Utility of Whole Slide Imaging for Intraoperative Consultation: Experience of a Large Academic Center.

CONTEXT.­: In the United States, review of digital whole slide images (WSIs) using specific systems is approved for primary diagnosis but has not been implemented for intraoperative consultation. OBJECTIVE.­: To evaluate the safety of review of WSIs and compare the efficiency of review of WSIs and glass slides (GSs) for intraoperative consultation. DESIGN.­: Ninety-one cases previously submitted for frozen section evaluation were randomly selected from 8 different anatomic pathology subspecialties. GSs from these cases were scanned on a Leica Aperio AT2 scanner at ×20 magnification (0.25 µm/pixel). The slides were deidentified, and a short relevant clinical history was provided for each slide. Nine board-certified general pathologists who do not routinely establish primary diagnoses using WSIs reviewed the WSIs using Leica Aperio ImageScope viewing software. After a washout period of 2-3 weeks, the pathologists reviewed the corresponding GSs using a light microscope (Olympus BX43). The pathologists recorded the diagnosis and time to reach the diagnosis. Intraobserver concordance, time to diagnosis, and specificity and sensitivity compared to the original diagnosis were evaluated. RESULTS.­: The rate of intraobserver concordance between GS results and WSI results was 93.7%. Mean time to diagnosis was 1.25 minutes for GSs and 1.76 minutes for WSIs (P < .001). Specificity was 91% for GSs and 90% for WSIs; sensitivity was 92% for GSs and 92% for WSIs. CONCLUSIONS.­: Time to diagnosis was longer with WSIs than with GSs, and scanning GSs and uploading the data to whole slide imaging systems takes time. However, review of WSIs appears to be a safe alternative to review of GSs. Use of WSIs allows reporting from a remote site during a public health emergency such as the COVID-19 pandemic and facilitates subspecialty histopathology services.

Assessment of spilled toxic bait by wild pigs and potential risk to non-target species.

BACKGROUND: In 2018, a sodium nitrite (SN)-based toxic bait for invasive wild pigs (hereafter wild pigs; Sus scrofa), was evaluated to determine its effectiveness in reducing local wild pig populations in Texas. Localized population reductions of >70% were achieved, but spillage of bait outside wild pig-specific feeders (bait stations) caused by feeding wild pigs resulted in the deaths of non-target animals. To evaluate risks to non-target animals, we tested whether bait presentation influenced the total amount of bait spilled by wild pigs and estimated the associated risk to non-target species. RESULTS: We found that bait spilled outside bait stations could be reduced by >90% when compacted in trays, as opposed to being manually crumbled into pieces. We documented a mean spill rate of 0.913 g of bait per wild pig. Conservative risk assessments for nine non-target species for which SN toxicity data exist indicate that there is relatively low risk of lethal exposure, apart from zebra finches (Taeniopygia guttata) and white mice. Our results indicate that there may be enough spilled bait per feeding wild pig to kill 9.5 or 3.5 individuals of these species, respectively. Other species assessed range from 0.002 to 0.406 potential mortalities per wild pig. CONCLUSION: We demonstrated that the amount of bait spilled by wild pigs during feeding and the associated risk to non-target animals can be minimized by presenting the bait compacted in trays within bait stations. We recommend that baits be tightly compacted and secured in bait stations to minimize risks to non-target animals from spilled bait by wild pigs. © 2023 Society of Chemical Industry. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Patients not taking a previously prescribed bone active medication now prescribed medication through Ontario FLS.

