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Sarcopenia has been shown to have significant adverse health outcomes in a range of patient populations. Particularly, sarcopenic patients having cancer surgery are a unique group who demonstrate poorer post-operative outcomes. Currently, the gold standard in diagnosing sarcopenia is through the use of computed tomography. However, the widespread use of imaging to diagnose patients with sarcopenia is neither cost-effective nor practical. Identifying a serum biomarker or a simple mobility scoring system as an alternative diagnostic tool may aid in identifying more patients at risk of sarcopenia. C1q, a novel biomarker, has previously been shown to correlate with sarcopenia. Similarly, we sought to explore whether mobility scores may provide a useful surrogate marker for sarcopenia.This was a prospective cohort study of patients who presented for colorectal cancer surgery between the dates of 6/10/2016 and 4/10/2017 at John Hunter Hospital. Computed tomography was utilized to calculate the psoas area at the L3 spinal level. Pre-operative blood samples were obtained for C1q analysis and de Morton Mobility Index (DEMMI) was also performed.A total of 51 patients were included in the study. The median age of the patients were 69 years old. We did not demonstrate a correlation between serum C1q and DEMMI scores with psoas area.Our findings suggest that neither C1q nor DEMMI scores are correlated with psoas area in a colorectal cancer population.

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.

Preoperative skin antiseptics are used prior to surgery to reduce the risk of surgical site infection (SSI). There is debate as to which is the most effective. The aim of this network meta-analysis (NMA) is to compare the effectiveness of different skin preparations at reducing SSIs in patients undergoing incisional surgery.The study protocol was published in PROSPERO (CRD4202181599) a priori with predefined search terms and inclusion/exclusion criteria. The skin preparations for comparison were: chlorhexidine/alcohol (CHA), chlorhexidine/water (CHW), poviodine/alcohol (PVIA), poviodine/water (PVIW). The records identified were screened by two authors independently by title, abstract and in full text. The revised tool for risk-of bias (ROB2) assessment was used.Twenty-nine RCTs involving 15 796 patients were included in the NMA. A significant but small increase in the odds of infection was seen in the PVIW group compared to the CHA group (OR 1.34, 95%CrI 1.09-1.64), but other comparisons were not statistically significantly different. Ranking the treatment arms showed there was a 64% probability that CHA is the most effective and a 62.7% probability that PVIW is the least effective treatment.Chlorhexidine/alcohol (CHA) was found to be the most effective for prevention of superficial and deep SSI while PVIW was the least. There was no differences seen between CHA and PVIA, or CHW and PVIW. The superiority of CHA is likely due to the effect of the alcohol in the base. Hence the choice between CHA and PVIA should be based on health and cost considerations.

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.

Background: High response rates for patient surveys are required in medical literature to ensure non-response bias is minimised. It is often difficult to achieve a satisfactory response rate as patient engagement in surveys is decreasing. A major barrier to phone surveys is getting patients to answer calls from unknown numbers. Purpose: To design a methodology which boosts response rates for telephone-based patient surveys. Research Design: We prospectively analysed the effectiveness of our methodology for increasing patient participation using caller ID and text messanging. Study Sample: Two waves totalling 1313 patients were contacted for participation in a patient survey for a descriptive quantitative and qualitative cohort study using our developed methadology. Data Analysis: We analysed the timepoints at which successful contact was made when using caller ID and text messanging. Results: We achieved a call answer rate of 85.4%, which was a 70.8% increase when compared to a similar patient cohort contacted via blocked caller ID (i.e. with privacy settings). Conclusion: We have developed a simple, inexpensive methodology which, when tested outside the Australian setting and for other projects, shows promise for increasing patient survey response rate.

