bluuebunny/crossref_metadata_2025 huggingface dataset:
A review of inherited cancer susceptibility syndromes
Authors: Brown Gina R. , Simon Madeline , Wentling Chris , Spencer Danielle M. , Parker Ashley N. , Rogers Corey A.
Published: November 2020

Inherited cancer syndromes are caused by genetic mutations that place patients at an increased risk for developing cancer. Although most cancers are not caused by genetic inheritance, clinicians must understand these syndromes and be able to recognize their common characteristics. A thorough family history and identification of common patterns as well as specific clinical signs and symptoms can help with early recognition. This article describes symptoms of the more common cancer syndromes, including hereditary breast and ovarian cancer, Li-Fraumeni, Lynch, familial adenomatous polyposis, retinoblastoma, multiple endocrine neoplasia, and von Hippel-Lindau. Important patient education regarding genetic testing also is covered.
Advanced kidney disease
Authors: Puzantian Houry , Mead Daniel R.
Published: November 2020

Nonnephrology NPs often encounter patients with advanced chronic kidney disease. As patients transition to nephrology care, NPs need to communicate with them about their disease status and treatment. This article describes the treatment approach in patients with advanced kidney disease including medical management, hemodialysis, peritoneal dialysis, and transplantation.
Managing postoperative pain with opioid-sparing therapies
Authors: Barnett Taylor , Denke Linda
Published: November 2020

The analgesic properties of opioids make them valuable pharmacologic options for patients with severe post-op pain, but healthcare providers must be cautious due to opioid-related adverse reactions. This article reviews select nonopioid adjuvant and adjunctive medications, as well as select nonpharmacologic therapies, as part of a multimodal approach to postoperative analgesia. The role of nurses in assessing, monitoring, and educating patients is also explored.
Caring for patients with a traumatic spinal cord injury
Authors: Hills Teresa E.
Published: November 2020

The physical, emotional, and financial impact of a traumatic spinal cord injury (TSCI) can be devastating. This article discusses the pathophysiology of TSCI, medical and surgical management during the acute and subacute phases of injury, and nursing care for patients with TSCI.
Effect on Patient Safety of a Resident Physician Schedule Without 24-Hour Shifts
Authors: Landrigan Christopher P. , Rahman Shadab A. , Sullivan Jason P. , Vittinghoff Eric , Barger Laura K. , Sanderson Amy L. , Wright Kenneth P. , O'Brien Conor S. , Qadri Salim , St Hilaire Melissa A. , Halbower Ann C. , Segar Jeffrey L. , McGuire John K. , Vitiello Michael V. , de la Iglesia Horacio O. , Poynter Sue E. , Yu Pearl L. , Zee Phyllis C. , Lockley Steven W. , Stone Katie L. , Czeisler Charles A.
Published: November 2020

(Abstracted from N Engl J Med 2020;382:2514–2523)

Over the last 4 decades, a body of literature has studied the effect of extended shifts (working ≥24 hours) for resident physicians on their alertness and performance, and by extension, patient safety. Since then, the results of further studies have been inconsistent.
Trainee Wellness and Safety in the Context of COVID-19: The Experience of One Institution
Authors: Kemp Michael T. , Rivard Samantha J. , Anderson Sara , Audu Christopher O. , Barrett Meredith , Fry Brian T. , Lane Megan , Vu Joceline V. , Young Bree Ann C. , Englesbe Michael , Sandhu Gurjit , Coleman Dawn M.
Published: November 2020

The COVID-19 pandemic has had significant ramifications for provider well-being. During these unprecedented and challenging times, one institution’s Department of Surgery put in place several important initiatives for promoting the well-being of trainees as they were redeployed to provide care to COVID-19 patients. In this article, the authors describe these initiatives, which fall into 3 broad categories: redeploying faculty and trainees, ensuring provider safety, and promoting trainee wellness.

The redeployment initiatives are the following: reframing the team mindset, creating a culture of grace and forgiveness, establishing a multidisciplinary wellness committee, promoting centralized leadership, providing clear communication, coordinating between departments and programs, implementing phased restructuring of the department’s services, establishing scheduling flexibility and redundancy, adhering to training regulations, designating a trainee ombudsperson, assessing physical health risks for high-risk individuals, and planning for structured deimplementation.

Initiatives specific to promoting provider safety are appointing a trainee safety advocate, guaranteeing personal protective equipment and relevant information about these materials, providing guidance regarding safe practices at home, and offering alternative housing options when necessary.

Finally, the initiatives put in place to directly promote trainee wellness are establishing an environment of psychological safety, providing mental health resources, maintaining the educational missions, solidifying a sense of community by showing appreciation, being attentive to childcare, and using social media to promote community morale.

