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.

Educating for Quality Transgender Health Care: A Survey Study of Medical Students

BACKGROUND

The worse health outcomes suffered by transgender patients is compounded by the lack of training that students receive on addressing the needs of this population. Medical students are future doctors, and in this role, they should be learning to provide care to all of their potential patients.

METHODS

This study uses pretest-posttest design to assess the impact of a teaching session on students' responses across three themes: understanding, education, and profession. Students and members of the public (n = 25) attended a 2-h teaching session covering important topics in relation to transgender health. Assessment was carried out using a six-question survey that gathered responses on a Likert scale.

RESULTS

Level of understanding showed a significant increase (P < 0.05), as did one of the questions associated with profession (comfort seeing a transgender patient for a gender issue). The questions on education showed no significant change with the majority of students believing in the importance of learning about transgender health care. Despite the teaching session, there was no increase in the comfort level of medical students' with seeing a transgender patient for a nongender issue.

DISCUSSION

: Medical students are ready to be part of reducing the barriers to quality health care for transgender people. Education delivered with the help of the transgender community and specialist doctors can equip medical students with the understanding and level of education required to provide care to all of their patients.

Food-Energy-Water Crises in the United States and China: Commonalities and Asynchronous Experiences Support Integration of Global Efforts

Food, energy, and water (FEW) systems have been recognized as an issue of critical global importance. Understanding the mechanisms that govern the FEW nexus is essential to develop solutions and avoid humanitarian crises of displacement, famine, and disease. The U.S. and China are the world's leading economies. Although the two nations are shaped by fundamentally different political and economic systems, they share FEW trajectories in several complementary ways. These realities place the U.S. and China in unique positions to engage in problem definition, dialogue, actions, and transdisciplinary convergence of research to achieve productive solutions addressing FEW challenges. By comparing the nexus and functions of the FEW systems in the two nations, this perspective aims to facilitate collaborative innovations that reduce disciplinary silos, mitigate FEW challenges, and enhance environmental sustainability. The review of experiences and challenges facing the U.S. and China also offers valuable insights for other nations seeking to achieve sustainable development goals.

The impact of perioperative music on abdominal surgery patients' experience of postoperative pain: A systematic review and meta-analysis

OBJECTIVE

Music interventions have been analysed for their use in many surgical specialties, but they have not yet been reviewed in relation to abdominal surgery. This systematic review and meta-analysis examines the effect that listening to music perioperatively has on the postoperative pain of abdominal surgery patients.

METHODS

A systematic search of PubMed, Cochrane Library and Scopus was undertaken to identify randomised controlled trials comparing a music intervention with standard care, where self-reported postoperative pain was included as an outcome. Study quality was then assessed by the author in conjunction with Robot Reviewer software based on the Cochrane bias methodology, and a meta-analysis was performed using standard mean difference and a random-effects model.

RESULTS

Twelve studies met the inclusion criteria for review, and eight studies (2217 subjects) had appropriate data reporting to be included in the meta-analysis. Half of the reviewed studies concluded a significant positive impact on postoperative pain and the meta-analysis reinforced this hypothesis (p < 0.001). There was minimal difference in impact between intra and postoperative interventions, or between patient or researcher selected music.

CONCLUSIONS

This review supports the use of music in the perioperative period for abdominal surgery patients as a low cost adjunct to pharmaceutical pain relief.

Towards more sustainable agricultural landscapes: Lessons from Northwestern Mexico and the Western Highlands of Guatemala

A systematic process for assessing progress toward landscape sustainability goals is developed and tested. Application of the approach builds capacity and promotes continual improvements in management practices, thus enabling timely action to address changing conditions while progressing toward locally defined goals. We consider how the approach applies to agricultural landscapes, that is farm ecosystem interactions with the environment and human well-being. We present lessons learned from applying the assessment approach in two contrasting situations: large, high-input, commercial agriculture in northwestern Mexico and small, low-input family farms in the Western Highlands of Guatemala. Applying the approach reveals five attributes required for success and the means to achieve those conditions. (1) Having a capable local champion for the project is critical. (2) Implementation of the approach must be in concert with local people and organizations as well as with regional and national policies and programs. (3) Identification and engagement of key stakeholders is essential. (4) Application of the approach is not meant to be a one-time effort but rather an ongoing and systematic process. (5) Engagement and buy-in from stakeholders including multiple agency levels is essential for allocation of necessary resources and logistic support in the continuing implementation of the approach.

