Computed tomographic measurement of canine urine concentration.

Computed tomography (CT) is able to measure the attenuation of urine in Hounsfield units (HU) on abdominal imaging studies. This study was designed to measure the correlation of urine attenuation with urine specific gravity in urine samples of 40 dogs, providing a noninvasive measure of urine concentration. The HU of urine explained 72% of the variance in measured urine specific gravity [R2 = 0.72, F(1,38) = 95.55, P < 0.001]. This noninvasive measurement can be used to estimate urine concentration in dogs undergoing abdominal CT imaging.

Mesure de la concentration de l'urine canine par tomodensitométrie. La tomodensitométrie (TO) peut mesurer l'atténuation de l'urine en unités Hounsfield (UH) dans des études d'imagerie abdominale. Cette étude a été conçue pour mesurer la corrélation de l'atténuation de l'urine avec la gravité spécifique de l'urine dans des échantillons d'urine de 40 chiens, ce qui a fourni une mesure non invasive de la concentration de l'urine. Les UH de l'urine ont expliqué 72 % des variances dans la gravité spécifique de l'urine mesurée [R2 = 0,72, F(1,38) = 95,55, P < 0,001]. Cette mesure non invasive peut servir à estimer la concentration de l'urine des chiens subissant une imagerie abdominale réalisée par tomodensitométrie.(Traduit par Isabelle Vallières).

Hematologic, Plasma Biochemical, and Lipid Panel Reference Intervals in Orange-winged Amazon Parrots ( Amazona amazonica ).

To establish reference intervals in orange-winged Amazon parrots ( Amazona amazonica ) for the complete blood count, plasma biochemical values, and lipid panel and to evaluate age- and sex-related variations, blood samples were obtained from 29 healthy juvenile and adult parrots. Concentrations of total protein, bile acids, phosphorus, total cholesterol, low-density-lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol were significantly higher in adult compared with juvenile birds, while uric acid concentration was significantly higher in juveniles. The white blood cell count, lymphocyte count, and phosphorus and potassium concentrations were significantly higher in females, while chloride concentration was significantly higher in males. In this species, direct measurement of LDL-C resulted in lower concentrations than LDL-C calculated with the Friedewald formula. Assessment of the agreement between the calculated and measured LDL-C concentrations indicated a systematic bias of 19.1 mg/dL and a proportional bias of 1.07. A correction factor of -19 mg/L could be applied to the Friedewald formula, to obtain a result closer to the measured LDL-C, providing clinically acceptable (<20% difference) agreement in 66% of the samples. Triglyceride concentrations within the range measured in healthy birds of the present study did not significantly affect the bias between calculated and directly measured LDL-C. Further studies are needed to investigate the impact of nutritional factors, genetics, and exercise on biochemistry and lipoprotein panel analytes in orange-winged Amazon parrots.

Smart and Fast Blood Counting of Trace Volumes of Body Fluids from Various Mammalian Species Using a Compact, Custom-Built Microscope Cytometer.

We report an accurate method to count red blood cells, platelets, and white blood cells, as well as to determine hemoglobin in the blood of humans, horses, dogs, cats, and cows. Red and white blood cell counts can also be performed on human body fluids such as cerebrospinal fluid, synovial fluid, and peritoneal fluid. The approach consists of using a compact, custom-built microscope to record large field-of-view, bright-field, and fluorescence images of samples that are stained with a single dye and using automatic algorithms to count blood cells and detect hemoglobin. The total process takes about 15 min, including 5 min for sample preparation, and 10 min for data collection and analysis. The minimum volume of blood needed for the test is 0.5 µL, which allows for minimally invasive sample collection such as using a finger prick rather than a venous draw. Blood counts were compared to gold-standard automated clinical instruments, with excellent agreement between the two methods as determined by a Bland-Altman analysis. Accuracy of counts on body fluids was consistent with hand counting by a trained clinical lab scientist, where our instrument demonstrated an approximately 100-fold lower limit of detection compared to current automated methods. The combination of a compact, custom-built instrument, simple sample collection and preparation, and automated analysis demonstrates that this approach could benefit global health through use in low-resource settings where central hematology laboratories are not accessible.

Refocusing the Military Health System to support Role 4 definitive care in future large-scale combat operations.

