Neuronal nicotinic acetylcholine receptor of the central amygdala modulates the ethanol-induced tolerance to anxiolysis and withdrawal-induced anxiety in male rats.

The nicotine acetylcholinergic receptor (nAchR) in the central nucleus of the amygdala (CeA) is known to modulate anxiety traits as well as ethanol-induced behavioral effects. Therefore, the present study investigated the role of CeA nAChR in the tolerance to ethanol anxiolysis and withdrawal-induced anxiety-related effects in rats on elevated plus maze (EPM). To develop ethanol dependence, rats were given free access to an ethanol-containing liquid diet for 10 days. To assess the development of tolerance, separate groups of rats were challenged with ethanol (2 g/kg, i.p.) on days 1, 3, 5, 7 and 10 during the period of ethanol exposure, followed by an EPM assessment. Moreover, expression of ethanol withdrawal was induced after switching ethanol-dependent rats to a liquid diet on day 11, and withdrawal-induced anxiety-like behavior was noted at different post-withdrawal time points using the EPM test. The ethanol-dependent rats were pretreated with intra-CeA (i.CeA) (bilateral) injections of nicotine (0.25 µg/rat) or mecamylamine (MEC) (5 ng/rat) before the challenge dose of ethanol on subthreshold tolerance on the 5th day or on peak tolerance day, that is, 7th or 10th, and before assessment of postwithdrawal anxiety on the 11th day on EPM. Bilateral i.CeA preadministration of nicotine before the challenge dose of ethanol on days 5, 7 and 10 exhibited enhanced tolerance, while injection of MEC, completely mitigated the tolerance to the ethanol-induced antianxiety effect. On the other hand, ethanol-withdrawn rats pretreated i.CeA with nicotine exacerbated while pretreatment with MEC, alleviated the ethanol withdrawal-induced anxiety on all time points. Thus, the present investigation indicates that stimulation of nAChR in CeA negatively modulates the ethanol-induced chronic behavioral effects on anxiety in rats. It is proposed that nAChR antagonists might be useful in the treatment of alcohol use disorder and ethanol withdrawal-related anxiety-like behavior.

Effect of salt, alkali and combined stresses on root system architecture and ion profiling in a diverse panel of oat (Avena spp.).

The co-occurrence of salinisation and alkalisation is quite frequent in problematic soils and poses an immediate threat to food, feed and nutritional security. In the present study, root system architectural traits (RSAs) and ion profiling were evaluated in 21 genotypes of Avena species to understand the effect of salinity-alkalinity stress. The oat genotypes were grown on germination paper and 5-day-old seedlings were transferred to a hydroponic system for up to 30days. These seedlings were subjected to seven treatments: T0 , treatment control (Hoagland solution); T1 , moderate salinity (50mM); T2 , high salinity (100mM); T3 , moderate alkalinity (15mM); T4 , high alkalinity (30mM); T5 , combined moderate salinity-alkalinity (50mM+15mM); and T6 , combined high salinity-alkalinity (100mM and 30mM) by using NaCl+Na2 SO4 (saline) and NaHCO3 +Na2 CO3 (alkaline) salts equivalently. The root traits, such as total root area (TRA), total root length (TRL), total root diameter (TRD), total root volume (TRV), root tips (RT), root segments (RS), root fork (RF) and root biomass (RB) were found to be statistically significant (P + and K+ content analysis in root and shoot tissues revealed the ion homeostasis capacity of different Avena accessions under stress treatments. Principal component analysis (PCA) covered almost 83.0% of genetic variation and revealed that the sharing of TRA, RT, RS and RF traits was significantly high. Biplot analysis showed a highly significant correlation matrix (P <0.01) between the pairs of RT and RS, TRL and RS, and RT and RF. Based on PCA ranking and relative value for stress tolerance, IG-20-1183, IG-20-894, IG-20-718 and IG-20-425 expressed tolerance to salinity (T2), IG-20-425 (alkalinity; T4) and IG-20-1183, IG-20-894 and IG-20-1004 were tolerant to salt-alkali treatment (T6). Multi-trait stability index (MTSI) analysis identified three stable oat genotypes (IG-20-714, IG-20-894 and IG-20-425) under multiple environments and these lines can be used in salinity-alkalinity affected areas after yield trials or as donor lines for combined stresses in future breeding programs.

