Attitudes of anesthetists towards an anesthesia-led nurse practitioner model for low-risk colonoscopy procedures: a cross-sectional survey.

BACKGROUND: The mounting pressure on the Australian healthcare system is driving a continual exploration of areas to improve patient care and access and to maximize utilization of our workforce. We hypothesized that there would be support by anesthetists employed at our hospital for the design, development, and potential implementation of an anesthesia-led nurse practitioner (NP) model for low-risk colonoscopy patients. METHODS: We conducted a cross-sectional, mixed methods study to ascertain the attitudes and acceptability of anesthetists towards a proposed anesthesia-led NP model for low-risk colonoscopy patients. An online survey using commercial software and theoretical questions pertaining to participants' attitudes towards an anesthesia-led NP model was e-mailed to consultant anesthetists. Participants were also invited to participate in a voluntary 20-min face-to-face interview. RESULTS: A total of 60 survey responses were received from a pool of 100 anesthetists (response rate = 60%, accounting for 8.04% margin of error). Despite the theoretical benefits of improved patient access to colonoscopy services, most anesthetists were not willing to participate in the supervision and training of NPs. The predominant themes underlying their lack of support for the program were a perception that patient safety would be compromised compared to the current model of anesthesia-led care, the model does not meet the Australian and New Zealand College of Anesthetists guidelines for procedural sedation and analgesia, and the program may be a public liability prone to litigation in the event of an adverse outcome. Concerns about consumer acceptance and cost-effectiveness were also raised. Finally, participants thought the model should be pilot tested to better understand consumer attitudes, logistical feasibility, patient and proceduralist attitudes, clinical governance, and, importantly, patient safety. CONCLUSIONS: Most anesthetists working in a single-center university hospital did not support an anesthesia-led NP model for low-risk colonoscopy patients. Patient safety, violations of the current Australian and New Zealand College of Anesthetists guidelines on procedural sedation, and logistical feasibility were significant barriers to the acceptance of the model. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, 12619001036101.

MRI Evidence of Altered Callosal Sodium in Mild Traumatic Brain Injury.

BACKGROUND AND PURPOSE: Mild traumatic brain injury is a leading cause of death and disability worldwide with 42 million cases reported annually, increasing the need to understand the underlying pathophysiology because this could help guide the development of targeted therapy. White matter, particularly the corpus callosum, is susceptible to injury. Animal models suggest stretch-induced mechanoporation of the axonal membrane resulting in ionic shifts and altered sodium ion distribution. The purpose of this study was to compare the distribution of total sodium concentration in the corpus callosum between patients with mild traumatic brain injury and controls using sodium (23Na) MR imaging. MATERIALS AND METHODS: Eleven patients with a history of mild traumatic brain injury and 10 age- and sex-matched controls underwent sodium (23Na) MR imaging using a 3T scanner. Total sodium concentration was measured in the genu, body, and splenium of the corpus callosum with 5-mm ROIs; total sodium concentration of the genu-to-splenium ratio was calculated and compared between patients and controls. RESULTS: Higher total sodium concentration in the genu (49.28 versus 43.29 mmol/L, P = .01) and lower total sodium concentration in the splenium (which was not statistically significant; 38.35 versus 44.06 mmol/L, P = .08) was seen in patients with mild traumatic brain injury compared with controls. The ratio of genu total sodium concentration to splenium total sodium concentration was also higher in patients with mild traumatic brain injury (1.3 versus 1.01, P = .001). CONCLUSIONS: Complex differences are seen in callosal total sodium concentration in symptomatic patients with mild traumatic brain injury, supporting the notion of ionic dysfunction in the pathogenesis of mild traumatic brain injury. The total sodium concentration appears to be altered beyond the immediate postinjury phase, and further work is needed to understand the relationship to persistent symptoms and outcome.

Edge effect of strained bilayer nanofilms for tunable multistability and actuation.

We employed both theoretical and computational models supported by experiments to study the multistable behavior of an edge-effect driven Si/Cr micro-claw. Our study showed that individual micro-claws demonstrate either monostability or bistability as the magnitude of the edge effect is varied.

Peptidyl Arginine Deiminases and Neurodegenerative Diseases.

Peptidyl arginine deiminases (PADs) are a small group of isozymes that convert Arg residues on the surface of proteins into citrulline residues, typically as a part of posttranslational processing. PADs are present in most of the tissues, and the isozyme distribution is tissue-specific. In the past 15 years, it is becoming apparent that PADs are either upregulated or their catalytic activity is enhanced in certain disease conditions, including neurological diseases. In particular, hypercitrullinated proteins and elevated PAD activities are discovered in neurodegenerative conditions such as multiple sclerosis, Alzheimer's disease etc. This review article reviews the status of PAD enzymes as targets in neurodegenerative conditions, and briefly outlines the efforts in medicinal chemistry to identify PAD inhibitors for the treatment of various neurodegenerative conditions.

Detection and measurement of oral malodor in chronic periodontitis patients and its correlation with levels of select oral anaerobes in subgingival plaque.

