A noninvasive postoperative clinical score to identify patients at risk for postoperative pulmonary complications: the Air-Test Score.

BACKGROUND: Postoperative pulmonary complications (PPCs) negatively affect morbidity, healthcare costs and postsurgical survival. Preoperative and intraoperative peripheral oxyhemoglobin saturation (SpO2) levels are independent risk factors for postoperative pulmonary complications (PPCs). The air-test assesses the value of SpO2 while breathing room-air. We aimed at building a clinical score that includes the air-test for predicting the risk for PPCs. METHODS: This is a development and validation study in patients -randomly divided into two cohorts- from a large randomized clinical trial (iPROVE) that enrolled 964 intermediate-to-high risk patients scheduled for abdominal surgery. Arterial oxygenation was assessed on room-air in the preoperative period (preoperative air-test) and 3h after admission to the postoperative care unit (postoperative air-test). The air-test was defined as positive or negative if SpO2 was ≤96% or >96%, respectively. Positive air-tests were stratified into weak (93-96%) or strong (<93%). The primary outcome was a composite of moderate-to-severe PPCs during the first seven postoperative days. RESULTS: A total of 902 patients were included in the final analysis (542 in the development cohort and 360 in the validation cohort). Regression analysis identified five independent risk factors for PPC: age, type of surgery, pre- and postoperative air-test, and atelectasis. The area under the receiver operating characteristic curve (AUC) was 0.79 (95% CI: 0.75-0.82) when including these five independent predictors. We built a simplified score termed "air-test score" by using only the pre- and postoperative SpO2, resulting in an AUC of 0.72 (95% CI: 0.67-0.76) for the derivation and 0.72 (95% CI: 0.66-0.78) for the validation cohort, respectively. The air-test score stratified patients into four levels of risk, with PPCs ranging from <15% to >75%. CONCLUSIONS: The simple, non-invasive and inexpensive bedside air-test score, evaluating pre- and postoperatively SpO2 measured on room-air, helps to predict the risk for PPCs.

Individualised perioperative open-lung approach versus standard protective ventilation in abdominal surgery (iPROVE): a randomised controlled trial.

BACKGROUND: The effects of individualised perioperative lung-protective ventilation (based on the open-lung approach [OLA]) on postoperative complications is unknown. We aimed to investigate the effects of intraoperative and postoperative ventilatory management in patients scheduled for abdominal surgery, compared with standard protective ventilation. METHODS: We did this prospective, multicentre, randomised controlled trial in 21 teaching hospitals in Spain. We enrolled patients who were aged 18 years or older, were scheduled to have abdominal surgery with an expected time of longer than 2 h, had intermediate-to-high-risk of developing postoperative pulmonary complications, and who had a body-mass index less than 35 kg/m2. Patients were randomly assigned (1:1:1:1) online to receive one of four lung-protective ventilation strategies using low tidal volume plus positive end-expiratory pressure (PEEP): open-lung approach (OLA)-iCPAP (individualised intraoperative ventilation [individualised PEEP after a lung recruitment manoeuvre] plus individualised postoperative continuous positive airway pressure [CPAP]), OLA-CPAP (intraoperative individualised ventilation plus postoperative CPAP), STD-CPAP (standard intraoperative ventilation plus postoperative CPAP), or STD-O2 (standard intraoperative ventilation plus standard postoperative oxygen therapy). Patients were masked to treatment allocation. Investigators were not masked in the operating and postoperative rooms; after 24 h, data were given to a second investigator who was masked to allocations. The primary outcome was a composite of pulmonary and systemic complications during the first 7 postoperative days. We did the primary analysis using the modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02158923. FINDINGS: Between Jan 2, 2015, and May 18, 2016, we enrolled 1012 eligible patients. Data were available for 967 patients, whom we included in the final analysis. Risk of pulmonary and systemic complications did not differ for patients in OLA-iCPAP (110 [46%] of 241, relative risk 0·89 [95% CI 0·74-1·07; p=0·25]), OLA-CPAP (111 [47%] of 238, 0·91 [0·76-1·09; p=0·35]), or STD-CPAP groups (118 [48%] of 244, 0·95 [0·80-1·14; p=0·65]) when compared with patients in the STD-O2 group (125 [51%] of 244). Intraoperatively, PEEP was increased in 69 (14%) of patients in the standard perioperative ventilation groups because of hypoxaemia, and no patients from either of the OLA groups required rescue manoeuvres. INTERPRETATION: In patients who have major abdominal surgery, the different perioperative open lung approaches tested in this study did not reduce the risk of postoperative complications when compared with standard lung-protective mechanical ventilation. FUNDING: Instituto de Salud Carlos III of the Spanish Ministry of Economy and Competitiveness, and Grants Programme of the European Society of Anaesthesiology.

