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.

Improvements in Clinical Outcomes in Children with Cystic Fibrosis aged Six and 16 years

Aims Our aim was to assess if outcomes for cystic fibrosis (CF) patients at six & sixteen years of age have improved in the last 17 years looking at FEV1, BMI and death. Methods A retrospective observational study using a prospectively maintained database of CF patients at Cork University Hospital. Results 84 patients were included in the 16-year-old data and 89 patients were included in the six-year-old data. The mean FEV1 and BMI (16 years) for the 2002-2007 group was 72.9±21.0% and 18.9±2.53 respectively, 2008-2013 group was 75.4±27.2% and 19.8±2.7 and for the 2014-2018 group was 95.2±16.0% and 22.9±4.1. The percentage of patients (16 years) with chronic pseudomonas status was 37.9% (11/30) in the 2002-2007 group, 51.6 % (16/31) in the 2008-2013 group and 4.2% (1/24) in the 2014-2018 group. The relationship between FEV1 and FVC with BMI remained significant in multivariate analysis (P <0.001). The mean FEV1 (six years) for the 2002-2007 group was 90.7±16.1%, 2008-2013 group was 99.3±17.9% and for the 2014-2018 group was 100.9±15.8%. Conclusions Improvements in FEV1 and BMI aged six and 16 years are notable as well as a significant decline in the number of patients with chronic pseudomonas.

Can you elaborate on that? Addressing participants' need for cognition in computer-tailored health behavior interventions

Computer-tailored interventions, which deliver health messages adjusted based on characteristics of the message recipient, can effectively improve a range of health behaviours. Typically, the content of the message is tailored to user demographics, health behaviours and social cognitive factors (e.g., intentions, attitudes, self-efficacy, perceived social support) to increase message relevance, and thus the extent to which the message is read, considered and translated into attitude and behaviour change. Some researchers have suggested that the efficacy of computer-tailored interventions may be further enhanced by adapting messages to suit recipients' need for cognition (NFC) - a personality trait describing how individuals tend to process information. However, the likely impact of doing so, especially when tailored in conjunction with other variables, requires further consideration. It is possible that intervention effects may be reduced in some circumstances due to interactions with other variables (e.g., perceived relevance) that also influence information processing. From a practical point of view, it is also necessary to consider how to optimally operationalise and measure NFC if it is to be a useful tailoring variable. This paper aims to facilitate further research in this area by critically examining these issues based on relevant theories and existing evidence.

Predicting which type of push notification content motivates users to engage in a self-monitoring app

Despite the unprecedented access to self-monitoring health apps, lack of optimal user engagement remains a significant challenge. Push notification prompts with contextually tailored messages offers a promising strategy to improve engagement. To increase the efficacy of push-notifications on engaging individuals with health apps, greater attention to the modifiable components of push notifications that influence responsiveness is needed. This study examines the effect of message content and frequency of push notifications, along with past app usage on responding to notifications within 24 h, and engaging with self-monitoring in JOOL Health smartphone app. Mixed models were applied on a de-identified data set of 18,000 contextually tailored push notifications sent by JOOL Health App to 1414 participants. The content in sent messages on behavioural topics were mapped into either tailored suggestions or tailored insights. Our findings suggest that push notifications with tailored suggestions were more effective overall in encouraging self-monitoring, but amongst frequent app users, push-notifications containing insights was associated with greater self-monitoring. People who were not using the app as frequently were less likely to respond to a prompt. This study suggests that push-notification content does have an impact on subsequent use of key app features, and app developers should consider what content is likely to work best for who, and under what circumstances. Secondary data-analysis of commercial apps presents a unique opportunity to elucidate and optimize health behaviors.

A systematic review of physical activity-based behaviour change interventions reaching men with prostate cancer

PURPOSE

Men who are survivors of prostate cancer report a variety of psychological and physical factors contributing to a lower quality of life, and physical activity can assist to mitigate these issues. This review aims to provide a summary of physical activity behaviour change trials targeting prostate cancer survivors, assess the feasibility of these interventions and, if possible, identify intervention and study characteristics associated with significant intervention effects.

METHOD

Four databases (PubMed, CINAHL, PsycINFO and EMBASE) were systematically searched for randomised controlled trials containing at least one behavioural outcome relating to physical activity published up until July 2016. Forward and backwards, hand, key author citation searching and known research were also considered.

RESULTS

From a total of 13, 828 titles, the search resulted in 12 studies (6 prostate cancer only and 6 mixed cancer interventions), eight of which found positive results most often related immediately to post-intervention aerobic activity. Factors relating to efficacy were not conclusive due to the heterogeneity of studies and lack of cancer-specific data in mixed cancer trials. Future research focusing on intervention reach, maintenance of intervention effects and resistance training outcomes is needed.

CONCLUSION

There is preliminary evidence to suggest that a variety of physical activity behaviour change interventions targeting men with a history of prostate cancer can be efficacious, at least in the short term. Experimental studies are required to identify key intervention features.

IMPLICATIONS FOR CANCER SURVIVORS

Physical activity interventions can assist prostate cancer survivors in relation to short-term lifestyle change, though more evidence is required to improve the clarity of factors related to efficacy.

Clusters of health behaviours in Queensland adults are associated with different socio-demographic characteristics

Background

The co-occurrence of unhealthy lifestyles, calls for interventions that target multiple health behaviours. This study investigates the clustering of health behaviours and examines demographic differences between each cluster.

