Performance of cardiopulmonary exercise testing for the prediction of post-operative complications in non cardiopulmonary surgery: A systematic review.

INTRODUCTION: Cardiopulmonary exercise testing (CPET) is widely used within the United Kingdom for preoperative risk stratification. Despite this, CPET's performance in predicting adverse events has not been systematically evaluated within the framework of classifier performance. METHODS: After prospective registration on PROSPERO (CRD42018095508) we systematically identified studies where CPET was used to aid in the prognostication of mortality, cardiorespiratory complications, and unplanned intensive care unit (ICU) admission in individuals undergoing non-cardiopulmonary surgery. For all included studies we extracted or calculated measures of predictive performance whilst identifying and critiquing predictive models encompassing CPET derived variables. RESULTS: We identified 36 studies for qualitative review, from 27 of which measures of classifier performance could be calculated. We found studies to be highly heterogeneous in methodology and quality with high potential for bias and confounding. We found seven studies that presented risk prediction models for outcomes of interest. Of these, only four studies outlined a clear process of model development; assessment of discrimination and calibration were performed in only two and only one study undertook internal validation. No scores were externally validated. Systematically identified and calculated measures of test performance for CPET demonstrated mixed performance. Data was most complete for anaerobic threshold (AT) based predictions: calculated sensitivities ranged from 20-100% when used for predicting risk of mortality with high negative predictive values (96-100%). In contrast, positive predictive value (PPV) was poor (2.9-42.1%). PPV appeared to be generally higher for cardiorespiratory complications, with similar sensitivities. Similar patterns were seen for the association of Peak VO2 (sensitivity 85.7-100%, PPV 2.7-5.9%) and VE/VCO2 (Sensitivity 27.8%-100%, PPV 3.4-7.1%) with mortality. CONCLUSIONS: In general CPET's 'rule-out' capability appears better than its ability to 'rule-in' complications. Poor PPV may reflect the frequency of complications in studied populations. Our calculated estimates of classifier performance suggest the need for a balanced interpretation of the pros and cons of CPET guided pre-operative risk stratification.

Accelerometery as a measure of modifiable physical activity in high-risk elderly preoperative patients: a prospective observational pilot study.

OBJECTIVES: To use wrist-worn accelerometers (Axivity AX3) to establish normative physical activity (PA) and acceptability data for the high-risk elderly preoperative population, to assess whether PA could be modified by a prehabilitation intervention as part of routine care, to assess any correlation between accelerometer-measured PA and self-reported PA and to assess the acceptability of wearing wrist-worn accelerometers in this population. STUDY DESIGN: Prospective, observational, pilot study. SETTING: Single National Health Service Hospital. PARTICIPANTS: Frail patients≥65 years awaiting major surgery referred to a multidisciplinary preoperative clinic at which they received a routine intervention aimed at improving their PA. 35 patients were recruited. Average age 79.9 years (SD=5.6). PRIMARY OUTCOMES: Normative PA data measured as a mean daily Euclidean norm minus one (ENMO) in milli-gravitational units (mg). SECONDARY OUTCOMES: Measure PA levels (mg) following a routine preoperative intervention. Determine correlation between patient-reported PA (measured using the Physical Activity Scale for the Elderly) and accelerometer-measured PA (mg). Assess acceptability of wearing a wrist-worn accelerometer measured using Visual Analogue Scale (VAS) questionnaire and device wear time (hours). RESULTS: Median baseline daily PA was 14.3 mg (IQR 9.75-22.04) with an improvement in PA detected following the intervention (median ENMO post intervention 20.91 mg (IQR 14.83-27.53), p=0.022). There was no significant correlation between accelerometer-measured and self-reported PA (baseline ρ=0.162 (p=0.4), post intervention ρ=-0.144 (p=0.5)). We found high acceptability ratings (median score of 10/10 on VAS, IQR 8-10) and wear-time compliance (163.2 hours (IQR 150-167.5) preintervention and 166.1 hours (IQR 162.5-167) post intervention). CONCLUSIONS: Accelerometery is acceptable to this population and increases in PA levels measured following an unoptimised routine clinical intervention which indicates that health behavioural change interventions may be successful during the preoperative period. Accelerometers may therefore be a useful tool to design and validate interventions for improving PA in this setting. TRIAL REGISTRATION NUMBER: NCT03737903.