Dataset of forest landowner survey to assess interest in supplying woody biomass in two Southeastern United States fuelsheds

This article presents data from a recent mail survey of forest landowners regarding their land ownership characteristics and motivations, past and future management activities, and owner perceptions of bioenergy and its impact on forests. The data presented in this article are related to the research article entitled ‘Opportunities and Attitudes of Private Forest Landowners in Supplying Woody Biomass for Renewable Energy’ [1]. The survey was conducted in the Atlantic Coastal Plain of the United States, where two primary ports exporting wood pellets to Europe are located. Specifically, the data include responses on forest characteristics, forest management activities, knowledge and interest in woody biomass for energy production, and sociodemographic variables. Additionally, landowner decisions for supplying wood for traditional forest products and biomass for energy were modeled. More than 2900 forest landowners were contacted, with 707 owners providing completed surveys.

Dataset of timberland variables used to assess forest conditions in two Southeastern United States׳ fuelsheds

The data presented in this article are related to the research article entitled “How is wood-based pellet production affecting forest conditions in the southeastern United States?” (Dale et al., 2017) [1]. This article describes how United States Forest Service (USFS) Forest Inventory and Analysis (FIA) data from multiple state inventories were aggregated and used to extract ten annual timberland variables for trend analysis in two case study bioenergy fuelshed areas. This dataset is made publically available to enable critical or extended analyses of changes in forest conditions, either for the fuelshed areas supplying the ports of Savannah, Georgia and Chesapeake, Virginia, or for other southeastern US forested areas contributing biomass to the export wood pellet industry.

Comparing scales of environmental effects from gasoline and ethanol production

Understanding the environmental effects of alternative fuel production is critical to characterizing the sustainability of energy resources to inform policy and regulatory decisions. The magnitudes of these environmental effects vary according to the intensity and scale of fuel production along each step of the supply chain. We compare the spatial extent and temporal duration of ethanol and gasoline production processes and environmental effects based on a literature review and then synthesize the scale differences on space-time diagrams. Comprehensive assessment of any fuel-production system is a moving target, and our analysis shows that decisions regarding the selection of spatial and temporal boundaries of analysis have tremendous influences on the comparisons. Effects that strongly differentiate gasoline and ethanol-supply chains in terms of scale are associated with when and where energy resources are formed and how they are extracted. Although both gasoline and ethanol production may result in negative environmental effects, this study indicates that ethanol production traced through a supply chain may impact less area and result in more easily reversed effects of a shorter duration than gasoline production.

Environmental indicators of biofuel sustainability: what about context?

Indicators of the environmental sustainability of biofuel production, distribution, and use should be selected, measured, and interpreted with respect to the context in which they are used. The context of a sustainability assessment includes the purpose, the particular biofuel production and distribution system, policy conditions, stakeholder values, location, temporal influences, spatial scale, baselines, and reference scenarios. We recommend that biofuel sustainability questions be formulated with respect to the context, that appropriate indicators of environmental sustainability be developed or selected from more generic suites, and that decision makers consider context in ascribing meaning to indicators. In addition, considerations such as technical objectives, varying values and perspectives of stakeholder groups, indicator cost, and availability and reliability of data need to be understood and considered. Sustainability indicators for biofuels are most useful if adequate historical data are available, information can be collected at appropriate spatial and temporal scales, organizations are committed to use indicator information in the decision-making process, and indicators can effectively guide behavior toward more sustainable practices.

Communicating about bioenergy sustainability

Defining and measuring sustainability of bioenergy systems are difficult because the systems are complex, the science is in early stages of development, and there is a need to generalize what are inherently context-specific enterprises. These challenges, and the fact that decisions are being made now, create a need for improved communications among scientists as well as between scientists and decision makers. In order for scientists to provide information that is useful to decision makers, they need to come to an agreement on how to measure and report potential risks and benefits of diverse energy alternatives in a way that allows decision makers to compare options. Scientists also need to develop approaches that contribute information about problems and opportunities relevant to policy and decision making. The need for clear communication is especially important at this time when there is a plethora of scientific papers and reports and it is difficult for the public or decision makers to assess the merits of each analysis. We propose three communication guidelines for scientists whose work can contribute to decision making: (1) relationships between the question and the analytical approach should be clearly defined and make common sense; (2) the information should be presented in a manner that non-scientists can understand; and (3) the implications of methods, assumptions, and limitations should be clear. The scientists' job is to analyze information to build a better understanding of environmental, cultural, and socioeconomic aspects of the sustainability of energy alternatives. The scientific process requires transparency, debate, review, and collaboration across disciplines and time. This paper serves as an introduction to the papers in the special issue on "Sustainability of Bioenergy Systems: Cradle to Grave" because scientific communication is essential to developing more sustainable energy systems. Together these four papers provide a framework under which the effects of bioenergy can be assessed and compared to other energy alternatives to foster sustainability.

