Depth of Anesthesia and Postoperative Delirium Abbott, Thomas E F; Pearse, Rupert M
JAMA : the journal of the American Medical Association,
02/2019, Letnik:
321, Številka:
5
Journal Article
Despite evidence of high activity, the number of surgical procedures performed in UK hospitals, their cost and subsequent mortality remain unclear.
Time-trend ecological study using hospital episode ...data from England, Scotland, Wales and Northern Ireland. The primary outcome was the number of in-hospital procedures, grouped using three increasingly specific categories of surgery. Secondary outcomes were all-cause mortality, length of hospital stay and healthcare costs according to standard National Health Service tariffs.
Between April 1, 2009 and March 31, 2014, 39 631 801 surgical patient episodes were recorded. There was an annual average of 7 926 360 procedures (inclusive category), 5 104 165 procedures (intermediate category) and 1 526 421 procedures (restrictive category). This equates to 12 537, 8073 and 2414 procedures per 100 000 population per year, respectively. On average there were 85 181 deaths (1.1%) within 30 days of a procedure each year, rising to 178 040 deaths (2.3%) after 90 days. Approximately 62.8% of all procedures were day cases. Median length of stay for in-patient procedures was 1.7 (1.3–2.0) days. The total cost of surgery over the 5 yr period was £54.6 billion ($104.4 billion), representing an average annual cost of £10.9 billion (inclusive), £9.5 billion (intermediate) and £5.6 billion (restrictive). For each category, the number of procedures increased each year, while mortality decreased. One-third of all mortalities in national death registers occurred within 90 days of a procedure (inclusive category).
The number of surgical procedures in the UK varies widely according to definition. The number of procedures is slowly increasing whilst the number of deaths is decreasing.
The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of ...blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS).
Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery.
After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio OR, 1.27 1.07-1.50; P < .01), myocardial infarction (OR, 1.34 1.05-1.70; P = .02), and mortality (OR, 2.65 2.06-3.41; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 1.05-1.39; P = .01) and mortality (OR, 1.81 1.39-2.37; P < .01), but not myocardial infarction (OR, 1.21 0.98-1.49; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 1.01-1.34; P = .04) and myocardial infarction (OR, 1.34 1.09-1.64; P = .01) but, paradoxically, reduced mortality (OR, 0.76 0.58-0.99; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 0.59-0.82; P < .01), myocardial infarction (OR, 0.75 0.58-0.97; P = .03), and mortality (OR, 0.58 0.41-0.81; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 1.15-1.76; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 1.03-1.40; P = .02).
Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.
Autism spectrum disorder (ASD) is characterized by atypical brain network organization, but findings have been inconsistent. While methodological and maturational factors have been considered, the ...network specificity of connectivity abnormalities remains incompletely understood. We investigated intrinsic functional connectivity (iFC) for four "core" functional networks-default-mode (DMN), salience (SN), and left (lECN) and right executive control (rECN). Resting-state functional MRI data from 75 children and adolescents (37 ASD, 38 typically developing TD) were included. Functional connectivity within and between networks was analyzed for regions of interest (ROIs) and whole brain, compared between groups, and correlated with behavioral scores. ROI analyses showed overconnectivity (ASD > TD), especially between DMN and ECN. Whole-brain results were mixed. While predominant overconnectivity was found for DMN (posterior cingulate seed) and rECN (right inferior parietal seed), predominant underconnectivity was found for SN (right anterior insula seed) and lECN (left inferior parietal seed). In the ASD group, reduced SN integrity was associated with sensory and sociocommunicative symptoms. In conclusion, atypical connectivity in ASD is network-specific, ranging from extensive overconnectivity (DMN, rECN) to extensive underconnectivity (SN, lECN). Links between iFC and behavior differed between groups. Core symptomatology in the ASD group was predominantly related to connectivity within the salience network.
Motivation: The sequencing of tumors and their matched normals is frequently used to study the genetic composition of cancer. Despite this fact, there remains a dearth of available software tools ...designed to compare sequences in pairs of samples and identify sites that are likely to be unique to one sample.
