Post-Cesarean Opioid Use after Implementation of Enhanced Recovery after Surgery Protocol

OBJECTIVE

This study aimed to evaluate whether implementation of an enhanced recovery after surgery (ERAS) protocol is associated with lower maternal opioid use after cesarean delivery (CD).

STUDY DESIGN

We performed a pre- and postimplementation (PRE and POST, respectively) study of an ERAS protocol for cesarean deliveries. ERAS is a multimodal, multidisciplinary perioperative approach. The four pillars of our protocol include education, pain management, nutrition, and early ambulation. Patients were counseled by their outpatient providers and given an educational booklet. Pain management included gabapentin and acetaminophen immediately prior to spinal anesthesia. Postoperatively patients received scheduled acetaminophen and ibuprofen. Oxycodone was initiated as needed 24 hours after spinal analgesia. Preoperative diet consisted of clear carbohydrate drink consumed 2 hours prior to scheduled operative time with advancement as tolerated immediately postoperation. Women with a body mass index (BMI) <40 kg/m² and scheduled CD were eligible for ERAS. PRE patients were randomly selected from repeat cesarean deliveries (RCDs) at a single site from October 2017 to September 2018, BMI <40 kg/m², without trial of labor. The POST cohort included women who participated in ERAS from October 2018 to June 2019. PRE and POST demographic and clinical characteristics were compared. Primary outcome was total postoperative morphine milligram equivalents (MMEs). Secondary outcomes included length of stay (LOS) and maximum postoperative day 2 (POD2) pain score.

RESULTS

All women in PRE (n = 70) had RCD compared with 66.2% (49/74) in POST. Median total postoperative MMEs were 140.0 (interquartile range [IQR]: 87.5-182.5) in PRE compared with 0.0 (IQR: 0.0-72.5) in POST (p < 0.001). Median LOS in PRE was 4.02 days (IQR: 3.26-4.27) compared with 2.37 days (IQR: 2.21-3.26) in POST (p < 0.001). Mean maximum POD2 pain score was 5.28 (standard deviation [SD] = 1.86) in PRE compared with 4.67 (SD = 1.63) in POST (p = 0.04).

CONCLUSION

ERAS protocol was associated with decreased postoperative opioid use, shorter LOS, and decreased pain after CD.

KEY POINTS

· ERAS protocol was associated with decreased postoperative opioid use after CD.. · ERAS protocol was associated with shorter length of stay after CD.. · ERAS protocol was associated with decreased postoperative pain after CD..

Dark Energy Survey Year 1 Results: Cosmological Constraints from Cluster Abundances, Weak Lensing, and Galaxy Correlations

We present the first joint analysis of cluster abundances and auto or cross-correlations of three cosmic tracer fields: galaxy density, weak gravitational lensing shear, and cluster density split by optical richness. From a joint analysis (4×2pt+N) of cluster abundances, three cluster cross-correlations, and the auto correlations of the galaxy density measured from the first year data of the Dark Energy Survey, we obtain Ω_{m}=0.305_{-0.038}^{+0.055} and σ_{8}=0.783_{-0.054}^{+0.064}. This result is consistent with constraints from the DES-Y1 galaxy clustering and weak lensing two-point correlation functions for the flat νΛCDM model. Consequently, we combine cluster abundances and all two-point correlations from across all three cosmic tracer fields (6×2pt+N) and find improved constraints on cosmological parameters as well as on the cluster observable-mass scaling relation. This analysis is an important advance in both optical cluster cosmology and multiprobe analyses of upcoming wide imaging surveys.

Detection of Cross-Correlation between Gravitational Lensing and γ Rays

In recent years, many γ-ray sources have been identified, yet the unresolved component hosts valuable information on the faintest emission. In order to extract it, a cross-correlation with gravitational tracers of matter in the Universe has been shown to be a promising tool. We report here the first identification of a cross-correlation signal between γ rays and the distribution of mass in the Universe probed by weak gravitational lensing. We use data from the Dark Energy Survey Y1 weak lensing data and the Fermi Large Area Telescope 9-yr γ-ray data, obtaining a signal-to-noise ratio of 5.3. The signal is mostly localized at small angular scales and high γ-ray energies, with a hint of correlation at extended separation. Blazar emission is likely the origin of the small-scale effect. We investigate implications of the large-scale component in terms of astrophysical sources and particle dark matter emission.