Glycerol as a source of designer solvents: physicochemical properties of low melting mixtures containing glycerol ethers and ammonium salts.

In this work we report the preparation of mixtures of several alkyl glyceryl ethers, as hydrogen bond donor compounds, with two ammonium salts, choline chloride and N,N,N-triethyl-2,3-dihydroxypropan-1-aminium chloride. The stability of the mixtures at different molar ratios and temperatures has been evaluated in order to determine the formation of low melting mixtures. Liquid and stable mixtures have been characterized and their physico-chemical properties such as density, viscosity, refractive index, conductivity and surface tension have been measured in the temperature range of 293.15 K to 343.15 K. Comparison of the mixtures prepared herein with the ones containing glycerol and choline chloride evidences the possibility of tuning the physico-chemical properties by changing the substitution pattern in the hydrogen bond donor compound or in the ammonium salt, thus broadening the scope of application of these mixtures.

Influence of Polarity and Activation Energy in Microwave-Assisted Organic Synthesis (MAOS).

The aim of this work was to determine the parameters that have decisive roles in microwave-assisted reactions and to develop a model, using computational chemistry, to predict a priori the type of reactions that can be improved under microwaves. For this purpose, a computational study was carried out on a variety of reactions, which have been reported to be improved under microwave irradiation. This comprises six types of reactions. The outcomes obtained in this study indicate that the most influential parameters are activation energy, enthalpy, and the polarity of all the species that participate. In addition to this, in most cases, slower reacting systems observe a much greater improvement under microwave irradiation. Furthermore, for these reactions, the presence of a polar component in the reaction (solvent, reagent, susceptor, etc.) is necessary for strong coupling with the electromagnetic radiation. We also quantified that an activation energy of 20-30 kcal mol(-1) and a polarity (µ) between 7-20 D of the species involved in the process is required to obtain significant improvements under microwave irradiation.

Polytopic bis(oxazoline)-based ligands for recoverable catalytic systems applied to the enantioselective Henry reaction.

Several kinds of polytopic chiral ligands (including ditopic, tritopic and tetratopic), based on the bis(oxazoline) and azabis(oxazoline) motifs, have been tested in the preparation of recoverable catalytic systems for the Henry reaction. The results obtained with the different ligands are, in general, good, but they point to the existence of a delicate balance between the coordinating ability of the ligand, the catalytic activity and the recovery of the catalyst by formation of the coordination polymer, related to the easiness to form oligomeric species in solution.

[Single port laparoscopic colostomy using the glove technique]. / Colostomía laparoscópica por puerto único con técnica de guante.

The single port surgery with glove technique is a novel process, suitable to the present day economic and technological moment. Colostomies are surgical interventions suitable to its application. We describe the surgical method and outcome of patients who underwent colostomy by single port glove technique within the years 2011 and 2012, in two hospitals in Asturias, Spain. We carried out six sigmoid colostomies. Four patients had tumoral pathology, another a perineal necrotizing fasciitis, and the sixth, a patient with Crohn's disease and complex perianal fistulas. The average age of the patients, four men and two women, was 54 years (range 42-67 years). The average intervention time was 42 minutes (range 30-65 minutes). There were no complications during the surgery or in the postoperative period. In our facilities material expenditure was reduced to half as regards other conventional single port devices. The glove technique represents the most economic and least invasive approach for the surgical procedure of stomas, in our experience considered a simple, safe and easily reproducible technique.

Colostomía laparoscópica por puerto único con técnica de guante / Single port laparoscopic colostomy using the glove technique

La cirugía por puerto único con técnica de guante (glove port) es un abordaje adecuado al momento económico y tecnológico que vivimos. Entre las intervenciones susceptibles de su aplicación está la realización de colostomías. Describimos la técnica quirúrgica y resultados de los pacientes a los que se realizó colostomía por puerto único con técnica de guante, a lo largo de los años 2011 y 2012, en dos hospitales de Asturias, España. Realizamos seis colostomías sigmoideas. Cuatro pacientes presentaban enfermedad tumoral, otro caso fue por una fascitis necrosante perineal, y el sexto un paciente con enfermedad de Crohn y fístulas perianales complejas. La edad media de los pacientes, cuatro hombres y dos mujeres, fue de 54 años (rango 42-67 años). El tiempo medio de intervención fue de 42 minutos (rango 30-65 minutos). No hubo complicaciones durante la cirugía ni en el postoperatorio. En nuestro medio, el gasto en material se redujo a la mitad con respecto a otros dispositivos convencionales de puerto único. La técnica de guante representa el abordaje por puerto único más económico y mínimamente invasivo para la realización de estomas, siendo en nuestra experiencia una técnica sencilla, segura y fácilmente reproducible.