The initiatives to carry out the department’s strategy presented in this article, which were well received by both faculty and trainee members of the authors’ community, may be employed in other departments and even outside the context of COVID-19. The authors hope that colleagues at other institutions and departments, independent of specialty, will find the initiatives described here helpful during, and perhaps after, the pandemic as they develop their own institution-specific strategies to promote trainee wellness.
Surgical Interventions for COPD
Authors: Ashraf Obaid , Disilvio Briana , Young Meilin , Ghosh Sohini , Cheema Tariq
Published: November 2020

Chronic obstructive pulmonary disease (COPD) treatment is aimed at managing the disease rather than cure, with a focus on improving quality of life and decreasing exacerbations. Interventional therapies, including lung volume reduction surgery, bullectomy, lung transplantation, and bronchoscopic lung volume reduction treatment using endobronchial valves, are treatment options for patients with COPD who are symptomatic due to hyperinflation despite optimal medical management. We will review the current literature to provide a comprehensive summary of the currently available scientific data, discuss typical treatment-related side effects, and evidence-based management approach and recommendations for patient selection in clinical practice.
Advocating for a Loved One in the Setting of Uncertainty
Authors: Umberger Reba A. , Todt Kendrea , Talbott Elizabeth , Sparks Laurie , Thomas Sandra P.
Published: November 2020

Background

The trajectory of recovery after sepsis varies. Survivors may have considerable ongoing limitations, requiring a caregiver for a prolonged period.

Objectives

To learn about experiences, quality of life, coping, resilience, and social support of caregiver caring for survivors of sepsis.

Methods

We conducted a convergent mixed-methods study, recruiting informal caregivers of patients who had survived sepsis in the past year and were readmitted to the intensive care unit with sepsis. Individual face-to-face, semistructured interviews and validated surveys on quality of life, coping, caregiver burden, resilience, and social support were administered to caregivers. Interview transcripts were analyzed using content analysis. Surveys were scored and summarized using descriptive statistics.

Results

Caregivers were primarily middle-aged, White, and female. Half were spouses of their care recipient. Caregivers reported some deficits in mobility, pain, and anxiety/depression. Coping styles varied, with engaged coping being more prevalent. Most caregivers reported mild to moderate burden, all reported either normal or high resilience levels, and types of social support were similar. However, interviews and survey findings were not always consistent. Major themes that emerged from the analysis included (1) advocating for and protecting their loved one, (2) coping with caregiving, (3) uncertain future, (4) rewards of caregiving, and (5) need to optimize communication with family.

Discussion

Caregivers of sepsis survivors are protective of their care recipient and use a variety of strategies to advocate for their loved one and to cope with the uncertainty involved in a new intensive care unit admission. More advocacy and support are needed for this population.
Socioeconomic, behavioural and sexual-health factors associated with nutritional status of female commercial sex workers in Dhaka city, Bangladesh: a cross-sectional study
Authors: Kawser Mahbuba , Khan Muhammad Nazrul Islam , Hossain Kazi Jahangir , Islam Sheikh Nazrul
Published: November 2020

Objectives:

To investigate the prevalence of nutitional status of female commercial sex workers (FCSWs) in Dhaka city and to determine which socio-economic, behavioural and sexual health practices associated with chronic energy deficiency (CED) and overweight/obesity.

Methods:

Cross-sectional study conducted among 635 FCSWs (308 hotel-based/HBSWs and 327 floating-based/FBSWs). Research tools were pretested questionnaire and anthropometric measurement (height–weight). Multistage sampling technique was employed to collect the data according to probability proportional to size from 7 hotels and 3 spots. Socio-demographic, sexual-health and behavioural data were collected by direct interview of the FCSWs from working places and were processed by statistical software package. Multinomial logistic regression model was used to determine the factors influencing BMI kg/m2 of FCSWs.

Results:

Mean age of the FCSWs was 21.1 years with a range of 14 to 55 years. Vast majority of FCSWs were illiterate (65.8%), widowed/separated/abandoned (44.6%) followed by 43.5% married. Prevalence of CED (<18.5 kg/m2) and overweight/obesity (≥25) was 22.8% and 16.3%, respectively. CED rate was almost doubled among FBSWs than HBSWs (P < .001). From the fitted MNLR model, variables like being HBSWs [odds ratio (OR) = .518], no mass media exposure (OR = 2.29) are found to be significant (P < .05) in the model of normal BMI verses CED. Similarly, being HBSWs (OR = 2.2), <26 years age (OR = .418), one-time coital frequency with normal clients (OR = .412), 1 to 7 days monthly absent (OR = .381), no alcohol consumption (OR = .149), drug habit (cannabis) (OR = .441), monthly income ≤7000 BDT (OR = .487) are found to be significant in the model of normal BMI verses overweight/obesity.

Conclusion:

FCSWs face double burden of malnutrition. Older age, higher income, being hotel-based FCSW, frequency of coitus, monthly abstinence from sex work, regular alcohol consumption and taking no drug are influential factors for overweight/obesity while being floating FCSW and having no mass media items (TV/Radio) are important determinants of CED.
Accreditation 101: Develop, Assess, and Report Program Goals
Authors: Snyder Jennifer A. , Quincy Brenda
Published: November 2020

The aim of this article is to highlight the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) accreditation requirements for PA program goals, describe methods for writing effective goals, provide examples and analysis of hypothetical goals, and encourage the use of effective reporting strategies. Programs are encouraged to use one of 3 mnemonic conventions with each providing a useful framework for identifying key elements of goals: FAST, SMART, and Objectives and Key Results. These 3 acronyms are easy to remember and will yield goals that are consistent with the requirements of ARC-PA.
In-vitro evaluation of commonly used beverages on tensile strength of different suture materials used in dental surgeries
Authors: Abullais Shahabe Saquib , Alqahtani Nabeeh Abdullah , Alkhulban Raed Mofarh , Alamer Sarah Hassan , Khan Abdul Ahad , Pimple Sandeep
Published: November 2020

Sutures are used for the approximation of incised flaps, assistance in primary healing, and hemorrhage control. In oral and periodontal surgery, the appropriate selection of suture material is vital for favorable healing.

