Clinical risk stratification of paediatric renal transplant recipients using C1q and C3d fixing of de novo donor-specific antibodies

Introduction: We have previously shown that children who developed de novo donor-specific human leukocyte antigen (HLA) antibodies (DSA) had greater decline in allograft function. We hypothesised that patients with complement-activating DSA would have poorer renal allograft outcomes. Methods: A total of 75 children developed DSA in the original study. The first positive DSA sample was subsequently tested for C1q and C3d fixing. The primary event was defined as 50% reduction from baseline estimated glomerular filtration rate and was analysed using the Kaplan–Meier estimator. Results: Of 65 patients tested, 32 (49%) and 23 (35%) tested positive for C1q and C3d fixing, respectively. Of the 32 C1q-positive (c1q+) patients, 13 (41%) did not show concomitant C3d fixing. The mean fluorescence intensity values of the original immunoglobulin G DSA correlated poorly with complement-fixing positivity (C1q: adjusted R2 0.072; C3d: adjusted R2 0.11; p < 0.05). C1q+ antibodies were associated with acute tubulitis [0.75 ± 0.18 (C1q+) vs. 0.25 ± 0.08 (C1q−) episodes per patient (mean ± standard error of the mean; p < 0.05] but not with worse long-term renal allograft dysfunction (median time to primary event 5.9 (C1q+) vs. 6.4 (C1q−) years; hazard ratio (HR) 0.74; 95% confidence ratio (CI) 0.30–1.81; p = 0.58]. C3d-positive (C3d+) antibodies were associated with positive C4d histological staining [47% (C3d+) vs. 20% (C3d−); p = 0.04] and with significantly worse long-term allograft dysfunction [median time to primary event: 5.6 (C3d+) vs. 6.5 (C3d−) years; HR 0.38; 95% CI 0.15–0.97; p = 0.04]. Conclusion: Assessment of C3d fixing as part of prospective HLA monitoring can potentially aid stratification of patients at the highest risk of long-term renal allograft dysfunction

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Imaging near-surface defects using step-frequency ground-penetrating radar

Step-Frequency GPR (SFGPR) investigations were carried out at the location of a crude oil storage tank at a petroleum refinery. The storage tank was founded on an elevated platform (tank-pad). Subsidence of a portion of the tank-pad led to cracking of its bottom steel plates and subsequent leakage of crude oil. SFGPR imaging was done within and outside the tank, in the frequency range of 10-260 MHz, to understand the cause of the subsidence. Complex signal analysis was useful in identifying a series of cavities in the subsurface, in the depth range of 2-15 m, close to the location of subsidence of the tank-pad. In order to stabilize the foundation of the tank, the subsurface area infested with cavities was grouted systematically. SFGPR imaging was done again after grouting, in the same area in the same manner to evaluate the efficacy of grouting and check for presence of remnant cavities. Results of the SFGPR investigations, before and after grouting, which aided restoration of the foundation of the oil tank, are discussed

Imaging weak zones in the foundation using frequency domain attenuation tomography

Cross-hole imaging method using Time Domain (TD) and Frequency Domain (FD) parts of cross-hole radar tomography data acquired using Step Frequency Ground Penetrating Radar (SFGPR) was implemented. This method was adopted for imaging foundation of a dam to check if the foundation was free of geological weak zones. The dam site is characterised by massive and jointed-phyllites associated with major and minor shears. The cross-hole radar tomography data was acquired in the frequency bandwidth of 250 MHz, from the deepest level gallery up to a depth of 40 m in the foundation. In TD, first arrival time and amplitudes of radio waves were inverted using Simultaneous Iterative Reconstruction Technique (SIRT) resulting in velocity and attenuation tomograms. The tomograms showed nearly uniform velocity or attenuation structure in the respective tomographic plane. Subsequently, cross-hole radar tomography data was analysed in FD for a variation of spectrum-amplitude at different frequencies. Amplitudes picked at each single frequency were then inverted using SIRT for obtaining frequency domain attenuation tomogram (FDAT). The FDAT clearly showed presence of anomalous high attenuation zones in the depth range of 23-33 m of the tomographic plane. The anomalous zones in the attenuation tomogram are weak zones in the foundation. To validate the above observations, cross-hole seismic tomography was also done in the same boreholes. Cross-hole seismic tomography results showed low velocity (p-wave) zones around the same location corresponding to the high attenuation zone in FDAT, bringing the dormant weak zone to light. This enabled fine-tuning of the reinforcement design and strengthening the weak zone. This paper discusses the cross-hole radar tomography imaging method, the results of its application in imaging weak zones in the foundation and the comparison of cross-hole radar tomography results (in TD and FD) with the cross-hole seismic tomography results. (c) 2013 Elsevier B.V. All rights reserved