The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Isolation and characterization of a novel leaf-inhabiting osmo-, salt-, and alkali-tolerant Yarrowia lipolytica yeast strain

Salt-excreting leaves of Atriplex halimus plants harvested in the central Negev Highlands of Israel were screened for yeasts inhabiting their surfaces. Several aerobic, moderately salt- and alkali-tolerant yeasts were isolated. One of the isolates (tentatively designated S-8) was identified as Yarrowia lipolytica (Wick.) van der Walt and Arx, on the basis of its morphological, biochemical/physiological characteristics, and of quantitative chemotaxonomic and molecular marker analyses. However, the strain is distinguished from the known members of the type Y. lipolytica strain by its pronounced osmo-, salt-, and pH tolerance. Cells displayed a unique capacity to grow over a wide pH range (from 3.5 to 11.5) with a pH optimum at 4.5 to 7.5. It is proposed that the S-8 strain be assigned to a single Y. lipolytica species as its anamorpha, or as a new variety, Y. lipolytica var. alkalitolerance. The ecophysiological properties and biotechnological potentials of the new strain are discussed.

Properties of the cysteine-less Pho84 phosphate transporter of Saccharomyces cerevisiae

The derepressible Pho84 high-affinity phosphate permease of Saccharomyces cerevisiae, encoded by the PHO84 gene belongs to a family of phosphate:proton symporters (PHS). The protein contains 12 native cysteine residues of which five are predicted to be located in putative transmembrane regions III, VI, VIII, IX, and X, and the remaining seven in the hydrophilic domains of the protein. Here we report on the construction of a Pho84 transporter devoid of cysteine residues (C-less) in which all 12 native residues were replaced with serines using PCR mutagenesis and the functional consequences of this. Our results clearly demonstrate that the C-less Pho84 variant is able to support growth of yeast cells to the same extent as the wild-type Pho84 and is stably expressed under derepressible conditions and is fully active in proton-coupled phosphate transport across the yeast plasma membrane.

Phosphate permeases of Saccharomyces cerevisiae

The PHO84 and PHO89 genes of Saccharomyces cerevisiae encode two high-affinity phosphate cotransporters of the plasma membrane. Hydropathy analysis suggests a secondary structure arrangements of the proteins in 12 transmembrane domains. The derepressible Pho84 and Pho89 transporters appear to have characteristic similarities with the phosphate transporters of Neurospora crassa. The Pho84 protein catalyzes a proton-coupled phosphate transport at acidic pH, while the Pho89 protein catalyzes a sodium-dependent phosphate uptake at alkaline pH. The Pho84 transporter can be stably overproduced in the cytoplasmic membrane of Escherichia coli, purified and reconstituted in a functional state into proteoliposomes.

Isolation and characterization of membrane vesicles of Saccharomyces cerevisiae harboring the high-affinity phosphate transporter

Membrane vesicles with an inside-out orientation were isolated from the plasma membrane of Saccharomyces cerevisiae by an improved aqueous two-phase partitioning technique. The activity of the orthovanadate-sensitive H+-pumping ATPase, the plasma membrane marker, was highly enriched by the partitioning technique. The obtained results suggest that the membrane vesicles produced were predominantly oriented inside-out. The isolated plasma membrane vesicles displayed cross-reactions with antibodies raised against synthetic peptide corresponding to the N-terminal (residues 1-10) and the C-terminal (residues 578-597) regions of the plasma membrane phosphate transporter encoded by the PHO84 gene and the H+-pumping ATPase of S. cerevisiae. The purified membrane vesicles catalyzed a derepressible inhibitor-sensitive phosphate uptake at levels comparable with the situation in intact cells of S. cerevisiae indicating that transport of phosphate across the membrane is both functional and bidirectional. The PHO84 transporter harbored in isolated plasma membranes could moreover be enriched in a high state of purity by immunoaffinity chromatography using immobilized anti-PHO84 antibodies.

