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.

Influenza virus positivity and circulating subtypes among cases of influenza-like illness and severe acute respiratory infection, Egypt, 2012-2015

Information on the prevalence of influenza, circulating virus subtypes and seasonality is essential for selecting strains for annual vaccines and for planning immunization programmes. Data were obtained from the 13 sentinel surveillance sites throughout Egypt during 2012-2015. Laboratory-confirmed influenza was found in 13% of cases of influenza-like illness (ILI) and 18% of cases of severe acute respiratory infection (SARI); positivity for influenza was similar in cases of ILI and SARI in patients up to 15 years of age but increased for SARI and decreased for ILI in people aged ≥ 15 years. The most commonly observed influenza virus subtypes were B followed by A/ H3 in ILI cases, and A/H1N1 followed by B in SARI cases. The seasonality of influenza in ILI cases was November- February, and that in SARI cases was November-March, peaking in January.

A prospective study on hyperglycemia and retinopathy of prematurity

OBJECTIVE

Retinopathy of prematurity (ROP) constitutes a significant morbidity in premature infants that can lead to blindness. Multiple retrospective studies have identified neonatal hyperglycemia as a risk for developing ROP. However, in the absence of any reported prospective study, it is not clear whether hyperglycemia is associated with ROP independent of the commonly associated comorbidities. The objective of this study was to investigate whether hyperglycemia in premature infants is independently associated with ROP.

STUDY DESIGN

Premature infants (<1500 g or⩽32 weeks gestational age) were enrolled in a prospective longitudinal cohort study. All demographic, clinical and laboratory data were collected. Bedside whole-blood glucose concentration was measured every 8 h daily for 7 days. For any glucose reading<50 or>150 mg dl(-1), serum sample was sent to the laboratory for confirmation. Hyperglycemia was defined as any blood glucose level⩾150 mg dl(-1). ROP patients were compared with non-ROP patients in a bivariate analysis. Variables significantly associated with ROP were studied in a logistic regression model.

RESULT

A total of 65 patients were enrolled with gestational age 31.1±1.2 weeks and birth weight 1385±226 g. Thirty-one patients (48%) were identified with hyperglycemia. On eye examination, 19 cases (29.2%) had ROP (13 with stage 1, 4 with stage 2 and 2 with stage 3). There were more cases of ROP in the hyperglycemia group compared with the euglycemia group (45% vs 15%, P=0.007). Patients who developed ROP had significantly higher maximum and average glucose concentrations when compared with non-ROP patients. Multiple factors have been associated with ROP on bivariate analysis, including gestational age, exposure to oxygen, respiratory support and poor weight gain. However, in a logistic regression model including all significant variables, average blood glucose in the first week of life was the factor independently associated with ROP with an odds ratio of: 1.77 (95% confidence interval: 1.08 to 2.86), P=0.024.

CONCLUSION

In a cohort of premature infants, elevated average blood glucose concentrations in the first week of life is independently associated with the development of ROP.

Caecal volvulus as a rare complication of laparoscopic adjustable gastric banding

Adjustable gastric band insertion is performed for the treatment of morbid obesity. There are multiple complications associated with this procedure but caecal volvulus is not commonly associated with this procedure. A case of caecal volvulus as a late complication post laparoscopic gastric band insertion is presented requiring surgical repair with uncomplicated post-operative recovery.

Imaging findings in Idiopathic lobular granulomattous mastitis, case report and review of literature

Idiopathic lobular granulomatous mastititis is a rare inflammatory disease of the breast. Since the clinical manifestations simulate those of mammary malignancy, it is often misdiagnosed. We report a case in a 25 yrs old Egyptian woman who had presented with complaint of a painful mass in her right breast of 3 months duration. Clinical and radiological examinations were indeterminate of its nature and the diagnosis was established by histopathogical, microbiological and serological tests. Review of relevant literature mention the features of Idiopathic lobular granulomatous mastititis, which impose significant challenge on clinical, radiological and even histopathological diagnosis. These correlate well with our case scenario also. Complete resection of the lesions and/or administration of steroids are usually the recommended treatment, however about 38% patients may experience recurrence. Hence proper post treatment follow up is mandatory. Awareness among the clinicians, radiologists and pathologists about this disease entity is required and multi disciplinary approach is imperative to establish the diagnosis. We hope to convey these facts through this article with the review of relevant literature.