The aim of the present in-vitro experiment was to evaluate the tensile strengths of 4 different types of suture materials (silk, polygalactine 910, polypropylene, chromic catgut) by simulating potential short-term intraoral exposure to various beverages (saliva, Arabic coffee, tea, cola).

A total of 280 suture specimens were prepared, out of which 10 specimens from each group were selected for pre-immersion testing. Remaining suture specimens were immersed in 4 different thermostatically controlled media (1 control [artificial saliva], 3 tests [Cola drink, Arabic coffee, Tea]). Tensile strength was measured at pre-immersion, 3, 7, and 14 days using a universal tensile testing machine. The maximum load required to break the suture material was recorded in Newton.

At day 3, tea caused significant reduction in tensile strength of silk and cola caused significant reduction in tensile strengths of polygalactine 910 and chromic catgut. Whereas, at day 7, silk and polypropylene retained their tensile strengths better than others.

The authors recommend precaution in the use of these beverages in the first postoperative week, to avoid adverse effect on the mechanical strength of sutures. When exposure to these beverages are anticipated, it is better to use polypropylene sutures that resists rapid fall in tensile strengths in the early postoperative period.
Analysis of Pediatric Oncology Nursing Research in Mainland China, 2008–2018
Authors: Luo Yuan-hui , Yin Shu-hui , Xu Jing , Challinor Julia
Published: November 2020

Background

Up-to-date research from low- and middle-income countries is needed to inform local pediatric cancer nursing care and share best practices from these settings. Access to all current Chinese-language publications on pediatric oncology nursing research is limited because of a language barrier.

Objective

The aim of this study was to document the volume, type of research study, and yearly and geographical distribution of published pediatric oncology nursing research in Mainland China and evaluate their content and quality.

Methods

A systematic search was performed for published pediatric oncology research conducted by nurses in Mainland China (2008–2018), using 3 English databases and 3 Chinese databases. Included articles were evaluated using the Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal for strength and quality of evidence.

Results

A total of 133 articles were included: 106 in Chinese and 27 in English. Most studies showed level III evidence (88/133) and were rated as good quality (81/133). The most frequently researched topics were psychosocial care, clinical nursing practice, and psychometric testing, which accounted for 63.2% of all publications.

Conclusions

Progress in pediatric oncology nursing research capacity among Mainland China is promising. To gain higher-quality evidence and make existing evidence transferable for nursing practice, optimization of specific research topics is still needed.

Implications for Practice

In Mainland China, developing interventions to address the symptoms of children with cancer and caregivers’ psychosocial issues based on local nursing research should be prioritized. Some synthesized findings of this review may serve as guidance for the future of pediatric oncology nursing science in similar settings.
Rectus Fascia Versus Fascia Lata for Autologous Fascial Pubovaginal Sling: A Single-Center Comparison of Perioperative and Functional Outcomes
Authors: Peng Michelle , Sussman Rachael D. , Escobar Christina , Palmerola Ricardo , Pape Dominique M. , Smilen Scott S. , Rosenblum Nirit , Brucker Benjamin M. , Peyronnet Benoit , Nitti Victor W.
Published: November 2020

(Abstracted from Female Pelvic Med Reconstr Surg 2020;26:493–497)

Worldwide, there has been a decline in the use of synthetic slings due to mesh-related complications and litigation. This has led to increased interest in native tissue prolapse repair using pubovaginal slings.
Effect of a Patient-Centered Decision Support Tool on Rates of Trial of Labor After Previous Cesarean Delivery: The PROCEED Randomized Clinical Trial
Authors: Kuppermann Miriam , Kaimal Anjali J. , Blat Cinthia , Gonzalez Juan , Thiet Mari-Paule , Bermingham Yamilee , Altshuler Anna L. , Bryant Allison S. , Bacchetti Peter , Grobman William A.
Published: November 2020

(Abstracted from JAMA 2020;323:2151–2159)

Reducing cesarean delivery rates is an important health goal, given its association with maternal morbidity: as cesarean delivery rates increase, so does maternal morbidity. Contributing to the rising rate of cesarean delivery is the less frequent use of the trial-of-labor approach among pregnant women after previous cesarean delivery.
Meta-analysis on Serial Intervals and Reproductive Rates for SARS-CoV-2
Authors: Hussein Mohammad , Toraih Eman , Elshazli Rami , Fawzy Manal , Houghton August , Tatum Danielle , Killackey Mary , Kandil Emad , Duchesne Juan
Published: November 2020

Objective:

The aim of this study was to systematically review and meta-analyze all literature reporting the basic reproductive number (R0), effective reproductive number (Re or Rt), and the serial interval (SI) values of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection.

Summary Background Data:

To assess the rate at which an infectious disease can spread in a population, the 2 measures, R0 and Re or Rt, are widely used. One of the parameters which influence the calculations is the SI, the period between symptom onset in an infector and an infectee.

Methods:

Web of Science, PubMed, Scopus, and Science Direct searching up to May 10, 2020, was performed. A continuous random-effect model was applied using the DerSimonian-Laird (inverse variance) method. Heterogeneity and publication bias were assessed.

