Mental Health Trends in Patients With Symptomatic Macromastia After Reduction Mammoplasty.

BACKGROUND: Symptomatic macromastia can significantly affect both physical and mental health. Although previous studies suggested that breast reduction (BR) improves quality of life and mental health conditions, they were limited to smaller sample sizes and largely based on survey feedback. This study aims to further assess the impact of BR on mental health outcomes, specifically looking at prescribing patterns for common antidepressants. METHODS: A national insurance-based database was utilized for data collection. Patients with a diagnosis of macromastia (ICD-10 N62) between the years 2010 and 2021 that either underwent bilateral BR (CPT 19318) or did not undergo BR were included in the study. Demographics and medical comorbidities were compared. Among those who underwent BR, preoperative and postoperative rates of mental health diagnoses and antidepressant use were compared. Logistic regression analysis was performed to determine variables associated with surgery. RESULTS: Patients with a history of macromastia with a history of BR were compared with those with a history of macromastia without BR. A significantly higher percentage of patients in the BR group reported a history of depression (48.5%), obesity (55.7%), and selective serotonin reuptake inhibitor (SSRI)/serotonin-norepinephrine reuptake inhibitor (SNRI) use (55.3%) when compared with that of the no-reduction group (46.3%, 50.8%, and 52.6%). Patients with history of depression and obesity were more likely to undergo BR (odds ratio of 1.11 and 1.31). Patients who underwent BR had significantly reduced rates of mental health outcomes including depression (38.6% to 27.4%), anxiety (4.3% to 3.1%), and SSRI or SNRI prescriptions (46.3% to 29.5%) postoperatively. CONCLUSIONS: Patients who underwent BR for symptomatic macromastia showed significantly reduced rates of depression, anxiety, and most importantly, rates of SSRI/SNRI prescriptions postoperatively when compared to those who did not undergo BR for symptomatic macromastia.

Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: Randomized Controlled Trial.

BACKGROUND: Transversus Abdominis Plane (TAP) blocks improve pain control and reduce narcotic medication requirements in various surgical procedures. Liposomal bupivacaine may provide more sustained analgesia. This study compares pain related outcomes between standard bupivacaine and liposomal bupivacaine TAP blocks after autologous breast reconstruction. METHODS: Prospective single-center, single-blinded, randomized controlled trial between March 2021 and December 2022. DIEP flap breast reconstruction patients in a standardized Enhanced Recovery After Surgery (ERAS) pathway were randomized to receive intraoperative TAPs with either bupivacaine / epinephrine (control) or liposomal bupivacaine / bupivacaine / epinephrine (experimental). Primary outcome was postoperative narcotic medication requirements, with secondary outcomes of pain scores, length of stay (LOS), and narcotic medication refills. RESULTS: 117 patients met inclusion criteria (59 control, 58 experimental). Patient demographics, comorbidities, breast pathologic variables, surgery laterality and immediate versus delayed reconstruction status were equivalent between groups. Control group had significantly higher average pain scores postoperatively (4.3 vs. 3.6, p=0.004). However, there were no significant differences in mean narcotic use (66.9 MME vs 60.2 MME, p=0.47). Both LOS and postoperative narcotic prescription refills were equivalent between groups (2.1 vs 2.2 days, p = 0.55, 22% vs 17.2%, p=0.52). CONCLUSION: Addition of liposomal bupivacaine to standard bupivacaine TAP block mixture in a standardized ERAS protocol did not demonstrate a significant reduction in postoperative narcotic requirements after DIEP flap breast reconstruction compared to standard bupivacaine alone. Patient-reported pain scores, however, were lower among liposomal bupivacaine patients after the initial 24 hours postoperatively and consistent with a longer duration of analgesia.

Development of organic three-phase laminar flow microfluidic chip for extraction of ginsenosides from Panax ginseng.