The single port surgery with glove technique is a novel process, suitable to the present day economic and technological moment .Colostomies are surgical interventions suitable to its application. We describe the surgical method and outcome of patients who underwent colostomy by single port glove technique within the years 2011 and 2012, in two hospitals in Asturias, Spain. We carried out six sigmoid colostomies. Four patients had tumoral pathology, another a perineal necrotizing fasciitis, and the sixth, a patient with Crohn's disease and complex peri-anal fistulas. The average age of the patients, four men and two women, was 54 years (range 42-67 years). The average intervention time was 42 minutes (range 30-65 minutes). There were no complications during the surgery or in the postoperative period. In our facilities material expenditure was reduced to half as regards other conventional single port devices. The glove technique represents the most economic and least invasive approach for the surgical procedure of stomas, in our experience considered a simple, safe and easily reproducible technique.

Predicting the enantioselectivity of the copper-catalysed cyclopropanation of alkenes by using quantitative quadrant-diagram representations of the catalysts.

We present a new methodology to predict the enantioselectivity of asymmetric catalysis based on quantitative quadrant-diagram representations of the catalysts and quantitative structure-selectivity relationship (QSSR) modelling. To account for quadrant occupation, we used two types of molecular steric descriptors: the Taft-Charton steric parameter (ν(Charton)) and the distance-weighted volume (V(W) ). By assigning the value of the steric descriptors to each of the positions of the quadrant diagram, we generated the independent variables to build the multidimensional QSSR models. The methodology was applied to predict the enantioselectivity in the cyclopropanation of styrene catalysed by copper complexes. The dataset comprised 30 chiral ligands belonging to four different oxazoline-based ligand families: bis- (Box), azabis- (AzaBox), quinolinyl- (Quinox) and pyridyl-oxazoline (Pyox). In the first-order approximation, we generated QSSR models with good predictive ability (r(2) =0.89 and q(2) =0.88). The derived stereochemical model indicated that placing very large groups at two diagonal quadrants and leaving free the other two might be enough to obtain an enantioselective catalyst. Fitting the data to a higher-order polynomial, which included crossterms between the descriptors of the quadrants, resulted in an improvement of the predicting ability of the QSSR model (r(2) =0.96 and q(2) =0.93). This suggests that the relationship between the steric hindrance and the enantioselectivity is non-linear, and that bulky substituents in diagonal quadrants operate synergistically. We believe that the quantitative quadrant-diagram-based QSSR modelling is a further conceptual tool that can be used to predict the selectivity of chiral catalysts and other aspects of catalytic performance.

Bis(oxazoline)-based coordination polymers: a recoverable system for enantioselective Henry reactions.

An efficient release-capture strategy for the recovery and reuse of enantioselective catalysts in the Henry reaction is described. This strategy is based on the precipitation of an insoluble coordination polymer at the end of each reaction, allowing easy separation from products. The coordination polymer is formed through aggregation of Cu(II) ions with ditopic bisoxazoline-based chiral ligands. Up to 11 catalytic cycles have been conducted keeping good yields and enantioselectivities.

Multiphase enantioselective Kharasch-Sosnovsky allylic oxidation based on neoteric solvents and copper complexes of ditopic ligands.

Recoverable multiphase enantioselective catalytic systems for the Kharasch-Sosnovsky oxidation of cycloalkenes with tert-butyl peroxybenzoate are described, based on the use of [BMIM][PF(6)] and a new solvent derived from glycerol as the catalyst reservoir phases, and chiral copper complexes with different ligands from the bis(oxazoline) family. The best results are obtained with the glycerol-derived solvent and a recently described azabisoxazoline-based ditopic ligand, allowing up to four uses of the catalytic phase with good results.

Accurate calculation of chemical shifts in highly dynamic H2@C60 through an integrated quantum mechanics/molecular dynamics scheme.

A new protocol combining classical MD simulations and DFT calculations is presented to accurately estimate the (1)H NMR chemical shifts of highly mobile guest-host systems and their thermal dependence. This strategy has been successfully applied for the hydrogen molecule trapped into C(60) fullerene, an unresolved and challenging prototypical case for which experimental values have never been reproduced. The dependence of the final values on the theoretical method and their implications to avoid over interpretation of the obtained results are carefully described.

Can enantioselectivity be computed in enthalpic barrierless reactions? The case of Cu(I)-catalyzed cyclopropanation of alkenes.

An extensive computational study has been carried out on different catalytic systems for cyclopropanation reactions based on copper. Most DFT schemes used present drawbacks that preclude the calculation of accurate absolute kinetic properties (energy barriers) of such systems, excepting the M05 and M06 suites of density functionals. On the other hand, there is a wide range of DFT methods capable of reproducing relative energy values, which can be easily translated into selectivities. Most of the theoretical levels used tend to overestimate activation barriers, allowing the location of the transition state (TS) on the potential-energy surface (PES) of the most reactive systems, which are probably artifacts of the method. However, after a thorough analysis of the calculated PES, and the origin of the energy differences obtained for the different alkene approaches in chiral systems, it is found that energy differences are almost constant over a wide range of geometries covering the reaction channel zone in which the true TS on the Gibbs free-energy surface (GFES) lies. Therefore, many computational schemes can still be used confidently to explain and predict enantioselectivities in these systems.

