Novel Liver Injury Phenotypes and Outcomes in Clinical Trial Participants with Pulmonary Hypertension.

RATIONALE: Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) cause right ventricular dysfunction which can impact other solid organs. However, the profiles and consequences of hepatic injury due to PAH and CTEPH have not been well-studied. OBJECTIVES: We aimed to identify underlying patterns of liver injury in a cohort of PAH and CTEPH patients enrolled in 15 randomized clinical trials conducted between 1998 and 2014. METHODS: We used unsupervised machine learning to identify liver injury clusters in 13 trials and validated the findings in two additional trials. We then determined whether these liver injury clusters were associated with clinical outcomes or treatment effect heterogeneity. MEASUREMENTS AND MAIN RESULTS: Our training dataset included 4,219 patients and our validation dataset included 1,756 patients with serum total bilirubin, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and albumin data. Using k-means clustering, we identified phenotypes with no liver injury, hepatocellular injury, cholestatic injury, and combined injury patterns. Patients in the cholestatic injury liver cluster had the shortest time to clinical worsening and the highest risk of mortality. The cholestatic injury group also experienced the greatest placebo-corrected treatment effect on six-minute walk distance. Randomization to the experimental arm transitioned patients to a healthier liver status. CONCLUSIONS: Liver injury was associated with adverse outcomes in patients with PAH and CTEPH. Randomization to active treatment had beneficial effects on liver health compared to placebo. The role of liver disease (often subclinical) in determining outcomes warrants prospective studies.

Novel Liver Injury Phenotypes and Outcomes in Pulmonary Arterial Hypertension.

Background: Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are disorders of the pulmonary vasculature that cause right ventricular dysfunction. Systemic consequences of right ventricular dysfunction include damage to other solid organs, such as the liver. However, the profiles and consequences of hepatic injury due to PAH and CTEPH have not been well-studied. Methods: We aimed to identify underlying patterns of liver injury in a cohort of PAH and CTEPH patients enrolled in 15 randomized clinical trials conducted between 1998 and 2012. We used unsupervised machine learning to identify liver injury clusters in 13 trials and validated the findings in two additional trials. We then determined whether these liver injury clusters were associated with clinical outcomes or treatment effect heterogeneity. Results: Our training dataset included 4,219 patients and our validation dataset included 1,756 patients with complete liver laboratory panels (serum total bilirubin, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and albumin). Using k-means clustering paired with factor analysis, we identified four unique liver phenotypes (no liver injury, hepatocellular injury, cholestatic injury, and combined injury patterns). Patients in the cholestatic injury liver cluster had the shortest time to clinical worsening and highest chance of worsening World Health Organization functional class. Randomization to the experimental arm was associated with a transition to healthier liver clusters compared to randomization to the control arm. The cholestatic injury group experienced the greatest placebo-corrected treatment benefit in terms of six-minute walk distance. Conclusions: Liver injury patterns were associated with adverse outcomes in patients with PAH and CTEPH. Randomization to active treatment of pulmonary hypertension in these clinical trials had beneficial effects on liver health compared to placebo. The independent role of liver disease (often subclinical) in determining outcomes warrants prospective studies of the clinical utility of liver phenotyping for PAH prognosis and contribution to clinical disease.

Complications and outcomes of thoracoscopic-assisted lung lobectomy in dogs.

