Safety of Next Day Discharge After Lobectomy: Have We Broken the Speed Limit?

BACKGROUND: Utilizing our standardized approach to air leak reduction (STAR) protocol has led to a continual decrease in the need for inpatient recovery after lobectomy. Although next-day discharges do occur, the current literature, to our knowledge, has not addressed their safety. We analyzed our STAR data set to study this group and their outcomes. METHODS: A retrospective review of prospectively collected data from the STAR data set was performed. Characteristics were compared between patients discharged on postoperative day (POD) 1 and those with longer admissions. Outcome data was analyzed. RESULTS: From June 2010 through June 2017, 390 patients underwent lobectomy and met study criteria. Of these, 150 (38%) were discharged on POD 1 versus 240 (62%) who were discharged later (mean length of stay, 3.9 days). There was no increase in morbidity, mortality, or 30-day readmission between the 2 groups. Distinguishing characteristics of the POD 1 group included more nonsmokers, use of a minimally invasive technique, and a lower incidence of prolonged air leak. FEV1 (forced expiratory volume in 1 second) and Dlco (diffusing capacity of the lung for carbon monoxide) data were also favorable in the POD 1 group. The percentage of patients sent home POD 1 increased from an average of 23% over the first 3 years of the study to 63% over the last 3 years. CONCLUSIONS: Appropriately identified patients can safely go home on POD 1 after lobectomy without an increase in 30-day readmission, morbidity, or mortality. A continued focus on lobectomy length of stay reduction has the capacity to increase patient satisfaction and lead to reduction in health care costs.

Performance of an ICD algorithm to detect lead noise and reduce inappropriate shocks.

BACKGROUND: Implantable cardioverter-defibrillators (ICD) provide treatment for life-threatening ventricular tachyarrhythmias. Failure of the pace/sense conductor of an ICD lead can cause noise on the sensing electrogram (EGM) that may be misinterpreted as ventricular activity, triggering inappropriate therapy. An algorithm based upon the confirmation of ventricular activity from a far-field EGM has been developed to reduce inappropriate therapies resulting from this type of lead failure, while ensuring that appropriate therapy is delivered. The objectives of this study were to evaluate the algorithm's ability to discriminate lead noise from ventricular tachycardia/ventricular fibrillation (VT/VF) and to determine whether it inhibits inappropriate shocks without delaying appropriate shocks. METHODS: The algorithm was prospectively tested using near- and far-field EGM recordings from patients in three conditions: normal sinus rhythm with sustained and non-sustained lead noise via manipulation of the ICD pocket or lead system, and VT/VF induced during defibrillation threshold testing. The recordings were played through a bench-top device running the algorithm with the diagnosis, time to diagnosis, and inhibition of therapy documented. RESULTS: The algorithm detected noise and withheld inappropriate therapy in 231 of 238 recordings of sustained lead noise that would otherwise have been diagnosed as VT/VF (97.1%). Non-sustained lead noise was correctly diagnosed in 47 of the 52 recordings (90.4%). The device appropriately identified all 853 recordings of VT/VF (100%), without an increase in the time to detection (0.01 ± 0.14 s). CONCLUSIONS: The SecureSense(TM) algorithm correctly diagnosed sustained and non-sustained lead noise recordings without compromising detection of VT/VF. Use of the algorithm may reduce inappropriate shocks and alert clinicians to lead noise indicative of lead failure.

Scheduled repeat CT scanning for traumatic brain injury remains important in assessing head injury progression.

BACKGROUND: Scheduled repeat brain CT (SRBCT) is used to monitor progression of traumatic brain injury (TBI). Previous studies have suggested that routine SRBCT can be replaced by an unscheduled repeat brain CT after deterioration on serial neurological examination. In this study, we evaluated if SRBCT has a role in the management of TBI. STUDY DESIGN: Retrospective observational study of 1,019 consecutive adult patients admitted to a Level I trauma center with CT evidence of TBI on initial brain CT (IBCT). All patients with intracranial pathology on IBCT were scheduled for SRBCT and underwent sequential neurological physical examinations. Interventions (surgical or medical) after IBCT, SRBCT, or neurological change were recorded. RESULTS: One thousand nineteen patients with IBCT evidence of TBI were identified from the trauma registry during a 50-month study period beginning in November 2001. Eighty-six (8.9%) of these patients went directly for craniotomy. After exclusions, 887 patients were analyzed. A total of 692 (78%) patients had a no worse first SRBCT and neurologic changes requiring intervention later developed in 11 (1.6%) of these patients. One hundred ninety-five (22%) patients had a worse first SRBCT, with 14 (7.2%) requiring immediate intervention. Seven (3.6%) worse first SRBCT patients had a subsequent SRBCT that worsened, leading to an intervention. A neurologic change that precipitated an intervention developed subsequently in an additional 19 (9.7%) patients with a worse first SRBCT. Chi-square analysis demonstrated that a first SRBCT that was worse was more likely to result in an intervention than if the first SRBCT was no worse. CONCLUSIONS: A worse SRBCT is more likely to result in neurologic intervention. SRBCT remains useful in assessing patients with TBI.

