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There is an increasing demand for fisheries resources worldwide. For example, the Asian markets have traditionally consumed sea cucumber as a delicacy and their buoyant economies have promoted demand for it in recent years. The brown sea cucumber Isostichopus fuscus is the most valuable species from the Eastern Pacific and it has been almost depleted due to overfishing. In this work, we analyzed data of sea cucumber abundance collected monthly (October 2014–December 2016) along the west coast of the Gulf of California (29.95 oN – 28.05 oN) in 1,107 swath (25 × 2 m) quadrats performed at 118 sites with the goal of determining if current fishing quotas are sustainable. We applied a Bayesian hierarchical modelling approach with integrated nested Laplace approximation (INLA) to this data to account for spatial structure in the data when calculating densities. The observed density ranged from a minimum of 0 to a maximum of 0.58 ind/m2, with an average of 0.03 ind/m2 in suitable habitat, defined as the habitat less than 30 m deep and with hard substrate. There are large spatial variations in abundance, but the overall mean suitable habitat is 15.7% (min = 7.8%, max = 28.8%) of the total fishing area. Current quotas are usually higher than 5% of the lower bounds of population density estimates. We propose, among other management measures, that quotas should be granted taking into account the spatial structure of sea cucumber densities as well as the proportion of suitable area within each estate. Given the high levels of illegal fishing within the Gulf of California, it is imperative that quotas are based on the lower bounds of spatially explicit density estimates – along with increased surveillance and enforcement – if the long-term commercial sustainability of the fishery is to be maintained.

5081 Background: Studies have shown that localized PCs may resist neoadjuvant androgen receptor (AR)-targeted therapies as a result of persistent intraprostatic androgens, likely arising through upregulation of steroidogenic enzymes. Therefore, we sought to evaluate clinical effects of combinatorial AR-targeted therapy, including indomethacin (Indo) to inhibit the steroidogenic enzyme AKR1C3, in men with high risk PC undergoing radical prostatectomy (RP). Methods: This was an open label, single-site, Phase II neoadjuvant trial in men with localized high to very-high risk PC, as defined by NCCN criteria. Patients received 12 weeks of neoadjuvant apalutamide (Apa), abiraterone (Abi) plus prednisone, degarelix, and Indo at their respective FDA-approved doses followed by RP. The primary objective was to determine the pathologic complete response (pCR) rate. Secondary objectives included assessing for minimal residual disease (MRD) (i.e. ≤0.25 cm3 tumor volume corrected for cellularity), measuring intraprostatic androgens and assessing molecular features associated with drug resistance. Twenty evaluable patients provided 91% power (one-sided alpha = 7.5%) to detect a difference in pCR rate of 5% (H0) vs. 25% (H1). Results: Twenty-two patients enrolled and 20 were evaluable for the primary endpoint (1 patient came off to pursue stereotactic radiosurgery; 1 was removed after developing grade 2 transaminitis). At baseline, the median PSA was 10.1 ng/mL (4.4-159.4), 4 (20%) patients had Gleason grade group (GG) 4 disease and 16 had GG 5 disease. At RP, 1 (5%) patient had a pCR, 6 (30%) had MRD, 18 (90%) had ypT3 disease and 7 (35%) had lymph node (LN) metastases. Treatment was generally well tolerated and adverse events were consistent with each individual drug’s known safety profile. Additional follow up data and correlative work will be presented at the meeting. Conclusions: In our cohort of men with high-risk PC, pCR rates remained low even with combinatorial AR-directed therapy. Ongoing pharmacodynamic studies aimed at determining if Indo effectively inhibited AKR1C3 will provide important insights regarding the utility of targeting this steroidogenic enzyme. Clinical trial information: NCT02849990.

Importance The existing readmission quality metric does not meaningfully distinguish readmissions associated with surgical quality from those that are not associated with surgical quality and thus may not reflect the quality of surgical care. Objective To compare a quality metric that classifies readmissions associated with surgical quality with the existing metric of any unplanned readmission in a surgical population. Design, Setting, and Participants Cohort study using US nationwide administrative data collected on 4 high-volume surgical procedures performed at 103 Veterans Affairs hospitals from October 1, 2007, through September 30, 2014. Data analysis was conducted from October 1, 2017, to January 24, 2019. Main Outcomes and Measures Hospital-level rates of unplanned readmission (existing metric) and surgical readmissions associated with surgical quality (new metric) in the 30 days following hospital discharge for an inpatient surgical procedure. Results The study population included 109 258 patients who underwent surgery at 103 hospitals. Patients were majority male (94.1%) and white (78.2%) with a mean (SD) age of 64.0 (10.0) years at the time of surgery. After case-mix adjustment, 30-day surgical readmissions ranged from 4.6% (95% CI, 4.5%-4.8%) among knee arthroplasties to 11.1% (95% CI, 10.9%-11.3%) among colorectal resections. The new surgical readmission metric was significantly correlated with facility-level postdischarge complications for all procedures, with ρ coefficients ranging from 0.33 (95% CI, 0.13-0.51) for cholecystectomy to 0.52 (95% CI, 0.38-0.68) for colorectal resection. Correlations between postdischarge complications and the new surgical readmission metric were higher than correlations between complications and the existing readmission metric for all procedures examined (knee arthroplasty: 0.50 vs 0.48; hip replacement: 0.44 vs 0.18; colorectal resection: 0.52 vs 0.42; and cholecystectomy: 0.33 vs 0.10). When compared with using the existing readmission metric, using the new surgical readmission metric could change hip replacement–associated payment penalty determinations in 28.4% of hospitals and knee arthroplasty–associated penalties in 26.0% of hospitals. Conclusions and Relevance In this study, surgical quality–associated readmissions were more correlated with postdischarge complications at a higher rate than were unplanned readmissions. Thus, a metric based on such readmissions may be a better measure of surgical care quality. This work provides an important step in the development of future value-based payments and promotes evidence-based quality metrics targeting the quality of surgical care.

