Survival after postoperative morbidity: a longitudinal observational cohort study

Prolonged morbidity after surgery is associated with a risk of premature death for a longer duration than perhaps is commonly thought; however, this risk falls with time. We suggest that prolonged postoperative morbidity measured in this way may be a valid indicator of the quality of surgical healthcare. Our findings reinforce the importance of research and quality improvement initiatives aimed at reducing the duration and severity of postoperative complication

High altitude-related hypertensive crisis and acute kidney injury in an asymptomatic healthy individual

BACKGROUND: High-altitude exposure causes a mild to moderate rise in systolic and diastolic blood pressure. This case report describes the first documented case of a hypertensive crisis at altitude, as well as the first report of the occurrence of acute kidney injury in the context of altitude-related hypertension. CASE PRESENTATION: A healthy, previously normotensive 30-year old, embarked on a trek to Everest Base Camp (5300 m). During his 11-day ascent the subject developed increasingly worsening hypertension. In the absence of symptoms, the individual initially elected to remain at altitude as had previously been the plan. However, an increase in the severity of his hypertension to a peak of 223/119 mmHg resulted in a decision to descend. On descent he was found to have an acute kidney injury that subsequently resolved spontaneously. His blood pressure reverted to normal at sea level and subsequent investigations including a transthoracic echocardiogram, cardiac magnetic resonance imaging, renal ultrasound, and urinary catecholamines were normal. CONCLUSION: This report challenges the view that transient rises in blood pressure at altitude are without immediate risk. We review the evidence that altitude induces hypertension and discuss the implications for the management of hypertension at altitude

The Postoperative Morbidity Survey was validated and used to describe morbidity after major surgery.

OBJECTIVES: To describe the reliability and validity of the Postoperative Morbidity Survey (POMS). To describe the level and pattern of short-term postoperative morbidity after major elective surgery using the POMS. STUDY DESIGN AND SETTING: This was a prospective cohort study of 439 adults undergoing major elective surgery in a UK teaching hospital. The POMS, an 18-item survey that address nine domains of postoperative morbidity, was recorded on postoperative days 3, 5, 8, and 15. RESULTS: Inter-rater reliability was perfect for 11/18 items (Kappa=1.0), with Kappa=0.94 for 6/18 items. A priori hypotheses that the POMS would discriminate between patients with known measures of morbidity risk, and predict length of stay were generally supported through observation of data trends, and there was statistically significant evidence of construct validity for all but the wound and neurological domains. POMS-defined morbidity was present in 325 of 433 patients (75.1%) remaining in hospital on postoperative day 3 after surgery, 231 of 407 patients (56.8%) on day 5, 138 of 299 patients (46.2%) on day 8, and 70 of 111 patients (63.1%) on day 15. Gastrointestinal (47.4%), infectious (46.5%), pain-related (40.3%), pulmonary (39.4%), and renal problems (33.3%) were the most common forms of morbidity. CONCLUSION: The POMS is a reliable and valid survey of short-term postoperative morbidity in major elective surgery. Many patients remain in hospital without any morbidity as recorded by the POMS

South-north asymmetry of field-aligned currents in the magnetotail observed by Cluster

We statistically investigated features of the field-aligned current (FAC) distribution in plasma sheet boundary layers between 17 and 19 RE in the magnetotail using the curlometer technique to calculate the current from four-point magnetic field measurements taken in 2001. The results show that the FAC distribution in the plasma sheet boundary layers in the magnetotail has dusk-dawn asymmetry, earthward-tailward (polarity) asymmetry, and north-south asymmetry. The occurrence and polarities of FACs in the Northern Hemisphere are different from those in the Southern Hemisphere. The average density and the standard deviation of the FACs that are most likely to be connected to the Earth are 4.90 nA m−2 and 2.55 nA m−2 in the Northern Hemisphere and 4.21 nA m−2 and 1.80 nA m−2 in the Southern Hemisphere, respectively. For investigating the mechanism of the north-south asymmetry, we mapped the FACs along the field line into the polar region. The footprints of the FACs also show a difference between the Southern and Northern hemispheres (as a function of mapped latitude). These characteristics suggest a north-south asymmetry of the FACs in the magnetosphere. Further investigation is needed to identify the causes of this asymmetry, although the configuration of the magnetosphere, the polar cap boundary, the conductivity in the ionosphere, or the various solar wind-magnetosphere interaction processes all may be contributors. That the FAC densities are different between the hemispheres suggests that an important source of these currents must be a voltage generator

Changes in labial capillary density on ascent to and descent from high altitude.

