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.

Genome-wide analysis of canine oral malignant melanoma metastasis-associated gene expression

Oral malignant melanoma (OMM) is the most common canine melanocytic neoplasm. Overlap between the somatic mutation profiles of canine OMM and human mucosal melanomas suggest a shared UV-independent molecular aetiology. In common with human mucosal melanomas, most canine OMM metastasise. There is no reliable means of predicting canine OMM metastasis, and systemic therapies for metastatic disease are largely palliative. Herein, we employed exon microarrays for comparative expression profiling of FFPE biopsies of 18 primary canine OMM that metastasised and 10 primary OMM that did not metastasise. Genes displaying metastasis-associated expression may be targets for anti-metastasis treatments, and biomarkers of OMM metastasis. Reduced expression of CXCL12 in the metastasising OMMs implies that the CXCR4/CXCL12 axis may be involved in OMM metastasis. Increased expression of APOBEC3A in the metastasising OMMs may indicate APOBEC3A-induced double-strand DNA breaks and pro-metastatic hypermutation. DNA double strand breakage triggers the DNA damage response network and two Fanconi anaemia DNA repair pathway members showed elevated expression in the metastasising OMMs. Cross-validation was employed to test a Linear Discriminant Analysis classifier based upon the RT-qPCR-measured expression levels of CXCL12, APOBEC3A and RPL29. Classification accuracies of 94% (metastasising OMMs) and 86% (non-metastasising OMMs) were estimated.

Genome-wide association study across European and African American ancestries identifies a SNP in DNMT3B contributing to nicotine dependence

Cigarette smoking is a leading cause of preventable mortality worldwide. Nicotine dependence, which reduces the likelihood of quitting smoking, is a heritable trait with firmly established associations with sequence variants in nicotine acetylcholine receptor genes and at other loci. To search for additional loci, we conducted a genome-wide association study (GWAS) meta-analysis of nicotine dependence, totaling 38,602 smokers (28,677 Europeans/European Americans and 9925 African Americans) across 15 studies. In this largest-ever GWAS meta-analysis for nicotine dependence and the largest-ever cross-ancestry GWAS meta-analysis for any smoking phenotype, we reconfirmed the well-known CHRNA5-CHRNA3-CHRNB4 genes and further yielded a novel association in the DNA methyltransferase gene DNMT3B. The intronic DNMT3B rs910083-C allele (frequency=44-77%) was associated with increased risk of nicotine dependence at P=3.7 × 10-8 (odds ratio (OR)=1.06 and 95% confidence interval (CI)=1.04-1.07 for severe vs mild dependence). The association was independently confirmed in the UK Biobank (N=48,931) using heavy vs never smoking as a proxy phenotype (P=3.6 × 10-4, OR=1.05, and 95% CI=1.02-1.08). Rs910083-C is also associated with increased risk of squamous cell lung carcinoma in the International Lung Cancer Consortium (N=60,586, meta-analysis P=0.0095, OR=1.05, and 95% CI=1.01-1.09). Moreover, rs910083-C was implicated as a cis-methylation quantitative trait locus (QTL) variant associated with higher DNMT3B methylation in fetal brain (N=166, P=2.3 × 10-26) and a cis-expression QTL variant associated with higher DNMT3B expression in adult cerebellum from the Genotype-Tissue Expression project (N=103, P=3.0 × 10-6) and the independent Brain eQTL Almanac (N=134, P=0.028). This novel DNMT3B cis-acting QTL variant highlights the importance of genetically influenced regulation in brain on the risks of nicotine dependence, heavy smoking and consequent lung cancer.

A177 BIRTH COHORT SCREENING FOR HEPATITIS C IN AN OUTPATIENT ENDOSCOPY UNIT: A PILOT STUDY

Background

Chronic hepatitis C (HCV) is a curable asymptomatic infection that can progress to liver failure and hepatocellular carcinoma if left untreated. The Canadian Liver Foundation (CLF) recommends one-time HCV screening in all Canadians born from 1945–1975. A large proportion of outpatient endoscopic procedures are for colon cancer screening in this birth cohort providing an opportunity for HCV screening and linkage to HCV care.

Aims

We aimed to assess the feasibility of developing a targeted birth-cohort HCV screening program in the outpatient endoscopy setting.

