Large ecosystem-scale effects of restoration fail to mitigate impacts of land-use legacies in longleaf pine savannas.

Ecological restoration is a global priority, with potential to reverse biodiversity declines and promote ecosystem functioning. Yet, successful restoration is challenged by lingering legacies of past land-use activities, which are pervasive on lands available for restoration. Although legacies can persist for centuries following cessation of human land uses such as agriculture, we currently lack understanding of how land-use legacies affect entire ecosystems, how they influence restoration outcomes, or whether restoration can mitigate legacy effects. Using a large-scale experiment, we evaluated how restoration by tree thinning and land-use legacies from prior cultivation and subsequent conversion to pine plantations affect fire-suppressed longleaf pine savannas. We evaluated 45 ecological properties across four categories: 1) abiotic attributes, 2) organism abundances, 3) species diversity, and 4) species interactions. The effects of restoration and land-use legacies were pervasive, shaping all categories of properties, with restoration effects roughly twice the magnitude of legacy effects. Restoration effects were of comparable magnitude in savannas with and without a history of intensive human land use; however, restoration did not mitigate numerous legacy effects present prior to restoration. As a result, savannas with a history of intensive human land use supported altered properties, especially related to soils, even after restoration. The signature of past human land-use activities can be remarkably persistent in the face of intensive restoration, influencing the outcome of restoration across diverse ecological properties. Understanding and mitigating land-use legacies will maximize the potential to restore degraded ecosystems.

PedBotLab: A Novel Video Game-Based Robotic Ankle Platform Created for Therapeutic Exercise for Children With Neurological Impairments.

AIMS: Assess the potential benefits of using PedBotLab, a clinic based robotic ankle platform with integrated video game software, to improve ankle active and passive range of motion, strength, selective motor control, gait efficiency, and balance. METHODS: Ten participants with static neurological injuries and independent ambulation participated in a 10-week pilot study (Pro00013680) to assess feasibility and efficacy of PedBotLab as a therapeutic device twice weekly. Isometric ankle strength, passive and active ankle range of motion, plantarflexor spasticity, selective motor control of the lower extremity, balance, and gait speed were measured pre- and post-trial. RESULTS: Statistically significant improvements were seen in flexibility, active range of motion, and strength in multiple planes of ankle motion. Ankle dorsiflexion with knee flexion and knee extension demonstrated statistically significant results in all outcome measures. No significant changes were observed in gait speed outcomes. CONCLUSIONS: The use of PedbotLab can lead to improvements in ankle strength, flexibility, and active range of motion for children with static neurological injuries. Future studies aim to evaluate the effect on gait quality and work toward developing a home-based device.

High likelihood of actionable pathogenic variant detection in breast cancer genes in women with very early onset breast cancer.

BACKGROUND: While the likelihood of identifying constitutional breast cancer-associated BRCA1, BRCA2 and TP53 pathogenic variants (PVs) increases with earlier diagnosis age, little is known about the correlation with age at diagnosis in other predisposition genes. Here, we assessed the contribution of known breast cancer-associated genes to very early onset disease. METHODS: Sequencing of BRCA1, BRCA2, TP53 and CHEK2 c.1100delC was undertaken in women with breast cancer diagnosed ≤30 years. Those testing negative were screened for PVs in a minimum of eight additional breast cancer-associated genes. Rates of PVs were compared with cases ≤30 years from the Prospective study of Outcomes in Sporadic vs Hereditary breast cancer (POSH) study. RESULTS: Testing 379 women with breast cancer aged ≤30 years identified 75 PVs (19.7%) in BRCA1, 35 (9.2%) in BRCA2, 22 (5.8%) in TP53 and 2 (0.5%) CHEK2 c.1100delC. Extended screening of 184 PV negative women only identified eight additional actionable PVs. BRCA1/2 PVs were more common in women aged 26-30 years than in younger women (p=0.0083) although the younger age group had rates more similar to those in the POSH cohort. Out of 26 women with ductal carcinoma in situ (DCIS) alone, most were high-grade and 11/26 (42.3%) had a PV (TP53=6, BRCA2=2, BRCA1=2, PALB2=1). This PV yield is similar to the 61 (48.8%) BRCA1/2 PVs identified in 125 women with triple-negative breast cancer. The POSH cohort specifically excluded pure DCIS which may explain lower TP53 PV rates in this group (1.7%). CONCLUSION: The rates of BRCA1, BRCA2 and TP53 PVs are high in very early onset breast cancer, with limited benefit from testing of additional breast cancer-associated genes.