In an Ontario fracture liaison service (FLS), we compared medication prescription rates among patients not taking a previously prescribed bone active medication to those with no previous prescription. Prescription rates were similar between these two groups of patients. The FLS provided a secondary opportunity for patients to initiate bone active medication. PURPOSE: We compared bone active medication prescription rates among patients presenting to an Ontario fracture liaison service (FLS) who reported not taking a previously prescribed bone active medication to those with no history of prescription. METHODS: Eligible patients were those screened in 39 fracture clinics between July 1, 2017, and September 15, 2019, who were not taking bone active medication at the time of screening and classified as high risk for future fracture based on CAROC or FRAX. Sociodemographic and clinical risk factor variables were assessed at screening. Bone active medication prescription rate was assessed within 6 months of screening and defined as having received a prescription for the medication from either a specialist or primary care provider. In cases where a specialist report was not available, patient self-reported data were collected. The chi-square test of independence was used to assess differences in prescription rates. RESULTS: Of 17,575 patients screened, eligible patients were 350 with a previous prescription and 2644 without a previous prescription. Compared with patients who reported no previous prescription, those who had a previous prescription were older, more likely to be female and to report a previous fracture, and less likely to smoke. There was no statistically significant difference between the medication prescription rate of patients with a previous prescription (73.7%) compared to patients with no previous prescription (70.7%) (p = 0.157). CONCLUSION: A large jurisdiction-wide FLS approach provided a secondary opportunity to patients who were not taking a previously prescribed bone active medication to initiate that medication.

Whole-Genome Sequencing of Common Salivary Gland Carcinomas: Subtype-Restricted and Shared Genetic Alterations.

PURPOSE: Salivary gland carcinomas (SGCs) are pathologically classified into several widely diverse subtypes, of which adenoid cystic carcinoma (ACC), mucoepidermoid carcinoma (MEC), and salivary duct carcinoma (SDC) are the most commonly encountered. A comparative genetic analysis of these subtypes provides detailed information on the genetic alterations that are associated with their tumorigenesis and may lead to the identification of biomarkers to guide tumor-specific clinical trials. EXPERIMENTAL DESIGN: Whole-genome sequencing of 58 common SGCs (20 ACCs, 20 SDCs, and 18 MECs) was performed to catalog structural variations, copy number, rearrangements, and driver mutations. Data were bioinformatically analyzed and correlated with clinicopathologic parameters, and selected targets were validated. RESULTS: Novel and recurrent type-specific and shared genetic alterations were identified within and among 3 subtypes. Mutually exclusive canonical fusion and nonfusion genomic alterations were identified in both ACC and MEC. In ACCs, loss of chromosome 12q was dominant in MYB or MYBL1 fusion-positive tumors and mutations of NOTCH pathway were more common in these fusion negatives. In MECs, CRTC1-MAML2 fusion-positive tumors showed frequent BAP1 mutation, and tumors lacking this fusion were enriched with LRFN1 mutation. SDCs displayed considerable genetic instability, lacked recurrent chromosomal rearrangements, and demonstrated nonoverlapping TP53 mutation and ERBB2 amplification in a subset of tumors. Limited genetic alterations, including focal amplifications of 8q21-q23, were shared by all subtypes and were associated with poor survival. CONCLUSIONS: This study delineates type-specific and shared genetic alterations that are associated with early phenotypic commitment and the biologic progression of common SGCs. These alterations, upon validation, could serve as biomarkers in tumor-specific clinical trials.

Patients 80 + have similar medication initiation rates to those aged 50-79 in Ontario FLS.

Among individuals presenting to an Ontario FLS, we compared bone active medication initiation rates of patients 80 years and older with those 50-79 years old. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates between the two age groups INTRODUCTION: A Fracture Liaison Service (FLS) offers post-fracture services to individuals over the age of 50 years and could potentially address age inequities in pharmacotherapy often observed for older adults. Among individuals presenting to an Ontario FLS and classified as being at high risk for future fracture, our objective was to compare bone active medication initiation rates of patients 80 years and older with those 50-79 years old. METHODS: In 39 FLS fracture clinics across Ontario, Canada, fracture prevention coordinators identified, assessed, and facilitated the referral of eligible patients for bone densitometry, fracture risk assessment, and implementation of pharmacotherapy in patients classified as high risk for future fracture. Variables assessed at baseline included age, sex, marital status, living location, fracture location, history of previous fracture, parent's history of hip fracture, history of falls, and fracture risk status. At 6 months, bone active medication initiation was assessed in patients classified as high risk for future fracture. The Chi-square test of independence was used to compare medication initiation rates between patients 80 + and those 50-79 years old. RESULTS: Our sample size consisted of 808 patients aged 50-79 years and 346 aged 80 + years. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates of patients 50-79 and 80 + years old (76.9% versus 73.7%, p = 0.251). CONCLUSION: A systematic approach to identifying patients at high risk for future fracture and tailoring treatment recommendations to these patients appeared to eliminate differences in treatment initiation rates based on older age.

