A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery.

BACKGROUND: Current data addressing the role of robotic surgery for the management of colorectal disease are primarily from single-institution and case-matched comparative studies as well as administrative database analyses. The purpose of this study was to compare minimally invasive surgery outcomes using a large regional protocol-driven database devoted to surgical quality, improvement in patient outcomes, and cost-effectiveness. METHODS: This is a retrospective cohort study from the prospectively collected Michigan Surgical Quality Collaborative registry designed to compare outcomes of patients who underwent elective laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations between July 1, 2012 and October 7, 2014. We adjusted for differences in baseline covariates between cases with different surgical approaches using propensity score quintiles modeled on patient demographics, general health factors, diagnosis, and preoperative co-morbidities. The primary outcomes were conversion rates and hospital length of stay. Secondary outcomes included operative time, and postoperative morbidity and mortality. RESULTS: A total of 2735 minimally invasive colorectal operations met inclusion criteria. Conversion rates were lower with robotic as compared to laparoscopic operations, and this was statistically significant for rectal resections (colon 9.0 vs. 16.9%, p < 0.06; rectum 7.8 vs. 21.2%, p < 0.001). The adjusted length of stay for robotic colon operations (4.00 days, 95% CI 3.63-4.40) was significantly shorter compared to laparoscopic (4.41 days, 95% CI 4.17-4.66; p = 0.04) and hand-assisted laparoscopic cases (4.44 days, 95% CI 4.13-4.78; p = 0.008). There were no significant differences in overall postoperative complications among groups. CONCLUSIONS: When compared to conventional laparoscopy, the robotic platform is associated with significantly fewer conversions to open for rectal operations, and significantly shorter length of hospital stay for colon operations, without increasing overall postoperative morbidity. These findings and the recent upgrades in minimally invasive technology warrant continued evaluation of the role of the robotic platform in colorectal surgery.

Newly implemented enhanced recovery pathway positively impacts hospital length of stay.

BACKGROUND: Enhanced recovery pathways (ERPs) are thought to improve surgical outcomes by standardizing perioperative patient care established in evidence-based literature. The objective of this study was to determine the impact of a colorectal surgery ERP on hospital length of stay (LOS) and other patient outcomes. METHODS: This is a comparative effectiveness study of patients undergoing elective colorectal surgery 2 years prior (pre-ERP group) and 2 years after (ERP group) implementation of an ERP program. The primary outcome was hospital LOS. Secondary outcomes included postoperative complications, 30-day readmissions, and 30-day reoperations. Multivariable regression analyses were utilized to control for patient factors, general health factors, diagnosis, surgeon, colon versus rectal operations, and open versus minimally invasive operations-laparoscopic and robotic. An ERP checklist was developed to track adherence to components of the pathway. RESULTS: The study population included 1036 patients: 523 in the pre-ERP group and 513 in the ERP group. Unadjusted LOS was significantly shorter in the ERP group than the control pre-ERP group [3 (IQR 3.5) vs 5 days (IQR 4.6); p < 0.0001]. Multivariable regression analysis confirmed the reduction in LOS, controlling for age, colon/rectum procedure, open/laparoscopic/robotic approach, primary diagnosis, and alvimopan use. Postoperative outcomes were not significantly different between groups except for 30-day readmissions, which were unexpectedly higher in the ERP group (14.6 vs 8.7 %, p = 0.04). CONCLUSIONS: A newly implemented ERP on a dedicated colorectal surgery service in an academic non-university hospital setting resulted in shorter hospital LOS, but increased readmissions, for patients undergoing elective open and minimally invasive colon and rectal surgery. Future multi-institutional studies are needed to understand the impact of ERP on postoperative complications and readmissions.

Chlorhexidine with isopropyl alcohol versus iodine povacrylex with isopropyl alcohol and alcohol- versus nonalcohol-based skin preparations: the incidence of and readmissions for surgical site infections after colorectal operations.

