From mild to gangrenous cholecystitis, laparoscopic cholecystectomy is safe 24 hours a day.

OBJECTIVES: Laparoscopic cholecystectomy (LC) at night remains controversial. Prior studies have not controlled for disease severity. We analyzed outcomes of LC performed day vs. night while controlling for the Parkland Grading Scale for Cholecystitis (PGS). METHODS: Analysis of the AAST multicenter evaluation of cholecystitis database was performed. Exclusion criteria included non-operative cases, open operations, and missing PGS. Cases were divided based on operation start time. PGS was used to control for disease severity. Outcomes included operative time, use of bailout techniques and complications. RESULTS: Of 759 procedures identified, 16% were nighttime LC. No differences in demographics, comorbidities, physiologic variables and PGS were noted. Operative time (108.6 min vs 105.6), bailout techniques (8.3% vs 7.4%) and complications (9.9% vs 11.3%) were similar between groups. CONCLUSION: Regardless of severity, laparoscopic cholecystectomy is safe 24-h a day. Operations performed at night have a similar complication profile to those performed during the day.

ACS NSQIP Surgical Risk Calculator: Pilot Analysis on Feasibility in an Academic Safety Net Hospital.

BACKGROUND: Hospitals are looking for effective methods to track outcomes that are risk-adjusted for patient population characteristics. This is especially relevant for safety net hospitals (SNHs) servicing high-risk populations and in an era of quality-based reimbursement incentives. One such program with these goals is the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). This is an institution-based quality audit whereby we determined the presence and consistency of charted data required to compute perioperative risk in the ACS NSQIP risk calculator. MATERIALS AND METHODS: A retrospective chart review of 28 elective colorectal procedures was performed at an urban, academic SNH over a 1-y period. For each case, it was determined whether the required NSQIP variables were readily presented via preoperative documentation. Univariate and bivariate statistics were employed to compare data field completion rates. RESULTS: Of the 28 reviewed patient charts, none (n = 0) had all preoperative risk documentation required to complete an ACS NSQIP risk analysis. 89.3% of charts (n = 25) had ≤ 55% of required data to complete a risk assessment. However on bivariate analysis, demographic variables were more likely to have been recorded (P < 0.001) than other risk factors. CONCLUSIONS: Preoperative risk assessment and corresponding charting practices at the SNH reviewed was fragmented and incomplete. There was lack of definitive documentation of risk factors and preoperative interventions used to modulate risk. Under current reimbursement models such as the MACRA Quality Payment Program, these findings are crucial for like-institutions to consider to critically evaluate their own documentation practices.

Prevention of fall-related injuries in the elderly: An Eastern Association for the Surgery of Trauma practice management guideline

"BACKGROUND: Fall-related injuries among the elderly (age 65 and older) are the cause of nearly 750,000 hospitalizations and 25,000 deaths per year in the United States, yet prevention research is lagging. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, the Eastern Association for the Surgery of Trauma produced this practice management guideline to answer the following injury prevention-related population, intervention, comparator, outcomes (PICO) questions:PICO 1: Should bone mineral-enhancing agents be used to prevent fall-related injuries in the elderly?PICO 2: Should hip protectors be used to prevent fall-related injuries in the elderly?PICO 3: Should exercise programs be used to prevent fall-related injuries in the elderly?PICO 4: Should physical environment modifications be used to prevent fall-related injuries in the elderly?PICO 5: Should risk factor screening be used to prevent fall-related injuries in the elderly?PICO 6: Should multiple interventions tailored to the population or individual be used to prevent fall-related injuries in the elderly? METHODS: A comprehensive search and review of all the available literature was performed. We used the GRADE methodology to assess the breadth and quality of the data specific to our PICO questions. RESULTS: We reviewed 50 articles that met our inclusion and exclusion criteria as they applied to our PICO questions. CONCLUSION: Given the data constraints, we offer the following suggestions and recommendations:PICO 1: We conditionally recommend vitamin D and calcium supplementation for frail elderly individuals.PICO 2: We conditionally recommend hip protectors for frail elderly individuals, in the appropriate environment.PICO 3: We conditionally recommend evidence-based exercise programs for frail elderly individuals.PICO 4: We conditionally recommend physical environment modification for frail elderly people.PICO 5: We conditionally recommend frailty screening for the elderly.PICO 6: We strongly recommend risk stratification with targeted comprehensive risk-reduction strategies tailored to particular high-risk groups. LEVEL OF EVIDENCE: Systematic review, level III"

