Patient positioning and its impact on perioperative outcomes in children: A narrative review.

Patient positioning interacts with a number of body systems and can impact clinically important perioperative outcomes. In this educational review, we present the available evidence on the impact that patient positioning can have in the pediatric perioperative setting. A literature search was conducted using search terms that focused on pediatric perioperative outcomes prioritized by contemporary research in this area. Several key themes were identified: the effects of positioning on respiratory outcomes, cardiovascular outcomes, enteral function, patient and carer-centered outcomes, and soft issue injuries. We encountered considerable heterogeneity in research in this area. There may be a role for lateral positioning to reduce respiratory adverse outcomes, head elevation for intubation and improved oxygenation, and upright positioning to reduce peri-procedural anxiety.

Congenital subglottic cyst: a rare cause for sudden airway compromise in a newborn.

A full-term infant developed stridor, respiratory distress and hypercarbia shortly after birth requiring urgent airway intervention. The patient underwent urgent intubation via rigid bronchoscopy. The diagnosis of congenital subglottic cyst was made. The cyst was decompressed and the patient was extubated the following day. On repeat laryngoscopy 1 month later, there was no residual disease and the patient remained symptom free. Congenital subglottic cysts are extremely rare and the diagnosis can be either missed or misdiagnosed with more common causes of stridor, such as laryngomalacia. Subglottic cysts may cause total airway obstruction and even death if they are large enough and not treated immediately.

Sex, mating and repeatability of Drosophila melanogaster longevity.

Costs of reproduction are seemingly ubiquitous across the animal kingdom, and these reproductive costs are generally defined by increased reproduction leading to decreases in other fitness components, often longevity. However, some recent reports question whether reproductive costs exist in every species or population. To provide insight on this issue, we sought to determine the extent to which genetic variation might play a role in one type of reproductive cost-survival-using Drosophila melanogaster. We found, surprisingly, no costs of reproduction nor sex differences in longevity across all 15 genetic backgrounds in two cohorts. We did find significant variation within some genotypes, though these were much smaller than expected. We also observed that small laboratory changes lead to significant changes in longevity within genotypes, suggesting that longevity repeatability in flies may be difficult. We finally compared our results to previously published longevities and found that reproducibility is similar to what we saw in our own laboratory, further suggesting that stochasticity is a strong component of fruit fly lifespan. Overall, our results suggest that there are still large gaps in our knowledge about the effects of sex and mating, as well as genetic background and laboratory conditions on lifespan reproducibility.

Barriers to Enhanced Recovery after Surgery after Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Enhanced Recovery after Surgery (ERAS) protocols lead to expedited discharges and decreased cost. Bariatric centers have adopted such programs for safely discharging patients after sleeve gastrectomy (LSG) on the first postoperative day (POD1). Despite pathways, some bariatric patients cannot be discharged on POD1. STUDY DESIGN: We performed a retrospective review of patients undergoing LSG, from 2013 through 2016, in a center of excellence, using a standardized enhanced recovery pathway. Patient variables and perioperative factors were analyzed, including multivariate regressions, for predictors of early discharge. RESULTS: There were 573 patients who underwent LSG (83% female, mean age of 46.3 ± 11.7 years, and BMI of 46.0 ± 6.6 kg/m2). Mean hospital stay was 1.7 days ± 1.0 SD. Early discharge occurred in 38.2% of patients. Independently, early operating room start times and treated obstructive sleep apnea were associated with earlier discharge (p < 0.05). In contrast, preoperative opioid use, history of psychiatric illness, chronic kidney disease, and revision cases delayed discharge (p < 0.05). Age, sex, American Society of Anesthesiologists (ASA) class, diabetes, congestive heart failure, hypertension, distance to home, and insurance status were not significant. On regression modeling, early operating room start time and treated obstructive sleep apnea (OSA) reduced length of stay (LOS) (p < 0.05), while creatinine >1.5 mg/dL, ejection fraction < 50%, and increased case duration increased LOS (p < 0.05). Fifteen patients were readmitted within 30 days (2.6%). CONCLUSIONS: Several clinical and operative factors affect early discharge after LSG. Knowing factors that enhance the success of ERAS as well as the causes and corrections for failed implementation allow teams to optimally direct care pathway resources.

