Overstay and Readmission in Ear, Nose, and Throat Day Surgery-Factors Affecting Postanesthesia Course.

AIMS: Many procedures in ear, nose, and throat (ENT) day surgery are carried out under local anesthesia in Finland, whereas many other countries use general anesthesia. We investigated overstay and readmission rates in local and general anesthesia at Helsinki University Hospital. MATERIAL AND METHODS: We conducted a retrospective study on ENT (n = 1011) day surgery patients within a 3-month period using the hospital's surgery database to collect data pertaining to anesthesia, overstays, readmissions, and contacts within 30 days of surgery. OBJECTIVES: We examined the effect of American Society of Anesthesiologists (ASA) class, age, sex, type of procedure, and anesthesia type on overstay, contact, and readmission rates. RESULTS: A multivariable logistic regression model included ASA class, age, sex, type of procedure, and anesthesia (local vs general). Sex, age, and type of procedure had an effect on the outcomes of overstay, readmission, or contact. With general anesthesia, 3.2% (n = 23) had an overstay or readmission compared to 1.4% (n = 4) after local anesthesia. This was mainly explained by the number of study outcomes in tonsillar surgery that was performed only in general anesthesia. CONCLUSIONS: Day surgery could be done safely using local anesthesia, as the number of study outcomes was no greater than in general anesthesia. Sex, type of procedure, and age affected the rate of study outcomes, but ASA class and anesthesia form did not. Our overstay, contact, and readmission rates are on the same level, or lower, than in international studies.

Root causes of extended length of stay and unplanned readmissions after orthopedic surgery and hand surgery: a retrospective observational cohort study.

BACKGROUND: While previous studies have evaluated the effect of some patient characteristics (e.g. gender, American Society of Anesthesiologists (ASA) class and comorbidity) on outcome in orthopedic and hand day surgery, more detailed information on anesthesia related factors has previously been lacking. Our goal was to investigate the perioperative factors that affect overstay, readmission and contact after day surgery in order to find certain patient profiles more prone to problemed outcomes after day surgery. METHODS: We examined orthopedic and hand day surgery at an orthopedic day surgery unit of Helsinki University Hospital. Patient data of all adult orthopedic and hand day surgery patients (n = 542) over a 3-month period (January 1 - March 31, 2015) operated on at the unit were collected retrospectively using the hospital's surgery database. These data comprised anesthesia and patient records with a follow-up period of 30 days post-operation. Patients under the age of 16 and patients not eligible for day surgery were excluded. Patient records were searched for an outcome of overstay, readmission or contact with the emergency room or policlinic. Pearson chi-square test, Fischer's exact test and multivariable logistic regression were used to analyze the effect of various perioperative factors on postoperative outcome. RESULTS: Various patient and anesthesia related factors were examined for their significance in the outcomes of overstay, readmission or contact. Female gender (p = 0.043), total amount of fentanyl (p = 0.00), use of remifentanil (p = 0.036), other pain medication during procedure (p = 0.005) and administration of antiemetic medication (p = 0.048) emerged as statistically significant on outcome after day surgery. CONCLUSIONS: Overstay and readmission in orthopedic and hand day surgery were clearly connected with female patients undergoing general anesthesia and needing larger amounts of intraoperative opioids. By favoring local and regional anesthesia, side effects of general anesthesia, as well as recovery time, will decrease.

Traumatic brain injury patients' family members' evaluations of the social support provided by healthcare professionals in acute care hospitals.

