Not all flaps are created equal: Assessing the impact of active smoking in muscle-only versus perforator flaps for patients undergoing nonelective extremity-free tissue transfer-A case control study.

INTRODUCTION: Active smoking is known to impair wound healing following free tissue transfer for reconstruction due to its vasoconstrictive effect on the microcirculation. The aim of this study was to evaluate the impact of flap selection on flap loss, in nonelective, traumatic extremity-free soft tissue transfer in active smokers. METHODS: All patients undergoing a free tissue transfer for acute trauma of the extremity at a level I trauma center from 2011 to 2017 were identified. Breast reconstruction and osseous/osseocutaneous flaps were excluded. The study population was divided in two groups based on the type of flap used (muscle versus perforator flap). Factors known to be associated with impaired wound healing were extracted from the database. Primary outcome was major smoking related complications (complete/partial flap loss). Secondary outcomes included minor flap-related complications (infection, dehiscence) and donor site complications. The impact of smoking was assessed for the different type of flaps using multivariate analyses. RESULTS: A total of 118 flaps were identified during the study period. Out of those, 52 were perforator-based fasciocutaneous flaps, while 66 were muscle flaps. Active smoking status resulted in a statistically significant increase in the incidence of major and minor complications in the perforator flap group (36% vs. 4%, adjusted odds ratio, AOR [95%CI]: 2.31[1.48,19.30], adj-p = 0.021 and 32% vs. 17%, AOR [95% CI]: 1.23[1.11,14.31], adj-p = 0.034) but had no impact in the muscle group. CONCLUSIONS: The present study suggests a higher incidence of flap related complications in smokers when a perforator flap was selected but no impact when a muscle flap was utilized.

Reflective Listening Visualization: Enhancing Interdisciplinary Disaster Research through the Use of Visualization Techniques.

Reflective Listening Visualization is an interdisciplinary research method and iterative process that includes the participation and involvement of multiple team members of different disciplines when (1) conducting in-depth interviews, (2) performing thematic analysis of the interview data, (3) using the emergent themes as basis to design visual representations of the themes, (4) presenting the visuals back to the interviewee for feedback, and (5) using the feedback to confirm the visual, refine the existing visual, or to create a new visual. Fundamentally, the Reflective Listening Visualization technique is an enhanced communication tool that aims to increase the community member's voice and to verify the understanding of their experiences, ideas, and concerns while also enhancing the interdisciplinary learning potential of the research team. In this article, we describe the Reflective Listening Visualization process and discuss how the Reflective Listening Visualization process allows for (1) improved communication between interdisciplinary team members, (2) understanding of residents' wants and needs for their community, (3) increasing rapport with residents, (4) building trust between residents and between residents and researchers, (5) accurate representation of residents ideas, and (6) community members to become motivated about the possibilities of the future of their community.

Impact of Cardiac Risk Factors in the Postsurgical Outcomes of Patients With Cleft Lip.

ABSTRACT: Congenital cardiac comorbidities represent a potentially elevated risk for complications in patients undergoing cleft lip repair. National databases, such as the National Surgical Quality Improvement Program Pediatric (NSQIP-P) allow for analysis of large national datasets to assess these risks and potential complications. The aim of this study is to assess the risk of complications in patients undergoing cleft lip repair with congenital cardiac co-morbidities using the NSQIP-P.The 2012 to 2014 NSQIP-P databases were queried for patients undergoing cleft lip repair. Data abstracted for analysis included demographic, clinical, and outcomes data. Patients with cleft lip were stratified based on the presence or absence of congenital cardiac comorbidities. Univariate analysis and step-wise, forward logistic regression were performed to compare these groups.Nationally, between 2012 and 2014, 2126 patients underwent cleft lip repair, 227 with cardiac disease, and 1899 without cardiac disease. Weights were similar between the groups at the time of surgery, though patients with cardiac comorbidities were older. Postoperatively, cardiac disease patients were more likely to experience an adverse event. Specifically, they were more likely to experience reintubation, reoperation, longer length of stay, and death. Rates of surgical site infection and dehiscence were not different between the groups.This study demonstrates that cleft lip repair in patients with congenital heart defects is safe. However, patients undergoing cleft lip repair with comorbid congenital cardiac disease were more likely to experience adverse events. Cardiac patients require special preoperative evaluation before repair of their cleft lip, but do not appear to experience worse wound-related outcomes.

Interprofessional Simulation to Improve the Understanding of Obstetric Sepsis.

