Obesity and Associated Outcomes for Blunt vs Penetrating Mechanism in Trauma Laparotomy Patients

Obesity in trauma patients is an established risk factor contributing to postoperative complications, but the relationship between body mass index (BMI) and trauma patient outcomes is not well-defined, especially when stratified by mechanism of injury. We surveyed the trauma laparotomy registry at an academic level 1 trauma center over a 3-year period to identify mortality, injury severity score, and hospital length of stay (hLOS) outcome measures across BMI classes, with further stratification by mechanism of injury: blunt vs penetrating trauma. A total of 442 patients were included with mean age 44.6 (SD = 18.7) and mean BMI 28.55 (SD = 7.37). These were subdivided into blunt trauma (n = 313) and penetrating trauma (n = 129). Within the blunt trauma subgroup, the hLOS among patients who survived hospitalization significantly increased 9% for each successive BMI class (P = .022, 95% CI = 1.29-17.5). We conclude that successive increase in BMI class is associated with longer hospital stay for blunt trauma patient survivors requiring laparotomy, though additional analysis is needed to establish this relationship to other outcome measures and among penetrating trauma patients.

Providers' Perceptions Versus Practices Inform Pediatric Colorectal Enhanced Recovery After Surgery Implementation

INTRODUCTION

There are many barriers to the implementation of an enhanced recovery after surgery (ERAS) pathway. The aim of this study was to compare surgeon and anesthesia perceptions with current practices prior to the initiation of an ERAS protocol in pediatric colorectal patients and to use that information to inform ERAS implementation.

METHODS

This was a mixed method single institution study of barriers to implementation of an ERAS pathway at a free-standing children's hospital. Anesthesiologists and surgeons at a free-standing children's hospital were surveyed regarding current practices of ERAS components. A retrospective chart review was performed of 5- to 18-y-old patients undergoing colorectal procedures between 2013 and 2017, followed by the initiation of an ERAS pathway, and a prospective chart review for 18 mo postimplementation.

RESULTS

The response rate was 100% (n = 7) for surgeons and 60% (n = 9) for anesthesiologists. Preoperative nonopioid analgesics and regional anesthesia were rarely used. Intraoperatively, 54.7% of patients had a fluid balance of <10 cc/kg/h and normothermia was achieved in only 38.7%. Mechanical bowel prep was frequently utilized (48%). Median nil per os time was significantly longer than required at 12 h. Postoperatively, 42.9% of surgeons reported that patients could have clears on postoperative day zero, 28.6% on postoperative day one, and 28.6% after flatus. In reality, 53.3% of patients were started on clears after flatus, with a median time of 2 d. Most surgeons (85.7%) expected patients to get out of bed once awake from anesthesia; however, median time that patients were out of bed was postoperative day one. While most surgeons reported frequent use of acetaminophen and/or ketorolac, only 69.3% received any nonopioid analgesic postoperatively, with only 41.3% receiving two or more nonopioid analgesics. Nonopioid analgesia showed the highest rates of improvement from retrospective to prospective: preoperative use of analgesics increased from 5.3% to 41.2% (P < 0.0001), postoperative use of acetaminophen increased by 27.4% (P = 0.5), Toradol by 45.5% (P = 0.11), and gabapentin by 86.7% (P < 0.0001). Postoperative nausea/vomiting prophylaxis with >1 class of antiemetic increased from 8% to 47.1% (P < 0.001). The length of stay was unchanged (5.7 versus 4.4 d, P = 0.14).

CONCLUSIONS

For the successful implementation of an ERAS protocol, perceptions versus reality must be assessed to determine current practices and identify barriers to implementation.

A Safe Approach to Percutaneous Tracheostomy for COVID-19 Patients in Intensive Care

The novel coronavirus disease 2019 (COVID-19) has placed a burden on critical care facilities worldwide. Patients who remain critically unwell with COVID-19 require prolonged periods of ventilation, and the burden of both the resources during a pandemic and the slow respiratory wean must be managed. Percutaneous tracheostomies are commonplace in long-term intensive care patients, yet little is known about their role in COVID-19, particularly how operator safety is maintained during the procedure.

Here, we describe an approach designed to minimize cross-infection of the operators undertaking percutaneous tracheostomies within this subset of patients. Focus should be on non-technical skills, prolonged periods of pre-oxygenation, and minimal ventilation during the procedure to minimize the risk of aerosolization generated from an open breathing system. Our modified technique demonstrates successful early experiences with no operators testing positive for COVID-19 or developing symptoms following any performed procedure.