ABSTRACT: The last 20 years of sustained combat operations during the Global War on Terror generated significant advancements in combat casualty care. Improvements in point-of-injury care, en route care, and forward surgical care appropriately aligned with the survival, evacuation, and return to duty needs of the small-scale unconventional conflict. However, casualty numbers in large-scale combat operations have brought into focus the critical need for modernized casualty receiving and convalescence: Role 4 definitive care. Historically, World War II was the most recent conflict in which the United States fought in multiple operational theaters, with hundreds of thousands of combat casualties returned to the continental United States. These numbers necessitated the establishment of a "Zone of the Interior," which integrated military and civilian health care networks for definitive treatment and rehabilitation of casualties. Current security threats demand refocusing and bolstering the Military Health System's definitive care capabilities to maximize its force regeneration capacity in a similar fashion. Medical force generation, medical force sustainment and readiness, and integrated casualty care capabilities are three pillars that must be developed for Military Health System readiness of Role 4 definitive care in future large-scale contingencies against near-peer/peer adversaries.

Effects of hyperglycemia and continuous intravenous insulin on outcomes of surgical patients.

BACKGROUND: Hyperglycemia in critically ill patients has been associated with increased morbidity and mortality. It is unclear to what degree hyperglycemia should be regulated in a mixed surgical population. STUDY DESIGN: A retrospective chart review of 210 surgical patients in the intensive care unit (ICU) was performed. All patients were placed on an intravenous insulin protocol targeted to a blood glucose (BG) of 80-140 mg/dL. Outcomes were compared between surgical patients with controlled BG levels (80-140 mg/dL) versus uncontrolled levels (>140 mg/dL). RESULTS: The mortality rate of this population was 12%, 5% in the controlled BG group compared with 18% in the uncontrolled BG group (P < 0.01). After adjusting for covariates, the mortality rate of the uncontrolled blood glucose group was significantly greater (OR = 4.8, 95% CI 1.4-20; P = 0.02). The overall hypoglycemic rate was <1%, and was not associated with a higher mortality, P = 0.60. A greater mortality rate was associated with patients who spent a greater time with blood glucose values >181 mg/dL (OR = 1.3, 95% CI 1.1-1.6; P = 0.01). CONCLUSIONS: Increased mortality was associated with surgical patients in the uncontrolled blood glucose group compared with patients who were well controlled with insulin therapy. These results are comparable to previous studies and indicate that surgical patients are a population who may benefit from tighter glycemic control. Further investigations through prospective randomized studies are needed to fully evaluate the effects of hyperglycemia in a diverse surgical population as well as specific surgical subspecialties.

Effects of combination dobutamine and vasopressin therapy on microcirculatory blood flow in a porcine model of severe endotoxic shock.

BACKGROUND: Dobutamine (DB) has been recommended in combination with vasopressor therapy in septic shock, given its reported ability to improve mesenteric and microcirculatory perfusion. Vasopressin (VP) is typically reserved as a second-line agent due to the concern of ischemia. The purpose of our study was to determine whether combination DB and VP therapy improved microcirculatory blood flow in severe endotoxic shock. METHODS: Septic shock was induced in 20 anesthetized piglets with injection of E. coli endotoxin. DB (10 µg/kg/min, n = 5) and VP (0.04 units/min, n = 10) were administered alone and in combination (n = 15). Measurements were compared at baseline, following endotoxin administration, and following treatment. Microcirculatory blood flow was determined via the injection of colored microspheres. RESULTS: VP completely reversed endotoxin-mediated hypotension with a mean arterial pressure (MAP) of 85 ± 4.5 mm Hg, which was not significantly altered with the addition of DB (77 ± 4.9 mm Hg). Endotoxin uniformly depressed cardiac output (CO) from baseline (227 ± 10.7 versus 174 ± 12.4 mL/min/kg) despite treatment with VP alone or in combination with DB. The addition of DB did not improve the CO in this severe septic shock model. VP was found to shunt microcirculatory flow from the skin and GI tract to vital organs such as the brain, liver, and kidneys, which was not altered with the addition of DB. CONCLUSIONS: Results indicate that DB is ineffective in increasing CO or improving mesenteric blood flow when used with physiologic replacement doses of VP. In combination, DB is unable to overcome the blood flow distribution achieved with VP administration alone in severe endotoxic shock.

