Evaluation of an ultrasound-guided freeze-core biopsy system for canine and feline brain tumors.

Objective: To determine if a single brain biopsy utilizing a freeze-core needle harvest system Cassi II under ultrasound guidance provides a diagnostic sample; to evaluate the technique's efficacy in procuring diagnostic samples in comparison with "open" surgical biopsies; and to describe intraoperative complications associated with the technique. Study design: Experimental clinical study. Animals: Seventeen dogs and four cats with magnetic resonance imaging (MRI) diagnoses of readily surgically accessible intracranial masses. Methods: Immediately prior to surgical biopsy (SB), freeze-core biopsy (FCB) sample was obtained from each patient under ultrasound guidance. Results: Histopathology results from single FCB samples were found to be in 100% agreement with the SB samples. Freezing artifact was minimal and did not interfere with histopathologic interpretation. There were no intraoperative complications specifically attributable to the use of the FCB system. Conclusion: Based on the results of this small experimental study, the FCB system is expected to safely yield diagnostic quality intracranial masses biopsy specimens. Clinical significance: This system has the potential of obtaining diagnostic biopsies of more deeply seated brain lesions (i.e., intra-axial tumors considered inaccessible or with large risks/difficulties by standard surgical means) which would provide a definitive diagnosis to guide appropriate therapy.

Biopsy and histologic findings of the dura mater at the level of the foramen magnum in 121 CKCS with Chiari-like malformation.

To describe histopathologic features found in dural biopsies of Cavalier King Charles Spaniels (CKCS) with Chiari-like malformation (CM) and identify any associations between age, duration of clinical signs, syrinx location or syringomyelia (SM, and quality of life (QOL). The medical records of 121 consecutive client owned CKCS with CM and SM, confirmed by whole body magnetic resonance imaging (MRI), that underwent foramen magnum decompression (FMD) with cranioplasty and durectomy with biopsy from 2006 to 2016 were retrospectively reviewed. Dural biopsies were submitted to a board-certified veterinary pathologist for histopathologic interpretation. The chi-square test was used to analyze associations between histologic findings and categorical variables. For continuous measures, the Kruskal-Wallis non-parametric test was used to compare distributions across pathology categories. A result was considered statistically significant at the p < 0.05 level of significance. The mean age, duration of pre-surgical clinical signs, and pre-operative QOL (1-5 scale) were 44.27 months, 44.78 weeks, and 2.72, respectively. Syringomyelia was found in the cervical region only in 39 of 121 (32.23%) of dogs, in the cervical and thoracic region only in 17 of 121 (14.05%) of dogs, and in the cervical, thoracic, and lumbar region combined in 65 of 121 (53.72%) of dogs. Sixty-six of one hundred twenty-one (54.55%) dural biopsy specimens had histopathology changes; fifty-five (45.45%) did not. Forty-three of one hundred twenty-one (35.54%) dural biopsy specimens had osseous metaplasia, 16 of 121 (13.22%) had evidence of fibrosis, 4 of 121 (3.31%) had arachnoid hyperplasia, and 3 of 121 (2.48%) had evidence of mineralization. Most dogs with CM were found to have histopathologic changes in the dura at the time of FMD cranioplasty was performed. These dural changes can be observed in dogs experiencing clinical signs for a time period as short as 4 weeks prior to presentation. The histopathologic changes were not associated with age, breed, duration of clinical signs, the location of syringomyelia or QOL. The influence of histopathologic changes on long-term prognosis in dogs without dural decompression is unknown since all dogs in this study had dural resection.

Transfusion in Root Replacement for Aortic Dissection: The STS Adult Cardiac Surgery Database Analysis.