Sources of volatile organic compounds in Cairo's ambient air

The greater Cairo area suffers from extreme levels of gas and particulate phase air pollutants. In order to reduce the levels of ambient pollution, the USAID and the Egyptian Environmental Affairs Agency (EEAA) have supported the Cairo Air Improvement Project (CAIP). As part of this project, two intensive ambient monitoring studies were carried out during the period of February 22 to March 4 and October 27 to November 27, 1999. Volatile organic compounds (VOCs) were measured on a 24-h basis at six sampling stations during each of the intensive periods. During the February/March study, samples were collected daily, while in the October/November study samples were collected every other day. The six intensive measurement sites represented background levels, mobile source impacts, industrial impacts, and residential exposure. High levels of NMHC were observed at all locations. NMHC concentrations ranged from 365 ppb C at Helwan to 1,848 ppb C at El Qualaly during winter, 1999 and from 461 ppb C at Kaha to 2,037 ppb C at El Qualaly during fall, 1999. El Qualaly, the site chosen to represent mobile emissions, displayed the highest average NMHC concentrations of any site, by a factor of 2 or more. The highest mobile source contributions were estimated at this site. The major contributors to NMHC at all sites were mobile emissions, lead smelting, and compressed natural gas.

The role of US guided handheld vacuum assisted breast core biopsy (VACB) in the surgical management of breast nodules: preliminary report of KCCC experience

OBJECTIVE

The purpose of this study was to evaluate the role of US guided hand held vacuum-assisted breast core biopsy (VACB) in the surgical management of breast nodules.

MATERIALS AND METHODS

Twenty five breast nodules in twenty five women were subjected to US guided 11-gauge vacuum-assisted breast core biopsy over a period 22 months. Biopsies were performed using handheld 11-g VACB needle under US guidance using high-resolution US equipment with a 7.5-10 MHz linear transducer. A median of 12 specimens were obtained per lesion with insertion of a clip marker in place. Pre and post procedure imaging findings, complications, histologic outcome, and medical records were reviewed.

RESULTS

The patient median age was 50.16 years (range, 36- 72 years). Lesion median size was 1.7 cm (range 0.8-3.0 cm). Lesions were categorized using BI-RAD system as follow: 12 (48%) category 3, 11 (44%) category 4 and 2 (8%) as category 5. Six out of 25 (24%) lesions were palpable. The median time required to perform the biopsy was 25 min (range, 20-40 min). Complete removal of the lesion seen at sonography was achieved in 22/25 lesions (88%) and was significantly more frequent in lesions measuring < 1.5 cm than in larger lesions. Accuracy was 100 %. No repeat was asked. Surgical biopsy was spared in 24/25 (96%) patients. One case was referred for surgical excision upon pathologist advice.

CONCLUSION

In our small series, US guided vacuum-assisted beast core biopsy was a fast, less invasive, accurate method in diagnosing breast nodules. It is a cost effective procedure, accepted by the patient and led to sparing surgical procedure in 96 % of women. VACB has become an integral part in the management of breast nodules and further work is going on to assess the long-term outcome.

Sources of PM(10) and PM (2.5) in Cairo's ambient air

A source attribution study was performed to assess the contributions of specific pollutant source types to the observed particulate matter (PM) levels in the greater Cairo Area using the chemical mass balance (CMB) receptor model. Three intensive ambient monitoring studies were carried out during the period of February 21-March 3, 1999, October 27-November 27, 1999, and June 8-June 26, 2002. PM(10), PM(2.5), and polycyclic aromatic hydrocarbons (PAHs) were measured on a 24-h basis at six sampling stations during each of the intensive periods. The six intensive measurement sites represented background levels, mobile source impacts, industrial impacts, and residential exposure. Major contributors to PM(10) included geological material, mobile source emissions, and open burning. PM(2.5) tended to be dominated by mobile source emissions, open burning, and secondary species. This paper presents the results of the PM(10) and PM(2.5), source contribution estimates.

