Early removal of catheters in an Enhanced Recovery Pathway (ERP) with intrathecal opioid injection does not affect postoperative urinary outcomes

BACKGROUND

Postoperative urinary retention (POUR) and catheter-associated urinary tract infections (CAUTI) are associated with significantly longer hospital length-of-stay and increased costs.¹ This study investigates the effect of early removal of urinary catheters on POUR and CAUTI in patients undergoing an ERP with a preoperative intrathecal injection.

METHODS

Retrospective cohort study of a prospectively maintained database of patients who underwent elective colorectal surgery in an Enhanced Recovery pathway was compared to historical National Surgical Quality Improvement Program cohort of patients. Primary outcomes measured are 30-day POUR and postoperative CAUTI rates.

RESULTS

The overall POUR rate of ERP patients compared to non-ERP patients was significantly less (8% vs. 13%, p < 0.05). CAUTI rates were not significantly different between pre-ERP and ERP patients (1.2 vs 2.3%, p = 0.19).

CONCLUSIONS

For patients undergoing ERP with a preoperative intrathecal opioid injection, early removal of urinary catheter significantly decreased POUR and did not significantly affect CAUTI rates.

SUMMARY

The effect of early removal of urinary catheters on postoperative urinary retention and catheter-associated UTI rates in patients undergoing an ERP with a single preoperative intrathecal opioid injection was studied. Early urinary catheter removal after intrathecal injection was associated with decreased rates of POUR and equivalent CAUTI rates.

Sustained improvement of psoriatic lesions in the course of sublingual immunotherapy for airborne allergens: clinical evidence of cross-tolerance

A patient with psoriasis is presented who was treated with sublingual immunotherapy for airborne allergens for allergic rhinitis. Allergic rhinitis and psoriasis have entirely different cytokine profiles and result from different aberrations of the immune response. Furthermore, T-cell activation in the two diseases uses different presentation systems, psoriasis being a CD8 cytotoxic cell response requiring presentation through the Major Histocompatibility Complex I, while allergic rhinitis and its treatment with sublingual immunotherapy depend on CD4 T-helper cells and presentation by the Major Histocompatibility Complex II. The rapid and impressive improvement of the psoriatic lesions in the presented patient may, along with evidence of subsiding Th1 activity, give rise to the hypothesis that tolerogenic-to-allergen changes induced by sublingual immunotherapy may induce cross-tolerance and the selective emergence of cytotoxic T cell clones with lessened psoriasis-producing activity.

Expression, purification and use of the soluble domain of Lactobacillus paracasei beta-fructosidase to optimise production of bioethanol from grass fructans

Microbial inulinases find application in food, pharmaceutical and biofuel industries. Here, a novel Lactobacillus paracasei beta-fructosidase was overexpressed as truncated cytosolic protein ((t)fosEp) in Escherichia coli. Purified (t)fosEp was thermostable (10-50 degrees C) with a pH optimum of 5; it showed highest affinity for bacterial levan (beta[2-6] linked fructose) followed by nystose, chicory inulin, 1-kestose (beta[2-1] linkages) and sucrose (K(m) values of 0.5, 15, 15.6, 49 and 398 mM, respectively). Hydrolysis of polyfructose moieties in agriculturally-sourced grass juice (GJ) with (t)fosEp resulted in the release of >13 mg/ml more bioavailable fructose than was measured in untreated GJ. Bioethanol yields from fermentation experiments with Brewer's yeast and GJ+(t)fosEp were >25% higher than those achieved using untreated GJ feedstock (36.5[+/-4.3] and 28.2[+/-2.7]mg ethanol/ml, respectively). This constitutes the first specific study of the potential to ferment ethanol from grass juice and the utility of a novel core domain of beta-fructosidase from L. paracasei.

Hyperhomocysteinemia associated with poor recall in the third National Health and Nutrition Examination Survey

BACKGROUND

High circulating total homocysteine (tHcy) concentrations are associated with stroke, which is a major cause of cognitive dysfunction. Blood homocysteine concentrations are inversely correlated with performance on some cognitive-function tests and a relation was recently shown between hyperhomocysteinemia and Alzheimer disease.

OBJECTIVE

The objective was to evaluate the relation between serum tHcy concentrations and performance on short delayed-recall tests of elderly men and women participating in the third National Health and Nutrition Examination Survey, phase 2 (1991--1994).

DESIGN

Subjects were aged > or =60 y. Subjects reported no previous stroke, completed > or =8 y of education, and took a test of delayed recall of story ideas (n = 1200) or words (n = 1270).