Characteristics of Patients Who Attend the 7- to 10-Day Postpartum Visit for Blood Pressure Evaluation.

OBJECTIVE: This study aimed to assess maternal characteristics that predict attendance of postpartum blood pressure evaluation in patients with hypertensive disorders of pregnancy (HDP). STUDY DESIGN: A retrospective case-control study of patients with HDP delivering at a single academic institution (2014-2018). Diagnosis of HDP included gestational hypertension, chronic hypertension, preeclampsia, and superimposed preeclampsia. Univariable and multivariable analyses were used to determine maternal characteristics independently associated with attendance of the 7- to 10-day postpartum blood pressure evaluation. RESULTS: Of the 1,041 patients included in the analysis, 603 (57.9%) attended the 7- to 10-day postpartum blood pressure check. Maternal sociodemographic, clinical, and obstetric factors differed significantly between patients who attended the postpartum blood pressure visit and those who did not. In univariable analyses, nulliparity, non-Hispanic black race and ethnicity, public insurance, HDP with severe features, cesarean birth, gestational age at delivery, receipt of magnesium, mild-range blood pressures on day of discharge, and initiation of antihypertensive medication were associated with attendance of the 7- to 10-day postpartum visit. In multivariable analysis, factors significantly associated with higher odds of attending the blood pressure visit were nulliparity (adjusted odds ratio [aOR]: 1.58; 95% confidence interval: [CI]: 1.14-2.17), severe HDP (aOR: 1.94, 95% CI: 1.44-2.61), and cesarean birth (aOR: 1.92, 95% CI: 1.43-2.59). In contrast, factors associated with lower odds of attendance were non-Hispanic black race and ethnicity compared with non-Hispanic white (aOR: 0.68, 95% CI: 0.47-0.97), and public insurance (aOR: 0.65, 95% CI: 0.45-0.93) compared with private insurance. CONCLUSION: Clinical factors such as nulliparity, severe HDP, and cesarean birth were associated with higher rates of postpartum blood pressure evaluation attendance, whereas sociodemographic factors such as maternal non-Hispanic black race and ethnicity and public insurance were associated with lower odds of postpartum blood pressure check attendance. KEY POINTS: · A total of 57.9% of patients with HDP attended in person postpartum blood pressure check.. · Nulliparity, severe features of HDP, and cesarean birth were associated with higher rates of attendance.. · Non-Hispanic black race and ethnicity and public insurance were associated with lower attendance..

Body image and psychosocial well-being among UK military personnel and veterans who sustained appearance-altering conflict injuries.

A modest but significant number of military personnel sustained injuries during deployments resulting in an altered-appearance (e.g., limb loss and/or scarring). Civilian research indicates that appearance-altering injuries can affect psychosocial wellbeing, yet little is known about the impact of such injuries among injured personnel. This study aimed to understand the psychosocial impact of appearance-altering injuries and possible support needs among UK military personnel and veterans. Semi-structured interviews with 23 military participants who sustained appearance-altering injuries during deployments or training since 1969 were conducted. The interviews were analyzed using reflexive thematic analysis, identifying six master themes. These themes indicate that in the context of broader recovery experiences, military personnel and veterans experience a variety of psychosocial difficulties related to their changed appearance. While some of these are consistent with evidence from civilians, military-related nuances in the challenges, protective experiences, coping approaches, and preferences for support are evident. Personnel and veterans with appearance-altering injuries may require specific support for adjusting to their changed appearance and related difficulties. However, barriers to acknowledging appearance concerns were identified. Implications for support provision and future research are discussed.

Dead but Not Forgotten: How Extracellular DNA, Moisture, and Space Modulate the Horizontal Transfer of Extracellular Antibiotic Resistance Genes in Soil.