Inconsistent identification of pit bull-type dogs by shelter staff.

Shelter staff and veterinarians routinely make subjective dog breed identification based on appearance, but their accuracy regarding pit bull-type breeds is unknown. The purpose of this study was to measure agreement among shelter staff in assigning pit bull-type breed designations to shelter dogs and to compare breed assignments with DNA breed signatures. In this prospective cross-sectional study, four staff members at each of four different shelters recorded their suspected breed(s) for 30 dogs; there was a total of 16 breed assessors and 120 dogs. The terms American pit bull terrier, American Staffordshire terrier, Staffordshire bull terrier, pit bull, and their mixes were included in the study definition of 'pit bull-type breeds.' Using visual identification only, the median inter-observer agreements and kappa values in pair-wise comparisons of each of the staff breed assignments for pit bull-type breed vs. not pit bull-type breed ranged from 76% to 83% and from 0.44 to 0.52 (moderate agreement), respectively. Whole blood was submitted to a commercial DNA testing laboratory for breed identification. Whereas DNA breed signatures identified only 25 dogs (21%) as pit bull-type, shelter staff collectively identified 62 (52%) dogs as pit bull-type. Agreement between visual and DNA-based breed assignments varied among individuals, with sensitivity for pit bull-type identification ranging from 33% to 75% and specificity ranging from 52% to 100%. The median kappa value for inter-observer agreement with DNA results at each shelter ranged from 0.1 to 0.48 (poor to moderate). Lack of consistency among shelter staff indicated that visual identification of pit bull-type dogs was unreliable.

Use of visual and permanent identification for pets by veterinary clinics.

It is estimated that more than 5 million stray dogs and cats enter animal shelters in the USA each year, but less than half are ever reunited with their owners. Lost pets with identification microchips are up to 21 times more likely to be reunited than those without. Finders of lost pets are more likely to consult veterinarians than shelters for assistance, and pet owners look first to veterinarians for advice regarding pet health, protection, and welfare. An online survey of 1086 veterinary clinics in the South-Eastern USA was conducted to evaluate how veterinary clinics functioned as a part of the pet identification network. Scanning and microchip implants were offered by 91% of surveyed clinics and 41% used 'global' scanners capable of detecting all currently used microchip brands. Clinics more frequently relied on pet owners to register contact information rather than providing this service for clients (52% vs. 43%, respectively). Even though lost dogs are more likely to be reunited with owners than lost cats, microchips and collars were more likely to be recommended for all dogs (85% and 93%, respectively) than for all cats (67% and 61%, respectively). Only half of clinics that recommended identification collars made them available to their clients. Veterinarians can protect animals, pet owners and the human-animal bond by integrating pet identification into preventive health care.

A pilot study to investigate the effects of combined dehumidification and HEPA filtration on dew point and airborne mold spore counts in day care centers.