Use of therapeutic caffeine in acute care postoperative and critical care settings: a scoping review

BACKGROUND

Caffeine is the most utilised psychoactive drug worldwide. However, caffeine withdrawal and the therapeutic use of caffeine in intensive care and in the perioperative period have not been well summarised. Our objective was to conduct a scoping review of caffeine withdrawal and use in the intensive care unit (ICU) and postoperative patients.

METHODS

PubMed, Embase, CINAHL Complete, Scopus and Web of Science were systematically searched for studies investigating the effects of caffeine withdrawal or administration in ICU patients and in the perioperative period. Areas of recent systematic review such as pain or post-dural puncture headache were not included in this review. Studies were limited to adults.

RESULTS

Of 2268 articles screened, 26 were included and grouped into two themes of caffeine use in in the perioperative period and in the ICU. Caffeine withdrawal in the postoperative period increases the incidence of headache, which can be effectively treated prophylactically with perioperative caffeine. There were no studies investigating caffeine withdrawal or effect on sleep wake cycles, daytime somnolence, or delirium in the intensive care setting. Administration of caffeine results in faster emergence from sedation and anaesthesia, particularly in individuals who are at high risk of post-extubation complications. There has only been one study investigating caffeine administration to facilitate post-anaesthetic emergence in ICU. Caffeine administration appears to be safe in moderate doses in the perioperative period and in the intensive care setting.

CONCLUSIONS

Although caffeine is widely used, there is a paucity of studies investigating withdrawal or therapeutic effects in patients admitted to ICU and further novel studies are a priority.

Occurrence and determinants of enterococcal bloodstream infections: a population-based study

Background: Although enterococci are common causes of bloodstream infections (BSIs), few studies have examined their epidemiology in non-selected populations.Objective: To examine the incidence and risk factors for development of enterococcal BSI.Methods: Surveillance for incident enterococcal BSI was conducted among all residents of the western interior of British Columbia, Canada during 2011-2018.Results: The overall annual incidence was 10.0 per 100,000 and was 6.6 and 2.7 per 100,000 for E. faecalis and E. faecium, respectively. Among the overall cohort of 145 incident cases of enterococcal BSI, 22 (15.2%) were community-associated, 63 (43.5%) were healthcare associated and 60 (41.4%) were hospital-onset. Enterococcal BSI was predominantly a disease of older adults with rare cases occurring among those aged less than 40 years. Males showed significantly increased risk compared to females (14.3 vs. 5.6 per 100,000; incidence rate ratio; IRR; 2.6; 95% confidence interval; CI; 1.8-3.8; p < .0001) and this was most pronounced with advanced age. Several co-morbid illnesses were associated with increased risk (IRR; 95% CI) for development of enterococcal BSI most importantly cancer (8.8; 6.0-12.9; p < .0001), congestive heart failure (5.7; 3.1-9.7; p < .0001), diabetes mellitus (4.4; 3.0-6.3; p < .0001) and stroke (3.7; 1.9-6.5; .0001). As compared to patients with E. faecalis, patients with E. faecium BSI were more likely to be of hospital-onset, more likely to have an intra-abdominal/pelvic focus, and trended towards higher 30-day case-fatality rate.Conclusions: Enterococci are relatively common causes of BSI. Although E faecalis and E faecium share commonalities they are epidemiologically distinguishable on several criteria.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Multiple autophosphorylations significantly enhance the endoribonuclease activity of human inositol requiring enzyme 1α

Background

Endoplasmic reticulum stress, caused by the presence of misfolded proteins, activates the stress sensor inositol-requiring enzyme 1α (IRE1α). The resulting increase in IRE1α RNase activity causes sequence-specific cleavage of X-box binding protein 1 (XBP1) mRNA, resulting in upregulation of the unfolded protein response and cellular adaptation to stress. The precise mechanism of human IRE1α activation is currently unclear. The role of IRE1α kinase activity is disputed, as results from the generation of various kinase-inactivating mutations in either yeast or human cells are discordant. Kinase activity can also be made redundant by small molecules which bind the ATP binding site. We set out to uncover a role for IRE1α kinase activity using wild-type cytosolic protein constructs.

Results

We show that concentration-dependent oligomerisation is sufficient to cause IRE1α cytosolic domain RNase activity in vitro. We demonstrate a role for the kinase activity by showing that autophosphorylation enhances RNase activity. Inclusion of the IRE1α linker domain in protein constructs allows hyperphosphorylation and further enhancement of RNase activity, highlighting the importance of kinase activity. We show that IRE1α phosphorylation status correlates with an increased propensity to form oligomeric complexes and that forced dimerisation causes great enhancement in RNase activity. In addition we demonstrate that even when IRE1α is forced to dimerise, by a GST-tag, phospho-enhancement of activity is still observed.

