Graft Preparation with Intraoperative Vancomycin Decreases Infection After ACL Reconstruction: A Review of 1,640 Cases.

BACKGROUND: Reported infection rates following anterior cruciate ligament (ACL) reconstruction are low, but infections are associated with high morbidity including reoperations and inferior clinical outcomes. The purpose of the current study was to investigate the rate of infection after ACL reconstruction with and without graft preparation with a vancomycin irrigant. METHODS: All ACL reconstructions performed between May 2009 and August 2018 at a single academic institution were reviewed and categorized based on vancomycin use. Patients with <90-day follow-up, intraoperative graft preparation with an antibiotic other than vancomycin, or previous ipsilateral knee infection were excluded. Infection was defined as a return to the operating room for irrigation and debridement within 90 days after ACL reconstruction. Descriptive and inferential statistical analysis using t tests and Poisson regression were performed, with significance defined as p < 0.05. RESULTS: In total, 1,640 patients (952 males; 58.0%) with a mean age (and standard deviation) of 27.7 ± 11.4 years underwent ACL reconstruction (1,379 primary procedures; 84.1%) and were included for analysis. Intraoperative vancomycin was used in 798 cases (48.7%), whereas 842 ACL reconstructions (51.3%) were performed without intraoperative vancomycin. In total, 11 reconstructions (0.7%) were followed by infection, which occurred in 10 (1.2%) of the patients in whom the graft was not soaked in vancomycin and in 1 (0.1%) of the patients in whom the graft was soaked in vancomycin (p = 0.032). Age (p = 0.571), sex (p = 0.707), smoking (p = 0.407), surgeon (p = 0.124), and insurance type (p = 0.616) were not associated with postoperative infection risk. Autograft use was associated with decreased infections (p = 0.045). There was an 89.4% relative risk reduction with the use of intraoperative vancomycin. An increased body mass index (BMI) (p = 0.029), increased operative time (p = 0.001), and the absence of ACL graft preparation with vancomycin (p = 0.032) independently predicted postoperative infection. CONCLUSIONS: The use of vancomycin-soaked grafts was associated with a 10-fold reduction in infection after ACL reconstruction (0.1% versus 1.2%; p = 0.032). Other risk factors for infection after ACL reconstruction included increased BMI and increased operative time. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Emergency department patient satisfaction: customer service training improves patient satisfaction and ratings of physician and nurse skill.

Customer service initiatives in healthcare have become a popular way of attempting to improve patient satisfaction. This study investigates the effect of clinically focused customer service training on patient satisfaction in the setting of a 62,000-visit emergency department and level I trauma center. Analysis of patient complaints, patient compliments, and a statistically verified patient-satisfaction survey indicate that (1) all 14 key quality characteristics identified in the survey increased dramatically in the study period; (2) patient complaints decreased by over 70 percent from 2.6 per 1,000 emergency department (ED) visits to 0.6 per 1,000 ED visits following customer service training; and (3) patient compliments increased more than 100 percent from 1.1 per 1,000 ED visits to 2.3 per 1,000 ED visits. The most dramatic improvement in the patient satisfaction survey came in ratings of skill of the emergency physician, likelihood of returning, skill of the emergency department nurse, and overall satisfaction. These results show that clinically focused customer service training improves patient satisfaction and ratings of physician and nurse skill. They also suggest that such training may offer a substantial competitive market advantage, as well as improve the patients' perception of quality and outcome.

Are they patients or customers?

Imagine you could reduce complaints in your institution from 2.5 to .5 per 1,000 patient encounters, while simultaneously increasing patient compliments from .5 to 5.1 per 1,000 patients. Imagine that you could have 10 times as many delighted customers as complainers. In fact, that's what happened at Inova Fairfax Hospital's Department of Emergency Medicine, Falls Church, VA.

Oleanane triterpene saponins from the Chinese medicinal herb Clinopodium chinensis.