Methods

In total, 934 adults from Queensland, Australia completed a cross-sectional survey assessing multiple health behaviours. A two-step hierarchical cluster analysis using multiple iterations identified the optimal number of clusters and the subset of distinguishing health behaviour variables. Univariate analyses of variance and chi-squared tests assessed difference in health behaviours by socio-demographic factors and clusters.

Results

Three clusters were identified: the ‘lower risk’ cluster (n = 436) reported the healthiest profile and met all public health guidelines. The ‘elevated risk’ cluster (n = 105) reported a range of unhealthy behaviours such as excessive alcohol consumption, sitting time, fast-food consumption, smoking, inactivity and a lack of fruit and vegetables. The ‘moderate risk behaviour’ cluster (n = 393) demonstrated some unhealthy behaviours with low physical activity levels and poor dietary outcomes. The ‘elevated risk’ cluster were significantly younger and more socio-economically disadvantaged than both the ‘lower and moderate risk’ clusters.

Discussion

Younger people who live in more deprived areas were largely within the ‘elevated risk’ cluster and represent an important population for MHBC interventions given their wide range of unhealthy behaviours.

Abstract P6-12-06: Effect and moderators of exercise on fatigue in patients with breast cancer: Meta-analysis of individual patient data

Background - Fatigue is one of the most common and disabling complaints in patients with breast cancer and can effectively be reduced by physical exercise, with small to moderate effect sizes. To identify heterogeneity in responses to exercise and to further personalize exercise prescriptions, moderators of exercise effects on fatigue should be investigated. However, most randomized controlled trials (RCTs) are not adequately powered for such analyses. Therefore we conducted meta-analyses using the individual patient data of several exercise RCTs. The aim is to investigate the effect and moderators of physical exercise on cancer-related fatigue in patients with breast cancer.

Methods - Within the Predicting OptimaL cAncer RehabIlitation and Supportive care (POLARIS) consortium, principal investigators of 34 exercise RCTs worldwide have shared their individual patient data. Twenty-two of these RCTs included patients with breast cancer with a total sample size of 3,061. Different questionnaires to assess level of fatigue were used, which was acknowledged by using z-scores in the analysis. A one-step individual patient data meta-analysis, using a linear mixed-effect model adjusted for baseline fatigue, with a random intercept on study (to account for study clustering) was undertaken to investigate effect of exercise on fatigue. The result, a between-group difference in z-scores, corresponds to a Cohen's d effect size. An interaction term was included in the model to assess potential moderators including demographic (age, marital status, education), clinical (body mass index, presence of distant metastasis), intervention-related (intervention timing, delivery mode and duration), and exercise-related (exercise type, frequency, intensity, duration) characteristics.

Results – Exercise significantly reduced fatigue reported by women with breast cancer (β= -0.15, 95% CI -0.21;-0.09). This effect did not differ significantly between patients with different demographic and clinical characteristics (p-valuesinteraction &gt;0.05). Also, neither timing (during or post-treatment) and duration of the intervention, nor exercise-related factors moderated intervention effects on fatigue. Supervised exercise had significantly larger effects on fatigue than unsupervised exercise (βdifference= -0.17, 95%CI -0.28;-0.05). Compared to the control group, supervised exercise significantly improved fatigue (β = -0.21, 95%CI = -0.28;-0.14), while unsupervised exercise did not (β = -0.04, 95%CI = -0.14;0.06).

Conclusion – Exercise significantly reduces fatigue in patients with breast cancer across subgroups formed on the basis of age, marital status, education level, body mass index, and presence of distant metastasis. The effect of exercise is significantly larger when performed under supervision. Hence, exercise, and preferably supervised exercise, represents a viable intervention for the prevention and treatment of fatigue among patients with breast cancer.

Citation Format: van Vulpen JK, Sweegers MG, Kalter J, Peeters PH, Courneya KS, Newton RU, Aaronson NK, Jacobsen PB, Steindorf K, Stuiver MM, Hayes S, Mesters I, Knoop H, Goedendorp M, Mutrie N, Thorsen L, Schmidt M, Sonke GS, Bohus M, James EL, Oldenburg HS, Velthuis MJ, Nollet F, Wenzel J, Wiskemann J, Galvão DA, Chinapaw MJ, Irwin ML, Griffith KA, van Weert E, Daley AJ, McConnachie A, Schulz K-H, Short CE, Plotnikoff RC, Potthoff K, van Beurden M, van Harten WH, Schmitz KH, Winters-Stone KM, Taaffe DR, van Mechelen W, Kersten M-J, Verdonck-de Leeuw IM, Brug J, Buffart LM, May AM. Effect and moderators of exercise on fatigue in patients with breast cancer: Meta-analysis of individual patient data [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-06.

Designing more engaging computer-tailored physical activity behaviour change interventions for breast cancer survivors: lessons from the iMove More for Life study

BACKGROUND

Participating in regular physical activity is a recommended cancer recovery strategy for breast cancer survivors. However, tailored support services are not widely available and most survivors are insufficiently active to obtain health benefits. Delivering tailored programs via the Internet offers one promising approach. However, recent evaluations of such programs suggest that major improvements are needed to ensure programs meet the needs of users and are delivered in an engaging way. Understanding participants' experiences with current programs can help to inform the next generation of systems.

PURPOSE

The purposes of this study are to explore breast cancer survivor's perspectives of and experiences using a novel computer-tailored intervention and to describe recommendations for future iterations.

