Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children's Hospital.

OBJECTIVES: Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. METHODS: We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated. RESULTS: A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed (P < 0.0001), prescriptions filled (P = 0.009), and opioid doses taken (P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call (P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed. CONCLUSIONS: Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control.

Clinical and microbiological characterization of Salmonella spp. isolates from patients treated in a university hospital in South America between 2012-2021: a cohort study.

BACKGROUND: Salmonellosis is a major cause of morbidity and mortality and one of the most frequent etiologies of diarrhea in the world. Mortality due to Salmonellosis in Latin America still poorly understood, and there is a lack of studies that evaluate resistance and clinical manifestations. The aims of this study were to characterize patients infected with Salmonella spp. seen in a university hospital in Colombia between 2012 and 2021, to evaluate trends in antibiotic resistance and to determine the proportion of overall mortality and related factors. METHODS: Retrospective observational study. All patients with microbiological diagnosis of Salmonella spp. were included. The sociodemographic, clinical and microbiological characteristics were described, and the proportion of antibiotic resistant isolates per year was estimated. The prevalence of mortality according to age groups was calculated. Log binomial regression models were used to establish factors associated with mortality. RESULTS: Five hundred twenty-two patients were analyzed. Salmonellosis accounted for 0.01% of all medical consultations. The median age was 16 years old. The most common clinical presentation was gastroenteric syndrome (77.1%) and symptoms included diarrhea (79.1%), fever (66.7%), abdominal pain (39.6%) and vomiting (35.2%). Of the Salmonella spp. isolates, 78.2% were not classified, 19.1% corresponded to non-typhoidal Salmonella and 2.7% to Salmonella typhi. Mortality occurs in 4.02% of the patients and was higher in patients with hematologic malignancy (11.6%). When analyzing by age group, the proportion of deaths was 2.8% in patients aged 15 years or younger, while in those older than 15 years it was 5.4%. Factors associated to mortality where bacteremia (aPR = 3.41 CI95%: 1.08-10.76) and to require treatment in the ICU (aPR = 8.13 CI95%: 1.82-37.76). In the last 10 years there has been a steady increase in resistance rates to ciprofloxacin, ampicillin, ampicillin/sulbactam and ceftriaxone, reaching rates above 60% in recent years. CONCLUSIONS: Despite improved availability of antibiotics for the treatment of salmonellosis in the past decades, mortality due to salmonellosis continues occurring in children and adults, mainly in patients with hematological malignancies and bacteremia. Antibiotic resistance rates have increased significantly over the last 10 years. Public health strategies for the control of this disease should be strengthened, especially in vulnerable populations.

Co-Infection between Dengue Virus and SARS-CoV-2 in Cali, Colombia.

The co-occurrence of COVID-19 with endemic diseases is a public health concern that may affect patient prognosis and outcomes. The objective of this study was to describe the clinical characteristics of patients with dengue virus (DENV) and SARS-CoV-2 co-infections and compare their outcomes against those of COVID-19 patients without dengue. A cross-sectional study was conducted in patients with SARS-CoV-2 infection who attended a single center in Cali, Colombia, from March 2020 to March 2021. All patients who were tested by both real-time polymerase chain reaction for SARS-CoV-2 and IgM/NS1 for DENV were included. Dengue was diagnosed as having either an IgM- or an NS1- positive test. A total of 90 patients were included (72 with COVID-19 only and 18 with co-infection). Patients with co-infection had more dyspnea (61.1% versus 22.2%; P = 0.003) as well as higher oxygen desaturation (53.3% versus 13.4%; P = 0.002) and neutrophil-to-lymphocyte ratio (5.59 versus 3.84; P = 0.038) than patients with COVID-19 alone. The proportion of patients classified with moderate to severe COVID-19 was higher in the co-infection group (88.3% versus 47.8%; P = 0.002). Also, co-infection was associated with an increased need for mechanical ventilation (P = 0.06), intensive care unit (ICU) initial management (P = 0.02), and ICU admission during hospitalization (P = 0.04) compared with COVID-19 only. The ICU mortality rate was 66.6% in patients with co-infection versus 29.4% in patients infected with only SARS-CoV-2 (P < 0.05). The possibility of DENV and SARS-CoV2 co-infection occurred in the convergence of both epidemic waves. Co-infection was associated with worse clinical outcomes and higher mortality in ICU-admitted patients than in patients with the COVID-19 only.