BACKGROUND: Surgical site infections are a major cause of morbidity and mortality after colorectal operations. Preparation of the surgical site with antiseptic solutions is an essential part of wound infection prevention. To date, there is no universal consensus regarding which preparation is most efficacious. OBJECTIVE: This study compared 2.0% chlorhexidine with 70.0% isopropyl alcohol versus 0.7% iodine povacrylex with 74.0% isopropyl alcohol and alcohol-based versus nonalcohol-based skin preparations with regard to efficacy in preventing postoperative wound infections. DESIGN: This is a retrospective study from 2 prospectively collected statewide databases combined. A propensity score model was used to adjust for differences between the groups in patient demographics, characteristics, comorbidities, and laboratory values. SETTINGS: The multicenter data set used in this analysis represents a variety of academic and community hospitals within the state of Michigan from January 2010 through June 2012. PATIENTS: Patients over the age of 18 years who underwent clean-contaminated colorectal operations were included. MAIN OUTCOME MEASURES: The incidence of superficial surgical site infections, any surgical site infection, any wound complication, and readmission within 30 days for surgical site infection were measured. RESULTS: When 2.0% chlorhexidine with 70.0% isopropyl alcohol (n = 425) and 0.7% iodine povacrylex with 74.0% isopropyl alcohol (n = 115) were compared, a total of 540 colorectal cases met inclusion criteria. When alcohol-based (n = 610) and nonalcohol-based (n = 177) skin preparations were compared, a total of 787 colorectal cases met inclusion criteria. There was no significant difference in the propensity-adjusted odds for having any of the 4 outcomes of interest when comparing 2.0% chlorhexidine with 70.0% isopropyl alcohol to 0.7% iodine povacrylex with 74.0% isopropyl alcohol and when comparing alcohol-based with nonalcohol-based skin preparations. LIMITATIONS: This was a nonrandomized study performed retrospectively based on data collected within the state of Michigan. CONCLUSIONS: The use of 2.0% chlorhexidine with 70.0% isopropyl alcohol versus 0.7% iodine povacrylex with 74.0% isopropyl alcohol or alcohol-based versus nonalcohol-based skin preparations does not significantly influence the incidence of surgical site infections or readmission within 30 days for surgical site infection after clean-contaminated colorectal operations.

Nonsteroidal Anti-inflammatory Drugs: Do They Increase the Risk of Anastomotic Leaks Following Colorectal Operations?

BACKGROUND: Nonsteroidal anti-inflammatory drugs have become an important component of narcotic-sparing postoperative pain management protocols. However, conflicting evidence exists regarding the adverse association of nonsteroidal anti-inflammatory drug use with intestinal anastomotic healing in colorectal surgery. OBJECTIVE: This study compares patients receiving nonsteroidal anti-inflammatory drugs on postoperative day 1 with patients who did not receive nonsteroidal anti-inflammatory drugs with regard to the occurrence of anastomotic leaks. DESIGN: This is a retrospective study from a protocol-driven prospectively collected statewide database. A propensity score model was used to adjust for differences between the groups in patient demographics, characteristics, comorbidities, and laboratory values. SETTINGS: The multicenter data set used in this analysis represents a variety of academic and community hospitals within the state of Michigan from July 2012 through February 2014. PATIENTS: Nonpregnant patients over the age of 18 who underwent colon and rectal surgery with bowel anastomosis were selected. MAIN OUTCOME MEASURES: Occurrence of anastomotic leak, composite surgical site infection, sepsis, and death within 30 days of surgery were the primary outcomes measured. RESULTS: A total of 4360 patients met inclusion criteria, of which 1297 (29.7%) received nonsteroidal anti-inflammatory drugs and 3063 (70.3%) did not receive nonsteroidal anti-inflammatory drugs. There was no statistically significant difference between the 2 groups in the proportion of cases with anastomotic leak (OR, 1.33; CI, 0.86-2.05; p = 0.20), composite surgical site infection (OR, 1.26; CI, 0.96-1.66; p = 0.09), or death within 30 days (OR, 0.58; CI, 0.28-1.19; p = 0.14). There was a significantly greater risk of sepsis for patients given nonsteroidal anti-inflammatory drugs than for those patients not given nonsteroidal anti-inflammatory drugs (OR, 1.47; CI, 1.05-2.06; p = 0.03). LIMITATIONS: This is a nonrandomized study performed retrospectively, and it is based on data collected only within a subset of hospitals in the state of Michigan. CONCLUSIONS: No statistically significant increase in the proportion of patients with anastomotic leak was observed when prescribing nonsteroidal anti-inflammatory drugs for analgesia in the early postoperative period for patients undergoing elective colorectal surgery. Unexpectedly, there was an increased risk of sepsis that warrants further investigation (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A192, for a synopsis of this study).