Effectiveness of an oral health education seminar for paediatric and family medicine residents

AIM

To assess the immediate effect of a 60-minute oral health educational seminar for paediatric and family medicine residents in improving their knowledge, attitude, likelihoodtowards incorporating oral health preventive practice in their current practices to well-child visits, and confidence in identifying and referring patients with dental trauma.

MATERIALS AND METHODS

Baseline pre- and post-test design was used to evaluate the immediate effect of a 60-minute PowerPoint oral health educational seminar given to the paediatric and family medicine residents.

STATISTICS

Multiple-choice items were used and the pre- and post-test data were analysed with McNemar and Wilcoxon signed-rank tests. A p-value <0.05 was considered statistically significant.

RESULTS

Sixty-eight residents participated in the oral health educational seminar and completed the questionnaire. The mean age of participants was 29.9 years old (SD ±4.8 yrs.). Immediately following a 60-minute oral health educational seminar, there was an overall significant increase in participants' knowledge, attitudes and likelihood towards incorporating oral health preventive practice in their current practices to well-child visits (p<0.05). More confidence in identifying and referring patients with dental trauma was reported by 100% of participants.

CONCLUSIONS

A 60-minute oral health educational seminar was effective in improving paediatric and family medicine residents' immediate knowledge, attitude, and likelihood towards incorporating oral health preventive practice in their current practices to well-child visits. Significantly more residents felt more confident in identifying and referring patients with dental trauma. Key messages: an oral health educational seminar can be effective in improving paediatric and family medicine residents' immediate knowledge, attitude, and likelihood towards incorporating oral health preventive practice in their current practices to well-child visits.

Probabilistic dietary exposure to ethyl carbamate from fermented foods and alcoholic beverages in the Korean population

The occurrence of ethyl carbamate was investigated in fermented foods and alcoholic beverages of the Korean total diet study. The concentrations of ethyl carbamate ranged from not detected to 166.5 μg kg^-1. Dietary exposure to ethyl carbamate was estimated by the probabilistic method. Estimated intakes of ethyl carbamate from foods and alcoholic beverages were 4.12 ng kg^-1 body weight (bw) per day for average consumers and 12.37 ng kg^-1 bw/day for 95th percentile high consumers. The major foods contributing to ethyl carbamate exposure were soy sauce (63%), followed by maesilju (plum liqueur, 30%), whisky (5%), and bokbunjaju (black raspberry wine, 2%). On the basis of the benchmark dose lower confidence limit 10% (BMDL₁₀) of 0.3 mg kg^-1 bw/day, margins of exposure were 128,000 for mean exposure and 40,000 for 95th percentile exposure. This indicates that the exposure of the Korean general population for ethyl carbamate is of low concern. However, careful vigilance should be continued for high consumers of fermented foods and alcoholic beverages.

Photoplethysmography sampling frequency: pilot assessment of how low can we go to analyze pulse rate variability with reliability?

Pulse rate variability (PRV) analysis appears as the first alternative to heart rate variability analysis for wearable devices; however, there is a constraint on computational load and energy consumption for the limited system resources available to the devices. Considering that adjustment of the sampling frequency is one of the strategies for reducing computational load and power consumption, this study aimed to investigate the influence of sampling frequency (f _s) on PRV analysis and to find the minimum sampling frequency while maintaining reliability. We generated 5000, 2500, 1000, 500, 250, 100, 50, 25, 20, 15, 10, 5 Hz down-sampled photoplethysmograms from 10 kHz-sampled PPGs and derived time- and frequency-domain variables of the PRV. These included AVNN, SDNN, SDSD, RMSSD, NN50, pNN50, total power, VLF, LF, HF, LF/HF, nLF and nHF for each down-sampled signal. Derived variables were compared with heart rate variability of the 10 kHz-sampled electrocardiograms, and then statistically investigated using one-way ANOVA test and Bland-Altman analysis. As a result, significant differences (P  <  0.05) were found for SDNN, SDSD, RMSSD, NN50, pNN50, TP, HF, LF/HF, nLF and nHF, but not for AVNN, VLF and LF. Based on the post hoc tests, it was found that the NN50 and pNN50, SDSD and RMSSD, LF/HF and nHF, SDNN, TP and nLF analysis had significant differences at f _s  ⩽  20 Hz, f _s  ⩽  15 Hz, f _s  ⩽10 Hz; f _s  =  5 Hz, respectively. In other words, a significant difference was not seen for any variable if the f _s was greater than 25 Hz. Consequently, our pilot study suggests that analysis of variability in the time and frequency domain from pulse rate obtained through PPG may be potentially as reliable as that derived from the analysis of the electrocardiogram, provided that f _s  ⩾25 Hz sampling frequency is used.

