Revision total knee replacement finances: a detailed cost-analysis of operative practice at a regional tertiary referral centre.

BACKGROUND: The revision knee complexity classification (RKCC) stratifies knee revision operations depending on their level of complexity from simple revisions (R1) to highly complex cases (R3). Current financial codes used for calculation of reimbursement for knee revision services provided at the Trust, rely on patients' comorbidities. However, previous research has demonstrated that this approach may not yield an accurate financial account of knee revision arthroplasty cost. This is a single centre study from a secondary and tertiary revision unit, with work previously presented by the authors demonstrating that the majority of complex revision knee replacement within the region, take place in this unit. The aims of this study were to illustrate the current cost profile and renumeration service currently in place for revision knee and show the differences in cost based on complexity of the operation. METHODS: In this retrospective study, 90 cases who underwent revision knee operations in 2019 were analysed. Data was obtained from a tertiary referral centre where the episodes had occurred. Mean cost, tariff, and subsequent deficit were calculated for the R1, R2 and R3 episodes. RESULTS: R2 and R3 episodes were significantly more expensive than R1 episodes. The increase in cost between R3 and R2 episodes was not significant. The total cost of the revision operations was £1,162,343. Tariffs received for R2 and R3 revision operations were significantly more expensive than R1 operations. However, the increase in tariffs received for R3 operations was not significant in relation to R2 operations. The total amount of tariffs received by the Trust was £ 770,996 generating a net deficit of - £ 391,347. CONCLUSION: Current financial coding for revision knee does not accurately predict costs associated with revision knee surgery. Net deficit varies depending on the RKCC grade of the knee revision episode with more complex operations resulting in a higher mean net deficit. Implementation of the RKCC could prove to be a useful tool in generating an accurate prediction of the cost associated with knee revision surgery.

Exploring the Effects of Acute Stress Exposure on Lumpfish Plasma and Liver Biomarkers.

This study aimed to expand knowledge on lumpfish stress physiology by investigating the effects of acute stress on primary (i.e., cortisol) and secondary (e.g., metabolites) stress responses, as well as oxidative stress biomarkers, from stress exposure to a recovery phase. The results showed that the lumpfish physiological response to 1 min air exposure is mild, in line with recent studies, and comparable to that described for white sturgeons. Cortisol seems to be the most reliable acute stress biomarker in lumpfish, with a significant increase in plasma 30 min after stress exposure, returning to resting levels 2 h after exposure. In contrast, glucose and lactate were not significantly altered by short-term air exposure. Effects on hepatic energy mobilisation were also detected following the acute stress. This study showed that acute 1 min air exposure seems tolerable, allowing a swift recovery. However, more studies on the impacts of air exposure and repeated acute stressors on lumpfish stress and immune responses are required to develop industry standards for lumpfish health and welfare monitoring.

Genomic Signatures of Local Adaptation under High Gene Flow in Lumpfish-Implications for Broodstock Provenance Sourcing and Larval Production.

Aquaculture of the lumpfish (Cyclopterus lumpus L.) has become a large, lucrative industry owing to the escalating demand for "cleaner fish" to minimise sea lice infestations in Atlantic salmon mariculture farms. We used over 10K genome-wide single nucleotide polymorphisms (SNPs) to investigate the spatial patterns of genomic variation in the lumpfish along the coast of Norway and across the North Atlantic. Moreover, we applied three genome scans for outliers and two genotype-environment association tests to assess the signatures and patterns of local adaptation under extensive gene flow. With our 'global' sampling regime, we found two major genetic groups of lumpfish, i.e., the western and eastern Atlantic. Regionally in Norway, we found marginal evidence of population structure, where the population genomic analysis revealed a small portion of individuals with a different genetic ancestry. Nevertheless, we found strong support for local adaption under high gene flow in the Norwegian lumpfish and identified over 380 high-confidence environment-associated loci linked to gene sets with a key role in biological processes associated with environmental pressures and embryonic development. Our results bridge population genetic/genomics studies with seascape genomics studies and will facilitate genome-enabled monitoring of the genetic impacts of escapees and allow for genetic-informed broodstock selection and management in Norway.

