NICE guidance on sepsis is of limited value in postoperative colorectal patients: the scores that cry ‘wolf!’

Background and aimsLate recognition of sepsis and consequent death remains a problem. To address this, the National Institute for Health and Care Excellence has published updated guidance recommending the use of the Quick Sequential Organ Failure Assessment (Q-SOFA) score when assessing patients at risk of sepsis following the publication of the Third International Consensus Definitions for Sepsis and Septic Shock. The trauma from major surgery produces a systemic inflammatory response syndrome (SIRS) postoperatively as part of its natural history, which may falsely trigger scoring systems. We aimed to assess the accuracy of Q-SOFA and SIRS criteria as recommended scores for early detection of sepsis and septic complications in the first 48hrs after colorectal cancer surgery.MethodsWe reviewed all elective major colorectal operations in a single centre during a 12-month period from prospectively maintained electronic records.ResultsOne hundred and thirty nine patients were included in this study. In all, 29 patients developed postoperative infective complications in hospital. Nineteen patients triggered on SIRS without developing infective complications, while 42 patients triggered on Q-SOFA with no infective complications. The area under the ROC curve was 0.52 for Q-SOFA and 0.67 for SIRS.DiscussionQ-SOFA appears to perform little better than a coin toss at identifying postoperative sepsis after colorectal cancer resection and is inferior to the SIRS criteria. More work is required to assess whether a combination of scoring criteria, biochemical markers and automated tools could increase accurate detection of postoperative infection and trigger early intervention

Seasonal forecasts of North Atlantic tropical cyclone activity in the North American Multi-Model Ensemble

The North American Multi-Model Ensemble (NMME)-Phase II models are evaluated in terms of their retrospective seasonal forecast skill of the North Atlantic (NA) tropical cyclone (TC) activity, with a focus on TC frequency. The TC identification and tracking algorithm is modified to accommodate model data at daily resolution. It is also applied to three reanalysis products at the spatial and temporal resolution of the NMME-Phase II ensemble to allow for a more objective estimation of forecast skill. When used with the reanalysis data, the TC tracking generates realistic climatological distributions of the NA TC formation and tracks, and represents the interannual variability of the NA TC frequency quite well. Forecasts with the multi-model ensemble (MME) when initialized in April and later tend to have skill in predicting the NA seasonal TC counts (and TC days). At longer leads, the skill is low or marginal, although one of the models produces skillful forecasts when initialized as early as January and February. At short lead times, while demonstrating the highest skill levels the MME also tends to significantly outperform the individual models and attain skill comparable to the reanalysis. In addition, the short-lead MME forecasts are quite reliable. At regional scales, the skill is rather limited and mostly present in the western tropical NA and the Caribbean Sea. It is found that the overall MME forecast skill is limited by poor representation of the low-frequency variability in the predicted TC frequency, and large fluctuations in skill on decadal time scales. Addressing these deficiencies is thought to increase the value of the NMME ensemble in providing operational guidance

Exploration of Shared Genetic Architecture Between Subcortical Brain Volumes and Anorexia Nervosa

In MRI scans of patients with anorexia nervosa (AN), reductions in brain volume are often apparent. However, it is unknown whether such brain abnormalities are influenced by genetic determinants that partially overlap with those underlying AN. Here, we used a battery of methods (LD score regression, genetic risk scores, sign test, SNP effect concordance analysis, and Mendelian randomization) to investigate the genetic covariation between subcortical brain volumes and risk for AN based on summary measures retrieved from genome-wide association studies of regional brain volumes (ENIGMA consortium, n = 13,170) and genetic risk for AN (PGC-ED consortium, n = 14,477). Genetic correlations ranged from − 0.10 to 0.23 (all p > 0.05). There were some signs of an inverse concordance between greater thalamus volume and risk for AN (permuted p = 0.009, 95% CI: [0.005, 0.017]). A genetic variant in the vicinity of ZW10, a gene involved in cell division, and neurotransmitter and immune system relevant genes, in particular DRD2, was significantly associated with AN only after conditioning on its association with caudate volume (pFDR = 0.025). Another genetic variant linked to LRRC4C, important in axonal and synaptic development, reached significance after conditioning on hippocampal volume (pFDR = 0.021). In this comprehensive set of analyses and based on the largest available sample sizes to date, there was weak evidence for associations between risk for AN and risk for abnormal subcortical brain volumes at a global level (that is, common variant genetic architecture), but suggestive evidence for effects of single genetic markers. Highly powered multimodal brain- and disorder-related genome-wide studies are needed to further dissect the shared genetic influences on brain structure and risk for AN

Adaptation to climate change: contemporary challenges and perspectives

Over the past few decades, attempts at adaptation to climate change (current and future) in the Pacific Islands have largely failed to be either effective or sustained. Among the many reasons for this failure may be that most adaptation strategies have been designed and driven by outsiders rather than by persons familiar with island contexts and diversity, especially the sociocultural nuances of particular situations. In a series of eight thematic case studies, written by scientists with an intimate understanding of the Pacific Islands, this chapter explores the reasons behind adaptation failure and explains what needs to improve in the future for adaptation to be both effective and sustained. Case studies focus on rural seawalls, relocation and peripherality as a proxy for autonomous community coping, climate finance, island food systems, adaptation project design, livelihood sustainability and inter-island resettlement. The goal of this chapter is to inform stakeholders how to optimise outcomes from future adaptation interventions, something that is becoming daily more urgent as the pace of twenty-first century climate change increases

Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference

Background: The last 30 years have witnessed a significant increase in the diagnosis of early-stage rectal cancer and the development of new strategies to reduce the treatment-related morbidity. Currently, there is no consensus on the definition of early rectal cancer (ERC), and the best management of ERC has not been yet defined. The European Association for Endoscopic Surgery in collaboration with the European Society of Coloproctology developed this consensus conference to provide recommendations on ERC diagnosis, staging and treatment based on the available evidence. Methods: A multidisciplinary group of experts selected on their clinical and scientific expertise was invited to critically review the literature and to formulate evidence-based recommendations by the Delphi method. Recommendations were discussed at the plenary session of the 14th World Congress of Endoscopic Surgery, Paris, 26 June 2014, and then posted on the EAES website for open discussion. Results: Tumour biopsy has a low accuracy. Digital rectal examination plays a key role in the pre-operative work-up. Magnification chromoendoscopy, endoscopic ultrasound and magnetic resonance imaging are complementary staging modalities. Endoscopic submucosal dissection and transanal endoscopic microsurgery are the two established approaches for local excision (LE) of selected ERC. The role of all organ-sparing approaches including neoadjuvant therapies followed by LE should be formally assessed by randomized controlled trials. Rectal resection and total mesorectal excision is indicated in the presence of unfavourable features at the pathological evaluation of the LE specimen. The laparoscopic approach has better short-term outcomes and similar oncologic results when compared with open surgery. Conclusions: The management of ERC should always be based on a multidisciplinary approach, aiming to increase the rate of organ-preserving procedures without jeopardizing survival