A statewide assessment of surgical site infection following colectomy: the role of oral antibiotics.

OBJECTIVE: To determine the utility of adding oral nonabsorbable antibiotics to the bowel prep prior to elective colon surgery. SUMMARY BACKGROUND DATA: Bowel preparation prior to colectomy remains controversial. We hypothesized that mechanical bowel preparation with oral antibiotics (compared with without) was associated with lower rates of surgical site infection (SSI). METHODS: Twenty-four Michigan hospitals participated in the Michigan Surgical Quality Collaborative-Colectomy Best Practices Project. Standard perioperative data, bowel preparation process measures, and Clostridium difficile colitis outcomes were prospectively collected. Among patients receiving mechanical bowel preparation, a logistic regression model generated a propensity score that allowed us to match cases differing only in whether or not they had received oral antibiotics. RESULTS: Overall, 2011 elective colectomies were performed over 16 months. Mechanical bowel prep without oral antibiotics was administered to 49.6% of patients, whereas 36.4% received a mechanical prep and oral antibiotics. Propensity analysis created 370 paired cases (differing only in receiving oral antibiotics). Patients receiving oral antibiotics were less likely to have any SSI (4.5% vs. 11.8%, P = 0.0001), to have an organ space infection (1.8% vs. 4.2%, P = 0.044) and to have a superficial SSI (2.6% vs. 7.6%, P = 0.001). Patients receiving bowel prep with oral antibiotics were also less likely to have a prolonged ileus (3.9% vs. 8.6%, P = 0.011) and had similar rates of C. difficile colitis (1.3% vs. 1.8%, P = 0.58). CONCLUSIONS: Most patients in Michigan receive mechanical bowel preparation prior to elective colectomy. Oral antibiotics may reduce the incidence of SSI.

Trial of a survey instrument to establish the hurricane preparedness of and medical impact on a vulnerable, older population.

INTRODUCTION: Millions of vulnerable, elderly individuals live in coastal areas susceptible to hurricanes and are at risk for adverse health outcomes. The purpose of this study was to determine the status of preparedness for and possible health consequences of a hurricane on a vulnerable, but experienced, elderly population. PROBLEM: Preparedness guidelines have been published, but it is unclear how well-prepared elderly individuals are for hurricanes, and what impact hurricanes may have on their health. METHODS: Five hundred forty-seven ambulatory patients who attended an urban teaching hospital's geriatrics clinic in Florida were surveyed. A 25-question survey that asked whether subjects followed the American Red Cross guidelines for hurricane preparation was developed. The participants were asked what hurricane supplies they had, and whether they would need to evacuate or utilize storm-proof window shutters. They also were queried about definitions and their understanding of hurricane warnings. Three possible health impacts during the two weeks following Hurricane Wilma in 2005 were asked: (1) falls; (2) missed medication; and (3) missed doctor's appointments. An additional 105 patients in the same clinic were asked about the same three health outcomes one and one-half years after the hurricane struck. RESULTS: Two-thirds of respondents were missing at least one supply item. A multivariate analysis indicated that there was no relationship between the subjects' demographic characteristics and the possession of the suggested disaster supplies. Although 36% would need to evacuate, only 56% of these 36% had a plan. Only 63% had storm-proof windows or shutters, and of these, only 46% could install them. Gasoline-powered electrical generators can be useful, but also a source of morbidity or mortality following a hurricane. For example, this study found that 28% of respondents had generators, but only 46% knew how to use them. Subjects immediately after the hurricane missed fewer doses of medication than at other times (3.4% vs. 6.7%; p < 0.0001) and fell slightly less often (8.8% vs. 12.9%; p < 0.0001). However, there were significantly more missed doctors appointments after the hurricane (11.6% vs. 0.1%, p < 0.0001). CONCLUSIONS: The survey indicated that even a well-experienced population lacks adequate hurricane preparation. Most still are vulnerable in at least one aspect of preparation. The elderly may be more likely to miss medical appointments immediately following a hurricane. Interventions to improve hurricane preparedness should be piloted.