Impact of Palliative Interventions on Survival of Patients with Unresected Pancreatic Cancer: Review of the 2010-2016 National Cancer Database.

INTRODUCTION: Palliative interventions (PI) are offered to patients with pancreatic cancer with the aim of enhancing quality of life and improving overall survival (OS). The purpose of this study was to determine the impact of PI on survival amongst patients with unresected pancreatic cancer. METHODS: Patients with stage I-IV unresected pancreatic adenocarcinoma were identified using the 2010-2016 National Cancer Database. The cohort was stratified by PI received: palliative surgery (PS), radiation therapy (RT), chemotherapy (CT), pain management (PM), or a combination (COM) of the preceding. Kaplan-Meier method with log-rank test was used to compare and estimate OS based on the PI received. A multivariate proportional hazards model was utilized to identify predictors of survival. RESULTS: 25,995 patients were identified, of which 24.3% received PS, 7.7% RT, 40.8% CT, 16.6% PM, and 10.6% COM. The median OS was 4.9 months, with stage III patients having the highest and stage IV the lowest OS (7.8 vs 4.0 months). Across all stages, PM yielded the lowest median OS and CT the highest (P < .001). Despite this, the stage IV cohort was the only group in which CT (81%) accounted for the largest proportion of PI received (P < .001). Although all PI were identified as positive predictors of survival on multivariate analysis, CT had the strongest association (HR .43; 95% CI, .55-.60, P = .001). CONCLUSION: PI offers a survival advantage to patients with pancreatic adenocarcinoma. Further studies to examine the observed limited use of CT in earlier disease stages are warranted.

White-Tailed Deer Spatial Distribution in Relation to '4-Poster' Tick Control Devices in Suburbia.

Deer are keystone hosts for adult ticks and have enabled the spread of tick distributions. The '4-Poster' deer bait station was developed by the United States Department of Agriculture to control ticks feeding on free-ranging deer. Although effective in certain scenarios, '4-Poster' deer treatment stations require the use of bait to attract deer to one location, which may cause increased deer disease transmission rates and habitat damage. To better understand and manage the impact of baited '4-Poster' stations on deer movements, we captured and GPS-monitored 35 deer as part of an integrated pest management project. Fifteen '4-Poster' stations were deployed among three suburban county parks to control ticks. To quantify the effects of '4-Poster' stations, we calculated deer movement metrics before and after feeders were filled with whole kernel corn, and we gathered information on visitation rates to feeders. Overall, 83.3% of collared deer visited a feeder and revisited approximately every 5 days. After feeders were refilled, collared deer were ~5% closer to feeders and conspecifics than before filling. Males used a higher percentage of available feeders and visited them more throughout the deployment periods. Although these nuanced alterations in behavior may not be strong enough to increase local deer abundance, in light of infectious diseases affecting deer populations and effective '4-Poster' densities, the core range shifts and clustering after refilling bait may be a cause for concern. As such, trade-offs between conflicting management goals should be carefully considered when deploying '4-Poster' stations.

Trapping White-Tailed Deer (Artiodactyla: Cervidae) in Suburbia for Study of Tick-Host Interaction.

Live capture of white-tailed deer (Odocoileus virginianus) (Zimmermann, 1780) is often necessary for research, population control, disease monitoring, and parasite surveillance. We provide our deer trapping protocol used in a tick-host vector ecology research project and recommendations to improve efficiency of deer trapping programs using drop nets in suburban areas. We captured 125 deer across two trapping seasons. Generally, lower daily minimum temperatures were related to increased capture probability, along with the presence of snow. Our most successful trapping sites were less forested, contained more fragmentation, and greater proportion of human development (buildings, roads, recreational fields). To improve future suburban deer trapping success, trapping efforts should include areas dominated by recreational fields and should not emphasize remote, heavily forested, less fragmented parks. Concurrently, our study illustrated the heterogeneous nature of tick distributions, and we collected most ticks from one trapping site with moderate parameter values between the extremes of the most developed and least developed trapping sites. This emphasized the need to distribute trapping sites to not only increase your capture success but to also trap in areas across varying levels of urbanization and fragmentation to increase the probability of parasite collection.