METHODS

Qualitative data from a sub-sample of iMove More for Life study participants were analysed thematically to identify key themes. Participants long-term goals for participating in the program were explored by analysing open-ended data extracted from action plans completed during the intervention (n = 370). Participants negative and positive perceptions of the website and recommendations for improvement were explored using data extracted from open-ended survey items collected at the immediate intervention follow-up (n = 156).

RESULTS

The majority of participants reported multi-faceted goals, consisting of two or more outcomes they hoped to achieve within a year. While clear themes were identified (e.g. 'being satisfied with body weight'), there was considerable variability in the scope of the goal (e.g. desired weight loss ranged from 2 to 30 kg). Participants' perceptions of the website were mixed, but clear indications were provided of how intervention content and structure could be improved.

CONCLUSIONS

This study provides insight into how to better accommodate breast cancer survivors in the future and ultimately design more engaging computer-tailored interventions.

The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: introduction, methodology and recommendation overview

STUDY DESIGN

Clinical practice guidelines.

OBJECTIVES

The objective was to develop the first Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI).

SETTING

The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada.

METHODS

The guidelines were developed in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations.

RESULTS

The Working Group developed 12 recommendations for screening and diagnosis, 12 recommendations for treatment and 5 recommendations for models of care. Important clinical considerations accompany each recommendation.

CONCLUSIONS

The Working Group recommendations for the management of neuropathic pain after SCI should be used to inform practice.

TaylorActive--Examining the effectiveness of web-based personally-tailored videos to increase physical activity: a randomised controlled trial protocol

BACKGROUND

Physical inactivity levels are unacceptably high and effective interventions that can increase physical activity in large populations at low cost are urgently needed. Web-based interventions that use computer-tailoring have shown to be effective, though people tend to 'skim' and 'scan' text on the Internet rather than thoroughly read it. The use of online videos is, however, popular and engaging. Therefore, the aim of this 3-group randomised controlled trial is to examine whether a web-based physical activity intervention that provides personally-tailored videos is more effective when compared with traditional personally-tailored text-based intervention and a control group.

METHODS/DESIGN

In total 510 Australians will be recruited through social media advertisements, e-mail and third party databases. Participants will be randomised to one of three groups: text-tailored, video-tailored, or control. All groups will gain access to the same web-based platform and a library containing brief physical activity articles. The text-tailored group will additionally have access to 8 sessions of personalised physical activity advice that is instantaneously generated based on responses to brief online surveys. The theory-based advice will be provided over a period of 3 months and address constructs such as self-efficacy, motivation, goal setting, intentions, social support, attitudes, barriers, outcome expectancies, relapse prevention and feedback on performance. Text-tailored participants will also be able to complete 7 action plans to help them plan what, when, where, who with, and how they will become more active. Participants in the video-tailored group will gain access to the same intervention content as those in the text-tailored group, however all sessions will be provided as personalised videos rather than text on a webpage. The control group will only gain access to the library with generic physical activity articles. The primary outcome is objectively measured physical activity. Secondary outcomes include website engagement and retention, quality of life, depression, anxiety, stress, sitting time, sleep and psychosocial correlates of physical activity. Outcomes will be measured at baseline, 3, and 9 months.

DISCUSSION

This study presents an ideal opportunity to study the effectiveness of an isolated feature within a web-based physical activity intervention and the knowledge generated from this study will help to increase intervention effectiveness.

TRIAL REGISTRATION

Australian New-Zealand Clinical Trial Registry: ACTRN12615000057583 . Registered 22 January 2015. CQUniversity Ethics Project Number: H14/07-163.

How social cognitive theory can help oncology-based health professionals promote physical activity among breast cancer survivors

PURPOSE

The majority of post treatment breast cancer survivors do not engage in physical activity (PA) at the recommended level. The promotion of PA among this group has the potential to dramatically improve quality of life and health outcomes. To maximise effectiveness, programs should be theory-based and address key determinants of PA behaviour. Social Cognitive Theory (SCT) has shown particular promise for developing and guiding PA interventions, but future research regarding how each SCT construct relates to PA among this group is needed. This study aims to explore how core SCT constructs impact on PA participation among post treatment breast cancer survivors, and gain greater insights into how to shape PA program strategies that will be appealing and effective for this group.

METHODS

Post treatment breast cancer survivors were recruited from the Breast Cancer Network Australia's review and survey group. Semi-structured telephone interviews examined PA patterns and SCT constructs and data were analysed thematically.

RESULTS

Eight post treatment breast cancer survivors participated in the study. Changes in activity level since diagnosis were common; in most cases this reflected a decline in PA. Key social cognitive and environmental influences on PA were described under the following themes: knowledge, outcome expectations, self-efficacy and personal, behavioural and environment facilitators and inhibitors.

CONCLUSION

The results of this study demonstrate the utility of SCT for guiding PA programs. Insight into how social cognitive factors may influence PA behaviour in this group is offered and direction for how oncology-based health professionals can promote PA among breast cancer survivors is provided.

Cod and God: Dr Wilfred Grenfell in Newfoundland

Wilfred Thomason Grenfell (1865-1940) began his medical career working for the National Mission for Deep Sea Fishermen on the North Sea. In 1892, the Mission sent him to Newfoundland to invesitigate the living and working conditions of the fishermen there. He spent most of his life improving conditions for the settlers on the coasts of Newfoundland and Labrador. His unorthodox methods and difficult personality brought him into conflict with the authorities. In spite of this, he achieved significant changes for the Newfoundlanders in medical care, education and economic prospects.

