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1.
Prog Transplant ; : 1526924820958116, 2020 Sep 22.
Artigo em Inglês | MEDLINE | ID: mdl-32959728

RESUMO

Public Health Service increased risk donor kidneys are discarded 50% more often than nonincreased risk donor kidneys despite equivalent patient and graft survival outcomes. Patient and provider biases as well as challenges in risk interpretation contribute to the underuse of increased risk donor organs. As the ultimate decision to accept or reject an increased risk donor organ results from the patient-provider conversation, there is an opportunity to improve this dialogue. This report introduces the best-case/worst-case communication guide for structuring high-stake conversations on increased risk kidney offers between transplant providers and their patients. Through best case/worst case, providers focus on eliciting patient values and long-term goals. The patient's unique context can then inform an individualized discussion of "best," "worst," and "most likely" outcomes and support the provider's ultimate recommendation. Transplant providers are encouraged to adopt this communication strategy to enhance shared decision-making and improve patient outcomes.

2.
Chem Commun (Camb) ; 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32975275

RESUMO

Benzene and acetonitrile are two of the most commonly used solvents found in almost every chemical laboratory. Titan is one other place in the solar system that has large amounts of these compounds. On Titan, organic molecules are produced in the atmosphere and carried to the surface where they can mineralize. Here, we report the phase diagram of mixtures of acetonitrile and benzene, and provide an account of the structure and composition of the phases. To mimic the environment on Titan more accurately, we tested the stability of the structure under liquid ethane. The results provide new insights into the structure and stability of potential extraterrestrial minerals. In light of Dragonfly, NASA's upcoming mission to Titan, revisiting the fundamental chemistry of the smallest molecules with modern methods and techniques can have significant contributions to this epochal mission and can open new research directions in chemistry.

3.
J Am Coll Surg ; 2020 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-32891797

RESUMO

BACKGROUND: With growing telehealth utilization, understanding factors affecting patient follow-up in traditional and telehealth settings is important. Few data exist examining the utilization of telehealth compared to traditional settings. Bridging this gap is critical to optimizing telehealth utilization and reducing barriers. STUDY DESIGN: A retrospective cohort study of return and post-operative (electronic video [eClinic] and traditional) visits from January 2018 - March 2020 at single tertiary care center. There were 12,359 unique first-encounter patients with 903 eClinic and 11,456 traditional visits. 11,547 patients completed visits while 812 patients did not show up. Multivariable logistic regression modeling was performed to identify factors associated with no-show. County-level mapping was used to identify patterns in no-show rates. RESULTS: eClinic patients had twice the odds of no-show compared to traditional clinic (p<0.001). Age was inversely proportional to odds of no-show with each additional decade associated with a 16% decrease in these odds (p<0.001). African-American patients have greater odds of no-show compared to Caucasian patients (OR 2.47; 95% CI 1.95-3.13, p<0.001). Marital statuses of single and legal separation were associated with higher odds of no-show compared to married marital status (p<0.001 and p=0.04, respectively). Minimally-invasive and endocrine surgery clinics had lower odds of no-show compared with acute care surgery clinic (p<0.001 for both). County-level no-show rates demonstrate similar patterns between clinic settings. CONCLUSIONS: Several factors are associated with increased odds of no-show including the visit being in eClinic. County-level analysis suggests no-show variation is not dependent on geographical location. Understanding these patterns allows for prospective identification of barriers and development of interventions to optimize access and patient care.