Feasibility and Impact of a Student-Led, Semi-Structured, Near-Peer Student Guides Program on Navigating Through Medical School.

BACKGROUND: Mentorship is critical to developing health professionals. Near-peer mentorship pairs senior mentors with junior peers to help navigate academic, professional, and social aspects of training. METHODS: In this convergent parallel mixed methods study, we assessed the feasibility, usability, professional and social impact, and barriers to implementation of a 16-week semi-structured, near-peer, student guides program involving 39 first year medical students (MS1s) and 41 fourth year medical students (MS4s). Student enrollment was quantified, guide-guidee meetings tracked, and > 2 meetings defined as feasible. Meeting topics, impact on student advising, and barriers to sustainability were contextualized qualitatively. RESULTS: Twenty-two percent of all MS4s and 46% of MS1s enrolled in the program; 67% of guides facilitated the requisite two meetings with their group, which was less than our predetermined feasibility criteria of 75%. Most guide-guidee interactions occurred in person (91%), but text messages (82%) and video/mobile messaging apps (78%) were also used. Ninety-two percent of guidees recommended the program, and 85% were satisfied with guidance received. Barriers included meeting coordination, infrequent meetings, and informal meeting structure. CONCLUSIONS: While the program was infeasible by predefined frequency criteria, participant satisfaction was high and academic, professional, and social benefits of near-peers were reported. In response, programmatic revisions now incorporate centralized support for meetings, e-mentorship, and guide training.

Stress-Dosed Glucocorticoids and Mineralocorticoids Before Intensive Endurance Exercise in Primary Adrenal Insufficiency.

Patients with primary adrenal insufficiency (PAI) require increased doses of glucocorticoids and mineralocorticoids during stressors, such as surgery, trauma, and sepsis. Although current guidelines exist for dose adjustments in these situations, there is no accepted dosing regimen for patients with PAI participating in intensive endurance exercise. Given the extensive physiologic stress of events, such as marathons, triathlons, and similar events, it is likely that a "stress-dose" of adrenal replacement therapy will not only prevent adrenal crisis, but also improve performance. A 50-year-old male endurance athlete with known PAI reported severe fatigue, nausea, and malaise after competing in prior marathons and intensive endurance exercise. After supplementing with glucocorticoids and mineralocorticoids before competition, he experienced decreased symptoms and improved performance. To better care for these patients, further studies should be conducted to provide safe and effective glucocorticoid and mineralocorticoid dose adjustments before intensive endurance exercise.

Performing Under Pressure: Varsity Athletes Excel in Medical School.

PURPOSE: The admission process for medical school relies on objective and subjective measures of personal achievement, and selecting successful medical students is a daunting task for admission committees. While there is a significant body of literature examining MCAT scores and undergraduate grade point average (GPA) with medical school performance, there is a paucity of research on impact of specific student accomplishments on future performance. We hypothesize participation in a varsity collegiate sport will correlate with higher performance during medical school. METHODS: A retrospective review of four medical school classes at a single institution was completed. Each student's admission application was examined for at least 1 year of participation in a varsity-level sport at their respective undergraduate institution. A total of 62 athletes (16.36%) were identified out of 441 total students. Multiple medical school performance metrics were obtained for each student. RESULTS: There was no difference in MCAT scores between athletes and non-athlete medical students. There was a significant difference in step 1, step 2 CK, NBME shelf exams, cumulative year 3 performance, and AOA status with the athletes outperforming their peers. CONCLUSION: Students who participate in collegiate varsity athletics excel in medical school. One explanation for this finding may be participation in high-stakes athletic training and competition results in development of specific attributes beneficial in medical school. These attributes may include receptiveness to criticism, time management, resiliency, team participation, and performing under pressure. Additional research is needed to elucidate the attributes that determine improved medical school performance, such that medical educators can utilize this knowledge to better prepare all students for the rigors of medical school.