Expression and purification of the high-affinity phosphate transporter of Saccharomyces cerevisiae

The plasma membrane high-affinity phosphate permease of Saccharomyces cerevisiae has been overproduced as a stable membrane-bound chimeric protein in Escherichia coli. Construction of a chimera between the permease and a peptide containing 10 consecutive histidine residues allowed selective binding of the chimera to a chelating column charged with Ni2+, and elution with imidazole in a high state of purity. Approximately 5 mg purified His10-permease was obtained from 3 g (wet mass) cells. The purified phosphate permease chimera catalyzes uncoupler-sensitive phosphate transport after reconstitution into proteoliposomes.

Effects of histamine on vascular resistance and protein permeability in the isolated dually perfused guinea-pig placenta

The possibility that histamine can affect both the vascular resistance and permeability of the isolated dually perfused guinea-pig placenta has been investigated. Change from control to histamine (2.7 x 10(-4)M) perfusion of the fetal circulation elicited a significant (P less than 0.01, paired 't' test) maximum increase of 1.17 +/- 0.14 (SEM) kPa in fetal perfusion pressure 3 min later, representing a 33% rise. This vasoconstriction was completely blocked by the H1 antagonist diphenhydramine (10(-4)M) but not by the H2 receptor antagonist cimetidine (10(-4)M). In the same experiments the clearance (calculated as the ratio of fetal to maternal perfusate concentration times fetal flow-rate) of a macromolecular tracer, anionic horseradish peroxidase from the maternal to fetal circulation was significantly increased (P less than 0.05, paired 't' test) when steady state (15-20 min of perfusion) values were compared, from 5.9 +/- 1.7 (SEM) microliter min-1 placenta-1 to 12.9 +/- 3.5 (SEM) microliter min-1 placenta-1 (n = 20) for control and histamine respectively. By contrast the steady state clearance (calculated as before) of a smaller hydrophilic tracer, 51Cr-EDTA, was not significantly affected, being 587 +/- 59 (SEM) microliter min-1 placenta-1 in control and 587 +/- 55 (SEM) microliter min-1 placenta-1 (n = 20) with histamine perfusion. When histamine was perfused simultaneously with an H1 or H2 antagonist there was no change in anionic horseradish peroxidase clearance. Electron microscopy of placentas perfused with histamine failed to reveal any obvious alteration in morphology or anionic horseradish peroxidase localisation as compared to placenta perfused without histamine. This study thus demonstrates that histamine may cause changes in the macromolecular permeability of the placenta as well as vasoconstriction of the placental vasculature.

Molecular charge effects on the protein permeability of the guinea-pig placenta

The effect of molecular charge on protein permeability of the dually perfused guinea-pig placenta has been investigated by measurement of the permeability surface area products (PS) and observation of the ultrastructural localization of cationic horseradish peroxidase (cHRP) and anionic horseradish peroxidase (aHRP) molecules. Steady-state PS calculated from the experimental data was 0.032 +/- 0.0045 and 0.0045 +/- 0.0008 ml min-1 (mean +/- s.e.m.) for cHRP and aHRP respectively (P less than 0.01). The PS for a diffusional marker, 51Cr-ethylenediaminetetraacetic acid, showed no significant difference between the two groups. Ultrastructurally, placentae perfused with cHRP showed fewer microvilli and a dilated interstitial space compared with placentae perfused with aHRP; large vacuoles were also found in the syncytiotrophoblast in the former but not in the latter tissue. Reaction product in placentae perfused with cHRP was localized to the maternal-facing plasma membrane of the syncytiotrophoblast, in vacuoles and vesicles of the syncytiotrophoblast, and also in the basement membrane of the interstitial space, whereas placentae perfused with aHRP only had reaction product in vesicles in the syncytiotrophoblast. These results suggest that anionic sites in the guinea-pig placenta affect its permeability to charged proteins, cationic molecules inducing structural changes associated with increased permeability.