Temporal expression of CD184(CXCR4) and CD171(L1CAM) identifies distinct early developmental stages of human retinal ganglion cells in embryonic stem cell derived retina

Human retinal ganglion cells (RGCs) derived from pluripotent stem cells (PSCs) have anticipated value for human disease study, drug screening, and therapeutic applications; however, their full potential remains underdeveloped. To characterize RGCs in human embryonic stem cell (hESC) derived retinal organoids we examined RGC markers and surface antigen expression and made comparisons to human fetal retina. RGCs in both tissues exhibited CD184 and CD171 expression and distinct expression patterns of the RGC markers BRN3 and RBPMS. The retinal progenitor cells (RPCs) of retinal organoids expressed CD184, consistent with its expression in the neuroblastic layer in fetal retina. In retinal organoids CD184 expression was enhanced in RGC competent RPCs and high CD184 expression was retained on post-mitotic RGC precursors; CD171 was detected on maturing RGCs. The differential expression timing of CD184 and CD171 permits identification and enrichment of RGCs from retinal organoids at differing maturation states from committed progenitors to differentiating neurons. These observations will facilitate molecular characterization of PSC-derived RGCs during differentiation, critical knowledge for establishing the veracity of these in vitro produced cells. Furthermore, observations made in the retinal organoid model closely parallel those in human fetal retina further validating use of retinal organoid to model early retinal development.

Algorithms and Applications for the Same-Decision Probability

When making decisions under uncertainty, the optimal choices are often difficult to discern, especially if not enough information has been gathered. Two key questions in this regard relate to whether one should stop the information gathering process and commit to a decision (stopping criterion), and if not, what information to gather next (selection criterion). In this paper, we show that the recently introduced notion, Same-Decision Probability (SDP), can be useful as both a stopping and a selection criterion, as it can provide additional insight and allow for robust decision making in a variety of scenarios. This query has been shown to be highly intractable, being PP^PP-complete, and is exemplary of a class of queries which correspond to the computation of certain expectations. We propose the first exact algorithm for computing the SDP, and demonstrate its effectiveness on several real and synthetic networks. Finally, we present new complexity results, such as the complexity of computing the SDP on models with a Naive Bayes structure. Additionally, we prove that computing the non-myopic value of information is complete for the same complexity class as computing the SDP.

Quantifying CFSE Label Decay in Flow Cytometry Data

We developed a series of models for the label decay in cell proliferation assays when the intracellular dye carboxyfluorescein succinimidyl ester (CFSE) is used as a staining agent. Data collected from two healthy patients were used to validate the models and to compare the models with the Akiake Information Criteria. The distinguishing features of multiple decay rates in the data are readily characterized and explained via time dependent decay models such as the logistic and Gompertz models.

The psychopathological characteristics of treatment discontinuation group in 6-month treatment with paliperidone ER

OBJECTIVE

To examine the demographic and psychopathological characteristics of the treatment discontinuation group compared with patients who completed with paliperidone ER treatment for 6 months.

METHODS

A total of 984 patients meeting the DSM-IV criteria for schizophrenia who switched their antipsychotics were recruited from 61 sites in five countries in Southeast Asia. The patients with early discontinuation were then compared with those who completed the 6-month treatment in terms of demographic and psychopathological variables at baseline and also at the end of the evaluation period, which included PANSS score, sleep quality, daytime drowsiness, PSP score, ESRS score and clinical global impression-severity (CGI-S) score. Finally, logistic regression analysis was applied to determine predictive factors that were associated with discontinuation.

RESULTS

Of 984 patients, 284 patients (28.9%) discontinued without completing the 6-month treatment period with paliperidone. Significant differences in patient baseline characteristics for the discontinuation group compared with the completion group were observed for gender, number of previous hospitalisations with psychosis, PANSS total score and all of its subscales, daytime drowsiness score, total ESRS score, CGI-S, PSP and Insight. Patients who completed the study period had significantly better scores in all psychopathology variables compared with the discontinuation group at the end of the evaluation period. Numbers of previous hospitalisations because of psychosis, being exposed with first generation antipsychotics, gender and PANSS total scores were found to be significant predictors of discontinuation.