Antibiotic-resistant bacteria and the spread of antibiotic resistance genes (ARGs) pose a serious risk to human and veterinary health. While many studies focus on the movement of live antibiotic-resistant bacteria to the environment, it is unclear whether extracellular ARGs (eARGs) from dead cells can transfer to live bacteria to facilitate the evolution of antibiotic resistance in nature. Here, we use eARGs from dead, antibiotic-resistant Pseudomonas stutzeri cells to track the movement of eARGs to live P. stutzeri cells via natural transformation, a mechanism of horizontal gene transfer involving the genomic integration of eARGs. In sterile, antibiotic-free agricultural soil, we manipulated the eARG concentration, soil moisture, and proximity to eARGs. We found that transformation occurred in soils inoculated with just 0.25 µg of eDNA g-1 soil, indicating that even low concentrations of soil eDNA can facilitate transformation (previous estimates suggested ∼2 to 40 µg eDNA g-1 soil). When eDNA was increased to 5 µg g-1 soil, there was a 5-fold increase in the number of antibiotic-resistant P. stutzeri cells. We found that eARGs were transformed under soil moistures typical of terrestrial systems (5 to 30% gravimetric water content) but inhibited at very high soil moistures (>30%). Overall, this work demonstrates that dead bacteria and their eARGs are an overlooked path to antibiotic resistance. More generally, the spread of eARGs in antibiotic-free soil suggests that transformation allows genetic variants to establish in the absence of antibiotic selection and that the soil environment plays a critical role in regulating transformation. IMPORTANCE Bacterial death can release eARGs into the environment. Agricultural soils can contain upwards of 109 ARGs g-1 soil, which may facilitate the movement of eARGs from dead to live bacteria through a mechanism of horizontal gene transfer called natural transformation. Here, we track the spread of eARGs from dead, antibiotic-resistant Pseudomonas stutzeri cells to live antibiotic-susceptible P. stutzeri cells in sterile agricultural soil. Transformation increased with the abundance of eARGs and occurred in soils ranging from 5 to 40% gravimetric soil moisture but was lowest in wet soils (>30%). Transformants appeared in soil after 24 h and persisted for up to 15 days even when eDNA concentrations were only a fraction of those found in field soils. Overall, our results show that natural transformation allows eARGs to spread and persist in antibiotic-free soils and that the biological activity of eDNA after bacterial death makes environmental eARGs a public health concern.

Development and validation of retrospective electronic frailty index using operational data of aged care homes.

BACKGROUND: Although elderly population is generally frail, it is important to closely monitor their health deterioration to improve the care and support in residential aged care homes (RACs). Currently, the best identification approach is through time-consuming regular geriatric assessments. This study aimed to develop and validate a retrospective electronic frailty index (reFI) to track the health status of people staying at RACs using the daily routine operational data records. METHODS: We have access to patient records from the Royal Freemasons Benevolent Institution RACs (Australia) over the age of 65, spanning 2010 to 2021. The reFI was developed using the cumulative deficit frailty model whose value was calculated as the ratio of number of present frailty deficits to the total possible frailty indicators (32). Frailty categories were defined using population quartiles. 1, 3 and 5-year mortality were used for validation. Survival analysis was performed using Kaplan-Meier estimate. Hazard ratios (HRs) were estimated using Cox regression analyses and the association was assessed using receiver operating characteristic (ROC) curves. RESULTS: Two thousand five hundred eighty-eight residents were assessed, with an average length of stay of 1.2 ± 2.2 years. The RAC cohort was generally frail with an average reFI of 0.21 ± 0.11. According to the Kaplan-Meier estimate, survival varied significantly across different frailty categories (p < 0.01). The estimated hazard ratios (HRs) were 1.12 (95% CI 1.09-1.15), 1.11 (95% CI 1.07-1.14), and 1.1 (95% CI 1.04-1.17) at 1, 3 and 5 years. The ROC analysis of the reFI for mortality outcome showed an area under the curve (AUC) of ≥0.60 for 1, 3 and 5-year mortality. CONCLUSION: A novel reFI was developed using the routine data recorded at RACs. reFI can identify changes in the frailty index over time for elderly people, that could potentially help in creating personalised care plans for addressing their health deterioration.