Four oleanne triterpene saponins, 3beta,16beta, 23-trihydroxy-keton-13beta,28-epoxyolean-9(11)-en-3-yl -[beta-D-glucopranosyl(1-->2)]-[beta-D-glucopyranosyl(1-->3)]-beta -D-fucopyranoside [1] (clinopodiside D), 16beta-propionyl-3beta,23-dihydroxyoleana-11-21-dien-3 -yl-[beta-D-glucopyranosyl(1-->2)]-[beta-D-glucopranosyl(1-->3)]-b eta-D-fucopyranoside [2] (clinipodiside E), 3beta,16beta,21alpha,23,28-pentahydroxy-11-methoxyolean++ +-12-en-3-yl-[beta-D-glucopyranolyl(1-->2)]-[beta-D-glucopyranosyl (1-->3)]-beta-D-fucopyranoside [3] (clinopodiside F), and 3beta,16beta,21beta,23,28-pentahydroxyoleana-11,13(18) -dien-3-yl-[beta-D-glucopyranosyl(1-->2)]-[beta-D-glucopyranosyl(1 -->3)]-beta-D-fucopyranoside [4] (clinopodiside G), were isolated and purified from the plant Clinopodium chinensis. Their structures were elucidated on the basis of interpretation of nmr and ms data and from chemical evidence. The results are of potential interest for medicinal reasons.

Triterpenoid saponins from Gypsophila oldhamiana.

Three new triterpenoid saponins were isolated from the roots of Gypsophila oldhamiana. Their structures were elucidated, using a combination of homonuclear and heteronuclear 2D nmr and fabms, as 3-0-beta-D-galactopyranosyl-(1-->2)-[beta-D-xylopyranolyl-(1-->3)] -beta-D-glucuronopyranosyl quillaic acid methyl ester [1], 3-0-beta-D-galactopyranosyl-(1-->2)-[beta-D-xylopyranosyl-(1-->3)]-beta- D-glucuronopyranosyl gypsogenin methyl ester [2], and 3-0-beta-D-galactopyranolsyl-(1-->2)-[beta-D-xylopyranosyl-(1-->3) ]-beta-D-glucuronopyranosyl quillaic acid 28-[0-beta-D-fucopyranosyl(1-->4)-beta-D-glucopyranosyl(1-->3)]-alpha-L- rhamnopyranosyl] ester.

Triterpenoid saponins from Clinopodium chinensis.

Two new triterpenoid saponins, 3 beta,16 beta,23-trihydroxy-13,28-epoxyolean- 11-en-3-yl-[beta-D-glucopyranosyl(1-->4)-beta-D-glucopyranosyl(1-->3)]- [beta-D-glucopyranosyl(1-->2)]-beta-D-fucopyranoside[1](clinopodiside B) and 28-O-beta-D-glucopyranosyl-3 beta,23-dihydroxyoleana-12,21-dien-3-yl-beta-D-glucopyranosy l-(1-->3)-beta-D- fucopyranoside [3] (clinopodiside C), together with three known saikosaponins, buddlejasaponins IV, IVa, and IVb, have been isolated from the plant, Clinopodium chinensis, and characterized using chemical evidence and spectroscopic methods, in particular 2D nmr spectroscopy.

Foliage constituents of douglas fir (Pseudotsuga menziesii (Mirb.) Franco (Pinaceae)): Their seasonal variation and potential role in douglas fir resistance and silviculture management.

Seasonal changes in the production of primary nutrients (soluble carbohydrates) and secondary metabolites (terpenes, monomeric phenolics, and tannins) in the current needle tissue of Douglas fir were investigated. All four classes of compounds showed significant seasonal changes in concentration during foliage development. Most terpenes increased significantly in concentration from June 11 to August 3, and then showed declining concentrations to September 20. The most dramatic and significant seasonal increases occurred inα-pinene, camphene, and bornyl acetate concentrations. The monomeric phenolics chlorogenic acid, taxifolin glucoside, quercetin galactoside, and those unknown phenolics showed an overall trend of declining in concentration from June 11 through September 20. However, considerable variation between sampling dates in the concentration of these phenolics was noted. Tannin concentration decreased significantly from June 11 to July 9, and then increased in concentration to the September 20 sampling date. Fructose, galactose, glucose, and sucrose tended to decrease from June 11 to September 20. However, significant variation between sampling dates was evident in these compounds as well. Galactose was the major compound in the soluble carbohydrate fraction, amounting to almost 80% of the total concentration throughout the growing season. These data suggest that if phenolics and tannins function as defenses, they would only affect second- and possibly third-instar budworm larvae during the time that these instars mine the buds. Camphene,α-pinene, and bornyl acetate increased in concentration throughout the growing season and may be effective deterrents to the budworm. Both bornyl acetate and camphene have been shown in field and laboratory studies to increase larval mortality and adversely affect budworm larval growth. Carbohydrates generally act as nutrients that enhance herbivore growth. However, in a previous study, galactose was found to cause reduced budworm larval growth and increased larval mortality.

