A Monte Carlo simulation-based health risk assessment of heavy metals in soils of the tropical region in southern China.

The disturbance of ecological stability may take place in tropical regions due to the elevated biomass density resulting from heavy metal and other contaminant pollution. In this study, 62 valid soil samples were collected from Sanya. Source analysis of heavy metals in the area was carried out using absolute principal component-multiple linear regression receptor modelling (APCS-MLR); the comprehensive ecological risk of the study area was assessed based on pollution sources; the Monte-Carlo model was used to accurately predict the health risk of pollution sources in the study area. The results showed that: The average contents of soil heavy metals Cu, Ni and Cd in Sanya were 5.53, 6.56 and 11.66 times higher than the background values of heavy metals. The results of soil geo-accumulation index (Igeo) showed that Cr, Mo, Mn and Zn were unpolluted to moderately polluted, Cu and Ni were moderately polluted, and Cd was moderately polluted to strongly polluted. The main sources of heavy metal pollution were natural sources (57.99%), agricultural sources (38.44%) and traffic sources (3.57%). Natural and agricultural sources were jointly identified as priority control pollution sources and Cd was the priority control pollution element for soil ecological risk. Heavy metal content in Sanya did not pose a non-carcinogenic risk to the population, but there was a carcinogenic risk to children. The element Zn had a high carcinogenic risk to children, and was a priority controlling pollutant element for the risk of human health, with agricultural sources as the priority controlling pollutant source.

The Global Leadership Initiative on Malnutrition criteria for diagnosis of malnutrition and outcomes prediction in emergency abdominal surgery.

OBJECTIVES: Malnutrition has adverse postoperative outcomes, especially in emergency surgery. Among the numerous tools for nutritional assessment, this study aims to investigate malnutrition diagnosed by Global Leadership Initiative on Malnutrition criteria and the Global Leadership Initiative on Malnutrition predictive value for outcomes after emergency abdominal surgery. METHODS: This was a prospective observational study. Among the 468 patients undergoing emergency abdominal surgery admitted to a department of emergency surgery from June 2020 to December 2021, 53 patients were not eligible for enrollment, and 19 patients had missing data. Thus, the final number of participants was 396. Muscle mass was evaluated by skeletal muscle index at the third lumbar vertebra on computed tomography scans, and the lower quartile was defined as the threshold of muscle mass reduction. The associations of Global Leadership Initiative on Malnutrition, Global Leadership Initiative on Malnutrition (muscle mass reduction excluded), and skeletal muscle index with in-hospital mortality, postoperative complications, and postoperative stay were evaluated using χ2. In addition, confounding factors were screened, regression models were established, and the Global Leadership Initiative on Malnutrition predictive value was analyzed for clinical outcome. Ethical approval was obtained from the appropriate department. RESULTS: Malnutrition was observed in 19.9% of the total 396 patients based on the Global Leadership Initiative on Malnutrition and in 12.4% on the Global Leadership Initiative on Malnutrition (muscle mass reduction excluded). Sarcopenia by skeletal muscle index was found in 24.7% of patients. Univariate analysis indicated that in-hospital mortality, postoperative complications, infective complication rate, and postoperative hospital stay were significantly higher in malnourished and sarcopenic patients. Multivariate analysis found that malnutrition diagnosed by the Global Leadership Initiative on Malnutrition was predictive for complications, infective complications, and postoperative stay (total postoperative complications: odds ratio = 3.620; 95% CI, 1.635-8.015; P = 0.002; infective complications: odds ratio = 3.127; 95% CI, 1.194-8.192; P = 0.020; and postoperative stay: regression coefficient = 2.622; P = 0.022). The Global Leadership Initiative on Malnutrition (muscle mass reduction excluded) identified postoperative complications and postoperative stay (total postoperative complications: odds ratio = 3.364; 95% CI, 1.247-9.075; P = 0.017 and postoperative stay: regression coefficient = 3.547; P = 0.009). Sarcopenia by skeletal muscle index was a risk factor for postoperative complications (odds ratio = 3.366; 95% CI, 1.587-7.140; P = 0.002). CONCLUSION: The Global Leadership Initiative on Malnutrition and Global Leadership Initiative on Malnutritison (muscle mass reduction excluded) had predictive value for adverse clinical outcomes due to malnutrition in patients undergoing emergency abdominal surgery.

