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Ambulatory surgery centers (ASC) serve an important role for hospital systems of increasing operating capacity and offloading patient volume. When seeking to perform more complex cancer surgeries at an ASC, a systematic approach with care pathways can yield success by facilitating quick recovery for patients and reducing complication rates. End-to-end patient engagement is a key component of patient-centered care at the Josie Robertson Surgery Center and begins the moment the decision to have surgery is made and extends to the postdischarge period to track recovery. Engagement includes comprehensive education, standardization of processes, and setting clear expectations for recovery and discharge.

Minimally invasive operative techniques and enhanced recovery after surgery (ERAS) protocols have transformed clinical practice and made it possible to perform increasingly complex oncologic procedures in the ambulatory setting, with recovery at home after a single overnight stay. Capitalizing on these changes, Memorial Sloan Kettering Cancer Center's Josie Robertson Surgery Center (JRSC), a freestanding ambulatory surgery facility, was established to provide both outpatient procedures and several surgeries that had previously been performed in the inpatient setting, newly transitioned to this ambulatory extended recovery (AXR) model. However, the JRSC core mission goes beyond rapid recovery, aiming to be an innovation center with a focus on superlative patient experience and engagement, efficiency, and data-driven continuous improvement. Here, we describe the JRSC genesis, design, care model, and outcome tracking and quality improvement efforts to provide an example of successful, patient-centered surgical care for select patients undergoing relatively complex procedures in an ambulatory setting.

Acute postoperative pain affects time to opioid cessation and quality of life, and is associated with chronic pain. Effective screening tools are needed to identify patients at increased risk of experiencing more severe acute postoperative pain, and who may benefit from multimodal analgesia and early pain management referral. In this study, we develop a nomogram to preoperatively identify patients at high risk of moderate-severe pain following mastectomy.Demographic, psychosocial, and clinical variables were retrospectively assessed in 1195 consecutive patients who underwent mastectomy from January 2019 to December 2020 and had pain scores available from a post-discharge questionnaire. We examined pain severity on postoperative days 1-5, with moderate-severe pain as the outcome of interest. Multivariable logistic regression was performed to identify variables associated with moderate-severe pain in a training cohort of 956 patients. The final model was determined using the Akaike information criterion. A nomogram was constructed using this model, which also included a priori selected clinically relevant variables. Internal validation was performed in the remaining cohort of 239 patients.In the training cohort, 297 patients reported no-mild pain and 659 reported moderate-severe pain. High body mass index (p = 0.042), preoperative Distress Thermometer score ≥4 (p = 0.012), and bilateral surgery (p = 0.003) predicted moderate-severe pain. The resulting nomogram accurately predicted moderate-severe pain in the validation cohort (AUC = 0.735).This nomogram incorporates eight preoperative variables to provide a risk estimate of acute moderate-severe pain following mastectomy. Preoperative risk stratification can identify patients who may benefit from individually tailored perioperative pain management strategies and early postoperative interventions to treat pain and assist with opioid tapering.

Although pectoralis (PECS) blocks are commonly used for breast surgery, recommendations regarding the efficacy of these blocks have thus far not been developed by any professional anesthesia society. Given the potential impact of PECS blocks on analgesia after outpatient breast surgery, The Society for Ambulatory Anesthesia (SAMBA) convened a task force to develop a practice advisory on the use of this analgesic technique. In this practice advisory, we compare the efficacy of PECS blocks with systemic analgesia, local infiltration anesthesia, and paravertebral blockade. Our objectives were to advise on two clinical questions. (1) Does PECS-1 and/or -2 blockade provide more effective analgesia for breast-conserving surgery than either systemic analgesics or surgeon-provided local infiltration anesthesia? (2) Does PECS-1 and/or -2 blockade provide equivalent analgesia for mastectomy compared with a paravertebral block (PVB)? Among patients undergoing breast-conserving surgery, PECS blocks moderately reduce postoperative opioid use, prolong time to analgesic rescue, and decrease postoperative pain scores when compared with systemic analgesics. SAMBA recommends the use of a PECS-1 or -2 blockade in the absence of systemic analgesia (Strength of Recommendation A). No evidence currently exists that strongly favors the use of PECS blocks over surgeon-performed local infiltration in this surgical population. SAMBA cannot recommend PECS blocks over surgical infiltration (Strength of Recommendation C). For patients undergoing a mastectomy, a PECS block may provide an opioid-sparing effect similar to that achieved with PVB; SAMBA recommends the use of a PECS block if a patient is unable to receive a PVB (Strength of Recommendation A).

