The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Effects of ultraviolet radiation and temperature on the ultrastructure of zoospores of the brown macroalga Laminaria hyperborea

The interactive effects of an 8 h exposure to UV radiation and altered temperatures on the ultrastructure and germination of zoospores of the sublittoral brown alga Laminaria hyperborea (Gunn.) Foslie were investigated for the first time. Spores were exposed to four temperatures (2, 7, 12 and 17 degrees C) and three light regimes (PAR, PAR + UV-A, PAR + UV-A+UV-B). Freshly-released spores of L. hyperborea lack a cell wall and contain a nucleus with fine granular nucleoplasm and a nucleolus, one chloroplast, several mitochondria, dictyosomes and an endoplasmatic reticulum. Further, several kinds of so-called adhesive vesicles, lipid globuli and physodes containing UV-absorbing phlorotannins are embedded in the cytoplasm. No eye-spot is present. Physodes were found but they were rare and small. After an 8 h exposure to UV-B, the nucleoplasm had a mottled structure, chloroplasts contained plastoglobuli, the structure of the mitochondria changed from crista- to sacculus-type and germination was strongly inhibited at all temperatures. UV-A only had an impact on the ultrastructure at the highest temperature tested. The strongest effects were found at 17 degrees C, where germination was reduced to 35%, 32% and 9% after exposure to PAR, PAR+UV-A and PAR + UV-A + UV-B, respectively. This study indicates that UV-B radiation has strong damaging effects on the physiology and ultrastructure of zoospores of L. hyperborea. The results are important for developing scenarios for the effect of enhanced UV radiation and increasing temperatures caused by global climate changes.

[Men and women--aspects of sexological counseling in the aging]

In our times, sexuality has become an essential part of life for aging people. For the aging, psychosocial and biological changes, as well as increasing morbidity present challenges to a satisfying sexual life. Hence, the demand grows for health-care providers with basic sexological knowledge and counseling abilities. This article discusses relationships between frequent sexual difficulties and aging related organic processes. A therapeutic concept, the "Sexocorporal Approach", is introduced. This approach is based on a model of ongoing sexual development throughout the lifetime enabling adaptation to new life phases and limiting circumstances through sexual learning processes. Aside from pharmacological treatment, the encouragement of sexual learning presents an effective therapeutic approach for practitioners that can be easily learned and applied.

Functional and mutational analysis of p19, a DNA transfer protein with muramidase activity

Protein P19 encoded by the conjugative resistance plasmid R1 has been identified as being one member of a large family of muramidases encoded by bacteriophages and by type III and type IV secretion systems. We carried out a mutational analysis to investigate the function of protein P19 and used in vivo complementation assays to test those of several P19 mutants. The results indicated that conserved residues present in the presumed catalytic center of P19 are absolutely essential for its function in conjugation of plasmid R1 and infection by the RNA phage R17. Overexpression of protein P19 in an early growth phase resulted in a massive lysis of Escherichia coli cells in liquid culture, as indicated by a rapid and distinct decrease in cell culture densities after induction. Change of the proposed catalytic glutamate at position 44 to glutamine completely abolished this effect. P19-induced cell lysis was directly shown by transmission and scanning electron microscopy. Typically, P19-overexpressing cells showed bulges protruding from the cell surfaces. Our interpretation is that these protrusions arose from a localized and spatially confined disruption of the bacterial cell wall. To our knowledge such an effect has not previously been documented for any member of the lytic transglycosylase family. From the data presented here, we conclude that protein P19 possesses the proposed localized peptidoglycan-hydrolyzing activity. This activity would be a prerequisite for efficient penetration of the cell envelope by the DNA translocation complex encoded by the conjugative plasmid.

Effects of ultraviolet radiation on photosynthesis and related enzyme reactions of marine macroalgae

Changes in physiological parameters related to photosynthesis were studied in five macroalgal species from Spitsbergen (Monostroma arcticum, Laminaria solidungula, Alaria esculenta, Palmaria palmata, Phycodrys rubens) during a 72-h exposure to UV radiation. Maximal quantum yield of photochemistry (Fv/Fm) and maximal electron transport rate (ETRmax) were measured with a pulse-amplitude-modulated fluorometer; the activity of the Calvin cycle enzymes ribulose-1,5-bisphosphate carboxylase/oxygenase (Rubisco) and glyceraldehyde-3-phosphate dehydrogenase (G3PDH) were estimated using a photometric test. Proteins of crude extracts were separated by SDS gel electrophoresis and changes in cellular concentrations of Rubisco were determined. Moreover, the concentration of chlorophyll a (Ch1 a), and protein content, were measured photometrically. In all species, Ch1 a content, maximal quantum yield as well as ETRmax decreased during the UV treatment. Changes in ETRmax were related to the changes in the overall activity of Rubisco. Analysis of SDS gels showed that in P. rubens, L. solidungula, M. arcticum and A. esculenta decreasing Rubisco activity partly resulted from a degradation of the enzyme. However, in A. esculenta, the formation of a high-molecular-weight polypeptide was observed. In all species, the activity of Rubisco was more strongly impaired than that of G3PDH. Exposure to UV resulted in loss of total protein only in the deepwater species L. solidungula and P. rubens. The different sensitivities to UV exposure of the species tested reflect their zonation pattern in the field.

