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.

Large area highly ordered monolayer composite microsphere arrays - fabrication and tunable surface plasmon linewidth

A route to produce highly ordered two-dimensional periodic composite microsphere/gel arrays by using a sol–gel coassembly method was proposed and demonstrated. The proposed semi-infiltrated ordered monolayer PS microsphere/gel array affords a flexible platform to produce versatile plasmonic structures through either adjusting the gel infiltration height or sputtered metal film thickness. Fabrication factors, such as environmental humidity, evaporation temperature, and tetraethyl orthosilicate solution concentration, that will affect the quality of the monolayer film were experimentally investigated. Pair correlation function was applied to evaluate the order degree of the experimental results, which reveals the high uniformity of the composite microsphere arrays (CSAs). By adjusting metal film thickness, the figures of merit of propagating surface plasmons excited on CSAs or concave arrays can be tuned under normal incidence.

Surface plasmons on co-assembled large area highly ordered monolayer composite sphere arrays exhibit tunable linewidth.

Skill and knowledge retention after training in cardiopulmonary ultrasound in Ghana: an impact assessment of bedside ultrasound training in a resource-limited setting

OBJECTIVE

Brief training courses in bedside ultrasound are commonly done by visiting faculty in low-income and middle-income countries, and positive short-term effects have been reported. Long-term outcomes are poorly understood. We held a training course on a cardiopulmonary ultrasound (CPUS) protocol over two separate 10-day periods in 2016. In 2017, 9-11 months after the initial training, we assessed skill and knowledge retention as well as perceived impact on local practice.

METHODS

A written test using six clinical vignettes and an observed structured clinical examination were used to assess theoretical knowledge and practical skills. Additionally, in-person interviews and a written survey were completed with the physicians who had participated in the initial training.

RESULTS

All 20 participants passed the written and clinical examination. The median follow-up test score was 10 out of 12, compared with a median score of 12 on a test completed immediately after the initial training. Physicians identified the ability to narrow their differential diagnosis and to initiate critical interventions earlier than without ultrasound as a key benefit of the CPUS training. They rated the cardiac, abdominal and inferior vena cava components of the CPUS protocol as most relevant to their everyday practice.

CONCLUSION

Long-term ultrasound knowledge and skill retention was high after a brief and intensive training intervention at an academic tertiary hospital in Ghana. Clinicians reported improvements in patient care and local practice patterns.

Cumulative exposure to biological therapy and risk of cancer in patients with psoriasis: a meta-analysis of Psonet studies from Israel, Italy, Spain, the U.K. and Republic of Ireland

BACKGROUND

Cancer risk following long-term exposure to systemic immunomodulatory therapies in patients with psoriasis is possible.

OBJECTIVES

To assess a dose-response relationship between cumulative length of exposure to biological therapy and risk of cancer.

METHODS

Four national studies (a healthcare database from Israel, and prospective cohorts form Italy, Spain and the U.K. and Republic of Ireland) collaborating through Psonet (European Registry of Psoriasis) participated in these nested case-control studies, including nearly 60 000 person-years of observation. 'Cases' were patients who developed an incident cancer. Patients with previous cancers and benign or in situ tumours were excluded. Four cancer-free controls were matched to each case on year of birth, sex, geographic area and registration year. Follow-up for controls was censored at the date of cancer diagnosis for the matched case. Conditional logistic regression was performed by each registry. Results were pooled using random-effects meta-analysis.

RESULTS

A total of 728 cases and 2671 controls were identified. After matching, differences between cases and controls were present for the Charlson Comorbidity Index in all three registries, and in the prevalence of previous exposure to psoralen-ultraviolet A and smoking (the British Association of Dermatologists Biologic Interventions Register only). The risk of first cancers was not significantly associated with cumulative exposure to biologics (adjusted odds ratio per year of exposure 1·02, 95% confidence interval 0·92-1·13). Results were similar if squamous and basal cell carcinomas were included in the outcome.

CONCLUSIONS

Cumulative length of exposure to biological therapies in patients with psoriasis in real-world clinical practice does not appear to be linked to a higher risk of cancer after several years of use.

High-Responsivity Photodetection by a Self-Catalyzed Phase-Pure p-GaAs Nanowire

Defects are detrimental for optoelectronics devices, such as stacking faults can form carrier-transportation barriers, and foreign impurities (Au) with deep-energy levels can form carrier traps and nonradiative recombination centers. Here, self-catalyzed p-type GaAs nanowires (NWs) with a pure zinc blende (ZB) structure are first developed, and then a photodetector made from these NWs is fabricated. Due to the absence of stacking faults and suppression of large amount of defects with deep energy levels, the photodetector exhibits room-temperature high photoresponsivity of 1.45 × 10⁵ A W^-1 and excellent specific detectivity (D*) up to 1.48 × 10¹⁴ Jones for a low-intensity light signal of wavelength 632.8 nm, which outperforms previously reported NW-based photodetectors. These results demonstrate these self-catalyzed pure-ZB GaAs NWs to be promising candidates for optoelectronics applications.

