Improving Neuromuscular Monitoring Through Education-Based Interventions and Studying Its Association With Adverse Postoperative Outcomes: A Retrospective Observational Study.

BACKGROUND: We assessed the association between education-based interventions, the frequency of train-of-four (TOF) monitoring, and postoperative outcomes. METHODS: We studied adults undergoing noncardiac surgery from February 1, 2020 through October 31, 2021. Our education-based interventions consisted of 3 phases. An interrupted time-series analysis, adjusting for patient- and procedure-related characteristics and secular trends over time, was used to assess the associations between education-based interventions and the frequency of TOF monitoring, postoperative pulmonary complications (PPCs), 90-day mortality, and sugammadex dosage. For each outcome and intervention phase, we tested whether the intervention at that phase was associated with an immediate change in the outcome or its trend (weekly rate of change) over time. In a sensitivity analysis, the association between education-based interventions and postoperative outcomes was adjusted for TOF monitoring. RESULTS: Of 19,422 cases, 11,636 (59.9%) had documented TOF monitoring. Monitoring frequency increased from 44.2% in the first week of preintervention stage to 83.4% in the final week of the postintervention phase. During the preintervention phase, the odds of TOF monitoring trended upward by 0.5% per week (odds ratio [OR], 1.005; 95% confidence interval [CI], 1.002-1.007). Phase 1 saw an immediate 54% increase (OR, 1.54; 95% CI, 1.33-1.79) in the odds, and the trend OR increased by 3% (OR, 1.03; 95% CI, 1.01-1.05) to 1.035, or 3.5% per week (joint Wald test, P < .001). Phase 2 was associated with a further immediate 29% increase (OR, 1.29; 95% CI, 1.02-1.64) but no significant association with trend (OR, 0.96; 95% CI, 0.93-1.01) of TOF monitoring (joint test, P = .04). Phase 3 and postintervention phase were not significantly associated with the frequency of TOF monitoring (joint test, P = .16 and P = .61). The study phases were not significantly associated with PPCs or sugammadex administration. The trend OR for 90-day mortality was larger by 24% (OR, 1.24; 95% CI, 1.06-1.45; joint test, P = .03) in phase 2 versus phase 1, from a weekly decrease of 8% to a weekly increase of 14%. However, this trend reversed again at the transition from phase 3 to the postintervention phase (OR, 0.82; 95% CI, 0.68-0.99; joint test, P = .05), from a 14% weekly increase to a 6.2% weekly decrease in the odds of 90-day mortality. In sensitivity analyses, adjusting for TOF monitoring, we found similar associations between study initiatives and postoperative outcomes. TOF monitoring was associated with lower odds of PPCs (OR, 0.69; 95% CI, 0.55-0.86) and 90-day mortality (OR, 0.79; 95% CI, 0.63-0.98), but not sugammadex dosing (mean difference, -0.02; 95% CI, -0.04 to 0.01). CONCLUSIONS: Our education-based interventions were associated with both TOF utilization and 90-day mortality but were not associated with either the odds of PPCs or sugammadex dosing. TOF monitoring was associated with reduced odds of PPCs and 90-day mortality.

Oral versus intravenous antibiotics in the treatment of uncomplicated colonic diverticulitis: results of a randomized non-inferiority control trial.

BACKGROUND: Colonic diverticular disease is common and its incidence increases with age, with uncomplicated diverticulitis being the most common acute presentation (1). This typically results in inpatient admission, placing a significant burden on healthcare services (2). We aimed to determine the safety and effectiveness of using intravenous or oral antibiotics in the treatment of uncomplicated diverticulitis on 30-day unplanned admissions, c-reactive protein (CRP), White Cell Count (WCC), pain resolution, cessation of pain medication, return to normal nutrition, and return to normal bowel function. METHODS: This single centre, 2-arm, parallel, 1:1, unblinded non-inferiority randomized controlled trial compared the safety and efficacy of oral antibiotics versus intravenous antibiotics in the outpatient treatment of uncomplicated colonic diverticulitis. Inclusion criteria were patients older than 18 years of age with CT proven acute uncomplicated colonic diverticulitis (Modified Hinchey Classification Stage 0-1a). Patients were randomly allocated receive either intravenous or oral antibiotics, both groups being treated in the outpatient setting with a Hospital in the Home (HITH) service. The primary outcome was the 30-day unplanned admission rate, secondary outcomes were biochemical markers, time to pain resolution, time to cessation of pain medication, time to return to normal function and time to return to normal bowel function. RESULTS: In total 118 patients who presented with uncomplicated colonic diverticulitis were recruited into the trial. Fifty-eight participants were treated with IV antibiotics, and 60 were given oral antibiotics. We found there was no significant difference between groups with regards to 30-day unplanned admissions or inflammatory markers. There was also no significant difference with regards to time to pain resolution, cessation of pain medication use, return to normal nutrition, or return to normal bowel function. CONCLUSION: Outpatient management of uncomplicated diverticulitis with oral antibiotics proved equally as safe and efficacious as intravenous antibiotic treatment in this randomized non-inferiority control trial.

