I text for I COUGH: A clinical pilot study to evaluate the impact of text messaging upon postoperative ambulation in the hospital

BACKGROUND

The "I COUGH" protocol is associated with improved postoperative pulmonary outcomes, and ambulation is an essential component. I COUGH is an acronym for Incentive spirometry, Coughing, Oral care, Understanding (patient and staff education), Getting-out-of-bed, and Head-of-bed elevation. This trial sought to enhance one component, specifically ambulation after operations.

METHODS

Randomized trial of inpatients in a safety-net, academic medical center. The intervention group received standard I COUGH education along with text message reminders to ambulate postoperatively, whereas the control group received standard education alone. Postoperative walking frequency was compared to each participant's ambulation on the day prior to enrollment.

RESULTS

The intervention group had an average improvement of 1.8 ± 1.8 walks per day per patient, while the average change for the control group was 0.2 ± 1.0 walks per day per patient. This represents a 9-fold increase in ambulation for the intervention group (p = 0.03).

CONCLUSIONS

Implementation of text message reminders increased ambulation and improved adherence to the I COUGH protocol following operations. This system should be further investigated as an adjunct to postoperative care.

Two novel risk factors for postoperative venous thromboembolism: A reconsideration of standard risk assessment and prophylaxis

BACKGROUND

Postoperative venous thromboembolism (VTE) is usually preventable with adequate prophylaxis. In an institutional study, patients with emergency operations (EO), multiple operations (MO), and perioperative sepsis (PS) were more likely to develop VTE despite standard prophylaxis.

METHODS

General surgery patients in the NSQIP database from 2011 to 2014 were stratified into VTE and non-VTE groups, and statistical analyses were performed.

RESULTS

Among 1,610,086 patients, 13,673 (0.8%) were diagnosed with VTE. The VTE odds ratios for patients with EO, MO and PS were 1.4 (95%CI:1.3-1.5), 1.9 (95%CI:1.7-2.0), and 2.4 (95%CI:2.2-2.5), respectively. VTE odds ratios increased with concurrence of two factors (EO+PS: 2.0 (95%CI:1.9-2.2)) (EO+MO: 2.3 (95%CI:1.9-2.7)) (MO+PS: 2.5 (95%CI:2.2-2.7)) and further still for patients with all three factors (2.7, 95%CI:2.4-3.0).

CONCLUSION

General surgery patients with EO, MO, or PS have a greater likelihood of developing postoperative VTE. These factors are not necessarily captured in contemporary risk assessment models that guide chemoprophylaxis, and so these high-risk patients may receive insufficient prophylaxis.

The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One Decade of Experience

BACKGROUND

Surgical quality improvement programs can provide meaningful benefits for patient outcomes, but sustainability of initial success is rarely described. In response to data that revealed a greater than predicted likelihood of postoperative pulmonary complications in one hospital, the study team designed a standardized program to improve care. This study offers a long-term perspective of the effort, including special challenges and lessons learned about sustaining success.

METHODS

A before-after study was conducted at an academic safety-net hospital. A multidisciplinary team developed tactics to reduce pulmonary complications, designated by the acronym I COUGH: Incentive spirometry, Coughing/deep breathing, Oral care, Understanding (education), Getting out of bed, and Head of bed elevation. Clinical practices were audited and compared to actual and risk-adjusted pulmonary outcomes.

RESULTS

Improvements in compliance with the I COUGH elements were initially promising, but baseline behaviors eventually returned. Adverse outcomes have inversely correlated with process adherence in "sawtooth" patterns. Rejuvenation efforts have successively extended beyond the literal principles of the acronym to foster broader institutional commitment to perioperative pulmonary care, restoring favorable trends in both process and outcomes. A more comprehensive I COUGH program now extends beyond the acronym, applying numerous concepts to support the original program.

CONCLUSION

I COUGH, a standardized perioperative pulmonary care program, initially improved performance and reduced pulmonary complications. However, loss of early program momentum corresponded with a return to baseline outcomes. Fortunately, an overall favorable trend has resulted from a coordinated rededication to I COUGH that requires steadfast commitment and creative responses to numerous cultural barriers.

Evaluation of a Standardized Risk-Based Venous Thromboembolism Prophylaxis Protocol in the Setting of Thyroid and Parathyroid Surgery

BACKGROUND

An elevated odds ratio for venous thromboembolism (VTE) prompted development of a Caprini risk assessment and risk-based prophylaxis protocol for all general surgery patients. This system includes pre- and postoperative prophylactic heparin as well as extended courses of low molecular weight heparin for high-risk patients. This study evaluated the safety of this chemoprophylaxis program in thyroid and parathyroid surgery.

STUDY DESIGN

A retrospective review was conducted of all general surgery patients undergoing thyroid or parathyroid operations after implementation of the Caprini prophylaxis protocol. Descriptive statistics were performed to evaluate bleeding complications, risk score categories, and chemoprophylaxis.