OBJECTIVE: To describe complications and outcomes of dogs undergoing thoracoscopic-assisted (TA) lung lobectomy. STUDY DESIGN: Multi-institutional, retrospective study. ANIMALS: Client-owned dogs (n = 30). METHODS: Medical records of dogs that underwent TA lung lobectomy were reviewed. Signalment, bodyweight, clinical signs, imaging findings, surgical variables, complications, and short-term/long-term outcome were assessed. Thoracoscopic-assisted lung lobectomy was performed with a mini-thoracotomy. RESULTS: Twelve intraoperative complications were recorded in 11 dogs, 6 requiring conversion to open thoracotomy. Reasons for conversion were reported in 5/6 dogs and included adhesions (2), difficultly manipulating the lesion through the mini-thoracotomy (2), and acute oxygen desaturation (1). One lung ventilation was successful in 4 of the 7 dogs in which this was attempted. A linear stapling device (DST series Medtronic, Minneapolis, Minnesota) was used for lung lobe ligation in 14 dogs. Twenty-three dogs underwent surgery for a neoplastic lesion, with 19 of these being carcinoma. The median lesion size was 4.3 cm (range 1-10 cm); margins were clean, except in 1 dog. Complications were documented in 8 dogs prior to discharge, 5 of these being classified as mild. Twenty-nine dogs were discharged at a median of 47 h postoperatively (range 24-120 h). Death was reported in 9 dogs, with a median survival time of 168 days (range 70-868 days). CONCLUSION: Thoracoscopic-assisted lung lobectomy was achieved with few major complications in the population reported here. Dogs were able to be discharged from hospital quickly, with most surviving beyond the follow-up period. CLINICAL SIGNIFICANCE: Thoracoscopic-assisted lung lobectomy may be considered to facilitate the excision of larger pulmonary lesions or to treat smaller dogs, in which a thoracoscopic excision may be technically more challenging.

Right ventricular myocardial energetic model for evaluating right heart function in pulmonary arterial hypertension.

BACKGROUND: Pulmonary arterial hypertension (PAH) increases right ventricular (RV) workload and decreases myocardial oxygen reserve, eventually leading to poor cardiac output. This study created and assessed a novel model of RV work output based on RV hemodynamics and oxygen supply, allowing new insight into causal mechanisms of RV dysfunction. METHODS: The RV function model was built upon an earlier, left ventricular model and further adjusted for more accurate clinical use. The model assumes that RV total power output (1) is the sum of isovolumic and stroke power and (2) is linearly related to its right coronary artery oxygen supply. Thus, when right coronary artery flow is limited or isovolumic power is elevated, less energy is available for producing cardiac output. The original and adjusted models were validated via data from patients with idiopathic PAH (n = 14) and large animals (n = 6) that underwent acute pulmonary banding with or without hypoxia. RESULTS: Both models demonstrated strong, significant correlations between RV oxygen consumption rate and RV total power output for PAH patients (original model, R2  = 0.66; adjusted model, R2  = 0.78) and sheep (original, R2  = 0.85; adjusted, R2  = 0.86). Furthermore, the models demonstrate a significant inverse relationship between required oxygen consumption and RV efficiency (stroke power/total power) (p < 0.001). Lastly, higher NYHA class was indicative of lower RV efficiency and higher oxygen consumption (p = 0.013). CONCLUSION: Right ventricular total power output can be accurately estimated directly from pulmonary hemodynamics and right coronary perfusion during PAH. This model highlights the increased vulnerability of PAH patients with compromised right coronary flow coupled with high afterload.

Complications and outcomes associated with laparoscopic-assisted splenectomy in dogs.

OBJECTIVE: To report the perioperative characteristics and outcomes of dogs undergoing laparoscopic-assisted splenectomy (LAS). ANIMALS: 136 client-owned dogs. PROCEDURES: Multicentric retrospective study. Medical records of dogs undergoing LAS for treatment of naturally occurring splenic disease from January 1, 2014, to July 31, 2020, were reviewed. History, signalment, physical examination and preoperative diagnostic test results, procedural information, complications, duration of hospitalization, histopathologic diagnosis, and perioperative outcomes were recorded. Perioperative complications were defined using the Veterinary Cooperative Oncology Group - Common Terminology Criteria for Adverse Events (VCOG-CTCAE v2) guidelines. RESULTS: LAS was performed for treatment of a splenic mass (124/136 [91%]), immune-mediated disease (7/136 [5%]), splenomegaly (4/136 [3%]), or immune-mediated disease in conjunction with a splenic mass (1/136 [1%]). Median splenic mass size was 1.3 cm3/kg body weight. Conversion to open laparotomy occurred in 5.9% (8/136) of dogs. Complications occurred in 78 dogs, with all being grade 2 or lower. Median surgical time was 47 minutes, and median postoperative hospital stay was 28 hours. All but 1 dog survived to discharge, the exception being postoperative death due to a suspected portal vein thrombus. CLINICAL RELEVANCE: In the dogs of this report, LAS was associated with low rates of major complications, morbidity, and mortality when performed for a variety of splenic pathologies. Minimally invasive surgeons can consider the LAS technique to perform total splenectomy in dogs without hemoabdomen and with spleens with modest-sized splenic masses up to 55.2 cm3/kg, with minimal rates of complications, morbidity, and mortality.