UNLABELLED: Meteorological factors such as relative humidity directly correlate with airborne fungal levels outdoors and indoors. While dehumidification alone is effective at reducing moisture necessary for mold growth, it is inadequate as a single intervention as it does not remove viable and non-viable fungal spores that are potentially allergenic. The purpose of this pilot study was to investigate whether dehumidification in combination with high-efficiency particulate arrestance (HEPA) filtration is effective at reducing airborne mold spore levels in day care centers. Two day care centers within a 2-mile radius of each other were selected. Day care center A was 2 years old with eight rooms while day care center B was 15 years old with six rooms. A high efficiency Santa Fe dehumidification unit equipped with a HEPA filter was installed in half the rooms (intervention) of each day care facility. Electronic HOBO data loggers continuously measured outdoor and indoor room dew point and temperature every 2 h throughout the study. Dew point and airborne fungal spore measurements from selected rooms with controlled air conditions were analyzed by comparing baseline measurements to those obtained at subsequent time periods over 1 year. Regression models accounted for correlations between measurements in the same room over time. Intervention resulted in a lowered average dew point from baseline by 8.8 degrees C compared with a decrease of 7.1 degrees C in non-intervention rooms across all time periods in both facilities (P<0.001). Fungal analyses demonstrated lower baseline (P=0.06) and follow-up means in intervention rooms (P<0.05), however the change from baseline to end of follow-up differed between intervention and non-intervention rooms in the two facilities. Log transformation was applied to approximate normality of fungal measurements. Dehumidification with HEPA filtration was effective at controlling indoor dew point in both facilities and at reducing airborne culturable fungal spore levels in one of the two facilities. These preliminary results provide a scientific rationale for using this intervention in future studies designed to investigate the impact of indoor mold exposure on health outcomes. PRACTICAL IMPLICATIONS: Poor indoor air quality is a recognized cause or contributing factor to health effects. Dampness and humidity have been linked to upper and lower respiratory symptoms in children and adults. This study indicates that reducing indoor relative humidity and airborne mold spore levels using high-efficiency dehumidification units equipped with HEPA filtration is feasible even in work facilities such as day care centers where traffic in and out of the building is difficult to regulate. Clinicians should emphasize to their patients the importance of dehumidification and HEPA filtration to improve indoor air quality in the home and workplace.

The tissue distribution and functional characterization of human VR1.

The irritant action of capsaicin is mediated by the vanilloid receptor, VR1, which is expressed in sensory neurons termed nociceptors. Capsaicin also desensitizes nociceptors and, thus, is useful clinically as an analgesic. Given the potential importance of VR1 in pain, we have cloned the human capsaicin receptor, hVR1, from a human dorsal root ganglia (DRG) cDNA library. Human VR1 protein is 85% identical to the rat VR1 and many of the amino acid differences are concentrated at the amino and carboxyl termini. VR1 is expressed in DRG as an approximately 4.2 kilobase RNA, and is also expressed in the central nervous system and in the kidney. Capsaicin (EC(50) = 853 nM), low pH (<5.5), and noxious heat (44 degrees C) activate hVR1 expressed in Xenopus oocytes. Subthreshold pH (6.4) sensitizes VR1 to capsaicin (EC(50) = 221 nM). This study demonstrates the similarity of human and rat VR1 in integrating multiple noxious stimuli.

Converting enzyme inhibitors cause pressure-independent resetting of baroreflex control of sympathetic outflow.

The current study was performed to determine whether baroreflex resetting after acute administration of converting enzyme inhibitors (CEIs) was dependent on the concomitant decrease in mean arterial pressure (MAP). Reflex changes in lumbar sympathetic nerve activity (LSNA) due to increases and decreases in MAP [i.v. phenylephrine (PE) and nitroprusside infusions] were determined in normotensive and renal hypertensive (1-kidney, 1-clip) anesthetized WKY rats 1) before (control), 2) 15 min after intravenous captopril (2 mg/kg) or enalaprilat (300 micrograms), and 3) 15 min after MAP was returned to pre-CEI levels with intravenous PE. CEIs decreased MAP and caused a leftward shift of the MAP-LSNA curve toward a lower operating pressure range in all hypertensive and in one group of normotensive rats. The baroreflex curve remained shifted to the left even after MAP was restored to pre-CEI levels by infusion of PE. Thus CEIs cause a pressure-independent resetting of baroreflex control of sympathetic outflow within 15 min. This effect of CEIs is most likely due to elimination of a central nervous system effect of circulating angiotensin II and could contribute to the antihypertensive actions of this class of compounds.

