text:
Play simon game :
Classic simon game online:
The classic simon game online with 4 keys of different colours. You will love this memory game!!!
This game is the online version of the simon electronic game. Indeed, it looks just like the official simon game, with its circular design and its four large keys of different colors: red, green, blue and yellow. Each key is linked to a different electronic sound which help the player to memorize the series of illuminated keys.
How to play free simon game online:
Try to memorize the series of illuminated keys and reproduce it, at each step a new key is added to the series and the game becomes more difficult. The game is over when the first error is committed by the player (when the player press the wrong illuminated key).
The purpose of the game is to reproduce the longest series of colors / sounds randomly generated by the game.
You can change the game's difficulty level thanks to the buttons located below the game. The default mode is "auto", this means that the speed will gradually increase. For beginners, we recommend that you start with a slow speed game. If the sound effects of the game bothers you, you can also mute the sound thanks to the button located at the top right corner of the game.
This game is now responsive, so it's compatible with all devices: desktop, tablets and smartphones. The content and the game adjust automatically to your device, so do not hesitate to play on a tablet or a smartphone.
Why play simon memory game:
The simon game is a great exercise for training the memory while having fun. More you play to this game and more your boost and improve your memory. It's an excellent and famous memory game. The series of illuminated keys is randomly generated, so the game is endless and you can play as many times as you like!
All online simon games on Memozor are free and unlimited.
Game created on Tuesday, 23 January 2018
Last modified on Saturday, 27 April 2019
More in this category: « Simon game - animals Simon game - Piano version »


Designed for mounting above travelling steel oven band or indeed underneath, between the baking and return surfaces, as might be the case for Jaffa Cake production, an existing processing line, tray conveyor which might already exist, or integrally built with its own depositing conveyor.
Can be equipped with an integral depositing conveyor & a biscuit dispensing and biscuit aligning unit.
Essentially constructed to accommodate our range of volumetric depositing manifolds but can be equipped with various types of pressurised plain, combination and marshmallow wire cut manifolds as well.


text:
Numanlar is a village in the Kastamonu District, Kastamonu Province, Turkey. Its population is 113 (2021).

References

Villages in Kastamonu District

redpajama_set_name: RedPajamaWikipedia


text:
Мулява () — поселення в общині Іванчна Гориця, Осреднєсловенський регіон, Словенія. Висота над рівнем моря: 319,3 м.

Відомі люди
Йосип Юрчич (1844—1881) — словенський письменник й журналіст

Посилання

 Статистичне бюро Республіки Словенія, населення, 2002

Населені пункти Словенії


Stink bugs are an emerging threat to soybean and corn production in the Midwest. The brown marmorated stink bug (BMSB) is invading the region, and was found for the first time in Minnesota soybean last summer (see image below with arrows indicating some key features for identification). In addition, there are reports from the region of increasing abundance of some of the native stink bug species. As part of our response to this emerging threat, we recently wrote an article reviewing the identification, biology and management of stink bugs in soybean and corn, which can be accessed through the Journal of Integrated Pest Management.


text:
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    <!-- From: file:/Users/Nish/Source/nishanil-git/googleio/android/src/main/res/values-sw360dp/styles.xml -->
    <eat-comment />

    <style name="LoginHelpText">
        <item name="android:textSize">@dimen/text_size_large</item>
        <item name="android:lineSpacingMultiplier">1.1</item>
        <item name="android:textColor">@color/body_text_1</item>
        <item name="android:fontFamily">sans-serif-light</item>
    </style>

</resources>

redpajama_set_name: RedPajamaGithub


Only during a time when we are in desperate need do we understand how much Allah really does take care of us.
2- Doesn't blame Allah- He could have said, "Allah you tested me with adversity", but rather said "adversity has touched me", showing the respect to Allah that is part of our etiquette in du'a.
3- He asks for Allah's Mercy– In spite of all that has gone on, the Prophet still asks for Allah's mercy. He has not lost hope in Allah's mercy in spite of all that has happened.


In 1948 the International Student Union (Internationaler Studentenbund) and the Student Movement for Transnational Federation (Studentenbewegung für übernationale Föderation e.V., ISSF) started to think about common features of the European states. ASA emerged in the 1960s as a program administrated by students who organized work and study stays in the so-called "Third World".
1960 the first 10 participants went to Sudan; in the following years the number increased to 70 to 80 participants. In the beginning ASA was financed by the students, their work on German building sites in the host countries and donations from private and public donors.
Over the years, ASA became more successful and more and more people wanted to participate. The growing organizational needs outgrew the possibilities of a student union with a volunteer administration.
1966 - the student initiative advanced into a civil law association, the "Foundation Study Group for International Encounters and Studies Abroad" (Stiftung Studienkreis für internationale Begegnung und Auslandsstudien). They organized international circles to discuss development issues and development policy in about 30 universities and the number of participants grew further.
1982 - the ASA-Program was administered by the Carl Duisberg Society (CDG).
1984 - young professionals who had completed their non-academic vocational training were included in the program.
1987/88 - the opportunity to take part in work and study visits was also given to members of partner organizations in Africa, Asia and Latin America – a first step to overcome the one-way attitude of development policy.
2003 - the ASA-Program started building a European network of like-minded organizations and young people committed to development policy. The common objective is to create global education across borders. The European cooperation program was named GLEN"Global Education Network of Young Europeans". Today GLEN comprises partner organizations in 10 European countries and promotes development education in the north.
2006 EURIZONS (European Tour for Global Responsibility) started as a project of GLEN. Eurizons was a hitchhiking-project during which young Europeans hitchhiked through eight countries to inform people about the Millennium Development Goals of the United Nations.
2008 - the ASA-Program started the program "ASApreneurs - Shaping a Sustainable World". The program promotes the development of leadership skills for sustainability in the economy.
Alongside the ASA-Program (with the "ASA-Basic", "ASASouth-North", "ASA-Kommunal, ASApreneurs - Shaping a Sustainable World" and "GLEN"), two other programs with new target groups were developed within ASA: ENSA the "School Exchange Program" in 2005, which promotes mutual educational exchange between German schools and schools in partner countries of the South. ASA has also worked with "weltwärts" since 2008 in cooperation with the German Development Service - which is now part of the GIZ. "weltwärts" is a volunteer program of the Federal Ministry for Economic Cooperation and Development (BMZ) in Germany. "ASA-weltwärts" selects the participants and organizes the preparation and follow-up seminars of "weltwärts" volunteers who are sent out by the GIZ.
2010 - ASA celebrated its 50th anniversary. There were a lot of projects and activities through out the year, former participants came together and ASA received birthday wishes from all over the world.
Since 2012 ASA has been part of the newly founded Engagement Global-Service for Development Initiatives. We are looking forward to the new challenges and the next 50 years!