Present knowledge of how the microcirculation is altered by prolonged exposure to hypoxia at high altitude is incomplete and modification of existing analytical techniques may improve our knowledge considerably. We set out to use a novel simplified method of measuring in vivo capillary density during an expedition to high altitude using a CytoCam incident dark field imaging video-microscope. The simplified method of data capture involved recording one-second images of the mucosal surface of the inner lip to reveal data about microvasculature density in ten individuals. This was done on ascent to, and descent from, high altitude. Analysis was conducted offline by two independent investigators blinded to the participant identity, testing conditions and the imaging site.  Additionally we monitored haemoglobin concentration and haematocrit data to see if we could support or refute mechanisms of altered density relating to vessel recruitment. Repeated sets of paired values were compared using Kruskall Wallis Analysis of Variance tests, whilst comparisons of values between sites was by related samples Wilcoxon Signed Rank Test. Correlation between different variables was performed using Spearman's rank correlation coefficient, and concordance between analysing investigators using intra-class correlation coefficient. There was a significant increase in capillary density from London on ascent to high altitude; median capillaries per field of view area increased from 22.8 to 25.3 (p=0.021). There was a further increase in vessel density during the six weeks spent at altitude (25.3 to 32.5, p=0.017). Moreover, vessel density remained high on descent to Kathmandu (31.0 capillaries per field of view area), despite a significant decrease in haemoglobin concentration and haematocrit. Using a simplified technique, we have demonstrated an increase in capillary density on early and sustained exposure to hypobaric hypoxia at thigh altitude, and that this remains elevated on descent to normoxia. The technique is simple, reliable and reproducible

Testing nowcasts of the ionospheric convection from the expanding and contracting polar cap model

The expanding/contracting polar cap (ECPC) model, or the time-dependent Dungey cycle, provides a theoretical framework for understanding solar wind-magnetosphere-ionosphere coupling. The ECPC describes the relationship between magnetopause reconnection and substorm growth phase, magnetotail reconnection and substorm expansion phase, associated changes in auroral morphology, and ionospheric convective motions. Despite the many successes of the model, there has yet to be a rigorous test of the predictions or nowcasts made regarding ionospheric convection, which remains a final hurdle for the validation of the ECPC. In this study we undertake a comparison of ionospheric convection, as measured in situ by ion drift meters on board DMSP (Defense Meteorological Satellite Program) satellites and from the ground by SuperDARN (Super Dual Auroral Radar Network), with motions nowcasted by a theoretical model. The model is coupled to measurements of changes in the size of the polar cap made using global auroral imagery from the IMAGE FUV (Imager for Magnetopause to Aurora Global Exploration Far Ultraviolet) instrument, as well as the dayside reconnection rate, estimated using the OMNI data set. The results show that we can largely nowcast the magnitudes of ionospheric convection flows using the context of our understanding of magnetic reconnection at the magnetopause and in the magnetotail

Anarchy in the UK('s most famous fortress): comradeship and cupidity in Gibraltar and neighbouring Spain, 1890-1902

This article is the first to investigate the growth of anarchist ideology and tactics in Gibraltar and the surrounding Spanish region, the Campo de Gibraltar, in the period 1890-1902. We draw upon hitherto unused material from both The National Archives in London and the Gibraltar Government Archives. By doing so, we demonstrate that during this period Gibraltarian and Spanish workers came together, not only to defend and advance their interests by direct action, such as strikes and attacks on employers, but also to advance educational and social causes too. Indeed, by 1898-9 the appeal of this movement was so strong that an attempt by the British Social Democratic Federation to establish a more constitutionalist approach to industrial relations failed. By 1902, the power of anarchist movements and tactics concerned employers in Gibraltar so greatly that they engineered a lock-out – styled a general strike by local workers – and successfully smashed the organising power of the local movement. Meanwhile, on the Spanish side of the frontier a massacre engineered by the local Spanish authorities resulted in the deaths of a number of activists and a hiatus in the movement that would last until the Great War of 1914-18