Clinical efficacy and safety of dexmedetomidine and buprenorphine, butorphanol or diazepam for canine hip radiography

OBJECTIVES

To investigate the usefulness of dexmedetomidine for restraint and sedation during hip radiographic examination of hip-extended or stress-radiography views when combined with either buprenorphine, butorphanol or diazepam.

METHODS

One hundred and twenty-seven client-owned clinically healthy golden retrievers or rottweilers were enrolled in a clinical trial that compared hip-extended and PennHIP methods for diagnosing hip dysplasia and were randomly allocated to receive dexmedetomidine or medetomidine in combination with buprenorphine, butorphanol or diazepam. Subjective assessments were made for response to pain, response to noise, palpebral reflex, muscle tone and overall quality of sedation; non-invasive physiological variables were also recorded.

RESULTS

Overall quality of sedation was graded as good or excellent for dogs administered with a combination of butorphanol or diazepam. However, more dogs that received a combination involving buprenorphine had overall a relatively poorer quality of sedation and required additional administration of buprenorphine before the radiographic procedure could commence. Once sedated, clinically sufficient muscle relaxation accompanied by a very low proportion of dogs responding to pain or noise stimuli were observed in all treatment groups. Heart and respiratory rate, and procedure and recovery times were similar for all treatment groups, and no adverse events were observed during the study.

CLINICAL SIGNIFICANCE

Dexmedetomidine sedative protocols, particularly in combination with butorphanol and diazepam, can be used effectively and safely in dogs for radiographic procedures.

The multi-disciplinary evaluation of a national agri-environment scheme

With an increasing amount of public funds being spent on agri-environmental schemes effective methods have to be developed to evaluate them. As many schemes have multiple objectives there is a need for a multi-disciplinary approach to any evaluation. A method was developed to assess the degree to which ecological, landscape, historical and access objectives for the Countryside Stewardship Scheme (CSS) in England have been met. The method used a sample of 484 agreements for which data were collected from surveys, a desk study and an interview with the agreement holder. These data were then evaluated by an expert team of an ecologist, landscape architect, landscape historian, and a social scientist specializing in rural affairs. The team were subsequently brought together with a Chair to discuss their findings for each agreement, allocating scores for each of five criteria: agreement negotiation; appropriateness, environmental effectiveness, compliance and side effects. The additionality that each agreement was likely to provide was also assessed. The results of this process suggest that in the majority of cases the CSS agreements should maintain or enhance the environment in terms of ecology, landscape, and landscape history and increase public enjoyment of the countryside. Thirty-six percent of agreements showed high additionality and 38% medium additionality which demonstrates that the CSS is likely to provide a benefit to society. Agreement negotiation, predicted environmental effectiveness and predicted compliance all improved significantly over the period 1996-98. Recommendations made from this project have been implemented by the Government department to improve the CSS. The multi-disciplinary method was successful and, with further development, could be used for assessment of any agri-environment scheme, or potentially any conservation project or broader 'rural development' scheme encompassing environmental, economic and social objectives. A key to success is the need for the criteria to be tailored for the project concerned and clearly established at the beginning.

A comparison of propofol infusion and propofol/isoflurane anaesthesia in dexmedetomidine premedicated dogs

The effects of propofol infusion were compared with propofol/isoflurane anaesthesia in six beagles premedicated with 10 microg/kg intramuscular (i.m.) dexmedetomidine. The suitability of a cold pressor test (CPT) as a stress stimulus in dogs was also studied. Each dog received isoflurane (end tidal 1.0%, induction with propofol) with and without CPT; propofol (200 microg/kg/min, induction with propofol) with and without CPT; premedication alone with and without CPT in a randomized block study in six separate sessions. Heart rate and arterial blood pressures and gases were monitored. Plasma catecholamine, beta-endorphin and cortisol concentrations were measured. Recovery profile was observed. Blood pressures stayed within normal reference range but the dogs were bradycardic (mean heart rate < 70 bpm). PaCO2 concentration during anaesthesia was higher in the propofol group (mean > 57 mmHg) when compared with isoflurane (mean < 52 mmHg). Recovery times were longer with propofol than when compared with the other treatments. The mean extubation times were 8 +/- 3.4 and 23 +/- 6.3 min after propofol/isoflurane and propofol anaesthesia, respectively. The endocrine stress response was similar in all treatments except for lower adrenaline level after propofol infusion at the end of the recovery period. Cold pressor test produced variable responses and was not a reliable stress stimulus in the present study. Propofol/isoflurane anaesthesia was considered more useful than propofol infusion because of milder degree of respiratory depression and faster recovery.

High-dose methylprednisolone for acute closed spinal cord injury--only a treatment option

BACKGROUND

A systematic review of the evidence pertaining to methylprednisolone infusion following acute spinal cord injury was conducted in order to address the persistent confusion about the utility of this treatment.

METHODS

A committee of neurosurgical and orthopedic spine specialists, emergency physicians and physiatrists engaged in active clinical practice conducted an electronic database search for articles about acute spinal cord injuries and steroids, from January 1, 1966 to April 2001, that was supplemented by a manual search of reference lists, requests for unpublished additional information, translations of foreign language references and study protocols from the author of a Cochrane systematic review and Pharmacia Inc. The evidence was graded and recommendations were developed by consensus.

RESULTS

One hundred and fifty-seven citations that specifically addressed spinal cord injuries and methylprednisolone were retrieved and 64 reviewed. Recommendations were based on one Cochrane systematic review, six Level I clinical studies and seven Level II clinical studies that addressed changes in neurological function and complications following methylprednisolone therapy.