Modification of Cellulose Acetate Microfiltration Membranes Using Graphene Oxide-Polyethyleneimine for Enhanced Dye Rejection.

Pressure-based membrane processes represent excellent water resource recovery prospects from industrial waste streams. In contrast with conventional pretreatment technologies, studies have shown that membrane pretreatment applications, such as microfiltration (MF), are more cost-effective and improve the results of the overall treatment processes. Hence, enhancing rejection efficiency of MF will enhance the performance of any downstream treatment processes. In this study, 0.45 µm cellulose acetate (CA) microfiltration membranes were modified by vacuum filtration-assisted layer-by-layer deposition of bilayers composed of negatively charged graphene oxide (GO) and positively charged polyethyleneimine (PEI). The performance of 1-, 2-, and 4-bilayer GO-PEI-modified membranes were investigated for their dye-rejection of anionic eriochrome black T (EBT) dye and cationic methylene blue (MB) dye in a cross-flow membrane module. As the number of bilayers on the membrane increased, the membrane thicknesses increased, and the deionized (DI) water flux through the membranes decreased from 4877 LMH/bar for the control (no bilayer) membrane to 2890 LMH/bar for the 4-bilayer membrane. Conversely, the dye-rejection performance of the modified membranes increased as increasing bilayers of GO-PEI deposited on the membranes. The anionic EBT dye saw superior rejection (~90% rejection) compared to the cationic MB dye (~80% rejection), which can be attributable to the electrostatic repulsion between the negatively charged GO surface and anionic EBT dye. After 50% recovery of the saline and dye-laden feed water, there was an observed drop in DI water fluxes of ~40-41% and 36%, respectively. There was also a slight increase in EBT dye-rejection during the composite feed-water experiments, attributed to the precipitation of salts on the membrane feed side or pore spaces, which subsequently reduce the membrane pore sizes.

An Evaluation of Pediatric Gastrocutaneous Fistula Closure Through the Punch Excision of Epithelized Tract Procedure.

BACKGROUND: Persistent gastrocutaneous fistulae frequently complicate gastrostomy tube placement. A minimally invasive technique for tract closure employing balloon catheter retraction and punch excision of the epithelized tract (PEET) was recently reported. We hypothesized the PEET technique of closure would lead to decreased complications without an increased incidence of recurrence. METHODS: We conducted a single-center retrospective cohort study evaluating children who underwent gastrocutaneous fistula (GCF) closure 1/1/2018-12/31/2021, comparing patients who underwent the PEET procedure to those repaired with layered closure. Procedure duration and outcomes were additionally compared to the 2018-2019 National Surgical Quality Improvement Program (NSQIP) Participant Use File (PUF) database. RESULTS: Sixty-two children underwent operative GCF closure, including 25 with PEET and 37 traditional layered closure. Procedural time was significantly decreased employing PEET (14 vs 26 minutes, P < .0001), less than half the national median by the NSQIP PUF database of 292 GCF closures (14 vs 34.5 minutes, P < .0001). Those repaired with the PEET method experienced no episodes of recurrence, surgical site infection, readmission, reoperation, or mortality within 30 days of the procedure. Conversely, in traditional closure, there was a 24.3% complication rate, including 7 surgical site infections, 1 readmission, and 2 unplanned reoperations. National procedural complication rate by NSQIP PUF was 5.5%, with a 4.8% rate of surgical site infection, .3% reoperation incidence, and .3% mortality. DISCUSSION: Our study suggests GCF closure employing the PEET procedure is a safe, more efficient method of tract closure than the traditional layered closure technique.

In-vitro Chemopreventive Potential of a Chromone from Bomarea setacea (ALSTROEMERIACEAE) against Colorectal Cancer.