Methods

This is a cross-sectional study of patients born from 1945–1975 presenting to the outpatient endoscopy unit at Hotel Dieu Hospital in Kingston, Ontario in September, 2016. Patients were scheduled for upper endoscopy, colonoscopy, and/or sigmoidoscopy. All patients were given written information on HCV and the CLF recommendation of birth-cohort screening. Patients were then asked to complete a short survey regarding previous HCV screening and acceptance of being screened during their endoscopy visit.

Results

During a 30 day period, 95% (223/235) of eligible patients completed the survey. The cohort was 53% female with a median age of 59 years (IQR 52–66 years). 83% had either never been screened or were unaware of their HCV status. Overall, 87% of participants would be accepting of HCV screening during their endoscopy visit, 9% would not accept screening and 4% stated they were unsure. These results suggest that almost 2,000 patients could be targeted for HCV screening in the endoscopy unit annually.

Conclusions

Most patients born from 1945–1975 presenting for outpatient endoscopy have not been screened for HCV but are accepting of screening during their procedural visit. This identifies a target population for the development of an HCV screening program to increase HCV identification and facilitate linkage to HCV care.

Funding Agencies

None

TLR9 re-expression in cancer cells extends the S-phase and stabilizes p16(INK4a) protein expression

Toll-like receptor 9 (TLR9) recognizes bacterial, viral or cell damage-associated DNA, which initiates innate immune responses. We have previously shown that TLR9 expression is downregulated in several viral induced cancers including HPV16-induced cervical neoplasia. Findings supported that downregulation of TLR9 expression is involved in loss of anti-viral innate immunity allowing an efficient viral replication. Here we investigated the role of TLR9 in altering the growth of transformed epithelial cells. Re-introducing TLR9 under the control of an exogenous promoter in cervical or head and neck cancer patient-derived cells reduced cell proliferation, colony formation and prevented independent growth of cells under soft agar. Neither TLR3, 7, nor the TLR adapter protein MyD88 expression had any effect on cell proliferation, indicating that TLR9 has a unique role in controlling cell growth. The reduction of cell growth was not due to apoptosis or necrosis, yet we observed that cells expressing TLR9 were slower in entering the S-phase of the cell cycle. Microarray-based gene expression profiling analysis highlighted a strong interferon (IFN) signature in TLR9-expressing head and neck cancer cells, with an increase in IFN-type I and IL-29 expression (IFN-type III), yet neither IFN-type I nor IL-29 production was responsible for the block in cell growth. We observed that the protein half-life of p16(INK4a) was increased in TLR9-expressing cells. Taken together, these data show for the first time that TLR9 affects the cell cycle by regulating p16(INK4a) post-translational modifications and highlights the role of TLR9 in the events that lead to carcinogenesis.

Altered expression of two zinc transporters, SLC30A5 and SLC30A6, underlies a mammary gland disorder of reduced zinc secretion into milk

Two cases of zinc deficiency in breastfed neonates were investigated where zinc levels in the mothers' milk were reduced by more than 75 % compared to normal. The objective of this study was to find the molecular basis of the maternal zinc deficiency condition. Significant reductions in mRNA expression and protein levels of the zinc transporters SLC30A5 and SLC30A6 were found in maternal tissue, suggesting a causal link to the zinc-deficient milk. Novel splice variants of the SLC30A6 transcript were detected. No modifications were found in coding regions, or in transcription binding sites of promoter regions or in 5' and 3' untranslated regions of both transporters in lymphoblasts and fibroblasts isolated from both mothers. Altered DNA methylation in SLC30A5 at two CpG sites was detected and may account for the reduced levels of SLC30A5 mRNA and protein in lymphoblasts. Reduced SLC30A6 mRNA and protein levels in lymphoblasts may be secondary to reduced SLC30A5 expression, as they function as a heterodimer in zinc transport. In conclusion, two cases of zinc deficiency are linked to low levels of the SLC30A5 and SLC30A6 zinc transporters. These two zinc transporters have not been previously associated with zinc deficiency in milk.

FGF receptor genes and breast cancer susceptibility: results from the Breast Cancer Association Consortium

BACKGROUND

Breast cancer is one of the most common malignancies in women. Genome-wide association studies have identified FGFR2 as a breast cancer susceptibility gene. Common variation in other fibroblast growth factor (FGF) receptors might also modify risk. We tested this hypothesis by studying genotyped single-nucleotide polymorphisms (SNPs) and imputed SNPs in FGFR1, FGFR3, FGFR4 and FGFRL1 in the Breast Cancer Association Consortium.