CONCLUSIONS

There is insufficient evidence to support the use of high-dose methylprednisolone within eight hours following an acute closed spinal cord injury as a treatment standard or as a guideline for treatment. Methylprednisolone, prescribed as a bolus intravenous infusion of 30 mg per kilogram of body weight over fifteen minutes within eight hours of closed spinal cord injury, followed 45 minutes later by an infusion of 5.4 mg per kilogram of body weight per hour for 23 hours, is only a treatment option for which there is weak clinical evidence (Level I- to II-1). There is insufficient evidence to support extending methylprednisolone infusion beyond 23 hours if chosen as a treatment option.

Subclinical anaemia of chronic disease in adult patients with cystic fibrosis

Patients with chronic hypoxaemia develop secondary polycythaemia that improves oxygen-carrying capacity. Therefore, normal haemoglobin and haematocrit values in the presence of chronic arterial hypoxaemia in cystic fibrosis constitute 'relative anaemia'. We sought to determine the cause of this relative anaemia in patients with cystic fibrosis. We studied haematological indices and oxygen saturation in healthy volunteers (n=17) and in adult patients with cystic fibrosis (n=15). Patients with cystic fibrosis had lower resting arterial oxygen saturation when compared with normal volunteers (P<0.0001), and exercise led to a greater reduction in arterial oxygen saturation (P<0.0001). However, haemoglobin and haematocrit values in patients with cystic fibrosis did not significantly differ from normal volunteers. Serum iron (P=0.002), transferrin (P=0.02), and total iron-binding capacity (P=0.01) were lower in patients with cystic fibrosis. There were no significant differences in serum ferritin, percentage iron saturation, serum erythropoietin or red cell volume between the groups. The data presented demonstrate a characteristic picture of anaemia of chronic disease in adult patients with cystic fibrosis, except for normal haemoglobin and haematocrit values. Normal haemoglobin and haematocrit values in patients with cystic fibrosis appear to represent a combination of the effects of arterial hypoxaemia promoting polycythaemia, counterbalanced by chronic inflammation promoting anaemia of chronic disease.

Increased pyruvate flux capacities account for diet-induced increases in gluconeogenesis in vitro

High-fat (HF) and high-sucrose (SU) diets increase gluconeogenesis. The present study was designed to determine the contributions of pyruvate dehydrogenase, pyruvate carboxylase, phosphoenolpyruvate carboxykinase (PEPCK), and pyruvate kinase fluxes to this accelerated gluconeogenesis (GNEO) in the absence and presence of fatty acids. Male Sprague-Dawley rats were fed an HF, SU, or starch (ST) diet for 1 wk, and hepatocytes or mitochondria were isolated. In the absence of palmitate, the tracer estimated rates of GNEO (nmol. min(-1). mg(-1)) were elevated in hepatocytes isolated from SU (32.3 +/- 1.8) and HF (35.4 +/- 1.8) vs. ST (22.8 +/- 1.5). Pyruvate carboxylase and PEPCK flux rates (nmol. min(-1). mg(-1)) were increased in the SU (47.5 +/- 2.2 and 34.8 +/- 1.5) and HF (49.4 +/- 1.8 and 38.2 +/- 1.8) groups compared with the ST group (32.8 +/- 3.2 and 44.3 +/- 2.0). Palmitate (250-1,000 microM) stimulation of these fluxes was not significantly different among groups. Bromopalmitate, an inhibitor of fat oxidation, abolished differences in GNEO, pyruvate carboxylase, and PEPCK fluxes in HF and SU vs. ST. In isolated mitochondria, pyruvate carboxylation and palmitoyl carnitine oxidation were not significantly different among groups. The results of this study suggest that the increased gluconeogenic flux observed with HF and SU diets is associated with an increased pyruvate flux through pyruvate carboxylase and PEPCK. Moreover, the ability of bromopalmitate to normalize gluconeogenic fluxes suggests that endogenous fatty acids contribute to diet-induced increases in GNEO.

Incidence of pressure ulcers in a neurologic intensive care unit

OBJECTIVES

To determine the risk factors for pressure ulceration in an intensive care setting, to evaluate the Braden scale as a predictor of pressure ulcer risk in critically ill patients, and to determine whether pressure ulcers are likely to occur early in the hospital stay.

DESIGN

Cohort study of patients with no preexisting ulcers with a 3-month enrollment period.

SETTING

The neurologic intensive care unit and the neurologic intermediate unit at a primary care/referral hospital with a level I trauma center.

PATIENTS

A total of 186 patients entered the study.

INTERVENTION

Within 12 hrs of admittance, initial assessment, photographs, and Braden score were completed. Patients were re-examined every 4 days or at discharge from the unit, whichever came first.

MAIN OUTCOME MEASURES

Determining risk factors for pressure ulcers, performing detailed statistical analyses, and testing the usefulness of the Braden score as a predictor of pressure ulcer risk.

RESULTS

Twenty-three of 186 patients developed at least one pressure ulcer (incidence = 12.4%) after an average stay of 6.4 days. The Braden scale, which measures six characteristics of skin condition and patient status, proved to be a primary predictor of ulcer development. No ulcers developed in the 69 patients whose Braden score was 16 or higher. The likelihood of developing a pressure sore was predicted mathematically from the Braden score. However, being underweight was a significant and distinct factor in pressure ulcer development.

CONCLUSIONS

Pressure ulcers may develop within the first week of hospitalization in the intensive care unit. Patients at risk have Braden scores of < or = 16 and are more likely to be underweight. These results suggest that aggressive preventive care should be focused on those patients with Braden scores of < or = 13 and/or a low body mass index at admission.