Concrete is the most extensively used material in construction and is generally relatively resistant, but under certain environmental conditions it is susceptible to microbially influenced degradation (MID) by bacteria, algae and fungi. Filamentous fungi, including Fusarium oxysporum, Aspergillus niger and Cladosporium sphaerospermum, are widely detected on corroded concrete surfaces. However, in contrast to bacteria, the extent of, and factors influencing, fungal influenced degradation (FID) of concrete are poorly understood. The extensive presence and survival ability of fungi in concrete may be explained by their remarkable environmental adaptability and capacity to modify potentially extreme environments, including alkaline pH conditions found in concrete, facilitating its exploitation by, and growth of, the organism. Furthermore, fungi produce dormant, resistant spores that remain viable and survive for long periods of time, cellular autolysis conserves resources to maintain viability and growth in low nutrient conditions, and the mycelial network facilitates the transport of nutrients, substrates, water and oxygen (O2) within fungal colonies. The concrete environment is rich in calcium (Ca), which is essential for hyphal growth, and the requirement for this important nutrient may explain why fungi grow in and exploit concrete as a resource. The identified mechanisms responsible for the FID of concrete, include: (1) the formation and leaching of soluble Ca salts from the reaction of organic acids secreted by fungal cells with Ca in concrete; (2) expansion due to formation of insoluble Ca salts, such as Ca citrate, from the reaction with fungal organic acids; (3) crack development by ettringite formation from the secretion of the enzyme, keratinase, and amino acids; and (4) potential mechanical attack by fungal hyphal growth and extension into solubilisation zones and cracks. The mechanisms of FID operate simultaneously and potentially have important, yet currently underestimated, consequences for the aesthetic, functional and structural properties of concrete structures. However, direct evidence of internal decay induced by fungal hyphae is lacking, and physical and chemical research is required to demonstrate the potential extent and significance of internal FID of concrete.

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.

Abstract Enzymes are high value industrial bio-catalysts with extensive applications in a wide range of manufacturing and processing sectors, including the agricultural, food and household care industries. The catalytic efficiency of enzymes can be several orders higher compared to inorganic chemical catalysts under mild conditions. However, the nutrient medium necessary for biomass culture represents a significant cost to industrial enzyme production. Activated sludge (AS) is a waste product of biological wastewater treatment and consists of microbial biomass that degrades organic matter by producing substantial quantities of hydrolytic enzymes. Therefore, enzyme recovery from AS offers an alternative, potentially viable approach to industrial enzyme production. Enzyme extraction from disrupted AS flocs is technically feasible and has been demonstrated at experimental-scale. A critical review of disruption techniques identified sonication as potentially the most effective and suitable method for enzyme extraction, which can be scaled up and is a familiar technology to the water industry. The yields of different enzymes are influenced by wastewater treatment conditions, and particularly the composition, and can also be controlled by feeding sludge with specific target substrates. Nevertheless, hydrolytic enzymes can be effectively extracted directly from waste AS without specific modifications to standard wastewater treatment processes. Purification, concentration and stabilisation/immobilisation techniques can also greatly expand the industrial application and increase the economic value and marketability of enzyme products extracted from AS. Concentrated and purified AS enzymes could readily substitute inorganic and/or commercial bioenzyme catalysts in many industrial applications including, for example, leather processing, and in detergent and animal feed formulation. Enzyme extraction from AS therefore offers significant economic benefits to the Water Industry by recovering valuable resources from wastewater. They can also optimise important waste treatment processes, such as the anaerobic digestion (AD) of sewage sludge, increasing biogas and renewable energy production. The enzyme-extracted sludge exhibits improved treatment properties, such as increased settleability, dewaterability, and anaerobic digestibility for biogas production, assisting sludge management by wastewater treatment plants (WWTPs) and enabling the further utilisation of the residual sludge. Graphic Abstract

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.

