Does complexity relate to compensation? A comparison of relative value units in initial versus recurrent inguinal hernia repair.

PURPOSE: Work relative value units (wRVUs) can be used as a compensation model based on the effort required for providing a service and helps to determine adequate compensation for physicians. Thus, more complex surgical procedures that require greater technical skills and time should yield greater compensation. There are limited data comparing wRVUs and operative times within common general surgery procedures such as inguinal hernia repair. This study aims to compare mean operative times and wRVUs per minute between primary and recurrent inguinal hernia repairs, the latter being considered as a more difficult procedure to perform. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was performed to identify all patients undergoing primary inguinal hernia repair and recurrent inguinal hernia repair by general surgeons over a 6-year period (2012-2017). Calculation and comparison of mean operative times, wRVUs, and wRVU per minute were performed. RESULTS: A total of 134,391 patients were included in the analysis. 121,235 underwent primary inguinal repair and 13,156 patients underwent repair of recurrent inguinal hernia. Patients were distributed within open/reducible, open/incarcerated and laparoscopy groups. Mean operative time and RVUs were greater for recurrent inguinal procedures (p < 0.0001). Consistently, RVU per minute was also found to be higher for recurrent procedures within the different groups analyzed. CONCLUSION: Appropriately, general surgeons are reimbursed at a higher rate per minute in recurrent cases, regardless of the technique used.

Popular pharmaceutical residues in hospital wastewater: quantification and qualification of degradation products by mass spectroscopy after treatment with membrane bioreactor.

The occurrence of drugs in wastewater has been considered an imminent risk to the population, for the treatments used are usually ineffective. The presence of four popular drug residues (metformin, paracetamol, tetracycline, and enalapril) in hospital effluents, by using ultra-fast liquid chromatography tandem mass spectrometry (UFLC-MS/MS) with electrospray (ESI) ionization, and removal/degradation by membrane bioreactor (MBR) system are investigated in this study. For analysis method, all standard calibration curves showed satisfactory linearity (R (2) ≥ 0.993) within a relatively wide range. The recovery was between 70.4 and 105.0 %, and the relative standard deviation (RSD) values were within the ranges of 8.2 and 13.5 %. The effluent samples were collected at the end of the process treated in a bench-scale MBR treatment system and preconcentrated on solid-phase extraction (SPE) cartridges. Following that procedure, the chemical analysis demonstrated that the MBR system was effective in enalapril 94.3 ± 7.63 %, tetracycline 99.4 ± 0.02 %, and paracetamol 98.8 ± 0.86 % removal. However, the polar metformin was less effectively removed (35.4 ± 12.49 %). Moreover, the degradation products were investigated using high-resolution mass spectrometry (HRMS) by quadrupole-time of flight (Q-TOF), which has been indicated a tetracycline metabolite. In order to investigate the environmental impact, the wastewater potential risk was evaluated. The risk quotient (RQ) by measure environmental concentration (MEC) and its predicted no effect concentration (PNEC) ratio (RQ = MEC/PNEC) was between 0.003 (enalapril) to 0.815 (paracetamol). Finally, this work demonstrates that UFLC-MS/MS (ESI-Q) is a sensitive and selective method for drug analysis in wastewater and with ESI-Q-TOF has the accuracy required for determining the degradation products of these compounds. Also, it indicated that membrane bioreactor systems represent a new generation of processes that have proved to outperform conventional treatment showing better effluent quality. The removal capacity studied in this work demonstrates the efficiency of this process.

Environmental engineering education for developing countries: framework for the future.

This paper presents the existing philosophy, approach, criteria and delivery of environmental engineering education (E3) for developing countries. In general, environmental engineering is being taught in almost all major universities in developing countries, mostly under civil engineering degree programmes. There is an urgent need to address specific inputs that are particularly important for developing countries with respect to the reality of urbanisation and industrialisation. The main component of E3 in the near future will remain on basic sanitation in most developing countries, with special emphasis on the consumer-demand approach. In order to substantially overcome environmental problems in developing countries, E3 should include integrated urban water management, sustainable sanitation, appropriate technology, cleaner production, wastewater minimisation and financial framework.

Bidirectional transcriptional activity of PGK-neomycin and unexpected embryonic lethality in heterozygote chimeric knockout mice.