CONCLUSION

Patients who discontinued early from a 6-month treatment period with Paliperidone have some characteristic differences compared with completion patients. Many factors including frequent hospitalisations, female gender, high PANSS score (indicating more disease severity) and previous exposure to first generation of antipsychotic agent might lead patients to discontinue from treatment.

Drug-induced methaemoglobinaemia following elective coronary artery bypass grafting

Dapsone can alter the oxygen carrying capacity of haemoglobin. Some patients are more susceptible to these effects because of genetic factors, comorbidities or peri-operative factors such as anaemia. We present a 57-year-old lady who underwent elective coronary artery bypass grafting. Deterioration in neurological and respiratory condition prompted a review of her drug treatment. A combination of long-term dapsone therapy, co-existing cardiac and respiratory disease, postoperative anaemia and renal impairment contributed to her decompensation, despite a relatively low level of methaemoglobin. Successful management included stopping dapsone therapy, supportive care and administration of ascorbic acid.

Selective control of cyanobacteria in eutrophic pond by a combined device of ultrasonication and water pumps

A combined device consisting of an ultrasonic apparatus and water pumps was operated in a eutrophic pond to study its effect on the control of cyanobacteria as compared with those of a non-treated, neighboring pond. The combined apparatus seemed to be enough to spread the sonicated water to the whole surface of a 9,000 m3 pond. Although the high rainfall in 2003 resulted in an overall dominance of diatoms, cyanobacterial growth was significantly inhibited by the apparatus in the treated pond. In addition, the chlorophyll-a concentration and total algae in the treated pond were 61 and 53%, respectively, of the levels in the control pond. The reduced algal growth (7% of the control) by the combined apparatus was mainly due to the inhibition on the growth of cyanobacteria. The cyanobacterial proportion in the treated pond, however, increased significantly for several days, when the apparatus was stopped. Meanwhile, the proportion of green algae increased in the treated pond. The successful selective control of cyanobacteria using the combined apparatus suggests that ultrasonication can be a practical method to control bloom and toxin production in eutrophic waters.

Harvesting of Spirulina platensis by cellular flotation and growth stage determination

AIM

To investigate an effective harvesting method for Spirulina platensis.

METHODS AND RESULTS

Eighty per cent of S. platensis cells in the logarithmic growth phase were harvested by flotation when the cells were set in a static condition for 2 h. The optimum harvesting time was about day 6 of cultivation. The flotation activity of S. platensis cells was enhanced by the addition of NaCl.

CONCLUSIONS

The harvesting of S. platensis by flotation is a cost-effective and straightforward method that can retain the algal quality. The optimum harvesting time of S. platensis can be predicted by the cellular protein to carbon ratio.

SIGNIFICANCE AND IMPACT OF THE STUDY

Flotation harvesting is also applicable to other cyanobacteria with gas vesicles.

Harvesting of Spirulina platensis by cellular flotation and growth stage determination

AIM

To investigate an effective harvesting method for Spirulina platensis.

METHODS AND RESULTS

Eighty per cent of S. platensis cells in the logarithmic growth phase were harvested by flotation when the cells were set in a static condition for 2 h. The optimum harvesting time was about day 6 of cultivation. The flotation activity of S. platensis cells was enhanced by the addition of NaCl.

CONCLUSIONS

The harvesting of S. platensis by flotation is a cost-effective and straightforward method that can retain the algal quality. The optimum harvesting time of S. platensis can be predicted by the cellular protein to carbon ratio.

SIGNIFICANCE AND IMPACT OF THE STUDY

Flotation harvesting is also applicable to other cyanobacteria with gas vesicles.

