Historical baleen plates indicate that once abundant Antarctic blue and fin whales demonstrated distinct migratory and foraging strategies.

Southern hemisphere blue (Balaenoptera musculus intermedia) and fin (Balaenoptera physalus) whales are the largest predators in the Southern Ocean, with similarities in morphology and distribution. Yet, understanding of their life history and foraging is limited due to current low abundances and limited ecological data. To address these gaps, historic Antarctic blue (n = 5) and fin (n = 5) whale baleen plates, collected in 1947-1948 and recently rediscovered in the Smithsonian National Museum of Natural History, were analyzed for bulk (δ13C and δ15N) stable isotopes. Regular oscillations in isotopic ratios, interpreted as annual cycles, revealed that baleen plates contain approximately 6 years (14.35 ± 1.20 cm year-1) of life history data in blue whales and 4 years (16.52 ± 1.86 cm year-1) in fin whales. Isotopic results suggest that: (1) while in the Southern Ocean, blue and fin whales likely fed at the same trophic level but demonstrated niche differentiation; (2) fin whales appear to have had more regular annual migrations; and (3) fin whales may have migrated to ecologically distinct sub-Antarctic waters annually while some blue whales may have resided year-round in the Southern Ocean. These results reveal differences in ecological niche and life history strategies between Antarctic blue and fin whales during a time period when their populations were more abundant than today, and before major human-driven climatic changes occurred in the Southern Ocean.

Was It Worth It? Critical Evaluation of a Novel Outcomes Measure in Oncologic Palliative Surgery.

BACKGROUND: Patient selection for palliative surgery is complex, and appropriate outcomes measures are incompletely defined. We explored the usefulness of a specific outcomes measure "was it worth it" in patients after palliative-intent operations for advanced malignancy. STUDY DESIGN: A retrospective review of a comprehensive longitudinal palliative surgery database was performed at an academic tertiary care center. All patients who underwent palliative-intent operation for advanced cancer from 2003 to 2022 were included. Patient satisfaction ("was it worth it") was reported within 30 days of operation after palliative-intent surgery. RESULTS: A total of 180 patients were identified, and 81.7% self-reported that their palliative surgery was "worth it." Patients who reported that their surgery was "not worth it" were significantly older and were more likely to have recurrent symptoms and to need reoperation. There was no significant difference in overall, recurrence-free, and reoperation-free survival for patients when comparing "worth it" with "not worth it." Initial symptom improvement was not significantly different between groups. Age older than 65 years (hazard ratio 0.25, 95% CI 0.07 to 0.80, p = 0.03), family engagement (hazard ratio 6.71, 95% CI 1.49 to 31.8, p = 0.01), and need for reoperation (hazard ratio 0.042, 95% CI 0.01 to 0.16, p < 0.0001) were all independently associated with patients reporting that their operation was "worth it." CONCLUSIONS: Here we demonstrate that simply asking a patient "was it worth it" after a palliative-intent operation identifies a distinct cohort of patients that traditional outcomes measures fail to distinguish. Family engagement and durability of an intervention are critical factors in determining patient satisfaction after palliative intervention. These data highlight the need for highly individualized care with special attention paid to patients self-reporting that their operation was "not worth it."

Integrated postoperative care model for older colorectal surgery patients improves outcomes and reduces healthcare costs.

BACKGROUND: Older surgical patients have an increased risk for postoperative complications, driving up healthcare costs. We determined if postoperative co-management of older surgery patients is associated with postoperative outcomes and hospital costs. METHODS: Retrospective data were collected for patients ≥70 years old undergoing colorectal surgery at a community teaching hospital. Patient outcomes were compared between those receiving postoperative surgery co-management care through the Optimization of Senior Care and Recovery (OSCAR) program and controls who received standard of care. Main outcome measures were postoperative complications and hospital charges, 30-day readmission rate, length of stay (LOS), and transfer to intensive care during hospitalization. Multivariable linear regression was used to model total charge and multivariable logistic regression to model complications, adjusted for multiple variables (e.g., age, sex, race, body mass index, Charlson Comorbidity Index [CCI], American Society of Anesthesiologists score, surgery duration). RESULTS: All 187 patients in the OSCAR and control groups had a similar mean CCI score of 2.7 (p = 0.95). Compared to the control group, OSCAR recipients experienced less postoperative delirium (17% vs. 8%; p = 0.05), cardiac arrhythmia (12% vs. 3%; p = 0.03), and clinical worsening requiring transfer to intensive care (20% vs. 6%; p < 0.005). OSCAR group patients had a shorter mean LOS among high-risk patients (CCI ≥3) (-1.8 days; p = 0.09) and those ≥80 years old (-2.3 days; p = 0.07) compared to the control group. Mean total hospital charge was $10,297 less per patient in the OSCAR group (p = 0.01), with $17,832 less per patient with CCI ≥3 (p = 0.01), than the control group. CONCLUSIONS: A co-management care approach after colorectal surgery in older patients improves outcomes and decreases costs, with the most benefit going to the oldest patients and those with higher comorbidity scores.