Chemoprevention with natural products may provide important alternatives in the search for new drugs to treat cancer. Thus, the ethanol extract of Bomarea setacea and its secondary metabolite (chromone) were evaluated in-vitro in SW480 and SW620 human adenocarcinoma colon cells to identify a possible effect on cell growth, antiproliferative and/or proapoptotic activity. The ethanol extract did not show growth inhibition of these cell lines 48 h after treatment; besides, it required higher concentration and time to have an antiproliferative effect. On the other hand, although the chromone was not as active as the reference drug (5-FU), it displayed a greater selectivity, being 156-fold more selective against SW480 cells (SI => 100) and 255-fold against SW620 cells (SI => 86,9). Additionally, the chromone caused an important arrest in G2/M (44.18%) with an important accumulation in subG0/G1 phase in SW620 cells, inducing loss in mitochondrial membrane potential and damage in the cell membrane of both cell lines, with activation of caspase 3, suggesting an apoptotic process independent of ROS production and p53 activation.

A multi-institutional review of endovenous thermal ablation of the saphenous vein finds male sex and use of anticoagulation are predictors of long-term failure.

BACKGROUND: To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins. METHODS: A review of our EVA database (1998-2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate. RESULTS: 542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46-018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69-0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate. CONCLUSION: Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate.

Transcriptome network data in larval zebrafish (Danio rerio) following exposure to the phenylpyrazole fipronil.

Fipronil is a phenylpyrazole pesticide that is used in both residential and agricultural applications. Fipronil is detected in run-off and water systems that are near areas in which the pesticide has been applied. The pesticide acts to antagonize gamma aminobutyric acid receptors, leading to over-excitation in the central nervous system. Fipronil has relatively high toxicity to fish, but the mechanisms underlying the toxicity are not well understood in embryonic stages. Zebrafish embryos were exposed to a single concentration of fipronil for 48 h at ∼3-4 h-post-fertilization. Following a 7-day depuration phase, transcriptome and behavioral analyses were conducted. Transcriptomics identified neural processes as those differentially expressed with different doses of fipronil (0.2 µg, 200 µg and 2 mg fipronil/L). Gene networks associated with astrocyte differentiation, myelination, neural tube development, brain stem response, innervation, nerve regeneration, astrocyte differentiation, among other pathways were altered with exposure. In addition, miRNA-related events are disrupted by fipronil exposure and genes associated with primary or pri-miRNA processing were increased in larval fish exposed to the pesticide. These data present putative mechanisms associated with neurological impacts at later ages of zebrafish. This is important because it is not clear how early exposure to pesticides like fipronil affect central nervous system function and organisms later in life.

Residual molecular and behavioral effects of the phenylpyrazole pesticide fipronil in larval zebrafish (Danio rerio) following a pulse embryonic exposure.

Pesticides are typically applied to crops as acute applications, and residual effects of such intermittent exposures are not often characterized in developing fish. Fipronil is an agricultural pesticide that inhibits γ-amino-butyric acid (GABA) gated chloride channels. In this study, zebrafish (Danio rerio) embryos were exposed for 48 h (starting at ~3 h post fertilization, hpf) to various concentrations of fipronil (0.02 µg/L up to 4000 µg/L). Following this acute exposure, a subset of fish was transferred to clean water for a 7-day depuration phase. We hypothesized that a pulse exposure to fipronil during critical periods of central nervous system development would adversely affect fish later in life. After a 48 hour pulse exposure, survival was reduced in embryos exposed to 2 µg fipronil/L or greater. However, there was no further mortality during the depuration phase, nor were there changes in body length nor notochord length in larvae 9 dpf (days post-fertilization) compared to controls. Additional experiments were carried out at higher concentrations over 96 h (up to 4 dpf) to also elucidate developmental effects and teratogenicity of fipronil (43.7 µg/L up to 4370 µg/L). Fipronil at these higher concentrations significantly impacted the development of zebrafish, and the following morphometric and teratogenic effects were observed in 4 dpf fish; reduced body length, yolk sac and pericardial edema, reduced midbrain length, reduced optic and otic diameter, and truncation of the lower jaw. In depurated fish, we hypothesized that there would exist residual effects of exposure at the molecular level. Transcriptome profiling was therefore conducted on 9 dpf depurated larvae exposed initially for 48 h to one dose of either 0.2 µg/L, 200 µg/L or 2000 µg/L fipronil. The expression of gene networks associated with glycogen and omega-3-fatty acid metabolism were decreased in larvae exposed to each of the three concentrations of fipronil, suggesting metabolic disruption. Moreover, transcriptomics revealed that fipronil suppressed gene networks related to light-dark adaptation, photoperiod sensing, and circadian rhythm. Based on these data, we tested fish for altered behavioral responses in a Light-Dark preference test. Larvae exposed to >200 µg fipronil/L as embryos showed fewer number of visits (20-30% less) to the dark zone compared to controls. Larvae also spent a lower amount of time in the dark zone compared to controls, suggesting that fipronil strengthened dark avoidance behavior which is indicative of anxiety. This study demonstrates that a short pulse exposure to fipronil can affect transcriptome networks for metabolism, circadian rhythm, and response to light in fish after depuration, and these molecular responses are hypothesized to be related to aberrant behavioral effects observed in the light-dark preference test.

