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Nawoor-Quinn Z, Oliver A, Raobaikady R, Mohammad K, Cone S, Kasivisvanathan R. The Marsden Morbidity Index: the derivation and validation of a simple risk index scoring system using cardiopulmonary exercise testing variables to predict morbidity in high-risk patients having major cancer surgery. Perioper Med (Lond) 2022; 11:48. [PMID: 36138428 PMCID: PMC9494857 DOI: 10.1186/s13741-022-00279-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Morbidity and mortality risk prediction tools are increasingly being used as part of preoperative assessment of patients presenting for major abdominal surgery. Cardiopulmonary exercise testing (CPET) can predict which patients undergoing major abdominal surgery are at risk of complications. The primary objective of this study was to identify preoperative variables including those derived from CPET, which were associated with inpatient morbidity in high-risk patients following major abdominal cancer surgery. The secondary objective was to use these variables to derive and validate a morbidity risk prediction tool. Methods We conducted a retrospective cohort analysis of consecutive adult patients who had CPET as part of their preoperative work-up for major abdominal cancer surgery. Morbidity was a composite outcome, defined by the Clavien-Dindo score and/or the postoperative morbidity survey (POMS) score which was assessed on postoperative day 7. A risk prediction tool was devised using variables from the first analysis which was then applied prospectively to a matched cohort of patients. Results A total of 1398 patients were included in the first phase of the analysis between June 2010 and May 2017. Of these, 540 patients (38.6%) experienced postoperative morbidity. CPET variables deemed significant (p < 0.01) were anaerobic threshold (AT), maximal oxygen consumption at maximal exercise capacity (VO2 max), and ventilatory equivalent for carbon dioxide at anaerobic threshold (AT VE/VCO2). In addition to the CPET findings and the type of surgery the patient underwent, eight preoperative variables that were associated with postoperative morbidity were identified. These include age, WHO category, body mass index (BMI), prior transient ischaemic attack (TIA) or stroke, chronic renal impairment, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and cancer stage. Both sets of variables were then combined to produce a validated morbidity risk prediction scoring tool called the Marsden Morbidity Index. In the second phase of the analysis, this tool was applied prospectively to 424 patients between June 2017 and December 2018. With an area under the curve (AUC) of 0.79, this new model had a sensitivity of 74.2%, specificity of 78.1%, a positive predictive value (PPV) of 79.7%, and a negative predictive value of (NPV) of 79%. Conclusion Our study showed that of the CPET variables, AT, VO2 max, and AT VE/VCO2 were shown to be associated with postoperative surgical morbidity following major abdominal oncological surgery. When combined with a number of preoperative comorbidities commonly associated with increased risk of postoperative morbidity, we created a useful institutional scoring system for predicting which patients will experience adverse events. However, this system needs further validation in other centres performing oncological surgery.
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Affiliation(s)
- Z Nawoor-Quinn
- Department of Anaesthesia and Critical Care, The Royal Marsden, London, UK.
| | - A Oliver
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - R Raobaikady
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - K Mohammad
- Department of Anaesthesia, University College London Hospitals, London, UK
| | - S Cone
- The Royal Marsden Hospital and The Royal Marsden NHS Foundation Trust, Fulham Road, Chelsea, London, SW3 6JJ, UK
| | - R Kasivisvanathan
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
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Heightman M, Prashar J, Hillman TE, Marks M, Livingston R, Ridsdale HA, Bell R, Zandi M, McNamara P, Chauhan A, Denneny E, Astin R, Purcell H, Attree E, Hishmeh L, Prescott G, Evans R, Mehta P, Brennan E, Brown JS, Porter J, Logan S, Wall E, Dehbi HM, Cone S, Banerjee A. Post-COVID-19 assessment in a specialist clinical service: a 12-month, single-centre, prospective study in 1325 individuals. BMJ Open Respir Res 2021; 8:8/1/e001041. [PMID: 34764200 PMCID: PMC8587466 DOI: 10.1136/bmjresp-2021-001041] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/29/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Post-COVID-19 complications require simultaneous characterisation and management