METHODS

Data were combined from 49 studies, including 53 835 cases and 50 156 controls, of which 89 050 (46 450 cases and 42 600 controls) were of European ancestry, 12 893 (6269 cases and 6624 controls) of Asian and 2048 (1116 cases and 932 controls) of African ancestry. Associations with risk of breast cancer, overall and by disease sub-type, were assessed using unconditional logistic regression.

RESULTS

Little evidence of association with breast cancer risk was observed for SNPs in the FGF receptor genes. The strongest evidence in European women was for rs743682 in FGFR3; the estimated per-allele odds ratio was 1.05 (95% confidence interval=1.02-1.09, P=0.0020), which is substantially lower than that observed for SNPs in FGFR2.

CONCLUSION

Our results suggest that common variants in the other FGF receptors are not associated with risk of breast cancer to the degree observed for FGFR2.

Influence of DNMT genotype on global and site specific DNA methylation patterns in neonates and pregnant women

This study examines the relationship between common genetic variation within DNA methyltransferase genes and inter-individual variation in DNA methylation. Eleven polymorphisms spanning DNMT1 and DNMT3B were genotyped. Global and gene specific (IGF2, IGFBP3, ZNT5) DNA methylation was quantified by LUMA and bisulfite Pyrosequencing assays, respectively, in neonatal cord blood and in maternal peripheral blood. Associations between maternal genotype and maternal methylation (n (≈) 333), neonatal genotype and neonatal methylation (n (≈) 454), and maternal genotype and neonatal methylation (n (≈) 137) were assessed. The findings of this study provide some support to the hypothesis that genetic variation in DNA methylating enzymes influence DNA methylation at global and gene-specific levels; however observations were not robust to correction for multiple testing. More comprehensive analysis of the influence of genetic variation on global and site specific DNA methylation is warranted.

IgM deposition in skin biopsies from patients with primary biliary cirrhosis

Immunofluorescence studies on skin biopsies from 14 patients with primary biliary cirrhosis (PBC) showed granular papillary deposition of IgM in all. In addition, 6 patients had C3 deposition. Control patients with various other liver diseases, idiopathic high plasma levels of igM and extrahepatic cholestasis were only sporadically positive for IgM and not at all for C3. IgM deposition in dermal papillae in PBC does not merely reflect high plasma IgM levels or cholestasis but probably represents an immunochemically abnormal IgM population.

Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross-sectional study

BACKGROUND AND AIMS

There is variation in the identification, analysis and reporting of significant events in general practice. Consistency is desired to optimise learning from, and reporting of, patient safety incidents. We examined levels of agreement among different groups of general practitioners (GPs) on the grading, analysis and reporting of selected significant event scenarios.

METHOD

Cross-sectional postal questionnaire survey of 162 GPs split into five professional groups in the west of Scotland. Differences in grading severity and willingness to formally analyse and report seven significant event scenarios were examined using analysis of variance (ANOVA). Differences in proportions were calculated together with 95% confidence intervals.

RESULTS

122 GPs responded (77%). No difference was found in the grading severity of significant events by GP groups. Increased grading severity was linked to the willingness of GP groups to analyse and report that event (p<0.05). A preference to anonymously report all event scenarios to a national educational body was reported (p<0.05). The majority of respondents were not willing to involve patients in relevant event analyses (83-100%).

CONCLUSIONS

The strong levels of agreement suggest that GPs can prioritise relevant significant events for formal analysis and reporting. Focused guidance should be developed to encourage their engagement with the patient safety agenda, optimise learning from safety-relevant events and increase reporting opportunities. Exploration is required of the reasons why GPs may prefer an educational body as a potential reporting source or may be unwilling to include patients in relevant event analyses.

Animal genomics for animal health report: critical needs, problems to be solved, potential solutions, and a roadmap for moving forward

The first International Symposium on Animal Genomics for Animal Health, held at the World Organisation for Animal Health (OIE) Headquarter, 23-25 October, 2007, Paris, France, assembled more than 250 participants representing research organizations from 26 countries. The symposium included a roundtable discussion on critical needs, challenges and opportunities, and a forward look at the potential applications of animal genomics in animal health research. The aim of the roundtable discussion was to foster a dialogue between scientists working at the cutting edge of animal genomics research and animal health scientists. In an effort to broaden the perspective of the roundtable discussion, the organizers set out four priority areas to advance the use of genome-enabled technologies in animal health research. Contributions were obtained through open discussions and a questionnaire distributed at the start of the symposium. This symposium report provides detailed summaries ofthe outcome ofthe roundtable discussion for each of the four priority areas. For each priority, the problems needing to be solved, according to the views of the participants, are identified, including potential solutions, recommendations, and lastly, concrete steps that could be taken to address these problems. This report serves as a roadmap to steer research priorities in animal genomics research.

