Providers' Perceptions Versus Practices Inform Pediatric Colorectal Enhanced Recovery After Surgery Implementation.

INTRODUCTION: There are many barriers to the implementation of an enhanced recovery after surgery (ERAS) pathway. The aim of this study was to compare surgeon and anesthesia perceptions with current practices prior to the initiation of an ERAS protocol in pediatric colorectal patients and to use that information to inform ERAS implementation. METHODS: This was a mixed method single institution study of barriers to implementation of an ERAS pathway at a free-standing children's hospital. Anesthesiologists and surgeons at a free-standing children's hospital were surveyed regarding current practices of ERAS components. A retrospective chart review was performed of 5- to 18-y-old patients undergoing colorectal procedures between 2013 and 2017, followed by the initiation of an ERAS pathway, and a prospective chart review for 18 mo postimplementation. RESULTS: The response rate was 100% (n = 7) for surgeons and 60% (n = 9) for anesthesiologists. Preoperative nonopioid analgesics and regional anesthesia were rarely used. Intraoperatively, 54.7% of patients had a fluid balance of <10 cc/kg/h and normothermia was achieved in only 38.7%. Mechanical bowel prep was frequently utilized (48%). Median nil per os time was significantly longer than required at 12 h. Postoperatively, 42.9% of surgeons reported that patients could have clears on postoperative day zero, 28.6% on postoperative day one, and 28.6% after flatus. In reality, 53.3% of patients were started on clears after flatus, with a median time of 2 d. Most surgeons (85.7%) expected patients to get out of bed once awake from anesthesia; however, median time that patients were out of bed was postoperative day one. While most surgeons reported frequent use of acetaminophen and/or ketorolac, only 69.3% received any nonopioid analgesic postoperatively, with only 41.3% receiving two or more nonopioid analgesics. Nonopioid analgesia showed the highest rates of improvement from retrospective to prospective: preoperative use of analgesics increased from 5.3% to 41.2% (P < 0.0001), postoperative use of acetaminophen increased by 27.4% (P = 0.5), Toradol by 45.5% (P = 0.11), and gabapentin by 86.7% (P < 0.0001). Postoperative nausea/vomiting prophylaxis with >1 class of antiemetic increased from 8% to 47.1% (P < 0.001). The length of stay was unchanged (5.7 versus 4.4 d, P = 0.14). CONCLUSIONS: For the successful implementation of an ERAS protocol, perceptions versus reality must be assessed to determine current practices and identify barriers to implementation.

Iron Quantum Dots Electro-Assembling on Vulcan XC-72R: Hydrogen Peroxide Generation for Space Applications.

Highly dispersed iron-based quantum dots (QDs) onto powdered Vulcan XC-72R substrate were successfully electrodeposited by the rotating disk slurry electrodeposition (RoDSE) technique. Our findings through chemical physics characterization revealed that the continuous electron pathway interaction between the interface metal-carbon is controlled. The rotating ring-disk electrode (RRDE) and the prototype generation unit (PGU) of in-situ H2O2 generation in fuel cell experiments revealed a high activity for the oxygen reduction reaction (ORR) via two-electron pathway. These results establish the Fe/Vulcan catalyst at a competitive level for space and terrestrial new materials carriers, specifically for the in-situ H2O2 production. Transmission electron microscopy (TEM) analysis reveals the well-dispersed Fe-based quantum dots with a particle size of 4 nm. The structural and chemical-physical characterization through induced coupled plasma-optical emission spectroscopy (ICP-OES), transmission scanning electron microscopy (STEM), X-ray diffraction (XRD), Raman spectroscopy, X-ray photoelectron spectroscopy (XPS), and X-ray absorption spectroscopy (XAS); reveals that, under atmospheric conditions, our quantum dots system is a Fe2+/3+/Fe3+ combination. The QDs oxidation state tunability was showed by the applied potential. The obtention of H2O2 under the compatibility conditions of the drinking water resources available in the International Space Station (ISS) enhances the applicability of this iron- and carbon-based materials for in-situ H2O2 production in future space scenarios. Terrestrial and space abundance of iron and carbon, combined with its low toxicity and high stability, consolidates this present work to be further extended for the large-scale production of Fe-based nanoparticles for several applications.