Postoperative hyperglycemia and adverse outcomes in patients undergoing colorectal surgery: results from the Michigan surgical quality collaborative database.

PURPOSE: Our objective was to assess the relationship between high blood glucose levels (BG) in the early postoperative period and the incidence of surgical site infections (SSIs), sepsis, and death following colorectal operations. METHODS: The Michigan Surgical Quality Collaborative database was queried for colorectal operations from July 2012 to December 2013. Normoglycemic (BG < 180 mg/dL) and hyperglycemic (BG ≥ 180 mg/dL) groups were defined by using the highest BG within the first 72 h postoperatively. Outcomes of interest included the incidence of superficial, deep, and organ/space SSIs, sepsis, and death within 30 days. Initial unadjusted analysis was followed by propensity score matching and multiple logistic regression modeling after adjusting for significant predictors. Separate analyses were performed for previously diagnosed diabetic and non-diabetic patients. RESULTS: A total of 5145 cases met inclusion criteria, of which 1072 were diabetic. For diabetic patients, there was a marginally significant association between high BG and superficial SSI in the unadjusted analysis (OR = 1.75, p = 0.056), but not in the adjusted analysis (OR = 1.35, p = 0.39). There was no significant relationship between elevated BG and deep SSI, organ/space SSI, sepsis, or death among diabetic patients. For non-diabetic patients, there was a significant association between high BG and superficial SSI (OR = 1.53, p = 0.03), sepsis (OR = 1.61, p < 0.01), and death (OR = 2.26, p < 0.01), but not deep or organ/space SSI. CONCLUSIONS: Following colorectal operations, superficial SSI, sepsis, and death are associated with postoperative serum hyperglycemia in patients without diabetes, but not those with diabetes. Vigilant postoperative BG monitoring is critical for all patients undergoing colorectal surgery.

Bacterial Communities and Midgut Microbiota Associated with Mosquito Populations from Waste Tires in East-Central Illinois.

Mosquito-microbe interactions tend to influence larval nutrition, immunity, and development, as well as fitness and vectorial capacity of adults. Understanding the role of different bacterial species not only improves our knowledge of the physiological and ecological consequences of these interactions, but also provides the basis for developing novel strategies for controlling mosquito-borne diseases. We used culture-dependent and culture-independent techniques to characterize the bacterial composition and abundance in water and midgut samples of larval and adult females of Aedes japonicus (Theobald), Aedes triseriatus (Say), and Culex restuans (Theobald) collected from waste tires at two wooded study sites in Urbana, IL. The phylum-specific real-time quantitative polymerase chain reaction assay revealed a higher proportion of Actinobacteria and a lower proportion of gamma-Proteobacteria and Bacteroidetes in water samples and larval midguts compared to adult female midguts. Only 15 of the 57 bacterial species isolated in this study occurred in both study sites. The number of bacterial species was highest in water samples (28 species from Trelease Woods; 25 species from South Farms), intermediate in larval midguts (13 species from Ae. japonicus; 12 species from Ae. triseriatus; 8 species from Cx. restuans), and lowest in adult female midguts (2 species from Ae. japonicus; 3 species from Ae. triseriatus). These findings suggest that the composition and richness of bacterial communities varies both between habitats and among mosquito species and that the reduction in bacteria diversity during metamorphosis is more evident among bacteria detected using the culture-dependent method.

Abdominal ultrasound versus hepato-imino diacetic acid scan in diagnosing acute cholecystitis--what is the real benefit?

