The effect of a bundle intervention for ambulatory otorhinolaryngology procedures on same-day case cancellation rate and associated costs.

Cancellations within 24 h of planned elective surgical procedures reduce operating theatre efficiency, add unnecessary costs and negatively affect patient experience. We implemented a bundle intervention that aimed to reduce same-day case cancellations. This consisted of communication tools to improve patient engagement and new screening instruments (automated estimation of ASA physical status and case cancellation risk score plus four screening questions) to identify patients in advance (ideally before case booking) who needed comprehensive pre-operative risk stratification. We studied patients scheduled for ambulatory surgery with the otorhinolaryngology service at a single centre from April 2021 to December 2022. Multivariable logistic regression and interrupted time-series analyses were used to analyse the effects of this intervention on case cancellations within 24 h and costs. We analysed 1548 consecutive scheduled cases. Cancellation within 24 h occurred in 114 of 929 (12.3%) cases pre-intervention and 52 of 619 (8.4%) cases post-intervention. The cancellation rate decreased by 2.7% (95%CI 1.6-3.7%, p < 0.01) during the first month, followed by a monthly decrease of 0.2% (95%CI 0.1-0.4%, p < 0.01). This resulted in an estimated $150,200 (£118,755; €138,370) or 35.3% cost saving (p < 0.01). Median (IQR [range]) number of days between case scheduling and day of surgery decreased from 34 (21-61 [0-288]) pre-intervention to 31 (20-51 [1-250]) post-intervention (p < 0.01). Patient engagement via the electronic health record patient portal or text messaging increased from 75.9% at baseline to 90.8% (p < 0.01) post-intervention. The primary reason for case cancellation was patients' missed appointment on the day of surgery, which decreased from 7.2% pre-intervention to 4.5% post-intervention (p = 0.03). An anaesthetist-driven, clinical informatics-based bundle intervention decreases same-day case cancellation rate and associated costs in patients scheduled for ambulatory otorhinolaryngology surgery.

Implementation of a new strategy to improve the peri-operative management of neuromuscular blockade and its effects on postoperative pulmonary complications.

Inappropriate dosing of neostigmine for antagonism of neuromuscular blockade has been associated with postoperative pulmonary complications. We evaluated the effects of a quality improvement initiative tailored to optimise the use of neostigmine in antagonising neuromuscular blockade on postoperative pulmonary complications, costs and duration of hospital stay. The quality improvement initiative consisted of: a reduction in available neostigmine aliquot sizes; a cognitive aid; an educational component; and a financial incentive for the intra-operative documentation of train-of-four measurement before administration of neostigmine. We conducted a pre-specified analysis of data obtained in our quality improvement study. Additional analyses were conducted in a propensity-matched cohort. An interrupted time series design was used to discriminate between the intervention and a counterfactual scenario. We analysed 12,025 consecutive surgical cases performed in 2015. Postoperative pulmonary complications occurred in 220 (7.5%) of 2937 cases pre-intervention and 568 (6.3%) of 9088 cases post-intervention. Adjusted regression analyses showed significantly a lower risk of postoperative pulmonary complications (OR 0.73 (95%CI 0.61-0.88); p = 0.001), lower costs (incidence rate ratio 0.95 (95%CI 0.93-0.97); p < 0.001) and shorter duration of hospital stay (incidence rate ratio 0.91 (95%CI 0.87-0.94); p < 0.001) after implementation of the quality improvement initiative. Analyses in a propensity-matched sample (n = 2936 per group) and interrupted time series analysis (n = 27,202 cases) confirmed the findings. Our data show that a local, multifaceted quality improvement initiative can enhance the quality of intra-operative neuromuscular blocking agent utilisation, thereby reducing the incidence of postoperative pulmonary complications.

The association of postoperative pulmonary complications in 109,360 patients with pressure-controlled or volume-controlled ventilation.

