The Association between Preoperative Blood Pressures and Postoperative Adverse Events.

BACKGROUND: The relationship between postoperative adverse events and blood pressures in the preoperative period remains poorly understood. This study tested the hypothesis that day-of-surgery preoperative blood pressures are associated with postoperative adverse events. METHODS: We conducted a retrospective, observational study of adult patients having elective procedures requiring an inpatient stay between November 2017 and July 2021 at Vanderbilt University Medical Center to examine the independent associations between preoperative systolic and diastolic blood pressures (SBP, DBP) recorded immediately before anesthesia care and number of postoperative adverse events - myocardial injury, stroke, acute kidney injury (AKI), and mortality, while adjusting for potential confounders. We used multivariable ordinal logistic regression to model the relationship. RESULTS: The analysis included 57,389 cases. The overall incidence of myocardial injury, stroke, AKI, and mortality within 30 days of surgery was 3.4% (1,967 events), 0.4% (223), 10.2% (5,871), and 2.1% (1,223), respectively. The independent associations between both SBP and DBP measurements and number of postoperative adverse events were found to be U-shaped, with greater risk both above and below SBP 143 mmHg and DBP 86 mmHg - the troughs of the curves. The associations were strongest at SBP 173 mmHg (adjusted odds ratio [aOR] 1.212 versus 143 mmHg; 95% CI, 1.021 to 1.439; p = 0.028), SBP 93 mmHg (aOR 1.339 versus 143 mmHg; 95% CI, 1.211 to 1.479; p < 0.001), DBP 106 mmHg (aOR 1.294 versus 86 mmHg; 95% CI, 1.003 to 1.17671; p = 0.048), and DBP 46 mmHg (aOR 1.399 versus 86 mmHg; 95% CI, 1.244 to 1.558; p < 0.001). CONCLUSIONS: Preoperative blood pressures both below and above a specific threshold were independently associated with a higher number of postoperative adverse events, but the data do not support specific strategies for managing patients with low or high blood pressure on the day of surgery.

Angiotensin-II for vasoplegia following cardiac surgery.

INTRODUCTION: The objective of this study was to describe the implementation and outcomes of a protocol outlining angiotensin-II utilization for vasoplegia following cardiac surgery. METHODS: This was a retrospective chart review at a single-center university hospital. Included patients received angiotensin-II for vasoplegia refractory to standard interventions, including norepinephrine 20 mcg/min and vasopressin 0.04 units/min, following cardiac surgery between April 2021 and April 2022. RESULTS: 30 patients received angiotensin-II for refractory vasoplegia. Adjunctive agents at angiotensin-II initiation included corticosteroids (26 patients; 87%), epinephrine (26 patients; 87%), dobutamine (17 patients; 57%), dopamine (9 patients; 30%), milrinone (2 patients; 7%), and hydroxocobalamin (4 patients; 13%). At 3 hours, the median mean arterial pressure increased from baseline (70 vs 61.5 mmHg, p = .0006). Median norepinephrine doses at angiotensin-II initiation, 1 hour, 3 hours, and angiotensin-II discontinuation were 0.22, 0.16 (p = .0023), 0.10 (p < .0001), and 0.07 (p < .0001) mcg/kg/min. Median dobutamine doses decreased throughout angiotensin-II infusion from eight to six mcg/kg/min (p = .0313). Other vasoactive medication doses were unchanged. Three patients (10%) subsequently received hydroxocobalamin. Thirteen (43.3%) and five (16.7%) patients experienced mortality by day 28 and venous or arterial thrombosis events, respectively. CONCLUSIONS: The administration of angiotensin-II to vasoplegic patients following cardiac surgery was associated with increased mean arterial pressure, reduced norepinephrine dosages, and reduced dobutamine dosages.

Factors that hinder post-traumatic growth: A systematic review.

People who experience major life crises often report post-traumatic stress. However, the literature suggests that traumatic experiences can also be "catalysts" for positive change (i.e., post-traumatic growth; PTG). PTG can include improved relationships, new possibilities for one's life, a greater appreciation for life, a greater sense of personal strength, and spiritual development. Furthermore, it has been suggested that PTG may decrease feelings of distress following exposure to trauma. While a large number of factors may help promote PTG, others may impede the development of growth (e.g., attachment style). These factors constitute key aspects for clinicians working with victims of trauma. Thus, this review aims to present these hindering factors in order to provide guidance for trauma psychologists and future research.

