PATHway to success: Implementation of a multiprofessional acute trauma health care team decreased length of stay and cost in patients with neurological injury requiring tracheostomy.

BACKGROUND: The aim of this study was to determine whether the implementation of a dedicated multiprofessional acute trauma health care (mPATH) team would decrease length of stay without adversely impacting outcomes of patients with severe traumatic brain and spinal cord injuries. The mPATH team was comprised of a physical, occupational, speech, and respiratory therapist, nurse navigator, social worker, advanced care provider, and physician who performed rounds on the subset of trauma patients with these injuries from the intensive care unit to discharge. METHODS: Following the formation and implementation of the mPATH team at our Level I trauma center, a retrospective cohort study was performed comparing patients in the year immediately prior to the introduction of the mPATH team (n = 60) to those in the first full year following implementation (n = 70). Demographics were collected for both groups. Inclusion criteria were Glasgow Coma Scale score less than 8 on postinjury Day 2, all paraplegic and quadriplegic patients, and patients older than 55 years with central cord syndrome who underwent tracheostomy. The primary endpoint was length of stay; secondary endpoints were time to tracheostomy, days to evaluation by occupational, physical, and speech therapy, 30-day readmission, and 30-day mortality. RESULTS: The median time to evaluation by occupational, physical, and speech therapy was universally decreased. Injury Severity Score was 27 in both cohorts. Time to tracheostomy and length of stay were both decreased. Thirty-day readmission and mortality rates remained unchanged. A cost savings of US $11,238 per index hospitalization was observed. CONCLUSION: In the year following the initiation of the mPATH team, we observed earlier time to occupational, physical, and speech therapist evaluation, decreased length of stay, and cost savings in severe traumatic brain and spinal cord injury patients requiring tracheostomy compared with our historical control. These benefits were observed without adversely impacting 30-day readmission or mortality. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Limited alpine climatic warming and modeled phenology advancement for three alpine species in the Northeast United States.

UNLABELLED: • PREMISE OF THE STUDY: Most alpine plants in the Northeast United States are perennial and flower early in the growing season, extending their limited growing season. Concurrently, they risk the loss of reproductive efforts to late frosts. Quantifying long-term trends in northeastern alpine flower phenology and late-spring/early-summer frost risk is limited by a dearth of phenology and climate data, except for Mount Washington, New Hampshire (1916 m a.s.l.).• METHODS: Logistic phenology models for three northeastern US alpine species (Diapensia lapponica, Carex bigelowii and Vaccinium vitis-idaea) were developed from 4 yr (2008-2011) of phenology and air temperature measurements from 12 plots proximate to Mount Washington's long-term summit meteorological station. Plot-level air temperature, the logistic phenology models, and Mount Washington's climate data were used to hindcast model yearly (1935-2011) floral phenology and frost damage risk for the focal species.• KEY RESULTS: Day of year and air growing degree-days with threshold temperatures of -4°C (D. lapponica and C. bigelowii) and -2°C (V. vitis-idaea) best predicted flowering. Modeled historic flowering dates trended significantly earlier but the 77-yr change was small (1.2-2.1 d) and did not significantly increase early-flowering risk from late-spring/early-summer frost damage.• CONCLUSIONS: Modeled trends in phenological advancement and sensitivity for three northeastern alpine species are less pronounced compared with lower elevations in the region, and this small shift in flower timing did not increase risk of frost damage. Potential reasons for limited earlier phenological advancement at higher elevations include a slower warming trend and increased cloud exposure with elevation and/or inadequate chilling requirements.

Repeat colonoscopy's value in gastrointestinal bleeding.