Role of Douglas fir (Pseudotsuga menziesii) carbohydrates in resistance to budworm (Choristoneura occidentalis).

The current year's growth of Douglas fir contains galactose, unusual in that this carbohydrate makes up 78.7% of the total carbohydrate fraction. An agar diet study was undertaken to determine the effects of galactose, other carbohydrates, and terpenes on western spruce budworm larval mortality, growth rate, and adult biomas production. All concentrations of the carbohydrates and terpenes tested, as well as other mineral elements not tested, were typical of the current year's foliage of Douglas fir. In experiment I, the diet containing 5.61% total carbohydrate did not significantly affect larval mortality when compared to the control diet. However, diets containing 9.45% and 15% total carbohydrate concentrations significantly increased larval mortality 64% and 96.1%, respectively, when compared to the control. Also in experiment I, terpenes alone (78.9% morality) and terpenes in combination with 9.45% and 15% total carbohydrates significantly increased larval mortality (97.2% and 100%, respectively) when compared to mortality on the control diet (44%). To determine which carbohydrate was causing the adverse effect, 6% glucose, 6% fructose, and 6% galactose were placed individually and in combination with terpenes in diets in experiment II. The 6% galactose diet significantly increased larval mortality and reduced growth rate when compared to the control, glucose, and fructose diets. Glucose resulted in 16% less larval mortality, significantly enhanced female larval growth rate and pupal weight, but did not affect male larval growth rate and pupal weight, when compared to the control. Fructose resulted in a significant decrease in larval mortality and a general trend of enhanced female and male larval growth rate and pupal weight. Larval mortality on terpenes alone was not significantly different from the control, but terpenes with 6% galactose increased larval mortality and decreased female and male growth rate and pupal weight significantly when compared to glucose-terpene and fructose-terpene diets. No significant interactions were found between carbohydrates and terpenes in either experiment.

Genetic contribution to risk of smoking initiation: comparisons across birth cohorts and across cultures.

Self-report data on smoking initiation (whether the respondent admitted ever having smoked) were obtained from three large adult twin samples (Australia, N = 3,808 pairs; Virginia, N = 2,145 pairs; AARP, N = 3,620 pairs). Data were broken down into birth cohorts, and genetic models were fitted to test whether the decline, in more recent birth cohorts, in the percentage of individuals becoming smokers has led to a change in the relative contributions of genes and environment to risk of becoming a smoker. Despite a marked change in the proportion of male respondents who reported ever having smoked, we found no evidence for cohort differences in genetic and environmental effects (no Genotype x Cohort interaction). Significant differences in genetic and environmental parameters were found between sexes, and between the Australian and the two U.S. samples. In the U.S. samples, estimates of the genetic contribution to risk of becoming a smoker were 60% in men, 51% in women. In the Australian sample, heritability estimates were 33% in men, but 67% in women. Significant shared environmental effects on smoking initiation also were found, accounting for 23% of the variance in U.S. men, 28% of the variance in U.S. women, 39% of the variance in Australian men, and 15% of the variance in Australian women. In models that allowed for the environmental impact of cotwin smoking on a twin's risk of smoking initiation, estimates of the direct genetic contribution to risk of smoking initiation were comparable or higher (49-58% in U.S. women and 71% in Australian women; 58-61% in U.S. men, and 37% in Australian men).

Effects of resource manipulation on the correlation between total phenolics and astringency in Douglas-fir.

