Lack of impact of nil-per-os (NPO) time on goal-directed fluid delivery in first case versus afternoon case starts: a retrospective cohort study.

BACKGROUND: Goal Directed Fluid Therapy (GDFT) represents an objective fluid replacement algorithm. The effect of provider variability remains a confounder. Overhydration worsens perioperative morbidity and mortality; therefore, the impact of the calculated NPO deficit prior to the operating room may reach harm. METHODS: A retrospective single-institution study analyzed patients at UC Irvine Medical Center main operating rooms from September 1, 2013 through September 1, 2015 receiving GDFT. The primary study question asked if GDFT suggested different fluid delivery after different NPO periods, while reducing inter-provider variability. We created two patient groups distinguished by 0715 surgical start time or start time after 1200. We analyzed fluid administration totals with either a 1:1 crystalloid to colloid ratio or a 3:1 ratio. We performed direct group-wise testing on total administered volume expressed as total ml, total ml/hr., and total ml/kg/hr. between the first case start (AM) and afternoon case (PM) groups. A linear regression model included all baseline covariates that differed between groups as well as plausible confounding factors for differing fluid needs. Finally, we combined all patients from both groups, and created NPO time to total administered fluid scatterplots to assess the effect of patient-reported NPO time on fluid administration. RESULTS: Whether reported by total administered volume or net fluid volume, and whether we expressed the sum as ml, ml/hr., or ml/kg/hr., the AM group received more fluid on average than the PM group in all cases. In the general linear models, for all significant independent variables evaluated, AM vs PM case start did not reach significance in both cases at p = 0.64 and p = 0.19, respectively. In scatterplots of NPO time to fluid volumes, absolute adjusted and unadjusted R2 values are < 0.01 for each plot, indicating virtually non-existent correlations between uncorrected NPO time and fluid volumes measured. CONCLUSIONS: This study showed NPO periods do not influence a patient's volume status just prior to presentation to the operating room for surgical intervention. We hope this data will influence the practice of providers routinely replacing calculated NPO period volume deficit; particularly with those presenting with later surgical case start times.

Long-term continental changes in wing length, but not bill length, of a long-distance migratory shorebird.

We compiled a >50-year record of morphometrics for semipalmated sandpipers (Calidris pusilla), a shorebird species with a Nearctic breeding distribution and intercontinental migration to South America. Our data included >57,000 individuals captured 1972-2015 at five breeding locations and three major stopover sites, plus 139 museum specimens collected in earlier decades. Wing length increased by ca. 1.5 mm (>1%) prior to 1980, followed by a decrease of 3.85 mm (nearly 4%) over the subsequent 35 years. This can account for previously reported changes in metrics at a migratory stopover site from 1985 to 2006. Wing length decreased at a rate of 1,098 darwins, or 0.176 haldanes, within the ranges of other field studies of phenotypic change. Bill length, in contrast, showed no consistent change over the full period of our study. Decreased body size as a universal response of animal populations to climate warming, and several other potential mechanisms, are unable to account for the increasing and decreasing wing length pattern observed. We propose that the post-WWII near-extirpation of falcon populations and their post-1973 recovery driven by the widespread use and subsequent limitation on DDT in North America selected initially for greater flight efficiency and latterly for greater agility. This predation danger hypothesis accounts for many features of the morphometric data and deserves further investigation in this and other species.

Effects of Modification of Pain Protocol on Incidence of Post Operative Nausea and Vomiting.

