Review of Risk Assessment Tools to Predict Morbidity and Mortality in Elderly Surgical Patients Brief title: Review of surgical risk assessment tools

Background Informed surgical consent requires accurate estimation of risks and benefits. Multiple risk assessment tools are available; however, most are not widely used or are specific to certain interventions. Assessing surgical risk is especially challenging in elderly patients because of their range of comorbidities, level of frailty, or severity of illness and a number of available surgical interventions. Data sources We searched MEDLINE from January 2014 to July 2017 for studies that used risk assessment tools in studies on elderly surgical patients. We then sought the original articles describing each assessment tool and subsequent validation studies. Conclusions We identified risk assessment tools that can improve surgical risk assessment in elderly surgical patients. The majority of the identified tools are not commonly used for pre-operative risk assessment. NSQIP-PMP, mFI and SURPAS are promising tools. Age is commonly used to predict risk, but frailty may be a more appropriate measure

Post-glacial sea-level change along the Pacific coast of North America

Sea-level history since the Last Glacial Maximum on the Pacific margin of North America is complex and heterogeneous owing to regional differences in crustal deformation (neotectonics), changes in global ocean volumes (eustasy) and the depression and rebound of the Earth\u27s crust in response to ice sheets on land (isostasy). At the Last Glacial Maximum, the Cordilleran Ice Sheet depressed the crust over which it formed and created a raised forebulge along peripheral areas offshore. This, combined with different tectonic settings along the coast, resulted in divergent relative sea-level responses during the Holocene. For example, sea level was up to 200 m higher than present in the lower Fraser Valley region of southwest British Columbia, due largely to isostatic depression. At the same time, sea level was 150 m lower than present in Haida Gwaii, on the northern coast of British Columbia, due to the combined effects of the forebulge raising the land and lower eustatic sea level. A forebulge also developed in parts of southeast Alaska resulting in post-glacial sea levels at least 122 m lower than present and possibly as low as 165 m. On the coasts of Washington and Oregon, as well as south-central Alaska, neotectonics and eustasy seem to have played larger roles than isostatic adjustments in controlling relative sea-level changes

Is current preoperative frailty assessment adequate?

Preoperative frailty predicts adverse postoperative outcomes. Recommendations for preoperative assessment of elderly patients include performing a frailty assessment. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical health care professionals’ perception and use of frailty assessment for perioperative care. We surveyed local health care employees to assess their attitudes toward and practices for frail patients. Nurses and allied health professionals were more likely than surgeons to agree frailty should play a role in planning a patient’s care. Lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians understanding that frailty affects their patients’ outcomes. Results of this survey suggest further training in frailty issues and the use of frailty assessment instruments is necessary and could improve the uptake of such tools for perioperative care planning

Is current preoperative frailty assessment adequate?

Preoperative frailty predicts adverse postoperative outcomes. Recommendations for preoperative assessment of elderly patients include performing a frailty assessment. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical health care professionals’ perception and use of frailty assessment for perioperative care. We surveyed local health care employees to assess their attitudes toward and practices for frail patients. Nurses and allied health professionals were more likely than surgeons to agree frailty should play a role in planning a patient’s care. Lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians understanding that frailty affects their patients’ outcomes. Results of this survey suggest further training in frailty issues and the use of frailty assessment instruments is necessary and could improve the uptake of such tools for perioperative care planning

A post-glacial sea level hinge on the central Pacific coast of Canada

Post-glacial sea level dynamics during the last 15,000 calendar years are highly variable along the Pacific coast of Canada. During the Last Glacial Maximum, the Earth\u27s crust was depressed by ice loading along the mainland inner coast and relative sea levels were as much as 200 m higher than today. In contrast, some outer coastal areas experienced a glacial forebulge (uplift) effect that caused relative sea levels to drop to as much as 150 m below present levels. Between these inner and outer coasts, we hypothesize that there would have been an area where sea level remained relatively stable, despite regional and global trends in sea level change. To address this hypothesis, we use pond basin coring, diatom analysis, archaeological site testing, sedimentary exposure sampling, and radiocarbon dating to construct sea level histories for the Hakai Passage region. Our data include 106 newly reported radiocarbon ages from key coastal sites that together support the thesis that this area has experienced a relatively stable sea level over the last 15,000 calendar years. These findings are significant in that they indicate a relatively stable coastal environment amenable to long-term human occupation and settlement of the area. Our results will help inform future archaeological investigations in the region

