Unexpected Term Neonatal Intensive Care Unit Admissions and a Potential Role for Centralized Remote Fetal Monitoring.

OBJECTIVE: Centralized remote fetal monitoring (CRFM) has been proposed as a method to improve the performance of intrapartum fetal heart rate (FHR) monitoring and perinatal outcomes. The purpose of this study is to determine whether CRFM was associated with a reduction in unexpected term neonatal intensive care unit (NICU) admissions. STUDY DESIGN: A pre-post design was used to examine the effectiveness of CRFM which was implemented in stages across five hospitals. The exposure group was all women who underwent intrapartum monitoring via CRFM. The unexposed group was of women who delivered at the same hospitals prior to implementation of CRFM. Pregnancies with expected NICU admissions, gestational age <37 weeks, birth weight <2,500 g, or major fetal anomalies detected prenatally were excluded. The primary outcome was unexpected term NICU admission; secondary outcomes were cesarean and operative vaginal delivery (OVD), and 5-minute Apgar's score of <7 rates. Maternal and delivery characteristics were examined with Student's t, Wilcoxon's, Chi-square, and Fisher's exact tests. Multivariable logistic regression was performed to control for potential confounders. RESULTS: There were 19,392 live births included in this analysis. In the univariable analysis, the odds of unexpected term NICU admission was lower among the CRFM exposed group compared with the unexposed group (odds ratio [OR] = 0.86, 95% confidence interval [CI]: 0.75-0.99; p = 0.038). In multivariable analysis, this did not reach statistical significance (OR = 0.92, 95% CI: 0.79-1.06; p = 0.24). Cesarean and OVD were less likely in the exposed group (OR = 0.91, 95% CI: 0.85-0.97; p = 0.008) and (OR = 0.70, 95% CI: 0.59-0.83, p < 0.001), respectively, in univariable analysis. When adjusted for potential confounders, the effect remained statistically significant for cesarean delivery (OR = 0.92, 95% CI: 0.85-0.98; p = 0.012). When adjusted for hospital, OVD rate was lower at the highest volume and highest acuity site (OR = 0.48, 95% CI: 0.36-0.65, p < 0.001). CONCLUSION: In some practice settings, utilization of a CRFM system may decrease the risk of unexpected term NICU admission, cesarean, and OVD rate. KEY POINTS: · CRFM may decrease unexpected term NICU admissions in some clinical settings.. · CRFM may decrease cesarean delivery rates in some clinical settings.. · CRFM may decrease OVD rates in some clinical settings..

Liposomal Bupivacaine Transversus Abdominis Plane Blocks in Laparoscopic Colorectal Resections: A Single-Institution Randomized Controlled Trial.