Development and testing of an assessment instrument for the formative peer review of significant event analyses

AIM

To establish the content validity and specific aspects of reliability for an assessment instrument designed to provide formative feedback to general practitioners (GPs) on the quality of their written analysis of a significant event.

METHODS

Content validity was quantified by application of a content validity index. Reliability testing involved a nested design, with 5 cells, each containing 4 assessors, rating 20 unique significant event analysis (SEA) reports (10 each from experienced GPs and GPs in training) using the assessment instrument. The variance attributable to each identified variable in the study was established by analysis of variance. Generalisability theory was then used to investigate the instrument's ability to discriminate among SEA reports.

RESULTS

Content validity was demonstrated with at least 8 of 10 experts endorsing all 10 items of the assessment instrument. The overall G coefficient for the instrument was moderate to good (G>0.70), indicating that the instrument can provide consistent information on the standard achieved by the SEA report. There was moderate inter-rater reliability (G>0.60) when four raters were used to judge the quality of the SEA.

CONCLUSIONS

This study provides the first steps towards validating an instrument that can provide educational feedback to GPs on their analysis of significant events. The key area identified to improve instrument reliability is variation among peer assessors in their assessment of SEA reports. Further validity and reliability testing should be carried out to provide GPs, their appraisers and contractual bodies with a validated feedback instrument on this aspect of the general practice quality agenda.

A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment

OBJECTIVES

To explore the influences and perceived benefits behind general practitioners' willingness to participate in significant event analysis (SEA) and educational peer assessment.

DESIGN

Qualitative analysis of focus group transcripts.

SETTING

Greater Glasgow Primary Care Trust.

PARTICIPANTS

Two focus group sessions involving 21 principals in general practice (GPs).

MAIN OUTCOME MEASURES

GPs' perceptions of the reasons for and benefits of participating in SEA and associated educational peer assessment.

RESULTS

Pressure from accreditation bodies and regulatory authorities makes SEA compulsory for most participants who believe more in-depth event analyses are undertaken as a result. Some believed SEA was not an onerous activity while others argued that this depended on the complexity of the event. SEA that is linked to a complaint investigation may provide credible evidence to patients that their complaint is taken seriously. Writing up an event analysis is viewed as an educational process and may act as a form of personal catharsis for some. Event analyses are submitted for peer assessment for educational reward but are highly selective because of concerns about confidentiality, litigation, or professional embarrassment. Most participants disregard the opportunities to learn from "positive" significant events in favour of problem ones. Peer assessment is valued because there is a perception that it enhances knowledge of the SEA technique and the validity of event analyses, which participants find reassuring.

CONCLUSIONS

This small study reports mainly positive feedback from a select group of GPs on the merits of SEA and peer assessment.

A pilot study of the feasibility of trainee hospital doctors undertaking significant event analysis

Participating in significant event analysis is proposed as an important method of reflective learning that can enhance patient care and safety. Peer review is one way of making informed judgments on the ability of participants to apply the technique.

Awareness and analysis of a significant event by general practitioners: a cross sectional survey

OBJECTIVES

To determine the extent to which general practitioners (GPs) were aware of a recent significant event and whether a structured analysis of this event was undertaken to minimise the perceived risk of recurrence.

DESIGN

Cross sectional survey using a postal questionnaire.

SETTING

Greater Glasgow primary care trust.

PARTICIPANTS

466 principals in general practice from 188 surgeries.

MAIN OUTCOME MEASURES

GPs' self-reported personal and practice characteristics, awareness of a recent significant event, participation in the structured analysis of the identified significant event, perceived chance of recurrence, forums for discussing and analysing significant events, and levels of primary care team involvement.

RESULTS

Four hundred and sixty six GPs (76%) responded to the survey. GPs from single handed practices were less likely to respond than those in multi-partner training and non-training practices. 401 (86%) reported being aware of a recent significant event; lack of awareness was clearly associated with GPs from non-training practices. 219 (55%) had performed all the necessary stages of a structured analysis (as determined by the authors) of the significant event. GPs from training practices were more likely to report participation in the structured analysis of the recent event, to perceive the chance of this event recurring as "nil" or "very low", and to report significant event discussions taking place.

