Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

The role of the 5f valence orbitals of early actinides in chemical bonding

One of the long standing debates in actinide chemistry is the level of localization and participation of the actinide 5f valence orbitals in covalent bonds across the actinide series. Here we illuminate the role of the 5f valence orbitals of uranium, neptunium and plutonium in chemical bonding using advanced spectroscopies: actinide M4,5 HR-XANES and 3d4f RIXS. Results reveal that the 5f orbitals are active in the chemical bonding for uranium and neptunium, shown by significant variations in the level of their localization evidenced in the spectra. In contrast, the 5f orbitals of plutonium appear localized and surprisingly insensitive to different bonding environments. We envisage that this report of using relative energy differences between the 5fδ/φ and 5fπ*/5fσ* orbitals as a qualitative measure of overlap-driven actinyl bond covalency will spark activity, and extend to numerous applications of RIXS and HR-XANES to gain new insights into the electronic structures of the actinide elements.

Whole-genome sequencing reveals activation-induced cytidine deaminase signatures during indolent chronic lymphocytic leukaemia evolution

Patients with chromosome 13q deletion or normal cytogenetics represent the majority of chronic lymphocytic leukaemia (CLL) cases, yet have relatively few driver mutations. To better understand their genomic landscape, here we perform whole-genome sequencing on a cohort of patients enriched with these cytogenetic characteristics. Mutations in known CLL drivers are seen in only 33% of this cohort, and associated with normal cytogenetics and unmutated IGHV. The most commonly mutated gene in our cohort, IGLL5, shows a mutational pattern suggestive of activation-induced cytidine deaminase (AID) activity. Unsupervised analysis of mutational signatures demonstrates the activities of canonical AID (c-AID), leading to clustered mutations near active transcriptional start sites; non-canonical AID (nc-AID), leading to genome-wide non-clustered mutations, and an ageing signature responsible for most mutations. Using mutation clonality to infer time of onset, we find that while ageing and c-AID activities are ongoing, nc-AID-associated mutations likely occur earlier in tumour evolution.

The oncogenic events driving indolent chronic lymphocytic leukaemia are relatively unknown. Here, the authors perform whole genome sequencing on 30 such tumours and identify recurrent mutations in IGLL5 and two activation induced cytidine deaminase signatures that are operative at different stages of CLL evolution.

Providing monovalent oral polio vaccine type 1 to newborns: findings from a pilot birth-dose project in Moradabad district, India

PROBLEM

Poliovirus transmission remained a public health challenge in western Uttar Pradesh, India in late 2005 and early 2006. In 2006, the India Expert Advisory Group for Polio Eradication concluded that, given the peak incidence of polio among children 6 to 12 months of age, a targeted birth dose of oral polio vaccine may be necessary to interrupt intense poliovirus transmission in high risk areas.

APPROACH

The Government of Uttar Pradesh, the National Polio Surveillance Project and the United Nations Children's Fund (UNICEF) implemented a pilot birth-dose project aimed at identifying and vaccinating all newborns with a dose of oral polio vaccine within 72 hours of birth in an effort to evaluate operational feasibility and potential impact on population immunity.

LOCAL SETTING

The project was piloted in Moradabad district: zone 7 in Moradabad City (urban setting), Kunderki block (rural setting) and in select birthing hospitals.

RELEVANT CHANGES

Between July 2006 and February 2007, 9740 newborns were identified, of which 6369 (65%) were vaccinated by project personnel within 72 hours of birth. Project coverage (for total newborns vaccinated) ranged from 39% (in zone 7) to 76% (in Kunderki block) of the estimated number of newborns vaccinated during previous supplemental immunization activities.

LESSONS LEARNED

Birth-dose coverage among newborns was lower than expected. Expansion costs were estimated to be high, with marginal impact. The project, however, provided opportunities to strengthen newborn tracking systems which have increased the number of newborns and young infants vaccinated during supplemental immunization activities and enrolled in routine programmes.

