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.

POS1147 CHALLENGES IN CONDUCTING PRAGMATIC CARE STRATEGY STUDIES IN OSTEOPOROSIS: PATIENT PERCEPTIONS

Background

Large pragmatic osteoporosis studies to improve outcomes are needed. Direct-to-patient studies have highest generalizability but achieving sufficient sample size is difficult; recruitment challenges represent an important consideration given limited participant eligibility and interest. The Fracture Liaison Service (FLS), a team approach to post-fracture care, is a secondary fracture prevention method that has significantly improved outcomes internationally.

Objectives

Our goal was to evaluate the interest, barriers, and lessons learned in recruiting participants for a future trial assessing remote FLS approaches for post-fracture care.

Methods

We used ICD10 fracture codes to identify patients > 50 years of age with a documented hip/pelvis, spine, humerus, or wrist fracture in the previous 1 year. We excluded patients with i) prescriptions for osteoporosis medications (e.g., bisphosphonates, parathyroid hormone analogs, denosumab, romosozumab, raloxifene) in the prior 1 year; ii) an ICD10 code for end-stage renal disease, non-osteoporotic metabolic bone disease, malignant neoplasm, or motor vehicle accident. In December 2021, research assistants reviewed electronic health records (EHR) of potentially eligible patients for evidence of additional serious illness limiting life expectancy to < 1 year or non-ambulatory status prior to fracture. Research assistants called preliminary eligible patients that met inclusion and exclusion criteria and asked them to complete a survey by phone. Interest in a FLS future clinical trial was evaluated using a Likert scale (1=“Definitely would not volunteer”, to 5=“Definitely would volunteer”). We used descriptive statistics to analyze baseline demographic, clinical characteristics, and interest. This pilot was approved by the UAB Institutional Review Board (IRB-300008310-005).

Results

We identified 1,577 patients > 50 years of age with a fracture. After applying exclusion criteria, we identified 869 preliminary eligible patients. Over 3 weeks, we screened the medical records of a random sample of half of the preliminary eligible patient cohort (n=414), of whom we contacted 271 patients determined potentially eligible, and successfully reached 141 (52% of those contacted) by phone. A total of 108 (77% of those reached) persons, mean (SD) age 69.5 (11.5) years, 40% men, 21% Black or non-white Hispanics completed the survey. Among those contacted, 68 (63%, interest rate) said they would be very or highly interested in participating in a future clinical trial evaluating FLS approaches. Among the 40 (37%) people who said they were not sure, unlikely or very unlikely to volunteer the most common reasons cited were “I don’t want to participate in a study” (33%); “I don’t feel well enough to participate” (10%); “I don’t understand what the study is for” (3%). From this pilot, we calculated a refined eligibility/interest rate of 9.1% among those patients preliminarily identified as eligible using administrative data alone.

Conclusion

Based on our pilot, we estimate that approximately 9% of eligible patients with fractures will be interested in enrolling in a future comparative effectiveness study to prevent recurrent fragility fractures. We identified several potential modifiable barriers to clinical trial recruitment. Patient perceptions collected from this pilot will inform enrollment strategies, which can be incorporated early when planning direct-to-patient pragmatic osteoporosis studies to achieve recruitment goals.

Disclosure of Interests

Lesley Jackson: None declared, Ellen McNeeley: None declared, Norma C. Techarukpong: None declared, Faith Mugeta: None declared, Kiara Aaron: None declared, Amy Mudano: None declared, Jeanne Merchant: None declared, Kellie Warren: None declared, Jeff Foster: None declared, Kenneth Saag Grant/research support from: Amgen, Horizon, LG Chem, Radius, SOBI, Maria Danila Grant/research support from: Pfizer, Horizon

Phase I/II study of gemcitabine and exisulind as second-line therapy in patients with advanced non-small cell lung cancer

BACKGROUND

The study was designed to evaluate the safety and efficacy of exisulind, a selective apoptotic antineoplastic drug, in combination with gemcitabine as second-line therapy in patients with progressing advanced non-small cell lung cancer.

