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.

Increased exposure to loading is associated with decreased plantar soft tissue hardness in people with diabetes and neuropathy

AIMS

Literature indicates that altered plantar loading in people with diabetes could trigger changes in plantar soft tissue biomechanics which, in turn, could affect the risk for ulceration. To stimulate more research in this area, this study uses in vivo testing to investigate the link between plantar loading and tissue hardness.

METHODS

Tissue hardness and plantar pressure distribution were measured for six plantar areas in 39 people with diabetes and peripheral neuropathy.

RESULTS

Spearman correlation analysis revealed that increased pressure time integral at the 1st metatarsal-head region (r = -0.354, n = 39, P = 0.027) or at the heel (r = -0.378, n = 39, P = 0.018) was associated with reduced hardness in the same regions. After accounting for confounding parameters, generalised estimating equations analysis also showed that 10% increase in pressure time integral at the heel was associated with ≈ 1 unit reduction in hardness in the same region.

CONCLUSIONS

For the first time, this study reveals that people with diabetes and neuropathy who tend to load their feet more heavily also tend to have plantar soft tissues with lower hardness. The observed difference in tissue hardness is likely to affect the tissue's vulnerability to overload injury. More research will be needed to explore the implications of the observed association for the risk of ulceration.

Photodiagnostic services in the UK and Republic of Ireland: a British Photodermatology Group Workshop Report

BACKGROUND

Photodiagnostic investigations are essential for the accurate diagnosis of abnormal cutaneous photosensitivity and provide important information for the management of patients with photodermatoses (cutaneous photosensitivity disorders). Although photodiagnosis has been undertaken since the early 1970s, specialist services in the United Kingdom (UK) and Republic of Ireland are limited and there is no formal guidance on diagnostic approach. Indeed, there is a limited literature in this area of methodology and diagnostic practice.

OBJECTIVES

The primary objective was to undertake a British Photodermatology Group Workshop to review the role and activities of specialist centres in the UK and Republic of Ireland in order to ascertain whether there were consensus practices. Secondary objectives were to identify key priorities for service, training and research.

METHODS

An initial detailed survey review of current activities was undertaken prior to the Workshop and data from this survey were used to inform discussion at the Workshop, which was attended by key photodermatology experts from the UK and Republic of Ireland.

RESULTS/CONCLUSIONS

We have undertaken a detailed review of current Photodiagnostic Services in the UK and Republic of Ireland and report on our findings from the 12 centres and we have identified key areas of consensus practice. This is an important step in the process of standardising and optimising procedures and protocols and defining minimum clinical standards for photodiagnostic investigations, which are of such diagnostic importance in Dermatology.

Negotiating boundaries of care: an interpretative phenomenological analysis of the relational conflicts surrounding home mechanical ventilation following traumatic spinal cord injury

Objectives: The aim of this study is to explore the phenomena of mechanical ventilation following traumatic spinal cord injury from three simultaneous perspectives; patients who require full-time mechanical ventilation (n = 8), their informal family carers (n = 8) and their formal carers (n = 11). We focus upon the intra and inter- personal challenges of establishing boundaries within the triad. Design: Qualitative study. Methods: Semi-structured interviews were transcribed verbatim and analysed using interpretative phenomenological analysis (IPA). In order to encapsulate the inter-subjective, multi-dimensional and relational aspects of the experience, we focussed on recurrent themes which were independently reported across all three participant groups. Results: One major inter-connected recurrent theme was identified: 1) 'Negotiating boundaries of care and finding a "fit"'. It centres around establishing a 'line', or a boundary, which was imperative for retaining a sense of independence (for patients), a sense of home and privacy (for informal carers) and difficulties balancing complex care provision with the needs of family members so as not to cross that 'line' (for formal carers). Conclusions: The findings highlight the need for focussing on a 'fit' within the triad, balancing boundaries of care in order to establish a productive, satisfactory psycho-social environment for all three participant groups to live and/or work within. Recommendations for both future care provision and future research are suggested.

