in society and believe economic growth is more likely to be spurred by a reduction in taxes rather than in public investments. Moreover, we find that identifying with the Tea Party has a conservatizing influence on their economic issue positions. While we find that partisanship, class, and in some cases, age, serve to modify the views of some evangelicals, by and large, evangelicals have come to embrace the conservative fiscal message promoted by both the Republican Party and the Tea Party movement.

We present the case of a 29-year-old woman who attended a surgical outpatient clinic with symptoms of perianal fissure due to syphilitic infection. This uncommon aetiology of a common condition is often alluded to in textbooks, but little information exists in the scientific literature regarding the pathogenesis, presentation and treatment of fissure-in-ano secondary to syphilis. We present the case and an overview of the topic aimed at surgeons and clinicians who manage patients with perianal pathology. Syphilis is far from a disease of antiquity; in patients presenting with fissure-in-ano a thorough sexual history and sexually transmissible infection screening in at-risk groups may avoid mis-diagnosis, community transmission and unnecessary procedures.

Ileostomy formation is a fundamental component in the surgical management of many gastrointestinal diseases and like all intra-abdominal surgeries, small bowel obstruction is a recognized complication. In this paper we discuss a case of a 44-year-old female who previously had a loop ileostomy for slow bowel transit in the presence of spinal bifida. She presented for subsequent total colectomy because of ongoing pain due to chronic colonic dilation. At surgery, the stoma was not revised and the efferent loop was divided at the peritoneal level of the anterior abdominal wall. Six days postoperatively, the patient developed a small bowel obstruction as a result of the remnant efferent loop within the anterior abdominal wall, forming a cystic mass compressing the ileostomy, requiring surgical intervention. As far as we are aware, this is the first case of small bowel obstruction described due to this unusual etiology.

Acute biliary pain is the most common presentation of gallstone disease. Untreated patients risk recurrent pain, cholecystitis, obstructive jaundice, pancreatitis and multiple hospital presentations. We examine the outcome of implementing a policy to offer laparoscopic cholecystectomy on index presentation to patients with biliary colic in a tertiary hospital in Australia.This is a retrospective cohort study of adult patients presenting to the emergency department (ED) with biliary pain during three 12-month periods. Outcomes in Group A, 3 years prior to policy implementation, were compared with groups 2 and 7 years post implementation (Groups B and C). Primary outcomes were representations to ED, admission rate and time to cholecystectomy.A total of 584 patients presented with biliary colic during the three study periods. Of these, 391 underwent cholecystectomy with three Strasberg Type A bile leaks and no bile duct injuries. The policy increased admission rates (A = 15.8%, B = 62.9%, C = 29.5%, P0.001) and surgery on index presentation (A = 12.0%, B = 60.7%, C = 27.4%, P0.001). There was a decline in time to cholecystectomy (days) (A = 143, B = 15, C = 31, P0.001), post-operative length of stay (days) (A = 3.6, B = 3.2, C = 2.0, P0.05) and representation rates to ED (A = 42.1%, B = 7.1%, C = 19.9%, P0.001). There was a decline in policy adherence in the later cohort.Index hospital admission and cholecystectomy for biliary colic decrease patient representations, time to surgery, post-operative stay and complications of gallstone disease. This study demonstrates the impact of the policy with initial improvement, the dangers of policy attrition and the need for continued reinforcement.

Background Endovascular intervention for chronic total occlusions (CTOs) in aortoiliac occlusive disease (AIOD) poses technical challenges. In this manuscript, our experience of fine needle recanalization for the treatment of iliac artery CTO is described. Method A prospective database recorded treatment of 11 limbs in 11 patients since 2011 using this technique. The majority of these CTO were of the common iliac artery (n = 9). Results Technical success rate was 91% (n = 10). One failed case was due to tortuous iliac anatomy. There was no restenosis of the treated segments at 8 weeks and no major complications, perforations, major limb loss, or periprocedural mortality. Conclusions This technique is a safe and viable adjunct for difficult CTO in AIOD with suitable anatomy. It benefits from being a simple, low-profile, low-cost coaxial system and should be part of the armamentarium with other advanced endovascular techniques.

This article seeks to explore utilitarian conceptions of personhood which for a long time have been employed as part of a rational moral justification for the termination of pregnancy. Michael Tooley's desires-based rights approach to personhood presented in his work Abortion and Infanticide is considered and, it is argued, is found wanting when one considers unconscious adults and their ability to desire life. This article will offer that unconscious sleeping individuals only have the potential to regain the capacity to value their own life and, as such, under Tooley's formula for personhood, temporarily lose their status as a person. Following this, John Harris's utilitarian views on the status of the sleeping adult will be considered and deconstructed to show that, like Tooley, his ascription for personhood falls down at the sleeping adult. This article illustrates that utilitarian conceptions of personhood leave the sleeping adult human devoid of the rights of a person and hence render the value of this consquentialist theory, with regard to the idea of personhood, in severe doubt. The paper argues that utilitarian conceptions of personhood do little more than obstruct the worthy debate over the morality of abortion.