Results:

A total of 39 articles met the eligibility criteria. Our results demonstrated the mean SI was 5.45 days, with the 95% confidence interval (CI) of 4.23 to 6.66. Pooled estimates for reproduction rates was 3.14 (95% CI: 2.69–3.59) for R0 and 3.18 (95% CI: 2.89–3.47) for Rt. Subgroup analysis by geographical region and date of publication revealed variations over both time and geography in calculated R0 and Rt values. As time has progressed, predicted R0 and Rt values had decreased globally.

Conclusions:

The study findings indicate that one SARS-CoV-2-infected person is likely to infect 3 persons, supporting that COVID-19 is a highly contagious disease. As an essential objective metrics implied in risk assessment for this emerging pandemic, monitoring R0 and Re is necessary to indicate the effectiveness or failures of mitigation efforts.
Preoperative Hepatic and Regional Arterial Chemotherapy in Patients Who Underwent Curative Colorectal Cancer Resection
Authors: Zhu Dexiang , Xia Jianguo , Gu Yan , Lin Jianjiang , Ding Kefeng , Zhou Bo , Liang Fei , Liu Tianshu , Qin Chunzhi , Wei Ye , Ren Li , Zhong Yunshi , Wang Jianhua , Yan Zhiping , Cheng Jiemin , Chen Jingwen , Chang Wenju , Zhan Shaokang , Ding Yongbin , Huo Haizhong , Liu Fanlong , Sun Junhui , Qin Xinyu , Xu Jianmin
Published: November 2020

Objective:

To evaluate the effects of the addition of preoperative hepatic and regional arterial chemotherapy (PHRAC) on prognosis of stage II and III colorectal cancer (CRC) in a multicenter setting.

Summary of Background Data:

Our previous single-center pilot trial suggested that PHRAC in combination with surgical resection could reduce the occurrence of liver metastasis (LM) and improve survival in CRC patients.

Methods:

A prospective multi-center randomized controlled trial was conducted from December 2008 to December 2012 at 5 hospitals in China. Eligible patients with clinical stage II or III CRC who underwent curative resection were randomized to receive PHRAC plus adjuvant therapy (PHRAC arm) or adjuvant therapy alone (control arm). The primary endpoint was DFS. Secondary endpoints were cumulative LM rates, overall survival (OS), and safety (NCT00643877).

Results:

A total of 688 patients from 5 centers in China were randomly assigned (1:1) to each arm. The five-year DFS rate was 77% in the PHRAC arm and 65% in the control arm (HR = 0.61, 95% CI 0.46–0.81; P = 0.001). The 5-year LM rates were 7% and 16% in the PHRAC and control arms, respectively (HR = 0.37, 95% CI 0.22–0.63; P < 0.001). The 5-year OS rate was 84% in the PHRAC arm and 76% in the control arm (HR = 0.61, 95% CI 0.43–0.86; P = 0.005). There were no significant differences regarding treatment related morbidity or mortality between the two arms.

Conclusions:

The addition of PHRAC could improve DFS in patients with stage II and III CRC. It reduced the incidence of LM and improved OS without compromising patient safety.

Trial Registration:

ClinicalTrials.gov identifier: NCT00643877.
Distinct Genomic Profiles are Associated With Conversion to Resection and Survival in Patients With Initially Unresectable Colorectal Liver Metastases Treated With Systemic and Hepatic Artery Chemotherapy
Authors: Datta Jashodeep , Narayan Raja R. , Goldman Debra A. , Chatila Walid K. , Gonen Mithat , Strong James , Balachandran Vinod P. , Drebin Jeffrey A. , Kingham T. Peter , Jarnagin William R. , Schultz Nikolaus , Kemeny Nancy E. , D’Angelica Michael I.
Published: November 2020

Objective:

To examine genomic correlates of conversion to resection (CTR and overall survival (OS) in patients with initially unresectable colorectal liver metastasis (IU-CRLM) treated with combination systemic and hepatic artery infusion (HAI) chemotherapy.

Background:

In patients presenting with IU-CRLM, combination systemic and HAI chemotherapy enables CTR with associated long-term OS in a subset of patients. Genomic correlates of CTR and OS in IU-CRLM have not been previously explored.

Methods:

Specimens from IU-CRLM patients receiving systemic/HAI chemotherapy (2003–2017) were submitted for next-generation sequencing. Fisher Exact test assessed associations with CTR, and Kaplan-Meier/Cox methods assessed associations with OS from HAI initiation.

Results:

Of 128 IU-CRLM patients, 51 (40%) underwent CTR at median 6 months (range: 3–35) from HAI initiation. CTR and persistently unresectable cohorts differed significantly in preoperative systemic chemotherapy exposure, node-positive primary status, and size of largest liver metastasis. Median and 5-year OS was 66 months and 51%. CTR was associated with prolonged survival (time-dependent HR 0.23,95% CI: 0.12–0.46, P < 0.001). The most frequently altered genes were APC (81%), TP53 (77%), and KRAS (37%). Oncogenic mutations in SOX9 and BRAF were associated with CTR. BRAF mutations, any RAS pathway alterations, and co-altered RAS/RAF-TP53 mutations were

associated with worse survival. Classification and regression tree analysis defined prognostically relevant clusters of genomic risk to reveal co-altered RAS/RAF-TP53 as the highest risk subgroup. Co-altered RAS/RAF-TP53 remained independently associated with worse survival (HR 2.52, 95% CI: 1.37–4.64, P = 0.003) after controlling for CTR, number of liver metastases, and preoperative extrahepatic disease.