to plan policy and health system responses. We describe the 12-month experience of the first UK dedicated post-COVID-19 clinical service to include hospitalised and non-hospitalised patients. Methods In a single-centre, observational analysis, we report the demographics, symptoms, comorbidities, investigations, treatments, functional recovery, specialist referral and rehabilitation of 1325 individuals assessed at the University College London Hospitals post-COVID-19 service between April 2020 and April 2021, comparing by referral route: posthospitalised (PH), non-hospitalised (NH) and post emergency department (PED). Symptoms associated with poor recovery or inability to return to work full time were assessed using multivariable logistic regression. Results 1325 individuals were assessed (PH: 547, 41.3%; PED: 212, 16%; NH: 566, 42.7%). Compared with the PH and PED groups, the NH group were younger (median 44.6 (35.6–52.8) years vs 58.3 (47.0–67.7) years and 48.5 (39.4–55.7) years), more likely to be female (68.2%, 43.0% and 59.9%), less likely to be of ethnic minority (30.9%, 52.7% and 41.0%) or seen later after symptom onset (median (IQR): 194 (118–298) days, 69 (51–111) days and 76 (55–128) days; all p<0.0001). All groups had similar rates of onward specialist referral (NH 18.7%, PH 16.1% and PED 18.9%, p=0.452) and were more likely to require support for breathlessness (23.7%, 5.5% and 15.1%, p<0.001) and fatigue (17.8%, 4.8% and 8.0%, p<0.001). Hospitalised patients had higher rates of pulmonary emboli, persistent lung interstitial abnormalities and other organ impairment. 716 (54.0%) individuals reported <75% optimal health (median 70%, IQR 55%–85%). Less than half of employed individuals could return to work full time at first assessment. Conclusion Post-COVID-19 symptoms were significant in PH and NH patients, with significant ongoing healthcare needs and utilisation. Trials of interventions and patient-centred pathways for diagnostic and treatment approaches are urgently required.
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Affiliation(s)
- Melissa Heightman
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Jai Prashar
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
| | - Toby E Hillman
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael Marks
- University College London Hospitals NHS Foundation Trust, London, UK.,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Robert Bell
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
| | - Michael Zandi
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Patricia McNamara
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Alisha Chauhan
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Emma Denneny
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
| | - Ronan Astin
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Helen Purcell
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | | | - Rebecca Evans
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
| | - Puja Mehta
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
| | - Ewen Brennan
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Jeremy S Brown
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
| | - Joanna Porter
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
| | - Sarah Logan
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Emma Wall
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK.,Francis Crick Institute, London, UK
| | | | - Stephen Cone
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Amitava Banerjee
- University College London Hospitals NHS Foundation Trust, London, UK .,University College London, London, UK.,Barts Health NHS Trust, London, UK
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Cone S, Mistretta V, Lambert N, Huwart A. [Community-acquired Staphylococcus aureus pneumonia]. Rev Med Liege 2021; 76:595-597. [PMID: 34357710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
We report a clinical case of a patient hospitalized for community-acquired Staphylococcus aureus pneumonia. A 26-year-old patient with no medical history went to the emergency department for fever. He quickly developed acute respiratory failure and community-acquired Staphylococcus aureus pneumonia as well as bacteremia were confirmed. This pulmonary infection is rare but can affect all age groups and occur in a variety of ways. Patients with community-acquired Staphylococcus aureus pneumonia have more severe clinical outcomes than those with community-acquired pneumonia caused by other germs. The article discusses the main characteristics of community-acquired Staphylococcus aureus pneumonia and recalls the recommendations in case of bacteremia with Staphylococcus aureus.