Significant cell uptake of Gd(III)-diphenylphosphoryl-diphenylphosphonium complexes: evidence for a new conformationally-dependent tumour cell targeting vector.

The synthesis, characterisation, and tumour cell uptake of six novel Gd(III)-diphenylphosphoryl-diphenylphosphonium complexes are reported. The propyl-linked Gd(III) complexes can accumulate inside human glioma cells at prodigious levels, approaching 1200%, over the parent triphenylphosphonium salts. DFT and quantum chemical topology analyses support a new type of conformationally-dependent tumour cell targeting vector.

Parenting, Pesticides and Adolescent Psychological Adjustment: A Brief Report.

Pesticides used to control insects, such as pyrethroids, are neurotoxicants, yet adolescent researchers often overlook their potential role in adolescent psychological adjustment. This brief report is guided by bioecological theory and considers the possible independent and interactive effects of environmental pyrethroid pesticide exposure for adolescent depressive symptoms. Self-reported adolescent appraisals of the parent-child relationship and depressive symptoms were obtained from a convenience sample of impoverished, predominantly Latino urban youth (n = 44). Exposure to environmental pyrethroids was obtained from wipe samples using a standardized protocol. Parent-adolescent conflict was higher in households with bifenthrin than those without, and adolescent depressive symptoms were elevated in homes where cypermethrin was detected. In addition, the presence of bifenthrin in the home attenuated the protective effects of parental involvement on adolescent depressive symptoms. The current results suggest that adolescent mental health researchers must consider the synergistic combinations of adolescents' environments' physical and social features. Given the endemic presence of pesticides and their neurotoxic function, pesticide exposure may demand specific attention.

Colonization with Gastrointestinal Pathogens Prior to Hematopoietic Cell Transplantation and Associated Clinical Implications.

Infectious diarrhea following hematopoietic cell transplantation (HCT) significantly contributes to morbidity and mortality. Most HCT recipients experience diarrhea in the post-transplantation period, and infectious pathogens are frequently detected during diarrheal episodes. However, little is known about how frequently these patients are colonized with gastrointestinal (GI) pathogens before their transplantation and whether colonization predicts future diarrheal illness. We sought to determine how frequently HCT recipients are colonized with GI pathogens before HCT and the degree to which pre-HCT colonization predicts post-transplantation infectious diarrheal illness. We conducted a prospective cohort study of allogeneic and autologous HCT recipients at a single center between December 2016 and January 2019. Stool samples were collected during the week before HCT, and formed samples were evaluated for the presence of 22 diarrheal pathogens using the BioFire FilmArray GI panel. We determined the frequency with which participants were colonized with each pathogen and identified factors associated with colonization. We then determined how frequently pretransplantation colonization led to post-transplantation diarrheal infections due to the colonizing pathogen and whether colonization was associated with increased number of days of post-transplantation diarrhea during the transplant hospitalization. We enrolled 112 asymptomatic patients (allogeneic, 61%; autologous, 39%) who had a formed stool specimen before HCT, of whom 41 (37%) had a GI pathogen detected. The most commonly detected organisms were Clostridioides difficile (n = 21; 19%), Yersinia enterocolitica (n = 9; 8%), enteropathogenic Escherichia coli (EPEC) (n = 6; 6%), and norovirus (n = 5; 4%). Female sex and previous C. difficile infection were associated with C. difficile colonization, and having non-Hodgkin lymphoma was associated with being colonized with a diarrheal pathogen other than C. difficile. Thirteen of 21 patients (62%) with pretransplantation C. difficile colonization developed a clinical C. difficile infection post-transplantation, and 8 of 10 patients (80%) colonized with EPEC or enteroaggregative E. coli developed post-transplantation infections due to their colonizing pathogen. Pretransplantation C. difficile colonization was also associated with an increased duration of post-transplantation diarrhea (P = .048). Conversely, none of the 9 patients with pretransplantation Yersinia enterocolitica colonization developed a post-transplantation Y. enterocolitica infection. Patients admitted for HCT are frequently colonized with a diverse range of GI pathogens. Colonization with C. difficile colonization and diarrheagenic E. coli is frequently associated with post-transplantation diarrheal infections caused by these organisms, but the clinical significance of colonization with other GI pathogens is not clear.