A Novel Minimally Invasive Technique for Treatment of Unicameral Bone Cysts.

Management of unicameral bone cysts (UBC) remain controversial. These cysts seldom heal spontaneously or even after pathological fracture. Sometimes these cysts can be very large and incredibly troublesome to the patient. Various treatments exist with variable success rates. We present our experience of treating these lesions by continuous drainage. Over a seven year period, six patients with unicameral bone cysts were treated by inserting a modified drain into the wall of the cyst. The aim of surgery was to place the drain in a dependent area of the cyst, through the cortex allowing for continuous drainage. This was achieved through a small incision under radiographic control. A cement restrictor (usually used for femoral canal plugging during total hip replacements) was modified and inserted to prevent closure of the drain site. A redivac drain was passed through the plug into the cyst. The drain was left in place for a week to establish an epithelialized pathway which hopefully would remain patent, into the subcutaneous tissues, after the drain had been removed. There were four males and two females in the group and the age range was 6 -12 years. Four of the lesions were in the upper humerus, one in the proximal femur and the other one in the proximal tibia. Healing was rated according to the modified Neer classification. Grade 1 (healed) and Grade 2 (healed with defect) was defined as excellent outcome. Persistent /Recurrent cysts (Grade 3 and 4) were noted as unsatisfactory. Five cases were completely healed. Only one had a further fracture and there were no recurrent fractures. All the patients reported complete comfort and they all were able to re-engage in recreational activities without restriction. We think that reducing the intra-medullary pressure in these lesions will lead to healing. We report a safe and minimally invasive technique for the management of UBC.

Fixation of olecranon fractures and osteotomies using compression screws: a simple solution to a common problem. A study of cases.

Olecranon fractures are common skeletal injuries accounting for approximately 10% of upper extremity fractures in adults. Simple non-comminuted fractures are traditionally fixed using the tension band wiring technique. This technique, however, has several complications, most commonly prominence of the metalwork frequently requiring surgery for removal. We describe a retrospective review of a new method of fixation for these fractures using partially threaded screws in an attempt to avoid these complications. We used two 3.5 and/or 4 mm partially threaded screws to fix seven simple olecranon fractures and two olecranon osteotomies. Notes and clinic letters of all nine patients were reviewed for demographic data, operation details and complications. Radiographs were reviewed at final clinical follow-up. The Mayo Elbow Performance Score was completed during a telephone consultation. One patient injured her elbow postoperatively, which resulted in fragmentation of the proximal segment and loss of fixation. In one patient the tip of the screws broke after a fall but this did not result in loss of fixation. There were no problems with metalwork prominence or skin irritation in any of the patients. Two patients had low scores due to loss of fixation, and severely comminuted supracondylar fracture of the humerus. Six patients had good scores. We believe that use of AO compression screws is a valid method for the fixation of simple fractures of the olecranon. It is a safe technique and has several advantages over tension band fixation. There is minimal tissue dissection and operating time is decreased. There is minimal risk of metalwork prominence as screws obtain good purchase in the anterior cortex of ulna. Good interfragmentary compression is achieved as screws are perpendicular to the fracture line and two screws provide good rotational stability. Protection of fixation for 1014 days does not result in significant loss of range of motion. Further clinical and biomechanical studies are suggested to compare this technique with other methods of fixation of olecranon fractures.

Parents' religious coping styles in the first year after their child's cystic fibrosis diagnosis.

Parents of children diagnosed with cystic fibrosis described it as "devastating." Given religion's importance to many Americans, parents may utilize religious coping. Relatively little is known about parents' use of religious coping to handle their child's illness. Interviews with 15 parents about their use of religion in the year following their child's cystic fibrosis diagnosis were coded for religious coping styles. Sixteen styles were identified. Positive religious coping styles were more frequent than negative styles (previously associated with poorer health outcomes), and occurred more frequently than in other studies. Religious coping styles used to make meaning, gain control, or seek comfort/intimacy with God were equally prevalent. The most common styles were: Pleading, Collaboration, Benevolent Religious Reappraisals, and Seeking Spiritual Support. Parents described active rather than passive coping styles. Religious coping involving religious others was rare. Clinical attention to negative religious coping may prevent it becoming chronic and negatively affecting health.