Central cholinergic transmission affects the compulsive-like behavior of mice in marble-burying test.

The presence of the cholinergic system in the brain areas implicated in the precipitation of obsessive-compulsive behavior (OCB) has been reported but the exact role of the central cholinergic system therein is still unexplored. Therefore, the current study assessed the effect of cholinergic analogs on central administration on the marble-burying behavior (MBB) of mice, a behavior correlated with OCB. The result reveals that the enhancement of central cholinergic transmission in mice achieved by intracerebroventricular (i.c.v.) injection of acetylcholine (0.01 µg) (Subeffective: 0.1 and 0.5 µg), cholinesterase inhibitor, neostigmine (0.1, 0.3, 0.5 µg/mouse) and neuronal nicotinic acetylcholine receptor agonist, nicotine (0.1, 2 µg/mouse) significantly attenuated the number of marbles buried by mice in MBB test without affecting basal locomotor activity. Similarly, central injection of mAChR antagonist, atropine (0.1, 0.5, 5 µg/mouse), nAChR antagonist, mecamylamine (0.1, 0.5, 3 µg/mouse) per se also reduced the MBB in mice, indicative of anti-OCB like effect of all the tested cholinergic mAChR or nAChR agonist and antagonist. Surprisingly, i.c.v. injection of acetylcholine (0.01 µg), and neostigmine (0.1 µg) failed to elicit an anti-OCB-like effect in mice pre-treated (i.c.v.) with atropine (0.1 µg), or mecamylamine (0.1 µg). Thus, the findings of the present investigationdelineate the role of central cholinergic transmission in the compulsive-like behavior of mice probably via mAChR or nAChR stimulation.

Miocene phytolith and diatom dataset from 10.3Myo diatomite formation, Fernley, Nevada, USA.

Phytoliths are opal silica particles formed within plant tissues. Diatoms are aquatic, single-celled photosynthetic algae with silica skeletons. Phytolith and diatom morphotypes vary depending on local environmental and climatic conditions and because their silicate structures preserve well, the study of phytolith and diatom morphotypes can be used to better understand paleoclimatic and paleoenvironmental dynamics and changes. This article presents original data from an 820cm-deep stratigraphy excavated at the Hazen diatomite deposits, a high-elevation desert paleolake in the Fernley District, Northern Nevada, USA. The site has been studied for an assemblage of fossilized threespine stickleback, Gasterosteus doryssus, that reveal adaptive evolution. For this study, a total of 157 samples were extracted at 20 cm intervals covering approximately 24,500 years. After extraction, the samples were mounted on slides and viewed under 400-1000x light microscopy, enabling classification of 14 phytolith and 45 diatom morphotypes. Our data support paleoenvironmental reconstructions of the Hazen Miocene paleolake.

Spontaneous Coronary Artery Disease (SCAD) in a Patient With Systemic Lupus Erythematosus (SLE).

Spontaneous coronary artery dissection (SCAD) is a rare phenomenon that emerges as an acute coronary syndrome (ACS) and sudden cardiac death, especially in young women. We report a case of a woman with systemic lupus erythematosus (SLE) who presented with syncope and was found to have SCAD.

Prenatal SARS-CoV-2 infection alters postpartum human milk-derived extracellular vesicles.

