Implementation of Positive Advanced Recovery Connections in Primary and Secondary Mental Health Care-A Registered Advanced Nurse Practitioner-Led Initiative.

AIM(S): This study reports on the implementation of a registered advanced nurse practitioner intervention. Aims include improving access, service user outcomes and integration between primary and secondary care. DESIGN: This paper reports the quantitative results of a mixed methods implementation study. Qualitative data are reported separately. The PARiHS framework informs the implementation process itself, with considerations for nurses and other healthcare professionals explored. METHODS: The CORE-OM 34 item rating scale was administered both pre- and post-intervention. Service user attendances in secondary care was monitored. RESULTS: Findings suggest that the intervention was associated with clinically significant improvements in global or generic distress, reported by service users, as evidenced by changes in the CORE-OM scores. Access to care was recorded at an average of 3.6 days. Implementation science supported effective and safe implementation with clear governance structures. CONCLUSION: Registered advanced nurse practice in mental health clinics which provide full episodes of care results in improved integration and may be associated with positive patient outcomes. Implementation science is taught on Irish nursing programmes and this is important if innovative services are to be embedded in the healthcare system. IMPACT: The development of a model of care for mental health Registered Advanced Nurse Practitioners at the interface of primary and secondary care settings may be merited. Positive Advanced Recovery Connections may be associated with improving mental health outcomes and bolstering integration of primary and secondary care services. The utilisation of implementation science highlights the need for collaboration with all stakeholders to overcome barriers and recognise facilitators to attain the necessary model of integrated care. PATIENT AND PUBLIC CONTRIBUTION: Peer recovery input was provided by members of the service Recovery College, with participation evident in all stages of the project. The psychosocial assessment template was also co-designed.

Coping with COVID-19: ventilator splitting with differential driving pressures using standard hospital equipment.

The global COVID-19 pandemic has led to a worldwide shortage of ventilators. This shortage has initiated discussions on how to support multiple patients with a single ventilator (ventilator splitting). Ventilator splitting is incompletely tested, experimental and the effects have not been fully characterised. This study investigated the effect of ventilator splitting on system variables (inspiratory pressure, flow and volume) and the possibility of different ventilation targets for each limb using only standard hospital equipment. Experiments were conducted on two test lungs with different compliances (0.02 l.cmH2 O-1 and 0.04 l.cmH2 O-1 ). The ventilator was used in both pressure and volume control modes and was set to ventilate the low compliance lungs at end-tidal volumes of 500 ± 20 ml. A flow restrictor apparatus consisting of a Hoffman clamp and tracheal tube was connected in series to the inspiratory limb of the high compliance test lungs and the resistance modified to achieve end-tidal volumes of 500 ± 20 ml. The restriction apparatus successfully modified the inspiratory pressure, minute ventilation and volume delivered to the high compliance test lungs in both pressure control (27.3-17.8 cmH2 O, 15.2-8.0 l.min-1 and 980-499 ml, respectively) and volume control (21.0-16.7 cmH2 O, 10.7-7.9 l.min-1 and 659-498 ml, respectively) ventilation modes. Ventilator splitting is not condoned by the authors. However, these experiments demonstrate the capacity to simultaneously ventilate two test lungs of different compliances, and using only standard hospital equipment, modify the delivered pressure, flow and volume in each test lung.

A breeding index to rank beef bulls for use on dairy females to maximize profit.