Clinical Readiness Program: Refocusing the Military Health System.

INTRODUCTION: The Military Health System serves to globally provide health services and trained medical forces. Military providers possess variable levels of deployment preparedness. The aim of the Clinical Readiness Program is to develop and assess the knowledge, skills, and abilities (KSAs) needed for combat casualty care. METHODS: The Clinical Readiness Program developed a KSA metric for general and orthopedic surgery. The KSA methodology underwent a proof of concept in six medical treatment facilities. RESULTS: The KSA metric feasibly quantifies the combat relevance of surgical practice. Orthopedic surgeons are more likely than general surgeons to meet the threshold. Medical treatment facilities do not provide enough demand for general surgery services to achieve readiness. CONCLUSION: The Clinical Readiness Program identifies imbalances between the health care delivery and readiness missions. To close the readiness gap, the Military Health System needs to recapture high KSA value procedures, expand access to care, and/or partner with civilian institutions.

Burnout in medical students: examining the prevalence and associated factors.

OBJECTIVE: Burnout has been described as a syndrome of emotional exhaustion, depersonalization, and decreased personal accomplishment, and may originate during medical school. The objective of this study is to determine the prevalence of burnout and contributing factors in medical students. METHODS: A survey was administered to 249 medical students using a modified Maslach Burnout Inventory Human Services Survey (MBI-HSS) and scales of stressors, assessment of workload, relaxation, control, accomplishment, support systems, and demographics. RESULTS: Moderate or high degree of burnout was seen in 21% of the first year class, 41% of the second year class, 43% of the third year class, and 31% of the fourth year class (P < 0.05). Lower support, higher stress, and lack of control over one's life were significantly related to burnout using multivariate analysis. CONCLUSIONS: Burnout progressively develops over the course of medical education, while a high level of support and low stress decreased burnout.

Achieving Mastery of General Surgery Operative Skill in the Army Healthcare System.

INTRODUCTION: Operative case volumes for military surgeons are reported to be significantly lower than civilian counterparts. Among the concern that this raises is an inability of military surgeons to achieve mastery of their craft. MATERIAL AND METHODS: Annual surgical case reports were obtained from seven Army military treatment facilities (MTF) for 2012-2016. Operative case volume and cumulative operative time were calculated for active duty general surgeons and for individual MTFs. Subgroup analyses were also performed based upon rank. Results were extrapolated to calculate the amount of time it would take to reach a cumulative of 10,000 hours of operative time (the a priori definition for achieving mastery). RESULTS: One hundred and two active duty general surgeons operated at the seven MTFs during the study period and met the inclusion criteria. The average surgeon performed 108 ± 68 cases/year. The average surgeon operated 122 ± 82 hours/year. At this rate, it would take over 80 years to reach mastery of surgery. When stratified based upon rank, Majors averaged 113 ± 75 hours/year, Lieutenant Colonels averaged 170 ± 100 hours/year, and Colonels averaged 136 ± 101 hours/year (p < 0.05). When stratified based upon individual MTF, surgeons at the busiest facility averaged 187 ± 103 hours/year and those at the least busy facility averaged 85 ± 56 hours/year (p < 0.05). CONCLUSIONS: Obtaining mastery of general surgery is a nearly impossible proposition given the current care models at Army MTFs. Alternative staffing and patient care models should be developed if Army surgeons are to be masters at their craft.

Femoral Hernias: Analysis of Preoperative Risk Factors and 30-Day Outcomes of Initial Groin Hernias Using ACS-NSQIP.