Interactive Videodisc as an Instructional Tool in Medical Education

At a time when medical educators are actively revising the undergraduate medical school curriculum to make it more responsive to exigencies ofthe 21st century, the use of interactivevide.odisc technology may well prove to be a significant addition. Using interactive videodisc technology may be instrumental in reducing the amount of a large lecture didactic learning and improving small group problem-solving sessions that better synthesize factual knowledge. It also provides important and valuable exposure to varieties of computer technology that play an increasingly important role in training and medical practice.

An RNA-Seq transcriptome analysis of orthophosphate-deficient white lupin reveals novel insights into phosphorus acclimation in plants

Phosphorus, in its orthophosphate form (P(i)), is one of the most limiting macronutrients in soils for plant growth and development. However, the whole-genome molecular mechanisms contributing to plant acclimation to P(i) deficiency remain largely unknown. White lupin (Lupinus albus) has evolved unique adaptations for growth in P(i)-deficient soils, including the development of cluster roots to increase root surface area. In this study, we utilized RNA-Seq technology to assess global gene expression in white lupin cluster roots, normal roots, and leaves in response to P(i) supply. We de novo assembled 277,224,180 Illumina reads from 12 complementary DNA libraries to build what is to our knowledge the first white lupin gene index (LAGI 1.0). This index contains 125,821 unique sequences with an average length of 1,155 bp. Of these sequences, 50,734 were transcriptionally active (reads per kilobase per million reads ≥ 3), representing approximately 7.8% of the white lupin genome, using the predicted genome size of Lupinus angustifolius as a reference. We identified a total of 2,128 sequences differentially expressed in response to P(i) deficiency with a 2-fold or greater change and P ≤ 0.05. Twelve sequences were consistently differentially expressed due to P(i) deficiency stress in three species, Arabidopsis (Arabidopsis thaliana), potato (Solanum tuberosum), and white lupin, making them ideal candidates to monitor the P(i) status of plants. Additionally, classic physiological experiments were coupled with RNA-Seq data to examine the role of cytokinin and gibberellic acid in P(i) deficiency-induced cluster root development. This global gene expression analysis provides new insights into the biochemical and molecular mechanisms involved in the acclimation to P(i) deficiency.

Contrast imaging ultrasound detects abnormalities in the marmoset ovary

The development of a functional vascular tree within the primate ovary is critical for reproductive health. To determine the efficacy of contrast agents to image the microvascular environment within the primate ovary, contrast ultrasonography was performed in six reproductive-aged female common marmosets (Callithrix jacchus) during the late luteal phase of the cycle, following injection of Sonovue™. Regions of interest (ROIs), representing the corpus luteum (CL) and noncorpus luteum ovarian tissue (NCLOT), were selected during gray-scale B-mode ultrasound imaging. The magnitude of backscatter intensity of CL and NCLOT ROIs were calculated in XnView, post hoc: subsequent gamma-variate modeling was implemented in Matlab to determine perfusion parameters. Histological analysis of these ovaries revealed a total of 11 CL, nine of which were identified during contrast ultrasonography. The median enhancement ratio was significantly increased in the CL (5.54AU; 95% CI -2.21-68.71) compared to the NCLOT (2.82AU; 95% CI 2.73-15.06; P < 0.05). There was no difference in time parameters between the CL and NCLOT. An additional avascular ROI was identified in the ovary of Animal 5, both histologically and by ultrasonography. This cystic ROI displayed a markedly lower enhancement ratio (0.79AU) and higher time parameters than mean CL and NCLOT, including time to peak and time to wash out. These data demonstrate, for the first time, the ability of commercially available contrast agents, to differentiate structures within the nonhuman primate ovary. Contrast-enhanced ultrasonography has a promising future in reproductive medicine.