Human milk-derived extracellular vesicles (HMEVs) are crucial functional components in breast milk, contributing to infant health and development. Maternal conditions could affect HMEV cargos; however, the impact of SARS-CoV-2 infection on HMEVs remains unknown. This study evaluated the influence of SARS-CoV-2 infection during pregnancy on postpartum HMEV molecules. Milk samples (9 prenatal SARS-CoV-2 vs. 9 controls) were retrieved from the IMPRINT birth cohort. After defatting and casein micelle disaggregation, 1 mL milk was subjected to a sequential process of centrifugation, ultrafiltration, and qEV-size exclusion chromatography. Particle and protein characterizations were performed following the MISEV2018 guidelines. EV lysates were analyzed through proteomics and miRNA sequencing, while the intact EVs were biotinylated for surfaceomic analysis. Multi-Omics was employed to predict HMEV functions associated with prenatal SARS-CoV-2 infection. Demographic data between the prenatal SARS-CoV-2 and control groups were similar. The median duration from maternal SARS-CoV-2 test positivity to milk collection was 3 months (range: 1-6 months). Transmission electron microscopy showed the cup-shaped nanoparticles. Nanoparticle tracking analysis demonstrated particle diameters of <200 nm and yields of >1e11 particles from 1 mL milk. Western immunoblots detected ALIX, CD9 and HSP70, supporting the presence of HMEVs in the isolates. Thousands of HMEV cargos and hundreds of surface proteins were identified and compared. Multi-Omics predicted that mothers with prenatal SARS-CoV-2 infection produced HMEVs with enhanced functionalities involving metabolic reprogramming and mucosal tissue development, while mitigating inflammation and lower EV transmigration potential. Our findings suggest that SARS-CoV-2 infection during pregnancy boosts mucosal site-specific functions of HMEVs, potentially protecting infants against viral infections. Further prospective studies should be pursued to reevaluate the short- and long-term benefits of breastfeeding in the post-COVID era.

Exploring the experience of family caregivers of children with medical complexity during COVID-19: a qualitative study.

BACKGROUND AND OBJECTIVES: Children with medical complexity have been disproportionately impacted by the COVID-19 pandemic and the associated changes in healthcare delivery. The primary objective of this study was to gain a thorough understanding of the lived experiences of family caregivers of children with medical complexity during the pandemic. METHODS: We conducted semi-structured interviews with family caregivers of children with medical complexity from a tertiary pediatric hospital. Interview questions focused on the aspects of caregiving for children with medical complexity, impact on caregiver mental and physical well-being, changes to daily life secondary to the pandemic, and experiences receiving care in the healthcare system. Interviews were conducted until thematic saturation was achieved. Interviews were audio recorded, deidentified, transcribed verbatim, coded and analyzed using content analysis. RESULTS: Twelve semi-structured interviews were conducted. The interviews revealed three major themes and several associated subthemes: (1) experiences with the healthcare system amid the pandemic (lack of access to healthcare services and increased hospital restrictions, negative clinical interactions and communication breakdowns, virtual care use); (2) common challenges during the pandemic (financial strain, balancing multiple roles, inadequate homecare nursing); and (3) the pandemic's impact on family caregiver well-being (mental toll, physical toll). CONCLUSIONS: Family caregivers of children with medical complexity experienced mental and physical burden due to the intense nature of their caregiving responsibilities that were exacerbated during the pandemic. Our results highlight key priorities for the development of effective interventions to support family caregivers and their children.

Updates on LI-RADS Treatment Response Criteria for Hepatocellular Carcinoma: Focusing on MRI.

As the incidence of hepatocellular carcinoma (HCC) and subsequent treatments with liver-directed therapies rise, the complexity of assessing lesion response has also increased. The Liver Imaging Reporting and Data Systems (LI-RADS) treatment response algorithm (LI-RADS TRA) was created to standardize the assessment of response after locoregional therapy (LRT) on contrast-enhanced CT or MRI. Originally created based on expert opinion, these guidelines are currently undergoing revision based on emerging evidence. While many studies support the use of LR-TRA for evaluation of HCC response after thermal ablation and intra-arterial embolic therapy, data suggest a need for refinements to improve assessment after radiation therapy. In this manuscript, we review expected MR imaging findings after different forms of LRT, clarify how to apply the current LI-RADS TRA by type of LRT, explore emerging literature on LI-RADS TRA, and highlight future updates to the algorithm. EVIDENCE LEVEL: 3. TECHNICAL EFFICACY: Stage 2.

Low educational quality and trustworthiness of YouTube videos by physiotherapists on shoulder joint mobilization techniques: a descriptive study.