In an effort to create a conventional knockout mouse model for multiple endocrine neoplasia type 1 (MEN1), we targeted disruption of the mouse Men1 gene through homologous recombination in ES cells. Men1 exons 2-4 were replaced by a PGK-neomycin cassette inserted in the opposite direction of Men1 transcription (Men1(MSK/+)). Unexpectedly, the Men1 conventional knockout was lethal in heterozygous, chimeric animals. Analysis of embryos revealed late gestational lethality with some embryos showing omphalocele. This was a very surprising phenotype, given that humans and mice that are heterozygotes for loss of function mutations in MEN1 are phenotypically normal except for a risk of endocrine tumors. Northern analysis of Men1(MSK/+) embryonic stem cell RNA revealed the presence of an abundant, novel transcript of 2.1 kb, in addition to the expected wild-type transcripts of 2.7 kb and 3.1 kb. RT-PCR analysis identified this aberrant transcript as arising from the antisense strand of the PGK promoter. We hypothesize that this transcript is producing either a toxic effect at the RNA level, or a dominant negative effect through the production of an amino-terminal truncated protein product. This example serves as a cautionary reminder that mouse knockouts using PGK-neo may sometimes display phenotypes that reflect more than just the loss of function of the targeted gene.

Direct removal in the mouse of a floxed neo gene from a three-loxP conditional knockout allele by two novel approaches.

The presence in an intron of the ploxP-neo-loxP cassette often results in severe interference with gene expression. Consequently, many investigators selectively remove the ploxP-neo-loxP cassette by transient expression of Cre in ES cells. Although effective, the added manipulation of the ES cells may reduce the likelihood that a clone will be able to transmit via the germline. Therefore, we developed two novel approaches that remove the ploxP-neo-loxP by Cre-mediated recombination in mouse. First, the ploxP-neo-loxP-containing mice were crossed with EIIa-Cre transgenic mice. Second, a Cre-expression plasmid was injected into pronuclei of fertilized eggs bearing the ploxP-neo-loxP allele. Both approaches produced mosaic mice with partial and complete excision. These mosaic mice were then mated, and the neo-less conditional knockout allele was found in the offspring after screening only a few litters. These procedures provide options for removing neo directly in the mouse in addition to the commonly used approach that deletes neo in ES cells.

A mouse model of multiple endocrine neoplasia, type 1, develops multiple endocrine tumors.

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant cancer syndrome, characterized primarily by multiple tumors in the parathyroid glands, endocrine pancreas, and anterior pituitary. Other tumors, including gastrinoma, carcinoid, adrenal cortical tumors, angiofibroma, collagenoma, and lipoma, also occur in some patients. Individuals with MEN1 almost always have loss-of-function mutations in the MEN1 gene on chromosome 11, and endocrine tumors arising in these patients usually show somatic loss of the remaining wild-type allele. To examine the role of MEN1 in tumor formation, a mouse model was generated through homologous recombination of the mouse homolog Men1. Homozygous mice die in utero at embryonic days 11.5-12.5, whereas heterozygous mice develop features remarkably similar to those of the human disorder. As early as 9 months, pancreatic islets show a range of lesions from hyperplasia to insulin-producing islet cell tumors, and parathyroid adenomas are also frequently observed. Larger, more numerous tumors involving pancreatic islets, parathyroids, thyroid, adrenal cortex, and pituitary are seen by 16 months. All of the tumors tested to date show loss of the wild-type Men1 allele, further supporting its role as a tumor suppressor gene.

Genetic evidence for a role for Src family kinases in TNF family receptor signaling and cell survival.

Mutant src(-/-) mice have osteopetrosis resulting from defective osteoclasts, the cells that resorb bone. However, signaling pathways involving Src family members in osteoclasts remain unclear. We demonstrate that expression of a truncated Src molecule, Src251, lacking the kinase domain, induces osteopetrosis in wild-type and src(+/-) mice and worsens osteopetrosis in src(-/-) mice by a novel mechanism, increased osteoclast apoptosis. Induction of apoptosis by Src251 requires a functional SH2, but not an SH3, domain and is associated with reduced AKT kinase activity. Expression of Src251 dramatically reduces osteoclast survival in response to RANKL/TRANCE/OPGL, providing evidence that Src family kinases are required in vivo for survival signaling pathways downstream from TNF family receptors.

Comparison of risk factors for obesity in young, nonobese African-American and Caucasian women.

OBJECTIVE: To determine whether specific risk factors for obesity were more evident in young, normal-weight African-American (AA) compared to Caucasian-American (CA) women. DESIGN: Cross-sectional age-matched study. SUBJECTS: Young, nonobese, sedentary AA (n= 13, 22.5y of age, 23.6% body fat) and CA women (n = 11, 21.5y of age, 24.0% body fat). MEASUREMENTS: Aerobic physical fitness (peak VO2), resting metabolic rate (RMR), resting and submaximal exercise fat oxidation rates, total daily energy expenditure (TDEE) by the doubly-labeled water method, physical activity energy expenditure (PAEE), skeletal muscle glycolytic (phosphofructokinase activity (PFK)) and beta-oxidative (beta-hydroxy-acyl CoA dehydrogenase (beta-HADH)) activity, and insulin sensitivity estimated by the insulin-augmented frequently sampled intravenous glucose tolerance test. RESULTS: The AA and CA subjects were similar in age, body mass index and body composition, but the AA women exhibited lower peak VO2. There were no group differences in RMR adjusted for body composition, or in the rates of submaximal exercise energy expenditure or fat oxidation, and no difference in skeletal muscle beta-HADH or PFK activity. The AA women exhibited lower insulin sensitivity and greater acute insulin response to glucose. The mean TDEE for the AA women was only 74% that of the CA women, primarily due to a lower physical activity energy expenditure (AA group: xPAEE = 1,246+/-438 kJ/day; CA group: x= 3,310+/-466 kJ/day. CONCLUSION: These data indicate that PAEE and its correlates of peak aerobic capacity and insulin sensitivity are lower in young, nonobese AA women compared to their CA counterparts.