BACKGROUND: Acute cholecystitis is one of the most common surgical problems, yet substantial debate remains over the utility of simple examination, abdominal ultrasound (AUS), or advanced imaging such as hepato-imino diacetic acid (HIDA) scan to support the diagnosis. MATERIALS AND METHODS: The preoperative diagnostic workup of patients who underwent cholecystectomy with histologically confirmed acute cholecystitis was reviewed to calculate the sensitivity of AUS, HIDA scan, or both. In addition, the sensitivity of the commonly described ultrasonographic findings was assessed. RESULTS: From 2010 through 2012, 406 patients among 9087 reviewed charts presented to the emergency department with acute upper abdominal pain and met inclusion criteria. 32.5% (N = 132) of patients underwent AUS only, 11.3% (N = 46) underwent HIDA scan only, and 56.2% (N = 228) had both studies performed for workup. 52.7% (N = 214) of patients had histopathologically confirmed acute cholecystitis. The sensitivities of AUS, HIDA, and AUS combined with HIDA for acute cholecystitis were 73.3% (95% confidence interval [CI] = 66.3%-79.5%), 91.7% (95% CI = 86.2%-95.5%), and 97.7% (95% CI = 93.4%-99.5%), respectively. Although of limited sensitivity, AUS findings of sonographic Murphy sign, gallbladder distension, and gallbladder wall thickening were associated with a diagnosis of acute cholecystitis. CONCLUSIONS: The sensitivity of AUS for diagnosing acute cholecystitis in patients with acute upper abdominal pain is limited. The addition of a HIDA scan in the diagnostic workup significantly improves sensitivity and can add valuable information in the appropriate clinical setting.

The importance of oxidases in the tolerance of deciduous leaf infusions by Aedes (Stegomyia) aegypti and Aedes (Stegomyia) albopictus (Diptera: Culicidae).

Aedes (Stegomyia) aegypti (L.) and Aedes (Stegomyia) albopictus (Skuse) larvae rely on oxidases to reduce toxicity of water soluble toxins from some senescent tree leaf infusions. The mortality of third instar Ae. aegypti larvae in live oak and pin oak leaf infusions increased significantly in the presence of piperonyl butoxide (PBO), a broad inhibitor of cytochrome P450s (CYPs). In contrast, PBO treatment did not increase mortality in water controls or infusions of northern red oak or sugar maple leaf infusions for Ae. aegypti larvae. A similar pattern was observed for Ae. albopictus larvae, that is, an increase in mortality when CYPs were inhibited in live oak leaf infusions and no increase in sugar maple leaf infusions or water controls. However, the fresh live oak leaf infusion (5 d old) was the most toxic infusion to Ae. aegypti, but appeared less toxic to Ae. albopictus than the older infusions. A direct comparison of survival between the two Aedes species revealed Ae. aegypti exhibited a greater mortality than Ae. albopictus in PBO-treated live oak leaf infusions. These findings suggest that toxic components of some leaf litter in larval habitats may impose cryptic energy costs (detoxification).

Classic Whipple versus pylorus-preserving pancreaticoduodenectomy in the ACS NSQIP.

BACKGROUND: The classic Whipple operation carries substantial risk of complications. A pylorus-preserving pancreaticoduodenectomy might confer the benefit of decreased perioperative morbidity, but existing data comparing both techniques are inconclusive. METHODS: Using a propensity score model to adjust for potentially confounding differences in patient characteristics, 30-d mortality, operative time, red blood cell transfusion requirements, major complications, and length of hospital stay were compared between both techniques in the American College of Surgeons' National Surgical Quality Improvement Program database. Separate analyses were carried out for underlying malignancy or benign disease, as defined by International Classification of Diseases, Ninth Revision codes. RESULTS: A total of 6988 pancreaticoduodenectomies from 2005 through 2010 were included. In 5424 patients (77.6%) with underlying malignancy, there were no significant differences for 30-d mortality (2.4% versus 2.8%, P = 0.33) and major organ system complications (all P > 0.10). Patients undergoing the classic Whipple operation had a significantly longer operative time (389 versus 366 min, P < 0.01), longer length of hospital stay (13.1 versus 12.0 days, P < 0.01), and higher red blood cell transfusion requirements (1.0 versus 0.8 units, P < 0.01). Results were similar for 1564 patients (22.4%) with underlying benign disease, except for a higher occurrence of postoperative pulmonary (P = 0.02) and renal (P = 0.05) complications in patients undergoing the classic Whipple operation. CONCLUSIONS: Short-term outcomes after classic and pylorus-preserving pancreaticoduodenectomy in this large, multicenter database are excellent, without significant differences in postoperative mortality and most major organ system complications. However, small advantages in resource and blood utilization may be accomplished with the pylorus-preserving technique.