Diagnostic and public health investigation of Mycobacterium tuberculosis infection in a dog in Ontario, Canada.

A 4-y-old, female mixed-breed dog was presented to the Ontario Veterinary College for further evaluation of multiple pulmonary and hepatic masses, intrathoracic lymphadenitis, and recent development of a pyogranulomatous pleural effusion. Along with other comprehensive tests, a thoracic lymph node biopsy was performed, and Mycobacterium tuberculosis complex infection was confirmed by real-time PCR. The dog's condition declined post-operatively, and euthanasia was elected. Postmortem examination confirmed severe granulomatous pneumonia, hepatitis, intrathoracic and intraabdominal lymphadenitis, omentitis, and nephritis. Line-probe assays performed on samples collected postmortem confirmed the species as M. tuberculosis. 24-loci MIRU-VNTR genotyping, spoligotyping, and whole-genome sequencing revealed relations to known human isolates, but no epidemiologic link to these cases was investigated. Given the concern for potential human exposure during this animal's disease course, a public health investigation was initiated; 45 individuals were tested for M. tuberculosis exposure, and no subsequent human infections related to this animal were identified. Our case highlights the need for more readily available, minimally invasive testing for the diagnosis of canine mycobacteriosis, and highlights the ability of canid species to act as potential contributors to the epidemiology of M. tuberculosis infections.

Understanding the role of religion in shaping cross-national and domestic attitudes and interest in abortion, homosexuality, and pornography using traditional and Google search data.

Over the last 20 years, internet usage has increased substantially, providing an inexpensive source of data that may be less prone to bias and could provide a greater number of meso and macro units. However, validating big data and their usefulness has been challenging. This study uses established sources to validate Google Trends' search interest in the "Bible" across US Designated Market Areas and "Ramadan" across nations, establishing a potential new source of religion data. We then use these measures to show that people from religiously conservative US areas and countries are more likely to disapprove of homosexuality, abortion and pornography. Conversely, Americans from conservative religious areas are also more likely to search for these topics; and cross-national interest in Islam is associated with increased interest in pornography. Our study offers insight into Google Trends' potential for social science research and a roadmap on how to use these data.

Therapeutic Ultrasound Triggered Silk Fibroin Scaffold Degradation.

A patient's capacity for tissue regeneration varies based on age, nutritional status, disease state, lifestyle, and gender. Because regeneration cannot be predicted prior to biomaterial implantation, there is a need for responsive biomaterials with adaptive, personalized degradation profiles to improve regenerative outcomes. This study reports a new approach to use therapeutic ultrasound as a means of altering the degradation profile of silk fibroin biomaterials noninvasively postimplantation. By evaluating changes in weight, porosity, surface morphology, compressive modulus, and chemical structure, it is concluded that therapeutic ultrasound can trigger enhanced degradation of silk fibroin scaffolds noninvasively. By removing microbubbles on the scaffold surface, it is found that acoustic cavitation is the mechanism responsible for changing the degradation profile. This method is proved to be safe for human cells with no negative effects on cell viability or metabolism. Sonication through human skin also effectively triggers scaffold degradation, increasing the clinical relevance of these results. These findings suggest that silk is an ultrasound-responsive biomaterial, where the degradation profile can be adjusted noninvasively to improve regenerative outcomes.

Enrichment Benefits of Risk Algorithms for Pulmonary Arterial Hypertension Clinical Trials.