The desire to increase profit on dairy farms necessitates consideration of the revenue attainable from the sale of surplus calves for meat production. However, the generation of calves that are expected to excel in efficiency of growth and carcass merit must not be achieved to the detriment of the dairy female and her ability to calve and re-establish pregnancy early postcalving without any compromise in milk production. Given the relatively high heritability of many traits associated with calving performance and carcass merit, and the tendency for many of these traits to be moderately to strongly antagonistic, a breeding index that encompasses both calving performance and meat production could be a useful tool to fill the void in supporting decisions on bull selection. The objective of the present study was to derive a dairy-beef index (DBI) framework to rank beef bulls for use on dairy females with the aim of striking a balance between the efficiency of valuable meat growth in the calf and the subsequent performance of the dam. Traits considered for inclusion in this DBI were (1) direct calving difficulty; (2) direct gestation length; (3) calf mortality; (4) feed intake; (5) carcass merit reflected by carcass weight, conformation, and fat and the ability to achieve minimum standards for each; (6) docility; and (7) whether the calf was polled. Each trait was weighted by its respective economic weight, most of which were derived from the analyses of available phenotypic data, supplemented with some assumptions on costs and prices. The genetic merit for a range of performance metrics of 3,835 artificial insemination beef bulls from 14 breeds ranked on this proposed DBI was compared with an index comprising only direct calving difficulty and gestation length (the 2 generally most important characteristics of dairy farmers when selecting beef bulls). Within the Angus breed (i.e., the beef breed most commonly used on dairy females), the correlation between the DBI and the index of genetic merit for direct calving difficulty plus gestation length was 0.74; the mean of the within-breed correlations across all other breeds was 0.87. The ranking of breeds changed considerably when ranked based on the top 20 artificial insemination bulls excelling in the DBI versus excelling in the index of calving difficulty and gestation length. Dairy breeds ranked highest on the index of calving difficulty and gestation length, whereas the Holstein and Friesian breeds were intermediate on the DBI; the Jersey breed was one of the poorest breeds on DBI, superior only to the Charolais breed. The results clearly demonstrate that superior carcass and growth performance can be achieved with the appropriate selection of beef bulls for use on dairy females with only a very modest increase in collateral effect on cow performance (i.e., 2-3% greater dystocia expected and a 6-d-longer gestation length).

Assessment of the genetic and economic impact of performance recording and genotyping in Australian commercial sheep operations.

With the new opportunities from DNA technology, multitier breeding schemes have the potential to become more effective and more integrated. Integrated breeding schemes can also be better adapted to account for potential genotype by environment interactions (G × E) between tiers. In this case, phenotypic and genotype information from lower tiers becomes more valuable as it involves measurement of traits that directly represent the breeding objective. The objective of this study was to compare scenarios that represented different selection strategies and their economic effectiveness in fine-wool commercial sheep operations that exploit multitier breeding structures. Genomic selection (GS) applied in the multiplier and the commercial tier presented the largest additional revenue among all scenarios, as it resulted in the largest amount of genetic progress. The largest benefits from GS were outweighed by the genotyping costs, which made DNA parentage the most feasible strategy for the multiplier tier, resulting in the highest cumulative net present value (CNPV). The benefits of phenotypes and genotype information from the commercial environment were larger in the presence of G × E between the nucleus and the commercial tier. The CNPV was larger with a 50% reduction in genotyping costs, which increased the returns of GS scenarios by 2.7-fold on average. Higher selection intensity when selecting multiplier rams also resulted in larger benefits. In this case, returns for the breeding scheme were 3.5-fold higher when 33% of multiplier males were selected based on commercial information, compared to scenarios selecting 50% of the available multiplier rams. The benefits of collecting commercial phenotypes and genotypes were long term, which means that return on investment often took more than 10 years to be achieved, and were largely dependent on two-stage selection to reduce cost while maintaining selection efficiency and on the cost of a genotype test.

New breeding objectives and selection indices for the Australian dairy industry.

This study comprises an update of the economic values for dairy traits for the Australian industry and the formulation of updated selection indices. An economic model, which calculates partial economic values for each trait individually, was developed to determine the economic implications of selective dairy breeding, based on the effect of trait changes on the profit of commercial dairy farms in Australia. Selection indices were developed from economic values, which were transformed into base economic weights by including the discounted genetic expressions coefficients. Economic weights (in Australian dollars) were 1.79, 6.92, -0.10, -5.44, 8.84, 7.68, 1.07, 4.86, 1.91, 3.51, 4.90, 0.31, 2.03, 2.00, and 0.59, for milk fat (kg), milk protein (kg), milk volume (L), body weight (kg), survival (%), residual survival (%), somatic cell count (cells/mL), fertility (%), mammary system [Australian Breeding Value (ABV) unit], temperament (ABV unit), milking speed (ABV unit), udder depth (%), overall type (%), fore udder attachment (%), and pin set (%), respectively. The updated economic weights presented in this study constituted the basis of the definition for 3 new indices. These indices were developed from combination of bioeconomic principles, patterns of farmer preferences for trait improvements, and desired gains approaches. The 3 indices, Balanced Performance Index, Health Weighted Index, and Type Weighted Index, have been released to the industry.

An evaluation of alternative selection indexes for a non-linear profit trait approaching its economic optimum.

