Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Unified View of Magnetic Nanoparticle Separation under Magnetophoresis

The migration process of magnetic nanoparticles and colloids in solution under the influence of magnetic field gradients, which is also known as magnetophoresis, is an essential step in the separation technology used in various biomedical and engineering applications. Many works have demonstrated that in specific situations, separation can be performed easily with the weak magnetic field gradients created by permanent magnets, a process known as low-gradient magnetic separation (LGMS). Due to the level of complexity involved, it is not possible to understand the observed kinetics of LGMS within the classical view of magnetophoresis. Our experimental and theoretical investigations in the last years unravelled the existence of two novel physical effects that speed up the magnetophoresis kinetics and explain the observed feasibility of LGMS. Those two effects are (i) cooperative magnetophoresis (due to the cooperative motion of strongly interacting particles) and (ii) magnetophoresis-induced convection (fluid dynamics instability originating from inhomogeneous magnetic gradients). In this feature article, we present a unified view of magnetophoresis based on the extensive research done on these effects. We present the physical basis of each effect and also propose a classification of magnetophoresis into four distinct regimes. This classification is based on the range of values of two dimensionless quantities, namely, aggregation parameter N* and magnetic Grashof number Grm, which include all of the dependency of LGMS on various physical parameters (such as particle properties, thermodynamic parameters, fluid properties, and magnetic field properties). This analysis provides a holistic view of the classification of transport mechanisms in LGMS, which could be particularly useful in the design of magnetic separators for engineering applications.The authors thank Lluis M. Martinez of Sepmag Systems SL for sharing images of magnetic separators and for invaluable discussions during the last few years about magnetic separation. We also thank Fernando Martinez-Pedrero (UB) for sharing images of his samples. J.L.’s work is financially supported by an LRGS grant from the Ministry of Education Malaysia (project number 67215001). S.S.L. acknowledges the support of UTARRF (project number IPSR/RMC/UTARRF/2019-C2/L04). J.C. acknowledges financial support by Spain’s Ministerio de Ciencia, Innovación y Universidades under grant no. RTI2018-097876-B-C22 (MCIU/AEI/FEDER, UE). J.F. is supported by the Spanish Ministry of Science and Innovation through research grant RTI2018-096273-B-I00 and the Severo Ochoa Programme for Centres of Excellence in R&D (SEV-2015-0496) awarded to ICMAB.Peer reviewe

Pentacyclic and hexacyclic cucurbitacins from Elaeocarpus petiolatus

Four undescribed cucurbitacins, designated as petiolaticins A–D, and four known cucurbitacins were isolated from the bark and leaves of Elaeocarpus petiolatus (Jack) Wall. Their chemical structures were elucidated based on detailed analyses of the NMR and MS data. The absolute configuration of petiolaticin A was also determined by X-ray diffraction analysis. Petiolaticin A represents a cucurbitacin derivative incorporating a 3,4-epoxyfuranyl-bearing side chain, while petiolaticin B possesses a furopyranyl unit fused to the tetracyclic cucurbitane core structure. Petiolaticins A, B, and D were evaluated in vitro against a panel of human breast, pancreatic, and colorectal cancer cell lines. Petiolaticin A exhibited the greatest cytotoxicity against the MDA-MB-468, MDA-MB-231, MCF-7, and SW48 cell lines (IC50 7.4, 9.2, 9.3, and 4.6 μM, respectively). Additionally, petiolaticin D, 16α,23α-epoxy-3β,20β-dihydroxy-10αH,23βH-cucurbit-5,24-dien-11-one, and 16α,23α-epoxy-3β,20β-dihydroxy-10αH,23βH-cucurbit-5,24-dien-11-one 3-O-β-D-glucopyranoside were tested for their ability to inhibit cell entry of a pseudotyped virus bearing the hemagglutinin envelope protein of a highly pathogenic avian influenza virus. Petiolaticin D showed the highest inhibition (44.3%), followed by 16α,23α-epoxy-3β,20β-dihydroxy-10αH,23βH-cucurbit-5,24-dien-11-one (21.0%), and 16α,23α-epoxy-3β,20β-dihydroxy-10αH,23βH-cucurbit-5,24-dien-11-one 3-O-β-D-glucopyranoside showed limited inhibition (9.0%). These preliminary biological assays have demonstrated that petiolaticins A and D possess anticancer and antiviral properties, respectively, which warrant for further investigations