Pesticide-induced release from competition among competing Aedes aegypti and Aedes albopictus (Diptera: Culicidae).

Competitive interactions between mosquitoes Aedes aegypti (L.) and Aedes albopictus (Skuse) may depend on environmental conditions. Pesticides may alleviate density-dependent competition for limited food, and a differential species response to sublethal concentrations may modify interspecific competition. We tested the hypothesis that exposure to malathion alters interspecific resource competition between these two species. In the absence of malathion, Ae. aegypti survivorship and per capita rate of population change were negatively affected by increasing densities of Ae. albopictus. However, the asymmetrical negative effect ofAe. albopictus on Ae. aegypti was eliminated in the presence of malathion. In addition, the presence of malathion resulted in shorter development time compared with the controls. The relative importance of pesticide-mediated coexistence in nature has not been evaluated, so its role in mediating coexistence is unclear; however, these findings underscore the potential of environmental concentrations of malathion, and perhaps other pesticides to facilitate coexistence between species.

Postoperative surgical site infections after ventral/incisional hernia repair: a comparison of open and laparoscopic outcomes.

BACKGROUND: The purpose of this study was to compare the incidence of postoperative surgical site infections (SSIs), operative times (OTs), and length of hospital stay (LOS) after open and laparoscopic ventral/incisional hernia repair (VIHR) using multicenter, prospectively collected data. METHODS: The incidence of postoperative SSIs, OTs, and LOS was determined for cases of VIHR in the American College of Surgeons' National Surgical Quality Improvement Program database in 2009 and 2010. Open and laparoscopic techniques were compared using a propensity score model to adjust for differences in patient demographics, characteristics, comorbidities, and laboratory values. RESULTS: A total of 26,766 cases met the inclusion criteria; 21,463 cases were open procedures (reducible, n = 15,520 [72 %]; incarcerated/strangulated, n = 5,943 [28 %]), and 5,303 cases were laparoscopic procedures (reducible, n = 3,883 [73 %]; incarcerated/strangulated, n = 1,420 [27 %]). Propensity score adjusted odds ratios (ORs) were significantly different between open and laparoscopic VIHR for reducible and incarcerated/strangulated hernias with regard to superficial SSI (OR 5.5, p < 0.01 and OR 3.1, p < 0.01, respectively), deep SSI (OR 6.9, p < 0.01, and OR 8.0, p < 0.01, respectively) and wound disruption (OR 4.6, p < 0.01 and OR 9.3, p = 0.03, respectively). The risk for organ/space SSI was significantly greater for open operations among reducible hernias (OR 1.9, p = 0.02), but there was no significant difference between the open and laparoscopic repair groups for incarcerated/strangulated hernias (OR 0.8, p = 0.41). The OT was significantly longer for laparoscopic procedures, both for reducible (98.5 vs. 84.9 min, p < 0.01) and incarcerated/strangulated hernias (96.4 vs. 81.2 min, p < 0.01). LOS (mean, 95 % confidence interval) was significantly longer for open repairs for both reducible (open = 2.79, 2.59-3.00; laparoscopic = 2.39, 2.20-2.60; p < 0.01) and incarcerated/strangulated (open = 2.64, 2.55-2.73; laparoscopic = 2.17, 2.02-2.33; p < 0.01) hernias. CONCLUSIONS: Laparoscopic VIHR for reducible and incarcerated/strangulated hernias is associated with shorter LOS and decreased risk for superficial SSI, deep SSI, and wound disruption, but longer OTs when compared to open repair.

West Nile virus infection rates and avian serology in east-central Illinois.

