Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study.

BACKGROUND: The Duke Activity Status Index (DASI) questionnaire might help incorporate self-reported functional capacity into preoperative risk assessment. Nonetheless, prognostically important thresholds in DASI scores remain unclear. We conducted a nested cohort analysis of the Measurement of Exercise Tolerance before Surgery (METS) study to characterise the association of preoperative DASI scores with postoperative death or complications. METHODS: The analysis included 1546 participants (≥40 yr of age) at an elevated cardiac risk who had inpatient noncardiac surgery. The primary outcome was 30-day death or myocardial injury. The secondary outcomes were 30-day death or myocardial infarction, in-hospital moderate-to-severe complications, and 1 yr death or new disability. Multivariable logistic regression modelling was used to characterise the adjusted association of preoperative DASI scores with outcomes. RESULTS: The DASI score had non-linear associations with outcomes. Self-reported functional capacity better than a DASI score of 34 was associated with reduced odds of 30-day death or myocardial injury (odds ratio: 0.97 per 1 point increase above 34; 95% confidence interval [CI]: 0.96-0.99) and 1 yr death or new disability (odds ratio: 0.96 per 1 point increase above 34; 95% CI: 0.92-0.99). Self-reported functional capacity worse than a DASI score of 34 was associated with increased odds of 30-day death or myocardial infarction (odds ratio: 1.05 per 1 point decrease below 34; 95% CI: 1.00-1.09), and moderate-to-severe complications (odds ratio: 1.03 per 1 point decrease below 34; 95% CI: 1.01-1.05). CONCLUSIONS: A DASI score of 34 represents a threshold for identifying patients at risk for myocardial injury, myocardial infarction, moderate-to-severe complications, and new disability.

Role of betasatellite in the pathogenesis of a bipartite begomovirus affecting tomato in India.

Betasatellites are commonly associated with tomato leaf curl disease caused by begomoviruses in India. This study demonstrates the role of a betasatellite in the pathogenesis of tomato leaf curl New Delhi virus (ToLCNDV), a bipartite begomovirus affecting tomato in India. For infection, accumulation, systemic movement and disease induction by ToLCNDV, co-infection by the associated betasatellite was not essential, as the DNA A alone of ToLCNDV could infect tomato and Nicotiana benthamiana and induce mild symptoms, but DNA B or Cotton leaf curl Multan betasatellite (CLCuMB) was required for development of typical leaf curl symptoms. The symptoms were most severe in plants infected with all three components, indicating a role of the betasatellite in the pathogenesis of ToLCNDV. The plants infected with ToLCNDV DNA A alone had limited accumulation of viral DNA, which increased by many times in plants co-infected with DNA B or/and betasatellite. However, the plants infected with all three components accumulated 20 times less betasatellite DNA than the plants infected with DNA A and betasatellite. The increase in the amount of viral DNAs was also reflected in the commensurate increase in symptom severity and transmissibility by whitefly, Bemisia tabaci.

Complete genome sequence of an isolate of Clerodendron yellow mosaic virus--a new begomovirus from India.

Clerodendron inerme, a common hedge plant grown in India, is affected by a yellow mosaic disease caused by a begomovirus. In the present study, the complete genome (DNA A) of this virus was cloned and sequenced. The total size of DNA A is 2760 nucleotides. The genome of this virus contains six open reading frames and a non-coding intergenic region of 293 nucleotides. Nucleotide sequence comparison analysis revealed maximum sequence identity with Papaya leaf curl virus-Pakistan [Pakistan:Cotton:2002] (73.9%). As this virus had less than 89% identity with other begomoviruses, it was identified as a new begomovirus species and tentatively, named as Clerodendron yellow mosaic virus-[India:New Delhi:2007] (ClYMV-[IN:ND:07]).

Distinct morpho-physiological and biochemical features of arid and hyper-arid ecotypes of Ziziphus nummularia under drought suggest its higher tolerance compared with semi-arid ecotype.

