A practical risk scale for predicting morbidity and mortality in the emergency general surgical setting: A prospective multi-center study

BACKGROUND

Low albumin is a prognostic factor associated with poor surgical outcomes. We aimed to examine the predicative ability of easily obtainable point-of-care variables in combination, to derive a practical risk scale for predicting older adults at risk of poor outcomes on admission to the emergency general surgical setting.

METHODS

This is an international multi-center prospective cohort study conducted as part of the Older Persons Surgical Outcomes Collaboration (www.OPSOC.eu). The effect of having hypoalbuminemia (defined as albumin ≤3.5 g/dL) on selected outcomes was examined using fully adjusted multivariable models. In a subgroup of patients with hypoalbuminemia, we observed four risk characteristics (Male, Anemia, Low albumin, Eighty-five and over [MALE]). Subsequently, the impact of incremental increase in MALE score (each characteristic scoring 1 point (maximum score 4) on measured outcomes was assessed.

RESULTS

The cohort consisted of 1406 older patients with median (IQR) age of 76 (70-83) years. In fully adjusted models, hypoalbuminemia was significantly associated with undergoing emergency surgery (1.32 (95%CI 1.03-1.70); p = 0.03), 30-day mortality (4.23 (2.22-8.08); p < 0.001), 90-day mortality (3.36 (2.14-5.28); p < 0.001) (primary outcome), and increased hospital length of stay, irrespective of whether a patient received emergency surgical intervention. Every point increase in MALE score was associated with higher odds of mortality, with a MALE score of 4 being associated with 30-day mortality (adjusted OR(95% CI) = 33.38 (3.86-288.7); p = 0.001) and 90-day mortality (11.37 (3.85-33.59); p < 0.001) compared to the reference category of those with MALE score 0.

CONCLUSIONS

The easy to use and practical MALE risk score calculated at point of care identifies older adults at a greater risk of poor outcomes, thereby allowing clinicians to prioritize patients who may benefit from early comprehensive geriatric assessment in the emergency general surgical setting.

Efficacy of β-mannanase on broiler growth performance and energy utilization in the presence of increasing dietary galactomannan

An experiment was conducted to investigate the impact of β-mannanase inclusion on growth performance, viscosity, and energy utilization in broilers fed diets varying in galactomannan (GM) concentrations. Treatments were arranged as a 3 (GM concentration) × 3 (β-mannanase inclusion) factorial randomized complete block design with 12 replicates of 29 male broilers per replicate for a 42-d experiment. Efforts were made to reduce the amount of soybean meal, and thus GM, in the basal diet with guar gum included at 0, 0.21, or 0.42% to achieve a GM supplementation of 1,500 and 3,000 ppm, respectively. Beta-mannanase was included at 0, 200, or 400 g/ton. Broilers were fed a starter (d 0 to 14), grower (d 15 to 28), and finisher diets (d 29 to 42). Growth performance was monitored and ileal contents collected on d 14, 28, and 42 to determine ileal digestible energy (IDE) and intestinal viscosity. Increasing levels of GM negatively (P < 0.05) influenced body weight (BW) following the starter and grower periods and increased (P < 0.01) mortality corrected feed conversion ratio (FCR) throughout the study. Reduced growth performance was associated with increased (P < 0.05) intestinal viscosity and decreased (P < 0.05) IDE when GM inclusion was increased. Inclusion of β-mannanase in diets containing supplemental GM on d 28, increased average BW to levels similar to diets without supplemental GM. Improvements in FCR were also observed with β-mannanase inclusion in diets containing supplemental GM. Ileal digestible energy was increased (P < 0.05) with the addition of β-mannanase on d 28 of age. Multiple interactions in growth performance, intestinal viscosity, and IDE were associated with β-mannanase administration. In conclusion, β-mannanase improved IDE, reduced intestinal viscosity, and improved growth performance; however, the observed benefit was dependent upon dietary GM concentration.

Changes in immune and metabolic gut response in broilers fed β-mannanase in β-mannan-containing diets

β-galactomannans found in soy-based broiler feed are known to cause physiological effects that are hypothesized to be related to gut inflammation. Previous studies have shown that the incorporation of β-mannanase in the diet or as a supplement results in improvements to certain performance parameters related to gut health and feed conversion. Using kinome analysis, we characterized the mechanism of β-galactomannan activity and supplementation with β-mannanase on the gut of commercial broilers to understand the mode of action. Two doses of β-mannanase (200 and 400 g/ton of feed) with and without inclusion of additional β-galactomannan (3,000 ppm) were tested at 3 time points (d 14, d 28, and d 42 post hatch). Broilers were fed starter (d 0 to 14), grower (d 15 to 28), and finisher diets (d 29 to 42). Jejuna were collected from birds from each treatment condition and time point. Cluster analysis of the kinome data showed that birds clustered first by age, then predominantly by whether β-mannanase had been included in the diet. Biological pathway analysis showed that the inclusion of additional β-galactomannan into the diet resulted in increased signaling related to immune response, relative to our normal control diet (with reduced soybean meal). The addition of β-mannanase to the enhanced β-galactomannan diet eliminated the majority of this immune-related signaling, indicating that the feed-induced immune response within the jejuna had been eliminated by the addition of β-mannanase. We also saw changes in specific metabolic and gut function pathways in birds fed β-mannanase. These observed changes in β-mannanase-fed birds are likely the mechanism for the enhanced performance and feed conversion observed in birds given β-mannanase in their diets.