Interactions among bioenergy feedstock choices, landscape dynamics, and land use

Landscape implications of bioenergy feedstock choices are significant and depend on land-use practices and their environmental impacts. Although land-use changes and carbon emissions associated with bioenergy feedstock production are dynamic and complicated, lignocellulosic feedstocks may offer opportunities that enhance sustainability when compared to other transportation fuel alternatives. For bioenergy sustainability, major drivers and concerns revolve around energy security, food production, land productivity, soil carbon and erosion, greenhouse gas emissions, biodiversity, air quality, and water quantity and quality. The many implications of bioenergy feedstock choices require several indicators at multiple scales to provide a more complete accounting of effects. Ultimately, the long-term sustainability of bioenergy feedstock resources (as well as food supplies) throughout the world depends on land-use practices and landscape dynamics. Land-management decisions often invoke trade-offs among potential environmental effects and social and economic factors as well as future opportunities for resource use. The hypothesis being addressed in this paper is that sustainability of bioenergy feedstock production can be achieved via appropriately designed crop residue and perennial lignocellulosic systems. We find that decision makers need scientific advancements and adequate data that both provide quantitative and qualitative measures of the effects of bioenergy feedstock choices at different spatial and temporal scales and allow fair comparisons among available options for renewable liquid fuels.

Modeling transient response of forests to climate change

Our hypothesis is that a high diversity of dominant life forms in Tennessee forests conveys resilience to disturbance such as climate change. Because of uncertainty in climate change and their effects, three climate change scenarios for 2030 and 2080 from three General Circulation Models (GCMs) were used to simulate a range of potential climate conditions for the state. These climate changes derive from the Intergovernmental Panel on Climate Change (IPCC) "A1B" storyline that assumes rapid global economic growth. The precipitation and temperature projections from the three GCMs for 2030 and 2080 were related to changes in five ecological provinces using the monthly record of temperature and precipitation from 1980 to 1997 for each 1km cell across the state as aggregated into the provinces. Temperatures are projected to increase in all ecological provinces in all months for all three GCMs for both 2030 and 2080. Precipitation differences from the long-term average are more complex but less striking. The forest ecosystem model LINKAGES was used to simulate conditions for five ecological provinces from 1989 to 2300. Average output projects changes in tree diversity and species composition in all ecological provinces in Tennessee with the greatest changes in the Southern Mixed Forest province. Projected declines in total tree biomass are followed by biomass recovery as species replacement occurs in stands. The Southern Mixed Forest province results in less diversity in dominant trees as well as lower overall biomass than projections for the other four provinces. The biomass and composition changes projected in this study differ from forest dynamics expected without climate change. These results suggest that biomass recovery following climate change is linked to dominant tree diversity in the southeastern forest of the US. The generality of this observation warrants further investigation, for it relates to ways that forest management may influence climate change effects.

Enhancing the ecological risk assessment process

The Ecological Processes and Effects Committee of the US Environmental Protection Agency Science Advisory Board conducted a self-initiated study and convened a public workshop to characterize the state of the ecological risk assessment (ERA), with a view toward advancing the science and application of the process. That survey and analysis of ERA in decision making shows that such assessments have been most effective when clear management goals were included in the problem formulation; translated into information needs; and developed in collaboration with decision makers, assessors, scientists, and stakeholders. This process is best facilitated when risk managers, risk assessors, and stakeholders are engaged in an ongoing dialogue about problem formulation. Identification and acknowledgment of uncertainties that have the potential to profoundly affect the results and outcome of risk assessments also improves assessment effectiveness. Thus we suggest 1) through peer review of ERAs be conducted at the problem formulation stage and 2) the predictive power of risk-based decision making be expanded to reduce uncertainties through analytical and methodological approaches like life cycle analysis. Risk assessment and monitoring programs need better integration to reduce uncertainty and to evaluate risk management decision outcomes. Postdecision audit programs should be initiated to evaluate the environmental outcomes of risk-based decisions. In addition, a process should be developed to demonstrate how monitoring data can be used to reduce uncertainties. Ecological risk assessments should include the effects of chemical and nonchemical stressors at multiple levels of biological organization and spatial scale, and the extent and resolution of the pertinent scales and levels of organization should be explicitly considered during problem formulation. An approach to interpreting lines of evidence and weight of evidence is critically needed for complex assessments, and it would be useful to develop case studies and/or standards of practice for interpreting lines of evidence. In addition, tools for cumulative risk assessment should be developed because contaminants are often released into stressed environments.