4.
BMJ Qual Saf ; 2020 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-32938775

RESUMO

BACKGROUND: Opioids are prescribed in excess after surgery. We leveraged our continuous quality improvement infrastructure to implement opioid prescribing guidelines and subsequently evaluate changes in postoperative opioid prescribing, consumption and patient satisfaction/pain in a statewide regional health system. METHODS: We collected data regarding postoperative prescription size, opioid consumption and patient-reported outcomes from February 2017 to May 2019, from a 70-hospital surgical collaborative. Three iterations of prescribing guidelines were released. An interrupted time series analysis before and after each guideline release was performed. Linear regression was used to identify trends in consumption and patient-reported outcomes over time. RESULTS: We included 36 022 patients from 69 hospitals who underwent one of nine procedures in the guidelines, of which 15 174 (37.3%) had complete patient-reported outcomes data following surgery. Before the intervention, prescription size was decreasing over time (slope: -0.7 tablets of 5 mg oxycodone/month, 95% CI -1.0 to -0.5 tablets, p<0.001). After the first guideline release, prescription size declined by -1.4 tablets/month (95% CI -1.8 to -1.0 tablets, p<0.001). The difference between these slopes was significant (p=0.006). The second guideline release resulted in a relative increase in slope (-0.3 tablets/month, 95% CI -0.1 to -0.6, p<0.001). The third guideline release resulted in no change (p=0.563 for the intervention). Overall, mean (SD) prescription size decreased from 25 (17) tablets of 5 mg oxycodone to 12 (8) tablets. Opioid consumption also decreased from 11 (16) to 5 (7) tablets (p<0.001), while satisfaction and postoperative pain remained unchanged. CONCLUSIONS: The use of procedure-specific prescribing guidelines reduced statewide postoperative opioid prescribing by 50% while providing satisfactory pain care. These results demonstrate meaningful impact on opioid prescribing using evidence-based best practices and serve as an example of successful utilisation of a regional health collaborative for quality improvement.

5.
Can J Surg ; 63(5): E374-E382, 2020 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-32856886

RESUMO

Background: The New Brunswick Heart Centre (NBHC) entered a contractual partnership with Integrated Health Solutions (IHS) to help address increasing wait times in the province of New Brunswick. Methods: Team leaders were identified from each of the target areas, including surgeons, anesthesiologists, nurses (operating room, intensive care unit [ICU] and postoperative ward), access coordinators and administrators. The methodology used was based on Lean principles and involved exercises by stakeholders aimed at identifying opportunities for improvement. A weekly dashboard was created to monitor and facilitate improvement efforts. No additional hospital beds or operating room theatres were added during the study period. Results: After 2 years, the annual number of cardiac surgical interventions increased from 788 to 873, representing a 10.8% increase in capacity. The best median wait time for patients decreased from 52 to 35 days (35% reduction). The best 90th percentile wait time decreased from 126 to 98 days (22% reduction). The overall increase in capacity could be explained in part by the significant increase in fast tracking from the ICU to the ward (> 2-fold) or bypassing the ICU altogether (4-fold increase reaching 13%). Despite these successes, challenges persist as the number of OR cancellations remained around 7.5% of all cases, mainly because of limited ICU resources. Conclusion: The NBHC-IHS partnership on this project has resulted in excellent engagement by stakeholders and promoted team cohesiveness. Furthermore, it has allowed significant reorganization and realignment of efforts to limit wait times and maximize overall capacity.

6.
J Surg Educ ; 2020 Jul 29.
Artigo em Inglês | MEDLINE | ID: mdl-32739442

RESUMO

OBJECTIVE: We describe a multilevel, collaborative research group for trainees and faculty engaging in transplant surgery research within one institution. DESIGN: Transplant Research, Education, and Engagement (TREE) was designed to develop trainees' research skills and foster enthusiasm in transplant surgery along the educational continuum. Our research model intentionally empowers junior researchers, including undergraduates and medical students, to assume active roles on a range of research projects and contribute new ideas within a welcoming research and learning environment. SETTING: Section of Transplant Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan. PARTICIPANTS: Undergraduate premedical students, first through fourth year medical students, general surgery residents, transplant surgery fellows, and transplant surgery faculty. RESULTS: TREE was founded in September 2019 and has grown to include over 30 active members who meet weekly and collaborate virtually on a range of research projects, many of which are led by students. Trainees can assume both mentee and mentor roles and build their research, presentation and writing skills while collaborating academically. CONCLUSIONS: Our model has increased trainees' engagement in transplant research projects and fosters early enthusiasm for the field. This model can be feasibly replicated at other institutions and within other subspecialties.