BACKGROUND: Transversus abdominis plane blocks improve postoperative pain after colon and rectal resections, but the benefits of liposomal bupivacaine use for these blocks have not been clearly demonstrated. OBJECTIVE: This study aimed to determine whether using liposomal bupivacaine in transversus abdominis plane blocks improves postoperative pain and reduces opioid use after colorectal surgery compared to standard bupivacaine. DESIGN: This study was a single-blinded, single-institution, prospective randomized controlled trial comparing liposomal bupivacaine to standard bupivacaine in transversus abdominis plane blocks in patients undergoing elective colon and rectal resections. SETTINGS: This study was conducted at a single-institution academic medical center with 6 staff colorectal surgeons and 2 colorectal surgery fellows. PATIENTS: Ninety-six patients aged 18 to 85 years were assessed for eligibility; 76 were included and randomly assigned to 2 groups of 38 patients. INTERVENTIONS: Patients in the experimental group received liposomal bupivacaine transversus abdominis plane blocks, whereas the control group received standard bupivacaine blocks. MAIN OUTCOME MEASURES: The primary outcome was maximum pain score on postoperative day 2. Secondary outcomes included daily maximum and average pain scores in the 3 days after surgery, as well as daily morphine milligram equivalent use and length of hospital stay. RESULTS: Patients receiving liposomal bupivacaine blocks had lower maximum pain scores on the day of surgery (mean, 6.5 vs 7.7; p = 0.008). No other difference was found between groups with respect to maximum or average pain scores at any time point postoperatively, nor was there any difference in morphine milligram equivalents used or length of stay (median, 3.1 d). LIMITATIONS: This was a single-institution study with only patients blinded to group assignment. CONCLUSIONS: Liposomal bupivacaine use in transversus abdominis plane blocks for patients undergoing laparoscopic colorectal resections does not seem to improve postoperative pain, nor does it reduce narcotic use or decrease length of stay. Given its cost, use of liposomal bupivacaine in transversus abdominis plane blocks is not justified for colon and rectal resections. See Video Abstract at http://links.lww.com/DCR/B979 . CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov . Identifier: NCT04781075. BLOQUEOS TAP DE BUPIVACANA LIPOSOMAL EN RESECCIONES COLORRECTALES LAPAROSCPICAS UN ENSAYO CONTROLADO ALEATORIO DE UNA SOLA INSTITUCIN: ANTECEDENTES:Los bloqueos del plano transverso del abdomen, mejoran el dolor posoperatorio después de las resecciones de colon y recto, pero los beneficios del uso de bupivacaína liposomal para estos bloqueos, no se han demostrado claramente.OBJETIVO:Investigar la eficacia de la inyección con tejido adiposo autólogo recién recolectado en fístulas anales criptoglandulares complejas.DISEÑO:Ensayo controlado, aleatorio, prospectivo, simple ciego, de una sola institución, que compara la bupivacaína liposomal con la bupivacaína estándar en bloqueos del plano transverso del abdomen, en pacientes sometidos a resecciones electivas de colon y recto. Identificador de ClinicalTrials.gov : NCT04781075.ENTORNO CLINICO:Centro médico académico de una sola institución con seis cirujanos de plantilla y becarios de cirugía colorrectal.PACIENTES:Se evaluó la elegibilidad de 96 pacientes de 18 a 85 años; 76 fueron incluidos y aleatorizados en dos grupos de 38 pacientes.INTERVENCIONES:Los pacientes del grupo experimental recibieron bloqueos del plano transverso del abdomen con bupivacaína liposomal, mientras que el grupo de control recibió bloqueos de bupivacaína estándar.PRINCIPALES MEDIDAS DE VALORACION:El resultado primario fue la puntuación máxima de dolor en el segundo día posoperatorio. Los resultados secundarios incluyeron las puntuaciones máximas y medias diarias de dolor en los 3 días posteriores a la cirugía, así como el uso diario equivalente en miligramos de morfina y la duración de la estancia hospitalaria.RESULTADOS:Los pacientes que recibieron bloqueos de bupivacaína liposomal, tuvieron puntuaciones máximas de dolor más bajas, el día de la cirugía (media 6,5 frente a 7,7, p = 0,008). No hubo ninguna otra diferencia entre los grupos con respecto a las puntuaciones de dolor máximas o promedio en cualquier momento después de la operación, ni hubo ninguna diferencia en los equivalentes de miligramos de morfina utilizados o la duración de la estancia (mediana de 3,1 días).LIMITACIONES:Estudio de una sola institución con cegamiento de un solo paciente.CONCLUSIONES:El uso de bupivacaína liposomal en bloqueos del plano transverso del abdomen, para pacientes sometidos a resecciones colorrectales laparoscópicas, no parece mejorar el dolor posoperatorio, ni reduce el uso de narcóticos ni la duración de la estancia hospitalaria. Dado su costo, el uso de bupivacaína liposomal en bloqueos TAP no está justificado para resecciones de colon y recto. Consulte Video Resumen en http://links.lww.com/DCR/B797 . Traducción Dr. Fidel Ruiz Healy.

Direct Oral Anticoagulants Versus Warfarin for Venous Thromboembolism Prophylaxis in Patients With Nephrotic Syndrome: A Retrospective Cohort Study.

