Age-Related Brain Atrophy and the Positive Effects of Behavioral Enrichment in Middle-Aged Beagles.

Aging dogs serve as a valuable preclinical model for Alzheimer's disease (AD) due to their natural age-related development of ß-amyloid (Aß) plaques, human-like metabolism, and large brains that are ideal for studying structural brain aging trajectories from serial neuroimaging. Here we examined the effects of chronic treatment with the calcineurin inhibitor (CNI) tacrolimus or the nuclear factor of activated T cells (NFAT)-inhibiting compound Q134R on age-related canine brain atrophy from a longitudinal study in middle-aged beagles (36 females, 7 males) undergoing behavioral enrichment. Annual MRI was analyzed using modern, automated techniques for region-of-interest-based and voxel-based volumetric assessments. We found that the frontal lobe showed accelerated atrophy with age, while the caudate nucleus remained relatively stable. Remarkably, the hippocampus increased in volume in all dogs. None of these changes were influenced by tacrolimus or Q134R treatment. Our results suggest that behavioral enrichment can prevent atrophy and increase the volume of the hippocampus but does not prevent aging-associated prefrontal cortex atrophy.

Artificial Intelligence-Driven Morphology-Based Enrichment of Malignant Cells from Body Fluid.

Cell morphology is a fundamental feature used to evaluate patient specimens in pathologic analysis. However, traditional cytopathology analysis of patient effusion samples is limited by low tumor cell abundance coupled with the high background of nonmalignant cells, restricting the ability of downstream molecular and functional analyses to identify actionable therapeutic targets. We applied the Deepcell platform that combines microfluidic sorting, brightfield imaging, and real-time deep learning interpretations based on multidimensional morphology to enrich carcinoma cells from malignant effusions without cell staining or labels. Carcinoma cell enrichment was validated with whole genome sequencing and targeted mutation analysis, which showed a higher sensitivity for detection of tumor fractions and critical somatic variant mutations that were initially at low levels or undetectable in presort patient samples. Our study demonstrates the feasibility and added value of supplementing traditional morphology-based cytology with deep learning, multidimensional morphology analysis, and microfluidic sorting.

Emergency department utilization among patients who receive outpatient specialty care for headache: A retrospective cohort study analysis.

OBJECTIVES: To compare clinical characteristics among outpatient headache clinic patients who do and do not self-report visiting the emergency department for headache. BACKGROUND: Headache is the fourth most common reason for emergency department visits, compromising 1%-3% of visits. Limited data exist about patients who are seen in an outpatient headache clinic but still opt to frequent the emergency department. Clinical characteristics may differ between patients who self-report emergency department use and those who do not. Understanding these differences may help identify which patients are at greatest risk for emergency department overutilization. METHODS: This observational cohort study included adults treated at the Cleveland Clinic Headache Center between October 12, 2015 and September 11, 2019, who completed self-reported questionnaires. Associations between self-reported emergency department utilization and demographics, clinical characteristics, and patient-reported outcome measures (PROMs: Headache Impact Test [HIT-6], headache days per month, current headache/face pain, Patient Health Questionnaire-9 [PHQ-9], Patient-Reported Outcomes Measurement Information System [PROMIS] Global Health [GH]) were evaluated. RESULTS: Of the 10,073 patients (mean age 44.7 ± 14.9, 78.1% [7872/10,073] female, 80.3% [8087/10,073] White patients) included in the study, 34.5% (3478/10,073) reported visiting the emergency department at least once during the study period. Characteristics significantly associated with self-reported emergency department utilization included younger age (odds ratio = 0.81 [95% CI = 0.78-0.85] per decade), Black patients (vs. White patients) (1.47 [1.26-1.71]), Medicaid (vs. private insurance) (1.50 [1.29-1.74]), and worse area deprivation index (1.04 [1.02-1.07]). Additionally, worse PROMs were associated with greater odds of emergency department utilization: higher (worse) HIT-6 (1.35 [1.30-1.41] per 5-point increase), higher (worse) PHQ-9 (1.14 [1.09-1.20] per 5-point increase), and lower (worse) PROMIS-GH Physical Health T-scores (0.93 [0.88-0.97]) per 5-point increase. CONCLUSION: Our study identified several characteristics associated with self-reported emergency department utilization for headache. Worse PROM scores may be helpful in identifying which patients are at greater risk for utilizing the emergency department.