We thought that the rate of postoperative pulmonary complications might be higher after pressure-controlled ventilation than after volume-controlled ventilation. We analysed peri-operative data recorded for 109,360 adults, whose lungs were mechanically ventilated during surgery at three hospitals in Massachusetts, USA. We used multivariable regression and propensity score matching. Postoperative pulmonary complications were more common after pressure-controlled ventilation, odds ratio (95%CI) 1.29 (1.21-1.37), p < 0.001. Tidal volumes and driving pressures were more varied with pressure-controlled ventilation compared with volume-controlled ventilation: mean (SD) variance from the median 1.61 (1.36) ml.kg-1 vs. 1.23 (1.11) ml.kg-1 , p < 0.001; and 3.91 (3.47) cmH2 O vs. 3.40 (2.69) cmH2 O, p < 0.001. The odds ratio (95%CI) of pulmonary complications after pressure-controlled ventilation compared with volume-controlled ventilation at positive end-expiratory pressures < 5 cmH2 O was 1.40 (1.26-1.55) and 1.20 (1.11-1.31) when ≥ 5 cmH2 O, both p < 0.001, a relative risk ratio of 1.17 (1.03-1.33), p = 0.023. The odds ratio (95%CI) of pulmonary complications after pressure-controlled ventilation compared with volume-controlled ventilation at driving pressures of < 19 cmH2 O was 1.37 (1.27-1.48), p < 0.001, and 1.16 (1.04-1.30) when ≥ 19 cmH2 O, p = 0.011, a relative risk ratio of 1.18 (1.07-1.30), p = 0.016. Our data support volume-controlled ventilation during surgery, particularly for patients more likely to suffer postoperative pulmonary complications.

Oxidative stress markers in plasma and urine of prepubertal patients with type 1 diabetes mellitus.

Markers of oxidative stress were studied in plasma and urine of prepubertal patients with type 1 diabetes mellitus (DM1) with less than 5 years of disease (n = 27). The results were compared to healthy, age- and sex-matched control children (n = 27). Oxidative stress parameters evaluated included advanced oxidation protein products (AOPP), total peroxyl radical-trapping antioxidant parameter (TRAP), and F2-isoprostanes (8-epi-prostaglandin-F2: 8-isoPGF2alpha). No statistically significant differences were found for any of the oxidative stress markers assessed between patients with DM1 and controls. In addition, weight, height, and routine metabolic tests, including creatininemia and cholesterol levels, were similar between the groups. The lack of significant differences between healthy controls and patients with DM1 suggests that treatment is able to counteract the increase in free radical production.

TNFa increases in vitro migration of human HPV18-positive SW756 cervical carcinoma cells

TNFa has been associated with both, tumor survival and apoptosis. This cytokine is also involved in promoting cell migration during wound healing and tumorigenesis. SW756 is a HPV18-positive cervical carcinoma cell line, which has been used to study different mechanisms of cervical cancer progression. An in vitro assay of scratch wound healing onto monolayers of SW756 cells was used to assess the effect of TNFa on cell migration into a wound space. It was found that SW756 cells have the ability to migrate, but not proliferate in response to scratch wounding in a serum-free medium supplemented with TNFa. RT-PCR analysis showed that SW756 cells express TNFa mRNA when incubated in medium with and without serum. Wound closure and migration rate of SW756 cells were significantly increased in the presence of serum-free media supplemented with TNFa (10 ng/mL) as compared to serum-free media, and media supplemented with either anti-TNFa antibody or both TNFa and anti-TNFa antibody (p<0.05). The results showed a stimulatory effect of TNFa on the migration of SW756 cervical carcinoma cells, suggesting a novel and important role for TNFa in cervical cancer progression.

Expression of apoptotic and cell proliferation regulatory proteins in actinic cheilitis.

BACKGROUND: Actinic cheilitis (AC) is a pre-malignant lesion caused by ultraviolet (UV) radiation. The apoptotic proteins p53, bax, bcl-2, and the proliferation marker Ki-67, are known to play an important role in UV-exposed skin and carcinomas, therefore, these markers were assessed in AC and compared with normal lip and oral mucosa. METHODS: AC (n = 13), normal lip (n = 7) and oral mucosa (n = 6) biopsies were stained immunohistochemically for p53, bax, bcl-2 and Ki-67, to determine their expression and distribution. RESULTS: p53 was over-expressed in AC as compared with normal lip and oral mucosa (P < 0.003). Although bcl-2 expression was higher in AC than in oral mucosa (P < 0.002), it was significantly reduced as compared with normal lip (P < 0.04). Bax expression remained unchanged, and Ki-67 was significantly increased in AC and normal lip as compared with oral mucosa (P < 0.05). CONCLUSION: The results suggest that DNA-damaged cells by UV radiation in AC are eliminated by apoptosis.

Characterization of mast cell subpopulations in lip cancer.