BACKGROUND: Compared to general anesthesia, regional anesthesia confers several benefits including improved pain control and decreased postoperative opioid consumption. While the benefits of peripheral nerve blocks (PNB) have been well studied, there is little epidemiological data on PNB usage in mastectomy and lumpectomy procedures. The primary objective of our study was to assess national trends of the annual proportion of PNB use in breast surgery from 2010 to 2018. We also identified factors associated with PNB use for breast surgery. METHODS: We identified lumpectomy and mastectomy surgical cases with and without PNB between 2010 and 2018 using the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR). We modeled the nonlinear association between year of procedure and PNB use with segmented mixed-effects logistic regression clustered on facility identifier. The association between PNB use and year of procedure, age, sex, American Society of Anesthesiologists Physical Status (ASA PS), facility type, facility region, weekday, and tissue expander use was also modeled using mixed-effects logistic regression. RESULTS: Of the 189,854 surgical cases from 2010 to 2018 that met criteria, 86.2% were lumpectomy cases and 13.8% were mastectomy cases. The proportion of lumpectomy cases with PNB was

In social systems ranging from ant colonies to human society, behavioural specialization—consistent individual differences in behaviour—is commonplace: individuals can specialize in the tasks they perform (division of labour (DOL)), the political behaviour they exhibit (political polarization) or the non-task behaviours they exhibit (personalities). Across these contexts, behavioural specialization often co-occurs with modular and assortative social networks, such that individuals tend to associate with others that have the same behavioural specialization. This raises the question of whether a common mechanism could drive co-emergent behavioural specialization and social network structure across contexts. To investigate this question, here we extend a model of self-organized DOL to account for social influence and interaction bias among individuals—social dynamics that have been shown to drive political polarization. We find that these same social dynamics can also drive emergent DOL by forming a feedback loop that reinforces behavioural differences between individuals, a feedback loop that is impacted by group size. Moreover, this feedback loop also results in modular and assortative social network structure, whereby individuals associate strongly with those performing the same task. Our findings suggest that DOL and political polarization—two social phenomena not typically considered together—may actually share a common social mechanism. This mechanism may result in social organization in many contexts beyond task performance and political behaviour.

Although enhanced recovery pathways were initially implemented in inpatients, their principles are relevant in the ambulatory setting. Opioid minimization and addressing pain and nausea through multimodal analgesia, regional anesthesia, and robust preoperative education programs are integral to the success of ambulatory enhanced recovery programs. Rather than measurements of length of stay as in traditional inpatient programs, the focus of enhanced recovery programs in ambulatory surgery should be on improved quality of recovery, pain management, and early ambulation.

STUDY OBJECTIVE: An increasing number of overweight and obese patients are presenting for ambulatory surgical procedures and may be at risk of complications including longer surgeries, longer length of stay (LOS), and possible increase in unanticipated return visits or hospital admissions. DESIGN: Observational study using prospectively-collected data. SETTING: Freestanding and hospital-based ambulatory surgery facilities. PATIENTS AND INTERVENTIONS: 13,957 patients underwent ambulatory cancer surgery procedures at the Josie Robertson Surgery Center (JRSC) since opening in 2016, and 4591 patients eligible for ambulatory surgery at JRSC underwent surgery at the main hospital during the same timeframe. MEASUREMENTS: We assessed whether BMI was associated with increased operative time, post-operative LOS, hospital transfer after surgery, or hospital readmission or urgent care center visits within 30 days. Using multivariable logistic regression, we assessed whether BMI was associated with decision to do surgery at JRSC controlling for age, ASA score and surgical service. MAIN RESULTS: While higher BMI was associated with a higher rate of transfer out of JRSC (p=0.014), the difference in rate was small (mean risk 0.8% for BMI 25 vs 1.3% for BMI 40, difference in risk 0.52%, 95% CI 0.05%, 1.0%). We found no evidence that higher BMI increased the risk of urgent care visits or readmissions within 30 days or outpatient LOS (p=0.7 for all). There was a statistically but not clinically significant difference in operative time for outpatient procedures (p =