Surgical outcomes and complications of bedside tracheostomy in the ICU for patients on ECMO.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) is increasingly employed in the management of patients with severe cardiac and pulmonary dysfunction. Patients commonly require tracheostomy for ventilator liberation. Though bedside percutaneous tracheostomy is commonly performed, it has the potential for increased complications, both surgical and with the ECMO circuit. We examined surgical outcomes of bedside percutaneous tracheostomy in the ECMO population. METHODS: Patients were identified from an institutional database for bedside procedures. Demographics and data on complications were recorded. Descriptive statistics were calculated. RESULTS: 37 patients on ECMO at the time of tracheostomy were identified. Median age and BMI were 43.2 and 28.0, respectively. 33 patients (89%) were on VV ECMO, and 4 (11%) were on VA ECMO. All were on anticoagulation prior to tracheostomy, which was held for 4 h before and after the procedure in all cases. There were no procedure-related deaths or airway losses. No patients experienced periprocedural clotting events of their ECMO circuit or oxygenator within 24 h. 3 patients (8%) required reintervention (re-exploration or bronchoscopy) for bleeding. Four other patients (10%) had minor bleeding controlled with packing. One patient had pneumomediastinum which resolved without intervention, and one had an occlusion of their tracheostomy which was treated with tracheostomy exchange. CONCLUSIONS: Bedside percutaneous tracheostomy is feasible for patients on ECMO. Further study is needed to determine specific risk factors for complications and means to mitigate these. Bedside percutaneous tracheostomy may be considered as part of the management of patients on ECMO to help facilitate liberation from mechanical support.

Case report of high-dose hydroxocobalamin in the treatment of vasoplegic syndrome during liver transplantation.

A 66-year-old man with cryptogenic cirrhosis secondary to nonalcoholic steatohepatitis presented for orthotopic liver transplantation. Following organ reperfusion, the patient developed vasoplegic syndrome, with arterial blood pressures of approximately 60-70/30-40 mm Hg (mean arterial pressure [MAP] <45 mm Hg) for >90 minutes. He required high-dose norepinephrine and vasopressin infusions, as well as i.v. bolus doses of norepinephrine and vasopressin to reach a goal MAP> 60 mm Hg. There was minimal response to a 2 mg/kg i.v. bolus of methylene blue. Following the administration of 5 g of i.v.hydroxocobalamin, the patient had a profound improvement in arterial blood pressure, with subsequent discontinuation of the vasopressin infusion and rapid reduction of norepinephrine infusion from 20 to 2 µg/min. While there have been several reports of the efficacy of hydroxocobalamin for vasoplegia after cardiopulmonary bypass, there have been only limited cases of hydroxocobalamin used in liver transplantation, and none with high-dose administration. We present a case of vasoplegic syndrome during liver transplantation that was refractory to high-dose vasopressors and methylene blue but responsive to high-dose i.v. hydroxocobalamin.

Daily morphine administration increases impulsivity in rats responding under a 5-choice serial reaction time task.

BACKGROUND AND PURPOSE: Repeated administration of a µ opioid receptor agonist can enhance some forms of impulsivity, such as delay discounting. However, it is unclear whether repeated administration alters motor impulsivity. EXPERIMENTAL APPROACH: We examined the effects of acute administration of morphine and amphetamine prior to and during daily morphine administration in rats responding under a five-choice serial reaction time task. Rats (n = 5) were trained to detect a brief flash of light presented randomly in one of five response holes; responding in the target hole delivered food, whereas responding in the wrong hole or responding prior to illumination of the target stimulus (premature response) initiated a timeout. Premature responding served as an index of motor impulsivity. KEY RESULTS: Administered acutely, morphine (0.1-10 mg·kg(-1) , i.p.) increased omissions and modestly, although not significantly, premature responding without affecting response accuracy; amphetamine (0.1-1.78 mg·kg(-1) , i.p.) increased premature responding without changing omissions or response accuracy. After 3 weeks of 10 mg·kg(-1) ·day(-1) morphine, tolerance developed to its effects on omissions whereas premature responding increased approximately fourfold, compared with baseline. Effects of amphetamine were not significantly affected by daily morphine administration. CONCLUSIONS AND IMPLICATIONS: These data suggest that repeated administration of morphine increased effects of morphine on motor impulsivity, although tolerance developed to other effects, such as omissions. To the extent that impulsivity is a risk factor for drug abuse, repeated administration of µ opioid receptor agonists, for recreational or therapeutic purposes, might increase impulsivity and thus the risk for drug abuse.