Frailty Exists in Younger Adults Admitted as Surgical Emergency Leading to Adverse Outcomes

BACKGROUND

Frailty is prevalent in the older adult population (≥65 years of age) and results in adverse outcomes in the emergency general surgical population.

OBJECTIVE

To determine whether frailty exists in the younger adult emergency surgical population (<65 years) and what influence frailty may have on patient related outcomes.

DESIGN

Prospective observational cohort study.

SETTING

Emergency general surgical admissions.

PARTICIPANTS

All patients ≥40 years divided into 2 groups: younger adults (40-64.9 years) and older adult comparative group (≥65).

MEASUREMENTS

Over a 6-month time frame the following data was collected: demographics; Scottish Index of Multiple Deprivation (SIMD); blood markers; multi-morbidities, polypharmacy and cognition. Frailty was assessed by completion of the Canadian Study of Health and Ageing (CSHA). Each patient was followed up for 90 days to allow determination of length of stay, re-admission and mortality.

RESULTS

82 young adults were included and the prevalence of frailty was 16% (versus older adults 38%; p=0.001) and associated with: multi-morbidity; poly-pharmacy; cognitive impairment; and deprivation. Frailty in older adults was only significantly associated with increasing age.

CONCLUSIONS

This novel study has found that frailty exists in 16% of younger adults admitted to emergency general surgical units, potentially leading to adverse short and long-term outcomes. Strategies need to be developed that identify and treat frailty in this vulnerable younger adult population.

The inferomedial femoral neck is compromised by age but not disease: Fracture toughness and the multifactorial mechanisms comprising reference point microindentation

The influence of ageing on the fracture mechanics of cortical bone tissue is well documented, though little is known about if and how related material properties are further affected in two of the most prominent musculoskeletal diseases, osteoporosis and osteoarthritis (OA). The femoral neck, in close proximity to the most pertinent osteoporotic fracture site and near the hip joint affected by osteoarthritis, is a site of particular interest for investigation. We have recently shown that Reference Point micro-Indentation (RPI) detects differences between cortical bone from the femoral neck of healthy, osteoporotic fractured and osteoarthritic hip replacement patients. RPI is a new technique with potential for in vivo bone quality assessment. However, interpretation of RPI results is limited because the specific changes in bone properties with pathology are not well understood and, further, because it is not conclusive what properties are being assessed by RPI. Here, we investigate whether the differences previously detected between healthy and diseased cortical bone from the femoral neck might reflect changes in fracture toughness. Together with this, we investigate which additional properties are reflected in RPI measures. RPI (using the Biodent device) and fracture toughness tests were conducted on samples from the inferomedial neck of bone resected from donors with: OA (41 samples from 15 donors), osteoporosis (48 samples from 14 donors) and non age-matched cadaveric controls (37 samples from 10 donoros) with no history of bone disease. Further, a subset of indented samples were imaged using micro-computed tomography (3 osteoporotic and 4 control samples each from different donors) as well as fluorescence microscopy in combination with serial sectioning after basic fuchsin staining (7 osteoporotic and 5 control samples from 5 osteoporotic and 5 control donors). In this study, the bulk indentation and fracture resistance properties of the inferomedial femoral neck in osteoporotic fracture, severe OA and control bone were comparable (p > 0.05 for fracture properties and <10% difference for indentation) but fracture toughness reduced with advancing age (7.0% per decade, r = -0.36, p = 0.029). Further, RPI properties (in particular, the indentation distance increase, IDI) showed partial correlation with fracture toughness (r = -0.40, p = 0.023) or derived elastic modulus (r = -0.40, p = 0.023). Multimodal indent imaging revealed evidence of toughening mechanisms (i.e. crack deflection, bridging and microcracking), elastoplastic response (in terms of the non-conical imprint shape and presence of pile-up) and correlation of RPI with damage extent (up to r = 0.79, p = 0.034) and indent size (up to r = 0.82, p < 0.001). Therefore, crack resistance, deformation resistance and, additionally, micro-structure (porosity: r = 0.93, p = 0.002 as well as pore proximity: r = -0.55, p = 0.027 for correlation with IDI) are all contributory to RPI. Consequently, it becomes clear that RPI measures represent a multitude of properties, various aspects of bone quality, but are not necessarily strongly correlated to a single mechanical property. In addition, osteoporosis or osteoarthritis do not seem to further influence fracture toughness of the inferomedial femoral neck beyond natural ageing. Since bone is highly heterogeneous, whether this finding can be extended to the whole femoral neck or whether it also holds true for other femoral neck quadrants or other material properties remains to be shown.