Rationale: Event-driven primary endpoints are increasingly used in pulmonary arterial hypertension clinical trials, substantially increasing required sample sizes and trial lengths. The U.S. Food and Drug Administration advocates the use of prognostic enrichment of clinical trials by preselecting a patient population with increased likelihood of experiencing the trial's primary endpoint.Objectives: This study compares validated clinical scales of risk (Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension, the French score, and Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management [REVEAL] 2.0) to identify patients who are likely to experience a clinical worsening event for trial enrichment.Methods: Baseline data from three pulmonary arterial hypertension clinical trials (AMBITION [a Study of First-Line Ambrisentan and Tadalafil Combination Therapy in Subjects with Pulmonary Arterial Hypertension], SERAPHIN [Study of Macitentan on Morbidity and Mortality in Patients with Symptomatic Pulmonary Arterial Hypertension], and GRIPHON [Selexipag in Pulmonary Arterial Hypertension]) were pooled and standardized. Receiver operating curves were used to measure each algorithm's performance in predicting clinical worsening within the pooled placebo cohort. Power simulations were conducted to determine sample size and treatment time reductions for multiple enrichment strategies. A cost analysis was performed to illustrate potential financial savings by applying enrichment to GRIPHON.Measurements and Main Results: All risk algorithms were compared using area under the receiver operating curve and substantially outperformed prediction per New York Heart Association Functional Class. The REVEAL 2.0's risk grouping provided the greatest time and sample size savings in AMBITION and GRIPHON for all enrichment strategies but lacked appropriate inputs (i.e., N-terminal-proB-type natriuretic peptide) to perform as well in SERAPHIN. Cost analysis applied to GRIPHON demonstrated the greatest financial benefit by enrolling patients with a REVEAL score ≥8.Conclusions: This preliminary study demonstrates the feasibility of risk algorithms for pulmonary arterial hypertension trial enrichment and a need for further investigation.

Development and Validation of an Abridged Version of the REVEAL 2.0 Risk Score Calculator, REVEAL Lite 2, for Use in Patients With Pulmonary Arterial Hypertension.

BACKGROUND: Achievement of low-risk status is a treatment goal in pulmonary arterial hypertension (PAH). Risk assessment often is performed using multiparameter tools, such as the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) risk calculator. Risk calculators that assess fewer variables without compromising validity may expedite risk assessment in the routine clinic setting. We describe the development and validation of REVEAL Lite 2, an abridged version of REVEAL 2.0. RESEARCH QUESTION: Can a simplified version of the REVEAL 2.0 risk assessment calculator for patients with PAH be developed and validated? STUDY DESIGN AND METHODS: REVEAL Lite 2 includes six noninvasive variables-functional class (FC), vital signs (systolic BP [SBP] and heart rate), 6-min walk distance (6MWD), brain natriuretic peptide (BNP)/N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and renal insufficiency (by estimated glomerular filtration rate [eGFR])-and was validated in a series of analyses (Kaplan-Meier, concordance index, Cox proportional hazard model, and multivariate analysis). RESULTS: REVEAL Lite 2 approximates REVEAL 2.0 at discriminating low, intermediate, and high risk for 1-year mortality in patients in the REVEAL registry. The model indicated that the most highly predictive REVEAL Lite 2 parameter was BNP/NT-proBNP, followed by 6MWD and FC. Even if multiple, less predictive variables (heart rate, SBP, eGFR) were missing, REVEAL Lite 2 still discriminated among risk groups. INTERPRETATION: REVEAL Lite 2, an abridged version of REVEAL 2.0, provides a simplified method of risk assessment that can be implemented routinely in daily clinical practice. REVEAL Lite 2 is a robust tool that provides discrimination among patients at low, intermediate, and high risk of 1-year mortality. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00370214; URL: www.clinicaltrials.gov.

Risk stratification in pulmonary arterial hypertension using Bayesian analysis.