Microplastics in agricultural soils on the coastal plain: Spatial characteristics, influencing factors and sources.

Farmland is a major sink for microplastics (MPs), but research on MPs in coastal plain soil, particularly their occurrence in agricultural areas with changing coastlines, is limited. Here, we investigated the distribution, influencing factors and sources of MPs in a typical agricultural county near the southeast coast of China considering different human activities and soil property changes. The average MP concentration in farmland soils was 314 items/kg, ranging from 70.2 to 851.3 items/kg. MPs increased first and then decreased from inland to the coast, and this trend was greatly affected by coastline expansion. Bulk density, clay and textile points of interest (POIs) are the major factors affecting MPs in farmland. Network analysis was used to divide the whole MP community into two modules, and the average similarity between each MP community and the other 25.5 MP communities was >0.5. Overall, the similarity of the MP community tended to decrease with increasing geographical distance (P < 0.01). In the soil environmental factors group, bulk density and clay affected the total MP abundance, accounting for 14.7 % and 9.4 % of MPs, respectively. After fitting 8 types of POIs and the total MP diversity integrated index (MDII) of farmland, washing POIs (R2 = 0.65, P < 0.01) displayed the greatest and most significant fit with MDII, followed by clothing POIs (R2 = 0.29, P < 0.01). The MDII-POI results showed that the major POI sources of soil MPs were clothing manufacturing and washing POIs. Unlike in urban areas, automobile service POIs, packaging POIs and textile POIs had no significant relationship with the MDII, which may be related to the population and economic development scale. The results emphasize the importance of investigating MP occurrence and sources in coastal agricultural areas to promote the effective management of MPs and plastic emissions in land-sea transition zones.

Trends in the occurrence and accumulation of microplastics in urban soil of Nanjing and their policy implications.

Urban soil is an important sink of terrestrial microplastics (MPs), and understanding their distribution over time is essential for effective pollution management. Here, based on soil MP data from Nanjing, a typical megacity in eastern China, this study analyzed MP accumulation trends using decision tree and time series network based on soil attributes, POI (point of interest), and human activity factors such as urban industrial structure, transportation, water use. We also evaluated the impact of plastic policy interventions. In the past 15 years, MPs in urban soil in Nanjing have gradually increased, and highly polluted areas have also grown. From 2010 to 2020, the concentration of MPs in urban soil increased from 326.7 items/kg to 480.9 items/kg, with high pollution areas expanding from only 2.0 km2 (0.7 %) to 48.7 km2 (14.9 %). The accumulation of MPs was also influenced by changing factors due to urbanization. In the early 21st century, residential areas had the largest effect, while in the later period, public passenger transport and domestic water consumption were the dominant factors. The scenarios simulation suggests recent plastic intervention policies have helped alleviate this rate of increase, but MP source management (e.g., laundry fibers, tire wear) still needs improvement. By the proposed method, the past trend of microplastics in urban soil and their relationship with soil properties and human activities can be accurately revealed, which will be helpful for the formulation of countermeasures to mitigate regional soil MP pollution.

A modified receptor model for source apportionment of sediment polycyclic aromatic hydrocarbons.

Polycyclic aromatic hydrocarbons (PAHs) have become a serious threat to human health and ecological security due to their persistence and high toxicity. Lake sediments are in a relatively closed environment, so PAHs and other pollutants can be preserved for a long time. Accurate analysis of the sources of PAHs in sediments is an important prerequisite for PAH pollution control. However, the existing PAHs source resolution receptor model (the absolute principal component analysis - multilinear regression (APCA-MLR) and positive matrix factorization (PMF)) has many defects, such as great uncertainty in the process of matrix rotation. In this study, we collected sediment samples from Taihu Lake and tested their PAH content, and the existing receptor model was improved. High PAH contents were distributed in Meiliang Bay, Zhushan Bay, Gonghu Bay and areas close to the shore. "High-High" areas were distributed in Meiliang Bay, Gonghu Bay and areas close to the shore. "Low-Low" areas appeared in the central and southern parts of Taihu Lake. The results show that the improved positive matrix factorization partition computing (PMF-PC) model is significantly better than the APCA-MLR and PMF models in terms of both numerical simulation accuracy and the spatial distribution consistency of PAHs. The correlations (R2) between the measured and simulated values of low-molecular-weight PAHs (L-PAHs), high-molecular-weight PAHs (H-PAHs) and PAHs were 0.992, 0.989 and 0.993, respectively. The contributions of biomass sources, coal combustion sources and petroleum sources to PAHs in Taihu Lake sediments reached 16.7%, 31.7% and 51.6%, respectively. Fossil fuel sources were mainly concentrated in areas near the shore, and the contribution was lower in areas far from the shore. Although the algorithm still needs to be improved, the PMF-PC model may become a useful tool for the source apportionment of PAHs in sediments.