Applied biotransformations in green solvents.

The definite interest in implementing sustainable industrial technologies has impelled the use of biocatalysts (enzymes or cells), leading to high chemo-, regio- and stereoselectivities under mild conditions. As usual substrates are not soluble in water, the employ of organic solvents is mandatory. We will focus on different attempts to combine the valuable properties of green solvents with the advantages of using biocatalysts for developing cleaner synthetic processes.

Stereoselectivity induced by support confinement effects. Aza-pyridinoxazolines: A new family of C(1)-symmetric ligands for copper-catalyzed enantioselective cyclopropanation reactions.

Aza-pyridinoxazoline ligands, a new class of C(1)-symmetric ligands, are described and tested in the heterogeneous enantioselective catalysis of a cyclopropanation reaction, with the aim of improving surface confinement effects by the clay support on the reaction stereoselectivity. In the case of trans/cis diastereoselectivity, these surface effects lead to a systematic reversal of selectivity, cis-cyclopropanes being favored. Regarding the enantioselectivities, support confinement has a positive effect in the case of major cis-cyclopropane products, leading to moderate enantioselectivity values (60% ee). A theoretical (DFT) mechanistic study is carried out to explain the origin of the enantioselectivity in the homogeneous phase at a molecular level, and to get insights on the geometries of the key intermediates and transition structures.

Enantioselective catalysis with chiral complexes immobilized on nanostructured supports.

In this tutorial review, we discuss how recycling and stability advantages alone are frequently not sufficient to justify the effort necessary to immobilize chiral complexes unless additional advantages are found. Nanostructured solids with well-controlled surfaces and pores may act as nanoreactors, hindering or even blocking some of the reaction channels, and hence modifying the stereochemical result of the reaction. The use of support effects to improve or change the enantioselectivity is emerging as an interesting field, whose understanding might allow, in the near future, the design of chiral ligands better adapted to this strategy.

Linking homogeneous and heterogeneous enantioselective catalysis through a self-assembled coordination polymer.

Combining the advantages of homogeneous and heterogeneous enantioselective catalysis is possible through self-supported copper coordination polymers, based on a new kind of ditopic chiral ligand bearing two azabis(oxazoline) moieties. When the coordination polymer is used to catalyze a cyclopropanation reaction, it becomes soluble in reaction conditions but precipitates after reaction completion, allowing easy recovery and efficient reuse in the same reaction up to 14 times.

An efficient and straightforward access to sulfur substituted [2.2]paracyclophanes: application to stereoselective sulfenate salt alkylation.

A straightforward and high-yielding access to various [2.2]paracyclophanes possessing a sulfur-based functional group is reported, the key step being a SEAr reaction mediated by a sulfonium salt. The versatility of the methodology was exemplified by an original application in sulfenate salt chemistry, from which a remarkable chirality transfer was observed.

C1-symmetric versus C2-symmetric ligands in enantioselective copper-bis(oxazoline)-catalyzed cyclopropanation reactions.

A thorough experimental and theoretical study of the enantioselective cyclopropanation of alkenes catalyzed by chiral bis(oxazoline)- and azabis(oxazoline)-copper complexes, which comprise a new family of ligands that lack C2 symmetry, has been conducted. Surprisingly high enantioselectivities were observed with some of these ligands, which were rationalized on the basis of molecular modeling studies. The course of the asymmetric induction in connection with ligand symmetry and the implications for supported enantioselective catalysts are discussed.

Diagnostic yield and impact of capsule endoscopy on management of patients with gastrointestinal bleeding of obscure origin.

This study assessed diagnostic yield and impact of capsule endoscopy on patient management. Seventy-five patients with obscure gastrointestinal bleeding were included. Clinical and followup information was collected by review of patient records and with personal contact with the referring physicians. All previous clinical information and interventions after capsule endoscopy and clinical outcome were noted. The indication was obscure-overt gastrointestinal bleeding in 36 patients (48%) and obscure-occult gastrointestinal bleeding in 39 patients (52%). Overall diagnostic yield was 66.7% considering relevant lesions. Followup was available in 31 patients. Capsule endoscopy changed clinical management in 61.4%. Multivariate analysis showed that patients with another potential source of bleeding and patients whose onset was hematochezia were not good candidates for capsule endoscopy. Capsule endoscopy has a high diagnostic yield and a positive influence on clinical management in a high proportion of patients with obscure gastrointestinal bleeding.