BACKGROUND: Transfusion in acute aortic syndromes has been studied in a limited fashion. We sought to describe contemporary transfusion practice for root replacement in acute (Stanford) type A aortic dissection. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was interrogated to identify patients who underwent primary aortic root replacement for acute (Stanford) type A aortic dissection (July 2014 to June 2017). Patients (n = 1558) were stratified by type of root replacement. Multivariate regression was used to determine those variables associated with transfusion and postoperative morbidity. RESULTS: Transfusion was required in 90.5% of cases (n = 1410). Operative mortality for all patients was 17.3% (261 deaths). Intraoperative red blood cell transfusion portended reduced short-term survival (odds ratio [OR] 2.00, P = .025). Massive postoperative transfusion was associated with prolonged ventilation (OR 13.47, P < .001), sepsis (OR 4.13, P < .001), and new dialysis-dependent renal failure (OR 2.43, P < .001). Women were more likely to require transfusion (OR 3.03, P < .001), as were patients who had coronary artery bypass (OR 1.57, P = .009), and those in shock (OR 2.27, P < .001). Valve-sparing aortic root replacement was associated with reduced transfusion requirements vs composite roots. Institutional case volume was not appreciably correlated with transfusion. CONCLUSIONS: Most patients undergoing root replacement for aortic dissection require blood products. Composite root replacement is associated with a greater likelihood of transfusion than a valve-sparing operation. Transfusion independently foreshadows greater operative mortality.

Cardiotoxicity screening of long-term, breast cancer survivors-The CAROLE (Cardiac-Related Oncologic Late Effects) Study.

BACKGROUND: Long-term breast cancer survivors are at risk for cardiotoxicity after treatment, but there is insufficient evidence to provide long-term (~10 years) cardiovascular disease (CVD) screening recommendations. We sought to evaluate a tri-modality CVD screening approach. METHODS: This single-arm, feasibility study enrolled 201 breast cancer patients treated ≥6 years prior without CVD at diagnosis. Patients were sub-grouped: cardiotoxic (left-sided) radiation (RT), cardiotoxic (anthracycline-based) chemotherapy, both cardiotoxic chemotherapy and RT, and neither cardiotoxic treatment. Patients underwent electrocardiogram (EKG), transthoracic echocardiogram with strain (TTE with GLS), and coronary artery calcium computed tomography (CAC CT). The primary endpoint was preclinical or clinical CVD. RESULTS: Median age was 50 (29-65) at diagnosis and 63 (37-77) at imaging; median interval was 11.5 years (6.7-14.5). Among sub-groups, 44% had no cardiotoxic treatment, 31.5% had cardiotoxic RT, 16% had cardiotoxic chemotherapy, and 8.5% had both. Overall, 77.6% showed preclinical and/or clinical CVD and 51.5% showed clinical CVD. Per modality, rates of any CVD and clinical CVD were, respectively: 27.1%/10.0% on EKG, 50.0%/25.3% on TTE with GLS, and 50.8%/45.8% on CAC CT. No statistical difference was seen among the treatment subgroups (NS, χ2 test, p = 0.58/p = 0.15). CONCLUSION: This study identified a high incidence of CVD in heterogenous long-term breast cancer survivors, most >10 years post-treatment. Over half had clinical CVD findings warranting follow-up and/or intervention. Each imaging test independently contributed to the detection rate. This provides early evidence that long-term cardiac screening may be of value to a wider group of breast cancer survivors than previously recognized.

Survival models to support shared decision-making about advance care planning for people with advanced stage cystic fibrosis.