Contributions of Surgical Critical Care Program Directors Society to the training of surgeons.

BACKGROUND: In 1986, Surgical Critical Care (SCC) was formally recognized as a specialty by the American Board of Surgery (ABS), however it took another two decades to develop a formal national training structure in SCC. In 2003, the program directors of SCC fellowships began to meet and the Surgical Critical Care Program Directors Society (SCCPDS) was officially formed in 2004, with recognition of the SCCPDS as a non-profit organization in 2008. Over the next several years, and in conjunction with other interested groups, such as the American Association for the Surgery of Trauma (AAST) and the Society of Critical Care Medicine (SCCM), SCCPDS created a formal curriculum, developed a unified system for the fellowship application process, and increased recruitment and match such that now approximately 1 in 6 general surgery graduates are pursuing training in SCC. In discussion with past and present leadership of SCCPDS, there are several ongoing initiatives to further improve the educational opportunities of the fellows and increase inclusion of other organizations and other specialties interested in SCC. The purpose of this article is to discuss the role of SCCPDS in the development and evolution of SCC and Acute Care Surgery (ACS) training. LEVEL OF EVIDENCE: Expert Opinion; Level V.

Deep RNA sequencing of intensive care unit patients with COVID-19.

COVID-19 has impacted millions of patients across the world. Molecular testing occurring now identifies the presence of the virus at the sampling site: nasopharynx, nares, or oral cavity. RNA sequencing has the potential to establish both the presence of the virus and define the host's response in COVID-19. Single center, prospective study of patients with COVID-19 admitted to the intensive care unit where deep RNA sequencing (> 100 million reads) of peripheral blood with computational biology analysis was done. All patients had positive SARS-CoV-2 PCR. Clinical data was prospectively collected. We enrolled fifteen patients at a single hospital. Patients were critically ill with a mortality of 47% and 67% were on a ventilator. All the patients had the SARS-CoV-2 RNA identified in the blood in addition to RNA from other viruses, bacteria, and archaea. The expression of many immune modulating genes, including PD-L1 and PD-L2, were significantly different in patients who died from COVID-19. Some proteins were influenced by alternative transcription and splicing events, as seen in HLA-C, HLA-E, NRP1 and NRP2. Entropy calculated from alternative RNA splicing and transcription start/end predicted mortality in these patients. Current upper respiratory tract testing for COVID-19 only determines if the virus is present. Deep RNA sequencing with appropriate computational biology may provide important prognostic information and point to therapeutic foci to be precisely targeted in future studies.

Outcomes of PEG placement by acute care surgeons compared to those placed by gastroenterology.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tubes are placed by gastroenterologists (GI) and surgeons throughout the country. At Rhode Island Hospital, before July of 2017, all PEGs were placed by GI. In July of 2017, in response to a growing need for PEGs, acute care surgeons (ACS) also began performing PEGs at the bedside in ICUs. The purpose of this study was to review and compare outcomes of PEG tubes placed by ACS and GI. METHODS: Retrospective chart review of patients who received a PEG placed by ACS or GI at the bedside in any ICU from December 2016 to September 2019. Charts were reviewed for the following outcomes: Success rates of placing PEG, duration of procedure, major complications, and death. Secondary outcomes included discharge disposition, and rates of comfort measures only after PEG. RESULTS: In 2017, 75% of PEGs were placed by GI and 25% surgery. In 2018, 47% were placed by GI and 53% by surgery. In 2019, 33% were placed by GI and 67% by surgery. There was no significant difference in success rates between surgery (146/156 93.6%) and GI (173/185 93.5%) (p 0.97). On average, GI performed the procedure faster than surgery [Median 10 (7-16) min vs 16 (13-21) mins, respectively, p < 0.001]. There were no significant differences between groups in any of the PEG outcomes or complications investigated. CONCLUSION: Bedside PEG tube placement appears to be a safe procedure in the ICU population. GI and Surgery had nearly identical success rates in placing PEGs. GI performed the procedure faster than surgery. There were no significant differences in the reviewed patient outcomes or complications between PEGs placed by ACS or GI. Of note, when a complication occurred, ACS PEG patients typically were managed in the OR while GI tended to re-PEG patients highlighting a potential difference in management that should be further investigated.