INTRODUCTION: Physiotherapists and students may be vulnerable to false information and may learn faulty treatment techniques due to inadequate educational quality and uncertainty about sources and trustworthiness of YouTube videos. OBJECTIVE: To investigate educational quality, trustworthiness, and content completeness of joint mobilization techniques demonstrating videos available on YouTube. DESIGN: This is a descriptive study. METHODS: We performed a YouTube search on 1st April 2019, using the keyword 'Maitland joint mobilization technique for shoulder joint'. Three academic physiotherapists independently rated each video for educational quality, trustworthiness, and content completeness using the Global Quality Score, Journal of American Medical Association (JAMA) Benchmark Criteria and joint mobilization content completeness scale, respectively. RESULTS: Fifteen videos were included in the study. The median number of views for videos was 1263 (IQR 578-1478), and the median duration was 140 seconds (IQR 71-301 seconds). Most videos had low content quality (87%), poor joint mobilization content completeness (80%), and limited trustworthiness. All videos had low source quality (100%). CONCLUSIONS: There is a lack of quality information on shoulder joint mobilization techniques on YouTube, which makes it a limited educational tool for physiotherapists and students.

Prognosis and Diagnostic Biomarkers of Mild Traumatic Brain Injury: Current Status and Future Prospects.

Mild traumatic brain injury (mTBI) is the most prevalent type of TBI (80-90%). It is characterized by a loss consciousness for less than 30 minutes, post-traumatic amnesia for less than 24 hours, and Glasgow Coma Score of 13-15. Accurately diagnosing mTBIs can be a challenge because the majority of these injuries do not show noticeable or visible changes on neuroimaging studies. Appropriate determination of mTBI is tremendously important because it might lead in some cases to post-concussion syndrome, cognitive impairments including attention, memory, and speed of information processing problems. The scientists have studied different methods to improve mTBI diagnosis and enhanced approaches that would accurately determine the severity of the trauma. The present review focuses on discussing the role of biomarkers as potential key factors in diagnosing mTBI. The present review focuses on 1) protein based peripheral and CNS markers, 2) genetic biomarkers, 3) imaging biomarkers, 4) neurophysiological biomarkers, and 5) clinical trials in mTBI. Each section provides information and characteristics on different biomarkers for mTBI.

Association of hospital factors and socioeconomic status with the utilization of minimally invasive surgery for colorectal cancer over a decade.

BACKGROUND: Surgical resection is a mainstay of treatment for colorectal cancer (CRC). Minimally invasive surgery (MIS) has been shown to have improved outcomes compared to open procedures for colorectal malignancy. While use of MIS has been increasing, there remains large variability in its implementation at the hospital and patient level. OBJECTIVE: The purpose of this study was to identify disparities in sex, race, location, patient income status, insurance status, hospital region, bed size and teaching status for the use of MIS in the treatment of CRC. METHODS: This was a retrospective cohort study using the Nationwide Inpatient Sample Database. Between 2008 and 2017, there were 412,292 hospitalizations of adult patients undergoing elective colectomy for CRC. The primary outcome was use of MIS during hospitalization. RESULTS: Overall, the frequency of open colectomies was higher than MIS (56.56% vs. 43.44%). Black patients were associated with decreased odds of MIS use during hospitalization compared to White patients (OR 0.921, p = 0.0011). As the county population where patients resided decreased, odds of MIS also significantly decreased as compared to central counties of metropolitan areas. As income decreased below the reference of $71,000, odds of MIS also significantly decreased. Medicaid and uninsured patients had decreased odds of MIS use during hospitalization compared to private insurance (OR 0.751, p < 0.0001 and OR 0.629, p < 0.0001 respectively). Rural and urban non-teaching hospitals were associated with decreased odds of MIS as compared to urban teaching hospitals (OR 0.523, p < 0.0001 and OR 0.837, p < 0.0001 respectively). Hospitals with a small bed size were also associated with decreased MIS during hospitalizations (OR 0.888, p < 0.0001). CONCLUSIONS: Marked hospital level and socioeconomic disparities exist for utilization of MIS for colorectal cancer. Strategies targeted at reducing these gaps have the potential to improve surgical outcomes and cancer survival.