BACKGROUND: Lip squamous cell carcinoma (SCC) is the most common form of oral cancer. Human mast cells (MCs), which are increased in lip SCC, are classified by their protease content in tryptase-positive (MC(T)) and tryptase/chymase-positive (MC(TC)). MC proteases are associated with tumor progression and angiogenesis. The aim of this study was to quantify and characterize MC subpopulations in lip SCC. METHODS: Serial sections from lip SCC (n = 21) and normal lip vermilion (n = 8) biopsies were stained immunohistochemically for tryptase and enzymehistochemically for chymase to determine MC subpopulation density and distribution. RESULTS: MC(T) and MC(TC) were increased in lip SCC when compared with normal lip (P < 0.0001), where MC(T) predominated over MC(TC) (P < 0.01). In lip SCC neither subpopulation predominated. Regarding distribution, MC(T) were higher than MC(TC) at the intratumoral stroma, whereas MC(TC) were higher than MC(T) at the peritumoral stroma (P < 0.01). CONCLUSIONS: The results suggest that MC subpopulations may contribute to lip SCC progression. While intratumoral MC(T) may stimulate angiogenesis, peritumoral MC(TC) may promote extracellular matrix degradation and tumor progression at the invasion front.

TNFalpha increases in vitro migration of human HPV18-positive SW756 cervical carcinoma cells.

TNFalpha has been associated with both, tumor survival and apoptosis. This cytokine is also involved in promoting cell migration during wound healing and tumorigenesis. SW756 is a HPV18-positive cervical carcinoma cell line, which has been used to study different mechanisms of cervical cancer progression. An in vitro assay of scratch wound healing onto monolayers of SW756 cells was used to assess the effect of TNFalpha on cell migration into a wound space. It was found that SW756 cells have the ability to migrate, but not proliferate in response to scratch wounding in a serum-free medium supplemented with TNFalpha. RT-PCR analysis showed that SW756 cells express TNFalpha mRNA when incubated in medium with and without serum. Wound closure and migration rate of SW756 cells were significantly increased in the presence of serum-free media supplemented with TNFalpha (10 ng/mL) as compared to serum-free media, and media supplemented with either anti-TNFalpha antibody or both TNFalpha and anti-TNFalpha antibody (p < 0.05). The results showed a stimulatory effect of TNFalpha on the migration of SW756 cervical carcinoma cells, suggesting a novel and important role for TNFalpha in cervical cancer progression.

Increased mast cell density and protease content in actinic cheilitis.

BACKGROUND: Actinic cheilitis (AC) is a pre-malignant lesion caused by ultraviolet (UV) radiation and characterized by epithelial and connective tissue alterations. Mast cells (MCs), key contributors to solar elastosis in murine UV-irradiated skin, were characterized in order to assess their potential contribution to connective tissue degeneration in AC. METHODS: Actinic cheilitis (n = 15) and normal lip (n = 8) biopsies were stained immunohistochemically for tryptase and enzymehistochemically for chymase to determine MC density and protease content. MC subpopulations (i.e. MC(T) containing only tryptase, and MC(TC) containing chymase and tryptase) and their distribution were also determined. RESULTS: Mast cells and their proteases were increased in AC as compared with normal lip (P < 0.0001), and appeared degranulated especially around elastotic areas. MC(T) predominated over MC(TC) in AC and normal lip (P < 0.05). However, in AC MC(T) were increased in the epithelium/connective junction and connective area (P < 0.05), while in normal lip MC(T) predominated in connective and submucosal areas (P < 0.05). CONCLUSION: The results suggest that increased MC density and protease content may contribute to elastosis formation in AC. In addition, changes in MC(T) distribution may favor AC malignization.

Uterine mast cells: a new hypothesis to understand how we are born

Birth is the result of complex, well-defined, and coordinated events, that are tightly regulated by endocrine, nervous, and immune responses, and take place primarily in the female reproductive tract. Various mechanisms and mediators involved in pregnancy, labor, and delivery, are highly conserved among different mammalian species and mast cells emerge as potential and crucial participants in these processes, as it is discussed in this review.

Role of mast cells in gastrointestinal mucosal defense

The purpose of this review, based on studies from our laboratory as well as from others, is to summarize salient features of mast cell immunobiology and to describe their associations with gastrointestinal mucosal defense. Gastrointestinal mast cells are involved in many pathologic effects, such as food hypersensitivity. On the other hand, they also play a protective role in defense against parasitic and microbial infections. Thus, they have both positive and negative effects, but presently the mechanisms that control the balance of these various effects are poorly known. It has been suggested that stabilization of mast cells may be a key mechanism to protect the gastrointestinal tract from injury. Few molecules are known to possess both mast cell stabilizing and gastrointestinal cytoprotective activity. These include zinc compounds, sodium cromoglycate, FPL 52694, ketotifen, aloe vera, certain flavonoids such as quercetin, some sulfated proteoglycans such as chondroitin sulfate and dehydroleucodine. Dehydroleucodine, a sesquiterpene lactone isolated from Artemisia douglasiana Besser, exhibits anti-inflammatory and gastrointestinal cytoprotective action. The lactone stimulates mucus production, and inhibits histamine and serotonin release from intestinal mast cells. The lactone could act as a selective mast cell stabilizer by releasing cytoprotective factors and inhibiting pro-inflammatory mast cell mediators.