The use of photoperiods to provide year round spawning in lumpfish Cyclopterus lumpus.

In order to provide year round spawning broodstock, lumpfish (initial size 746 g and 24.9 cm) were reared under four different photoperiod regimes from January 2017 to July 2018. One group was reared under simulated natural photoperiod (LDN, control group) for Tromsø (70°N). The second group was transferred to continuous light (LD240) on 30 January 2017 and reared at LD24:0 throughout the trial period. Two compressed and phase advanced photoperiods were also established. Both groups were moved from LDN to LD24:0 on 30 January 2017, and after that reared at compressed natural photoperiods where the annual photoperiod was compressed down to six months (L6) or nine months (L9) for the duration of the study. Spawning time was shifted in both compressed groups during both years of the study. Spawning activity in the second year of the study was higher and followed more closely the expected spawning period in the compressed and the LDN groups. Spawning in the LD240 group was spread out over the experimental period with no distinct peak in spawning. A seasonal and pronounced drop in condition factor was found for females in the L9, L6 and the LDN groups. This post-spawning loss in condition was closely related to the spawning activity of each group. The current findings suggest that photoperiod has a strong influence on the timing of lumpfish maturation and can be used as an efficient and inexpensive tool to secure lumpfish reproduction operations i.e. year-round supply of egg and milt and/or timing with optimal temperature regimes.

It works! Lumpfish can significantly lower sea lice infestation in large-scale salmon farming.

To assess the efficacy of lumpfish grazing on attached sea lice on Atlantic salmon, six large-scale sea cages, (130 m circumference, 37,688 m3 volume) each stocked with approximately 200,000 salmon 0+ smolts, were stocked with a 4, 6 and 8% density (8000, 12,000 and 16,000, respectively) of lumpfish. The sea cages without lumpfish acted as controls. Sea lice infestation levels on the salmon were monitored weekly and bi-weekly from 6 October to 17 May the subsequent year. Mortality of the lumpfish rose with decreasing sea temperatures to around 0.8% week-1 and did not vary between the lumpfish groups. There were clear signs of lumpfish grazing on sea lice, with significantly lower average levels of chalimus, pre-adult and adult female Lepeophtheirus salmonis and Caligus elongatus sea lice per salmon. Lumpfish in the high density (8%) group reduced the mature female L. salmonis to levels equal to or lower than the counts recorded prior to the start of the study. Overall, the present results indicate that lumpfish are a suitable cold-water option for biological delousing of Atlantic salmon in large-scale production conditions.

Role of Early Palliative Care Interventions in Hematological Malignancies and Bone Marrow Transplant Patients: Barriers and Potential Solutions.

INTRODUCTION: Despite advances in palliative care management of physical, psychological, and emotional symptoms along the spectrum of chronic conditions, early palliative care interventions are not used frequently and comprehensively in bone marrow transplant units. METHODS: The literature review of PubMed articles in English published until December 2017. RESULTS: Patients with hematologic malignancies and bone marrow transplant interventions are a heterogeneous group. The majority experience symptoms associated with induction or condition regimens. Curative intent of treatment is the norm. Pain, mucositis, nausea and vomiting, diarrhea, psychological, spiritual, and emotional concerns may not be properly and comprehensively tackled by primary oncology and bone marrow transplant teams. Quality of life may be decreased due to the presence of these symptoms. Obstacles to early palliative care interventions include overestimation of survival, focus on curative intent with underestimation of palliative care needs, lack of a comprehensive understanding of hematologic malignancies and bone marrow transplant process on the side of palliative care providers, and logistical restrictions. Potential interventions include education of oncologists, palliative care providers, patients, integration of models of care pre- and posttreatment and bone marrow transplantation, development of guidelines, institutional commitment and leadership in creating new initiatives, clinical research activities to measure outcomes, and community-based participatory research. CONCLUSIONS: Early palliative care interventions are beneficial for patients with hematologic malignancies and bone marrow transplant processes. Better understanding of barriers to its implementation and development of creative initiatives is of paramount importance. New research endeavors should focus on providers' attitudes toward patients and communities.

