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.

Phenolic, flavonoid and anthocyanin contents of local sweet potato (Ipomoea batatas)

The sweet potato (Ipomoea batatas) is an annual herb of the family Convolvulaceae and ranked as the world's seventh most important food crop with a major contribution to energy and phytochemical source of nutrition. Three different conditions of sweet potatoes are unpeeled tuber (UPSP), peeled tuber (PSP) and skin of tuber (SSP). The objective of this study is to evaluate the phytochemical availability (total phenolic contents (TPC), total flavonoid contents (TFC) and anthocyanin content) in the different parts of the sweet potato tuber. Folin-Ciocalteau (FC) assay showed that phenolic contents for UPSP (41.14±1.69 mg GAE/100 g dry basis) and PSP (42.24±2.19 mg GAE/100 g dry basis) were significantly (50%) higher than SSP (26.01±2.04 mg GAE/100 g dry basis). In terms of flavonoid content, the highest value was retained in PSP (9.55±0.82 mg quercetin/100 g dry basis) followed by UPSP (3.30±0.19 mg quercetin/100 g dry basis) and SSP (1.43 ± 0.03 mg quercetin/100 g dry basis). PSP (9.43±0.08 mg/100 dry basis) had a higher anthocyanin content compared to UPSP (5.21±0.02 b mg/100 g dry basis) and SSP (5.21±0.02 b mg/100 g dry basis). The phytochemical properties were available in all conditions of the sweet potato. However, PSP was suggested to be the most preferable condition for further processing in the sweet potato industry.

Molecular dynamics simulations of sodium alginate/sulfonated graphene oxide membranes properties

The influence of methanol as a solvent on the properties of sodium alginate/sulfonated graphene oxide (SA/SGO) membranes was explored in water-methanol mixed conditions with various methanol concentrations and temperatures through molecular dynamics simulations. The methanol uptake of the membrane showed an isolation phase determined from the simulation results. The distance between the sulfonic acid groups increased in higher methanol concentrations, as observed from S-S RDFs. Furthermore, the distance between the SA-chain RDFs and the solvent molecules was analysed to determine a) the affinity of water towards the sulfonic acid groups and b) the affinity of the aromatic backbone of the SA towards methanol molecules. A decrease in water molecule diffusion led to an increase in methanol diffusion and uptake. SA/SGO membranes exhibited a smaller diffusion coefficient than that for the Nafion membranes, as calculated from simulation results and compared to the experimental work. Additionally, the diffusion ability increased at higher temperatures for all permeants. The interaction information obtained is useful for DMFC applications.

Enhanced Proton Conductivity and Methanol Permeability Reduction via Sodium Alginate Electrolyte-Sulfonated Graphene Oxide Bio-membrane

The high methanol crossover and high cost of Nafion® membrane are the major challenges for direct methanol fuel cell application. With the aim of solving these problems, a non-Nafion polymer electrolyte membrane with low methanol permeability and high proton conductivity based on the sodium alginate (SA) polymer as the matrix and sulfonated graphene oxide (SGO) as an inorganic filler (0.02-0.2 wt%) was prepared by a simple solution casting technique. The strong electrostatic attraction between -SO₃H of SGO and the sodium alginate polymer increased the mechanical stability, optimized the water absorption and thus inhibited the methanol crossover in the membrane. The optimum properties and performances were presented by the SA/SGO membrane with a loading of 0.2 wt% SGO, which gave a proton conductivity of 13.2 × 10^-3 Scm^-1, and the methanol permeability was 1.535 × 10^-7 cm² s^-1 at 25 °C, far below that of Nafion (25.1 × 10^-7 cm² s^-1) at 25 °C. The mechanical properties of the sodium alginate polymer in terms of tensile strength and elongation at break were improved by the addition of SGO.