Assessing the efficacy of perioperative carprofen administration in dogs undergoing surgical repair of a ruptured cranial cruciate ligament

Twenty-one otherwise healthy dogs that presented for surgical repair of a ruptured cranial cruciate ligament were blindly and randomly given either carprofen (2.2 mg/kg body weight, orally) or a placebo beginning 12 hours preoperatively and continuing every 12 hours for a total of three doses. The patients were assessed for postoperative pain using a subjective pain score and given oxymorphone (0.1 mg/kg body weight, intramuscularly) every four hours if the pain score was 2 or greater. Blood samples were also collected to determine serum cortisol levels. There was a significant increase in serum cortisol levels in the immediate postoperative period in both the placebo group and the carprofen group (p less than 0.05). There was no significant difference in the percentage of increase in serum cortisol levels between the two groups. No correlation was evident between the serum cortisol levels and the corresponding pain scores in either group. This subjective method of assessing postoperative pain was not accurate and should not be relied upon for determination of postoperative analgesic administration. Perioperative oral administration of carprofen did not appear to be effective in controlling postoperative pain in these patients.

IgA myeloma of donor origin arising 7 years after allogeneic renal transplant

We report the case of a 38-year-old man who developed IgA myeloma of donor origin 7 years after allogeneic renal transplant. The diagnosis of multiple myeloma was unequivocal and based on positive results from serum electrophoresis, skeletal survey and bone marrow investigations. The donor origin of the myeloma cells was confirmed by DNA fingerprinting. We believe this is the first reported case of disseminated multiple myeloma of donor origin developing after allogeneic renal transplant and, as such, gives some insight into the natural history and biology of the disease.

Detomidine-propofol anesthesia for abdominal surgery in horses

OBJECTIVE

To evaluate propofol for induction and maintenance of anesthesia, after detomidine premedication, in horses undergoing abdominal surgery for creation of an experimental intestinal adhesion model.

STUDY DESIGN

Prospective study.

ANIMALS

Twelve horses (424 +/- 81 kg) from 1 to 20 years of age (5 females, 7 males).

METHODS

Horses were premedicated with detomidine (0.015 mg/kg i.v.) 20 to 25 minutes before induction, and a propofol bolus (2 mg/kg i.v.) was administered for induction. Propofol infusion (0.2 mg/kg/min i.v.) was used to maintain anesthesia. The infusion rate was adjusted to maintain an acceptable anesthetic plane as determined by muscle relaxation, occular signs, response to surgery, and cardiopulmonary responses. Oxygen (15 L/min) was insufflated through an endotracheal tube as necessary to maintain the SpO2 greater than 90%. Systolic (SAP), mean (MAP), and diastolic (DAP) arterial pressures, heart rate (HR), electrocardiogram (ECG), respiratory rate (RR), SpO2 (via pulse oximetry), and nasal temperature were recorded at 15 minute intervals, before premedication and after induction of anesthesia. Arterial blood gas samples were collected at the same times. Objective data are reported as mean (+/-SD); subjective data are reported as medians (range).

RESULTS

Propofol (2.0 mg/kg i.v.) induced anesthesia (mean bolus time, 85 sec) within 24 sec (+/-22 sec) after the bolus was completed. Induction was good in 10 horses; 2 horses showed signs of excitement and these two inductions were not smooth. Propofol infusion (0.18 mg/kg/min +/- 0.04) was used to maintain anesthesia for 61 +/- 19 minutes with the horses in dorsal recumbency. Mean SAP, DAP, and MAP increased significantly over time from 131 to 148, 89 to 101, and 105 to 121 mm Hg, respectively. Mean HR varied over time from 43 to 45 beats/min, whereas mean RR increased significantly over anesthesia time from 4 to 6 breaths/min. Mean arterial pH decreased from a baseline of 7.41 +/- 0.07 to 7.30 +/- 0.05 at 15 minutes of anesthesia, then increased towards baseline values. Mean PaCO2 values increased during anesthesia, ranging from 47 to 61 mm Hg whereas PaO2 values decreased from baseline (97 +/- 20 mm Hg), ranging from 42 to 57 mm Hg. Muscle relaxation was good and no horses moved during surgery: Recovery was good in 9 horses and acceptable in 3; mean recovery time was 67 +/- 29 minutes with 2.4 +/- 2.4 attempts necessary for the horses to stand.

CONCLUSIONS

Detomidine-propofol anesthesia in horses in dorsal recumbency was associated with little cardiovascular depression, but hypoxemia and respiratory depression occurred and some excitement was seen on induction.

CLINICAL RELEVANCE

Detomidine-propofol anesthesia is not recommended for surgical procedures in horses if dorsal recumbency is necessary and supplemental oxygen is not available (eg, field anesthesia).