Maritime Interdiction Operations in Logistically Barren Environments

Includes supplementary materialThis report contains analysis that shows that existing technology exists to improve Maritime Interdiction Operations (MIO) by approximately 30%. Furthermore, analysis contained herein will aid MIO planning for future operations. Since MIOs are an inherently dangerous, but necessary activity with far reaching implications to theater political and economic dynamics, this improvement is of great interest. MIO is a Naval solution to the problems of smuggling weapons, explosives, people and narcotics. MIO, when employed correctly has the potential to save lives and limit economic/political damage.N

A Bis-benzopyrroloisoquinoline Alkaloid Incorporating a Cyclobutane Core and a Chlorophenanthroindolizidine Alkaloid with Cytotoxic Activity from <i>Ficus fistulosa</i> var. <i>tengerensis</i>

Tengerensine (<b>1</b>), isolated as a racemate and constituted from a pair of bis-benzopyrroloisoquinoline enantiomers, and tengechlorenine (<b>2</b>), purified as a scalemic mixture and constituted from a pair of chlorinated phenanthroindolizidine enantiomers, were isolated from the leaves of <i>Ficus fistulosa</i> var. <i>tengerensis</i>, along with three other known alkaloids. The structures of <b>1</b> and <b>2</b> were determined by spectroscopic data interpretation and X-ray diffraction analysis. The enantiomers of <b>1</b> were separated by chiral-phase HPLC, and the absolute configurations of (+)-<b>1</b> and (−)-<b>1</b> were established via experimental and calculated ECD data. Compound <b>1</b> is notable in being a rare unsymmetrical cyclobutane adduct and is the first example of a dimeric benzopyrroloisoquinoline alkaloid, while compound <b>2</b> represents the first naturally occurring halogenated phenanthroindolizidine alkaloid. Compound (+)-<b>1</b> displayed a selective in vitro cytotoxic effect against MDA-MB-468 cells (IC₅₀ 7.4 μM), while compound <b>2</b> showed pronounced in vitro cytotoxic activity against all three breast cancer cell lines tested (MDA-MB-468, MDA-MB-231, and MCF7; IC₅₀ values of 0.038–0.91 μM)

Blomia tropicalis–Specific TCR Transgenic Th2 Cells Induce Inducible BALT and Severe Asthma in Mice by an IL-4/IL-13–Dependent Mechanism

Previous studies have highlighted the importance of lung-draining lymph nodes in the respiratory allergic immune response, whereas the lung parenchymal immune system has been largely neglected. We describe a new in vivo model of respiratory sensitization to Blomia tropicalis, the principal asthma allergen in the tropics, in which the immune response is focused on the lung parenchyma by transfer of Th2 cells from a novel TCR transgenic mouse, specific for the major B. tropicalis allergen Blo t 5, that targets the lung rather than the draining lymph nodes. Transfer of highly polarized transgenic CD4 effector Th2 cells, termed BT-II, followed by repeated inhalation of Blo t 5 expands these cells in the lung &gt;100-fold, and subsequent Blo t 5 challenge induced decreased body temperature, reduction in movement, and a fall in specific lung compliance unseen in conventional mouse asthma models following a physiological allergen challenge. These mice exhibit lung eosinophilia; smooth muscle cell, collagen, and goblet cell hyperplasia; hyper IgE syndrome; mucus plugging; and extensive inducible BALT. In addition, there is a fall in total lung volume and forced expiratory volume at 100 ms. These pathophysiological changes were substantially reduced and, in some cases, completely abolished by administration of neutralizing mAbs specific for IL-4 and IL-13 on weeks 1, 2, and 3. This IL-4/IL-13-dependent inducible BALT model will be useful for investigating the pathophysiological mechanisms that underlie asthma and the development of more effective drugs for treating severe asthma

Blomia tropicalis-Specific TCR Transgenic Th2 Cells Induce Inducible BALT and Severe Asthma in Mice by an IL-4/IL-13-Dependent Mechanism

10.4049/jimmunol.1502676JOURNAL OF IMMUNOLOGY197103771-378