CONCLUSIONS

Most GPs were aware of a recent significant event and participated in the structured analysis of this event. The wider primary care team participated in the analysis process where GPs considered this involvement relevant. There is variation in the depth of and approach to significant event analysis within general practice, which may have implications for the application of the technique as part of the NHS quality agenda.

Who owns Australia's water--elements of an effective regulatory model

This paper identifies and describes a number of global trends in regulatory theory and legal scholarship. It points out the huge level of complexity demanded by globalisation and the unfortunate complication of this is that there is legal indeterminacy. The legal indeterminacy springs from the desire to amend and alter existing models. That has been the thrust of the Council of Australian Governments changes to adapt and add huge amounts of complexity to a flawed system. This paper argues that an effective water regulatory model requires a fundamental re-examination of the concept of water ownership and a capturing by the State of the right to allocate rainfall. This foundation is effective and the way forward to deal with the key issues in this transition phase. The second key element to an effective regulatory model is the concept of performance-based assessment. This requires information and schemes to be set up to work out ways to monitor and evaluate the performance of the utility on selected criteria. For Australia at present there is a dire lack of agreed criteria on these key issues and these have the potential to pull apart the whole process. The key issues are indigenous rights, governance issues, public participation, alteration of pre-existing rights and incorporation of environmental requirements.

Limited role for IVUS in the endovascular repair of aortoiliac aneurysms

BACKGROUND

To determine the need for routine versus selective intraoperative IVUS during endovascular aortoiliac aneurysm (AIA) repair.

METHODS

One-hundred and eighty-eight endovascular AIA repairs performed over a 5-year period were reviewed and included in the study. Surgeon-made aorto-uni-femoral grafts (n=78) and industry-made bifurcated or tube grafts (n=110) were used. In the initial 51 cases IVUS was routinely performed. In the latter 137 cases IVUS was used selectively. In this group graft deformities suspected on completion angiography or pullback pressure measurements were treated with balloon dilatation and stenting. IVUS was then performed only in the presence of a persistent pressure gradient or inconclusive angiographic findings.

RESULTS

In the initial 51 cases IVUS revealed 20 lesions of which 8 were not initially detected angiographically and which required further treatment. In the latter 137 cases IVUS was necessary in only 1 case, and guided the treatment of an angiographically undetectable lesion. There have been no late episodes of graft compression, kinking, or thrombosis in the selective IVUS group.

CONCLUSIONS

The use of pullback pressure measurements with a low threshold for angioplasty and stenting, especially in unsupported grafts, followed by the selective use of IVUS decreases the overall requirement for IVUS and its associated costs.

Is risk associated with drinking water in Australia of significant concern to justify mandatory regulation?

Presently in Australia there are no mandatory drinking water standards. Here we argue that the risk associated with drinking water in Australia is of a dimension discernible to warrant mandatory regulations. The catchments that supply the major metropolitan areas of Sydney and Adelaide, and the groundwater for the city of Perth have been seriously compromised by the encroachment of development and activities. Melbourne in the past has generally relied on a closed catchment reservoir system; however, population growth in the near future will sequester the full online operation of additional reservoirs, which have multiple land use catchments. In addition to the current landscape circumstances, the management of a water system in itself proposes significant issues of risk. Two critical assumptions that are unique to a mass medium substance like water and dramatically alter the appraisal of risk are: (1) very large numbers of people are potentially exposed, and (2) small changes in contaminant levels may have adverse population outcomes. It is also known that water reticulation systems frequently suffer from contamination problems caused solely by the distribution system, and optimal management of these facilities would best be served by statutory protected transparency and dedicated water quality programs. In 1979, an Australian parliamentary committee stated that an "uncontaminated water supply is" a "basic requirement for the obtainment of good health"; however, recent surveys of Australian water systems show many are not meeting basic water quality criteria, and many communities are not receiving regular monitoring or testing as required by government authorized Australian drinking water guidelines. Exacerbating this situation is the lack of reporting and statutory endorsed standardized procedures to ensure information is properly and promptly recorded and that data are centralized for maximum benefit. The evaluation of risk associated with drinking water in Australia is often hampered by inadequate or incomplete data. Lastly, regional and rural water supplies face a vast array of contemporary problems and experiences that include widespread usage of pesticides and agricultural chemicals. In recent years, the Darling River has experienced the worst algal bloom known to man, and this river system not only supplies a number of regional and rural towns with water, but eventually connects with the River Murray, which supplies the State of South Australia with approximately 50% of its water requirements.