RESULTS

After adjustment for sex, age, race-ethnicity, income, years of education, and serum creatinine concentration, subjects in the upper half of the folate distribution recalled, on average, >4 of 6 story ideas; subjects with lower folate status recalled significantly fewer ideas (P < 0.001). Of the subjects with low folate status, story recall was significantly poorer in those with serum tHcy concentrations above the 80th percentile of the distribution (13.7 micromol/L) than in those with lower tHcy concentrations (P < 0.03). The odds ratio relating hyperhomocysteinemia to recall of > or =1 of 3 previously learned words was 0.3 (95% CI: 0.2, 0.7) after adjustment for the 5 demographic factors alone and was 0.4 (0.2, 0.9) after further adjustment for serum folate concentration.

CONCLUSION

Hyperhomocysteinemia is related to poor recall and this association was partially independent of folate status.

Hyperhomocysteinemia and hypercholesterolemia associated with hypothyroidism in the third US National Health and Nutrition Examination Survey

Hypothyroid (thyroid stimulating hormone (TSH)> or =20 mIU/l; N=32) participants in the third National Health and Nutrition Examination Survey, Phase 2 (1991-1994) were compared with non-hypothyroid subjects (0.5 mIU/l<TSH<20 mIU/l; N=6490) to examine the relationship between hypothyroidism and hyperhomocysteinemia (serum total homocysteine>12 micromol/l) and hypercholesterolemia (serum total cholesterol>6.2 mmol/l). After controlling for age, gender, and race ethnicity, the odds ratios (95% confidence interval (CI)) relating hypothyroidism to hyperhomocysteinemia and high total cholesterol were 4.9 (1.8-14.0) and 8.0 (2.9-21.9), respectively. Based on 26 hypothyroid and 5811 non-hypothyroid subjects with triglyceride concentration < or =2.82 mmol/l, the odds ratio for the relationship between hypothyroidism and high low-density lipoprotein (LDL)-cholesterol (>4.6 mmol/l by the Friedewald equation) was 5.3 (95% CI, 1.3-20.9). Adding additional terms to the multivariate logistic regression model had little effect on the odds ratios relating hypothyroidism to high total or LDL-cholesterol, but adding terms for serum creatinine concentration >123.8 micromol/l and for red blood cell folate and serum vitamin B-12 concentrations resulted in an attenuated, but still significant (P<0.05), odds ratio relating hypothyroidism to hyperhomocysteinemia (2.5; 95% CI, 1.0-6.1). Controlling for cigarette smoking, heart attack/stroke history, body mass index, and serum albumin concentration did not affect the odds ratios. Hyperhomocysteinemia and hypercholesterolemia could help to explain the increased risk for arteriosclerotic coronary artery disease in hypothyroidism.

Serum total homocysteine concentration is related to self-reported heart attack or stroke history among men and women in the NHANES III

High circulating total homocysteine (tHcy) concentration, which is influenced by folate and vitamin B-12 status, is a suspected cause of cardiovascular events. This relation has been investigated in both case-control and prospective studies but has not been evaluated for different sex x age subgroups of the general U.S. population. We used data on adult (i.e., aged > or =40 y) male (n = 1097) and female (n = 1107) participants in the third National Health and Nutrition Examination Survey, excluding diabetics and those supplemented with estrogen, vitamins or minerals, to evaluate the association between serum tHcy concentration and self-report of heart attack or stroke. After adjustment for age, race-ethnicity, smoking, blood pressure, blood pressure medication, body mass index and serum concentrations of creatinine and cholesterol, past events were reported 2.4 (95% confidence interval 1.0-5.5) times as often by men with tHcy concentration of >12 micromol/L as by men with lower values. The odds ratio for women was 2.6 (95% confidence interval 1.1-6.6) after adjustment for the same factors plus menopausal status. A stronger relation in men aged < or =60 y compared with older men may help reconcile conflicting results of earlier studies.

Total homocysteine and estrogen status indicators in the Third National Health and Nutrition Examination Survey