BACKGROUND: For people with advanced stage cystic fibrosis (CF), tailored survival estimates could facilitate preparation for decision-making in the event of acutely deteriorating respiratory function. METHODS: We used the US CF Foundation national database (2008-2013) to identify adult people with incident advanced stage CF (forced expiratory volume in 1 s (FEV1) ≤45% predicted). Using the lasso method for variable selection, we divided the dataset into training and validation samples (2:1), and developed two multivariable Cox proportional hazards models to calculate probabilities of survival from baseline (T0 model), and from 1 year after (T12 model). We also performed Kaplan-Meier survival analyses. RESULTS: 4752 people were included. For the T0 model, FEV1; insurance; non-invasive ventilation; supplemental oxygen; Burkholderia colonisation; cirrhosis; depression; dialysis; current smoking; unclassifiable mutation class and cumulative CF exacerbations predicted increased mortality. Baseline transplant evaluation status of 'accepted, on waiting list' predicted decreased mortality. For the T12 model, interim decrease in FEV1 >10%, and pulmonary exacerbations additionally increased predicted mortality. Lung transplantation was associated with lower mortality. Of the 4752, 93.5%, 86.4%, 79.7% and 73.9% survived to 1, 2, 3 and 4 years, respectively, without considering any confounding variables. The models had moderate predictive ability indicated by the area under the time-dependent receiver operating characteristic curve (0.787, 95% CI 0.769 to 0.794 for T0 model; and 0.779, 95% CI 0.767 to 0.797 for T12 model). CONCLUSION: We have developed models predicting survival in people with incident advanced stage CF, which can be reapplied over time to support shared decision-making about end-of-life treatment choices and lung transplantation. These estimates must be updated as data become available regarding long-term outcomes for people treated with CF transmembrane conductance regulator modulators.

Adapting a home telemonitoring intervention for underserved Hispanic/Latino patients with type 2 diabetes: an acceptability and feasibility study.

BACKGROUND: Home telemonitoring is a promising approach to optimizing outcomes for patients with Type 2 Diabetes; however, this care strategy has not been adapted for use with understudied and underserved Hispanic/Latinos (H/L) patients with Type 2 Diabetes. METHODS: A formative, Community-Based Participatory Research approach was used to adapt a home telemonitoring intervention to facilitate acceptability and feasibility for vulnerable H/L patients. Utilizing the ADAPT-ITT framework, key stakeholders were engaged over an 8-month iterative process using a combination of strategies, including focus groups and structured interviews. Nine Community Advisory Board, Patient Advisory, and Provider Panel Committee focus group discussions were conducted, in English and Spanish, to garner stakeholder input before intervention implementation. Focus groups and structured interviews were also conducted with 12 patients enrolled in a 1-month pilot study, to obtain feedback from patients in the home to further adapt the intervention. Focus groups and structured interviews were approximately 2 hours and 30 min, respectively. All focus groups and structured interviews were audio-recorded and professionally transcribed. Structural coding was used to mark responses to topical questions in the moderator and interview guides. RESULTS: Two major themes emerged from qualitative analyses of Community Advisory Board/subcommittee focus group data. The first major theme involved intervention components to maximize acceptance/usability. Subthemes included tablet screens (e.g., privacy/identity concerns; enlarging font sizes; lighter tablet to facilitate portability); cultural incongruence (e.g., language translation/literacy, foods, actors "who look like me"); nursing staff (e.g., ensuring accessibility; appointment flexibility); and, educational videos (e.g., the importance of information repetition). A second major theme involved suggested changes to the randomized control trial study structure to maximize participation, including a major restructuring of the consenting process and changes designed to optimize recruitment strategies. Themes from pilot participant focus group/structured interviews were similar to those of the Community Advisory Board such as the need to address and simplify a burdensome consenting process, the importance of assuring privacy, and an accessible, culturally congruent nurse. CONCLUSIONS: These findings identify important adaptation recommendations from the stakeholder and potential user perspective that should be considered when implementing home telemonitoring for underserved patients with Type 2 Diabetes. TRIAL REGISTRATION: NCT03960424; ClinicalTrials.gov (US National Institutes of Health). Registered 23 May 2019. Registered prior to data collection. https://www.clinicaltrials.gov/ct2/show/NCT03960424?term=NCT03960424&draw=2&rank=1.

Transfusion in Elective Aortic Root Replacement: Analysis of the STS Adult Cardiac Surgery Database.