On Independence Day of 2018, parents Tisha and AJ Calhoun were filled with joy and relief when their daughter Pearly Jo ("PJ") let out three huge cries after being born at just 23 weeks gestation, a sign she may survive despite being born so early.
Only weighing 1.1 pounds, Pearly Jo is considered a "micro-preemie" and is the youngest surviving baby at Baylor Scott and White Medical Center in McKinney, Texas.
After spending 136 days in Baylor Scott and White Medical Center, Pearly Jo finally got to go home, weighing a healthy nine pounds. She never experienced any infection or needed surgery, though she did get a brain bleed which is not uncommon for a premature baby.
The Calhouns have been trying to conceive a child for a long time, having experienced a miscarriage before becoming pregnant with Pearly Jo.
"For years after our first miscarriage I would lay my head on AJ's shoulder every night and cry and say, 'When will we have a baby?'" Trisha Calhoun said.
Pearly Jo was born when her mother was delivered at just 23 weeks due to a incompetent cervix.
"I just had to keep repeating to myself, my husband reassured me. We are going to leave the hospital with a live baby. I will survive labor," Trisha Calhoun explained.
Premature babies born at 23 weeks only have a 37 percent chance of survival, and only an astonishing 15 percent leave the NICU without any serious medical problems so Pearly Jo is a miracle baby to both her parents and to the hospital.
Model, Kate Grant, a 20 year old woman with Down Syndrome, has become a new ambassador for Benefit Cosmetics.


Click to read our Newsletters.
When confidential data is lost or stolen, this is called a data breach. Happens with alarming regularity.
Power saving features on a PC, laptop, printer or monitor, designed to turn off or put on standby any part of the system that is not needed.
How To Apply For Membership of SeniorNet Hutt City On Line.
You can complete the form on the left side of the on line application page here.
This form is in two pages. Click the Continue button at the end of page 1 to continue on page two.
Complete all the sections marked with a red asterisk (they are mandatory) and the other questions as appropriate.
Then click the button at the end of the form to submit it. You will receive a confirming email.
© 2019 SeniorNet Hutt City Inc.


Central Darling Shire Council is a rural shire in the Far West Region of New South Wales encompassing the communities of Wilcannia, Menindee, Ivanhoe, Tilpa, White Cliffs, Darnick, Sunset Strip, Copi Hollow and Mossgiel.
"To promote the Central Darling Shire area by encouraging development through effective leadership, community involvement and facilitation of services."
Central Darling Shire Council encompasses four towns, being Wilcannia, Ivanhoe, Menindee and White Cliffs. There are also several villages including Sunset Strip and Tilpa. The area of the Shire is over 53,000 sq klms, but the popluation is only approximately 2,600.
Community services are run by Section 355 Committees of Council, e.g. community halls, swimming pools, commons and saleyards.
Launch of the Darling River Run will be held at Menindee on the 25th March 2009. For more information click here.
Council takes this opportunity to remind householders that the raw water that is supplied by Council is not recommended for any domestic use and is not for human consumption.
Central Darling Shire is the largest Shire in NSW and yet has the smallest population. It covers an area about the size of the main island of Tasmania and yet has a population of less than 2000 people. The Shire is extremely diverse with four main communities that are all different in their commerce, geography and cultures.
Wilcannia, the administration centre of the Shire has a fascinating history of river heritage having once been the prime port for the shipping of wool for the entire western district of NSW. It has a large number of sandstone buildings and a rich indigenous culture.
For more on our history visit our website.


text:
America can't stay in Afghanistan forever, but it matters how we leave
(CNN)As President Trump seeks to draw down US troops from Afghanistan and Iraq, some have argued the decision is about bringing an end to America's endless wars. But the real issue is how to create e…
by Gayle Tzemach Lemmon Women and Foreign Policy Program
Biden Can Clean Up Trump's Israeli-Palestinian Policy Mess, But Can He Broker Peace?
The president-elect knows only too well the failures of all the presidents who preceded him, and the hardening of positions that's occurred on both sides.
by Martin S. Indyk Middle East Program
If coronavirus spreads to this population, it could be catastrophic
"I have no idea where my friends are," the teenage girl told me as we stood under the bright sun of a brisk winter morning. It was last December, and I was visiting Washokani camp, a displaced person…
by Gayle Tzemach Lemmon
The Only Sensible Iran Strategy Is Containment
The most effective plan against the Islamic Republic has always been the most obvious—and the one nobody in Washington seems willing to try.
by Steven A. Cook Middle East Program
Brexit's Finish Line Is Only the "End of the Beginning" for Britain and the European Union
The United Kingdom faces numerous uncertainties as Brexit nears its nominal finish line.
by Stewart M. Patrick
Huawei, the U.S., and Its Anxious Allies
Trump must not play security card in China trade war.
by Edward Alden Renewing America
Why the New York Knicks Keep Dunking on Erdogan
The 7-foot center Enes Kanter has become a symbol of Turkey's never-ending purge—and a potential assassination target.
by Steven A. Cook
The Saudis Are Killing America's Middle East Policy
Mohammad bin Salman isn't just ruining his own reputation—he's spoiling Washington's policies across the region.

redpajama_set_name: RedPajamaCommonCrawl


The white modern chandelier has three types, the 6-lights type, the 3-lights type and the 9-lights type. You can choose the suitable size according to the room size. The iron material is durable that can guarantee the quality. The bright and efficient lighting can also offer a comfortable space.


text:
Stenoma platyphylla is een vlinder uit de familie van de sikkelmotten (Oecophoridae). De wetenschappelijke naam van de soort is voor het eerst geldig gepubliceerd in 1916 door Meyrick.

platyphylla


text:
'use strict';

const { exec } = require('child_process');
const { promisify } = require('util');
const execAsync = promisify(exec);
const log = require('./log');
const debug = require('debug')('changelog:getPreviousTag');

function cmdDone({code, stdout}) {
  debug('returning from git tag');
  //I think this command it's actually not working and always return empty
  // Consider trying git describe --abbrev=0 --tags
  if (code) {
    throw 'Could not return previous git tag';
  } else {
    return stdout.replace('\n', '');
  }
}

function getPreviousTag() {

  if (this.options.tag) {
    return Promise.resolve(this.options.tag);
  } else if (this.options.tag === false) {
    return Promise.resolve(false);
  } else {
    log.call(this, 'debug', 'Getting last tag');
    //IF we dont find a previous tag, we get all the commits from the beggining - The bigbang of the code
    debug('calling git tag command');
    return execAsync(this.cmd.gitTag).then(cmdDone.bind(this));
  }

}

module.exports = getPreviousTag;