The possibility that estrogen status modulates total homocysteine concentration, a risk factor for vascular occlusion, was examined in a representative sample of the US population, the Third National Health and Nutrition Examination Survey (phase 2), 1991-1994. The geometric mean serum total homocysteine concentration was compared among population subgroups differing on inferred estrogen status, after adjusting for potential confounding by age, race-ethnicity, smoking, and the serum concentration of creatinine, folate, and vitamin B-12. Premenopausal women aged 17-54 years had a lower mean serum total homocysteine concentration (8.1 micromol/liter, 95% confidence interval (CI): 7.9, 8.2) than men in the same age range (8.9 micromol/liter, 95% CI: 8.6, 9.3). In the age range 17-44 years, pregnant women (6.0 micromol/liter, 95% CI: 5.4, 6.8), but not oral contraceptive users (7.9 micromol/liter, 95% CI: 7.6, 8.2), had a lower mean serum total homocysteine concentration than nonpregnant, non-oral-contraceptive-using women (8.1 micromol/liter, 95% CI: 7.9, 8.2). The mean serum total homocysteine concentration of estrogen-using women aged > or = 55 years (9.5 micromol/liter, 95% CI: 8.9, 10.1) was significantly decreased relative to nonestrogen users (10.7 micromol/liter, 95% CI: 10.3, 11.1) and men (10.4 micromol/liter, 95% CI: 9.8, 11.0) in the same age range. These findings suggest that higher estrogen status is associated with a decreased mean serum total homocysteine concentration, independent of nutritional status and muscle mass, and that estrogen may explain the previously reported male-female difference in total homocysteine concentration.

Tympanostomy tubes: types, indications, techniques, and complications

This article reviews current concepts and applications involving tympanostomy tubes. The various types of tympanostomy tubes, indications, complications, and techniques are discussed. Applications ranging from otitis media to dysfunction of the eustachian tube associated with nasopharyngeal carcinoma are included. Experience drawn from patient care and currently published studies support the conclusions made in this article.

Mutation detection by ligation to complete n-mer DNA arrays

A new approach to comparative nucleic acid sequence analysis is described that uses the ligation of DNA targets to high-density arrays containing complete sets of covalently attached oligonucleotides of length eight and nine. The combination of enzymatic or chemical ligation with a directed comparative analysis avoids many of the intrinsic difficulties associated with hybridization-based de novo sequence reconstruction methods described previously. Double-stranded DNA targets were fragmented and labeled to produce quasirandom populations of 5' termini suitable for ligation and detection on the arrays. Kilobase-size DNA targets were used to demonstrate that complete n-mer arrays can correctly verify known sequences and can determine the presence of sequence differences relative to a reference. By use of 9-mer arrays, sequences of 1.2-kb targets were verified with >99.9% accuracy. Mutations in target sequences were detected by directly comparing the intensity pattern obtained for an unknown with that obtained for a known reference sequence. For targets of moderate length (1.2 kb), 100% of the mutations in the queried sequences were detected with 9-mer arrays. For higher complexity targets (2.5 and 16.6 kb), a relatively high percentage of mutations (90% and 66%, respectively) were correctly identified with a low false-positive rate of <0.03 percent. The methods described provide a general approach to analyzing nucleic acid samples on the basis of the interpretation of sequence-specific patterns of hybridization and ligation on complete n-mer oligonucleotide arrays.

Large-scale identification, mapping, and genotyping of single-nucleotide polymorphisms in the human genome

Single-nucleotide polymorphisms (SNPs) are the most frequent type of variation in the human genome, and they provide powerful tools for a variety of medical genetic studies. In a large-scale survey for SNPs, 2.3 megabases of human genomic DNA was examined by a combination of gel-based sequencing and high-density variation-detection DNA chips. A total of 3241 candidate SNPs were identified. A genetic map was constructed showing the location of 2227 of these SNPs. Prototype genotyping chips were developed that allow simultaneous genotyping of 500 SNPs. The results provide a characterization of human diversity at the nucleotide level and demonstrate the feasibility of large-scale identification of human SNPs.

Accessing genetic information with high-density DNA arrays

Rapid access to genetic information is central to the revolution taking place in molecular genetics. The simultaneous analysis of the entire human mitochondrial genome is described here. DNA arrays containing up to 135,000 probes complementary to the 16.6-kilobase human mitochondrial genome were generated by light-directed chemical synthesis. A two-color labeling scheme was developed that allows simultaneous comparison of a polymorphic target to a reference DNA or RNA. Complete hybridization patterns were revealed in a matter of minutes. Sequence polymorphisms were detected with single-base resolution and unprecedented efficiency. The methods described are generic and can be used to address a variety of questions in molecular genetics including gene expression, genetic linkage, and genetic variability.