BACKGROUND: Data on blood use in proximal aortic surgery is limited. This study sought to establish quality benchmarks in the pattern of transfusion during elective aortic root replacement. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried to identify all patients who underwent primary elective aortic root replacement between July 2014 and June 2017. Multivariable negative binomial regressions were used to determine whether perioperative transfusion was associated with demographic or procedural factors. Multivariable logistic regression analysis was performed for clinical outcomes. RESULTS: Of 5559 patients analyzed, 38.95% (n = 2165) received no blood products. Patients who had a valve-sparing root replacement were less likely to undergo transfusion than those who received composite roots (bioprosthetic or mechanical valves) or homografts. The 30-day mortality for all patients was 2.57% (n = 143). Transfusion was associated with an increased risk of death at 30 days (odds ratio [OR], 1.833; P = .012), more frequent reoperation for bleeding (OR, 1.766; P < .001), prolonged ventilation (OR, 1.935; P < .001), a longer postoperative hospital stay (OR, 1.056; P < .001), and a higher incidence of new dialysis-dependent renal failure (OR, 2.088; P = .003). There was no correlation between institutional case volume and transfusion practice. CONCLUSIONS: Elective aortic root replacement can be performed with acceptable requirements for blood products. Composite root replacement has a greater likelihood of transfusion than does a valve-sparing procedure. Transfusion is independently associated with more complications after elective aortic root surgery, including 30-day mortality.

Histopathologic characteristics of biopsies from dogs undergoing surgery with concurrent gross splenic and hepatic masses: 125 cases (2012-2016).

OBJECTIVE: To investigate the histopathologic characteristics of concurrent splenic and liver masses in dogs undergoing splenectomy and liver mass biopsy/resection. Medical records of 125 client-owned dogs found to have splenic mass or masses and a liver mass or masses during surgery were examined. Signalment (age, sex, breed), body weight, and results of histopathology were recorded for all dogs. RESULTS: Twenty-seven percent (34/125) of the dogs in this study had no evidence of malignancy in either the liver or the spleen. Sixty of 125 dogs (48.0%) had malignancy in the spleen and liver, and 56 (56/60, 93.3%) of those dogs had the same malignancy in both organs. Signalment was similar to that in other reports of splenic pathology. In this clinical population of dogs, 27% of dogs with concurrent gross splenic and liver masses discovered intraoperatively had benign lesions in both locations and therefore had a favorable prognosis.

Does obtaining an initial magnetic resonance imaging decrease the reamputation rates in the diabetic foot?

OBJECTIVE: Diabetes mellitus (DM) through its over glycosylation of neurovascular structures and resultant peripheral neuropathy continues to be the major risk factor for pedal amputation. Repetitive trauma to the insensate foot results in diabetic foot ulcers, which are at high risk to develop osteomyelitis. Many patients who present with diabetic foot complications will undergo one or more pedal amputations during the course of their disease. The purpose of this study was to determine if obtaining an initial magnetic resonance imaging (MRI), prior to the first amputation, is associated with a decreased rate of reamputation in the diabetic foot. Our hypothesis was that the rate of reamputation may be associated with underutilization of obtaining an initial MRI, useful in presurgical planning. This study was designed to determine whether there was an association between the reamputation rate in diabetic patients and utilization of MRI in the presurgical planning and prior to initial forefoot amputations. METHODS: Following approval by our institutional review board, our study design consisted of a retrospective cohort analysis of 413 patients at Staten Island University Hospital, a 700-bed tertiary referral center between 2008 and 2013 who underwent an initial great toe (hallux) amputation. Of the 413 patients with a hallux amputation, there were 368 eligible patients who had a history of DM with documented hemoglobin A1c (HbA1c) within 3 months of the initial first ray (hallux and first metatarsal) amputation and available radiographic data. Statistical analysis compared the incidence rates of reamputation between patients who underwent initial MRI and those who did not obtain an initial MRI prior to their first amputation. The reamputation rate was compared after adjustment for age, gender, ethnicity, HbA1c, cardiovascular disease, hypoalbuminemia, smoking, body mass index, and prior antibiotic treatment. RESULTS: The results of our statistical analysis failed to reveal a significant association between obtaining an initial MRI and the reamputation rate. We did, however, find a statistical association between obtaining an early MRI and decreased mortality rates. DISCUSSION: Obtaining an early MRI was not associated with the reamputation rate incidence in the treatment of the diabetic foot. It did, however, have a statistically significant association with the mortality rate as demonstrated by the increased survival rate in patients undergoing MRI prior to initial amputation.

