Effect of Pharmacoprophylaxis on Postoperative Outcomes in Adult Elective Colorectal Surgery: A Multi-Center Retrospective Cohort Study within an Enhanced Recovery after Surgery Framework.

BACKGROUND: The application of enhanced recovery after surgery principles decreases postoperative complications (POCs), length of stay (LOS), and readmissions. Pharmacoprophylaxis decreases morbidity, but the effect of specific regimens on clinical outcomes is unclear. METHODS AND MATERIALS: Records of 476 randomly selected adult patients who underwent elective colorectal surgeries (ECRS) at 10 US hospitals were abstracted. Primary outcomes were surgical site infection (SSI), venous thromboembolism (VTE), postoperative nausea and vomiting (PONV), pain, and ileus rates. Secondary outcomes included LOS and 7- and 30-day readmission rates. RESULTS: POC rates were SSI (3.4%), VTE (1.5%), PONV (47.9%), pain (58.1%), and ileus (16.1%). Cefazolin 2 g/metronidazole 500 mg and ertapenem 1 g were associated with the shortest LOS; cefotetan 2 g and cefoxitin 2 g with the longest LOS. No SSI occurred with ertapenem and cefotetan. More Caucasians than Blacks received oral antibiotics before intravenous antibiotics without impact. Enoxaparin 40 mg subcutaneously daily was the most common inpatient and discharge VTE prophylaxis. All in-hospital VTEs occurred with unfractionated heparin. Most received rescue rather than around-the-clock antiemetics. Scopolamine patches, spinal opioids, and IV lidocaine continuous infusion were associated with lower PONV. Transversus abdominis plane block with long-acting local anesthetics, celecoxib, non-anesthetic ketamine bolus, ketorolac IV, lidocaine IV, and pregabalin were associated with lower in-hospital pain severity rates. Gabapentinoids and alvimopan were associated with lower ileus rates. Acetaminophen, alvimopan, famotidine, and lidocaine patches were associated with shorter LOS. CONCLUSIONS: Significant differences in pharmacotherapy regimens that may improve primary and secondary outcomes in ECRS were identified. In adult ECRS, cefotetan or ertapenem may be better regimens for preventing in-hospital SSI, while ertapenem or C/M may lead to shorter LOS. The value of OA to prevent SSI was not demonstrated. Inpatient enoxaparin, compared to UFH, may reduce VTE rates with a similar LOS. A minority of patients had a documented PONV risk assessment, and a majority used as-needed rather than around-the-clock strategies. Preoperative scopolamine patches continued postoperatively may lower PONV and PDNV severity and shorter LOS. Alvimopan may reduce ileus and shorten LOS. Anesthesia that includes TAP block, ketorolac IV, and pregabalin use may lead to reduced pain rates. Acetaminophen, alvimopan, famotidine, and lidocaine patches may shorten LOS. Given the challenges of pain management and the incidence of PONV/PDNV found in this study, additional studies should be conducted to determine optimal opioid-free anesthesia and the benefit of newer antiemetics on patient outcomes. Moreover, future research should identify latent pharmacotherapy variables that impact patient outcomes, correlate pertinent laboratory results, and examine the impact of order or care sets used for ECRS at study hospitals.

An Analysis of Over-the-Counter Cannabidiol Products in the United Kingdom.

Introduction: Over-the-counter cannabidiol (CBD) products have seen unprecedented recent growth in the United Kingdom. However, analysis of these predominantly unregulated products from other countries tells us that they are often mislabeled or contain unlabeled and potentially dangerous chemicals. Thus, the aim of the present study was to analyze CBD oils available in the United Kingdom. Materials and Methods: Phytocannabinoids, residual solvent, and heavy metals were measured blinded in 29 widely available CBD products by an independent testing facility using high-performance liquid chromatography with diode-array detection for cannabinoids, Headspace-gas chromatography-flame ionization detector and gas chromatography-mass spectrometry for residual solvents, and inductively coupled plasma-mass spectrometry for heavy metals. Results: The mean advertised CBD content was 4.5%, and the actual mean measured CBD content of products was 3.2% (p=0.053, Mann-Whitney test). Only 11/29 (38%) products were within 10% of the advertised CBD content. Fifty five percent of products had measurable levels of the controlled substances Δ9-tetrahydrocannabinol (mean content 0.04%) or cannabinol (mean content 0.01%), as well as most other phytocannabinoid compounds including cannabidiolic acid (CBDA), cannabidivarin (CBDV), and cannabidivarin acid (CBDVA). Detectable levels of N-pentane, ethanol, isopropanol, heptane, lead, and arsenic were found in many of the CBD products, but these were within acceptable levels. Conclusions: As demonstrated in other countries, the quality of over-the-counter CBD products in the United Kingdom can be substandard, particularly with regard to CBD content, and often contains levels of controlled substances. We recommend that these products be more strictly regulated for consumer welfare.