Stimulation of dorsal hippocampal histaminergic transmission mitigates the expression of ethanol withdrawal-induced despair in mice.

Garnered literature points toward the role of the dorsal hippocampus (CA1) in ethanol withdrawal-induced responses, wherein a strong presence of the histaminergic system is also reported. Therefore, the present study investigated the effect of an enhanced CA1 histaminergic transmission on the expression of chronic ethanol withdrawal-induced despair in mice on the tail suspension test (TST). The results revealed that mice who were on an ethanol-fed diet (5.96%, v/v) for 8 days exhibited maximum immobility time on the TST, and decreased locomotion at 24 h post-ethanol withdrawal (10th day), indicating ethanol withdrawal-induced despair. Enhancement of CA1 histaminergic activity achieved by the treatment of intra-CA1 microinjection of histaminergic agents such as histamine (0.1, 10 µg/mouse, bilateral), the histamine precursor l-histidine (1, 10 µg/mouse, bilateral), the histamine neuronal releaser/H3 receptor antagonist thioperamide (2, 10 µg/mouse, bilateral), the histamine H1 receptor agonist FMPH (2, 6.5 µg/mouse, bilateral), or the H2 receptor agonist amthamine (0.1, 0.5 µg/mouse, bilateral) to ethanol-withdrawn mice, 10 min before the 24-h post-ethanol withdrawal time point, significantly alleviated the expression of ethanol withdrawal-induced despair in mice on the TST. On the other hand, only the pre-treatment of the histamine H1 receptor agonist FMPH (2, 6.5 µg/mouse, intra-CA1 bilateral) reversed the reduction in locomotor activity induced in ethanol-withdrawn mice, whereas other employed histaminergic agents were devoid of any effect on this behavior. Therefore, our findings indicate that an enhanced CA1 histaminergic transmission, probably via stimulation of CA1 postsynaptic histamine H1 or H2 receptor, could preclude the behavioral despair, while H1 stimulation affects motor deficit expressed after ethanol withdrawal.

Central histaminergic transmission modulates the expression of chronic nicotine withdrawal induced anxiety-like and somatic behavior in mice.

The present study investigated the plausible modulatory role of central histaminergic transmission on the expression of nicotine withdrawal induced anxiety and somatic behavior in mice. Abrupt cessation of chronic nicotine (2 mg/kg, i.p. × 3/day) treatment for 12 days to mice, expressed increased anxiety in light & dark test and total abstinence (somatic) score at 24 h post nicotine withdrawal time. The somatic signs includes a composite score of all behaviors such as grooming, rearing, jumping, body shakes, forelimb tremors, head shakes, abdominal constrictions, scratching, empty mouth chewing or teeth chattering, genital licking, tail licking. Mice exhibited higher expression to nicotine withdrawal induced anxiety in light & dark test at 24 h post-nicotine withdrawal time on pre-treatment centrally (i.c.v) with histaminergic agents like histamine (0.1, 50 µg/mouse), histamine H3 receptor inverse agonist, thioperamide (2, 10 µg/mouse), histamine H1 receptor agonist, FMPH (2, 6.5 µg/mouse) or H2 receptor agonist amthamine (0.1, 0.5 µg/mouse) or intraperitoneally (i.p.) with histamine precursor, l-histidine (250, 500 mg/kg) as compared to control nicotine withdrawn animals. Furthermore, mice pre-treated with all these histaminergic agents except histamine H1 receptor agonist, FMPH shows exacerbated expression to post-nicotine withdrawal induced total abstinence (somatic) score in mice. On the other hand, central injection of selective histamine H1 receptor antagonist, cetirizine (0.1 µg/mouse, i.c.v.) or H2 receptor antagonist, ranitidine (50 µg/mouse, i.c.v) to mice 10 min before 24 h post-nicotine withdrawal time completely alleviated the expression of nicotine withdrawal induced anxiety and somatic behavior. Thus, it can be contemplated that the blockade of central histamine H1 or H2 receptor during the nicotine withdrawal phase could be a novel approach to mitigate the nicotine withdrawal associated anxiety-like manifestations. Contribution of endogenous histamine via H1 or H2 receptor stimulation in the nicotine withdrawal induced anxiety and somatic behavior is proposed.