Medical Infrared Imaging of Normal and Dysplastic Elbows in Dogs.

OBJECTIVE: To investigate the ability of medical infrared imaging to differentiate between normal canine elbows and those with abnormal elbows (elbow dysplasia). STUDY DESIGN: Prospective cohort study. ANIMALS: Dogs with normal (n = 15) and abnormal (n = 14) elbows. METHODS: Infrared imaging was performed on all dogs and data analyzed via descriptive statistics and image pattern analysis software. Animals with elbow dysplasia had arthroscopic procedures to confirm the presence of elbow disease. RESULTS: Computer recognition pattern analysis was up to 100% correct in identifying abnormal elbows and normal elbows, with the medial images most consistent. The caudal, lateral, and cranial images correctly identified 83-100% abnormal elbows. The caudal and lateral images correctly identified 83% normal elbows. A significant difference in temperature was found between normal and abnormal elbows for the cranial full region of interest, lateral images, and each quadrant. CONCLUSION: Medical infrared imaging was able to correctly identify known abnormal and known normal elbows in dogs.

Acute surgical pulmonary embolectomy: a 9-year retrospective analysis.

Acute pulmonary embolism is a substantial cause of morbidity and death. Although the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines recommend surgical pulmonary embolectomy in patients with acute pulmonary embolism associated with hypotension, there are few reports of 30-day mortality rates. We performed a retrospective review of acute pulmonary embolectomy procedures performed in 96 consecutive patients who had severe, globally hypokinetic right ventricular dysfunction as determined by transthoracic echocardiography. Data on patients who were treated from January 2003 through December 2011 were derived from health system databases of the New York State Cardiac Surgery Reporting System and the Society of Thoracic Surgeons. The data represent procedures performed at 3 tertiary care facilities within a large health system operating in the New York City metropolitan area. The overall 30-day mortality rate was 4.2%. Most patients (68 [73.9%]) were discharged home or to rehabilitation facilities (23 [25%]). Hemodynamically stable patients with severe, globally hypokinetic right ventricular dysfunction had a 30-day mortality rate of 1.4%, with a postoperative mean length of stay of 9.1 days. Comparable findings for hemodynamically unstable patients were 12.5% and 13.4 days, respectively. Acute pulmonary embolectomy can be a viable procedure for patients with severe, globally hypokinetic right ventricular dysfunction, with or without hemodynamic compromise; however, caution is warranted. Our outcomes might be dependent upon institutional capability, experience, surgical ability, and careful patient selection.

Medical infrared imaging (thermography) of type I thoracolumbar disk disease in chondrodystrophic dogs.

OBJECTIVE: To: (1) determine the success of medical infrared imaging (MII) in identifying dogs with TLIVDD, (2) compare MII localization with magnetic resonance imaging (MRI) results and surgical findings, and (3) determine if the MII pattern returns to that of normal dogs 10 weeks after decompression surgery. STUDY DESIGN: Prospective case series. ANIMALS: Chondrodystrophic dogs (n = 58) with Type I TLIVDD and 14 chondrodystrophic dogs with no evidence of TLIVDD. METHODS: Complete neurologic examination, MII, and MRI studies were performed on all dogs. Dogs with type I TLIVDD had decompressive surgery and follow-up MII was performed at 10 weeks. Pattern analysis software was used to differentiate between clinical and control dogs, and statistical analysis using anatomic regions of interest on the dorsal views were used to determine lesion location. Recheck MII results were compared with control and pre-surgical images. RESULTS: Computer recognition pattern analysis was 90% successful in differentiating normal dogs from dogs affected by TLIVDD and 97% successful in identifying the abnormal intervertebral disc space in dogs with TLIVDD. Statistical comparisons of the ROI mean temperature were unable to determine the location of the disc herniation. Recheck MII patterns did not normalize and more closely resembled the clinical group. CONCLUSIONS: MII was 90% successful differentiating between normal dogs and 97% successful in identifying the abnormal intervertebral disc space in dogs with TLIVDD. Abnormal intervertebral disc space localization using ROI mean temperature analysis was not successful. MII patterns 10 weeks after surgery do not normalize.