Inhibition of delta-like ligand 4 induces luteal hypervascularization followed by functional and structural luteolysis in the primate ovary

Using specific inhibitors established that angiogenesis in the ovarian follicle and corpus luteum is driven by vascular endothelial growth factor. Recently, it has been demonstrated that the Notch ligand, delta-like ligand 4 (Dll4) negatively regulates vascular endothelial growth factor-mediated vessel sprouting and branching. To investigate the role of Dll4 in regulation of the ovarian vasculature, we administered a neutralizing antibody to Dll4 to marmosets at the periovulatory period. The vasculature was examined on luteal d 3 or d 10: angiogenesis was determined by incorporation of bromodeoxyuridine, staining for CD31 and cell death by staining for activated caspase-3. Ovulatory progesterone rises were monitored to determine effects of treatment on luteal function and time to recover normal cycles in a separate group of animals. Additionally, animals were treated in the follicular or midluteal phase to determine effects of Dll4 inhibition on follicular development and luteal function. Controls were treated with human IgG (Fc). Corpora lutea from marmosets treated during the periovulatory period exhibited increased angiogenesis and increased vascular density on luteal d 3, but plasma progesterone was significantly suppressed. By luteal d 10, corpora lutea in treated ovaries were significantly reduced in size, with involution of luteal cells, increased cell death, and suppressed plasma progesterone concentrations. In contrast, initiation of anti-Dll4 treatment during the midluteal phase produced only a slight suppression of progesterone for the remainder of the cycle. Moreover, Dll4 inhibition had no appreciable effect on follicular development. These results show that Dll4 has a specific and critical role in the development of the normal luteal vasculature.

White lupin cluster root acclimation to phosphorus deficiency and root hair development involve unique glycerophosphodiester phosphodiesterases

White lupin (Lupinus albus) is a legume that is very efficient in accessing unavailable phosphorus (Pi). It develops short, densely clustered tertiary lateral roots (cluster/proteoid roots) in response to Pi limitation. In this report, we characterize two glycerophosphodiester phosphodiesterase (GPX-PDE) genes (GPX-PDE1 and GPX-PDE2) from white lupin and propose a role for these two GPX-PDEs in root hair growth and development and in a Pi stress-induced phospholipid degradation pathway in cluster roots. Both GPX-PDE1 and GPX-PDE2 are highly expressed in Pi-deficient cluster roots, particularly in root hairs, epidermal cells, and vascular bundles. Expression of both genes is a function of both Pi availability and photosynthate. GPX-PDE1 Pi deficiency-induced expression is attenuated as photosynthate is deprived, while that of GPX-PDE2 is strikingly enhanced. Yeast complementation assays and in vitro enzyme assays revealed that GPX-PDE1 shows catalytic activity with glycerophosphocholine while GPX-PDE2 shows highest activity with glycerophosphoinositol. Cell-free protein extracts from Pi-deficient cluster roots display GPX-PDE enzyme activity for both glycerophosphocholine and glycerophosphoinositol. Knockdown of expression of GPX-PDE through RNA interference resulted in impaired root hair development and density. We propose that white lupin GPX-PDE1 and GPX-PDE2 are involved in the acclimation to Pi limitation by enhancing glycerophosphodiester degradation and mediating root hair development.

Examining the effect of spinal cord injury on emotional awareness, expressivity and memory for emotional material

The prevailing view on the effects of spinal cord injury (SCI) on emotion is that it dampens emotional experience due to a loss of peripheral bodily feedback, with the higher the lesion on the spinal cord the greater the reduction in the intensity of emotional experience. This view persists despite many studies showing an absence of such an emotional impairment in people with SCI. This study specifically aimed to investigate whether total cervical-6 spinal cord transection (i) reduces emotional expressivity and emotional awareness (ii) impairs memory for emotional material. The study contained three groups: 24 patients with SCI, 20 orthopaedic injury control (OIC) patients and 20 young adult controls. A mixed factor design was employed to examine between group and within subject differences. Participants completed the Levels of Emotional Awareness Scale (LEAS), the Berkeley Expressivity Questionnaire (BEQ), and viewed an emotionally arousing slide presentation. Thirty minutes post viewing, participants completed memory tests for the presentation. SCI patients reported greater present levels of emotional expressivity compared with perceived levels prior to their injuries. SCI and OIC groups did not differ on any of the emotional awareness variables. There was also no evidence that SCI leads to impairment in memory for emotional events. This study's findings contradict the mainstream view in the cognitive neuroscience of emotion that SCI dampens emotional experience.