A Low-fidelity Model for Office-based Hysteroscopy with a Vaginoscopic Approach.

STUDY OBJECTIVE: Hysteroscopy is an established method for the diagnosis and treatment of intrauterine pathology. A vaginoscopic approach for office-based hysteroscopy confers less pain; however, trainees report lack of confidence with this procedure. We sought to create a low-fidelity simulation model for office-based hysteroscopy with a vaginoscopic approach and to evaluate the validity and reliability of this model. DESIGN: Prospective cohort study. SETTING: A single academic medical center. PARTICIPANTS: Eligible participants included obstetrics and gynecology residents and attendings who regularly perform hysteroscopy. INTERVENTIONS: The vaginoscopy model was created with an inanimate female pelvis simulator with an exam glove placed within the vagina. Following 2 instructional videos, participants performed a hysteroscopy simulation with a vaginoscopic approach. The primary outcome was total score on a modified Global Rating Scale and Objective Structured Assessment of Technical Skills. The Objective Structured Assessment of Technical Skills outlines a series of steps that must be performed and was created with assistance from experts in hysteroscopy for providing content-oriented evidence of validity. Time to complete each task and total time were tracked. Participants completed a postprocedure survey assessing the model and experience. MEASUREMENTS AND MAIN RESULTS: A total of 30 physicians participated, with 20 residents (9 junior and 11 senior) and 10 attendings. Attending physicians completed the simulation faster than junior residents (197.2 ± 30.9 vs 289.8 ± 107.4 seconds, p = .022). On the Global Rating Scale, both attending physicians and senior residents scored significantly higher than junior residents (26.1 ± 2.4 vs 22.5 ± 3.7, p = .01). Postsurvey data demonstrated that 93.3% of all participants were satisfied with simulation, 96.6% found it useful, 80% found it realistic, and 93% indicated that they may use this technique in the future. CONCLUSION: This study shows our low-fidelity model to be effective and useful and to improve confidence for vaginoscopic approach to hysteroscopy. Further studies are needed to assess ability to predict or improve clinical and surgical skills.

PedBotHome: A Video Game-Based Robotic Ankle Device Created for Home Exercise in Children With Neurological Impairments.

PURPOSE: This pilot study assesses the feasibility of using PedBotHome to promote adherence to a home exercise program, the ability of the device to withstand frequent use, and changes in participant ankle mobility.PedBotHome is a robotic ankle device with integrated video game software designed to improve ankle mobility in children with cerebral palsy. METHODS: Eight participants enrolled in a 28-day trial of PedBotHome. Ankle strength, range of motion, and plantar flexor spasticity were measured pre- and posttrial. Performance was monitored remotely, and game settings were modified weekly by physical therapists. RESULTS: Four participants met the study goal of 20 days of use. There were statistically significant improvements in ankle strength, spasticity, and range of motion. CONCLUSIONS: PedBotHome is a feasible device to engage children with static neurological injuries in ankle home exercise. This pilot study expands the paradigm for future innovative home-based robotic rehabilitation.

Contributions of environmental and maternal transmission to the assembly of leaf fungal endophyte communities.

Leaf fungal endophytes (LFEs) contribute to plant growth and responses to stress. Fungi colonize leaves through maternal transmission, e.g. via the seed, and through environmental transmission, e.g. via aerial dispersal. The relative importance of these two pathways in assembly and function of the LFE community is poorly understood. We used amplicon sequencing to track switchgrass (Panicum virgatum) LFEs in a greenhouse and field experiment as communities assembled from seed endophytes and rain fungi (integration of wet and dry aerial dispersal) in germinating seeds, seedlings, and adult plants. Rain fungi varied temporally and hosted a greater portion of switchgrass LFE richness (greater than 65%) than were found in seed endophytes (greater than 25%). Exposure of germinating seeds to rain inoculum increased dissimilarity between LFE communities and seed endophytes, increasing the abundance of rain-derived taxa, but did not change diversity. In the field, seedling LFE composition changed more over time, with a decline in seed-derived taxa and an increase in richness, in response to environmental transmission than LFEs of adult plants. We show that environmental transmission is an important driver of LFE assembly, and likely plant growth, but its influence depends on both the conditions at the time of colonization and plant life stage.