Adult leukemia and proximity-based surrogates for exposure to Pilgrim plant's nuclear emissions

Possible associations between adult leukemia incidence and proximity-based surrogate measures of potential for exposure to radioactive emissions from the Pilgrim nuclear power plant in Plymouth, Massachusetts, were investigated. Included in this study were 105 nonchronic lymphocytic leukemia cases, diagnosed between 1978 and 1986 at age 13 y or older, that occurred in 22 towns near Pilgrim; population controls numbered 208. Residence within 4 mi (6.4 km) of Pilgrim during "high-emissions" years was related to case-control status (adjusted odds ratio [OR] = 3.88, 95% confidence interval [95% CI] = 0.81-10.64). A high "exposure" score (i.e., a value that accounted for downwind time) was also related to case-control status (OR = 3.46, 95% CI = 1.50-7.96). Some statistically significant dose-response trends were found. Cautious interpretation of associations is warranted in light of the low levels of reported emissions.

Lived experiences, values, and behavior of effective nurse faculty

This study explored the lived experiences of effective female nurse faculty. The study was guided by a feminist framework. A field study was the specific qualitative approach employed. The research addressed the question: What are the lived experiences of effective female nurse faculty? In addition, four subquestions related to the conceptual framework were explored. The sample was composed of 11 women from National League for Nursing-accredited baccalaureate and higher-degree nursing programs in Virginia who were identified by their peers as being effective in the nurse faculty role. Data were collected through use of unstructured interviews, passive participant observations, and document review. The study yielded themes related to values and effective teaching behaviors. Conclusions of the study were: (1) the feminist framework developed for the study was generally helpful for understanding the women studied; (2) effective female nurse faculty are a work in progress; (3) because they value hard work, caring, interaction, a sense of humor, the worth of others, and learning, subjects were able to develop into effective female nurse faculty; and (4) these women maintain their effectiveness by constantly growing and changing as well as by finding a sense of fit between organizational values and personal values.

Magnetic resonance imaging of perilymphatic fistula

Perilymphatic fistula (PLF) is considered to be a most challenging otologic issue. There are no currently agreed upon objective tests for the diagnosis of PLF. In an effort to improve diagnostic accuracy in patients with suspected PLF, a novel diagnostic test involving magnetic resonance (MR) contrast imaging was designed. An experimental PLF was created in the cochlear round window membrane of healthy adult cats. Since cochlear perilymph is thought to be an ultrafiltrate of cerebral spinal fluid, gadodiamide (gadolinium-diethylenetriamine penta-acetic acid [DTPA] bismethylamide), a nonionic paramagnetic contrast agent, was injected intrathecally in an attempt to enhance imaging of the created fistula. Post-contrast images of the fistualized cochlea demonstrate a significant increase in the signal intensity of the cochlear perilymph with pooling of enhanced perilymph observed in the ipsilateral mastoid bulla. Magnetic resonance contrast imaging may prove to be a valuable technique in human studies involving perilymphatic fistula.

Contemporary skin grafting in otologic surgery

In the post-operative healing phase following external auditory canalplasty or open cavity mastoidectomy, problematic epithelialization of surfaces may ensue. Exposed surfaces or surface epithelialized with tissues other than skin may predispose to secondary infection and result in recurrent otorrhea. Split-thickness skin grafts can be useful in promoting healing of exposed canal and mastoid cavity surfaces. Our experience and methodology for harvesting and placing these grafts are reviewed. The indications, management, and complications of split-thickness otologic skin grafting will be presented.

The perforated tympanic membrane

Tympanic membrane perforations typically result from trauma or acute otitis media. Most perforations do not cause more than a mild conductive hearing loss, aural fullness and mild tinnitus. Blood, purulent secretions and other debris should be carefully suctioned out of the canal and the perforation size and location described. Irrigation and pneumatic otoscopy should be avoided. A history of vertigo, nausea and vomiting and an audiogram showing a conductive hearing loss of more than 30 dB suggest disruption of the ossicular chain. Profound sensorineural loss may signify inner ear nerve damage. Mastoid radiographs and computed tomographic scans may be useful in cases of significant trauma and infection. Most small perforations resolve spontaneously. The affected ear should be kept dry. Oral and topical antibiotics may be prescribed for perforations related to acute otitis media. Otolaryngologic referral may be necessary to evaluate traumatic perforations associated with vertigo or significant hearing loss, perforations from chronic otitis media or perforations from acute otitis media that do not heal within one month.

Perilymphatic fistula: surgical experience in the United States

One survey sent to 6953 individual otolaryngologic practices and 106 departments of otolaryngology at teaching hospitals in the United States, and a more limited survey of 75 patients operated on for perilymphatic fistula (PLF) at the House Ear Institute, addressed aspects of managing PLF: surgical incidence, reliability of diagnostic test, preoperative observations, and disability after surgery. Of surgeons sampled, 93% estimated incidence of PLF surgery to be less than or equal to 1 per 1000 otolaryngologic outpatient visits. The most reliable diagnostic indicators were history, symptomatology, and tympanometric and electronystagmographic fistula tests. About 72% of surgeons reported less than 4 weeks' average delay before surgery. Most surgeons and patients (greater than or equal to 70%) rated length of disability before return to work, exposure to noise, travel by airplane, swimming, and heavy lifting, at several weeks to several months. Diving was the most restricted activity. Results suggest that incidence of surgery and disability with PFL in the United States is very limited.