Creating Disability-Competent Medical Students Via Community Outreach.

INTRODUCTION: Medical students often have limited exposure to providing care to physically and cognitively disabled patients. To address this gap, Involvement with Disability Education and Advancement (IDEA) was started in 2015 at Rutgers New Jersey Medical School (NJMS). The organization provides NJMS students the opportunity to visit a school dedicated to disabled students and lead educational sessions on health topics. MATERIALS AND METHODS: We conducted a survey study in 2018 to compare comfort levels between IDEA members and non-members in eliciting information from and providing medical attention to nonverbal, cognitively impaired, and physically disabled patients. The survey-based study utilized yes/no questions, and a Likert scale questionnaire to determine IDEA member and non-member comfort levels in working with various disabilities. Statistical analysis was performed using SAS Enterprise Guide 7.1; p value < 0.05 was considered statistically significant. RESULTS AND DISCUSSION: A total of 56 responses (19 members, 37 non-members) were analyzed. Regardless of IDEA membership, medical students of all years perceived themselves to have more comfort caring for physically disabled than cognitively impaired or nonverbal patients. IDEA members also recorded higher comfort levels with eliciting information from cognitively impaired patients and lower comfort levels with providing medical attention to physically disabled patients. IMPLICATIONS: IDEA members may have increased comfort interacting with cognitively impaired individuals due to their regular experience and lower levels of comfort providing medical attention to physically disabled patients due to awareness of complex problems specific to the population. The current results warrant continued data collection and further evaluation.

Factors Associated with Disparities in Appropriate Statin Therapy in an Outpatient Inner City Population.

Lipid-lowering therapies are essential for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The aim of this study is to identify discrepancies between cholesterol management guidelines and current practice with a focus on statin treatment in an underserved population based in a large single urban medical center. Among 1042 reviewed records, we identified 464 statin-eligible patients. Age was 61.0 ± 10.4 years and 53.9% were female. Most patients were black (47.2%), followed by Hispanic (45.7%) and white (5.0%). In total, 82.1% of patients were prescribed a statin. An appropriate statin was not prescribed in 32.4% of statin-eligible patients who qualified based only on a 10-year ASCVD risk of ≥7.5%. After adjustment for gender and health insurance status, appropriate statin treatment was independently associated with age >55 years (OR = 4.59 (95% CI 1.09-16.66), p = 0.026), hypertension (OR = 2.38 (95% CI 1.29-4.38), p = 0.005) and chronic kidney disease (OR = 3.95 (95% CI 1.42-14.30), p = 0.017). Factors independently associated with statin undertreatment were black race (OR = 0.42 (95% CI 0.23-0.77), p = 0.005) and statin-eligibility based solely on an elevated 10-year ASCVD risk (OR = 0.14 (95% CI 0.07-0.25), p < 0.001). Hispanic patients were more likely to be on appropriate statin therapy when compared to black patients (86.8% vs. 77.2%). Statin underprescription is seen in approximately one out of five eligible patients and is independently associated with black race, younger age, fewer comorbidities and eligibility via 10-year ASCVD risk only. Hispanic patients are more likely to be on appropriate statin therapy compared to black patients.

Laparoscopy improves failure to rescue compared to open surgery for emergent colectomy.