Efficacy and risks from a modified sodium nitrite toxic bait for wild pigs.

BACKGROUND: Wild pigs (Sus scrofa) are a destructive invasive species throughout many regions of the world. In 2018, a field evaluation of an early prototype of a sodium nitrite (SN) toxic bait in the United States revealed wild pigs dropped large amounts of the toxic bait outside the pig-specific bait stations while feeding, and thus subsequent hazards for non-target animals. We modified the SN-toxic bait formulation, the design of the bait station, and the baiting strategy to reduce dropped bait. We tested the modifications in Queensland, Australia (December 2018), Alabama, USA (August 2019), and Texas, USA (March 2020) under differing climatic and seasonal conditions for one night. RESULTS: Cumulatively we found 161 carcasses of all age classes of wild pigs using systematic transects. Remote camera indices indicated high lethality for wild pigs, achieving population reductions of 76.3 to 90.4%. Wild pigs dropped only small particles of SN-toxic bait (average = 55.5 g per bait site), which represented a 19-fold decrease from the previous trial. Despite this reduction, we found three Australian ravens (Corvus coronoides) in Queensland, two Virginia opossums (Didelphis virginiana) in Alabama, and 35 granivorous-passerine birds (mostly dark-eyed juncos [Junco hyemalis]) in Texas dead from consuming the dropped bait. We did not detect any population-level effects for those species. CONCLUSION: Our modifications were effective at reducing populations of wild pigs, but the deaths of non-target species require further steps to minimize these hazards. Next steps will include evaluating various deterrent devices for birds the morning after SN-toxic bait has been offered. Published 2020. This article is a U.S. Government work and is in the public domain in the USA.

Educational booklet reinforces knowledge of osteoporosis and influences intentions to improve bone health in previously diagnosed and treated patients.

We examined individuals' experiences using an educational booklet developed by the Ontario Osteoporosis Strategy. The booklet appeared to motivate individuals to make changes to their existing management of their bone health and served as a reference tool reaffirming current practices and beliefs for others. INTRODUCTION: The purpose of this study was to examine individuals' experiences of the educational booklet and explore the influence of the booklet on individuals' beliefs and actions regarding their bone health. METHODS: Eligible individuals were those who had been prescribed medication to treat low bone mass. One-on-one telephone interviews were conducted over an 18-month period. Participants were interviewed for approximately 1 hour and asked to provide their feedback on the booklet, and to discuss what they were doing with respect to the recommendations made in the booklet. RESULTS: We interviewed 50 participants who ranged in age from 58 to 89. The overall impression of the booklet was positive. Participants described the language in the booklet as clear and easy to understand. Participants stated that they would have appreciated receiving this tool at the onset of their diagnosis. Forty-two participants had already taken action, or expressed an intention to make changes, to their existing routines to improve their bone health. In contrast, eight participants used the booklet to reaffirm current practices and beliefs. For these individuals, the recommendations made in the booklet were consistent with what they had already been doing. CONCLUSION: The booklet can engage patients in discussions about bone health. The booklet appeared to motivate individuals to make changes to their existing routines in an effort to achieve better health outcomes for their bone health. Providing a tool like this to people recently diagnosed with a bone health issue may prove to be beneficial.