Rapid colonoscopy preparation using bolus lukewarm saline combined with sequential posture changes: a randomized controlled trial.

OBJECTIVE: In this randomized clinical trial, we have compared the Shudh™ colon cleanse (SCC) with HalfLytely(®) colon prep (HCP) to evaluate the efficacy, bowel preparation time (BPT), adverse events, electrolyte abnormalities and patient acceptability. METHODS: Patients were randomized to receive either SCC (n = 65) or HCP (n = 68). All colonoscopies were performed by a single, blinded endoscopist. Colon prep was evaluated on a 5 point grading scale. Statistical non-inferiority was pre-defined as a difference of <15 % in the lower limit of the 95.5 % confidence interval for the treatment difference. Data that were collected include bowel prep score, BPT, adverse events, electrolyte abnormalities and patient acceptability. RESULTS: Bowel preparation efficacy was rated as "successful" for 59/65 (90.7 %) in SCC versus 66/68 (97.1 %) in HCP. This gave a success difference of -6.4 % with a 1-sided 95 % lower confidence limit (LCI) for the difference = -13.3 % (non-inferiority p = 0.25). This difference fell within the predefined limit for non-inferiority. The average BPT for SCC was 1.9 h versus 10.9 in HCP (p < 0.001). No serious adverse events were reported in either group. None of the patients in either group had any clinically significant electrolyte imbalance. Patient ratings for palatability and willingness to repeat were significantly better for SCC (p < 0.05). CONCLUSION: SCC was found to not be inferior to PEG with regards to the quality of bowel preparation. It is worth highlighting that a major advantage of SCC is shorter BPT.

Ethnicity, race, and advance directives in an inpatient palliative care consultation service.

OBJECTIVE: Although race and ethnic background are known to be important factors in the completion of advance directives, there is a dearth of literature specifically investigating the effect of race and ethnicity on advance directive completion rate after palliative care consultation (PCC). METHOD: A chart review of all patients seen by the PCC service in an academic hospital over a 9-month period was performed. Data were compiled using gender, race, ethnicity, religion, and primary diagnosis. For this study, advance directives were defined as: "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI). RESULTS: Of the 400 medical records reviewed, 57% of patients were female and 71.3% documented their religion as Christian. The most common documented diagnosis was cancer (39.5%). Forty-seven percent reported their race as white. White patients completed more advance directives than did nonwhite patients both before (25.67% vs. 12.68%) and after (59.36% vs. 40.84%) PCC. There was a significantly higher proportion of whites who signed an advance directive after a PCC than of nonwhites (p = 0.021); of the 139 whites who did not have an advance directive at admission, 63 signed an advance directive after a PCC compared with 186/60 nonwhites (45% vs. 32%, respectively, p = 0.021). Further analysis revealed that African Americans differed from whites in the likelihood of advance directive execution rates pre-PCC, but not post-PCC. SIGNIFICANCE OF RESULTS: This study demonstrates the impact of a PCC on the completion of advance directives, on both whites and nonwhites. The PCC Intervention significantly reduced differences between whites and African Americans in completing advance directives, which have been consistently documented in the end-of-life literature.

Our experience with two cardioplegic solutions: dextrose versus non-dextrose in adult cardiac surgery.

Intraoperative hyperglycemia has been observed to be associated with increased morbidity and mortality after cardiac surgery. Dextrose cardioplegia is used for its cardioprotective effects but may lead to intraoperative hyperglycemia and more postoperative complications. This was a retrospective observational study. Patient records (n = 2301) were accessed from a large database at a tertiary care facility. The two groups (dextrose vs. nondextrose) were then matched using preoperative variables of age, sex, body mass index, wound exposure time, preoperative HbA1c levels, renal failure, hypertension, and prior cerebrovascular disease. The following outcomes were recorded: 30-day mortality, sternal wound infection, stroke, and highest glucose level on cardiopulmonary bypass. The dextrose cardioplegia group showed statistically higher intraoperative glucose levels (272.76 +/- 55.92 vs. 182.79 +/- 45, p value = .0001). There was no difference in postoperative mortality, sternal wound infections or stroke incidence, nor in other secondary outcomes. The type of cardioplegia solution was shown to affect glucose levels; however, there was no effect on postoperative complication rates.