Gadolinium theranostics for the diagnosis and treatment of cancer.

According to the World Health Organization (WHO), there were 18.1 million new cancer cases and 9.6 million cancer deaths reported worldwide in 2018. These numbers are expected to rise over the next decade, and the development of new and effective cancer treatments and diagnostic tools is urgently required, particularly for aggressive and intractable malignant cancers such as those of the brain. An exciting field of cancer research involves combining therapeutic and diagnostic tools into a single 'theranostic' platform. The role of theranostics in the personalized management of oncology patients is increasing, as is the demand for new types of theranostic agents. Some of the most promising cancer theranostics exploit the lanthanoid metal gadolinium, an element possessing favourable therapeutic and imaging properties.

Synthesis and tumour cell uptake studies of gadolinium(III)-phosphonium complexes.

The synthesis of a new series of Gd(III)-arylphosphonium complexes is described and the solution stability of selected compounds is reported. Their lipophilicity and uptake in human glial (SVG p12) and human glioblastoma multiforme (T98G) cell lines are presented. The in vitro cytotoxicity of all complexes was determined to be low at therapeutically-relevant concentrations. Selected Gd(III) complexes are potential candidates for further investigation as theranostic agents.

A Case Report Describing Three Cases of Challenging or Failed Intubation after Cervical Spine Surgery: A Peril of Early Extubation.

Postoperative airway complications can be a common, yet perhaps underappreciated, complication in patients undergoing cervical spine surgery. Presented here are three cases in which patients experienced postoperative airway compromise, resulting in difficulty establishing a secure airway following cervical spine operations. Establishing factors that contribute to airway complications after cervical spine surgery can aid in early identification of high-risk patients to create an appropriate airway management strategy. Ultimately, the frequency of airway difficulty after removal of the endotracheal tube in patients undergoing cervical spine surgery should not be taken lightly.

Quantitative in vivo whole genome motility screen reveals novel therapeutic targets to block cancer metastasis.

Metastasis is the most lethal aspect of cancer, yet current therapeutic strategies do not target its key rate-limiting steps. We have previously shown that the entry of cancer cells into the blood stream, or intravasation, is highly dependent upon in vivo cancer cell motility, making it an attractive therapeutic target. To systemically identify genes required for tumor cell motility in an in vivo tumor microenvironment, we established a novel quantitative in vivo screening platform based on intravital imaging of human cancer metastasis in ex ovo avian embryos. Utilizing this platform to screen a genome-wide shRNA library, we identified a panel of novel genes whose function is required for productive cancer cell motility in vivo, and whose expression is closely associated with metastatic risk in human cancers. The RNAi-mediated inhibition of these gene targets resulted in a nearly total (>99.5%) block of spontaneous cancer metastasis in vivo.

Comparing the Bioburden Measured by Adenosine Triphosphate (ATP) Luminescence Technology to Contact Plate-Based Microbiologic Sampling to Assess the Cleanliness of the Patient Care Environment.

The correlation between ATP concentration and bacterial burden in the patient care environment was assessed. These findings suggest that a correlation exists between ATP concentration and bacterial burden, and they generally support ATP technology manufacturer-recommended cutoff values. Despite relatively modest discriminative ability, this technology may serve as a useful proxy for cleanliness.Infect Control Hosp Epidemiol 2018;39:622-624.

