Patients undergoing colorectal surgery at a Veterans Affairs Hospital do not experience racial disparity in length of stay either before or after implementing an enhanced recovery pathway.

BACKGROUND: Enhanced Recovery Pathways (ERP) have been shown to reduce racial disparities following surgery. The objective of this study is to determine whether ERP implementation mitigates racial disparities at a Veterans Affairs Hospital. METHODS: A retrospective cohort study was conducted using data obtained from the Veterans Affairs Surgical Quality Improvement Program. All patients undergoing elective colorectal surgery following ERP implementation were included. Current procedural terminology (CPT) codes were used to identify patients who underwent similar procedures prior to ERP implementation. RESULTS: Our study included 417 patients (314 pre-ERP vs. 103 ERP), 97.1% of which were male, with an average age of 62.32 (interquartile range (IQR): 25-90). ERP patients overall had a significantly shorter post-operative length of stay (pLOS) vs. pre-ERP patients (median 4 days (IQR: 3-6.5) vs. 6 days (IQR: 4-9) days (p < 0.001)). Within the pre-ERP group, median pLOS for both races was 6 days (IQR: 4-6; p < 0.976) and both groups experienced a decrease in median pLOS (4 vs. 6 days; p < 0.009 and p < 0.001) following ERP implementation. CONCLUSIONS: Racial disparities did not exist in patients undergoing elective surgery at a single VA Medical Center. Implementation of an ERP significantly reduced pLOS for black and white patients.

Management of patients in a combined thyroid eye clinic in secondary care.

The European Group on Graves' Orbitopathy (EUGOGO) recommends the use of specialised multidisciplinary clinics for the management of thyroid eye disease (TED). In the UK, many patients with TED are managed outside of specialised clinics. We describe the organisation of a combined TED clinic in a secondary care setting and present the result of a prospective audit of the patient characteristics and outcomes during the first four years of a combined TED clinic. Of a total of 132 patients referred to the TED clinic, 114 (86 %) had TED (90 females, median age 56 years; range 17-90 years). At presentation, 77 (67 %) were current or ex-smokers and 99 (87 %) were biochemically euthyroid. Median duration of eye symptoms was 12 months. Fifty-two percent, 45 and 3 had mild, moderate-to-severe and sight-threatening TED, respectively. Only 18 % of patients had a clinical activity score (CAS) of ≥3. Sixty-nine patients (61 %) required follow-up appointments in the TED clinic. In those who required follow-up, 43 % (n = 30) received either immunosuppressive or surgical treatment. CAS improved from first to final visit, with 29 % (n = 20) having a CAS of ≥3 at the first visit and 1 % (n = 1) at the final visit (p = 0.0001). There was also a decrease in prevalence of smoking and thyroid dysfunction at the final visit. A multidisciplinary specialised TED clinic offers an optimal setting for managing patients with TED; however, patients are often referred late to a specialist TED clinic.

Simple model of arch support: Relevance to Charcot Neuroarthropathy.

BACKGROUND: Charcot neuropathy is a common complication resulting from poorly controlled diabetes and peripheral neuropathy leading to the collapse, and ultimately the breakdown, of the midfoot. Mechanically, it is likely that a compromised arch support in this, or any other patient group that experiences foot flattening, would be associated with slippage at the distal and proximal interface regions of the plantar surface of the foot and the adjacent support surface. This slippage, although difficult to quantify with standard motion capture systems used in a gait laboratory, could potentially be assessed with systems for monitoring interface shear stresses. However, before investing in such systems, a correlation between arch flattening and interface shear stresses needs to be verified. METHODS: For this purpose, a sagittal plane model of a foot was developed using a multi-body dynamics package (MSC Adams). This model mimicked a subject swaying back and forth, and was constructed to show the dependence of interface stresses on altered arch support. FINDINGS: The model's predictions matched typical FootSTEPS data: lengthening of the arch of 1-2 mm, sway oscillations of 0.22-0.33 s and frictional force differences (calcaneus relative to forefoot) of 60 N. Of clinical relevance, when the stiffness of the plantar spring (representing aponeurosis and intrinsic muscles) was reduced by 10%, the frictional force difference increased by about 6.5%. INTERPRETATION: The clinical implications of this study are that, while arch lengthening of less than 2 mm might be difficult to measure reliably in a gait lab, using shear sensors under the forefoot and hindfoot should allow arch support to be assessed in a repeatable manner.

Does Medicaid payer status affect patient's shoulder outcomes after shoulder arthroplasty?