There is much debate surrounding the ideal antiseptic skin preparation agent to reduce postoperative surgical site infection. International guidelines suggest that chlorhexidine- and alcohol-containing compounds have superior efficacy. However, there are minimal clinical trials specifically looking at skin preparation agents for colorectal surgery.The aim of this study was to compare the efficacy of chlorhexidine in alcohol versus povidone-iodine in alcohol versus povidone-iodine in aqueous solution for the prevention of surgical site infection in colorectal surgery.This is a prospective, 3-armed, randomized controlled trial.This study was conducted at the 800-bed John Hunter Hospital and Newcastle Private Hospital, with all subspecialty services in New South Wales, Australia.All eligible, consenting adults undergoing colorectal surgery between July 2015 and December 2018 were included.Patients were andomized to receive preincision skin preparation with one of the following: chlorhexidine in 70% alcohol, povidone-iodine in 70% alcohol, or povidone-iodine in aqueous solution.The primary measure was surgical site infection within 30 days.A total of 482 patients were randomized to chlorhexidine in alcohol, povidone-iodine in alcohol, or aqueous povidone-iodine. The overall surgical site infection rate was 22% (107/482). There was no difference in rates of surgical site infection: 20.6% (29/141), 22.8% (44/193), and 23.0% (34/148), respectively ( p = 0.5267). There was no difference in complication rates: 54.6% (77/141), 46.1% (89/193), and 49.3% (73/148), respectively ( p = 0.1762). The median length of stay was 6 days in all 3 groups.This is a subset analysis of a larger clinical trial for all forms of incisional surgery (the NewSKIN Prep trial), and noninferiority cannot be assessed. Changes in government regulations resulted in a change from 0.5% chlorhexidine in 70% ethanol to 2% chlorhexidine in 70% ethanol during the trial.This large, prospective, randomized clinical trial appears to indicate that there is no difference in surgical site infection, complications, or length of stay among the 3 commonest forms of skin preparation in colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B875 .New Zealand Clinical Trials registry: ACTRN12615000021572Agentes antisépticos para la preparación de la piel para prevenir la infección del sitio quirúrgico en la cirugía colorrectal: un ensayo clínico aleatorizado de tres grupos.Existe un gran debate en torno al agente de preparación de la piel antiséptico ideal para reducir la infección posoperatoria del sitio quirúrgico. Las pautas internacionales sugieren que los compuestos que contienen clorhexidina y alcohol tienen una eficacia. Sin embargo, existen ensayos clínicos mínimos que analizan específicamente los agentes de preparación de la piel para la cirugía colorrectal.Comparar la eficacia de la clorhexidina en alcohol versus povidona yodada en alcohol versus povidona yodada en solución acuosa para la prevención de la infección del sitio quirúrgico en cirugía colorrectal.Este es un ensayo controlado aleatorio prospectivo de tres brazos.Este estudio se realizó en el Hospital John Hunter de 800 camas y el Hospital Privado de Newcastle con todos los servicios de subespecialidad en Nueva Gales del Sur, Australia.Se incluyeron todos los adultos elegibles que dieron su consentimiento para someterse a una cirugía colorrectal entre julio de 2015 y diciembre de 2018.Aleatorizados para recibir una preparación para la piel previa a la incisión con uno de: clorhexidina en alcohol al 70%, povidona yodada en alcohol al 70% o povidona yodada en solución acuosa.La medida principal fue la infección del sitio quirúrgico dentro de los 30 días.Un total de 482 pacientes fueron aleatorizados para recibir clorhexidina en alcohol, povidona yodada en alcohol o povidona yodada acuosa. La tasa global de infección del sitio quirúrgico fue del 22% (107/482). No hubo diferencias en las tasas de infección del sitio quirúrgico; 20,6% (29/141), 22,8% (44/193) y 23,0% (34/148) respectivamente; p = 0,5267. No hubo diferencia en las tasas de complicaciones; 54,6% (77/141), 46,1% (89/193) y 49,3% (73/148) respectivamente; p = 0,1762. La duración media de la estancia hospitalaria fue de 6,0 días en los tres grupos.Este es un análisis de subconjunto de un ensayo clínico más grande para todas las formas de cirugía incisional (el ensayo NewSKIN Prep) y no se puede evaluar la no inferioridad. Los cambios en las regulaciones gubernamentales dieron como resultado un cambio de clorhexidina al 0,5% en etanol al 70% a clorhexidina al 2% en etanol al 70% durante la prueba.Este gran ensayo clínico prospectivo y aleatorizado parece indicar que no hay diferencia en la infección del sitio quirúrgico, las complicaciones o la duración de la estancia entre las 3 formas más comunes de preparación de la piel en la cirugía colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B875 . (Traducción-Dr. Gonzalo Hagerman )Este ensayo se registró de forma prospectiva en el registro de ensayos clínicos de Australia Nueva Zelanda el 15/01/2015: ACTRN12615000021572.

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.