Increasing incidence of midterm and long-term complications after endovascular graft repair of abdominal aortic aneurysms: a note of caution based on a 9-year experience

OBJECTIVE

To analyze the late complications after endovascular graft repair of elective abdominal aortic aneurysms (AAAs) at the authors' institution since November 1992.

SUMMARY BACKGROUND DATA

Recently, the use of endovascular grafts for the treatment of AAAs has increased dramatically. However, there is little midterm or long-term proof of their efficacy.

METHODS

During the past 9 years, 239 endovascular graft repairs were performed for nonruptured AAAs, many (86%) in high-risk patients or in those with complex anatomy. The grafts used were Montefiore (n = 97), Ancure/EVT (n = 14), Vanguard (n = 16), Talent (n = 47), Excluder (n = 20), AneuRx (n = 29), and Zenith (n = 16). All but the AneuRx and Ancure repairs were performed as part of a U.S. phase 1 or phase 2 clinical trial under a Food and Drug Administration investigational device exemption. Procedural outcomes and follow-up results were prospectively recorded.

RESULTS

The major complication and death rates within 30 days of endovascular graft repair were 17.6% and 8.5%, respectively. The technical success rate with complete AAA exclusion was 88.7%. During follow-up to 75 months (mean +/- standard deviation, 15.7 +/- 6.3 months), 53 patients (22%) died of unrelated causes. Two AAAs treated with endovascular grafts ruptured and were surgically repaired, with one death. Other late complications included type 1 endoleak (n = 7), aortoduodenal fistula (n = 2), graft thrombosis/stenosis (n = 7), limb separation or fabric tear with a subsequent type 3 endoleak (n = 1), and a persistent type 2 endoleak (n = 13). Secondary intervention or surgery was required in 23 patients (10%). These included deployment of a second graft (n = 4), open AAA repair (n = 5), coil embolization (n = 6), extraanatomic bypass (n = 4), and stent placement (n = 3).

CONCLUSION

With longer follow-up, complications occurred with increasing frequency. Although most could be managed with some form of endovascular reintervention, some complications resulted in a high death rate. Although endovascular graft repair is less invasive and sometimes effective in the long term, it is often not a definitive procedure. These findings mandate long-term surveillance and prospective studies to prove the effectiveness of endovascular graft repair.

Novel antineoplastic isochalcones inhibit the expression of cyclooxygenase 1,2 and EGF in human prostate cancer cell line LNCaP

Experiments were conducted to determine the effects of novel anti-neoplastic isochalcones (DJ compounds), on cyclooxyegenase 1 and 2 (COX-1 and COX-2) enzyme expression in androgen receptor dependent human prostate cancer cell line LNCaP. Results from Western blot analysis and cell flow cytometry showed that DJ52 and DJ53 decreased the steady state levels of COX-1 and COX-2 protein levels in a dose dependent manner. In addition, DJ52 and DJ53 decreased the levels of epidermal growth factor (EGF) in LNCaP cells. In this study, we report that novel isochalcones decreased COX-1, COX-2 and EGF levels as well as LNCaP cellular growth in a dose responsive manner. Our findings indicate that relative decreases in COX-1, COX-2 and EGF expressions might serve as indicators of tumor growth inhibition in prostate neoplasms.

The evidence for rickettsial disease arising in New Zealand

AIM

To describe the first cases of serologically proven riskettsial disease reported in non-travelling New Zealanders.

METHODS

We used clinical and laboratory based surveillance, review of clinical records and patient interviews. Information collected included demographics, presenting signs and symptoms, laboratory results, treatment and outcome. A limited seroprevalence study of rural-living friends and relatives was performed. We tested for rickettsial antibodies in the sera of possums trapped on properties close to the area of residence of the first two cases.

RESULT

Serological results support the diagnosis of a rickettsial disease in nine patients. Clinical findings at presentation were nonspecific but included fever, rigors and headache. A rash was noted in four (44%). All had abnormal liver enzymes. Eight were hospitalised. No patient died but two were admitted to intensive care.

CONCLUSIONS

There is strong clinical and serological evidence that Rickettsia typhi (the causative organism of murine typhus) or a Rickettsia typhi-like organism is present in the greater Auckland region. To prove it, the organism will need to be cultured or rickettsial DNA detected by molecular methods. Rickettsial infection needs to be included in the differential diagnosis of patients presenting with fever, headache and myalgia, particularly in those with rural lifestyles at least in the greater Auckland area.