Severe hypokalaemia and weakness due to Nurofen misuse

Nephrotoxicity from non-steroidal anti-inflammatory drugs (NSAID) is well recognized. We report a case of severe hypokalaemia and weakness due to renal tubular acidosis in a young woman who was taking 40-60 tablets per day of Nurofen Plus (ibuprofen 200 mg and codeine phosphate 12.8 mg). Proprietary brands of ibuprofen are freely available to the public and those containing codeine may be potentially subject to abuse. This case highlights the need to be aware of this potential and of the life-threatening electrolyte and acid-base disturbances that might be encountered with the widespread availability of these types of NSAID.

acp Best Practice No 168. The investigation and management of obesity

Obesity is a chronic condition characterised by an excess of body fat. It is a complex disorder of appetite regulation and energy metabolism controlled by specific biological factors. In the past 10 years, great progress has been made in the scientific understanding of the pathophysiology of obesity and the interactions between genetic predisposition to weight gain and the environment. This article will review the current understanding of the pathophysiology and the approach to the investigation and management of obesity.

[Myocardial infarction in a pregnant woman during salbutamol therapy]

The authors report the case of a 31 year old woman at 30 weeks' gestation who developed a non-Q wave postero-lateral myocardial infarction during treatment with salbutamol. There were no complications and delivery took place at term normally. Coronary angiography was performed 3 months post-partum and was normal: the Methergin test was negative. Myocardial ischaemia occurring during treatment with a beta-2 mimetic in pregnancy is rare and hardly ever progresses to myocardial infarction. The usual mechanism of ischaemia is an imbalance of myocardial oxygen demand and supply. Myocardial oxygen consumption is naturally increased during pregnancy and excess intracellular calcium secondary to the beta-1 stimulation occurring with the use of beta-2 mimetic drugs further aggravates matters. This hypothesis raises the question of the value of calcium inhibitors in these forms of myocardial ischaemia.

The postoperative inflammatory response to injury following laparoscopic assisted vaginal hysterectomy versus abdominal hysterectomy

The magnitude of the inflammatory response to surgery depends on the degree of injury during surgical procedures. Laparoscopic techniques are generally associated with less postoperative pain and shorter hospital stay compared with open procedures, presumably due to less tissue injury and reduced inflammatory response. However, no study has been done, to our knowledge, to assess the inflammatory response to surgical trauma following laparoscopic assisted vaginal hysterectomy. We have, therefore, compared the magnitude of the inflammatory response to injury after laparoscopically assisted vaginal hysterectomy (11 patients) and abdominal hysterectomy (11 patients) by measuring serum C-reactive protein (CRP) and interleukin-6 (IL-6) on admission, and at 24 and 48 hours after the operation. Postoperatively, serum CRP rose significantly in both groups but levels in patients who underwent laparoscopically assisted vaginal hysterectomy were significantly lower than in those who underwent abdominal hysterectomy. Serum IL-6 rose significantly after abdominal hysterectomy but not after laparoscopically assisted vaginal hysterectomy. Our results show that the inflammatory response to surgical trauma was significantly less after laparoscopically assisted vaginal hysterectomy than after abdominal hysterectomy confirming that the laparoscopic procedure causes less tissue damage than the abdominal procedure.

Neopterin levels in alcohol-dependent patients

Chronic alcohol exposure appears to suppress cell-mediated immunity which may contribute to the high incidence of infections among alcohol-dependent patients. We measured serum neopterin, as a marker of macrophage function and T-lymphocyte activation, in 26 alcohol-dependent patients. The mean serum neopterin in these patients was significantly lower than the mean serum neopterin in matched controls. In those who abstained, the mean serum neopterin at 3 weeks rose and was no longer significantly different from controls. Our findings suggest that alcohol-dependent patients have suppressed macrophage function which may be reversible within 3 weeks of abstention.