Understanding the geographic role of different species of mosquito vectors and vertebrate hosts in West Nile virus (WNV) transmission cycles can facilitate the development and implementation of targeted surveillance and control measures. This study examined the relationship between WNV-antibody rates in birds and mosquito infection rates and bloodfeeding patterns in east-central Illinois. The earliest detection of WNV-RNA by reverse transcription-polymerase chain reaction TaqMan was from Culex restuans; however, amplification typically coincided with an increase in abundance of Cx. pipiens. Trap type influenced annual estimates of infection rates in Culex species, as well as estimation of blood meal source. Bird species with the highest WNV-antibody rates (i.e., Mourning Doves [Zenaida macroura], Northern Cardinals [Cardinalis cardinalis], American Robins [Turdus migratorius], and House Sparrows [Passer domesticus]) were also the common species found in Culex blood meals. Although antibody rates were not directly proportional to estimated avian abundance, the apparent availability of mammal species did influence proportion of mammal to bird blood meals. Antibody prevalence in the American Robin was lower than expected based on the strong attraction of Culex to American Robins for blood meals. Age-related differences in serology were evident, antibody rates increased in older groups of robins and sparrows, whereas 1st-year hatch and older adults of Mourning Doves and Northern Cardinals had equally high rates of antibody-positive serum samples. The vector and host interactions observed in east-central Illinois (Champaign County), an urban area surrounded by agriculture, are compared to studies in the densely population areas of southern Cook County.

Outcomes of carotid endarterectomy under general and regional anesthesia from the American College of Surgeons' National Surgical Quality Improvement Program.

OBJECTIVE: Despite multiple studies over more than 3 decades, there still is no consensus about the influence of anesthesia type on postoperative outcomes following carotid endarterectomy (CEA). The objective of this study was to investigate whether anesthesia type, either general anesthesia (GA) or regional anesthesia (RA), independently contributes to the risk of postoperative cardiovascular complications or death using the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) database. METHODS: Retrospective analysis of elective cases of CEA from 2005 through 2009 was performed. A propensity score model using 45 covariates, including demographic factors, comorbidities, stroke history, measures of general health, and laboratory values, was used to adjust for bias and to determine the independent influence of anesthesia type on postoperative stroke, myocardial infarction (MI), and death. RESULTS: Of 26,070 cases listed in the ACS NSQIP database, GA and RA were used in 22,054 (84.6%) and 4016 (15.4%) cases, respectively. Postoperative stroke, MI, and death occurred in 360 (1.63%), 133 (0.6%), and 154 (0.70%) patients of the GA group, respectively, and in 58 (1.44%), 11 (0.27%), and 27 (0.67%) patients of the RA group, respectively. Stratification by propensity score quintile and adjustment for covariates demonstrated GA to be a significant risk factor for postoperative MI with an adjusted odds ratio (OR) and confidence interval (CI) of 2.18 (95% CI, 1.17-4.04), P = .01 in the entire study population. The OR for MI was 5.41 (95% CI, 1.32-22.16; P = .019) in the subgroup of patients with preoperative neurologic symptoms, and 1.44 (95% CI, 0.71-2.90; P = .31) in the subgroup of patients without preoperative neurologic symptoms. CONCLUSIONS: This analysis of a large, prospectively collected and validated multicenter database indicates that GA for CEA is an independent risk factor for postoperative MI, particularly in patients with preoperative neurologic symptoms.

Risk factors for anastomotic leakage after colectomy.

BACKGROUND: Anastomotic leakage is a morbid and potentially fatal complication of colorectal surgery. Determination of pre- and intraoperative risk factors may identify patients requiring increased postoperative surveillance for this major complication. OBJECTIVE: The purpose of this study was to identify risk factors associated with anastomotic leakage after colectomy with primary intra-abdominal anastomosis. DESIGN: The prospective, statewide multicenter Michigan Surgical Quality Collaborative database was analyzed. SETTING: This study was performed at academic and community medical centers in the state of Michigan. PATIENTS: Included were all cases of open and laparoscopic colectomy with primary intra-abdominal anastomosis from 2007 through 2010. MAIN OUTCOME MEASURES: Univariate analysis followed by a multivariate logistic regression model was used to determine the influence of patient factors and operative events with respect to the incidence of postoperative anastomotic leakage. RESULTS: Inclusion criteria were met by 4340 cases. Anastomotic leakage occurred in 85 (3.2%) of the 2626 (60.5%) open colectomies, and in 51 (3.0%) of the 1714 (39.5%) laparoscopic procedures, which was not significantly different (p = 0.63). Significant risk factors associated with anastomotic leakage based on the multivariate logistic regression model were fecal contamination with OR 2.51, 95% CI, 1.16 to 5.45, p = 0.02; and intraoperative blood loss of more than 100 mL and 300 mL, with OR 1.62, 95% CI, 1.10 to 2.40, p = 0.02; and OR 2.22, 95% CI, 1.32 to 3.76, p = 0.003. LIMITATIONS: The Michigan Surgical Quality Collaborative colectomy project excluded high-risk rectal resections and low pelvic anastomoses. Information about operative technique and intraoperative events is limited, and anastomotic leakage was determined through chart review. CONCLUSION: Fecal contamination and increased blood loss during colectomy should raise suspicion for potential postoperative anastomotic leakage.