Objective: To reveal the C5a receptor-mediated monocyte-selective chemoattraction of the homo-dimer of guinea pig S19 ribosomal protein (RP S19), and to study the topological relationship between the RP S19 and C5a receptor genes. Methods: cDNA cloning and nucleotide sequencing, leukocyte chemotaxis measurement, and fluorescent in situ hybridization (FISH) were performed in the guinea pig. Results: The amino acid sequence of the guinea pig RP S19 deduced from the cDNA nucleotide sequence was identical to the human protein. The dimer of a recombinant RP S19 attracted guinea pig monocytes but suppressed neutrophil chemotactic movement. Both effects were C5a receptor-mediated. In the FISH analysis, the signals denoting the guinea pig RP S19 gene and C5a receptor gene completely overlapped each other. Conclusions: The guinea pig RP S19 dimer possessed a dual ligand effect, agonistic to the monocyte C5a receptor and antagonistic to the neutrophil receptor. The RP S19 and C5a receptor genes co-localized on the same chromosome.

EZH2 overexpression occurs in various malignancies and is associated with a poor outcome. We have so far demonstrated that EZH2 downregulates the important genes such as E-cadherin and RUNX3 by increasing histone H3K27 trimethylation. However, the mechanism of EZH2 overexpression in various cancer cells remains unclear. In this study we carried out a promoter analysis of the EZH2 gene and investigated whether a survival signal that is upregulated in cancer cells is related to overexpression at the transcription level. We also explored the clinical relevance of the signaling pathway that leads to EZH2 overexpression in breast cancer and demonstrated that MEK–ERK1/2–Elk–1 pathway leads to EZH2 overexpression. The triple-negative and ERBB2-overexpressing subtypes of breast cancer are known to contain more rapidly proliferating breast cancer cells. The signaling pathway connected to EZH2 overexpression was associated with both aggressive subtypes of breast cancer. We show the significance that overexpression of histone modifier protein EZH2 in cancer cells and our study could pave the way for EZH2 inhibition to become an efficient treatment for more aggressive breast cancers.

Emergency splenectomy should be considered in the presence of life-threatening bleeding due to idiopathic thrombocytopenic purpura (ITP) when other modalities fail to produce a rise in the platelet count [2]. In theory this seems reasonable, however, in practice, neurosurgeons still lack the experience needed to perform surgery safely, especially in cases of an extremely low platelet count (

Postoperative delirium occurs frequently following major surgery, especially after hepatectomy. We hypothesized that better methods of postoperative pain control would decrease postoperative delirium. To clarify the magnitude of postoperative pain and incidence of postoperative delirium in hepatectomy patients, subjects received patient-controlled epidural analgesia (PCEA) using bupivacaine and fentanyl (Group P), or continuous epidural mepivacaine (Group E) following intraoperative epidural administration of morphine. The magnitude of postoperative pain was estimated by use of an analgesic adjuvant and delirium was classified as mild (insomnia, disturbance of sleepwake cycle), moderate (disorientation, hallucination), or severe (restlessness, confusion, agitation), based on the medical records. Analgesic adjuvant usage was less in Group P than in Group E, while the incidences of moderate and severe delirium were significantly less frequent in Group P than in Group E (35.7% versus 75.0%, and 14.3% versus 50.0% respectively). Moreover, less amount of antipsychotic drugs was given in Group P than in Group E. These results suggest that the better pain relief and patient satisfaction provided by PCEA contributed to a decrease in the incidence of delirium, because of continuous opioid administration and patient-control analgesia. We concluded that PCEA with bupivacaine and fentanyl can limit postoperative delirium following hepatectomy.

Stomachs with multiple submucosal glands keep our attention because of their high risk for having gastric carcinomas, but little is known about the relationship between submucosal glands and occurring cancers. So we investigated the structure of submucosal glands including location of proliferating cells. We labeled proliferating cells of three stomachs with cancerous lesions by circulating artificial blood through the isolated organs with bromodeoxyuridine (BrdU). Serial sections of submucosal glands were stained with hematoxylin eosin, periodic acid Schiff, Alcian blue, high iron diamine-Alcian blue, concanavalin A paradox, galactose oxidase Schiff as well as anti-BrdU immunohistochemically. Results showed that most of submucosal glands were composed of functionally matured cells and these cells made regular structure just like those of mucosal layer. Labeling index of BrdU of these submucosal glands were low (0.2%-0.7%). Two atypical glands were seen, and labeling index were 2.6% and 22.2% respectively. In conclusion, submucosal glands of the stomachs were thought to be made by moving proliferating cells from mucosal layer to submucosal layer. So we saw these submucosal glands paracancerous lesions rather than precancerous ones. But we couldn't deny the possibility to occur cancerous lesions from atypical glands in submucosal glands.