BACKGROUND: Evidence supporting venous thromboembolism (VTE) prophylaxis with direct oral anticoagulants (DOACs) in patients with nephrotic syndrome (NS) is limited to case reports. OBJECTIVE: The purpose of this study was to compare bleeding and thromboembolic events in this population. METHODS: A retrospective cohort study was conducted in adults with NS initiated on a DOAC or warfarin for VTE prophylaxis between January 2013 and July 2021 within the Ochsner Health System. Patients with study drug exposure within the preceding 7 days, acute VTE within the preceding 6 months, or ≤7 days of study drug exposure were excluded. The primary outcome was the composite rate of major bleeding and clinically relevant nonmajor bleeding. Secondary outcomes included time to major bleeding and rate of new thromboembolic events. This study was approved by the Ochsner Health System Institutional Review Board. RESULTS: Twenty-five DOAC and 19 warfarin patients were included. The primary outcome occurred in 8% vs 26.3% (P = 0.21) of patients treated with a DOAC or warfarin, respectively, and was driven by major bleeding (4% vs 21%, P = 0.25). Other secondary outcomes were similar between cohorts. The study was limited by a small sample size. CONCLUSION AND RELEVANCE: Use of DOACs for VTE prophylaxis resulted in a nonstatistically significant, but clinically relevant lower rate of major bleeding compared to warfarin. This study provides comparative data showing safe and effective use of DOACs in patients with NS. Prospective, randomized studies are needed to confirm results.

Survey of Vaccine Hesitancy in Patients Visiting Three Tertiary-care Emergency Departments in Southeast Louisiana.

Objectives: Vaccine hesitancy has been a barrier to achieving herd immunity during the coronavirus 2019 (COVID-19) pandemic. Having low socioeconomic status and education levels, and being a person of color, are associated with higher COVID-19 infection risk and worse outcomes. These same groups are associated with higher vaccine hesitancy. The state of Louisiana has one of the lowest vaccination rates in the country. In this study we aimed to identify demographic, perspective, and health behavior factors associated with vaccine hesitancy in emergency departments (ED) in Southeast Louisiana. Methods: A cross-sectional survey was distributed at three tertiary-care hospital EDs. Patients >18 years old and not in acute distress were recruited between April-July 2021. The 37-item questionnaire addressed socioeconomic demographics, social determinants of health, COVID-19 safety practices, thoughts and perceptions on COVID-19 and vaccines, sources of COVID-19 and vaccine information, and trust in the healthcare system. Results: Overall, 247 patients completed our survey. Of those, 29.6% reported they were vaccine hesitant. These respondents were significantly more likely, when compared to vaccine-acceptant respondents, to never have married, to have some college education, make less than <$25,000 in household earnings yearly, be unsure whether vaccines prevent disease, not have discussed the COVID-19 vaccine with their primary care doctor, and to prefer to do their own research for COVID-19 vaccine information. We observed no statistically significant differences based on gender, race/ethnicity, parental status, area of living, or their perceived risk of needing hospitalization for treatment or dying from the virus. Conclusion: Vaccine hesitancy was associated with multiple socioeconomic factors, perspectives, and beliefs. Vaccine-hesitant individuals were more uncertain about the safety of the COVID-19 vaccine, the feasibility of obtaining the vaccine, and its efficacy. Public health interventions aimed at these findings and improving public trust in healthcare systems are needed to increase vaccine acceptance.

Maternal early warning criteria predict postpartum severe maternal morbidity and mortality after delivery hospitalization discharge: a case-control study.