Effects of overfeeding and high-fat diet on cardiosomatic parameters and cardiac structures in young and adult zebrafish.

Obesity is a complex global health problem because it is a risk factor for multiple chronic pathologies such as cardiovascular, endocrine, metabolic, and neoplastic diseases. It is considered a multicausal disease, and one of the determining factors is nutritional imbalances, which include high-fat diets. In this paper, we use the zebrafish model to assess the impact of overfeeding and a high-fat diet in somatic and cardiac parameters in young and adult zebrafish. The results show that fish receiving a high-fat diet showed greater weight gain compared to fish receiving a standard fat diet. Additionally, changes in the heart, including increases in size, a change in the triangular shape of the ventricle to a globular shape, and an increase in the thickness of the trabeculae of the spongy myocardium were observed. These changes could be indicators of cardiovascular overload. The results show that there is a direct relationship between the intake of a high-fat diet and obesity, which in turn can induce cardiac changes, supporting the hypothesis of the relationship between high-fat diets and cardiovascular risk factors. Given the genetic similarity between zebrafish and humans, these results could be extrapolated to human beings, and the findings similarly highlight the importance of incorporating a balanced diet from the early life stages to reduce the risk of cardiovascular disease.

Cardiac and somatic parameters in zebrafish: tools for the evaluation of cardiovascular function.

Cardiovascular diseases are a worldwide public health problem. To date, extensive research has been conducted to elucidate the pathophysiological mechanisms that trigger cardiovascular diseases and to evaluate therapeutic options. Animal models are widely used to achieve these goals, and zebrafish have emerged as a low-cost model that produces rapid results. Currently, a large body of research is devoted to the cardiovascular development and diverse cardiovascular disorders of zebrafish embryos and larvae. However, less research has been conducted on adult zebrafish specimens. In this study, we evaluated a method to obtain and to evaluate morphometric parameters (of both the entire animal and the heart) of adult zebrafish. We used these data to calculate additional parameters, such as body mass index, condition factor and cardiac somatic index. This method and its results can be used as reference for future studies that aim to evaluate the pathophysiological aspects of the zebrafish cardiovascular system.

Conocimientos médicos sobre enfermedades raras por parte de los profesionales de la salud / Medical knowledge on rare diseases of health professionals