Factors Associated with the Outcome of Very Elderly Patients with Large Hemispheric Infarction Treated with Medical Management Only.

BACKGROUND: Large ischemic stroke in the very elderly population is presumed to invariably carry a poor prognosis and clinicians may refrain from continuing intensive care. Many elderly patients are not surgical candidates, and there is a paucity of data outlining the real-world outcomes of continued medical management. Our objective is to identify the factors associated with the outcome of very elderly patients with large hemispheric infarction (LHI) treated with medical management alone. METHODS: We performed a retrospective review of all consecutive adults ≥ 70 years of age with LHI identified from a single center stroke registry between 2012 and 2016. Mean volume of infarction was calculated using the ABC/2 method. RESULTS: Of a total of 2335 patients, 71 (mean age 81 ± 7 years,) met inclusion criteria. Forty-one were women (58%). Mean admission National Institute of Health Stroke Score (NIHSS) was 21 ± 6. Intravenous tPA was administered in 30 (42%) and 9 (13%) patients underwent thrombectomy. Mean infarct volume was 175 ± 75 cc. Twenty-seven patients (38%) survived to hospital discharge; 6 (9%) eventually went home (albeit with mRS 4) and one (1%) went to assisted living. Multivariate logistic regression analysis found that admission NIHSS ≥ 20 (p = 0.0007) and mechanical ventilation within 48 h of admission (p = 0.0396) were independently associated with poor outcome. CONCLUSION: Ten percent of medically managed patients (≥ 70 years of age) with LHI can go home or to assisted living, but with a mRS of 4. Whether this is an acceptable outcome must be individualized on a case-by-case basis; however, poor prognosis should not be automatically presumed solely based on the combination of older age and a large stroke.

Mentored peer review of standardized manuscripts as a teaching tool for residents: a pilot randomized controlled multi-center study.

BACKGROUND: There is increasing need for peer reviewers as the scientific literature grows. Formal education in biostatistics and research methodology during residency training is lacking. In this pilot study, we addressed these issues by evaluating a novel method of teaching residents about biostatistics and research methodology using peer review of standardized manuscripts. We hypothesized that mentored peer review would improve resident knowledge and perception of these concepts more than non-mentored peer review, while improving review quality. METHODS: A partially blinded, randomized, controlled multi-center study was performed. Seventy-eight neurology residents from nine US neurology programs were randomized to receive mentoring from a local faculty member or not. Within a year, residents reviewed a baseline manuscript and four subsequent manuscripts, all with introduced errors designed to teach fundamental review concepts. In the mentored group, mentors discussed completed reviews with residents. Primary outcome measure was change in knowledge score between pre- and post-tests, measuring epidemiology and biostatistics knowledge. Secondary outcome measures included level of confidence in the use and interpretation of statistical concepts before and after intervention, and RQI score for baseline and final manuscripts. RESULTS: Sixty-four residents (82%) completed initial review with gradual decline in completion on subsequent reviews. Change in primary outcome, the difference between pre- and post-test knowledge scores, did not differ between mentored (-8.5%) and non-mentored (-13.9%) residents (p = 0.48). Significant differences in secondary outcomes (using 5-point Likert scale, 5 = strongly agree) included mentored residents reporting enhanced understanding of research methodology (3.69 vs 2.61; p = 0.001), understanding of manuscripts (3.73 vs 2.87; p = 0.006), and application of study results to clinical practice (3.65 vs 2.78; p = 0.005) compared to non-mentored residents. There was no difference between groups in level of interest in peer review (3.00 vs 3.09; p = 0.72) or the quality of manuscript review assessed by the Review Quality Instrument (RQI) (3.25 vs 3.06; p = 0.50). CONCLUSIONS: We used mentored peer review of standardized manuscripts to teach biostatistics and research methodology and introduce the peer review process to residents. Though knowledge level did not change, mentored residents had enhanced perception in their abilities to understand research methodology and manuscripts and apply study results to clinical practice.