BACKGROUND: Herbal extracts contain multiple active constituents, so the sample preparation based on the liquid-liquid extraction (LLE) is demanding, especially when a study subsequent to extraction is needed. Since the laminar flow occurring in microchannels can be formed between two miscible organic phases, a new method of extracting polar compounds from the crude extract of Panax ginseng Meyer in aqueous ethanol by pure n-butanol in the three-phase laminar flow microfluidic chip was established. METHODS: A new chip consisting of long microchannels with a guide structure was employed to improve the extraction efficiency caused by the low diffusion ability of saponins. The method was evaluated by using the extraction yields and purities of ginsenosides Rg1, Re and Rb1 as the indicators, and extraction conditions such as flow rate, temperature and other governing factors were optimized. RESULTS: Using the new chip method, the extraction efficiencies of ginsenoside Rg1, Re and Rb1 were 63.1%, 69.5% and 71.6%, respectively, which are higher than the 26% achieved in a previous report. The extraction yields of 1.53, 0.51, 0.90 mg/g were also higher than those obtained previously by the successive laminar flow microchip method. CONCLUSION: The proposed new microfluidic chip method has simplified the sample pretreatment steps to improve the yield of ginsenoside extraction from ginseng samples.

Vaccine traceability: Key learnings from the supply chain initiative by manufacturers from emerging countries.

The use of global standards, and the placement of barcodes and data matrix codes on vaccine labels and other levels of packaging are crucial elements for the traceability of finished vaccine products. Vaccine manufacturers are committed to improving health through their products, as vaccine production offers opportunities that can be leveraged to benefit immunization systems. In 2019 the Developing Countries Vaccine Manufacturers Network (DCVMN) created the Supply Chain Initiative aimed at prioritize and explore traceability opportunities; concomitantly procurement agencies announced traceability requirements for vaccine global supply. Vaccine traceability brings benefits including supply chain reliability and safety through enhanced product movement visibility, and a reduction of falsified and expired vaccines circulating in the supply chain. DCVMN has coordinated the development and implementation of global traceability standards, at both primary and secondary vaccine packaging levels, to encourage and enable sharing these experiences. Six pilot studies in four different countries showed successful implementation, and constituted part of larger vaccine traceability work within the respective organizations. The main findings from these pilot studies indicated that stepwise approaches to the adoption of traceability standards allowed vaccine manufacturers to learn by doing, initially with lower risk, and to spread their investments over time. Because the value of traceability is in its scale of adoption and the use of the data, it remains important for all stakeholders to engage in and prioritize the journey of vaccine traceability, but also to suitably manage the financial risks. The DCVMN Supply Chain Initiative has demonstrated that its members are committed to driving supply system changes that benefit immunization, while recognizing that supply chain traceability is part of a larger healthcare ecosystem and should be adopted by countries and immunization programmes as well.

Cerebellar Tonsillar Descent Mimicking Chiari Malformation.

Chiari I malformation has been defined as cerebellar tonsillar descent greater than 5 mm below the foramen magnum. Suboccipital decompression remains the mainstay of treatment for symptomatic patients. Other conditions sometimes have imaging features that mimic Chiari I malformation. These patients are at risk of misdiagnosis and mismanagement, including surgery that may be unnecessary or may even worsen the underlying condition. The aim of this study was to analyse a series of Chiari I malformation mimics and identify differentiating imaging features. The mimics are categorised as post-traumatic cranio-cervical junction arachnoiditis, dural band, spontaneous intracranial hypotension, idiopathic intracranial hypertension, and cysts. Better understanding of these conditions will assist with diagnosis and optimal management, including avoiding unnecessary surgery.

Evaluating accurate and efficient sampling strategies designed to measure social behavior and brush use in drylot housed cattle.

