Understanding the Clinical Implications of Resident Involvement in Uncommon Operations.

OBJECTIVE: The objective of this study was to examine uncommon operations in greater detail given that the outcomes of uncommon operations are largely understudied. This study examines the incidence of postoperative events and the role of the resident following uncommon operations. DESIGN: We identified uncommon general surgical operations using the ACS National Surgical Quality Improvement Program Participant Use file (2008-2011). Death or serious morbidity (DSM) within 30 days of the operation was the primary outcome of interest. Failure to rescue (FTR) and prolonged operative time (PRopt) were evaluated as secondary outcome measures. PRopt was defined as ≥90 percentile of operative time for each procedure type. Independent multivariate logistic regression models were generated to examine the impact of these descriptors on the outcomes of interest. SETTING/PARTICIPANTS: The dataset utilized was the United States National Surgical Quality Improvement Program Participant Use File which leverages data points from over 700 hospitals that range from primary to quaternary care centers. Resident participation was defined as resident involved (RI) or no resident involved (NRI), and stratified by postgraduate year (PGY): 1-3, 4-5, and 6+. RESULTS: Resident participant data was available for 21,453 (84.5%) uncommon operations with NRI in 25.4% (5447). With regard to resident participation, PGY1-3 were found in 12.6% (2699), PGY4-5 in 50.4% (10,817), and PGY6+ in 11.6% (2490). The overall observed DSM rate was 28.6% and the observed FTR rate was 5.8%. Overall, there was no difference in DSM by RI status (NRI: 1528; 28.1% vs RI: 4602; 28.8%; p = 0.324); however, PGY level was associated with DSM (PGY1-3: 774, 28.7%, PGY4-5: 3210, 29.7%, PGY6+: 618, 24.8%; p < 0.001). Any RI was associated with a lower rate of FTR (5.1%) when compared to NRI (8.3%, p < 0.001) with decreasing FTR events by increasing PGY (PGY1-3: 6.4%, PGY4-5: 5.2%, PGY6+: 3.3%; p < 0.001). After adjustment for patient risk factors, any RI remained associated with a lower likelihood of FTR than NRI (odds ratio: 0.65, 95% confidence interval: 0.49-0.87) while only the PGY4-5 and PGY6+ groups were associated with lower likelihood of FTR in comparison to NRI. RI was associated with PRopt in univariate and multivariable analyses. CONCLUSIONS: Uncommon operations were associated with substantial DSM. The involvement of PGY4-5 residents was associated with the greatest likelihood of DSM. With increasing PGY of the involved resident, cases with PGY > 5 demonstrated a lower likelihood of risk-adjusted FTR. The explanation for these findings is not clear; however, the involvement of more senior residents in the technical aspects of uncommon operations may lead to improved results.

Drug interactions between rifamycin antibiotics and hormonal contraception: a systematic review.

BACKGROUND: Rifamycin antibiotics are commonly used for treatment of tuberculosis, but may reduce the effectiveness of hormonal contraception (HC). OBJECTIVES: To determine whether interactions between rifamycins and HC result in decreased effectiveness or increased toxicity of either therapy. SEARCH STRATEGY: We searched MEDLINE, Embase, Cochrane and clinicaltrials.gov through May 2017. SELECTION CRITERIA: We included trials, cohort, and case-control studies addressing pregnancy rates, pharmacodynamics or pharmacokinetic (PK) outcomes when HC and rifamycins were administered together versus apart. Of 7291 original records identified, 11 met inclusion criteria after independent review by two authors. DATA COLLECTION AND ANALYSIS: Two authors independently abstracted study details and assessed study quality using the United States Preventive Services Task Force grading system. Findings are reported descriptively. MAIN RESULTS: Studies only addressed combined oral contraceptives (COCs) and none reported pregnancy rates. Quality ranged from good to poor. Rifampin increased the frequency of ovulation in two of four studies, and reduced estrogen and/or progestin exposure in five studies. Rifabutin led to smaller PK changes than rifampin in two studies. In one study each, rifaximin and rifalazil did not alter hormone PK. CONCLUSIONS: No studies evaluated pregnancy risk or non-oral HCs. PK and ovulation outcomes support a clinically concerning drug interaction between COCs and rifampin, and to a lesser extent rifabutin. Data are limited for other rifamycins. TWEETABLE ABSTRACT: Rifampin and rifabutin reduce systemic exposure of oral contraceptives, but no studies have evaluated pregnancy risk.