This study used simulation to evaluate the performance of alternative selection index configurations in the context of a breeding programme where a trait with a non-linear economic value is approaching an economic optimum. The simulation used a simple population structure that approximately mimics selection in dual purpose sheep flocks in New Zealand (NZ). In the NZ dual purpose sheep population, number of lambs born is a genetic trait that is approaching an economic optimum, while genetically correlated growth traits have linear economic values and are not approaching any optimum. The predominant view among theoretical livestock geneticists is that the optimal approach to select for nonlinear profit traits is to use a linear selection index and to update it regularly. However, there are some nonlinear index approaches that have not been evaluated. This study assessed the efficiency of the following four alternative selection index approaches in terms of genetic progress relative to each other: (i) a linear index, (ii) a linear index updated regularly, (iii) a nonlinear (quadratic) index, and (iv) a NLF index (nonlinear index below the optimum and then flat). The NLF approach does not reward or penalize animals for additional genetic merit beyond the trait optimum. It was found to be at least comparable in efficiency to the approach of regularly updating the linear index with short (15 year) and long (30 year) time frames. The relative efficiency of this approach was slightly reduced when the current average value of the nonlinear trait was close to the optimum. Finally, practical issues of industry application of indexes are considered and some potential practical benefits of efficient deployment of a NLF index in highly heterogeneous industries (breeds, flocks and production environments) such as in the NZ dual purpose sheep population are discussed.

Analyzing the heterogeneity of farmers' preferences for improvements in dairy cow traits using farmer typologies.

Giving consideration to farmers' preferences for improvements in animal traits when designing genetic selection tools such as selection indexes might increase the uptake of these tools. The increase in use of genetic selection tools will, in turn, assist in the realization of genetic gain in breeding programs. However, the determination of farmers' preferences is not trivial because of its large heterogeneity. The aim of this study was to quantify Australian dairy farmers' preferences for cow trait improvements to inform and ultimately direct the choice of traits and selection indexes in the 2014 review of the National Breeding Objective. A specific aim was to analyze the heterogeneity of preferences for cow trait improvements by determining whether there are farmer types that can be identified with specific patterns of preferences. We analyzed whether farmer types differed in farming system, socioeconomic profile, and attitudes toward breeding and genetic evaluation tools. An online survey was developed to explore farmers' preferences for improvement in 13 cow traits. The pairwise comparisons method was used to derive a ranking of the traits for each respondent. A total of 551 farmers fully completed the survey. A principal component analysis followed by a Ward hierarchical cluster analysis was used to group farmers according to their preferences. Three types of farmers were determined: (1) production-focused farmers, who gave the highest preference of all for improvements in protein yield, lactation persistency, feed efficiency, cow live weight, and milking speed; (2) functionality-focused farmers with the highest preferences of all for improvements in mastitis, lameness, and calving difficulty; and (3) type-focused farmers with the highest preferences of all for mammary system and type. Farmer types differed in their age, their attitudes toward genetic selection, and in the selection criteria they use. Surprisingly, farmer types did not differ for herd size, calving, feeding system, or breed. These results support the idea that preferences for cow trait improvements are intrinsic to farmers and not to production systems or breeds. As a result of this study, and some bioeconomic modeling (not included in this study), the Australian dairy industry has implemented a main index and 2 alternative indexes targeting the different farmer types described here.

Development of an index to rank dairy females on expected lifetime profit.

The objective of this study was to develop an index to rank dairy females on expected profit for the remainder of their lifetime, taking cognizance of both additive and nonadditive genetic merit, permanent environmental effects, and current states of the animal including the most recent calving date and cow parity. The cow own worth (COW) index is intended to be used for culling the expected least profitable females in a herd, as well as inform purchase and pricing decisions for trading of females. The framework of the COW index consisted of the profit accruing from (1) the current lactation, (2) future lactations, and (3) net replacement cost differential. The COW index was generated from estimated performance values (sum of additive genetic merit, nonadditive genetic merit, and permanent environmental effects) of traits, their respective net margin values, and transition probability matrices for month of calving, survival, and somatic cell count; the transition matrices were to account for predicted change in a cow's state in the future. Transition matrices were generated from 3,156,109 lactation records from the Irish national database between the years 2010 and 2013. Phenotypic performance records for 162,981 cows in the year 2012 were used to validate the COW index. Genetic and permanent environmental effects (where applicable) were available for these cows from the 2011 national genetic evaluations and used to calculate the COW index and their national breeding index values (includes only additive genetic effects). Cows were stratified per quartile within herd, based on their COW index value and national breeding index value. The correlation between individual animal COW index value and national breeding index value was 0.65. Month of calving of the cow in her current lactation explained 18% of the variation in the COW index, with the parity of the cow explaining an additional 3 percentage units of the variance in the COW index. Females ranking higher on the COW index yielded more milk and milk solids and calved earlier in the calving season than their lower ranking contemporaries. The difference in phenotypic performance between the best and worst quartiles was larger for cows ranked on COW index than cows ranked on the national breeding index. The COW index is useful to rank females before culling or purchasing decisions on expected profit and is complementary to the national breeding index, which identifies the most suitable females for breeding replacements.