Efficient sampling strategies expedite behavioral data collection. While multiple studies have evaluated sampling strategies for core behaviors in cattle, few have focused on social interactions. To identify sampling strategies that accurately captured cattle social behaviors and brush use feedlot steers (n = 3 pens; 9 steers/pen) were observed from 8:00 to 17:00. Average bout duration (sec), total duration per day (sec), and bout frequency were recorded for allogrooming, bar licking, tongue rolling, and brush utilization. Frequency was recorded for headbutting and mounting. Data was extracted from continuous observation datasets using eight different sampling strategies and the results subsequently compared. Differences among sampling strategies were evaluated using a non-parametric One-Way ANOVA Kruskal-Wallis Test. Pearson correlation evaluated the strength of association between a specific sampling strategy and continuous observations. Bout duration for allogrooming (P > 0.65), bar licking (P > 0.60), tongue rolling (P > 0.99), brush use (P > 0.99), and mounting frequency (P > 0.70) did not differ from continuous observations. Tongue rolling (r2 > 0.95, P <0.0001) and brush use (r2 > 0.70, P < 0.0003) were best captured when cattle were observed from 08:00 to 14:00. When cattle were continuously observed from 08:00 to 14:00 or for 15 minutes every 30 minutes, allogrooming (P > 0.2) (frequency, duration), bar licking (P > 0.95) (frequency, duration), brush use (P > 0.1) (frequency, duration), heat butt (P > 0.30) (frequency), or tongue rolling (P > 0.30) (frequency, duration) did not differ from continuous observations. Observing cattle for 15 minutes every 30 minutes yielded the highest accuracy for all behavioral metrics and was considered the most effective strategy for comprehensively evaluating cattle social behavior (r2 > 75; P < 0.05). These results provide insight into accurate and efficient sampling strategies that expedite social behavior data collection in cattle and will facilitate efficient generation of new knowledge regarding cattle social behaviors.

A Literature Review: Pet Bereavement and Coping Mechanisms.

The loss of a companion animal results in millions of pet owners grieving annually. To date, little information has been synthesized on the grief response and coping mechanisms of bereaved pet owners. The aim of this review was to examine the relationship between pet loss and owner grief response. Major themes included: factors that influence the grief response, the disenfranchised nature surrounding pet loss, ambiguous pet loss and coping mechanisms used. Across the 48 studies included in this review, bereaved pet owners frequently reported feelings of embarrassment and loneliness following the loss of their pet. Types of coping mechanisms used by bereaved pet owners were identified and included: isolation, social support, continuing bonds, memorialization, religion, and relationships with other animals. Overall, this review was able to identify a consensus among the literature that bereaved pet owners are likely to experience disenfranchisement surrounding their loss. Based on the present findings, suggestions for future research include a focus on the effectiveness of coping mechanisms used by bereaved pet owners.

Peripherally Inserted Central Line Catheters following Hand and Wrist Infections.

Hand and wrist infections may cause varying degrees of morbidity requiring antibiotic therapy of variable duration and often operative intervention. Peripherally inserted central line catheters (PICCs) are placed when an extended course of intravenous antibiotics is anticipated. The present study aims to analyze utilization and impact of PICC placement on the management of hand, wrist, and forearm infections. Methods: The PearlDiver Patients Records Database was queried to identify patients who underwent treatment for infection of the hand, wrist, and forearm between 2010 and 2018. Logistic regression analysis was utilized to evaluate the association of patient-related risk factors with PICC utilization, complications, readmissions, and length of stay (LOS). Results: A total of 24,665 patients with an upper extremity infection were included in the study. Ultimately, 416 patients required a PICC placement (1.69%). Patients with older age, male gender, certain medical comorbidities, and infection involving deeper structures were more likely to require a PICC. Ninety-day all-cause medical complication rates were significantly higher for the PICC group (19.7% versus 6.7%) compared to those without. Any hospital readmission rates were significantly higher for PICC group at 90 days (28.4% versus 6.3%) and 1 year (35.8% versus 10.9%). Readmission rates remained slightly higher at 1 year for both groups. The PICC group demonstrated significantly longer LOS by 2 days (7.72 days versus 5.14 days). Conclusion: While not required for the majority of hand, wrist, and forearm infections, PICC placement is associated with increased medical complications, more frequent hospital readmissions, and longer LOS.

Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study.

BACKGROUND: Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes. METHODS: Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared. RESULTS: Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria. CONCLUSION: Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.

