Effect of 6-minute colonoscopy withdrawal time policy on polyp detection rate in a community hospital.

In 2002, a U.S. Multi-Society Task Force on colorectal cancer recommended a 6-minute or more withdrawal time as an indicator of a quality colonoscopy. In 2006, found a correlation between longer withdrawal time and an increased rate in the detection of adenomas. In January 2008, the endoscopy department at our institution adopted the Multi-Society Task Force recommendation. The aim of our study was to evaluate the effect of a minimal 6-minute withdrawal time policy at our institution on polyp detection rate. All colonoscopies performed for screening indications from April 2007 to September 2008 were reviewed retrospectively. Group I (pre-policy) was compared with Group II (post-policy). Data collected included age, gender, indication, polyp detection rate, size, and withdrawal time. Unpaired t tests evaluated pre- and postprocedure results. Fisher's exact tests were used to compare detection rates between withdrawal time less than 6 minutes and more than 6 minutes. Mann-Whitney U Tests were performed to analyze the significance between the number of polyps detected for withdrawal time less than 6 minutes versus more than 6 minutes. A total of 1,342 colonoscopies were available for analysis in Group I and 1,316 in Group II. Polyp detection rate was 46.6% in Group I versus 48.2% in Group II (p = .39), a non-statistically significant difference; however, there was a trend toward identifying small- and medium-sized polyps in Group II. Small polyps can carry a risk of severe dysplasia (). Data were then analyzed for withdrawal time. The polyp detection rate was 20.9 in procedures that took less than 6 minutes versus 48.3 in those that took more than 6 minutes (p ≤ .01). In this study, a 6-minute or more withdrawal time increased the polyp detection rate by 133% for all polyp sizes, especially small and medium. Small polyps (5 mm or less) should be removed and not ignored. A 6-minute or more withdrawal time should be mandatory in those patients without a previous colon resection.

Development and large-scale production of human milk fat analog by fermentation of microalgae.

Background: Human milk contains a complex mixture of triacylglycerols (TAG), making it challenging to recreate using common ingredients. Objective: The study aimed to develop an innovative fermentation technique to produce essential human milk TAG, effectively tackling a significant hurdle in infant nutrition. Method: An in-depth analysis of the literature has been conducted to identify the specific TAG to be targeted. We used a microalgal oil production platform and a two-step procedure to modify its fatty acid and TAG composition. The palmitic acid (16:0) content has been increased by classical strain improvement techniques, followed by a step involving the expression of a lysophosphatidic acid acyltransferase (LPAAT) sequence capable of esterifying 16:0 specifically at the internal position (sn-2 palmitate) of TAG. Once the strain was stabilized, the fermentation was scaled up in a 50-L reactor to yield several kilograms of biomass. Subsequently, the oil was extracted and refined using standard oil processing conditions. Liquid chromatography-mass spectrometry was employed to monitor the TAG profile and the region specificity of 16:0 at the internal position (sn-2 palmitate) of TAG. Results: The initial strain had a 16:0 level of 25% of total fatty acids, which was increased to 30% by classical strain improvement. Simultaneously, the oleic acid level decreased from 61% to 57% of total fatty acids. Upon expression of an exogenous LPAAT gene, the level of the 16:0 esterified in the internal position of the TAG (sn-2 palmitate) increased by a factor of 10, to reach 73% of total palmitic acid. Consequently, the concentration of oleic acid in the internal position decreased from 81% to 22% of total fatty acids, with TAG analysis confirming that the primary TAG species in the oil was 1,3-dioleoyl-2-palmitoyl-glycerol (OPO). The 50-L-scale fermentation trial confirmed the strain's ability to produce oil with a yield of >150 g of oil per liter of fermentation broth in a timeframe of 5 days, rendering the process scalable for larger-scale industrialization. Conclusion: We have demonstrated the feasibility of producing a suitable TAG composition that can be effectively integrated into the formulations of infant nutrition in combination with other fats and oils to meet the infant feeding requirements.

Designing An Individualized EHR Learning Plan For Providers.

Electronic Health Records (EHRs) have been quickly implemented for meaningful use incentives; however these implementations have been associated with provider dissatisfaction and burnout. There are no previously reported instances of a comprehensive EHR educational program designed to engage providers and assist in improving efficiency and understanding of the EHR. Utilizing adult learning theory as a framework, Stanford Children's Health designed a tailored provider efficiency program with various inputs from: (1) provider specific EHR data; (2) provider survey data; and (3) structured observation sessions. This case report outlines the design of this individualized training program including team structure, resource requirements, and early provider response. CITATION: Stevens LA, DiAngi YT, Schremp JD, Martorana MJ, Miller RE, Lee TC, Pageler NM. Designing An Individualized EHR Learning Plan. Appl Clin Inform 2017; 8:924-935 https://doi.org/10.4338/040054.

Managing the megacity for global sustainability: the new york metropolitan region as an urban biosphere reserve.

The UNESCO World Network of Biosphere Reserves (WNBR), while not originally conceived to include urban areas, was intended to include sites representing all significant ecosystems with the goal of support for sustainable development locally and globally. Drawing on the example of the New York Metropolitan Region (NYMR), which has a population of 21.4 million, it is argued here that the eventual inclusion of the largest of the world's cities in WNBR not only is within the logic of the biosphere reserve concept, but would also benefit the network and its goals. The ecological significance of the NYMR, its role as a driver for global environmental change, as well as the efforts under way in the city to improve urban environmental management and governance are all examined. Potential added value to the WNBR of including megacities such as the NYMR is considered, in particular, regarding the sharing of best practices, lessons learned, and the strengthening of links between megacities and their global natural resource bases.

The determinants of attitudinal change among medical students participating in home care training: a multi-center study.

PURPOSE: To report attitudinal changes of medical students from five medical schools rotating through a home care program, and to determine which of the program characteristics influenced attitudes the most. METHOD: A survey instrument covering four home care domains (general attitudes, home-based therapies, home care training, and time and reimbursement) was designed and validated by the five schools involved. Using pre- and post-rotation scores, analyses were done to evaluate for attitudinal changes within and among schools. The programs had similar basic characteristics (home visits, attending physicians' involvement, didactics), but had differing degrees of these components. RESULTS: Significant improvements in attitude scores were found in three domains: general attitudes, homebased therapies, and home care training. For time and reimbursement, only three schools improved significantly between pre- and post-rotation scores. Among the five schools, there were significant differences in the homebased therapies and home care training domains (p <.05), and in the time and reimbursement domain the difference approached significance (p =.06). None of the students' characteristics but all of the programs' characteristics significantly correlated with changes in total scores. In the first multiple regression model, educational level (third year instead of fourth) was the only independent predictor of change in score, (adjusted r(2) =.14). In Model 2, the strongest predictor was "contact with physician-program director," followed by "number of visits" and "physician-precepted visits" (r(2) =.23). CONCLUSION: Educational home care programs of varying intensities can positively affect medical students' attitudes towards home care. At least three program characteristics, (the physician-program director, number of visits, and physician-precepted home visits), are important parts of a successful program.