We have had a change of staff since our last newsletter Sue Case retired as Missioner on 30th June 2016 and our new Missioner is Kirsten Bertram (there is an item from both in this newsletter), so welcome to Kirsten and I know she has already visited most of you to introduce herself but if she hasn't got to you yet she will be calling. Also Suzanne Nevison, our Assistant Missioner, has left to take up another position and we wish her well, but Suzanne intends to keep in contact with DTM, so she is not leaving us altogether.
We have just reached a moment in the life of the Darlington Town Mission when we have ended one chapter and are beginning a new one. I am sure that all who read this will now be aware that our Missioner, Sue Case, has now retired from the post. We said farewell to Sue as our Missioner at the Barbeque in All Saints' church grounds on Saturday 25th June. She received thanks from the Trustees, and a token gift, to show our appreciation.
I don't have any idea just how many Missioners there have been in the Town Mission's 175 years. It would make interest research to go to Crown Street Library (or wherever archives that have our records are kept) to read up our history. She is the for latest in a long line - for certain.
The close of a chapter is always a moment to reflect back; before we run forward into the new. I have been chairman of the Trustees only a couple of years, but it's long enough for me to be grateful to join with Sue as Missioner.
Part of my role is to attend every month the Management committee: this is the Missioner's opportunity to touch base with Mission officers to receive a report of all her activities during the past month as well as to plan for what is to come next. It has been heartening to read the catalogue of all the visits she makes to Friends (and this involves a number of practical details she takes into her hands to make life easier for a person living alone, and possibly with no family member nearby to sort out day to day problems, big or small). For one who is employed on a part time basis Sue has managed a huge number of such visits. It reflects her love for the job – yes; but equally her love for the Friends she comes alongside.
A recent Town Mission pamphlet (to inform people about what we do and invite new donors) sets out our mission in this way: We believe that: Every person is entitled to a good quality of life through fellowship and social support which combats isolation. To achieve this Darlington Town Mission: Carries out home and hospital visits; Provides practical information and support at home; Provides companionship to Friends individually or through group social events.
Sue has been the kingpin in achieving this for some 80 Friends. She is joined by her colleague, Suzanne, and a number of volunteers (drivers and visitors), especially for the monthly social visits to favoured venues; but the planning and organizing falls to her to do. She has shouldered all this with good humour; a good head for managing the detail, an easy manner and commendable teamwork. Her friendliness and approachableness are her gifts ideally suited for this job.
As this chapter of the mission closes, we can all agree that Sue has done her job well. Thank you, Sue! We now welcome her successor: Welcome Kirsten!
Hi everyone, I am Kirsten Bertram, the new Missioner. Some of you may have already met me as I made my way around Darlington towards the end of June, visiting some of you with Sue.
I hope you will bear with me as I get to know the role and find my feet! Sue has instructed me very well but now I must put it into practice so that you feel the service is as good as before!
I have a husband Keith who works for the National Health Service in Darlington in Administration and two teenagers, Pippa who is 18 and is about to go to University and Alistair who is 16 and has just done his GCSE exams. We also have a dog, called Ollie, who is a lively cross-breed.
In my working life I have been working in Accountancy jobs, had my own Traditional Sweet Shop and also have had a few voluntary roles at my Church, All Saints and Salutation, Blackwell. I have helped with the Pre-School, Worked in the Parish Office, helped with Sunday School and more recently have become the Secretary to the Parochial Church Council. I enjoy listening to music and going to the theatre.
I became aware of the Town Mission, after my father, was introduced to it a few years ago. He always told me of the nice outings he had experienced and spoke of how he liked being visited. The other people in his house also had visits from the Missioner and they also told me of the wonderful places they were taken to. They all felt they benefited considerably from the support of the Town Mission.
I hope that you all will continue to enjoy visits and fellowship on the outings and I hope to meet you all within the next few weeks.
I have decided to retire to spend more time with my family but I have enjoyed my five years as Missioner and my reward has been seeing the difference DTM makes. I have also made many new friends some sadly who are no longer with us but have left me with lasting memories and I like to think I have become a better person for it. The good news is we have Kirsten as our new Missioner and I know I am leaving you all in good hands.
I can't believe it is five years since I wrote a piece for the newsletter to introduce myself and here I am writing a piece to say goodbye, where have the years gone! One of the things being Missioner has made me more aware of is time, for some it goes too slow, many of our DTM Friends find time goes slowly when they are sat on their own day in and day. For some time goes too fast , there was never enough hours in the day for me while I was Missioner I was always wanting more time to get more done. It made me realise how priceless time is, no amount of money can buy time but you can give it to some one freely and it can be the best gift you could ever give them. Over the past five years I have been in a wonderful position of being able to give DTM Friends my time, even if just to visit for an hour a week, to see how much this meant to them has been so rewarding . It's because of this that I have decided to stay on as a volunteer so although it's goodbye as Missioner its not goodbye entirely, you don't get rid of me that easily!
Finally thank you for the many cards, gifts and good wishes I have received and also thank you to the Volunteers and Trustees for the wonderful support they have given me over the last five years, I look forward to working alongside them as a volunteer.
Well this is my last update of what's been happening since our last newsletter, I'm pleased to say the weather has improved at last the sun has been shining and its warmer. When it comes to good weather DTM seem to be blessed because we have had good weather at all of our outings so far this year. In March we were treated to a Palm Sunday Service and delicious afternoon tea provided by the Rotary Club. Our visit to Arcadia Garden Centre in April saw many of you coming out with bags - not full of plants but clothes , we had road closure problems on arrival but eventually all had a good time. Our May outing saw us all going in different directions but ending up in the same place at Bondgate Methodist Church for another of their wonderful afternoon teas. Plants were on the agenda again in June when we all travelled to Eggleston Hall Gardens and this time the bags were full of plants, a lovely scenic drive to get there and as ever tea and cake to finish. Finally to July and summer and with summer comes sunshine , although not always in the UK, but sunshine did come courtesy of Polam Hall School where we enjoyed their Sunshine Party and we were once again very well entertained by the pupils and, yes, you have guessed it, we were also once again very well fed. A huge thank you to the volunteer drivers who get us safely and comfortably to and from our outings and look after us while we are there.
As ever our very small fundraising team has managed to produce very big results. They are working constantly to raise funds to keep us going.
They are looking for willing volunteers to help in any way they can no matter what you can offer, even if it is just ideas. We have the street collection on Saturday 17th September in Cockerton 10am to 12pm are you able to come and stand with a collection box for ½ an hour, 1 hour or 2 hours. Quiz night Friday 14th October 7.30pm help with catering needed, Songs from the shows Friday 4th November 7pm again help with catering needed. If you able to give any sort of help at any of these events Brian or Anne Tyreman would love to hear from you telephone 01325 710229. Other ways you could help would be to buy a ticket and bring some Friends. The more people who attend, the more funds are raised for DTM.


This is not the first time that the Visual Icons have gone missing in the Add/Edit post page of WordPress.
As you can see from the image above the icons that allow you to edit the post are not there.
Also the post has been written with HTML tags in place which shouldn't be there.
The last time this happened on a blog of mine was when I reinstalled WordPress straight over copy of it on my server. I then found out that I had made some fundamental mistakes in my execution of this procedure that resulted in all manor of messed up files.
This time round it is a new clean install of WP on a new domain so I decided if I could get to the bottom of the problem and find out exactly what file of folder was either missing or corrupt.
It seems that the folder that was never fully downloaded to the server was the wp-includes/js folder. I ftp'd the js folder and the now everything seems ok.


text:
Q: Is it possible to filter and arrange a list by keyword relevance in javascript? Say I have a list of items with multiple classes (keywords) like

Cat

Wolf

Dog

Parrot

Lion

And then on the previous page a user selects 3 features from a select box and clicks next. Saving the keywords using localstorage, how can you, with javascript or jQuery, then display the list in order of most matching keywords?
So if I had input domestic, feline and wings the first item in the list would be Cat followed by Parrot, then Dog, Lion, and Wolf.