Evidence of a common founder for SCA12 in the Indian population

Spinocerebellar ataxia type 12 (SCA12) is an autosomal dominant cerebellar ataxia associated with the expansion of an unstable CAG repeat in the 5' region of the PPP2R2B gene on chromosome 5q31-5q32. We found that it accounts for approximately 16% (20/124) of all the autosomal dominant ataxia cases diagnosed in AIIMS, a major tertiary referral centre in North India. The length of the expanded allele in this population ranges from 51-69 CAG triplets. Interestingly, all the affected families belong to an endogamous population, which originated in the state of Haryana, India. We identified four novel SNPs and a dinucleotide marker spanning approximately 137 kb downstream of CAG repeat in the PPP2R2B gene. Analysis of 20 Indian SCA12 families and ethnically matched normal unrelated individuals revealed one haplotype to be significantly associated with the affected alleles (P= 0.000), clearly indicating the presence of a common founder for SCA12 in the Indian population. This haplotype was not shared by the American pedigree with SCA12. Therefore, the SCA12 expansion appears to have originated at least twice.

International perspectives: the profession of dietetics

A survey about the professional characteristics of dietetics practice was mailed to 109 countries and representatives from 61 countries responded. Using the Human Development Index (HDI), a measure that reflects the life expectancy, education, and income of the population of each nation, countries were categorized as high, medium, or low HDI. This allowed comparisons among the HDI scores in the areas of education, professional practice, education, and practice competencies. Responding countries were 36.1% high HDI, 49.2% middle HDI, 8.2% low HDI, and 6.6% were unclassified. Dietetics was a nationally recognized profession in 81% of countries, with most having a professional association that represented dietitians. Clinical dietetics was the most frequently selected area of practice, followed by food service. Undergraduate academic programs in dietetics were available in 79% of countries and 49% offered graduate degrees. Most respondents rated competencies in clinical and community nutrition, along with competencies in professional practice, as important to their work. The results of this study can serve as a baseline as the profession evolves. Leaders in the dietetics profession can use these results to identify areas that need improvement. Collaboration with the United Nations family and sources that fund global initiatives can help in providing resources for the advancement of the profession. When the effectiveness of dietitians is improved, favorable changes in nutritional well-being on the global level can be expected.

Novel reduced benzo[j]fluranthen-3-ones from Cladosporium cf. cladosporioides with cytokine production and tyrosine kinase inhibitory properties

A series of reduced benzo[j]fluoranthen-3-ones (1-4) was isolated from fermentations of a fungal strain CBUK20700 (CBS 100220), classified as Cladosporium cf. cladosporioides, during a microbial extract screening programme to identify inhibitors of anti-CD28-induced interleukin-2 (IL-2) production by Jurkat E6-1 cells as potential immunosuppressive agents. These compounds were also found to be tyrosine kinase inhibitors. The structures of compounds 1-4 were elucidated by spectroscopic methods including the HMQC, HMBC and NOESY NMR experiments. The most potent compound in the series, (6bS,7R,8S)-7-methoxy-4,8,9-trihydroxy-1,6b,7,8-tetrahydro-2H-benzo[j]fluoranthen-3-one (1) inhibited anti-CD28-induced IL-2 production and Abl tyrosine kinase with IC50 values of 400 and 60 nM respectively. The 6b-stereoisomeric 2 was a moderate inhibitor of both IL-2 production and Abl tyrosine kinase while the 8-oxo derivative 3 was inactive in both assays. The 8-O-methyl ether 4 was a moderate inhibitor of IL-2 production but exhibited potent inhibition of Abl tyrosine kinase with an IC50 of 45 nM.