Sepsis parameters are not well defined for the obstetric population, which can result in delayed recognition. The escape room-based simulation sought to improve obstetric providers' and nurses' understanding, identification, and timely treatment of maternal sepsis. Participants expressed interest and enthusiasm in using this learning style to improve care of the sepsis patient. This intervention proved beneficial to staff development educators as an innovative and effective way to improve interprofessional engagement and promote knowledge of maternal sepsis.

Impact of Cardiac Risk Factors in the Postsurgical Outcomes of Patients With Cleft Palate: Analysis of the 2012-2014 NSQIP Database.

OBJECTIVE: To assess the risk of complication in patients undergoing cleft palate repair with congenital cardiac comorbidities in a large, national cohort. DESIGN: Retrospective review. PATIENTS/SETTING: Using the 2012-2014 National Surgical Quality Improvement Program (NSQIP) Pediatric database, patients undergoing cleft palate repair were selected for analysis. Patients with cleft palate repairs were stratified based on the presence or absence congenital cardiac comorbidities. Univariate and stepwise forward logistic regression were conducted. MAIN OUTCOME MEASURES: It is hypothesized that risk of postoperative adverse events in patients with congenital cardiac comorbidities is higher than in patients without cardiac disease. RESULTS: Nationally, between 2012 and 2014, 3240 patients underwent cleft palate repair, 422 (13.0%) with cardiac disease, and 2818 (87.0%) without cardiac disease. Patients with cardiac disease were smaller (10.5 [6.6] kg vs 11.6 [8.6] kg, P < .01) and more likely to be premature (4.6% vs 13.0%, P < .01) compared to those without cardiac disease. Postoperatively, patients with cardiac conditions were more likely to experience an adverse event (8.8% vs 4.2%, P < .01). Specifically, they were more likely to experience reintubation (1.7% vs 0.4%, P < .01), reoperation (2.1% vs 0.6%, P < .01), and longer length of stay (2.7 [7.0] vs 1.6 [2.8] days, P < .01). Rates of surgical site infection and dehiscence were not different. CONCLUSIONS: Cleft palate repair in patients with concurrent congenital cardiac defects is a safe procedure but carries elevated risk in the postoperative period as demonstrated in this analysis of the NSQIP-Pediatric database. Technical risks are equivalent. Additional anesthesia and surgical awareness of these potential complications is essential to minimize perianesthesia risks.

Does Including Public Health Students on Interprofessional Teams Increase Attainment of Interprofessional Practice Competencies?

CONTEXT: Interprofessional education (IPE) creates dynamic experiential learning that can address social determinants of health that influence health outcomes. OBJECTIVE: To examine the effects of including public health students on IPE teams on the interprofessional practice domain constructs (values/ethics, roles/responsibilities, interprofessional communication, and teams and teamwork). METHODS: This single-case, mixed-methods study was performed using a grounded theory approach. Students from 8 graduate health sciences programs participated in an asynchronous, 6-week, online IPE learning activity. Three of the 4 interprofessional practice domain constructs were examined as outcome variables: participants' biomedical vs biopsychosocial patient approach (values/ethics); reported change in attitudes, beliefs, or values about other health professions (roles/responsibilities); and anticipated changes in future professional behaviors/interactions/approaches (teams and teamwork). Predictor variables were having an MPH participant on the IPE team, participants' enrollment in a clinical or nonclinical program, and student perception of the online format (interprofessional communication). RESULTS: Three hundred nineteen students were included, 261 from clinical and 58 from nonclinical programs. A significant association was found between having an MPH participant on the IPE teams and participants' awareness of the influence of social determinants of health (OR, 2.04; 95% CI, 1.13-3.66; P<.05). Program type was also significantly associated with awareness of the influence of social determinants of health, such that participants in nonclinical programs were significantly more likely to report the importance of social determinants of health in the care plan (OR, 3.68; 95% CI, 1.38-9.84; P<.01). Participants were significantly less likely to report future behavior change if they were in clinical programs (OR, 0.44; 95% CI, 0.23-0.86; P<.05) or if they disliked the online format (OR, 0.25; 95% CI, 0.14-0.42; P<.01). The model fit the data well (χ23=30.80; P<.001). CONCLUSION: Inclusion of MPH students on IPE teams has the potential to increase clinical participants' awareness of the influence of social determinants of health and interest in incorporating a biopsychosocial approach to health care.