The Impact of Second Coordination Sphere Methionine-Aromatic Interactions in Copper Proteins.

The interplay between the primary and secondary coordination spheres in biological metal sites plays an essential role in controlling their properties. Some of the clearest examples of this are from copper sites in blue and purple copper proteins. Many such proteins contain methionine (Met) in the primary coordination sphere as a weakly bound ligand to Cu. While the effects of replacing the coordinated Met are understood, less so is the importance of its second-sphere interactions. In this combined informatics and experimental study, we first present a bioinformatics investigation of the second-sphere environments in biological Met-Cu motifs. The most common interaction is between the Met-CH3 and the π-face of a phenylalanine (Phe) (81% of surveyed structures), tyrosine (Tyr) (11%), and tryptophan (Trp) (8%). In most cases, the Met-CH3 also forms a contact with a π-face of one of a Cu-ligating histidine-imidazole. Such interactions are widely distributed in different Cu proteins. Second, to explore the impact of the second-sphere interactions of Met, a series of artificial Pseudomonas aeruginosa azurin proteins were produced where the native Phe15 was replaced with Tyr or Trp. The proteins were characterized using optical and magnetic resonance spectroscopies, X-ray diffraction, electrochemistry, and an investigation of the time-resolved electron-transfer kinetics of photosensitizer-modified proteins. The influence of the Cu-Met-Aro interaction on azurin's physical properties is subtle, and the hallmarks of the azurin blue copper site are maintained. In the Phe15Trp variant, the mutation to Phe15 induces changes in Cu properties that are comparable to replacement of the weak Met ligand. The broader impacts of these widely distributed interactions are discussed.

Risk Factors for Prolonged Opioid Consumption in Lower Extremity Amputees.

Extremity amputation is a common procedure performed to treat a variety of different problems and affects quality of life in a number of ways. In addition to acute postoperative pain, amputations have been shown to cause chronic pain that is often neuropathic in many amputees. This study sought to better characterize the role of opioids in postoperative pain control in lower extremity amputees. METHODS: Patients who underwent lower extremity amputation between 2010 and 2018 were identified in a national insurance-claims database using ICD-9, ICD-10, and CPT codes. Patient demographics, comorbidities, perioperative opioid use, and prolonged postoperative opioid use were then determined for both groups. Descriptive statistics and logistic regression analysis were utilized to evaluate the association of patient-related risk factors and neuropathic pain conditions with perioperative and prolonged postoperative opioid use. RESULTS: In total, 2247 opioid-naive lower extremity amputees were identified. An estimated 54.7% of patients utilized opioids in the perioperative period, and 44.6% were found to have prolonged opioid use. Younger age (ages 40-50 versus older), history of chronic pain, migraines, lower back pain, Charlson Comorbidity Index greater than 1, preoperative benzodiazepine, muscle relaxant, anticonvulsant, and antidepressant use were all significantly related to prolonged postoperative opioid use. CONCLUSIONS: Prolonged postoperative opioid use is a problem that affects nearly half of lower extremity amputees and seems to be significantly related to the preoperative use of benzodiazepines, muscle relaxants, anticonvulsants, and antidepressants. Further research into the diagnosis and treatment of postamputation neuropathic pain is needed to prevent reliance on opioids in this patient population.

The importance of vaccine stockpiling to respond to epidemics and remediate global supply shortages affecting immunization: strategic challenges and risks identified by manufacturers.

While stockpiling vaccines adds another layer of complexity to vaccine manufacturing, it constitutes a crucial component of comprehensive disease preparedness and control strategies in public health management. Stockpiling provides the ability to immediately respond to epidemics, disease outbreaks, vaccine shortages or stock-outs at local, regional or global levels. Some stockpiles are static, not shipped until an emergency occurs; other stockpiles are rotating with vaccines used in on-going routine immunization programmes. Programmatic use indicates which vaccines to stockpile, the nature of the stockpile and the amount of vaccine to be held at any time. For immediate shipment, fully released product must be stockpiled with the challenge of monitoring remaining shelf-life requirements and the potential risk of expiry. Existing stockpiles are managed and financed globally under the purview of international organizations in the global immunization community, except for buffer stocks held by manufacturers for short periods. The added challenges to manufacturers of stockpiling vaccines, including storage, human resources and other related costs including vaccine destruction when no longer useable, needs to be recognized. This is all the more so with the likelihood of vaccine stockpiling becoming more prominent with changing disease patterns due to climate change and population movements, as well as the significant investment in the research and development of new epidemic prevention vaccines. While vaccine stockpiles managed and financed globally provide rapid response to country requests, more attention is needed in the future to ways that vaccine stockpiling can be brought under the direct purview of individual countries or regional groupings.