Geospatial mapping and resource utilization tool in support of a national smoke-free public housing rule.

OBJECTIVE: To advance public health support for the U.S. Department of Housing and Urban Development's smoke-free rule, the Centers for Disease Control and Prevention collaborated with the Georgia Institute of Technology to develop a geospatial mapping tool. The objective was to create a tool state and local public health agencies could use to tailor smoke-free educational materials and cessation interventions for specific public housing development resident populations. RESULTS: The resulting "Extinguish Tool" includes an interactive map of U.S. public housing developments (PHDs) and healthcare facilities that provides detailed information on individual PHDs, their proximity to existing healthcare facilities, and the demographic characteristics of residents. The tool also estimates the number of PHD residents who smoke cigarettes and calculates crude estimates of the potential economic benefits of providing cessation interventions to these residents. The geospatial mapping tool project serves as an example of a collaborative and innovative public health approach to protecting the health and well-being of the nation's two million public housing residents, including 760,000 children, from the harms of tobacco smoking and secondhand smoke exposure in the places where they live, play, and gather.

The effect of resident involvement on bariatric surgical outcomes: an ACS-NSQIP analysis.

BACKGROUND: Surgical residency training programs in the United States are modeled on the principle of graduated responsibility. Residents are given greater responsibility and autonomy in the operating room and during perioperative care as they gain surgical skills and progress through their training. The impact of this method of surgical training on patient outcomes remains unknown. The purpose of this study is to compare early patient morbidity and mortality after bariatric surgery in cases with and without resident participation using the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: All patients undergoing bariatric surgery from 2006 through 2010 were identified within the American College of Surgeons National Surgical Quality Improvement Program database. These patients were divided into three groups based on resident involvement in their surgery (no resident, senior-level resident, and junior-level resident). The effect of resident involvement and postgraduate year level on 30-d morbidity and mortality was investigated using composite outcomes, including cardiac events (acute myocardial infarction or cardiac arrest requiring cardiopulmonary resuscitation), pulmonary events (pneumonia, prolonged intubation, or unplanned reintubation), wound (superficial surgical site infection, deep surgical site infection, organ-space infection, or dehiscence), septic events (sepsis and septic shock), clotting events (pulmonary embolism and deep venous thrombosis), and renal events (urinary tract infection and acute kidney injury requiring dialysis). Length of hospital stay, unplanned return to the operating room, and 30-d mortality were also investigated. RESULTS: A total of 19,616 patients underwent bariatric surgery from the year 2006 through 2010; 8960 (45.7%) procedures were performed with resident involvement, with 5406 (36.7%) of these cases involving a senior-level resident. Operations involving a senior-level resident were more likely to experience postoperative cardiac events (P < 0.006), pulmonary events (P = 0.03), wound events (P = 0.01), septic events (P < 0.002), renal events (P ≤ 0.01), prolonged operative time (P < 0.0001), and a prolonged length of hospital stay (P < 0.0001) than those that involved either no resident or a junior-level resident. CONCLUSIONS: Although bariatric operations involving senior-level residents have more statistically significant morbidity outcomes, these morbidity outcomes are related more to perioperative care rather than intraoperative resident involvement. This suggests that more emphasis on perioperative progressive responsibility may be needed to match operative oversight.

The Influence of Palliative Care Consultation on Health-Care Resource Utilization During the Last 2 Months of Life: Report From an Integrated Palliative Care Program and Review of the Literature.