Poor Pre-operative Nutritional Status Is a Risk Factor of Post-operative Infections in Patients With Gastrointestinal Cancer-A Multicenter Prospective Cohort Study.

Objective: This study aimed to assess the prognostic value of the Nutritional Risk Score 2002 (NRS2002) and patient-generated subjective global assessment (PG-SGA) for post-operative infections in patients with gastric cancer (GC) and colorectal cancer (CRC) who underwent curative surgery. Methods: This prospective study included 1,493 GC patients and 879 CRC patients who underwent curative surgery at 18 hospitals in China between April 2017 and March 2020. The NRS2002 and PG-SGA were performed on the day of admission. The relationship between the nutritional status of patients before surgery and post-surgical incidence of infection was analyzed using univariate and multiple logistic regression analyses. Results: According to NRS2002, the prevalence of nutritional risk was 51.1% in GC patients and 63.9% in CRC patients. According to the PG-SGA, 38.9% of GC patients and 54.2% of CRC patients had malnutrition. Approximately 4.4% of the GC patients and 9.9% of the CRC patients developed infectious complications after surgery. The univariate and multiple logistic regression analyses showed that the risk of infections was significantly higher in GC patients with a high nutritional risk score (NRS2002 ≥5) than in those with a low score (NRS2002 <3), and the PG-SGA score was identified as a predictor of post-operative infection complications of CRC. Conclusion: The pre-operative nutritional status of patients with GC or CRC has an impact on post-operative infection occurrence. NRS2002 ≥5 was a risk factor for post-operative infection in patients with GC, and the PG-SGA B/C was a predictor of infections in patients with CRC.

Efficacy of the Oral Administration of Maltodextrin Fructose Before Major Abdominal Surgery: A Prospective, Multicenter Clinical Study.

BACKGROUND: To study the efficacy of the oral administration of maltodextrin and fructose before major abdominal surgery (MAS). METHODS: This prospective, multicenter, parallel-controlled, double-blind study included patients aged 45-70 years who underwent elective gastrectomy, colorectal resection, or duodenopancreatectomy. The intervention group (IG) was given 800 mL and 400 mL of a maltodextrin and fructose beverage at 10 h and 2 h before MAS, respectively, and the control group (CG) received water under the same experimental conditions. The primary endpoint was insulin resistance index (IRI), and the secondary endpoints were fasting blood glucose, fasting insulin, insulin secretion index, insulin sensitivity index, intraoperative blood glucose, subjective comfort score, and clinical outcome indicators. RESULTS: A total of 240 cases were screened, of which 231 cases were randomly divided into two groups: 114 in the IG and 117 in the CG. No time-treatment effect was detected for any endpoint. The IRI and fasting insulin were significantly lower in the IG than CG after MAS (p = 0.02 & P = 0.03). The scores for anxiety, appetite, and nausea were significantly lower in the IG than CG at 1 h before MAS. Compared with baseline, the scores for appetite and nausea decreased in the IG but increased in the CG. CONCLUSION: The oral administration of maltodextrin and fructose before MAS can improve preoperative subjective well-being and reduce postoperative insulin resistance without increasing the risk of gastrointestinal discomfort.

Microplastics in urban soils of Nanjing in eastern China: Occurrence, relationships, and sources.