A: Not using jQuery, you would have to put those words and their keywords into an array.
Then loop through them comparing them to the 3 selected words to give them a value/score.
Then you would have to order these words based on the their scores. Here is a link about sorting a javascript array :
How to sort an associative array by its values in Javascript?
Using that ordered array you can loop through it to create the list-items and dynamically write them into a div using the "innerHTML" property.
I would setup an array like so(there are several ways you could go about this):
var listItems = new Array();
function listItem(displayWord){
    this.word = displayWord;
    this.keywords = new Array();
    this.matches = 0;
}

listItems['cat'] = new listItem('cat');
listItems['cat'].keywords.push('domestic');
listItems['cat'].keywords.push('tail');
listItems['cat'].keywords.push('feline');

for (x in listItems) {
    for (var c = 1; c < listItems[x].keywords.length; c++) {

    }
}

A: var $ul = ..., // the list element
    keywords = ["domestic", "feline", "wings"]; // get that list from an input,
                                                // localstorage or whereever
$ul.children().sort(function(a, b) {
    var score = 0,
        $a = $(a),
        $b = $(b);
    for (var i=0; i<keywords.length; i++)
        score += $a.hasClass(keywords[i]) - $b.hasClass(keywords[i]);
        // if only a has the keyword, it adds 1, if only b has it 1 is substracted,
        // and if they both have if or not the score does not change.
    return score;
}).appendTo($ul); // re-append in the right order

This is a simple example of sorting a jQuery selection, you could make it more performant if you assigned each element a score of matching keywords and compared those numbers only.

redpajama_set_name: RedPajamaStackExchange


text:
PyTEC is a containerised Pyrolysis Waste Disposal System designs by QinetiQ and used in various military applications. The system converts waste products to thermal energy which can be used for energy generation.
The system was developed by Compact Power Ltd specifically for QinetiQ. The system was first fitted to  and is currently under evaluation for the US Army.

References

Thermal treatment
Waste treatment technology


text:
Beyond Tomorrow
A Heart's Root
Hypnos's Shadow
For Elizabeth
History of the House
Lee Paton's roots stem from England, Scotland and France, with each country having had a unique impact on the Paton family story and the history, heritage and nature of these places having an intimate influence over his collections today.
In 1066 during the Battle of Hastings, Duke William of Normandy awarded the Paton clan the Fleur-de-Lis as an emblem for their battle shields - a reward for their assistance in their fight against the English. An emblem which is still proudly displayed in the centre of the family's crest and often seen in detailed embroidery on Lee's designs. The family's tartan is also a regular sight in the collections, exclusively woven in the Highlands. The deep green and black shades of the wool were a result of the Victorian creation of chemical dyes and the fondness for bold palettes at the time, however the house also still produces a more historically authentic version. This is derived from fragments of tartan cloth more than two centuries old, dug up from the historic Culloden Moor in 1946.
Lee grew up surrounded by some of Britain's most poetic and charming landscapes - from Scottish lochs to the castles of Northumberland. He ultimately spent most of his childhood close to the rugged fells, valleys and tarns of the English Lake District. Known for its historic literary associations, it was home and inspiration to Britain's greatest romantic artists including Wordsworth, Keats, Lord Tennyson, Bysshe Shelley and Beatrix Potter.
Lee Paton studied menswear at the London College of Fashion, during which time he embarked upon several internships within the fashion industry. One such placement was a design internship at Alexander McQueen, which turned into a longer spell within the studio. With studies and a keen interest in historic and military tailoring, he was led to the home of British bespoke, London's Savile Row. Here, outside of his university classes he learned the ways of the street and the importance of bespoke craftsmanship. This was followed up with tutelage in the English countryside with one of the last existing traditional huntingwear tailors.
By graduation he had accumulated a strong list of high-profile clients who encouraged the development of his brand.
To refine his illustrative skills he attended Oxford University's Ruskin School of Art, an experience he credits as being one of the most influential for his vision of the couture maison he had founded.
Finally, between the Royal School of Needlework in London and Maison Lesage in Paris, he honed new skills in various methods of couture hand-embroidery. These institutions are guardians of an enduring, unique craft that has been passed down through generations. Techniques that are continued and adapted in Lee's creations and taught to his in-house team today. His designs present a rich mixture of traditional British crafts and tailoring with detailed hand-finishing and couture techniques of the early Parisian ateliers.
Upon establishing the house, he invited his mother to become involved, tasked with creating specialist pieces of knitwear for clients. Soon followed by his sister, a skilled embroiderer. Today, they will often return to assist with the most important client's orders. Work is created between London and the places still most dear to the house. His London atelier is located in a former tannery from where his ancestors worked as leather merchants in the early 20th Century. Additional craftsmanship takes place in the Lakes and Scotland.
Privacy is of the utmost importance and Paton's client list is extremely guarded. He dresses a range of clients: from private individuals and distinguished public figures to the women of several international royal households. His work has been featured in many British and overseas publications such as Vogue, Tatler, Harper's Bazaar, InStyle, Elle, and The Financial Times.
© 2021 Lee Paton. Theme by Clean Themes. Powered by Shopify