Morphological characterization of Badis species (Teleostei: Badidae) from Nepal.

We characterized morphological variation among 172 specimens of Badis sp. (Teleostei: Badidae), collected from across Nepal and previously identified as Badis badis, to investigate whether any represented an undescribed species. Size-corrected principal component analysis (PCA), cluster analysis (CA), and discriminant analysis (DA) revealed four significantly different groups. One group was characterized by shallower body depth and shorter pelvic to anal distance than other groups and lacked a cleithral blotch. It was identified as Badis andrewraoi, previously unknown from Nepal, yet represented in our sample by 19 specimens from small rivers in the southeastern part of the country. Distribution of the remaining groups, all identified as B. badis, did not correspond to a zoogeographic hypothesis relating to major river drainages. Instead, morphological differences among these groups was better explained by allometric shifts. We provide information on the distribution and ecology of B. andrewraoi and B. badis in Nepal.

Effects of parental PTSD on the cortisol response to dexamethasone administration in their adult offspring.

OBJECTIVE: The authors used a low-dose dexamethasone suppression test to examine the effect of a PTSD risk factor, parental PTSD, on cortisol negative feedback inhibition in adult offspring of Holocaust survivors with PTSD (N=13) versus without PTSD (N=12) as well as a comparison group of offspring whose parents had no Holocaust exposure (N=16). METHOD: Blood samples were obtained at 8:00 a.m. for the determination of baseline cortisol. Participants ingested 0.5 mg of dexamethasone at 11:00 p.m., and blood samples were obtained again at 8:00 a.m. the following day. RESULTS: Enhanced cortisol suppression in response to dexamethasone was associated primarily with parental PTSD status, with minimal contribution of subjects' own trauma-related symptoms. CONCLUSIONS: Enhanced cortisol negative feedback inhibition may be associated with PTSD because it is related to the PTSD risk factor of parental PTSD.

Modifying the Standard Disk Model for the Ultraviolet Spectral Analysis of Disk-dominated Cataclysmic Variables. I. The Novalikes MV Lyrae, BZ Camelopardalis, and V592 Cassiopeiae.

The standard disk is often inadequate to model disk-dominated cataclysmic variables (CVs) and generates a spectrum that is bluer than the observed UV spectra. X-ray observations of these systems reveal an optically thin boundary layer (BL) expected to appear as an inner hole in the disk. Consequently, we truncate the inner disk. However, instead of removing the inner disk, we impose the no-shear boundary condition at the truncation radius, thereby lowering the disk temperature and generating a spectrum that better fits the UV data. With our modified disk, we analyze the archival UV spectra of three novalikes that cannot be fitted with standard disks. For the VY Scl systems MV Lyr and BZ Cam, we fit a hot inflated white dwarf (WD) with a cold modified disk ( [Formula: see text] ~ a few 10-9M⊙ yr-1). For V592 Cas, the slightly modified disk ( [Formula: see text] ~ 6 × 10-9M⊙ yr-1) completely dominates the UV. These results are consistent with Swift X-ray observations of these systems, revealing BLs merged with ADAF-like flows and/or hot coronae, where the advection of energy is likely launching an outflow and heating the WD, thereby explaining the high WD temperature in VY Scl systems. This is further supported by the fact that the X-ray hardness ratio increases with the shallowness of the UV slope in a small CV sample we examine. Furthermore, for 105 disk-dominated systems, the International Ultraviolet Explorer spectra UV slope decreases in the same order as the ratio of the X-ray flux to optical/UV flux: from SU UMa's, to U Gem's, Z Cam's, UX UMa's, and VY Scl's.

Longitudinal assessment of dissociation in Holocaust survivors with and without PTSD and nonexposed aged Jewish adults.

The trajectory of posttraumatic stress disorder (PTSD) and PTSD-related symptoms in relation to aging is not well understood. We previously observed higher levels of dissociation as measured by the Dissociative Experiences Scale (DES) among older Holocaust survivors with, compared to those without, PTSD, though scores on the DES in Holocaust survivors were markedly lower than those that had been reported for younger cohorts. We undertook a longitudinal evaluation of dissociation in Holocaust survivors. Twenty-six Holocaust survivors with current PTSD, 30 Holocaust survivors without current PTSD, and 19 nonexposed were evaluated at the initial evaluation and subsequently 8.11 years later. Repeated measures analysis of variance (ANOVA) on the DES scores from these times demonstrated a significant main effect for time and a significant group by time interaction, reflecting a marked decline in Holocaust survivors, particularly those with PTSD. Controlling for age obliterated the effect of time, but not the group by time interaction. A similar pattern was shown with The Clinician Administered PTSD Scale (CAPS) scores. Different symptoms related to PTSD show different trajectories of change with age, with dissociation appearing to be less prominent with age.

Are adult offspring reliable informants about parental PTSD? A validation study.