Gastrointestinal symptoms after pelvic radiotherapy: a national survey of gastroenterologists.

PURPOSE: Seventeen thousand patients receive treatment with radical pelvic radiotherapy annually in the UK. Up to 50% develop significant gastrointestinal symptoms. The National Cancer Survivorship Initiative has identified access to specialist medical care for those with complications after cancer as one of their four key needs. We aimed to determine the current practice of British gastroenterologists with regards to chronic gastrointestinal symptoms after pelvic radiotherapy. METHODS: A questionnaire was developed and sent up to a maximum of five times to all UK consultant gastroenterologists. RESULTS: Eight hundred sixty-six gastroenterologists were approached and 165 (20%) responded. Sixty-one percent saw one to four patients annually with bowel symptoms after radiotherapy. Eighteen percent rate the current treatments as effective "often" or "most of the time". Forty-seven percent of gastroenterologists consider themselves "confident with basic cases", with 11% "confident in all cases". Fifty-nine percent thinks a gastroenterologist with a specialist interest should manage these patients. Although only 29% thinks a specific service is required for these patients, 34% rates the current service as inadequate. The ideal service was considered to be gastroenterology-led, multidisciplinary and regional. Low referral rates, poor evidence-base and poor funding are cited as reasons for the current patchy services. CONCLUSIONS: The low response rate contrasts with that from a parallel survey of clinical oncologists. This may reflect the opinion that radiation-induced bowel toxicity is not a significant issue, which may be because only a small proportion of patients are referred to gastroenterologists. The development of new, evidence-based gastroenterology-led services is considered the optimal way to meet the needs of these patients.

Late-onset bowel dysfunction after pelvic radiotherapy: a national survey of current practice and opinions of clinical oncologists.

AIMS: Seventeen thousand patients receive treatment with radical pelvic radiotherapy annually in the UK. It is common for patients to develop gastrointestinal symptoms after treatment. The aim of this study was to determine the current practice of clinical oncologists in the UK with respect to late-onset bowel dysfunction after pelvic radiotherapy, and to discuss the wider issues surrounding current and future service provision for this patient group. MATERIALS AND METHODS: A questionnaire was developed to establish current practice. This was sent to the 314 clinical oncologists in the UK who treat pelvic malignancies up to a maximum of three times. RESULTS: One hundred and ninety (61%) responses were received. Most oncologists (76%) screen for gastrointestinal dysfunction after pelvic radiotherapy, usually through history taking rather than formal tools. Clinical oncologists view toxicity as a significant problem, with most estimating that up to 24% of patients at 1 year have bowel symptoms. Most oncologists refer less than 50% of their symptomatic patients, with most referring less than 10%. These referrals are 31% to a gastroenterologist, 23% to a gastrointestinal surgeon and 33% to both. Most (58%) do not have access to a gastroenterologist or a gastrointestinal surgeon with a specialist interest in their area. Sixty-five per cent of oncologists think a service is required specifically for patients with bowel dysfunction after pelvic radiotherapy, but half (52%) think that the current service in their area is inadequate. CONCLUSIONS: Clinical oncologists recognise late-onset bowel dysfunction after pelvic radiotherapy as a significant problem, but one that is linked to poor recognition of symptoms and an inadequate patchy service.

A large HPGe detector for the non-destructive radioassay of an ultra-low-background counting facility.

We present the use of a low background counting facility, equipped with a p-type 80% relative efficiency HPGe detector, protected by active and passive shielding, and large enough to count a 10 in photo-multiplier tube (PMT). A GEANT4 Monte-Carlo of this detector was developed and tuned to 3% accuracy. We report the U, Th, and K content in three different types of PMTs used in current neutrino experiments, with accuracies of ~10ppb for U and Th and of ~15ppm for K.