BACKGROUND: Low socioeconomic status and Medicaid insurance as a primary payer have been shown to influence resource utilization and risk-adjusted outcomes for total joint arthroplasty. The purpose of this study was to assess the effects of Medicaid primary payer status on outcomes following shoulder arthroplasty (SA). MATERIALS AND METHODS: A retrospective review of shoulder surgery patients was undertaken to identify a matched cohort of 51 patients who underwent SA and were stratified based on insurance type into two cohorts: 28 Medicaid (M) patients and 23 non-Medicaid (NM) patients. Baseline demographics, resource utilization, and outcomes were compared as well as pre-and-postoperative patient-reported outcomes (PRO) and functional scores. PRO scores included the American shoulder and elbow surgeons score (ASES), the Penn shoulder score (PSS), and the subjective shoulder value (SSV). RESULTS: There were no statistically significant differences in demographics, comorbidities, or preoperative baseline scores between the cohorts, except for age (M: 55.3 years; NM: 67.5 years; p ≤ 0.001) and smoking status (M: 13 patients; NM: 4 patients; p = 0.029). Medicaid patients showed a slightly higher rate of missed follow-ups (M: 1.1 vs. NM: 0.9; p = 0.370). All Medicaid and non-Medicaid patients experienced significant improvement on PRO scores and active forward flexion. Medicaid patients demonstrated equivalent final postoperative scores for ASES (M: 65; NM: 57; p = 0.454), PSS (M: 63; NM: 51; p = 0.242), SSV (M: 70; NM: 69; p = 1.0) and range of motion measurements. DISCUSSION: Overall results suggest that Medicaid patients can expect significant improvement after SA and the same level of PRO's compared to non-Medicaid-insured population. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Design, Treatment Study.

Multicolor particle shadow accelerometry.

This paper describes the extension of multicolor particle shadow velocimetry (CPSV) to the measurement of local acceleration in an Eulerian frame of reference. A validation experiment was conducted on a pendulous disk undergoing unsteady rigid body rotation. Angular velocity and acceleration profiles by CPSA are presented along with a comparison to recordings by an accelerometer mounted on the pendulum. CPSA is also demonstrated in a fully-developed turbulent pipe flow. Profiles of standard deviation of the local acceleration in the near wall region (0< y + <75) are compared to similar measurements by Christensen and Adrian. A favorable comparison is found between CPSA and particle image accelerometry (PIA). The effect of acceleration time delay, or the time between two velocity estimates, on local acceleration estimates is discussed.

Correcting for color crosstalk and chromatic aberration in multicolor particle shadow velocimetry.

Color crosstalk and chromatic aberration can bias estimates of fluid velocity measured by color particle shadow velocimetry (CPSV), using multicolor illumination and a color camera. This article describes corrections to remove these bias errors, and their evaluation. Color crosstalk removal is demonstrated with linear unmixing. It is also shown that chromatic aberrations may be removed using either scale calibration, or by processing an image illuminated by all colors simultaneously. CPSV measurements of a fully developed turbulent pipe flow of glycerin were conducted. Corrected velocity statistics from these measurements were compared to both single-color PSV and LDV measurements and showed excellent agreement to fourth-order, to well into the viscous sublayer. Recommendations for practical assessment and correction of color aberration and color crosstalk are discussed.

Autoantibodies to human alpha6 integrin in patients with oral pemphigoid.

Mucous membrane pemphigoid or cicatricial pemphigoid is a mucocutaneous blistering disease characterized by autoantibodies to different molecules in the basement membrane zone. Our objectives were to identify the target antigen recognized by sera from 20 untreated patients with pemphigoid disease limited to the oral cavity, and to determine the pathogenicity of autoantibodies in oral pemphigoid, with an organ culture model. We conducted indirect immunofluorescence, immunoblot, and immunoprecipitation assays, with accompanying absorption experiments, using normal human skin, conjunctiva and gingiva, bovine gingiva and a tumor cell line, which were reacted with sera from patients with oral pemphigoid, anti-alpha6 antibody, and control sera. Sera of oral pemphigoid patients selectively and specifically bound to human alpha6 integrin, a 120-kDa protein present in gingiva and the tumor cell line. Oral pemphigoid sera and anti-alpha6 antibody produced separation of epithelium from basement membrane (blister formation) of normal human buccal mucosa, after 48 hours, in organ culture.

Distribution of neurotoxic esterase activity in the brain of control and diisopropyl phosphorofluoridate-treated hens: in vivo and in vitro exposure.

Neurotoxic esterase (NTE) is a protein which is hypothesized to be the site where certain organophosphorus compounds act to produce delayed-onset neurotoxicity. Adult white Leghorn hens (Gallus domesticus) were injected subcutaneously (0.5 mg/kg and 2.0 mg/kg) with diisopropyl phosphorofluoridate (DFP). Control and DFP-treated hens were killed 24 h after treatment and their brains sectioned into telencephalic, cerebellar, diencephalic, mesencephalic, metencephalic tegmentum, and myelencephalic portions. NTE activity was highest in the telencephalon and cerebellum, and brainstem activity progressively decreased moving caudally with the myelencephalon approaching reported spinal cord levels. Percent inhibition of NTE by DFP (0.5 mg/kg and 2.0 mg/kg) did not differ among brain regions or whole brain. The IC50's for DFP were not significantly different either among brain regions or whole brain. The results suggest that nervous system regions with higher NTE levels are protected from delayed neuropathy by virtue of overabundant NTE activity.

A rapid screening-level method to optimize location of infiltration ponds.