Autologous bone marrow transplantation for childhood acute lymphoblastic leukaemia in second remission - long-term follow-up

From 1984 to 1996, 31 consecutive children without sibling donors, aged 5-19 years (median 8) with acute lymphoblastic leukaemia (ALL) in second complete remission (CR), received unpurged autologous bone marrow transplantation (ABMT) after melphalan and single fraction total body irradiation (TBI). ABMT was performed using fresh unmanipulated marrow harvested after standard reinduction and consolidation therapy 2-11 months (median 5) after relapse. With a median survival of 2.9 years the probability of survival for all patients in continuing second CR was 45.1% (95% CI, 24%-62%) after 5 years. Regimen-related and non-leukaemia mortality was 7% (95% CI, 2%-26%). The longest time to second relapse from ABMT was 3.1 years. Pituitary and gonadal dysfunction requiring hormonal replacement therapy occurred in the majority of long-term survivors. Twelve patients developed cataracts. ABMT with melphalan/single fraction TBI has proved an effective anti-leukaemia treatment with low regimen-related mortality but significant long-term morbidity. The current approach of allogeneic BMT from an unrelated donor when no sibling donor is available, following conditioning with cyclophosphamide/ fractionated TBI has resulted in a reduced relapse rate and improved short-term overall survival in the treatment of relapsed childhood ALL. However, long-term results are awaited.

A novel (6S)-4,6-dimethyldodeca-2E,4E-dienoyl ester of phomalactone and related alpha-pyrone esters from a Phomopsis sp. with cytokine production inhibitory activity

A series of novel 6-substituted 5,6-dihydro-5-hydroxy-alpha-pyrone esters, 1 approximately 3, isolated from fermentations of a Phomopsis sp. (Xenova culture collection no. X22502) have been identified as inhibitors of lipopolysaccharide (LPS)-induced cytokine production. These include the (6S)-4,6-dimethyldodecadien-2E,4E-dienoyl ester of phomalactone, 1, and two analogues bearing a prop-2E-enoic acid moiety at the 6-position of the alpha-pyrone ring. (6S)-4,6-Dimethyl-2E,4E-dienoic acid, 4, and a hydroxylated analogue, 5, were also isolated and characterised. The most potent cytokine production inhibitor was 1, which inhibited LPS-induced tumour necrosis factor alpha (TNFalpha) production by U937 cells and LPS-induced interleukin 1beta (IL-1beta) production by peripheral blood mononuclear cells (PBMC) with IC50 values of 80 nM and 190 nM respectively. The effect of 1 in PBMC was selective for IL-1beta relative to TNFalpha. The inhibition of IL-1beta production by 1 involved a post-translational mechanism of action at the level of IL-1beta secretion as demonstrated by the lack of an effect on cell-associated IL-1beta production. 1 showed no effect on the activity of caspase 1 in cytosolic extracts from the THP1 monocytic cell line.

Oral lichen planus update: clinical characteristics, treatment responses, and malignant transformation

PURPOSE

To assess the current profile and the natural disease history of patients with oral lichen planus (OLP) and evaluate their responses to treatment.

MATERIALS AND METHODS

Ninety-five community-referred patients with OLP, who were examined in our Oral Medicine Clinic between May 1995 and August 1996, comprised the study group.

RESULTS

The OLP patients had been followed for 1-20 years (mean 6.1). The average age at first-recognized onset was 59 years, and there was a 2.3 to 1 female predominance. Only five of the patients knew of a family history of lichen planus. There were no evident associations with smoking, candida, systemic disease or medications. Of the 222 involved mucosal sites, the buccal mucosa was involved most often (79%) and the erosive form was most frequent. Of 70 patients who received systemic and/or topical corticosteroid treatment for pain (83%) or annoying irritation (17%), all but five obtained complete or satisfactory relief. A squamous cell carcinoma developed at a lesion site in three patients (3.2%) during the observation period.