Is a 'healthy diet' and a 'calcium-rich diet' the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education.

BACKGROUND: In the present study, we aimed to (i) examine perceptions of achieving calcium and vitamin D recommended dietary allowance (RDA) and (ii) determine how participants talked about food in relation to RDA recommendations. METHODS: Participants aged ≥50 years who were prescribed osteoporosis medication and received two modes of bone health education were eligible. Relying on a qualitative description design, we interviewed participants 1 month after they had attended an education session and received a self-management booklet. Calcium and vitamin D intakes were estimated by in-depth questions about diet and supplements and compared with perceptions of achieved RDA levels. Interview transcripts were analysed based on an analytic hierarchical process. RESULTS: Forty-five participants (29 reporting previous fragility fractures) were included. Calcium and vitamin D RDA appeared to be potentially achieved by 64% and 93% of participants, respectively, primarily because of reliance on supplements. Few participants talked about vitamin D in relation to food intake and 49% of participants were unclear about the calcium content of food. Most considered that a healthy diet was equivalent to a calcium-rich diet. We noted no differences in our findings in the subset of individuals with fragility fractures. CONCLUSIONS: Despite reporting a prescription for osteoporosis medication and receiving bone health education, a substantial number of individuals appeared to have sub-optimal calcium levels. This may be attributed to the challenge of achieving RDA with diet alone and the misconception of a healthy diet as a calcium-rich diet.

Exposure of a population of invasive wild pigs to simulated toxic bait containing biomarker: implications for population reduction.

BACKGROUND: An international effort to develop an acute and humane toxic bait for invasive wild pigs (Sus scrofa) is underway to curtail their expansion. We evaluated the ability to expose a population of wild pigs to a simulated toxic bait (i.e., placebo bait containing a biomarker, rhodamine B, in lieu of the toxic ingredient) to gain insight on potential population reduction. We used 28 GPS-collars and sampled 428 wild pigs to examine their vibrissae for evidence of consuming the bait. RESULTS: We estimated that 91% of wild pigs within 0.75 km of bait sites (total area = 16.8 km2 ) consumed the simulated toxic bait, exposing them to possible lethal effects. Bait sites spaced 0.75-1.5 km apart achieved optimal delivery of the bait, but wild pigs ranging ≥ 3 km away were susceptible. Use of wild pig-specific bait stations resulted in no non-target species directly accessing the bait. CONCLUSION: Results demonstrate the potential for exposing a large proportion of wild pigs to a toxic bait in similar ecosystems. Toxic baits may be an effective tool for reducing wild pig populations especially if used as part of an integrated pest management strategy. Investigation of risks associated with a field-deployment of the toxic bait is needed. © 2018 Society of Chemical Industry.

Potential secondary poisoning risks to non-targets from a sodium nitrite toxic bait for invasive wild pigs.

BACKGROUND: An acute and orally delivered toxic bait containing micro-encapsulated sodium nitrite (MESN), is under development to provide a novel and humane technology to help curtail damage caused by invasive wild pigs (Sus scrofa). We evaluated potential secondary risks for non-target species by: testing whether four different types of micro-encapsulation coatings could reduce vomiting by invasive wild pigs, testing the levels of residual sodium nitrite (SN) in tissues of invasive wild pigs, testing the environmental persistence of SN in vomitus, and conducting a risk assessment for scavengers. RESULTS: Micro-encapsulation coatings did not affect the frequency of vomiting. We identified no risk of secondary poisoning for non-target scavengers that consume muscle, eyes, and livers of invasive wild pig carcasses because residual SN from the toxic bait was not detected in those tissues. The risk of secondary poisoning from consuming vomitus appeared low because ∼90% of the SN was metabolized or broken down prior to vomiting, and continued to degrade after being exposed to the environment. Secondary poisoning could occur for common scavengers that consume approximately ≥15% of their daily dietary requirements of digestive tract tissues or undigested bait from carcasses of invasive wild pigs in a rapid, single-feeding event. The likelihood of this occurring in a natural setting is unknown. The digestive tracts of poisoned invasive wild pigs contained an average of ∼4.35 mg/g of residual SN. CONCLUSION: Data from this study suggest no risks of secondary poisoning for non-target species (including humans) that consume muscle, liver, or eyes of invasive wild pigs poisoned with a MESN toxic bait. More species-specific testing for scavengers that consume digestive tract tissues and undigested bait is needed to reduce uncertainty about these potential risks. © 2017 Society of Chemical Industry.

