Association Between Preoperative Diabetes Control and Postoperative Adverse Events Among Veterans Health Administration Patients With Diabetes Who Underwent Elective Ambulatory Hernia Surgery.

This cohort study examines the association between same-day preoperative glycemic control and postoperative adverse events among patients with diabetes undergoing ambulatory hernia surgery.

Characteristics of Interval Colorectal Cancer: A Canadian Retrospective Population-Level Analysis from Newfoundland and Labrador.

Interval colorectal cancers (I-CRCs) arise during the interval time period between scheduled colonoscopies. Predicting which patients are at risk of I-CRCs remains an elusive undertaking, but evidence would suggest that most I-CRCs arise from lesions missed on index endoscopy. The procedural factors that lead to missed lesions are numerous and lack consensus in the literature. In Canada, the province of Newfoundland and Labrador has the highest incidence of CRCs. In this study our aim was to examine I-CRCs (3-60 months after last colonoscopy) in NL through a population-level analysis covering 67% of the province from 2001-2018. We estimated the I-CRC rate to be up to 9.3%. Median age of I-CRC diagnosis was 67.1 years with an interval time of 2.9 years. About 57% of these tumors occurred proximal to the splenic flexure, with 53% presenting as local disease. No temporal differences were observed in interval time or tumor distribution. On univariate and multivariable logistical regression, risk of right-sided I-CRC did not correlate to the index colonoscopy indication, bowel preparation quality, size of largest polyp removed, colonoscopy completion rate, or stage at presentation. Improvements in synoptic reporting utilization and national registries are needed to identity risk factors and reduce I-CRC frequency.

Development of an Anatomical Silicone Model for Simulation-based Medical Training of Obstetric Anal Sphincter Injury Repair in Bangladesh.

Advancing global healthcare in developing countries has traditionally been an area of interest for many North American medical organizations, as they strive to improve patient outcomes by helping to control disease and death-related illnesses. Women's healthcare in developing countries, in particular, presents a unique set of complexities, revealing high maternal mortality statistics surrounding pregnancy, labor, and childbirth, which is often tied to home births without medically trained attendants. In September 2018, Team Broken Earth, a Canadian-based outreach initiative, hosted a three-day women's healthcare course in Dhaka, Bangladesh, which included simulation-based training stations, for the purpose of advancing clinical skills and education in regards to local labor and delivery. The training stations included the prevention of shoulder dystocia, helping babies breathe, the application of uterine compression sutures, and the repair of obstetric anal sphincter injuries (OASIS). The OASIS management station provided an opportunity to practice anal sphincter repair on anatomically accurate silicone models, which was a focus of the training course due to the high frequency of such injuries in rural Bangladesh. Evaluation surveys were supplied to workshop participants to capture their feedback about the use of the OASIS models and their efficacy as a training tool in Bangladesh. Overall, the models were considered superior as compared to pre-existing training methods, which traditionally involve textbook education and hands-on learning in emergency birthing scenarios by non-medically trained attendants. Two minor iterative improvements were suggested during the Team Broken Earth workshops in Dhaka, Bangladesh, with regards to improving the models for future use: (a) the ethnicity coloring of the models should be more inclusive, especially when delivering training in international countries, and (b) future silicone models should include the addition of mesh across the bottom layer to ensure participants fingers did not rupture the enclosed vaginal canal while suturing. The purpose of this technical report is to determine the efficacy of a silicone OASIS model, developed for practicing high-risk laceration repair that can occur during childbirth, which presents in higher frequency in developing countries, such as Bangladesh, due to the number of rural at-home deliveries. The original study in this series involved the investigation of silicone perineal repair models focusing on first- and second-degree lacerations, which were used at the Remote and Rural Conference in St. John's, Newfoundland, in April 2018. The facilitators distributed the first iteration of the models to conference participants and collected participant feedback, which concluded that several improvements were required to enhance the models for medical training purposes. With the iterative revisions complete, the model is now under further validation testing to determine its efficacy within simulation-based medical education (SBME) and clinical skill maintenance. This technical report is the second in the series and includes the most recent third and fourth-degree silicone models as well as all suggested improvements from previous clinical feedback.