The correlation between total phenolics and tannin content within a species is often considered to be suitably strong to allow researchers to assume, with some degree of confidence, that levels of one will approximately parallel the other. However, the manipulation of resource availability could lead to disproportionate changes in total phenolics and tannins and/or in the specific monomers of which these fractions are composed, thus altering the correlation between these components. In order to test this hypothesis, we examined the correlation between foliar levels of total phenolics (as measured by the ferric chloride assay) and tannins (as measured by an astringency assay) in Douglas-fir (Pseudotsuga menziesii Mirb. Franco) before and after the manipulation of nitrogen and water availability. Prior to manipulation of resources, the correlation between total phenolics and tannins was strong and highly significant (r(2)=0.869;P < 0.001). This correlation was considerably weaker and not statistically significant following resource manipulation (r(2) = 0.392; 0.20

Rehabilitation exercises for common sports injuries.

Residual weakness after joint injury is a risk factor for recurrent injury. A rehabilitation program helps patients recover strength and helps prevent further injuries. Orthopedic injuries account for 10 percent of visits to family physicians, yet many primary care physicians do not routinely prescribe rehabilitation exercises for injured patients. Illustrations of exercises for the hip, knee, ankle and shoulder are included as a reference for family physicians to use when prescribing rehabilitation exercises.

The role of data-driven planning and coalition development in preventing cardiovascular disease.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States. Effective programs for the prevention and control of CVD need to include data-based planning and evaluation at the State and local levels. The authors describe the development of data-driven planning and intervention strategies in Missouri. Statewide planning activities have resulted in the formation of an advisory committee and development of a State plan, a resource directory, and training courses. Analysis of mortality data revealed an unusual concentration of CVD deaths in the southeast portion of the State. Local coalitions are being developed in each of six counties in this region to reduce the prevalence of CVD risk factors. A regional behavioral risk factor survey of 1,006 adults identified key risk factors that will be addressed by the coalitions. These data suggested that physical inactivity, obesity, and hypertension are especially acute problems in the area. Key components of the local coalition development included providing localized data and obtaining the strong commitment of the local health departments. Expanded use of chronic disease surveillance data for planning and evaluation will increase the probability that localities, States, and the nation will achieve Year 2000 Health Objectives. The data-based planning process is described as a possible model for use by other States and localities.

Responses of the western spruce budworm to varying levels of nitrogen and terpenes.

An agar diet study using western spruce budworm populations from Idaho and New Mexico was carried out to determine the effects of varying concentrations of nitrogen, beta-pinene, and bornyl acetate on larval growth and survival. Increased availability of nitrogen resulted in increased larval growth rate and survival to the adult stage. Larval growth rates from the Idaho population were higher on the high-nitrogen diet than were growth rates from the New Mexico population. The high level of beta-pinene improved larval growth at the high-nitrogen concentration. Bornyl acetate significantly reduced larval growth at both the low and high levels of nitrogen although the effect was greatest with the high-nitrogen diet. High bornyl acetate concentrations also significantly reduced survival to the adult stage. At high-nitrogen levels, a high concentration of bornyl acetate reduced larval growth rates and adult survival to a level similar to that occurring at the low nitrogen and low bornyl acetate concentrations.

Tannin, nitrogen, and cell wall composition of green vs. senescent Douglas-fir foliage : Within- and between-stand differences in stands of unequal density.

Tannin, cell wall, and nitrogen composition of green foliage and needle litter of similar-aged Douglas-fir (Pseudotsuga menziesii Mirb. Franco) from two stands differing in density and crown closure were compared. Trees in the closed-canopy stand had a lower basal area growth rate than those in the open-canopy stand. Stands did not differ in wood basal area/ha or forest floor C/N ratios, but the closed-canopy stand had a significantly larger accumulation of forest floor biomass and significantly higher levels of field-extractable nitrogen and nitrogen mineralization rates. Green foliage from trees in the closed-canopy stand had significantly lower nitrogen, astringency, and lignin contents, but higher cellulose concentration than trees in the open-canopy stand. These trends, inconsistent with the inverse relationship often observed between nitrogen and polyphenol contents of foliage, may result from differences in relative resource availability in the two stands. In contrast to green foliage, needle litter from the two stands had comparable contents of nitrogen, cellulose, and lignin, but astringency was significantly higher in litter from the closed-canopy stand. It is suggested that, within the constraints imposed by site conditions, evergreens may alter the tannin composition of senescing foliage, potentially affecting herbivory and decomposition differently.