Although microplastic (MP) pollution has been defined as a new global challenge by the United Nations Environment Programme, their abundance and composition has only been studied in-depth within farmland soil, while minimal attention has been placed on urban soil contamination. Accordingly, within the current study, MP abundance and composition is investigated within urban soil from green spaces in Nanjing, eastern China. The average MP abundance in soil was 461 ± 222 items/kg and primarily comprised fibers (39.1%) and fragments (37.7%). MPs <1000 µm in size accounted for 83.7% of the total content and white MPs were the most abundant (26.5%). The dominant polymers were polyethylene glycol terephthalate (32.0%) and polypropylene (20.5%). Moreover, relationship network analysis generated three distinct MP modules based on community similarity. Indeed, the degree of similarity increased by ∼26.8% per kilometer. Furthermore, application of a forward selective optimal multiple regression model identified clay, sand, longitude, and points of interest for recycling bins (RecyclePOI) as the primary spatial and soil environmental factors affecting MP abundance and composition. Additionally, five potential sources of MPs were identified based on the MP diversity integrated index fitting results, and point of interest density (MDII-POI) source analysis (R2 = 0.21-0.62; P < 0.05). In particular, the point of interest of express delivery points (ExpressPOI) were important sources of plastic emissions as they are widely distributed throughout urban and fringe areas. Collectively, the findings of this study provide novel insights regarding quantitative source appointment and regional ecological control of MPs in urban soil.

Study on the risk of soil heavy metal pollution in typical developed cities in eastern China.

Enrichment of heavy metals in urban soils has become a major regional environmental risk. At present, research on the soil heavy metals in cities lacks risk spatial correlation analyses between different heavy metals, and there is a relative lack of assessments of the ecological and health risks. We selected Wuxi, a typical developed city of eastern China, collected and tested the contents of heavy metals in the urban soils of Wuxi in May 2020. Combined with Pb isotope analysis, ecological and health risk assessment, we found that the high heavy metal concentrations in Wuxi are mainly located in the central and western regions, and that the changes in spatial fluctuation are relatively small. The Pb isotopes in the urban soils of Wuxi are distributed in areas, such as those are related to coal combustion, automobile exhaust and urban garbage, indicating that the heavy metals in the urban soils of Wuxi are affected by human activities such as coal combustion and automobile exhaust. The average value of the potential ecological risk index of soil heavy metal Cd is 80.3 (the threshold: 40), which represents a high-risk state. Whether adults or children, the risk of soil heavy metals via ingestion is much higher than that through skin exposure. High health risk values are present in the central area of Wuxi and decrease in a ring-shaped pattern, which is similar to the population distribution of Wuxi and greatly increases the potential risk from soil heavy metals, which should be given close attention. We should develop and use clean energy to replace petroleum fossil fuels, especially in densely populated areas. This study provides technical support for the prevention and control of urban heavy metal pollution.

Effect of Early vs Late Supplemental Parenteral Nutrition in Patients Undergoing Abdominal Surgery: A Randomized Clinical Trial.

Importance: The effect of and optimal timing for initiating supplemental parenteral nutrition (SPN) remain unclear after major abdominal surgery for patients in whom energy targets cannot be met by enteral nutrition (EN) alone. Objective: To examine the effect of early supplemental parenteral nutrition (E-SPN) (day 3 after surgery) or late supplemental parenteral nutrition (L-SPN) (day 8 after surgery) on the incidence of nosocomial infections in patients undergoing major abdominal surgery who are at high nutritional risk and have poor tolerance to EN. Design, Setting, and Participants: A multicenter randomized clinical trial was conducted from April 1, 2017, to December 31, 2018, in the general surgery department of 11 tertiary hospitals in China. Participants were those undergoing major abdominal surgery with high nutritional risk and poor tolerance to EN (≤30% of energy targets from EN on postoperative day 2, calculated as 25 and 30 kcal/kg of ideal body weight daily for women and men, respectively) and an expected postoperative hospital stay longer than 7 days. Data analysis was performed from February 1 to October 31, 2020. Interventions: Random allocation to E-SPN (starting on day 3 after surgery) or L-SPN (starting on day 8 after surgery). Main Outcomes and Measures: The primary outcome was the incidence of nosocomial infections between postoperative day 3 and hospital discharge. Results: A total of 230 patients (mean [SD] age, 60.1 [11.2] years; 140 men [61.1%]; all patients were of Han race and Asian ethnicity) were randomized (115 to the E-SPN group and 115 to the L-SPN group). One patient in the L-SPN group withdrew informed consent before the intervention. The E-SPN group received more mean (SD) energy delivery between days 3 and 7 compared with the L-SPN group (26.5 [7.4] vs 15.1 [4.8] kcal/kg daily; P < .001). The E-SPN group had significantly fewer nosocomial infections compared with the L-SPN group (10/115 [8.7%] vs 21/114 [18.4%]; risk difference, 9.7%; 95% CI, 0.9%-18.5%; P = .04). No significant differences were found between the E-SPN group and the L-SPN group in the mean (SD) number of noninfectious complications (31/115 [27.0%] vs 38/114 [33.3%]; risk difference, 6.4%; 95% CI, -5.5% to 18.2%; P = .32), total adverse events (75/115 [65.2%] vs 82/114 [71.9%]; risk difference, 6.7%; 95% CI, -5.3% to 18.7%; P = .32), and rates of other secondary outcomes. A significant difference was found in the mean (SD) number of therapeutic antibiotic days between the E-SPN group and the L-SPN group (6.0 [0.8] vs 7.0 [1.1] days; mean difference, 1.0 days; 95% CI, 0.2-1.9 days; P = .01). Conclusion and Relevance: In this randomized clinical trial, E-SPN was associated with reduced nosocomial infections in patients undergoing abdominal surgery and seems to be a favorable strategy for patients with high nutritional risk and poor tolerance to EN after major abdominal surgery. Trial Registration: ClinicalTrials.gov Identifier: NCT03115957.