Tree species in the arid and semi-arid regions use various strategies to combat drought stress. Ziziphus nummularia (Burm. f.) Wight et Arn., native to the Thar Desert in India, is highly drought-tolerant. To identify the most drought-tolerant ecotype of Z. nummularia, one ecotype each from semi-arid (Godhra, annual rainfall >750 mm), arid (Bikaner, 250-350 mm) and hyper-arid (Jaisalmer, <150 mm) regions was selected along with two other Ziziphus species, Ziziphus mauritiana Lamk. and Ziziphus rotundifolia Lamk., and screened for parameters contributing to drought tolerance. Among these, Z. nummularia (Jaisalmer) (CIAHZN-J) was the most drought - tolerant. The tolerance nature of CIAHZN-J was associated with increased membrane stability, root length and number, length of hairs and thorns, root dry/fresh weight ratio, seed germination (at -0.5 MPa), proline content (31-fold), catalase and sugar content (two- to three-fold). Apart from these characteristics, it also exhibited the longest duration to reach highest cumulative drought stress rating, maintained higher relative water content for a longer period of time with reduced leaf size, leaf rolling and falling of older leaves, and displayed sustained shoot growth during drought stress. To determine drought tolerance in Ziziphus, we developed a morphological symptom-based screening technique in this study. Additionally, transcriptome profiling of CIAHZN-J in response to drought revealed the up-regulation of genes involved in sugar metabolism and transport, abscisic acid biosynthesis, osmoregulation, reactive oxygen species homeostasis and maintaining water potential. Expression profiles and semi-quantitative reverse transcription PCR results further correlated with the physiological and biochemical mechanisms. In conclusion, CIAHZN-J is an excellent genetic stock for the identification of drought-responsive genes and can also be deployed in crop improvement programs for drought tolerance.

Molecular diversity of the DNA-beta satellites associated with tomato leaf curl disease in India.

DNA-beta satellites, referred to here as betasatellites, were found associated with tomato leaf curl disease (ToLCD) in India. The size of eight betasatellites isolated from different geographical locations in India varied from 1353 to 1424 nt; these molecules had an ORF beta C1, an adenine-rich region, and a satellite conserved region. Their nucleotide sequence identity varied from 45 to 93%. In phylogenetic analysis, these betasatellites grouped according to their geographic locations rather than the host species. Two new betasatellites, tomato leaf curl Bangalore betasatellite and tomato leaf curl Maharashtra betasatellite, were identified.

Anaesthetic management of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei: a retrospective audit.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to improve quality of life and survival rates in patients suffering from pseudomyxoma peritonei. The procedure is long and associated with significant intraoperative blood loss. As such, the anaesthetic management of patients undergoing this procedure can be challenging. The aim of this paper is to describe our perioperative management of pseudomyxoma peritonei patients who received CRS and to report a retrospective audit of our outcomes and complications over a six-year period at a large tertiary centre. A total of 70 patients were included, of whom three (4.3%) had CRS alone, 42 (60.0%) had CRS with HIPEC, and 25 (35.7%) had CRS with HIPEC and early postoperative intraperitoneal chemotherapy. There were no intraoperative deaths. A total of four patients (5.7%) died during their hospital admission. At one-year follow-up, six patients (9.0%) had died, and at the end of the study 15 (22.4%) had died. No statistically significant difference in blood loss was seen between patients who received tranexamic acid (30 patients, 42.9%) and those who did not, but the incidence of deep venous thrombosis was much higher (10/30 versus 1/40). Different intravenous fluid strategies appeared not to influence the incidence of postoperative acute renal failure. Further research is required to evaluate the effects of intraoperative tranexamic acid and different intraoperative fluid strategies on outcomes in patients undergoing CRS with HIPEC.

Perioperative assessment of older surgical patients using a frailty index-feasibility and association with adverse post-operative outcomes.