Results: In this article, we describe the mathematical basis of our SomaticSniper software for comparing tumor and normal pairs. We estimate its sensitivity and precision, and present several common sources of error resulting in miscalls.
Availability and implementation: Binaries are freely available for download at http://gmt.genome.wustl.edu/somatic-sniper/current/, implemented in C and supported on Linux and Mac OS X.
Contact:
delarson@wustl.edu; lding@wustl.edu
Supplementary information:
Supplementary data are available at Bioinformatics online.
Upper-limb prosthesis users continue to reject devices despite continued research efforts. Today, the passive topology of body-powered prehensors, which physically transmits grasp force and position ...data between user and device, results in improved performance over myoelectric alternatives. However, the loads and postures on the user's body also result in discomfort, fatigue, and worsened grasp force control. Despite the long history and everyday adoption of body-powered prehensors in society, the measurement of how specific body loads and postures affect grasp performance and user experience has yet to be systematically studied. In this work, we present a body-powered prosthesis emulator to independently change required input forces and motions to study the positive and negative effects provided by the inherent haptic feedback. Using a simulated grasping task, we collect functional and qualitative data from 15 participants using a shoulder harness interface. Outcomes show that lowering required input motions and forces independently reduces negative outcomes, with diminishing returns below 1:1 output mappings. Given the tradeoff between force and motion in traditional body-powered transmissions, a transmission ratio of 1:1 balances both requirements. The purpose of this study is to inform future prehensor designs that leverage the transparency of body-power to deliver high functionality while mitigating user discomfort.
Post-operative infections occur frequently following major surgery. The magnitude of the post-operative immune response is associated with an increased risk of post-operative infections, although the ...mechanisms driving post-operative immune-dysfunction and the potential reversibility of this response with immune stimulants are not well understood. This study aims to describe the immediate immune response to major surgery and establish links to both post-operative infection and functional aspects of immune dysregulation. We also investigate the potential of clinically available immune stimulants to reverse features of post-operative immune-dysfunction.
Patients over 45 years old undergoing elective gastro-intestinal surgery with planned post-operative surgical ICU admission were recruited. The expression of selected genes was determined pre-operatively and at 2, 24 and 48 hours post-operatively using qRT-PCR. Circulating levels of Interleukin-10 protein were determined by ELISA. Peri-operative cell surface monocyte HLA-DR (mHLA-DR) expression was determined using flow cytometry. Gene expression and mHLA-DR levels were determined in healthy monocytes cultured in peri-operative serum with and without neutralising antibodies and immune stimulants.
119 patients were recruited; 44 developed a post-operative infection. Interleukin-10 mRNA and protein increased 4-fold post-operatively (P<0.0001), peaking within 2 hours of the procedure. Higher post-operative Interleukin-10 mRNA (P = 0.007) and protein (P = 0.001) levels were associated with an increased risk of infection. Cell surface mHLA-DR expression fell post-operatively (P<0.0001). Reduced production, rather than intracellular sequestration, accounted for the post-operative decline in cell surface mHLA-DR expression. Interleukin-10 antibody prevented the decrease in mHLA-DR expression observed when post-operative serum was added to healthy monocytes. GM-CSF and IFN-γ prevented the decline in mHLA-DR production through distinct pathways.
Monocyte dysfunction and features of immune suppression occur frequently after major surgery. Greater post-operative Interleukin-10 production is associated with later infection. Interleukin-10 is an important mediator of post-operative reductions in mHLA-DR expression, while clinically available immune stimulants can restore mHLA-DR levels.
