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Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central euvolemia and to avoid excess salt and water. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an individualized fluid management plan. As part of this plan, excess crystalloid should be avoided in all patients. For low-risk patients undergoing low-risk surgery, a “zero-balance” approach might be sufficient. In addition, for most patients undergoing major surgery, individualized goal-directed fluid therapy (GDFT) is recommended. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and “permissive oliguria” could be tolerated.

Background Buffered intravenous fluid preparations contain substrates to maintain acid-base status. The objective of this systematic review was to compare the effects of buffered and non-buffered fluids administered during the perioperative period on clinical and biochemical outcomes. Methods We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library until May 2017 and included all randomised controlled trials that evaluated buffered versus non-buffered fluids, whether crystalloid or colloid, administered to surgical patients. We assessed the selected studies for risk of bias and graded the level of evidence in accordance with Cochrane recommendations. Results We identified 19 publications of 18 randomised controlled trials, totalling 1096 participants. Mean difference (MD) in postoperative pH was 0.05 units lower immediately following surgery in the non-buffered group (12 studies of 720 participants; 95% confidence interval (CI) 0.04 to 0.07; I 2  = 61%). This difference did not persist on postoperative day 1. Serum chloride concentration was higher in the non-buffered group at the end of surgery (10 trials of 530 participants; MD 6.77 mmol/L, 95% CI 3.38 to 10.17). This effect persisted until postoperative day 1 (5 trials of 258 participants; MD 8.48 mmol/L, 95% CI 1.08 to 15.88). Quality of this evidence was moderate. We identified variable protocols for fluid administration and total volumes of fluid administered to patients intraoperatively. Outcome data was variably reported at disparate time points and with heterogeneous patient groups. Consequently, the effect size and overall confidence interval was reduced, despite the relatively low inherent risk of bias. There was insufficient evidence on the effect of fluid composition on mortality and organ dysfunction. Confidence intervals of this outcome were wide and the quality of evidence was low (3 trials of 276 participants for mortality; odds ratio (OR) 1.85, 95% CI 0.37 to 9.33; I 2  = 0%). Conclusions Small effect sizes for biochemical outcomes and lack of correlated clinical follow-up data mean that robust conclusions on major morbidity and mortality associated with buffered versus non-buffered perioperative fluid choices are still lacking. Buffered fluid may have biochemical benefits, including a significant reduction in postoperative hyperchloraemia and metabolic acidosis.

This retrospective study compares the safety and efficacy of hepatic parenchymal transection using vascular staplers (VS) and the crush-clamp (CC) technique. Demographics, clinicopathologic data, treatments, and postoperative outcomes from patients who underwent VS or CC hepatic parenchymal transection were compared. From 1996–2006, 99 and 112 patients underwent hepatic transection with VS and CC, respectively. Compared to CC, VS transection was associated with less operative time (median 210 vs 275 minutes), blood loss (median 250 vs 500 mL), and postoperative red blood cell (RBC) transfusion (29% vs 44%), all P < .05. VS transection was not associated with RBC transfusion on multivariate analysis. There were no differences in rates of positive resection margins (9% vs 13%), postoperative mortality (2% vs 4%), overall morbidity (32% vs 29%), and severe morbidity (20% vs. 23%), all P > .05. Hepatic parenchymal transection with VS can be accomplished with similar safety and efficacy as CC transection.

Fluid resuscitation is an essential part of managing patients with major trauma, as well as in the perioperative setting. Common misconceptions exist regarding the role of fluid therapy in maintaining, enhancing or inhibiting normal coagulation and haemostasis. This review provides an overview of the basic coagulation processes, as well as the influence of intravenous crystalloid and colloid preparations on haemostasis and coagulation. The use of point-of-care devices is encouraged as a feasible way of monitoring these effects in the acute setting.