This study aimed to examine the feasibility of using a frailty index (FI) based on comprehensive geriatric assessment (CGA), to assess the level of frailty in older surgical patients preoperatively and to evaluate the association of FI-CGA with poorer postoperative outcomes. Two hundred and forty-six patients aged ≥70 years undergoing intermediate- to high-risk surgery in a tertiary hospital were recruited. Frailty was assessed using a 57-item FI-CGA form, with fit, intermediate frail, and frail patients defined as FI ≤0.25, >0.25 to 0.4, and >0.4, respectively. Adverse outcomes were ascertained at 30 days and 12 months post-surgery. Logistic regression models assessed the relationship between FI and adverse outcomes, adjusting for age, gender and acuity of surgery. The mean age of the participants was 79 years (standard deviation [SD] 6.5%), 52% were female, 91% were admitted from the community, 43% underwent acute surgery, and 19% were assessed as frail. The FI-CGA form was reported as being easy to apply, with a low patient refusal rate (2.2%). The majority of items were easy to rate, although inter-rater reliability was not tested. In relation to outcomes, greater frailty was associated with increased 12-month mortality (6.4%, 15.6%, and 23% for fit, intermediate frail, and frail patients respectively, P=0.01) and 12-month hospital readmissions (33.9%, 48.9%, and 60% respectively, P=0.004). There were no statistically significant differences between fit, intermediate frail, and frail groups in perioperative adverse events (17.4%, 23.3%, and 19.1% respectively, P=0.577) or 30-day postoperative complications (35.8%, 47.8%, and 46.8% respectively, P=0.183). Our findings suggest that it is feasible to use the FI-CGA to assess frailty preoperatively, and that using the FI-CGA may identify patients at high risk of adverse long-term outcomes.

Interventions for protecting renal function in the perioperative period.

BACKGROUND: A number of methods have been used to try to protect kidney function in patients undergoing surgery. These include the administration of dopamine, diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors and hydration fluids. OBJECTIVES: For this review, we selected randomized controlled trials, which employed different methods to protect renal function during the perioperative period. In examining these trials, we looked at outcomes such as renal failure and mortality, as well as changes in the renal function tests, including urine output, creatinine clearance, free water clearance, fractional excretion of sodium and renal plasma flow. SEARCH STRATEGY: We searched the Cochrane Central register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2004), MEDLINE (1966 to 2004) and EMBASE (1988 to 2004) and hand searched six journals (British Journal of Anaesthesia; Anesthesia and Analgesia; Anesthesiology; Annals of Surgery; Journal of Thoracic and Cardiovascular Surgery and Journal of Vascular Surgery). SELECTION CRITERIA: We selected all randomized controlled trials in adult population undergoing surgery where a treatment measure was used for the purpose of renal protection in the perioperative period. DATA COLLECTION AND ANALYSIS: We selected 37 studies for inclusion in this review. As well as analysis of the data from all the studies, we also performed subgroup analysis for type of interventions, types of surgical procedures and those with pre-existing renal dysfunction. We undertook sensitivity analysis on studies with high methodological quality. MAIN RESULTS: The review included data from 37 studies, comprising a total of 1227 patients. Of these, 658 received some form of treatment and 569 acted as controls. The interventions were mostly employing different pharmaceutical agents such as dopamine, diuretics, calcium channel blockers. ACE inhibitors or selected hydration fluids. The results indicated that certain interventions showed some benefits, but all the results suffered from significant heterogeneity. Hence we can draw no conclusions about the effectiveness of these interventions in protecting the kidneys during surgery. AUTHORS' CONCLUSIONS: There is no reliable evidence from available literature to suggest that interventions during surgery can protect the kidneys from damage. However, there is a need for more studies of high methodological quality. One particular area for further studies may be on patients with pre-existing renal dysfunction undergoing surgery.