Immediate vs. gradual advancement to goal of enteral nutrition after elective abdominal surgery: A multicenter non-inferiority randomized trial.

BACKGROUND & AIMS: The strategy of increasing the postoperative enteral nutrition dose to the target goal has not yet been clarified. This study aimed to determine whether an immediate goal-dose enteral nutrition (IGEN) strategy is non-inferior to a gradual goal-dose enteral nutrition (GGEN) strategy in reducing infections in patients undergoing abdominal surgery involving the organs of the digestive system. METHODS: This randomized controlled trial enrolled postoperative patients with nutritional risk screening 2002 scores ≥3 from 11 Chinese hospitals. Energy targets were calculated as 25 kcal/kg and 30 kcal/kg of ideal body weight for women and men, respectively. Patients were randomly assigned 1:1 to IGEN or GGEN group after enteral tolerance was confirmed (30% of the target on day 2). The IGEN group immediately started receiving 100% of the caloric requirements on day 3, while the GGEN group received 40% progressing to 80% of target on day 7. The primary endpoint was the infection rate until discharge, based on the intention-to-treat population. RESULTS: A total of 411 patients were enrolled and randomized to the IGEN and GGEN groups, and five patients did not receive the allocated intervention. A total of 406 patients were included in the primary analysis, with 199 and 207 in the IGEN and GGEN groups, respectively. Infection was observed in 17/199 (8.5%) in the IGEN group and 19/207 (9.2%) in the GGEN group, respectively (difference, -0.6%; [95% confidence interval (CI), -6.2%-4.9%]; P = 0.009 for non-inferiority test). There were significantly more gastrointestinal intolerance events with IGEN than with GGEN (58/199 [29.1%] vs. 32/207 [15.5%], P < 0.001). All other secondary endpoints were non-significant. CONCLUSIONS: Among postoperative patients at nutritional risk, IGEN was non-inferior to GGEN in regards to infectious complications. IGEN was associated with more gastrointestinal intolerance events. It showed that IGEN cannot be considered to be clinically directive. ClinicalTrials.gov (#NCT03117348).

Temporal and spatial distributions and sources of heavy metals in atmospheric deposition in western Taihu Lake, China.

Heavy metals in atmospheric dust can directly pollute the soil, water and sediment, causing serious harm to human health. In this study, the temporal and spatial distribution characteristics of heavy metals in atmospheric deposition in western Taihu Lake were studied. We established 10 sampling sites to collect atmospheric deposition for two years in different seasons. The atmospheric deposition flux follows the order urban area (95.6 g m-2·a-1) > suburban area (80.2 g m-2·a-1) > forestland (56.8 g m-2·a-1). The concentrations of heavy metals in atmospheric deposition show trends of high values in the winter and low values in the summer and are significantly negatively correlated with distance from the city. The pollution level of Igeo-Cd is 6, which is very high, and that of E-Cd is 219, which means high risk. Heavy metals in atmospheric deposition are mainly taken up via hand-mouth intake, and the harm to children is significantly higher than the harm to adults. The highest health risk assessment values for the four analyzed heavy metals in atmospheric deposition are located near the city and in suburbs (within 5 km of the city center), that is, in areas where human activities are concentrated. The health risk assessment values in areas outside the suburbs are low; these areas are less affected by human activities. The health risk assessment values of heavy metals in the winter and spring are higher than those in the summer and autumn. The Pb isotope ratios show that the main sources of heavy metals in atmospheric deposition and local soil are human activities, such as industry and coal combustion, with less input from natural sources. Heavy metals in atmospheric deposition in the western part of Taihu Lake not only directly threaten local human health but also enter Taihu Lake, posing a serious threat to the Taihu Lake ecosystem.