RESULTS

Of 1,012 consecutive patients, 72% were determined to be at low/moderate risk for VTE, 26% were high risk, and 2% were highest risk. Only 29% of eligible high/highest-risk patients actually received extended prophylaxis after discharge. Fifteen patients (1.5%) developed wound hematomas that required evacuations, 12 of them within 24 hours of the index operation. Among patients who developed bleeding complications, 5 (33%) had Caprini scores indicating low/moderate-risk for VTE, and 10 (67%) were in the high/highest-risk categories. Only 1 patient developed a delayed hematoma that required a return to the hospital for evacuation. One patient developed a VTE complication.

CONCLUSIONS

Although the incidence of VTE is quite low for patients undergoing thyroid and parathyroid operations, the Caprini prophylaxis protocol identifies a subset of high-risk patients who may benefit from extended VTE prophylaxis without the likelihood of added harm. Conversely, Caprini scores might also select low-risk patients who require no chemoprophylaxis, possibly reducing risks of hemorrhage.

I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program

IMPORTANCE

Postoperative pulmonary complications can be a devastating consequence of surgery. Validated strategies to reduce these adverse outcomes are needed.

OBJECTIVES

To design, implement, and determine the efficacy of a suite of interventions for reducing postoperative pulmonary complications.

DESIGN

A before-after trial comparing our National Surgical Quality Improvement Program (NSQIP) pulmonary outcomes before and after implementing I COUGH, a multidisciplinary pulmonary care program.

SETTING

An urban, academic, safety-net hospital.

PARTICIPANTS

All patients who underwent general or vascular surgery at our institution during a 1-year period before and after implementation of I COUGH.

INTERVENTIONS

A multidisciplinary team developed a strategy to reduce pulmonary complications based on comprehensive patient and family education and a set of standardized electronic physician orders to specify early postoperative mobilization and pulmonary care. Designated by the acronym I COUGH, the program emphasizes incentive spirometry, coughing and deep breathing, oral care (brushing teeth and using mouthwash twice daily), understanding (patient and family education), getting out of bed at least 3 times daily, and head-of-bed elevation. Nursing and physician education promoted a culture of mobilization and I COUGH interventions. I COUGH was implemented for all general surgery and vascular surgery patients at our institution in August 2010.

MAIN OUTCOMES AND MEASURES

The NSQIP-reported incidence and risk-adjusted ratios of postoperative pneumonia and unplanned intubation, which NSQIP reports as observed-expected (OE) ratios for the 1-year period before implementing I COUGH and as odds ratios (ORs, statistically comparable to OE ratios) for the period after its implementation.

RESULTS

Before implementation of I COUGH, our incidence of postoperative pneumonia was 2.6%, falling to 1.6% after its implementation, and risk-adjusted outcomes fell from an OE ratio of 2.13 to an OR of 1.58. The incidence of unplanned intubations was 2.0% before I COUGH and 1.2% after I COUGH, with risk-adjusted outcomes decreasing from an OE ratio of 2.10 to an OR of 1.31.

CONCLUSIONS AND RELEVANCE

I COUGH, a standardized postoperative care program emphasizing patient education, early mobilization, and pulmonary interventions, reduced the incidence of postoperative pneumonia and unplanned intubation among our patients.

Varroa-tolerant Italian honey bees introduced from Brazil were not more efficient in defending themselves against the mite Varroa destructor than Carniolan bees in Germany

In Europe and North America honey bees cannot be kept without chemical treatments against Varroa destructor. Nevertheless, in Brazil an isolated population of Italian honey bees has been kept on an island since 1984 without treatment against this mite. The infestation rates in these colonies have decreased over the years. We looked for possible varroa-tolerance factors in six Italian honey bee colonies prepared with queens from this Brazilian island population, compared to six Carniolan colonies, both tested at the same site in Germany. One such factor was the percentage of damaged mites in the colony debris, which has been reported as an indicator of colony tolerance to varroa. A mean of 35.8% of the varroa mites collected from the bottoms of the Italian bee colonies were found damaged, among which 19.1% were still alive. A significantly greater proportion of damaged mites were found in the Carniolan bees (42.3%) and 22.5% were collected alive. The most frequent kind of damage found was damaged legs alone, affecting 47.4% of the mites collected from debris in Italian bees, which was similar to the amount found in Carniolan colonies (46%). The mean infestation rate by the varroa mite in the worker brood cells in the Italian bee colonies was 3.9% in June and 3.5% in July, and in drone brood cells it was 19.3% in June. In the Carniolan honey bee colonies the mean infestation rates in worker brood cells were 3.0 and 6.7%, respectively in the months of June and July and 19.7% in drone brood cells in June. In conclusion, the 'Varroa-tolerant' Italian honey bees introduced from Brazil produced lower percentages of damaged mites (Varroa destructor) in hive debris and had similar brood infestation rates when compared to 'susceptible' Carniolan bees in Germany. In spite of the apparent adaptation of this population of Italian bees in Brazil, we found no indication of superiority of these bees when we examined the proportions of damaged mites and the varroa-infestation rates, compared to Carniloan bees kept in the same apiary in Germany.