Allograft incorporation: a biomechanical evaluation in a rat model

Allogeneic bone from Sprague-Dawley rat femurs was subjected to levels of freezing and/or irradiation that are known to have produced changes in the associated immune responses to these grafts. This bone was transplanted into an experimentally created gap in the femur of Lewis rats. The subsequent healing of the transplants in the Lewis rats was studied at 2, 4, 8, and 16 weeks after transplantation using torsion testing to failure. There was no clear advantageous biologic response in the union of the grafted material accompanying the alterations in immunologic response as measured by biomechanical testing of the proximal osteosynthesis site in torsion. The torsional strength of all of these groups remained lower than that of intact bone. Furthermore, none of the frozen and/or irradiated allografts exceeded the strength of the fresh allograft at a statistically significant level.

Prosthetic patch remnants to treat infected arterial grafts

PURPOSE

Our previous experience with the traditional management of infected prosthetic arterial grafts, which included graft excision and vein patch repair of the involved artery, was complicated by a high incidence of vein patch rupture. This study assessed the treatment of infected prosthetic grafts with subtotal graft excision and oversewing of small graft remnants.

METHODS

During the last 20 years, we treated 53 wounds involving 45 infected prosthetic grafts in 42 patients by means of subtotal graft excision and oversewing of a residual 2- to 3-mm graft remnant (patch) at an intact arterial anastomosis. This technique was selectively used to maintain patency of small-diameter arteries (41 common femoral, five deep femoral, three axillary, two iliac, and two popliteal), which were critical for limb salvage or amputation healing. This strategy avoided difficult dissection of the underlying artery in scarred wounds and obviated the placement of a new patch in an infected field. Graft remnants were polytetrafluoroethylene in 51 cases and Dacron in two cases. Of the 45 grafts, 31 were occluded and 14 were patent. All infected tissue was widely debrided, wet-to-dry dressing changes were performed three times daily, and appropriate intravenous antibiotics were administered for at least 1 week. Secondary bypass grafting procedures were performed as needed to achieve limb salvage. The follow-up period in surviving patients averaged 32 months (range, 1 to 218 months).

RESULTS

No complications were directly attributable to prosthetic patch remnants in 92% of cases (49 of 53 cases). Six of 42 patients (14%) died during hospitalization (three of cardiac complications and three of sepsis with multiple organ failure). Two infected pseudoaneurysms developed 8 and 34 months after surgery, and two wounds failed to heal. Sixteen secondary bypass grafting procedures were necessary to achieve limb salvage. Patch oversewing led to limb salvage without the need for secondary revascularization in 26 other cases and to the successful healing of 10 amputated limbs when secondary revascularization was not possible.

CONCLUSION

Prosthetic patch remnants are a useful adjunct that simplify management of infected prosthetic grafts, are associated with a low incidence of wound complications, and help maintain patency of essential collaterals to achieve limb salvage or heal an amputation.

Efficient grating-tuned mid-infrared Cr2+:CdSe laser

Room-temperature, all-solid-state, broadly tunable laser operation of Cr(2+) -doped CdSe has been demonstrated. Pumping with a Q -switched Tm, Ho:YLF laser running at a 1-kHz repetition rate achieved broadband output of 500 mW at 2.6 microm with 48% absorbed power slope efficiency. With reduced efficiency, as much as 815 mW of power was obtained. With a diffraction grating, the Cr(2+): CdSe laser was tuned from 2.3 to 2.9 microm with 10-nm bandwidth (FWHM) and output power up to 350 mW.

Revisiting the effectiveness of methadone treatment on crime reductions in the 1990s

This study examines the relationship between methadone treatment and the criminal activity of 126 individuals participating in treatment during the early 1990s. The primary question addressed is to what extent is methadone maintenance treatment associated with reductions in crime? Although prior studies in the 1970s and early 1980s showed significant decreases in crime for individuals in treatment programs, criteria for remaining in this treatment modality have changed in recent years, particularly with the advent of acquired immune deficiency syndrome and the need to reduce intravenous drug use. A pre-post study design is employed spanning a 6-year time period of subject recruitment and follow-up (1987-1993). Uniform administrative records on arrests are used for the analyses. A multiple regression model is employed to explain the variance in the number of arrests 2 years following program admission, with prior criminal history, prior and current drug treatment, and current cocaine use employed as explanatory variables. Results indicate that treatment retention has only a slight, though significant, effect on reducing criminal activity during treatment. Two other factors that appear to increase arrest activity are the use of cocaine and prior criminal history. The fact that arrests did not decrease during a treatment period of 18 months on average requires more investigation in light of the increase in cocaine use in this population.