Predicting Anastomotic Leak After Elective Colectomy: Utility of a Modified Frailty Index.

BACKGROUND: Anastomotic leak is the most dreaded complication following colonic resection. While patient frailty is increasingly being recognized as a risk factor for surgical morbidity and mortality, the current colorectal body of literature has not assessed the relationship between frailty and anastomotic leak. OBJECTIVE: Evaluate the relationship between patient frailty and anastomotic leak as well as patient frailty and failure to rescue in patients who experienced an anastomotic leak. DESIGN: Retrospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program Database from 2015 to 2017. PATIENTS: Patients with the diagnosis of colonic neoplasia undergoing an elective colectomy during the study time period. MAIN OUTCOME MEASURE: Anastomotic leak, failure to rescue. RESULTS: A total of 30,180 elective colectomies for neoplasia were identified. The leak rate was 2.9% (n = 880). Compared to nonfrail patients, frail patients were at increased odds of anastomotic leak (frailty score = 1: OR 1.34, 95% CI 1.10-1.63; frailty score = 2: OR 1.32, 95% CI 1.04-1.68; frailty score = 3: OR = 2.41, 95% CI 1.47-3.96). After an anastomotic leak, compared to nonfrail patient, a greater proportion of frail patients experienced mortality (3.4% vs 5.9%), septic shock (16.1% vs 21.0%), myocardial infarction (1.1% vs 2.9%), and pneumonia (6.8% vs 11.8%). Furthermore, the odds of mortality, septic shock, myocardial infarction, and pneumonia increased in frail patients with higher frailty scores. LIMITATIONS: Potential misclassification bias from lack of a strict definition of anastomotic leak and retrospective design of the study. CONCLUSION: Frail patients undergoing colectomy for colonic neoplasia are at increased risk of an anastomotic leak. Furthermore, once a leak occurs, they are more vulnerable to failure to rescue. See Video Abstract at http://links.lww.com/DCR/B784. PREDICCIN DE LA FUGA ANASTOMTICA DESPUS DE UNA COLECTOMA ELECTIVA UTILIDAD DE UN NDICE DE FRAGILIDAD MODIFICADO: ANTECEDENTES:La fuga anastomótica es la complicación más temida después de la resección colónica. Si bien la fragilidad del paciente se reconoce cada vez más como un factor de riesgo de morbilidad y mortalidad quirúrgicas, la bibliografía colorrectal actual no ha evaluado la relación entre la fragilidad y la fuga anastomótica.OBJETIVO:Evaluar la relación entre la fragilidad del paciente y la fuga anastomótica, así como la fragilidad del paciente y la falta de rescate en pacientes que sufrieron una fuga anastomótica.DISEÑO:Estudio de cohorte retrospectivo.AJUSTE:Base de datos del Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Estadounidense de Cirujanos de 2015 a 2017.PACIENTES:Pacientes con diagnóstico de neoplasia de colon sometidos a colectomía electiva durante el período de estudio.PRINCIPAL MEDIDA DE RESULTADO:Fuga anastomótica, falta de rescate.RESULTADOS:Se identificaron 30.180 colectomías electivas por neoplasia. La tasa de fuga fue del 2,9% (n = 880). En comparación con los pacientes no frágiles, los pacientes frágiles tenían mayores probabilidades de fuga anastomótica para (puntuación de fragilidad = 1: OR = 1,34, IC del 95%: 1,10-1,63; puntuación de fragilidad = 2: OR = 1,32, IC del 95%: 1,04- 1,68; puntuación de fragilidad = 3: OR 2,41; IC del 95%: 1,47-3,96). Después de una fuga anastomótica, en comparación con un paciente no frágil, una mayor proporción de pacientes frágiles experimentó mortalidad (3,4% frente a 5,9%), choque séptico (16,1% frente a 21,0%), infarto de miocardio (1,1% frente a 2,9%) y neumonía (6,8% vs 11,8%). Además, las probabilidades de mortalidad, choque séptico, infarto de miocardio y neumonía aumentaron en pacientes frágiles con puntuaciones de fragilidad más altas.LIMITACIONES:Posible sesgo de clasificación errónea debido a la falta de una definición estricta de fuga anastomótica, diseño retrospectivo del estudio.CONCLUSIÓN:Los pacientes frágiles sometidos a colectomía por neoplasia de colon tienen un mayor riesgo de una fuga anastomótica. Además, una vez que ocurre una fuga, son más vulnerables a fallas en el rescate. Consulte Video Resumen en http://links.lww.com/DCR/B784.

