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.

External carotid artery pseudoaneurysm following upper respiratory infection masquerading as a pharyngeal abscess in an 8-month-old

Pseudoaneurysms are very rare with an incidence of less than 0.1% in the pediatric population. Approximately 30 cases of carotid artery aneurysms in children have been published in the literature, usually affecting children over one year of age. We present one of the youngest cases in the literature; the patient is an 8-month old female with a strep throat infection complicated by pseudoaneurysm development of the external carotid artery. Because of the rarity of these lesions, there is little known regarding the types of clinical presentation and management. They are commonly the result of direct arterial trauma; however, they can also occur secondary to infection, connective tissue disease or arteritis. We are presenting a case with a highly atypical presentation. When present, pseudoaneurysms harbor the potential risk of life-threatening hemorrhage and warrant immediate management. It is important to be aware of cases and the treatment modalities used to guide future diagnosis and planning.

Final results for the neutron -asymmetry parameter A0 from the UCNA experiment

The UCNA experiment was designed to measure the neutron β-asymmetry parameter A0 using polarized ultracold neutrons (UCN). UCN produced via downscattering in solid deuterium were polarized via transport through a 7 T magnetic field, and then directed to a 1 T solenoidal electron spectrometer, where the decay electrons were detected in electron detector packages located on the two ends of the spectrometer. A value for A0 was then extracted from the asymmetry in the numbers of counts in the two detector packages. We summarize all of the results from the UCNA experiment, obtained during run periods in 2007, 2008–2009, 2010, and 2011–2013, which ultimately culminated in a 0.67% precision result for A0.

Primed mesenchymal stem cells package exosomes with metabolites associated with immunomodulation

Mesenchymal stem cell (MSC) based therapies are currently being evaluated as a putative therapeutic in numerous human clinical trials. Recent reports have established that exosomes mediate much of the therapeutic properties of MSCs. Exosomes are nanovesicles which mediate intercellular communication, transmitting signals between cells which regulate a diverse range of biological processes. MSC-derived exosomes are packaged with numerous types of proteins and RNAs, however, their metabolomic and lipidomic profiles to date have not been well characterized. We previously reported that MSCs, in response to priming culture conditions that mimic the in vivo microenvironmental niche, substantially modulate cellular signaling and significantly increase the secretion of exosomes. Here we report that MSCs exposed to such priming conditions undergo glycolytic reprogramming, which homogenizes MSCs' metabolomic profile. In addition, we establish that exosomes derive from primed MSCs are packaged with numerous metabolites that have been directly associated with immunomodulation, including M2 macrophage polarization and regulatory T lymphocyte induction.

Status of the UCN experiment

The neutron is the simplest nuclear system that can be used to probe the structure of the weak interaction and search for physics beyond the standard model. Measurements of neutron lifetime and β-decay correlation coefficients with precisions of 0.02% and 0.1%, respectively, would allow for stringent constraints on new physics. The UCNτ experiment uses an asymmetric magneto-gravitational UCN trap with in situ counting of surviving neutrons to measure the neutron lifetime, τn = 877.7s (0.7s)stat (+0.4/−0.2s)sys. We discuss the recent result from UCNτ, the status of ongoing data collection and analysis, and the path toward a 0.25 s measurement of the neutron lifetime with UCNτ.

Search for neutron dark decay: n → χ + e+e−

In January, 2018, Fornal and Grinstein proposed that a previously unobserved neutron decay branch to a dark matter particle (χ) could account for the discrepancy in the neutron lifetime observed in two different types of experiments. One of the possible final states discussed includes a single χ along with an e+e− pair. We use data from the UCNA (Ultracold Neutron Asymmetry) experiment to set limits on this decay channel. Coincident electron-like events are detected with ∼ 4π acceptance using a pair of detectors that observe a volume of stored Ultracold Neutrons (UCNs). We use the timing information of coincidence events to select candidate dark sector particle decays by applying a timing calibration and selecting events within a physically-forbidden timing region for conventional n → p + e- + ν̅e decays. The summed kinetic energy (Ee+e−) from such events is reconstructed and used to set limits, as a function of the χ mass, on the branching fraction for this decay channel.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

'Be Clear on Cancer': the impact of the UK National Bowel Cancer Awareness Campaign

AIM

The National Bowel Cancer Awareness Campaign ('Be Clear on Cancer') was launched by the UK government in January 2012, encouraging people with bowel symptoms to present to primary care. Our aim was to evaluate the impact of the campaign on colorectal services in secondary care.