Legionella as a lower respiratory pathogen in north India

One hundred patients of lower respiratory tract infection (LRTI) were prospectively studied over 2 years to find out if Legionella is a causative agent in these patients. In addition, 50 environmental samples and 50 age and sex matched controls were studied. Culture and direct fluorescent antibody testing (DFA) of respiratory tract secretions, and serodiagnosis by indirect immunofluorescence (IIF) and ELISA, were employed to detect Legionella. Respiratory tract secretions from all patients were negative for Legionella on culture and DFA. Low antibody titters to Legionella were observed in 21 patients and these could be attributed to cross reaction with other gram-negative bacteria. All environmental samples and controls tested negative for Legionella. Legionella does not seem to be an important lower respiratory tract pathogen in this part of the country and empirical addition of erythromycin to treatment regimens for pneumonia is not warranted in our setting.

Efficacy of combination therapy with insulin and oral hypoglycemic agents in patients with type II diabetes during a 1-year period

In this retrospective study, the authors assess the efficacy of combined insulin and oral hypoglycemic agents (OHAs) in controlling glycemic levels, as well as lipid levels and insulin requirements, in 48 patients with type II diabetes mellitus during a 1-year period. Thirty-two of these patients had secondary failure to an OHA (group 1). Sixteen patients (group 2) were taking high doses of insulin alone. Overall, 64.6% of all the patients responded to the combination therapy and insulin at 6 months. Response was defined as a decrease in hemoglobin A1c of more than 0.5%. At 12 months, 50% of these patients continued to respond to this regimen. No significant differences were seen in the patients' total cholesterol and triglyceride levels between responders and nonresponders in each group. After 1 year of combination OHA and insulin therapy, 50% of the patients showed a 21.4% reduction in their daily insulin dose.

Three-dimensional image reconstruction using interferometric data from a limited field of view with noise

A reconstruction of phase objects using an algebraic reconstruction technique in an unconfined environment from multidirectional interferometric data is presented. The effect of noise on the data from the interference patterns is studied. It is shown that in the presence of noise the number of iterations need to be critically evaluated; otherwise the solution tends to diverge. Criteria used to quantify the noise are presented. Also shown is a relationship between noise and the required number of iterations, which yields the least error in reconstruction. This procedure is applied to experimentally obtained interferometric data.

Nutrition across the woman's life cycle. Special emphasis on pregnancy

Nutrition plays a crucial role in the maintenance of health of a woman throughout life, but assumes an even more important role during growth, pregnancy, lactation, and menopause. The nutrient reserves accumulated during other, nonstressful periods of life are of vital importance during these phases of physiological stress. Requirements for various nutrients, such as protein, carbohydrate, fat, minerals, and vitamins, throughout life are qualitatively similar; however, they change quantitatively with the rate and intensity of physiological processes taking place within the body. Pregnant and lactating women require more energy, protein, iron, calcium, and vitamins to meet their increased needs. Rapid growth during infancy, childhood, and adolescence also increases the requirements for essential nutrients. In the elderly female, it is important to decrease energy consumption as the basal metabolic rate declines. However, minerals and vitamins, particularly calcium, thiamine, and pyridoxine, continue to be as essential in the elderly population as in adult women.

Mechanism of lipid accumulation in rats fed wheat diets

Young, weanling rats fed wheat as a sole source of protein have been shown to develop periportal liver lipid infiltration. An attempt has been made to study the mechanism by which these lipid changes are produced. Weanling, male albino rats were fed three diets containing 10% protein based on wheat, wheat fortified with 0.2% lysine or casein, as control. Plasma and liver lipids, incorporation of [1-(14)C]acetate and [U-14C]glucose into hepatic lipids and triglycerides were studied after 6 weeks of feeding. Results of radioactive incorporation studies indicated that hepatic lipogenesis was depressed in rats fed wheat diets. However, adrenal cortical function as well as increased mobilization of lipids from adipose tissue was observed in these rats. Impaired secretion of lipids from liver to plasma is another factor which may be responsible for hepatic lipid accumulation in rats fed the lysine-deficient diet. Rats fed the lysine fortified wheat diet represented a more normal metabolic state though some features of protein deficiency were evident in this group too.