The Obesity Paradox in Elderly Patients Undergoing Emergency Surgery: A Nationwide Analysis.

BACKGROUND: Obesity has long been considered a risk factor for postoperative adverse events in surgery. We sought to study the impact of body mass index (BMI) on the clinical outcomes of the high-risk emergency general surgery (EGS) elderly patients. METHODS: All EGS ≥65 years old patients in the 2007-2016 ACS-NSQIP database, identified using the variables 'emergency' and 'surgspec,' were included. Patients were classified into five groups: normal weight: BMI <25 kg/m2, overweight: BMI ≥25 kg/m2 and <30 kg/m2, Class I: BMI ≥30 kg/m2 and <35 kg/m2, Class II: BMI ≥35 kg/m2 and <40 kg/m2, and Class III: BMI ≥40 kg/m2. Patients with BMI<18.5 kg/m2 were excluded. Multivariable logistic regression models were built to assess the relationship between obesity and 30-day postoperative mortality, overall morbidity, and individual postoperative complications after adjusting for demographics (e.g., age, gender), comorbidities (e.g., diabetes mellitus, heart failure), laboratory tests (e.g., white blood cell count, albumin), and operative complexity (e.g., ASA classification). RESULTS: A total of 78,704 patients were included, of which 26,011 were overweight (33.1%), 13,897 (17.6%) had Class I obesity, 5904 (7.5%) had Class II obesity, and 4490 (5.7%) had Class III obesity. On multivariable analyses, compared to the nonobese, patients who are overweight or with Class I-III obesity paradoxically had a lower risk of mortality, bleeding requiring transfusion, pneumonia, stroke and myocardial infarction (MI). Additionally, the incidence of MI and stroke decreased in a stepwise fashion as BMI progressed from overweight to severely obese (MI: OR: 0.84 [0.73-0.95], OR: 0.73 [0.62-0.86], OR: 0.66 [0.52-0.83], OR: 0.51 [0.38-0.68]; stroke: OR: 0.80 [0.65-0.99], OR: 0.79 [0.62-1.02], OR: 0.71 [0.50-1.00], OR: 0.43 [0.28-0.68]). CONCLUSION: In our study of elderly EGS patients, overweight and obese patients had a lower risk of mortality, bleeding requiring transfusion, pneumonia, reintubation, stroke, and MI. Further studies are needed to confirm and investigate the obesity paradox in this patient population.

Cadmium pollution of soil-rice ecosystems in rice cultivation dominated regions in China: A review.

Cd accumulation in paddy soils and its subsequent transfer to the food chain are widespread environmental issues, which has been extensively investigated in China. However, most studies focused on regional scales and these results may not be applicable to present the Cd contamination status in soil-rice ecosystems at a national scale. Therefore, based on collected data from China's rice cultivation dominated regions, this study provides the Cd pollution level of paddy soils and rice grains in China. Results indicates that the Yangtze River basin, especially Hunan, required more attention due to the elevated Cd concentrations in soil-rice ecosystems. Moreover, this review summarizes the significant natural and anthropogenic sources, transport and accumulation mechanism as well as the influencing factors of Cd in soil-rice ecosystems. The wide occurrence of Cd contamination in paddy soils derived primarily from mining activities, intensive application of phosphates fertilizers and e-waste. Physicochemical characteristics of soil, soil microorganisms, temperature as well as the physiological features of rice plants all contribute to Cd accumulation in rice grains, which can be controlled to mitigate Cd accumulation in rice grains. This review will provide a scientific reference for Cd pollution control and management with respect to paddy field ecosystems in China and other countries.

General Versus Neuraxial Anesthesia for Appendectomy: A Multicenter International Study.