Extraction and characterization of lignin from oil palm biomass via ionic liquid dissolution and non-toxic aluminium potassium sulfate dodecahydrate precipitation processes

The objective of this study is to extract and characterize lignin from oil palm biomass (OPB) by dissolution in 1-butyl-3-methylimidazolium chloride ([bmim][Cl]), followed by the lignin extraction through the CO2 gas purging prior to addition of aluminum potassium sulfate dodecahydrate (AlK(SO4)2 · 12H2O). The lignin yield, Y(L) (%wt.) was found to be dependent of the types of OPB observed for all precipitation methods used. The lignin recovery, RL (%wt.) obtained from CO2-AlK(SO4)2 · 12H2O precipitation was, however dependent on the types of OPB, which contradicted to that of the acidified H2SO4 and HCl solutions of pH 0.7 and 2 precipitations. Only about 54% of lignin was recovered from the OPB. The FTIR results indicate that the monodispersed lignin was successfully extracted from the OPT, OPF and OPEFB having a molecular weight (MW) of 1331, 1263 and 1473 g/mol, and degradation temperature of 215, 207.5 and 272 °C, respectively.

Comparative analysis between multilevel sectioning with conventional haematoxylin and eosin staining and immunohistochemistry for detecting nodal micrometastases with stage I and II colorectal cancers

Management of patients with stage II colorectal carcinomas remains challenging as 20 - 30% of them will develop recurrence. It is postulated that these patients may harbour nodal micrometastases which are imperceptible by routine histopathological evaluation. The aims of our study were to evaluate (1) the feasibility of multilevel sectioning method utilizing haematoxylin and eosin stain and immunohistochemistry technique with cytokeratin AE1/AE3, in detecting micrometastases in histologically-negative lymph nodes, and (2) correlation between nodal micrometastases with clinicopathological parameters. Sixty two stage I and II cases with a total of 635 lymph nodes were reviewed. Five-level haematoxylin and eosin staining and one-level cytokeratin AE1/AE3 immunostaining were performed on all lymph nodes retrieved. The findings were correlated with clinicopathological parameters. Two (3.2%) lymph nodes in two patients (one in each) were found to harbour micrometastases detected by both methods. With cytokeratin AE1/AE3, we successfully identified four (6.5%) patients with isolated tumour cells, but none through the multilevel sectioning method. Nodal micrometastases detected by both multilevel sectioning and immunohistochemistry methods were not associated with larger tumour size, higher depth of invasion, poorer tumour grade, disease recurrence or distant metastasis. We conclude that there is no difference between the two methods in detecting nodal micrometastases. Therefore it is opined that multilevel sectioning is a feasible and yet inexpensive method that may be incorporated into routine practice to detect nodal micrometastases in centres with limited resources.

Parasitic infections among Orang Asli (aborigine) in the Cameron Highlands, Malaysia

In April 2004, an outbreak of acute diarrheal illness occurred among the Orang Asli (aborigine) in the Cameron Highlands, Pahang State, Peninsular Malaysia, where rotavirus was later implicated as the cause. In the course of the epidemic investigation, stool samples were collected and examined for infectious agents including parasites. Soil transmitted helminthes (STH), namely Ascaris lumbricoides (25.7%), Trichuris trichiura (31.1%) and hookworm (8.1%), and intestinal protozoa, which included Giardia lamblia (17.6%), Entamoeba histolytica/E. dispar (9.4%), Blastocystis hominis (8.1%) and Cryptosporidium parvum (2.7%), were detected. Forty-four (59.5%) were infected with at least one parasite, 24 (32.4%), 12 (16.2%) and 8 (10.8%) had single, double and triple parasitic infections, respectively. STH were prevalent with infections occurring as early as in infancy. Giardia lamblia, though the most commonly found parasite in samples from symptomatic subjects, was within the normally reported rate of giardiasis among the various communities in Malaysia, and was an unlikely cause of the outbreak. However, heavy pre-existing parasitic infections could have contributed to the severity of the rotavirus diarrheal outbreak.

Field evaluation of cypermethrin and cyfluthrin against dengue vectors in a housing estate in Malaysia

Cynoff 25ULV (cypermethrin 25 g/l) and Solfac UL015 (cyfluthrin 1.5% w/v) were evaluated against the sentinel sugar-fed adults and 4th-instar larvae of Aedes aegypti in a housing estate endemic of dengue in Malaysia. The impact of both pyrethroids on field populations of Aedes albopictus and Aedes aegypti larvae was monitored weekly using bottle containers. Both Cynoff 25ULV and Solfac UL015 showed adulticidal effects and larvicidal effects. This field trial using Cynoff 25ULV against dengue vectors showed its potential for use in dengue vector control programs.