Identification and mechanistic basis of non-ACE2 blocking neutralizing antibodies from COVID-19 patients with deep RNA sequencing and molecular dynamics simulations.

Variants of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) continue to cause disease and impair the effectiveness of treatments. The therapeutic potential of convergent neutralizing antibodies (NAbs) from fully recovered patients has been explored in several early stages of novel drugs. Here, we identified initially elicited NAbs (Ig Heavy, Ig lambda, Ig kappa) in response to COVID-19 infection in patients admitted to the intensive care unit at a single center with deep RNA sequencing (>100 million reads) of peripheral blood as a diagnostic tool for predicting the severity of the disease and as a means to pinpoint specific compensatory NAb treatments. Clinical data were prospectively collected at multiple time points during ICU admission, and amino acid sequences for the NAb CDR3 segments were identified. Patients who survived severe COVID-19 had significantly more of a Class 3 antibody (C135) to SARS-CoV-2 compared to non-survivors (15059.4 vs. 1412.7, p = 0.016). In addition to highlighting the utility of RNA sequencing in revealing unique NAb profiles in COVID-19 patients with different outcomes, we provided a physical basis for our findings via atomistic modeling combined with molecular dynamics simulations. We established the interactions of the Class 3 NAb C135 with the SARS-CoV-2 spike protein, proposing a mechanistic basis for inhibition via multiple conformations that can effectively prevent ACE2 from binding to the spike protein, despite C135 not directly blocking the ACE2 binding motif. Overall, we demonstrate that deep RNA sequencing combined with structural modeling offers the new potential to identify and understand novel therapeutic(s) NAbs in individuals lacking certain immune responses due to their poor endogenous production. Our results suggest a possible window of opportunity for administration of such NAbs when their full sequence becomes available. A method involving rapid deep RNA sequencing of patients infected with SARS-CoV-2 or its variants at the earliest infection time could help to develop personalized treatments using the identified specific NAbs.

Lymphopenia following pancreaticoduodenectomy is associated with pancreatic fistula formation.

BACKGROUNDS/AIMS: Post-operative pancreatic fistulas (POPF) are a major source of morbidity following pancreaticoduodenectomy (PD). This study aims to investigate if persistent lymphopenia, a known marker of sepsis, can act as an additional marker of POPF with clinical implications that could help direct drain management. METHODS: A retrospective chart review of all patients who underwent PD in a single hospital network from 2008 to 2018. Persistent lymphopenia was defined as lymphopenia beyond post-operative day #3. RESULTS: Of the 201 patients who underwent PD during the study period 161 patients had relevant laboratory data, 81 of whom had persistent lymphopenia. 17 patients with persistent lymphopenia went on to develop a POPF, compared to 7 patients without. Persistent lymphopenia had a negative predictive value of 91.3%. Multivariate analysis revealed only persistent lymphopenia as being independently associated with POPF (HR 2.57, 95% CI 1.07-6.643, p=0.039). Patients with persistent lymphopenia were more likely to have a complication requiring intervention (56.8% vs 35.0%, p<0.001). CONCLUSIONS: Persistent lymphopenia is a readily available early marker of POPF that holds the potential to identify clinically relevant POPF in patients where no surgical drain is present, and to act as an adjunct of drain amylase helping to guide drain management.