BACKGROUND: In resource-limited countries, open appendectomy is still performed under general anesthesia (GA) or neuraxial anesthesia (NA). We sought to compare the postoperative outcomes of appendectomy under NA versus GA. METHODS: We conducted a post hoc analysis of the International Patterns of Opioid Prescribing (iPOP) multicenter study. All patients ≥ 16 years-old who underwent an open appendectomy between October 2016 and March 2017 in one of the 14 participating hospitals were included. Patients were stratified into two groups: NA-defined as spinal or epidural-and GA. All-cause morbidity, hospital length of stay (LOS), and pain severity were assessed using univariate analysis followed by multivariable logistic regression adjusting for the following preoperative characteristics: age, gender, body mass index (BMI), smoking, history of opioid use, emergency status, and country. RESULTS: A total of 655 patients were included, 353 of which were in the NA group and 302 in the GA group. The countries operating under NA were Colombia (39%), Thailand (31%), China (23%), and Brazil (7%). Overall, NA patients were younger (mean age (SD): 34.5 (14.4) vs. 40.7 (17.9), p-value < 0.001) and had a lower BMI (mean (SD): 23.5 (3.8) vs. 24.3 (5.2), p-value = 0.040) than GA patients. On multivariable analysis, NA was independently associated with less postoperative complications (OR, 95% CI: 0.30 [0.10-0.94]) and shorter hospital LOS (LOS > 3 days, OR, 95% CI: 0.47 [0.32-0.68]) compared to GA. There was no difference in postoperative pain severity between the two techniques. CONCLUSIONS: Open appendectomy performed under NA is associated with improved outcomes compared to that performed under GA. Further randomized controlled studies should examine the safety and value of NA in lower abdominal surgery.

Pain or No Pain, We Will Give You Opioids: Relationship Between Number of Opioid Pills Prescribed and Severity of Pain after Operation in US vs Non-US Patients.

BACKGROUND: Patients in the US receive disproportionally higher amounts of opioids after operations compared with their non-US counterparts. We aimed to assess the relationship between perceived pain severity after operation and the amount of opioid medications prescribed at discharge in US vs non-US patients. METHODS: We conducted a post-hoc analysis of the International Patterns of Opioid Prescribing multicenter study. Patients 16 years and older who underwent appendectomy, cholecystectomy, or inguinal herniorrhaphy in 1 of 14 participating hospitals across 8 countries between October 2016 and March 2017 were included. In hospitals where pain severity was assessed using a 0 to 10 visual analog scale before hospital discharge, patients were stratified into the following groups, depending on the pain severity: none, mild (1 to 3), moderate (4 to 6), and severe (7 to 10). The number of opioid prescriptions, total number of pills, and oral morphine equivalents prescribed were calculated for each group and US and non-US patients were compared. RESULTS: A total of 2,024 patients were included. Eighty-three percent of US patients without pain were prescribed opioids compared with 8.7% of non-US patients without pain (p < 0.001). The number of opioid prescriptions, number of pills, and oral morphine equivalents prescribed were similar across the 4 pain severity groups in US patients (p > 0.05). In contrast, the number of opioid prescriptions, number of opioid pills, and oral morphine equivalents prescribed among non-US patients were incrementally higher as the pain severity progressed from no pain to severe pain (all, p < 0.05). CONCLUSIONS: US patients are prescribed opioids at high rates and doses regardless of pain severity. Additional efforts should be directed toward tailoring opioid prescriptions to patients' needs.

The Geriatric Nutritional Risk Index is a powerful predictor of adverse outcome in the elderly emergency surgery patient.

BACKGROUND: The degree to which malnutrition impacts perioperative outcomes in the elderly emergency surgery (ES) patient remains unknown. We aimed to study the relationship between malnutrition, as measured by the Geriatric Nutritional Risk Index (GNRI), and postoperative outcomes in elderly patients undergoing ES. METHODS: Using the 2007 to 2016 American College of Surgeons National Surgical Quality Improvement Program database, all patients 65 years or older undergoing ES were included in our study. The GNRI, defined as (1.489 × albumin [g/L]) + (41.7 × [weight/ideal weight]) was calculated for each patient in the database. Patients with missing height, weight, or preoperative albumin data were excluded. Patients were divided into four malnutrition groups: very severe (GNRI < 73), severe (GNRI, 73-82), moderate (GNRI, 82-92), and mild (GNRI, 92-98). Geriatric Nutritional Risk Index greater than 98 constituted the normal nutrition group. Risk-adjusted multivariable logistic regressions were performed to study the relationship between malnutrition-measured using either GNRI, albumin level, or body mass index less than 18.5 kg/m-and the following postoperative outcomes: 30-day mortality, 30-day morbidity (including infectious and noninfectious complications), and hospital length of stay. The relationship between GNRI score and 30-day mortality for six common ES procedures was then assessed. RESULTS: A total of 82,725 patients were included in the final analyses. Of these, 55,214 were malnourished with GNRI less than 98 (66.74%). Risk-adjusted multivariable analyses showed that, as malnutrition worsened from mild to very severe, the risk of mortality, morbidity, and the hospital length of stay progressively increased (all p < 0.05). Patients with very severe malnutrition had at least a twofold increased likelihood of mortality (odds ratio [OR], 2.79; 95% confidence interval [CI], 2.57-3.03), deep vein thrombosis (OR, 2.07; 95% CI, 1.77-2.42), and respiratory failure (OR, 1.95; 95% CI, 1.81-2.11). Geriatric Nutritional Risk Index predicted mortality better than albumin or body mass index alone for ES. CONCLUSION: Malnutrition, measured using GNRI, is a strong independent predictor of adverse outcomes in the elderly ES patient and could be used to assess the nutrition status and counsel patients (and families) preoperatively. LEVEL OF EVIDENCE: Prognostic study, Level IV.