Associations between prenatal phthalate exposure and sex-typed play behavior in preschool age boys and girls.

Phthalates, a class of chemicals found widely in consumer products including plastic toys, food contaminants and food packaging, personal care products, cosmetics, air fresheners, and some medications, have been shown to be anti-androgenic in numerous laboratory and epidemiological studies. In a prior cohort enrolled in 2000-2002, we observed associations between prenatal urinary concentrations of di-ethyl hexyl phthalate (DEHP) and dibutyl phthalate (DBP) metabolites and less male-typed play behavior in preschool age boys. The aim of this study was to examine phthalate exposure in pregnancy in relation to play behavior at age 4 years in a larger cohort of pregnant women enrolled in The Infant Development and the Environment Study (TIDES) between 2010 and 2012 at four study sites (Minneapolis, MN; Rochester, NY; San Francisco, CA; Seattle, WA). Maternal urinary metabolites of DEHP, DiBP, DnBP, BBzP, and DEP were measured during the first (n=498) and third trimester (n=468) and mothers completed the Preschool Activities Inventory (PSAI), a validated maternal questionnaire designed to assess child toy preference and sex-typed play behavior when children were 4-5 years of age. After adjusting for child age, maternal education, race, urine dilution, parental attitudes about opposite sex-typed play behavior, and presence of a same sex older sibling, we observed associations between first trimester (mean 10.7±2.1 weeks gestation) (log10) SpG-adjusted MnBP, MiBP, and MBzP and lower masculine scores in boys (ß-coefficient [95% confidence intervals]: MnBP -2.18, [-4.16, -0.20]), MiBP -2.1[-4.3,0.1], and MBzP -2.42 [-4.12, -0.71]). In girls, first trimester maternal urinary MBzP was associated with lower masculine scores (-2.12 [-3.98,-0.25]), while third trimester (mean 32.8±3.0 weeks gestation) maternal urinary MiBP was associated with higher masculine scores (2.69 [0.68,4.70]). Third trimester maternal urinary phthalate levels were not associated with play behavior in boys. These findings in boys are largely consistent with previous studies that report that prenatal phthalate exposure is associated with less masculine play behavior. No associations in girls have been previously reported.

Patient experience with enhanced recovery and early discharge after minimally invasive sacrocolpopexy: a qualitative study.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to describe patient experiences with an enhanced recovery protocol (ERP) after minimally invasive sacrocolpopexy (SCP). METHODS: We conducted 14 semi-structured telephone interviews with women who had undergone SCP and were discharged the day of the surgery (POD#0, n = 7) or spent 1 night at the hospital (POD#1, n = 7). Interviews occurred between 2 and 6 weeks after surgery. We explored the following topics: patient preparedness, preoperative education, physical recovery, emotional recovery, and overall perception of the ERP. Interviewing continued until thematic saturation was achieved. All interviews were recorded, transcribed, and analyzed to identify relevant themes. RESULTS: Both POD#0 and POD#1 discharge patients reported largely positive experiences regarding their preparation for surgery, at-home recovery, and access to follow-up care. Yet for some patients, the accelerated pace of the ERP felt rushed and was perceived as an absence of care rather than as an advance in treatment. Patients that elected to stay the night lived farther from ready access to care, had less robust systems of postoperative support, and worried more about the management of their pre-existing conditions. CONCLUSIONS: Our research found that despite having consistently positive impressions of the ERP, patients shared common anxieties surrounding their surgeries including worries about access to care and the prospect of going home with a urinary catheter. Furthermore, we found that the therapeutic value of protocol recommendations such as early discharge must be made explicit to patients and often individualized to avoid being interpreted as sub-standard care.

Subjective Memory Complaints in White and African American Participants.