METHOD

Suspected cancer 2-week-wait (2WW) patients 3 months before and 3 months after the launch of the campaign were included. Demographics, reason for referral, investigations performed, cost analysis and eventual diagnoses were collected.

RESULTS

Three hundred and forty-three patients [median age 70 (36-100) years, 194 (57%) women] were seen and investigated in the 3 months prior to the launch of the campaign at an average cost of £575 per patient. Twenty-seven (8%) were diagnosed with lower gastrointestinal cancer and 29 (8%) with polyps. In the 3 months following the launch, 544 patients [median age 68 (30-92) years, 290 (53%) women] were reviewed (59% increase; P = 0.004). The 'did not attend' rate fell from 10% to 1%. Thirty-two (6%) patients were diagnosed with a lower gastrointestinal cancer and 20 (4%) with colorectal polyps. The cost per colorectal cancer detected rose from £7585.58 before the campaign to £9662.72 after launch (P = 0.04).

CONCLUSION

The 'Be Clear on Cancer' campaign has substantially increased the number of referrals under the 2WW rule, but mainly in the worried well. This has increased demands on both resources (59% more tests) and finance. Cost per cancer detected rose by 27% with no increase in funding to support the increased activity.

Family Planning Information, Education and Communication: Current Activities in the People's Republic of China

Based on observation of family planning activities in China in 1989 and 1990, this article takes a close look at education and publicity to promote family planning. Today these activities rely heavily on modern communication technology, especially TV and video, and continue to reflect an urban bias in content. The absence of male involvement in family planning was also noted. Family planning education has been strengthened in certain areas with the "five phases" approach and with the organization of "key households." The Family Planning Association with is 200,000 grassroots associations throughout the country and its 17,000,000 members has greatly increased the manpower pool for the delivery of educational services. It has also been instrumental in developing insurance schemes for one child families, and in some areas the primary function of Association members is surveillance aimed at detecting unplanned pregnancies. There is a need for improved training in the development of educational materials for family planning and in the provision of contraceptive services in rural areas.

Bronchoalveolar lavage in children with cystic fibrosis: how many lobes should be sampled?

BACKGROUND

The European Respiratory Society guidance on bronchoalveolar lavage (BAL) in children was published in 2000. It recommended taking one BAL specimen from the most affected lobe or from the right middle lobe in diffuse disease. In 2007, the European Respiratory Society modified the recommendations for children with cystic fibrosis (CF), suggesting two BAL specimens (right middle lobe and the lingula or the most affected lobe).

OBJECTIVE

To determine if BAL samples from one or two lobes give the full picture of lower airway infection in children with CF.

DESIGN, SETTING AND PATIENTS

A retrospective review of all paediatric patients with CF who underwent flexible bronchoscopy between May 2007 and May 2009 was undertaken.

MAIN OUTCOME MEASURES

As BAL specimens from all six lobes were collected, the BAL results were reviewed to identify if positive cultures would have been missed if only one lobe (right middle or most affected) or two lobes (right middle plus the lingula or most affected) had been sampled.

RESULTS

The results of 39 bronchoscopic procedures in 31 children were reviewed. The BAL samples were taken from 6 lobes in all 39 procedures. Had only one lobe been used, 26 positive cultures (14 organisms) would have been missed in 11 patients. Had two lobes been used, 12 positive cultures (8 organisms) would have been missed in 7 patients.

CONCLUSION

A single-lobe BAL is insufficient in assessing patients with CF for lower airway infection. Even when BAL specimens are taken from two lobes, a number of infections may be missed.

