The NELA risk prediction model for emergency laparotomies discriminates well between low- and high-risk patients and is suitable for producing risk-adjusted provider mortality statistics.

Background: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups. Methods: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. Results: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and leastdeprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76e0.92]; Q3: 0.84 [0.76e0.92]; Q4: 0.87 [0.79e0.96]; Q5 [least deprived]: 0.77 [0.70e0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association. Conclusions: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.

Calcineurin (protein phosphatase 2B) is a calcium-dependent serine-threonine phosphatase. It has diverse roles and is centrally involved in synaptic plasticity. The catalytic A subunit of calcineurin has three isoforms, alpha, beta and gamma. Their expression and ontogeny in the brain has not been systematically investigated; such data become important with a report that PPP3CC, the gene encoding calcineurin Agamma, is a susceptibility gene for schizophrenia, and the finding that its expression is decreased in the disorder. We used in situ hybridization histochemistry to measure the relative transcript abundance of calcineurin Agamma and the other catalytic isoforms, Aalpha and Abeta, during development of the Sprague-Dawley rat hippocampus and cerebellum. All three isoforms are present in both regions at all time points [embryonic day 19 (E19) to postnatal day 42 (P42)] and undergo developmental regulation, but differ in their ontogenic profile. Calcineurin Aalpha and Abeta mRNAs increased from E19 through to adulthood, whereas Agamma mRNA was most highly expressed during early developmental stages. Calcineurin Aalpha and Abeta mRNAs positively correlated with synaptophysin mRNA (a synaptic marker), whilst Agamma mRNA was either unrelated to, or negatively correlated, with this transcript. These data confirm that all three calcineurin A subunits are expressed in the rodent brain, and indicate that calcineurin Agamma may have different roles than Aalpha and Abeta. The data also suggest a potential importance of calcineurin Agamma in neurodevelopment, and in the genetically influenced neurodevelopmental disturbance that is thought to underlie schizophrenia.

This systematic review suggests that socioeconomic deprivation influences mortality after colorectal surgery.

ObjectivesTo evaluate whether distance and estimated travel time to hospital for patients undergoing emergency laparotomy is associated with postoperative mortality.DesignNational cohort study using data from the National Emergency Laparotomy Audit.Setting171 National Health Service hospitals in England and Wales.Participants22 772 adult patients undergoing emergency surgery on the gastrointestinal tract between 2013 and 2016.Main outcome measuresMortality from any cause and in any place at 30 and 90 days after surgery.ResultsMedian on-road distance between home and hospital was 8.4 km (IQR 4.7–16.7 km) with a median estimated travel time of 16 min. Median time from hospital admission to operating theatre was 12.7 hours. Older patients live on average further from hospital and patients from areas of increased socioeconomic deprivation live on average less far away.We included estimated travel time as a continuous variable in multilevel logistic regression models adjusting for important confounders and found no evidence for an association with 30-day mortality (OR per 10 min of travel time=1.02, 95% CI 0.97 to 1.06, p=0.512) or 90-day mortality (OR 1.02, 95 % CI 0.97 to 1.06, p=0.472).The results were similar when we limited our analysis to the subgroup of 5386 patients undergoing the most urgent surgery. 30-day mortality: OR=1.02 (95% CI 0.95 to 1.10, p=0.574) and 90-day mortality: OR=1.01 (95% CI 0.94 to 1.08, p=0.858).ConclusionsIn the UK NHS, estimated travel time between home and hospital was not a primary determinant of short-term mortality following emergency gastrointestinal surgery.

No abstract

It is known that delivery of enteral nutrition in the Intensive Care Unit (ICU) is often suboptimal (1) . Our ICU provides care to a wide range of clinical areas including trauma. In a recent audit we identified that on average only 68 % (range 0 to 117%) of prescribed feed was delivered. Routinely our 'first-line' choice of enteral tube feed is a 1 kcal/ml feed containing 0.04 g protein per kcal. We wished to identify the adequacy of protein delivery against estimated requirements when using this feed.We used previously collected audit data of 50 consecutive admissions to the ICU at the Royal London Hospital. Data collected included weight (estimated or actual), height/measured length, calculated BMI, estimated energy and protein requirements (calculated using accepted guidelines(1) ), feed prescription and daily volume of feed delivered. The amount of protein from the prescribed volume of feed was compared to daily estimated protein requirements.Of the 50 patients, 22 were excluded from analysis (15 were not enterally tube fed or not assessed by a dietitian due to a short admission, two had parenteral nutrition and five were prescribed an alternative enteral tube feed). The remaining 28 patients were prescribed a standard polymeric feed (1 kcal/ml, 0.04 g protein/kcal) which met patients' estimated energy requirements. 27 (96 %) of these prescriptions did not meet estimated protein requirements and one (4 %) met estimated requirements.Enteral tube feeds with higher protein content are available in the United Kingdom (two alternative formulations of available feeds are given below). We therefore calculated the required volume of feed that would be required for each patient in our audit using these alternative feeds. From this we predicted protein delivered if using the two alternative feed formulations (assuming 100% delivery). Both alternative higher protein content feeds improved the number of patients that would have a feed prescription meeting their estimated protein requirements. The alternative feed containing 1 kcal/ml and 0.062 g protein/kcal was most successful at meeting patients' estimated protein requirements (82 % of patients).Protein delivery using a standard 1 kcal/ml feed (0.04 g protein/kcal) did not meet requirements for most patients. Protein delivery is further reduced when feed delivery is inadequate. An enteral tube feed with increased protein should be considered on our ICU. Strategies to improve enteral feed delivery are also required. factors impeding adequate delivery.

High-frequency jet ventilation (HFJV) can reduce organ movement that otherwise complicates percutaneous image-guided ablation (IGA) procedures. This study describes feasibility and safety of the technique in routine use. We describe our method for the use of HFJV and present 169 consecutive cases, including IGA of tumors of the lung, liver, kidney, and pancreas. Intended oncological treatment was delivered in all cases and HFJV used for the duration of treatment in all except one case. We describe the characteristics of patients, procedures, and adverse events. It is feasible to use HFJV as the routine standard of care for IGA.