BACKGROUND: We reviewed 104 consecutive deaths of veterans receiving care in the Dayton VA Medical Center from October 10, 2015 to April 11, 2016. The purpose of our study was to test our hypothesis that palliative care consultation would be associated with reduced health care resource utilization for individuals approaching end of life. METHODS: Medical records were reviewed and data entry recorded on a spreadsheet. Non-parametric statistical methods were used to compare four outcome variables from veterans with palliative care consultation (PCC) vs. those without PCC. These variables included the number of ED visits, hospitalizations, hospital days, and ICU days all during the last two months of life. Predictor variables included PCC vs. no PCC and PCC before vs. PCC during the last two months of life. The study sample was comprised of 102 patients after excluding two outlier cases with ethical challenges in surrogate decision-making. RESULTS: Of the 102 consecutive veteran deaths, palliative care consultation was associated with a lower number of ICU days during the last two months of life. For 96 veterans with PCC, the frequency of ED visits and acute care hospitalizations, as well as the number of ICU and hospital days, were all significantly less after PCC compared to before PCC during the last two months of life. The timing of PCC had no effect on the outcomes of interest. CONCLUSION: Palliative care consultation has a notable effect on health care resource utilization during the last two months of life.

Impact of Appropriate Use on the Estimated Radiation Risk to Men and Women Undergoing Radionuclide Myocardial Perfusion Imaging.

UNLABELLED: The impact of appropriate use criteria (AUC) for myocardial perfusion imaging (MPI) with SPECT on the estimated lifetime attributable risk (LAR) of cancer is unknown. METHODS: A cohort of 1,511 consecutive patients who underwent clinically indicated (99m)Tc-setamibi MPI were categorized into appropriate/uncertain (n = 823) versus inappropriate (n = 688) use groups according to the 2009 AUC and were prospectively followed for 27 ± 10 mo. Logistic regression models were used to determine the annualized probability of major adverse cardiac events (MACE) of cardiac death or myocardial infarction and the probability of revascularization within 6 mo of MPI, accounting for relevant covariates. We determined LAR for each subject on the basis of accepted risk estimates. We calculated MPI's benefit-to-risk ratios, defined by the annualized predicted MACE-to-LAR ratio and the predicted 6-mo-revascularization-to-LAR ratio. RESULTS: During follow-up, there were 22 MACE and 29 6-mo revascularizations. The administered radioactivity and effective radiation doses absorbed were similar between the study groups. Patients with inappropriate MPI had significantly higher LAR (median, 0.08% vs. 0.06%, P < 0.001), lower predicted MACE-to-LAR ratio (median, 1.5 vs. 4.3, P < 0.001), and lower predicted 6-mo-revascularization-to-LAR ratio (median, 5.4 vs. 15.5, P < 0.001). Women had higher LAR (median, 0.08% vs. 0.07%, P < 0.001) and lower predicted MACE-to-LAR ratio (median, 1.9 vs. 3.3, P < 0.001) and 6-mo-revascularization-to-LAR ratio (median, 4.4 vs. 17.5, P < 0.001). However, appropriate/uncertain use negated the difference between men and women in LAR (P = 0.94) and the predicted MACE-to-LAR ratio (P = 0.97). CONCLUSION: Inappropriate MPI use is associated with excess cancer risk and lower MPI's benefit-to-risk ratio. Appropriate/uncertain use neutralizes the sex gap in LAR with MPI.

Appropriate use criteria for SPECT myocardial perfusion imaging: Are they appropriate for women?

