Textbook outcome: A novel metric in heart transplantation outcomes.

OBJECTIVE: Assessing heart transplant program quality using short-term survival is insufficient. We define and validate the composite metric textbook outcome and examine its association with overall survival. METHODS: We identified all primary, isolated adult heart transplants in the United Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files from May 1, 2005, to December 31, 2017. Textbook outcome was defined as length of stay 30 days or less; ejection fraction greater than 50% during 1-year follow-up; functional status 80% to 100% at 1 year; freedom from acute rejection, dialysis, and stroke during the index hospitalization; and freedom from graft failure, dialysis, rejection, retransplantation, and mortality during the first year post-transplant. Univariate and multivariate analyses were performed. Factors independently associated with textbook outcome were used to create a predictive nomogram. Conditional survival at 1 year was measured. RESULTS: A total of 24,620 patients were identified with 11,169 (45.4%, 95% confidence interval, 44.7-46.0) experiencing textbook outcome. Patients with textbook outcome were more likely free from preoperative mechanical support (odds ratio, 3.504, 95% confidence interval, 2.766 to 4.439, P < .001), free from preoperative dialysis (odds ratio, 2.295, 95% confidence interval, 1.868-2.819, P < .001), to be not hospitalized (odds ratio, 1.264, 95% confidence interval, 1.183-1.349, P < .001), to be nondiabetic (odds ratio, 1.187, 95% confidence interval, 1.113-1.266, P < .001), and to be nonsmokers (odds ratio, 1.160, 95% confidence interval,1.097-1.228, P < .001). Patients with textbook outcome have improved long-term survival relative to patients without textbook outcome who survive at least 1 year (hazard ratio for death, 0.547, 95% confidence interval, 0.504-0.593, P < .001). CONCLUSIONS: Textbook outcome is an alternative means of examining heart transplant outcomes and is associated with long-term survival. The use of textbook outcome as an adjunctive metric provides a holistic view of patient and center outcomes.

The Host-Microbiome Response to Hyperbaric Oxygen Therapy in Ulcerative Colitis Patients.

BACKGROUND & AIMS: Hyperbaric oxygen therapy (HBOT) is a promising treatment for moderate-to-severe ulcerative colitis. However, our current understanding of the host and microbial response to HBOT remains unclear. This study examined the molecular mechanisms underpinning HBOT using a multi-omic strategy. METHODS: Pre- and post-intervention mucosal biopsies, tissue, and fecal samples were collected from HBOT phase 2 clinical trials. Biopsies and fecal samples were subjected to shotgun metaproteomics, metabolomics, 16s rRNA sequencing, and metagenomics. Tissue was subjected to bulk RNA sequencing and digital spatial profiling (DSP) for single-cell RNA and protein analysis, and immunohistochemistry was performed. Fecal samples were also used for colonization experiments in IL10-/- germ-free UC mouse models. RESULTS: Proteomics identified negative associations between HBOT response and neutrophil azurophilic granule abundance. DSP identified an HBOT-specific reduction of neutrophil STAT3, which was confirmed by immunohistochemistry. HBOT decreased microbial diversity with a proportional increase in Firmicutes and a secondary bile acid lithocholic acid. A major source of the reduction in diversity was the loss of mucus-adherent taxa, resulting in increased MUC2 levels post-HBOT. Targeted database searching revealed strain-level associations between Akkermansia muciniphila and HBOT response status. Colonization of IL10-/- with stool obtained from HBOT responders resulted in lower colitis activity compared with non-responders, with no differences in STAT3 expression, suggesting complementary but independent host and microbial responses. CONCLUSIONS: HBOT reduces host neutrophil STAT3 and azurophilic granule activity in UC patients and changes in microbial composition and metabolism in ways that improve colitis activity. Intestinal microbiota, especially strain level variations in A muciniphila, may contribute to HBOT non-response.

Impairments in episodic future thinking for positive events and anticipatory pleasure in major depression.

