It's complicated: The relationship of non-narcotic medications and postoperative opioid use in radical cystectomy patients.

INTRODUCTION: The effect of individual non-narcotic analgesics in cystectomy enhanced recovery after surgery (ERAS) is unknown. Additionally, many non-narcotic medications are associated with side effects pertinent to the cystectomy population. To better understand the actual use and utility of these medications, we sought to characterize the association between non-narcotic medications and milligram morphine equivalent (MME) narcotic score during the postoperative inpatient stay. METHODS: We reviewed 260 consecutive ERAS cystectomy patients. The MME impact of non-narcotic compliance and cumulative dose of medication received was evaluated separately with general linear models. We also assessed relationship of non-narcotic compliance to patient reported pain score, length of stay (LOS), and time to return of bowel function (ROBF) and performed manual review of postoperative documentation to identify reasons for medication noncompliance. RESULTS: Compliance with postoperative acetaminophen, gabapentin, and ketorolac was low. There was an inverse relationship between ketorolac dose and MME on postoperative day 1 (-0.026 MME/mg; P = 0.004) and postoperative day 2 (-0.33 MME/mg; P < 0.001). Compliance with ketorolac was associated with lower MME on postoperative day 1 (26.1 MME v. 33.6 MME; P = 0.023). There were no such associations identified with gabapentin or acetaminophen. Gabapentin compliance was associated with earlier ROBF (3.7 days v. 4.3 days; P = 0.006). Ketorolac compliance was associated with lower pain score on POD1 (3.25 VAS v. 4.07 VAS; P = 0.019) and POD2 (3.05 VAS v. 3.85 VAS; P = 0.040) There was no association between medication compliance and LOS. The most common reasons identified for non-compliance with gabapentin and ketorolac were renal function concerns (38% and 40% respectively), bleeding concerns with ketorolac (20%) and concerns for neurologic adverse effect with gabapentin (16%). CONCLUSION: Compliance with non-narcotic medications in our ERAS cystectomy protocol was poor. There was a modest association with ketorolac and postoperative MME but no association with gabapentin or acetaminophen. Further study will clarify the role of these medications for cystectomy patients. Component specific analysis of protocolized care is valuable and may alter care pathways.

Persistent opioid and benzodiazepine use after radical cystectomy in enhanced recovery after surgery (ERAS) patients.

OBJECTIVES: Opioid use, misuse, and diversion is of paramount concern in the United States. Radical cystectomy is typically managed with some component of opioid pain control. We evaluated persistent opioid and benzodiazepine use after radical cystectomy and assessed the impact of their preoperative use on this outcome. We also explored associations between preoperative use and perioperative outcomes. METHODS AND MATERIALS: We used prospectively maintained data from our enhanced recovery after surgery (ERAS) cystectomy database and the Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM) database to identify controlled substance prescriptions for radical cystectomy patients. We separated patients by frequency of preoperative opioid and/or benzodiazepine prescriptions (0, 1, 2+) and used these cohorts to explore persistent use (prescription 3-12 months after surgery) alongside perioperative outcomes. RESULTS: Our cohort included 257 patients undergoing cystectomy at a single institution from 2017 to 2021. Preoperative opioid and benzodiazepine prescriptions were documented for 120 (46.7%) and 26 (10.1%) patients, respectively. Persistent opioid use was observed in 20 (14.6%) of opioid-naive patients (no prescriptions in 9 months prior to surgery) while 13 (19.7%) patients with 1 preoperative prescription and 28 (51.9%) patients with 2 or more preoperative prescriptions demonstrated persistent use. New persistent benzodiazepine use occurred in 6 (2.6%) patients. Overall persistent benzodiazepine use was present in 11 (4.3%) patients. In a multivariable model, preoperative opioid and benzodiazepine prescriptions were associated with persistent opioid use (P < 0.001; P = 0.027 respectively). No association was identified between preoperative opioid or benzodiazepine usage and perioperative outcomes including length of stay, return of bowel function, inpatient opioid usage, inpatient or discharge complications, readmissions, or emergency department visits. Inpatient pain scores were noted to be higher in patients with ≥ 2 preoperative opioid prescriptions (P = 0.037). CONCLUSIONS: Persistent opioid use was present in 23.7% of patients, with a new persistent use rate of 14.6%. Benzodiazepine use was less frequent than opioids, with a small number demonstrating new persistent use. Preoperative opioid and benzodiazepine use is associated with persistent opioid use postoperatively. Preoperative opioid and benzodiazepine use did not affect perioperative outcomes in our cohort.

