Longer Operative Time for Lower Extremity Bypass Surgery is Associated With Inferior Outcomes.

INTRODUCTION: This study aims to assess the association of operative time with the postoperative length of stay and unplanned return to the operating room in patients undergoing femoral to below knee popliteal bypasses, stratified by autologous vein graft or polytetrafluoroethylene (PTFE). MATERIALS AND METHODS: A retrospective analysis of vascular quality initiative database (2003-2021). The selected patients were grouped into the following: vein bypass (group I) and PTFE (group II) patients. Each group was further stratified by a median split of operative time (i.e., 210 min for autologous vein and 155 min for PTFE) to study the outcomes. The outcomes were assessed by univariate and multivariate approach. RESULTS: Of the 10,902 patients studied, 3570 (32.7%) were in the autologous vein group, while 7332 (67.3%) were in the PTFE group. Univariate analysis revealed autologous vein and PTFE graft recipients that had increased operative times were associated with a longer mean postoperative length of stay and a higher incidence of all-cause return to the operating room. In PTFE group, patients with prolonged operative times were also found to be associated with higher incidence of major amputation, surgical site infection, and cardiovascular events, along with loss of primary patency within a year. CONCLUSIONS: For patients undergoing femoral to below knee popliteal bypasses using an autologous vein or PTFE, longer operative times were associated with inferior outcomes. Mortality was not found to be associated with prolonged operative time.

A Custom-Made Newborn Screening Test for Wilson's Disease in Puerto Rico.

Background Wilson's disease (WD) is an autosomal recessive progressive, disabling, life-threatening disease. Although early diagnosis and treatment can halt disease progression and reverse disability, diagnosis is often challenging, with a mean diagnostic delay of approximately two years. At least 98% of WD-causing variants are in the ATPase copper transporting beta (ATP7B) gene. Identifying ATP7B mutations that cause WD in Puerto Rico will allow newborn screening for WD, as well as preventive, life-saving treatment. Methodology TaqMan genotyping assays were performed on 174 random volunteers in southwestern Puerto Rico and on three independent WD cases for rs367956522 and rs140708492, single-nucleotide polymorphisms (SNPs) composing a WD-causing haplotype. A polymerase chain reaction followed by Sanger DNA sequencing confirmed the case genotypes. Bioinformatics analyses were performed on ATP7B polymorphisms present in The 1000 Genomes Project (1KGP) database for Puerto Rico. Results rs367956522 is always inherited together with rs140708492 but not vice versa. The three independent WD cases were homozygous for both SNPs, but the evidence strongly suggested that rs367956522 is the pathogenic variant. The 1KGP database revealed the presence of only one other likely pathogenic ATP7B variant, rs191312027 (Gly869Arg). Together, both variants may be responsible for causing WD in one of every 14,156 Puerto Ricans. Both are likely of European origin. Conclusions Genotyping probes for both variants are readily commercially available. Thus, rapid, inexpensive newborn screening for rs367956522 and rs191312027 is strongly recommended. Although these two variants may account for all or the vast majority of WD cases in Puerto Rico, other ATP7B polymorphisms described or not described in this study might also be pathogenic.

Institution of Monthly Anesthesia Quality Reports Does Not Reduce Postoperative Complications despite Improved Metric Compliance.

While quality programs have been shown to improve provider compliance, few have demonstrated conclusive improvements in patient outcomes. We hypothesized that there would be increased metric compliance and decreased postoperative complications after initiation of an anesthesiology quality improvement program at our institution. We performed a retrospective study of all adult inpatients having anesthesia for a twelve-month period that spanned six months before and after program implementation. The primary outcome was the rate of complications in the post-implementation period. Secondary outcomes included the change in proportion of complications and compliance with quality metrics. We studied a total of 9620 adult inpatient cases, subdivided into pre- and post-implementation groups (4832 vs 4788.) After multivariate model adjustment, the rate of any complication (our primary outcome) was not significantly changed (32% to 31%; adjusted P = 0.410.) Of the individual complications, only wound infection (2.0% to 1.5%; adjusted P = 0.020) showed a statistically significant decrease. Statistically and clinically significant increases in compliance were seen for the BP-02 Avoiding Monitoring Gaps metric (81% to 93%, P < 0.001), both neuromuscular blockade metrics (NMB-01 76% to 91%, P < 0.001; NMB-02 95% to 97%, P = 0.006), both tidal volume metrics (PUL-01 84% to 93%, P < 0.001; PUL-02 30% to 45%, P < 0.001), and the TEMP-02 Core Temperature Measurement metric (88% to 94%, P < 0.001). Implementation of a comprehensive quality feedback program improved metric compliance but was not associated with a change in postoperative complications.

Improved Compliance With Anesthesia Quality Measures After Implementation of Automated Monthly Feedback.

