Effects of social housing on alcohol intake in mice depend on the non-social environment.

Background: Excessive alcohol consumption leads to serious health problems. Mechanisms regulating the consumption of alcohol are insufficiently understood. Previous preclinical studies suggested that non-social environmental and social environmental complexities can regulate alcohol consumption in opposite directions. However, previous studies did not include all conditions and/or did not include female rodents. Therefore, in this study, we examined the effects of social versus single housing in standard versus non-standard housing conditions in male and female mice. Methods: Adult C57BL/6 J mice were housed in either standard shoebox cages or in automated Herdsman 2 (HM2) cages and exposed to a two-bottle choice procedure with 3% or 6% ethanol versus water for 5 days. The HM2 cages use radiotracking devices to measure the fluid consumption of individual mice in an undisturbed and automated manner. In both housing conditions, mice were housed either at one or at four per cage. Results: In standard cages, group housing of animals decreased alcohol consumption and water consumption. In HM2 cages, group housing significantly increased ethanol preference and decreased water intake. There were no significant differences in these effects between male and female animals. These observations were similar for 3 and 6% ethanol solutions but were more pronounced for the latter. The effects of social environment on ethanol preference in HM2 cages were accompanied by an increase in the number of approaches to the ethanol solution and a decrease in the number of approaches to water. The differences in ethanol intake could not be explained by differences in locomotor or exploratory activity as socially housed mice showed fewer non-consummatory visits to the ethanol solutions than single-housed animals. In addition, we observed that significant changes in behaviors measuring the approach to the fluid were not always accompanied by significant changes in fluid consumption, and vice versa, suggesting that it is important to assess both measures of motivation to consume alcohol. Conclusion: Our results indicate that the direction of the effects of social environment on alcohol intake in mice depends on the non-social housing environment. Understanding mechanisms by which social and non-social housing conditions modulate alcohol intake could suggest approaches to counteract environmental factors enhancing hazardous alcohol consumption.

Compensatory reserve and pulse character: Enhanced potential to predict urgency for transfusion and other life-saving interventions after traumatic injury.

BACKGROUND: Field triage of trauma patients requires timely assessment of physiologic status to determine resuscitative needs. Vital signs and rudimentary assessments such as pulse character (PC) are used by first responders to guide decision making. The compensatory reserve measurement (CRM) has demonstrated utility as an easily interpretable method for assessing patient status. We hypothesized that the ability to identify injured patients requiring transfusion and other life-saving interventions (LSI) using a measurement of pulse character could be enhanced by the addition of the CRM. METHODS: We performed a prospective observational study on 300 trauma patients admitted to a level I trauma center. CRM was recorded continuously after device placement on arrival. Patient demographics, field and trauma resuscitation unit vital signs, therapeutic interventions, and outcomes were collected. A field SBP <100 mmHg was utilized as a surrogate for abnormal PC as previously validated. A patient with a CRM threshold value of <60% was considered clinically compromised with a risk of onset of decompensated shock. Data were analyzed to assess the capacity of CRM and pulse character separately or in combination to predict LSI defined as need for transfusion, intubation, tube thoracostomy, or operative/ angiographic hemorrhage control. RESULTS: An improvement in the predictive capability for LSI, transfusion, or a composite outcome was demonstrated by the combination of CRM and PC compared to either measure alone. CONCLUSIONS: Combining PC assessment with CRM has the potential to enhance the recognition of injured patients requiring life-saving intervention thus improving sensitivity of decision support for prehospital providers.

Compensatory reserve detects subclinical shock with more expeditious prediction for need of life-saving interventions compared to systolic blood pressure and blood lactate.

