Decreasing length of stay in bariatric surgery: The power of suggestion.

OBJECTIVE: Enhanced recovery has been utilized to decrease length of stay and cost in bariatric surgery. We have recently focused efforts on pre-operative education with regards to discharge on the first post-operative day. The aim of this study was to determine the effectiveness of pre-operative education on discharge timing and readmission rates. METHODS: A retrospective review was conducted after revising discharge expectation education. Patients undergoing first time bariatric operations were included. Early group education focused on average patient stay of 2 postoperative days. Revised education informed patients they could go home on the first post-operative day. RESULTS: A total of 125 patients met inclusion criteria. Implementation of preoperative education was associated with a decrease in mean LOS and greater percentage of patients discharged on post-operative day one. There was no difference in readmission and complication rates. CONCLUSION: Effective pre-operative education can decrease length of stay in first time laparoscopic bariatric surgery.

Weight loss in overweight patients maintained on atypical antipsychotic agents.

BACKGROUND: Weight gain and associated medical morbidity offset the reduction of extrapyramidal side effects associated with atypical antipsychotics. Efforts to control weight in antipsychotic-treated patients have yielded limited success. METHODS: We studied the impact of an intensive 24-week program of diet, exercise, and counseling in 17 chronically psychotic patients (10 women, seven men) who entered at high average body weight (105.0+/-18.4 kg) and body mass index (BMI) (36.6+/-4.6 kg/m(2)). A total of 12 subjects who completed the initial 24 weeks elected to participate in an additional 24-week, less intensive extension phase. RESULTS: By 24 weeks, weight-loss/patient averaged 6.0 kg (5.7%) and BMI decreased to 34.5 (by 5.7%). Blood pressure decreased from 130/83 to 116/74 (11% improvement), pulse fell slightly, and serum cholesterol and triglyceride concentrations changed nonsignificantly. With less intensive management for another 24 weeks, subjects regained minimal weight (0.43 kg). CONCLUSIONS: These findings add to the emerging view that weight gain is a major health problem associated with modern antipsychotic drugs and that labor-intensive weight-control efforts in patients requiring antipsychotic treatment yield clinically promising benefits. Improved treatments without weight-gain risk are needed.

Comparison of daily urine, sweat, and skin swabs among cocaine users.

This study (1) compares urine, skin swabs, and PharmChek sweat patches for monitoring drug use; (2) measures possible environmental contamination in recent cocaine (COC) users; and (3) evaluates various immunoassays (IA) for screening COC in diverse matrices. Unique aspects include daily urine monitoring of 10 participants for 4 weeks, multiple monitoring methods, analysis for all specimens by IA and gas chromatography (GC)/mass spectrometry (MS), and the potential for continued illicit drug use by participants. Urine served as the "gold standard" specimen for determining drug use. Only cocaine and related substances were detected. Trace amounts of drugs were found on the skin (<50 ng per swab) of urine-negative participants' hands or forehead. In contrast, larger quantities of COC were found on the skin of individuals with BE-positive urines or individuals living with drug users (up to 20 microg per swab). Patch COC amounts among the three regular users (250-9000, 0-240, 160-22,000 ng per patch) exceeded BE (50-950, none, 30-2200 ng per patch). Pre-swabs, valuable for interpreting the source or time frame of positive patch results, contained substantial COC (38-1160, 0-152, 34-762 ng per swab) prior to patch application; therefore, patch results may represent current use, prior use, contamination, or a combination. In three individuals with no indication of cocaine use, false positives (defined as sweat patch positive when urine specimens were <300ng BE/ml) occurred at a 7% rate. Proposed cut-off concentrations of 75 ng cocaine per patch and 300 ng BE/ml urine curtail the incidence of false positives in this limited population. Three immunoassays were compared to screen specimens for cocaine: a modified, manual Microgenics CEDIA; a Cozart ELISA; and an OraSure ELISA. CEDIA's limit of detection (LOD) was 81ng/ml, compared with LODs of 4 ng/ml for the Cozart ELISA and 1.5 ng/ml for the OraSure ELISA. Cozart correlated with OraSure results for COC concentrations <2000 ng per swab (n=117), r(2)=0.79.

Mucosal iodine staining improves endoscopic visualization of squamous dysplasia and squamous cell carcinoma of the esophagus in Linxian, China.