Risk factors and clinical relevance of positive intraoperative bacterial cultures in dogs with total hip replacement.

OBJECTIVE: To report incidence and relevance of positive intraoperative total hip replacement (THR) bacterial cultures taken at the time of surgical closure in dogs having unilateral THR. STUDY DESIGN: Retrospective case series. ANIMALS: Dogs (n = 100) with cemented (CFX), cementless (BFX), or hybrid THR. METHODS: Medical records (January 2007-March 2010) of dogs that had THR were reviewed. Signalment, type and side of THR, concurrent surgery, operative and anesthetic times, intraoperative coxofemoral closing (CC) bacterial culture results, organism cultured, duration of postoperative antibiotic administration, physical examination findings at 3 weeks, 3 months, and at 6 months to 1 year after surgery, radiographic findings at 3 months and between 6 months and 1 year after surgery, and incidence of complications were retrieved. RESULTS: There was a significant difference in duration of surgery between CC culture negative and CC culture positive groups (103.27 minutes versus 122.50 minutes, respectively, P < .038) and in total anesthetic time between CC culture negative and culture positive groups (165.20 minutes versus 189.50 minutes, respectively, P < .038). There was no significant difference between CC culture negative and culture positive groups for median age (30 months versus 39 months, respectively, P < .75), median weight (36.91 kg versus 35.68 kg, respectively, P < .61), median clinical signs (4 months versus 3.5 months, respectively, P < .65), sex (males 44.32% versus females 25.00%, respectively, P < .20), laterality (left 55.68% versus right 50.00%, respectively, P < .71), concurrent surgery (extracapsular lateral imbrication/medial patella luxation/lateral patella luxation [ECLI/MPL/LPL] 22.73% versus none 25.00%, respectively, P < 1.00), and THR type (hybrid 17.05% versus 25.00% respectively; CFX 60.23% versus 75.0%; BFX 22.73% versus 0.0%; Fisher's exact test P < .17). CONCLUSIONS: Surgical and anesthetic duration were significantly associated with positive CC culture results. Positive CC culture results were not associated with adverse results at 3 months and at 6-month to 1-year follow-up evaluation.

The impact of a palliative care unit on mortality rate and length of stay for medical intensive care unit patients.

OBJECTIVE: This study evaluates the impact of a 10-bed inpatient palliative care unit (PCU) on medical intensive care unit (MICU) mortality and length of stay (LOS) for terminally ill patients following the opening of an inpatient PCU. We hypothesized that MICU mortality and LOS would be reduced through the creation of a more appropriate location of care for critically ill MICU patients who were dying. METHOD: We performed a retrospective electronic database review of all MICU discharges from January 1, 2006 through December 31, 2009 (5,035 cases). Data collected included MICU mortality, MICU LOS, and mean age. The PCU opened on January 1, 2008. We compared location of death for MICU patients during the 2-year period before and the 2-year period after the opening of the PCU. RESULTS: Our data showed that the mean MICU mortality and MICU LOS both significantly decreased following the opening of the PCU, from 21 to 15.8% (p = 0.003), and from 4.6 to 4.0 days (p = 0.014), respectively. SIGNIFICANCE OF RESULTS: The creation of an inpatient PCU resulted in a statistically significant reduction in both MICU mortality rate and MICU LOS, as terminally ill patients were transitioned out of the MICU to the PCU for end-of-life care. Our data support the hypothesis that a dedicated inpatient PCU, capable of providing care to patients requiring mechanical ventilation or vasoactive agents, can protect terminally ill patients from an ICU death, while providing more appropriate care to dying patients and their loved ones.