The impact of fragility fractures on work and characteristics associated with time to return to work.

We examined the impact of fragility fractures on the work outcomes of employed patients. The majority successfully returned to their previous jobs in a short amount of time, and productivity loss at work was low. Our findings underscore the fast recovery rates of working fragility fracture patients. INTRODUCTION: The purpose of this study is to describe the impact of fragility fractures on the work outcomes of patients who were employed at the time of their fracture. METHODS: A self-report anonymous survey was mailed to fragility fracture patients over 50 who were screened as part of the quality assurance programs of fracture clinics across 35 hospitals in Ontario, Canada. Measures of return to work (RTW), at-work productivity loss (Work Limitations Questionnaire), and sociodemographic, fracture-related, and job characteristics were included in the survey. Kaplan-Meier estimates of the cumulative proportion of patients still off work were computed. Factors associated with RTW time following a fragility fracture were examined using Cox proportional hazards modeling. RESULTS: Of 275 participants, 242 (88 %) returned to work. Of these, the median RTW time was 20.5 days. About 86 % returned to the same job, duties, and hours as before their injury. Among full-time workers, the median number of lost hours due to presenteeism was 2.9 h (Q1-Q3 0.4-8.1 h). The median cost of presenteeism was $75.30 based on the month prior to survey completion. In multivariable analyses, female gender, needing surgery, and medium/heavy work requirements were associated with longer RTW time. Earlier RTW time was associated with elbow fracture and feeling completely better at time of survey completion. CONCLUSIONS: The majority of fragility fracture patients successfully returned to their previous jobs in a short amount of time, and productivity loss at work was low. Our findings underscore their fast recovery rates and give reason for optimism regarding the resilience of this population.

The role of Vitamin B12 in the critically ill--a review.

Vitamin B12 is an essential micronutrient, as humans have no capacity to produce the vitamin and it needs to be ingested from animal proteins. The ingested Vitamin B12 undergoes a complex process of absorption and assimilation. Vitamin B12 is essential for cellular function. Deficiency affects 15% of patients older than 65 and results in haematological and neurological disorders. Low levels of Vitamin B12 may also be an independent risk factor for coronary artery disease. High levels of Vitamin B12 are associated with inflammation and represent a poor outlook for critically ill patients. Treatment of Vitamin B12 deficiency is simple, but may be lifelong.

Bait Preference of Free-Ranging Feral Swine for Delivery of a Novel Toxicant.

Invasive feral swine (Sus scrofa) cause extensive damage to agricultural and wildlife resources throughout the United States. Development of sodium nitrite as a new, orally delivered toxicant is underway to provide an additional tool to curtail growth and expansion of feral swine populations. A micro-encapsulation coating around sodium nitrite is used to minimize detection by feral swine and maximize stability for the reactive molecule. To maximize uptake of this toxicant by feral swine, development a bait matrix is needed to 1) protect the micro-encapsulation coating so that sodium nitrite remains undetectable to feral swine, 2) achieve a high degree of acceptance by feral swine, and 3) be minimally appealing to non-target species. With these purposes, a field evaluation at 88 sites in south-central Texas was conducted using remote cameras to evaluate preferences by feral swine for several oil-based bait matrices including uncolored peanut paste, black-colored peanut paste, and peanut-based slurry mixed onto whole-kernel corn. These placebo baits were compared to a reference food, whole-kernel corn, known to be readily taken by feral swine (i.e., control). The amount of bait consumed by feral swine was also estimated using remote cameras and grid boards at 5 additional sites. On initial exposure, feral swine showed reduced visitations to the uncolored peanut paste and peanut slurry treatments. This reduced visitation subsided by the end of the treatment period, suggesting that feral swine needed time to accept these bait types. The black-colored peanut paste was visited equally to the control throughout the study, and enough of this matrix was consumed to deliver lethal doses of micro-encapsulated sodium nitrite to most feral swine during 1-2 feeding events. None of the treatment matrices reduced visitations by nontarget species, but feral swine dominated visitations for all matrices. It was concluded that black-colored peanut paste achieved satisfactory preference and consumption by feral swine, and no discernable preference by non-target species, compared to the other treatments.