INTRODUCTION: We conducted a prospective observational study on 205 trauma patients at a level I trauma facility to test the hypothesis that a compensatory reserve measurement (CRM) would identify higher risk for progression to shock and/or need a life-saving interventions (LSIs) earlier than systolic blood pressure (SBP) and blood lactate (LAC). METHODS: A composite outcome metric included blood transfusion, procedural LSI, and mortality. Discrete measures assessed as abnormal (ab) were SBP <90 mmHg, CRM <60%, and LAC >2.0. A graded categorization of shock was defined as: no shock (normal [n] SBP [n-SBP], n-CRM, n-LAC); sub-clinical shock (ab-CRM, n-SBP, n-LAC); occult shock (n-SBP, ab-CRM, ab-LAC); or overt shock (ab-SBP, ab-CRM, ab-LAC). RESULTS: Three patients displayed overt shock, 53 displayed sub-clinical shock, and 149 displayed no shock. After incorporating lactate into the analysis, 86 patients demonstrated no shock, 25 were classified as sub-clinical shock, 91 were classified as occult shock, and 3 were characterized as overt shock. Each shock subcategory revealed a graded increase requiring LSI and transfusion. Initial CRM was associated with progression to shock (odds ratio = 0.97; p < .001) at an earlier time than SBP or LAC. CONCLUSIONS: Initial CRM uncovers a clinically relevant subset of patients who are not detected by SBP and LAC. Our results suggest CRM could be used to more expeditiously identify injured patients likely to deteriorate to shock, with requirements for blood transfusion or procedural LSI.

Wireless, Skin-Interfaced Devices for Pediatric Critical Care: Application to Continuous, Noninvasive Blood Pressure Monitoring.

Indwelling arterial lines, the clinical gold standard for continuous blood pressure (BP) monitoring in the pediatric intensive care unit (PICU), have significant drawbacks due to their invasive nature, ischemic risk, and impediment to natural body movement. A noninvasive, wireless, and accurate alternative would greatly improve the quality of patient care. Recently introduced classes of wireless, skin-interfaced devices offer capabilities in continuous, precise monitoring of physiologic waveforms and vital signs in pediatric and neonatal patients, but have not yet been employed for continuous tracking of systolic and diastolic BP-critical for guiding clinical decision-making in the PICU. The results presented here focus on materials and mechanics that optimize the system-level properties of these devices to enhance their reliable use in this context, achieving full compatibility with the range of body sizes, skin types, and sterilization schemes typically encountered in the PICU. Systematic analysis of the data from these devices on 23 pediatric patients, yields derived, noninvasive BP values that can be quantitatively validated against direct recordings from arterial lines. The results from this diverse cohort, including those under pharmacological protocols, suggest that wireless, skin-interfaced devices can, in certain circumstances of practical utility, accurately and continuously monitor BP in the PICU patient population.

Compensatory Reserve Index: Performance of A Novel Monitoring Technology to Identify the Bleeding Trauma Patient.

INTRODUCTION: Hemorrhage is one of the most substantial causes of death after traumatic injury. Standard measures, including systolic blood pressure (SBP), are poor surrogate indicators of physiologic compromise until compensatory mechanisms have been overwhelmed. Compensatory Reserve Index (CRI) is a novel monitoring technology with the ability to assess physiologic reserve. We hypothesized CRI would be a better predictor of physiologic compromise secondary to hemorrhage than traditional vital signs. METHODS: A prospective observational study of 89 subjects meeting trauma center activation criteria at a single level I trauma center was conducted from October 2015 to February 2016. Data collected included demographics, SBP, heart rate, and requirement for hemorrhage-associated, life-saving intervention (LSI) (i.e., operation or angiography for hemorrhage, local or tourniquet control of external bleeding, and transfusion >2 units PRBC). Receiver-operator characteristic (ROC) curves were formulated and appropriate thresholds were calculated to compare relative value of the metrics for predictive modeling. RESULTS: For predicting hemorrhage-related LSI, CRI demonstrated a sensitivity of 83% and a negative predictive value (NPV) of 91% as compared with SBP with a sensitivity to detect hemorrhage of 26% (P < 0.05) and an NPV of 78%. ROC curves generated from admission CRI and SBP measures demonstrated values of 0.83 and 0.62, respectively. CRI identified significant hemorrhage requiring potentially life-saving therapy more reliably than SBP (P < 0.05). CONCLUSION: The CRI device demonstrated superior capacity over systolic blood pressure in predicting the need for posttraumatic hemorrhage intervention in the acute resuscitation phase after injury.