BACKGROUND: The predictors of postpartum severe maternal morbidity and mortality have not been well-described using patient-level data. OBJECTIVE: This study aimed to evaluate the application of maternal early warning criteria in the postpartum period and generate a preliminary predictive model for severe maternal morbidity and mortality occurring after delivery hospitalization discharge until 42 days postpartum. STUDY DESIGN: A retrospective case-control study was conducted from January 2013 to September 2020. Cases were identified from electronic medical records using the International Classification of Diseases, Tenth Revision codes for Centers for Disease Control and Prevention-defined severe maternal morbidity. Patients meeting the criteria for severe maternal morbidity and mortality from delivery hospitalization discharge until 42 days postpartum were matched for delivery hospital and year with the controls in an approximate 1:2 fashion. The objective was to identify the demographic and clinical risk factors during the antepartum through postpartum periods for postpartum severe maternal morbidity and mortality. Multivariable logistic regression was performed to estimate the risks, and a receiver operating characteristic curve was derived to evaluate the model. RESULTS: Ninety cases of postpartum severe maternal morbidity and mortality that occurred following delivery hospitalization discharge were identified. These were matched with 175 controls. Women with postpartum severe maternal morbidity and mortality had more postpartum assessments (mean: 1.7 vs 1.4, P=.005) and a higher frequency of maternal early warning criteria (58% [52/90] vs 2% [3/175]; P<.001) preceding the diagnosis of severe maternal morbidity and mortality than controls. Black women had higher odds of postpartum severe maternal morbidity and mortality than White women (odds ratio, 1.93; 95% confidence interval, 1.14-3.27). Women with maternal early warning criteria during postpartum assessments were more likely to experience subsequent postpartum severe maternal morbidity and mortality (odds ratio, 67.2; 95% confidence interval, 21.3-211.6) than women with no maternal early warning criteria. Although the point estimate was different in Black women (odds ratio, 161.8; 95% confidence interval, 8.9 to >999) than White women (odds ratio, 47.9; 95% confidence interval, 13.8-167.1), the effect modification between the maternal early warning criteria and race was not statistically significant (P=.93). In a multivariable model, race, body mass index, cesarean delivery, and maternal early warning criteria at postpartum assessments were associated with subsequent severe maternal morbidity and mortality, with an area under the curve of 0.905 (95% confidence interval, 0.864-0.946). CONCLUSION: Maternal early warning criteria are associated with increased odds of postpartum severe maternal morbidity and mortality. A straightforward model that includes race, body mass index, cesarean delivery, and presence of maternal early warning criteria appears to be a promising tool to identify those at risk for postpartum severe maternal morbidity and mortality following delivery hospitalization discharge. This is an important first step in improving the ability to recognize and respond to conditions preceding postpartum severe maternal morbidity. These findings should be validated in a prospective cohort.

Association of Skin Incision Type With Postoperative Cesarean Delivery Complications in Morbidly Obese Patients.

OBJECTIVE: To assess whether Pfannenstiel skin incision compared with vertical skin incision was associated with postcesarean delivery wound complications in morbidly obese women. METHODS: We assembled a retrospective cohort of patients with body mass index (BMI) of 40 or higher who delivered by cesarean between July 2012 and May 2019. The primary outcome was a composite wound morbidity (until 42 days postpartum) including wound separation, infection, and dehiscence. Secondary outcomes included individual composite components plus select maternal and neonatal outcomes. Comparisons of demographics and outcomes were made by χ2 and t test. Logistic regression was performed. Subgroup analysis was performed according to location of vertical skin incision in relation to the umbilicus. RESULTS: A total of 3,901 patients were included. To account for imbalances in demographics between exposure groups, vertical and Pfannenstiel skin incision patients were matched in a 1:4 fashion for age, BMI, smoking status, and diabetes. The frequency of wound morbidity was 13.2% overall. There was no difference in the primary outcome when comparing Pfannenstiel with vertical skin incision (adjusted odds ratio [aOR] 1.5, 95% CI 0.8-2.8). Patients with a vertical skin incision were more likely to undergo vertical hysterotomy (aOR 138.7, 95% CI 46.9-410) and transfusion (aOR 5.4, 95% CI 1.8-16.5). When vertical skin incision was classified into supraumbilical and infraumbilical, and compared with Pfannenstiel skin incision, infraumbilical vertical skin incision was associated with increased wound morbidity (odds ratio [OR] 2.46, 95% CI 1.4-4.5) and wound infection (OR 2.5, 95% CI 1.4-4.6) compared with Pfannenstiel. Both types of vertical skin incision were associated with increased odds of vertical hysterotomy and transfusion when compared with Pfannenstiel. CONCLUSION: In morbidly obese women who underwent cesarean delivery, the frequency of postoperative wound morbidity was similar after Pfannenstiel and vertical skin incisions.

A pediatric surgeon's dilemma: does cholecystectomy improve symptoms of biliary dyskinesia?