Molecular analysis of SCARECROW genes expressed in white lupin cluster roots

The Scarecrow (SCR) transcription factor plays a crucial role in root cell radial patterning and is required for maintenance of the quiescent centre and differentiation of the endodermis. In response to phosphorus (P) deficiency, white lupin (Lupinus albus L.) root surface area increases some 50-fold to 70-fold due to the development of cluster (proteoid) roots. Previously it was reported that SCR-like expressed sequence tags (ESTs) were expressed during early cluster root development. Here the cloning of two white lupin SCR genes, LaSCR1 and LaSCR2, is reported. The predicted amino acid sequences of both LaSCR gene products are highly similar to AtSCR and contain C-terminal conserved GRAS family domains. LaSCR1 and LaSCR2 transcript accumulation localized to the endodermis of both normal and cluster roots as shown by in situ hybridization and gene promoter::reporter staining. Transcript analysis as evaluated by quantitative real-time-PCR (qRT-PCR) and RNA gel hybridization indicated that the two LaSCR genes are expressed predominantly in roots. Expression of LaSCR genes was not directly responsive to the P status of the plant but was a function of cluster root development. Suppression of LaSCR1 in transformed roots of lupin and Medicago via RNAi (RNA interference) delivered through Agrobacterium rhizogenes resulted in decreased root numbers, reflecting the potential role of LaSCR1 in maintaining root growth in these species. The results suggest that the functional orthologues of AtSCR have been characterized.

Extramammary Paget's disease treated with topical and systemic photodynamic therapy

Surgical excision and radiotherapy for extramammary Paget's disease (EMPD) at specific sites such as the groin and genitalia is often inappropriate. An 80-year-old man with histologically proven EMPD of the left groin and scrotum was referred for PDT. The lesion and normal skin thickness were measured by a 20MHz, two-dimensional 'B' ultrasound scanner (US). δ-5-Aminolaevulinic acid (ALA), was applied followed 6h later by irradiation using a filtered xenon-arc lamp. Clinical improvement was apparent four weeks after first PDT session with a reduction in ulceration and lesion size and moderate thickness reduction on US. Superficial ulceration recurred 9 months after the fifth treatment. This recurrence was treated with intravenously administered porfimer sodium. This, followed by one topical PDT treatment resulted in significant clinical and US cure and the patient remains disease free at 1-year follow-up.

Performance of irradiated Teia anartoides (Lepidoptera: Lymantriidae) in urban Auckland, New Zealand

The Australian moth Teia anartoides Walker has been the target of a major eradication program in Auckland, New Zealand. Information on cold torpor and dispersal was needed to help interpret catches of sterile and wild males in female-baited delta traps operated in a grid of up to 1,696 traps at 500-m spacings across the city. Laboratory experiments indicated male flight was enabled at temperatures above 17 degrees C (confirmed by field trapping of wild and recaptured moths). Male survival in the field or in field cages was determined to be limited to approximately 4 d. Sterilization of males for dispersal studies was achieved by exposing male pupae to either 160 or 100 Gy by using 1.25 MeV gamma rays from a Cobalt source, before release as fluorescent-dyed emerged adults. Dispersal was determined by recapture of males in the trapping grid of 1,696 delta traps baited with virgin female moths and placed at spacings of 50-500 m. Irradiated sterile males dispersed up to a maximum recorded distance of 4,500 m (160 Gy) and 10,000 m (100 Gy). At 100 Gy, the median dispersal distance was 300 m, with 90% of males dispersing 1,600 m or less.