BACKGROUND: Current risk stratification tools in pulmonary arterial hypertension (PAH) are limited in their discriminatory abilities, partly due to the assumption that prognostic clinical variables have an independent and linear relationship to clinical outcomes. We sought to demonstrate the utility of Bayesian network-based machine learning in enhancing the predictive ability of an existing state-of-the-art risk stratification tool, REVEAL 2.0. METHODS: We derived a tree-augmented naïve Bayes model (titled PHORA) to predict 1-year survival in PAH patients included in the REVEAL registry, using the same variables and cut-points found in REVEAL 2.0. PHORA models were validated internally (within the REVEAL registry) and externally (in the COMPERA and PHSANZ registries). Patients were classified as low-, intermediate- and high-risk (<5%, 5-20% and >10% 12-month mortality, respectively) based on the 2015 European Society of Cardiology/European Respiratory Society guidelines. RESULTS: PHORA had an area under the curve (AUC) of 0.80 for predicting 1-year survival, which was an improvement over REVEAL 2.0 (AUC 0.76). When validated in the COMPERA and PHSANZ registries, PHORA demonstrated an AUC of 0.74 and 0.80, respectively. 1-year survival rates predicted by PHORA were greater for patients with lower risk scores and poorer for those with higher risk scores (p<0.001), with excellent separation between low-, intermediate- and high-risk groups in all three registries. CONCLUSION: Our Bayesian network-derived risk prediction model, PHORA, demonstrated an improvement in discrimination over existing models. This is reflective of the ability of Bayesian network-based models to account for the interrelationships between clinical variables on outcome, and tolerance to missing data elements when calculating predictions.

Pneumoperitoneum in Veterinary Laparoscopy: A Review.

Objective: To review the effects of carbon dioxide pneumoperitoneum during laparoscopy, evaluate alternative techniques to establishing a working space and compare this to current recommendations in veterinary surgery. Study Design: Literature review. Sample Population: 92 peer-reviewed articles. Methods: An electronic database search identified human and veterinary literature on the effects of pneumoperitoneum (carbon dioxide insufflation for laparoscopy) and alternatives with a focus on adaptation to the veterinary field. Results: Laparoscopy is the preferred surgical approach for many human and several veterinary procedures due to the lower morbidity associated with minimally invasive surgery, compared to laparotomy. The establishment of a pneumoperitoneum with a gas most commonly facilitates a working space. Carbon dioxide is the preferred gas for insufflation as it is inert, inexpensive, noncombustible, colorless, excreted by the lungs and highly soluble in water. Detrimental side effects such as acidosis, hypercapnia, reduction in cardiac output, decreased pulmonary compliance, hypothermia and post-operative pain have been associated with a pneumoperitoneum established with CO2 insufflation. As such alternatives have been suggested such as helium, nitrous oxide, warmed and humidified carbon dioxide and gasless laparoscopy. None of these alternatives have found a consistent benefit over standard carbon dioxide insufflation. Conclusions: The physiologic alterations seen with CO2 insufflation at the current recommended intra-abdominal pressures are mild and of transient duration. Clinical Significance: The current recommendations in veterinary laparoscopy for a pneumoperitoneum using carbon dioxide appear to be safe and effective.

Home and Community-Based Physical Therapist Management of Adults With Post-Intensive Care Syndrome.

More than 4 million adults survive a stay in the intensive care unit each year, with many experiencing new or worsening physical disability, mental health problems, and/or cognitive impairments, known as post-intensive care syndrome (PICS). Given the prevalence and magnitude of physical impairments after critical illness, many survivors, including those recovering from COVID-19, could benefit from physical therapist services after hospital discharge. However, due to the relatively recent recognition and characterization of PICS, there may be limited awareness and understanding of PICS among physical therapists practicing in home health care and community-based settings. This lack of awareness may lead to inappropriate and/or inadequate rehabilitation service provision. While this perspective article provides information relevant to all physical therapists, it is aimed toward those providing rehabilitation services outside of the acute and postacute inpatient settings. This article reports the prevalence and clinical presentation of PICS and provides recommendations for physical examination and outcomes measures, plan of care, and intervention strategies. The importance of providing patient and family education, coordinating community resources including referring to other health care team members, and community-based rehabilitation service options is emphasized. Finally, this perspective article discusses current challenges for optimizing outcomes for people with PICS and suggests future directions for research and practice.

Determination of optimal location for thoracoscopic-assisted pulmonary surgery for lung lobectomy in cats.