Attend: A Two-Pronged Trial to Eliminate No Shows in Diagnostic Imaging at a Community-Based Hospital.

PURPOSE: Diagnostic imaging (DI) at Niagara Health, like other hospitals, experiences challenges with patients who do not attend their scheduled appointments, resulting in a "no show." Reducing no show percentages presents an opportunity to improve upon wait lists within specific modalities such as magnetic resonance imaging (MRI) and to reduce the loss of productivity for this high-demand resource. AIM: To reduce the MRI no-show percent in DI at two community hospitals from 6.5% to 5% through patient engagement via mailed reminder letters and education at the primary care level. METHODS: Our two-pronged approach included interventions at community hospitals and at the primary care level. Reminder letters were mailed to patients with their appointment time and other pertinent information to allow for an increased number of patients reminded about appointments and a second means of reminder. At the primary care level, an information package was sent to various independent physicians for distribution to patients requiring an MRI scan, outlining benefits of showing up to the scheduled appointment to educate patients and improve attendance at DI. RESULTS: The mailing letter resulted in a significant reduction from 7.1% to 6.3% in overall no shows across two community hospitals (P = .04). The true effect of the letter was likely masked by increased wait times during the study period, which correlates with increased no-show percentages. The first trial of the information pamphlet among five practices for 1 month resulted in a nonsignificant reduction of no shows from 19% to 3% (P = .125). The second trial among 19 practices for 3 months led to a significant reduction of no shows from 7.7% to 4.2% (P = .007). CONCLUSIONS: Both the methods, the mailing letter and patient-information pamphlet, provide promising results in regard to reducing the no-show percentage among patients seen in DI for MRI appointments.

Investigating the Efficacy of Anatomical Silicone Models Developed from a 3D Printed Mold for Perineal Repair Suturing Simulation.

There is a scarcity of affordable, validated, standardized and anatomically correct silicone perineum models for the rehearsal of postpartum laceration repair. The purpose of this technical report is to describe and validate evidence for a silicone, perineal repair model created from a 3D printed mold for medical resident training and clinical skills maintenance. A pre-existing model from an open-source royalty-free website was purchased and converted using Fusion360TM (Autodesk Inc., San Rafael, CA, USA) into a stereolithography (.stl) file and altered to produce a negative mold. Using a spatula, a fine silicone layer was first applied inside the mold, followed by a small piece of flesh-colored mesh netting material within the perineal surface area, fitting the width of the mold. The mesh was pressed into the thin layer of silicone, which was meant to provide anatomical structure to prevent the sutures from tearing through the silicone. The remainder of the silicone mix was then poured into the mold, which required three hours to fully set before being removed from the mold. Twelve silicone models were produced and used during a one-hour workshop at the Rural and Remote Conference by 16 obstetrics and gynecology residents and practicing rural physicians, and four facilitators. At the end of the workshop, the participants were provided with a qualitative survey and asked to rate the perceived realism and educational effectiveness of the silicone perineum model as compared to pre-existing simulation models that they have used previously. The overall workshop participant feedback was positive, noting that the models provided more realistic visualization for the suturing simulation of first- and second-degree perineal injuries. The silicone models were considered to be useful in simulation training when attempting first- and second-degreeperineum suturing techniques within a confined space. The overall feedback was positive, noting that they provided more realistic visualization experience compared to pre-existing simulation models, such as beef tongues and synthetic sponges. The feedback from the participants and facilitators included thoughts about how to add additional mesh to the silicone model so the subcutaneous and vaginal plane sutures would hold, as well as increase the size of the vaginal canal size to more accurately represent a postpartum repair. There were also suggestions to alter the colour of the model to be flesh-toned as opposed to pink, to more accurately simulate human tissue. Silicone perineum models, created from a 3D printed mold, are an economical training tool as compared to commercially available, cost prohibitive models. They also provide anatomically accurate simulation training opportunities for residents to learn and maintain clinical skills in perineal repair, as compared to beef tongues and synthetic sponges, which have previously been used in obstetrics and gynecology simulation-based medical education.