BACKGROUND: Several studies have reported that women are more likely to receive inappropriate SPECT myocardial perfusion imaging (MPI), suggesting gender disparity in AUC determination. We investigated the impact of gender on the diagnostic and prognostic utility of AUC. METHODS AND RESULTS: We analyzed a multi-site prospective cohort of 1511 consecutive patients (43.5% women) who underwent outpatient, community-based SPECT-MPI. Subjects were stratified into gender groups and appropriateness subgroups, and followed for 27 ± 10 months for cardiac death, myocardial infarction, and coronary revascularization. Women were more likely to receive inappropriate MPI (60.7% vs 33.8%, P < .001). Irrespective of appropriateness, women were less likely to have an abnormal MPI (6.1% vs 14.9%, P < .001), even after adjusting for clinical covariates [odds ratio = 0.40 (95% confidence interval = 0.26-0.60), P < .001]. Irrespective of appropriateness, women were at lower risk for MACE (composite of cardiac death, myocardial infarction, or coronary revascularization) after adjusting for clinical and imaging covariates [hazard ratio = 0.49 (95% confidence interval = 0.28-0.86), P = .01]. There was no interaction between gender and appropriateness group as a determinant of abnormal MPI or MACE (interaction P values ≥ .26), indicating that female gender was associated with similar relative risk of an abnormal MPI and MACE irrespective of appropriateness group. Abnormal MPI was similarly predictive of increased hazard of MACE in both genders, regardless of appropriateness (interaction P values ≥ .46). CONCLUSION: In this multi-site cohort, there was no demonstrable gender-based differential impact of AUC on the diagnostic or prognostic utility of SPECT-MPI. The study validates the methods used in determining risk in the AUC algorithm and endorses the widespread application of AUC in men and women.

Impact of insurance carrier, prior authorization, and socioeconomic status on appropriate use of SPECT myocardial perfusion imaging in private community-based office practice.

BACKGROUND: The impact of health insurance carrier and socioeconomic status (SES) on the adherence to appropriate use criteria (AUC) for radionuclide myocardial perfusion imaging (MPI) is unknown. HYPOTHESIS: Health insurance carrier's prior authorization and patient's SES impact adherence to AUC for MPI in a fee-for-service setting. METHODS: We conducted a prospective cohort study of 1511 consecutive patients who underwent outpatient MPI in a multi-site, office-based, fee-for-service setting. The patients were stratified according to the 2009 AUC into appropriate/uncertain appropriateness and inappropriate use groups. Insurance status was categorized as Medicare (does not require prior authorization) vs commercial (requires prior authorization). Socioeconomic status was determined by the median household income in the ZIP code of residence. RESULTS: The proportion of patients with Medicare was 33% vs 67% with commercial insurance. The rate of inappropriate use was higher among patients with commercial insurance vs Medicare (55% vs 24%; P < 0.001); this difference was not significant after adjusting for confounders known to impact AUC determination (odds ratio: 1.06, 95% confidence interval: 0.62-1.82, P = 0.82). The mean annual household income in the residential areas of patients with inappropriate use as compared to those with appropriate/uncertain use was $72 000 ± 21 000 vs $68 000 ± 20 000, respectively (P < 0.001). After adjusting for covariates known to impact AUC determination, SES (top vs bottom quartile income area) was not independently predictive of inappropriate MPI use (odds ratio: 0.9, 95% confidence interval: 0.53-1.52, P = 0.69). CONCLUSIONS: Insurance carriers prior authorization and SES do not seem to play a significant role in determining physicians adherence to AUC for MPI.

Mitotic asynchrony induces transforming growth factor-ß1 secretion from airway epithelium.

We recently proposed that mitotic asynchrony in repairing tissue may underlie chronic inflammation and fibrosis, where immune cell infiltration is secondary to proinflammatory cross-talk among asynchronously repairing adjacent tissues. Building on our previous finding that mitotic asynchrony is associated with proinflammatory/fibrotic cytokine secretion (e.g., transforming growth factor [TGF]-ß1), here we provide evidence supporting cause-and-effect. Under normal conditions, primary airway epithelial basal cell populations undergo mitosis synchronously and do not secrete proinflammatory or profibrotic cytokines. However, when pairs of nonasthmatic cultures were mitotically synchronized at 12 hours off-set and then combined, the mixed cell populations secreted elevated levels of TGF-ß1. This shows that mitotic asynchrony is not only associated with but is also causative of TGF-ß1 secretion. The secreted cytokines and other mediators from asthmatic cells were not the cause of asynchronous regeneration; synchronously mitotic nonasthmatic epithelia exposed to conditioned media from asthmatic cells did not show changes in mitotic synchrony. We also tested if resynchronization of regenerating asthmatic airway epithelia reduces TGF-ß1 secretion and found that pulse-dosed dexamethasone, simvastatin, and aphidicolin were all effective. We therefore propose a new model for chronic inflammatory and fibrotic conditions where an underlying factor is mitotic asynchrony.