To evaluate correctly the proliferative activity of tumor cells, it is necessary to clarify not only S-phase fraction but also the growth fraction of tumor tissues. We used combined BrdU and DNA polymerase alpha (pol-alpha) immunohistochemistry to gastric biopsy specimens, and analyzed the proliferation of the neoplastic lesions of various degrees of malignancy. The results were as follows: The distribution of pol-alpha positive cells were almost the same as that of BrdU positive cells, but the percentage of pol-alpha positive cells was higher than that of BrdU positive cells irrespective of the mucosal specimens. In the adenomas, both BrdU and pol-alpha positive cells distributed generally superficially in the mucosal layer. In the well differentiated adenocarcinomas, both BrdU and pol-alpha positive cells distributed diffusely in the deeper layer of the mucosa. The ratio of the number of BrdU positive cells to that of pol-alpha positive cells, which means the S-phase fraction in the growth fraction, was higher in the tumor and that higher in the well differentiated adenocarcinomas than that of the adenomas. In conclusion, the combined BrdU and pol-alpha immunohistochemistry in gastric biopsy specimens are useful to evaluate the degree of malignancy.

Cytochrome b558 is an important constituent of the superoxide-generating system in neutrophils and B lymphocytes. In this paper, the topology of the cytochrome in human neutrophil membrane was studied using antibodies raised in rabbits against synthetic peptides corresponding to various regions in the large and small subunits of the cytochrome. The antibodies recognized the cytochrome subunits in immunoblots and the cytochrome in situ. An antibody raised against residues 150-172 in the large subunit (anti-L123) bound to intact neutrophils, indicating that this region is exposed to the outside of the cells. In contrast, antibodies raised against any of the carboxyl-terminal regions of the large and small subunits (anti-LC and anti-SC, respectively) or the amino-terminal region of the small subunit (anti-SN), bound to neutrophils only after the cells were made permeable by freezing and thawing. The region close to the carboxyl terminus of the large subunit was digested by extracellularly added papain and, as a result, an 18-kDa carboxyl-terminal fragment was detected. Thus the carboxyl-terminal region of the large subunit is cytoplasmic and/or buried in the membrane, and the region around residues 369-398 is exposed on the cell surface. In contrast to the large subunits, the small subunit in neutrophils was resistant to any of the proteinases tested, although the subunit in membrane or Triton-solubilized preparation was digestible with papain. These results indicate that the large subunit of cytochrome b558 is a transmembrane protein with at least two regions exposed on the cell surface and that the carboxyl terminus of this subunit and both termini of the small subunit are exposed to the cytoplasmic side.

Reported is the case of a 64 year old man with a hyperplastic polyp of the stomach that underwent malignant changes. The polyp had been followed up both endoscopically and histologically for 10 years. As it proved difficult to diagnose the malignant changes of the polyp through its endoscopic appearance, a part of polypectomized materials was studied by in vitro labeling of the S-phase cells with BrdU. Although the background hyperplastic mucosa somewhat preserved an irregular generative cell zone, the zonal distribution of the labeled cells were completely disturbed in the areas that underwent a malignant transformation, and labeled cells were often seen in the surface areas of the cancerous glands. It is important to study malignant changes in the hyperplastic polyps of the stomach from a cellular kinetic aspect.

So as to study the cell proliferation in a case with triple gastric cancers, we labeled an operated whole stomach with bromodeoxyuridine (BrdU) by the isolated organ perfusion system using artificial blood. Anti-BrdU immunohistochemical staining of sections from every part of the stomach was performed, and 3 separated cancerous lesions were all diagnosed as well differentiated adenocarcinomas. The labeling index (L.I.) of the cancerous lesions were found to differ from part to part. However, the L.I. tended to be higher in the superficial mucosal areas and in the cell-dense areas of the submucosa. In the almost normal fundic glands, the labeled zone was localized in the neck of the glands. The more metaplastic gastritis was advanced, the more the labeled zone shifted irregularly toward the bottom of the glands. Whenever the interstinal metaplasia was completed, the labeled zone was localized in the bottom of the glands. This method was found useful in studying the cell proliferation in the stomach without causing any harm to the human body.