Assessment of Sensory Thresholds in Dogs using Mechanical and Hot Thermal Quantitative Sensory Testing.

Quantitative sensory testing (QST) is used to evaluate the function of the somatosensory system in dogs by assessing the response to applied mechanical and thermal stimuli. QST is used to determine normal dogs' sensory thresholds and evaluate alterations in peripheral and central sensory pathways caused by various disease states, including osteoarthritis, spinal cord injury, and cranial cruciate ligament rupture. Mechanical sensory thresholds are measured by electronic von Frey anesthesiometers and pressure algometers. They are determined as the force at which the dog exhibits a response indicating conscious stimulus perception. Hot thermal sensory thresholds are the latency to respond to a fixed or ramped temperature stimulus applied by a contact thermode. Following a consistent protocol for performing QST and paying attention to details of the testing environment, procedure, and individual study subjects are critical for obtaining accurate QST results for dogs. Protocols for the standardized collection of QST data in dogs have not been described in detail. QST should be performed in a quiet, distraction-free environment that is comfortable for the dog, the QST operator, and the handler. Ensuring that the dog is calm, relaxed, and properly positioned for each measurement helps produce reliable, consistent responses to the stimuli and makes the testing process more manageable. The QST operator and handler should be familiar and comfortable with handling dogs and interpreting dogs' behavioral responses to potentially painful stimuli to determine the endpoint of testing, reduce stress, and maintain safety during the testing process.

Technical contribution: use of continuous recording video monitoring of maintenance and pain behaviors in piglets after surgical castration to validate six continuous time sampling periods for behavior scoring.

Castration is a painful procedure routinely performed on piglets. Specific periods relative to castration and time sampling rules are used widely to quantify deviations in piglet's behavior associated with castration rather than assessing behavior for the entire trial period. However, very limited work has evaluated time sampling recording rules to quantify behavioral changes to piglets undergoing castration. Therefore, the objective of this study was to validate the accuracy of six continuous time sampling periods (5, 10, 15, 20, 30, and 45 min), to quantify piglet behavior post-castration when compared with a full 60-min observation period. Sixteen Yorkshire-Landrace x Duroc piglets were surgically castrated. Data were collected using continuous observation (recording rule) of each individual male piglet per litter for 60-min post-castration. The 60-min continuous behavioral data set was then subdivided into six data subsets for each defined continuous time sampling period (5, 10, 15, 20, 30, and 45 min). Data from each continuous time sampling period and the full period data were analyzed using both a generalized linear mixed model and linear regression analysis. For the generalized linear mixed model, 30- and 45-min continuous time sampling periods were not different (P > 0.05) when compared with the full observation period data for all behaviors. For the linear regression analysis, affiliative interaction, sitting, walking, huddled up, prostrated, scratching, spasms, and trembling behaviors met the pairwise comparison accuracy criteria: [1) the coefficient of determination (R2) was > 0.90, 2) the intercept did not differ from 0 (P > 0.05), and 3) the slope did not differ from 1 (P > 0.05)] at the 45-min continuous time sampling period compared to full observation period. Results from this study suggest that a 45-min continuous time sampling period would be necessary to accurately investigate piglet behavior during the acute pain sensitivity time post-castration when considering both maintenance and pain-associated behaviors.

Quality Improvement: Effect of Standardized Plastic Surgery Consultation Note Templates on Charge Capture.

