Comparison of National Surgical Quality Improvement Program Surgical Risk Calculator and Trauma and Injury Severity Score Risk Assessment Tools in Predicting Outcomes in High-Risk Operative Trauma Patients

BACKGROUND

The Trauma and Injury Severity Score (TRISS) uses anatomic/physiologic variables to predict outcomes. The National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC) includes functional status and comorbidities. It is unclear which of these tools is superior for high-risk trauma patients (American Society of Anesthesiologists Physical Status (ASA-PS) class IV or V). This study compares risk prediction of TRISS and NSQIP-SRC for mortality, length of stay (LOS), and complications for high-risk operative trauma patients.

METHODS

This is a prospective study of high-risk (ASA-PS IV or V) trauma patients (≥18 years-old) undergoing surgery at 4 trauma centers. We compared TRISS vs NSQIP-SRC vs NSQIP-SRC + TRISS for ability to predict mortality, LOS, and complications using linear, logistic, and negative binomial regression.

RESULTS

Of 284 patients, 48 (16.9%) died. The median LOS was 16 days and number of complications was 1. TRISS + NSQIP-SRC best predicted mortality (AUROC: .877 vs .723 vs .843, P = .0018) and number of complications (pseudo-R2/median error (ME) 5.26%/1.15 vs 3.39%/1.33 vs 2.07%/1.41, P < .001) compared to NSQIP-SRC or TRISS, but there was no difference between TRISS + NSQIP-SRC and NSQIP-SRC with LOS prediction (P = .43).

DISCUSSION

For high-risk operative trauma patients, TRISS + NSQIP-SRC performed better at predicting mortality and number of complications compared to NSQIP-SRC or TRISS alone but similar to NSQIP-SRC alone for LOS. Thus, future risk prediction and comparisons across trauma centers for high-risk operative trauma patients should include a combination of anatomic/physiologic data, comorbidities, and functional status.

Adolescent use and co-use of tobacco and cannabis in California: The roles of local policy and density of tobacco, vape, and cannabis retailers around schools

Adolescent tobacco use (particularly vaping) and co-use of cannabis and tobacco have increased, leading some jurisdictions to implement policies intended to reduce youth access to these products; however, their impacts remain unclear. We examine associations between local policy, density of tobacco, vape, and cannabis retailers around schools, and adolescent use and co-use of tobacco/vape and cannabis. We combined 2018 statewide California (US) data on: (a) jurisdiction-level policies related to tobacco and cannabis retail environments, (b) jurisdiction-level sociodemographic composition, (c) retailer locations (tobacco, vape, and cannabis shops), and (d) survey data on 534,176 middle and high school students (California Healthy Kids Survey). Structural equation models examined how local policies and retailer density near schools are associated with frequency of past 30-day cigarette smoking or vaping, cannabis use, and co-use of tobacco/vape and cannabis, controlling for jurisdiction-, school-, and individual-level confounders. Stricter retail environment policies were associated with lower odds of past-month use of tobacco/vape, cannabis, and co-use of tobacco/vape and cannabis. Stronger tobacco/vape policies were associated with higher tobacco/vape retailer density near schools, while stronger cannabis policies and overall policy strength (tobacco/vape and cannabis combined) were associated with lower cannabis and combined retailer densities (summed tobacco/vape and cannabis), respectively. Tobacco/vape shop density near schools was positively associated with tobacco/vape use odds, as was summed retailer density near schools and co-use of tobacco, cannabis. Considering jurisdiction-level tobacco and cannabis control policies are associated with adolescent use of these substances, policymakers may proactively leverage such policies to curb youth tobacco and cannabis use.

Correction: Hom et al. Cognitive Function during the Prodromal Stage of Alzheimer's Disease in Down Syndrome: Comparing Models. BrainSci. 2021, 11, 1220

We would like to submit the following correction to our recently published paper [...].