Many types of bioresource materials are beneficially recycled in agriculture for soil improvement and as alternative bedding materials for livestock, but they also potentially transfer contaminants into plant and animal foods. Representative types of industrial and municipal bioresources were selected to assess the extent of organic chemical contamination, including: (i) land applied materials: treated sewage sludge (biosolids), meat and bone meal ash (MBMA), poultry litter ash (PLA), paper sludge ash (PSA) and compost-like-output (CLO), and (ii) bedding materials: recycled waste wood (RWW), dried paper sludge (DPS), paper sludge ash (PSA) and shredded cardboard. The materials generally contained lower concentrations of polychlorinated dibenzo-p-dioxins/dibenzofurans (PCDD/Fs) and dioxin-like polychlorinated biphenyls (PCBs) relative to earlier reports, indicating the decline in environmental emissions of these established contaminants. However, concentrations of polycyclic aromatic hydrocarbons (PAHs) remain elevated in biosolids samples from urban catchments. Polybrominated dibenzo-p dioxins/dibenzofurans (PBDD/Fs) were present in larger amounts in biosolids and CLO compared to their chlorinated counterparts and hence are of potentially greater significance in contemporary materials. The presence of non ortho polychlorinated biphenyls (PCBs) in DPS was probably due to non-legacy sources of PCBs in paper production. Flame retardent chemicals were one of the most significant and extensive groups of contaminants found in the bioresource materials. Decabromodiphenylether (deca-BDE) was the most abundant polybrominated diphenyl ether (PBDE) and may explain the formation and high concentrations of PBDD/Fs detected. Emerging flame retardant compounds, including: decabromodiphenylethane (DBDPE) and organophosphate flame retardants (OPFRs), were also detected in several of the materials. The profile of perfluoroalkyl substances (PFAS) depended on the type of waste category; perfluoroundecanoic acid (PFUnDA) was the most significant PFAS for DPS, whereas perfluorooctane sulfonate (PFOS) was dominant in biosolids and CLO. The concentrations of polychlorinated alkanes (PCAs) and di-2-ethylhexyl phthalate (DEHP) were generally much larger than the other contaminants measured, indicating that there are major anthropogenic sources of these potentially hazardous chemicals entering the environment. The study results suggest that continued vigilance is required to control emissions and sources of these contaminants to support the beneficial use of secondary bioresource materials.

Sewage sludge is the essential by‐product of wastewater treatment and approaching 100% of the sludge generated in the United Kingdom is recycled to agricultural land. In collaboration with three major Water Utility companies in the United Kingdom, a critical statistical analysis of historical and contemporary sludge quality data was completed to demonstrate the long‐term patterns and improvements in the trace element (TE) content of sludge recycled to agriculture since 1989, and to indicate the current status of sludge quality in the United Kingdom. Comparisons with pollutant emission inventory data showed most of the TE concentrations in sludge were strongly linked to declining environmental emissions. A soil accumulation model showed that zinc and copper would be the first to approach their statutory soil limits in the long term and that nickel, cadmium, lead and mercury are no longer significant and, from a practical perspective, could be removed from the regulatory controls on agricultural use.

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.

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.

Organic contaminants (OCs), such as pharmaceuticals, personal care products, flame retardants, and plasticisers, are societally ubiquitous, environmentally hazardous, and structurally diverse chemical compounds whose recalcitrance to conventional wastewater treatment necessitates the development of more effective remedial alternatives. The engineered application of ligninolytic oxidoreductase fungal enzymes, principally white-rot laccase, lignin peroxidase, and manganese peroxidase, has been identified as a particularly promising approach for OC remediation due to their strong oxidative power, broad substrate specificity, low energy consumption, environmental benignity, and cultivability from lignocellulosic waste. By applying an understanding of the mechanisms by which substrate properties influence enzyme activity, a set of semi-quantitative physicochemical criteria (redox potential, hydrophobicity, steric bulk and pKa) was formulated, against which the oxidoreductase degradation susceptibility of twenty-five representative OCs was assessed. Ionisable, compact, and electron donating group (EDG) rich pharmaceuticals and antibiotics were judged the most susceptible, whilst hydrophilic, bulky, and electron withdrawing group (EWG) rich polyhalogenated compounds were judged the least susceptible. OC susceptibility scores were in general agreement with the removal rates reported for experimental oxidoreductase treatments (R2 = 0.60). Based on this fundamental knowledge, and recent developments in enzyme immobilisation techniques, microbiological enzymic treatment strategies are proposed to formulate a new generation of biological wastewater treatment processes for the biodegradation of environmentally challenging OC compounds.

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.

Untreated sewage sludge potentially contains a wide range of enteric pathogens that present a risk to human health. Mesophilic anaerobic digestion (MAD) is the most-favoured process for sewage sludge treatment in the United Kingdom. It is a well-established approach to sludge stabilisation, but the mechanisms responsible for pathogen removal are poorly understood. Operational data collected by Thames Water from conventional MAD sites were statistically scrutinised to examine the effects of primary and secondary digestion on the removal of the enteric indicator bacteria, Escherichia coli, by using the IBM SPSS statistical software package for ANOVA, post-hoc and multiple regression analysis. The results showed that the process temperature conditions at the MAD plants were equivalent to or exceeded the minimum estimated by the analysis necessary to comply with the 2 log10 removal standard for E. coli. The results also showed that primary digestion conditions (specifically temperature) sublethally damaged E. coli and increased decay in secondary digestion and therefore over the whole digestion process.

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.