Estimating aerodynamic roughness over complex surface terrain

Surface roughness plays a key role in determining aerodynamic roughness length (zo) and shear velocity, both of which are fundamental for determining wind erosion threshold and potential. While zo can be quantified from wind measurements, large proportions of wind erosion prone surfaces remain too remote for this to be a viable approach. Alternative approaches therefore seek to relate zo to morphological roughness metrics. However, dust-emitting landscapes typically consist of complex small-scale surface roughness patterns and few metrics exist for these surfaces which can be used to predict zo for modeling wind erosion potential. In this study terrestrial laser scanning was used to characterize the roughness of typical dust-emitting surfaces (playa and sandar) where element protrusion heights ranged from 1 to 199 mm, over which vertical wind velocity profiles were collected to enable estimation of zo. Our data suggest that, although a reasonable relationship (R2 > 0.79) is apparent between 3-D roughness density and zo, the spacing of morphological elements is far less powerful in explaining variations in zo than metrics based on surface roughness height (R2 > 0.92). This finding is in juxtaposition to wind erosion models that assume the spacing of larger-scale isolated roughness elements is most important in determining zo. Rather, our data show that any metric based on element protrusion height has a higher likelihood of successfully predicting zo. This finding has important implications for the development of wind erosion and dust emission models that seek to predict the efficiency of aeolian processes in remote terrestrial and planetary environments

The association of peri-operative scores, including frailty, with outcomes after unscheduled surgery

Summary Postoperative hospital stay is longer for frail, older patients, who are more likely to experience prolonged postoperative morbidity and reduced long‐term survival. We recorded in‐hospital mortality, morbidity and length of stay for 164 patients aged at least 65 years after unscheduled surgery. We evaluated pre‐operative frailty with the 7‐point Clinical Frailty Scale: 81 patients were ‘not vulnerable’ (frailty score 1–3) and 83 were ‘vulnerable or frail’ (frailty score urn:x-wiley:00032409:media:anae14269:anae14269-math-0001 4), with mean (SD) ages of 74.7 (7.5) years vs. 79.4 (8.3) years, respectively, p < 0.001. Within 30 postoperative days 8/164 (5%) patients died, all with frailty scores urn:x-wiley:00032409:media:anae14269:anae14269-math-0002 4, p = 0.007. Postoperative morbidity was less frequent in patients categorised as ‘not vulnerable’ on four out of the six days it was measured (days 3, 5, 8, 14, 23, 28). Median (IQR [range]) postoperative stay was 9 (6–18 [2–221]) days for patients with frailty scores 1–3, and 22 (12–33 [2–270]) days for patients with score urn:x-wiley:00032409:media:anae14269:anae14269-math-0003 4, p < 0.001. Four variables independently associated with hospital discharge, hazard ratio (95%CI): E‐POSSUM, 0.74 (0.60–0.92), p = 0.007; ASA 2, 0.35 (0.13–0.98), p = 0.046, ASA 3, 0.17 (0.06–0.47), p = 0.001 and ASA 4/5, 0.08 (0.02–0.28), p < 0.001; operative severity ‘major +’, 0.69 (0.41–1.08), p = 0.10 and the Surgical Outcome Risk Tool, 7.75 (0.81–74.40), p = 0.08

Interlinkages: Governance for Sustainability Chapter 8

The Earth functions as a system: atmosphere, land, water, biodiversity and human society are all linked in a complex web of interactions and feedbacks. Environment and development challenges are interlinked across thematic, institutional and geographic boundaries through social and environmental processes. The state of knowledge on these interlinkages and implications for human well-being are highlighted in the following messages: Environmental change and development challenges are caused by the same sets of drivers. They include population change, economic processes, scientific and technological innovations, distribution patterns, and cultural, social, political and institutional processes

Local Response in Health Emergencies: Key Considerations for Addressing the COVID-19 Pandemic in Informal Urban Settlements

This paper highlights the major challenges and considerations for addressing COVID-19 in informal settlements. It discusses what is known about vulnerabilities and how to support local protective action. There is heightened concern about informal urban settlements because of the combination of population density and inadequate access to water and sanitation, which makes standard advice about social distancing and washing hands implausible. There are further challenges to do with the lack of reliable data and the social, political and economic contexts in each setting that will influence vulnerability and possibilities for action. The potential health impacts of COVID-19 are immense in informal settlements, but if control measures are poorly executed these could also have severe negative impacts. Public health interventions must be balanced with social and economic interventions, especially in relation to the informal economy upon which many poor urban residents depend. Local residents, leaders and communitybased groups must be engaged and resourced to develop locally appropriate control strategies, in partnership with local governments and authorities. Historically, informal settlements and their residents have been stigmatized, blamed, and subjected to rules and regulations that are unaffordable or unfeasible to adhere to. Responses to COVID-19 should not repeat these mistakes. Priorities for enabling effective control measures include: collaborating with local residents who have unsurpassed knowledge of relevant spatial and social infrastructures, strengthening coordination with local governments, and investing in improved data for monitoring the response in informal settlements