Factors associated with death from lymphoma in a single center study

e19566

Background: It is well known that age, stage, and performance status are important prognostic factors in predicting survival of patients diagnosed with lymphoid malignancies. At the VA Healthcare System, many patients have comorbidities and poor performance status. We evaluated the association of clinical outcomes with lymphoma stage, subtype and performance status in US Veterans. Methods: This retrospective study included patients diagnosed with a lymphoid malignancy including diffuse large B-cell lymphoma (DLBCL), chronic lymphocytic leukemia (CLL), follicular lymphoma (FL), marginal zone lymphoma (MZL), mantle cell lymphoma (MCL), and peripheral T-cell lymphoma (PTCL) from January 2008 - December 2021 at the VA Long Beach Healthcare System (n = 221). Endpoints included clinically relevant hematological and non-hematological adverse events (AE), and death from lymphoma (with death from other causes as competing events). Variables of interest included aggressive lymphomas (DLBCL and PTCL, n = 85) vs indolent lymphomas (CLL, FL, MZL and MCL, n = 149), stage (early [0-2] vs advanced [3-4]), age at diagnosis (continuous variable), and performance status (Eastern Cooperative Oncology Group [ECOG] scale: good [0-2] vs poor [3-4]). Logistic regression and Cox models with Fine and Gray competing risk were performed. Results: In patients receiving first line therapy, performance status, disease type, stage, and age at diagnosis did not predict development of clinically relevant AEs with an odds ratio [OR] of 4.1 (p = 0.12, 95% CI 0.70-24), 0.36 (p = 0.06, 95% CI 0.12-1.0), 1.5 (p = 0.39, 95% CI 0.58-4.0), and 1.0 (p = 0.12, 95% 0.99-1.1), respectively. Patients with worse performance status (ECOG 3-4) and advancing age did not have a statistically higher risk of dying from lymphoma vs other causes: performance status: HR 1.7, p = 0.26, 95% CI 0.67-4.3 and age: HR 1.02, p = 0.11, 95% CI 1.0-1.1. In a multivariate analysis, patients with more advanced stage and aggressive subtype were more likely to die from lymphoma vs other causes (hazard ratio [HR] 4.1; p < 0.001, 95% CI 2.2-7.8 and 3.1; p = < 0.0001, 95% CI 1.7-5.5), respectively. Conclusions: The fact that performance status may not predict the development of AEs with first line therapy for lymphoid malignancies is relevant to clinical decision making. However, our findings need confirmation in larger prospective studies.

Comparison of National Surgical Quality Improvement Program Surgical Risk Calculator, Trauma and Injury Severity Score, and American Society of Anesthesiologists Physical Status to predict operative trauma mortality in elderly patients

BACKGROUND

The Trauma and Injury Severity Score (TRISS) uses anatomical and physiologic variables to predict mortality. Elderly (65 years or older) trauma patients have increased mortality and morbidity for a given TRISS, in part because of functional status and comorbidities. These factors are incorporated into the American Society of Anesthesiologists Physical Status (ASA-PS) and National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC). We hypothesized scoring tools using comorbidities and functional status to be superior at predicting mortality, hospital length of stay (LOS), and complications in elderly trauma patients undergoing operation.

METHODS

Four level I trauma centers prospectively collected data on elderly trauma patients undergoing surgery within 24 hours of admission. Using logistic regression, five scoring models were compared: ASA-PS, NSQIP-SRC, TRISS, TRISS-ASA-PS, and TRISS-NSQIP-SRC.Brier scores and area under the receiver operator characteristics curve were calculated to compare mortality prediction. Adjusted R2 and root mean squared error were used to compare LOS and predictive ability for number of complications.