Synthesis and structure-activity relationships study of dithiolethiones as inducers of glutathione in the SH-SY5Y neuroblastoma cell line.

Parkinson's disease is a neurodegenerative disorder that involves the degeneration of nigrostriatal dopaminergic neurons. Elevated levels of reactive oxygen species have been shown to deplete cellular levels of the ubiquitous antioxidant glutathione, leading to oxidative stress and eventual neuronal cell death. Dithiolethiones, a class of sulfur-containing heterocyclic molecules, have been shown to induce cellular production of glutathione in a variety of tissues, but have not been extensively evaluated in neurons. Herein, we report the synthesis and preliminary structure-activity relationships study of several substituted dithiolethiones. Three molecules were identified (D3T, CPDT, and 2d) that potently induced cellular glutathione in the SH-SY5Y neuroblastoma cell line. Furthermore, these compounds were found to provide neuroprotection in the 6-hydroxydopamine model of neurotoxicity. This study suggests that dithiolethione-mediated neuroprotection may have potential as a disease-modifying antiparkinsonian therapy.

'It is the situation that makes it difficult': experiences of nursing students faced with a high-stakes drug calculation test.

Test anxiety affects the learning, performance and well-being of students, and it increases as the stakes get higher. Norwegian nursing students must pass a drug calculation test with a flawless performance if they are to qualify as nurses. The aim of the current study was to investigate the test anxiety experiences of students faced with such a high-stakes test. We used a mixed methods approach where the data were collected using a survey questionnaire and a focus group interview. In total, 203 freshman nursing students completed the questionnaire, six of whom also participated in the focus group interview. The survey results showed that 44.3% of the students reported high mathematics test anxiety in the months before the drug calculation test. More than 12% of the high-anxiety students reported a low mathematics self-concept. High and medium self-concept students also experienced high test anxiety. Our analysis of the focus group interview data confirmed that the high stakes of the test increased the test anxiety dramatically.

Phylogenetic analysis of symbionts in feather-feeding lice of the genus Columbicola: evidence for repeated symbiont replacements.

BACKGROUND: Many groups of insects have obligate bacterial symbionts that are vertically transmitted. Such associations are typically characterized by the presence of a monophyletic group of bacteria living in a well-defined host clade. In addition the phylogeny of the symbiotic bacteria is typically congruent with that of the host, signifying co-speciation. Here we show that bacteria living in a single genus of feather lice, Columbicola (Insecta: Phthiraptera), present an exception to this typical pattern. RESULTS: The phylogeny of Columbicola spp. symbionts revealed the presence of three candidate clades, with the most species-rich clade having a comb-like topology with very short internodes and long terminal branches. Evolutionary simulations indicate that this topology is characteristic of a process of repeated symbiont replacement over a brief time period. The two remaining candidate clades in our study exhibit high levels of nucleotide substitution, suggesting accelerated molecular evolution due to relaxed purifying selection or smaller effective population size, which is typical of many vertically transmitted insect symbionts. Representatives of the fast-evolving and slow-evolving symbiont lineages exhibit the same localization, migration, and transmission patterns in their hosts, implying direct replacement. CONCLUSIONS: Our findings suggest that repeated, independent symbiont replacements have taken place over the course of the relatively recent radiation of Columbicola spp. These results are compatible with the notion that lice and other insects have the capability to acquire novel symbionts through the domestication of progenitor strains residing in their local environment.

Attenuation of the sensing capabilities of PhoQ in transition to obligate insect-bacterial association.

Sodalis glossinidius, a maternally inherited endosymbiont of the tsetse fly, maintains genes encoding homologues of the PhoP-PhoQ two-component regulatory system. This two-component system has been extensively studied in facultative bacterial pathogens and is known to serve as an environmental magnesium sensor and a regulator of key virulence determinants. In the current study, we show that the inactivation of the response regulator, phoP, renders S. glossinidius sensitive to insect derived cationic antimicrobial peptides (AMPs). The resulting mutant strain displays reduced expression of genes involved in the structural modification of lipid A that facilitates resistance to AMPs. In addition, the inactivation of phoP alters the expression of type-III secretion system (TTSS) genes encoded within three distinct chromosomal regions, indicating that PhoP-PhoQ also serves as a master regulator of TTSS gene expression. In the absence of phoP, S. glossinidius is unable to superinfect either its natural tsetse fly host or a closely related hippoboscid louse fly. Furthermore, we show that the S. glossinidius PhoQ sensor kinase has undergone functional adaptations that result in a substantially diminished ability to sense ancestral signals. The loss of PhoQ's sensory capability is predicted to represent a novel adaptation to the static symbiotic lifestyle, allowing S. glossinidius to constitutively express genes that facilitate resistance to host derived AMPs.