Relating Worry and Executive Functioning During Childhood: The Moderating Role of Age.

The associations between worry and executive functioning across development have not been previously explored. Examining the interrelationships between these variables in childhood may further elucidate the cognitive nature of worry as well as its developmental course. Hypotheses predicted that difficulties with executive functioning would correlate with child worry; based on extant literature, age-related hypotheses were proposed for particular aspects of executive functioning. Children (N = 130) participated in the present study. Difficulties with executive functioning and child worry were assessed. Results demonstrated that each executive functioning subscale correlated with worry. The relations between worry and several facets of executive functioning were no longer significant at older ages, while the relations between worry and the facets of inhibition, shifting, and emotional control did not demonstrate age-related interaction effects. Overall, the findings suggest that worry is associated with executive functioning at young ages and that this association takes distinct forms during different childhood stages.

Biomarkers of dissolved oxygen stress in oysters: a tool for restoration and management efforts.

The frequency and intensity of anoxic and hypoxic events are increasing worldwide, creating stress on the organisms that inhabit affected waters. To understand the effects of low dissolved oxygen stress on oysters, hatchery-reared oysters were placed in cages and deployed along with continuously recording environmental data sondes at a reef site in Mobile Bay, AL that typically experiences low oxygen conditions. To detect and measure sublethal stress, we measured growth and survival of oysters as well as expression of three biomarkers, heat shock protein 70 (HSP70), hypoxia inducible factor (HIF) and phospho-p38 MAP kinase, in tissues from juvenile and adult oysters. Survival rates were high for both juvenile and adult oysters. Expression levels of each of the 3 isoforms of HSP 70 were negatively correlated to dissolved oxygen (DO) concentrations, suggesting that HSP 70 is useful to quantify sublethal effects of DO stress. Results for HIF and phospho-p38 MAP kinase were inconclusive. Test deployments of oysters to assess expression of HSP 70 relative to environmental conditions will be useful, in addition to measuring abiotic factors, to identify appropriate sites for restoration, particularly to capture negative effects of habitat quality on biota before lethal impacts are incurred.

Meeting the information needs of lower income cancer survivors: results of a randomized control trial evaluating the american cancer society's "I can cope".

The American Cancer Society is a leader in the development of cancer survivorship resources. One resource of the American Cancer Society is the I Can Cope program, an educational program for cancer survivors and their families. Evaluations of this program indicate that cancer patients highly rate its objectives. Yet, there are gaps in the understanding of the full impact of the program on diverse cancer survivors. In this study, the authors used a randomized trial to evaluate the program. Participants included 140 low-income survivors (79% Black; 38% breast cancer) from community hospitals who were randomized to 4 sessions of I Can Cope (learning about cancer; understanding cancer treatments; relieving cancer pain; and keeping well in mind and body) or 4 sessions of a wellness intervention (humor, meditation, relaxation, and music therapy). The authors' primary outcome was "met information needs." After controlling for covariates, their analysis indicated that I Can Cope was no more effective than the wellness intervention in addressing survivor information needs relative to the learning objectives. Participants provided high overall ratings for both interventions. Self-efficacy for obtaining advice about cancer, age, education, and income were associated with information needs. Educational programs tailored to levels of self-efficacy and patient demographics may be needed.

Meeting the challenges of global nuclear medicine technologist training in the 21st century: the IAEA Distance Assisted Training (DAT) program.