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Affiliation(s)
- S Cone
- Service de Biologie clinique, Clinique André Renard, Herstal, Belgique
| | - V Mistretta
- Service de Biologie clinique, Clinique André Renard, Herstal, Belgique
| | - N Lambert
- Service de Médecine interne, Clinique André Renard, Herstal, Belgique
| | - A Huwart
- Service de Biologie clinique, Clinique André Renard, Herstal, Belgique
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Kasivisvanathan R, Abbassi-Ghadi N, McLeod ADM, Oliver A, Rao Baikady R, Jhanji S, Cone S, Wigmore T. Cardiopulmonary exercise testing for predicting postoperative morbidity in patients undergoing hepatic resection surgery. HPB (Oxford) 2015; 17:637-43. [PMID: 25994624 PMCID: PMC4474512 DOI: 10.1111/hpb.12420] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/23/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Cardiopulmonary exercise testing (CPET) may predict which patients are at risk for adverse outcomes after major abdominal surgery. The primary aim of this study was to determine whether CPET variables are predicative of morbidity. METHODS High-risk patients undergoing elective, one-stage, open hepatic resection were preoperatively assessed using CPET. Morbidity, as defined by the Postoperative Morbidity Survey (POMS), was assessed on postoperative day 3. RESULTS A total of 104 patients underwent preoperative CPET and were included in the analysis. Of these, 73 patients (70.2%) experienced postoperative morbidity. Oxygen consumption at anaerobic threshold (V˙O2 at AT, ml/kg/min) was the only CPET predictor of postoperative morbidity on multivariable analysis, with an area under the curve (AUC) of 0.66 [95% confidence interval (CI) 0.55-0.76]. In patients requiring a major hepatic resection (three or more segments), a V˙O2 at AT of <10.2 ml/kg/min gave an AUC of 0.79 (95% CI 0.68-0.86) with 83.9% sensitivity and 52.0% specificity, 80.6% positive predictive value and 62.5% negative predictive value. CONCLUSIONS The application of a cut-off value for V˙O2 at AT of <10.2 ml/kg/min in patients undergoing major hepatic resection may be useful for predicting which patients will experience morbidity.
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Affiliation(s)
| | - Nima Abbassi-Ghadi
- Department of Surgery and Cancer, Imperial College London, St Mary's HospitalLondon, UK
| | - Andrew D M McLeod
- Department of Anaesthesia and Critical Care, The Royal MarsdenLondon, UK
| | - Alex Oliver
- Department of Anaesthesia and Critical Care, The Royal MarsdenLondon, UK
| | | | - Shaman Jhanji
- Department of Anaesthesia and Critical Care, The Royal MarsdenLondon, UK
| | - Stephen Cone
- Department of Anaesthesia, University College London HospitalsLondon, UK
| | - Timothy Wigmore
- Department of Anaesthesia and Critical Care, The Royal MarsdenLondon, UK
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Abstract
INTRODUCTION An intermittent surgical services program in rural Ecuador was able to benefit from close collaboration between surgeons and primary care physicians through the use of telemedicine technologies. METHODS Inexpensive telemedicine workstations capable of patient documentation, imaging, and video-conferencing at extremely low bandwidth were established in collaborative primary care sites in rural Ecuador. Patients were screened for intermittent surgical services by primary caregivers according to the surgeons' guidelines. Real-time and store-and-forward telemedicine allowed appropriate collaborative, informed decision-making. Surgery was performed, and postoperative care was similarly handled by on-site, familiar primary caregivers. RESULTS To date, this system has been used in more than 124 patient encounters (74 preoperative and 50 postoperative visits). The system allowed advance screening of patients on the part of the surgeons, leading to cancellations for 9 patients. Postoperatively, the system allowed 100% concurrence in postoperative diagnoses between the primary caregivers and the surgeons. CONCLUSIONS Inexpensive, low-bandwidth telemedicine solutions can support intermittent surgical services by providing patients to have contact with specialist care through their familiar, local primary caregivers.
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Affiliation(s)
- Francisco Mora
- Medical Informatics and Technology Applications Consortium, Department of Surgery, Virginia Commonwealth University, PO Box 980480, Richmond, Virginia 23298, USA.