Comparison of breeding objectives across countries with application to sheep indexes in New Zealand and Ireland.

Breeding objectives and selection indexes underpin the direction, the extent and the economic implications of selection in livestock populations under specific production systems. The objective of this study was to describe the methodology to calculate correlations between national selection indexes and gain a deeper understanding of the factors influencing responses in economically important traits in both the New Zealand and Irish sheep industries. Moderate to strong correlations were calculated among indexes within and between countries, with the strongest correlation (0.86) between the New Zealand and Irish maternal indexes. In both countries, responses to selection in the maternal indexes are largely driven by growth traits; each index, however, has a different balance of traits. Ewe mature weight also accounts for an important proportion of overall response and has significant emphasis in both maternal indexes. The majority of emphasis in terminal indexes of both countries is on growth and meat traits. Results from this study indicate that differences between national breeding objectives are unlikely to be a barrier to exchange of gene stocks among countries. Future research should investigate the extent to which genotype-by-environment (G × E) interactions exist at the level of individual traits. The methodology presented in this study is robust and represents an opportunity to inform the potential merits of international exchange of germplasm.

Food cravings among bariatric surgery candidates.

PURPOSE: Food cravings are common, more prevalent in the obese, and may differ in those who pursue surgical treatment for obesity. Food craving tools are most often validated in non-clinical, non-obese samples. METHODS: In this retrospective study, 227 bariatric surgery candidates at a large medical center completed the Food Cravings Questionnaire-Trait (FCQ-T). The aim was to explore the factor structure of the FCQ-T. RESULTS: Principal components analysis with varimax rotation revealed a seven-factor structure that explained 70.89 % of the variance. The seven factors were: (1) preoccupation with food, (2) emotional triggers, (3) environmental cues, (4) loss of control, (5) relief from negative emotions, (6) guilt, and (7) physiological response. The preoccupation with food factor accounted for 49.46 % of the variance in responses. CONCLUSIONS: Unlike other populations, food cravings in bariatric surgery candidates appear to be related most to preoccupations with food.

Laparoscopic repair of gastro-duodenal fistula secondary to band erosion.

Laparoscopic gastric banding is one of the most common surgical treatments for morbid obesity performed worldwide. The procedure, however, has many well-documented risks and complications, including band erosion. We present here a gastric banding patient who was referred to our tertiary care centre after secondarily forming an entero-enteric fistula with complaints of pain, nausea, vomiting and severe reflux. She was successfully treated with laparoscopic dissection and due to her existing anatomy, and the patient's desire for continued weight loss, she was converted to Roux-en-Y gastric bypass.

Dissemination of the 2022 ASMBS and IFSO Guidelines for Bariatric Surgery: What Has Reached Primary Care Providers?

BACKGROUND: Only 1% of Americans eligible for metabolic and bariatric surgery (MBS) receive MBS. Prior studies have analyzed primary care provider (PCP) referral patterns and perceptions of MBS as a potential barrier to increasing MBS. However, less data exists regarding PCP knowledge of MBS indications and outcomes. Following the 2022 update to the indications for MBS by the ASMBS and IFSO, the number of eligible patients is only expected to increase. We evaluated PCP knowledge regarding the existence of the 2022 ASMBS and IFSO updated guidelines, MBS indications, and MBS outcomes. METHODS: An 11-question survey was emailed to primary care residents, advanced practice providers, and faculty at a single institution. RESULTS: Of 151 surveys distributed, 39.7% responded (n = 60). 95% were unaware of the 2022 updated guidelines. On multiple choice questions, 16.3% correctly identified the average weight loss from MBS, and 46.8% correctly answered the diabetes remission rate following MBS. Trainee answers were not statistically significant from practicing PCPs. Fifteen respondents had referred a patient for MBS, but this subgroup did not perform significantly better on the assessment. A total of 72.3% of respondents reported inadequate MBS education during their training, and 85.1% were interested in additional education. CONCLUSIONS: We present the first assessment of PCP MBS knowledge since the release of the 2022 updated ASMBS and IFSO guidelines. This study indicates a gap in PCPs' knowledge regarding the updated guidelines and represents an opportunity for collaboration with our primary care colleagues to provide further MBS education.