OBJECTIVE: To determine the optimal intercostal space (ICS) for thoracoscopic-assisted pulmonary surgery for lung lobectomy in cats. SAMPLE: 8 cat cadavers. PROCEDURES: Cadavers were placed in lateral recumbency. A 5-cm minithoracotomy incision was made in the middle third of ICS 4 through 7 on the left side and 4 through 8 on the right side, and a wound retractor device was placed. A camera port was made in the middle third of ICS 9. Each lung lobe was sequentially exteriorized at each respective ICS. A thoracoabdominal stapler was placed to simulate a lung lobectomy, and distance from the stapler anvil to the hilus was measured. RESULTS: For the left cranial lung lobe, there was no significant difference in median distance from the stapler anvil to the pulmonary hilus for ICS 4 through 6. Simulated lobectomy of the left caudal lung lobe performed at ICS 5 and 6 resulted in a significantly shorter distance, compared with lobectomy performed at ICS 4 and 7. Simulated lobectomy of the right cranial and right middle lung lobes performed at ICS 4 and 5 resulted in a significantly shorter distance, compared with lobectomy performed at ICS 7. Simulated lobectomy of the accessory and right caudal lung lobes at ICS 5 and 6 resulted in a significantly shorter distance than for lobectomy performed at ICS 8. CONCLUSIONS AND CLINICAL RELEVANCE: An optimal ICS for a minithoracotomy incision was determined for thoracoscopic-assisted lung lobectomy in cats.

Optimization of surgical approach for thoracoscopic-assisted pulmonary surgery in dogs.

OBJECTIVE: To determine the optimal intercostal space (ICS) to perform thoracoscopic-assisted lung lobectomy. STUDY DESIGN: Cadaveric study. ANIMALS: Six mature, medium-sized canine cadavers. METHODS: Cadavers were placed in right or left lateral recumbency. A 15-mm thoracoscopic cannula was inserted in the middle third of the 9th or 10th ICS. A wound retraction device was placed into a 7-cm minithoracotomy incision created in the middle third of the 4th-7th ICS on the left side and the 4th-8th ICS on the right side. The pulmonary ligaments were sectioned by using a combined intracorporeal and extracorporeal technique. Each lung lobe was sequentially withdrawn from the wound retraction device at the respective ICS and side. A thoracoabdominal stapler was positioned to simulate lung lobectomy, and the distance from the stapler anvil to the hilus was measured. RESULTS: Simulated thoracoscopic-assisted lung lobectomy performed at left or right ICS 4 and 5, compared with other ICS evaluated, resulted in a significantly shorter median distance from the stapler anvil to the pulmonary hilus of the left cranial and caudal lung lobes and right cranial and middle lung lobes, respectively (all P < .05). Lobectomy at right ICS 5 or 6 resulted in a significantly shorter median distance from the stapler anvil to the pulmonary hilus of the right caudal and accessory lung lobes, respectively (both P < .05). CONCLUSION: These data may inform minithoracotomy positioning to optimize tumor margin excision during thoracoscopic-assisted lung lobectomy for treatment of pulmonary neoplasia in dogs. CLINICAL SIGNIFICANCE: Complete lung lobectomy is possible by using the described thoracoscopic-assisted technique in normal, cadaveric lungs.

Effect of pneumoperitoneum with warmed humidified or standard-temperature carbon dioxide during laparoscopy on core body temperature, cardiorespiratory and thromboelastography variables, systemic inflammation, peritoneal response, and signs of postoperative pain in healthy mature dogs.