7.
Surg Endosc ; 2020 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-32749611

RESUMO

BACKGROUND: The purpose of this study was to analyze non-dysplastic Barrett's esophagus (NDBE) biopsy tissue and compare the rate of somatic DNA copy number alterations (CNAs) in patients who subsequently progressed to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) to those patients who did not. METHODS: A retrospectively collected database of Barrett's esophagus (BE) patients spanning a 16-year period was queried. Patients who progressed from NDBE to HGD or EAC were identified and compared to patients who did not. Initial biopsy specimens were microdissected and extracted DNA underwent Multiplex Ligation-dependent Probe Amplification (MLPA) for CNAs. Comparisons between progressors and non-progressors were made with Fisher's exact and two-sample t tests. Logistic regression assessed factors associated with progression. RESULTS: Of the 2459 patients in the BE database, 36 patients progressed from NDBE to either HGD or EAC. There were eight progressors who had biopsy specimens with adequate DNA for analysis. The progressor and non-progressor cohort had similar demographic information and medical history. The progressor group trended towards being older at diagnosis (72 ± 10 vs. 64 ± 13 years, p = 0.097) and fewer progressors reported reflux symptoms (50 vs. 94.7%, p < 0.001). Progressor specimens had more overall CNAs (75% vs. 33.6%, p = 0.026). On univariable analysis, there was an association between progression and absence of GERD symptoms (OR 16.54 [3.42-80.03], p = 0.001), any CNA (OR 5.10 [1.18-23.30], p = 0.035), and CNA in GATA6 or ERBB2 (OR 6.72 [1.18-38.22], p = 0.032). CONCLUSIONS: Patients who progressed from NDBE to HGD or EAC were older at first diagnosis of BE and fewer of the progressors reported symptoms of reflux when compared to non-progressors. Progression was associated with the presence of any CNA and specific CNAs in GATA6 or ERBB2.

8.
Med Teach ; : 1-4, 2020 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-32692590

RESUMO

The use of simulation as a tool for assessment in medical examinations is expanding. We describe 12 practical tips for the implementation of simulation based critical evaluation for the Objective Structured Clinical Examination (OSCE). The material in this article is a combination of personal experience and the available literature. Three themes are discussed encompassing simulation theory for the OSCE, practical features of simulation for the clinical examination and contingency planning. As clinical assessment evolves, the utility for simulation-based practice will advance alongside. An improved understanding of the processes for incorporating simulation into the OSCE will be of benefit to both the medical educator and the student.

9.
Nat Commun ; 11(1): 3087, 2020 06 18.
Artigo em Inglês | MEDLINE | ID: mdl-32555184

RESUMO

The design of stable adsorbents capable of selectively capturing dioxygen with a high reversible capacity is a crucial goal in functional materials development. Drawing inspiration from biological O2 carriers, we demonstrate that coupling metal-based electron transfer with secondary coordination sphere effects in the metal-organic framework Co2(OH)2(bbta) (H2bbta = 1H,5H-benzo(1,2-d:4,5-d')bistriazole) leads to strong and reversible adsorption of O2. In particular, moderate-strength hydrogen bonding stabilizes a cobalt(III)-superoxo species formed upon O2 adsorption. Notably, O2-binding in this material weakens as a function of loading, as a result of negative cooperativity arising from electronic effects within the extended framework lattice. This unprecedented behavior extends the tunable properties that can be used to design metal-organic frameworks for adsorption-based applications.