PURPOSE: Minimization of postoperative complications is important in patients with cancer. We wished to improve compliance with anesthesiology quality measures through staff education reinforced with automated monthly feedback. METHODS: The anesthesiology department implemented a program to capture and report quality metrics. After staff education, monthly e-mail reports were sent to each anesthesiology physician and nurse anesthetist to detail individual compliance rates for a set of quality measures. For each measure, the proportion of patient cases that passed the measure before and after implementation of the program was compared using a two-sample proportion test. RESULTS: After exclusions, we analyzed 15 of 23 quality measures. Of the 15 measures, 11 were process measures, and four were outcome measures. Of the 11 process measures, seven demonstrated statistically significant improvements (P < .01). The most improved measure was TEMP-02 (core temperature measurement), which increased from 69.6% to 85.7% (16.1% difference; P < .001). Also improved were PUL-02 (low tidal volume, less than 8 mL/kg ideal body weight; 15.4% difference; P < .001) and NMB-01 (train of four taken; 12.2% difference; P < .001). The outcome measure TEMP-03 (perioperative temperature management) had a statistically significant increase of a small magnitude (0.2% difference; P < .001). No other outcome measures showed statistically significant improvement. CONCLUSION: After implementation of a comprehensive quality improvement program, our group observed significant improvements in anesthesia quality measure compliance for several process measures. Future work is needed to determine if this initial success can be preserved and associated with improved outcomes.

Dopamine manipulations drive changes in information sampling in healthy volunteers.

BACKGROUND: Information sampling is the cognitive process of accumulating information before committing to a decision. Patients across numerous disorders show decreased information sampling relative to controls. AIMS: Here, we used the Beads and the Best Choice Tasks to study the role of dopamine signaling in information sampling. METHODS: Participants were given placebo, amisulpride, or ropinirole in each session, in a double-blind cross-over design. RESULTS: We found that ropinirole (agonist) increased the number of beads drawn in the Beads Task specifically when participants faced a loss, and decreased the rank of the chosen option in the Best Choice Task. CONCLUSIONS: These effects are likely driven by a combination of effects at presynaptic D2 receptors, which affect dopamine release, and post-synaptic D2 receptors. Increased D2 relative to D1 receptor activation in the striatum leads to increased sampling in the loss condition in the Beads Task. It also leads to choice of a poorer ranked option in the Best Choice Task. Decreased D2 relative to D1 receptor activation leads to decreased sampling in the Beads Task in the loss condition.

Ventral striatum lesions do not affect reinforcement learning with deterministic outcomes on slow time scales.

A large body of work has implicated the ventral striatum (VS) in aspects of reinforcement learning (RL). However, less work has directly examined the effects of lesions in the VS, or other forms of inactivation, on 2-armed bandit RL tasks. We have recently found that lesions in the VS in macaque monkeys affect learning with stochastic schedules but have minimal effects with deterministic schedules. The reasons for this are not currently clear. Because our previous work used short intertrial intervals, one possibility is that the animals were using working memory to bridge stimulus-reward associations from 1 trial to the next. In the present study, we examined learning of 60 pairs of objects, in which the animals received only 1 trial per day with each pair. The large number of object pairs and the long interval (approximately 24 hr) between trials with a given pair minimized the chances that the animals could use working memory to bridge trials. We found that monkeys with VS lesions were unimpaired relative to controls, which suggests that animals with VS lesions can still learn to select rewarded objects even when they cannot make use of working memory. (PsycINFO Database Record

Effects of Ventral Striatum Lesions on Stimulus-Based versus Action-Based Reinforcement Learning.

Learning the values of actions versus stimuli may depend on separable neural circuits. In the current study, we evaluated the performance of rhesus macaques with ventral striatum (VS) lesions on a two-arm bandit task that had randomly interleaved blocks of stimulus-based and action-based reinforcement learning (RL). Compared with controls, monkeys with VS lesions had deficits in learning to select rewarding images but not rewarding actions. We used a RL model to quantify learning and choice consistency and found that, in stimulus-based RL, the VS lesion monkeys were more influenced by negative feedback and had lower choice consistency than controls. Using a Bayesian model to parse the groups' learning strategies, we also found that VS lesion monkeys defaulted to an action-based choice strategy. Therefore, the VS is involved specifically in learning the value of stimuli, not actions.SIGNIFICANCE STATEMENT Reinforcement learning models of the ventral striatum (VS) often assume that it maintains an estimate of state value. This suggests that it plays a general role in learning whether rewards are assigned based on a chosen action or stimulus. In the present experiment, we examined the effects of VS lesions on monkeys' ability to learn that choosing a particular action or stimulus was more likely to lead to reward. We found that VS lesions caused a specific deficit in the monkeys' ability to discriminate between images with different values, whereas their ability to discriminate between actions with different values remained intact. Our results therefore suggest that the VS plays a specific role in learning to select rewarded stimuli.