Phenotypic heterogeneity of ZMPSTE24 deficiency.

A 4-year-old girl was referred to the Undiagnosed Diseases Network with a history of short stature, thin and translucent skin, macrocephaly, small hands, and camptodactyly. She had been diagnosed with possible Hallerman-Streiff syndrome. Her evaluation showed that she was mosaic for uniparental isodisomy of chromosome 1, which harbored a pathogenic c.1077dupT variant in ZMPSTE24 which predicts p.(Leu362fsX18). ZMPSTE24 is a zinc metalloproteinase that is involved in processing farnesylated proteins and pathogenic ZMPSTE24 variants cause accumulation of abnormal farnesylated forms of prelamin A. This, in turn, causes a spectrum of disease severity which is based on enzyme activity. The current patient has an intermediate form, which is a genocopy of severe Progeria.

A strategy for co-translational folding studies of ribosome-bound nascent chain complexes using NMR spectroscopy.

During biosynthesis on the ribosome, an elongating nascent polypeptide chain can begin to fold, in a process that is central to all living systems. Detailed structural studies of co-translational protein folding are now beginning to emerge; such studies were previously limited, at least in part, by the inherently dynamic nature of emerging nascent chains, which precluded most structural techniques. NMR spectroscopy is able to provide atomic-resolution information for ribosome-nascent chain complexes (RNCs), but it requires large quantities (≥10 mg) of homogeneous, isotopically labeled RNCs. Further challenges include limited sample working concentration and stability of the RNC sample (which contribute to weak NMR signals) and resonance broadening caused by attachment to the large (2.4-MDa) ribosomal complex. Here, we present a strategy to generate isotopically labeled RNCs in Escherichia coli that are suitable for NMR studies. Uniform translational arrest of the nascent chains is achieved using a stalling motif, and isotopically labeled RNCs are produced at high yield using high-cell-density E. coli growth conditions. Homogeneous RNCs are isolated by combining metal affinity chromatography (to isolate ribosome-bound species) with sucrose density centrifugation (to recover intact 70S monosomes). Sensitivity-optimized NMR spectroscopy is then applied to the RNCs, combined with a suite of parallel NMR and biochemical analyses to cross-validate their integrity, including RNC-optimized NMR diffusion measurements to report on ribosome attachment in situ. Comparative NMR studies of RNCs with the analogous isolated proteins permit a high-resolution description of the structure and dynamics of a nascent chain during its progressive biosynthesis on the ribosome.

A structural ensemble of a ribosome-nascent chain complex during cotranslational protein folding.

Although detailed pictures of ribosome structures are emerging, little is known about the structural and cotranslational folding properties of nascent polypeptide chains at the atomic level. Here we used solution-state NMR spectroscopy to define a structural ensemble of a ribosome-nascent chain complex (RNC) formed during protein biosynthesis in Escherichia coli, in which a pair of immunoglobulin-like domains adopts a folded N-terminal domain (FLN5) and a disordered but compact C-terminal domain (FLN6). To study how FLN5 acquires its native structure cotranslationally, we progressively shortened the RNC constructs. We found that the ribosome modulates the folding process, because the complete sequence of FLN5 emerged well beyond the tunnel before acquiring native structure, whereas FLN5 in isolation folded spontaneously, even when truncated. This finding suggests that regulating structure acquisition during biosynthesis can reduce the probability of misfolding, particularly of homologous domains.

Invadopodia are required for cancer cell extravasation and are a therapeutic target for metastasis.

Tumor cell extravasation is a key step during cancer metastasis, yet the precise mechanisms that regulate this dynamic process are unclear. We utilized a high-resolution time-lapse intravital imaging approach to visualize the dynamics of cancer cell extravasation in vivo. During intravascular migration, cancer cells form protrusive structures identified as invadopodia by their enrichment of MT1-MMP, cortactin, Tks4, and importantly Tks5, which localizes exclusively to invadopodia. Cancer cells extend invadopodia through the endothelium into the extravascular stroma prior to their extravasation at endothelial junctions. Genetic or pharmacological inhibition of invadopodia initiation (cortactin), maturation (Tks5), or function (Tks4) resulted in an abrogation of cancer cell extravasation and metastatic colony formation in an experimental mouse lung metastasis model. This provides direct evidence of a functional role for invadopodia during cancer cell extravasation and distant metastasis and reveals an opportunity for therapeutic intervention in this clinically important process.