Evaluation of missed influenza vaccination opportunities in the emergency department.

BACKGROUND: Seasonal influenza is associated with significant healthcare resource utilization. An estimated 490,000 hospitalizations and 34,000 deaths were attributed to influenza during the 2018-2019 season. Despite robust influenza vaccination programs in both the inpatient and outpatient setting, the emergency department (ED) represents a missed opportunity to vaccinate patients at high risk for influenza who do not have access to routine preventive care. Feasibility and implementation of ED-based influenza vaccination programs have been previously described but have stopped short of describing the predicted health resource impact. The goal of our study was to describe the potential impact of an influenza vaccination program in an urban adult emergency department population using historic patient data. METHODS: This was a retrospective study of all encounters within a tertiary care hospital-based ED and three freestanding EDs during influenza season (defined as October 1 - April 30) over a two-years, 2018-2020. Data was obtained from the electronic medical record (EPIC®). All ED encounters during the study period were screened for inclusion using ICD 10 codes. Patients with a confirmed positive influenza test and no documented influenza vaccine for the current season were reviewed for any ED encounter at least 14 days prior to the influenza-positive encounter and during the concurrent influenza season. These ED visits were deemed a missed opportunity to provide vaccination and potentially prevent the influenza-positive encounter. Healthcare resource utilization, including subsequent ED encounters and inpatient admissions, were evaluated for patients with a missed vaccination opportunity. RESULTS: A total of 116,140 ED encounters occurred during the study and were screened for inclusion. Of these, 2115 were influenza-positive encounters, which represented 1963 unique patients. There were 418 patients (21.3%) that had a missed opportunity to be vaccinated during an ED encounter at least 14 days prior to the influenza-positive encounter. Of those with a missed vaccination opportunity, 60 patients (14.4%) had subsequent influenza-related encounters, including 69 ED visits and 7 inpatient admissions. CONCLUSION: Patients presenting to the ED with influenza frequently had opportunities to be vaccinated during prior ED encounters. An ED-based influenza vaccination program could potentially reduce influenza-related burden on healthcare resources by preventing future influenza-related ED encounters and hospitalizations.

Hippocampal dentate gyrus integrity revealed with ultrahigh resolution diffusion imaging predicts memory performance in older adults.

Medial temporal lobe (MTL) atrophy is a core feature of age-related cognitive decline and Alzheimer's disease (AD). While regional volumes and thickness are often used as a proxy for neurodegeneration, they lack the sensitivity to serve as an accurate diagnostic test and indicate advanced neurodegeneration. Here, we used a submillimeter resolution diffusion weighted MRI sequence (ZOOMit) to quantify microstructural properties of hippocampal subfields in older adults (63-98 years old) using tensor derived measures: fractional anisotropy (FA) and mean diffusivity (MD). We demonstrate that the high-resolution sequence, and not a standard resolution sequence, identifies dissociable profiles for CA1, dentate gyrus (DG), and the collateral sulcus. Using ZOOMit, we show that advanced age is associated with increased MD of the CA1 and DG as well as decreased FA of the DG. Increased MD of the DG, reflecting decreased cellular density, mediated the relationship between age and word list recall. Further, increased MD in the DG, but not DG volume, was linked to worse spatial pattern separation. Our results demonstrate that ultrahigh-resolution diffusion imaging enables the detection of microstructural differences in hippocampal subfield integrity and will lead to novel insights into the mechanisms of age-related memory loss.