Propofol anesthesia

Although questions may still remain regarding the use of this unique sedative-hypnotic drug with anesthetic properties in high-risk patients, our studies have provided cardiopulmonary and neurological evidence of the efficacy and safety of propofol when used as an anesthetic under normal and selected impaired conditions in the dog. 1. Propofol can be safely and effectively used for the induction and maintenance of anesthesia in normal healthy dogs. Propofol is also a reliable and safe anesthetic agent when used during induced cardiovascular and pulmonary-impaired conditions without surgery. The propofol requirements to induce the safe and prompt induction of anesthesia prior to inhalant anesthesia with and without surgery have been determined. 2. The favorable recovery profile associated with propofol offers advantages over traditional anesthetics in clinical situations in which rapid recovery is important. Also, propofol compatibility with a large variety of preanesthetics may increase its use as a safe and reliable i.v. anesthetic for the induction and maintenance of general anesthesia and sedation in small animal veterinary practice. Although propofol has proven to be a valuable adjuvant during short ambulatory procedures, its use for the maintenance of general anesthesia has been questioned for surgery lasting more than 1 hour because of increased cost and marginal differences in recovery times compared with those of standard inhalant or balanced anesthetic techniques. When propofol is used for the maintenance of anesthesia in combination with a sedative/analgesic, the quality of anesthesia is improved as well as the ease with which the practitioner can titrate propofol; therefore, practitioners are able to use i.v. anesthetic techniques more effectively in their clinical practices. 3. Propofol can induce significant depression of respiratory function, characterized by a reduction in the rate of respiration. Potent alpha 2 sedative/analgesics (e.g., xylazine, medetomidine) or opioids (e.g., oxymorphone, butorphanol) increase the probability of respiratory depression during anesthesia. Appropriate consideration of dose reduction and speed of administration of propofol reduces the degree of depression. Cardiovascular changes induced by propofol administration consist of a slight decrease in arterial blood pressures (systolic, mean, diastolic) without a compensatory increase in heart rate. Selective premedicants markedly modify this characteristic response. 4. When coupled with subjective responses to painful stimuli, EEG responses during propofol anesthesia provide clear evidence that satisfactory anesthesia has been achieved in experimental dogs. When propofol is used as the only anesthetic agent, a higher dose is required to induce an equipotent level of CNS depression compared with the situation when dogs are premedicated. 5. The propofol induction dose requirement should be appropriately decreased by 20% to 80% when propofol is administered in combination with sedative or analgesic agents as part of a balanced technique as well as in elderly and debilitated patients. As a general recommendation, the dose of propofol should always be carefully titrated against the needs and responses of the individual patient, as there is considerable variability in anesthetic requirements among patients. Because propofol does not have marked analgesic effects and its metabolism is rapid, the use of local anesthetics, nonsteroidal anti-inflammatory agents, and opioids to provide postoperative analgesia improves the quality of recovery after propofol anesthesia. 6. The cardiovascular depressant effects of propofol are well tolerated in healthy animals, but these effects may be more problematic in high-risk patients with intrinsic cardiac disease as well as in those with systemic disease. In hypovolemic patients and those with limited cardiac reserve, even small induction doses of propofol (0.75-1.5 mg/kg i.v.) can produce profound hypotens

Pre-emptive kidney transplantation: the attractive alternative

BACKGROUND

Dialysis can be life-saving for patients with end-stage renal failure. However, not only is it associated with significant morbidity and a greater mortality than transplantation, but it is also expensive. Therefore renal transplantation is generally regarded as the treatment of choice for patients in whom this form of renal replacement therapy is appropriate. Transplantation usually takes place after a variable period of dialytic therapy, but pre-emptive kidney transplantation (PKT) has established itself as an attractive alternative.

MATERIALS AND METHODS

1463 consecutive first kidney transplants performed between January 1980 and December 1995 in a single centre were analysed. The 161 patients (11%) transplanted without prior dialysis were compared with the 1302 patients who had been dialysed prior to being transplanted. The pre-emptive group did not differ from the dialysis group in respect of donor age, donor and recipient gender, HLA mismatch, or cold ischaemic time, although there were more live donor transplants within the pre-emptive group.

RESULTS

Delayed graft function occurred more frequently in the dialysis group (25% vs 16%) but more patients experienced an acute rejection episode in the pre-emptive group (67 vs 55%). The actuarial graft survival in the pre-emptive group at 1, 5, and 10 years (84, 76 and 67%) was significantly higher than the respective values in the dialysis group (83, 69, and 56%). Within the live donor recipient cohort the survival advantage for the pre-emptive group was even more striking.

CONCLUSION

Pre-emptive kidney transplantation not only avoids the risks, cost, and inconvenience of dialysis, but is also associated with better graft survival than transplantation after a period of dialysis, particularly within the live donor cohort.

The use of propofol as an induction agent for halothane and isoflurane anesthesia in dogs

Cardiovascular, pulmonary, and quantitative electroencephalographic parameters were assessed in 12 anesthetized dogs to determine the compatibility of the injectable anesthetic propofol with halothane and isoflurane. No cases of apnea were observed during induction of anesthesia. An adequate level of anesthesia was established in each protocol as judged by both the lack of response to mechanical noxious stimuli (i.e., tail clamping) and evidence of reduction in total amplitude of brain wave activity. The initial propofol-mediated decrease in arterial blood pressure continued during either halothane (52.4%) or isoflurane (38%) anesthesia without a simultaneous increase in heart rate. The results of this study suggest that propofol, in combination with inhalant agents, can be used effectively and safely for canine anesthesia in veterinary practice.

Evaluation of selected cardiopulmonary and cerebral responses during medetomidine, propofol, and halothane anesthesia for laparoscopy in dogs

OBJECTIVES

To compare the dose-sparing effect of medetomidine on the propofol induction dose and concentration of halothane for maintenance of anesthesia during laparoscopy and to provide guidelines for effective and safe use of these anesthetics in dogs to ensure desirable perioperative analgesia.

ANIMALS

14 purpose-bred dogs.

