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Purpose: Patients want personalized information before surgery; most do not receive personalized risk estimates. Inadequate information contributes to poor experience and medicolegal complaints. We hypothesized that exposure to the Personalized Risk Evaluation and Decision Making in Preoperative Clinical Assessment (PREDICT) app, a personalized risk communication tool, would improve patient knowledge and satisfaction after anesthesiology consultations compared with standard care. Methods: We conducted a prospective clinical study (before-after design) and used patient-reported data to calculate personalized risks of morbidity, mortality, and expected length of stay using a locally calibrated National Surgical Quality Improvement Program risk calculator embedded in the PREDICT app. In the standard care (before) phase, the application’s materials and output were not available to participants; in the PREDICT app (after) phase, personalized risks were communicated. Our primary outcome was knowledge score after the anesthesiology consultation. Secondary outcomes included patient satisfaction, anxiety, feasibility, and acceptability. Results: We included 183 participants (90 before; 93 after). Compared with standard care phase, the PREDICT app phase had higher post-consultation: knowledge of risks (14.3% higher; 95% confidence interval [CI], 6.5 to 22.0; P< 0.001) and satisfaction (0.8 points; 95% CI, 0.1 to 1.4; P= 0.03). Anxiety was unchanged (− 1.9%; 95% CI, − 4.2 to 0.5; P= 0.13). Acceptability was high for patients and anesthesiologists. Conclusion: Exposure to a patient-facing, personalized risk communication app improved knowledge of personalized risk and increased satisfaction for adults before elective inpatient surgery. Trial registration: www.clinicaltrials.gov(NCT03422133); registered 5 February 2018.

Daily burn wound care for nonintubated patients involves administration of intravenous analgesic and sedation agents. Vital signs and oxygen saturation monitoring alone can result in late signs of oversedation and ineffective breathing. End-tidal carbon dioxide (EtCo2) monitoring provides immediate feedback of effective breathing during procedural sedation. The purpose of this study was to describe the nurse’s sedation and analgesic therapy management of nonintubated patients during burn wound care when EtCo2was used. This IRB approved study involved observing 22 burn nurses and 4 burn technicians during burn wound care of nonintubated patients. This descriptive, observational study compared adverse breathing/airway events, pain measurements, and sedation effectiveness, before and after introducing EtCo2monitoring. Patients observed in this study were similar in age, type and size of burn, and use of recreational substances. Nurses and technicians also had similar burn experience. No statistically significant findings were found in this study; however, nurses in practice longer were found to apply oxygen sooner, which prevented decreased oxygen saturation events. When EtCo2was used, less analgesia and sedation were required to maintain patient comfort. Time required for burn wound care was reduced by 22%, and 30% less overall analgesic and sedation agent dosages were administered after the introduction of EtCo2monitoring. EtCo2was found to enhance nurses’ assessment of patients’ response to intravenous analgesia and sedation effectiveness during burn wound care for nonintubated patients. Nurses with greater experience used oxygen sooner in the procedure, and patients had fewer decreases in SpO2.

ABSTRACTThe Canadian National Vaccine Safety network (CANVAS) gathers and analyzes safety data on individuals receiving the influenza vaccine during the early stages of annual influenza vaccination campaigns with data collected via participant surveys through the Internet. We sought to examine whether it was feasible to use a mobile application (app) to facilitate AEFI reporting for the CANVAS network. To explore this, we developed a novel smartphone app, recruited participants from a hospital influenza immunization clinic and by word of mouth and instructed them to download and utilize the app. The app reminded participants to complete the CANVAS AEFI surveillance surveys (“AEFI surveys”) on day 8 and 30, a survey capturing app usability metrics at day 30 (“usability survey”) and provided a mechanism to report AEFI events spontaneously throughout the whole study period. All survey results and spontaneous reports were recorded on a privacy compliant, cloud server. A software plug-in, Lookback, was used to record the on-screen experience of the app sessions. Of the 76 participants who consented to participate, 48(63%) successfully downloaded the app and created a profile. In total, 38 unique participants completed all of the required surveillance surveys; transmitting 1104 data points (survey question responses and spontaneous reports) from 83 completed surveys, including 21 usability surveys and one spontaneous report. In total, we received information on new or worsening health conditions after receiving the influenza vaccine from 11(28%) participants. Of the usability survey responses, 86% agreedor strongly agreedthat they would prefer to use a mobile app based reporting system instead of a web-based system. The single spontaneous report received was from a participant who had also reported using the Day 8 survey. Of Lookback observable sessions, an accurate transmission proportion of 100% (n=290) was reported for data points. We demonstrated that a mobile app can be used for AEFI reporting, although download and survey completion proportions suggest potential barriers to adoption. Future studies should examine implementation of mobile reporting in a broader audience and impact on the quality of reporting of adverse events following immunization.