The safety and effectiveness of a long-acting transdermal fentanyl solution compared with oxymorphone for the control of postoperative pain in dogs: a randomized, multicentered clinical study.

A prospective, double-blinded, positive-controlled, multicenter, noninferiority study was conducted to evaluate the safety and effectiveness of transdermal fentanyl solution (TFS) compared with oxymorphone for the control of postoperative pain in dogs. Five hundred and two (502) client-owned dogs were assigned to a single dose of TFS (2.7 mg/kg) applied 2-4 h prior to surgery or oxymorphone hydrochloride (0.22 mg/kg) administered subcutaneously 2-4 h prior to surgery and q6h through 90 h. Pain was evaluated over 4 days by blinded observers using a modified Glasgow composite pain scale, and the a priori criteria for treatment failure was a pain score ≥ 8 or adverse event necessitating withdrawal. Four TFS- and eight oxymorphone-treated dogs were withdrawn due to lack of pain control. Eighteen oxymorphone-treated, but no TFS-treated dogs were withdrawn due to severe adverse events. The one-sided upper 95% confidence interval of the difference between TFS and oxymorphone treatment failure rates was -5.3%. Adverse events associated with oxymorphone were greater in number and severity compared with TFS. It was concluded that a single administration of TFS was safe and noninferior to repeated injections of oxymorphone for the control of postoperative pain over 4 days at the dose rates of both formulations used in this study.

Calcium-activated chloride channels in the corpus cavernosum: recent developments and future of a key cellular component of the erectile process.

Calcium-activated chloride channels (CaCCs) are one of five families of chloride channels, ubiquitously expressed, and essential for a host of biological actions. CaCCs have key roles in processes as diverse as olfactory transduction and epithelial secretion, and also CaCCs are essential in smooth muscle contraction. The corpus cavernosum is a vascular smooth muscle that must relax to facilitate erections. Parasympathetic activation produces relaxation of the corpus cavernosum through a nitric oxide-dependent pathway, and sympathetic stimulation in both preventing and terminating erections by contracting the corpus cavernosum. Both these pathways affect activity of CaCCs. The past 5 years produced many successes in CaCC research. One key area of success was the identification of the elusive 'molecular candidate' of CaCCs, as the TMEM16A protein (dubbed anoctamin-1) and potentially other members of the anoctamin family of transmembrane proteins. However, enthusiasm has been somewhat tempered because of evidence that this family of proteins may not be responsible for calcium-activated chloride currents in certain epithelial tissues. Several studies identified specific inhibitors of CaCCs as well as specific inhibitors for anoctamin-1. Despite the number of recent achievements in this field there are many details that still need to be elucidated. Of particular value would be more details on the identity of the CaCCs in corpus cavernosum smooth muscle, using new inhibitors to gain insight into the signalling pathway, and the evaluation of whether inhibition of CaCCs provides any specific benefit in different models of ED.

Population pharmacokinetics of transdermal fentanyl solution following a single dose administered prior to soft tissue and orthopedic surgery in dogs.