BACKGROUND: Characteristic of the cardinal symptom of anhedonia, people with clinical depression report lower levels of anticipatory pleasure. However, the psychological mechanisms underlying these deficits are poorly understood. This is the first study to assess whether, and to what extent, phenomenological characteristics of episodic future thinking for positive future events are associated with anticipatory pleasure among depressed individuals. METHODS: Individuals with a Major Depressive Episode (MDE; N = 117) and without (N = 47) completed ratings scales for depressive symptoms and trait anticipatory and consummatory pleasure. They then provided descriptions of personally-relevant positive future events and rated them for phenomenological characteristics and state anticipatory pleasure. RESULTS: Between-groups analysis showed that those with MDE reported lower trait anticipatory and consummatory pleasure. They also simulated future events with less specificity, less detail/vividness, less use of mental imagery, less use of first-person perspective, less plausibility/perceived likelihood of occurring, and reported less associated state anticipatory pleasure. In regression analyses in the depressed group, lower scores for detail/vividness, mental imagery, and personal significance all uniquely predicted lower state anticipatory pleasure. LIMITATIONS: Cognitive functioning was not assessed, which may help clarify deficits that underpin these findings. History of previous depressive episodes in the comparison group were not assessed, which may mean the observed between-group effects are underestimated. CONCLUSIONS: This study provides further evidence of deficits in episodic future thinking and anticipatory pleasure in depressed individuals. It also establishes links between particular characteristics of episodic future thinking and state anticipatory pleasure, and indicates cognitive targets that may be amenable to intervention in order to reduce anhedonia.

Hydrologic and water quality performance of two aging and unmaintained dry detention basins receiving highway stormwater runoff.

Dry detention basins (DDBs) are a type of stormwater control measure (SCM) designed to provide flood storage, peak discharge reduction, and some water quality improvement through sedimentation. DDBs are ubiquitous in the urban environment, but are expensive to maintain. In this study, two overgrown DDBs near Raleigh, NC, receiving highway runoff were monitored for up to one year to quantify their water quality and hydrologic performance. Both basins, B1 and B2, have not received vegetation maintenance since construction in 2007. Flow-weighted composite samples were collected during storm events and analyzed for nutrients (Total Phosphorus (TP), Ortho-phosphorus (OP), Ammonia-N (NH3), NO2-3-N (NOX), and Total Kjeldahl Nitrogen (TKN)), total suspended solids (TSS), and total Cd, Cu, Pb, and Zn. An annual water balance was also conducted to quantify runoff volume reduction. Despite low influent concentrations from the highway, significant removal efficiencies were found for all constituents except NH3 in B1. TP, OP, NOX, TSS, and Zn were reduced in B2. Both basins achieved greater than 41% volume reduction through soil infiltration and evapotranspiration, resulting in significant pollutant load reductions for all detected constituents, between 59% and 79% in B1 and 35% and 81% in B2. This study provides evidence that overgrown and unmaintained DDBs can reduce pollutant concentrations comparable to those reported for maintained DDBs, while reducing more volume than standard DDBs. Moreover, carbon sequestration likely increases while maintenance costs decrease.

Integrated Practice Units: What Are They and How Can They Be Applied to Orthopaedic Trauma?

Musculoskeletal professionals are looking for opportunities to provide integrated patient-centered models of care. Integrated practice units (IPUs) are structurally and functionally organized around the patient's medical condition over a full cycle of care with a comprehensive range of services delivered by dedicated multidisciplinary teams. Although IPUs have been developed for chronic orthopaedic conditions, such as hip and knee osteoarthritis, relatively little has been explored in relation to orthopaedic trauma. Development of novel IPUs for managing musculoskeletal injuries may help surgeons to better contend with the substantial burden associated with these conditions on the quality of life of individual patients and society at large. This review explores the challenges and unmet needs unique to orthopaedic trauma that could be bridged by high-value, integrated patient-centered models of care. It also provides a framework for the design and implementation of IPUs and the rationale of this framework in 3 major populations: ambulatory trauma, fragility fractures, and complex polytrauma. To conclude, in this review, we consider the mechanism and impact of alternative payment models in this setting.

Sex differences in the regulation of brain IL-1ß in response to chronic stress.