AIMS AND OBJECTIVES: The study aimed to examine traumatic brain injury (TBI) patient family members' (FMs) experiences of the support they received from healthcare professionals in acute care hospitals. BACKGROUND: The length of hospitalisation following TBI is constantly decreasing, and patients may return home with several problems. FMs care for the patients at home although they may not be prepared for the patient's medical needs or financial burden of the illness. The burden which some FMs experience can impair patient care and rehabilitation outcomes. Therefore, FMs require support during acute phases of TBI treatment. DESIGN: A structured questionnaire was sent to 216 TBI patients FMs. The response rate was 47% (n = 102). METHODS: A structured questionnaire-based on a systematic literature review and a previous questionnaire on TBI patient FMs' perceptions of support-was developed and used in the data collection. The questionnaire included 46 statements and 11 background questions. Data were collected via an electronic questionnaire. The STROBE checklist was followed in reporting the study. RESULTS: A factor analysis identified five factors that describe the guidance of TBI patient FMs: guidance of TBI patients' symptoms and survival; benefits of guidance; needs-based guidance; guidance for use of services; and guidance methods. Most of the FMs (51%-88%) felt that they had not received enough guidance from healthcare professionals in acute care hospitals across all five aspects of support. CONCLUSIONS: The content of guidance should be developed, and healthcare staff should be trained to consider a FM's starting point when providing guidance. A calm environment, proper timing, sufficient information in different forms and professional healthcare staff were found to be key factors to comprehensive guidance. Involving FMs in the discharge process and rehabilitation of their loved ones both supports the abilities of caregivers and promotes the outcome of the patient's rehabilitation. RELEVANCE TO CLINICAL PRACTICE: This study provides varied information on the need for social support of TBI patients FMs in the early stages of treatment from the FMs' perspective. This research adopted the FM's perspective to identify various areas of social support that need to be developed so that the FMs of TBI patients receive enough support during the early stages of TBI treatment.

Seasonal comparison of moss bag technique against vertical snow samples for monitoring atmospheric pollution.

This is the first study seasonally applying Sphagnum papillosum moss bags and vertical snow samples for monitoring atmospheric pollution. Moss bags, exposed in January, were collected together with snow samples by early March 2012 near the Harjavalta Industrial Park in southwest Finland. Magnetic, chemical, scanning electron microscopy-energy dispersive X-ray spectroscopy (SEM-EDX), K-means clustering, and Tomlinson pollution load index (PLI) data showed parallel spatial trends of pollution dispersal for both materials. Results strengthen previous findings that concentrate and slag handling activities were important (dust) emission sources while the impact from Cu-Ni smelter's pipe remained secondary at closer distances. Statistically significant correlations existed between the variables of snow and moss bags. As a summary, both methods work well for sampling and are efficient pollutant accumulators. Moss bags can be used also in winter conditions and they provide more homogeneous and better controlled sampling method than snow samples.

A new framework for selecting environmental surrogates.

Surrogate concepts are used in all sub-disciplines of environmental science. However, controversy remains regarding the extent to which surrogates are useful for resolving environmental problems. Here, we argue that conflicts about the utility of surrogates (and the related concepts of indicators and proxies) often reflect context-specific differences in trade-offs between measurement accuracy and practical constraints. By examining different approaches for selecting and applying surrogates, we identify five trade-offs that correspond to key points of contention in the application of surrogates. We then present an 8-step Adaptive Surrogacy Framework that incorporates cross-disciplinary perspectives from a wide spectrum of the environmental sciences, aiming to unify surrogate concepts across disciplines and applications. Our synthesis of the science of surrogates is intended as a first step towards fully leveraging knowledge accumulated across disciplines, thus consolidating lessons learned so that they may be accessible to all those operating in different fields, yet facing similar hurdles.

The binding specificity of the marker antibodies Tra-1-60 and Tra-1-81 reveals a novel pluripotency-associated type 1 lactosamine epitope.