Prostate cancer grade downgrading at time of prostatectomy provides risk-stratification insight into future tumor behavior after prostatectomy.

BACKGROUND: Prostate biopsy (Bx) sampling-based diagnosis of prostate cancer (PCa) has well-described inaccuracy when compared against whole gland analysis upon prostatectomy. Although upgrading of PCa Grade Group (GG) is often described, the occurrence and prognostic implications of downgrading PCa GG at the time of radical prostatectomy (RP) is less understood. Our objective was to evaluate whether downgrading PCa GG at the time of RP was associated with future tumor behavior. METHODS: The SEER database was searched from 2010 to 2017 and patients were included if they were assigned pathological grades on both Bx and RP specimen. Patients were stratified into Bx GG > RP GG and Bx GG ≤ RP GG groups, and tumor behavior after treatment was examined. Cox regression was used for the survival analysis. RESULTS: Here, 99,835 patients were included in this study. A total of 18,516 (18.5%) patients encountered downgrading from Bx GG to RP GG. A downgrading of 1 grade occurred in 13,969 (75.4%) of these patients and of 2 or more grades occurred in 4547 (24.6%) patients. A history of higher Bx GG compared with RP GG increased the risk of cancer-specific mortality (CSM) for each given RP GG controlling for age, race, preop prostate-specific antigen level, percentage of positive biopsy cores, and pathologic TNM stages. Specifically, a history of high Bx GG conferred a 45% increased risk of CSM for any given RP GG (hazard ratio = 1.45 95% confidence interval = 1.16-1.82, p < 0.001). CONCLUSION: A history of higher Bx GG, and hence downgrading at the time of RP, demonstrates some value as a risk-stratification tool for future cancer outcomes after prostatectomy.

Cotesting for Human Immunodeficiency Virus and Sexually Transmitted Infections in the Emergency Department.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) and US Preventive Services Task Force (USPSTF) guidelines recommend screening for human immunodeficiency virus (HIV) in patients aged 15 to 65 years, as well as those at increased risk. Patients screened in the emergency department (ED) for gonorrhea (GC) and/or chlamydia represent an increased-risk population. Our aim was to assess compliance with CDC and USPSTF guidelines for HIV testing in a national sample of EDs. METHODS: We examined data from the 2010 to 2018 Nationwide Emergency Department Sample, which can be used to create national estimates of ED care to query tests for GC, chlamydia, HIV, and syphilis testing. Weighted proportions and 95% confidence intervals (CIs) were reported, and Rao-Scott χ 2 tests were used. RESULTS: We identified 13,443,831 (weighted n = 3,094,214) high-risk encounters in which GC/chlamydia testing was performed. HIV screening was performed in 3.9% (95% CI, 3.4-4.3) of such visits, and syphilis testing was performed in 2.9% (95% CI, 2.7-3.2). Only 1.5% of patients with increased risk encounters received both HIV and syphilis cotesting. CONCLUSIONS: Despite CDC and USPSTF recommendations for HIV and syphilis screening in patients undergoing STI evaluation, only a small proportion of patients are being tested. Further studies exploring the barriers to HIV screening in patients undergoing STI assessment in the ED may help inform future projects aimed at increasing guidance compliance.

Characterization of ophthalmic presentations to emergency departments in the United States: 2010-2018.