Postpartum subcutaneous emphysema with pneumomediastinum

We have presented a case of pneumomediastinum and subcutaneous emphysema in a 30 year old woman immediately post-partum. The underlying pulmonary pathophysiology and management are discussed.

Lymphadenopathy in the HIV-seropositive patient

The problem of lymphadenopathy in HIV-seropositive patients is reviewed, and indications for further study are presented. Implications for patients who later develop AIDS are discussed.

Otologic disease in the acquired immunodeficiency syndrome

It appears that true otologic manifestations of AIDS are rare and that incidental otologic disease associated with AIDS is more common. A review of the literature revealed that otitis externa, acute otitis media, recurrent acute otitis media, otitis media with effusion, chronic suppurative otitis media with cholesteatoma, and herpes zoster oticus may all represent incidental otologic disease occurring in patients with AIDS. Chronic otitis media without cholesteatoma (P carinii-infected aural polyps), sensorineural hearing loss, acceleration of otosyphilis from the latent stage, and development of Kaposi's sarcoma of the external auricle or nasopharynx may represent true otologic manifestations of AIDS.

The flexible/intact-bridge tympanomastoidectomy technique

A combination of otologic techniques has been presented in the step-wise surgical rationale that we call the flexible approach. The sequence of steps involved in the flexible approach allows the surgeon to adjust his or her surgery to the individual patient's needs. Very often, in patients with chronic otitis media, a middle ear reconstructive procedure (ossiculoplasty including lateralization of the malleus, removal of pathological tissue, insertion of an implant of silicone rubber sheets, and use of ventilation tubes with or without tympanic grafts) will obviate mastoidectomy. When a mastoidectomy is indicated, the IBM is a suitable procedure that encompasses the advantages of both closed and open mastoidectomy techniques.

Subglottic stenosis: retrospective analysis and proposal for standard reporting system

A retrospective analysis was undertaken reviewing management of 67 patients treated for subglottic stenosis (SGS) at the Children's Hospital National Medical Center (CHNMC) between 1980 and 1985. Forty-seven (90%) of the patients were followed for at least 18 months from the time diagnosis was made. Twenty-three (66%) of the patients followed for at least 18 months were successfully decannulated or had an adequate airway without tracheotomy. To compare efficacy of management of SGS at the CHNMC with management outcomes previously reported, a review of medical literature was undertaken and data from the most significant reports on management of SGS were collated and tabulated. Since analysis of published reports did not yield a consensus regarding optimal methods for management, and statistics in many published reports were absent or unclear, authors of the previously published reports were contacted personally by means of a letter and survey questionnaire. Results of the survey show that many authors have not performed a statistical review of their case data to determine relative efficacy of different surgical procedures. Thus, retrospective review of cases managed at the CHNMC as well as information obtained from leading experts in management of SGS indicate that there is no single optimal procedure or technique for management of all cases of SGS. Further, the way in which surgical procedures for management of SGS are being reported makes difficult the process of meaningfully comparing results reported by different surgeons. A reporting system is proposed that uses specific terms and objective parameters.

SLIPS. A data base system for computer storage and analysis of phonological errors

The analysis of phonological errors made by normal individuals (slips of the tongue) and brain-damaged patients (paraphasias) is a challenging problem. SLIPS is an experimental data base system for computer storage and analysis of such errors. This paper introduces SLIPS and describes its main features. Some of the problems that arise in analyzing phonological error data are explained, and examples of their solution are presented.

The comparative ultrastructure of fibrin induced by thrombin and by staphylocoagulase

Fibrin induced by the action of thrombin and by staphylocoagulase was studied by transmission electron microscopy. Periodic striations were consistently observed in the negatively stained preparations of both fibrins. When 4200 major periods in the thrombin fibrin system were measured the mean length was 228 A. For 3666 major periods in the coagulase fibrin system the mean length was 223 A. While the T test analysis of these values gave a value of 10, it is noteworthy that the differences are well within the scatter of periodicity reported in the literature for thrombin-induced fibrin. Gross inspection of the preparations indicated that the coagulase-induced fibrin had a knottier appearance and was accompanied by a greater amount of background debris than the thrombin-induced fibrin.