Frailty in Older Patients Undergoing Emergency Laparotomy: Results From the UK Observational Emergency Laparotomy and Frailty (ELF) Study.

OBJECTIVE: This study aimed to document the prevalence of frailty in older adults undergoing emergency laparotomy and to explore relationships between frailty and postoperative morbidity and mortality. SUMMARY BACKGROUND DATA: The majority of adults undergoing emergency laparotomy are older adults (≥65 y) that carry the highest mortality. Improved understanding is urgently needed to allow development of targeted interventions. METHODS: An observational multicenter (n=49) UK study was performed (March-June 2017). All older adults undergoing emergency laparotomy were included. Preoperative frailty score was calculated using the progressive Clinical Frailty Score (CFS): 1 (very fit) to 7 (severely frail). Primary outcome measures were the prevalence of frailty (CFS 5-7) and its association to mortality at 90 days postoperative. Secondary outcomes included 30-day mortality and morbidity, length of critical care, and overall hospital stay. RESULTS: A total of 937 older adults underwent emergency laparotomy: frailty was present in 20%. Ninety-day mortality was 19.5%. After age and sex adjustment, the risk of 90-day mortality was directly associated with frailty: CFS 5 adjusted odds ratio (aOR) 3.18 [95% confidence interval (CI), 1.24-8.14] and CFS 6/7 aOR 6·10 (95% CI, 2.26-16.45) compared with CFS 1. Similar associations were found for 30-day mortality. Increasing frailty was also associated with increased risk of complications, length of Intensive Care Unit, and overall hospital stay. CONCLUSIONS: A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.

Establishing spectrochemical changes in the natural history of oesophageal adenocarcinoma from tissue Raman mapping analysis.

Raman spectroscopy is a fast and sensitive technique able to identify molecular changes in biological specimens. Herein, we report on three cases where Raman microspectroscopy was used to distinguish normal vs. oesophageal adenocarcinoma (OAC) (case 1) and Barrett's oesophagus vs. OAC (cases 2 and 3) in a non-destructive and highly accurate fashion. Normal and OAC tissues were discriminated using principal component analysis plus linear discriminant analysis (PCA-LDA) with 97% accuracy (94% sensitivity and 100% specificity) (case 1); Barrett's oesophagus vs. OAC tissues were discriminated with accuracies ranging from 98 to 100% (97-100% sensitivity and 100% specificity). Spectral markers responsible for class differentiation were obtained through the difference-between-mean spectrum for each group and the PCA loadings, where C-O-C skeletal mode in ß-glucose (900 cm-1), lipids (967 cm-1), phosphodioxy (1296 cm-1), deoxyribose (1456 cm-1) and collagen (1445, 1665 cm-1) were associated with normal and OAC tissue differences. Phenylalanine (1003 cm-1), proline/collagen (1066, 1445 cm-1), phospholipids (1130 cm-1), CH2 angular deformation (1295 cm-1), disaccharides (1462 cm-1) and proteins (amide I, 1672/5 cm-1) were associated with Barrett's oesophagus and OAC tissue differences. These findings show the potential of using Raman microspectroscopy imaging for fast and accurate diagnoses of oesophageal pathologies and establishing subtle molecular changes predisposing to adenocarcinoma in a clinical setting. Graphical abstract Graphical abstract demonstrating how oesophageal tissue is processed through Raman mapping analysis in order to detect spectral differences between stages of oesophageal transformation to adenocarcinoma.

Attenuated total reflection Fourier-transform infrared spectral discrimination in human bodily fluids of oesophageal transformation to adenocarcinoma.