Predictors of insulin resistance in the obese with metabolic syndrome.

BACKGROUND: In the obese, the metabolic syndrome (MetS) is assumed to reflect insulin resistance. OBJECTIVE: To determine the predictors of insulin resistance in obese subjects with MetS. DESIGN: We used the 90th percentile of the homeostasis model assessment (HOMA) to define insulin resistance in 4958 nondiabetic adults evaluated in the National Health and Nutrition Examination Surveys, 1999-2004, and compared the 373 obese subjects who were insulin-resistant (HOMA 9.52+/-5.73) to a control group of 373 obese who had the highest sensitivity to insulin (HOMA 1.79+/-0.44). MEASUREMENTS: MetS was present in 312 (83.6%) obese with insulin resistance and in 156 (41.8%) obese from the insulin-sensitive control group. Demographic, metabolic, and lifestyle variables were analyzed with logistic regression. RESULTS: In a logistic model of insulin resistance given the presence of MetS, the significant predictors were triglycerides (P=0.0021), body mass index (P=0.0096), HDL-cholesterol (P=0.0098), age (P=0.0242) and smoking (P=0.0366). LIMITATIONS: Cross-sectional design prevents elucidation of causality for the association between insulin resistance and MetS. CONCLUSIONS: Insulin resistance is not an obligatory correlate of MetS in the obese. Its likelihood can be predicted by cigarette smoking and by the severity of obesity and dyslipidemia.

Altered dynamics of intestinal cell maturation in Apc1638N/+ mice.

Novel imaging of active transcription sites in interphase nuclei of intestinal epithelial cells in situ showed that key genes associated with Wnt and Notch signaling were dynamically regulated as the cells underwent normal maturation during their migration along the mouse crypt-villus axis (CVA). However, oscillating patterns of activation of these genes were displaced along this axis in the histologically normal intestinal mucosa of Apc(1638N/+) mice before tumor development. Gene expression profiling then showed that the normal reprogramming of cells along the CVA was dampened in the Apc(1638N/+) mice, with an overrepresentation of c-myc target genes among those loci affected in the mutant mice. Moreover, in the Apc(1638N/+) mice, there was a perturbed pattern of expression of lineage-specific markers along the CVA consistent with transcription site repression of the Math1 gene, and genes encoding enzymes of every step of the tricarboxylic acid cycle were downregulated in the crypt of Apc(1638N/+) mice compared with WT, but not in the villus. These changes may alter energy metabolism and generate a pseudohypoxic state, suggested by elevated expression of Hif1alpha and its target genes. Thus, although intestinal tumors develop in Apc(1638N/+) mice on focal loss or inactivation of the WT allele, our results show that in the Apc(1638N/+) mouse, inheritance of only a single WT Apc allele perturbs the dynamic and complex reprogramming underlying normal cell maturation, which links epithelial function and homeostasis with architectural organization of the intestine.

Cerebral malaria is associated with low levels of circulating endothelial progenitor cells in African children.

Damage to the cerebral microvasculature is a feature of cerebral malaria. Circulating endothelial progenitor cells are needed for microvascular repair. Based on this knowledge, we hypothesized that the failure to mobilize sufficient circulating endothelial progenitor cells to the cerebral microvasculature is a pathophysiologic feature of cerebral malaria. To test this hypothesis, we compared peripheral blood levels of CD34 (+)/VEGFR2(+) and CD34 (+)/CD133(+) cells and plasma levels of the chemokine stromal cell-derived growth factor 1 (SDF-1) in 214 children in Accra, Ghana. Children with cerebral malaria had lower levels of CD34 (+)/VEGFR2(+) and CD34 (+)/CD133(+) cells compared with those with uncomplicated malaria, asymptomatic parasitemia, or healthy controls. SDF-1 levels were higher in children with acute malaria compared with healthy controls. Together, these results uncover a potentially novel role for endothelial progenitor cell mobilization in the pathophysiology of cerebral malaria.