Circulating Angiogenic and Senescent T Lymphocytes in Ageing and Frailty.

BACKGROUND: There is a need to identify vascular and geroscience-relevant markers and mediators that can physiologically link ageing to vascular disease. There is evidence of specific T cell subsets, all influenced by age, that exert positive and negative effects on vascular health. CD31+, termed angiogenic T cells, have been linked to vascular repair whereas CD28null, termed senescent T cells, display pro-inflammatory and cytotoxic effector functions. OBJECTIVE: This study sought to determine the combined influence of increasing age and frailty status on these circulating CD31+ and CD28null T cell subsets. METHODS: This cross-sectional study recruited four different cohorts of men and women; young (20-30 years, n=22), older (65-75 years, n=17), robust non-frail (76+ years, n=17), and frail (76+ years, n=15) adults. Frailty was determined using the Fried Frailty method. T cell subsets were determined by whole blood flow cytometry based on the expression of CD3, CD4, CD8, CD31 and CD28. Cognitive impairment (CI) was measured via the Montreal Cognitive Assessment test. RESULTS: Whether expressed as circulating counts or as a % of total T cells, there was a progressive decrease (p<0.05) in CD31+ T cells with increasing age but paradoxically higher values (p<0.05) in the frail compared to the robust non-frail group. These changes were similar in the CD4+ and CD8+ fractions. CD28null T cells were considerably higher (p<0.05) in the frail compared to the robust non-frail group, including in the CD8+ (47% vs 29%, p<0.05) and CD4+ (4% vs 1%, p<0.05) fractions. CD28null T cell percentage was also higher (p<0.05) in those with moderate CI compared to mild CI and normal function. CONCLUSION: CD8+CD28null T cells are considerably elevated in frailty and with cognitive impairment and may serve as a useful target for intervention. Currently, the utility of CD31+ T cells as an ageing biomarker may be confined to healthy ageing cohorts.

Identifying selection strategies based on the practices and preferences of small ruminant farmers to improve the sustainability of their breeding systems.

Small ruminant farming is of socio-economic and environmental importance to many rural communities around the world. The SMARTER H2020 project aims to redefine genetic selection criteria to increase the sustainability of the sector. The objective of this study was to analyse the selection and breeding management practices of small ruminant producers and breeders, linked with socio-technical elements that shape them. The study is based on farm surveys using semi-structured interviews conducted in five countries (France, Spain, Italy, Greece, and Uruguay) across 272 producers and breeders of 13 sheep and goat breeds, and 15 breed × system combinations. The information was collected in four sections. The first and second sections dealt with general elements of structure and management of the system and the flock/herd. The third section focused on selection and breeding management practices: criteria for culling and replacement of females, selection criteria for males, use of estimated breeding values and global indexes, and preferences for indexing new traits to increase the sustainability of their system. The fourth section aimed to collect socio-technical information. We used a data abstraction method to standardise the representation of these data. A mixed data factor analysis followed by a hierarchical ascending classification allowed the characterisation of three profiles of selection and breeding management: (1) a profile of producers (n = 93) of small flocks/herds, with little knowledge or use of genetic selection and improvement tools (selection index, artificial insemination, performance recording); these farmers do not feel that new traits are needed to improve the sustainability of their system. (2) a profile of producers (n = 34) of multibreed flocks/herds that rely significantly on grazing; they are familiar with genetic tools, they currently use AI; they would like the indexes to include more health and robustness characteristics, to make their animals more resistant and to increase the sustainability of their system. And (3) a profile of producers or breeders (n = 145) of large flocks/herds, with specific culling criteria; these farmers are satisfied with the current indexes to maintain the sustainability of their system. These results are elements that can be used by private breeding companies and associations to support the evolution of selection objectives to increase the resilience of animals and to improve the sustainability of the small ruminant breeding systems.

Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment-The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study.