10.
Artigo em Inglês | MEDLINE | ID: mdl-32502731

RESUMO

OBJECTIVE: Many insurance payers are hesitating to cover interventional treatments in patients with isolated symptomatic varicose veins. In this study, we sought to determine the outcomes of patients with varicose veins who were treated with venous ablation alone or ablation plus phlebectomy using the Vascular Quality Initiative Varicose Vein Registry. METHODS: Using data from the Varicose Vein Registry between January 2015 and March 2019, we investigated immediate postoperative as well as long-term clinical and patient-reported outcomes among patients with documented symptomatic C2 disease undergoing truncal endovenous ablations alone and combined ablation and phlebectomy. Preprocedural and postprocedural comparisons were performed using t-test, χ2 test, or nonparametric tests when appropriate. Multivariable ordinal logistic regression was performed on ordinal outcome variables. RESULTS: Among 3375 patients with symptomatic C2 disease, 40.1% of patients (1376) underwent isolated truncal ablation and 59.9% (1999) underwent ablation and phlebectomy. Complications overall were low (8.6%) and varied between 8.4% and 8.7% in patients undergoing ablation alone and ablation plus phlebectomy, respectively (P = .820). The most common complication noted was paresthesia, 3.4% overall, which occurred more commonly after ablation and phlebectomy (4.5%) than after ablation alone (1.3%; P < .001). An improvement in Venous Clinical Severity Score (VCSS) was experienced by 87.4% of patients; median change in VCSS was 4 points (interquartile range [IQR], 2-5 points), with an improvement of 3 points among patients undergoing ablation alone (IQR, 1-5 points) and 5 points among patients undergoing ablation and phlebectomy (IQR, 3-5 points; P < .001). An improvement in overall symptoms was experienced by 94.4% of patients (median improvement, 11 points; (maximum, 30 points), with more significant decreases among patients undergoing ablation and phlebectomy (median, 12 points; IQR, 8-17 points) compared with ablation alone (median, 9 points; IQR, 5-13 points; P < .001). CONCLUSIONS: Among patients with isolated symptomatic varicose veins (C2 disease), ablation and ablation with phlebectomy are safe and effective in improving both patient-reported outcomes and clinical severity (VCSS). Given these data, payers should continue to cover these treatments.

11.
Artigo em Inglês | MEDLINE | ID: mdl-32592853

RESUMO

OBJECTIVE: Few studies have investigated outcomes after truncal endovenous ablation in patients with combined deep and superficial reflux and no studies have evaluated patient-reported outcomes. METHODS: We investigated the short- and long-term clinical and patient-reported outcomes among patients with and without deep venous reflux undergoing truncal endovenous ablation from 2015 to 2019 in the Vascular Quality Initiative. Preprocedural and postprocedural comparisons were performed using the t-test, χ2, or their nonparametric counterpart when appropriate. Multivariable logistic regression models were used to assess for confounding. RESULTS: A total of 4881 patients were included, of which 2254 (46.2%) had combined deep and superficial reflux. The median follow-up was 336.5 days. Patients with deep reflux were less likely to be female (65.9% vs 69.9%; P = .003), more likely to be Caucasian (90.2% vs 86.5%; P = .003) and had no difference in BMI (30.6 ± 7.5 vs 30.6 ± 7.2; P = .904). Additionally, no difference was seen in rates of prior varicose vein treatments, number of pregnancies, or history of deep venous thrombosis; however, patients without deep reflux were more likely to be on anticoagulation at the time of the procedure (10.9% vs 8.1%; P < .001). Patients without deep reflux had slightly higher median preprocedural Venous Clinical Severity Score (VCSS) scores (8 [interquartile range (IQR), 6-10]) vs 7 [IQR, 6-10]; P = .005) as well as postprocedural VCSS scores (5 [IQR, 3-7] vs 4 [IQR, 2-6]; P < .001). The median change in VCSS from before to after the procedure was lower for patients without deep reflux (3 [IQR, 1.0-5.5] vs 3.5 [IQR, 1-6]; P = .006). Total symptom score was higher for patients without deep reflux both before (median, 14 [IQR, 10-19] vs median, 13.5 [IQR, 9.5-18]; P = .005) and postprocedurally (median, 4 [IQR, 1-9] vs median, 3.25 [IQR, 1-7]; P < .001), but no difference was seen in change in symptom score (median, 8 [IQR, 4-13] vs median, 9 [IQR, 4-13]; P = .172). Patients with deep reflux had substantially higher rates of complications (10.4% vs 3.0%; P < .001), with a particular increase in proximal thrombus extension (3.1% vs 1.1%; P < .001). After controlling for confounding, this estimate of effect size for any complication increased (odds ratio, 5.72; 95% confidence interval, 2.21-14.81; P < .001). CONCLUSIONS: No significant difference is seen in total symptom improvement when patients undergo truncal endovenous ablation with concomitant deep venous reflux, although a greater improvement was seen in VCSS score in these patients. Patients with deep venous reflux had a significantly increased rate of complications, independent of confounding variables, and should be counseled appropriately before the decision for treatment.