INTRODUCTION: Oral malodor is generally ascribable to oral microbial putrefaction generating malodorous volatile sulfur compounds. The aim of the present study is to correlate organoleptic recordings with a small handheld portable volatile sulfide monitor and periodontal clinical parameters and correlate the levels of halitosis causing bacteria in plaque between baseline, 1-week, and 1-month. MATERIALS AND METHODS: A total of 20 systemically healthy subjects with self-reported halitosis were subjected to organoleptic examination and FitScan(®). Subgingival plaque samples for anaerobic culturing were harvested followed by an assessment of plaque index (PI), gingival bleeding index (GBI), and pocket probing depth. Data derived were subjected to statistical analysis using Wilcoxon signed rank test and Spearman's rank test (P < 0.05). RESULTS: No correlation was seen between organoleptic measurements and portable volatile sulfide monitor at any time interval. There was a statistically significant (P < 0.05) correlation between the scores of PI, gingival index, GBI, and myeloproliferative disease with organoleptic readings at all-time intervals. Anaerobic culture has shown to identify Fusobacterium species, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia. However, no correlation could be established in between total microbial load with organoleptic and FitScan(®) reading at any time interval (P < 0.05). CONCLUSION: Significant correlation could be established between organoleptic readings and periodontal parameters.

An evaluation of multimodal spinal cord monitoring in scoliosis surgery: a single centre experience of 354 operations.

PURPOSE: To evaluate the effectiveness of multimodal intraoperative neuromonitoring in the early detection of impending spinal cord injury during surgery for spinal deformity. METHOD: A retrospective review of prospectively collected data in 354 consecutive spinal deformity operations from June 2003 to October 2013. Patients were sub-grouped according to demographics, diagnosis and operative features. Post-operative neurological deficit was defined as either spinal cord, nerve root or transient deficit. RESULTS: Combined monitoring with SSEPs and MEPs was possible in 315 cases. The overall incidence of significant alerts was 7.1 % and overall permanent neurological deficit was 1.6 %. When results were collated, the overall combined sensitivity of multimodal monitoring was 100 % with a specificity of 99.3 %. CONCLUSIONS: Multimodal monitoring allows early detection of impending neurological deficit that is superior to a single monitoring modality. To achieve optimal use of monitoring, continuous communication between surgical, anaesthetic and neurophysiology teams are required. As a result of our experience we have incorporated in our consent procedure the discussion of monitoring and the possibility of needing to abandon the procedure, and completing in a staged fashion at a later date. We believe multimodal monitoring is the current gold standard for complex spinal deformity surgery.

Rheumatoid arthritis: a review and dental care considerations.

Rheumatoid arthritis (RA), is a chronic multisystem disease of presumed autoimmune etiology. Medical complications due to RA and its treatment may affect the provision of oral health care. Associated syndromes may contribute to a patient's susceptibility to infections and impaired hemostasis. Therefore oral health care providers need to recognize and identify modificationsof dental care based on the medical status of patients with RA. As with many other chronic conditions, early intervention can reduce the severity of the disease. Furthermore, oral health care providers play an important role in the overall care of these patients as it relates to early recognition, as well as control of the disease.

Isolated intrahepatic biliary dilatation in a patient with acquired immune deficiency syndrome (AIDS): AIDS cholangiopathy versus incidental unilobar Caroli's disease.

We describe a case of possible monolobar Caroli's disease in a patient with acquired immune deficiency syndrome (AIDS) who presented with features of cholangitis. Diagnostic workup, which included endoscopic retrograde cholangiography, revealed focal intrahepatic biliary dilatation confined to the right lobe. The patient subsequently underwent right hepatic lobectomy. Pathology revealed multiple cysts filled with calculi and inflammation in the cyst walls. Special stain results for fungi and acid-fast organisms were negative. The presence of advanced AIDS in this patient raised the possibility of this being a possible manifestation of AIDS cholangiopathy.

zA map for sequence analysis of the Arabidopsis thaliana genome.

Arabidopsis thaliana has emerged as a model system for studies of plant genetics and development, and its genome has been targeted for sequencing by an international consortium (the Arabidopsis Genome Initiative; http://genome-www. stanford.edu/Arabidopsis/agi.html). To support the genome-sequencing effort, we fingerprinted more than 20,000 BACs (ref. 2) from two high-quality publicly available libraries, generating an estimated 17-fold redundant coverage of the genome, and used the fingerprints to nucleate assembly of the data by computer. Subsequent manual revision of the assemblies resulted in the incorporation of 19,661 fingerprinted BACs into 169 ordered sets of overlapping clones ('contigs'), each containing at least 3 clones. These contigs are ideal for parallel selection of BACs for large-scale sequencing and have supported the generation of more than 5.8 Mb of finished genome sequence submitted to GenBank; analysis of the sequence has confirmed the integrity of contigs constructed using this fingerprint data. Placement of contigs onto chromosomes can now be performed, and is being pursued by groups involved in both sequencing and positional cloning studies. To our knowledge, these data provide the first example of whole-genome random BAC fingerprint analysis of a eucaryote, and have provided a model essential to efforts aimed at generating similar databases of fingerprint contigs to support sequencing of other complex genomes, including that of human.