Emergent colectomy is performed in thousands of Americans each year and carries significant morbidity and mortality. Although laparoscopy has gained favor in the elective setting, its impact on failure to rescue has not been studied on a population level for emergent colectomy. The purpose of this study was to compare failure to rescue following laparoscopic versus open colectomy in the emergency setting. This was a retrospective cohort study of The American College of Surgeons National Surgical Quality Improvement Program. Adult patients undergoing emergent colectomy between 2005 and 2018 were selected and stratified into laparoscopic or open surgery groups using the Current Procedural Terminology codes. Propensity matching was performed based on the demographic and comorbidity data. Main outcomes were failure to rescue, mortality, overall morbidity, individual complications, and length of hospital stay. After matching, 11,484 cases were included for analysis, of which 3829 were laparoscopic. Overall, open colectomy conferred higher odds of failure to rescue (OR 1.71, 95% CI 1.42-2.08), mortality (OR 1.72, 95% CI 1.44-2.07), and morbidity (OR 1.73, 95% CI 1.60-1.88) vs laparoscopic cases. Open surgery significantly increased the risk of nearly all measured postoperative complications including return to operating room (OR 1.25, 95% CI 1.08-1.45), ventilator use > 48 h (OR 2.43, 95% CI 2.03-2.93), and septic shock (OR 2.34, 95% CI 1.97-2.80). Hospital length of stay was shorter for patients undergoing laparoscopic (10.4 days) vs open (12.3 days) colectomy (p < 0.0001). This study demonstrates the safety and efficacy of the laparoscopic approach for emergent colectomy vs open surgery. Laparoscopy was associated with improved complications rates, mortality, and failure to rescue, indicating that it is a promising option to improve patient outcomes during emergent colectomy.

Laparoscopic colectomy for diverticulitis in patients with pre-operative respiratory comorbidity: analysis of post-operative outcomes in the United States from 2005 to 2017.

BACKGROUND: Current studies suggest that laparoscopic colorectal surgery is an advantageous alternative to open surgery due to improved post-operative outcomes in high-risk patient groups. Limited data is currently available on the benefits of minimally invasive colectomy for diverticulitis in patients with significant pre-operative respiratory comorbidities. STUDY DESIGN: The NSQIP 2005-2017 datasets were used to identify patients that underwent partial colectomies due to diverticulitis. Partial colectomy cases were identified using CPT codes and then filtered to include only ICD 9 and 10 codes for diverticulitis. Pre-operative respiratory comorbidities included dyspnea, chronic obstructive pulmonary disease (COPD), and smoking status. Propensity matching was performed based on patient demographic and pre-operative risk factor data to create comparable groups for each respiratory comorbidity subset. Outcomes of interest were 30-day post-operative mortality and morbidity, incidence of return to operating room (ROR), and hospital length of stay (LoS). Laparoscopy and open surgery groups were compared using Chi square tests for categorical variables and t tests for continuous variables. A p value less than 0.05 was considered statistically significant. RESULTS: Among 70,420 cases with diverticulitis, 15,237 cases were identified as smokers, 3934 had dyspnea, and 3219 had COPD. Patients that had open procedures had significantly greater odds of mortality (OR 2.624 for smokers; OR 2.698 for dyspnea; OR 2.663 for COPD), morbidity (OR 2.590 for smokers; OR 2.344 for dyspnea; OR 2.883 for COPD), wound complication (OR 1.989 for smokers; OR 1.461 for dyspnea; OR 1.956 for COPD), and ROR (OR 1.184 for smokers; OR 1.634 for dyspnea; OR 1.975 for COPD). Laparoscopic procedures resulted in significantly lower average LoS (5.34 vs. 9.46 days for smokers; 6.84 vs. 11.06 days for dyspnea; 7.41 vs. 12.62 days for COPD; all p < .0001). CONCLUSION: Laparoscopic colectomy for diverticulitis diagnosis for a matched cohort of patients with pre-operative respiratory comorbidities such as smoking status, dyspnea, and COPD resulted in significantly improved post-operative outcomes, lower odds of mortality and morbidity, and shorter LoS.

Evaluation of provider documentation patterns as a tool to deliver ongoing patient-centred diabetes education and support.