Conclusions

Taken together these experiments support the hypothesis that phosphorylation is important in modulating IRE1α RNase activity which is achieved by increasing the propensity of IRE1α to dimerise. This work supports the development of IRE1α kinase inhibitors for use in the treatment of secretory cancers.

Effects of green macroalgal blooms on the meiofauna community structure in the Bay of Cádiz

The effect of macroalgal blooms on the abundance and community structure of intertidal sediment meiofauna was studied using an in situ enclosure experiments (Bay of Cádiz, Spain). Meiofaunal abundance (3500-41,000 ind 10 cm⁻²) was three to sevenfold higher in the presence of macroalgae. Nematoda were the dominant taxon both in Control (52-82%) and Macroalgae plots (92-96%), followed by Harpacticoida Copepoda and Ostracoda. Non-metric Multi-Dimensional Scaling (MDS) analysis clearly separated the meiofaunal community from Control and Macroalgae plots. Organic matter, organic carbon, total nitrogen, chlorophyll a and freeze-lysable inorganic nutrients were higher in Macroalgae plots, and were highly correlated with the horizontal MDS axis separating Control and Macroalgae meiofaunal communities. Meiofaunal abundance and taxonomic composition in the Bay of Cádiz seem to be bottom-up controlled either through a grazer system based on microphytobenthos in bare sediments or through a decomposer system in macroalgae affected sediments.

SU-E-T-205: MLC Predictive Maintenance Using Statistical Process Control Analysis

PURPOSE

MLC failure increases accelerator downtime and negatively affects the clinic treatment delivery schedule. This study investigates the use of Statistical Process Control (SPC), a modern quality control methodology, to retrospectively evaluate MLC performance data thereby predicting the impending failure of individual MLC leaves.

METHODS

SPC, a methodology which detects exceptional variability in a process, was used to analyze MLC leaf velocity data. A MLC velocity test is performed weekly on all leaves during morning QA. The leaves sweep 15 cm across the radiation field with the gantry pointing down. The leaf speed is analyzed from the generated dynalog file using quality assurance software. MLC leaf speeds in which a known motor failure occurred (8) and those in which no motor replacement was performed (11) were retrospectively evaluated for a 71 week period. SPC individual and moving range (I/MR) charts were used in the analysis. The I/MR chart limits were calculated using the first twenty weeks of data and set at 3 standard deviations from the mean.

RESULTS

The MLCs in which a motor failure occurred followed two general trends: (a) no data indicating a change in leaf speed prior to failure (5 of 8) and (b) a series of data points exceeding the limit prior to motor failure (3 of 8). I/MR charts for a high percentage (8 of 11) of the non-replaced MLC motors indicated that only a single point exceeded the limit. These single point excesses were deemed false positives.

CONCLUSIONS

SPC analysis using MLC performance data may be helpful in detecting a significant percentage of impending failures of MLC motors. The ability to detect MLC failure may depend on the method of failure (i.e. gradual or catastrophic). Further study is needed to determine if increasing the sampling frequency could increase reliability. Project was support by a grant from Varian Medical Systems, Inc.

Epizooic metazoan meiobenthos associated with tubeworm and mussel aggregations from cold seeps of the northern Gulf of Mexico

The abundance and higher taxonomic composition of epizooic metazoan meiobenthic communities associated with mussel and tubeworm aggregations of hydrocarbon seeps at Green Canyon, Atwater Valley, and Alaminos Canyon in depths between 1400 and 2800 m were studied and compared to the infaunal community of non-seep sediments nearby. Epizooic meiofaunal abundances of associated meiobenthos living in tubeworm bushes and mussel beds at seeps were extremely low (usually <100 ind. 10 cm(-2)), similar to epizooic meiofauna at deep-sea hydrothermal vents, and the communities were composed primarily of nematodes, copepods, ostracods, and halacarids. In contrast, epizooic meiobenthic abundance is lower than previous studies have reported for infauna from seep sediments. Interestingly, non-seep sediments contained higher abundances and higher taxonomic diversity than epizooic seep communities, although in situ primary production is restricted to seeps.

Outcomes of a cardiovascular nutrition counseling program in African-Americans with elevated blood pressure or cholesterol level

OBJECTIVE

To evaluate a cardiovascular nutrition education package designed for African-American adults with a wide range of literacy skills.

DESIGN

Comparison of a self-help group and a full-instruction group; each group received nutrition counseling and clinical monitoring every 4 months.