Juvenile hormone titer in capped worker brood of Apis mellifera and reproduction in the bee mite Varroa jacobsoni

Juvenile hormone (JH) titers were recorded from fifth instar worker larvae of Apis mellifera carnica, Apis mellifera lamarckii, and Africanized honeybees kept under temperate and tropical climatic conditions. No differences in hormone titer according to honeybee race or climatic conditions were determined. However, the rate of reproduction of the ectoparasitic mite, Varroa jacobsoni, on larvae of the different honeybee races was highly variable. The possible role of honeybee JH in control of the parasite's reproduction is discussed.

Septic arthritis caused by Bacteroides fragilis

As improvements in bacteriologic techniques have enhanced the recovery of anaerobic bacteria from clinical specimens, there has been an increasing awareness of the role of anaerobes in disease. Bacteroides fragilis is the most common anaerobic organism found in clinical specimens. Although it is the anaerobe most frequently associated with bacteremia and a common isolate in intraabdominal infections, infections of the female genital tract, wounds, and abscesses, B. fragilis is a rare cause of septic arthritis. The isolation of this organism from four patients with septic arthritis in three Cleveland hospitals between 1978 and 1982 suggests that septic arthritis due to B. fragilis may be a more common clinical entity than previously appreciated. In this report we describe these cases and review the pertinent literature.

Intravenous and standard immune serum globulin preparations interfere with uptake of 125I-C3 onto sensitized erythrocytes and inhibit hemolytic complement activity

Antibody-sensitized sheep erythrocytes were used as a model to determine the effects of therapeutic immune serum globulin (ISG) preparations on the ability of this particulate activator to fix C3 and initiate hemolysis. Both standard and intravenous forms of ISG inhibit uptake of 125I-C3, presumably by competing for the deposition of "nascent" C3b molecules onto the erythrocytes. Both forms of ISG also inhibit hemolytic activity of whole serum or purified complement components. The inhibition appears to be a specific property of IgG itself, since similar inhibition was not caused by equivalent concentrations of human serum albumin, and was not affected by the buffer in which the ISG was dissolved. Interference with C3 uptake onto antibody-sensitized platelets and/or inhibition of hemolytic complement activity could contribute to the efficacy of high dose intravenous ISG in idiopathic thrombocytopenic purpura.

On the mechanism of the acridine orange sensitized photodynamic inactivation of lysozyme. II. Kinetics in presence of N-acetylglucosamine

The photodynamic deactivation of lysozyme in presence of acridine orange is caused by a reaction between singlet oxygen formed via the dye triplet state and the protein. In order to identify the region where the singlet oxygen reacts with the protein we have investigated the kinetics of the deactivation in presence ofthe inhibitor of the enzymatic reaction N-acetylglucosamine (GlcNAc). The overall experimental rate constant becomes slower with increasing saccharide concentrations. As we can exclude experimentally that this kinetical effect is caused in presence of the saccharide by a physical quenching of singlet oxygen or of the dye triplet state it has to be assumed that GlcNAc protects the surrounding of its bindings place at subsite C of the enzymatic center sterically against an attack of singlet oxygen. In this region three tryptophan residues are located, which could be sensitive against singlet oxygen. Surprisingly, however, it has been found that only those species are protected, in which a second saccharide molecule is bound to the protein, probably at subsite E at the enzymatic center, where no sensitive amino acid side chains are located.

On the mechanism of the acridine orange sensitized photodynamic inactivation of lysozyme. I. Basic kinetics

The kinetics of the photodynamic desactivation of lysozyme in presence of acridine orange as the sensitizer have been investigated in detail varying oxygen, protein, dye concentration, ionic strength and pH value. The kinetics can be approximately described as an over all pseudo-first-order rate process. Changing the solvent from water to D2O or by quenching experiments in presence of azide ions it could be shown that the desactivation of lysozyme is caused exclusively by singlet oxygen. The excited oxygen occurs via the triplet state of the dye with a rate constant considerably lower than that to be expected for a diffusionally controlled reaction. Singlet oxygen react chemically (desactivation, k=2.9 X 10(7) m(-1) sec(-1)) and physically (quenching process, k=4.1 X 10(8) m(-1) sec(-1)) with the enzyme. The kinetical analysis shows that additional chemical reaction between singlet oxygen and lysozyme would have only little influence on the kinetics of the desactivation as long as their products would be enzymatically active and their kinetical constants would be less than about 1 X 10(8) m(-1) sec(-1)).