Many countries have made significant investments in nuclear medicine (NM) technology with the acquisition of modern equipment and establishment of facilities, however, often appropriate training is not considered as part of these investments. Training for NM professionals is continually evolving, with a need to meet changing requirements in the workforce. Even places where established higher education courses are available, these do not necessarily cater to the practical component of training and the ever-changing technology that is central to medical imaging. The continuing advances in NM technology and growth of applications in quantitative clinical assessment place increases the pressure on technologists to learn and practice new techniques. Not only is training to understand new concepts limited but often there is inadequate training in the basics of NM and this can be a major constraint to the effective use of the evolving technology. Developing appropriate training programs for the broader international NM community is one of the goals of the International Atomic Energy Agency (IAEA). A particularly successful and relevant development has been the program on 'distance assisted training (DAT) for NM professionals'. The development of DAT was initiated in the 1990s through Australian Government funding, administered under auspices of the IAEA through its Regional Cooperative Agreement, involving most countries in Asia that are Member States of the IAEA. The project has resulted in the development of a set of training modules which are designed for use under direct supervision in the workplace, delivered through means of distance-learning. The program has undergone several revisions and peer reviews with the current version providing a comprehensive training package that is now available online. DAT has been utilized widely in Asia or the Pacific region, Latin America, and parts of Africa and Europe. Currently there are approximately 1000 registered participants, including persons providing student support, in the program.

Inverse correlation between resting motor threshold and corticomotor excitability after static magnetic stimulation of human motor cortex.

BACKGROUND: High-strength static magnetic field stimulation (SMS) results in a period of reduced corticomotor excitability that may be mediated through a decrease in membrane excitability. OBJECTIVE: As resting motor threshold (RMT) is thought to reflect membrane excitability, we hypothesized that SMS may increase RMT and that there would be an inverse relationship between RMT and motor-evoked potential (MEP) amplitude. METHODS: Ten healthy subjects (aged 20-29; 4 females) participated in a double-blinded crossover design comparing MEP amplitude and RMT before and after a 15-min period of SMS or sham stimulation over primary motor cortex (M1). RESULTS: MEP amplitude was initially significantly reduced post-SMS (∼20%), and returned to baseline by 6 min post-intervention. MEP amplitude and RMT were inversely correlated (r(2) = 0.924; P = 0.001). Sham stimulation had no effect on MEP amplitude (P = 0.969) or RMT (P = 0.549). CONCLUSION: After SMS, corticomotor excitability is transiently reduced in association with a correlated modulation of RMT. SMS after effects may be mediated in part by a reduction in membrane excitability, suggesting a possible role for non-synaptic (intrinsic) plasticity mechanisms.

Assimilation of oil-derived elements by oysters due to the Deepwater Horizon Oil Spill.

During and after the Deepwater Horizon Oil Spill (DWHOS), oysters (Crassostrea virginica) were exposed to oil and susceptible to incidental consumption of surface and subsurface oil materials. We determined the contribution of oil materials from the DWHOS to diet of oysters by comparing carbon (C) and nitrogen (N) stable isotope ratios in oyster shell to ratios in suspended particulate matter (SPM) and in fresh and weathered oil. Average δ(13)C and δ(15)N values in oyster shell (-21 ± 1‰ and 9-11‰, respectively) were consistent with consumption of naturally available SPM as opposed to values in oil (-27 ± 0.2‰, 1.6 ± 0.4‰). Stable isotope ratios in oyster adductor muscle were similar to shell for δ(15)N but not δ(13)C, suggesting either a recent shift in diet composition or differential assimilation of C between tissue types. We found no evidence of assimilation of oil-derived C and N and, therefore, no evidence of an oyster-based conduit to higher trophic levels. Trace elements in shell were inconclusive to corroborate oil exposure. These findings are not an indication that oysters were not exposed to oil; rather they imply oysters either did not consume oil-derived materials or consumed too little to be detectable compared to natural diet.

The SCRAP Rule: The derivation and internal validation of a clinical decision rule for computed tomography of the chest in blunt thoracic trauma.