METHODS

Patients whose disease progressed more than 3 months from completion of first-line chemotherapy were eligible for this phase I/II trial. Primary end points were maximally tolerated dose and time to progression. Patients in the phase I portion of the study were treated with gemcitabine (1250 mg/m) in combination with three escalated dose levels of exisulind. Treatment involved six cycles of gemcitabine and exisulind followed by exisulind maintenance. The study was subsequently expanded to phase II.

RESULTS

Thirty-nine patients (15 in phase I and 24 in phase II) were treated. The regimen was well tolerated with grade 3 fatigue and grade 3 constipation being dose-limiting toxicities. The maximally tolerated dose was not reached. Dose level 3 of exisulind (250 mg twice daily) in combination with gemcitabine was used for phase II. The overall response rates were 7% (phase I), 17% (phase II), and 13% (all). Median time to progression and median and 1-year survival, respectively, were 3.7 and 9.7 months and 33% (phase I); 4.3 and 9.4 months and 41% (phase II); and 4.1 and 9.4 months and 39% (all).

CONCLUSION

Although the study met its primary end point of improving time to progression (more than 4.1 months in phase II), we did not observe a clear survival advantage and thus do not plan to further investigate this schedule of gemcitabine and exisulind.

Financial loss and suicidal ideation in a rural community sample

OBJECTIVE

To examine the prevalence and correlates of suicidal ideation in a community-based rural sample.

METHOD

The sample was a random sample of people living in a single county in Iowa. Participants aged 18 or older (n=1617) were asked about suicidal ideation in the past year as well as mood, alcohol use, social support, and stressful life events.

RESULTS

About 8.2% of the sample reported suicidal ideation. Depressive symptoms, problems resulting from alcohol use, infrequent social contact and financial loss characterized the suicidal group.

CONCLUSION

Depressive symptoms were the strongest correlate of suicidal ideation in this rural sample. In the multivariate analysis, financial loss rather than low income remained a significant correlate of suicidal ideation after controlling for depression. This suggests that change in financial status rather than chronic poverty poses a risk for suicidal ideation.

Phase I clinical and pharmacokinetic study of NSC 655649, a rebeccamycin analogue, given in both single-dose and multiple-dose formats

PURPOSE

NSC 655649 was given in both single- and multiple-dose formats, to characterize maximum tolerated dose (MTD), toxicity, and pharmacokinetic profile.

EXPERIMENTAL DESIGN

Patients with advanced malignancies were treated with escalating doses of NSC 655649 in either a single-dose format (step 1) or a multiple-dose format (step 2). In step 1, NSC 655649 was given as a 30-60 min infusion. In step 2, the NSC 655649 dose was divided into three consecutive daily doses. Plasma and urine were sampled to assess the pharmacokinetic and excretory characteristics of NSC 655649. A total of 12 patients were enrolled at the MTD for the purpose of gender equity.

RESULTS

Forty-three patients were treated with NSC 655649 for a total of 108 cycles in step 1, and 26 patients were treated for a total of 41 cycles in step 2. The MTD for both steps 1 and 2 was determined to be 572 mg/m(2). Myelosuppression was the dose-limiting toxicity. Local venous irritation was generally grade 1-2 in severity but could only be adequately prevented by administration of study drug through central i.v. access. One patient with adenocarcinoma of unknown primary experienced a partial response on step 1. Four patients experienced stable disease of >100 days duration.

CONCLUSIONS

NSC 655649 may be safely given at an MTD of 572 mg/m(2) in both single-dose and multiple-dose formats. Optimally, this drug should be administered through central i.v. access.

Metal fume fever: a case report and literature review

Metal fume fever is a relatively uncommon presentation to the emergency department. Resulting from inhalation of metal oxides, it presents as an acute, self-limiting, flu-like symptom complex often misdiagnosed as a viral illness. We report a case of a 26-year-old male presenting with metal fume fever 4 h after oxycutting galvanized steel. The literature is reviewed with respect to pathogenesis, the common presenting symptom complex, investigations and current accepted management of metal fume fever.