Elevations in brain interleukin-1 beta (IL-1ß) during chronic stress exposure have been implicated in behavioral and cognitive impairments associated with depression and anxiety. Two critical regulators of brain IL-1ß production during times of stress are glucocorticoids and catecholamines. These hormones work in opposition to one another to inhibit (via glucocorticoid receptors) or stimulate (via beta-adrenergic receptors: ß-AR) IL-1ß production. While chronic stress often heightens both corticosterone and catecholamine levels, it remains unknown as to how chronic stress may affect the "yin-yang" balance between adrenergic stimulation and glucocorticoid suppression of brain IL-1ß. To investigate this further, male and female rats underwent 4 days of stress exposure or served as non-stressed controls. On day 5, animals were administered propranolol (ß-AR antagonist), metyrapone (a glucocorticoid synthesis inhibitor), vehicle, or both drugs and brain IL-1ß mRNA was measured by rtPCR in limbic brain areas. In males, administration of propranolol had no effect on IL-1ß expression in non-stressed controls but significantly reduced IL-1ß in the hippocampus and amygdala of chronically stressed animals. In females, propranolol significantly reduced IL-1ß in the amygdala and hypothalamus of both control and stressed rats. In male rats, metyrapone treatment significantly increased IL-1ß mRNA regardless of stress treatment in all brain areas, while in female rats metyrapone only increased IL-1ß in the hypothalamus. Interestingly, propranolol treatment blocked the metyrapone-induced increase in brain IL-1ß indicating the increase in brain IL-1ß following metyrapone treatment was due to increase ß-AR activation. Additional studies revealed that metyrapone significantly increases norepinephrine turnover in the hypothalamus and medial prefrontal cortex in male rats and that microglia appear to be the cell type contributing to the production of IL-1ß. Overall, data reveal that stress exposure in male rats affects the regulation of brain IL-1ß by the norepinephrine-ß-AR pathway, while stress had no effect in the regulation of brain IL-1ß in female rats.

Referrals of Plastic Surgery Patients to Integrative Medicine Centers: A Review of Resource Utility.

BACKGROUND: Integrative medicine (IM) centers are becoming more established nationwide and provide an expansive range of therapeutic services. Given the high prevalence of IM usage among plastic surgery patients, we sought to define referrals rates to IM centers by plastic surgeons to investigate (1) the role of IM in the continuous care process of plastic surgery patients and (2) whether IM centers are being effectively utilized. METHODS: Institutions with plastic surgery residency programs were identified using the American Medical Association's Fellowship and Residency Electronic Interactive Database Access System in January 2017. Data on the presence of a named IM center, director/administrator contact information, and types of therapeutic services offered were extracted. The total number of IM services at these centers was summed and tabulated for preliminary analyses. A survey questionnaire was sent to the center to ascertain referral patterns in February 2017. RESULTS: Of 96 institutions with plastic and reconstructive surgery residency programs in North America, 49 (51%) provide IM services, and 24 (25%) have affiliated named IM centers of which we attained a survey response from 13 (54.5%). Of these centers, 10 (76.9%) evaluate more than 50 patients per week. Patient referrals to these centers were primarily from the department of medicine (73.8%) as opposed to surgery (13.1%) (P < 0.0001). An average of 0.77% of surgical referrals, or 0.077% of all referrals, arose from plastic and reconstructive surgery. CONCLUSIONS: Plastic surgeons appear to infrequently refer patients to IM centers. Given the high prevalence of IM usage among our patient population, IM centers are an underutilized adjunct in the care of our patients. Further study into specific IM services that may benefit our patients would be helpful in increasing IM utilization in our field.

Integrative Medicine in Plastic Surgery: A Systematic Review of Our Literature.

BACKGROUND: Surveys have reported that as high as 80% of plastic surgery patients utilize integrative medicine approaches including natural products (NPs) and mind-body practices (MBPs). Little is known regarding the evidence of benefit of these integrative therapies specifically in a plastic surgery patient population. METHODS: We conducted a systematic review of studies in MEDLINE, PubMed, and EMBASE (inception through December 2016) evaluating integrative medicine among plastic surgery patients. Search terms included 76 separate NP and MBP interventions as listed in the 2013 American Board of Integrative Health Medicine Curriculum. Two independent reviewers extracted data from each study, including study type, population, intervention, outcomes, conclusions (beneficial, harmful, or neutral), year of publication, and journal type. Level of evidence was assessed according to the American Society of Plastic Surgeons Rating Levels of Evidence and Grading Recommendations. RESULTS: Of 29 studies analyzed, 13 studies (45%) evaluated NPs and 16 (55%) studied MBPs. Level II reproducible evidence supports use of arnica to decrease postoperative edema after rhinoplasty, onion extract to improve scar pigmentation, hypnosis to alleviate perioperative anxiety, and acupuncture to improve perioperative nausea. Level V evidence reports on the risk of bleeding in gingko and kelp use and the risk of infection in acupuncture use. After year 2000, 92% of NP studies versus 44% of MBP studies were published (P = 0.008). CONCLUSIONS: High-level evidence studies demonstrate promising results for the use of both NPs and MBPs in the care of plastic surgery patients. Further study in this field is warranted.

Examining the mediational role of psychological flexibility, pain catastrophizing, and visceral sensitivity in the relationship between psychological distress, irritable bowel symptom frequency, and quality of life.