Stage of breast cancer progression influences cellular response to activation of the WNT/planar cell polarity pathway.

Planar cell polarity (PCP) signaling has been shown in different studies to either promote or inhibit the malignancy of breast cancer. Using the 21T cell lines, which were derived from an individual patient and represent distinct stages of progression, we show that the prototypical PCP ligand, WNT5A, is expressed highest in 21MT-1 cells (invasive mammary carcinoma) and lowest in 21PT (atypical ductal hyperplasia) and 21NT (ductal carcinoma in situ) cells. Overexpression of WNT5A decreased spherical colony formation and increased invasion and in vivo extravasation only in 21NT cells; whereas overexpression increased migration of both 21PT and 21NT cells. WNT5A overexpression also increased RHOA expression of both cell lines and subsequent RHOA knockdown blocked WNT5A-induced migration, but only partially blocked WNT5A-induced invasion of 21NT cells. PCP can signal through VANGL1 to modulate AP-1 target genes (e.g. MMP3) and induce invasion. VANGL1 knockdown inhibited WNT5A-induced invasion of 21NT cells, but had no effect on WNT5A-induced migration of either 21PT or 21NT cells. WNT5A-induced MMP3 expression was seen only in 21NT cells, an effect that was VANGL1 dependent, but independent of AP-1. We thus provide evidence that PCP signaling can act in a context dependent manner to promote breast cancer progression.

A method for the incremental expansion of polyglutamine repeats in recombinant proteins.

The polyglutamine diseases are caused by the expansion of CAG repeats. A key step in understanding the disease mechanisms, at the DNA and protein level, is the ability to produce recombinant proteins with specific length glutamine tracts which is a time-consuming first step in setting up in vitro systems to study the effects of polyglutamine expansion. Described here is a PCR-based method for the amplification of CAG repeats, which we used to incrementally extend CAG length by 3-5 repeats per cycle. This method could be translated into various contexts where amplification of repeating elements is necessary.

Anesthesia for liver transplantation in US academic centers: institutional structure and perioperative care.

Investigators at a single institution have shown that the organization of the anesthesia team influences patient outcomes after liver transplant surgery. Little is known about how liver transplant anesthesiologists are organized to deliver care throughout the United States. Therefore, we collected quantitative survey data from adult liver transplant programs in good standing with national governing agencies so that we could describe team structure and duties. Information was collected from 2 surveys in a series of quantitative surveys conducted by the Liver Transplant Anesthesia Consortium. All data related to duties, criteria for team membership, interactions/communication with the multidisciplinary team, and service availability were collected and summarized. Thirty-four of 119 registered transplant centers were excluded (21 pediatric centers and 13 centers not certified by national governing agencies). Private practice sites (26) were later excluded because of a poor response rate. There were minimal changes in the compositions of the programs between the 2 surveys. All academic programs had distinct liver transplant anesthesia teams. Most had set criteria for membership and protocols outlining the preoperative evaluation, attended selection committees, and were always available for transplant surgery. Fewer were involved in postoperative care or were available for patients needing subsequent surgery. Most trends were associated with the center volume. In conclusion, some of the variance in team structure and responsibilities is probably related to resources available at the site of practice. However, similarities in specific duties across all teams suggest some degree of self-initiated specialization.

Molecular pathways to polyglutamine aggregation.

Over 100 human cellular proteins contain a repetitive polyglutamine tract, however, only nine ofthese proteins are associated with disease. In these proteins, the expanded polyQ tract perturbs the native conformation, resulting in an ordered aggregation process that leads to the formation of amyloid-like fibrils. The misfolding pathway involves the formation of prefibrillar oligomeric structures, which are proposed to be involved in cellular toxicity. Non-polyQ host protein regions modulate the misfolding pathway, suggesting an importance ofprotein context in aggregation. This chapter describes the current research regarding polyQ misfolding, with emphasis on the species populated during aggregation, suggesting an important role of protein context in modulating the aggregation pathway.