Progress towards using recombinant myxoma virus as a vector for fertility control in rabbits

The history of myxoma virus, its use in Australia as a mortality agent and the development of the virus as a vector for controlling fertility in wild rabbit populations in Australia is reviewed. Myxoma virus recombinants have been constructed to express model antigens. Four potential insertion sites in the genome have been identified and two have been used to construct single and double recombinant viruses expressing Escherichia coli enzymes beta-galactosidase and beta-glucuronidase. Another recombinant expressing an influenza virus haemagglutinin gene (A/PR8/34) induced high and sustained antibody responses following intradermal inoculation in rabbits. To demonstrate the potential of introducing a recombinant virus into wild rabbit populations, a virus containing a natural deletion was released at four field locations. Preliminary analysis of the data has shown that the introduced virus spread well on 3 of the 4 locations. The steps being taken to address the ethical and safety implications of the introduction of a recombinant virus into the field are discussed.

Accurate data: the basis of decision

This article provides an overview of the process for obtaining accurate data. Information about organizing data collection, managing data, and communicating findings is given to assist nurses in developing and evaluating data used in practice and clinical nursing research.

Identification of a cis-regulatory element mediating somatostatin inhibition of epidermal growth factor-stimulated gastrin gene transcription

Antral gastrin secretion and gene expression is inhibited by the paracrine release of somatostatin from antral D cells. Transforming growth factor-alpha and epidermal growth factor (EGF) stimulate gastrin reporter gene constructs when transfected into pituitary GH4 cells. Somatostatin inhibits EGF stimulation of gastrin gene expression, which is in part mediated at the level of transcriptional regulation as somatostatin inhibits EGF stimulation of gastrin reporter gene constructs. Somatostatin inhibition was abolished by pertussis toxin, indicating somatostatin inhibits transcription through the inhibitory G protein Gi. Somatostatin inhibition was unaffected by vanadate and okadaic acid, implying this inhibitory pathway is mediated neither through phosphotyrosine phosphatases nor serine/threonine phosphatases, respectively. Gastrin reporter genes containing 82 base pairs of the 5'-flanking DNA were sufficient to confer both EGF responsiveness and inhibition by somatostatin in GH4 cells. However, transcription of a gastrin reporter gene construct containing only the EGF response element (GGGGCGGGGTGGGGGG), located at -68 to -53, was stimulated by EGF but was not inhibited by somatostatin. Thus, somatostatin inhibits EGF-stimulated gastrin gene transcription by a mechanism other than by interfering with cell signals elicited by the EGF receptor. Since the 82 GASCAT is inhibited by somatostatin, this result also implies that sequences adjacent to the EGF response element contain a cis-regulatory element mediating transcriptional inhibition by somatostatin. This cis-element was located using gastrin reporter genes comprising sequential segments of the human gastrin promoter sequence from the transcriptional start site to -82 in the 5'-flanking DNA. Gastrin oligonucleotide constructs lacking the D oligonucleotide (gatcCATATGGCAGGGTA), located at -82 to -69 in the 5'-flanking DNA, were not inhibited by somatostatin, indicating that a somatostatin inhibitory cis-element is located between -82 and -69 in the 5'-flanking DNA of the human gastrin promoter.

Milk composition in the red-necked wallaby, Macropus rufogriseus banksianus (Marsupialia)

1. Milk samples were collected throughout lactation from 10 captive red-necked wallabies. 2. The milk solids content increased throughout lactation and was accompanied by major changes in the relative proportions of protein, lipid and carbohydrate. 3. The carbohydrate fraction consisted of oligosaccharides in the first half of lactation but changed subsequently to monosaccharides. 4. The quantitative and qualitative changes observed were similar to those recorded for other macropodids.

Milk composition in the eastern quoll, Dasyurus viverrinus (Marsupialia:Dasyuridae)

The milk constituents of Dasyurus viverrinus, a carnivorous marsupial, exhibited major quantitative and qualitative changes during the course of lactation. The milk produced in the early stages of lactation was dilute, about 13-16% (w/w) solids before 3 weeks with carbohydrate representing the major fraction. In the latter stages of lactation the milk was concentrated, around 30% solids, and lipid was the predominant fraction. Palmitic acid was the major fatty acid present in early-stage milk but oleic acid became predominant in milk after 10 weeks post-partum. The changes in milk composition in D. viverrinus were similar to those described for the milks of herbivorous marsupials which therefore suggests that this pattern may be uniform throughout the Marsupialia.