Deep RNA Sequencing of Intensive Care Unit Patients with COVID-19.

PURPOSE: COVID-19 has impacted millions of patients across the world. Molecular testing occurring now identifies the presence of the virus at the sampling site: nasopharynx, nares, or oral cavity. RNA sequencing has the potential to establish both the presence of the virus and define the host's response in COVID-19. METHODS: Single center, prospective study of patients with COVID-19 admitted to the intensive care unit where deep RNA sequencing (>100 million reads) of peripheral blood with computational biology analysis was done. All patients had positive SARS-CoV-2 PCR. Clinical data was prospectively collected. RESULTS: We enrolled fifteen patients at a single hospital. Patients were critically ill with a mortality of 47% and 67% were on a ventilator. All the patients had the SARS-CoV-2 RNA identified in the blood in addition to RNA from other viruses, bacteria, and archaea. The expression of many immune modulating genes, including PD-L1 and PD-L2, were significantly different in patients who died from COVID-19. Some proteins were influenced by alternative transcription and splicing events, as seen in HLA-C, HLA-E, NRP1 and NRP2. Entropy calculated from alternative RNA splicing and transcription start/end predicted mortality in these patients. CONCLUSIONS: Current upper respiratory tract testing for COVID-19 only determines if the virus is present. Deep RNA sequencing with appropriate computational biology may provide important prognostic information and point to therapeutic foci to be precisely targeted in future studies. TAKE HOME MESSAGE: Deep RNA sequencing provides a novel diagnostic tool for critically ill patients. Among ICU patients with COVID-19, RNA sequencings can identify gene expression, pathogens (including SARS-CoV-2), and can predict mortality. TWEET: Deep RNA sequencing is a novel technology that can assist in the care of critically ill COVID-19 patients & can be applied to other disease.

Improving the value of palliative surgery by optimizing patient selection: The role of long-term survival on high impact palliative intent operations.

BACKGROUND: In order to better characterize outcomes of palliative surgery (PS), we evaluated patients that experienced top quartile survival to elucidate predictors of high impact PS. METHODS: All PS performed on advanced cancer patients from 2003 to 2017 were identified from a PS database. RESULTS: 167 patients were identified. Multivariate analysis demonstrated the ability to rise from a chair was independently associated with top quartile survival (HR 7.61, 95% CI 2.12-48.82, p=0.008) as was the need for re-operation (HR 2.81, 95% CI 1.26-6.30, p=0.0012). Patients who were able to rise from a chair had significantly prolonged overall survival (320 vs 87 days, p < 0.001). CONCLUSIONS: Although not the primary goal, long-term survival can be achieved following PS and is associated with re-operation and the ability to rise from a chair. These patients experience the benefits of PS for a longer period of time, which in turn maximizes value and positive impact. SUMMARY: Long-term survival and symptom control can be achieved in highly selected advanced cancer patients following palliative surgery. The ability of the patient to independently rise from a chair and the provider to offer a re-operation when indicated are associated with long-term survival following a palliative operation.

Extreme diving in mammals: first estimates of behavioural aerobic dive limits in Cuvier's beaked whales.

We analysed 3680 dives from 23 satellite-linked tags deployed on Cuvier's beaked whales to assess the relationship between long duration dives and inter-deep dive intervals and to estimate aerobic dive limit (ADL). The median duration of presumed foraging dives was 59 min and 5% of dives exceeded 77.7 min. We found no relationship between the longest 5% of dive durations and the following inter-deep dive interval nor any relationship with the ventilation period immediately prior to or following a long dive. We suggest that Cuvier's beaked whales have low metabolic rates, high oxygen storage capacities and a high acid-buffering capacity to deal with the by-products of both aerobic and anaerobic metabolism, which enables them to extend dive durations and exploit their bathypelagic foraging habitats.

Inhalation injury is associated with long-term employment outcomes in the burn population: Findings from a cross-sectional examination of the Burn Model System National Database.