The expression of the epitopes recognized by the monoclonal antibodies Tra-1-60 and Tra-1-81 is routinely used to assess the pluripotency status of human embryonic stem cells (hESCs) and induced pluripotent stem (iPS) cells. Although it is known that the epitopes recognized by Tra-1-60 and Tra-1-81 are carbohydrates, the exact molecular identity of these epitopes has been unclear. Glycan array analysis with more than 500 oligosaccharide structures revealed specific binding of Tra-1-60 and Tra-1-81 to two molecules containing terminal type 1 lactosamine: Galß1-3GlcNAcß1-3Galß1-4GlcNAc and Galß1-3GlcNAcß1-3Galß1-4GlcNAcß1-6(Galß1-3GlcNAcß1-3)Galß1-4Glc. The type 1 disaccharide in itself was not sufficient for binding, indicating that the complete epitope requires an extended tetrasaccharide structure where the type 1 disaccharide is ß1,3-linked to type 2 lactosamine. Our mass spectrometric analysis complemented with glycosidase digestions of hESC O-glycans indicated the presence of the extended tetrasaccharide epitope on an O-glycan with the likely structure Galß1-3GlcNAcß1-3Galß1-4GlcNAcß1-6(Galß1-3)GalNAc. Thus, the present data indicate that the pluripotency marker antibodies Tra-1-60 and Tra-1-81 recognize the minimal epitope Galß1-3GlcNAcß1-3Galß1-4GlcNAc, which is present in hESCs as a part of a mucin-type O-glycan structure. The exact molecular identity of Tra-1-60 and Tra-1-81 is important for the development of improved tools to characterize the pluripotent phenotype.

Glycomics of bone marrow-derived mesenchymal stem cells can be used to evaluate their cellular differentiation stage.

Human mesenchymal stem cells (MSCs) are adult multipotent progenitor cells. They hold an enormous therapeutic potential, but at the moment there is little information on the properties of MSCs, including their surface structures. In the present study, we analyzed the mesenchymal stem cell glycome by using mass spectrometric profiling as well as a panel of glycan binding proteins. Structural verifications were obtained by nuclear magnetic resonance spectroscopy, mass spectrometric fragmentation, and glycosidase digestions. The MSC glycome was compared to the glycome of corresponding osteogenically differentiated cells. More than one hundred glycan signals were detected in mesenchymal stem cells and osteoblasts differentiated from them. The glycan profiles of MSCs and osteoblasts were consistently different in biological replicates, indicating that stem cells and osteoblasts have characteristic glycosylation features. Glycosylation features associated with MSCs rather than differentiated cells included high-mannose type N-glycans, linear poly-N-acetyllactosamine chains and alpha2-3-sialylation. Mesenchymal stem cells expressed SSEA-4 and sialyl Lewis x epitopes. Characteristic glycosylation features that appeared in differentiated osteoblasts included abundant sulfate ester modifications. The results show that glycosylation analysis can be used to evaluate MSC differentiation state.

N-glycolylneuraminic acid xenoantigen contamination of human embryonic and mesenchymal stem cells is substantially reversible.

Human embryonic and mesenchymal stem cell therapies may offer significant benefit to a large number of patients. Recently, however, human embryonic stem cell lines cultured on mouse feeder cells were reported to be contaminated by the xeno-carbohydrate N-glycolylneuraminic acid (Neu5Gc) and considered potentially unfit for human therapy. To determine the extent of the problem of Neu5Gc contamination for the development of stem cell therapies, we investigated whether it also occurs in cells cultured on human feeder cells and in mesenchymal stem cells, what are the sources of contamination, and whether the contamination is reversible. We found that N-glycolylneuraminic acid was present in embryonic stem cells cultured on human feeder cells, correlating with the presence of Neu5Gc in components of the commercial serum replacement culture medium. Similar contamination occurred in mesenchymal stem cells cultured in the presence of fetal bovine serum. The results suggest that the Neu5Gc is present in both glycoprotein and lipid-linked glycans, as detected by mass spectrometric analysis and monoclonal antibody staining, respectively. Significantly, the contamination was largely reversible in the progeny of both cell types, suggesting that decontaminated cells may be derived from existing stem cell lines. Although major complications have not been reported in the clinical trials with mesenchymal stem cells exposed to fetal bovine serum, the immunogenic contamination may potentially be reflected in the viability and efficacy of the transplanted cells and thus bias the published results. Definition of safe culture conditions for stem cells is essential for future development of cellular therapies.