Environmental epidemiologic investigations in the styrene-butadiene rubber production industry.

A review of the literature and an update that is in progress of a previous retrospective cohort mortality study of the styrene-1,3-butadiene industry are discussed. The follow-up has now been extended from April 1, 1976, through December 31, 1981, for plant B and December 31, 1982, for plant A. The person-years at risk of death have gone from 34,187 to 43,341 in plant A and from 19,742 to 26,314 in plant B. Among the death certificates received to date, observed deaths have increased in both plants, with increases in cancers of the trachea, bronchus and lung and in lymphosarcomas, reticulosarcomas, and cancers of the overall lymphatic and hematopoietic system.

Baroreflex control of sympathetic outflow in pregnant rats: effects of captopril.

Arterial baroreflex control of renal sympathetic nerve activity (RSNA) was compared in nonpregnant (NP) and near-term pregnant (P) chloralose-anesthetized rats. Baroreflex curves were obtained by recording reflex changes in RSNA (expressed as a percent of base line) due to increases and decreases in mean arterial pressure (MAP) [intravenous phenylephrine and nitroprusside (NTP)]. The slope, midpoint (EP50), and threshold pressures of the baroreflex curves were compared. Base-line MAP was significantly lower in the pregnant animals (P = 96 +/- 3 vs. NP = 113 +/- 5 mmHg). The baroreflex curves of pregnant animals also had significantly lower threshold (P = 95 +/- 3 vs. NP = 110 +/- 5 mmHg) and midpoint values (P = 105 +/- 4 vs. NP = 119 +/- 5 mmHg). The response to unloading the baroreceptors was attenuated in the pregnant animals as indicated by a decrease in slope of the NTP portion of the baroreflex curve (P = 0.95 +/- 0.17 vs. NP = 1.61 +/- 0.29% nerve activity/mmHg). Responses to blockade of angiotensin-converting enzyme with captopril (2 mg/kg iv) were also examined. There were no differences in EP50 or slope among the control, captopril, and recovery baroreflex curves within either the nonpregnant or pregnant animals. However, after captopril, MAP decreased to a greater extent in the pregnant rats, yet RSNA increased to the same level for the two groups. Thus pregnancy results in a leftward shift of the baroreflex function curve toward a lower operating pressure range. In addition, pregnant rats demonstrated an impaired ability to increase sympathetic outflow above base-line values in response to a hypotensive challenge.

Characterization of norepinephrine sensitivity in the maternal splanchnic circulation during pregnancy.

Vascular sensitivity to exogenous norepinephrine and transmural nerve stimulation was studied in the splanchnic bed of nonpregnant, early pregnant, and late pregnant rats. Resistance-size mesenteric arteries were removed from late pregnant (18 to 20 days), early pregnant (7 days), and nonpregnant cycling rats and mounted in a myograph system, which permits the precise setting of vessel circumference for the determination of norepinephrine sensitivity. Norepinephrine dose-response curves and frequency-response curves for transmural nerve stimulation were obtained in the presence and absence of cocaine, a specific inhibitor of neuronal reuptake. The mesenteric arteries of late pregnant rats were 1.5 times less sensitive to exogenous norepinephrine than arteries of both early pregnant and nonpregnant rats. Sensitivity to transmural nerve stimulation was decreased in both early and late pregnant rats compared with nonpregnant controls. Cocaine potentiated the response to both exogenous norepinephrine and transmural nerve stimulation in the pregnant rats so that responses between nonpregnant, early pregnant, and late pregnant rats were no longer different. This suggests a greater reuptake activity from pregnant rats. In conclusion, pregnancy is associated with a reduction in splanchnic norepinephrine sensitivity, which may be due partly to an increase in neuronal deactivation of norepinephrine. The maximum contractile response to norepinephrine also was decreased in late pregnancy, which suggests additional mechanisms for changes in norepinephrine vascular sensitivity.

Segregation of proteinase-negative mutants from heterozygous Candida albicans.