Aromatase inhibitors effectively prevent breast cancer recurrence and development of new contralateral tumours in postmenopausal women. We assessed the efficacy and safety of the aromatase inhibitor anastrozole for prevention of breast cancer in postmenopausal women who are at high risk of the disease. Between Feb 2, 2003, and Jan 31, 2012, we recruited postmenopausal women aged 40–70 years from 18 countries into an international, double-blind, randomised placebo-controlled trial. To be eligible, women had to be at increased risk of breast cancer (judged on the basis of specific criteria). Eligible women were randomly assigned (1:1) by central computer allocation to receive 1 mg oral anastrozole or matching placebo every day for 5 years. Randomisation was stratified by country and was done with blocks (size six, eight, or ten). All trial personnel, participants, and clinicians were masked to treatment allocation; only the trial statistician was unmasked. The primary endpoint was histologically confirmed breast cancer (invasive cancers or non-invasive ductal carcinoma in situ). Analyses were done by intention to treat. This trial is registered, number ISRCTN31488319. 1920 women were randomly assigned to receive anastrozole and 1944 to placebo. After a median follow-up of 5·0 years (IQR 3·0–7·1), 40 women in the anastrozole group (2%) and 85 in the placebo group (4%) had developed breast cancer (hazard ratio 0·47, 95% CI 0·32–0·68, p<0·0001). The predicted cumulative incidence of all breast cancers after 7 years was 5·6% in the placebo group and 2·8% in the anastrozole group. 18 deaths were reported in the anastrozole group and 17 in the placebo group, and no specific causes were more common in one group than the other (p=0·836). Anastrozole effectively reduces incidence of breast cancer in high-risk postmenopausal women. This finding, along with the fact that most of the side-effects associated with oestrogen deprivation were not attributable to treatment, provides support for the use of anastrozole in postmenopausal women at high risk of breast cancer. Cancer Research UK, the National Health and Medical Research Council Australia, Sanofi-Aventis, and AstraZeneca.

Policy makers and practitioners are in need of useful tools and models for assessing ecosystem service outcomes and the potential risks and opportunities of ecosystem management options. We utilize a state-and-transition model framework integrating dynamic soil and vegetation properties to examine multiple ecosystem services-specifically agricultural production, biodiversity and habitat, and soil health-across human created vegetation states in a managed oak woodland landscape in a Mediterranean climate. We found clear tradeoffs and synergies in management outcomes. Grassland states maximized agricultural productivity at a loss of soil health, biodiversity, and other ecosystem services. Synergies existed among multiple ecosystem services in savanna and woodland states with significantly larger nutrient pools, more diversity and native plant richness, and less invasive species. This integrative approach can be adapted to a diversity of working landscapes to provide useful information for science-based ecosystem service valuations, conservation decision making, and management effectiveness assessments.

Rangelands are a key global resource, providing a broad range of ecological services and economic benefits. California's predominantly annual rangelands cover ∼12% of the state's land area, and the forage production is highly heterogeneous, making balancing economic (grazing), conservation (habitat) and environmental (erosion/water quality) objectives a big challenge. Herein, we examined how climate and environmental factors regulate annual grassland forage production spatially across the state and among four ecoregions using machine learning models. We estimated annual forage production at 30 m resolution over a 14 year period (2004-2017) using satellite images and data fusion techniques. Our satellite-based estimation agreed well with independent field measurements, with a R2 of 0.83 and RMSE of 682 kg ha−1. Forage production (14 year average) showed large spatial variability (2940 ± 934 kg ha-1 yr-1; CV = 35%) across the study area. The gradient boosted regression tree with 11 feature variables explained 67% of the variability in forage production across the state. Precipitation amount, especially in November (germination) and April (rapid growth), was found as the dominant driver for spatial variation in forage production, especially in drier ecoregions and during drier years. Seasonal distribution of precipitation and minimum air temperature showed a relatively stronger control on forage production in wetter regions and during wet years. Additionally, solar energy became more important in wetter ecoregions. Drought reduced forage production from the long-term mean, i.e. a 33% ± 19% decrease in production (2397 ± 926 kg ha-1yr-1; CV = 38%) resulting from a 29% ± 5% decrease in precipitation. The machine learning based spatial analysis using 'big data' provided insights on impacts of climate and environmental factors on forage production variation at various scales. This study demonstrates a cost-effective approach for rapid mapping and assessment of annual forage production with the potential for near real-time application.

Neurospora crassa colonizes burnt grasslands in the wild and metabolizes both cellulose and hemicellulose from plant cell walls. When switched from a favored carbon source such as sucrose to cellulose, N. crassa dramatically upregulates expression and secretion of a wide variety of genes encoding lignocellulolytic enzymes. However, the means by which N. crassa and other filamentous fungi sense the presence of cellulose in the environment remains unclear. Here, we show that an N. crassa mutant carrying deletions of two genes encoding extracellular β-glucosidase enzymes and one intracellular β-glucosidase lacks β-glucosidase activity, but efficiently induces cellulase gene expression in the presence of cellobiose, cellotriose, or cellotetraose as a sole carbon source. These data indicate that cellobiose, or a modified version of cellobiose, functions as an inducer of lignocellulolytic gene expression in N. crassa. Furthermore, the inclusion of a deletion of the catabolite repressor gene, cre-1, in the triple β-glucosidase mutant resulted in a strain that produces higher concentrations of secreted active cellulases on cellobiose. Thus, the ability to induce cellulase gene expression using a common and soluble carbon source simplifies enzyme production and characterization, which could be applied to other cellulolytic filamentous fungi.