Femoral hernias are infrequently encountered groin hernias. The purpose of this study was to describe the natural history of femoral hernias by evaluating patient demographics, comorbidities, operative details, 30-day mortality, and risk factors for postoperative complications compared with inguinal hernias and in reducible versus incarcerated hernias. Overall 5360 femoral hernia repairs and 183,173 inguinal hernia repairs were identified using the 2005 to 2015 American College of Surgeon-National Surgical Quality Improvement Program's database. Univariate analysis was used to compare patient characteristics between femoral and inguinal hernias and between reducible and nonreducible femoral hernias. Multivariable logistic regression analyses were used to identify risk factors for 30-day postoperative complications after repair. Femoral hernias accounted for 2.8 per cent of initial groin hernias and 18.9 per cent of all groin hernias in females. A total of 56.5 per cent of initial femoral hernias were nonreducible and these patients were significantly older. Rates of small bowel resection (5.7 vs 0.3%, P < 0.0001), exploratory laparotomy (2.5% vs 0.4%, P < 0.0001), and diagnostic laparoscopy (2.0% vs 0.7%, P < 0.0001) were significantly higher in incarcerated femoral hernias compared with reducible femoral hernias. There were significantly higher rates of unplanned return to the OR, postoperative sepsis, and 30-day mortality in incarcerated femoral hernias versus reducible femoral hernias. Most femoral hernias present incarcerated in older, female patients. Femoral hernias present more commonly incarcerated in patients with significant comorbid diseases and are associated with significantly increased rates of systemic, local, major, and minor complications, return to OR, and mortality. Careful consideration should be given for the evaluation of intestinal viability in the acute setting.

Determination of Proper Timing for the Placement of Intra-Abdominal Mesh after Incidental Enterotomy in a Rodent Model (Rattus norvegicus).

Controversy exists regarding the appropriate timing for placement of permanent intra-abdominal mesh after inadvertent enterotomy during elective hernia repair. The aim of this study was to examine mesh placement at variable postoperative periods and the subsequent risk of infection. Fifty rodents were divided into five groups. Groups one to four underwent laparotomy, enterotomy, and repair. Physiomesh® was placed at the index operation one, three, or seven days postoperatively in Groups 1, 2, 3, and 4. Group 5 underwent mesh placement only. Necropsy with mesh harvest was performed seven days after placement. Cultures of mesh were obtained and Fisher's exact test was used to compare groups. Bacterial growth postsonication was identified in 30, 30, 50, and 90 per cent versus 20 per cent in controls. Compared with controls, there was significantly increased risk of mesh infection when it was placed seven days after enterotomy (P = 0.006). There was no significant difference in bacterial growth when mesh was placed at the time of enterotomy, one or three days later. The risk of bacterial contamination of permanent mesh placed immediately after inadvertent enterotomy during elective hernia repair is as safe as placing mesh at one or three days. Placing mesh at seven days significantly increased the risk of mesh contamination.

Multiple intravenous injections of allogeneic equine mesenchymal stem cells do not induce a systemic inflammatory response but do alter lymphocyte subsets in healthy horses.

INTRODUCTION: Intravenous (IV) injection of mesenchymal stem cells (MSCs) is used to treat systemic human diseases and disorders but is not routinely used in equine therapy. In horses, MSCs are isolated primarily from adipose tissue (AT) or bone marrow (BM) and used for treatment of orthopedic injuries through one or more local injections. The objective of this study was to determine the safety and lymphocyte response to multiple allogeneic IV injections of either AT-derived MSCs (AT-MSCs) or BM-derived MSCs (BM-MSCs) to healthy horses. METHODS: We injected three doses of 25 × 10(6) allogeneic MSCs from either AT or BM (a total of 75 × 10(6) MSCs per horse) into five and five, respectively, healthy horses. Horses were followed up for 35 days after the first MSC infusion. We evaluated host inflammatory and immune response, including total leukocyte numbers, serum cytokine concentration, and splenic lymphocyte subsets. RESULTS: Repeated injection of allogeneic AT-MSCs or BM-MSCs did not elicit any clinical adverse effects. Repeated BM-MSC injection resulted in increased blood CD8(+) T-cell numbers. Multiple BM-MSC injections also increased splenic regulatory T cell numbers compared with AT-MSC-injected horses but not controls. CONCLUSIONS: These data demonstrate that multiple IV injections of allogeneic MSCs are well tolerated by healthy horses. No clinical signs or clinico-pathologic measurements of organ toxicity or systemic inflammatory response were recorded. Increased numbers of circulating CD8(+) T cells after multiple IV injections of allogeneic BM-MSCs may indicate a mild allo-antigen-directed cytotoxic response. Safety and efficacy of allogeneic MSC IV infusions in sick horses remain to be determined.

Equine mesenchymal stem cells inhibit T cell proliferation through different mechanisms depending on tissue source.