12.
Sci Total Environ ; 732: 139217, 2020 Aug 25.
Artigo em Inglês | MEDLINE | ID: mdl-32438175

RESUMO

Data from 38,105 wells were used to characterize fluoride (F) occurrence in untreated United States (U.S.) groundwater. For domestic wells (n = 11,032), water from which is generally not purposely fluoridated or monitored for quality, 10.9% of the samples have F concentrations >0.7 mg/L (U.S. Public Health Service recommended optimal F concentration in drinking water for preventing tooth decay) (87% are <0.7 mg/L); 2.6% have F > 2 mg/L (EPA Secondary Maximum Contaminant Level, SMCL); and 0.6% have F > 4 mg/L (EPA MCL). The data indicate the biggest concern with F in domestic wells at the national scale could be one of under consumption of F with respect to the oral-health benchmark (0.7 mg/L). Elevated F concentrations relative to the SMCL and MCL are regionally important, particularly in the western U.S. Statistical comparisons of potentially important controlling factors in four F-concentration categories (<0.1-0.7 mg/L; >0.7-2 mg/L; >2-4 mg/L; >4 mg/L) at the national scale indicate the highest F-concentration category is associated with groundwater that has significantly greater pH values, TDS and alkalinity concentrations, and well depths, and lower Ca/Na ratios and mean annual precipitation, than the lowest F-concentration category. The relative importance of the controlling factors appears to be regionally variable. Three case studies illustrate the spatial variability in controlling factors using groundwater-age (groundwater residence time), water-isotope (evaporative concentration), and water-temperature (geothermal processes) data. Populations potentially served by domestic wells with F concentrations <0.7, >0.7, >2, and >4 mg/L are estimated to be ~28,200,000, ~3,110,000; ~522,000; and ~172,000 people, respectively, in 40 principal aquifers with at least 25 F analyses per aquifer.

13.
Artigo em Inglês | MEDLINE | ID: mdl-32470615

RESUMO

OBJECTIVE: Venous insufficiency is commonly bilateral, and patients often prefer single-episode care compared with staged procedures. Few studies have investigated clinical outcomes after unilateral vs bilateral venous ablation procedures or between staged and concurrent bilateral procedures. Here, we report data from the Vascular Quality Initiative regarding truncal venous ablation for chronic venous insufficiency. METHODS: Using data from the Vascular Quality Initiative, we investigated immediate postoperative as well as long-term clinical and patient-reported outcomes of patients undergoing unilateral vs bilateral truncal endovenous ablation from 2015 to 2019. We further investigated outcomes between staged bilateral and concurrent bilateral ablations. Preprocedural and postprocedural comparisons were performed using t-test, χ2 test, or their nonparametric counterpart when appropriate. Multivariable ordinal logistic regression was performed on ordinal outcome variables. RESULTS: A total of 5029 patients were included, of whom 3782 (75.2%) underwent unilateral procedures. Median follow-up was 227 days (interquartile range [IQR], 55-788 days). Unilateral patients were less likely to be female (67.0% vs 70.3%; P = .031) and white (86.3% vs 91.2%; P < .001) and had lower body mass index (30.3 ± 7.3 kg/m2 vs 31.8 ± 7.6 kg/m2; P < .001) compared with patients undergoing bilateral procedures. In addition, unilateral patients had fewer prior varicose vein treatments (23.0% vs 15.7%; P < .001) and had higher median preprocedural Venous Clinical Severity Score (VCSS; 8 [IQR, 6-10] vs 7 [IQR, 5.5-9]; P < .001). No difference was seen in complications (6.9% vs 8.2%; P = .292), and systemic complications were rare in both groups. No difference was seen in VCSS improvement after treatment (median, 3 [IQR, 1-6] for unilateral; median, 3 [IQR 1-5] for bilateral; P = .055). In comparing staged with concurrent bilateral procedures, there was no difference in overall complications (7.5% vs 12.2%; P = .144). Staged bilateral patients were older (56.9 ± 13.3 years vs 54.2 ± 12.9 years; P = .002), less likely to have had prior varicose vein treatment (14.3% vs 19.8%; P = .020), and more likely to be therapeutically anticoagulated (10.8% vs 6.5%; P = .028) compared with concurrent bilateral patients. Staged patients also have higher preprocedural VCSS compared with concurrent patients (median, 8 [IQR, 6-10] vs 7 [IQR, 5.5-9]; P < .001). In multivariable analysis, there was no difference in the likelihood of VCSS improvement for concurrent compared with staged procedures (odds ratio, 0.70; 95% confidence interval, 0.40-1.24; P = .226). CONCLUSIONS: Concurrent bilateral truncal endovenous ablation can be performed safely without increased morbidity compared with staged bilateral or unilateral ablations.