A rapid-screening technique was developed to identify lithologies that best disperse artificial recharge via surface infiltration and minimize effects on ground water chemistry. The technique prospectively evaluates basin infiltration rates and water chemistry influences by integrating geotechnical, hydraulic, and water quality data with column test data and numerical modeling. The technique was validated using field data collected from surface infiltration basins designed to recharge ground water pumped from the Pipeline pit gold mine in Nevada. Observed recharge rates at these infiltration sites correlated most significantly with depth to groundwater, with basins in coarse-grained lithologies performing better (0.45 to 0.85 m/day) than those with fine-grained layers (< 0.30 m/day). Observed water quality resulting from leaching of the previously unsaturated vadose zone showed a transitory (< six months) increase in solute concentrations followed by a decrease to baseline conditions, a phenomenon also observed in column tests that leached native soils with local ground water. Leaching of fine-grained soils with evaporites resulted in greater solute concentrations (TDS > 2000 mg/L) than coarse-grained soils (< 1200 mg/L). The results of HYDRUS_2D simulations using the accumulated data as input were in agreement with observed ground water chemistry downgradient of the infiltration basins for a variety of lithologies. Sites for infiltration basins can be rapidly screened to include areas with greatest depth to groundwater and in coarsest alluvial sediments, and impact to ground water chemistry can be reliably predicted using computer modeling and column test results.

Pediatric aneurysmal bone cyst of the distal tibia.

A rare, large pediatric aneurysmal bone cyst with pathologic fracture of the distal tibia of a 4-year-old female was presented. Classic radiographic and magnetic resonance imaging findings have been discussed. In a comprehensive review of the literature, aneurysmal bone cysts are an infrequently reported neoplasm of the foot and ankle bones. Lesions are characteristically seen in patients younger than 20 years of age, but rarely younger than 5 years. The benign cyst has a 2:1 female-to male predilection. In long bones, the lesion is typically metaphyseal in nature. Although the pathogenesis is still unknown, there exists the possibility of two types of aneurysmal bone cysts: a primary type without preexisting lesion and a secondary form associated with some other lesion. The diagnosis of aneurysmal bone cyst can be strongly suspected by correlating the radiographic and magnetic resonance imaging findings. For definitive diagnosis, accurate histologic evaluation is imperative to rule out any confusion or possibility with a malignant tumor.

The efficacy of three non-mammalian test systems in the identification of chemical teratogens.

This report concerns an evaluation of three in vitro teratogenesis tests: the Dugesia regeneration assay, the Hydra reaggregation assay and the Xenopus embryo assay. Our approach involves the establishment and/or refinement of test protocols, definition of endpoints, and evaluation of test performance by comparison with available results of in vivo mammalian studies. Chemicals used for preliminary evaluation studies were the known mammalian teratogens, vinblastine sulfate (VIN) and hydroxyurea (HU), a coeffective teratogen, cadmium chloride (Cd), and an National Toxicology Program priority chemical, 9-aminoacridine hydrochloride (9AA). The Dugesia assay takes advantage of the ability of beheaded flatworms to regenerate and can be completed in 7-14 days. Concentrations of VIN of 3.2 mg 1(-1) inhibited auricle formation and further regeneration observed in 3-6 days. Similarly, eyespot and auricle formation was blocked by HU (180 mg 1(-1) ). The duration of regeneration, measured as the time elapsed between decapitation and eye-spot formation (control = 5 days), was extended by 1-4 days during exposure to 9AA. Sublethal Cd had little effect on regeneration. The Hydra assay is an evaluation of the ability of dissociated cells to regenerate complete organisms when randomly reassociated. A teratogenic test substance is detected by observing the ratio of the minimal effective concentrations of a substance between intact organisms and regenerates. Compounds with a ratio greater than 2.0 are potential teratogens. The ratios determined for 9AA, VIN, HU and Cd, respectively, were 10.0, 4.0, 2.7 and 1.2. These results indicate that the first three compounds tested positive for teratogenesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Time-resolved temperature measurements in a laboratory flame using the optoacoustic beam-deflection method.

A method of obtaining time-resolved measurements of gas temperatures in a combustion environment is described. The noncontact optical laser-beam deflection technique utilizes rapid heating at a gas-solid interface as an acoustic source and is capable of acquiring localized temperature values at a repetition rate of >1 kHz. Measurements taken on a premixed propane-air laboratory flame show a 12.5-Hz thermal oscillation at the flame edge and no significant oscillation at the center.

Amniotic band syndrome.

Amniotic band syndrome is an uncommon, congenital fetal abnormality with multiple disfiguring and disabling manifestations. A wide spectrum of clinical deformities are encountered and range from simple ring constrictions to major craniofacial and visceral defects. Lower extremity limb malformations are extremely common and consist of asymmetric digital ring constrictions, distal atrophy, congenital intrauterine amputations, acrosyndactyly, lymphedema and clubfoot. Although debated, early amnion rupture with subsequent entanglement of fetal parts (mostly limbs and appendages) by amniotic strands is the primary theory of pathogenesis. The sporadic nature of this congenital anomaly is discussed, as well as a case study involving the surgical correction of an associated rigid clubfoot deformity.