The cytochrome P450 enzyme CYP96A15 is the midchain alkane hydroxylase responsible for formation of secondary alcohols and ketones in stem cuticular wax of Arabidopsis.

Most aerial surfaces of plants are covered by cuticular wax that is synthesized in epidermal cells. The wax mixture on the inflorescence stems of Arabidopsis (Arabidopsis thaliana) is dominated by alkanes, secondary alcohols, and ketones, all thought to be formed sequentially in the decarbonylation pathway of wax biosynthesis. Here, we used a reverse-genetic approach to identify a cytochrome P450 enzyme (CYP96A15) involved in wax biosynthesis and characterized it as a midchain alkane hydroxylase (MAH1). Stem wax of T-DNA insertional mutant alleles was found to be devoid of secondary alcohols and ketones (mah1-1) or to contain much lower levels of these components (mah1-2 and mah1-3) than wild type. All mutant lines also had increased alkane amounts, partially or fully compensating for the loss of other compound classes. In spite of the chemical variation between mutant and wild-type waxes, there were no discernible differences in the epicuticular wax crystals on the stem surfaces. Mutant stem wax phenotypes could be partially rescued by expression of wild-type MAH1 under the control of the native promoter as well as the cauliflower mosaic virus 35S promoter. Cauliflower mosaic virus 35S-driven overexpression of MAH1 led to ectopic accumulation of secondary alcohols and ketones in Arabidopsis leaf wax, where only traces of these compounds are found in the wild type. The newly formed leaf alcohols and ketones had midchain functional groups on or next to the central carbon, thus matching those compounds in wild-type stem wax. Taken together, mutant analyses and ectopic expression of MAH1 in leaves suggest that this enzyme can catalyze the hydroxylation reaction leading from alkanes to secondary alcohols and possibly also a second hydroxylation leading to the corresponding ketones. MAH1 expression was largely restricted to the expanding regions of the inflorescence stems, specifically to the epidermal pavement cells, but not in trichomes and guard cells. MAH1-green fluorescent protein fusion proteins localized to the endoplasmic reticulum, providing evidence that both intermediate and final products of the decarbonylation pathway are generated in this subcellular compartment and must subsequently be delivered to the plasma membrane for export toward the cuticle.

Characterization of Arabidopsis ABCG11/WBC11, an ATP binding cassette (ABC) transporter that is required for cuticular lipid secretion.

ABCG11/WBC11, an ATP binding cassette (ABC) transporter from Arabidopsis thaliana, is a key component of the export pathway for cuticular lipids. Arabidopsis wbc11 T-DNA insertional knock-out mutants exhibited lipidic inclusions inside epidermal cells similar to the previously characterized wax transporter mutant cer5, with a similar strong reduction in the alkanes of surface waxes. Moreover, the wbc11 knock-out mutants also showed defects not present in cer5, including post-genital organ fusions, stunted growth and a reduction in cutin load on the plant surface. A mutant line previously isolated in a forward genetics screen, called permeable leaves 1 (pel1), was identified as an allele of ABCG11/WBC11. The double knock-out wbc11 cer5 exhibited the same morphological and biochemical phenotypes as the wbc11 knock-out. A YFP-WBC11 fusion protein rescued a T-DNA knock-out mutant and was localized to the plasma membrane. These results show that WBC11 functions in secretion of surface waxes, possibly by interacting with CER5. However, unlike ABCG12/CER5, ABCG11/WBC11 is important to the normal process of cutin formation.

Bioassay-guided fractionation of antifouling compounds using computer-assisted motion analysis of brown algal spore swimming.

Antifouling extracts from the sea stars Astropecten articulatus and Luidia clathrata and from the brittle star Astrocyclus caecilia were fractionated by solid phase extraction and high performance liquid chromatography. Bioactive fractions were identified with the use of computer-assisted motion analysis-based bioassays utilising previously described Hincksia irregularis spore swimming behaviour parameters. Quantified parameters of spore movement were rate of change of direction (RCD) and speed (SPEE). The methods used initially required only 10 microg equivalent amounts of total crude extract and each resultant resolving step (normalised to 1 mg ml(-1) of crude, unfractionated extract) required far less material. Statistical analyses of RCD and ratios of RCD:SPEE values in experiments comparing swimming in the presence of extract fractions to controls revealed that both parameters were useful individually and in combination for efficiently following compound bioactivity throughout the fractionation procedure. This technique was also able to detect synergistic or additive interactions between compounds.

Individual and coupled effects of echinoderm extracts and surface hydrophobicity on spore settlement and germination in the brown alga Hincksia irregularis.