The Braden Scale for pressure ulcer risk: evaluating the predictive validity in Black and Latino/Hispanic elders

The purpose of this study was to examine the predictive validity of the Braden scale in predicting pressure sore risk and to determine the physiological and nonphysiological variables associated with the prediction of pressure ulcers in Black and Latino/Hispanic elders. A prospective clinical design ws used to conduct the study. Among 74 patients aged 60 years or older, 24 patients (32%) developed either a stage 1 or stage 2 pressure ulcer. Black elders had a higher incidence rate (21%) than Latino/Hispanic elders (11%). A 2-tailed Fisher's exact test revealed that the Braden scale with a cutoff score of 18 was highly associated with predicting Black elders aged 75 years and older who were at risk of developing pressure ulcers (p < or = .011). Sensitivity was 81% and specificity was 100%. The female gender was also a highly significant factor in the development of pressure ulcers (chi 2(1, N = 49) = 6.4, p < or = .011). Overall, the Braden scale was found to be a valid tool in predicting pressure ulcer risk in Black elders aged 75 years or older when a cutoff score of 18 is used.

Objective definition of shoulder dystocia: a prospective evaluation

OBJECTIVE

The current study was undertaken to validate the objective definition of shoulder dystocia in a prospectively evaluated group of patients.

STUDY DESIGN

Selected vaginal deliveries from January 1995 to December 1996 (N = 722) were evaluated for head-to-body delivery time and use of ancillary obstetric maneuvers. Charts were reviewed for perinatal and outcome data.

RESULTS

Ninety-nine deliveries were complicated by shoulder dystocia and 623 deliveries had no shoulder dystocia. The objective definition described infants with lower 1-minute Apgar scores and increased birth weight. All fetal injuries were in the shoulder dystocia group. Duration of the second stage was significantly associated with a diagnosis of shoulder dystocia. The risk of shoulder dystocia was increased with maternal diabetes, but it was not correlated with birth weight in diabetics.

CONCLUSIONS

The objective definition of shoulder dystocia identified a group of patients with an increased birth weight and risk of fetal injuries. The use of an objective definition will assist the evaluation of prophylactic and treatment proposals for shoulder dystocia.

Chickenpox monoarthritis: demonstration of varicella-zoster virus in joint fluid by polymerase chain reaction

A case of chickenpox monoarthritis is described. The presence of varicella zoster virus (VZV) within the joint was demonstrated by the detection of viral DNA in synovial fluid at a time when peripheral blood cells were negative. This strongly suggests a direct role of VZV in causing monoarthritis complicating chickenpox. The use of the polymerase chain reaction allows more rapid (2 days) confirmation of the diagnosis. Early enough diagnosis would raise the question of using acyclovir to shorten the duration of arthritis.

Validating the Braden Scale for the prediction of pressure ulcer risk in blacks and Latino/Hispanic elders: a pilot study

The purpose of this pilot study was to examine the Braden Scale for Predicting Pressure Sore Risk and determine which variables predict pressure ulcer risk in Black and Latino/Hispanic elders. A prospective clinical design was used to conduct the study. Among 36 patients, 60 years of age or older, 14 (38%) developed a pressure ulcer. A Fisher Exact test (2-tail) revealed that, at a cut-off score of 16, the Braden Scale significantly underpredicted those patients at risk for pressure ulcers (5.13 E-03). Sensitivity was 35 percent and specificity was 100 percent for a Braden Scale score of < or = 16.

Audit and summative assessment: system development and testing

Registrars in general practice have to submit an audit project as one of four parts of summative assessment. A criterion-referenced marking schedule has been developed in the West of Scotland, consisting of five independent criteria all of which have to be judged above minimum competence to pass. A system was developed to test the instrument using a marking exercise which calculated the sensitivity and specificity of the assessment process, for different combinations of assessors. One hundred and two registrar audit projects were then assessed by three independent assessors. Ninety-two (90%) passed and 10 projects (10%) were referred back to the registrar as being below minimum competence. After resubmission six projects (6%) passed, two projects (2%) were still below minimum competence, and two (2%) were not resubmitted. A referral process for assessing the audit projects of general practice registrars has been developed to maximize the opportunity of finding a project below minimum competence.