Transcranial Doppler Sonography: Atypical Dicrotic Pulse Waveforms in a Man with HIV Infection and Severe Cardiomyopathy.

A 27-year-old human immunodeficiency virus--positive man presented with abdominal pain. Computed tomography of the abdomen revealed large right pleural effusion, pericardial effusion and marked ascites with diffuse intra- and extraperitoneal lymphadenopathy. Echocardiography showed severely reduced left ventricular systolic function. After drainage of pleural and pericardial fluid, the patient developed severe hypotension and hypoxic respiratory failure. Extra- and intracranial neurovascular sonography demonstrated low carotid artery flow volume and dicrotic pulse waveforms in all vessels insonated bilaterally. This case report demonstrates an atypical dicrotic waveform pattern of transcranial Doppler in advanced ventricular dysfunction with shock.

Inpatient Falls: Improving assessment, documentation, and management.

A frequently occurring job during on-call and out-of-hours shifts is reviewing a patient following a fall with this often being the responsibility of the most junior and inexperienced doctors. Following a pilot audit we identified inconsistencies in medical assessment and documentation, with 50% of expected data points not recorded. Failure to complete a thorough assessment can lead to missed injuries, prolonged length of stay, and litigation. Using the plan, do, study, act (PDSA) cycle model this project sought to address this through providing teaching to junior doctors and the development of a pro-forma. Three style cycles of data collection were performed; a formal baseline dataset, after delivering a teaching session to new junior doctors and following the trial of the new fall pro-forma. We selected 15 to 17 patient notes to review at random during a one month period for each data collection cycle and compared the medical assessment to the standards outlined by the National Patient Safety Agency (NPSA) guidelines.[1] There were two key areas of improvement identified following the teaching session and introduction of the proforma. Documentation of a fall history was improved by nearly 30% being recorded in 100% of cases after the interventions. Documentation of a thorough musculoskeletal examination was improved from being recorded in just 54% of cases to 77% of cases; it was recorded in 100% of the cases where the proforma was used. The project demonstrated the need to improve documentation and assessment of a patient who has fallen. Initial data collection has shown that assessment and documentation were improved providing teaching to junior doctors and by use of the document. The pro-forma has since been incorporated into hospital policy and now forms the compulsory documentation expected of the doctors and nurses managing patients following a fall. Ensuring easy access to the proforma and re-auditing after editing the document will be the next steps.

Predictors of 30-day hospital readmission following ischemic and hemorrhagic stroke.

Stroke patients have a high rate of 30-day readmission. Understanding the characteristics of patients at high risk of readmission is critical. A retrospective case-control study was designed to determine factors associated with 30-day readmission after stroke. A total of 79 cases with acute ischemic or hemorrhagic strokes readmitted to the same hospital within 30 days were compared with 86 frequency-matched controls. Readmitted patients were more likely to have had ≥2 hospitalizations in the year prior to stroke (21.5% vs 2.3% in controls, P < .001), and in the multivariate model, admission National Institutes of Health Stroke Score (NIHSS; odds ratio [OR] = 1.072; 95% confidence interval [CI] = 1.021-1.126 per 1 point increase; P = .005), prior hospitalizations (OR = 2.205; 95% CI = 1.426-3.412 per admission; P < .001), and absence of hyperlipidemia (OR = 0.444; 95% CI = 0.221-0.894; P = .023) were independently associated with readmission. The research team concludes that admission NIHSS and frequent prior hospitalizations are associated with 30-day readmission after stroke. If validated, these characteristics identify high-risk patients and focus efforts to reduce readmission.