INTRODUCTION: Survival from refractory out of hospital cardiac arrest (OHCA) without timely return of spontaneous circulation (ROSC) utilising conventional advanced cardiac life support (ACLS) therapies is dismal. CHEER3 was a safety and feasibility study of pre-hospital deployed extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) for refractory OHCA in metropolitan Australia. METHODS: This was a single jurisdiction, single-arm feasibility study. Physicians, with pre-existing ECMO expertise, responded to witnessed OHCA, age < 65 yrs, within 30 min driving-time, using an ECMO equipped rapid response vehicle. If pre-hospital ECPR was undertaken, patients were transported to hospital for investigations and therapies including emergent coronary catheterisation, and standard intensive care (ICU) therapy until either cardiac and neurological recovery or palliation occurred. Analyses were descriptive. RESULTS: From February 2020 to May 2023, over 117 days, the team responded to 709 "potential cardiac arrest" emergency calls. 358 were confirmed OHCA. Time from emergency call to scene arrival was 27 min (15-37 min). 10 patients fulfilled the pre-defined inclusion criteria and all were successfully cannulated on scene. Time from emergency call to ECMO initiation was 50 min (35-62 min). Time from decision to ECMO support was 16 min (11-26 min). CPR duration was 46 min (32-62 min). All 10 patients were transferred to hospital for investigations and therapy. 4 patients (40%) survived to hospital discharge neurologically intact (CPC 1/2). CONCLUSION: Pre-hospital ECPR was feasible, using an experienced ECMO team from a single-centre. Overall survival was promising in this highly selected group. Further prospective studies are now warranted.

30-day morbidity and mortality after transoral robotic surgery for human papillomavirus (HPV) associated oropharyngeal squamous cell carcinoma: A retrospective analysis of two prospective adjuvant de-escalation trials (MC1273 & MC1675).

OBJECTIVE: Dose de-escalation of adjuvant therapy (DART) in patients with HPV(+)OPSCC was investigated in two prospective Phase II and III clinical trials (MC1273 and MC1675). We report the 30-day morbidity and mortality associated with primary TORS resection in patients enrolled in these trials. MATERIALS AND METHODS: Patients with HPV(+)OPSCC, who underwent TORS resection between 2013 and 2020 were considered in this analysis. The severity of postoperative transoral bleeding was graded using both the Hinni Grade (HG) transoral surgery bleeding scale and the Common Terminology for Adverse Events (CTCAE) v5.0. Post-surgical complications within 30 days of surgery, as well as rates of tracheostomy, PEG and nasogastric tube placement. RESULTS: 219 patients were included. A total of 7 (3.2 %) patients had a tracheostomy placed at the time of surgery, and all were decannulated within 26 days (median: 5, range: 2-26). There were 33 (15.1 %) returns to the emergency department (ED) with 10 (4.6 %) patients requiring readmission. Using the HG scale, 10 (4.6 %) patients experienced ≥ Grade 3 bleeding with no Grade 5 or 6 bleeds. In contrast, using the CTCAE scale, 15 patients (6.8 %) experienced ≥ Grade 3 bleeding with no Grade 5 bleeds. There was one post-operative death in a patient withdrawn from the trial, and no deaths related to hemorrhage. CONCLUSION AND RELEVANCE: TORS for HPV(+)OPSCC in carefully selected patients at a high volume center was associated with low morbidity and mortality.

All at-risk patients are not created equal: analysis of Braden pressure ulcer risk scores to identify specific risks.

PURPOSE: To improve identification of risk factors for pressure ulcer development and enhance targeted interventions and prevention strategies. SUBJECTS AND SETTING: The records of 12,566 adult patients hospitalized in intensive or progressive care units within Mayo Clinic were analyzed. Inclusion criteria were Braden Scale of 18 or less during the hospitalization; exclusion criteria were preexisting pressure ulcer or length of stay less than 24 hours. METHODS: This study is a retrospective cohort analysis of electronic medical record data from January 1, 2007, to December 31, 2007. Only iatrogenic stage 2 to 4 pressure ulcers were considered as incident events. Demographic and clinical data were extracted from the medical record, including total Braden Scale score and Braden subscale scores at hospital admission, length of stay, admission to the intensive care unit at the time of hospitalization, and presence of acute respiratory failure, acute renal failure, or diabetes. Time to event was calculated based on time from admission to pressure ulcer occurrence or to hospital discharge. RESULTS: Four hundred sixteen (3.3%) of patients developed a pressure ulcer during their hospitalizations. The Braden Scale score total by itself was found to be highly predictive of pressure ulcer development (P ≤ .0001, C = 0.71), as were all individual subscores. The friction/shear subscale had the greatest predictive power among Braden Scale scores (subscores and total score) (C = 0.83). The multivariate model after selection included 5 Braden Scale subscales, surgery, and acute respiratory failure (C = 0.91). CONCLUSIONS: The total Braden Scale score is predictive of pressure ulcer development but does not assist the clinician to develop an individualized targeted prevention plan. In contrast, the use of subscale scores can enhance prevention programs and resource utilization by focusing care on the risk factors specific to the individual patient.