Determination of the axial-vector weak coupling constant with ultracold neutrons

A precise measurement of the neutron decay β asymmetry A₀ has been carried out using polarized ultracold neutrons from the pulsed spallation ultracold neutron source at the Los Alamos Neutron Science Center. Combining data obtained in 2008 and 2009, we report A₀ = -0.119 66±0.000 89{-0.001 40}{+0.001 23}, from which we determine the ratio of the axial-vector to vector weak coupling of the nucleon g{A}/g{V}=-1.275 90{-0.004 45}{+0.004 09}.

Childhood evaluation of salmeterol tolerance--a double-blind randomized controlled trial

Long acting beta(2)-agonists (LABA) are widely used in children with asthma. Data from adults suggest that there is tachyphylaxis particularly to the bronchoprotective effects of LABA. There are no data in children. To determine whether LABA are subject to tachyphylaxis in school-aged children. Children were eligible for participation if they remained symptomatic on 400 microg of beclometasone dipropionate equivalent/day. Participants undertook a 4-wk run in period with open-label fluticasone 100 microg BD via Diskus. Children were then randomized to receive fluticasone 100 microg BD or salmeterol/fluticasone 50/100 microg BD via Diskus in a double-blind manner. Children underwent spirometry, cold air challenge and salbutamol reversibility testing at baseline, 4 and 8 wk. 37/42 children completed the study. There were significant improvements in basal FEV1 (% predicted) in the salmeterol/fluticasone group (n = 21) (+6.4% (95% CI: 2.4-10.5) p = 0.0033) but not in the fluticasone group (n = 16) [+1.2 (95% CI: -3.4 to 5.8) p = 0.5900]. There was a non-significant reduction in fall in FEV1 provoked by cold air in both groups. There was a significant lessening in the acute salbutamol response after 8 wk in the salmeterol/fluticasone group [-11.4% (95% CI: -17.6 to -5.2) p = 0.0010] but not in the fluticasone group [-1.6% (95% CI: -9.8 to 6.6) p = 0.6827]. Salmeterol/fluticasone therapy significantly improves basal FEV(1) in asthmatic children however, there is negligible additional bronchoprotection by week 4 of treatment and there is significant attenuation of salbutamol responsiveness when compared with fluticasone alone. Some of this reduction in salbutamol response may relate to the concurrent improvements in baseline lung function.

Case of cryptic malaria

We report a case of falciparum malaria in a renal transplant patient with no history of foreign travel. Three weeks previously she had been a hospital inpatient with cellulitis and had stayed on the same ward as a man with falciparum malaria acquired in Nigeria. There were no cases of malaria in other patients on the ward at the same time. The parasites from the two cases were genotypically indistinguishable. Despite a thorough investigation, reviewed by an expert external panel, no clear route of infection between the cases was identified. Patients with malaria should be considered highly infectious by the parenteral route. They should be managed with the infection control precautions used for patients with bloodborne virus infections. Our case reinforces the need for high levels of compliance with universal infection control procedures.

Further support for the association of CCR5 allelic variants with asthma susceptibility

English and German nuclear families containing multiple asthmatic children and asthmatic parents were analysed to retest a recently reported association between resistance to asthma and the delta32 allele of chemokine receptor 5 (CCR5). Analysis of the families by the transmission-disequilibrium test (TDT) revealed a non-significant trend in the English families that provided marginal confirmation of the association (P < 0.125), but no similar trend was observed in the German families. Case-control comparison of delta32 allele and genotype frequencies in asthmatic vs. non-asthmatic parents revealed a significantly lower frequency of delta32 in asthmatic English parents (P < 0.009) and a similar but non-significant trend in German parents (P < 0.265). Taken together, the pattern of results provides confirmation for the previously observed delta32-asthma association and indicates that susceptibility to asthma may be influenced by CCR5 or another gene in chromosomal region 3p21.

Inhaler devices for asthma: do we follow the guidelines?

BACKGROUND

Despite national guidelines for asthma treatment, many children have troublesome symptoms.

AIM

To assess the extent to which the use of inappropriate inhaler devices contributes to this problem.

METHODS

Of 14 813 questionnaires distributed to schoolchildren, 6996 (47%) were returned identifying 1444 children using asthma inhalers. Inhalers were categorised as age appropriate or inappropriate according to national guidelines and were compared with those used by 75 patients attending a hospital clinic.