Graphene quantum dots functionalised with rhamnolipid produced from bioconversion of palm kernel oil by Pseudomonas stutzeri BK-AB12MT as a photocatalyst.

Methylene blue (MB) is a common organic dye found in textile wastewater and can harm the environment. Rhamnolipid-functionalized graphene quantum dots (RL-GQDs) are a newly developed eco-friendly photocatalyst to degrade MB. This photocatalyst is synthesized from graphene quantum dots (GQDs) and rhamnolipid. GQDs are already promising visible-light photocatalysts to degrade organic dyes. However, GQDs are not promising photocatalysts due to their reusability and photocatalytic performance. In this work, we used rhamnolipid to modify GQDs' structure and enhance their photocatalytic performance. The rhamnolipid used in this work was produced from bioconversion of palm kernel oil by mutated bacterial cells of Pseudomonas stutzeri BK-AB12MT. Meanwhile, GQDs were synthesized using the bottom-up method by pyrolysing citric acid. Transmission electron microscopy and Fourier-Transform Infrared spectroscopy were used to characterize these hybrid materials. These characterization techniques verified the formation of RL-GQDs. To prove the photocatalytic performance of RL-GQDs, we investigated the photocatalytic activity under visible light compared to some common photocatalysts, such as zinc oxide and titanium dioxide. Our findings showed that RL-GQDs could be applied as an eco-friendly photocatalyst to replace TiO2 with a degradation efficiency of 59% ± 3% under visible light irradiation, higher than TiO2.

Impact of dedicated renal enhanced recovery after surgery (RERAS) program on postoperative opioid consumption and evaluation of surgeon-specific compliance to the program.

INTRODUCTION AND OBJECTIVE: Enhanced Recovery After Surgery (ERAS) protocols have been increasingly applied to urologic surgeries such as cystectomy and prostatectomy, though research defining protocols and outcomes for renal ERAS programs (RERAS) for nephrectomy remains limited. We aim to assess perioperative outcomes following implementation of our RERAS protocol modified from ERAS society cystectomy guidelines, as well as describe compliance with protocol guidelines. METHODS: We performed a retrospective cohort analysis of 400 patients who underwent partial or radical nephrectomy between October 2017 and August 2020. RERAS protocol was initiated September 30, 2018, and patients were categorized into pre- and post-RERAS implementation cohorts based on surgery date. Perioperative outcomes including complications, 30-day readmissions, length of stay, and opioid consumption were compared across pre- and post-RERAS cohorts. Protocol compliance was reported based on adherence to program recommendations. RESULTS: Among 400 patients included in analysis, the pre-RERAS cohort included 133 patients and the post-RERAS cohort included 267 patients. There were no differences in overall complications (P = 0.354) and 30-day readmissions (P = 0.078). Length of stay (P < 0.001) and postoperative opioid consumption (P < 0.001) were significantly reduced post-RERAS. We observed an increase in compliance with RERAS recommendations over time (P< 0.001). CONCLUSION: RERAS implementation was associated with decreased length of stay and opioid usage, underscoring the benefits of program adoption in an era of opioid dependence and strained hospital capacity. Successful initiation of a RERAS protocol requires intentional organization and buy in from all providers involved.

Urine versus stent cultures and clinical UTIs.

PURPOSE: Current American Urological Association guidelines recommend pre-operative antimicrobial therapy based on prior urine cultures (UC); however, the role of stent culture (SC) in urologic practice is unclear. We examined whether UC and SC differed at the time of stent removal, as well as the association, microbiology, and timing of subsequent UTIs as related to SC. METHODS: This was a retrospective review of 159 patients with ureteral stents for indications of urolithiasis, benign stricture, malignant obstruction, and kidney transplant. UC and SC were analyzed at the time of stent removal. Patients were followed for 12 months after stent removal for development, concordance, and timing of clinical UTIs. RESULTS: In 159 patients, 15% had positive UC and 45% had positive SC. Of patients who had positive SC, 66% had negative UC. All patients with positive UC had identical micro-organisms on SC; however, 33% of these had SC with additional micro-organisms. Relative to those with both negative UC and SC, patients with negative UC and positive SC had a 5.7 odds, and those with both positive UC and SC had a 13.6 odds of developing a clinical UTI within 12 months. Concordance of SC and future UTI was highest in those with post-operative sepsis, and those with Candida species on SC. CONCLUSIONS: SC was a unique risk factor for development of UTI within 12 months of stent removal. Clinicians should consider SC results when empirically treating those with post-operative sepsis or those with UTI after Candida on SC.