Conclusions:

Distinct genomic profiles are associated with CTR and survival in patients with IU-CRLM treated with HAI/systemic chemotherapy. Presence of SOX9, BRAF, and co-altered RAS/RAF-TP53 mutations are promising biomarkers that, when validated in larger datasets, may impact treatment of IU-CRLM patients.
Variation in Risk-standardized Rates and Causes of Unplanned Hospital Visits Within 7 Days of Hospital Outpatient Surgery
Authors: Desai Mayur M. , Zogg Cheryl K. , Ranasinghe Isuru , Parzynski Craig S. , Lin Zhenqiu , Gorbaty Marianna , Merrill Angela , Krumholz Harlan M. , Drye Elizabeth E.
Published: November 2020

Objectives:

The objectives of this study were to compare risk-standardized hospital visit ratios of the predicted to expected number of unplanned hospital visits within 7 days of same-day surgeries performed at US hospital outpatient departments (HOPDs) and to describe the causes of hospital visits.

Summary of Background Data:

More than half of procedures in the US are performed in outpatient settings, yet little is known about facility-level variation in short-term safety outcomes.

Methods:

The study cohort included 1,135,441 outpatient surgeries performed at 4058 hospitals between October 1, 2015 and September 30, 2016 among Medicare Fee-for-Service beneficiaries aged ≥65 years. Hospital-level, risk-standardized measure scores of unplanned hospital visits (emergency department visits, observation stays, and unplanned inpatient admissions) within 7 days of hospital outpatient surgery were calculated using hierarchical logistic regression modeling that adjusted for age, clinical comorbidities, and surgical procedural complexity.

Results:

Overall, 7.8% of hospital outpatient surgeries were followed by an unplanned hospital visit within 7 days. Many of the leading reasons for unplanned visits were for potentially preventable conditions, such as urinary retention, infection, and pain. We found considerable variation in the risk-standardized ratio score across hospitals. The 203 best-performing HOPDs, at or below the 5th percentile, had at least 22% fewer unplanned hospital visits than expected, whereas the 202 worst-performing HOPDs, at or above the 95th percentile, had at least 29% more post-surgical visits than expected, given their case and surgical procedure mix.

Conclusions:

Many patients experience an unplanned hospital visit within 7 days of hospital outpatient surgery, often for potentially preventable reasons. The observed variation in performance across hospitals suggests opportunities for quality improvement.
Implementation of Critical Care Response Teams in Ontario
Authors: Sapisochin Gonzalo , Muaddi Hala , Baxter Nancy N. , Stukel Therese A. , Lawless Bernard , Urbach David R.
Published: November 2020

Objective:

To evaluate whether introduction of CCRTs reduced mortality rates among patients who developed a postoperative complication, also referred to as FTR.

Background:

CCRTs were introduced to improve patients’ postoperative outcomes. Its effect on FTR continues to be actively investigated.

Methods:

We conducted a population-based retrospective cohort study using administrative data from Ontario, Canada. We identified 810,279 patients admitted to hospital for major surgical procedures between January 2004 and December 2014, with a washout period consisting of the 9 months before and after the implementation of CCRTs in January 2007. Difference-in-differences analysis among patients who developed a postoperative complication (n = 148,882) was used to estimate the association between CCRT implementation and FTR before and after CCRT implementation in hospitals that did – versus did not – implement CCRT during the study period.

Results:

A total of 810,279 patients were included, of whom 148,882 (18.4%) developed a postoperative surgical complication. Among patients who developed a postoperative complication, the overall proportion of FTR was 9.2% (n = 13,659). Among patients in hospitals that introduced CCRT, the RR of FTR was 0.84, [95% confidence interval (CI) 0.78–0.90] after implementation of CCRT, while over the same time period, the RR was 0.85 (95% CI 0.80–0.91) in hospitals that did not implement CCRT. The RR ratio (difference-indifferences) was 0.99 (95% CI 0.89–1.09). Among patients undergoing orthopedic surgery, the RR ratio was 0.84 (95% CI 0.75–0.95).

Conclusion:

Although implementation of CCRTs in hospitals in Ontario, Canada, did not reduce FTR among all surgical patients having surgery, CCRTs may reduce the risk of FTR among patients having orthopedic surgery.
Alzheimer’s Dementia After Exposure to Anesthesia and Surgery in the Elderly
Authors: Silber Jeffrey H. , Rosenbaum Paul R. , Reiter Joseph G. , Hill Alexander S. , Jain Siddharth , Wolk David A. , Small Dylan. , Hashemi Sean , Niknam Bijan A. , Neuman Mark D. , Fleisher Lee A. , Eckenhoff Roderic
Published: November 2020

Objective:

The aim of this study was to determine whether surgery and anesthesia in the elderly may promote Alzheimer disease and related dementias (ADRD).

Background:

There is a substantial conflicting literature concerning the hypothesis that surgery and anesthesia promotes ADRD. Much of the literature is confounded by indications for surgery or has small sample size. This study examines elderly patients with appendicitis, a common condition that strikes mostly at random after controlling for some known associations.

Methods:

A matched natural experiment of patients undergoing appendectomy for appendicitis versus control patients without appendicitis using Medicare data from 2002 to 2017, examining 54,996 patients without previous diagnoses of ADRD, cognitive impairment, or neurological degeneration, who developed appendicitis between ages 68 through 77 years and underwent an appendectomy (the ‘‘Appendectomy’’ treated group), matching them 5:1 to 274,980 controls, examining the subsequent hazard for developing ADRD.