Pd–Ag decorated g-C3N4 as an efficient photocatalyst for hydrogen production from water under direct solar light irradiation

Pd–Ag bimetallic and monometallic nanoparticles were decorated on g-C₃N₄ and evaluated for their ability to produce H₂ through water splitting reactions.

Overall survival analysis of EXAM, a phase III trial of cabozantinib in patients with radiographically progressive medullary thyroid carcinoma

BACKGROUND

Primary analysis of the double-blind, phase III Efficacy of XL184 (Cabozantinib) in Advanced Medullary Thyroid Cancer (EXAM) trial demonstrated significant improvement in progression-free survival with cabozantinib versus placebo in patients with progressive medullary thyroid cancer (MTC). Final analysis of overall survival (OS), a key secondary endpoint, was carried out after long-term follow-up.

PATIENTS AND METHODS

EXAM compared cabozantinib with placebo in 330 patients with documented radiographic progression of metastatic MTC. Patients were randomized (2:1) to cabozantinib (140 mg/day) or placebo. Final OS and updated safety data are reported.

RESULTS

Minimum follow-up was 42 months. Kaplan-Meier analysis showed a 5.5-month increase in median OS with cabozantinib versus placebo (26.6 versus 21.1 months) although the difference did not reach statistical significance [stratified hazard ratio (HR), 0.85; 95% confidence interval (CI), 0.64-1.12; P = 0.24]. In an exploratory assessment of OS, progression-free survival, and objective response rate, cabozantinib appeared to have a larger treatment effect in patients with RET M918T mutation-positive tumors compared with patients not harboring this mutation. For patients with RET M918T-positive disease, median OS was 44.3 months for cabozantinib versus 18.9 months for placebo [HR, 0.60; 95% CI, 0.38-0.94; P = 0.03 (not adjusted for multiple subgroup analyses)], with corresponding values of 20.2 versus 21.5 months (HR, 1.12; 95% CI, 0.70-1.82; P = 0.63) in the RET M918T-negative subgroup. Median treatment duration was 10.8 months with cabozantinib and 3.4 months with placebo. The safety profile for cabozantinib remained consistent with that of the primary analysis.

CONCLUSION

The secondary end point was not met in this final OS analysis from the trial of cabozantinib in patients with metastatic, radiographically progressive MTC. A statistically nonsignificant increase in OS was observed for cabozantinib compared with placebo. Exploratory analyses suggest that patients with RET M918T-positive tumors may experience a greater treatment benefit with cabozantinib.

TRIAL REGISTRATION NUMBER

NCT00704730.

Knowledge of diabetes among patients in the United Arab Emirates and trends since 2001: a study using the Michigan Diabetes Knowledge Test

Knowledge of diabetes among patients with the disease in the United Arab Emirates is essential for effective self-management. We assessed the level of diabetes-related knowledge among patients and compared it with that found in previous studies in the same city. A cross-sectional study, using an interviewer-administered questionnaire, was conducted at two clinics in Al Ain, United Arab Emirates. The Michigan Diabetes Knowledge Test, translated into Arabic, was used to assess knowledge of diabetes. Of 165 participants with diabetes, 130 (78.8%) were women. The mean knowledge score was low at 55% (6.6 out of a maximum possible score of 12, standard deviation 1.8). This is comparable to levels found in previous studies: 55.5% in 2001 and 68.2% in 2006. Misconceptions about the diabetic diet and blood testing were common. The level of diabetes-related knowledge has remained low since 2001. These results are of concern in view of the substantial investments made in diabetes care and health education in the region.

Titania supported MOF-199 derived Cu–Cu2O nanoparticles: highly efficient non-noble metal photocatalysts for hydrogen production from alcohol–water mixtures

Water splitting over Cu–Cu₂O/TiO₂ photocatalysts.

Drilling resistance: A method to investigate bone quality

PURPOSE

Bone drilling is a major part of orthopaedic surgery performed during the internal fixation of fractured bones. At present, information related to drilling force, drilling torque, rate of drill-bit penetration and drill-bit rotational speed is not available to orthopaedic surgeons, clinicians and researchers as bone drilling is performed manually.

METHODS

This study demonstrates that bone drilling force data if recorded in-vivo, during the repair of bone fractures, can provide information about the quality of the bone. To understand the variability and anisotropic behaviour of cortical bone tissue, specimens cut from three anatomic positions of pig and bovine were investigated at the same drilling speed and feed rate.

RESULTS

The experimental results showed that the drilling force does not only vary from one animal bone to another, but also vary within the same bone due to its changing microstructure. Drilling force does not give a direct indication of bone quality; therefore it has been correlated with screw pull-out force to provide a realistic estimation of the bone quality. A significantly high value of correlation (r2 = 0.93 for pig bones and r2 = 0.88 for bovine bones) between maximum drilling force and normalised screw pull-out strength was found.

CONCLUSIONS

The results show that drilling data can be used to indicate bone quality during orthopaedic surgery.