Characteristics of medium-scale travelling ionospheric disturbances observed near the Antarctic Peninsula by HF radar

We present a survey of medium-scale traveling ionospheric disturbances (MSTIDs) observed by a Super Dual Auroral Radar Network HF radar located in the Falkland Islands between May 2010 and April 2011. The radar has a field of view that overlooks the Antarctic Peninsula, a known hot spot of gravity wave activity. We present observations of radar ground-backscatter data, in which the signatures of MSTIDs are manifested as structured enhancements in echo power. Observed periods were in the range 30–80 min, corresponding to frequencies of 0.2–0.6 mHz. Wavelengths were generally in the range 200–800 km and phase speeds in the range 100–300 m s−1. These values are within the ranges typically associated with medium-scale gravity waves. We find a primary population of northward (equatorward) propagating MSTIDs, which demonstrate an association with enhanced solar wind-magnetosphere coupling and a smaller, westward propagating population, that could be associated with atmospheric gravity waves excited by winds over the Andean and Antarctic Peninsula mountains or by the high winds of the Antarctic Polar Vortex

Keratinocyte growth factor for the treatment of the acute respiratory distress syndrome (KARE): a randomised, double-blind, placebo-controlled phase 2 trial

<p>(<b>A</b>) Immunofluorescence signal for dystrophin is significantly reduced in the SSI heart (bottom left panel) compared with the immunofluorescent signal in the SHAM heart (upper left panel), and the SHAM+ALLN (upper right panel) and SSI+ALLN (bottom right panel) myocardium. (<b>B</b>) Protein levels of dystrophin in the SHAM, SSI, SHAM+ALLN and SSI+ALLN hearts were measured 24 h after the CLP procedure and were expressed in arbitrary units (AUs). α-Tubulin was used to determine equivalent loading conditions. The results (n = 6 per group) are representative of three different experiments. Scale bars indicate 50 μm.</p

Does hypoxia play a role in the development of sarcopenia in humans? Mechanistic insights from the Caudwell Xtreme Everest Expedition

OBJECTIVES: Sarcopenia refers to the involuntary loss of skeletal muscle and is a predictor of physical disability/mortality. Its pathogenesis is poorly understood, although roles for altered hypoxic signaling, oxidative stress, adipokines and inflammatory mediators have been suggested. Sarcopenia also occurs upon exposure to the hypoxia of high altitude. Using data from the Caudwell Xtreme Everest expedition we therefore sought to analyze the extent of hypoxia-induced body composition changes and identify putative pathways associated with fat-free mass (FFM) and fat mass (FM) loss. METHODS: After baseline testing in London (75m), 24 investigators ascended from Kathmandu (1300m) to Everest base camp (EBC 5300m) over 13 days. Fourteen investigators climbed above EBC, eight of whom reached the summit (8848m). Assessments were conducted at baseline, during ascent and after one, six and eight week(s) of arrival at EBC. Changes in body composition (FM, FFM, total body water, intra- and extra-cellular water) were measured by bioelectrical impedance. Biomarkers of nitric oxide and oxidative stress were measured together with adipokines, inflammatory, metabolic and vascular markers. RESULTS: Participants lost a substantial, but variable, amount of body weight (7.3±4.9kg by expedition end; p<0.001). A progressive loss of both FM and FFM was observed, and after eight weeks, the proportion of FFM loss was 48% greater than FM loss (p<0.008). Changes in protein carbonyls (p<0.001) were associated with a decline in FM whereas 4-hydroxynonenal (p<0.001) and IL-6 (p<0.001) correlated with FFM loss. GLP-1 (r=-0.45, p<0.001) and nitrite (r=-0.29, p<0.001) concentration changes were associated with FFM loss. In a multivariate model, GLP-1, insulin and nitrite were significant predictors of FFM loss while protein carbonyls were predicted FM loss. CONCLUSIONS: The putative role of GLP-1 and nitrite as mediators of the effects of hypoxia on FFM is an intriguing finding. If confirmed, nutritional and pharmacological interventions targeting these pathways may offer new avenues for prevention and treatment of sarcopenia