Mesenchymal stem cells (MSCs) are used in both human clinical trials and veterinary medicine for the treatment of inflammatory and immune-mediated diseases. MSCs modulate inflammation by decreasing the cells and products of the inflammatory response. Stimulated equine MSCs from bone marrow (BM), adipose tissue (AT), cord blood (CB), and umbilical cord tissue (CT) inhibit lymphocyte proliferation and decrease inflammatory cytokine production. We hypothesized that equine MSCs inhibit T cell proliferation through secreted mediators and that MSCs from different tissue sources decrease T cell proliferation through different mechanisms. To test our hypotheses, we inhibited interleukin-6 (IL-6), nitric oxide (NO), and prostaglandin E2 (PGE2) to determine their impact on stimulated T cell proliferation. We also determined how equine MSCs modulate lymphocyte proliferation either via cell cycle arrest or apoptosis. Inhibition of IL-6 or NO did not reverse the immunomodulatory effect of MSCs on activated T cells. In contrast, inhibition of PGE2 restored T cell proliferation, restored the secretion of tumor necrosis factor-α and interferon-γ, and increased IL-10 levels. MSCs from solid-tissue-derived sources, AT and CT, inhibited T cell proliferation through induction of lymphocyte apoptosis while blood-derived MSCs, BM and CB, induced lymphocyte cell cycle arrest. Equine MSCs from different tissue sources modulated immune cell function by both overlapping and unique mechanisms. MSC tissue source may determine immunomodulatory properties of MSCs and may have very practical implications for MSC selection in the application of MSC therapy.

Effect of diabetes mellitus on outcomes of hyperglycemia in a mixed medical surgical intensive care unit.

BACKGROUND: Intensive insulin therapy and degree of glycemic control in critically ill patients remains controversial, particularly in patients with diabetes mellitus. We hypothesized that diabetic patients who achieved tight glucose control with continuous insulin therapy would have less morbidity and lower mortality than diabetic patients with uncontrolled blood glucose. METHOD: A retrospective chart review was performed on 395 intensive care unit (ICU) patients that included 235 diabetic patients. All patients received an intravenous insulin protocol targeted to a blood glucose (BG) level of 80-140 mg/dl. Outcomes were compared between (a) nondiabetic and diabetic patients, (b) diabetic patients with controlled BG levels (80-140 mg/dl) versus uncontrolled levels (>140 mg/dl), and (c) diabetic survivors and nonsurvivors. RESULTS: Diabetic patients had a shorter ICU stay compared to nondiabetic patients (10 ± 0.7 vs 13 ± 1.1, p = .01). The mean BG of the diabetic patients was 25% higher on average in the uncontrolled group than in the controlled (166 ± 26 vs 130 ± 9.4 mg/dl, p < .01). There was no difference in ICU and hospital length of stay (LOS) between diabetic patients who were well controlled compared to those who were uncontrolled. Diabetic nonsurvivors had a significantly higher incidence of hypoglycemia (BG <60 mg/dl) compared to diabetic survivors. CONCLUSION: The results showed that a diagnosis of diabetes was not an independent predictor of mortality, and that diabetic patients who were uncontrolled did not have worse outcomes. Diabetic nonsurvivors were associated with a greater amount of hypoglycemic episodes, suggesting these patients may benefit from a more lenient blood glucose protocol.

Thoracoscopic decortication for advanced pediatric empyema.

BACKGROUND: Although tube thoracostomy with fibrinolytic agents and video-assisted thoracoscopic (VATS) decortication are relatively equivalent in the treatment of empyema with regard to time to patient defervescence and hospital discharge, the potential for greater benefit with VATS decortication in the setting of advanced empyema has not been explored fully. This paper describes our transition from a policy of drainage and antibiotics to primary operative management with VATS. We wanted to assess the safety and efficacy of primary operative management as a first-line treatment for advanced disease. METHODS: A retrospective review was conducted of 25 patients treated for stage 3 or 4 empyema. The primary endpoints were morbidity and death. The secondary endpoints were conversion to an open procedure, time to defervescence, and length of hospital stay. RESULTS: The morbidity rate was 16% with no deaths. No patient required conversion to open decortication. The mean time to defervescence was 3.2 days, and on average, patients were discharged on postoperative day 9. Patients were discharged home earlier when managed primarily with VATS. CONCLUSIONS: Video-assisted thoracoscopic decortication is a safe and effective treatment for pediatric stage 3 or 4 empyema.