The impact of donor cytokine gene polymorphisms on the incidence of cytomegalovirus infection after kidney transplantation.

Cytomegalovirus (CMV) seronegative recipients of kidneys from CMV seropositive donors are at a high risk of CMV infection after transplantation since viruses in the allograft may reactivate in patients without prior immunity. We hypothesized that the genetic background of the graft has an influence on the incidence of infection. Effects of IL10, IL6 and IFNG gene polymorphisms, known to affect CMV infectivity, were investigated in 71 CMV seronegative recipients of grafts from CMV seropositive cadaver donors. Donor IL10(-1082 AA) genotype reduced the incidence of CMV infection (p=0.031) and CMV episodes in these patients tended to occur later (AA: median 83 days, AG/GG: median 45 days, p=0.072). In multivariate analysis, other explaining factors than the donor IL10(-1082 AA) genotype alone did not improve Cox hazard model (HR=0.3, 95% CI=0.09-0.96, p=0.043). Recipient polymorphisms did not reduce the incidence of CMV infection. We conclude that donor IL10 gene polymorphisms may influence the likelihood of CMV infection in the high risk patients investigated.

Population-based audit of fresh-frozen plasma transfusion practices.

BACKGROUND: In contrast to decreasing red blood cell (RBC) consumption in Finland, the use of fresh-frozen plasma (FFP) has been increasing since the 1990s, suggesting that FFP use may not always be optimal. To improve transfusion practices, knowledge of current FFP use and regional, national, and international comparison is necessary. STUDY DESIGN AND METHODS: Nine (of 21) Finnish hospital districts participated. Data concerning FFP-transfused patients in the years 2002 and 2003 were collected from existing computerized medical records into a yearly updated database as part of a Finnish benchmarking project on blood component use. RESULTS: Data included 11,590 FFP-transfused patients and 60,240 FFP units (71.2% of Finnish FFP use) delivered to Finnish hospitals during the study period. FFP was transfused most often to surgery patients (62.8% of FFP transfusion hospital visits) with blood circulatory system problems (32.3% of surgically treated and FFP-transfused patients). In only 65.9 percent of FFP-transfused patients were coagulation variables measured at any point in the hospital episode, and FFP was usually transfused in paired doses. Mean FFP use in Finland is comparable to other countries. CONCLUSION: Although overall FFP use in Finland is similar to that of international figures, it does not ensure best practice. Perioperative staff, being the largest FFP user, should be encouraged to dose FFP based on coagulation variables and body weight. Improvement efforts should be directed to patient groups transfused with large amounts of FFP.

Effect of repeated apotransferrin administrations on serum iron parameters in patients undergoing myeloablative conditioning and allogeneic stem cell transplantation.

Myeloablative conditioning prior to allogeneic stem cell transplantation causes a rapid increase in transferrin saturation and potentially toxic non-transferrin-bound iron (NTBI) in plasma. We have studied the ability of repeatedly administered apotransferrin to maintain this iron in a transferrin-bound form. Twenty adult patients undergoing myeloablative conditioning and allogeneic stem cell transplantation were enrolled to receive apotransferrin with one of three dosage regimens. Ten consecutive patients with the same preconditioning were studied as controls. At the highest dose level, full transferrin saturation and appearance of NTBI were prevented in five of the eight patients. Serum iron increased significantly more in the patients receiving apotransferrin than in the controls and remained elevated until erythropoietic recovery. From the increment of iron saturation and the amount of endogenous and administered apotransferrin, an average 180 mumol of iron per day was bound to transferrin during the first 4 d after the start of the conditioning therapy. Thereafter, iron accumulation levelled off in most patients. The results suggested that about half of the amount of iron normally transported to erythropoiesis was initially released to plasma after induction of the erythroid arrest. Complete iron binding with apotransferrin would apparently require very high apotransferrin doses.

Co-expression of two mammalian glycosyltransferases in the yeast cell wall allows synthesis of sLex.