Las enfermedades raras (ER) se caracterizan por ser de baja prevalencia, crónicas, causar invalidez y alta morbimortalidad y afectan a tres millones de personas en España. Un diagnóstico precoz y un tratamiento adecuado disminuyen los efectos de la enfermedad y mejoran la calidad de vida de los afectados y sus familias. Objetivo: Valorar el grado de conocimientos de los profesionales de atención primaria(AP) de la salud acerca de las ER. Diseño: Estudio descriptivo transversal. Aplicación de un cuestionario diseñado a propósito del estudio para evaluar conocimientos médicos. Emplazamiento: AP del sistema sanitario público. Participantes: 128 profesionales de la salud (32.7% hombres, 67.3% mujeres). Mediciones principales: A través de la aplicación del cuestionario se midieron los conocimientos teóricos y la autopercepción relacionados con formación e información recibida sobre ER, unidades de referencia, registros y dispositivos de actuación. Resultados: Alto desconocimiento en los aspectos analizados. Los niveles menos puntuados (escala Likert: 1 a 5) están relacionados con los dispositivos de actuación(media = 1.95), seguidos por formación e información recibida (media = 2.12), unidades y registros de ER (media = 2.20). Conclusiones: Es necesario implementar medidas que mejoren el conocimiento de los profesionales de AP sobre las ER, ello repercutirá en mejorar la calidad de la atención al paciente y su familia. Nuestro cuestionario aporta una herramienta útil y adecuada para valorar qué aspectos se han mejorado, cómo hay que priorizar las actuaciones y evaluar el impacto de acciones formativas y de capacitación en el ámbito de las ER...

Zebrafish (Danio rerio): A Potential Model for Toxinological Studies.

Zebrafish are an emerging basic biomedical research model that has multiple advantages compared with other research models. Given that biotoxins, such as toxins, poisons, and venoms, represent health hazards to animals and humans, a low-cost biological model that is highly sensitive to biotoxins is useful to understand the damage caused by such agents and to develop biological tests to prevent and reduce the risk of poisoning in potential cases of bioterrorism or food contamination. In this article, a narrative review of the general aspects of zebrafish as a model in basic biomedical research and various studies in the field of toxinology that have used zebrafish as a biological model are presented. This information will provide useful material to beginner students and researchers who are interested in developing toxinological studies with the zebrafish model.

El ser humano como una totalidad / The human being as a totality

A través de este artículo se quiere invitar a los trabajadores de la salud a desarrollar o buscar mediosDe atención que mejoren el cuidado en salud de los seres humanos. Si bien el personal de salud conocelas maneras para desarrollar estos medios, parece olvidarlos. Debido a lo anterior cada día aumentanlas quejas de los usuarios acerca de los servicios recibidos. Todos los esfuerzos que se hagan paraimplementar medidas que conlleven a la humanización tendrán sentido; por ello el énfasis enprofundizar en los mismos, dada las necesidades del individuo considerado como una totalidad.

Through this paper we invite all health workers to improve care and treat given to patients becausethere is a lot of variables unminded of on delivering health service. Although health personnel isacquainted with these variables, their behavior leaves them behind, and thus patients’ claims increaseday after day. All efforts must be deployed to customize the health service bringing in humanity senseand insight into people’s needs.

Proyecto CARMEN Colombia: resumen ejecutivo / Colombiaïs CARMEN project: executive abstract

Las Enfermedades Crónicas no Transmisibles constituyen una prioridad para la salud pública en el país, debido a su elevado impacto incluso en las etapas más productivas de la vida y a la enorme carga social y económica que representan para el país por la demanda de atención médica, ausentismo laboral, discapacidad y muerte que ocasionan. Al hacer un análisis cuidadoso de la situación de salud en Colombia, se observa claramente la necesidad de abordar desde una perspectiva más integral la problemática de las Enfermedades Crónicas no Transmisibles, e intervenir con un enfoque intersectorial, los diferentes factores de riesgo que están provocando enfermedades, discapacidad y pérdidas prematuras de vidas humanas, deben tenerse en cuenta que estas intervenciones solo son posibles si se logra la incorporación de todas las instancias responsables de crear desde sus diferentes ámbitos entornos socio-económicos, físicos y culturales que promuevan la salud. La intersectorialidad se convierte entonces en la base fundamental para desarrollar metodologías integrales, interdisciplinarias y comunitarias que facilitan el control y apoyan la disminución de estas enfermedades. El presente documento contiene el resumen del Protocolo Nacional de CARMEN Colombia. El cual se ha construído y revisado con la colaboración de diferentes instituciones, que han contribuído con sus aportes en la priorización de problemas y la identificación de estrategias y alternativas de intervención