Clinical triggers for detection of fever and dehydration. Implications for long-term care nursing.

1. Fever is a common problem among long-term care residents, and the clinical manifestations of fever and infections may be vague or nonspecific. 2. The majority of fevers in this study were staff-detected versus resident-initiated; this implies that staff vigilance is important in the detection of fever. 3. Staff documentation of impaired oral intake during febrile episodes was associated highly with either elevated serum sodium or blood urea nitrogen/creatinine ratios. Therefore, nursing assessment and interventions to hydrate residents at the first indication of impaired oral intake may prevent dehydration. 4. Routine mandated vital signs were found to be of little or no value in detecting fevers.

Dehydration and death during febrile episodes in the nursing home.

OBJECTIVE: To determine the incidence of early hypernatremic dehydration among residents of a nursing home care unit (NHCU) presenting with significant febrile episodes (FE). DESIGN: Prospective cohort analytic study. FE were defined as temperature (T) > 100 degrees F oral (o) or 101 degrees F rectal (r) for > or = 24 hours. SETTING: NHCU in a Veterans Administration hospital. PATIENTS: A total of 130 residents of the NHCU were monitored for FE during a 4-month study period. MAIN OUTCOME MEASURES: Blood urea nitrogen (BUN)/creatinine (Cr) (abnormal > or = 25) and serum sodium (Na)(abnormal > or = 146 mmol/L) were drawn within 24-48 hours of the onset of all FE; documentation of impaired oral intake (OI) by staff; necessity of transfer to acute medical wards and mortality were recorded. RESULTS: There were 48 FE among 42 residents (39 M, 3 F; mean age 75 +/- 11.3). Maximum recorded T during the FE ranged from 100.1 degrees F-102.2 degrees F o and 101.2 degrees F-105.3 degrees F r. Laboratory values were available for 40/48 FE. Twenty-three percent (9/40) had elevated BUN/Cr ratios, 25% (10/40) had elevated serum Na, and 12.5% (5/40) had both. In patients noted to have impaired OI (n = 11) as documented by staff, increased serum Na or BUN/Cr ratio was observed in 82% (9/11). A random control group of 37 nonacutely ill, nonfebrile NHCU residents (33 M, 4 F; mean age 75 +/- 10.1) having routine annual laboratory tests revealed only 1 resident (age 95) with an elevated Na of 146 and BUN/Cr ratio of 26 and 1 resident with an increased BUN/Cr ratio of 28. None of the controls had any staff documentation of impaired OI. Of the 5 deaths in the febrile group with laboratory data (total deaths = 6; 14%), 100% had either elevated serum Na and/or elevated BUN/Cr ratios, and 80% (4/5) had both. Comparing the febrile group with controls, BUN/Cr ratios were found to be significantly elevated in the febrile group (P < 0.05). Serum sodium values were also significantly elevated in the febrile group (P < 0.01). CONCLUSIONS: Staff documentation of impaired OI was highly associated with either elevated serum Na or increased BUN/Cr ratios. These data show that many older NHCU patients with significant fevers often have early impaired OI and laboratory evidence of dehydration. These data indicate that staff should institute appropriate monitoring for dehydration at the time of earliest detection of fever in this population.

Measuring mouth moisture: a case study in instrument development.

This paper describes the process through which an instrument for measuring mouth moisture was developed. The need to create a means of quantifying mouth moisture was realized while planning studies of oral care. Nursing texts assert that one indicator of successful oral care is "moist mucous membranes," and research on oral care typically names mouth moisture as an outcome variable. Yet the measures used in nursing research to assess mouth moisture have been characterized by imprecision, questionable reliability, and disregard for congruence between conceptual and operational definitions. The paper begins by critiquing the instruments commonly used in mouth care research to assess moisture. Next, the methodical process of building ideas to construct a new instrument is described. Finally, the trials that were conducted to arrive at the instrument's final design, estimates of reliability and validity, and a procedure for use that would preserve the integrity of the instrument are discussed.