Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

KidsBrainIT: A New Multi-centre, Multi-disciplinary, Multi-national Paediatric Brain Monitoring Collaboration

OBJECTIVES

Validated optimal cerebral perfusion pressure (CPP) treatment thresholds in children do not exist. To improve the intensive care unit (ICU) management of the paediatric traumatic brain injury (TBI) population, we are forming a new paediatric multi-centre collaboration to recruit standardised ICU data for running and reporting upon models for assessing autoregulation and optimal CCP (CPPopt).

MATERIALS AND METHODS

We are adapting the adult BrainIT group's approach to develop a new Paediatric Brain Monitoring and Information Technology Group (KidsBrainIT), which will include a repository to store prospectively collected high-resolution physiological, clinical, and outcome data. In the first phase of this project there are 7 UK Paediatric Intensive Care Units, 1 Spanish, 1 Belgium, and 1 Romanian Centre interested in participating. In subsequent phases, we plan to open recruitment to other centres both within Europe, US and abroad. We are collaborating with the Leuven Group and plan to use their LAx (low-frequency autoregulation index), DATACAR (dynamic adaptive target of active cerebral autoregulation), CPPopt and visualisation methodologies. We also plan to use the continuous diffuse optical monitoring and tomography technology developed in Barcelona as an acute surrogate end-point for optimising brain perfusion. This technology allows non-invasive continuous monitoring of deep tissue perfusion and oxygenation in adults but its clinical application in infants and children with TBI has not been studied previously.

RESULTS

We report on the current status of setting up this new collaboration and also on pilot analyses in two centres which are the basis of our rationale for the need for a prospective validation study of CPPopt in children. Specifically, we demonstrated that CPPopt varied with time for each patient during their paediatric intensive care unit (PICU) stay, and the median overall CPPopt levels for children aged 2-6 years, 7-11 years and 12-16 years were 68.83, 68.09, and 72.17 mmHg respectively. Among survivors and patients with favourable outcome (GOS 4 and 5), there were significantly higher proportions with CPP monitoring time within CPPopt (p = 0.04 and p = 0.01 respectively).

CONCLUSIONS

There is a need and an interest in forming a multi-centre PICU collaboration for acquiring data and performing analyses for determining validated CPPopt thresholds in the paediatric TBI population. KidsBrainIT is being formed to meet that need.

The role of colonoscopy and CT colonography in patients presenting with symptoms of constipation

OBJECTIVE

There is controversy whether constipation as a primary presenting complaint is an indication for diagnostic colonoscopy. CT colonography (CTC) is a less invasive and more acceptable alternative. We compared the completion and sensitivity of colonoscopy with CTC in patients who presented with the primary symptom of constipation.

METHODS

A retrospective study was conducted which examined the first 100 colonoscopies and 100 CTCs carried out for the primary symptom of constipation from June 2012 to December 2013. The primary outcome measure was failure rate of the investigations. Secondary outcomes included reasons for failure and comparison of cost effectiveness between the two modalities.

RESULTS

A total of 200 patients were included in this study. Of these, the first consecutive 100 colonoscopies and 100 CTCs were included. One colonic cancer was detected in each of the CTC and the colonoscopy arm, respectively. 37 (37%) attempted colonoscopies were incomplete examinations. The most common reasons were discomfort (51.4%) and poor bowel preparation (27%). There was no failure of CTC. For 100 patients, CTC as a primary investigation was a more cost-effective investigation (p ≤ 0.01) costing £55,016 as compared with colonoscopy costing £73,666.

CONCLUSION

There is an unacceptably high failure rate of colonoscopy in patients who presented with the primary symptom of constipation. Hence, we propose that CTC may be an acceptable first-line investigation with a further colonoscopy/flexible sigmoidoscopy if lesions are detected. Advances in knowledge: First study to examine the use of CTC in patients with constipation.

Rheological properties of corn meal dough / Propiedades reológicas de la pasta de harina de maíz

The rheological properties of cooked corn meal dough were determined by squeezing flow, steady shear, and dynamic shear rheological methods. Under biaxial extension, the material exhibited strain- thinning behavior and the normal stress difference could be modeled as a function of biaxial strain rate, with a flow behavior index, n, of 0.38-0.52 and the biaxial consistency coefficient, Kb, ranging from 4.63 x 107 to 9.75 x 107 Pa.s". Steady and dynamic shear studies suggest that the dough exhibits shear-thinning behavior at a shear rate range of 1-40 s-1 and more viscous-like characteristics under dynamic conditions (0.5-10 s-1 frequency). Particle size distribution of the corn meal may affect some of the rheological properties ( K b, K, n) of the cooked dough. Further research is necessary to establish correlation between material variation and product quality for improvement of processes such as extrusion, baking or frying.

Tuberculosis case notification by private practitioners in Pune, India: how well are we doing?

SETTING

Pimpri Chinchwad Municipal Corporation area, Pune, India.

OBJECTIVE

To assess the proportion of private practitioners (PPs) who notified tuberculosis (TB) patients during February-April 2013 and their contribution to the overall number notified, and to determine their perceived challenges in reporting TB cases.

DESIGN

Mixed-method study including an analysis of notification data, followed by in-depth interviews with PPs. Interviews were transcribed and inductive content analysis was performed to derive themes.

RESULTS

Of 831 PPs, 533 (64%) participated in case notification; of these 87 (16%) notified at least one TB case during the study period. In all, 138 TB cases were notified by PPs, accounting for 20% of the total TB cases notified. Emerging themes among perceived challenges and barriers were lack of complete knowledge about TB notification, fear of a breach of patient confidentiality, lack of a simplified operational mechanism of notification, and lack of trust and coordination with the government health system.