Quorum sensing primes the oxidative stress response in the insect endosymbiont, Sodalis glossinidius.

BACKGROUND: Sodalis glossinidius, a maternally transmitted bacterial endosymbiont of tsetse flies (Glossina spp.), uses an acylated homoserine lactone (AHL)-based quorum sensing system to modulate gene expression in accordance with bacterial cell density. The S. glossinidius quorum sensing system relies on the function of two regulatory proteins; SogI (a LuxI homolog) synthesizes a signaling molecule, characterized as N-(3-oxohexanoyl) homoserine lactone (OHHL), and SogR1 (a LuxR homolog) interacts with OHHL to modulate transcription of specific target genes. METHODOLOGY/PRINCIPAL FINDINGS: We used a tiling microarray to analyze the S. glossinidius transcriptome in the presence and absence of exogenous OHHL. The major finding is that OHHL increases transcription of a large number of genes that are known to be involved in the oxidative stress response. We also show that the obligate symbiont of the rice weevil, Sitophilus oryzae (SOPE), maintains copies of the quorum sensing regulatory genes that are found in S. glossinidius. Molecular evolutionary analyses indicate that these sequences are evolving under stabilizing selection, consistent with the maintenance of their functions in the SOPE symbiosis. Finally, the expression studies in S. glossinidius also reveal that quorum sensing regulates the expression of a cryptic, degenerate gene (carA) that arose from an ancient deletion in the last common ancestor of S. glossinidius and SOPE. CONCLUSIONS/SIGNIFICANCE: This oxidative stress response is likely mandated under conditions of dense intracellular symbiont infection, when intense metabolic activity is expected to generate a heavy oxidative burden. Such conditions are known to arise in the bacteriocytes of grain weevils, which harbor dense intracellular infections of symbiotic bacteria that are closely related to S. glossinidius. The presence of a degenerate carA sequence in S. glossinidius and SOPE indicates the potential for neofunctionalization to occur during the process of genome degeneration.

The P4 metal binding site in RNase P RNA affects active site metal affinity through substrate positioning.

Although helix P4 in the catalytic domain of the RNase P ribozyme is known to coordinate magnesium ions important for activity, distinguishing between direct and indirect roles in catalysis has been difficult. Here, we provide evidence for an indirect role in catalysis by showing that while the universally conserved bulge of helix P4 is positioned 5 nt downstream of the cleavage site, changes in its structure can still purturb active site metal binding. Because changes in helix P4 also appear to alter its position relative to the pre-tRNA cleavage site, these data suggest that P4 contributes to catalytic metal ion binding through substrate positioning.

Detecting art forgeries using LA-ICP-MS incorporating the in situ application of laser-based collection technology.

The nature of art lends itself to forgery as a skilled and determined forger can mimic the techniques and styles of an artist to a level where even an expert can be duped. The authentication of paintings is a subjective process, but modern techniques may provide the means to provenance artist pigments based on elemental composition. This study applies laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) to the analysis of artist paints from different manufacturers to identify variation between the elemental association patterns of these materials. The technique facilitates comparison of the paints used by an artist with produced works of art to assist provenancing initiatives of questioned materials. The effects of the trace element profiles of the backing substrate and binder on analytical data were also identified. By applying the technique to paint scraped from real paintings, a limited database was created to allow comparison to be made with some of Australian artist, Kathleen O'Connor's artworks and assist in determining production chronology. Data from this study were able to facilitate comparison of blue paints from two different paintings and confirm their co-provenance consequently determining the relative production date of a separate painting of previously unknown age. Preliminary trials of a prototype collection device designed to reduce damage and allow for in situ sampling of artworks were also undertaken. The device, which allows direct laser-based sampling of a complete painting, was tested using a Francis Ryan painting. The prototype allows for the collection of debris directly generated by LA-ICP-MS of a predefined area of a painting prior to subsequent analysis using direct LA-ICP-MS. This collection method significantly minimizes the amount of damage produced by conventional sampling methods. Analyses of the debris collected, using the prototype, were found to be comparable to the scrapings of equivalent paint analysed using direct LA-ICP-MS analysis.