OBJECTIVE: To derive and internally validate a clinical decision rule that will rule out major thoracic injury in adult blunt trauma patients, reducing the unnecessary use of chest computed tomographic (CT) scans. METHODS: Data were retrospectively obtained from a chart review of all trauma patients presenting to a Canadian tertiary trauma care centre from 2005 to 2008, with those from April 2006 to March 2007 being used for the validation phase. Patients were included if they had an Injury Severity Score > 12 and chest CT at admission or a documented major thoracic injury noted in the trauma database. Patients with penetrating injury, a Glasgow Coma Scale (GCS) score ≤ 8, paralysis, or age < 16 years were excluded. RESULTS: There were 434 patients in the derivation group and 180 in the validation group who met the inclusion criteria. Using recursive partitioning, five clinical variables were found to be particularly predictive of injury. When these variables were normal, no patients had a major thoracic injury (sensitivity 100% [95% CI 98.4-100], specificity 46.9% [95% CI 44.2-46.9], and negative likelihood ratio 0.00 [95% CI 0.00-0.04]). The five variables were oxygen saturation (< 95% on room air or < 98% on any supplemental oxygen), chest radiograph, respiratory rate ≥ 25, chest auscultation, and thoracic palpation (SCRAP). In the validation group, the same five variables had a sensitivity of 100% (95% CI 96.2-100%), a specificity of 44.7% (95% CI 39.5-44.7%), and negative likelihood ratio of 0.00 (95% CI 0.00-0.10). CONCLUSIONS: In major blunt trauma with a GCS score > 8, the SCRAP variables have a 100% sensitivity for major thoracic injury in this retrospective study. These findings need to be prospectively validated prior to use in a clinical setting.

Interdisciplinary treatment of patients with multiple sclerosis and chronic pain: a descriptive study.

The objective of this study was to examine the efficacy of an interdisciplinary pain rehabilitation program in a multiple sclerosis (MS) population by evaluating changes in mood, pain, and functioning. This descriptive study examined 20 patients with chronic pain and MS who were admitted to the Cleveland Clinic's Chronic Pain Rehabilitation Program (CPRP) between 2000 and 2009. At both admission to and discharge from the CPRP, measures of pain, depression, and functioning were obtained using a pain visual analogue scale (VAS), the Beck Depression Inventory (BDI), the Depression Anxiety Stress Scale (DASS), and the Pain Disability Index (PDI). Outcomes for the MS patients were compared with those of patients without MS who had participated in the same program. The results showed that MS patients who completed the CPRP reported dramatic decreases in pain and depression and an increase in daily functioning. The benefits received by MS patients from the program were similar to those received by patients without MS. Thus programs like the CPRP can result in significant improvements in pain, depression, and functioning among people with MS.

Recruitment of low income, predominantly minority cancer survivors to a randomized trial of the I Can Cope cancer education program.

This report describes recruitment of minority cancer survivors for a randomized trial of I Can Cope, a support program of the American Cancer Society. Survivor Education and Evaluation (SURE), was designed to recruit patients, age 19 and older, with a primary cancer diagnosis. Recruitment was primarily carried out in a public hospital in Birmingham, Alabama. Of 373 patients approached, 226 were eligible for the study, 175 consented, and 140 were randomized during the 20-month recruitment period. Only 43 declined participation. This resulted in a 61.9% recruitment yield. The mean age of participants was 54.2 years (SD=10.9), 92 (65.7%) were female, and 111 (79.3%) were African American. Twenty-three different cancers were represented including breast (37.1%), colorectal (12.1%), hematologic (12.9%), and lung (7.1%). Over half (63%) had been diagnosed within 12 months. The experience of the SURE project provides evidence for optimism in recruiting racial minorities to cancer research studies.

Medication adherence among rural, low-income hypertensive adults: a randomized trial of a multimedia community-based intervention.