The extracellular acidic proteinase (EC 3.4.23.6) produced by Candida albicans has been reported to be a virulence factor. In studying the role of this proteinase in human disease, we determined the optimum conditions for stimulating proteinase production in order to isolate proteinase-negative (Prt-) mutants. We found that in liquid medium containing bovine serum albumin (BSA) as the sole nitrogen source, at pH 4 and 27 degrees C, the sensitivity of proteinase detection was considerably greater than when assayed on BSA agar at 37 degrees C. This observation is due, in part, to temperature sensitivity of proteinase induction. Nitrogen starvation did not induce proteinase. Proteinase production on agar was increased by adding 0.01% yeast extract (YE) to BSA medium. Using BSA + YE agar to isolate mutants, it was discovered that C. albicans ATCC 28366 was heterozygous for a Prt- mutation. Spontaneous Prt- mutants occurred at a frequency of 2 x 10(-3). Ultraviolet light increased the mitotic segregation of Prt- cells to a frequency of 1 x 10(-2). The Prt- phenotype showed a large inoculum effect, Prt- segregants reverted with a high frequency, and the revertants were unstable.

In vitro evidence for an inhibitory effect of atrial natriuretic peptide on vasopressin release.

The effect of Arg-atriopeptin III (ANP) on basal and stimulated (angiotensin II, acetylcholine and KCl depolarization) arginine vasopressin (AVP) release was characterized in the intact hypothalamo-neurohypophysial explant (HNS) and in isolated neurointermediate pituitary lobes (NIL). In initial experiments using 15-min incubation periods, ANP 10(-10) and 10(-9) M slightly inhibited basal AVP release in both NIL and HNS after a delay of at least 15 min. The most effective ANP concentration was 10(-10) M, and the inhibitory effect on AVP release was more marked in HNS (-52 +/- 5% of control compared to -29 +/- 8% for NIL). However, ANP 10(-10) M did not significantly attenuate KCl- or AII (10(-5) M)-stimulated AVP release from HNS after 15 min of exposure. When the incubation periods were increased to 30 min ANP 10(-10) and 10(-9) M significantly decreased AII-stimulated (10(-5) M) AVP release in a dose-dependent manner (p less than 0.05; p less than 0.01, respectively). The same concentrations of ANP did not significantly depress ACH-stimulated (10(-5) M) AVP release (p less than 0.1 for both concentrations). In summary, ANP generally inhibits AVP release in vitro by a slowly activated mechanism which appears to be specific for certain physiological stimuli. Although the site(s) of action cannot be absolutely localized to the ventral hypothalamus and/or the neurohypophysis, an effect in the hypothalamus seems very likely.

The Parsons visual acuity test for screening children 18 to 48 months old.

The Parsons visual acuity test (PVAT) uses modified Allen test targets for visual acuity assessment in young children and persons who are difficult to test. Using this method, we were able to obtain a visual acuity threshold in 44% of 18- to 24-month-old children and in 90% of children aged 25 to 36 months. At all ages tested, the mode for visual acuity was 20/30; however, the percentage of those with 20/20 increased with age. The decision whether to refer was correctly made by means of the PVAT criterion 83% of the time.

An analysis of exposure to styrene in the reinforced plastic boat-making industry.

To evaluate patterns of occupational exposure to styrene monomer in the boat-building industry, we conducted industrial hygiene surveys in seven fiberglass-reinforced plastic boat-fabrication plants. A total of 397 personal breathing zone air samples were collected on workers in four key job categories: gel coating and hull, deck, and small-parts lamination. We found that exposure to styrene in 234 (59%) of the personal samples exceeded the NIOSH-recommended time-weighted average (TWA) standard of 50 parts per million (ppm), and 96 (24%) of these samples exceeded the OSHA eight-hour TWA permissible exposure limit of 100 ppm. From highest to lowest average exposure potential, the job categories ranked in the following order: hull lamination (range 2-183 ppm, mean 78 ppm), deck lamination (range 12-160 ppm, mean 73 ppm), gel coating (range 5-94 ppm, mean 48 ppm), and small-parts lamination (range 9-130 ppm, mean 45 ppm). The former two categories composed a higher-exposure group, and the latter two tended to form a lower-exposure group. Exposures in these jobs appear to be proportional to resin consumption. Statistical analyses indicated that the parameter that most affects exposure potential is job category. Within a job category, part size, configuration, and surface area are important determinants of exposure. The principal reason for high exposures was the absence of control technologies and, in particular, the absence of adequate ventilation.