CONCLUSION

About two thirds of PPs participated in case notification and contributed significantly to the overall TB cases notified. India's national TB programme should focus on training PPs and targeted media communication campaigns, and establish alternative mechanisms for notification, such as the internet and mobile telephones, to overcome perceived barriers.

A rare presentation of complication arising from Meckel's diverticulum in the form of diverticulotransverse colonic fistula in an adult

Meckel's diverticulum is a common congenital malformation of the gastrointestinal tract, reported to be present in 2-4% of the population. Although most patients with Meckel's diverticulum remain asymptomatic throughout life, reports of acute inflammation, perforation, haemorrhage, intussusception, intestinal obstruction, vesicodiverticular fistulae and primary tumours are described. We present a rare diagnosis of diverticulotransverse colonic fistula and its management.

Equine model for soft-tissue regeneration

Soft-tissue regeneration methods currently yield suboptimal clinical outcomes due to loss of tissue volume and a lack of functional tissue regeneration. Grafted tissues and natural biomaterials often degrade or resorb too quickly, while most synthetic materials do not degrade. In previous research we demonstrated that soft-tissue regeneration can be supported using silk porous biomaterials for at least 18 months in vivo in a rodent model. In the present study, we scaled the system to a survival study using a large animal model and demonstrated the feasibility of these biomaterials for soft-tissue regeneration in adult horses. Both slow and rapidly degrading silk matrices were evaluated in subcutaneous pocket and intramuscular defect depots. We showed that we can effectively employ an equine model over 6 months to simultaneously evaluate many different implants, reducing the number of animals needed. Furthermore, we were able to tailor matrix degradation by varying the initial format of the implanted silk. Finally, we demonstrate ultrasound imaging of implants to be an effective means for tracking tissue regeneration and implant degradation.

Role of disrupted in schizophrenia 1 (DISC1) in stress-induced prefrontal cognitive dysfunction

Recent genetic studies have linked mental illness to alterations in disrupted in schizophrenia 1 (DISC1), a multifunctional scaffolding protein that regulates cyclic adenosine monophosphate (cAMP) signaling via interactions with phosphodiesterase 4 (PDE4). High levels of cAMP during stress exposure impair function of the prefrontal cortex (PFC), a region gravely afflicted in mental illness. As stress can aggravate mental illness, genetic insults to DISC1 may worsen symptoms by increasing cAMP levels. The current study examined whether viral knockdown (KD) of the Disc1 gene in rat PFC increases susceptibility to stress-induced PFC dysfunction. Rats were trained in a spatial working memory task before receiving infusions of (a) an active viral construct that knocked down Disc1 in PFC (DISC1 KD group), (b) a 'scrambled' construct that had no effect on Disc1 (Scrambled group), or (c) an active construct that reduced DISC1 expression dorsal to PFC (Anatomical Control group). Data were compared with an unoperated Control group. Cognitive performance was assessed following mild restraint stress that had no effect on normal animals. DISC1 KD rats were impaired by 1  h restraint stress, whereas Scrambled, Control, and Anatomical Control groups were unaffected. Thus, knocking down Disc1 in PFC reduced the threshold for stress-induced cognitive dysfunction, possibly through disinhibited cAMP signaling at neuronal network synapses. These findings may explain why patients with DISC1 mutations may be especially vulnerable to the effects of stress.

Acute lower back pain mapped by dermatomal scarification in urban Malawi

Lower back pain is a problem that affects many and generates an economic burden on the National Health Service. In modern days, although it is tempting to rely on specialist imaging for the initial investigation of back pain, it is often unnecessary. Comprehensive clinical examination is immediately available and should detect neurological impairments where they exist. A 32-year-old man from Malawi presented to clinic with lower back pain radiating to the right leg. Inspection revealed traditional scarification marks along the classical path of lumbar nerve root, which coincided with his L5 dermatomal pain. The distribution of his 'Mphini' along the typical path of lumbar nerve was identical to his myelography. This report strongly illustrates that in the Western medical setting, accurate history and examination would have allowed correct interpretation of these symptoms and correctly indicated the need for myelography.

Prediction of noisy chaotic time series using an optimal radial basis function neural network

This paper considers the problem of optimum prediction of noisy chaotic time series using a basis function neural network, in particular, the radial basis function (RBF) network. In the noiseless environment, predicting a chaotic time series is equivalent to approximating a nonlinear function. The optimal generalization is achieved when the number of hidden units of a RBF predictor approaches infinity. When noise exists, it is shown that an optimal RBF predictor should use a finite number of hidden units. To determine the structure of an optimal RBF predictor, we propose a new technique called the cross-validated subspace method to estimate the optimum number of hidden units. While the subspace technique is used to identify a suitable number of hidden units by detecting the dimension of the subspace spanned by the signal eigenvectors, the cross validation method is applied to prevent the problem of overfitting. The effectiveness of this new method is evaluated using simulated noisy chaotic time series as well as real-life oceanic radar signals. Results show that the proposed method can find the correct number of hidden units of an RBF network for an optimal prediction.

Spontaneous rupture of utero-ovarian vessels in pregnancy

Spontaneous rupture of utero-ovarian vessels in pregnancy is rare and usually involves utero-ovarian veins. Presenting symptoms include acute-onset abdominal pain and maternal hypovolemic shock secondary to haemoperitoneum. Although this condition had been documented over a century ago, an accurate diagnosis is rarely reached prior to laparotomy due to a multitude of other surgical and obstetrical presentations that may pose a similar clinical picture. In such an event an emergency exploratory laparotomy followed by caesarean section with ligation of the uterine vessels can help in preventing a maternal mortality.