Diagnostic tools for the detection of early-stage oesophageal adenocarcinoma (OAC) are urgently needed. Our aim was to develop an accurate and inexpensive method using biofluids (plasma, serum, saliva or urine) for detecting oesophageal stages through to OAC (squamous; inflammatory; Barrett's; low-grade dysplasia; high-grade dysplasia; OAC) using attenuated total reflection Fourier-transform infrared (ATR-FTIR) spectroscopy. ATR-FTIR spectroscopy coupled with variable selection methods, with successive projections or genetic algorithms (GA) combined with quadratic discriminant analysis (QDA) were employed to identify spectral biomarkers in biofluids for accurate diagnosis in a hospital setting of different stages through to OAC. Quality metrics (Accuracy, Sensitivity, Specificity and F-score) and biomarkers of disease were computed for each model. For plasma, GA-QDA models using 15 wavenumbers achieved 100% classification for four classes. For saliva, PCA-QDA models achieved 100% for the inflammatory stage and high-quality metrics for other classes. For serum, GA-QDA models achieved 100% performance for the OAC stage using 13 wavenumbers. For urine, PCA-QDA models achieved 100% performance for all classes. Selected wavenumbers using a Student's t-test (95% confidence interval) identified a differentiation of the stages on each biofluid: plasma (929 cm-1 to 1431 cm-1, associated with DNA/RNA and proteins); saliva (1000 cm-1 to 1150 cm-1, associated with DNA/RNA region); serum (1435 cm-1 to 1573 cm-1, associated with methyl groups of proteins and Amide II absorption); and, urine (1681 cm-1 to 1777 cm-1, associated with a high frequency vibration of an antiparallel ß-sheet of Amide I and stretching vibration of lipids). Our methods have demonstrated excellent efficacy for a rapid, cost-effective method of diagnosis for specific stages to OAC. These findings suggest a potential diagnostic tool for oesophageal cancer and could be translated into clinical practice.

Attenuated Total Reflection Fourier-Transform Infrared Spectral Discrimination in Human Tissue of Oesophageal Transformation to Adenocarcinoma.

This study presents ATR-FTIR (attenuated total reflectance Fourier-transform infrared) spectral analysis of ex vivo oesophageal tissue including all classifications to oesophageal adenocarcinoma (OAC). The article adds further validation to previous human tissue studies identifying the potential for ATR-FTIR spectroscopy in differentiating among all classes of oesophageal transformation to OAC. Tissue spectral analysis used principal component analysis quadratic discriminant analysis (PCA-QDA), successive projection algorithm quadratic discriminant analysis (SPA-QDA), and genetic algorithm quadratic discriminant analysis (GA-QDA) algorithms for variable selection and classification. The variables selected by SPA-QDA and GA-QDA discriminated tissue samples from Barrett's oesophagus (BO) to OAC with 100% accuracy on the basis of unique spectral "fingerprints" of their biochemical composition. Accuracy test results including sensitivity and specificity were determined. The best results were obtained with PCA-QDA, where tissues ranging from normal to OAC were correctly classified with 90.9% overall accuracy (71.4-100% sensitivity and 89.5-100% specificity), including the discrimination between normal and inflammatory tissue, which failed in SPA-QDA and GA-QDA. All the models revealed excellent results for distinguishing among BO, low-grade dysplasia (LGD), high-grade dysplasia (HGD), and OAC tissues (100% sensitivities and specificities). This study highlights the need for further work identifying potential biochemical markers using ATR-FTIR in tissue that could be utilised as an adjunct to histopathological diagnosis for early detection of neoplastic changes in susceptible epithelium.

Laparoscopic cholecystectomy for mild acute gallstone pancreatitis-indication itself is a good predictor of (minimal) intraoperative difficulty-a retrospective cohort study.

Objectives: The literature predicting difficulties during Laparoscopic Cholecystectomy (LC) for Acute Gallstone Pancreatitis (AGP) is mainly focused on the timing of operation. In our experience, LC for AGP is rarely difficult irrespective of the timing of operation. The aim of this study was to assess intra- operative difficulties in mild AGP patients to verify this observation. Material and Methods: A retrospective analysis of all consecutive patients who underwent LC for mild AGP between 2014 and 2018 in a single centre was performed. Patients with known alcohol abuse, post-endoscopic retrograde cholangiopancreaticography (ERCP) induced pancreatitis, and those with chronic pancreatitis were excluded. Univariate weighted analysis was performed with 11 factors, with a linear threshold boundary defined as the mean distance between the four degrees of difficulty (DoD 1-4). Results: Ninety-six patients (Male= 33, median age= 56; Female= 63, median age= 52) were analysed. Majority of the patients were an ASA of two (n= 50; 52%) with a median BMI of 28 (range 18-50). Five procedures were technically difficult (DoD≥ 3) and only one procedure was converted to open operation. Univariate analysis showed that duration of pancreatitis >6 days (p= 0.002) and evidence of acute cholecystitis (p <0.05) are associated with a difficult LC (DoD≥ 3). The rest of the factors did not influence DoD. Conclusion: Based on this result, we suggest that LC for mild AGP is rarely difficult, and this finding can be used in practice for selecting these patients for training lists.