BACKGROUND: Biliary dyskinesia (BD) is a well-established gallbladder pathology in adult patients and rates of cholecystectomy for BD continue to rise in the United States. Many pediatric patients with vague abdominal pain of variable duration are evaluated for biliary dyskinesia. It remains unknown which cohort of pediatric patients diagnosed with BD are most likely to have sustained improvement in symptoms following laparoscopic cholecystectomy. We aimed to determine whether cholecystectomy resulted in symptom relief and led to a reduction in the number of medical visits related to gastrointestinal (GI) symptoms after surgery. METHODS: We performed a multi-institution retrospective review of all children < 18 years of age who underwent laparoscopic cholecystectomy for BD between January 2013 and April 2018 in our hospital system. GI symptoms and clinical visits related to a GI complaint were assessed preoperatively. Patients were followed for 2 years after surgery. At 6 months and 2 years postoperatively, symptoms and the rate of medical visits related to a GI complaint were quantified and compared to the preoperative values. RESULTS: In total, 45 patients met our inclusion criteria. Of these, 82% of patients were female. The average age was 14 years old (± 2.6) and 56% of patients met the criteria for being overweight or obese. The mean gallbladder ejection fraction was 13% (± 10.8). All patients had abdominal pain, 82% (37/45) presented with nausea, and 51% (23/45) presented with post-prandial pain. Six months postoperatively, 58% of patients experienced resolution of their abdominal pain which decreased to 38% of patients after 2 years. Similarly, 59% had resolution of their nausea at 6 months compared to 43% at 2 years, and 100% had resolution of their post-prandial pain at 6 months compared to 91% at 2 years. The total number of clinical visits related to a GI complaint decreased from 2.6 (± 2.4) preoperatively to 1.0 (± 1.3) within 6 months postoperatively. When followed to 2 years postoperatively, the 6-month rate of clinical visits related to a GI complaint decreased from a mean of 2.6 preoperatively to 0.71 following surgery. CONCLUSIONS: Following cholecystectomy, we observed a high percentage of durable symptom resolution in those patients with BD who presented with post-prandial pain. Patients with non-food-related abdominal pain, with or without nausea and vomiting, had a lower rate of symptom resolution after surgery and the rate declined with time. For patients without post-prandial pain, evaluation and treatment of alternative sources of pain should be considered prior to surgery. Regardless of their presenting symptoms, patients who underwent surgery for BD had fewer clinical GI-related visits after surgery. However, no specific gallbladder ejection fraction or symptom alone was predictive of a lower rate of clinical visits postoperatively.

Reflux Disease and Laryngeal Neoplasia in Nonsmokers and Nondrinkers.

Gastroesophageal reflux disease (GERD) has been hypothesized as a risk factor for development of laryngeal cancer. A case-control study was performed to assess the association of laryngeal neoplasia with GERD. Cases consisted of patients with a history of laryngeal cancer or carcinoma in situ. Controls were patients without neoplasia who matched cases 2:1 on age, sex, race, and smoking history. Univariate and multivariate analyses were performed to assess risk of laryngeal neoplasia and GERD. In total, 2094 patients were included. Cases had higher rates of GERD. Univariate analysis demonstrated a positive association between GERD and laryngeal neoplasia (odds ratio, 1.33; 95% CI, 1.07-1.64). Multivariate analysis controlling for alcohol use history also demonstrated a positive association between GERD and laryngeal neoplasia (adjusted odds ratio, 1.29; 95% CI, 1.04-1.59). These results suggest increased odds of laryngeal carcinoma and carcinoma in situ in patients with GERD when controlling for smoking and drinking history.

Web-based patient portal access in an orthopedic adult reconstruction patient population.

BACKGROUND: We surveyed patients in an adult reconstruction practice as to their use of the Web-based portal provided by our electronic health record, seeking to reveal patterns of use and helpfulness. METHODS: A total of 150 completed surveys were received. The survey queried demographics, the number of clinic visits, Internet access, portal activation, portal use frequency, and portal information questions and how patients answered them. Helpfulness was rated from 1 (not helpful) to 5 (very helpful). Statistical analysis included bivariate analysis and logistic regression, with odds ratio (OR) and 95% confidence interval (CI) reported. RESULTS: The mean age was 67.6 years. Most were females (n = 97, 65.1%). Most (68.7%) patients used the portal. Younger age (OR, 0.94; CI, 0.90-0.99) and access to Internet (OR, 31.8; CI, 8.5-119.4) predicted portal use (P < .005), whereas gender and number of clinic visits did not (P > .373). Of all, 47.5% of patients were unclear about online chart information. Older age indicated being unclear of portal information (68.5 vs 66, P = .0002). Of those who clarified doubts regarding information (n = 67), 23 used the Internet (34.3%), 32 (47.7%) called the physician, and 12 (17.9%) asked a friend and/or family member. Most (90.3%) patients felt the portal was helpful in gathering health information. CONCLUSIONS: Age and Internet access affected portal usage; ability to understand chart information decreased with age. Most patients used the Internet or a family member to clarify doubts regarding portal information. The use of portal data resulted in 32 extra communications to the physician.