BACKGROUND: Both traumatic and nontraumatic ocular issues often present to the emergency department. Understanding the epidemiology of ocular presentations to the emergency department not only informs current resource allocation, but also provides opportunities to evaluate the efficacy of prior healthcare access interventions. PURPOSE: To characterize emergency department utilization in the United States for ophthalmic encounters between 2010 and 2018. METHODS: Cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey database, a nationally representative sample of United States emergency department visits. 4284 deidentified emergency department patient encounters with an ICD-10 ophthalmic diagnosis from 2010 to 2018 were analyzed. The main outcome measures were the composition and characteristics of ophthalmic emergency department encounters over time. MAIN FINDINGS: 4284 ophthalmic visits were identified which represented an estimated 23.1 million visits (95% CI, 20.8 million-25.5 million). 31.6% (95% CI, 29.6-33.8) of ophthalmic visits were traumatic. Conjunctivitis was the most common non-traumatic diagnosis (32.8%, 95% CI, 30.7-35.0), while superficial injury of the cornea was the most common traumatic diagnosis (13.9%, 95% CI, 12.5-15.3). A greater proportion of emergency department visits involving the sclera and cornea were made by men (58.7%, 95% CI, 53.7%-63.6%; P = 0.02), whereas more women visited for visual disturbances (57.8%, 95% CI, 51.3%-64.4%; P = 0.01). Longitudinal trends of ophthalmic visits revealed an increase in public insurance payers in 2014, which corresponds to Medicaid expansion and implementation of mandated coverage for pediatric vision care. After stratification, this increase continued to be present in nontraumatic visits, but not traumatic ones. CONCLUSIONS: Ophthalmic emergency department visits in the United States between 2010 and 2018 were typically for non-traumatic eye issues. Diagnoses varied greatly by patient demographics, such as age and gender. Understanding these variations is valuable for preparing emergency departments for ocular presentations and providing guidance for future practice.

Management of migraine in the emergency department: Findings from the 2010-2017 National Hospital Ambulatory Medical Care Surveys.

OBJECTIVE: The study objective was to describe trends in the medical management of migraine in the emergency department (ED) using the 2010-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets. METHODS: Using the 2010-2017 NHAMCS datasets, we analyzed visits with a discharge diagnosis of migraine. Drug prescription frequencies between years were compared with the Rao-Scott chi-squared test. Adjusted odds ratios of opioid administration from 2010 to 2017 were calculated using weighted multivariable logistic regression with sex, age, race/ethnicity, pain-score, primary expected source of payment, and year as predictor variables. RESULTS: Our analysis captured 1846 ED visits with a diagnosis of migraine from 2010 to 2017, representing a weighted average of 1.2 million US ED visits per year. Parenteral opioids were prescribed in 49% (95% CI: 40, 58) of visits in 2010 and 28% (95% CI: 15, 45) of visits in 2017 (p = 0.03). From 2010 to 2017, there was a 10% yearly decrease in opioid prescriptions. Metoclopramide and ketorolac were prescribed more frequently in years 2015 through 2017 than in 2010. Increased opioid administration was associated with female sex, older age, white race, higher pain score, and having Medicare or private insurance as the primary expected source of payment for all years. CONCLUSION: Opioid administration for migraine in EDs across the US declined 10% annually between 2010 and 2017, demonstrating improved adherence to migraine guidelines recommending against opioids. We identified several factors associated with opioid administration for migraine, identifying groups at higher risk for unnecessary opioids in the ED setting.

Race as a predictor of pathologic response to neoadjuvant chemotherapy at time of cystectomy for bladder cancer.

INTRODUCTION Complete pathologic response (pT0) at time of cystectomy after neoadjuvant chemotherapy (NAC) has been associated with significantly improved clinical outcomes. The goal of this study is to examine whether race is a predictor of pT0 response to NAC at time of cystectomy. MATERIALS AND METHODS: We analyzed the records of patients diagnosed with a non-metastatic (M0) muscle-invasive (cT2+) urothelial cell bladder cancer in the National Cancer Database (NCDB) who underwent a cystectomy from 2006 to 2014. The cohort was stratified by whether the patient received NAC prior to cystectomy. Univariate and multivariate logistic regression models were used to assess for the effect of race on pathologic complete response after NAC. RESULTS: We identified 16,036 patients of which 3,195 patients (19.9 %) were treated with NAC prior to cystectomy. The total number of African American (AA) patients in this study was 848 (5.3 %). Compared to Caucasian patients receiving NAC, AA patients had a greater proportion of females and had lower income and education. The rate of pT0 in the surgery only group was 2.7% compared to 15.0% (p < 0.001) for patients treated with NAC. On multivariate analysis, patients of AA race that received NAC were less likely to achieve pT0 (OR = 0.55, 95% CI: 0.31-0.98, p = 0.04) when controlling for age, sex, co-morbidities income, education and timing of cystectomy after starting NAC. CONCLUSIONS: Our results suggest that African American patients are less likely to achieve pathologic complete response to NAC prior to cystectomy.