RESULTS

From 122 subjects, 9 (7.4%) died, and the average LOS was 12.9 days (range, 1-110 days). National Surgical Quality Improvement Program Surgical Risk Calculator was superior to ASA-PS and TRISS at predicting mortality (area under the receiver operator characteristics curve, 0.978 vs. 0.768 vs. 0.903; p = 0.007). Furthermore, NSQIP-SRC was more accurate predicting LOS (R2, 25.9% vs. 13.3% vs. 20.5%) and complications (R2, 34.0% vs. 22.6% vs. 29.4%) compared with TRISS and ASA-PS. Adding TRISS to NSQIP-SRC improved predictive ability compared with NSQIP-SRC alone for complications (R2, 35.5% vs. 34.0%; p = 0.046). However, adding ASA-PS or TRISS to NSQIP-SRC did not improve the predictive ability for mortality or LOS.

CONCLUSION

The NSQIP-SRC, which includes comorbidities and functional status, had superior ability to predict mortality, LOS, and complications compared with TRISS alone in elderly trauma patients undergoing surgery.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Plant traits are differentially linked to performance in a semiarid ecosystem

A central principle in trait-based ecology is that trait variation has an adaptive value. However, uncertainty over which plant traits influence individual performance across environmental gradients may limit our ability to use traits to infer ecological processes at larger scales. To better understand which traits are linked to performance under different precipitation regimes, we measured above- and belowground traits, growth, and reproductive allocation for four annual and four perennial species from a coastal sage scrub community in California under conditions of 50%, 100%, and 150% ambient precipitation. Across water treatments, annual species displayed morphological trait values consistent with high rates of resource acquisition (e.g., low leaf mass per area, low root tissue density, high specific root length), and aboveground measures of resource acquisition (including photosynthetic rate and leaf N concentration) were positively associated with plant performance (reproductive allocation). Results from a structural equation model demonstrated that leaf traits explained 38% of the variation in reproductive allocation across the water gradient in annual species, while root traits accounted for only 6%. Although roots play a critical role in water uptake, more work is needed to understand the mechanisms by which root trait variation can influence performance in water-limited environments. Perennial species showed lower trait plasticity than annuals across the water gradient and were more variable as a group in terms of trait-performance relationships, indicating that species rely on different functional strategies to respond to drought. Our finding that species identity drives much of the variation in trait values and trait-performance relationships across a water gradient may simplify efforts to model ecological processes, such as productivity, that are potentially influenced by environmentally induced shifts in trait values.

Preferences of Type 1 Diabetic Patients on Devices for Islet Transplantation

Transplantation of pancreatic islets within a biomaterial device is currently under investigation in clinical trials for the treatment of patients with type 1 diabetes (T1D). Patients’ preferences on such implants could guide the designs of next-generation implantable devices; however, such information is not currently available. We surveyed the preferences of 482 patients with T1D on the size, shape, visibility, and transplantation site of islet containing implants. More than 83% of participants were willing to receive autologous stem cells, and there was no significant association between implant fabricated by one’s own stem cell with gender (χ² (1, n = 468) = 0.28; P = 0.6) or with age (χ² (4, n = 468) = 2.92; P = 0.6). Preferred location for islet transplantation within devices was under the skin (52.7%). 48.3% preferred microscopic disks, and 32.3% preferred a thin device (like a credit card). Moreover, 58.4% preferred the implant to be as small as possible, 25.4% did not care about visibility, and 16.2% preferred their implants not to be visible. Among female participants, 81% cared about the implant visibility, whereas this number was 64% for male respondents (χ² test (1, n = 468) = 16.34; P < 0.0001). 22% of those younger than 50 years of age and 30% of those older than 50 did not care about the visibility of implant (χ² test (4, n = 468) = 23.69; P < 0.0001). These results suggest that subcutaneous sites and micron-sized devices are preferred choices among patients with T1D who participated in our survey.