Interactions between selectins and their oligosaccharide-decorated counter-receptors play an important role in the initiation of leukocyte extravasation in inflammation. L-selectin ligands are O-glycosylated with sulphated sialyl Lewis X epitopes (sulpho-sLex). Synthetic sLex oligosaccharides have been shown to inhibit adhesion of lymphocytes to endothelium at sites of inflammation. Thus, they could be used to prevent undesirable inflammatory reactions such as rejection of organ transplants. In vitro synthesis of sLex glycans is dependent on the availability of recombinant glycosyltransferases. Here we expressed the catalytic domain of human alpha-1,3-fucosyltransferase VII in the yeasts Saccharomyces cerevisiae and Pichia pastoris. To promote proper folding and secretion competence of this catalytic domain in yeast, it was fused to the Hsp150 delta carrier, which is an N-terminal fragment of a secretory glycoprotein of S. cerevisiae. In both yeasts, the catalytic domain acquired an active conformation and the fusion protein was externalised, but remained mostly attached to the cell wall in a non-covalent fashion. Incubation of intact S. cerevisiae or P. pastoris cells with GDP-[14C]fucose and sialyl-alpha-2,3-N-acetyllactosamine resulted in synthesis of radioactive sLex, which diffused to the medium. Finally, we constructed an S. cerevisiae strain co-expressing the catalytic domains of alpha-2,3-sialyltransferase and alpha-1,3-fucosyltransferase VII, which were targeted to the cell wall. When these cells were provided with N-acetyllactosamine, CMP-sialic acid and GDP-[14C]fucose, radioactive sLex was produced to the medium. These data imply that yeast cells can provide a self-perpetuating source of fucosyltransferase activity immobilized in the cell wall, useful for the in vitro synthesis of sLex.

Validation of the Hsp150 polypeptide carrier and HSP150 promoter in expression of rat alpha2,3-sialyltransferase in yeasts.

Heterologous glycoproteins usually do not fold properly in yeast cells and fail to leave the endoplasmic reticulum. Here we show that the Hsp150Delta polypeptide carrier promoted proper folding and secretion of the catalytic ectodomain of rat alpha2,3-sialyltransferase (ST3Ne) in Pichia pastoris. The efficiency of the Hsp150Delta carrier in P. pastoris and Saccharomyces cerevisiae was at least as high as that of the MFalpha carrier. Most of Hsp150Delta-ST3Ne and MFalpha-ST3Ne remained noncovalently attached to the cell wall via the ST3Ne portion. The strength of the HSP150 promoter was found to be comparable to that of the GAL1 promoter.

Several polylactosamine-modifying glycosyltransferases also use internal GalNAcbeta1-4GlcNAc units of synthetic saccharides as acceptors.

The GalNAcbeta1-4GlcNAc determinant (LdN) occurs in some human and bovine glycoconjugates and also in lower vertebrates and invertebrates. It has been found in unsubstituted as well as terminally substituted forms at the distal end of conjugated glycans, but it has not been reported previously at truly internal positions of polylactosamine chains. Here, we describe enzyme-assisted conversion of LdNbeta1-OR oligosaccharides into GlcNAcbeta1-3GalNAcbeta1-4GlcNAcbeta1-OR. The extension reactions, catalyzed by human serum, were modeled after analogous beta3-GlcNAc transfer processes that generate GlcNAcbeta1-3Galbeta1-4GlcNAcbeta1-OR. The newly synthesized GlcNAcbeta1-3GalNAc linkages were unambiguously identified by nuclear magnetic resonance data, including the appropriate long-range correlations in heteronuclear multiple bond correlation spectra. The novel GlcNAcbeta1-3'LdN determinant proved to be a functional acceptor for several mammalian glycosyltransferases, suggesting that human polylactosamines may contain internal LdN units in many distinct forms. The GlcNAcbeta1-3'LdN determinant was unusually resistant toward jackbean beta-N-acetylhexosaminidase; the slow degradation should lead to a convenient method for the search of putative internal LdN determinants in natural polylactosamine chains.