Emergency Nurses' Knowledge, Attitudes, and Practices Related to Blood Sample Hemolysis Prevention: An Exploratory Descriptive Study.

INTRODUCTION: The aim of the study was to identify emergency nurses' knowledge, attitudes, and practices related to blood sample hemolysis prevention and explore associations between these factors and demographic characteristics. The current state is unknown. Understanding baseline knowledge, attitudes, and practices addresses a gap in the literature. METHOD: An exploratory, descriptive design with cross-sectional survey methodology employing a study-specific instrument was used. RESULTS: Request for participation email was sent to a random sample of 5000 Emergency Nurses Association members, and 427 usable surveys were returned (response rate = 8.5%). Mean years in nursing was 13.85 (standard deviation = 10.78), and 226 (52.9%) were certified emergency nurses. Only 85 participants (19.9%) answered all 3 knowledge questions correctly. Answering the 3 knowledge questions correctly was significantly associated with being a certified emergency nurse (χ2 = 7.15, P < .01). Participant responses to attitude items about the sequelae of blood sample hemolysis were skewed toward agreement, and most attitude items were associated with whom participants reported as being primarily responsible for phlebotomy. Emergency nurses remain primarily responsible for phlebotomy as well as addressing hemolyzed samples, but few reported that blood sample hemolysis was addressed at a departmental level. DISCUSSION: Findings suggest that emergency nurses lack some knowledge related to blood sample hemolysis prevention best practices. Attitudes toward phlebotomy practices may be 1 reason practice has not changed. Every effort should be made to prevent hemolyzed blood samples to decrease delays and costs in emergency care.

A tattoo granuloma with uveitis (TAGU) without sarcoidosis.

Tattooing is associated with a handful of potential complications. Short-term complications such as pain, pruritus, erythema, or swelling at the tattoo-site commonly occur from local skin trauma. Long-term complications tend to involve infections or immune-mediated reactions such as sarcoidosis. The sudden development of a papulonodular skin eruption affecting a particular pigment in a tattoo is often the initial manifestation of undiagnosed sarcoidosis in these patients. However, in a small number of individuals, the granulomatous change in the tattoo and uveitis occur in the absence of any evidence of sarcoidosis. A case is presented of a tattoo granuloma with uveitis (TAGU) without sarcoidosis.

A Multidisciplinary Technique for Concurrent Panniculectomy-Living Donor Renal Transplantation.

BACKGROUND: Recently, it has been shown that panniculectomy concurrent to living donor renal transplantation is a safe option for management of renal transplant recipients with a large focal pannus. This combined management requires precise coordination of teams. We describe the technique, timing, and sequence for combined renal transplantation and panniculectomy. METHODS: We conducted a retrospective chart review of adult patients (≥18 years old) who underwent simultaneous living donor renal transplantation-panniculectomy from 2015 to 2019. A multi-team approach that included urology, transplant, and plastic surgery was used to perform the combined operations. Typically, the plastic surgery team initiates the operation by performing the panniculectomy. This is followed by kidney transplantation and graft anastomosis. The plastic surgery team then completes the operation with closure of the wound. RESULTS: Twenty patients were identified. Most were male (12:8) with a mean age of 55 years and an average body mass index of 35 kg/m. The mean total operative duration was 394 minutes. On average, 17% of operating time was devoted to panniculectomy. At 90 days follow-up, there was 100% graft survival and all patients had primary graft function. There was a 25% wound complications rate and a 15% reoperation rate. CONCLUSION: By performing panniculectomy first in the sequence, concurrent panniculectomy provides wide exposure and a large operative field for transplantation. Wound closure by plastic surgeons may mitigate the high complication rate commonly seen in obese patients with end-stage renal disease. Future studies are needed to evaluate the cost-benefit of the combined living donor renal transplantation-panniculectomy.