Results:

The hazard ratio (HR) for developing ADRD or death was lower in the Appendectomy group than controls: HR = 0.96 [95% confidence interval (CI) 0.94–0.98], P < 0.0001, (28.2% in Appendectomy vs 29.1% in controls, at 7.5 years). The HR for death was 0.97 (95% CI 0.95–0.99), P = 0.002, (22.7% vs 23.1% at 7.5 years). The HR for developing ADRD alone was 0.89 (95% CI 0.86–0.92), P < 0.0001, (7.6% in Appendectomy vs 8.6% in controls, at 7.5 years). No subgroup analyses found significantly elevated rates of ADRD in the Appendectomy group.

Conclusion:

In this natural experiment involving 329,976 elderly patients, exposure to appendectomy surgery and anesthesia did not increase the subsequent rate of ADRD.
Variation in Surgical Spending Among the Highest Quality Hospitals for Cancer Surgery
Authors: Diaz Adrian , Nuliyalu Usha , Dimick Justin B. , Nathan Hari
Published: November 2020

Objective:

This study evaluates the variation in spending by the highest-quality hospitals performing complex cancer surgery in the United States.

Summary Background Data:

As mortality rates for high-risk cancer surgery have improved, increased attention has focused on other elements of quality, such as complications. However, high-value surgical care requires both high-quality care and cost savings. Therefore, understanding any residual cost variation among high-quality hospitals is essential to better direct efforts to achieve efficient, high-value care.

Methods:

Medicare beneficiaries age 65 to 99 who underwent surgery for pancreas, esophageal, lung, rectal, and colon cancer from 2014 to 2016 were identified. The highest-quality hospitals were identified as those in the quintile with the lowest risk- and reliability-adjusted serious complication rates for each operation. Within this cohort of high-quality hospitals, 30-day total episode, index hospitalization, physician, postacute care, and readmis-sion spending were analyzed. Logistic regression models were utilized to estimate the probability of postoperative outcomes and post-discharge resource utilization.

Results:

A total of 43,007 Medicare patients underwent either pancreas, esophageal, lung, rectal, or colon resection for cancer at a hospital within the highest-quality quintile. Among the highest quality hospitals, total episode spending ranged from $18,712 for colectomy to $38,054 for esophagectomy. Spending between the lowest- and highest spending hospitals varied from $1207 [confidence intervals (CI95%) $1195–$1220] or 6.6% of total episode spending in the lowest tertile for colectomy to $5706 (CI95% $5,506–$5906) or 16.1% of total episode spending in the lowest tertile for esophagectomy. The largest component of variation was from postacute care spending followed by readmission. For all operations, the risk-adjusted rate of postacute care facility utilization was lower among the lowest spending hospitals compared to the highest spending hospitals. For example, for pancreas the lowest-spending hospitals on average discharged patients to a postacute care facility at a rate of 18,6% (CI95% 16.2–20.9) compared to 31.0% (CI95% 28.2–33.9) in the highest-spending hospitals. In all operations, the risk-adjusted readmission rate was lower among the lowest-spending hospitals compared to the highest-spending hospitals. For instance, within the esophagus cohort, the lowest-spending hospitals had an average risk-adjusted readmission rate of 17.3% compared to 29.4% in the highest spending hospitals (P < .001).

Conclusions and Relevance:

Even among the highest-quality hospitals, significant cost variation persists among cancer operations. Postacute care variation, rather than residual variation in complication rates, explains the majority of this variation and represents an immediately actionable target for increased cost-efficiency.
Enhanced Recovery Protocols Reduce Mortality Across Eight Surgical Specialties at Academic and University-affiliated Community Hospitals
Authors: Esper Stephen A. , Holder-Murray Jennifer , Subramaniam Kathirvel , Boisen Michael , Kenkre Tanya S. , Meister Katie , Foos Steve , Wong Hesper , Howard-Quijano Kimberly , Mahajan Aman
Published: November 2020

Objective:

To determine if implementation of a simplified ERP across multiple surgical specialties in different hospitals is associated with improved short and long-term mortality. Secondary aims were to examine ERP effect on length of stay, 30-day readmission, discharge disposition, and complications.

Summary Background Data:

Enhanced recovery after surgery and various derivative ERPs have been successfully implemented. These protocols typically include elaborate sets of multimodal and multidisciplinary approaches, which can make implementation challenging or are variable across different specialties. Few studies have shown if a simplified version of ERP implemented across multiple surgical specialties can improve clinical outcomes.

Methods:

A simplified ERP with 7 key domains (minimally invasive surgical approach when feasible, pre-/intra-operative multimodal analgesia, postoperative multimodal analgesia, postoperative nausea and vomiting prophylaxis, early diet advancement, early ambulation, and early removal of urinary catheter) was implemented in 5 academic and community hospitals within a single health system. Patients who underwent nonemergent, major orthopedic or abdominal surgery including hip/knee replacement, hepatobiliary, colorectal, gynecology oncology, bariatric, general, and urological surgery were included. Propensity-matched, retrospective case-control analysis was performed on all eligible surgical patients between 2014 and 2017 after ERP implementation or in the 12 months preceding ERP implementation (control population).