PROCEDURE

Cardiopulmonary and electroencephalographic responses were determined during 2 anesthesia protocols in dogs scheduled for laparoscopy. Fifteen minutes before anesthesia induction, all dogs received atropine sulfate (0.02 mg/kg of body weight, i.m.). Seven dogs were then given propofol (6.6 mg/kg, i.v.); anesthesia was maintained with halothane in oxygen. The other dogs were given medetomidine hydrochloride (10 micrograms/kg, i.m.) 5 minutes after administration of atropine sulfate; anesthesia was then induced by administration of propofol (2.8 mg/kg, i.v.) and was maintained with halothane in oxygen.

RESULTS

The halothane concentration required for laparoscopy was lower in dogs given medetomidine. Anesthetic requirements were significantly increased during abdominal manipulation in both groups. Total amplitude of the electroencephalograph in medetomidine-treated dogs was not significantly lower than that in dogs not given medetomidine. Pulmonary responses were stable throughout all procedures. The primary cardiovascular response was an increase in blood pressure associated with the medetomidine-atropine preanesthetic combination. Significant differences in total amplitude or frequency shifts (spectral edge) of brain wave activity were not associated with surgical stimulation.

CONCLUSION

Lack of neurologic changes during laparoscopy supports the efficacy of either medetomidine-propofol-halothane or propofol-halothane combinations at higher concentrations to provide desirable analgesia and anesthesia in this group of dogs.

Multicenter randomized trial comparing tacrolimus (FK506) and cyclosporine in the prevention of renal allograft rejection: a report of the European Tacrolimus Multicenter Renal Study Group

BACKGROUND

To confirm the results of a number of studies conducted in Europe, the United States, and Japan, this multicenter, randomized trial compared the 12-month efficacy and safety of tacrolimus- and cyclosporine-based immunosuppressive regimens in the prevention of renal allograft rejection.

METHODS

A total of 448 renal transplant recipients were recruited from 15 centers and assigned to receive triple-drug therapy consisting of tacrolimus (n=303) or cyclosporine (n=145) in conjunction with azathioprine and low-dose corticosteroids.

RESULTS

At 12 months after transplantation, tacrolimus therapy was associated with a significant reduction in the frequency of both acute (tacrolimus 25.9% vs. cyclosporine 45.7%; P<0.001 [absolute difference: 19.8%, 95% confidence interval: 10.0-29.6%]) and corticosteroid-resistant rejection (11.3% vs. 21.6%; P=0.001 [absolute difference: 10.3%, 95% confidence interval: 2.5-18.2%]). Actuarial 1-year patient (tacrolimus 93.0% vs. cyclosporine 96.5%; P=0.140) and graft survival rates (82.5% vs. 86.2%; P=0.380) did not differ significantly between the two treatment groups. Overall, the safety profiles of the tacrolimus- and cyclosporine-based regimens were quite comparable. Infections, renal impairment, neurological complications, and gastrointestinal complaints were frequently reported but were mostly reversible in both groups. Higher incidences of elevated serum creatinine, tremor, diarrhea, hyperglycemia, diabetes mellitus, and angina pectoris were reported in the tacrolimus treatment group, whereas acne, arrhythmia, gingival hyperplasia, and hirsutism were more frequent with cyclosporine treatment.

CONCLUSIONS

The significant reduction in the incidence of episodes of allograft rejection observed with tacrolimus therapy may have important long-term implications given the prognostic influence of rejection on graft survival.

Laparoscopic cholecystectomy in adult cystic fibrosis

Two female patients with Cystic Fibrosis, attending the Adult Regional Cystic Fibrosis centre at the Cork University Hospital, were investigated for upper abdominal pain and found to have gallstones at ultrasonography. Laparoscopic cholecystectomy was performed successfully and, without complication, in both patients.

The use of propofol for induction of anaesthesia in dogs premeditated with acepromazine, butorphanol and acepromazine-butorphanol

Cardiovascular, pulmonary and anaesthetic-analgesic responses were evaluated in 18 male and female dogs to determine the effect of the injectable anaesthetic propofol used in conjuction with acepromazine and butorphanol. The dogs were randomly divided into three groups. Dogs in Group A were premeditated with 0.1 mg/kg of intramuscular acepromazine followed by an induction dose of 4.4 mg/kg of intravenous propofol; Group B received 0.2 mg/kg of intramuscular butorphanol and 4.4 mg/kg of intravenous propofol; dogs in Group AB were administered a premeditation combination of 0.1 mg/kg of intramuscular acepromazine and 0.2 mg/kg of intramuscular butorphanol, followed by induction with 3.3 mg/kg of intravenous propofol. The induction dose of propofol was given over a period of 30-60 seconds to determine responses and duration of anaesthesia. Observations recorded in the dogs included heart and respiratory rates, indirect arterial blood pressures (systolic, diastolic and mean), cardiac rhythm, end-tidal CO, tension, oxygen saturation, induction time, duration of anaesthesia, recovery time and adverse reactions. The depth of anaesthesia was assessed by the response to mechanical noxious stimuli (tail clamping), the degree of muscle relaxation and the strength of reflexes. Significant respiratory depression was seen after propofol induction in both groups receiving butorphanol with or without acepromazine. The incidence of apnea was 4/6 dogs in Group B, and 5/6 dogs in Group AB. The incidence of apnea was also correlated to the rate of propofol administration. Propofol-mediated decreases in arterial blood pressure were observed in all three groups. Moderate bradycardia (minimum value > 55 beats/min) was observed in both Groups B and AB. There were no cardiac dysrhythmias noted in any of the 18 dogs. The anaesthetic duration and recovery times were longer in dogs premeditated with acepromazine/butorphanol.