Use of the surgical Apgar score to guide postoperative care

Introduction

The surgical Apgar score (SAS) can predict 30-day major complications or death after surgery. Studies have validated the score in different patient populations and suggest it should be used to objectively guide postoperative care. We aimed to see whether using the SAS in a decisive approach in a future randomised controlled trial (RCT) would be likely to demonstrate an effect on postoperative care and clinical outcome.

Methods

A total of 143 adults undergoing general/vascular surgery in 9 National Health Service hospitals were recruited to a pilot single blinded RCT and the data for 139 of these were analysed. Participants were randomised to a control group with standard postoperative care or to an intervention group with care influenced (but not mandated) by the SAS (decisive approach). The notional primary outcome was 30-day major complications or death.

Results

Incidence of major complications was similar in both groups (control: 20/69 [29%], intervention: 23/70 [33%], p=0.622). Immediate admissions to the critical care unit was higher in the intervention group, especially in the SAS 0–4 subgroup (4/6 vs 2/7) although this was not statistically significant (p=0.310). Validity was also confirmed in area under the curve (AUC) analysis (AUC: 0.77).

Conclusions

This pilot study found that a future RCT to investigate the effect of using the SAS in a decisive approach may demonstrate a difference in postoperative care. However, significant changes to the design are needed if differences in clinical outcome are to be achieved reliably. These would include a wider array of postoperative interventions implemented using a quality improvement approach in a stepped wedge cluster design with blinded collection of outcome data.     

Construction of an ultrasound biopsy phantom

The technique for construction of an agar-based ultrasound biopsy phantom is described. Features include tissue equivalent reflectivity, long life and non-shadowing targets. The phantom is useful for learning the necesary co-ordination between needle and probe for ultrasound needle guidance. This skill should initially be practised in vitro, on a device such as this.     

Pelvic ultrasound measurements in normal girls

Pelvic ultrasound scans were carried out in 153 normal girls aged between 3 days and 14.9 years, in order to obtain reference data for ovarian volume, uterine length and uterine configuration. The right ovary was significantly larger than the left (by about 17%). Ovarian volume increased exponentially with age, over this age range. No relationship with pubertal stage (independent of age) could be demonstrated. Uterine length decreased from birth to 4 years, before steadily increasing. The fundalcervical ratio (FCR) decreased initially then increased to lie above 1.0 by 15 years of age. A midline endometrial echo was seen in half of the subjects aged less than 6 months, but otherwise it was not seen before 11.8 years of age or at Tanner stage B2. Smoothed reference centile curves for uterine length, right and left ovarian volume were produced, allowing z scores (or SD scores) to be calculated for each measurement.     

Participation of immune complexes in adenovirus infection

To determine the participation of immune complexes during adenovirus infection, we evaluated serum and necropsy specimens of patients with confirmed adenovirus infection of the lower respiratory tract. In lung and kidney from seven dead patients, immunofluorescence revealed the presence of hexon, immunoglobulins and complement. These patients had clinical manifestations of kidney dysfunction. In dead patients (3/3 in whom serum was available) neither anti-adenovirus antibodies nor adenovirus-specific immune complexes could be found in the final stage of the infection. However, two of these patients had anti-adenovirus antibodies and immune complexes in samples obtained early in the infection. Most patients (16/19) who survived the infection had circulating anti-adenovirus antibodies. Half also had immune complexes specific for adenovirus in some moment of the illness. This suggests that immune complexes arise during respiratory infection by adenovirus, probably contributing to its clinical picture.     

Annotation New perspectives on inflammation in atopic dermatitis

Recent information implicates the stimulation of T cells by Staphylococcus aureus antigens and exotoxins as a likely factor in provoking the inflammatory response in atopic dermatitis. S. aureus secrets exotoxins called superantigens, which stimulate a large proportion of T cells. In addition, protein A, a component of the cell wall of S. aureus , is a potent B cell mitogen. This understanding provides a rationale for attempting to reduce the staphylococcal skin colonization of patients with severe atopic dermatitis and correlates with the clinical observation in a number of situations of marked improvement in atopic dermatitis following antibiotic treatment.     

Recall phenomenon with the unusual presence of eccrine squamous syringometaplasia

Summary The recall phenomenon is an inflammatory reaction limited to a previously X-irradiated field when the patient is treated months or years later with certain drugs. Only a few cases have been reported in dermatological journals. We report a patient with lymphoma who was treated with low-dose abdominal irradiation and high-dose irradiation to the knees and who, 2 months laler, when chemotherapy was started, developed a pronounced inflammatory reaction limited to the areas treated with high-dose irradiation. A skin biopsy specimen showed features of radiation damage, marked epidermal changes and extensive eccrine squamous syringometaplasia. This case of the recall phenomenon is of interest because we have found that there is apparently a radiation dose threshold for this event, and because this is the first report of its association with eccrine squamous syringometaplasia.     

练习与有关知识对视错觉的影响(英文)

目的缪勒-莱尔错觉(Müller-Lyer illusion)是一种视错觉,即一条水平线段两端加上向外的箭头(fins-out),那么它看起来要比带有向内箭头(fins-in)的线段长些。本研究的目的是比较练习和有关知识对缪勒-莱尔错觉受试者感知精确度的不同影响。方法受试者为事先对缪勒-莱尔错觉不了解的大学生(共108人,其中对照组20人),他们被要求在缪勒-莱尔模型中调整一条可移动线段的长度,使其与另一条线段的长度相同。受试者要接受缪勒-莱尔递增测试和递减测试。测试共分三个阶段,每阶段20次(10次递增测试,10次递减测试)。在第三阶段测试开始前,实验组学习了缪勒-莱尔错觉的有关知识。结果在实验组中,第三阶段测试的偏差明显小于前两阶段。结论了解视错觉机制的有关知识对于帮助人们纠正视错觉很重要。