Effect of dehydroleucodine on histamine and serotonin release from mast cells in the isolated mouse jejunum.

OBJECTIVE AND DESIGN: DhL, a lactone isolated from Artemisia douglasiana, prevents gastrointestinal damage elicited by necrosis-inducing agents and exhibits antiinflammatory action. This work examines the effect of DhL on compound 48/80-induced histamine and serotonin release in the isolated mouse jejunum, to determine whether DhL inhibits mediator release from mast cells at the enteric level. MATERIAL: Thirty jejuna from male Balb-c mice were used for the studies. TREATMENT: Samples were incubated sequentially in 9 test tubes containing RBS or 10 microg/ml compound 48/80 or 1.6 mmol/l + 10 microg/ml compound 48/80 at 37 degrees C for 90 minutes (10 min per tube). METHODS: Histamine and serotonin release studies, quantification of granulated mast cells, and evaluation of mast cell ultrastructure were carried out. Differences between groups were determined using analysis of variance followed by Tukey-Kramer multiple comparisons test. RESULTS: Compound 48/80 increased histamine and serotonin release by the tissue (141.95 +/- 62.58 pg/mg tissue vs basal 5.45 +/- 1.04, P<0.01 and 20.04 +/- 2.81 vs basal 9.24 +/- 1.56 ng/ mg tissue, P<0.01, respectively), decreased the number of granulated submucosal mast cells (0.077 +/- 0.0035 vs basal 0.14 +/- 0.015, P<0.05), and elicited evident granule ultrastructural changes. These effects were reduced by dehydroleucodine (19.51 +/- 7.88, P<0.01; 12.69 +/- 1, P<0.05 and 0.143 +/- 0.014, P<0.05, respectively). CONCLUSION: The lactone inhibits compound 48/80-induced histamine and serotonin release from mast cells in the isolated mouse jejunum.

Estrogen receptors in mast cells from arterial walls.

We examined the presence of estrogen receptors (ER) in vascular mast cells and a possible genomic effect of estrogens on the expression of mast cell (MC) mediators such as chymase, TNF alpha, NOS and IL-10, which are known to affect the course of atherosclerosis. Immunocytochemical detection of mast cell tryptase and the co-localization of ERs in MCs from abdominal aortic vessels from 10 fertile woman, 10 postmenopausal women and 15 men was performed. The genomic expression of IL-10, TNF alpha, and NOS was analyzed by RT-PCR and chymase activity by spectrophotometry after 24 h incubation with 17-beta estradiol (0.2-0.5 ng/mL) in rat purified peritoneal MCs. A similar number of MCs were found in both intima and adventitia layers from men, and fertile and postmenopausal women, while ERs were detected only in the arterial walls from fertile women. The mRNA expressions of IL-10 and TNF alpha, as well as chymase activity, were not affected. A moderate increment of NO and both NOS, and a reduction in TNF alpha cytotoxicity was observed after incubating peritoneal MCs with 17-beta estradiol at a concentration of 0.5 ng/mL. Taken together, these results indicate that vascular MCs express ERs. The data demonstrate that estrogens can directly modify vascular MC activity. This is a novel mechanism of synergistic cooperation for the protective role of estrogens in the genesis of atherosclerosis.

Estrogen receptors in mast cells from arterial walls

We examined the presence of estrogen receptors (ER) in vascular mast cells and a possible genomic effect of estrogens on the expression of mast cell (MC) mediators such as chymase, TNF alpha, NOS and IL-10, which are known to affect the course of atherosclerosis. Immunocytochemical detection of mast cell tryptase and the co-localization of ERs in MCs from abdominal aortic vessels from 10 fertile woman, 10 postmenopausal women and 15 men was performed. The genomic expression of IL-10, TNF alpha, and NOS was analyzed by RT-PCR and chymase activity by spectrophotometry after 24 h incubation with 17-beta estradiol (0.2-0.5 ng/mL) in rat purified peritoneal MCs. A similar number of MCs were found in both intima and adventitia layers from men, and fertile and postmenopausal women, while ERs were detected only in the arterial walls from fertile women. The mRNA expressions of IL-10 and TNF alpha, as well as chymase activity, were not affected. A moderate increment of NO and both NOS, and a reduction in TNF alpha cytotoxicity was observed after incubating peritoneal MCs with 17-beta estradiol at a concentration of 0.5 ng/mL. Taken together, these results indicate that vascular MCs express ERs. The data demonstrate that estrogens can directly modify vascular MC activity. This is a novel mechanism of synergistic cooperation for the protective role of estrogens in the genesis of atherosclerosis.