OBJECTIVE: Subjective memory complaints (SMCs) are associated with mild cognitive impairment and dementia but are understudied in African Americans (AAs). We compared SMC endorsement in white and AA participants and evaluated predictors of diagnostic progression. METHODS: Initial visit variables, including SMC and memory performance, were compared within a cognitively normal race-matched sample of white and AA participants (Ntotal = 912; 456each race) to assess the presence and predictors of SMC, the predictors of future diagnostic progression, and the change in memory performance over time. RESULTS: More white (32.9%) than AA (24.3%) participants reported SMC (P < .01, ϕ = -.10). Subjective memory complaint was predicted by memory performance (B = -0.03, standard error [SE] = 0.013, odds ratio [OR] = .968, P < .05) and race (B = -0.99, SE = 0.080, OR = .373, P < .001). Subjective memory complaints and memory performance were associated with progression, χ2 (3, n = 912) = 102.37, P < .001. African American race (-2.05 ± 0.24 SE) and SMC (-0.45 ± 0.21 SE) were associated with worse memory performance at baseline and over time, χ2(3) = 13.54, P < .01. CONCLUSIONS: In contrast to previous research, our study found that SMC is associated with diagnostic progression and objective memory declines in both white and AA participants.

To Fix or Not To Fix: Controls on Free-Living Nitrogen Fixation in the Rhizosphere.

Free-living nitrogen fixation (FLNF) in the rhizosphere, or N fixation by heterotrophic bacteria living on/near root surfaces, is ubiquitous and a significant source of N in some terrestrial systems. FLNF is also of interest in crop production as an alternative to chemical fertilizer, potentially reducing production costs and ameliorating negative environmental impacts of fertilizer N additions. Despite this interest, a mechanistic understanding of controls (e.g., carbon, oxygen, nitrogen, and nutrient availability) on FLNF in the rhizosphere is lacking but necessary. FLNF is distinct from and occurs under more diverse and dynamic conditions than symbiotic N fixation; therefore, predicting FLNF rates and understanding controls on FLNF has proven difficult. This has led to large gaps in our understanding of FLNF, and studies aimed at identifying controls on FLNF are needed. Here, we provide a mechanistic overview of FLNF, including how various controls may influence FLNF in the rhizosphere in comparison with symbiotic N fixation occurring in plant nodules where environmental conditions are moderated by the plant. We apply this knowledge to a real-world example, the bioenergy crop switchgrass (Panicum virgatum), to provide context of how FLNF may function in a managed system. We also highlight future challenges to assessing FLNF and understanding how FLNF functions in the environment and significantly contributes to plant N availability and productivity.

Patient perceptions of same-day discharge after minimally invasive gynecologic and pelvic reconstructive surgery.

BACKGROUND: Studies have demonstrated that same-day discharge after minimally invasive gynecological and pelvic reconstructive surgery is safe and cost effective and does not result in increased readmissions when compared with inpatient surgery. However, few studies have assessed patient satisfaction with same-day discharge after minimally invasive gynecological and pelvic reconstructive surgery. Increased knowledge of patients' values allows for evidence-based, patient-centered perioperative care and guides perioperative counseling. OBJECTIVES: The objectives of the study were to evaluate patient perceptions of same-day discharge after minimally invasive gynecological and pelvic reconstructive surgery, to identify barriers to patient acceptance of same-day discharge, and to assess changes in patient acceptance before and after reading an evidence-based statement regarding same-day discharge. STUDY DESIGN: This is a cross-sectional survey study. All English-speaking new patients presenting to a subspecialty, benign gynecological surgery clinic, including female pelvic medicine and reconstructive surgery and minimally invasive gynecologic surgery providers, were invited to participate. The survey included an evidence-based statement about same-day discharge. Participants were asked to rate their comfort with same-day discharge before and after reading this statement. RESULTS: Ninety-six percent of women (208 of 216) who were approached completed the study. The majority rated their overall health and mental or emotional health as good or very good (61.1% and 64.9%). Most (82.7%) completed at least some college. Most (86.1%) reported having at least 1 prior surgery and 68.8% reported same-day discharge after a prior surgery: 74.8% rated their prior experience with same-day discharge favorably. The majority of respondents (86.1%) reported they would feel comfortable with same-day discharge. The most important cited reasons for going home the same day as surgery included sleeping in own bed (73.4%) and being with family (61.8%). The most important cited reasons for staying overnight in the hospital included anticipated better pain control (58.9%) and decreased overall complications (43.0%). Forty percent believed it would be easier to take care of a catheter if needed in the hospital. Patients who reported living alone and those 65 years old and older were less likely to feel comfortable with same-day discharge (odds ratio, 0.39, 95% confidence interval, 0.17-0.91). Of the 29 patients who reported at baseline that they would not feel comfortable with same-day discharge, most (65.5%) changed their minds after reading an evidence-based statement about same-day discharge. When asked if their surgeon recommended it, almost all patients (96.1%) reported they would feel comfortable with same-day discharge. CONCLUSION: Among new patients presenting to a subspecialty, benign gynecologic surgery clinic including female pelvic medicine and reconstructive surgery and minimally invasive gynecological surgery providers, most perceive same-day discharge favorably following minimally invasive gynecological and pelvic reconstructive surgery. Women who live alone and those aged 65 years and older feel less comfortable with same-day discharge. While an evidence-based statement regarding the benefits and safety of same-day discharge further improves patient acceptance, direct surgeon counseling may be more important to establish discharge goals.