INTRODUCTION: Inhalation injuries carry significant acute care burden including prolonged ventilator days and length of stay. However, few studies have examined post-acute outcomes of inhalation injury survivors. This study compares the long-term outcomes of burn survivors with and without inhalation injury. METHODS: Data collected by the Burn Model System National Database from 1993 to 2019 were analyzed. Demographic and clinical characteristics for adult burn survivors with and without inhalation injury were examined. Outcomes included employment status, Short Form-12/Veterans Rand-12 Physical Composite Score (SF-12/VR-12 PCS), Short Form-12/Veterans Rand-12 Mental Composite Score (SF-12/VR-12 MCS), and Satisfaction With Life Scale (SWLS) at 24 months post-injury. Regression models were used to assess the impacts of sociodemographic and clinical covariates on long-term outcome measures. All models controlled for demographic and clinical characteristics. RESULTS: Data from 1,871 individuals were analyzed (208 with inhalation injury; 1,663 without inhalation injury). The inhalation injury population had a median age of 40.1 years, 68.8% were male, and 69% were White, non-Hispanic. Individuals that sustained an inhalation injury had larger burn size, more operations, and longer lengths of hospital stay (p<0.001). Individuals with inhalation injury were less likely to be employed at 24 months post-injury compared to survivors without inhalation injury (OR = 0.63, p = 0.028). There were no significant differences in PCS, MCS, or SWLS scores between groups in adjusted regression analyses. CONCLUSIONS: Burn survivors with inhalation injury were significantly less likely to be employed at 24 months post-injury compared to survivors without inhalation injury. However, other health-related quality of life outcomes were similar between groups. This study suggests distinct long-term outcomes in adult burn survivors with inhalation injury which may inform future resource allocation and treatment paradigms.

Lack of Lymphocyte Recovery After Esophagectomy Predicts Overall and Recurrence-Free Survival.

BACKGROUND: Lymphocytes have become the target of cancer interventions through engineering or immune checkpoint antibodies. We previously found decreased lymphocyte counts to be a predictor of mortality and complications in trauma and cardiac surgery patients. We hypothesized lack of lymphocyte count recovery postoperatively would predict outcomes in esophagectomy patients. METHODS: A retrospective review of all patients undergoing esophagectomy for adenocarcinoma performed over 13 y at our center by a single surgeon after institutional review board approval was performed. Patients were grouped by postoperative lymphocytes counts: never low, low with recovery, and low without recovery. Resolution of lymphopenia was assessed by day 4. Primary end points were overall and recurrence-free survival. RESULTS: In total, 198 patients were included with a minimum 6-mo follow-up. Collectively the 5-y recurrence and overall survival rates were 36% and 50%, respectively. Recurrence was significantly higher at 5 y in patients with persistent lymphopenia (43%) compared with those who recovered (14% P = 0.0017) and those who never dropped (0% P = 0.0009). The persistent lymphopenia group had significantly lower survival (45%) compared with the two other groups (67% P = 0.0232). CONCLUSIONS: There is a significant decrease in the overall and recurrence-free survival in those patients whose lymphocyte count drops without recovery after their esophagectomy. These data imply differences in immune responses to the stress of surgery that can be measured with routine postoperative laboratory values and are indicative of overall outcomes.

The Resident Outcome Project: Increased Academic Productivity Associated with a Formal Clinical Research Curriculum.

PURPOSE: A formal 2-year clinical research project in conjunction with a system-based practice and practice-based learning and improvement curriculum was initiated for all residents in our program. Within the structure of this formal clinical research curriculum, residents are required to develop a research hypothesis, develop an appropriate study design, collect and analyze data, and present a completed project. METHODS: At the end of the PGY1 year, residents select a project with an emphasis on quality improvement or clinical outcomes. The first 6 months of the 2-year program are dedicated to the identification of a faculty mentor and submission of a formal proposal to both the departmental education committee and to the institutional IRB. Over the following 12 months, residents meet monthly for required group research meetings. The final 6 months are focused on data analysis and project completion. RESULTS: Seventy-five residents have successfully completed the clinical research program since it was initiated in 2002. Completed projects led to abstracts accepted at 33 national or regional meetings and 11 peer reviewed publications to date. In addition, 3 major hospital wide quality improvement measures were initiated based on project findings. Following the first peer reviewed publication associated with these research projects in 2006, there have been significant increases in not only the number of accepted abstracts from these resident projects (3/18 [17%] vs 30/57 [53%], p = 0.008) but also the total number of all accepted resident clinical research (mean accepted abstracts per year 7.9 vs 1.0, p = 0.009 and mean peer reviewed publications per year 6.8 vs 2.0, p = 0.003.) DISCUSSION: Increased academic productivity was observed after a formal resident clinical research program was initiated in our program. Resident research efforts extended beyond the specific initial outcome projects as skills gained allowed for future independent clinical research.