Directed evolution reveals the mechanism of HitRS signaling transduction in Bacillus anthracis.

Two component systems (TCSs) are a primary mechanism of signal sensing and response in bacteria. Systematic characterization of an entire TCS could provide a mechanistic understanding of these important signal transduction systems. Here, genetic selections were employed to dissect the molecular basis of signal transduction by the HitRS system that detects cell envelope stress in the pathogen Bacillus anthracis. Numerous point mutations were isolated within HitRS, 17 of which were in a 50-residue HAMP domain. Mutational analysis revealed the importance of hydrophobic interactions within the HAMP domain and highlighted its essentiality in TCS signaling. In addition, these data defined residues critical for activities intrinsic to HitRS, uncovered specific interactions among individual domains and between the two signaling proteins, and revealed that phosphotransfer is the rate-limiting step for signal transduction. Furthermore, this study establishes the use of unbiased genetic selections to study TCS signaling and provides a comprehensive mechanistic understanding of an entire TCS.

Comparison of guideline recommendations for antimicrobial prophylaxis in urologic procedures: variability, lack of consensus, and contradictions.

PURPOSE: This review assesses guideline discrepancies for urologic surgery antimicrobial prophylaxis and identifies opportunities for improvement of antimicrobial prophylaxis and stewardship. METHODS: Literature search using PubMed, Embase, Cochrane, and association websites identified guidelines for review from the American Urological Association, Canadian Urological Association, European Association of Urology, Japanese Urological Association, and Association of Health-System Pharmacists/Infectious Disease Society of America/Surgical Infection Society/Society for Healthcare Epidemiology of America. RESULTS: The greatest variability between guidelines was found in prophylaxis recommendations for prostate brachytherapy, transurethral resection of bladder tumor, extracorporeal shock wave lithotripsy (ESWL), and ureteroscopy with manipulation. Variability was also present in recommended duration of prophylaxis and recommended antibiotic. Contradictions between guidelines existed regarding prophylaxis for patients with indwelling stents undergoing ESWL, as well as for patients at risk of endocarditis undergoing urologic procedures. Procedures with the least variability in prophylaxis recommendation included diagnostic procedures (cystourethroscopy, urodynamic studies, and diagnostic ureteroscopy), transurethral resection of prostate, transrectal prostate biopsy, percutaneous nephrolithotomy, procedures involving prosthesis placement or intestine, and open or laparoscopic procedures. CONCLUSIONS: Consensus recommendations are present for several procedures, many of which still rely on non-urologic data. Several other procedures have variability in recommendations, generally due to a lack of strong data. The use of risk factors as indication for prophylaxis in many procedures is at times ambiguous and confusing. Together, these observations indicate a need for further research to provide more robust and consistent guidelines for antimicrobial prophylaxis and stewardship in the field of urology.

Two-component system cross-regulation integrates Bacillus anthracis response to heme and cell envelope stress.

Two-component signaling systems (TCSs) are one of the mechanisms that bacteria employ to sense and adapt to changes in the environment. A prototypical TCS functions as a phosphorelay from a membrane-bound sensor histidine kinase (HK) to a cytoplasmic response regulator (RR) that controls target gene expression. Despite significant homology in the signaling domains of HKs and RRs, TCSs are thought to typically function as linear systems with little to no cross-talk between non-cognate HK-RR pairs. Here we have identified several cell envelope acting compounds that stimulate a previously uncharacterized Bacillus anthracis TCS. Furthermore, this TCS cross-signals with the heme sensing TCS HssRS; therefore, we have named it HssRS interfacing TCS (HitRS). HssRS reciprocates cross-talk to HitRS, suggesting a link between heme toxicity and cell envelope stress. The signaling between HssRS and HitRS occurs in the parental B. anthracis strain; therefore, we classify HssRS-HitRS interactions as cross-regulation. Cross-talk between HssRS and HitRS occurs at both HK-RR and post-RR signaling junctions. Finally, HitRS also regulates a previously unstudied ABC transporter implicating this transporter in the response to cell envelope stress. This chemical biology approach to probing TCS signaling provides a new model for understanding how bacterial signaling networks are integrated to enable adaptation to complex environments such as those encountered during colonization of the vertebrate host.