Strategic Shift to a Diagnostic Model of Care in a Multi-Site Group Dental Practice.

BACKGROUND: Documenting standardized dental diagnostic terms represents an emerging change for how dentistry is practiced. We focused on a mid-sized dental group practice as it shifted to a policy of documenting patients' diagnoses using standardized terms in the electronic health record. METHODS: Kotter's change framework was translated into interview questions posed to the senior leadership in a mid-size dental group practice. In addition, quantitative content analyses were conducted on the written policies and forms before and after the implementation of standardized diagnosis documentation to assess the extent to which the forms and policies reflected the shift. Three reviewers analyzed the data individually and reached consensuses where needed. RESULTS: Kotter's guiding change framework explained the steps taken to 97 percent utilization rate of the Electronic Health Record and Dental Diagnostic Code. Of the 96 documents included in the forms and policy analysis, 31 documents were officially updated but only two added a diagnostic element. CONCLUSION: Change strategies established in the business literature hold utility for dental practices seeking diagnosis-centered care. PRACTICAL IMPLICATIONS: A practice that shifts to a diagnosis-driven care philosophy would be best served by ensuring that the change process follows a leadership framework that is calibrated to the organization's culture.

Effect of noninvasive vagus nerve stimulation on acute migraine: an open-label pilot study.

BACKGROUND: We sought to assess a novel, noninvasive, portable vagal nerve stimulator (nVNS) for acute treatment of migraine. METHODS: Participants with migraine with or without aura were eligible for an open-label, single-arm, multiple-attack study. Up to four migraine attacks were treated with two 90-second doses, at 15-minute intervals delivered to the right cervical branch of the vagus nerve within a six-week time period. Subjects were asked to self-treat at moderate or severe pain, or after 20 minutes of mild pain. RESULTS: Of 30 enrolled patients (25 females, five males, median age 39), two treated no attacks, and one treated aura only, leaving a Full Analysis Set of 27 treating 80 attacks with pain. An adverse event was reported in 13 patients, notably: neck twitching (n = 1), raspy voice (n = 1) and redness at the device site (n = 1). No unanticipated, serious or severe adverse events were reported. The pain-free rate at two hours was four of 19 (21%) for the first treated attack with a moderate or severe headache at baseline. For all moderate or severe attacks at baseline, the pain-free rate was 12/54 (22%). CONCLUSIONS: nVNS may be an effective and well-tolerated acute treatment for migraine in certain patients.

Induction of STEAP4 correlates with 1,25-dihydroxyvitamin D3 stimulation of adipogenesis in mesenchymal progenitor cells derived from human adipose tissue.

The vitamin D receptor (VDR) is expressed in human adipocytes and is transiently induced during early adipogenesis in mesenchymal progenitor cell models. VDR null mice exhibit enhanced energy expenditure and reduced adiposity even when fed high fat diets. Adipocyte-specific transgenic-expression of human VDR in mice enhances adipose tissue mass, indicating that VDR activation in adipocytes enhances lipid storage in vivo. In these studies, we conducted genomic profiling and differentiation assays in primary cultures of human adipose-derived mesenchymal progenitor cells to define the role of the VDR and its ligand 1,25-dihydroxyvitamin D3 (1,25D) in adipogenesis. In the presence of adipogenic media, 1,25D promoted lipid accumulation and enhanced the expression of FABP4, FASN, and PPARγ. Mesenchymal cells derived from 6-month old VDR null mice exhibited impaired adipogenesis ex vivo but differentiation was restored by stable expression of human VDR. STEAP4, a gene that encodes a metalloreductase linked to obesity, insulin sensitivity, metabolic homeostasis and inflammation, was highly induced in human adipose cells differentiated in the presence of 1,25D but was minimally affected by 1,25D in undifferentiated precursors. These studies provide a molecular basis for recent epidemiological associations between vitamin D status, body weight and insulin resistance which may have relevance for prevention or treatment of metabolic syndrome and obesity.