Identification of a novel common proviral integration site, flit-1, in feline leukemia virus induced thymic lymphoma.

A new proviral integration site for feline leukemia virus (FeLV), termed flit-1, was identified from feline thymic lymphoma. Among 35 FeLV-related tumors examined, 5 of 25 thymic lymphomas demonstrated proviral insertion within flit-1 locus whereas none of four alimentary and five multicentric lymphomas and one T-lymphoid leukemia examined had rearrangement in this region. Extensive sequence analysis has shown that flit-1, which is noncoding, is conserved on human chromosome 12 and mouse chromosome 15. The human and murine homologs of flit-1 are positioned approximately 30-kb upstream to activin-A receptor type II-like 1 (ACVRL1/ALK1) gene. Expression of ACVRL1 mRNA was examined in two of five lymphomas with flit-1 rearrangement and detected in both of the two whereas normal thymuses and seven lymphoid tumors without flit-1 rearrangement had no detectable expression. Therefore, flit-1 appears to represent a novel FeLV proviral common integration domain that may influence lymphomagenesis as insertional mutagenesis.

Epizootiology and management of feline leukemia virus in the Florida puma.

Feline leukemia virus (FeLV) was not detected in Florida pumas (Puma concolor coryi) in almost 20 yr of surveillance; however, the finding of two FeLV antigen-positive pumas during the 2002-2003 capture season led to an investigation of FeLV in the population. Between January 1990 and April 2007, the proportion of pumas testing FeLV antibody positive increased, with antibody-positive pumas concentrated in the northern portion of puma range. Five of 131 (4%) pumas sampled between July 2000 and April 2007 were viremic, with all cases clustered in Okaloacoochee Slough (OKS). Clinical signs and clinical pathology at capture were absent or included lymphadenopathy, moderate-to-severe anemia, and lymphopenia. All viremic pumas died; causes of death were septicemia (n=2), intraspecific aggression (n=2), and anemia/dehydration (n=1). Outcome after FeLV exposure in pumas was similar to that in domestic cats, with evidence of regressive, latent, and persistent infections. Management of the epizootic included vaccination, and as of April 2007, 52 free-ranging pumas had received one or more inoculations. Vaccinations were concentrated in OKS and in a band between OKS and the remainder of the puma population. There have been no new cases since July 2004; however, the potential for reintroduction of the virus remains.

Efficacy of a scheduled IV cocktail of antiemetics for the palliation of nausea and vomiting in a hospice population.

This is a retrospective analysis of 10 mg metoclopramide, 25 mg diphenhydramine, and 4 mg dexamethasone given intravenous piggyback every 6 hours for nausea or vomiting. Outcome measures were rapidity of symptom relief based on the self-report of the patient and nursing documentation of relief from symptoms of nausea or vomiting. Seven hundred and ninety seven patients were admitted to the inpatient hospice unit during a 2-year period. Sixty-three patients developed nausea or vomiting requiring the cocktail. Fifty-seven patients (90%) had objective response as reflected in nursing notes. Symptom relief was usually noted within 2 days with improvement in oral intake and enjoyment in activities, such as parties and family interactions. Partial relief was noted in patients with gastrointestinal malignancies and peritoneal carcinomatosis even with the addition of other antiemetics to the cocktail.

In vivo expression of GFP transgene delivered via a replicating feline leukemia virus.