Interaction of 5-HT2A and 5-HT2C receptors in R(-)-2,5-dimethoxy-4-iodoamphetamine-elicited head twitch behavior in mice.

Drug-elicited head-twitch behavior is a useful model for studying hallucinogen activity at 5-HT(2A) receptors in the mouse. Chemically diverse compounds active in this assay yield biphasic dose-effect curves, but there is no compelling explanation for the "descending" portion of these functions. A set of experiments was designed to test the hypothesis that the induction of head-twitch behavior is mediated by agonist actions at 5-HT(2A) receptors, whereas the inhibition of head-twitch behavior observed at higher doses results from competing agonist activity at 5-HT(2C) receptors. The effects of the phenethylamine hallucinogen R(-)-2,5-dimethoxy-4-iodoamphetamine (DOI) on head-twitch behavior were studied over a range of doses in the mouse, generating a characteristic biphasic dose-response curve. Pretreatment with the selective 5-HT(2A) antagonist (+)-(2,3-dimethoxyphenyl)-1-[2-(4-fluorophenylethyl)]-4-piperidine-methanol (M100907) shifted only the ascending limb of the DOI dose-effect function, whereas pretreatment with the nonselective 5-HT(2A/2C) antagonist 3-{2-[4-(4-fluorobenzoyl)piperidin-1-yl]ethyl}quinazoline-2,4(1H,3H)-dione (ketanserin) produced a parallel shift to the right in the DOI dose-response curve. Administration of the 5-HT(2C) agonist S-2-(chloro-5-fluoro-indol-l-yl)-1-methylethylamine (Ro 60-0175) noncompetitively inhibited DOI-elicited head-twitch behavior across the entire dose-effect function. Finally, pretreatment with the selective 5-HT(2C) antagonists 6-chloro-5-methyl-1-[(2-[2-methylpyrid-3-yloxy]pyrid-5yl)carbamoyl]indoline (SB242084) or 8-[5-(2,4-dimethoxy-5-(4-trifluoromethylphenylsulfonamido)phenyl-5-oxopentyl]-1,3,8-triazaspiro[4,5]decane-2,4-dione hydrochloride (RS 102221) did not alter DOI-elicited head-twitch behavior on the ascending limb of the dose-response curve but shifted the descending limb of the DOI dose-response function to the right. The results of these experiments provide strong evidence that DOI-elicited head-twitch behavior is a 5-HT(2A) agonist-mediated effect, with subsequent inhibition of head-twitch behavior being driven by competing 5-HT(2C) agonist activity.

Effects of a reimbursement incentive on enrollment in a weight control program.

OBJECTIVE: The objective was to examine the effect of offering a reimbursement incentive on the percentage of inquirers who enrolled in a weight control program and on weight loss and program attendance among enrollees. RESEARCH METHODS AND PROCEDURES: We used a sequential control-intervention design to observe how inquirers of the University of Alabama at Birmingham EatRight Lifestyle Program responded to an enrollment incentive for potential 50% ($150) reimbursement of the total program fee if they attended 10 of 12 classes and lost at least 6% of their current body weight. Inquirers had to be adults with a BMI >or=30 kg/m(2), seeking information about a weight control program, and informed of the program cost. Outcomes included proportion of inquirers enrolled, overall number of classes attended, and weight loss. RESULTS: Of the 401 people who inquired during the study periods, 24.5% and 25.0% enrolled in the intervention and control periods, respectively. There was a trend toward higher attendance in the intervention group, compared with the control group; there were no differences in percentage of weight loss. The odds of attending >or=10 classes were 2.4 times as high, and both losing >6% body weight and attending >or=10 classes were three times as high in the intervention subjects compared with controls, although non-significant. DISCUSSION: The potential of earning a performance-based reimbursement incentive did not affect enrollment in the EatRight Lifestyle Program. Performance-based incentives may be an ideal mechanism for extending coverage of weight-loss interventions by insurers because of limited financial risk and improved adherence.

Divergence in popular diets relative to diets consumed by Americans, and implications for diet selection.