Marine substrata possess cues that influence the behavior of fouling organisms. Initial adhesion of fouling algal zoospores to surfaces is also theorized to depend primarily upon interactions between substrata and spore cell bodies and flagellar membranes. In an effort to identify cues and surface characteristics that influence spore settlement and early development, the effects of bioactive echinoderm extracts, surface charge, and surface hydrophobicity were examined individually and in tandem on zoospore settlement and germination in Hincksia irregularis. Experiments utilizing 96-well plastic culture plates confirmed that spore settlement and germination were significantly affected by surface charge and hydrophobicity as well as by echinoderm metabolites, both individually and in tandem. Spore settlement rates in the dark over 30 min were > 400% higher on hydrophobic surfaces than on positively and negatively charged surfaces. Spore germling numbers were > 300% higher on hydrophobic surfaces than on positively and negatively charged surfaces when spores were allowed to settle in the light for 30 min and the settled spores allowed to subsequently germinate for 24 h. Spore germling numbers were consistently > 25% higher on hydrophobic surfaces than on positively and negatively charged surfaces when equal numbers of spores were allowed to completely settle in the light and subsequently germinate for 24 h. H. irregularis germ tube lengths were also significantly longer on positively charged plates than on negatively charged plates. All echinoderm extracts tested had significant effects on germination and settlement at levels below those of estimated ecological concentrations. Short-term (30 min) exposure and subsequent germination experiments indicated that higher concentrations of extracts had rapid toxic effects on algal spores. Synchronous effects of echinoderm extracts and plate charge upon spore settlement varied considerably and did not show a strong dose response relationship. Long-term (24 h) exposure of spores to echinoderm extracts had dosage dependent effects on germination and spore survival. The results of this study indicate that H. irregularis spores possess the capacity for complex responses to their environment, utilizing combined cues of surface charge, surface energy and biochemistry to determine where to settle and germinate. These responses may aid spores in the detection of suitable substrata and conditions for settlement in the marine environment.

A new antifouling bioassay monitoring brown algal spore swimming behaviour in the presence of echinoderm extracts.

Epibiosis, the colonization of biogenic surfaces by epibiotic organisms such as bacteria, filamentous algae, and sessile invertebrates, poses a major threat to the fitness and survival of macroorganisms which could potentially be fouled. Fouling of artificial submerged structures can also cause severe economic problems, making the need for refined bioassays to determine the efficacy of potential antifouling compounds even more important. The aim of this study was to use the distinct swimming behaviour of zoospores of the fouling brown alga Hincksia irregularis to develop a new laboratory antifouling bioassay to test the effect of marine natural products. Spores were exposed to different concentrations of aqueous and organic extracts from body walls of sympatric echinoderms (Asteroidea: Luidia clathrata, Astropecten articulatus; Ophiuroidea: Astrocyclus caecilia). Computer-assisted motion analysis was used to distinguish between the straight and fast swimming movements of undisturbed spores (controls) and the helical and erratic swimming patterns of chemically irritated spores, using the quantitative parameters rate of direction change (RCD) and swimming speed (SPD). The ratio RCD/SPD of spore swimming paths at extract treatments compared to controls can be used to quantify the detrimental effect of echinoderm extracts. Echinoderm extracts had significant effects on spore swimming behaviour at concentrations three orders of magnitude lower than that present naturally in the echinoderm body walls (mg extract/dry weight echinoderm body wall). Comparative studies on spore settlement and germination under similar treatment conditions show that changes in spore swimming behaviour reflect decreased fitness and survivourship of algal spores. It is suggested that this bioassay can be used to screen potential antifouling extracts and compounds at very low concentrations, making this assay particularly suitable for detection of concentration dependent effects and for bioassay-guided fractionation of extracts to identify active compounds.

Ventricular pacing or dual-chamber pacing for sinus-node dysfunction.

BACKGROUND: Dual-chamber (atrioventricular) and single-chamber (ventricular) pacing are alternative treatment approaches for sinus-node dysfunction that causes clinically significant bradycardia. However, it is unknown which type of pacing results in the better outcome. METHODS: We randomly assigned a total of 2010 patients with sinus-node dysfunction to dual-chamber pacing (1014 patients) or ventricular pacing (996 patients) and followed them for a median of 33.1 months. The primary end point was death from any cause or nonfatal stroke. Secondary end points included the composite of death, stroke, or hospitalization for heart failure; atrial fibrillation; heart-failure score; the pacemaker syndrome; and the quality of life. RESULTS: The incidence of the primary end point did not differ significantly between the dual-chamber group (21.5 percent) and the ventricular-paced group (23.0 percent, P=0.48). In patients assigned to dual-chamber pacing, the risk of atrial fibrillation was lower (hazard ratio, 0.79; 95 percent confidence interval, 0.66 to 0.94; P=0.008), and heart-failure scores were better (P<0.001). The differences in the rates of hospitalization for heart failure and of death, stroke, or hospitalization for heart failure were not significant in unadjusted analyses but became marginally significant in adjusted analyses. Dual-chamber pacing resulted in a small but measurable increase in the quality of life, as compared with ventricular pacing. CONCLUSIONS: In sinus-node dysfunction, dual-chamber pacing does not improve stroke-free survival, as compared with ventricular pacing. However, dual-chamber pacing reduces the risk of atrial fibrillation, reduces signs and symptoms of heart failure, and slightly improves the quality of life. Overall, dual-chamber pacing offers significant improvement as compared with ventricular pacing.