Towards screening Barrett's oesophagus: current guidelines, imaging modalities and future developments.

Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma (OAC). Although guidelines on the screening and surveillance exist in Barrett's oesophagus, the current strategies are inadequate. Oesophagogastroduodenoscopy (OGD) is the gold standard method in screening for Barrett's oesophagus. This invasive method is expensive with associated risks negating its use as a current screening tool for Barrett's oesophagus. This review explores current definitions, epidemiology, biomarkers, surveillance, and screening in Barrett's oesophagus. Imaging modalities applicable to this condition are discussed, in addition to future developments. There is an urgent need for an alternative non-invasive method of screening and/or surveillance which could be highly beneficial towards reducing waiting times, alleviating patient fears and reducing future costs in current healthcare services. Vibrational spectroscopy has been shown to be promising in categorising Barrett's oesophagus through to high-grade dysplasia (HGD) and OAC. These techniques need further validation through multicentre trials.

Raman spectral discrimination in human liquid biopsies of oesophageal transformation to adenocarcinoma.

The aim of this study was to determine whether Raman spectroscopy combined with chemometric analysis can be applied to interrogate biofluids (plasma, serum, saliva and urine) towards detecting oesophageal stages through to oesophageal adenocarcinoma [normal/squamous epithelium, inflammatory, Barrett's, low-grade dysplasia, high-grade dysplasia and oesophageal adenocarcinoma (OAC)]. The chemometric analysis of the spectral data was performed using principal component analysis, successive projections algorithm or genetic algorithm (GA) followed by quadratic discriminant analysis (QDA). The genetic algorithm quadratic discriminant analysis (GA-QDA) model using a few selected wavenumbers for saliva and urine samples achieved 100% classification for all classes. For plasma and serum, the GA-QDA model achieved excellent accuracy in all oesophageal stages (>90%). The main GA-QDA features responsible for sample discrimination were: 1012 cm-1 (C─O stretching of ribose), 1336 cm-1 (Amide III and CH2 wagging vibrations from glycine backbone), 1450 cm-1 (methylene deformation) and 1660 cm-1 (Amide I). The results of this study are promising and support the concept that Raman on biofluids may become a useful and objective diagnostic tool to identify oesophageal disease stages from squamous epithelium to OAC.

The surgical ward round checklist: improving patient safety and clinical documentation.

PURPOSE: The daily surgical ward round (WR) is a complex process. Key aspects of patient assessment can be missed or not be documented in case notes. Safety checklists used outside of medicine help standardize performance and minimize errors. Its implementation has been beneficial in the National Health Service. A structured WR checklist standardizes key aspects of care that need to be addressed on a daily surgical WR. To improve patient safety and documentation, we implemented a surgical WR checklist for daily surgical WRs at our hospital. We describe our experience of its implementation within the general surgical department of a teaching hospital in the UK. METHODS: A retrospective review of case note entries from surgical WRs (including Urology and Vascular surgery) was conducted between April 2015 and January 2016. WR entries of 72 case notes were audited for documentation of six parameters from the surgical WR checklist. A WR checklist label with the parameters was designed for use for each WR entry. A post-checklist implementation audit of 61 case notes was performed between Jan 2016 and August 2016. To assess outcome on patient safety, adverse events relating to these six parameters reported to the local clinical governance team were reviewed pre - and post-checklist implementation. RESULTS: Overall documentation of the six parameters improved following implementation of the WR checklist (pre-checklist=26% vs post-checklist=79%). Documentation of assessment of fluid balance improved from 8% to 76%. Subsequent audit at 3 months post-checklist implementation maintained improvement with documentation at 72%. CONCLUSION: The introduction of the surgical WR checklist has improved documentation of key aspects of patient care. The WR checklist benefits patient safety. It improves communication, documentation and ensures that key issues are not missed at patient assessment on WRs. A crucial factor for successful documentation is engagement by the senior clinicians and nursing staff on its benefits which ensures appropriate use of WR checklist labels occurs as doctors rotate through the surgical placement.