Enhanced recovery program for minimally invasive and vaginal urogynecologic surgery.

INTRODUCTION AND HYPOTHESIS: Enhanced recovery protocols (ERPs) are evidenced-based interventions designed to standardize perioperative care and expedite recovery to baseline functional status after surgery. There remains a paucity of data addressing the effect of ERPs on pelvic reconstructive surgery patients. METHODS: An ERP was implemented at our institution including: patient counseling, carbohydrate loading, avoidance of opioids, goal-directed fluid resuscitation, immediate postoperative feeding and early ambulation. Patients undergoing elective pelvic reconstructive surgery before and after implementation of the ERP were identified in this cohort study. RESULTS: One hundred eighteen patients underwent pelvic reconstructive surgery within the ERP compared with 76 historic controls. Reductions were seen in length of hospital stay (29.9 vs. 27.9 h, p = 0.04), total morphine equivalents (37.4 vs. 19.4 mg, p < 0.01) and total intravenous fluids administered (2.7 l vs. 1.5 l, p < 0.0001). Hospital discharges before noon doubled (32.9 vs. 60.2%, p < 0.01). More patients in the ERP group ambulated on the day of surgery (17.1 vs. 73.7%, p < 0.01) and ambulated at least two times the day following surgery (34.2 vs. 72.9%, p < 0.01). No differences were seen in average pain scores (highest pain score 7.39 vs. 7.37, p = 0.95), hospital readmissions (3.9 vs. 3.4%, p = 0.84), or postoperative complications (6.58 vs. 8.47%, p = 0.79). Patient satisfaction significantly improved. ERP was not associated with an increase in 30-day total hospital costs. CONCLUSIONS: Implementation of ERP for pelvic reconstructive surgery patients was associated with a reduced length of hospital stay, improved patient satisfaction, and decreased administration of intravenous fluids and opioids without an increase in complications, readmissions, or hospital costs.

The association between PTSD and cardiovascular disease and its risk factors in male veterans of the Iraq/Afghanistan conflicts: a systematic review.

Military personnel with Post-Traumatic Stress Disorder (PTSD) can experience high levels of mental and physical health comorbidity, potentially indicating a high level of functional impairment that can impact on both military readiness and later ill-health. There is strong evidence to implicate PTSD as a contributory factor to Cardiovascular Disease (CVD) among serving personnel and veterans. This systematic review focusses on the association between PTSD and cardiovascular disease/risk factors in male, military serving and ex-serving personnel who served in the Iraq/Afghanistan conflicts. PUBMED, MEDLINE, PILOTS, EMBASE, PSYCINFO, and PSYCARTICLES were searched using PRISMA guidelines. Three hundred and forty-three records were identified, of which 20 articles were selected. PTSD was positively associated with the development of CVD, specifically circulatory diseases, including hypertension. PTSD was also positively associated with the following risk factors: elevated heart rate, tobacco use, dyslipidaemia, and obesity. Conflicting data is presented regarding heart rate variability and inflammatory markers. Future studies would benefit from a standardized methodological approach to investigating PTSD and physical health manifestations. It is suggested that clinicians offer health advice for CVD at an earlier age for ex-/serving personnel with PTSD.