Intoxication and Flame Burn Injuries in Young Adults in the United States.

Flame injuries are the primary cause of burns in young adults. Although drug and alcohol intoxication has been associated with other types of trauma, its role in burn injury has not been well described in this population. The purpose of this study was to investigate the association of intoxication and flame burn injuries in young adults in the United States. The 2014 Nationwide Emergency Department Sample was queried for burn injury visits of young adult patients, 13-25 years old. This data is weighted to allow for national estimates. Burn mechanism and intoxication status were determined by International Classification of Diseases, Ninth Revision codes. Multivariable logistic regression analysis was used to assess the association of intoxication and emergency department (ED) visits due to flame burns, adjusting for patient age, gender, zip code median income, zip code rural-urban designation, timing of visit, and hospital region. Further analyses assessed the odds of admission or transfer, as a possible proxy of injury severity, in patients with flame or other burns, with and without intoxication adjusting for patient age, gender, primary insurance, and hospital trauma designation. There were 20,787 visits for patients 13-25 years old with burn injuries and 12.9% (n = 2678) had a codiagnosis of intoxication. There was an increasing proportion of intoxication by age (5.8% 13-17 years old, 25% 18-20 years old, 69% 21-25 years old, P < .001). ED visits for burns with a codiagnosis of intoxication had 1.34 times ([95% confidence interval (CI): 1.18, 1.52], P < .01) higher odds of having flame burns compared to other burn mechanisms. Those with flame burns and intoxication were most likely to be admitted or transferred when compared to nonflame, nonintoxication visits in the adjusted model (odds ratio [OR] 5.49, [95% CI: 4.29, 7.02], P < .01). Furthermore, the odds of admission or transfer in visits with the combined exposure of intoxication and flame mechanism were significantly higher than visits due to nonflame burns and intoxication (OR 2.75, [2.25, 3.36], P < .01) or flame burns without intoxication (OR 3.00, [95% CI: 2.61, 3.42], P < .01). This study identified a significant association between flame-burn-related ED visits and intoxication in the young adult population in the United States. In addition, the combination of flame mechanism and intoxication appears to result in more substantial injury compared with either exposure alone. The relationship seen between intoxication and flame burn injury underscores a major target for burn prevention efforts in the young adult population.

Diving behaviour of Cuvier's beaked whales (Ziphius cavirostris) off Cape Hatteras, North Carolina.

Cuvier's beaked whales exhibit exceptionally long and deep foraging dives. The species is little studied due to their deep-water, offshore distribution and limited time spent at the surface. We used LIMPET satellite tags to study the diving behaviour of Cuvier's beaked whales off Cape Hatteras, North Carolina from 2014 to 2016. We deployed 11 tags, recording 3242 h of behaviour data, encompassing 5926 dives. Dive types were highly bimodal; deep dives (greater than 800 m, n = 1408) had a median depth of 1456 m and median duration of 58.9 min; shallow dives (50-800 m, n = 4518) were to median depths of 280 m with a median duration of 18.7 min. Most surface intervals were very short (median 2.2 min), but all animals occasionally performed extended surface intervals. We found no diel differences in dive depth or the percentage of time spent deep diving, but whales spent significantly more time near the surface at night. Other populations of this species exhibit similar dive patterns, but with regional differences in depth, duration and inter-dive intervals. Satellite-linked tags allow for the collection of long periods of dive records, including the occurrence of anomalous behaviours, bringing new insights into the lives of these deep divers.

An Assessment of Fine Surgical KnotTying.