We previously described replication-competent feline leukemia virus (FeLV) vectors with high-level and stable expression of a green fluorescent protein (GFP) or a suicide transgene in cell cultures in vitro. Considering that FeLV might potentially be used to deliver therapeutic genes in vivo, we first evaluated the expression of the GFP gene introduced in cats by the FeLV, Rickard subgroup A (FRA) construct. Eight newborn kittens were either inoculated with pFRA-GFP plasmid DNA intradermally, or challenged intraperitoneally with FRA-GFP-infected feline fibroblasts. During a 12-week observation period, five cats were shown to be progressively viremic. Quantitative PCR and RT-PCR analyses of plasma and tissue samples from these cats showed that GFP was retained in FeLV DNA or RNA to a variable degree, ranging from 0.002 to 27.890%. Tissue DNA samples were analyzed by PCR for the status of GFP and the env-transgene complex. While the proviruses carrying the GFP transgene were shown to be minor species, all tissues, however, retained the full-length GFP transgene. Despite the occurrence of predominant species with various deletions in the viral genome, approximately 1-3% of the total cell population was GFP-positive in the lymphoid tissues as visualized by laser confocal microscopy. Co-localization of immunofluorescent cells indicated that CD3-positive T cells, dendritic cells and macrophages were the major targets for GFP expression. These findings on the detectable in vivo expression of GFP for as long as a period of 3 months could be viewed positively for contemplating a therapeutic strategy for control of FeLV infection in the cats.

Effects of calcitriol, seocalcitol, and medium-chain triglyceride on a canine transitional cell carcinoma cell line.

BACKGROUND: Transitional cell carcinoma (TCC) in dogs is associated with high morbidity and mortality. Calcitriol and its analog seocalcitol, combined with medium-chain triglyceride (MCT), have potential for the treatment of this disease. MATERIALS AND METHODS: TCC cells were treated with calcitriol or seocalcitol, alone or combined with MCT. Cell growth, cell cycle kinetics, vitamin D receptor (VDR) localization and expression, and Bcl-2 expression were measured. RESULTS: Canine TCC expresses high levels of nuclear VDR. Furthermore, calcitriol and seocalcitol significantly inhibited cell growth and calcitriol caused G0/G1 cell cycle arrest. Bcl-2 expression was slightly decreased in cells treated with these compounds, although no significant changes in VDR expression were observed. MCT enhanced the growth inhibitory effect of both compounds. CONCLUSION: Calcitriol and seocalcitol inhibited TCC cell growth via induction of cell cycle arrest and MCT enhanced this effect. Therefore, calcitriol and seocalcitol with MCT may have therapeutic potential for canine bladder cancer.

Expression of equine glucose transporter type 4 in skeletal muscle after glycogen-depleting exercise.

OBJECTIVES: To clone and sequence cDNA for equine insulin-responsive glucose transporter (glucose transporter type 4 [GLUT-4]) and determine effects of glycogen-depleting exercise and meal type after exercise on GLUT-4 gene expression in skeletal muscle of horses. SAMPLE POPULATION: Muscle biopsy specimens from 7 healthy adult horses. PROCEDURES: Total RNA was extracted from specimens, and GLUT-4 cDNA was synthesized and sequenced. Horses were exercised on 3 consecutive days. On the third day of exercise, for 8 hours after exercise, horses were either not fed, fed half of daily energy requirements as hay, or fed an isocaloric amount of corn. The GLUT-4 mRNA was determined by use of real-time reverse transcriptase-polymerase chain reaction in muscle biopsy specimens obtained before 3 consecutive days of exercise and within 10 minutes and 4, 8, and 24 hours after the third exercise bout. RESULTS: A 1,629-bp segment was sequenced, of which 1,530 bp corresponded to the coding region end encoded a protein of 509 amino acids. Expression of GLUT-4 gene increased by 2.3, 4.3, 3.3, and 2.6 times 10 minutes and 4, 8, and 24 hours after exercise, respectively, compared with that prior to exercise. No differences were observed in GLUT-4 gene expression among conditions of feed withholding, corn feeding, and hay feeding during the 8 hours postexercise. CONCLUSIONS AND CLINICAL RELEVANCE: Lack of increase of GLUT-4 gene expression after grain feeding and exercise may explain the apparently slower rate of glycogen synthesis after exercise in horses relative to that of other species.