BACKGROUND: In previous studies in the high risk population of Linxian, China, the majority of foci of high grade (moderate and severe) squamous dysplasia (HGD) and invasive squamous carcinoma (CA) of the esophagus were associated with endoscopically visible lesions that could be targeted for biopsy, but some foci of HGD were missed by routine endoscopic examination. This study examined whether spraying the mucosa with Lugol's iodine solution, which stains normal epithelium brown but leaves dysplasia and carcinoma unstained, could improve endoscopic detection and delineation of these lesions. METHODS: Two hundred twenty-five Linxian adults with balloon cytologic evidence of dysplasia or carcinoma underwent endoscopy. All visible lesions were described and photographed before and after staining with 1.2% Lugol's iodine solution. Biopsies were taken from all lesions visible before staining, from all unstained lesions (USLs) after applying the stain, and from representative control areas of stained mucosa. RESULTS: Two hundred fifty-three USLs and 255 control sites were biopsied. No complications occurred. Ninety-four biopsy sites contained HGD and 20 contained CA. Before staining, the sensitivity of visible lesions for identifying HGD or CA was 62%, and the specificity was 79%. After staining, the sensitivity of USLs for identifying HGD or CA was 96%, and the specificity was 63%. Eighty-eight percent of the HGD and CA lesions were larger or more clearly defined after staining. The diagnostic lesions in 17 of 31 patients with moderate dysplasia (55%), 8 of 35 patients with severe dysplasia (23%), and none of the 19 patients with invasive carcinoma (0%) were identified only after staining. CONCLUSIONS: Mucosal iodine staining improved endoscopic detection and delineation of HGD and CA in these patients. This simple technique is highly sensitive for identifying these precursor and invasive squamous lesions, and it should be used whenever optimal visualization of squamous mucosal abnormalities is required.

Domain-specific gender comparisons in identity development among college youth: ideology and relationships.

Gender comparisons were conducted in six social domains of identity development on 210 college students: occupation, religion, politics, dating, sex roles, and friendship. The identity research literature often combines domains to create more global estimates of identity development. Such an approach may obscure differences among the domains, each of which may have different implications for different societal contexts, and for males and females. Analyses were made for each domain, and for the combined ideological, interpersonal, and overall domain scores. Several gender differences were apparent when domain-specific analyses were examined. Males were more likely to explore and commit in politics, whereas females were more likely to explore in sex roles and to commit in religion and dating. In politics, fewer males were in the diffused status; in contrast, for dating and sex roles, there were fewer females in the diffused status. However, when combined scores were examined, there were no gender differences in identity status. The results suggest that some gender differences still remain in specific domains. The utility of including domain-specific analyses is suggested when gender comparisons are examined. Regardless of gender, more youth were diffused in political identity than in any other domain, suggesting political apathy among today's college youth.

A new system for defining endoscopic complications emphasizing the measure of importance.

BACKGROUND: Currently, there are no satisfactory systems for defining, classifying, and/or scoring endoscopic complications, although it would be important for quality assurance, comparative studies, and outcomes research. Recently the term "negative outcomes" was proposed rather than "complications," and an approach that incorporates "measures of importance" was added to compare negative outcomes. METHODS: A system was developed that defines, classifies, and grades negative outcomes with a scoring system based on measures of importance. Information was recorded on a Morbidity and Mortality (M & M) form, which was used at a monthly quality assurance (M & M) conference. Several measures of importance related to the immediate negative outcome (O) were quantified (effect of the complication on completion of the endoscopy, change in level of care, change in number of hospital days, necessity for new invasive procedures). The disability (D), defined as a residual or chronic negative outcome caused by the complication, was characterized and scored. Death (D) was also characterized, the value varying with circumstances. As a quantitative measure, an overall ODD score was used. RESULTS: One hundred twenty-three negative outcomes were retrospectively classified using the new M & M form and the ODD score was applied for 117 complications. Complications were ranked according to the ODD score. CONCLUSION: A system for defining, classifying, and grading negative outcomes of endoscopic procedures is proposed with a quantitative scoring system that emphasizes measures of importance. The ODD score looks at the immediate negative outcome and also the separate long-term issues of disability and death.

High-level expression of lacZ under control of the tac or trp promoter using runaway replication vectors in Escherichia coli.