BACKGROUND: A Perioperative Surgical Home (PSH) care model applies a standardized multidisciplinary approach to patient care using evidence-based medicine to modify and improve protocols. Analysis of patient outcome measures, such as postoperative nausea and vomiting (PONV), allows for refinement of existing protocols to improve patient care. We aim to compare the incidence of PONV in patients who underwent primary total joint arthroplasty before and after modification of our PSH pain protocol. METHODS: All total joint replacement PSH (TJR-PSH) patients who underwent primary THA (n=149) or TKA (n=212) in the study period were included. The modified protocol added a single dose of intravenous (IV) ketorolac given in the operating room and oxycodone immediate release orally instead of IV Hydromorphone in the Post Anesthesia Care Unit (PACU). The outcomes were (1) incidence of PONV and (2) average pain score in the PACU. We also examined the effect of primary anesthetic (spinal vs. GA) on these outcomes. The groups were compared using chi-square tests of proportions. RESULTS: The incidence of post-operative nausea in the PACU decreased significantly with the modified protocol (27.4% vs. 38.1%, p=0.0442). There was no difference in PONV based on choice of anesthetic or procedure. Average PACU pain scores did not differ significantly between the two protocols. CONCLUSION: Simple modifications to TJR-PSH multimodal pain management protocol, with decrease in IV narcotic use, resulted in a lower incidence of postoperative nausea, without compromising average PACU pain scores. This report demonstrates the need for continuous monitoring of PSH pathways and implementation of revisions as needed.

Feasibility of a Web-Based Self-management Intervention for Intermittent Urinary Catheter Users With Spinal Cord Injury.

PURPOSE: The purpose of this study was to evaluate the feasibility of a new Web-based intermittent catheter self-management intervention. DESIGN: We tested the acceptability and usability of intervention components, which included multiple Web-based materials (an online urinary diary adapted for mobile phone use and an educational booklet), 3 phone calls with a nurse, and a peer-led discussion forum. SUBJECTS AND SETTING: Thirty adults with spinal cord injury using intermittent catheterization for bladder drainage were enrolled; 26 participants received the nurses' phone-based consultations. METHODS: Preliminary effectiveness of new self-efficacy and self-management scales were evaluated using baseline and 3-month online surveys. Participants' perceived value of the intervention components, self-management changes, and suggestions were assessed with data from the 3-month surveys, followed by brief tape-recorded interviews. RESULTS: Several catheter practices improved somewhat over 3 months. The frequency of catheterizations every 4 to 6 hours increased from 71% to 77%. Self-management of neurogenic bladder dysfunction increased significantly (P = .032); participant comments indicated that fluid intake was the biggest change. Catheter-related self-efficacy and quality-of-life scores increased but not significantly. The frequency of urinary tract infection and pain did not change significantly. For feasibility, intervention components, with the exception of the forum, were rated highly by the majority of participants for usefulness, satisfaction (desired information), and Web-based usability. CONCLUSION: Further testing of this intervention is recommended in a multisite randomized clinical trial.

Development of a Web-Based Self-management Intervention for Intermittent Urinary Catheter Users With Spinal Cord Injury.

While Web-based interventions have proliferated recently, information in the literature is often lacking about how the intervention was developed. In response to that gap, this is a report of the development of a Web-based self-management intervention for intermittent urinary catheter users and pretesting with four adults with spinal cord injury living in the community. Two Web sites were created, one for recruitment and the other for the intervention itself. The intervention involved developing new Web-based technology, including an interactive urinary diary (with fluid intake/urine output and a journal), extensive catheter products information, three intervention nurse phone call consultations, and user-community discussion forums. Study participants completed an online survey and were interviewed twice about the enrollment process and their perceptions of their involvement in the intervention. Suggestions from the pretesting participants were used to revise the Web site applications prior to the next stage of research (a feasibility study). Numerous recommendations and comments were received related to content, interactivity of components, and usability. This article provides a description of how the Web sites were developed (including the technology and software programs used), issues encountered and what was done to address them, and how the Web-based intervention was modified for improvements.

A Web-Based Self-Management Intervention for Intermittent Catheter Users.

A new Web-based self-management intervention was developed for persons with spinal cord injury who use intermittent urinary catheters. Included are a description of the components, examples from the educational book, and multiple screen shots of the online urinary diary.

Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa.