Ability of transstadially infected Ixodes pacificus (Acari: Ixodidae) to transmit West Nile virus to song sparrows or western fence lizards.

The hypothesis that Ixodes pacificus Cooley & Kohls (Acari: Ixodidae) may serve as a reservoir and vector of West Nile virus (family Flaviviridae, genus Flavivirus, WNV) in California was tested by determining the ability of this tick species to become infected with the NY99 strain of WNV while feeding on viremic song sparrows, to maintain the infection transstadially, and then to transmit WNV to recipient naive song sparrows and western fence lizards during the nymphal stage. The percentage of ticks testing positive by reverse transcription-polymerase chain reaction (RT-PCR) decreased from 77% of 35 larvae at day 6 after ticks were transferred to donor song sparrows (day of detachment) to 23% of 35 nymphs at 59 d postinfestation (approximately 19 d after molting to the nymphal stage). However, the percentage of ticks positive by RT-PCR from which infectious virus was recovered by Vero cell assay decreased from 59% on day 6 to 12% on day 59, even though there was no statistically significant decrease in the quantity of RNA within positive ticks. Attempts to improve the sensitivity of plaque assays by blind passage through C6/36 cell cultures were unsuccessful. These data indicated that ticks maintained viral RNA but not necessarily infectious virus over time. Nymphs from larvae that fed on song sparrows with peak viremias ranging from 7.2 to 8.5 log10 plaque-forming units (PFU) per ml were used in transmission attempts. From one to seven RNA-positive nymphal ticks engorged and detached from each of four recipient song sparrows or western fence lizards. Blood samples from sparrows and lizards remained negative, indicating that transmission did not occur. An additional four lizards inoculated with 1,500 PFU of WNV developed moderate viremias, ranging from 4.2 to 5.6 log10 PFU/ml. Our data and data from previous studies collectively indicated that ixodid ticks were not able to experimentally transmit WNV and therefore most likely would not be important vectors in WNV transmission cycles.

The efficacy of an essential oil antiseptic mouthrinse vs. dental floss in controlling interproximal gingivitis: a comparative study.

BACKGROUND: The use of dental floss has long been considered to be effective in controlling interproximal plaque and gingivitis. The authors compared this method with that of use of a mouthrinse. METHODS: Subjects with mild-to-moderate gingivitis enrolled in a long-term, six-month study. They received a dental prophylaxis and were randomized into one of the three following treatment groups: brushing and rinsing with an essential oil-containing mouthrinse (the BEO group), brushing and flossing (the BF group) and brushing and rinsing with a control rinse (the B group). RESULTS: A total of 326 subjects were evaluated. The BEO and BF had significantly lower (P < .001) mean interproximal Modified Gingival Index, or MGI, scores than did the B group at six months. The BEO group had lower mean interproximal Plaque Index, or PI, scores than the other two groups at both three and six months. The BF group's mean PI score was significantly lower than the B group's mean score at six months only. The magnitude of reductions for the BEO and the BF groups (vs. the B group) in MGI were 11.1 percent and 4.3 percent and for PI were 20.0 percent and 3.4 percent, respectively. CONCLUSIONS: In conjunction with professional care (prophylaxis) and toothbrushing over six months, rinsing twice daily with an essential oil-containing mouthrinse was at least as good as flossing daily in reducing interproximal plaque and gingivitis. Clinical Implications. When weighing recommendations for oral hygiene home care, clinicians should consider that an essential oil-containing mouthrinse may be a useful adjunct in patients with gingival inflammation.

The pharmacodynamics of gatifloxacin and ciprofloxacin for pneumococci in an in vitro dynamic model: prediction of equiefficient doses.