The aim of the current study was to use Structural Equation Modelling (SEM) to examine whether psychological flexibility (i.e. mindfulness, acceptance, valued-living) mediates the relationship between distress, irritable bowel syndrome (IBS) symptom frequency, and quality of life (QoL). Ninety-two individuals participated in the study (12 male, 80 female, Mage = 36.24) by completing an online survey including measures of visceral sensitivity, distress, IBS-related QoL, mindfulness, bowel symptoms, pain catastrophizing, acceptance, and valued-living. A final model with excellent fit was identified. Psychological distress significantly and directly predicted pain catastrophizing, valued-living, and IBS symptom frequency. Pain catastrophizing directly predicted visceral sensitivity and acceptance, while visceral sensitivity significantly and directly predicted IBS symptom frequency and QoL. Symptom frequency also had a direct and significant relationship with QoL. The current findings suggest that interventions designed to address unhelpful cognitive processes related to visceral sensitivity, pain catastrophizing, and psychological distress may be of most benefit to IBS-related QoL.

Audiologic characteristics in a sample of recently-separated military Veterans: The Noise Outcomes in Servicemembers Epidemiology Study (NOISE Study).

Military Service Members are often exposed to high levels of occupational noise, solvents, and other exposures that can be damaging to the auditory system. Little is known about hearing loss and how it progresses in Veterans following military service. This epidemiology study is designed to evaluate and monitor a cohort of Veterans for 20 years or more to determine how hearing loss changes over time and how those changes are related to noise exposure and other ototoxic exposures encountered during military service. Data reported here are from baseline assessments of the first 100 study participants (84 males; 16 females; mean age 33.5 years; SD 8.8; range 21-58). Each participant was asked to complete a comprehensive audiologic examination and self-report questionnaires regarding sociodemographic characteristics, noise and solvent exposures, health conditions common among post-deployment Veterans, and the social and emotional consequences of hearing loss. For this relatively young cohort, 29% exhibited hearing loss, defined as average hearing threshold >20 dB HL in the conventional audiometric range. Forty-two percent exhibited hearing loss in the extended-high-frequency audiometric range using the same criterion (average hearing threshold >20 dB HL). Certain factors were found to be associated with poorer hearing in both conventional and extended-high-frequency ranges, including age, type of military branch, years of military service, number of military deployments, noise exposure, tinnitus, and a positive screen for post-traumatic stress disorder. Although the majority of participants had hearing within normal limits, 27% reported a self-perceived mild/moderate hearing handicap and 14% reported a significant handicap. Further research is needed to identify a cause for this discrepancy in audiologic results versus self-report. The information obtained from this longitudinal study could be used in future resource planning with the goal of preventing, as much as possible, the development of hearing loss during military service, and the exacerbation of prevalent hearing loss after military service and over Veterans' lifetimes.

Mechanical bowel preparation before laparoscopic hysterectomy: a randomized controlled trial.

OBJECTIVE: To examine the influence of mechanical bowel preparation on surgical field visualization during laparoscopic hysterectomy. METHODS: The study's primary outcome was the percentage of operations rated "good" or "excellent" in terms of surgical field visualization at the outset of the case by the primary surgeon. Additional measures included assessment of visualization during the case and patient perioperative comfort. The study was powered to detect a 20% absolute difference in the proportion of cases rated as "good" or "excellent." RESULTS: Seventy-three patients were assigned to mechanical bowel preparation and 73 to no mechanical bowel preparation. The groups were comparable regarding patient and surgery characteristics. No differences were found for this rating between groups (mechanical bowel preparation, 64 of 73 patients [87.7%], compared with no mechanical bowel preparation, 60 of 73 patients [82.2%], P=.36). Surgeons guessed patient assignment correctly 59% of the time (42 of 71 patients) with mechanical bowel preparation and 55% of the time (41 of 75 patients) with no mechanical bowel preparation. CONCLUSION: Mechanical bowel preparation is well-tolerated but does not influence surgical field visualization for laparoscopic hysterectomy. CLINICAL TRIAL REGISTRATION: ClinialTrials.gov, www.clinicaltrials.gov, NCT01576965.

Essential amino acid supplementation in patients following total knee arthroplasty.