Innovative Use Of Electronic Consultations In Preoperative Anesthesiology Evaluation At VA Medical Centers In New England.

Electronic consultations (e-consults) improve access to specialty care without requiring face-to-face patient visits. We conducted a mixed-methods descriptive study to understand the variability in e-consult use across anesthesiology departments in the Veterans Affairs New England Healthcare System (VANEHS). In the period 2012-15, the system experienced a rapid increase in the use of anesthesiology e-consults: 5,023 were sent in 2015, compared with 103 in 2012. Uptake across sites varied from near-universal use of e-consults for preoperative assessment to use for only selected low-risk patients or no use. Interviews with stakeholders revealed considerable differences in the perceived impact of e-consults on workflow and patient-centeredness. Clinicians at sites with high use of e-consults noted that they improved workflow efficiency. In comparison, clinicians at sites with low use preferentially valued face-to-face visits for some or all patients. The adoption of a health information technology innovation can alter the process of care delivery, depending on perceptions of its value by key stakeholders.

Enhanced Recovery After Surgery in Laparoscopic Surgery.

BACKGROUND: As part of an effort to maximize value in the perioperative setting, a paradigm shift is underway in the way that patients are cared for preoperatively, on the day of surgery, and postoperatively-a setting collectively known as the perioperative care. Enhanced Recovery After Surgery (ERAS®) is an evidence-based, patient-centered team approach to delivering high-quality perioperative care to surgical patients. METHODS: This review focuses on anesthesiologists, with their unique purview of perioperative setting, who are important drivers of change in the delivery of valuable perioperative care. ERAS care pathways begin in the preoperative setting by both preparing the patient for the psychological stress of surgery and optimizing the patient's medical and physiologic status so the body is ready for the physical demands of surgery. RESULTS: Minimization of perioperative fasting is important to maintain volume status-decreasing reliance on intravenous fluid administration, and to reduce protein catabolism around the time of surgery. Intraoperative management in ERAS pathways relies on goal-directed fluid therapy and opioid-sparing multimodal analgesia. Postoperatively, early feeding and ambulation, as well as discontinuation of extraneous lines and catheters facilitate patients' functional recovery. CONCLUSION: The laparoscopic approach to surgery, when possible, compliments ERAS techniques by reducing abdominal wall trauma and the resultant milieu of inflammatory, neurohumoral, and pain responses. Anesthesiologists driving change in the perioperative setting, in collaboration with surgeons and other disciplines, can improve value in healthcare and provide optimal outcomes that matter most to patients and healthcare providers alike.

Prehabilitation for the Enhanced Recovery After Surgery Patient.

BACKGROUND: Prehabilitation proposes that broad health interventions at the time of decision for surgery will improve the patient's starting functional status and therefore recovery. METHODS: The impact of preoperative exercise, preoperative nutrition, smoking cessation, alcohol cessation, anemia, and psychological support were reviewed. RESULTS: Interventions to improve the patient's underlying health typically improve recovery, although the duration and intensity necessary for meaningful surgical recovery benefit need further study. CONCLUSIONS: Preoperative health interventions may improve recovery in the postoperative period and patient health years later.

Publishing Trends in Two American Journals in Anesthesiology-Results of an 80-Year Geographical Survey.