A novel, long-acting transdermal fentanyl solution (TFS) that delivers sustained plasma fentanyl concentrations following a single application for the control of postoperative pain has recently been approved for use in dogs. The pharmacokinetics (PKs) of this formulation have been evaluated in healthy laboratory dogs, but they have not been reported in a clinical population of dogs for which it is indicated. Plasma fentanyl concentrations were determined from 215 dogs following a single, small-volume (∼50 µL/kg) dose of TFS administered 2-4 h prior to orthopedic or soft tissue surgery. A population PK model was fit, and a 1-compartment open PK model with first-order absorption and an absorption lag-time best described the data. No tested clinical covariates had a significant effect on the PKs. The final model adequately described the population PKs and gave results consistent with laboratory PK studies in healthy dogs. The PKs were primarily characterized by a rapid initial increase in plasma fentanyl concentrations and a long terminal half-life of 74.0 (95% C.I. [54.7-113]) h governed by flip-flop kinetics for the typical subject. The plasma fentanyl concentrations were sustained over days in the range considered to be analgesic for postoperative pain in dogs.

The effectiveness of a long-acting transdermal fentanyl solution compared to buprenorphine for the control of postoperative pain in dogs in a randomized, multicentered clinical study.

A prospective, double-blinded, positive-controlled, multicenter, noninferiority clinical study was conducted to evaluate the safety and effectiveness of a long-acting transdermal fentanyl solution (TFS) for the control of postoperative pain. Four hundred forty-five client-owned dogs of various breeds were randomly assigned to receive a single dose of TFS (2.6 mg/kg [∼50 µL/kg]) (N = 223) applied 2-4 h prior to surgery or buprenorphine (20 µg/kg) (N = 222) administered intramuscularly 2-4 h prior to surgery and every 6 h through 90 h. There were 159 (35.7%) males and 286 (64.3%) females ranging from 0.5 to 16 years of age and 3 to 98.5 kg enrolled. Pain was scored using the modified Glasgow Composite Pain Scale with an a priori dropout criteria of ≥ 8 (20 maximum score). The one-sided upper 95% confidence interval of the mean difference between fentanyl and buprenorphine treatment failures was 5.6%, which was not greater than the a priori selected margin difference of 15%. Adverse events attributed to either treatment were minimal in impact and were approximately equal between groups. Sustained plasma fentanyl concentrations provided by a single pre-emptive dose of TFS are safe and effective and are noninferior to repeated injections of buprenorphine in controlling postoperative pain over 4 days. This long-acting fentanyl formulation provides veterinarians with a novel, registered option for the control of postoperative pain in dogs that improves dosing compliance and potentially mitigates the disadvantages of oral, parenteral, and patch delivered opioids.

Increased Vitamin B12 levels are associated with mortality in critically ill medical patients.

BACKGROUND & AIMS: We describe an observational study in critically ill medical patients showing the association between serum Vitamin B12 levels measured on or near admission and the outcome in these patients. METHODS: We used the database of patients admitted to the Medical Intensive Care Unit (MICU) at the Hadassah-Hebrew University Medical Center in Jerusalem, Israel, to analyze associations between patient demographics, background, diagnoses and serum Vitamin B12 levels with hospital and 90 day outcomes. RESULTS: Higher mean Vitamin B12 levels were found in patients who did not survive their hospital stay (1719 pg/ml vs 1003 pg/ml, p < 0.01). Those who had died by 90 days after admission to the MICU also had higher Vitamin B12 levels than survivors (1593 pg/ml vs 990 pg/ml). Regression analysis showed that elevated Vitamin B12 levels were associated with increased 90 day mortality, even after controlling for other variables. Survival analysis also showed an increased mortality rate in patients with Vitamin B12 levels over 900 pg/ml (p < 0.0002). CONCLUSIONS: Our data show that high serum Vitamin B12 levels are associated with increased mortality in critically ill medical patients. We suggest that Vitamin B12 levels should be included in the work-up of all medical intensive care patients, particularly those with a chronic health history and increased severity of illness.