Association of Computed Tomography With Treatment and Timing of Care in Adult Patients With Peritonsillar Abscess.

Background: Peritonsillar abscess (PTA) is a common occurrence in adult patients, and an important question in such often-seen disease processes is whether we are treating these patients effectively, efficiently, and economically. We sought to determine if a diagnostic computed tomography (CT) scan was associated with a difference in clinical intervention in adult patients with PTA and if CT was associated with delaying this intervention. Methods: We conducted a retrospective case-control study examining therapeutic interventions in adults with PTA. Patients were divided into a control group (those diagnosed without CT, n=159) and a case group (those diagnosed with CT, n=203). Patients were examined for 3 outcomes: admission, bedside procedure (needle aspiration, incision/drainage), and surgical procedure (incision/drainage, tonsillectomy). In addition, we calculated times to admission, otolaryngology consultation, bedside procedure, and surgical procedure. Results: We found a significant association between CT and intervention, with the CT group more likely to be admitted (P< 0.001), the non-CT group more likely to undergo a bedside procedure (P<0.001), and the CT group more likely to undergo operative intervention (P=0.02). Mean times to otolaryngology consultation, admission, and bedside procedure were significantly longer in the CT group than in the non-CT group, determined by calculating the difference of the means with 95% confidence intervals for each comparison (P<0.001). Conclusion: We found that CT scans appear to be useful in the workup and treatment of adult patients with PTA, evidenced by significant differences in interventions between groups with and without CT scans. We also found that CT scans have the potential to delay these interventions, as the time to each intervention examined was significantly longer in patients who had a CT scan. Given the need to reduce cost, enhance efficiency, and eliminate harmful side effects (in this case, radiation exposure and delays in care), we question whether CT is the gold standard imaging method for diagnostic work up of PTA.

Improved Cost-Effectiveness and Blood Product Utilization From Instituting a Blood Ordering Algorithm for Cardiac Surgical Cases.

BACKGROUND: Results of a previous study revealed an over-ordering of blood products for cardiac surgery and led to the creation of a new blood ordering algorithm. This follow-up study has been conducted to evaluate improvement in ordering practices. METHODS: Retrospective data were collected for 171 patients who underwent coronary artery bypass grafting or valve surgery from March 2015 to March 2016 to determine the crossmatch-to-transfusion ratio (C:tx) and potential cost savings. Results were compared with pre-algorithm values and considered statistically significant if the 95% confidence interval did not include zero. RESULTS: Prior to the algorithm, 100% of patients undergoing cardiac surgery were crossmatched. After instituting the algorithm, this decreased to 15%. The overall C:tx decreased from 7.97 to 2.14. Cost savings were calculated as $114.79 (coronary artery bypass grafting) and $129.05 (valve surgery) per patient. CONCLUSIONS: The creation of a new algorithm to guide ordering practices has significantly improved the C:tx, reduced unnecessary crossmatching, and lowered costs.

Interval Colorectal Cancers at Ochsner Medical Center: Where Do We Stand?

BACKGROUND: An interval colorectal cancer is a cancer diagnosed prior to the recommended follow-up time from a previously negative colonoscopy. These cancers are thought to arise from a rapidly growing cancer, missed cancer, or incompletely resected adenomas. Our study aimed to identify interval cancers diagnosed during a 4-year period and to identify any potential risk factors associated with these cancers. Secondly, we compared our interval colorectal cancer rate with other published rates. METHODS: Our population included all patients who underwent colonoscopy for any indication between August 1, 2010 and July 31, 2014 (n=28,794), excluding individuals <18 years and patients with a history of inflammatory bowel disease, previously diagnosed colorectal cancer, or known hereditary cancer syndrome. Using a retrospective review of our institution's electronic medical record and data from the Louisiana Tumor Registry, we identified patients who were diagnosed with colorectal cancer. From these individuals, we reviewed and selected those who met the criteria for interval cancers. RESULTS: We identified 20 interval cancers during the 4-year study period. Based on the total number of index colonoscopies performed during the time period, our overall incidence rate was 0.07%. Approximately 1 interval cancer was diagnosed per 1,400 colonoscopy examinations. Our occurrence rate of 0.28 cases per 1,000 person-years of observation was less than or similar to the rates reported in other studies. CONCLUSION: Our study demonstrated that our institution has a low incidence of interval cancers, supporting the effectiveness of our cancer screening program. To further minimize interval colorectal cancers, we recommend the documentation and reporting of endoscopy quality measures, as well as close follow-up intervals or alternate examinations for patients who have poor bowel preparation or incomplete/difficult examinations.