PURPOSE: Examine the effectiveness of a community-based, multimedia intervention on medication adherence among hypertensive adults. DESIGN: Randomized controlled trial. SETTING: Rural south Alabama. SUBJECTS: Low-income adults (N  =  434) receiving medication at no charge from a public health department or a Federally Qualified Health Center. INTERVENTION: Both interventions were home-based and delivered via computer by a community health advisor. The adherence promotion (AP) intervention focused on theoretical variables related to adherence (e.g., barriers, decisional balance, and role models). The cancer control condition received general cancer information. MEASURES: Adherence was assessed by pill count. Other adherence-related variables, including barriers, self-efficacy, depression, and sociodemographic variables, were collected via a telephone survey. ANALYSIS: Chi-square analysis tested the hypothesis that a greater proportion of participants in the AP intervention are ≥80% adherent compared to the control group. General linear modeling examined adherence as a continuous variable. RESULTS: Participants receiving the intervention did not differ from individuals in the control group (51% vs. 49% adherent, respectively; p  =  .67). Clinic type predicted adherence (p < .0001), as did forgetting to take medications (p  =  .01) and difficulty getting to the clinic to obtain medications (p < .001). CONCLUSIONS: Multilevel interventions that focus on individual behavior and community-level targets (e.g., how health care is accessed and delivered) may be needed to improve medication adherence among low-income rural residents.

Forest type influences transmission of Phytophthora ramorum in California oak woodlands.

The transmission ecology of Phytophthora ramorum from bay laurel (Umbellularia californica) leaves was compared between mixed-evergreen and redwood forest types throughout winter and summer disease cycles in central, coastal California. In a preliminary multisite study, we found that abscission rates of infected leaves were higher at mixed-evergreen sites. In addition, final infection counts were slightly higher at mixed-evergreen sites or not significantly different than at redwood sites, in part due to competition from other foliar pathogens at redwood sites. In a subsequent, detailed study of paired sites where P. ramorum was the main foliar pathogen, summer survival of P. ramorum in bay laurel leaves was lower in mixed-evergreen forest due to lower recovery from infected attached leaves and higher abscission rates of infected leaves. Onset of inoculum production and new infections of bay laurel leaves occurred later in mixed-evergreen forest. Mean inoculum levels in rainwater and final infection counts on leaves were higher in redwood forest. Based on these two studies, lower summer survival of reservoir inoculum in bay laurel leaves in mixed-evergreen forest may result in delayed onset of both inoculum production and new infections, leading to slower disease progress in the early rainy season compared with redwood forest. Although final infection counts also will depend on other foliar pathogens and disease history, in sites where P. ramorum is the main foliar pathogen, these transmission patterns suggest higher rates of disease spread in redwood forests during rainy seasons of short or average length.

Tailoring cancer education and support programs for low-income, primarily African American cancer survivors.

PURPOSE/OBJECTIVES: to identify the information and stress-management topics of most interest to low-income, predominantly African American cancer survivors. RESEARCH APPROACH: descriptive, cross sectional. SETTING: outpatient oncology clinic in a public hospital in Birmingham, Alabama. PARTICIPANTS: 25 patients with cancer; 12 were men, 22 were African Americans, and 16 had a 12th-grade education or less. METHODOLOGIC APPROACH: patients ranked potential topics to be included in an educational curriculum. MAIN RESEARCH VARIABLES: quantitative rankings of information and stress-management priorities. FINDINGS: learning about cancer, understanding cancer treatments, relieving cancer pain, and keeping well in mind and body were the most highly ranked topics among those offered within the American Cancer Society's I Can Cope curriculum, which also included supportive topics such as mobilizing social support. The preferred stress-management topics were humor therapy, music therapy, meditation, and relaxation; lower-ranked topics included pet therapy and art as therapy. CONCLUSIONS: cancer survivors appear most interested in topics specific to their illness and treatment versus supportive topics. Stress management also received high rankings. INTERPRETATION: nurses have a key role in providing patient education and support. Tailoring education programs may better target specific needs and improve the quality of cancer care of underserved patients.