Microplastics in soils: A review of methods, occurrence, fate, transport, ecological and environmental risks.

The global prevalence of microplastics (MPs) poses a potential threat and unpredictable risk to the function and health of environmental systems. However, the research progress of soil MPs is restricted by the inherent technical inconformity and difficulties in analyzing particles in complex matrices. Here, we reviewed a selection of papers and then extrapolated a tentative standardized method for such analyses. The multiple sources of soil MPs in soil need to be quantified. Global monitoring data of soil MPs is far from sufficient. The interaction between MPs and different properties and environmental factors controls the migration and retention of MPs in soil. The migration behavior and key mechanisms of MPs in real-world environments remain to be determined. The presence of MPs threatens soil microbial-plant-animal ecosystem function and health, and may enter the human body through the food chain, although the extent of these hazards is currently debated. In particular, attention should be paid to the potential transport and ecotoxicological mechanisms of contaminants derived and adsorptive from MPs and of harmful microorganisms (such as pathogens) attached as biofilms. Although there exist preliminary studies on soil MPs, it is urgent to consider the diversity of MPs as a suite of contaminants and to systematically understand the sources, flux and effects of these artificial pollutants in time and space from the perspective of plastic environmental cycle. More comprehensive quantification of their environmental fate is undertaken to identify risks to global human and ecological systems. From the perspective of controlling soil MP pollution, the responsibility assignment of government manage-producer-consumer system and the strategy of remediation should be implemented. This review is helpful for providing an important roadmap and inspiration for the research methods and framework of soil MPs and facilitates the development of waste management and remediation strategies for regional soil MP contamination.

Opioids After Surgery in the United States Versus the Rest of the World: The International Patterns of Opioid Prescribing (iPOP) Multicenter Study.

OBJECTIVE: The International Patterns of Opioid Prescribing study compares postoperative opioid prescribing patterns in the United States (US) versus the rest of the world. SUMMARY OF BACKGROUND DATA: The US is in the middle of an unprecedented opioid epidemic. Diversion of unused opioids contributes to the opioid epidemic. METHODS: Patients ≥16 years old undergoing appendectomy, cholecystectomy, or inguinal hernia repair in 14 hospitals from 8 countries during a 6-month period were included. Medical records were systematically reviewed to identify: (1) preoperative, intraoperative, and postoperative characteristics, (2) opioid intake within 3 months preoperatively, (3) opioid prescription upon discharge, and (4) opioid refills within 3 months postoperatively. The median/range and mean/standard deviation of number of pills and OME were compared between the US and non-US patients. RESULTS: A total of 4690 patients were included. The mean age was 49 years, 47% were female, and 4% had opioid use history. Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients (P < 0.001). The median number of opioid pills and OME prescribed were 20 (0-135) and 150 (0-1680) mg for US versus 0 (0-50) and 0 (0-600) mg for non-US patients, respectively (both P < 0.001). The mean number of opioid pills and OME prescribed were 23.1 ±â€Š13.9 in US and 183.5 ±â€Š133.7 mg versus 0.8 ±â€Š3.9 and 4.6 ±â€Š27.7 mg in non-US patients, respectively (both P < 0.001). Opioid refill rates were 4.7% for US and 1.0% non-US patients (P < 0.001). CONCLUSIONS: US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US.