Effect of a Perioperative, Cardiac Output-Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery A Randomized Clinical Trial and Systematic Review

Importance: small trials suggest that postoperative outcomes may be improved by the use of cardiac output monitoring to guide administration of intravenous fluid and inotropic drugs as part of a hemodynamic therapy algorithm.Objective: to evaluate the clinical effectiveness of a perioperative, cardiac output–guided hemodynamic therapy algorithm.Design, setting, and participants: OPTIMISE was a pragmatic, multicenter, randomized, observer-blinded trial of 734 high-risk patients aged 50 years or older undergoing major gastrointestinal surgery at 17 acute care hospitals in the United Kingdom. An updated systematic review and meta-analysis were also conducted including randomized trials published from 1966 to February 2014.Interventions: patients were randomly assigned to a cardiac output–guided hemodynamic therapy algorithm for intravenous fluid and inotrope (dopexamine) infusion during and 6 hours following surgery (n=368) or to usual care (n=366).Main outcomes and measures: the primary outcome was a composite of predefined 30-day moderate or major complications and mortality. Secondary outcomes were morbidity on day 7; infection, critical care–free days, and all-cause mortality at 30 days; all-cause mortality at 180 days; and length of hospital stay.Results: baseline patient characteristics, clinical care, and volumes of intravenous fluid were similar between groups. Care was nonadherent to the allocated treatment for less than 10% of patients in each group. The primary outcome occurred in 36.6% of intervention and 43.4% of usual care participants (relative risk [RR], 0.84 [95% CI, 0.71-1.01]; absolute risk reduction, 6.8% [95% CI, ?0.3% to 13.9%]; P?=?.07). There was no significant difference between groups for any secondary outcomes. Five intervention patients (1.4%) experienced cardiovascular serious adverse events within 24 hours compared with none in the usual care group. Findings of the meta-analysis of 38 trials, including data from this study, suggest that the intervention is associated with fewer complications (intervention, 488/1548 [31.5%] vs control, 614/1476 [41.6%]; RR, 0.77 [95% CI, 0.71-0.83]) and a nonsignificant reduction in hospital, 28-day, or 30-day mortality (intervention, 159/3215 deaths [4.9%] vs control, 206/3160 deaths [6.5%]; RR, 0.82 [95% CI, 0.67-1.01]) and mortality at longest follow-up (intervention, 267/3215 deaths [8.3%] vs control, 327/3160 deaths [10.3%]; RR, 0.86 [95% CI, 0.74-1.00]).Conclusions and relevance: in a randomized trial of high-risk patients undergoing major gastrointestinal surgery, use of a cardiac output–guided hemodynamic therapy algorithm compared with usual care did not reduce a composite outcome of complications and 30-day mortality. However, inclusion of these data in an updated meta-analysis indicates that the intervention was associated with a reduction in complication rate

Invasive plants and pathogens in Australia

Exotic plants and pathogens introduced to Australia have had significant impacts on species, vegetation communities and on ecological processes. There are approximately 2700 exotic plant species that have become naturalised within Australia and of those, around 250 are considered problematic. The sources of introduction have shifted from Europe, Australasia and North America to South America more recently, with the vast majority of introductions associated with the horticultural industry. The proportion of exotic species within the flora increases from northern Australia to the southern areas of the continent, with successful invasion related to high human density and associated disturbance, particularly increased nutrients and high grazing pressure. This chapter describes the main functional types of plant invaders and their impacts across the major regions of Australia. Invasion by exotic woody invaders, plants, perennial grasses, annual herbs and grasses, vines and aquatic plants have caused substantial changes in vegetation structure and composition, with reduced native species diversity and changes in ecosystem processes, such as hydrological and fire regimes. This chapter also describes the impact of two important plant pathogens that have been introduced to Australia – phytophthora (Phytophthora cinnamomic) and myrtle rust (Puccinia psidii). These pathogens have both resulted in declines in abundance of some susceptible plant species and resultant changes in vegetation composition. Finally, we discuss current weed management approaches in Australia and future research directions

Possible control of introduced giant African land snails (Achatina spp.) by the reintroduced endemic skink Leiolopisma telfairii, Ile aux Aigrettes, Mauritius

The giant African land snail (Achatinafulica) is one of the world’s worst invasive species, out‐competing endemic snails, consuming native vegetation and potentially altering nutrient cycles. Attempts to eradicate the snail from islands have only been successful with incipient populations. We present correlative evidence that native island predators may act as an effective control agent for the snail. In 2000 a population of between 37,300 and 45,100 African land snails was estimated on the 26ha nature reserve island of Ile aux Aigrette, Mauritius. Between 2006 and 2007, 260 endemic Telfair’s skink Leiolopisma telfairii were reintroduced to the reserve. Snail population surveys in 2008 and 2009 showed that the introduced snail population had declined to 5,569 (± 3,630) and 6,871 (±5,379), respectively. Previous studies showed that the introduced snails were selective over other invertebrate prey items. We suggest that predation by the endemic skink has been an important causal factor behind the snail population decline