Femtosecond dynamics of metal-centered and ligand-to-metal charge-transfer (t2g-based) electronic excited states in various solvents: A comprehensive study of IrBr6 2.

The photophysical properties of intraconfigurational metal-centered (MC) and ligand-to-metal charge transfer (LMCT) states were studied in a prototype low spin heavy d5 transition metal complex, IrBr6 2-. The femtosecond-to-picosecond dynamics of this complex was investigated in solutions of drastically different polarity (acetonitrile, chloroform, and water) by means of ultrafast broadband transient absorption spectroscopy. We observed that the system, when excited into the third excited [second LMCT, 2Uu'(T1u)] state, undergoes distortion from the Franck-Condon geometry along the t2g vibrational mode as a result of the Jahn-Teller effect, followed by rapid internal conversion to populate (90 fs) the second excited [first LMCT, 2Ug'(T1g)] state. Vibrational decoherence and vibrational relaxation (∼400 fs) in 2Ug'(T1g) precede the decay of this state via internal conversion (time constants, 2.8 and 3 ps in CH3CN and CHCl3 and 0.76 ps in water), which can also be viewed as back electron transfer and which leads into the intraconfigurational MC 2Ug'(T2g) state. This is the lowest-excited state, from which the system returns to the ground state. This MC state is metastable in both CH3CN and CHCl3 (lifetime, ∼360 ps), but is quenched via OH-mediated energy transfer in aqueous environments, with the lifetime shortening up to 21 ps in aqueous solutions. The cascade relaxation mechanism is the same upon excitation into the second excited state. Excitation of IrBr6 2- in chloroform into higher 2Uu'(T2u), 2Eu″(T2u), and 2Eg'(T1g) states is observed to populate the third excited 2Uu'(T1u) state within 100 fs. These experiments allow us to resolve the ultrafast relaxation coordinate and emphasize that the excited-state Jahn-Teller effect is a driving force in the ultrafast dynamics, even for heavy transition metal complexes with very significant spin-orbit interactions.

Ten-year Outcomes of a Prospective Randomized Trial of Laparoscopic Gastric Bypass Versus Laparoscopic Gastric Banding.

OBJECTIVE: The primary endpoints of this study were long-term weight loss, morbidity, and changes in comorbidities and quality of life. BACKGROUND: Bariatric surgery is an effective option for the treatment of severe obesity and its related comorbidities. However, few studies have reported on the long-term outcome (>5 yrs) of bariatric surgery. METHODS: Between 2002 and 2007, 250 patients with a body mass index (BMI) of 35 to 60 kg/m were randomly assigned to undergo laparoscopic gastric bypass or laparoscopic gastric banding. After exclusions, 111 patients underwent gastric bypass and 86 patients underwent gastric banding. Factors predictive of improved weight loss were analyzed using multiple logistic regressions. RESULTS: At baseline, the mean age was 43 ±â€Š10 years and the mean BMI was 46.5 ±â€Š5.6 kg/m. At 10-year follow-up, the mean total body weight loss for the entire cohort was -37.5 ±â€Š19.4 kg, -42.4 ±â€Š19.6 kg for gastric bypass versus -27.4 ±â€Š14.5 kg for gastric banding. Late reoperation was significantly higher after gastric banding compared with the gastric bypass group (31.4% vs. 8.1%, respectively, P < 0.01). For the entire cohort, improvement or remission of diabetes occurred in 68%; 61% for hypertension; and 57% for dyslipidemia. The long-term mortality for the entire cohort was 1.0% at a mean follow-up of 9.5 ±â€Š0.4 years. Factors predictive of improved weight loss included the type of operation (ie, gastric bypass), female sex, and the absence of diabetes at baseline. At long-term follow-up, quality of life continues to be improved from baseline for both the groups. CONCLUSIONS: Bariatric surgery is an effective treatment for severe obesity with durable 10-year weight loss and improvement in comorbidities and quality of life. Compared with gastric banding, gastric bypass was associated with better long-term weight loss, lower rate of late reoperation, and improved remission of comorbidities.