Nivel de satisfacción de los pacientes acerca del cuidado de enfermería en las Salas de Observación; Servicio de Emergencia del Hospital Nacional Edgardo Rebagliatti Martins: 2010 / Level of satisfaction of patients about the nursing care in the Observation Room; Service of Emergency at the Hospital Edgardo Rebagliatti Martins: 2010

El objetivo fue determinar el nivel de satisfacción de los pacientes acerca del cuidado de enfermería en las Salas de Observación, Servicio de Emergencia del Hospital Nacional Edgardo Rebagliatti Martins e identificar el nivel de satisfacción, según las dimensiones accesibilidad, explica y facilita, conforta, se anticipa, mantiene relación de confianza, monitorea y hace seguimiento de los pacientes. Material y Método: El estudio fue de tipo cuantitativo, nivel aplicativo, método descriptivo simple de corte transversal. La muestra estuvo conformada por 40 pacientes. La técnica fue la entrevista y el instrumento el cuestionario CARE Q. Resultados: Del 100 por ciento (40), 45 por ciento (18) tienen un nivel de satisfacción alto, 40 por ciento (16) medio y los 15 por ciento (6) bajo. En la dimensión accesibilidad, 52.5 por ciento (21) tienen un nivel de satisfacción alto, 35 por ciento (14) medio y 12.5 por ciento (5) bajo; en la dimensión explica y facilita, 45 por ciento (18) tienen un nivel de satisfacción bajo, 30 por ciento (12) medio y 25 por ciento (10) alto; en la dimensión conforta, 50 por ciento (20) tienen un nivel de satisfacción medio, 27.5 por ciento (11) bajo y 22.5 por ciento (9) alto; en la dimensión se anticipa, 40 por ciento (16) tienen un nivel de satisfacción medio, 32.5 por ciento (13) alto y 27.5 por ciento (11) bajo; en la dimensión mantiene relación de confianza, 45 por ciento (18) alto, 35 por ciento (14) medio y 20 por ciento (8) bajo y en la dimensión monitorea y hace seguimiento, 80 por ciento (32) alto, 17.5 por ciento (7) medio y 2.5 por ciento (1) bajo. Conclusiones: La mayoría de los pacientes tienen un nivel de satisfacción entre medio y bajo, referidos el medio por que la enfermera acude rápidamente al llamado del paciente llamado, le informa sobre los grupos de ayuda para el control y el seguimiento de su enfermedad, lo motiva a identificar los elementos de su tratamiento...

The objective was to determine the level of patient satisfaction about the care of nursing observation rooms, emergency service of the National Hospital Edgardo Rebagliatti Martins and identify the level of satisfaction, according to the dimensions accessibility, explains and facilitates, supports them, are anticipates maintaining trust relationship, monitors and tracks patients. Materials and Methods: The study was a quantitative level application, simple descriptive method of cross section. The sample consisted of 40 patients. The technique was the interview and the questionnaire instrument CARE Q. Results: 100 per cent (40), 45 per cent (18) have a high satisfaction level, 40 per cent (16) medium and 15 per cent (6) under. The accessibility dimension, 52.5 per cent (21) have a high satisfaction level, 35 per cent (14) middle and 12.5 per cent (5) low, in the dimension explains and faciIitates, 45 per cent (18) have a low level of satisfaction, 30 per cent (12) medium and 25 per cent (10) high, in the comfort dimension, 50 per cent (20) have an average satisfaction level, 27.5 per cent (11) low and 22.5 per cent (9) high, in the dimension is expected, 40 per cent (16) have an average satisfaction level, 32.5 per cent (13) high and 27.5 per cent (11) low, in the dimension maintains a relationship of trust, 45 per cent (18) high, 35 per cent (14) middle and 20 per cent (8) low and the size monitors and tracks, 80 per cent (32) high, 17.5 per cent (7) medium and 2.5 per cent (1) under. Conclusions: Most patients have a level of satisfaction among medium and low, medium referrals that come quickly to the nurse called the patient named, tells about support groups for control and monitoring of their disease, what motivates identify elements of their treatment, helps you set reasonable goals, to find the best moment to talk about changes in their health, encourages you to ask questions to your doctor about your health situation, ensures the time set...