Redefining the abdominal seatbelt sign: Enhanced CT imaging metrics improve injury prediction.

INTRODUCTION: The abdominal seatbelt sign (ASBS) has an established association with abdominal injury, yet its definition remains ill-defined. We hypothesize specific imaging characteristics associated with the ASBS such as location above the pelvic brim and depth of abdominal wall contusion would better predict underlying injury and need for operative intervention. METHODS: We performed a retrospective chart review of subjects suffering from restrained motor vehicle collisions (MVC) evaluated at a level one trauma facility from 2010 to 2015. CT imaging was reviewed for the presence of a transverse abdominal wall contusion consistent with lap belt use. Contusion location was determined in relation to the anterior superior iliac spine (ASIS). Abdominal wall thickness as well as contusion depth were measured at the contusion level and an abdominal seatbelt sign depth index (ASBSI) was calculated. RESULTS: Sample size for the cohort was 551 subjects. Operative need was 19.73% in those with ASBS on CT (CT ASBS) above the ASIS and 4.05% (p-value < 0.01) in those with only clinical evidence of ASBS (CL ASBS). CT ASBS above the ASIS was associated with higher incidence of intra-abdominal injuries (31.97% vs 16.45%; p = 0.01) and a higher rate of abdominal operations (19.73% vs. 7.59%; p < 0.01) compared to below the ASIS. In contrast, CT ASBS below the ASIS was associated with a higher incidence of pelvic fractures (17.72% vs. 8.16%; p = 0.01) with fractures being an independent risk factor for abdominal injury requiring intervention. Logistic regression analyses and receiver-operator characteristic curves demonstrated ASBSI was significantly associated with abdominal injury requiring operative intervention. CONCLUSION: Characteristics of abdominal wall injury on imaging such as location and contusion depth (ASBSI) are better predictors of abdominal operative need than standard clinical measures. This analysis substantiates a novel diagnostic tool which may have the potential to facilitate clinical diagnosis and management decisions in patients with abdominal seatbelt sign.

SafeCare: An Innovative Approach for Improving Quality Through Standards, Benchmarking, and Improvement in Low- and Middle- Income Countries.

BACKGROUND: In low- and middle-income countries (LMICs), patients often have limited access to high-quality care because of a shortage of facilities and human resources, inefficiency of resource allocation, and limited health insurance. SafeCare was developed to provide innovative health care standards; surveyor training; a grading system for quality of care; a quality improvement process that is broken down into achievable, measurable steps to facilitate incremental improvement; and a private sector-supported health financing model. METHODS: Three organizations-PharmAccess Foundation, Joint Commission International, and the Council for Health Service Accreditation of Southern Africa-launched SafeCare in 2011 as a formal partnership. Five SafeCare levels of improvement are allocated on the basis of an algorithm that incorporates both the overall score and weighted criteria, so that certain high-risk criteria need to be in place before a facility can move to the next SafeCare certification level. A customized quality improvement plan based on the SafeCare assessment results lists the specific, measurable activities that should be undertaken to address gaps in quality found during the initial assessment and to meet the nextlevel SafeCare certificate. RESULTS: The standards have been implemented in more than 800 primary and secondary facilities by qualified local surveyors, in partnership with various local public and private partner organizations, in six sub-Saharan African countries (Ghana, Kenya, Nigeria, Namibia, Tanzania, and Zambia). CONCLUSION: Expanding access to care and improving health care quality in LMICs will require a coordinated effort between institutions and other stakeholders. SafeCare's standards and assessment methodology can help build trust between stakeholders and lay the foundation for country-led quality monitoring systems.

Integrated evaluation of cost, emissions, and resource potential for algal biofuels at the national scale.