Plant reestablishment 15 years after the debris avalanche at Mount St Helens, Washington

Vegetation has slowly reestablished on the debris avalanche deposit in the 15 years after the 1980 eruption of Mount St. Helens that created a 60-km(2) debris avalanche, the largest landslide in recorded history. There has been a gradual increase in species richness and cover, but only 61% of the species present on the mountain before the eruption have established on the debris avalanche deposit. Plant cover averages 38% and is extremely patchy. Life form composition changed over successional time, because part of the avalanche deposit was invaded by introduced plant species aerially seeded to reduce erosion, the site offers the opportunity to compare successional processes occurring with and without introduced species. Long-term recovery trends and effects of nonnative species on succession are important to understand since plant reestablishment practices often rely on nonnative species for enhancing vegetation recovery of denuded sites along road sides, strip mines, or other human-generated clearing. Fifteen years after the eruption and 10 years since the invasion by introduced species, plots invaded by nonnative species had greater vegetation cover and more native plant richness than plots that were not inundated. Significantly greater mortality of conifers occurred in the plots dominated by introduced species shortly after the invasion of those species, but no difference in conifer mortality occurred in the last 5 years. Even so, the plots dominated by introduced species still have fewer conifer trees. Thus, the short-term pulse of conifer mortality after the invasion of introduced species may have long-term effects on the recovery of the dominant vegetation. It will likely be decades before there is 100% plant cover on the debris avalanche deposit and a century or more before full recovery of the vegetation system.

The interplay between climate change, forests, and disturbances

Climate change affects forests both directly and indirectly through disturbances. Disturbances are a natural and integral part of forest ecosystems, and climate change can alter these natural interactions. When disturbances exceed their natural range of variation, the change in forest structure and function may be extreme. Each disturbance affects forests differently. Some disturbances have tight interactions with the species and forest communities which can be disrupted by climate change. Impacts of disturbances and thus of climate change are seen over a board spectrum of spatial and temporal scales. Future observations, research, and tool development are needed to further understand the interactions between climate change and forest disturbances.

Assessing Land-Use Impacts on Natural Resources

/ Much information is available on changes that occur in natural resources from both spatially-explicit data on environmental conditions and models of the interactions of these conditions and resources with human activities. The strategy for assessing land-use impacts on natural resources developed in this paper provides a framework for using relevant data and models to address questions of how management practices can promote both use and protection of resources. This assessment strategy integrates spatially explicit environmental data using geographic information systems (GIS) with computer models that simulate changes in land cover in response to land-use impacts. The computer models also simulate susceptibility of species to changes in habitat suitability and landscape patterns. The approach is applied to management of limestone barrens on the Oak Ridge Reservation in East Tennessee. Potential limestone barrens habitats are identified by overlaying appropriate soils, geology, slope, and land-use/land-cover conditions. Their validity is tested against known sites containing rare species that occur in these habitats. The location of habitats at risk in the aftermath of human activities is determined by using an available area model that identifies the size and proximity of sites that particular types of species can no longer use as habitat. The resulting risk map can be used in land management planning. The approach uses readily available in situ and remotely sensed data and is applicable to a wide range of locations and land-use scenarios. This approach can be refined based on needs identified by land managers and on the sensitivity of the results to the resolution of available resource information.KEY WORDS: Land management; Assessment; Habitat characterization; Limestone barrens; Ecological modeling; Geographic information systems

Wind dispersed seeds and plant recovery on the Mount St. Helens debris avalanche

Seed dispersal and plant establishment were monitored for 4 years on the debris avalanche created by the 1980 eruption of Mount St. Helens. The number of plants on the deposit increased over time to a high of almost 2 plants/m2 by 1983. The number of species per 250-m2 plot has increased to a mean of 10.3 in 1983 with 76 species being present over the entire deposit. Four years after the eruption only 30% of the species present before the eruption had reestablished themselves, and average plant cover was less than 1%. The debris avalanche has been invaded primarily via wind-dispersed seed of early successional species that survived or have become established in adjacent disturbed areas. Most of the early successional species on the avalanche have plumed seeds that are adapted not only for long distance dispersal, but also for being trapped in wet areas or by spider webs. Fluctuations in the density of seeds dispersed to the deposit were related to variation in precipitation. Neither seed abundance nor plant density correlated with absolute distance to a seed source or soil texture conditions. Colonization patterns are more influenced by the available biota and prevailing climate conditions than by substrate alterations resulting from the eruption.