The article provides suggestions to parents on how they can protect their children with special needs as they engage in online spaces. Topics discussed include benefits of the Internet, types of electronic devices that are beneficial to students including iPads and tablets, and significance of quality online social engagement. It also mentions the pitfalls inherent in Internet-based communication that parents should be aware of when considering their child's role in online communities.

Pancreatoduodenectomy offers the only chance of cure for patients with periampullary cancers. This, however, is a major undertaking in most patients and is associated with a significant morbidity and mortality. A multidisciplinary approach to the workup and follow-up of patients undergoing pancreatoduodenectomy was initiated at our institution to improve the diagnosis, resection rate, mortality and morbidity. We undertook the study to assess the effect of this approach on diagnosis, resection rates and short-term outcomes such as morbidity and mortality.

Although there are now clear associations between ulcer disease and infection with Helicobacter pylori or use of nonsteroidal anti-inflammatory drugs (NSAIDs), it remains unclear how these factors affect the ability of the gastroduodenal mucosa to resist injury (ie, mucosal defense). Progress has been made in understanding the factors that regulate mucus and bicarbonate secretion in the upper gastrointestinal tract, and the influence of antiulcer drugs (eg, lansoprazole, omeprazole) on these factors. The discovery of two isoforms of the enzyme responsible for prostaglandin synthesis has resulted in a reappraisal of the role of this class of mediators in mucosal defense, and an evaluation of the theory that selective inhibitors of the inducible form of this enzyme will be “Gl safe.” The most active area of research in mucosal defense over the past year was concerned with factors influencing mucosal repair. A number of growth factors have been identified as playing key roles in the ulcer healing process. Moreover, the role of these factors in improving the quality of ulcer healing has been carefully examined.

The term mucosal defense refers to the ability of the gastroduodenal mucosa to resist injury induced by luminal irritants. Although it is becoming clear that most, if not all, peptic ulcers can be attributed to either Helicobacter pylori or nonsteroidal anti-inflammatory drugs (NSAIDs), the importance of mucosal defense remains undiminished. Most people who are infected with H. pylori never develop an ulcer. Likewise, the majority of patients who regularly consume NSAIDsdo not develop gastric or duodenal ulcers. These observations strongly suggest that differences in the mucosal defensive response determine which patients who are exposed to H. pylori or NSAIDsdevelop an ulcer. Significant progress continues to be made in understanding the contribution of various components of the mucosal defense network to resistance to injury. This includes advances in understanding the regulation of mucus and bicarbonate secretion, the factors contributing to changes in mucosal blood flow in response to luminal irritants, and the role of the mucosal immune system in preventing or, in some cases, causing mucosal injury. Advances have also been made in understanding the mechanisms by which the mucosa adapts to repeated exposure to damaging agents and through which repair of ulcerated tissue occur

The recognition that most peptic ulcer disease occurs as a consequence of either Helicobacter pyloriinfection or ingestion of nonsteroidal anti-inflammatory drugs has renewed interest in the hypothesis that ulcer disease occurs principally as a consequence of impaired mucosal defense. Studies published over the past year have advanced our understanding of the many complex interactions among the various components of mucosal defense, such as the microcirculatory response, mucus and bicarbonate secretion, and restitution. It is becoming increasingly clear that mediators such as nitric oxide, previously regarded solely as vasoactive substances, also affect the epithelium, parietal cells, and mast cells to produce effects that alter mucosal resistance to injury. Progress has also been made in understanding the influence of many mediators and growth factors on the ability of the mucosa to repair damage.

The observation that a significant proportion of patients who are infected with Helicobacter pylorior who consume nonsteroidal anti-inflammatory drugs on a regular basis do not develop gastric or duodenal ulcers suggests that differences in host responses to these agents play an important role in the pathogenesis of the gastroduodenal injury. In the past year, significant progress has been made in understanding the contribution of various components of the “mucosal defense network” to resistance to injury. For example, advances have been made in understanding the mechanisms through which epithelial cells maintain their intracellular pH near neutrality in the face of significant luminal acid loads. The importance of nitric oxide and prostaglandins in the regulation of mucosal blood flow and other components of mucosal defense is becoming more clearly understood. Advances have been made in understanding the contribution of the mucosal immune system and the mediators and cytokines it produces in the responses of the mucosa to bacterial infection or ingestion of noxious substances. The role of the sensory afferent neurons in modulating mucosal defense has been the subject of a number of studies, as has been the mechanisms underlying restitution of the gastroduodenal epithelium, factors influencing healing of ulcers, and factors contributing to the adaptation of the stomach to repeated administration of nonsteroidal anti-inflammatory drugs.