We developed a short questionnaire--Parental PTSD Questionnaire--(PPQ), designed to assess the presence of posttraumatic stress disorder (PTSD) symptoms in parents. Fifty-eight adult offspring of Holocaust survivors (23 men and 35 women) completed the questionnaire about a parent who was independently evaluated by a trained clinician using the Clinician Administered PTSD Scale (CAPS). Only 5.2% of the offspring reported, "not knowing" if their parent had experienced 10 or fewer symptoms, while 56.9% provided estimates for all 17 items. There were no significant differences between lifetime frequencies of the individual symptoms as endorsed on the PPQ compared to the CAPS when subjects with completed PPQs were compared with CAPS. Interrater reliability between offspring and clinician was highly significant for each of the items when evaluated separately so as to include data for subjects who endorsed not knowing if a certain symptom had been present. Further studies are warranted to examine the psychometric properties of this measure.

Investigations of electrospray sample deposition for polymer MALDI mass spectrometry.

In the interest of a more thorough understanding of the relationship between sample deposition technique and the quality of data obtained using matrix-assisted laser desorption/ionization (MALDI) mass spectrometry, details of the electrospray (ES) process of sample deposition are investigated using a number of techniques. Sample morphology was observed with scanning electron microscopy (SEM) and atomic force microscopy (AFM), while matrix-enhanced secondary ion mass spectrometry (MESIMS) monitored surface coverage. Electrospray deposition reduces the analyte segregation that can occur during traditional dried droplet deposition for MALDI. We attribute statistically significant improvements in the reproducibility of signal intensity and MALDI average molecular mass measurements to the ES sample deposition technique.

Tri-alpha-naphthylbenzene as a crystalline or glassy matrix for matrix-assisted laser desorption/ionization: a model system for the study of effects of dispersion of polymer samples at a molecular level.

Tri-alpha-naphthylbenzene (TalphaNB) can exist as either a crystalline or glassy solid at ambient temperatures, making it a unique matrix in matrix-assisted laser desorption/ionization (MALDI) spectroscopy. Electrosprayed TalphaNB is crystalline and has a melting point of 180 +/- 2 degrees C, as measured by differential scanning calorimetry (DSC). A glass of TalphaNB is obtained upon heating above the crystalline melting point with a glass transition temperature of 68 +/- 2 degrees C having no remaining crystallinity. MALDI samples containing mass fraction 1% polystyrene (PS) are run in both the crystalline and amorphous states. In the crystalline state, there is a strong spectrum typical of PS, but upon melting and quenching to the glassy state, the MALDI signal disappears. If the transparent, amorphous sample is treated with 1-butanol, it becomes white, and the MALDI signal returns. DSC shows that the 1-butanol treatment leads to the return of some of the crystallinity. Small angle neutron scattering (SANS) shows that the crystalline state has large aggregations of PS while the amorphous state has molecularly dispersed PS molecules. MALDI gives strong signals only when there are large aggregations of polymer molecules, with individually dispersed molecules producing no signal.

The ischemic lung: Role of the bronchial arteries in lung function.

A patient with a dissecting aortic aneurysm, Type 1, developed acute pulmonary edema unexplained by the usual etiologic factors. Pathologic evidence that bronchial arterial circulation was interrupted led us to hypothesize that pulmonary edema could be due to ischemia of the bronchial circulation. To test this hypothesis, two chronic studies were done in dogs. The first study consisted of selective ligation of the right posterior bronchial artery at its origin at the fifth or sixth intercostal artery. After recovery from surgery, biopsies were taken from the ipsilateral and contralateral lung at time periods from 5 hours to 11 days. Ischemic damage was found in seven of eight dogs (87.5%), and was confined to the right lung. Histological examination revealed initial congestion within 8 hours, followed by pulmonary edema within 72 hours, and finally, disruption of alveolar septa with small emphysematous bullae on the eleventh postoperative day. The left lung remained normal in histological appearance. The second study consisted of transplanting the bronchial artery to the pulmonary artery to create a low pressure system and low O(2) content, and to simulate a regional shock situation. In five of six dogs (83.3%), the anastomosis was occluded within 72 hours, probably due to pressure competition from small collateral bronchial circulation. However, in these five dogs, pulmonary vascular resistance increased by 53%, intrapulmonary shunting increased by 83%, and the alveolar-to-arterial oxygen gradient increased by 150 mm Hg. Pulmonary edema was again confined to the right lung. Bronchial arteriograms demonstrated the extensive and variable distribution of the bronchial circulation in dogs. In the sixth dog, the anastomosis remained patent with a left-to-right shunt, due to a larger bronchial arterial collateral circulation. In this animal, the pulmonary arterial resistance, intrapulmonary shunting, and alveolar-arterial O(2) gradient were normal. Pulmonary edema was absent in lung biopsies. Bronchial circulation is discussed with respect to its clinical implications for lung transplants, shock, thoracic aneurysms, and mediastinal surgery. The results of this study suggest that the systemic bronchial circulation is important for normal lung function.