BACKGROUND: By the year 2030, 3.48 million older U.S. adults are projected to undergo total knee arthroplasty (TKA). Following this surgery, considerable muscle atrophy occurs, resulting in decreased strength and impaired functional mobility. Essential amino acids (EAAs) have been shown to attenuate muscle loss during periods of reduced activity and may be beneficial for TKA patients. METHODS: We used a double-blind, placebo-controlled, randomized clinical trial with 28 older adults undergoing TKA. Patients were randomized to ingest either 20 g of EAAs (n = 16) or placebo (n = 12) twice daily between meals for 1 week before and 2 weeks after TKA. At baseline, 2 weeks, and 6 weeks after TKA, an MRI was performed to determine mid-thigh muscle and adipose tissue volume. Muscle strength and functional mobility were also measured at these times. RESULTS: TKA patients receiving placebo exhibited greater quadriceps muscle atrophy, with a -14.3 ± 3.6% change from baseline to 2 weeks after surgery compared with -3.4 ± 3.1% for the EAA group (F = 5.16, P = 0.036) and a -18.4 ± 2.3% change from baseline to 6 weeks after surgery for placebo versus -6.2 ± 2.2% for the EAA group (F = 14.14, P = 0.001). EAAs also attenuated atrophy in the nonoperated quadriceps and in the hamstring and adductor muscles of both extremities. The EAA group performed better at 2 and 6 weeks after surgery on functional mobility tests (all P < 0.05). Change in quadriceps muscle atrophy was significantly associated with change in functional mobility (F = 5.78, P = 0.021). CONCLUSION: EAA treatment attenuated muscle atrophy and accelerated the return of functional mobility in older adults following TKA. TRIAL REGISTRATION: Clinicaltrials.gov NCT00760383.

The relationship between diet and breast cancer in men (United States).

OBJECTIVES: The purpose of this paper was to investigate the relationship between food and beverage consumption and the development of breast cancer in men. METHODS: Possible relationships of dietary factors to risk of breast cancer in men were assessed in a case-control study conducted between 1983 and 1986. Cases (N = 220) were ascertained from ten population-based cancer registries. Controls (N = 291) were selected by random-digit dialing (< age 65) and from Health Care Financing Administration Medicare beneficiary lists (> or = age 65). RESULTS: No trends in risk were observed with increasing intakes of specific foods, except for an increase in risk with citrus fruits. No increase in risk with increasing amounts of specific fats, vitamins, or minerals or with amounts of protein, fiber, carbohydrate, starches, nitrites, or alcohol consumed was observed, except for an increase in risk with dietary vitamin C consumption. A decreasing trend in risk with dietary niacin and with coffee and an increasing trend in risk with tea consumption were observed. No associations were found with use of any dietary supplements, including vitamin C. CONCLUSIONS: The observed associations are not consistent with findings from studies of breast cancer in women and probably do not represent causal relationships. Dietary factors are unlikely to be strong determinants of breast cancer in men.

Triaging patients in the latent phase of labor.

Many pregnant women who present to a hospital triage area, office, or clinic setting, or seek advice from a midwife by telephone, require early labor assessment. This article reviews parameters for normal and abnormal latent phase labor and discusses triage assessment and management strategies for the patient in latent phase labor.

Dietary factors and second primary cancers: a follow-up of oral and pharyngeal cancer patients.

To investigate the possible relationship between dietary factors and the development of multiple primary cancer, a nested case-control study was carried out within a cohort of 1,090 oral and pharyngeal cancer patients. This patient group, enrolled in 1984-1985 in a population-based case-control study conducted in four areas of the United States, was followed up through June 1989 for the occurrence of second primary cancer. Information on a number of risk factors, including diet, ascertained from interviews conducted at baseline (1984-1985) and at follow-up were compared between 80 patients with histologically confirmed second primary cancers (39% in the upper aerodigestive tract, 32% in the lung, 29% elsewhere) and 189 sex- and survival-matched control patients free of second cancers. Although few significant trends emerged, the results were suggestive of a protective effect provided by higher intake of vegetables. Risk of second primary cancers was 40-60% lower among those with the highest levels of intake for total vegetables and most vegetable subgroups, including dark yellow, cruciferous, and green leafy vegetables and legumes. Risks were also nonsignificantly lower among those with high consumption of vitamin C and carotenoids, with the adverse effects of alcohol being most evident among heavy drinkers with low vitamin C or carotenoid intake. There was also some evidence of an interaction between smoking and vitamin C consumption, but numbers of nonsmokers were small. Among other dietary factors considered, positive associations were found with increasing consumption of meats, liver, and retinol. The findings suggest that dietary factors contribute along with alcohol and smoking to the excess risks of second primary cancers among patients with oral and pharyngeal cancers.