Costs, emissions, and resource availability were modeled for the production of 5 billion gallons yr(-1) (5 BGY) of renewable diesel in the United States from Chlorella biomass by hydrothermal liquefaction (HTL). The HTL model utilized data from a continuous 1-L reactor including catalytic hydrothermal gasification of the aqueous phase, and catalytic hydrotreatment of the HTL oil. A biophysical algae growth model coupled with weather and pond simulations predicted biomass productivity from experimental growth parameters, allowing site-by-site and temporal prediction of biomass production. The 5 BGY scale required geographically and climatically distributed sites. Even though screening down to 5 BGY significantly reduced spatial and temporal variability, site-to-site, season-to-season, and interannual variations in productivity affected economic and environmental performance. Performance metrics based on annual average or peak productivity were inadequate; temporally and spatially explicit computations allowed more rigorous analysis of these dynamic systems. For example, 3-season operation with a winter shutdown was favored to avoid high greenhouse gas emissions, but economic performance was harmed by underutilized equipment during slow-growth periods. Thus, analysis of algal biofuel pathways must combine spatiotemporal resource assessment, economic analysis, and environmental analysis integrated over many sites when assessing national scale performance.

Does nasogastric tube decompression get used less often with laparoscopic and hand-assisted compared with open colectomy?

INTRODUCTION: Laparoscopic surgery is associated with well-known benefits, one of which is earlier return of bowel function. Since the laparoscopic approach to colon resections was introduced in the early 1990s, it has become the standard of care. Hand-assisted laparoscopic surgery (HALS) is a surgical approach in which dissection is facilitated by the surgeon's hand within the abdominal cavity during laparoscopy. The purpose of this study was to compare the incidence of postoperative ileus and the need for nasogastric tube (NGT) decompression in patients undergoing elective colon resections. METHODS AND PROCEDURES: Following institutional review board approval, we performed a retrospective review of a prospectively collected database. Included were patients who underwent elective left-sided large bowel resections between 2009 and 2012. Exclusion criteria were urgent operation, stoma creation, ASA IV classification, NGT left in place at the end of surgery, and postoperative anastomotic leakage. Patients were divided into three groups: laparoscopic surgery, HALS, and open surgery. We evaluated the incidence of postoperative ileus and the use of nasogastric decompression in each group. RESULTS: A total of 243 patients were included in this study; 73 patients underwent open surgery, 89 patients underwent HALS, and 81 patients underwent laparoscopic surgery. The proportion of patients who needed postoperative nasogastric decompression was significantly reduced in patients undergoing laparoscopic surgery (3.7%) or HALS (4.5%) compared with those who underwent open resection (17.8%). The time from surgery to first flatus and first bowel movement, the time to tolerate solid diet, and the total length of postoperative hospital stay also were all significantly reduced in the laparoscopic and HALS groups compared with the open surgery group. There were no significant differences in any of these measures between the laparoscopic group and the hand-assisted group. CONCLUSIONS: Like laparoscopy, HALS is associated with less postoperative ileus and necessitates less NGT decompression than does open surgery.

Quantitative uncertainty analysis of Life Cycle Assessment for algal biofuel production.

As a result of algae's promise as a renewable energy feedstock, numerous studies have used Life Cycle Assessment (LCA) to quantify the environmental performance of algal biofuels, yet there is no consensus of results among them. Our work, motivated by the lack of comprehensive uncertainty analysis in previous studies, uses a Monte Carlo approach to estimate ranges of expected values of LCA metrics by incorporating parameter variability with empirically specified distribution functions. Results show that large uncertainties exist at virtually all steps of the biofuel production process. Although our findings agree with a number of earlier studies on matters such as the need for wet lipid extraction, nutrients recovered from waste streams, and high energy coproducts, the ranges of reported LCA metrics show that uncertainty analysis is crucial for developing technologies, such as algal biofuels. In addition, the ranges of energy return on (energy) invested (EROI) values resulting from our analysis help explain the high variability in EROI values from earlier studies. Reporting results from LCA models as ranges, and not single values, will more reliably inform industry and policy makers on expected energetic and environmental performance of biofuels produced from microalgae.

Perspectives on nursing: using multimedia interviews to influence career decisions.

Students often have misconceptions regarding the reality of nursing and the opportunities available to nurses that sometimes result in poor choices related to pursuing nursing as a career. To help prenursing students make better-informed career decisions and address misunderstandings, faculty developed the DVD and Web site Perspectives on Nursing, a collection of 15 nurse interviews. The authors describe and discuss the project, the value of recorded nurses' stories, analysis of student feedback, and recommendations.