Subcellular localization and processing of the lytic transglycosylase of the conjugative plasmid R1

Protein P19 encoded by the conjugative resistance plasmid R1, is essential for efficient conjugative DNA transfer and infection by the pilus-specific RNA phage R17. Based on sequence homologies P19 belongs to a family of lysozyme-like virulence factors which are found in type III and type IV secretion systems. In this report we describe the processing and subcellular localization of P19. Pulse-chase experiments were used to demonstrate the processing of P19 by the signal peptidase I of Escherichia coli. Translocation of P19 across the inner membrane was shown by gene 19-phoA fusions. Cell fractionation studies of P19 expressing cells showed the presence of P19 in the membrane compartment. P19 was solubilized with the detergent Sarkosyl indicating an inner membrane localization. Using sucrose density gradient centrifugation to separate inner and outer membranes, P19 was found in both membrane fractions. Taken together, our data suggest that mature P19 is a periplasmic protein which may be attached to the proposed membrane-spanning DNA transport complex.

The essential transfer protein TraM binds to DNA as a tetramer

The TraM proteins encoded by F-like plasmids are sequence specific DNA binding proteins that are essential for conjugative DNA transfer. We investigated the quarternary structure and the DNA binding properties of the TraM wild-type protein of the resistance plasmid R1 and two mutant forms thereof. Size-exclusion chromatography and differential scanning calorimetry showed that purified TraM protein (amino acids 2-127) forms stable tetramers in solution. A truncated version of the protein termed TraMM26 (amino acids 2-56) forms dimers. Thus, the dimerization and tetramerization domains can be assigned to the N-terminal and C-terminal domains of TraM, respectively. Further analyses using chemical cross-linking and light scattering corroborated the preferentially tetrameric nature of the protein but also suggest that TraM has a tendency to form higher aggregates. Band-shift and fluorescence spectroscopy investigations of TraM-DNA complexes revealed that the TraM protein is also tetrameric when bound to its minimal DNA binding site. The deduced binding constant in the range of 10(8) M(-1) demonstrated a very strong binding of TraM to its preferred DNA sequence. Secondary structure analysis based on CD measurements showed that TraM is mainly alpha-helical with a significant increase in alpha-helicity (48 to 58%) upon DNA-binding, indicating an induced fit mechanism.

Wundt's views on sensations of innervation: a reevaluation

It is sometimes stated that Wundt believed in the primacy of 'sensations of innervation' in the control of eye and limb position, to the exclusion of afferent feedback. Wundt's own statements on the subject are traced through the six editions of the Grundzüge: he believed that sensations of innervation were a contributory factor along with peripheral feedback; but in the fourth edition he dropped the term and subsumed them under 'central sensations of senses', because increased neurophysiological knowledge made a literal interpretation of the original term impossible. In the fifth edition he developed a more precise model of central processes, described as 'sensory costimulation', and an additional idea of 'reproduced' or conditioned sensations. He mentions clinical evidence on the perception of eye and limb position of weight by paralysed and other subjects. This evidence is discussed in relation to modern theories. It is concluded that Wundt's later theories have some similarities with modern "hybrid' theories of efference-contingent afference.

The Mechanochemical Breakdown of Polystyrene by Vibromilling

The investigation presented here, including detection of nitrogen, the viscometric investigation, melting point determinations, the ultraviolet and infrared spectra, allow of the qualitative statement that macroradicals are formed in the mechanochemical breakdown of polystyrene by vibromilling. The slight differences between N2 and NO milling may be ascribed in part to a more rapid deactivation of the radicals. On the foundation of the existing knowledge of mechanochemistry there result interesting prospects for science and technology, e.g., the use of macro-radicals as polymerization initiators and as active types of block copolymers and graft polymers by reactions both with monomers and with macroradicals of other polymer materials.