The attenuation of ocean surface waves during seasonal ice cover is an important control on the evolution of Arctic coastlines. The spatial and temporal variations in this process have been ...challenging to resolve with conventional sampling using sparse arrays of moorings or buoys. We demonstrate a novel method for persistent observation of wave‐ice interactions using distributed acoustic sensing (DAS) along existing seafloor fiber optic telecommunications cables. DAS measurements span a 36‐km cross‐shore cable on the Beaufort Shelf from Oliktok Point, Alaska. DAS optical sensing of fiber strain‐rate provides a proxy for seafloor pressure, which we calibrate with wave buoy measurements during the ice‐free season (August 2022). We apply this calibration during the ice formation season (November 2021) to obtain unprecedented resolution of variable wave attenuation rates in new, partial ice cover. The location and strength of wave attenuation serve as proxies for ice coverage and thickness, especially during rapidly evolving events.
Plain Language Summary
Coasts globally are susceptible to erosion by ocean waves. In the Arctic, sea ice near the coast can serve as protection for much of the year. It is particularly challenging to measure waves and ice in this environment, which is necessary to understand the degree of buffering and project future changes. Typical ways of observing waves (e.g., buoys and underwater moorings) have lower success in coastal ice. We show a new way to observe waves and ice in these coastal regions using cables at the seabed deployed for internet connection. With the use of an instrument called an interrogator on shore, fibers in these cables can act like a series of hundreds of wave buoys. This allows us to see that waves are reduced at a variable rate throughout the ice. There are significant opportunities to learn more about the coastal Arctic using this novel technology and method.
Key Points
Seafloor fiber optic cables can be used to quantify surface waves in seasonally sea ice‐covered oceans
High spatial‐resolution wave observations may be used to study wave attenuation in ice at much finer resolution than previously possible
The rapid evolution of the location and strength of attenuation serves as proxy for the evolution of ice itself
Use of engineered nanoparticles (NPs) in consumer products is resulting in NPs in drinking water sources. Subsequent NP breakthrough into treated drinking water is a potential exposure route and ...human health threat.
In this study we investigated the breakthrough of common NPs--silver (Ag), titanium dioxide (TiO2), and zinc oxide (ZnO)--into finished drinking water following conventional and advanced treatment.
NPs were spiked into five experimental waters: groundwater, surface water, synthetic freshwater, synthetic freshwater containing natural organic matter, and tertiary wastewater effluent. Bench-scale coagulation/flocculation/sedimentation simulated conventional treatment, and microfiltration (MF) and ultrafiltration (UF) simulated advanced treatment. We monitored breakthrough of NPs into treated water by turbidity removal and inductively coupled plasma-mass spectrometry (ICP-MS).
Conventional treatment resulted in 2-20%, 3-8%, and 48-99% of Ag, TiO2, and ZnO NPs, respectively, or their dissolved ions remaining in finished water. Breakthrough following MF was 1-45% for Ag, 0-44% for TiO2, and 36-83% for ZnO. With UF, NP breakthrough was 0-2%, 0-4%, and 2-96% for Ag, TiO2, and ZnO, respectively. Variability was dependent on NP stability, with less breakthrough of aggregated NPs compared with stable NPs and dissolved NP ions.
Although a majority of aggregated or stable NPs were removed by simulated conventional and advanced treatment, NP metals were detectable in finished water. As environmental NP concentrations increase, we need to consider NPs as emerging drinking water contaminants and determine appropriate drinking water treatment processes to fully remove NPs in order to reduce their potential harmful health outcomes.
The effects of ingestion of engineered nanoparticles (NPs), especially via drinking water, are unknown. Using NPs spiked into synthetic water and cell culture media, we investigated cell death, ...oxidative stress, and inflammatory effects of silver (Ag), titanium dioxide (TiO
2
), and zinc oxide (ZnO) NPs on human intestinal Caco-2 and SW480 cells. ZnO NPs were cytotoxic to both cell lines, while Ag and TiO
2
NPs were toxic only at 100 mg/L to Caco-2 and SW480, respectively. ZnO NPs led to significant cell death in synthetic freshwaters with 1 % phosphate-buffered saline in both cell lines, while Ag and TiO
2
NPs in buffered water led to cell death in SW480 cells. NP exposures did not yield significant increased reactive oxygen species generation but all NP exposures led to increased IL-8 cytokine generation in both cell lines. These results indicate cell stress and cell death from NP exposures, with a varied response based on NP composition.
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