Imaging for neuro-ophthalmic and orbital disease - a review.

A literature review was performed by content experts in neuro-ophthalmology and neuroradiology using a systematic English-language Medline search (1994-2008) limited to articles with relevance to neuro-ophthalmic and orbital imaging. The information covered in this review includes: (i) the basic mechanics, indications and contraindications for cranial and orbital computed tomography and magnetic resonance (MR) imaging; (ii) the utility and indications for intravenous contrast, (iii) the use of specific MR sequences; (iv) the techniques and ophthalmic indications for computed tomography/MR angiography and venography; and (v) the techniques and indications for functional MR imaging, positron emission tomography scanning and single photon emission computed tomography. Throughout the review accurate and timely communication with the neuroradiologist regarding the clinical findings and suspected location of lesions is emphasized so as to optimize the ordering and interpretation of imaging studies for the ophthalmologist.

Giant cell arteritis presenting with cotton wool spots.

INTRODUCTION: Giant cell arteritis is a granulomatous arteritis that often presents to ophthalmology. METHODS: Case report. RESULTS: A 69-year-old female presented with moderate vision loss OD after suffering from severe, generalized head and neck pain over the previous 3 months. Fundus examination revealed multifocal cotton wool patches in the posterior pole surrounding the optic disc. A fluorescein angiogram OD demonstrated a large peripapillary choroidal filling defect. Erythrocyte sedimentation rate was 86 mm/hr and her C-reactive protein was 9.2 mg/dL. She was immediately started on intravenous corticosteroid therapy, and she noted rapid improvement of her symptoms. A temporal artery biopsy was positive for giant cell arteritis. CONCLUSION: Ophthalmologists should be aware that cotton wool patches may be the presenting sign of giant cell arteritis. Fluorescein angiography may be helpful in these cases to demonstrate concomitant choroidal ischemia.

Obesity and type 2 diabetes do not alter splanchnic cortisol production in humans.

CONTEXT: Cortisol is a potent regulator of carbohydrate, fat, and protein metabolism. OBJECTIVE: The objective of the study was to determine whether obesity alone or in combination with type 2 diabetes increases splanchnic and/or leg cortisol production. DESIGN: Splanchnic and leg cortisol production were measured using the hepatic and leg catheterization technique combined with infusion of D4-cortisol. SETTING: The study was conducted in a General Clinical Research Center. PARTICIPANTS: Nine lean nondiabetic, 10 obese nondiabetic, and 11 obese diabetic subjects were studied. INTERVENTIONS: Diabetic volunteers were withdrawn from their glucose-lowering medications before study. MAIN OUTCOME MEASURES: Rates of total body, splanchnic and leg cortisol, and D3-cortisol production were measured. RESULTS: Rates of splanchnic cortisol production equaled or exceeded those occurring in extrasplanchnic tissues (e.g. the adrenals) in all three groups. However, because concurrent splanchnic cortisol uptake also occurred, net splanchnic cortisol release was minimal. Splanchnic cortisol production and splanchnic D3-cortisol production (an index of splanchnic 11beta-hydroxysteroid dehydrogenase type 1 activity) did not differ among the three groups. In addition, splanchnic cortisol production did not correlate with either visceral fat or endogenous glucose production. On the other hand, splanchnic cortisol uptake was greater in the obese diabetic than lean nondiabetic subjects (25 +/- 2.9 vs. 15.3 +/- 2.5 microg/min; P < 0.05). Splanchnic, but not leg, D3-cortisol production was correlated with total body D3-cortisol production (r = 0.70; P < 0.001). CONCLUSIONS: Although large amounts of cortisol are produced within the splanchnic bed, implying high intrahepatic glucocorticoid concentrations, rates do not differ in lean and obese nondiabetic humans and are not influenced by the presence of type 2 diabetes mellitus. On the other hand, obesity but not diabetes increases splanchnic cortisol uptake.