CONTEXT: Given the seemingly disparate nature of popular weight-loss diets (WLDs), consumers may have a difficult time choosing one. We hypothesized that because most of these diets differ greatly from the way most Americans spontaneously eat, the choice of a WLD may be less critical than the decision to adopt any WLD. OBJECTIVE: To assess the degree of similarity among several popular WLDs and that between average diets of Americans and the WLDs as a whole. DESIGN: One-day menus were randomly selected or constructed from 16 popular diet books (resulting in 17 distinct diets). Usual dietary intakes of individuals were derived from the Continuing Survey of Food Intakes by Individuals (CSFII) 1994-96, 1998. MAIN OUTCOME MEASURES: Euclidean distances, based on 12 dietary variables, were calculated among the popular WLDs, as well as between the WLDs and intakes from the CSFII. RESULTS: Euclidean distances among the WLDs ranged from 1.99 to 15.24, with a mean of 6.12 +/- 2.83. Mean distance between individuals' intakes from the CSFII and the closest WLD was 3.63 +/- 1.24, while the mean distance between individuals' intakes and the farthest WLD was 10.58 +/- 1.10. Mean distance between individuals' intakes and the WLDs considered together was 6.04 +/- 1.10. CONCLUSIONS: While the mean Euclidean distances between individuals' intakes and popular WLDs demonstrated meaningful differences, the differences among the WLDs were slightly greater and, in multivariate space, surrounded the diets consumed by Americans. This may have implications for the selection of a WLD in persons seeking to lose weight.

Ultrasonographic endometrial thickness for diagnosing endometrial pathology in postmenopausal bleeding.

We conducted this retrospective analysis of our clinical data to identify the incidence of benign endometrial abnormalities, endometrial carcinoma and to find out the endometrial thickness (ET) cut-off point using trans-vaginal ultrasonography for patients with postmenopausal bleeding (PMB) referred to the Rapid Access Clinic in Northampton General Hospital. All women referred between April 2004 and April 2005 with PMB were included in this analysis. Final diagnostic outcome was classified into benign endometrial polyp, endometrial hyperplasia, endometrial carcinoma or normal (by excluding these pathologies). A total of 142 patients were included in this survey. The incidence of abnormal endometrial pathology was found to be 23.9% and 5% for endometrial carcinoma. Our results suggested that benign endometrial pathology is the most common cause of postmenopausal bleeding. Lowering the endometrial thickness cut-off point from 5 mm to 3 mm will not improve the diagnostic accuracy of endometrial carcinoma.

Physical activity patterns during weight maintenance following a low-energy density dietary intervention.

OBJECTIVE: The objective was to determine the role of physical activity (PA) and energy intake on weight maintenance among former University of Alabama at Birmingham EatRight Weight Management Program participants. RESEARCH METHODS AND PROCEDURES: Eighty-nine former participants completed follow-up visits > or =1 year after completing EatRight. BMI was calculated using measured height and weight. Diet intake was estimated from 4-day food records. PA was assessed using a module from the Behavioral Risk Factor Surveillance System Survey. Cut-off points were chosen based on the distribution of minutes of activity. For moderate and total activity, cut-off points were 0, 1 to 30, 31 to 60, and >60 minutes. For vigorous activity, the categories were 0, 1 to 20, 21 to 30, and >30 minutes. General linear models determined the association of PA with change in weight at follow-up controlling for gender and total energy intake (kcal/d). RESULTS: At follow-up, 80% (n = 71) of participants maintained (regained <5% of program end weight) their body weight and 20% had gained weight. Mean weight change was 1.0 +/- 6.5 kg. Maintainers consumed 384 fewer kcal/d on average. Maintainers had a lower energy density dietary pattern (1.58 vs. 2.01 kcal/g, p < 0.01). There was no significant difference in PA min/d reported by maintainers and gainers. DISCUSSION: Our results suggest that, despite being minimally active, weight-reduced individuals can successfully maintain their newly achieved body weight with appropriate caloric intake. Adopting a lower calorie, low energy density dietary pattern may reduce the amount of PA that is truly necessary for weight maintenance.

Weight maintenance 2 years after participation in a weight loss program promoting low-energy density foods.