A simple HPLC method for the separation of amphetamine isomers in urine and its application in differentiating between 'street' amphetamine and prescribed D-amphetamine

D-amphetamine has been increasingly prescribed to treat amphetamine abusers. Prescribing D-amphetamine requires laboratory evidence or confirmation of current use of 'street' amphetamine, using a method which should be capable of differentiating between 'street' amphetamine and prescribed D-amphetamine. We have developed a simple high-performance liquid chromatography (HPLC) method for the separation of the two isomers of amphetamine in urine and have assessed its use in differentiating between 'street' amphetamine and prescribed D-amphetamine. The method is reproducible, free from interference and has a detection limit of 0.1 microgram/mL for each isomer. Urine from patients prescribed D-amphetamine contained only a trace amount of L-amphetamine (less than 4%) whereas urine from those taking 'street' amphetamine contained more than 50% L-amphetamine. The method is applicable to confirmation of 'street' amphetamine misuse and for monitoring patient compliance with treatment. The presence of 4% or less L-amphetamine in urine would suggest that the patient is only taking prescribed D-amphetamine whereas the presence of L-amphetamine in higher concentrations suggests that the patient is taking 'street' amphetamine, with or without prescribed D-amphetamine.

Insulin-like growth factor 1 in patients with hypoglycaemia

Plasma insulin-like growth factor 1 (IGF-1) concentrations were measured in a group of patients with hypoglycaemia due to endogenous hyperinsulinism, and compared with those in a group of patients matched for age and sex with hypoglycaemia and appropriately suppressed insulin levels. Insulin-like growth factor 1 concentrations were significantly higher in the hyperinsulinaemic hypoglycaemic group than in either the hypoinsulinaemic hypoglycaemia group or a group of euglycaemic control subjects. These data provide further evidence that insulin promotes IGF-1 production and release from the liver.

Impaired renal tubular function in chronic alcoholics

Despite the well known effects of chronic alcohol abuse on the gastrointestinal, cardiovascular, nervous and endocrine systems, little information is available on its effect on renal function. To assess renal function we measured urinary excretion of albumin, alpha 1 microglobulin and retinol binding protein in 30 chronic alcoholic patients. Our data shows that 40% of chronic alcoholic patients have impaired renal tubular function.

Bone disease in chronic alcoholism: the value of plasma osteocalcin measurement

Osteoporosis is more common in chronic alcoholics than in age-matched controls. Possible aetiological factors are: malabsorption of calcium and vitamin D; liver disease and abnormal parathyroid function. The possibility that alcohol may directly affect osteoblastic function has, however, received little attention. We measured plasma osteocalcin, a protein synthesised specifically by osteoblasts, in chronic alcoholics. Our data show that these have low plasma osteocalcin but normal calcium, magnesium and parathormone, which suggest that alcohol may be directly toxic to osteoblasts.

The role of a clinical investigation unit in a district general hospital

Admitting patients to hospital solely for diagnosis is wasteful of resources and inconvenient for the patients. At St Luke's Hospital, Guildford, a clinical investigation unit has been found to provide a better alternative.

Biochemical studies of some non conventional sources of protein. Part 4. The proteins of mango waste stone kernels

The gross chemical composition, protein content and amino acid composition of mango stone kernels of four Egyptian varieties (Ewsi, Hendi, Fonso and Timour) were investigated. Carbohydrates are the main components of the seed. The protein content varies between 5.0 and 7.2% and the ether extract ranged from 10.8% to 13.6%. High glutamic acid, aspartic acid and leucine content and low concentration of sulfur-containing amino acids are characteristic for the proteins of mango kernels. Lysine level is also low, the concentration of other essential amino acids is acceptable. Sulfur-containing amino acids are the first limiting ones followed by lysine and threonine.

Post-traumatic diabetes insipidus combined with primary polydipsia

We describe a case of diabetes insipidus after head injury in which thirst persisted despite treatment with DDAVP and normal plasma osmolality. Symptoms were only completely relieved when plasma osmolality was below 270 mosmol/kg. We believe that this might have been due to hypothalamic injury causing resetting of the thirst osmostat. To our knowledge, this type of primary polydipsia has not been described before in association with diabetes insipidus following head injury.