Perineural Liposomal Bupivacaine for Postoperative Pain Control in Patients Undergoing Upper Extremity Orthopedic Surgery: A Prospective and Randomized Pilot Study.

BACKGROUND: Upper extremity surgery is commonly performed in the ambulatory setting and is associated with moderate to severe postoperative pain. METHODS: Patients scheduled for upper extremity orthopedic surgery with a peripheral nerve block were randomized to receive either an ultrasound-guided single-injection supraclavicular block or ultrasound-guided median, ulnar, and radial nerve blocks (forearm blocks) performed at the level of the mid to proximal forearm with liposomal bupivacaine (Exparel) combined with a short-acting supraclavicular block. A sham block was performed in an attempt to blind enrollees in the control group. We administered the EuroQol 5D-5L questionnaire preoperatively and on postoperative days 1-3 and considered the results the primary outcome of our investigation. Block procedure times, postanesthesia care unit (PACU) length of stay, instances of nausea/vomiting, need for narcotic administration, and patient satisfaction were also assessed. RESULTS: We observed no significant differences in postoperative EuroQol scores between the 2 groups and no significant differences in patient demographics, PACU length of stay, or side effects in the PACU. In some instances, the short-acting supraclavicular block resolved in the PACU, and these patients reported higher pain scores and required titration of analgesics prior to discharge. CONCLUSION: Larger prospective studies are needed to determine the safety and efficacy of liposomal bupivacaine in patients undergoing upper extremity surgery. Liposomal bupivacaine is currently only approved for local anesthetic infiltration use.

Pediatricians' Confidence and Behaviors in Smoking Cessation Promotion and Knowledge of the Smoking Cessation Trust.

BACKGROUND: Secondhand smoke exposure increases morbidity and mortality in children. Thirty-one percent of caregivers who accompany their children to the Ochsner Health Center for Children smoke, and none uses the services of the Smoking Cessation Trust (SCT), a free smoking cessation program for eligible Louisiana residents who began smoking before 1988. The objective of this study was 2-fold: first, to assess and compare pediatricians' confidence and behaviors in regard to smoking cessation promotion with caregivers, and second, to determine pediatricians' knowledge and comfort level with the SCT. METHODS: Pediatricians were given a questionnaire to assess 12 parameters regarding their confidence and practice when screening, counseling, and referring caregivers to smoking cessation programs. RESULTS: Thirty-six questionnaires were administered, of which 27 were completed (75%). Only 7.41% of respondents had formal training in smoking cessation, 18.52% had never heard of the SCT, and 92.59% do not refer to the SCT. All the pediatrician respondents stated that they were confident in their ability to screen for secondhand smoke exposure, 62.96% were confident in providing counseling, and 44.44% were confident in offering referrals. Most pediatricians very often or always screened for secondhand smoke exposure (77.78%); however, only 25.93% counseled smoking caregivers to quit, and only 11.11% provided a smoking cessation referral. Pediatricians stated that they were confident to screen, counsel, and refer caregivers; however, they were significantly less likely to report actually screening for secondhand smoke exposure (P<0.05), counseling (P<0.05), and referring caregivers (P<0.05). CONCLUSION: Efforts should be made to increase the rate by which pediatricians provide smoking cessation, counseling, and referrals to the SCT through education and training.

Correlates of improved influenza vaccination of healthcare personnel: a survey of hospitals in Louisiana.