Effect of temperature and insecticide stress on life-history traits of Culex restuans and Aedes albopictus (Diptera: Culicidae).

The chronic effects of exposure of Culex restuans (Theobald) and Aedes albopictus (Skuse) (Diptera: Culicidae) to low concentrations of malathion were examined by exposing larvae of the two species to four malathion doses at 20, 25, and 30 degrees C and maintaining the resulting adults at 25 degrees C. For both species, a significant temperature by malathion interaction on survival was found. Greater temperatures at the highest malathion dosage had significantly lower survivorship than in other treatments, but this effect was not observed at 20 degrees C. These results suggest that low temperature may buffer against some of the negative effects of malathion. For both species, temperature but not malathion had significant effects on female developmental time to adulthood and adult longevity. Temperature also affected adult female size for Ae. albopictus but not Cx. restuans. Ae. albopictus females developed faster as temperature increased, lived longer when larvae were maintained at 30 degrees C than at 20 degrees C, and were larger when larvae were maintained at 25 degrees C than at 20 or 30 degrees C. Cx. restuans females developed faster at 25 and 30 degrees C than at 20 degrees C and lived longer at 25 degrees C than at 20 or 30 degrees C. The estimated finite rate of increase (lambda') for Cx. restuans was significantly lower at 20 degrees C than at 25 and 30 degrees C, whereas that of Ae. albopictus was significantly influenced by an interaction between temperature and malathion with significantly lower lambda' at 20 degrees C than at 25 and 30 degrees C for all malathion treatments except 0.014 mg liter(-1). Understanding how pesticides interact with abiotic environmental conditions will contribute to management decisions about vector control practices.

Does intrathecal morphine sulfate provide preemptive analgesia for patients undergoing stapled hemorrhoidopexy?

OBJECTIVE: Surgical excision of hemorrhoids is characterized by a prolonged and painful postoperative course. This double-blind, randomized, prospective, controlled trial was conducted to determine if morphine sulfate provides additional pain relief after stapled hemorrhoidopexy when added to a standard lidocaine spinal anesthetic. It was hypothesized that the addition of morphine sulfate to a spinal anesthetic would decrease postoperative pain. INTERVENTIONS: Thirty-four patients were randomized prospectively to receive a spinal block with either lidocaine or lidocaine plus morphine sulfate. Patients were followed postoperatively for 42 days to record Numeric Pain Scale (NPS) values and to record analgesic use. Patients also filled out a Short Form 36 (SF-36) Health Survey Questionnaire preoperatively and at days 3, 14, and 28 after their operation to assess physical and mental well-being. Longitudinal mixed models were used to determine whether there was a difference in maximum pain, average pain, narcotic analgesic use, and physical or mental well-being over time. RESULTS: No group differences were found in maximum or average NPS, analgesic use, mental well-being, or time to complete pain relief. There was a four-point difference in mean scores for physical well-being, favoring the lidocaine plus morphine group. CONCLUSIONS: This study provides evidence that intrathecal morphine sulfate does not significantly alter postoperative pain, narcotic use, or well-being when used as preemptive analgesia for patients undergoing stapled hemorrhoidopexy.

Fundamental issues in mosquito surveillance for arboviral transmission.