Evaluation of perioperative predictors of acute kidney injury post orthotopic liver transplantation.

Acute kidney injury (AKI) is a common complication following orthotopic liver transplantation. It is associated with increased morbidity and mortality, as well as increased healthcare costs. The aetiology of AKI post liver transplantation is multifactorial and understanding these factors is pivotal in developing risk stratification and prevention strategies. This study aims to investigate the preoperative and intraoperative factors that may be associated with AKI in patients undergoing liver transplantation at the Princess Alexandra Hospital, Brisbane, Queensland. In our study, retrospective data of 97 consecutive orthotopic liver transplantations performed between January 2009 and August 2012 were recorded. Univariate and multivariate analyses were performed to investigate the preoperative and intraoperative risk factors for the development of AKI in this cohort. In the cohort of 97 patients who underwent orthotopic liver transplantation, 24 patients (25%) developed postoperative AKI. Univariate analysis demonstrated that high preoperative body mass index and intraoperative noradrenaline use were both associated with AKI. Multivariate analysis demonstrated that high body mass index, high Model for End-stage Liver Disease score and intraoperative noradrenaline use were associated with AKI. Overall mortaility was 4.1% during the study period and was not significantly different between the two groups. The high incidence of AKI following liver transplantation in this study cohort highlights the importance of this issue. This study has identified several potential pre- and intraoperative risk factors, providing a focus for patient surveillance and future research.

Anaphylaxis and other adverse reactions to blue dyes: a case series.

We report three cases of anaphylaxis during anaesthesia confirmed on intradermal testing to be related to patent blue V dye (Guerbet - Chemical Abstract Service 3536-49-0). All three cases were associated with moderate to severe hypotension. Two cases had delayed onset, and two were associated with a rash. None of the cases were associated with bronchospasm. In all three patients the interference with pulse oximetry readings contributed to difficulties in management. We recommend the use of a test dose of blue dye prior to surgery, as suggested in the manufacturer's product information. We also recommend high vigilance for possible allergic reactions when patent blue dyes are used for sentinel lymph node mapping, because the presentations may be atypical and the reduced pulse oximetry readings may be a distraction.

Cowpea golden mosaic disease in Gujarat is caused by a Mungbean yellow mosaic India virus isolate with a DNA B variant.

It has long been assumed that cowpea golden mosaic disease (CGMD) in southern Asia is caused by a begomovirus distinct from those causing disease in other legumes. The components of a begomovirus causing CGMD in western India were isolated, cloned and sequenced. Analysis of the sequences shows the virus to be an isolate of Mungbean yellow mosaic India virus, but with a distinct DNA B component with greater similarity to components of a second legume-infecting begomovirus occurring in the region, Mungbean yellow mosaic virus. The clones of the virus were readily infectious to cowpea, mungbean, blackgram and French bean by agroinoculation. However, the wild-type isolate was shown to be easily transmissible by whiteflies between cowpea plants but not to blackgram and mugbean, suggesting that the insect vector plays a major role in determining the natural host range of these viruses.

Use of sevoflurane in difficult airways.

Inhalational induction is one of the recognized methods for the management of difficult airway. Halothane is the usual choice of agent for this purpose. The relatively new agent sevoflurane, which is the least irritant of all the available agents, is emerging as a choice of inhalational agent for both adult and pediatric populations. There are various reports for and against the use of sevoflurane for the management of difficult airway. We describe the use of sevoflurane for the management of difficult airway in four patients presenting with airway problems.

An unusual cause of locked jaw and its airway management.

We describe the management of a patient impaled through the medial aspect of the left orbit by the brake lever of a mountain bike which immobilized her jaw by obstructing the right coronoid process of the mandible and blocked access to the mouth and trachea. The fire service used special equipment to cut out the rest of the bike from the handle bar. The patient with the penetrating brake lever attached to the handlebar in situ was transported to the hospital by rescue helicopter. The assessment and safe airway management and potential difficulties are discussed.