RESULTS

A total of 35% of "schools" and 4% of "clinic" children reported using an inappropriate inhaler device. Most were using metered dose inhalers alone. Twenty four per cent of "schools" children < or = 5 years old did not use a spacer. Both children and parents overestimated the child's ability to use their inhaler.

CONCLUSIONS

Large numbers of children are given inhalers they cannot use. To improve asthma care we must ensure that prescriptions reflect the age and ability of the child. Recent recommendations by the Department of Health in England and Wales stress the importance of seamless care between primary and secondary services. As the management of childhood asthma is guided primarily by secondary care providers, it is therefore imperative that general paediatricians know the difficulties and issues which are occurring in the community. This will enable them to lead and support necessary change.

How should airways resistance be measured in young children: mask or mouthpiece?

The reproducibility and acceptability of airways resistance measurements using the interrupter technique (MicroRint) obtained using a mouthpiece were compared with those using a face mask. Fifty children aged 4-7 yrs performed four sets of six Rint measurements; two using a mouthpiece and two using a face mask with integral mouthpiece. Complete data were obtained from 45 (90%) children using the mouthpiece and 43 (86%) children using the mask. The two methods were equally repeatable with comparable intraclass correlation coefficients (ICC) and coefficients of variation. Mean Rint values obtained using the mouthpiece were significantly lower than those using the face mask ((mean+/-SD) mouthpiece=0.81+/-0.18 kPa x L(-1) x s, mask=0.88+/-0.24 kPa x L(-1) x s p=0.0002). Although the mean paired differences between the two methods were small (0.07 kPa x L(-1) x s), the ICC and limits of agreement confirmed that the two methods could not be used interchangeably. Sixty-seven per cent of children preferred the face mask but this was more time-consuming (p = 0.03). Children did not produce more repeatable results using their preferred method, nor did they improve with practice. Repeatable airway resistance measurements using the interrupter technique can be obtained from young children using either a mouthpiece or a face mask, but there are significant clinical and statistical differences between the results obtained.

Eating orientation, postcessation weight gain, and continued abstinence among female smokers receiving an unsolicited smoking cessation intervention

Predictors of weight gain following smoking cessation were assessed among 1,219 female smokers enrolled in a health maintenance organization. Women randomized to the treatment group received a cessation intervention without regard to their interest in quitting smoking. It was hypothesized that cessation would result in subsequent weight gain and postcessation weight gain would be associated with scores on a modified Restraint Scale, the Disinhibition Scale, and a scale assessing tendency to eat during periods of negative affect. Persons who abstained from smoking over the 18-month study gained more weight than did intermittent smokers and continuous smokers, and among 762 women who reported at least 1 on-study attempt to quit smoking, 36% gained weight. Weight gain was associated with disinhibited eating and negative affect eating but not with restrained eating. Weight gain also was associated with continued abstinence from smoking.

Case study: trauma-related hallucinations

Proper differential diagnosis of psychiatric disorders with psychotic symptoms is imperative, as the treatment implications of the various conditions are quite different. A case study of a 5-year-old abused child with posttraumatic stress disorder is presented to illustrate some of the characteristic features of psychotic symptoms in traumatized children. Literature reviewed suggests that trauma-related hallucinations frequently contain content which is related to children's life experiences, are exacerbated by "triggers" and safety concerns, resolve with psychotherapy or psychosocial interventions, and are resistant to standard neuroleptic treatments. They are also associated with unique clinical, familial, developmental, and psychobiological correlates, and they require multifaceted treatment interventions.

Results from the 1995 National College Health Risk Behavior Survey

Results from the 1995 National College Health Risk Behavior Survey, which monitored health risk behaviors among US college and university undergraduates, suggest that many students' behaviors increase their likelihood of adverse health outcomes. During the 30 days preceding the survey, 34% of the participants had consumed five or more alcoholic drinks on at least one occasion, and 27% had drunk alcohol and driven a car. Thirty-one percent had smoked cigarettes regularly during their lifetimes, 49% had ever used marijuana, 30% had used a condom during their last sexual intercourse, 21% were overweight, and 38% had participated in vigorous physical activity on 3 or more of the 7 days preceding the survey. These data were analyzed by gender, age group, race and ethnicity, and institution type. They can be used by those responsible for the health and education of college students to reduce risks associated with the leading causes of mortality and morbidity.