Understanding Death in Children With Epilepsy.

Death in children with epilepsy is profoundly disturbing, with lasting effects on the family, community, and health care providers. The overall risk of death for children with epilepsy is about ten times that of the general population. However, the risk of premature death for children without associated neurological comorbidities is similar to that of the general population, and most deaths are related to the cause of the epilepsy or associated neurological disability, not seizures. The most common cause of seizure-related death in children with epilepsy is sudden unexpected death in epilepsy (SUDEP). SUDEP is relatively uncommon in childhood, but the risk increases if epilepsy persists into adulthood. Although the direct cause of SUDEP remains unknown, most often death follows a generalized convulsive seizure and the risk of SUDEP is strongly related to drug-resistant epilepsy and frequent generalized tonic-clonic seizures. The most effective SUDEP prevention strategy is to reduce the frequency of seizures, although a number of seizure detection devices are under development and in the future may prove to be useful for seizure detection for those at particularly high risk. There are distinct benefits for health care professionals to discuss mortality with the family soon after the diagnosis of epilepsy. An individual approach is appropriate. When a child with epilepsy dies, particularly if the death was unexpected, family grief may be profound. Physicians and other health care professionals have a critical role in supporting families that lose a child to epilepsy. This review will provide health care providers with information needed to discuss the risk of death in children with epilepsy and support families following a loss.

Morphine promotes autonomic learning.

Morphine (0.01-10 mg/kg) promoted rapid autonomic learning of discriminative, Pavlovian conditioned heart rate decelerations to tone signals in male and female rabbits, and the higher doses (1-10 mg/kg) promoted decelerative heart rate orienting reflexes to novel tones. Morphine dose dependently reduced heart rate acceleration to signaled shock but had no effect on heart rate acceleration to unsignaled shock. Morphine did not impair retention of cardiac conditioned reflexes, and its U-shaped dose effect, increasing conditioned heart rate discrimination early in training, reappeared in extinction. The authors propose that morphine promotes autonomic learning of preparatory, compensatory reflexes to signaled stressors that reduce their stressful effects. This action may mimic the normal, adaptive function of an endogenous messenger released by the Pavlovian contingency.

Outcomes of teen parenting programs in New Mexico.

Although teen pregnancy rates in the U.S. have recently declined, the need for programs for pregnant and parenting teens remains. This report presents information from 53 programs that served pregnant and parenting teens in New Mexico between 1997 and 2000. Data on 3,194 teens, including their characteristics, the services they received, and several key outcomes, are examined. These data indicate that the programs were successful in promoting educational attainment as well as gains in employment. Prevalence of late prenatal care and low birth weight babies was lower than statewide averages, and the rate of repeat pregnancy was lower than that reported by many other programs. How these programs achieved these results is discussed.

A case-cohort study of postoperative myocardial infarction: impact of anemia and cardioprotective medications.

OBJECTIVE: Postoperative myocardial infarction (poMI) is a serious and costly complication. Multiple risk factors for poMI are known, but the effect of anemia and cardioprotective medications have not been defined in real-world surgical practice. METHODS: Patients undergoing inpatient elective surgery were assessed at 17 hospitals from 2008 to 2011 for the occurrence of poMI (American Heart Association definition). Non-MI control patients were chosen randomly on the basis of case type. Descriptive, univariable, and multivariable statistical analysis were performed for primary outcomes of poMI and death at 30 days. RESULTS: Compared with controls (N = 304), patients with poMI (N = 222) were older (72 ± 11 vs 60 ± 17 years, P < .0001), had a lesser preoperative hematocrit (37 ± 6 vs 39 ± 5, P < .0001), more often were smokers, had a preoperative T-wave abnormality (21% vs 9%, P < .0001), and had a preoperative stress test with a fixed deficit (26% vs 3%; P < .001). Preoperative factors associated with poMI included peripheral vascular disease (odds ratio 2.6; 95% confidence interval 1.3-5.3), tobacco use (1.7; 1.01-2.9), history of percutaneous coronary angioplasty (2.8; 1.6-5.0), and age (1.05; 1.03-1.07), whereas hematocrit >35 (0.51; 0.32-0.82) and preoperative acetylsalicylic acid, ie, aspirin (0.59; 0.4-0.97) were protective. Preoperative ß-blockade, statin, and use of angiotensin-converting enzyme inhibitors were not associated with lesser rates of poMI. Non-MI complication rates were 23-fold greater in the poMI group compared with the control group (P < .0001). Mortality with poMI within 30 days was 11% compared with 0.3% in non-MI control patients (P < .0001). In patients with poMI, factors independently associated with death included use of epidurals (3.5; 1.07-11.4) and bleeding (4.2; 1.1-16), whereas preoperative use of aspirin (0.29; 0.1-0.88), and postoperative ß-blockade (0.18; 0.05-0.63) were protective. Cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass grafting after poMI was performed in 34% of those alive and 20% of those who died (P = .16). CONCLUSION: In the current era, poMI patients have a markedly increased risk of death. This risk is decreased with preoperative use of acetylsalicylic acid and post MI ß-blockade. Further study is warranted to explore the role of anemia and cardiac interventions after poMI.