text:
Bacterial Flagella, its types and Chemotaxis
January 24, 2021 May 12, 2022 Sangha Bijekar
Flagella is the motility organelle of the bacteria.
Flagella is known as motility or locomotor organelle and it looks hair like appendage. They are longer than pilli and fimbriae. Their structure is rigid and slender. The bacteria are able to swim in liquid media is due to the rotating movement of flagella. To perceive the flagellar movement, it is necessary to understand the structure of flagella.
Structure of Flagella –
The flagellum is composed of three parts –filament, basal body and hook. The filament is the longest portion that looks like hair, extended from plasma membrane and made up from the flagellin protein. The filament is connected to basal body by the hook. The basal body consists of different rings that acts like clamp and allow it to get fixed in cell wall and cytoplasmic membrane. The proteins associated with basal body acts like motor and provide energy for flagellar movement. Such proteins are called as Mot proteins (mot A and mot B). To regulate the action of motor protein, Fli proteins are employed and they acts like switches.
Textbookofbacteriology.net
The gram positive and gram negative bacteria differ in the composition and structure of cell wall. And hence, the basal body of flagella which is embedded in cell wall and plasma membrane also differs in gram positive and gram negative bacteria. The flagella of gram negative bacteria have four rings L, P, MS and they are embedded in cell wall and membrane whereas the C ring is present at the cytoplasmic side. It is made from FliG, FliM and FliN. The Gram-positive bacteria have only two rings, one is connected to peptidoglycan and other is connected to plasma membrane. These rings acts like bearing to this motor protein.
Online Science notes
Nakamura, S.; Minamino, T. Flagella-Driven Motility of Bacteria. Biomolecules 2019, 9, 279. https://doi.org/10.3390/biom9070279
The motor of flagella has two components – rotor and stator (just like a mechanical machine). The rotor rotates and Stator remains stationary. In gram negative bacteria, the rotor is made from MS and C ring protein whereas Mot A and Mot B acts as stator. Mot A and Mot B forms a channel in plasma membrane. The FliG protein of C ring interacts with stator. The energy that is required for working of motor is generated by proton gradient mechanism. This mechanism is similar that you have studied in Electron transport chain, where electrons is transferred from one to another in a chain and during this process the protons are pumped out. This forms the difference in H+ ions concentration across the plasma membrane forming proton gradient. In flagellar movement, the channel formed by mot A and B is used for movement of proton from higher to lower concentration. This movement of proton ion generates the energy.
http://www.bioinfo.org.cn/book/biochemistry/chapt18/
Based on the number and location of flagella, they are divided as Monotrichous, Amphitrichou,s lophotrichous and peritrichous. Monotrichous bacteria (trichous means hair), have one flagellum; if it is located at an end, it is said to be a polar flagellum. Amphitrichous bacteria (amphi means "on both sides") have a single flagellum at each pole. In contrast, lophotrichous bacteria (lopho means tuft) have a cluster of flagella at one or both ends. Flagella are spread fairly evenly over the whole surface of peritrichous (peri means "around") bacteria. Flagellation patterns are very useful in identifying bacteria. Bacteria without flagella are called as atrichous.
Carolina Biologicals
Difference and similarity between Flagella and cilia –
Flagella and cilia are the motility organelle. They both look like hair-like structures and show whip-like movement making the microorganism move. Cilia are much smaller than flagella. Cilia's size ranges from 5 to 20 um and flagella size ranges from 100 to 200 um. While whipping movement, the flagella and cilia generate helical or planar waves. When these waves originate from the base, the cell moves forward. Whereas, when the wave originates from the tip it pulls the cell back. Flagella may have lateral hair on its surface called mastigonemes. These mastigonemes are involved in changing the flagellar action. Suppose, if the wave is moving from base to tip, the flagella should move forward but instead mastigonemes pull the cell back. The cilia works like boat oars that stroke and propel the microorganism in the water.
Though the mechanism of movement is different but cilia and flagella have very similar ultrastructure. They are made of nine pairs of microtubules called axoneme. The 9 pairs of microtubule doublets are arranged in the circle around two central tubules. Such an arrangement is called the 9+2 pattern. The individual microtubules of the doublet have been named as subtubule A and B. In the doublet, subtubule A projects its two arms towards the neighbouring doublet. Subtubule A also projects a radial stroke towards the central sheath.
Willey. Prescott's Microbiology. New York: McGraw-Hill, 2011.
Chemotaxis
Flagella allow bacteria to show chemotaxis. Chemotaxis is a sensory phenomena of bacteria which directs the movement of bacteria. It is the movement of bacteria towards attractant and away from repellent. The sensing of attractant or nutrient and repellent or toxin is carried by chemoreceptors.
Chemotaxis revealed that the bacteria not always swin aimlessly but rather they move in specific direction as per the need. Scientist have demonstrated the movement of bacteria in the chemical gradient suspension. The sensory system is very sensitive to the concentrations of attractants and repellents. The bacteria senses the chemicals with the help of chemoreceptors, made up from special proteins. The chemoreceptors works like a transmitter, that sense the chemical and transmit the message. The chemoreceptors are located in plasma membrane and periplasmic space.
Bacteria move randomly in the absence of any chemical, it runs and tumble from time to time. But in presence of a chemical, bacterium tumble less and runs more. In case of Escherichia coli, when flagella rotates in counterclockwise the bacteria moves in the forward direction or runs. However, the clockwise movement of flagella cause bacteria to tumble.
The chemoreceptors are regulated at molecular level. The chemoreceptors consists of CheA, CheY and FliM proteins that shows cascade of reaction on interacting with nutrient. When Chemorectors interact or come in contact with nutrient, ATP phosphorylate CheA protein, the activate CheA protein donates its phosphate group to CheY protein. The activated CheY protein commune with FliM protein which acts like a switch and it is present as the base of the flagellum. The FliM cause and promote the flagellar movement in the anticlockwise direction enabling bacteria to run. When bacteria is not around any nutrient or chemoattractant, it maintains less phosphorylated CheA and CheY, allowing to bacteria to show walk like movement.
Cascade of flagella movement
To understand more in detail, Watch this video
https://www.mdpi.com/2218-273X/9/7/279
http://www.bioinfo.org.cn/book/biochemistry/chapt18/bio6.htm
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Back to Journals » Therapeutics and Clinical Risk Management » Volume 18
Nutritional and Physical Prehabilitation in Elective Orthopedic Surgery: Rationale and Proposal for Implementation
Authors Briguglio M , Wainwright TW
Received 30 September 2021
Accepted for publication 10 December 2021
Published 6 January 2022 Volume 2022:18 Pages 21—30
DOI https://doi.org/10.2147/TCRM.S341953
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 2
Editor who approved publication: Professor Garry Walsh
Download Article [PDF]
Matteo Briguglio,1 Thomas W Wainwright2,3
1IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy; 2Orthopaedic Research Institute, Bournemouth University, Bournemouth, UK; 3Physiotherapy Department, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
Correspondence: Matteo Briguglio
IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Via Riccardo Galeazzi 4, Milan, 20161, Italy
Abstract: In the past, good food and exercise were not considered effective interventions to promote recovery in orthopedic surgery, and prolonged bed rest with not many calories has been deemed sufficient for the proper health restoration until the end of the nineteenth century. The advancement of scientific knowledge proved just the opposite, thus pushing health professionals to sustain the nutritional status and physical fitness of surgical patients. Nevertheless, the impoverishment of lifestyles and the lengthening of life expectancy have invariably contrasted the strength of constitution, giving rise to two of the most hazardous conditions for orthopedic patients: malnutrition and sarcopenia, often hiding nutrient deficits and poor body composition. These conditions are known to be negative prognostic factors in several areas of major surgery, including hip replacement, knee replacement, and spine surgery. Scoring systems to screen for malnutrition and physical inabilities exist, but disciplined management of the derived risks remains untested, potentially hindering the implementation of research findings into practice. A methodical approach of preoperative analysis, critical monitoring, and risk correction before surgery could lead to a substantial improvement of the prognosis while warranting the safety of patients and the efficiency of enhanced recovery after surgery pathways. The aim of this article is to discuss from a dietetic and exercise perspective the ideal nutritional and physical prehabilitation to lay the foundations for designing the appropriate integration of dietitians and physiotherapists in a preoperative enhanced recovery pathway. This methodical analysis could effectively calculate the patient's risks, detect the best choices for resolving the risk, underline the ignored aspects of perioperative care, and represent a concrete means to integrate novel discoveries.