BACKGROUND: Effective medical record documentation is imperative for both patient care and reimbursement for care provided. The purpose of this study was to compare coding/billing patterns for plastic surgery consultations before and after implementation of a standardized documentation protocol. METHODS: Standardized hand, facial trauma, and general plastic surgery consult note templates were created. Following institutional approval, records were reviewed for all plastic surgery consultations from January to October 2019. Template notes were universally implemented in July 2019. Medical coding was performed by a certified professional coder using the 1995 Evaluation and Management Review Worksheet. Coding/billing patterns between groups were compared with and without standardized documentation using univariate analysis. RESULTS: Seventy-five consecutive preimplementation consult notes and 75 consecutive postimplementation consult notes were selected for review. Each group included 25 hand, 25 facial trauma, and 25 general plastic surgery consultation notes. The history and physical examination components of the visit code were more frequently coded as "comprehensive"postimplementation (P = 0.000). There was no significant difference in coding for medical decision making between the two groups (P = 0.340). The final visit code was significantly higher in the postimplementation group (45.3% 99254/99284 versus 2.7%, P = 0.000), and the charges were significantly higher post implementation-average charge per consult $250 versus $203 (P = 0.000) with a 22.8% increase in total charges generated. CONCLUSION: Utilization of standardized consultation note templates increases the accuracy of coding and associated billing of inpatient and emergency department plastic surgery consultations through documentation and reflection of level of service provided.

Association between Dog Owner Demographics and Decision to Seek Veterinary Care.

(1) Background: An important aspect of dog ownership is providing veterinary care. However, features of dog ownership differ across demographic groups and these may influence veterinary client decision making and behavior. The purpose of the present study was to elucidate relationships between American dog owner characteristics and willingness to seek veterinary care. (2) Methods: A total of 858 dog owners completed an online questionnaire asking participants to rate their level of likelihood to seek veterinary care for different medical conditions, answer supplemental questions about their previous veterinary barriers, and indicate barriers that prevent them from seeking veterinary care. (3) Results: Dog owners did not differ by demographics in their willingness to seek veterinary care. However, dog owner demographic groups varied in their relationship with their dog(s), previous behaviors accessing veterinary care, and barriers that make seeking veterinary care challenging. (4) Conclusions: Education, outreach and community-based veterinary medicine efforts should allocate resources to underserved communities identified within the context that they are affected by barriers to obtaining veterinary care for their dog(s).

Cohort profile: why do people keep hurting their back?

OBJECTIVE: Low back pain (LBP) is one of the most disabling and costly conditions worldwide. It remains unclear why many individuals experience persistent and recurrent symptoms after an acute episode whereas others do not. A longitudinal cohort study was established to address this problem. We aimed to; (1) evaluate whether promising and potentially modifiable biological, psychological, social and behavioural factors, along with their possible interactions, predict LBP outcome after an acute episode; (2) compare these factors between individuals with and without acute LBP; and (3) evaluate the time-course of changes in these factors from LBP onset. This paper outlines the methodology and compares baseline characteristics between acute LBP and control, and LBP participants with and without follow-up. RESULTS: 133 individuals with acute LBP and 74 pain-free individuals participated. Bio-psycho-social and behavioural measures were collected at baseline and 3-monthly for 12 months (LBP) or 3 months (control). Pain and disability were recorded fortnightly. Baseline characteristics were mostly similar between those who did and did not return for follow-up. Initial analyses of this cohort have revealed important insights into the pathways involved in acute-to-chronic LBP. These and future findings will provide new targets for treatment and prevention of persistent and recurrent LBP.

Changing trends in the clinicopathological features, practices and outcomes in the surgical management for cystic lesions of the pancreas and impact of the international guidelines: Single institution experience with 462 cases between 1995-2018.