RARgamma and Cdx1 interactions in vertebral patterning

Exogenous retinoic acid (RA) can evoke vertebral homeosis when administered during late gastrulation. These vertebral transformations correlate with alterations of the rostral limit of Hox gene expression in the prevertebrae, suggesting that retinoid signaling regulates the combinatorial expression of Hox genes dictating vertebral identity. Conversely, loss of certain RA receptors (RARs) results in anterior homeotic transformations principally affecting the cervical region. Despite these observations, the relationship between retinoid signaling, somitic Hox expression, and vertebral patterning is poorly understood. The members of the murine Cdx family (Cdx1, Cdx2, and Cdx4) are the homologues of Drosophila caudal and encode homeobox-containing transcription factors. Cdx1 homozygous null mutants exhibit anterior homeotic transformations, some of which are reminiscent of those in RARgamma null offspring. In Cdx1 mutants, these transformations occur concomitant with posteriorized prevertebral expression of certain Hox genes. Cdx1 has recently been demonstrated to be a direct RA target, suggesting an indirect means by which retinoid signaling may impact vertebral patterning. To further investigate this relationship, a complete allelic series of Cdx1-RARgamma mutants was generated and the skeletal phenotype assessed either following normal gestation or after administration of RA. Synergistic interactions between these null alleles were observed in compound mutants, and the full effects of exogenous RA on vertebral morphogenesis required Cdx1. These findings are consistent with a role for RA upstream of Cdx1 as regards axial patterning. However, exogenous RA attenuated several defects inherent to Cdx1 null mutants. This finding, together with the increased phenotypic severity of RARgamma-Cdx1 double null mutants relative to single nulls, suggests that these pathways also function in parallel, likely by converging on common targets.

A 30-month study of patient complaints at a major Australian hospital

Health practitioners often regard complaints about the quality of patient care in a negative light. However, complaints can indicate strategies to improve care. Therefore, an audit was undertaken of all formal complaints about patient care at a major Australian hospital over a 30-month period. The profile of complainants, the reasons for complaints, and the outcome were analysed. A total of 1308 complaints, concerning the care of 1267 patients, were received. The complaint rate was 1.12 per 1000 occasions of service. In all, 57% of complaints were lodged by advocates and 71% of complaints related to poor communication or to the treatment provided. In 97% of occasions, an explanation and/or an apology resulted. To date, no complaint has proceeded to litigation. Complaints are potentially useful quality assurance tools and can identify remediable system flaws. Health professionals and employers should understand why patients complain and be able to respond appropriately.

Regulation of gli activity by all-trans retinoic acid in mouse keratinocytes

Sonic hedgehog (Shh) signaling is essential for many normal developmental processes. The Shh signal is interpreted by the Gli transcription factors. Elevated Gli-1 expression has been associated with several neoplasms, including basal cell carcinoma. All-trans retinoic acid (RA) has strong effects on epidermal growth and differentiation and has been used for the treatment of various epithelial disorders. In this report, we show that RA can inhibit Gli activity in immortalized murine keratinocytes in a RA receptor-specific manner. This inhibition may occur, at least in part, through sequestration of the transcriptional coactivator cyclic AMP-responsive element-binding protein-binding protein and suggests a novel effect of retinoid excess on Shh signaling.

Complaints concerning the hospital care of elderly patients: a 12-month study of one hospital's experience

OBJECTIVE

to determine the number, instigators, nature and outcome of complaints concerning elderly patients treated at a single hospital over 1 year.

DESIGN

descriptive analysis of computerized data gathered prospectively; follow-up of complaints until resolution.

SETTING

large, urban, university teaching hospital in Australia.

SUBJECTS

all patients aged 65 years and above whose hospital care was the subject of complaint.

METHODS

analysis of computerized database of all complaints made in a single year.

RESULTS

1.44 complaints were made per 1000 occasions of service to elderly people (95% confidence intervals, 1.19 - 1.69). This was similar to the overall complaint rate of 1.32 per 1000 occasions of service for patients of all age groups (95% confidence intervals, 1.19- 1.45). However, 73% of complaints were made by advocates rather than by elderly patients themselves and 96% related to communication or treatment issues. Many complaints resulted in an explanation and/or an apology and, to date, none has resulted in litigation.

CONCLUSIONS

complaints concerning older hospitalized people are as common as those concerning younger patients. Analysis of complaints provides pointers for improvements in quality of care.