Defining T-cell-mediated immune responses in rotavirus-infected juvenile rhesus macaques

The appearance of virus-specific CD4(+) and/or CD8(+) T lymphocytes in peripheral blood of captive juvenile rhesus macaques (Macaca mulatta) was observed following rotavirus infection. These cell-mediated immune responses were measured following experimental or natural infection after rotavirus was isolated from stool specimens of asymptomatic animals. The virus isolated was a new strain of simian rotavirus that we named TUCH (for Tulane University and Cincinnati Children's Hospital). Restimulation of peripheral T lymphocytes by inactivated double- or triple-layered TUCH rotavirus particles containing either VP6 or VP4 and VP7 on their respective surfaces resulted in increased quantities of interleukin-6 (IL-6) and IL-12 in cell culture supernatants. Recall responses to rotavirus by CD4(+) and CD8(+) T lymphocytes were associated with accumulation of intracellular IL-6 and gamma interferon. Antigen presentation of TUCH rotavirus to lymphocytes was mediated via differentiated cultures of monocyte-derived dendritic (HLA-DR(+)) cells. This is the first report demonstrating cell-mediated immune responses to rotavirus in nonhuman primates. Further exploration of rhesus macaques in vaccine trials with human rotavirus vaccine candidates is the major objective of future studies.

The cell type-specific expression of the murine IL-13 gene is regulated by GATA-3

IL-13, a Th2 cell-specific cytokine, is a major effector molecule mediating several pathological features of allergic asthma. However, the transcriptional regulation of the IL-13 gene remains unclear. Here we demonstrate, by using intracellular cytokine staining, that IL-13 is not always coexpressed with other Th2 cytokines in normal Th cells on a single cell basis. In addition, we identified and cloned a minimal inducible and cell type-specific promoter of the murine IL-13 gene. The cell type specificity of the minimal IL-13 promoter is mediated by a functionally critical GATA-3 site that binds endogenous GATA-3 proteins, whereas the induction by PMA/ionomycin is mediated by distinct cis-acting elements. Furthermore, by expressing GATA-3 in wild-type and c-maf transgenic Th1 cells, we demonstrate that the expression of IL-13 is regulated by a mechanism distinct from that regulating the expression of IL-4, and that the expression of Th1 and Th2 cytokine genes does not have to be mutually exclusive in effector Th cells.

A novel group of phospholipase A2s preferentially expressed in type 2 helper T cells

We report a novel phospholipase A(2) (PLA(2)), group XII (GXII) PLA(2), distinct from other cysteine-rich groups with a catalytic histidine motif, by its 20-kDa size and distribution of the 14 cysteine residues within the protein. Alternative spliced forms with distinct subcellular localization, designated GXII-1 and GXII-2, were identified by reverse transcription-polymerase chain reaction. Importantly, GXII PLA(2)s, in particular GXII-2 PLA(2), and group V PLA(2), but not group X PLA(2), were selectively expressed in murine type 2 helper T (Th2) clones and in vitro differentiated mouse CD4 Th2 cells as compared with type 1 helper T clones and cells. Stimulation with anti-CD3 appreciably up-regulated expression of GXII PLA(2)s and group V PLA(2) by steady state analysis of the Th2 cells as compared with type 1 helper T cells. These results suggest that group XII and group V PLA(2)s might participate in helper T cell immune response through release of immediate second signals and generation of downstream eicosanoids.

Association between prenatal exposure to methylmercury and cognitive functioning in Seychellois children: a reanalysis of the McCarthy Scales of Children's Ability from the main cohort study

Methylmercury (MeHg) is a neurotoxicant whose high-dose effects first became known following a number of poisoning outbreaks that occurred worldwide. The primary human exposure is low dosage from fish consumption. Studies of fish-eating populations have not found a consistent pattern of association between exposures and outcomes. Therefore, examining specific areas of cognitive functioning has been suggested as an important approach to determine whether more subtle effects of MeHg exposure are present. In the Seychelles longitudinal study of prenatal and postnatal MeHg exposure from fish consumption and development, the McCarthy Scales of Children's Abilities (MSCA) were administered to children at age 66 months. No association between MeHg exposure and performance on the MSCA General Cognitive Index was identified. We analyzed these data further to determine whether associations were present on specific subscales of the MSCA. The standard MSCA subscales were analyzed. Then, more specific subscales of the MSCA were defined and analyzed utilizing a neuropsychological approach. The subscales were recombined to approximate the domains of cognitive functioning evaluated in the Faroes and New Zealand studies. Analyses of both the standard and the recombined MSCA subscales showed no adverse associations with MeHg exposure and neuropsychological endpoints. A positive association between postnatal MeHg exposure and performance on the MSCA Memory subscale was found. These findings are consistent with previous reports from the Seychelles study in that no adverse effects of MeHg exposure from fish consumption can be detected in this cohort.