BACKGROUND: Diabetes mellitus (DM) is one of the most common chronic diseases in the world. As a disease with long-term complications requiring changes in management, DM requires not only education at the time of diagnosis, but ongoing diabetes self-management education and support (DSME/S). In the United States, however, only a small proportion of people with DM receive DSME/S, although evidence supports benefits of ongoing DSME/S. The diabetes education that providers deliver during follow-up visits may be an important source for DSME/S for many people with DM. METHODS: We collected 200 clinic notes of follow-up visits for 100 adults with DM and studied the History of Present Illness (HPI) and Impression and Plan (I&P) sections. Using a codebook based on the seven principles of American Association of Diabetes Educators Self-Care Behaviors (AADE7), we conducted a multi-step deductive thematic analysis to determine the patterns of DSME/S information occurrence in clinic notes. Additionally, we used the generalised linear mixed models for investigating whether providers delivered DSME/S to people with DM based on patient characteristics. RESULTS: During follow-up visits, Monitoring was the most common self-care behaviour mentioned in both HPI and I&P sections. Being Active was the least common self-care behaviour mentioned in the HPI section and Healthy Coping was the least common self-care behaviour mentioned in the I&P section. We found providers delivered more information on Healthy Eating to men compared to women in I&P section. Generally, providers delivered DSME/S to people with DM regardless of patient characteristics. CONCLUSIONS: This study focused on the frequency distribution of information providers delivered to the people with DM during follow-up clinic visits based on the AADE7. The results may indicate a lack of patient-centred education when people with DM visit providers for ongoing management. Further studies are needed to identify the underlying reasons why providers have difficulty delivering patient-centred education.

Diabetes and Cardiovascular Disease: an Update.

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of mortality in people with diabetes. Our aim was to review the pathophysiology of CVD in diabetes, review related landmark trials, and discuss the cardiovascular benefit of glucose-lowering agents. We have also discussed the role of controversial anti-platelet therapy. RECENT FINDINGS: Recent studies have shown the impact of glucose-lowering agents on CVD in people with diabetes. Statins are now recommended for all patients with diabetes over the age of 40 regardless of the LDL level given the cardiovascular benefit of these drugs. Current recommendations suggest a blood pressure < 130/80 for individuals with high cardiovascular risk. Cardiovascular risk reduction should be an important part of the management of diabetes. Focusing solely on glycemic control may not be the best therapeutic strategy. Multifactorial risk reduction should be taken into account. Lipid-lowering agents and anti-hypertensives should be a corner stone of treatment of diabetes. With currently available data, glucose-lowering agents with cardiovascular benefit should be started early in the disease process.

A Qualitative Analysis of Malpractice Litigation in Cardiology Using Case Summaries Through a National Legal Database Analysis.

Introduction Physicians are increasingly practicing defensive medicine as a response to society's litigious climate. This study sought to characterize cardiology malpractice claims and elucidate the allegations underlying the use of defensive medicine. Methods The WestlawNext™ database was queried to obtain state and federal jury verdicts and settlements related to medical malpractice and cardiology that occurred in the United States between 2010 and 2015. Cardiology cases were identified using the search terms "medical malpractice" and "cardiology" and reviewed by two individuals utilizing available case documents. Duplicate and nonpertinent cases were excluded. Binary logistic regression models were created to predict the likelihood of defendant verdict, plaintiff verdict, and settlement based on the various reasons for litigation cited. Results Inclusion criteria were met in 166 cases. The plaintiffs were predominantly male (94 cases; 56.6%), and the average patient age was 53.3±17.5 years. More than half of the cases involved a cardiologist as a defendant. The most common reasons for litigation were: failure to treat (129; 77.7%), failure to diagnose (115; 69.3%), failure to refer/order diagnostic tests (107; 64.5%), and patient death (118; 71.1%). Among cases tried for failure to diagnose, the most commonly missed diagnosis was myocardial infarction. Cases most commonly resulted in a defendant verdict (94; 56.6%). However, odds of a plaintiff verdict were significantly higher when failure to diagnose was alleged with an odds ratio (OR) of 7.60 (95% confidence interval 1.14 - 50.87, p = 0.0365). Conclusions Failure to diagnose remains a commonly alleged base for litigation. In conclusion, our analysis suggests increased training for non-cardiologists in the recognition of the acute coronary syndrome and enhanced awareness of inherent biases among all physicians may facilitate reducing missed diagnoses.