Eating disorders are life-threatening conditions that are challenging to address; however, the primary care setting provides an important opportunity for critical medical and psychosocial intervention. The recently published Diagnostic and Statistical Manual of Mental Disorders, 5th ed., includes updated diagnostic criteria for anorexia nervosa (e.g., elimination of amenorrhea as a diagnostic criterion) and for bulimia nervosa (e.g., criterion for frequency of binge episodes decreased to an average of once per week). In addition to the role of environmental triggers and societal expectations of body size and shape, research has suggested that genes and discrete biochemical signals contribute to the development of eating disorders. Anorexia nervosa and bulimia nervosa occur most often in adolescent females and are often accompanied by depression and other comorbid psychiatric disorders. For low-weight patients with anorexia nervosa, virtually all physiologic systems are affected, ranging from hypotension and osteopenia to life-threatening arrhythmias, often requiring emergent assessment and hospitalization for metabolic stabilization. In patients with frequent purging or laxative abuse, the presence of electrolyte abnormalities requires prompt intervention. Family-based treatment is helpful for adolescents with anorexia nervosa, whereas short-term psychotherapy, such as cognitive behavior therapy, is effective for most patients with bulimia nervosa. The use of psychotropic medications is limited for anorexia nervosa, whereas treatment studies have shown a benefit of antidepressant medications for patients with bulimia nervosa. Treatment is most effective when it includes a multidisciplinary, teambased approach.

Automatic discourse connective detection in biomedical text.

OBJECTIVE: Relation extraction in biomedical text mining systems has largely focused on identifying clause-level relations, but increasing sophistication demands the recognition of relations at discourse level. A first step in identifying discourse relations involves the detection of discourse connectives: words or phrases used in text to express discourse relations. In this study supervised machine-learning approaches were developed and evaluated for automatically identifying discourse connectives in biomedical text. MATERIALS AND METHODS: Two supervised machine-learning models (support vector machines and conditional random fields) were explored for identifying discourse connectives in biomedical literature. In-domain supervised machine-learning classifiers were trained on the Biomedical Discourse Relation Bank, an annotated corpus of discourse relations over 24 full-text biomedical articles (~112,000 word tokens), a subset of the GENIA corpus. Novel domain adaptation techniques were also explored to leverage the larger open-domain Penn Discourse Treebank (~1 million word tokens). The models were evaluated using the standard evaluation metrics of precision, recall and F1 scores. RESULTS AND CONCLUSION: Supervised machine-learning approaches can automatically identify discourse connectives in biomedical text, and the novel domain adaptation techniques yielded the best performance: 0.761 F1 score. A demonstration version of the fully implemented classifier BioConn is available at: http://bioconn.askhermes.org.

Meningeal (postdural) puncture headache, unintentional dural puncture, and the epidural blood patch: a national survey of United States practice.

BACKGROUND: Meningeal (postdural) puncture headache (MPH) is a familiar iatrogenic complication. The optimal means of prevention, management, and treatment of this disorder are uncertain. The purpose of this study was to determine current practice among United States (USA) anesthesiologists regarding MPH as well as the related issues of unintentional dural puncture (UDP), the epidural blood patch (EBP), and proposed alternatives to the EBP. METHODS: A survey form was sent as a single mailing to each practicing USA member of the American Society of Regional Anesthesia and Pain Medicine in June 2006. RESULTS: Data were analyzed from 1024 returned survey forms (29.4% response rate). Major findings were as follows: Written institutional protocols for managing UDP and MPH are uncommon. The preferred method of immediately dealing with an UDP when providing analgesia for labor is to reattempt the epidural at another level (73.4%). When intrathecal catheters are used for labor analgesia, they are most often removed immediately after delivery (56.5%). After UDP in the obstetric setting, aggressive hydration and encouraging bed rest are the most frequently used prophylactic measures against the development of MPH. Frequently used treatment options for MPH include aggressive hydration, the EBP, oral caffeine, oral nonopioid analgesics, and bed rest. With the exception of a uniform blood volume (16-20 mL), procedural details of the EBP vary considerably among practitioners. The use of materials other than blood for epidural patch is uncommon. CONCLUSIONS: Various measures, many poorly supported by the literature, are used prophylactically after UDP and in the treatment of MPH. Despite being nearly universally used as treatment of MPH, the EBP procedure itself remains largely nonstandardized.