Corticosteroids alter hematopoiesis in vitro by enhancing human monocyte secretion of granulocyte colony-stimulating factor

The mechanism of corticosteroid alteration of hematopoiesis is not completely elucidated. Employing an endotoxin free system, we examined the mechanisms by which hydrocortisone succinate (HCS) enhanced human bone marrow (BM) colony forming unit granulocyte-macrophage (CFU-GM) proliferation. Interleukin-1beta (IL-1) (1 ng/mL), granulocyte-macrophage colony-stimulating factor (GM-CSF) (1 ng/mL), or the combination, induced minimal CFU-GM proliferation unless HCS was added to the cultures (10-25 vs. 80-125 colonies/4x10(5) BM mononuclear cells). Supernatants produced by incubating mononuclear cells with IL-1 + GM-CSF +/- HCS were examined for their capacity to induce CFU-GM proliferation: IL-1 and/or GM-CSF failed to induce supernatants capable of supporting CFU-GM proliferation unless HCS was present. Analysis of the cytokines produced by mononuclear cell subpopulations demonstrated that HCS markedly enhanced IL-1-induced monocyte secretion of granulocyte (G)-CSF. Furthermore, the minimal effective concentration of IL-1 required to induce G-CSF release was reduced 10-fold (from 1 to 0.1 ng/mL) and the G-CSF released was increased 5-fold at an IL-1 concentration of 1 ng/mL. In contrast, IL-1-induced monocyte secretion of tumor necrosis factor (TNF) was inhibited by HCS. HCS enhanced G-CSF secretion at physiologic concentrations (10 microg/dL), whereas progesterone had no effect. HCS alone had no effect on G-CSF secretion or mRNA expression while IL-1+HCS resulted in a 3-fold increase in G-CSF mRNA levels. These data suggest for the first time that corticosteroids increase secretion of an essential component of the lymphohematopoietic cytokine-growth factor system.

Hepatitis B control in China: knowledge and practices among village doctors

OBJECTIVES

To guide development of a hepatitis B control program in China, we investigated village doctors' sterilization practices, injection use, vaccination levels, and knowledge and counseling skills.

METHODS

The head doctor from each village health station in a rural county (n = 260) completed a self-administered questionnaire.

RESULTS

Of the respondents, 94.2% reported adequate sterilization of needles; however, inadequate sterilization of syringes and acupuncture needles was common. Injections were found to be frequent and profitable. Of head doctors, 16.2% reported that most infants in their villages are vaccinated against hepatitis B. There was very high knowledge of modes of hepatitis B transmission, but it was not used to formulate advice for a hypothetical carrier. Knowledge of the consequences, prevalence, and use of condoms to prevent sexual transmission was lower.

CONCLUSIONS

The sterilization of acupuncture needles, reuse of syringes, and frequent injections are practices that may transmit the hepatitis B virus. Research into issues of vaccine acceptance is needed to expand immunization. A review of treatment practices and better training in counseling for village doctors is suggested.

A multisectoral approach to primary health care in Fujian, China

The government of Yongan in Fujian province has developed a multisectoral primary health care program in the rural community of Dahu with the aim of reaching "Health for All" by 1993. In keeping with the spirit of the Alma Ata declaration and the tradition of local self-reliance in China, the program has involved the entire community and is financed almost exclusively at the local level. Community leaders were trained in the importance of primary health care so that they could serve as role models. The project includes school health education, domestic hygiene education, reconstruction of homes to separate the kitchen, toilet and animals pens, road construction to eliminate dust, environmental sanitation, occupational health, and the upgrading of health care facilities. A number of local ordinances regarding construction, zoning and smoking have also been instituted. The results of the project's first year of implementation in two villages indicate that construction of the new road is near completion, and access to clean water is almost universal. Gains are also reported in the percentage of the population receiving physical examinations, the number of health stations that now meet state standards, and the number of homes that are constructed according to the new guidelines.