La2O3 Promoted Pd/rGO Electro-catalysts for Formic Acid Oxidation

High activity, a low rate of CO poisoning, and long-term stability of Pd electro-catalysts are necessary for practical use as an anode material in direct formic acid fuel cells. Achieving a high degree of Pd nanoparticle dispersion on a carbon support, without agglomeration, while maintaining a facile electron transfer through the catalyst surface are two challenging tasks to be overcome in fulfilling this aim. Herein, we report the effect of addition of La/La-oxides on the efficiency of Pd nanoparticles supported on reduced graphene oxide (rGO) for formic acid electro-oxidation reaction. A series of electro-catalysts with different Pd-La molar ratios were successfully synthesized and characterized using a range of techniques including PXRD, XPS, TEM, FTIR, and Raman spectroscopy and then tested as anode materials for direct formic acid fuel cells. We explore that the lanthanum species (La/La-oxide) significantly promote the activity and stability of Pd catalyst toward electrocatalytic oxidation of formic acid. The metallic ratio is found to be critical, and the activity order of various catalysts is observed as follows; Pd₃₀La₇₀/rGO > Pd₈₀La₂₀/rGO > Pd₇₀La₃₀ rGO. The obtained mass specific activity for Pd₃₀La₇₀/rGO (986.42 A/g) is 2.18 times higher than that for Pd/rGO (451 A/g) and 16 times higher than that for Pd/C (61.5 A/g) at given onset peak potentials. The high activity and stability of the electro-catalysts are attributed to the uniform dispersion of Pd nanoparticles over the rGO support, as evidenced from TEM images. It is believed that the role of La species in promoting the catalyst activity is to disperse the catalyst particles during synthesis and to facilitate the electron transfer via providing a suitable pathway during electrochemical testing.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Shrinking of silicon nanocrystals embedded in an amorphous silicon oxide matrix during rapid thermal annealing in a forming gas atmosphere

We report the effect of hydrogen on the crystallization process of silicon nanocrystals embedded in a silicon oxide matrix. We show that hydrogen gas during annealing leads to a lower sub-band gap absorption, indicating passivation of defects created during annealing. Samples annealed in pure nitrogen show expected trends according to crystallization theory. Samples annealed in forming gas, however, deviate from this trend. Their crystallinity decreases for increased annealing time. Furthermore, we observe a decrease in the mean nanocrystal size and the size distribution broadens, indicating that hydrogen causes a size reduction of the silicon nanocrystals.

Two results in the theory of queues

In this paper it is shown that the distribution of the instant of service of a customer is symmetric as between the distributions of service and interarrival time. Also U(t), the expected number of departures in (0, t), is a delayed renewal function for the GI/M/1 queue.

Burden of rheumatological disorders in a tertiary care hospital

OBJECTIVE

T To evaluate the frequency of different rheumatological disorders in patients visiting a tertiary care centre.

METHODS

The retrospective analysis was conducted at the Rheumatology Clinic of Jinnah Postgraduate Medical Centre, Karachi, and comprised prospectively collected data of patients with different musculoskeletal disorders from February 2004 to February 2014. Detailed history, examination and laboratory investigations were recorded in a pre-designed structured proforma. The frequency, demographic characteristics and associated co-morbidities were studied. SPSS 17 was used for statistical analysis.

RESULTS

Of the 603 patients whose data was analysed, 460(76.3%) were women and 143(23.7%) were men. Overall mean age of the patients was 35.2±12 years. Rheumatoid arthritis was diagnosed in 458(76%) patients, systemic lupus erythematosus in 42(7%) ankylosing spondylitis in 32(5.3%), mixed connective tissue disease in 22(3.6%) and scleroderma in 12(2%) patients.

CONCLUSIONS

Rheumatological disorders constitute a major disease burden in a relatively young population of patients. RA was the most common disorder seen in our clinic, as seen elsewhere also, followed by SLE, AS, MCTD, etc.

Supplemental exogenous NPK application alters biochemical processes to improve yield and drought tolerance in wheat (Triticum aestivum L.)

The recent food security issues, combined with the threats from climate change, demand future farming systems to be more precise and accurate to fulfill the ever increasing global food requirements. The role of nutrients such as nitrogen (N), phosphorous (P), and potassium (K) in stimulating plant growth and development is well established; however, little is known about their function, if applied in combination, in improving crop yields under environmental stresses like drought. The aim of this study was to evaluate the effects of combined foliar spray of supplemental NPK (NPKc) on physiological and biochemical mechanisms that enhance the drought tolerance potential of wheat for improved yield. Foliar NPKc markedly influenced the accumulation of osmoprotectants and activity of both nitrogen assimilation and antioxidant enzymes. It significantly improved the concentration of proline (66 %), total soluble sugars (37 %), and total soluble proteins (10 %) and enhanced the activity of nitrate reductase, nitrite reductase, catalase, and peroxidase by 47, 45, 19, and 8 %, respectively, with respect to no spray under water-deficit conditions which, in turn, improve the yield and yield components. The accumulation of osmolytes and activity of antioxidant machinery were more pronounced in drought tolerant (Bhakkar-02) than sensitive genotype (Shafaq-06).