Keywords: hip replacement, knee replacement, malnutrition, sarcopenia, enhanced recovery after surgery, quality of health care
The importance of maintaining a good nutritional status and physical ability for proper health restoration after orthopedic surgery has been broadly acknowledged. The inefficiency of the muscular system, nutrient deficits, the excess of body fat or being underweight are known to be a common burden for older patients undergoing orthopedic surgery,1,2 with poor nutritional and physical status both being associated with worse outcomes after hip,3,4 knee,5,6 and spine surgery.7,8 Hospitals have been consequently pushed to incorporate viable methods of preoperative nutritional and physical risk management in the field of elective surgery as several weeks may pass between the day of planning and the day of admission. Optimization plans for major orthopedic surgery exist9,10 together with the knowledge that fragile patients may have the most to gain from these multimodal approaches.11 However, it is a common belief that the rush to design these holistic approaches came at the expense of precision medicine interventions, with single disciplines of nutritional and physical supports not being appropriately planned, tested, or evidenced.12–14 Several scoring systems to identify malnutritional statuses or physical inabilities are in fact used, but how does this actually change practice? What corrective and monitoring path should the patient follow in order to reduce the nutrition-related and physical-related risks of postoperative complications? There is the need for a way of effectively controlling nutrition-related and physical-related hazards to look at whether planning a nutritional and physical prehabilitation will actually result in better outcomes. It is therefore necessary to refer to a methodical approach of risk observation and management that is schematic (essential but not limited), detailed (leaving nothing to chance), and inclusive (broad adaptable spectrum).15 The Hazard Analysis and Critical Control Points (HACCP) system could provide the framework to define an effective optimization protocol in preparation for surgery, accounting for all the variables involved. This safety control system was pioneered by the National Aeronautics and Space Administration of the United States for astronauts' food during early space flights,16 and outlines all the set of procedures to follow to keep under control microbiological, chemical, or physical contaminations.17 The goal of this perspective article is not to propose nutritional or exercise recommendations. We aim to present how the HACCP-derived methodology of critical analysis and risk correction could be used to effectively manage preoperative nutritional and physical hazards, such as malnutrition and sarcopenia, in order to lead to a substantial improvement of the preoperative optimization while warranting patients' safety and system efficiency.
The Methodology of Prehabilitation in Elective Orthopedic Surgery
The following seven principles of the HACCP system were adapted for the purpose of our article.
Bullet Points 1 – The Seven Principles of HACCP
I. Identify the hazards that must be prevented, eliminated, or reduced.
II. Identify the critical control points where an inspection is necessary.
III. Calculate the limits that distinguish acceptability from unacceptability.
IV. Define monitoring actions.
V. Plan interventions to correct the risk out of control.
VI. Prepare the documentation.
VII. Define surveillance procedures.
The Analysis of the Preoperative Hazards to Prevent, Eliminate, or Reduce
In orthopedic surgery, there are different nutrition-related and physical-related hazardous situations that can potentially cause a negative outcome after surgery. For the purpose of this article, we can categorise the hazardous nutrition-related aspects in dietary (eg, poor diet), biochemical (eg, deficits of blood nutrients), and anthropometric (eg, poor body composition). Similarly, the hazards associated with physical inability can be functional (eg, reduced muscle strength or imbalance) and anthropometric (eg, reduced lean mass). Although it is not the aim of this article to show original data from the literature, statistics in Table 1 summarize some of the most acknowledged hazardous conditions, the associated outcomes, and the nature of the relationship between the two factors (directly or indirectly proportional).
Table 1 Examples of Preoperative Nutritional and Physical Hazards, Their Extensions, and the Associated Consequences After Surgery That are Reasonable to Expect in Elective Orthopedic Surgery
The analysis of these hazards to prevent, eliminate, or reduce should follow these sequential steps of risk identification and analysis:
Bullet Points 2 – Risk Analysis
Identification of the Hazard (H), Consequences (O), and Severity (SO).
Estimation of the association between the H and O.
Estimation of the Probability of occurrence of the Hazard (PH).
Estimation of the efficacy of corrective procedures (β) and efficiency of personnel (ε).
Calculation of the risk (R).
The fulfilment of these sequential steps has the subsequent implication of determining if the nutritional and physical status would require precautionary or corrective measures in order to avoid negative postoperative consequences. Notably, the risk is distinguished from a hazard as the former refers to the probability. Importantly, the analysis should account for detailed demographic characteristics, environmental exposures, and consequences of these exposures. The risk analysis calculation (see Supplementary 1) culminates with the equation that identifies the preoperative nutritional and/or physical risk of patients undergoing elective orthopedic surgery.
R = risk.
SO = severity of consequences.
PH = probability of occurrence of the hazard.
β = beta factor from Greek "βελτίωση" (veltíosi, improvement), which depends on the efficacy of interventions.
ε = epsilon factor from Greek "εκπαίδευση" (ekpaídefsi, education), which depends on staff training.
∑(τ) = summation of each vulnerable condition called.
Tau factor from Greek "τρωτό" (trotó, vulnerability).
∑(φ) = summation of each burden called.
Phi factor from Greek "φoρТio" (fortío, burden).
∑(α) = summation of each root cause called.
Alpha factor from Greek "αγένεια" (agéneia, incivility).
This final equation accounts for conditions of vulnerability, environmental pressures18 that might expose the patient to increased risks for adverse outcomes, the efficacy of the corrective procedures (β), and efficiency of personnel (ε) that influences the proper execution of procedures.19 Further considerations about β and ε are discussed in the paragraphs concerning the surveillance procedures and the prerequisites, respectively. Considering that we cannot modify factors τ, φ, or α, the R can be reduced through 1) nutritional and physical prehabilitation interventions that optimize the strength of constitution of orthopedic patients (reduced PH), 2) the conduction of research initiatives that innovate protocol efficacy (increased β), 3) training programs that keep the staff updated on the correct executions of the operations (increased ε).
The Critical Control Points (CCPs)
The CCPs are the phases, between the operational steps, where an inspection is feasible and in which a loss of control of one of the hazards and their extensions in Table 1 could lead to an unacceptable health risk. The identification of the Critical Control Points (CCPs) requires a schematic and detailed approach, with the reasoning eventually analysing the existing operational phases of the preoperative flow. At the level of the CCPs, it is possible and necessary to prevent, eliminate, or reduce to an acceptable extent the risk of negative outcomes after surgery. The CCPs are identified through a decision tree (see Supplementary 2, adapted from a reference of interest)20 that analyses each phase of the process in sequence and discusses the questions on the basis of the hazards, the monitoring actions, and the interventions. As an example, we propose three CCPs to be integrated into the prehabilitation path of care. The CCP I is the "Assessment of the nutritional and physical status. This phase can be integrated into the usual pre-admission evaluation. At this stage, it is very likely to find a condition whose risk and severity is worth monitoring, like poor iron status, excessive body weight, reduced muscle mass, and poor balance. The CCP II is the "Control of the adherence to the program". If the first control phase involved the prescription of corrective actions (dietary and exercise interventions), this second control phase would be useful for monitoring the adherence to interventional indications. Several hazardous malnutritional and sedentary factors stem from home environment, and long scheduling periods can worsen the R. Telephone contact could provide reinforcement measures/additive actions necessary to ensure patients' confidence. The CCP III is the second "Assessment of the nutritional and physical status" before surgery. This point includes either a confirmation of surgery in case of risk control after the application of corrective protocols or a delay of surgery in case the risk still undermines the appropriate postoperative recovery.