Measuring farmers' attitude towards breeding tools: the Livestock Breeding Attitude Scale.

Under-use of genetic improvement tools and low participation in breeding programmes are key drivers of breeding programmes under-performance. Both aspects are heavily influenced by farmers attitudes which, to date, have not been analysed in an objective and systematic manner. A key factor constraining the implementation of attitudinal studies towards livestock breeding tools is the lack of a reference scale for measuring attitudes. In this research, we provide the livestock breeding sector with such a reference measure. We developed the scale following the standardized psychometric methodologies and statistical tools. Then, as a case study, we used the scale to explore the attitudes of beef and dairy sheep farmers in Australia, New Zealand and Spain and analysed farmer and farming system factors related to those attitudes. Fourteen sheep and beef breed associations facilitated the implementation of a survey of 547 farmers, generating data that was used for the scale evaluation. The relationship between attitudinal factors and farmer and farming system factors was analysed using generalized linear models across and within breeds. The results suggest that the 8-item definitive scale we have developed is appropriate to measure farmer attitudes. We found that attitudes towards genetic improvement tools have two components; i) traditional selection and ii) genetic and genomic selection combined. This means that positive attitudes towards traditional phenotypic selection do not necessarily imply a negative attitude towards genetic and genomic selection tools. Farmer attitudes varied greatly not only across the studied breeds, species and countries, but also within them. High-educated farmers of business-oriented farms tend to have the most negative attitude towards traditional selection. However, attitudes towards genetic and genomic selection tools could not be linked to these factors. Finally, we found that the breed raised had a large effect on farmer attitude. These findings may help in the evolution of breeding programmes by identifying both the farmers most inclined to uptake breeding innovations in the early stages of its establishment and the farmers who would be more reluctant to participate in such programmes, thus informing where to focus extension efforts.

The practice of pancreatic resection after Roux-en-Y gastric bypass.

The morbid obesity epidemic in the United States has resulted in increasing numbers of patients who have undergone Roux-en-Y gastric bypass who require surgical management of nonbariatric disorders. When pancreatic resection is indicated in bariatric patients, consideration of the altered foregut anatomy can be applied to the principles of pancreatic resection to foster effective techniques that minimize operative complications. A retrospective review and analysis of bariatric patients who underwent pancreatic resection at the Medical University of South Carolina Digestive Center over a 2-year period (2006 to 2007) was conducted to assess indications for operation, operative techniques, and postoperative outcome in patients with previous Roux-en-Y gastric bypass. There were five patients (four female, one male) identified with a mean age of 35 years (range, 32-50 years). The mean time interval from gastric bypass to pancreatic resection was 42.6 months (range, 10-72 months). Indications for pancreatic operations were islet hyperplasia in two patients, chronic pancreatitis in two, and serous cystadenoma in one. Two patients underwent duodenal-preserving pancreatic head resection (Beger procedure) and three underwent distal pancreatectomy and splenectomy. Mean length of hospital stay was 11.4 days (range, 5-22 days). Two patients had extended hospital stay as a result of gastrointestinal ileus. There was no other operative morbidity or mortality. Mean length of patient follow up was 9.8 months (range, 1-17 months). Specific operative techniques used in pancreatic head resection were duodenal preservation, pancreatic drainage with an omega loop constructed from a mid-Roux limb, and excluded stomach gastrostomy. Techniques used in pancreatic tail and body resection were splenectomy discontinuous from pancreatectomy, division of the splenic vein and artery at the pancreatic neck early in surgery, retrograde dissection of the pancreas body and tail, and dissection of the body and tail posterior to the Roux limb leaving the Roux limb intact. Pancreatic resection after Roux-en-Y gastric bypass is safe and effective when using prescribed operative principles that minimize disruption of the foregut reconstruction and adds protection to the gastric remnant with a gastrostomy for decompression and access for enteral alimentation when necessary.