AIM: To assess the diagnostic yield and clinical value of early repeat colonoscopies for indications other than colorectal cancer (CRC) screening/surveillance. METHODS: A retrospective review of patients who had more than one colonoscopy performed for the same indication within a three year time frame at our tertiary care referral hospital between January 1, 2000 and January 1, 2010 was conducted. Exclusion criteria included repeat colonoscopies performed for CRC screening/surveillance, poor bowel preparation, suspected complications from the index procedure, and incomplete initial procedure. Primary outcome was new endoscopic finding that led to an endoscopic therapeutic intervention or any change in clinical management. Clinical parameters including age, sex, race, interval between procedures, indication of the procedure, presenting symptoms, severity of symptoms, hemodynamic instability, duration between onset of symptoms and when the procedure was performed, change in endoscopist, withdrawal time, location of colonic lesions and improvement of quality of bowel preparation were analyzed using bivariate analysis and logistic regression analysis to examine correlation with this primary outcome. RESULTS: Among 19  772 colonoscopies performed during the above mentioned period, 947 colonoscopies (4.79%) were repeat colonoscopies performed within 3 years from the index procedure. Out of these repeat colonoscopies, 139 patient pairs met the inclusion criteria. The majority of repeat colonoscopies were for lower gastrointestinal bleeding (88.4%), change in bowel habits (6.4%) and abdominal pain (5%). Among 139 eligible patient pairs of colonoscopies, only repeat colonoscopies that were done for lower gastrointestinal bleeding and abdominal pain produced endoscopic findings that led to a change in management [25 out of 123 (20.33%) and 2 out of 7 (28.57%), respectively]. When looking at only recurrent lower gastrointestinal bleeding cases, new endoscopic findings included 8 previously undetected hemorrhoid lesions (6.5%), 7 actively bleeding lesions requiring endoscopic intervention, which included 3 bleeding arterio-venous malformations (2.43%), 2 bleeding radiation colitis (1.6%), and 2 bleeding internal hemorrhoids (1.6%), 5 previously undetected tubular adenomas [4 were smaller than 1 cm (4.9%) and 1 was larger than 1 cm (0.8%)], 3 radiation colitis (2.43%), 1 rectal ulcer (0.8%), and 1 previously undetected right sided colon cancer (0.8%). Of the 25 new endoscopic findings, 18 (72%) were found when repeat colonoscopy was done within the first year after the index procedure. These findings were 1 rectal ulcer, 3 radiation colitis, 4 new hemorrhoid lesions, 3 previously undetected tubular adenomas, and 7 actively bleeding lesions requiring endoscopic intervention. Of all parameters analyzed, only the interval between procedures less than one year was associated with higher likelihood of finding a clinically significant change in repeat colonoscopy (odds ratios of interval between procedures of 1-2 year and 2-3 year compared to 0-1 year were 0.09; 95%CI 0.01-0.74, P = 0.025 and 0.26; 95%CI 0.09-0.72, P = 0.010 respectively). No complications were observed among all 139 colonoscopy pairs. CONCLUSION: There is clinical value of repeating a colonoscopy for recurrent lower gastrointestinal bleeding, especially within the first year after the index procedure.

2D motility tracking of Pseudomonas putida KT2440 in growth phases using video microscopy.

Pseudomonas putida KT2440 is a gram negative motile soil bacterium important in bioremediation and biotechnology. Thus, it is important to understand its motility characteristics as individuals and in populations. Population characteristics were determined using a modified Gompertz model. Video microscopy and imaging software were utilized to analyze two dimensional (2D) bacteria movement tracks to quantify individual bacteria behavior. It was determined that inoculum density increased the lag time as seeding densities decreased, and that the maximum specific growth rate decreased as seeding densities increased. Average bacterial velocity remained relatively similar throughout the exponential growth phase (~20.9 µm/s), while maximum velocities peak early in the exponential growth phase at a velocity of 51.2 µm/s. P. putida KT2440 also favors smaller turn angles indicating that they often continue in the same direction after a change in flagella rotation throughout the exponential growth phase.

Acute liver failure as a rare initial manifestation of peripheral T-cell lymphoma.

Acute liver failure (ALF) is an uncommon disease in the United States, affecting more than 2 000 people each year. Of all the various causes, malignant infiltration is one of the least well known and carries with it a high mortality. We describe a case of ALF as the presenting manifestation of peripheral T-cell lymphoma in an elderly woman. By reporting this case, we hope to increase early recognition of this disease process in order to potentially improve treatment outcomes.

Solid phase synthesis of a metronidazole oligonucleotide conjugate.

Direct, solid phase synthesis of an oligonucleotide conjugate of the antibiotic drug metronidazole was accomplished by the phosphoramidite method. Removal of protecting groups and cleavage from the controlled pore glass (CPG) solid support was successful using mild conditions (20% Et(3)N in pyridine, then conc. NH(3) (aq) at rt for 30 min) whereas standard conditions (conc. NH(3) (aq) at 55 degrees C for 16 h) cleaved the drug.