Enhanced activity against Streptococcus pneumoniae is one of the putative advantages of gatifloxacin over older fluoroquinolones such as ciprofloxacin. This study examined ciprofloxacin and gatifloxacin pharmacodynamics against two differentially susceptible clinical isolates of S. pneumoniae (gatifloxacin MIC, 0.125 and 2 mg/L; ciprofloxacin MIC, 1 and 32 mg/L). The pharmacokinetics of gatifloxacin (single dose) and ciprofloxacin (two 12 hourly doses) with half-lives of 6 and 5 h, respectively, were simulated using a two-compartment dynamic model. The AUC/MIC ratios in the peripheral compartments that contain bacterial cultures varied over a four- to five-fold range, from 11 to 48 h with ciprofloxacin and from 15 to 78 h with gatifloxacin. The intensity of the antimicrobial effect (IE) increased with increasing AUC/MIC ratios in a strain-independent fashion, although different relationships of IE to log AUC/MIC were inherent for each drug (r2 0.73 for gatifloxacin and r2 0.94 for ciprofloxacin). Subsequently, the respective dose-response relationships of gatifloxacin and ciprofloxacin for a hypothetical strain of S. pneumoniae with MIC equal to the MIC50 were modelled. Based on these relationships, the equiefficient doses of gatifloxacin and ciprofloxacin were predicted for MIC50S of 0.4 and 1 mg/L, respectively. Gatifloxacin 400 mg was predicted to be equiefficient to ciprofloxacin 1400 mg. To provide the same anti-pneumococcal effect as the usual 1000 mg daily dose of ciprofloxacin, the respective daily dose of gatifloxacin could be as low as 180 mg. This in vitro study demonstrates advantages of gatifloxacin relative to ciprofloxacin in terms of the dose-dependent total antimicrobial effect.

Measuring clinical performance: comparison and validity of telephone survey and administrative data.

OBJECTIVE: To compare and validate self-reported telephone survey and administrative data for two Health Plan Employer Data and Information Set (HEDIS) performance measures: mammography and diabetic retinal exams. DATA SOURCES/STUDY SETTING: A telephone survey was administered to approximately 700 women and 600 persons with diabetes randomly chosen from each of two health maintenance organizations (HMOs). STUDY DESIGN: Agreement of survey and administrative data was assessed by using kappa coefficients. Validity measures were assessed by comparing survey and administrative data results to a standard: when the two sources agreed, that was accepted as the standard; when they differed, confirmatory information was sought from medical records to establish the standard. When confirmatory information was not available ranges of estimates consistent with the data were constructed by first assuming that all persons for whom no information was available had received the service and alternately that they had not received the service. PRINCIPAL FINDINGS: The kappas for mammography were .65 at both HMOs; for retinal exam they were .38 and .40. Sensitivity for both data sources was consistently high. However, specificity was lower for survey (range .44 to .66) than administrative data (.99 to 1.00). The positive predictive value was high for mammography using either data source but differed for retinal exam (survey .69 to .78; administrative data .99 to 1.00). CONCLUSIONS: Administrative and survey data performed consistently in both HMOs. Although administrative data appeared to have greater specificity than survey data the validity and utility of different data sources for performance measurement have only begun to be explored.

EVT endovascular graft for abdominal aortic aneurysm.

BACKGROUND: A variety of prostheses are now available for the endovascular treatment of abdominal aortic aneurysm (AAA). Significant advantages of the EVT device are its unibody design, secure hook attachment system and graft fabric approximating that used in conventional surgery. METHODS: Implantation of the EVT device was attempted in 60 patients who were studied prospectively with an analysis of subsequent problems encountered. RESULTS: Conversion to open repair was required in four cases (6.7%). There were nine tube grafts inserted, 13 aorto-unilateral iliac with crossover grafts and 34 aorto-bi-iliac grafts. There was one death (mortality 1.7%). Endoleaks were identified in eight patients (14%), none of which were proximal; three sealed spontaneously, two were treated with coil embolization, two are being observed and one patient had an iliac attachment converted to an open anastomosis. Access vessel problems were seen in 21 patients (35%); two-thirds were corrected at the time of initial surgery. Seven patients (12%) had primary graft limb problems identified and treated before leaving the operating room. Nine patients (16%) developed secondary graft limb problems, which were diagnosed and treated after the initial surgery. Endovascular treatment was used in eight and was successful in six with surgical revision required in two. On review of these cases to assess if the problem could have been predicted at the time of initial surgery, it was felt that more aggressive treatment of intraoperatively diagnosed graft limb stenoses, even though considered mild, may have prevented 50% of subsequent secondary graft limb occlusions. CONCLUSION: Although the EVT device has significant advantages in the endovascular management of aortic aneurysm, potential graft limb problems need to be actively identified with the majority able to be successfully managed by supplementary endovascular techniques.