This paper reviews the major advances made during the past year in understanding the ability of the gastroduodenal mucosa to resist injury. In particular, advances have been made in our understanding of the neural pathways and chemical messengers that mediate the hyperemic response to superficial injury; the regulation of gastric and duodenal bicarbonate secretion; the importance of mucus in mucosal defense and the physical properties that contribute to this role; the endogenous enzymes that prevent or reduce oxidant-induced injury; and the contribution of growth factors, polyamines, and prostaglandins to adaptive responses to injury.

Escherichia coliK12 is a laboratory strain considered nonpathogenic. The purpose of this study was to examine the effect of E. coliK12 infection on colonic structure and function. Suckling rabbits were infected at 10 days of age with 6 × 109CFU E. coliby intragastric inoculation and were examined 4 to 5 days later. Segments of ileum and proximal and distal colon were removed for light and electron microscopy, and NaCl transport was examined in vitro under short‐circuited conditions in Ussing chambers. Infection did not cause weight loss or diarrhea. Colonic mucosa was inflamed with infiltration by polymorpho‐nuclear neutrophils mainly in the lamina propria. The proximal and distal colon exhibited reduced Na+absorption. The proximal colon also showed increased Cl‐secretion; the ileum was unaffected. Infection with E. coliK12 disrupts the epithelium and alters ion transport in the colon, probably as a result of mucosal inflammation. The changes indicate that nonpathogenic E. colihave the potential to cause intestinal disease.

Background:The effect of enterohemorrhagic Escherichia coli0157:H7 infection on intestinal morphology and solute transport was examined. Methods:New Zealand white rabbits, aged 10 days, were infected with E. colistrain EDL933 (0157:H7 containing the 60-megadalton plasmid-encoding adhesion factors VT1and VT2) and compared with controls. Small and large intestinal histology and solute transport were studied 5 days after inoculation. Ion transport in the distal colon was also examined in animals infected with different strains encoding a combination of pathogenic factors. Results:Infection with EDL933 induced diarrhea and mucosal disease in the colon, inhibited colonic Na+absorption, and stimulated of Cl−secretion, but had no impact on the small intestine. Infection with strains A7785-C3A (0157:H7, plasmid−, VT1+, VT2+) and 85–170 (0157:H7, plasmid+, VT−) induced similar transport changes to EDL933. C600/1 (E. coliK-12, plasmid+, VT1+) decreased Na+and Cl−absorption only. Conclusions:Abnormalities of colonic structure and ion transport could account for diarrhea production, but pathogenic factors other than the 60-megadalton plasmid-encoding adhesion factor and verotoxins appear to be involved in enterohemorrhagic E. coliinfection.

Background/Aims: Escherichia coli0157:H7 infection induces diarrhea, severe colitis, and colonic electrolyte transport abnormalities characterized by decreased Na absorption and Cl secretion. The aim of this study was to examine the role of the host inflammatory response in inducing distal colonic transport changes during infection with E. coli0157:H7. Methods:New Zealand white rabbits aged 10 days were infected with E. coli0157:H7 strain EDL933 (plasmid+, verotoxin 1+, verotoxin 2+). Studies were performed daily from day 1 to day 5 postinfection and compared with uninfected controls (10 days old). Distal colonic ion transport was studied in vitro under short-circuited conditions in Ussing chambers, and tissue inflammation was assessed by mucosal myeloperoxidase activities and mucosal neutrophil (polymorphonuclear neutrophil [PMN]) counts. In a second study, PMN infiltration was inhibited by an anti-CD18 (leukocyte adhesion molecule) monoclonal antibody, IB4, and histology and transport were studied on day 5 postinfection. Results:Infection with 0157:H7 induced diarrhea and inhibition of Na absorption by day 3. Cl secretion occurred on day 5, coincident with tissue infiltration with PMN. Pretreatment with IB4prevented histological damage and tissue infiltration with PMN, and it inhibited the transport abnormalities induced by infection alone. Conclusions:Infection with 0157:H7 reduces Na absorption and stimulates Cl secretion in the distal colon. Disruption of the epithelium and changes in colonic electrolyte transport during enterohemorrhagic E. coliare mediated by the host inflammatory response.