Acute meningococcal epiglottitis and septicaemia in a 65-y-old man.

We report a case of acute meningococcal epiglottitis in a 65-y-old man. He was noted to have stridor of acute onset. We highlight the importance of the diagnosis of acute epiglottitis, early establishment of an airway and appropriate antibiotic therapy. This case report mainly concerns the association of unusual pathogen Neisseria meningitidis and adult acute epiglottitis.

High prevalence of antiphospholipid antibodies in Asian cancer patients with thrombosis.

Thrombotic complications are a significant cause of morbidity and mortality in cancer patients. Studies in Caucasian populations have shown that up to one-third of such patients test positive to antiphospholipid antibodies. Our aim was to determine the prevalence and serotypes of antiphospholipid antibodies in an unselected group of Asian cancer patients with thrombosis. All patients with cancer-related thrombosis seen in the Department of Hematology-Oncology and Radiation Oncology were enrolled in this study. The study period was from April 2000 to May 2001. Antiphospholipid antibodies tests were performed, namely lupus anticoagulant screen, anticardiolipin antibodies (IgG and IgM) and anti-beta-2 glycoprotein I antibodies (B2 GPI) IgG, IgM and IgA. Thirty-three patients were recruited. There were 14 males and 19 females, with an age range of 35-78 years of age. Of those enrolled, there were 25 Chinese, five Malays and three Indians. The patients had several cancer types: 11 (36.7%) patients had adenocarcinoma as the histological cell type. Of the 33 patients, 75.8% had stage IV disease. Arterial thrombosis was seen in eight patients (24.2%), and venous thrombosis occurred in 29 patients (87.9%). Antiphospholipid antibodies were positive in 60.6% of the patients, of which anti-B2GPI IgA antibody was the most prevalent antiphospholipid present (46.9%). The presence of anti-beta-2 glycoprotein I IgA antibody was associated with strokes, extensive and recurrent venous thrombosis, and coincident arterial and venous thrombosis. A high prevalence of antiphospholipid antibodies (60.6%) was found in Asian patients with cancer-related thrombosis. The presence of antiphospholipid antibodies, particularly anti B2GPI IgA, may identify a subset of cancer patients who are at high risk of developing thrombotic complications, and further studies are warranted.

Conditions for laryngeal mask insertion. A comparison of propofol versus sevoflurane with or without alfentanil.

One hundred unpremedicated ASA 1 or 2 patients scheduled for elective surgery were divided equally into four groups and recruited into this prospective, randomised parallel groups study. Induction was with propofol 2.5 mg.kg-1 or vital-capacity breath induction with sevoflurane (> 7% in the inspiratory gas) in 65% nitrous oxide and oxygen, or gaseous induction with sevoflurane plus alfentanil 5 micrograms.kg-1 or propofol 2.5 mg.kg-1 and alfentanil 5 micrograms.kg-1. The conditions for laryngeal mask insertion were assessed and graded on a three-point scale using six variables. The overall condition for laryngeal mask insertion was assessed as excellent, satisfactory or poor on the basis of total score in each group. Excellent or satisfactory conditions were observed in 25 (100%) patients in the sevoflurane-alfentanil group, 22 (88%) in the propofol-alfentanil group and 16 (64%) patients each in the propofol and sevoflurane groups (p < 0.001). A sevoflurane-alfentanil combination provides better conditions for laryngeal mask insertion when compared with sevoflurane alone, or a propofol-alfentanil combination.

The effect of music on anaesthetists' psychomotor performance.

Music is frequently played in operating theatres, but may prove distracting to anaesthetists. We undertook a laboratory-based study of the effects of music on the psychomotor performance of 12 anaesthetic trainees. Using part of the computer-based PsychE psychomotor evaluation programme, we were unable to demonstrate any effect of self-chosen music, silence, white noise or classical music on their performance in these tests.