Racial factors and the risk of chronic pancreatitis.

OBJECTIVE: It is unclear why some alcohol abusers develop alcoholic cirrhosis whereas others contract chronic pancreatitis. The aim of this study was to examine the importance of race as a risk factor for the development of chronic pancreatitis. METHODS: We compared the racial status of 1883 patients discharged with a first-listed diagnosis of two diseases strongly related to alcohol abuse: 433 patients with chronic pancreatitis (ICD 5771) and 1450 patients with alcoholic cirrhosis (ICD 5712). Information came from discharge statistics maintained by two acute care hospitals in New York City and one acute care hospital in Lisbon, Portugal. The study period included the years 1989-1996 in the US and 1989-1994 in Portugal. RESULTS: A total of 215 (50%) of the 433 chronic pancreatitis patients were black compared with 333 (23%) of the 1450 patients with alcoholic cirrhosis. When adjusted for sex and hospital site, patients with pancreatitis were significantly more likely to be black than patients with cirrhosis (odds ratio 2.5, 95% confidence interval 1.9-3.2, p < 0.001). CONCLUSIONS: In comparison with white patients, black patients are two to three times more likely to be hospitalized for chronic pancreatitis than alcoholic cirrhosis. This highly significant (p < 0.001) difference was observed in both men and women: in three different hospitals, and in two different countries. The explanation is unknown, but could be related to racial differences in diet, type or quantity of alcohol consumption, smoking, or ability to detoxify substances harmful to the liver or pancreas.

Giant true diverticulum of sigmoid colon.

A case of giant true diverticulum of the sigmoid colon, manifesting as pain and abdominal mass is presented. The patient is asymptomatic after resection of the diverticulum and end-to-end anastomosis of the colon.

Prognostic criteria in Clostridium difficile colitis.

OBJECTIVE: To determine the prognostic factors in Clostridium difficile (CD) colitis. METHODS: We conducted a retrospective study of proven cases of CD colitis in l8 months. Seventy six patients (from a 605-bed community hospital in the Bronx, NY) with proven CD colitis were studied. Mortality in patients with CD colitis was also examined. RESULTS: Seventy six patients with proven CD colitis were admitted between January 1993 and June 1994. Eighteen patients died during the same admission. Upon admission, serum albumin was less than 25 g/L in 12 (20.6%) of the survivors and in eight (44%) of the deceased patients (p <0.05). A fall in serum albumin levels was noted with the onset of symptoms of CD colitis in those who survived as well as in those who died, with a greater fall of 11.2 g/L (range 10-20 g/L) in patients who died compared with a fall of 6 g/L (range 5-10 g/L)in those who survived (p <0.05). Use of more than three antibiotics was noted in 13 (72%) of those who died and in 18 (31%) of those who survived (p <0.05). Persistence of CD cytotoxin 7 or more days after initiation of treatment was present in 14 (77%) of those who died and in eight (13%) of the survivors (p <0.01). Duration of hospitalization correlated with the development of CD colitis (35.89 vs 11.7 days) with no significant difference between survivors and deceased patients with CD colitis. Factors such as age, sex, residence, past medical history score, mean score of presenting complaints of CD colitis, history of prior episodes CD colitis, and mean number of recurrent episodes showed no difference in mortality. CONCLUSION: Factors predictive of an increased mortality in patients with CD colitis include a serum albumin of less than 25 g/L on admission, a fall in serum albumin level of greater than 11 g/L at the onset of symptoms of CD colitis, use of three or more antibiotics, and persistence of positive CD cytotoxin in the stool after completion of 7 or more days of treatment.

Carrier detection of haemophilia A using DNA markers in families with an isolated affected male.

The carrier status of women in five families with an isolated haemophilia male was assessed by pedigree analysis, coagulation factor assays and DNA markers. In three families, ten women could be given very low risks of being carriers based on DNA analysis. In two of the families the DNA markers identified the mutation as originating in either the maternal or maternal grandfather's germ cell. Combined DNA and coagulation data suggested that the affected male in a third family was a de novo mutation. DNA analysis of the affected male in another family identified a large deletion of the F8 gene which was present in his mother and three sisters, suggesting that the grandmother was a carrier. A combination of coagulation factor data and DNA marker assessment can determine the carrier status of the majority of females in families with isolated affected haemophilia A males.

Recombination between the factor VIII gene and the DXS52 locus gives the most probable genetic order as centromere-fra(X)-DXS15-DXS52-F8C-telomere.

The linkage relationship between the factor VIII gene (F8C) and the DXS52 locus was examined in 8 families. Two recombinations were identified in 35 informative meioses (Zmax = 5.67; theta = 0.05), one in a family with hemophilia A, the other in a family with the fra(X) syndrome. Based on the latter recombination, the most probable order of loci was determined to be centromere-fra(X)-DXS15-DXS52-F8C-telomere. When these data are added to those reported previously the most probable genetic distance between F8C and DXS52 is 3 cM (Z = 14.62). Identification of these and other recombinations suggests that the use of DXS52 as a genetic marker for carrier detection and prenatal diagnosis of hemophilia A has an error rate between 3-5%.