The identification of critical control points is not to be underestimated. The definition of a CCP would involve the implementation of a monitoring system (principle IV of bullet points 1), which could encompass the use of different medical equipment and dedicated staff. If the patient was found to be at high risk, a dedicated room would be needed to ensure the proper interview with the dedicated healthcare professional. Moreover, the proper identification ensures the effective design and application of the corrective measures (principle V of bullet points 1). If a hazard has been identified at a stage where no control measure exists, the process would need an earlier or later phase to include the corrective intervention, which may be not always feasible.
Reference for Critical Ranges
At the level of CCPs, control measures must remain within acceptable ranges as far as it is concerned for patient safety. The critical intervals distinguish acceptability from unacceptability, demonstrating that a critical point is under/out of control. The measures of interest related to the hazards shown in Table 1 can be the conditions themselves (malnutrition and sarcopenia) or their extensions (eg, circulating blood parameters of nutrients or muscle strength). For instance, if the diagnostic tool for malnutrition (eg, MNA–SF)21 or sarcopenia (eg, U-Test)22 has been validated and/or tested on the population and setting of interest, then its performance is probably better than single extensional parameters. However, very often direct diagnostic tools do not indicate which factor to correct, the type of corrective action, or they are not specific to the orthopedic population (eg, the patient may be less performance not because there is sarcopenia but because of pain and crutches). More easily, the hazards are controlled by measuring and adjusting their related extensional parameters as the ones proposed in Table 1. Reference ranges can be inferred from different sources: national regulations, international guidelines, expert opinions, consensus, literature on a similar population and comparable setting, personal experience in the field, or results from surveillance. It is important to consider that the critical reference ranges, which demarcate the acceptable from the unacceptable, do not necessarily coincide with diagnostic values. They should indicate ranges beyond which there is an increased likelihood of being malnourished or sarcopenic. It is always advisable to translate the measure of interest into a quantitative variable to facilitate standardization between patients. For example, it is better to measure the concentration of circulating hemoglobin rather than asking the patient if he/she consumes iron-rich foods, or to measure gait speed rather than asking for his/her confidence in walking. Algorithm-derived judgments could effectively incorporate the nature of the condition (eg, low hemoglobin because of poor iron intake or disease-related?). Some examples of cut-off values can be waist circumference >80 cm (central obesity), <0.8/kg/day (protein intakes), <0.8 m/s (slowness), or <20 kg of handgrip strength (weakness). Monitoring techniques will then be able to provide rapid interpretations of the results, taking prompt corrective measures. The final goal is to set the boundaries at each CCP within which control measures must remain.
Monitoring of Critical Parameters
A strategic monitoring program at each critical point is a key element to identify a loss of control in a precise, accurate, and timely manner. The question to be asked is "Where and when is there more tendency to lose control of the extensional parameters of the hazards?". Monitoring techniques must be identified for each parameter along with the relative frequency of checking. There are three general classes of monitoring techniques used to check whether a critical control point is within the reference limits. The physical techniques are relatively fast, with immediate results and direct associations with the physical ability, but the disadvantages are the need for equipment and the dependence on the skills and experience of the operator (medium accuracy). The biochemical parameters are precise, but there is the need for laboratory resources, the results are not always associated with the clinical feature (therefore not relevant), and there is the dependence on the sample processing (medium-high accuracy). The observation/interview techniques are fast, cheap, and accessible, but they are not easily correlated to the clinical feature and depend on the skills and experience of the operator (low accuracy). Whatever type of monitoring technique, it is important to record the results on specific forms, to be signed by the operator, and made available during surveillance procedures. Monitoring actions listed above are part of a planned sequence of activities.
Bullet Points 3 – Steps for Monitoring
Define the monitoring procedures for each CCP.
Indicate the monitoring technique to be used.
Plan the "when" and the "how often".
Designate the dedicated executive staff.
Anticipates the interpretation of the results.
Start considering the corrective actions.
In the preoperative managing of elective orthopedic surgery, an example of a monitoring procedure could be a blood test (biochemical monitoring) to assess the level of ferritin (extensional parameter of malnutrition) at the level of the CCP I in order the check if malnutrition is under control. After the identification of this parameter out of reference ranges, it would be much easier to intervene for restoring iron homeostasis through corrective protocols. Monitoring actions should be focused on parameters that are known to be critically associated with the clinical outcome in order to maximize the effectiveness of the risk analysis and corrective protocols.
Corrective Protocols
An effective control system requires that the hazardous nutrition-derived and physical-derived factors are treatable, implying that they can be prevented, eliminated, or reduced to acceptable levels. Considering the different ranges of risks, each resulting score should include corresponding corrective actions (see Table 2).
Table 2 Examples of Risk Scoring and Corresponding Corrective Actions That May Be Adopted at the CCPs in Elective Orthopedic Surgery
Corrective actions comprise procedures that prevent the occurrence of problems, keep the process under control when there is a tendency to deviate from the limits, and that handle the risk once a deviation has occurred. Four types of corrective actions can therefore be planned: preventive protocols (targeted for the single patient at low risk or population medicine approach for consecutive patients),23 corrective protocols (for the patient at medium-high risk), reinforcements (strengthening adherence to indications), and repressive actions (for the patient when there is not enough time to correct the high risk). The programming of corrective measures must follow a pre-established sequence of actions to be applied without hesitation when the monitoring detects a deviation from the boundaries of acceptability.
Bullet Points 4 – Steps for Corrective Protocols
Define the interventions for each CCP.
Plan the protocols (preventive, corrective, reinforcement, or repressive).
Plan the means and the time frame.
Activate dedicated monitoring techniques according to the protocol.