Nitroprusside stimulates contractility and the synthesis of 14C-acetylated PAF-like substances in estrogen primed-mouse uterine horns.

We investigated the effect of sodium nitroprusside (SNP), a donor of nitric oxide, on the formation of platelet-activating factor (PAF) and uterine contractility in mouse uterine horns from mice treated with estrogen. Because the major pathway of PAF synthesis is the remodeling pathway in uterine tissue, we evaluated the incorporation of 14C-acetate into PAF-like molecules. Our results showed that SNP (100-300 mumol/L) caused a transient increase in the synthesis of PAF, which remained cell-associated. The addition of SNP (100-300 mumol/L) to a mouse uterine horn in an isolated organ bath preparation evoked a transient increase in contractility, which was inhibited by hemoglobin (2 micrograms/mL), a nitric oxide scavenger, but not by methylene blue (10 mumol/L), a guanylate cyclase inhibitor. The pharmacological characteristics of the contractions evoked by SNP resembled those evoked after mast cell activation, in that they were blocked by ritodrine (a beta 2 adrenergic agonist, 0.1 mumol/L); indomethacin (a cyclooxygenase inhibitor, 10 mumol/L); ketotifen (a mast cell stabilizer, 1.0 mumol/L); cromolyn sodium (a mast cell stabilizer, 100 mumol/L); pyrilamine (an H1 antagonist, 10 mumol/L); and ketanserine (5HT2 antagonist, 0.1 mumol/L). These data demonstrate that nitric oxide generated from SNP stimulated the synthesis of PAF and evoked contractility in uterine horns from mice treated with estrogen. This result suggests the possibility that these tissue conditions might be favorable for the generation of peroxynitrites, possible mediators of both effects. It is also shown that the contractility evoked by the addition of SNP was not due to production of PAF, because its antagonist, WEB 2086 (10-30 mumol/L, a concentration that blocked contractions evoked by PAF 1 nmol/L), had no effect on the SNP-evoked contractions.

Oxytocin inhibits the uptake of serotonin into uterine mast cells.

The uptake of serotonin (5HT) into mouse uterine horns, the localization of sites at which this amine could be stored and the effect of oxytocin on 5HT uptake were studied. To analyze the characteristics of the 5HT uptake process, the tissue was incubated with [3H]serotonin. The uptake of [3H]5HT was Na+ dependent and saturable (Kmapp: 166 +/- 15 nM, Vmax: 404 +/- 25 fmol/mg tissue, 30 min (diestrous); and Km: 165 +/- 39 nM, Vmax: 276 +/- 43 fmol/mg tissue, 30 min (estrous), n = 6), and was inhibited by imipramine, fluoxetine and 6-nitroquipazine (IC50: 2; 0.09 and 0.5 nM, respectively). In the myometrium the main 5HT uptake process was localized in uterine mast cells. This was determined by treating the uterine horns with 6-hydroxydopamine, by using an immunocytochemical approach and by studying the outflow of 3H under the action of stimuli directed to either mast cells (compound 48/80: 10 microgram/ml) or sympathetic nerves (high K+: 100 mM and veratridine: 20 microM) in uterine preparations. Oxytocin inhibited [3H]5HT uptake into uterine mast cells during estrus, but not in ovarectomized mice treated with progesterone. Maximal inhibition was attained at 0.03 nM, with a significant reduction in both Kmapp and Vmax (87 +/- 15 nM and 184 +/- 36 fmol/mg tissue/30 min, n = 3, respectively). This effect was reversed by the addition of OVT16, an oxytocin antagonist, at a concentration of 4 nM (Kmapp 158 +/- 35 nM, Vmax: 278 +/- 24 fmol/mg tissue, 30 min, n = 3). These findings support a new potential role of oxytocin and mast cells as a local regulators of serotonin bioavailability in myometrium. Because serotonin is recognized as an important endogenous uterotonic compound, this effect could be considered as an indirect action of oxytocin that may contribute to its potency as a labor inducer after genomic effects of estrogens are expressed in uterine tissue.