To determine the utility of coupling runaway replication to the expression of cloned genes under the control of strong promoters, lacZ transcriptional fusions to the trp or tac promoter (Ptrp or Ptac) were constructed using plasmids in which the copy number is thermally regulated. Cells containing these plasmids were able to produce beta-galactosidase to levels between 3700 and 46,000 Miller units when induced only by a temperature upshift. The addition of the appropriate chemical inducer, either IPTG (isopropyl-beta-D-thiogalactopyranoside) or IAA (3-beta-indoleacrylic acid), did not significantly enhance the thermal induction. The Ptac-controlled and Ptrp-controlled lacZ induction differed slightly in that the Ptac-controlled thermal induction exhibited a lag of approximately 1.5 h as compared to both chemical and thermal induction, whereas in the case of Ptrp-controlled induction, an increase in beta-galactosidase expression above background occurred at approximately the same time regardless of the means of induction. The best vector, a Ptrp-controlled lacZ fusion carried on a runaway replication vector having a basal copy number of 10, was able to mediate the expression of beta-galactosidase to approximately 40,000 Miller units of beta-galactosidase comprising 25% of the total cell protein at 17 h postinduction under optimal conditions for protein yield. In these cells, lysis occurred as lacZ was maximally expressed. Under noninducing conditions, the plasmids were stable for at least 60 generations in the absence of antibiotic in batch culture.

International Interface Standard for Food Databases.

An International Interface Standard for Food Databases is under development to help overcome the technical and semantic barriers to the use of food-related databases. The Interface Standard is a system for efficient storage of all relevant descriptive information about foods. The schema for the Standard consists of ten components--food/food product identification, food names, LANGUAL factors, other food descriptors, other descriptive coding systems, ingredients/recipes, standards, substances, organizations, and data sources. The Interface allows for retrievals of data associated with specific foods from databases by using queries based on any of a wide variety of descriptive terms. The schema of the Interface has been completed; the remaining work is to build the computer software to provide access to, and use of, the schema.

Regulated expression of the Alcaligenes eutrophus pha biosynthesis genes in Escherichia coli.

A novel poly-beta-hydroxybutyrate (PHB) production system in which the expression and gene dosage of the Alcaligenes eutrophus pha biosynthetic operon were effectively regulated by cultivation temperature was constructed in Escherichia coli. The pha operon was fused to the negatively regulated tac promoter and cloned into a vector in which the copy number is temperature dependent. A two-phase process was employed to produce PHB during fed-batch growth. In the growth phase, the culture was maintained at a low temperature. Under this condition, the plasmid copy number was depressed and the number of LacI proteins was sufficient to repress tacupha transcription. The production phase was initiated by temperature upshift. At the elevated temperature, the number of plasmids surpassed the number of LacI repressors, which resulted in rapid induction of tacupha transcription, synthesis of poly-beta-hydroxyalkanoate-specific proteins, and polymer synthesis. During the production phase, the PHB production rate was 1.07 g of PHB liter-1 h-1 under optimized conditions. This rate is comparable to that of bacteria which naturally produce this polymer.

Adolescent identity exploration: a test of Erikson's theory of transitional crisis.

This research investigated Erikson's theory that adolescent identity exploration is associated with a variety of symptoms, such as fluctuations in ego strength, mood swings, rebelliousness, and heightened physical complaints. A sample of 82 high school students completed the Minnesota Multiphasic Personality Inventory (MMPI) and the Ego-Identity Interview. Identity exploration was correlated with 23 major clinical scales and the 14 Frequently Scored Scales of the MMPI. A factor analysis revealed seven scales loading on a single factor, which accounted for 39% of the variance in exploration. The items in the factor suggested a pattern consistent with Erikson's theory of adolescent crisis, and was labeled the Identity Exploration Crisis (IEC) factor. Adolescents who were actively engaged in identity exploration were more likely to produce a personality pattern characterized by self-doubt, confusion, disturbed thinking impulsivity, conflicts with parents and other authority figures, reduced ego strength, and increased physical symptoms.

Characterization of the sigma 38-dependent expression of a core Escherichia coli starvation gene, pexB.

A reverse genetics approach was used to clone a pex starvation gene that codes for an 18-kDa polypeptide, designated PexB. Single-copy pexB-lacZ operon fusions were constructed to study transcriptional regulation and the promoter region of this gene. The induction by carbon starvation or osmotic stress was transcriptional and controlled by sigma 38 but was independent of this sigma factor by the oxidative stress; presumably, it was sigma 70 mediated under the latter stress. During nitrogen starvation, the induction was controlled at the posttranscriptional level. The pexB upstream region contained 245 nucleotides within which sequences approximating the consensus for cyclic AMP receptor protein and integration host factor binding sites were discernible. Deletion of 164 bp of the upstream region, which included these consensus sequences, did not affect starvation-or osmotic stress-mediated induction of pexB but abolished its induction by oxidative stress. The same start site was used in transcription during carbon starvation, osmotic stress, or oxidative stress, suggesting that the pexB promoter can be recognized in vivo by both sigma 38 and sigma 70, depending, presumably, on the presence of appropriate transcriptional factors. The -10 and -35 regions of pexB resembled those of some but not all genes known to be controlled by sigma 38.