Taking less than prescribed: medication nonadherence and provider-patient relationships in lower-income, rural minority adults with hypertension.

Control of hypertension remains poor, and lack of adherence to medication is considered a primary reason. Few studies have examined the reasons for medication nonadherence in African American, lower-income, rural adults receiving medications at no personal cost. Moreover, our understanding of how the provider-patient relationship influences adherence in this population is limited. In this study, the authors (1) examined reasons for taking less medication than prescribed and (2) examined the association between provider-patient variables and medication adherence. A total of 434 participants (94.8% African American) were included. The most frequently endorsed reasons for taking less medication than prescribed were not having blood pressure medicine when it was time to take a dose (36%), running out of medicine (35%), bothered by side effects (29%), and a change in one's daily routine (27%). Nonadherent individuals were significantly more likely to report discomfort with asking the health provider questions (74% vs 63%), were more likely to report that health care visits were stressful (25% vs 16%), and exhibited more depressive symptoms (58% vs 45%). Adherent patients had lower blood pressure (systolic: 133±15.8 mm Hg vs 138±17.6 mm Hg, P value=.002; diastolic: 80±9.8 mm Hg vs 83±11 mm Hg, P value=.003) than individuals who were less adherent. Clinicians providing care to rural, poor hypertensive patients should routinely assess self-management behaviors, logistical barriers, and emotional health. Creating clinical encounters that minimize the stressful nature of the visit and encourage patient question-asking behavior may also be important for the optimal management of hypertension.

Personal communication in primary and secondary cancer prevention: evolving discussions, emerging challenges.

Over the past several years, the science of cancer communication has been recognized as integral to the dissemination of cancer prevention and control strategies in both the general population as well as higher-risk groups. In this article we draw upon current literature and small group discussion in the 2008 Society for Behavioral Medicine Cancer Special Interest Group Pre-Conference Workshop on Cancer Communication to identify current findings, critical challenges, and future opportunities regarding personal communication of primary and secondary prevention of cancer. We organize our article with six critical questions: (1) What are the most important directions of research in this area? (2) Does personal cancer communication work through rational processes, or are affective and nonrational processes also involved? (3) Are our efforts adequate to reach underserved populations? (4) Are naturalistic communicative contexts given adequate consideration? (5) Has the field been adequately informed by social psychological and communication theories? (6) What are the best outcomes to document communication effectiveness? Our goals are to initiate thought and collaborative efforts among communication, public health, and behavioral science experts, as well as to establish research priorities at the interface of communication and cancer prevention and control sciences.

Cancer and patient-physician communication.

As patients are increasingly involved in the selection of their care, communication between health care providers and patients takes on new importance. The present article reviews the most common approaches to improve patient communication, distinguishing among patient-directed and provider-directed approaches, as well as introducing multimedia programs designed to enhance communication. We conclude by delineating new critical areas for future research including peer-to-peer patient communication and the challenges brought on by new technologies.

The relation between women's body esteem and friendships with gay men.

Women who associate with gay men are often portrayed as physically unattractive and lacking in both self-confidence and attention from straight men. However, many women report enhanced self-esteem and feelings of attractiveness as a result of attention from their gay friends. It is well established that body esteem can be negatively impacted by certain peer processes, yet there is a dearth of quantitative research on positive peer influences on women's body esteem. We tested two hypotheses: (a) women with gay male friends have poor body esteem and are rejected by heterosexual men, and (b) more contact with gay men is positively related to body esteem. Participants were 154 heterosexual women, who completed measures of their friendships with gay men, straight men and women, body esteem, relationship involvement and break-ups. Results supported the hypothesis that women's body esteem, specifically feelings of sexual attractiveness, is positively associated with friendships with gay men.