Loss-of-function alanyl-tRNA synthetase mutations cause an autosomal-recessive early-onset epileptic encephalopathy with persistent myelination defect.

Mutations in genes encoding aminoacyl-tRNA synthetases are known to cause leukodystrophies and genetic leukoencephalopathies-heritable disorders that result in white matter abnormalities in the central nervous system. Here we report three individuals (two siblings and an unrelated individual) with severe infantile epileptic encephalopathy, clubfoot, absent deep tendon reflexes, extrapyramidal symptoms, and persistently deficient myelination on MRI. Analysis by whole exome sequencing identified mutations in the nuclear-encoded alanyl-tRNA synthetase (AARS) in these two unrelated families: the two affected siblings are compound heterozygous for p.Lys81Thr and p.Arg751Gly AARS, and the single affected child is homozygous for p.Arg751Gly AARS. The two identified mutations were found to result in a significant reduction in function. Mutations in AARS were previously associated with an autosomal-dominant inherited form of axonal neuropathy, Charcot-Marie-Tooth disease type 2N (CMT2N). The autosomal-recessive AARS mutations identified in the individuals described here, however, cause a severe infantile epileptic encephalopathy with a central myelin defect and peripheral neuropathy, demonstrating that defects of alanyl-tRNA charging can result in a wide spectrum of disease manifestations.

Mutations in SZT2 result in early-onset epileptic encephalopathy and leukoencephalopathy.

Early-onset epileptic encephalopathies (EOEEs) are a genetically heterogeneous collection of severe epilepsies often associated with psychomotor regression. Mutations in SZT2, a known seizure threshold regulator gene, are a newly identified cause of EOEE. We present an individual with EOEE, macrocephaly, and developmental regression with compound heterozygous mutations in SZT2 as identified by whole exome sequencing. Serial imaging characterized the novel finding of progressive loss of central myelination. This case expands our clinical understanding of the SZT2-phenotype and emphasizes the role of this gene in the diagnostic investigation for EOEE and leukoencephalopathies.

Review of enhanced recovery programs in benign gynecologic surgery.

INTRODUCTION AND HYPOTHESIS: Enhanced recovery programs (ERPs) are evidence-based protocols designed to improve functional rehabilitation after surgery. ERPs have gained widespread acceptance in many surgical disciplines, and their use leads to significant improvements in patient outcomes while reducing hospital length of stay (LOS). There remains a paucity of data on the use of ERPs in benign gynecologic surgery. The purpose of this review was to evaluate current literature on the use of ERP concepts in benign gynecologic surgery. METHODS: A systematic search of PubMed, CINAHL, Web of Science, and the Cochrane databases was conducted, cross-referencing search terms related to gynecologic surgery and ERP concepts. The search was limited to publications available in English. Studies published prior to 2000, and those involving gynecologic oncology, nonadult patients, and outpatient surgery were excluded. RESULTS: Nine studies were included in the analysis. Due to heterogeneity of the included studies, no statistical pooling was possible and comparison between studies was limited to their respective themes. Primary study outcomes included LOS, postoperative nausea and vomiting (PONV), pain management, patient satisfaction, and hospital costs. Five studies investigated ERPs, two evaluated measures to improve PONV, and four focused on unique aspects of pain management. Across the studies, ERPs that focused on the patients' basic symptoms and recovery were found to have equal, if not better, outcomes than standard practice. CONCLUSIONS: This integrative review supports the implementation of ERPs in benign gynecologic surgery. The results showed that the use of ERPs decreased LOS, improved pain scores, and reduced hospital costs, without increasing perioperative complications. We suggest additional randomized controlled trials of ERP concepts in benign gynecologic surgery to support their more widespread use and application.