Nursing management in an endoscopy setting.

Textbooks and articles that address the issues and responsibilities of a nurse manager generally focus on the role of the nurse manager in a hospital setting. While many of the principles set forth in these publications may be appropriately used by the nurse manager working in an endoscopy setting, certain characteristics of GI nursing are unique in terms of managing the delivery of patient care, managing staff, and managing self. This article describes these critical "3Ms" of nursing management and offers practical guidelines to the GI nurse manager.

Prospective evaluation of complications in an endoscopy unit: use of the A/S/G/E quality care guidelines.

In 1989, the American Society for Gastrointestinal Endoscopy released a quality assurance monograph in which a procedure review process was outlined. The major elements of the program for quality assurance in gastrointestinal endoscopy included: (1) procedure reports, (2) an endoscopic unit record, and (3) a procedure review. This study was designed to use the procedure review process to determine the incidence of complications, to identify quality assurance issues, and to determine whether audits and/or studies would result from this process. To make a meaningful interpretation as to what constitutes an important complication, a classification to define potential problems was established. Using this classification, a complication was identified in 64 of 3287 procedures (1.9%). These complications were discussed in a monthly morbidity and mortality conference. Additionally, 21 quality assurance issues were identified that led to four studies addressing these quality assurance issues.

The putative sigma factor KatF has a central role in development of starvation-mediated general resistance in Escherichia coli.

KatF is required for the expression of some 32 carbon starvation proteins in Escherichia coli including 6 previously identified as Pex. Mutants with the katF gene survive carbon and nitrogen starvation poorly. Many of the KatF-regulated starvation proteins are common to those induced by other stresses, and the mutant failed to develop starvation-mediated cross protection to osmotic, oxidative, and heat stresses. Furthermore, thermal resistance was not induced in the mutant by heat preadaptation, and it exhibited an altered pattern of protein synthesis at elevated temperature. Thus, KatF is a major switch that controls the starvation-mediated resistant state in E. coli.

Limited benefit of atropine as premedication for colonoscopy.

A prospective double-blind trial was performed comparing atropine (0.5 mg) by slow intravenous administration to placebo as premedication for colonoscopy, to assess the possible beneficial effects of this vagolytic agent on the performance and safety of the procedure. A total of 77 patients was randomly assigned to receive atropine (38 patients) or placebo (39 patients) before colonoscopy in conjunction with our standard initial medications for conscious sedation (meperidine, 0.4 mg/kg and midazolam, 0.03 mg/kg). Total procedure time was 31 min for the atropine group and 35 min for the placebo group (p greater than 0.05), and there was no overall difference in the total amount of intra-procedural medications required. No statistically significant differences were observed relative to the number or severity of vagal episodes, and neither the endoscopist nor the patients noted any differences in the ease or tolerance of the procedure (p greater than 0.05). Although these results fail to demonstrate a significant benefit of atropine when given routinely as premedication for colonoscopy, this study does not rule out the potential usefulness of atropine in counteracting vagal episodes when they occur.

Nursing care for the patient receiving conscious sedation during gastrointestinal endoscopic procedures.

The delivery of health care in the field of gastroenterology is expanding, thus changing the traditional roles of the GI physician and nurse. As these roles increase in responsibility, the management of the GI patient may need to be redefined. The purpose of this paper is to focus on changes in the care of the GI patient by presenting the different concepts of monitoring, describing the nursing components that are essential for the safe management of GI patients, defining the role of automatic monitoring devices and offering nursing guidelines based on these recommendations.

Effect of selection, mutation, and linkage on the equilibrium structure of selfing systems.

One-, two- and three-locus models of selection and mutation in completely self-fertilizing populations are examined. Equilibrium frequencies can be determined for these systems. Numerical analyses indicate that random genetic drift attributable to selfing plays a major role in determining equilibrium frequencies, even when strong directional selection is operating. Linkage has no effect on marginal gene frequencies or single-locus heterozygosity at equilibrium. The only model of those examined which leads to linkage disequilibrium is disruptive selection. In that model, selection reinforced the effect of selfing in favoring the homozygous genotypes.