Mortality patterns among styrene-exposed boatbuilders.

In order to test the hypothesis that leukemia and lymphoma may be associated with exposure to styrene, cause-of-death patterns were studied at two reinforced plastic boatbuilding facilities. There were 5,021 workers who met the criterion of having worked at the two plants between 1959 and 1978. Based on industrial hygiene surveys conducted at the two plants, 2,060 individuals were determined to have worked in departments classified as having high exposure to styrene. There were 176 deaths observed among the total cohort, in comparison to 195.3 deaths expected (standardized mortality ratio [SMR] = 90). Among the high styrene exposure group, 47 deaths were observed in comparison to 41.5 deaths expected (SMR = 113). No leukemia or lymphoma deaths were observed in either the high exposure group or the total cohort. An excess of accidental deaths among the high exposure group (18 observed vs 12.4 expected) did not appear to be due to styrene's acute central nervous system effects, since none of the individuals were employed at the facilities at the time of their death. However, the possibility of a chronic effect could not be dismissed. While leukemia and lymphoma did not appear to be related to styrene exposure, the study had little statistical power to detect excesses of these diseases, due to the short length of observation and the young age of most cohort members. It was concluded that the cohort should provide increasingly useful information on chronic styrene toxicity as the population ages and the observation period increases.

Cancer mortality patterns by work category in three Texas oil refineries.

A previous proportionate mortality ratio analysis revealed elevated mortality from brain tumors, stomach cancer, leukemia, and other cancers among OCAW members employed in three Texas oil refineries. In order to evaluate these findings, complete work histories of cases and a matched set of controls who died from other causes of death were obtained from company personnel records. Work histories were summarized by classifying each job title and department entry into one of several broad work categories of refinery unit operations. A worker was considered "exposed" to a work category if he was known to have worked at least 1 day in the category 15 or more years prior to his death. Maximum likelihood estimates of the relative risk for brain tumor, stomach cancer, and leukemia were calculated by work category using a procedure for matched case-control data. No strong associations for brain tumor risk were seen with any work categories. A slight association for leukemia was seen among workers in the Treating category, which included unit operations that reduce the level of aromatic and sulfur constituents of petroleum products and combine them with additives to improve their quality. Stomach cancer risk was elevated among maintenance workers and workers exposed to lubricating oils and paraffin wax processing.

UV-induced mitotic co-segregation of genetic markers in Candida albicans: Evidence for linkage.

Parasexual genetic studies of the medically important yeast Candida albicans were performed using the method of UV-induced mitotic segregation. UV-ir-radiation of the Hoffmann-La Roche type culture of C. albicans yielded a limited spectrum of mutants at a relatively high frequency. This observation suggested natural heterozygosity. Canavanine-sensitive (CanS) segregants were induced at a frequency of 7.6 × 10(-3). Double mutants that were both CanS and methionine (Met(-)) auxotrophs were induced at a frequency of 7.4 × 10(-3). The single Met(-) segregant class was missing indicating linkage. UV-induced CanS or Met(-)CanS segregants occurred occasionally in twin-sectored colonies. Analyses of the sectors as well as the observed and missing classes of segregants indicated that gens met and can are linked in the cis configuration. The proposed gene order is: centromere -met - can. Thus, it is concluded that the Hoffmann-La Roche strain of C. albicans is naturally heterozygous at two linked loci. These findings are consistent with diploidy.