Robotic-assisted single-port donor nephrectomy using the da Vinci single-site platform.

BACKGROUND: Although single-port donor nephrectomy offers improved cosmetic outcomes, technical challenges have limited its application to selected centers. Our center has performed over 400 single-port donor nephrectomies. The da Vinci single-site robotic platform was utilized in an effort to overcome the steric, visualization, ergonomic, and other technical limitations associated with the single-port approach. MATERIALS AND METHODS: Food and Drug Administration device exemption was obtained. Selection criteria for kidney donation included body mass index <35, left kidney donors, and ≤2 renal arteries. After colonic mobilization using standard single-port techniques, the robotic approach was utilized for ureteral complex and hilar dissection. RESULTS: Three cases were performed using the robotic single-site platform. Average total operative time was 262 ±â€¯42 min including 82 ±â€¯16 min of robotic use. Docking time took 20 ±â€¯10 min. Blood loss averaged 77 ±â€¯64 mL. No intraoperative complications occurred, and all procedures were completed with our standard laparoscopic single-port approach. CONCLUSIONS: This is the first clinical experience of robotic-assisted donor nephrectomy utilizing the da Vinci single-site platform. Our experience supported the safety of this approach but found that the technology added cost and complexity without tangible benefit. Development of articulating instruments, energy, and stapling devices will be necessary for increased application of robotic single-site surgery for donor nephrectomy.

Minimally invasive donor nephrectomy: current state of the art.

BACKGROUND: The concept of a minimally invasive live donor nephrectomy developed over 20 years ago. Surgeons gained expertise with the laparoscopic technique and utilized multiple variations that are now utilized in transplant centers throughout the world. Recent modifications include laparoendoscopic single-site and robotic approaches that have been adopted by an additional smaller set of programs. PURPOSE: Review was performed of the following eight different surgical approaches to a "minimally invasive" live donor nephrectomy: laparoscopic (LDN), hand-assisted laparoscopic (HALDN), retroperitoneoscopic (RLDN), hand-assisted retroperitoneoscopic (HARS), single-port laparoscopic (LESS), robotic-assisted laparoscopic (RALDN), mini open, and natural orifice transluminal endoscopic (NOTES). The techniques are described and summaries of available outcomes and complications are presented. CONCLUSIONS: Traditional surgical techniques of open donor nephrectomy have transitioned to minimally invasive techniques. With adoption of these techniques as the preferred approach, several variations have and continue to evolve. The current minimally invasive donor nephrectomy techniques share low complication rates and excellent outcomes.

Clinical pharmacy services in the emergency department.

The emergency department (ED) is a fast-paced, high-risk, and often overburdened work environment. Formal policy statements from several notable organizations, including the American College of Emergency Physicians (ACEP) and the American Society of Health-System Pharmacists (ASHP), have recognized the importance of clinical pharmacists in the emergency medicine (EM) setting. EM clinical pharmacists work alongside emergency physicians and nurses at the bedside to optimize pharmacotherapy, improve patient safety, increase efficiency and cost-effectiveness of care, facilitate antibiotic stewardship, educate patients and clinicians, and contribute to scholarly efforts. This paper examines the history of EM clinical pharmacists and associated training programs, the diverse responsibilities and roles of EM clinical pharmacists, their impact on clinical and financial outcomes, and proposes a conceptual model for EM clinical pharmacist integration into ED patient care. Finally, barriers to implementing EM clinical pharmacy programs and limitations are considered.