INTRODUCTION: The impact on clinical practice of the international guidelines including the Sendai Guidelines (SG06) and Fukuoka Guidelines (FG12) on the management of cystic lesions of the pancreas (CLP) has not been well-studied. The primary aim was to examine the changing trends and outcomes in the surgical management of CLP in our institution over time and to determine the impact of these guidelines on our institution practice. METHODS: 462 patients with surgically-treated CLP were retrospectively reviewed and classified under the 2 guidelines. The cohort was divided into 3 time periods: 1998-2006, 2007-2012 and 2013 to 2018. RESULTS: Comparison across the 3 time periods demonstrated significantly increasing frequency of older patients, asymptomatic CLP, male gender, smaller tumor size, elevated Ca 19-9, use of magnetic resonance imaging (MRI) and use of endoscopic ultrasound (EUS) prior to surgery. There was also significantly increasing frequency of adherence to the international guidelines as evidenced by the increasing proportion of HRSG06 and HRFG12 CLP with a corresponding lower proportion of LRSG06 and LRFG12 being resected. This resulted in a significantly higher proportion of resected CLP whereby the final pathology confirmed that a surgery was actually indicated. CONCLUSIONS: Over time, there was increasing adherence to the international guidelines for the selection of patients for surgical resection as evidenced by the significantly increasing proportion of HRSG06 and HRFG06 CLPs undergoing surgery. This was associated with a significantly higher proportion of patients with a definitive indication for surgery. These suggested that over time, there was a continuous improvement in our selection of appropriate CLP for surgical treatment.

Validation of the clinical utility of 4 guidelines in the initial triage of mucinous cystic lesions of the pancreas based on cross-sectional imaging: Experience with 188 surgically-treated patients.

INTRODUCTION: Over the years, several guidelines have been introduced to guide management of mucinous pancreatic cystic neoplasms (mPCN). In this study, we aimed to evaluate and compare the clinically utility of the Sendai-06, Fukuoka-12, Fukuoka-17 and European-18 guidelines in predicting malignancy of mPCN. METHODS: One hundred and eighty-eight patients with mucinous cystic neoplasms (MCN) or intraductal papillary mucinous neoplasm (IPMN) who underwent surgery were retrospectively reviewed and classified under the 4 guidelines. Malignancy was defined as high grade dysplasia and invasive carcinoma. RESULTS: Raised CA19-9>37U/ml, enhancing mural nodule≥5 mm and main pancreatic duct≥10 mm were significantly associated with malignancy on multivariate analysis. Increasing number of high risk features, absolute indications (European-18), worrisome risk or relative indications (European-18) were significantly associated with an increased likelihood of malignancy. The positive predictive values (PPV) of high risk features for Sendai-06, Fukuoka-12, Fukuoka-17 and absolute indications (European-18) for malignancy were 53%, 76%, 78% and 78% respectively. The negative predictive values (NPV) of the Sendai-06, Fukuoka-12 and Fukuoka-17 were 100%, while that of the European-18 was 92%. Risk of malignancy for patients with ≥4 worrisome features (Fukuoka-17) and ≥3 relative indications (European-18) was 66.7% and 75.0% respectively. CONCLUSIONS: All 4 guidelines studied were useful in the initial triage of mPCN for the risk stratification of malignancy. The Fukuoka-17 had the highest PPV and NPV.

Identifying Barriers to Implementing Pain Management for Piglet Castration: A Focus Group of Swine Veterinarians.

Surgical castration is a painful husbandry procedure performed on piglets in the United States (US) to improve meat quality. Veterinarians play a crucial role in developing pain management protocols. However, providing pain management for castration is not common practice in US swine production systems. Therefore, the objective of the present study is to identify factors influencing swine veterinarian decision-making in regard to pain management protocols for piglet castration using focus group methodologies. Swine veterinarians (n = 21) were recruited to participate in one of three focus groups. Audio recordings were transcribed verbatim and analyzed by two independent coders who identified three areas of focus, including (1) the lack of approved products validated for efficacy, (2) economic limitations and challenges, and (3) deficient guidelines and training for veterinarians to develop protocols. Although participating veterinarians acknowledged the importance of pain management from an animal welfare standpoint, these barriers must be addressed to ensure that castration pain can be successfully mitigated on-farm.