OBJECTIVE: Observational study designed to determine weight outcomes and associated dietary intake patterns for a sample of participants > or =1 year after completing the University of Alabama at Birmingham EatRight Weight Management Program. RESEARCH METHODS AND PROCEDURES: Seventy-four former participants (64% women) completed follow-up visits > or =1 year after participating in EatRight, which promotes low-energy density, high-complex carbohydrate foods. Weight maintenance was defined as gaining <5% of body weight since completion of the EatRight program and staying below their program entry weight. Those who gained > or =5% of their body weight since completion were classified as gainers. RESULTS: During EatRight, participants of the follow-up study lost an average of 4.0 kg. After a mean follow-up time of 2.2 years, the average weight change was +0.59 kg (mean BMI, 32.5 kg/m(2)). Seventy-eight percent of participants gained <5% of their body weight; 46% had no weight regain or continued weight loss. Unadjusted mean intake for maintainers was 1608 kcal, whereas calorie intake for gainers was 1989 kcal. Despite eating slightly fewer calories (adjusted difference, 244; p = 0.058), maintainers ate a similar amount of food, resulting in a lower energy-density pattern (p = 0.016) compared with those who regained > or =5% of body weight. Gainers also reported consuming larger portions of several food groups. DISCUSSION: Our results indicate that low-energy-density eating habits are associated with long-term weight maintenance. Those who maintain weight after the EatRight program consume a low-energy-density dietary pattern and smaller portions of food groups potentially high in energy density than those who regain weight.

Glycemic index and glycemic load of popular weight-loss diets.

CONTEXT: Carbohydrate-restricted diets have been popular in recent years. The theoretical glycemic impact of these diets, compared with other popular weight-loss diets, has not been reported. OBJECTIVE: To assess the glycemic index (GI) and glycemic load (GL) of 2 popular, carbohydrate-restricted diets (South Beach and Sugar Busters!) and compare them with a low-fat, high-carbohydrate diet (Ornish) and a moderate-fat, moderate-carbohydrate diet (EatRight). DESIGN: All available sample menus provided in the book for each diet were extracted and included in the analyses. GI values for all carbohydrate-containing foods were assigned based on a published list. GL values were determined based on these GI values and recommended serving sizes. MAIN OUTCOME MEASURES: Median daily GI and GL values were calculated for each diet and for each phase of South Beach and each meal pattern of EatRight. RESULTS: The median daily GLs of South Beach and Sugar Busters! (34 and 48, respectively) were less than one half those of Ornish and EatRight (113 and 104, respectively). Adjusting the diets to 1500 kcal attenuated the differences slightly. The median daily GIs of the diets were in a very narrow range (46-53); however, South Beach (46) was significantly lower than Ornish (53). CONCLUSIONS: The GLs of 2 carbohydrate-restricted diets were significantly lower than those of a low-fat, high-carbohydrate diet and a moderate-fat, moderate-carbohydrate diet. The differences were due primarily to lower carbohydrate content rather than to differences in overall GIs of the diets.

Effect of adding and removing N-glycosylation recognition sites on the thermostability of barley alpha-glucosidase.

The thermostability of alpha-glucosidase is important because the conversion of starch to fermentable sugars during the industrial production of beer and fuel ethanol typically occurs at relatively high temperatures (60-75 degrees C). Barley (Hordeum vulgare) alpha-glucosidase is unstable at these elevated temperatures; however, the alpha-glucosidase from sugar beet (Beta vulgaris) is stable at these temperatures. An alignment of the deduced amino acid sequences of barley and sugar beet alpha-glucosidases revealed considerable differences in the number and position of N-glycosylation recognition sites (NGRS). Other researchers have shown that additions or removals of NGRS resulted in either the stabilization or destabilization of the enzymes at elevated temperatures. NGRS present in the barley sequence and absent in the sugar beet sequence were removed via site-directed mutagenesis from the barley protein. Recognition sites absent in the barley sequence and present in the sugar beet sequence were added via mutagenesis into the barley alpha-glucosidase. Two mutations significantly increased thermostability, one mutation significantly decreased thermostability and five mutations had little effect on alpha-glucosidase thermostability.