OBJECTIVE To evaluate effects of pneumoperitoneum created with warmed humidified CO2 (WHCO2) during laparoscopy on core body temperature, cardiorespiratory and thromboelastography variables, systemic inflammation, peritoneal response, and signs of postoperative pain in healthy mature dogs. ANIMALS 6 mature purpose-bred dogs. PROCEDURES In a randomized crossover study, each dog was anesthetized twice, and pneumoperitoneum was created with standard-temperature CO2 (STCO2; 22°C and 0% relative humidity) and WHCO2 (37°C and 98% relative humidity). Data were collected during each procedure, including core body temperature, cardiorespiratory and thromboelastography variables, and inflammatory biomarkers. Peritoneal biopsy specimens were collected and evaluated with scanning electron microscopy. Dogs were assessed for signs of postoperative pain. RESULTS Mean core body temperature was significantly lower (35.2°C; 95% confidence interval, 34.5° to 35.8°C) with WHCO2 than with STCO2 (35.9°C; 95% confidence interval, 35.3° to 36.6°C) across all time points. Cardiac index increased during the procedure for both treatments but was not significantly different between treatments. Thromboelastography variables did not differ significantly between treatments as indicated by the coagulation index. Subjective evaluation of peritoneal biopsy specimens revealed mesothelial cell loss with STCO2. There was no significant difference in circulating C-reactive protein or interleukin-6 concentrations. There was a significant increase in the number of postoperative pain scores > 0 for the WHCO2 treatment versus the STCO2 treatment. CONCLUSIONS AND CLINICAL RELEVANCE Analysis of these data suggested that effects on evaluated variables attributable to the use of WHCO2 for creating pneumoperitoneum in healthy mature dogs undergoing laparoscopy did not differ from effects for the use of STCO2.

Physical Impairments Associated With Post-Intensive Care Syndrome: Systematic Review Based on the World Health Organization's International Classification of Functioning, Disability and Health Framework.

Background: Post-intensive care syndrome (PICS) is a constellation of new or worsening impairments in physical, mental, or cognitive abilities or a combination of these in individuals who have survived critical illness requiring intensive care. Purpose: The 2 purposes of this systematic review were to identify the scope and magnitude of physical problems associated with PICS during the first year after critical illness and to use the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to elucidate impairments of body functions and structures, activity limitations, and participation restrictions associated with PICS. Data Sources: Ovid MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, CINAHL Plus with Full Text (EBSCO), Web of Science, and Embase were searched from inception until March 7, 2017. Study Selection: Two reviewers screened titles, abstracts, and full text to independently determine study eligibility based on inclusion and exclusion criteria. Data Extraction: Study methodological quality was assessed using the Newcastle-Ottawa Scale. Data describing study methods, design, and participant outcomes were extracted. Data Synthesis: Fifteen studies were eligible for review. Within the first year following critical illness, people who had received intensive care experienced impairments in all 3 domains of the ICF (body functions and structures, activity limitations, and participation restrictions). These impairments included decreased pulmonary function, reduced strength of respiratory and limb muscles, reduced 6-minute walk test distance, reduced ability to perform activities of daily living and instrumental activities of daily living, and reduced ability to return to driving and paid employment. Limitations: The inclusion of only 15 observational studies in this review may limit the generalizability of the findings. Conclusions: During the first year following critical illness, individuals with PICS experienced physical impairments in all 3 domains of the ICF.

The validity of open-source data when assessing jail suicides.

BACKGROUND: The Bureau of Justice Statistics' Deaths in Custody Reporting Program is the primary source for jail suicide research, though the data is restricted from general dissemination. This study is the first to examine whether jail suicide data obtained from publicly available sources can help inform our understanding of this serious public health problem. METHODS: Of the 304 suicides that were reported through the DCRP in 2009, roughly 56 percent (N = 170) of those suicides were identified through the open-source search protocol. Each of the sources was assessed based on how much information was collected on the incident and the types of variables available. A descriptive analysis was then conducted on the variables that were present in both data sources. The four variables present in each data source were: (1) demographic characteristics of the victim, (2) the location of occurrence within the facility, (3) the location of occurrence by state, and (4) the size of the facility. RESULTS: Findings demonstrate that the prevalence and correlates of jail suicides are extremely similar in both open-source and official data. However, for almost every variable measured, open-source data captured as much information as official data did, if not more. Further, variables not found in official data were identified in the open-source database, thus allowing researchers to have a more nuanced understanding of the situational characteristics of the event. CONCLUSIONS: This research provides support for the argument in favor of including open-source data in jail suicide research as it illustrates how open-source data can be used to provide additional information not originally found in official data. In sum, this research is vital in terms of possible suicide prevention, which may be directly linked to being able to manipulate environmental factors.