Movement-Modulation of Local Power and Phase Amplitude Coupling in Bilateral Globus Pallidus Interna in Parkinson Disease

There is converging evidence that bilateral basal ganglia motor networks jointly support normal movement behaviors including unilateral movements. The extent and manner in which these networks interact during lateralized movement remains unclear. In this study, simultaneously recorded bilateral Globus Pallidus interna (GPi) local field potentials (LFP) were examined from 19 subjects with idiopathic Parkinson disease (PD), while undergoing awake deep brain stimulation (DBS) implantation. Recordings were carried out during two behavioral states; rest and cued left hand movement (finger tapping). The state-dependent effects on α- β oscillatory power and β phase-encoded phase amplitude coupling (PAC), including symmetrical and assymetrical changes between hemispheres, were identified. Unilateral hand movement resulted in symmetrical oscillatory power suppression within bilateral GPi at α (8-12 Hz) and high β (21-35 Hz) and increase in power of high frequency oscillations (HFO, 200-300 Hz) frequency bands. Asymmetrical attenuation was also observed at both low β (13-20 Hz) and low γ (40-80 Hz) bands within the contralateral GPi (P = 0.009). In addition, unilateral movement effects on PAC were confined to the contralateral GPi with attenuation of both low β-low γ and β-HFO PAC (P < 0.05). Further analysis showed that the lateralized attenuation of low β and low γ power did not correlate with low β-low γ PAC changes. The overall coherence between bilateral GPi was not significantly altered with unilateral movement, however the preferred phase difference in the high β range increased from 0.23 (±1.31) radians during rest to 1.99 (±0.78) radians during movement execution. Together, the present results suggest that unilateral motor control involves bilateral basal ganglia networks with movement features differentially encoded by distinct frequency bands. The lateralization of low β and low γ attenuation with movement suggests that these frequency bands are specific to the motor act whereas symmetrical expression of α, high β, and HFO oscillations best correspond to motor state. The restriction of movement-related PAC modulation to the contralateral GPi indicates that cross-frequency interactions appear to be associated with lateralized movements. Despite no significant movement-related changes in the interhemispheric coherence, the increase in phase difference suggests that the communication between bilateral GPi is altered with unilateral movement.

New anthropometric classification scheme of preoperative nutritional status in children: a retrospective observational cohort study

OBJECTIVE

WHO uses anthropometric classification scheme of childhood acute and chronic malnutrition based on low body mass index (BMI) ('wasting') and height for age ('stunting'), respectively. The goal of this study was to describe a novel two-axis nutritional classification scheme to (1) characterise nutritional profiles in children undergoing abdominal surgery and (2) characterise relationships between preoperative nutritional status and postoperative morbidity.

DESIGN

This was a retrospective observational cohort study.

SETTING

The setting was 50 hospitals caring for children in North America that participated in the American College of Surgeons National Surgical Quality Improvement Program Paediatric from 2011 to 2013.

PARTICIPANTS

Children >28 days who underwent major abdominal operations were identified.

INTERVENTIONS/MAIN PREDICTOR

The cohort of children was divided into five nutritional profile groups based on both BMI and height for age Z-scores: (1) underweight/short, (2) underweight/tall, (3) overweight/short, (4) overweight/tall and (5) non-outliers (controls).

MAIN OUTCOME MEASURES

Multiple variable logistic regressions were used to quantify the association between 30-day morbidity and nutritional profile groups while adjusting for procedure case mix, age and American Society of Anaesthesiologists class.

RESULTS

A total of 39 520 cases distributed as follows: underweight/short (656, 2.2%); underweight/tall (252, 0.8%); overweight/short (733, 2.4%) and overweight/tall (1534, 5.1%). Regression analyses revealed increased adjusted odds of composite morbidity (35%) and reintervention events (75%) in the underweight/short group, while overweight/short patients had increased adjusted odds of composite morbidity and healthcare-associated infections (43%), and reintervention events (79%) compared with controls.

CONCLUSION

Stratification of preoperative nutritional status using a scheme incorporating both BMI and height for age is feasible. Further research is needed to validate this nutritional risk classification scheme for other surgical procedures in children.