Psychological influences on acceptance of postsurgical treatment in cancer patients.

OBJECTIVE: Many cancer patients fail to complete treatment for reasons that are unclear in previous research which, nevertheless, suggested hypotheses for this study about the characteristics of the patients and their consultations. METHOD: 158 adults with breast cancer or other cancers who had been chosen for postsurgical treatment in the Lister Hospital or the Mount Vernon Hospital had completed published questionnaires to assess either (n=74) personal attributes or circumstances viz. locus of health control, health habits, support, affiliative drive, anxiety, depression, or (n=84) their attitudes to cancer or their consultations, viz. the Mental Attitudes to Cancer Scales, Trust in Physicians, Perceived Empathy, and Satisfaction With Recent and Diagnostic Consultations. RESULTS: 32% then failed to complete treatment. In logistic multiple regression analyses, only diagnosis (P=.0001), gender (P=.005), and treatment center (P=.0002) predicted this although the effect of gender was not significant among patients without breast cancer. Among the patients without breast cancer intended for the Mount Vernon Hospital, a National Cancer Centre, fewer completed treatment than those did not complete. CONCLUSION: The breast cancer patients, unlike women with other cancers, and patients referred to the local hospital rather than the regional cancer center, were more likely to complete treatment. Thus, uptake of treatment may be favored by accessibility and familiarity of its source and by the unique impact in women of breast cancer and the wider public attention given to that illness. Research on patients' expectations, fears, and corresponding experiences of treatment, rather than personal attributes, should clarify failure to complete cancer treatment especially in patients without breast pathology.

Synthesis and biological evaluation of destruxin A and related analogs.

This report describes the development of an efficient solid-phase synthesis protocol and adaptation of reported solution phase procedures for the synthesis of the cyclic depsihexapeptide destruxin A and related analogs. The solid-phase method described is based on standard Fmoc peptide chemistry, including a new synthetic method for the assembly of the depsi bond-containing unit. In order to select analogs of destruxin A for synthesis and evaluation of insecticidal activity, the work of Hellberg et al., describing a set of Z-descriptors for amino acid side-chains comparing their physicochemical properties, was utilized. Destruxin A and 27 different analogs with structural variations in four residues were synthesized and insecticidal activity was evaluated via injections into tobacco budworm (Heliothis virescens) larvae. Several destruxin A analogs were found to be at least as potent as the native compound.

The effect of growth hormone on craniofacial growth and dental maturation in Turner syndrome.

Serial cephalometric and panoramic radiographs from a mixed longitudinal group of 28 subjects with Turner syndrome (TS), age 4.4-19.0 years, were evaluated for annualized growth increments of the craniofacial complex and dental development and were compared with a longitudinal control group from the Burlington growth study. The short and retrognathic face characteristic of the syndrome was due largely to the increased cranial base angle, decreased posterior face height, and decreased mandibular length, all of which were significantly different from the controls. Although increases in statural height occurred in the TS children who were treated with human growth hormone (GH), there was little or no effect on growth of the jaws, particularly in the older subjects, and the characteristic facies of the syndrome persisted. Dental development was advanced in all TS subjects, and GH administration had no effect on the rate of dental development.

Self-reported childhood sexual and physical abuse and adult HIV-risk behaviors and heavy drinking.