OBJECTIVE: Operating room simulation exercises have been well established as an effective means of improving confidence, task engagement, and learning retention among surgical residents. We have established a cost-effective model and scoring system assessing resident skills to tie secure surgical knots with minimal tension. DESIGN: A circular grid divided into 18 segments was placed underlying an aluminum can. Trainees tie 20 surgical square knots scored for time and total knot length. Movement of the can outside the grid served as a scoring penalty. Recorded were time, length of the 20 knots, and number of segments exposed at exercise end. A score was developed to identify a progression of skills with PGY level. All outcomes were compared between classes using ANOVA. SETTING: Brown University/Rhode Island Hospital Department of Surgery. PARTICIPANTS: Surgical residents (PGY1-PGY5) and participating attending surgeons employed by Rhode Island Hospital. RESULTS: Knot length and exposed segments showed trends of improved scores with ascending PGY level. Only average time attained statistical significance. Overall scores improved with PGY level: Composite scores significantly improved when comparing PGY1 to PGY3, PGY5, and Attending surgeons (p = 0.016, 0.011, and 0.011, respectively). Time significantly improved when comparing PGY1 to PGY3 and Attending surgeons (77vs. 50 and 47 seconds, p = 0.019 and 0.022 respectively). Composite scores were not significantly different above PGY3. CONCLUSIONS: A low fidelity, high impact knot tying model has been developed to assess the ability to securely tie surgical knots while minimizing tension, with linear increases in scores that appear to plateau at the PGY3 level.

Population of Patients With Traumatic Brain Injury in Skilled Nursing Facilities: A Decade of Change.

OBJECTIVE: To describe the natural history of patients with traumatic brain injury (TBI) admitted to skilled nursing facilities (SNFs) following hospitalizations. SETTING: Between 2005 and 2014. PARTICIPANTS: Adults who had incident admissions to skilled nursing facilities (SNFs) with a diagnosis of TBI. DESIGN: Retrospective review of the Minimum Data Set. MAIN MEASURES: Main variables were cognitive and physical function, length of stay, presence of feeding tube, terminal condition, and dementia. RESULTS: Incident admissions to SNFs increased annually from 17 247 patients to 20 787 from 2005 to 2014. The percentage of patients with activities of daily living score 23 or more decreased from 25% to 14% (P < .05). The overall percentage of patients with severe cognitive impairment decreased from 18% to 10% (P < .05). More patients had a diagnosis of dementia in 2014 compared with previous years (P < .05), and the presence of a terminal condition increased from 1% to 1.5% over the 10-year period (P < .05). The percentage of patients who stayed fewer than 30 days was noted to increase steadily over the 10 years, starting with 48% in 2005 and ending with 53% in 2013 (P < .05). CONCLUSION: Understanding past trends in TBI admissions to SNFs is necessary to guide appropriate discharge and predict future demand, as well as inform SNF policy and practice necessary to care for this subgroup of patients.

Changes in the process of alternative RNA splicing results in soluble B and T lymphocyte attenuator with biological and clinical implications in critical illness.

BACKGROUND: Critically ill patients with sepsis and acute respiratory distress syndrome have severely altered physiology and immune system modifications. RNA splicing is a basic molecular mechanism influenced by physiologic alterations. Immune checkpoint inhibitors, such as B and T Lymphocyte Attenuator (BTLA) have previously been shown to influence outcomes in critical illness. We hypothesize altered physiology in critical illness results in alternative RNA splicing of the immune checkpoint protein, BTLA, resulting in a soluble form with biologic and clinical significance. METHODS: Samples were collected from critically ill humans and mice. Levels soluble BTLA (sBTLA) were measured. Ex vivo experiments assessing for cellular proliferation and cytokine production were done using splenocytes from critically ill mice cultured with sBTLA. Deep RNA sequencing was done to look for alternative splicing of BTLA. sBTLA levels were fitted to models to predict sepsis diagnosis. RESULTS: sBTLA is increased in the blood of critically ill humans and mice and can predict a sepsis diagnosis on hospital day 0 in humans. Alternative RNA splicing results in a premature stop codon that results in the soluble form. sBTLA has a clinically relevant impact as splenocytes from mice with critical illness cultured with soluble BTLA have increased cellular proliferation. CONCLUSION: sBTLA is produced as a result of alternative RNA splicing. This isoform of BTLA has biological significance through changes in cellular proliferation and can predict the diagnosis of sepsis.