OBJECTIVE: To describe practices for influenza vaccination of healthcare personnel (HCP) with emphasis on correlates of increased vaccination rates. DESIGN: Survey. PARTICIPANTS: Volunteer sample of hospitals in Louisiana. METHODS: All hospitals in Louisiana were invited to participate. A 17-item questionnaire inquired about the hospital type, patients served, characteristics of the vaccination campaign, and the resulting vaccination rate. RESULTS: Of 254 hospitals, 153 (60%) participated and were included in the 124 responses that were received. Most programs (64%) required that HCP either receive the vaccine or sign a declination form, and the rest were exclusively voluntary (36%); no program made vaccination a condition of employment. The median vaccination rate was 67%, and the vaccination rate was higher among hospitals that were accredited by the Joint Commission; provided acute care; served children, pregnant women, oncology patients, or intensive care unit patients; required a signed declination form; or imposed consequences for unvaccinated HCP (the most common of which was to require that a mask be worn on patient contact). Hospitals that provided free vaccine, made vaccine widely available, advertised the program extensively, required a declination form, and imposed consequences had the highest vaccination rates (median, 86%; range, 81%-91%). CONCLUSIONS: The rate of influenza vaccination of HCP remains low among the hospitals surveyed. Recommended practices may not be enough to reach 90% vaccination rates unless a signed declination requirement and consequences are implemented. Wearing a mask is a strong consequence. Demanding influenza vaccination as a condition of employment was not reported as a practice by the participating hospitals.

Gene expression in mononuclear cells from patients with inflammatory bowel disease.

OBJECTIVES: Discovery of Nod2 as the inflammatory bowel disease 1 (IBD1) susceptibility gene has brought to light the significance of mononuclear cells in inflammatory bowel disease pathogenesis. The purpose of this study was to examine changes in gene expression in peripheral blood mononuclear cells in patients with untreated Crohn's disease (CD) and ulcerative colitis (UC) as compared to patients with other inflammatory gastrointestinal disorders and to healthy controls. METHODS: We used a 2400 gene cDNA glass slide array (MICROMAX) to examine gene expression in peripheral blood mononuclear cells from seven patients with Crohn's disease, five patients with ulcerative colitis, 10 patients with other inflammatory gastrointestinal disorders, and 22 age- and sex-matched controls. Results. Novel categories of genes differentially expressed in Crohn's disease and ulcerative colitis patients included genes regulating hematopoietic cell differentiation and leukemogenesis, lipid raft-associated signaling, the actin cytoskeleton, and vesicular trafficking. CONCLUSIONS: Altered gene expression in mononuclear cells may contribute to inflammatory bowel disease pathogenesis.

Association of the T allele of an intronic single nucleotide polymorphism in the colony stimulating factor 1 receptor with Crohn's disease: a case-control study.

BACKGROUND: Polymorphisms in several genes (NOD2, MDR1, SLC22A4) have been associated with susceptibility to Crohn's disease. Identification of the remaining Crohn's susceptibility genes is essential for the development of disease-specific targets for immunotherapy. Using gene expression analysis, we identified a differentially expressed gene on 5q33, the colony stimulating factor 1 receptor (CSF1R) gene, and hypothesized that it is a Crohn's susceptibility gene. The CSF1R gene is involved in monocyte to macrophage differentiation and in innate immunity. METHODS: Patients provided informed consent prior to entry into the study as approved by the Institutional Review Board at LSU Health Sciences Center. We performed forward and reverse sequencing of genomic DNA from 111 unrelated patients with Crohn's disease and 108 controls. We also stained paraffin-embedded, ileal and colonic tissue sections from patients with Crohn's disease and controls with a polyclonal antibody raised against the human CSF1R protein. RESULTS: A single nucleotide polymorphism (A2033T) near a Runx1 binding site in the eleventh intron of the colony stimulating factor 1 receptor was identified. The T allele of this single nucleotide polymorphism occurred in 27% of patients with Crohn's disease but in only 13% of controls (X2 = 6.74, p < 0.01, odds ratio (O.R.) = 2.49, 1.23 < O.R. < 5.01). Using immunohistochemistry, positive staining with a polyclonal antibody to CSF1R was observed in the superficial epithelium of ileal and colonic tissue sections. CONCLUSIONS: We conclude that the colony stimulating factor receptor 1 gene may be a susceptibility gene for Crohn's disease.