Role of nutritional status and intervention in oesophageal cancer treated with definitive chemoradiotherapy: outcomes from SCOPE1

BACKGROUND

Malnutrition is common in oesophageal cancer. We aimed to identify nutritional prognostic factors and survival outcomes associated with nutritional intervention in the SCOPE1 (Study of Chemoradiotherapy in OesoPhageal Cancer with or without Erbitux) trial.

METHODS

Two hundred and fifty eight patients were randomly allocated to definitive chemoradiotherapy (dCRT) +/- cetuximab. Nutritional Risk Index (NRI) scores were calculated; NRI<100 identified patients at risk of malnutrition. Nutritional intervention included dietary advice, oral supplementation or major intervention (enteral feeding/tube placement). Univariable and multivariable analyses using Cox proportional hazard modelling were conducted.

RESULTS

At baseline NRI<100 strongly predicted for reduced overall survival (hazard ratio (HR) 12.45, 95% CI 5.24-29.57; P<0.001). Nutritional intervention improved survival if provided at baseline (dietary advice (HR 0.12, P=0.004), oral supplementation (HR 0.13, P<0.001) or major intervention (HR 0.13, P=0.003)), but not if provided later in the treatment course. Cetuximab patients receiving major nutritional intervention had worse outcomes compared with controls (13 vs 28 months, P=0.003).

CONCLUSIONS

Pre-treatment assessment and correction of malnutrition may improve survival outcomes in oesophageal cancer patients treated with dCRT. Nutritional Risk Index is a simple and objective screening tool to identify patients at risk of malnutrition.

Canadian inter-laboratory organically bound tritium (OBT) analysis exercise

Tritium emissions are one of the main concerns with regard to CANDU reactors and Canadian nuclear facilities. After the Fukushima accident, the Canadian Nuclear Regulatory Commission suggested that models used in risk assessment of Canadian nuclear facilities be firmly based on measured data. Procedures for measurement of tritium as HTO (tritiated water) are well established, but there are no standard methods and certified reference materials for measurement of organically bound tritium (OBT) in environmental samples. This paper describes and discusses an inter-laboratory comparison study in which OBT in three different dried environmental samples (fish, Swiss chard and potato) was measured to evaluate OBT analysis methods currently used by CANDU Owners Group (COG) members. The variations in the measured OBT activity concentrations between all laboratories were less than approximately 20%, with a total uncertainty between 11 and 17%. Based on the results using the dried samples, the current OBT analysis methods for combustion, distillation and counting are generally acceptable. However, a complete consensus OBT analysis methodology with respect to freeze-drying, rinsing, combustion, distillation and counting is required. Also, an exercise using low-level tritium samples (less than 100 Bq/L or 20 Bq/kg-fresh) would be useful in the near future to more fully evaluate the current OBT analysis methods.

Intervention Now To Eliminate Repeat Unintended Pregnancy in Teenagers (INTERUPT): a systematic review of intervention effectiveness and cost-effectiveness, qualitative and realist synthesis of implementation factors and user engagement

BACKGROUND

The UK has the highest rate of teenage pregnancies in Western Europe, a fifth are repeat pregnancies. Unintended conceptions can result in emotional, psychological and educational harm to teenage girls, often with enduring implications for their life chances. Babies of teenage mothers have increased mortality in their first year and increased risk of poverty, educational underachievement and unemployment later in life, with associated societal costs.

METHODS AND ANALYSIS

We will conduct a streamed, mixed-methods systematic review to find and evaluate interventions designed to reduce repeat unintended teen pregnancies.

OUR AIMS ARE TO IDENTIFY

 Who is at greater risk of repeat unintended pregnancies? Which interventions are effective, cost-effective, how they work, in what setting and for whom? What are the barriers and facilitators to intervention uptake? Traditional electronic database searches will be augmented by targeted searches for evidence 'clusters' and guided by an advisory group of experts and stakeholders. To address the topic's inherent complexities, we will use a highly structured, innovative and iterative approach combining methodological techniques tailored to each stream of evidence. Quantitative data will be synthesised with reference to Cochrane guidelines for public health interventions. Qualitative evidence addressing facilitators and barriers to the uptake of interventions, experience and acceptability of interventions will be synthesised thematically. We will apply the principles of realist synthesis to uncover theories and mechanisms underpinning interventions. We will conduct an integration and overarching narrative of findings authenticated by client group feedback.

ETHICS AND DISSEMINATION

We will publish the complete review in 'Health Technology Assessment' and sections in specialist peer-reviewed journals. We will present at national and international conferences in the fields of public health, reproductive medicine and review methodology. Findings will be fed back to service users and practitioners via workshops run by the partner collaborators.

TRAIL REGISTRATION NUMBER

PROSPERO CRD42012003168.

COCHRANE REGISTRATION NUMBER

i=fertility/0068.