BACKGROUND: We examined publication trends in two major American journals devoted to anesthesia to understand the geographical distribution of authorship and attempt to decipher the factors that influence this distribution. METHODS: In addition to bibliometric information for all articles published in Anesthesiology between 1941 and 2010 and Anesthesia & Analgesia between 1931 and 2010, we also collected information about the country, continent, and medical school or institution from which the articles were submitted. RESULTS: The top five countries that published research in these journals were the United States, Japan, Germany, Canada, and France. More than 50% of the published articles were submitted from the United States. However, US publications have steadily and significantly declined over the decades. Contributions from Europe and Asia (especially China) have shown marked increases. US spending on research, especially biomedical research, has remained essentially unchanged and declined in some areas, whereas it has increased steadily in some of the other countries we discuss. CONCLUSIONS: There is a significantly increased prominence in publishing from countries other than the United States. The reasons for this include the convenience of Web-based submission, an increased desire by researchers from around the world to publish in journals considered prestigious, English becoming the preferred language of communication amongst academicians in science, the advent of globalization, and a decrease in public research funding in the United States relative to other countries.

ß-Glucosidase 2 (GBA2) activity and imino sugar pharmacology.

ß-Glucosidase 2 (GBA2) is an enzyme that cleaves the membrane lipid glucosylceramide into glucose and ceramide. The GBA2 gene is mutated in genetic neurological diseases (hereditary spastic paraplegia and cerebellar ataxia). Pharmacologically, GBA2 is reversibly inhibited by alkylated imino sugars that are in clinical use or are being developed for this purpose. We have addressed the ambiguity surrounding one of the defining characteristics of GBA2, which is its sensitivity to inhibition by conduritol B epoxide (CBE). We found that CBE inhibited GBA2, in vitro and in live cells, in a time-dependent fashion, which is typical for mechanism-based enzyme inactivators. Compared with the well characterized impact of CBE on the lysosomal glucosylceramide-degrading enzyme (glucocerebrosidase, GBA), CBE inactivated GBA2 less efficiently, due to a lower affinity for this enzyme (higher KI) and a lower rate of enzyme inactivation (k(inact)). In contrast to CBE, N-butyldeoxygalactonojirimycin exclusively inhibited GBA2. Accordingly, we propose to redefine GBA2 activity as the ß-glucosidase that is sensitive to inhibition by N-butyldeoxygalactonojirimycin. Revised as such, GBA2 activity 1) was optimal at pH 5.5-6.0; 2) accounted for a much higher proportion of detergent-independent membrane-associated ß-glucosidase activity; 3) was more variable among mouse tissues and neuroblastoma and monocyte cell lines; and 4) was more sensitive to inhibition by N-butyldeoxynojirimycin (miglustat, Zavesca®), in comparison with earlier studies. Our evaluation of GBA2 makes it possible to assess its activity more accurately, which will be helpful in analyzing its physiological roles and involvement in disease and in the pharmacological profiling of monosaccharide mimetics.

A general P300 brain-computer interface presentation paradigm based on performance guided constraints.

An electroencephalographic-based brain-computer interface (BCI) can provide a non-muscular method of communication. A general model for P300-based BCI stimulus presentations is introduced--the "m choose n" or C(m (number of flashes per sequence), n (number of flashes per item)) paradigm, which is a universal extension of the previously reported checkerboard paradigm (CBP). C(m,n) captures all possible (unconstrained) ways to flash target items, and then applies constraints to enhance ERP's produced by attended matrix items. We explore a C(36,5) instance of C(m,n) called the "five flash paradigm" (FFP) and compare its performance to the CBP. Eight subjects were tested in each paradigm, counter-balanced. Twelve minutes of calibration data were used as input to a stepwise linear discriminant analysis to derive classification coefficients used for online classification. Accuracy was consistently high for FFP (88%) and CBP (90%); information transfer rate was significantly higher for the FFP (63 bpm) than the CBP (48 bpm). The C(m,n) is a novel and effective general strategy for organizing stimulus groups. Appropriate choices for "m," "n," and specific constraints can improve presentation paradigms by adjusting the parameters in a subject specific manner. This may be especially important for people with neuromuscular disabilities.