Elastin preparations were isolated from human thoracic aorta, from atherosclerotic and from grossly normal regions. A relatively mild procedure was used to avoid hot alkaline extraction and autoclaving. The elastase digest of the aortic elastin was chromatographed on a Sephadex G-100 column and separated into two fractions: A (larger molecular weight) and B (smaller molecular weight). The ratio of fraction A to total aortic elastin increased with age and the development of the atherosclerosis. Amino acid and sugar analyses showed that fraction A consistently contained more polar amino acids, hexose, hexosamine and l -fucose, and less sialic acid, in comparison with fraction B. Part of the elastin preparation was incubated with human low-density lipoprotein; a considerable amount of lipid, especially cholesterol, was transferred from the lipoprotein to the elastin. Estimation of protein and cholesterol in fractions A and B of the elastase hydrolyzate of incubated elastin showed that most of the cholesterol taken up by elastin had been in fraction A. The increased proportion of fraction A in aortic elastin derived from plaque areas appeared responsible for the marked lipid-binding capacity of plaque elastin.

Recently, it has been reported that paromomycin sulfate has marked anthelmintic efficacy against tapeworm infections in man. In the present study this drug was used in the treatment of 14 cases of diphyllobothriasis latum and 1 case of taeniasis saginata. Also, the actions of paromomycin sulfate on Diphyllobothrium ditremum and D. erinacei were examined pharmacologically using Magnus apparatus and biochemical methods. The results obtained were as follows. For the treatment, a total of 50 mg/kg of paromomycin sulfate divided into 2 doses was given orally at intervals of 30 minutes. Two hours after medication, 20 g of magnesium sulfate dissolved in 200--300 ml of water was given as purgative. One or 2 worms were found in the stools of 11 cases with D. latum and 1 case with T. saginata within 24 hours after medication, but scolex was found in only 2 of them. All cases were negative for the eggs or segments in stool examinations at 1 and 3 months after treatment. Except 1 case complained mild and transient vomiting no side effects were noticed. All cases showed no abnormality in blood examination, liver function test and urinalysis. Both of the proglottids of D. ditremum and D. erinacei showed muscle relaxation in Tyrode solution containing 10(-4) g/ml of paromomycin sulfate. In D. ditremum the recovery of muscle tonus was observed within 10--15 minutes after affection of this drug, while the persistence of muscle relaxation was seen in D. erinacei. The activity of phosphoglucose isomerase was slightly inhibited by 10(-3) M paromomycin sulfate while those of hexokinase, phosphofructokinase and glucose-6-phosphate dehydrogenase were not inhibited. In phosphoenolpyruvate-succinate pathway, the activity of fumarate reductase was slightly inhibited 10(-3) M paromomycin sulfate while those of phosphoenolpyruvate carboxykinase and malate dehydrogenase were not inhibited.

In order to evaluate low serum alpha-1-antitrypsin level as a contributory factor of combined emphysema in silicotic patients, serum alpha-1-antitrypsin analysis was carried out in 80 patients with silicosis. Low serum alpha-1-antitrypsin level was found in 5 patients. Large opacities were observed roentgenologically in only 1 out of these 5 cases in contrast to 31 of the other 75 cases. Also the suggestive findings for the emphysema were showed in 4 of these 5 cases while such findings were found on their chest X-ray films in only 43 of the other 75 cases. FEV 1.0% below 50 were calculated in 3 of the 5 cases, on the contrary in 22 of the 75 cases. RV above 50% predicted value was showed by all the 5 low antitrypsin patients, in contrast to only 25 of other 74 cases. The silicotic patients with low serum alpha-1-antitrypsin concentration are most likely to have an association with a high incidence of complicated emphysema.

The sugar composition of glycoproteins isolated from sclerotic and adjacent healthy areas of 10 Japanese thoracic aortas was studied. Of the component sugars of glycoprotein, sialic acid was decreased in the presence of atherosclerotic changes of the aorta. The correlation between the total hexose content of glycoprotein and atherosclerosis was not decisive. Gas-liquid chromatographic analyses showed that the difference in mutual ratios of isomeric hexoses (mannose, galactose and glucose) between aortas was more conspicuous than that between sclerotic and healthy areas of the same aortas. In addition to galactose and mannose, glucose was detected in all the samples analysed.

THE seromucoid fraction, one of the ‘acute phase react ants’, has been shown by many investigators to be increased significantly in the blood in a large number of unrelated disease states. This protein fraction1 is known to contain as major component α1-acid glyco-protein2 or orosomucoid3 and several minor components including haptoglobin, 3S α1-glycoprotein and Zn- and Ba-α2-glycoproteins4,5. The question has now been investigated whether α1-acid glycoprotein derived from pathological plasma is identical to or different from that prepared from normal blood.