Infiltration of leucocytes into the mucosa is a hallmark feature of a number of inflammatory bowel disorders, most notably Crohn’s disease and ulcerative colitis. The interactions between circulating leucocytes and the vascular endothelium that permit leucocyte migration to a site of injury or infection are mediated via a variety of adhesion molecules. There is now ample evidence for alterations in adhesion molecule expression and function in inflammatory bowel disorders. This raises the possibility that adhesion molecules could be targets for novel therapies. Indeed, many existing anti-inflammatory drugs are capable of modulating adhesion molecule expression or function. Moreover, intensive research is under way to develop more selective and effective modulators of adhesion molecules, in the hope that they will be useful for treating various inflammatory disorders.

Escherichia coliK12 is a laboratory strain considered nonpathogenic. The purpose of this study was to examine the effect of E. coliK12 infection on colonic structure and function.

THANK YOU Just a quick note to say thank you so very much for your help ordering the Christmas present for my Dad, Danny Egg. We returned to Texas in '94, and I became a Master Gardener and I write a garden column for Lufkin Daily News. Texas Gardener has been an important part of my gardening success. [Extracted from the article]

To ensure the effectiveness of increasingly complex immunization programs in upper-middle and high-income settings, comprehensive information systems are needed to track immunization uptake at individual and population levels. The maturity of cloud systems and mobile technologies has created new possibilities for immunization information systems. In this paper, we describe a vision for the next generation of digital immunization information systems for upper-middle and high-income settings based on our experience in Canada. These systems center on the premise that the public is engaged and informed about the immunization process beyond their interaction with primary care, and that they will be a contributor and auditor of immunization data. The digital immunization system of the future will facilitate reporting of adverse events following immunization, issue digital immunization receipts, permit identification of areas of need and allow for delivery of interventions targeting these areas. Through features like immunization reminders and targeted immunization promotion campaigns, the system will reduce many of the known barriers that influence immunization rates. In light of the global COVID-19 pandemic, adaptive digital public health information systems will be required to guide the rollout and post-market surveillance of the SARS-CoV-2 vaccine.

ABSTRACTDespite the best efforts of local healthcare workers and health officials, Nunavut, a large geographical region in Northern Canada, has struggled with outbreaks of vaccine-preventable diseases (VPD). We contend that the implementation of an immunisation information system (IIS) could strengthen prevention and response efforts to this and future outbreaks of vaccine-preventable diseases. Developing an IIS in Nunavut that builds on the existing CANImmunize infrastructure would reduce the cost and complexity of developing a new IIS, and allow Nunavut to benefit from the ongoing efforts to secure data on the CANImmunize platform. Such a system would enable the identification of individuals and subpopulations at highest risk of infection based on vaccine series completion and permit the exploration of the underlying causes of outbreaks in the territory through consideration of demographic and temporal factors. Confirmed high rates of vaccination in the context of an outbreak would indicate potential issues with vaccine efficacy while low rates of vaccination would suggest that efforts should be devoted to increasing vaccine coverage. This approach could also lay the foundation for infrastructure expansion to other remote and/or Indigenous communities where geographical and accessibility issues complicate health care utilisation and monitoring, both in Canada and internationally.

Studies in the past year have clarified several aspects of gastroduodenal defense. An explanation for the mucus layer's ability to allow free passage of secreted acid while acting as a barrier to luminal acid has been suggested. Further insights have been gained into the role of surfaceactive phospholipids in defense and the regulation and actions of mucosal bicarbonate. Microcirculatory mechanisms of defense and injury, including the complex roles of nitric oxide, sensory afferent nerves, mast cells, and neutrophils, and the coupling of blood flow to acid secretion have been further elucidated. Other elements of the mucosal immune system, such as macrophages, plasma cells, and cytokines, have been found to modulate both defense and injury. Finally, progress has been made in better understanding the actions of a number of growth factors in mucosal defense and repair.

A longitudinal study of growth of southern elephant seals, Mirounga leonina, during their first foraging trip was undertaken at Macquarie Island. On average, body mass increased by 75% while foraging at sea, with individuals growing at 0.34 ± 0.12 (s.d.) kg day-1 (n = 64), and spending 182 ± 51 days (n = 64) at sea. Relatively smaller changes in body length were recorded during the same period, suggesting that growth was composed primarily of adjustments to body composition, rather than increases in gross body size. This may be in response to the functional demands of pelagic life. Body size established early in life (birth mass and departure mass) positively influenced body mass upon return from the first foraging trip. Growth rate, however, was negatively related to departure mass for females, and this is hypothesised to be related to sex differences in body composition, as well as intrasex differences in foraging skills, diving ability and food- conversion efficiency. Despite this, there was no detectable age-specific sexual dimorphism in the first year of life. Animals that were at sea longer tended to return in better body condition. Interspecific comparison suggests that southern elephant seals grow more than do northern elephant seals, Mirounga angustirostris, and this difference may be related to prey abundance and distribution.