Results:

A total of 9492 patients (5185 ERP and 4307 controls) underwent ERP eligible surgery during the study period. Three thousand three hundred sixty-seven ERP patients were matched by surgical specialty and hospital site to control non-ERP patients. Short and long-term mortality was improved in ERP patients: 30 day: ERP 0.2% versus control 0.6% (P = 0.002); 1-year: ERP 3.9% versus control 5.1% (P < 0.0001); 2-year: ERP 6.2% versus control 9.0% (P < 0.0001). Length of stay was significantly lower in ERP patients (ERP: 3.9 ± 3.8 days; control: 4.8 ± 5.0 days, P < 0.0001). ERP patients were also less likely to be discharged to a facility (ERP: 11.3%; control: 14.8%, P < 0.0001). There was no significant difference for 30-day readmission. All complications except venous thromboembolism were significantly reduced in the ERP population (P < 0.02).

Conclusions:

A simplified ERP can uniformly be implemented across multiple surgical specialties and hospital types. ERPs improve short and long-term mortality, clinical outcomes, length of stay, and discharge disposition to home.
Distinct immunologic endotypes are associated with clinical trajectory after severe blunt trauma and hemorrhagic shock
Authors: Brakenridge Scott C. , Wang Zhongkai , Cox Michael , Raymond Steven , Hawkins Russell , Darden Dijoia , Ghita Gabriela , Brumback Babette , Cuschieri Joseph , Maier Ronald V. , Moore Frederick A. , Mohr Alicia M. , Efron Philip A. , Moldawer Lyle L.
Published: November 2020

BACKGROUND

The genomic/cytokine “storm” after severe trauma is well described. However, the differing composition, magnitude and resolution of this response, and its relationship to clinical outcomes remain unclear.

METHODS

This is a secondary analysis of a prospective longitudinal cohort study of severely injured trauma patients in hemorrhagic shock. Peripheral blood sampling was performed at 0.5, 1, 4, 7, 14, and 28 days after injury for measurement of circulating immune biomarkers. K-means clustering using overall mean and trajectory slope of selected immunologic biomarkers were used to identify distinct temporal immunologic endotypes. Endotypes were compared with known clinical trajectories defined as early death (<14 days), chronic critical illness (CCI) (ICU length of stay of ≥14 days with persistent organ dysfunction), and rapid recovery (RAP) (ICU length of stay of <14 days with organ recovery).

RESULTS

The cohort included 102 subjects enrolled across 2 level 1 trauma centers. We identified three distinct immunologic endotypes (iA, iB, and iC), each with unique associations to clinical trajectory. Endotype iA (n = 47) exhibited a moderate initial proinflammatory response followed by a return to immunologic homeostasis, with a primary clinical trajectory of RAP (n = 44, 93.6%). Endotype iB (n = 44) exhibited an early hyperinflammatory response with persistent inflammation and immunosuppression, with the highest incidence of CCI (n = 10, 22.7%). Endotype iC (n = 11) exhibited a similar hyperinflammatory response, but with rapid return to immunologic homeostasis and a predominant trajectory of RAP (n = 9, 81.8%). Patients with endotype iB had the highest severity/duration of organ dysfunction and highest incidence of nosocomial infections (50%, p = 0.001), and endotype iB was the predominant endotype of patients who developed CCI (10 of 13 patients, 76.9%; p = 0.002).

CONCLUSION

We identified three distinct immunologic endotypes after severe injury differing the magnitude and duration of the early response. The clinical trajectory of CCI is characterized by an endotype (iB) defined by persistent alteration in inflammation/immunosuppression and is associated with poor clinical outcomes.

LEVEL OF EVIDENCE

Prognostic, level III.
Two independent introductions of SARS-CoV-2 into the Iranian outbreak
Authors: Fattahi Zohreh , Mohseni Marzieh , Jalalvand Khadijeh , Moghadam Fatemeh Aghakhani , Ghaziasadi Azam , Keshavarzi Fatemeh , Yavarian Jila , Jafarpour Ali , Mortazavi Seyedeh elham , Ghodratpour Fatemeh , Behravan Hanieh , Khazeni Mohammad , Momeni Seyed Amir , Jahanzad Issa , Moradi Abdolvahab , Tabarraei Alijan , Azimi Sadegh Ali , Kord Ebrahim , Hashemi-Shahri Seyed Mohammad , Azaran Azarakhsh , Yousefi Farid , Mokhames Zakiye , Soleimani Alireza , Ghafari Shokouh , Ziaee Masood , Habibzadeh Shahram , Jeddi Farhad , Hadadi Azar , Abdollahi Alireza , Kaydani Gholam Abbas , Soltani Saber , Mokhtari-Azad Talat , Najafipour Reza , Malekzadeh Reza , Kahrizi Kimia , Jazayeri Seyed Mohammad , Najmabadi Hossein
Published: November 2020

The SARS-CoV-2 virus has been rapidly spreading globally since December 2019, triggering a pandemic, soon after its emergence, with now more than one million deaths around the world. While Iran was among the first countries confronted with rapid spread of virus in February, no real-time SARS-CoV-2 whole-genome tracking is performed in the country.