The hair collar sign as a marker for neural tube defects.

The hair collar sign has been described as a marker of cranial dysraphism, including encephaloceles, meningoceles, and heterotropic brain tissue. This report describes a male born with a hair collar sign who subsequently was found to have a Klippel-Feil anomaly, diastematomyelia, multiple segmental spine and rib anomalies, and a translocation between chromosomes 1 and 4; t(1;4) (q44;q10). While not previously documented, spine abnormalities may be an associated abnormality with the hair collar sign. Physicians should consider radiographic evaluation of the spine in all newborns with a hair collar sign, as well as genetic screening.

Middle ear admittance and hearing abnormalities in individuals with osteoarthritis.

In osteoarthritis, the joint cartilage breaks down. Cartilage exists within the incudomalleolar and incudostapedial joints. In addition, the cartilage-covered base of the stapes footplate is bound to the cartilage-covered rim of the oval window by the annular ligament. Thus, higher prevalence of middle ear abnormalities and hearing loss can be expected in osteoarthritis due to degeneration of the cartilage and the subsequent abnormal repair response. In this study, tympanometric and audiometric data were obtained from 15 individuals diagnosed with osteoarthritis and 15 gender- and age-matched individuals without the diagnosis of arthritis. Results showed a significantly higher prevalence of middle ear abnormalities and hearing loss in ears with arthritis when compared to the control group. Interestingly, osteoarthritis and hearing loss are considered among the top chronic health concerns in older individuals although the connection between these two conditions has not been previously reported.

Cryptosporidiosis: a brief literature review and update regarding Cryptosporidium in feces of Canada geese (Branta canadensis).

Canada geese are increasingly abundant in Ohio, with large nesting populations throughout the state, and goose feces contaminate grassy areas and pavements in many public, commercial, and residential sites. In 1999 the authors found a high prevalence of Giardia, Campylobacter, and especially Cryptosporidium in collected feces of Canada geese. The purpose of this follow-up study was to survey known Canada geese sites in three counties in Ohio (Lucas, Ottawa, and Wood) and to determine the prevalence of sites testing positive for Cryptosporidium. The sites included golf courses, cemeteries, public parks, and health care and teaching facilities. At each of 11 sites, 12 goose feces of wet and loose appearance were collected and manually compressed into one composite sample representing that site. The samples were tested for Cryptosporidium with a sensitive monoclonal enzyme immunoassay (EIA) method. In 2000 and 2001, nine of 11 sites (81.8 percent) and nine of 10 sites (90 percent), respectively, were positive for Cryptosporidium. The species or genotypes of Cryptosporidium found in the geese feces and their potential to infect humans is unknown. A survey of the literature indicates, however, that while C. parvum (human genotype) is the main cause of cryptosporidiosis in humans, C. parvum (zoonotic genotypes), C. meleagridis (bird genotype), and C. felis (cat genotype) have occasionally been isolated from infected people. Further research is required to define the public health importance of Cryptosporidium in feces of Canada geese and other bird species.

Smallpox vaccine: contraindications, administration, and adverse reactions.

Since the terrorist attacks of September 11, 2001, and the anthrax exposures in the following weeks, concern that smallpox could be used as a biologic weapon has increased. Public health departments and the U.S. military have begun the process of vaccinating soldiers and civilian first-responders. Smallpox vaccination carries some serious risks: approximately one in 1 million primary vaccinees and one in 4 million revaccinees will die from adverse vaccine reactions. The most serious side effects of smallpox vaccine include progressive vaccinia, postvaccinial central nervous system disease, and eczema vaccinatum. Some of these reactions can be treated with vaccinia immune globulin or cidofovir. Proper patient screening and site care are essential. Family physicians must learn to screen potential vaccinees for contraindications (e.g., immunodeficiency, immunosuppression, certain skin and eye diseases, pregnancy, lactation, allergy to the vaccine or its components, moderate or severe intercurrent illness) and to treat vaccine-associated adverse reactions.