Possible control of introduced giant African land snails (Achatina spp.) by the reintroduced endemic skink Leiolopisma telfairii, Ile aux Aigrettes, Mauritius

The giant African land snail (Achatina fulica) is one of the world’s worst invasive species, out‐competing endemic snails, consuming native vegetation and potentially altering nutrient cycles. Attempts to eradicate the snail from islands have only been successful with incipient populations. We present correlative evidence that native island predators may act as an effective control agent for the snail. In 2000 a population of between 37,300 and 45,100 African land snails was estimated on the 26ha nature reserve island of Ile aux Aigrette, Mauritius. Between 2006 and 2007, 260 endemic Telfair’s skink Leiolopisma telfairii were reintroduced to the reserve. Snail population surveys in 2008 and 2009 showed that the introduced snail population had declined to 5,569 (± 3,630) and 6,871 (±5,379), respectively. Previous studies showed that the introduced snails were selective over other invertebrate prey items. We suggest that predation by the endemic skink has been an important causal factor behind the snail population decline

Pregnancy and neonatal outcomes of COVID -19: coreporting of common outcomes from PAN-COVID and AAP-SONPM registries

Objective Few large cohort studies have reported data on maternal, fetal, perinatal and neonatal outcomes associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection in pregnancy. We report the outcome of infected pregnancies from a collaboration formed early during the pandemic between the investigators of two registries, the UK and Global Pregnancy and Neonatal outcomes in COVID‐19 (PAN‐COVID) study and the American Academy of Pediatrics (AAP) Section on Neonatal–Perinatal Medicine (SONPM) National Perinatal COVID‐19 Registry. Methods This was an analysis of data from the PAN‐COVID registry (1 January to 25 July 2020), which includes pregnancies with suspected or confirmed maternal SARS‐CoV‐2 infection at any stage in pregnancy, and the AAP‐SONPM National Perinatal COVID‐19 registry (4 April to 8 August 2020), which includes pregnancies with positive maternal testing for SARS‐CoV‐2 from 14 days before delivery to 3 days after delivery. The registries collected data on maternal, fetal, perinatal and neonatal outcomes. The PAN‐COVID results are presented overall for pregnancies with suspected or confirmed SARS‐CoV‐2 infection and separately in those with confirmed infection. Results We report on 4005 pregnant women with suspected or confirmed SARS‐CoV‐2 infection (1606 from PAN‐COVID and 2399 from AAP‐SONPM). For obstetric outcomes, in PAN‐COVID overall and in those with confirmed infection in PAN‐COVID and AAP‐SONPM, respectively, maternal death occurred in 0.5%, 0.5% and 0.2% of cases, early neonatal death in 0.2%, 0.3% and 0.3% of cases and stillbirth in 0.5%, 0.6% and 0.4% of cases. Delivery was preterm (< 37 weeks' gestation) in 12.0% of all women in PAN‐COVID, in 16.1% of those women with confirmed infection in PAN‐COVID and in 15.7% of women in AAP‐SONPM. Extreme preterm delivery (< 27 weeks' gestation) occurred in 0.5% of cases in PAN‐COVID and 0.3% in AAP‐SONPM. Neonatal SARS‐CoV‐2 infection was reported in 0.9% of all deliveries in PAN‐COVID overall, in 2.0% in those with confirmed infection in PAN‐COVID and in 1.8% in AAP‐SONPM; the proportions of neonates tested were 9.5%, 20.7% and 87.2%, respectively. The rates of a small‐for‐gestational‐age (SGA) neonate were 8.2% in PAN‐COVID overall, 9.7% in those with confirmed infection and 9.6% in AAP‐SONPM. Mean gestational‐age‐adjusted birth‐weight Z‐scores were −0.03 in PAN‐COVID and −0.18 in AAP‐SONPM. Conclusions The findings from the UK and USA registries of pregnancies with SARS‐CoV‐2 infection were remarkably concordant. Preterm delivery affected a higher proportion of women than expected based on historical and contemporaneous national data. The proportions of pregnancies affected by stillbirth, a SGA infant or early neonatal death were comparable to those in historical and contemporaneous UK and USA data. Although maternal death was uncommon, the rate was higher than expected based on UK and USA population data, which is likely explained by underascertainment of women affected by milder or asymptomatic infection in pregnancy in the PAN‐COVID study, although not in the AAP‐SONPM study. The data presented support strong guidance for enhanced precautions to prevent SARS‐CoV‐2 infection in pregnancy, particularly in the context of increased risks of preterm delivery and maternal mortality, and for priority vaccination of pregnant women and women planning pregnancy. Copyright © 2021 ISUOG. Published by John Wiley & Sons Ltd