SUBJECTS

Three hundred thirty African-American adults, aged 40 to 70 years, with elevated cholesterol level or high blood pressure were randomly assigned to the self-help or full-instruction group; 255 completed the 12-month follow-up.

INTERVENTIONS

Counseling to reduce intake of dietary fat, cholesterol, and sodium was based on Cardiovascular Dietary Education System (CARDES) materials, which included food-picture cards, a nutrition guide (self-help and full-instruction group), a video and audiotape series, and 4 classes (full-instruction group only).

MAIN OUTCOME MEASURES

Changes in lipid levels and blood pressure after 12 months.

STATISTICAL ANALYSES PERFORMED

Primary analyses consisted of repeated-measures analysis of variance to examine effects of time and randomization group on outcomes.

RESULTS

Total cholesterol and low-density lipoprotein cholesterol level decreased by 7% to 8% in the self-help and full-instruction groups of men and women (P < .01). The ratio of total cholesterol to high-density lipoprotein cholesterol (HDL-C) decreased in both groups of women and in the men in the full-instruction group (P < .01). In full-instruction and self-help participants with elevated blood pressure at baseline, systolic blood pressure decreased by 7 to 11 mm Hg and diastolic blood pressure decreased by 4 to 7 mm Hg (P < .01). Outcomes did not differ by literacy scores but were positively related to the reported initial frequency of using CARDES materials.

APPLICATIONS/CONCLUSIONS

These results suggest that periodic nutrition counseling based on CARDES materials used for home study can enhance management of lipid levels and blood pressure in African-American outpatients.

Higher lifetime prevalence of respiratory diseases in panic disorder?

Current and past frequencies of respiratory diseases were assessed in 30 patients with panic disorder, 30 patients with obsessive-compulsive disorder, and 30 patients with eating disorders. Lifetime prevalence of respiratory disorders was significantly higher in patients with panic disorder (47%) than in patients with either obsessive-compulsive disorder (13%) or eating disorder (13%). Point prevalences showed no differences.

Uveal melanoma presenting as post-traumatic choroidal hemorrhage and panophthalmitis

A 63-year-old Caucasian man presented with loss of vision in one eye. The loss of vision was considered to be due to a post-traumatic intraocular hemorrhage. He developed panophthalmitis 3 months later and necrosis in a malignant melanoma was diagnosed. The diagnosis of melanoma in patients with blind eyes and opaque ocular media is discussed.

Anophthalmos. Report of two cases

Two infants were found to have bilateral anophthalmos and other congenital anomalies. Secondary anophthalmia was diagnosed in one patient who showed malformations of the brain and an absence of ocular tissues including the optic nerves. The other patient had degenerative (consecutive) anophthalmos; fragments of ocular tissues including the optic nerves were found in the orbits.

Serum prolactin levels in normal women and in women with disorders of menstruation

The mean (+/-SD) serum prolactin (PRL) level of 78 normal premenopausal women was 10-6+/-3-0 ng/ml, and this was significantly different from that of post-menopausal women (8-2+/-4-0 ng/ml) and women taking combined oral contraceptive preparations (12-2+/-4-0 ng/ml). No significant differences were found between follicular and luteal phase PRL levels. Serum PRL levels higher than the ranges given above were found in 31 of 87 patients with secondary amenorrhoea and two of 41 patients with oligomenorrhoea. Nine of the 33 patients with hyperprolactinaemia did not have galactorrhoea. Only two of the patients with hyperprolactinaemia had pituitary tumours evident on skull X-ray films. Serum PRL levels were of value in predicting the likely success in achieving ovulation with clomiphene citrate or CB-154; clomiphene citrate was less likely to be successful in the presence of hyperprolactinaemia, whereas the reverse applied for treatment with CB-154.

Congenital dyserythropoietic anaemia with erythroblastic multinuclearity

A case of congenital dyserythropoietic anaemia with erythroblastic multinuclearity in a 36-year-old woman is described and the literature reviewed. The syndrome is characterized by a protracted clinical course, a relatively mild anaemia, a low reticulocyte count, slight hyperbilirubinaemia, splenomegaly, pronounced erythroid hyperplasia with reversal of the myeloid erythroid ratio, and in particular by the presence of multinucleated erythroblasts in the marrow. The picture of ineffective erythropoiesis is confirmed by erythrokinetic studies. The present case is the forty-first to be described in the literature and is the third from Britain. Thirty-one of these have occurred in seven families but a family history has been lacking in the remaining ten. The onset of anaemia occurred in childhood in 21 of the 41 cases.