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Rodas EB, Latifi R, Cone S, Broderick TJ, Doarn CR, Merrell RC. Telesurgical presence and consultation for open surgery. Arch Surg 2002; 137:1360-3; discussion 1363. [PMID: 12470100 DOI: 10.1001/archsurg.137.12.1360] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Edgar B Rodas
- Medical Informatics and Technology Applications Consortium, Department of Surgery, Virginia Commonwealth University, PO Box 980480, 1101 E Marshall St, Richmond, VA 23298, USA
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Tobimatsu S, Celesia GG, Cone S, Gujrati M. Electroretinograms to checkerboard pattern reversal in cats: physiological characteristics and effect of retrograde degeneration of ganglion cells. Electroencephalogr Clin Neurophysiol 1989; 73:341-52. [PMID: 2477220 DOI: 10.1016/0013-4694(89)90112-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Pattern electroretinograms (P-ERGs) evoked by alternating checks were studied in cats. Spatial frequency functions for transient and steady-state P-ERG waves showed a bimodal distribution with a preferred frequency at 0.6-0.75 c/deg and a second amplitude increase at frequencies lower than 0.5 c/deg. Decreasing the pattern luminance by 0.5 log units produced a shift of the spatial tuning curve toward lower spatial frequencies. No temporal tuning was noted in the temporal frequency functions. The bimodal distribution suggests that at spatial frequencies higher than 0.5 c/deg, the tuning reflects a 'contrast response' originating in cells with center surround organization. At spatial frequencies below 0.5 c/deg, the 'luminance response' becomes predominant and is generated in cells sensitive to mean luminance changes. Transient and steady-state P-ERGs to medium and high spatial frequencies were abolished by section of the optic nerve, while low spatial frequency stimuli at or below 0.3 c/deg continued to evoke P-ERGs at 1, 5 and 10 months after surgery. Quantitative whole mount retina microscopic examination confirmed the retrograde degeneration of the ganglion cells. It is concluded that both transient and steady-state P-ERGs to small and medium spatial frequencies checks are predominantly related to ganglion cell activity, while P-ERGs to low spatial frequencies reflect preganglionic cell activity.
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Affiliation(s)
- S Tobimatsu
- Department of Neurology and Neuropathology, Loyola University of Chicago, Stritch School of Medicine, Maywood, IL 60153
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Celesia GG, Kaufman D, Cone S. Effects of age and sex on pattern electroretinograms and visual evoked potentials. Electroencephalogr Clin Neurophysiol 1987; 68:161-71. [PMID: 2436875 DOI: 10.1016/0168-5597(87)90023-2] [Citation(s) in RCA: 113] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pattern-electroretinograms (P-ERGs) and visual evoked potentials (VEPs) were simultaneously recorded in 112 normal individuals aged 20-75. Two-sized checks subtending 15' and 31' were used as stimuli. A weighted regression analysis was used to determine which of the variables, sex or age, was significant. The latency of the a and b wave of the P-ERGs showed a progressive increase with age but no difference between sexes. The effect was statistically significant for both 15' and 31' checks. There was no statistically significant aging effect for VEPs elicited by 31' checks. Aging, however, affected N70, P100, and the interpeak interval between b wave to N70 and b wave to P100 for responses to 15' checks. Shorter VEP latencies were noted in females for both 15' and 31' checks. The simultaneous recording of P-ERGs and VEPs has demonstrated that aging is a major variable at the retinal level. The effects on the a and b waves are mostly due to optic changes with aging and only partially to aging changes in the neuronal retinal circuitry. The effect of aging on VEPs is different for different size stimuli. The cause is a random neuronal cell loss in the visual pathways from the optic nerve to the visual cortex as the individual ages. The difference in VEP data between sexes may be related to anatomical size and hormonal influences.
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Abstract
Two percent of normal controls noted that drinking coffee made their hands shaky. Eight percent of essential tremor and 6% of Parkinson's disease patients thought that coffee worsened their tremor. In formal tests, a single oral dose of caffeine (325 mg) did not increase physiologic, essential tremor, or parkinsonian tremor at 1, 2, or 3 hours after ingestion. Caffeine only infrequently induces tremor in normal people, and it does not exacerbate pathologic tremor.
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Abstract
We studied 18 patients with essential tremor for difficulty with handwriting, drinking, eating, fine manipulations, and embarrassment. Propranolol and primidone reduced the amplitude of both postural and kinetic tremor. Handwriting, drinking, and eating were improved with therapy, but fine manipulations and motor performance on tapping and pegboard tests were unaltered. Embarrassment remained unchanged. Essential tremor is not a benign condition; disability can be only partly reversed with drug therapy.
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Abstract
The effect of clonidine treatment (average dose 0.4 mg/day) was investigated in 10 patients with essential tremor in a double-blind placebo-controlled design. Tremor amplitude and frequency were recorded with an accelerometer. Tremor was not significantly altered by clonidine therapy. Side effects were common. It is concluded that clonidine is not effective treatment for essential tremor.
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Affiliation(s)
- W Koller
- Department of Neurology, Loyola Medical Center, Maywood, IL 60153
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