Contribution of environmental fibers to respiratory cancer

This article reviews studies of the carcinogenicity of mineral fibers, notably asbestos, and presents seven major recommendations for further research. Mineral fibers represent the greatest cause--after cigarette smoke--of respiratory cancer due to air pollutants. Past asbestos exposure may currently account for 2000 mesothelioma deaths per year and 4000 to 6000 lung cancer deaths per year. All major commercial types of asbestos (crocidolite, amosite, and chrysotile) can cause each of the major asbestos-related respiratory diseases. Lung cancers in asbestos-exposed individuals probably do not have a different distribution of histological types from that of non-asbestos-related lung cancers. Nonoccupational exposures are likely to be associated with malignant disease outcomes qualitatively similar to those associated with occupational exposures. Further investigations of fibers are needed to characterize the relationships among physicochemical properties, patterns of migration and clearance, dose, and adverse health effects. Transmission electron microscopy has been found to be the preferred method of analysis of environmental fibers. Relations among time factors (e.g., age at first exposure), dose, and risk for adverse health effects require analyses of existing and new epidemiologic studies of exposed cohorts. Concomitant exposure, behavioral factors, and host factors affecting susceptibility to asbestos should be identified.

Acute effects of the work environment on pulmonary functions of swine confinement workers

A sample population of owner/operators of swine confinement production facilities (21 subjects in 21 different facilities) were tested by spirometry immediately before and after a 4-hr work period. These confinement workers had statistically significant decrements in flow rates ranging from 3.3% (mean FVC) to 11.9% (mean FEF25-75). The air within the work environment was sampled for particulates and gases during the exposure period. There was suggestive evidence for a dose-response association between environmental exposures to carbon dioxide (CO2) and hydrogen sulfide (H2S). There was also some evidence for an additive relationship between smoking and work environment exposure on decline in lung function. The results of this study indicate that those working in swine confinement buildings experience irritation to the respiratory tract which is manifest by decreased flow rates. These findings suggest this exposure represents an emerging occupational health hazard. Further studies are warranted to assess the potential for chronic or irreversible damage to the respiratory tract.

Changes in milk composition during lactation in the tammar wallaby (Macropus eugenii)

Milk samples were obtained at regular intervals throughout lactation from tammar wallabies (M. eugenii). Total solids represented only 12% (w/w) of the milk at the commencement of lactation and gradually increased to about 40% at 36 weeks. Milk proteins represented 4% (w/w) of whole milk during the first 18 weeks of lactation, followed by a rapid increase to around 13% (w/w) at 36 weeks. Sodium and potassium concentrations were high in early samples of milk but declined to minimal values at 30 weeks. The milk was isosmotic to the plasma at all stages.

Changes in Milk Composition During Lactation in the Tammar Wallaby (Macropus Eugenii)

Milk samples were obtained at regular intervals throughout lactation from tammar wallabies (M. eugenii). Total solids represented only 12 % (w/w) of the milk at the commencement of lactation and gradually increased to about 40% at 36 weeks. Milk proteins represented 4% (w/w) of whole milk during the first 18 weeks of lactation, followed by a rapid increase to around 13 % (w/w) at 36 weeks. Sodium and potassium concentrations were high in early samples of milk but declined to minimal values at 30 weeks. The milk was isosmotic to the plasma at all stages.

Occupational safety and health implications of increased coal utilization

An area of major concern in considering increased coal production and utilization is the health and safety of increased numbers of workers who mine, process, or utilize coal. Hazards related to mining activities in the past have been especially serious, resulting in many mine related accidental deaths, disabling injuries, and disability and death from chronic lung disease. Underground coal mines are clearly less safe than surface mines. Over one-third of currently employed underground miners experience chronic lung disease. Other stresses include noise and extremes of heat and cold. Newly emphasized technologies of the use of diesel powered mining equipment and the use of longwall mining techniques may be associated with serious health effects. Workers at coal-fired power plants are also potentially at risk of occupational diseases. Occupational safety and health aspects of coal mining are understood well enough today to justify implementing necessary and technically feasible and available control measures to minimize potential problems associated with increased coal production and use in the future. Increased emphasis on safety and health training for inexperienced coal miners expected to enter the work force is clearly needed. The recently enacted Federal Mine Safety and Health Act of 1977 will provide impetus for increased control over hazards in coal mining.