To address this issue, we provided 50 whole-genome sequences of viral isolates ascertained from different geographical locations in Iran during March-July 2020. The corresponding analysis on origins, transmission dynamics and genetic diversity, represented at least two introductions of the virus into the country, constructing two major clusters defined as B.4 and B.1*. The first entry of the virus occurred around 26 December 2019, as suggested by the time to the most recent common ancestor, followed by a rapid community transmission, led to dominancy of B.4 lineage in early epidemic till the end of June. Gradually, reduction in dominancy of B.4 occurred possibly as a result of other entries of the virus, followed by surge of B.1.* lineages, as of mid-May.

Remarkably, variation tracking of the virus indicated the increase in frequency of D614G mutation, along with B.1* lineages, which showed continuity till October 2020.

According to possible role of D614G in increased infectivity and transmission of the virus, and considering the current high prevalence of the disease, dominancy of this lineage may push the country into a critical health situation. Therefore, current data warns for considering stronger prohibition strategies preventing the incidence of larger crisis in future.
Divergence in a stress regulatory network underlies differential growth control
Authors: Sun Ying , Oh Dong-Ha , Duan Lina , Ramachandran Prashanth , Ramirez Andrea , Bartlett Anna , Dassanayake Maheshi , Dinneny José R.
Published: November 2020

The phytohormone abscisic acid (ABA) is a central regulator of acclimation during environmental stress. While some plants exhibit tremendous stress resilience, it has been unclear whether differences in ABA response underlie such adaptations. Here we establish a cross-species gene regulatory network (GRN) for ABA to identify broadly conserved, core components of the ABA signaling network and peripheral pathways exhibiting species-specific connectivity. Genes that are broadly conserved in the network share promoter architecture and patterns of gene expression. Networks associated with growth hormones exhibited highly divergent wiring of their ABA network leading to changes in the physiological outcome of signaling. Together our study provides a model for understanding how GRN subcircuits deploy different growth regulatory states across ecologically diverse species.

One Sentence Summary

Comparative studies reveal core and peripheral stress-mediated gene networks driving divergent growth control in plants.
Massive occurrence of benthic plastic debris at the abyssal seafloor beneath the Kuroshio Extension, the North West Pacific
Authors: Nakajima Ryota , Tsuchiya Masashi , Yabuki Akinori , Masuda Shuhei , Kitahashi Tomo , Nagano Yuriko , Ikuta Tetsuro , Isobe Noriyuki , Nakata Haruhiko , Ritchie Heather , Oguri Kazumasa , Osafune Satoshi , Kawamura Kiichiro , Suzukawa Maki , Yamauchi Takuya , Iijima Koichi , Yoshida Takao , Chiba Sanae , Fujikura Katsunori
Published: November 2020

The deep-sea is considered to be an ultimate sink for marine plastic debris. The abyssal (3500-6500 m) covers the bulk of the deep ocean floor yet little is known about the extent of plastic debris on the abyssal seafloor. We undertook a quantitative assessment of debris presents on the abyssal seafloor (5700-5800 m depth) beneath the Kuroshio Extension current system in the Northwest Pacific, which is one of the major transit points for massive amounts of debris sourced from Asia that are entering the North Pacific Ocean. The dominant type of debris was single-use plastics-mainly bags and food packaging. The density of plastic debris (average 4561 items km−2) in the abyssal zone was the highest recorded for an abyssal plain, suggesting that the deep-sea basin of the Northwest Pacific is a significant reservoir of plastic debris.
Entropy, complexity, and maturity in children’s neural responses during naturalistic mathematics learning
Authors: Amalric Marie , Cantlon Jessica F.
Published: November 2020

Abstract

A major goal of human neuroscience is to understand how the brain functions in the real world, and to measure neural processes under naturalistic conditions that are more ecologically valid than traditional laboratory tasks. A critical step toward this goal is understanding how neural activity during real world naturalistic tasks relates to neural activity in more traditional laboratory tasks. In the present study, we used intersubject correlations to locate reliable stimulus-driven neural processes among children and adults in naturalistic and laboratory versions of a mathematics task that shared the same content. We show that relative to a control condition with grammatical content, naturalistic and simplified mathematics tasks evoked overlapping activation within brain regions previously associated with math semantics. We further examined the temporal properties of children’s neural responses during the naturalistic and laboratory tasks to determine whether temporal patterns of neural activity change over development, or dissociate based on semantic or task content. We introduce a rather novel measure, not yet used in fMRI studies of child learning: neural multiscale entropy. In addition to showing new evidence of naturalistic mathematics processing in the developing brain, we show that neural maturity and neural entropy are two independent but complementary markers of functional brain development. We discuss the implications of these results for the development of neural complexity in children.
Inferring parameters of cancer evolution from sequencing and clinical data
Authors: Lee Nathan , Bozic Ivana
Published: November 2020

As a cancer develops, its cells accrue new mutations, resulting in a heterogeneous, complex genomic profile. We make use of this heterogeneity to derive simple, analytic estimates of parameters driving carcinogenesis and reconstruct the timeline of selective events following initiation of an individual cancer. Using stochastic computer simulations of cancer growth, we show that we can accurately estimate mutation rate, time before and after a driver event occurred, and growth rates of both initiated cancer cells and subsequently appearing subclones. We demonstrate that in order to obtain accurate estimates of mutation rate and timing of events, observed mutation counts should be corrected to account for clonal mutations that occurred after the founding of the tumor, as well as sequencing coverage. We apply our methodology to reconstruct the individual evolutionary histories of chronic lymphocytic leukemia patients, finding that the parental leukemic clone typically appears within the first fifteen years of life.