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J Gen Intern Med ; 35(7): 2193-2194, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32314133
19.
Am J Transplant ; 20(9): 2530-2539, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32243667

RESUMO

Bariatric surgery is effective among patients with previous transplant in limited case series. However, the perioperative safety of bariatric surgery in this patient population is poorly understood. Therefore, we assessed the safety of bariatric surgery among previous-transplant patients using a database that captures >92% of all US bariatric procedures. All primary, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures between 2017 and 2018 were identified from the MBSAQIP dataset. Patients with previous transplant (n = 610) were compared with patients without previous transplant (n = 321 447). Primary outcomes were 30 day readmissions, surgical complications, medical complications, and death. Multivariable logistic regression with predictive margins was used to compare outcomes. Previous transplant patients experienced higher incidence of readmissions (8.0% vs 3.5%), surgical complications (5.0% vs 2.7%), and medical complications (4.3% vs 1.5%). There was no difference in incidence of death (0.2% vs 0.1%). Among individual complications, there no statistical differences in intraabdominal leak, unplanned reoperation, myocardial infarction, or infectious complications. Baseline estimated glomerular filtration rate was found to be a strong moderator of primary outcomes, with the highest risk of complications occurring at the lowest baseline estimated glomerular filtration rate. Given the many long-term benefits of bariatric surgery among patients with previous transplant, our findings should not preclude this patient population from operative consideration.

20.
Inorg Chem ; 2020 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-32196322

RESUMO

Spin-phonon coupling plays a critical role in magnetic relaxation in single-molecule magnets (SMMs) and molecular qubits. Yet, few studies of its nature have been conducted. Phonons here refer to both intermolecular and intramolecular vibrations. In the current work, we show spin-phonon couplings between IR-active phonons in a lanthanide molecular complex and Kramers doublets (from the crystal field). For the SMM Er[N(SiMe3)2]3 (1, Me = methyl), the couplings are observed in the far-IR magnetospectroscopy (FIRMS) of crystals with coupling constants ≈ 2-3 cm-1. In particular, one of the magnetic excitations couples to at least two phonon excitations. The FIRMS reveals at least three magnetic excitations (within the 4I15/2 ground state/manifold; hereafter, manifold) at 0 T at 104, ∼180, and 245 cm-1, corresponding to transitions from the ground state, MJ = ±15/2, to the first three excited states, MJ = ±13/2, ±11/2, and ±9/2, respectively. The transition between the ground and first excited Kramers doublet in 1 is also observed in inelastic neutron scattering (INS) spectroscopy, moving to a higher energy with an increasing magnetic field. INS also gives complete phonon spectra of 1. Periodic DFT computations provide the energies of all phonon excitations, which compare well with the spectra from INS, supporting the assignment of the inter-Kramers doublet (magnetic) transitions in the spectra. The current studies unveil and measure the spin-phonon couplings in a typical lanthanide complex and throw light on the origin of the spin-phonon entanglement.

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