Policy, Practice, and Research Agenda for Emergency Medical Services Oversight: A Systematic Review and Environmental Scan.

Introduction In a 2015 report, the Institute of Medicine (IOM; Washington, DC USA), now the National Academy of Medicine (NAM; Washington, DC USA), stated that the field of Emergency Medical Services (EMS) exhibits signs of fragmentation; an absence of system-wide coordination and planning; and a lack of federal, state, and local accountability. The NAM recommended clarifying what roles the federal government, state governments, and local communities play in the oversight and evaluation of EMS system performance, and how they may better work together to improve care. OBJECTIVE: This systematic literature review and environmental scan addresses NAM's recommendations by answering two research questions: (1) what aspects of EMS systems are most measured in the peer-reviewed and grey literatures, and (2) what do these measures and studies suggest for high-quality EMS oversight? METHODS: To answer these questions, a systematic literature review was conducted in the PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), Web of Science (Thomson Reuters; New York, New York USA), SCOPUS (Elsevier; Amsterdam, Netherlands), and EMBASE (Elsevier; Amsterdam, Netherlands) databases for peer-reviewed literature and for grey literature; targeted web searches of 10 EMS-related government agencies and professional organizations were performed. Inclusion criteria required peer-reviewed literature to be published between 1966-2016 and grey literature to be published between 1996-2016. A total of 1,476 peer-reviewed titles were reviewed, 76 were retrieved for full-text review, and 58 were retained and coded in the qualitative software Dedoose (Manhattan Beach, California USA) using a codebook of themes. Categorizations of measure type and level of application were assigned to the extracted data. Targeted websites were systematically reviewed and 115 relevant grey literature documents were retrieved. RESULTS: A total of 58 peer-reviewed articles met inclusion criteria; 46 included process, 36 outcomes, and 18 structural measures. Most studies applied quality measures at the personnel level (40), followed by the agency (28) and system of care (28), and few at the oversight level (5). Numerous grey literature articles provided principles for high-quality EMS oversight. CONCLUSIONS: Limited quality measurement at the oversight level is an important gap in the peer-reviewed literature. The grey literature is ahead in this realm and can guide the policy and research agenda for EMS oversight quality measurement. Taymour RK , Abir M , Chamberlin M , Dunne RB , Lowell M , Wahl K , Scott J . Policy, practice, and research agenda for Emergency Medical Services oversight: a systematic review and environmental scan. Prehosp Disaster Med. 2018;33(1):89-97.

Malignant collision tumors in two dogs.

CASE DESCRIPTION A 13-year-old Labrador Retriever with a 4-cm-diameter ulcerated perianal mass and a 12-year-old Golden Retriever with a 5-cm-diameter ulcerated caudolateral abdominal mass were brought to a referral oncology practice for evaluation of the dermal masses. Both masses were resected with wide margins without reported postoperative complications. For both dogs, a diagnosis of collision tumor was made. The database of the Veterinary Diagnostic Laboratories at Colorado State University was searched for other examples of collision tumors in dogs. CLINICAL FINDINGS Histologic assessment of the masses revealed collision tumors in both patients. The perianal mass was diagnosed as a perianal gland carcinoma with adjacent hemangiosarcoma. The flank mass was diagnosed as a fibrosarcoma with an adjacent mast cell tumor. The university database search of sample submissions in 2008 through 2014 for the keywords collision, admixed, or adjacent yielded 37 additional cases of dogs with malignant nontesticular collision tumors. TREATMENT AND OUTCOME Both dogs were treated with surgery alone and received no adjunctive treatments. Both tumors were completely excised. There was no evidence of either local tumor recurrence or metastasis in the Labrador Retriever and the Golden Retriever at 1,009 and 433 days after surgery, respectively. CLINICAL RELEVANCE Collision tumors are rare, and there is minimal information regarding treatment recommendations and outcome for animals with collision tumors. On the basis of the 2 cases described in this report, the outcome associated with treatment of collision tumors may be similar to the expected outcome for treatment of any of the individual tumor types in dogs.