Prophylactic antibiotic practices for colectomy in Michigan.

BACKGROUND: Although there are guidelines for prophylactic intravenous antibiotics in colorectal surgery, the objective of this study was to determine the extent to which these guidelines are followed. METHODS: Twenty-seven Michigan hospitals participated in a colectomy quality-improvement project. In addition to the American College of Surgeons-National Surgical Quality Improvement Program variables, these hospitals collect 25 additional data points on processes of care for colectomy cases. RESULTS: From 2007 to 2009, 3,002 patients had colectomy surgery and were eligible for analysis of antibiotic practices. Prophylactic antibiotics were given in 99.5% of cases; 81.4% of antibiotic choices were Surgical Care Improvement Project-compliant, and 90.8% of dosing was within 60 minutes before surgical incision. Recommended weight-adjusted dosing was performed in 56.8% of cases, and only 6.0% of antibiotics were redosed appropriately. Practices varied by hospital. CONCLUSIONS: Prophylactic antibiotic use for colectomy in Michigan hospitals did not conform to recommended practices. These findings hold the promise for targeted quality-improvement initiatives.

Translational regulation of XIAP expression and cell survival during hypoxia in human cholangiocarcinoma.

BACKGROUND & AIMS: Tumor progression is promoted by the ability of tumor cells to resist adverse environmental conditions such as hypoxia. We have shown that translational dysregulation contributes to transformed cell growth in malignant cholangiocytes. Translational regulation of gene expression can contribute to an immediate and rapid response to environmental changes such as hypoxia. Thus, our aims were to assess translational mechanisms involved in cell survival during hypoxia and to identify specific translationally regulated proteins involved in the cellular response to hypoxia. METHODS: Cell viability and apoptosis in response to hypoxia were assessed in human cholangiocarcinoma cells. Translational processes were deregulated by cycloheximide or rapamycin or by targeted deletion of eukaryotic initiation factor (eIF)-4E, a rate-limiting translational initiation factor using small interfering RNA (siRNA). A protein antibody microarray was used to screen for eIF-4E-dependent proteins expressed during hypoxia. Expression of the X-linked inhibitor of apoptosis (XIAP) was decreased using siRNA. RESULTS: Malignant cholangiocytes are resistant to hypoxia-induced apoptosis. Furthermore, cell survival during hypoxia required protein translation. eIF-4E was over expressed in malignant cholangiocytes. Reduction in eIF-4E expression by siRNA decreased tumor cell resistance to hypoxia, increased caspase-3 activation and apoptosis, and decreased cell survival compared with controls. XIAP was identified as a translationally regulated protein expressed during hypoxia. Modulation of XIAP expression by siRNA decreases cell death during hypoxia in vitro and in vivo. CONCLUSIONS: Human cholangiocarcinoma cells are highly resistant to hypoxia. Translational regulation of survival proteins such as XIAP is a mechanism mediating cholangiocarcinoma survival during hypoxia.