Marked spatiotemporal variabilities in mosquito infection of arboviruses, exemplified by the transmission of West Nile virus (WNV) in America, require adaptive strategies for mosquito sampling, pool screening and data analyses. Currently there is a lack of reliable and consistent measures of risk exposure, which may compromise comparison of surveillance data. Based on quantitative reasoning, we critically examined fundamental issues regarding mosquito sampling design and estimation of transmission intensity. Two surveillance strategies were proposed, each with a distinct focus, i.e. targeted surveillance for detection of low rates of mosquito infection and extensive surveillance for evaluation of risk exposure with high levels of mosquito infection. We strongly recommend the use of indicators embodying both mosquito abundance and infection rates as measures of risk exposure. Aggregation of surveillance data over long periods of time and across broad areas obscures patterns of focal arboviral transmission. We believe that these quantitative issues, once addressed by mosquito surveillance programs, can improve the epidemiological intelligence of arbovirus transmission.

Identification of male specimens of the Culex pipiens complex (Diptera: Culicidae) in the hybrid zone using morphology and molecular techniques.

The identification of the members of the Culex pipiens L. complex in arbovirus surveillance programs relies heavily on the use of morphology. In this work, we studied Cx. pipiens complex male mosquitoes collected from nine different locations, from northern, southern, and the hybrid zone sites in North America; Cairo, Egypt; and Nairobi, Kenya. Specimens were identified using DV/D ratio and also using amplification of the acetylcholinesterase (ACE.2) gene by both conventional and real-time polymerase chain reaction, and examination of the CQ11 locus. Consistent with previous findings, the morphological and molecular identifications did not always agree, particularly in regions of extensive introgression. There was an increased frequency of hybrid forms in late summer and early fall in Champaign Co., IL, that is north of the previously described Cx. pipiens complex hybrid zone. This represents an expansion of the North American hybrid zone. The biological and epidemiological relevance of the high degree of introgression and the late season increase in the proportion of intermediate forms is discussed.

Pain control with continuous infusion preperitoneal wound catheters versus continuous epidural analgesia in colon and rectal surgery: A randomized controlled trial.

OBJECTIVE: To compare continuous infusion preperitoneal wound catheters (CPA) versus continuous epidural analgesia (CEA) after elective colorectal surgery. METHODS: An open-label equivalence trial randomizing patients to CPA or CEA. Primary outcomes were postoperative pain as determined by numeric pain scores and supplemental narcotic analgesia requirements. Secondary outcomes included incidence of complications and patient health status measured with the SF-36 Health Survey (Acute Form). RESULTS: 98 patients were randomized [CPA (N = 50, 51.0%); CEA (N = 48, 49.0%)]. 90 patients were included [ CPA 46 (51.1%); CEA 44 (48.9%)]. Pain scores were significantly higher in the CPA group in the PACU (p = 0.04) and on the day of surgery (p < 0.01) as well as supplemental narcotic requirements on POD 0 (p = 0.02). No significant differences were noted in postoperative complications between groups, aggregate SF-36 scores and SF-36 subscale scores. CONCLUSIONS: Continuous epidural analgesia provided superior pain control following colorectal surgery in the PACU and on the day of surgery. The secondary endpoints of return of bowel function, length of stay, and adjusted SF-36 were not affected by choice of peri-operative pain control.

A real-time TaqMan polymerase chain reaction for the identification of Culex vectors of West Nile and Saint Louis encephalitis viruses in North America.

In North America, West Nile and St. Louis encephalitis viruses have been detected in a wide range of vector species, but the majority of isolations continue to be from pools of mixed mosquitoes in the Culex subgenus Culex. Unfortunately, the morphologic identification of these important disease vectors is often difficult, particularly in regions of sympatry. We developed a sensitive real-time TaqMan polymerase chain reaction assay that allows reliable identification of Culex mosquitoes including Culex pipiens pipiens, Cx. p. quinquefasciatus, Cx. restuans, Cx. salinarius, Cx. nigripalpus, and Cx. tarsalis. Primers and fluorogenic probes specific to each species were designed based on sequences of the acetylcholinesterase gene (Ace2). Both immature and adult mosquitoes were successfully identified as individuals and as mixed species pools. This identification technique provides the basis for a rapid, sensitive, and high-throughput method for expounding the species-specific contribution of vectors to various phases of arbovirus transmission.