The decision to adopt a specific type of action mainly depends on the level of risk, when it is detected, and what is the efficacy of the means used in the corrective protocol. For instance, if a high risk of malnutrition is detected at the level of CCP I, which may be weeks before surgery, it is possible to intervene with nutritional prehabilitation that is able to correct the abnormality in time. If a high risk is detected during the CCP III, which may be close to surgery, it may be necessary to delay/suppress the orthopedic procedure. It should also be taken into account the time it takes for the parameter to fall within the reference limits and the possibility of interacting with the patient (in person or remotely). For example, the correction of circulating vitamin D can take as little as three weeks24 as well as the restoration of iron homeostasis23 or the overall physical function.25 Different control measures may be necessary to control a single hazard and, conversely, a distinct control measure can control multiple hazards. For instance, a balanced preoperative diet could correct vitamin deficiencies while integrating exercise interventions. The improvement of a parameter can be more rapid if the corrective protocol integrates the two dimensions (eg, exercise plus protein supplementation) and if it is tailored according to the patient's propensities (eg, liking or disliking of vegetables, preference for cycling, single dish for dinner) and home environment (eg, lack of kitchen scale, physical activity in the living room or in the park, grocery shopping once every two weeks to the far supermarket). The experience of the prehabilitation team should provide the knowledge about the appropriate model for correcting the extensional parameters out of reference ranges. Research analyses are vital to confirm the efficacy of routine interventions or investigate novel approaches to complete the risk analysis (factor β). How to manage the compliance to the corrective programs? Additive monitoring techniques may be integrated into the usual path of care if, for instance, the assessment at the CCP I reveals a tendency to low adherence from prescribed therapies (see Figure 1 for the building of the preoperative flow, with the three corrective actions integrated into the final prehabilitation path of care).
Figure 1 Building of the nutritional and physical prehabilitation in elective orthopedic surgery. (A) The preoperative flow of patients undergoing elective orthopedic surgery can be displayed through the operative steps (blue frames). (B) The addition of three critical control phases (CCPs, double gray frame) between the operative steps is useful in order to detect any risk to be prevented, eliminated, or reduced to an acceptable extent. (C) The final integration of the preoperative flow with different interventional procedures (red dotted frame) allows the efficient management of the patient's nutritional and physical risks through preventive, corrective, reinforcements, or repressive actions.
Both the risk analysis and the control system should be documented, including all procedures (prescriptive documentation) and records from monitoring/interventions (consultative documentation). Appropriate documenting is required to reconstruct a patient's history and to provide evidence of the process integrity in following the steps of bullet points 1, 2, 3, and 4. The minimum standards of documentation should describe, for example, the relevant pathological history, the vulnerable conditions, the burdens and root causes, the risk analysis findings, the critical parameters assessed, the clinical impression, the plan for preoperative care, the legible identity of the executive members of the staff, the patient progress (response and change in treatment), the revision of extensional parameters and risk analysis findings. The documents should be appropriately archived and made available in case of surveillance procedures. Clearly, the digitization of report forms and archiving systems is of fundamental utility to reduce operational times and speed up data extraction procedures.
Surveillance Procedures
Monitoring aims to observe the status of the parameter while surveillance aims at verifying the effect of the control measures, confirming or not that the path is supporting the patient's health. Surveillance procedures comprise different modalities, like periodic reviews of the entire prehabilitation flow, an inspection of each CCP to confirm safety, or verification of the correct execution of all the planned actions. The frequency of surveillance should be based on the complexity of the preoperative flow and on the likelihood that estimated risks may occur.
Bullet Points 5 – Key Elements for Defining Surveillance
Designation of the surveillance team.
Random analysis at critical points.
Audit of prescriptive and consultative documents.
Validation of critical limits and monitoring techniques.
Confirmation that hazards are kept under control.
Investigations on the proper application of corrective procedures.
Research initiatives to validate current/new corrective protocols (to increase β factor).
The last point is of extreme importance. One of the main goals of prehabilitation is the constant endowment of "the best possible nutritional and exercise management". The increase of the β factor in the equation of risk analysis would reduce the R, and therefore research studies should be persistently conducted in parallel to clinical practice. Once a new and more effective protocol is discovered, the entire preoperative flow must be modified, incorporating changes of documentation to ensure updated information. Concerning the role assignment, the surveillance team should comprise members different from the executive and monitoring staff. Conversely, other individuals can perform multiple executive and monitoring tasks, but all relevant information should be available to all team members.
The Seven Prerequisites of Prehabilitation
The health of orthopedic patients cannot solely derive from the support actions established through the HACCP-derived nutritional and physical prehabilitation. 1) Environment preventive measures are an important rudiment and should routinely interest the workplace and personnel, such as hygiene procedures and calibration/maintenance of equipment. 2) Training programs, such as information campaigns or focused courses, should keep staff informed of the most recent advancements because untrained hospital personnel could nullify operational, monitoring, of corrective procedures (the greater the ε factor in the equation of risk analysis the lower the R). 3) The team of specialists of the prehabilitation program should preferably involve different healthcare professionals, in order to bring together the whole spectrum of knowledge to lay the groundwork for a reliable, precise/accurate, and effective program. 4) The experts in charge of research initiatives should have knowledge about the Good Clinical Practices (GCP) inherent in human research in order to conduct and report high-level clinical trials. 5) Quality improvement resources should be used to provide pictorial displays of the phases and the decision-making procedures, with any upgrading resulting in a modification of the original flowchart or algorithm in order to advance the visual exactness. 6) The hospital food system should comply with various standards (HACCP principles), including quality raw materials to guarantee hospitalized patients the best possible nutrition. 7) Any dietary supplement of interest should follow the appropriate management procedures, with the involvement of the hospital pharmacy playing an essential role.
In the current panorama, the main indications for orthopedic surgery include end-stage degenerations like coxarthrosis, gonarthrosis, and vertebral deformities that are typical of multi-frail individuals.26,27 The increasing demand for these orthopedic procedures contrasts with the complex phenotypes of old orthopedic patients progressively malnourished and sarcopenic,2,28 giving rise to complex pathological spectra like sarcopenic obesity.29 Examinations into modifiable risk factors acknowledged preoperative malnutritional status and physical inability as critical factors for patient's distress.30 Collectively, these two conditions reduce the strength of constitution necessary to cope with the physiological stressors of orthopedic surgery (see Supplementary 3 for the typical nutrition-related and physical-related factors affecting patients undergoing elective orthopedic surgery). Multidisciplinary approaches like the ERAS or the HEPAS (Healthy Eating, Physical Activity, and Sleep hygiene)2,31 appear to be very useful in the most fragile individuals. However, they lack of systematic assessments, methodology of interventions, and suggestions on the management of monitoring procedures. This lack of methodology could hide important aspects of preoperative care and hinder the implementation of research findings into practice. In this context, the use of the flexible principles of the HACCP system may allow the adoption of an essential, detailed, and inclusive method for process analysis, critical monitoring, and lifestyle-derived risk correction before elective procedures. An effective nutritional and physical prehabilitation could enhance the physiological reserves and the overall resilience of old orthopedic patients (see Figure 2). If the seven prerequisites are met (hygiene practices, training, multidisciplinarity, research integrity, visualization, food safety, and supplement management), the design of the orthopedic prehabilitation is certainly enabled, with the equation of risk analysis efficiently considering both patient-related (τ, φ, and α) and process (β and ε) factors. The management of malnutrition and physical inabilities is not sufficient to improve the clinical outcome of orthopedic patients, but it is reasonable to say that it is a necessary requirement for the effectiveness of the entire path of care.
Figure 2 The application of the hazard analysis and critical control point (HACCP) system in elective orthopedic surgery, with a focus on nutrition-related and physical-related factors.
The authors report no conflicts of interest in this work.
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