CONTEXT: Although studies of clinical samples have identified links between childhood abuse, especially sexual abuse, and adult health-risk behaviors, the generalizability of these findings to the population and the relative importance of different types of abuse in men and women are not known. OBJECTIVE: To estimate the risk of self-reported adult HIV-risk behaviors and heavy drinking that is associated with self-reported childhood histories of physical and/or sexual abuse for men and women in a general-population sample, after controlling for age and education. A second objective is to determine whether, among women, early and chronic sexual abuse is associated with heightened risk compared to later or less extensive abuse. DESIGN: A population-based telephone survey, the 1997 Washington State Behavioral Risk Factor Surveillance System (BRFSS), asked a representative sample of adults whether they had ever been physically or sexually abused in childhood, and if so, the age at first occurrence and number of occurrences. The survey also asked about levels of alcohol use and, for those under 50 years, about HIV-risk behaviors. PARTICIPANTS: Three thousand four hundred seventy-three English-speaking non-institutionalized civilian adults in Washington State. MAIN OUTCOME MEASURES: Self-reported HIV-risk behaviors in the past year and heavy drinking in the past month. RESULTS: We identified associations between reported abuse history and each health-risk behavior that we examined. For women, early and chronic sexual abuse (occurring without nonsexual physical abuse) was associated with more than a 7-fold increase in HIV-risk behaviors (odds ratio [OR], 7.4; 95% confidence intervals [CI] 2.4 to 23.5); and any sexual abuse, combined with physical abuse, was associated with a 5-fold increase in these risk behaviors (OR, 5.0; 95% CI, 2.2 to 11.5). For women, only combined sexual and physical abuse was associated with heavy drinking (OR, 6.2; 95% CI, 2.2 to 16.9). Physical abuse alone was not associated with either health-risk behavior for women. For men, any sexual abuse was associated with an 8-fold increase in HIV-risk behaviors (OR, 7.9; 95% CI, 1.8 to 35.1). Physical abuse alone was associated with a 3-fold increase in risk of HIV-risk behaviors (OR, 3.2; 95% CI, 1.3 to 7.9) and a similar increase in risk of heavy drinking (OR, 3.2; 95% CI, 1.8 to 5.5). Although only 29% of the women and 19% of the men who were asked about HIV-risk behaviors reported any history of childhood abuse, these accounted for 51% and 50% of those reporting HIV-risk behaviors, respectively. For heavy drinking the corresponding figures were 25% of the women and 23% of the men reporting any abuse, who accounted for 45% and 33% of those reporting heavy drinking, respectively. CONCLUSIONS: Efforts to prevent or remediate adult health-risk behaviors should consider the possibility of a history of childhood abuse, as one third to one half of those reporting HIV-risk behaviors or heavy drinking in a general-population survey also reported childhood abuse.

Comparative activities of ciprofloxacin and levofloxacin against Streptococcus pneumoniae in an In vitro dynamic model.

The activities of levofloxacin (500 mg every 24 h) and ciprofloxacin (750 mg every 12 h) against six pneumococcal isolates in an in vitro dynamic model were compared. For one strain, levofloxacin reduced the inoculum by over 4 log CFU/ml and ciprofloxacin reduced the inoculum by over 2 log CFU/ml. For four isolates, both drugs reduced inocula by 4 log CFU/ml within 6 h, suggesting that this dose of ciprofloxacin should be as effective as levofloxacin against these pneumococci.

Decisions concerning the allocation of scarce medical resources.

This paper aimed to determine the criteria participants use to make decisions about scarce medical resources (allocation to use a kidney machine). It varied information about patients on 4 factors (sex, smoking, employment status, community service). It also set out to see if decisions made in groups differed from aggregated decisions of those made alone. In the first study, participants completed a simple questionnaire requiring them to rank-order sixteen hypothetical patients. In the second study, a group discussion (in groups of three participants) preceded the group putting an agreed rating on the identical questionnaire. Participants favoured patients who were employed, non-smokers and participated in community service. This suggests that participants adopted a utilitarian moral ideology. Participants' smoking habits interacted with the hypothetical patients' smoking habits, indicating in-group favouritism. In the second study it was found that when the decision was made in a group of three it amplifies the decision made by an individual. In this sense there was clear evidence of group polarization.

A simple structure-based calculator for estimating vapor pressure.

The development of an estimator for vapor pressure based upon organic functional groups is described. This vapor pressure calculator permits prediction of vapor pressure for a wide range of structural classes. The statistical quality of the derived coefficients is presented as well as the quality of the prediction of the training set of compounds. The calculator is then used to predict the vapor pressure of recently introduced agrochemicals to illustrate its performance. The significance of this calculator is that the agrochemical scientist can readily estimate the effects on vapor pressure of altering specific structural features of a molecule.