Normal mammalian brain ageing is characterised by the selective loss of discrete populations of dendritic spines and synapses, particularly affecting neuroanatomical regions such as the hippocampus. Although previous investigations have quantified this morphologically, the molecular pathways orchestrating preferential synaptic vulnerability remain to be elucidated.Using quantitative proteomics and healthy rhesus macaque and human patient brain regional tissues, we have comprehensively profiled the temporal expression of the synaptic proteome throughout the adult lifespan in differentially vulnerable brain regions. Comparative profiling of hippocampal (age-vulnerable) and occipital cortex (age-resistant) synapses revealed discrete and dynamic alterations in the synaptic proteome, which appear unequivocally conserved between species. The generation of these unique and important datasets will aid in delineating the molecular mechanisms underpinning primate brain ageing, in addition to deciphering the regulatory biochemical cascades governing neurodegenerative disease pathogenesis.

This presentation discusses methodological strengths and limitations of using experience sampling methods (ESM) with an older exemplar population. As illustrated in the preceding papers and in this presentation, ESM provided rich information about the dynamics of civic engagement exemplars’ experience and the ecology of their daily lives impossible to obtain with other methods. This study was conducted despite a number of apparent barriers. For example, the sample of civic engagement exemplars was dispersed across the country, precluding person-to-person walkthroughs. In addition, although technological advances enable ESM researchers to utilize increasingly sophisticated technology for data collection, there were also concerns as to whether the participant experience would be hindered by introducing novel technology to the sample. Lessons of general interest gleaned from both researchers and participants will be discussed and methods of addressing these issues will be described.

Bacterial vaginosis (BV), a common condition in women, is associated with increased shedding of HIV in the female genital tract. While the Lactobacillus species that comprise a healthy vaginal microbiota produce lactic acid, the bacteria common in BV produce high concentrations of short chain fatty acids (SCFAs) and succinic acid. Macrophages are abundant in the lower genital tract mucosa and are thought to play an important role in HIV infection. In this study, we investigated whether SCFAs and succinic acid impacted HIV expression in monocyte-derived macrophages. Monocytes differentiated with either granulocyte-macrophage colony-stimulating factor (GM-CSF) or macrophage colony-stimulating factor (M-CSF) were infected with either HIVBal or an HIV-luciferase reporter virus and treated with SCFAs, succinic acid, or lactic acid. Butyric acid suppressed HIV expression while succinic acid significantly increased expression in macrophages differentiated with either GM-CSF or M-CSF. Acetic, propionic, and lactic acids had no effect on HIV expression. Only succinic acid resulted in a significant increase in interleukin-8 production by infected macrophages. Our results suggest that succinic acid present in increased concentrations in the genital tract of women with BV plays a pro-inflammatory role and increases HIV expression. This could be one factor contributing to increased virus shedding seen in women with BV.

Purpose: To understand rural community-dwelling older adult participants' shared values, beliefs, and behaviours related to exercise as self-care. Methods: We conducted a constructivist-focused ethnography involving semi-structured interviews and participant observation with 17 individuals 65 years and older. Interviews were transcribed and inductively coded to develop themes related to exercise, self-care, and exercise as self-care. Field notes were triangulated with follow-up interviews and dialogue between authors to enhance interpretation. Results: Participants described exercise broadly as movement and not as a central self-care behaviour. However, awareness of the importance and health-related benefits of exercise increased after a significant personal health-related event. Participants preferred exercise that was enjoyable and previously experienced. Conclusions: Prescribing exercise for older adults may be particularly effective if the focus is on enjoyable and previously experienced physical activity and if it incorporates interpretation of exercise guidelines and training principles in relation to chronic conditions and potential health benefits.

Spasticity is common after stroke and other neurological conditions and causes considerable limitations of movement, activities of daily living and participation. Interaction with other components of the upper motor neurone syndrome (UMNS) and the heterogeneity of patients' presentations together with limited tools for outcome measurement have hampered the production of randomised controlled trial data for management strategies. Specialist multi-disciplinary goal-centered management programmes are the mainstay of treatment. Pharmacological therapies have limited effect, and physical and positional management are crucial. Targeted intramuscular botulinum toxin injection is now the most popular pharmacological treatment. Intrathecal therapies also play a lesser role. A team approach and holistic assessment are essential to beneficial outcomes.

Tropical peat swamp forests (TPSF) are being rapidly deforested, leading to disturbed hydrology, wildfires and carbon loss. Cost-effective methods are needed to increase the scale of restoration activities. One method is to inoculate seedlings with their corresponding mycorrhizae species, thereby increasing performance during nursery cultivation, although the benefits post-transplantation are less well understood. This study considered two TPSF tree species, Shorea balangeran and Dyera polyphylla (syn. Dyera lowii), and their mycorrhiza; Scleroderma columnare (S. balangeran) and Glomus clarum and Gigaspora decipiens (D. polyphylla). The performance of non-inoculated and inoculated seedlings was compared following transplantation into five forest zones, representing a gradient from intact to degraded TPSF. In the degraded area, both inoculated seedling species supported higher colonization levels compared to non-inoculated seedlings. Both tree species showed high survival rates in all forest zones, and survival, growth and biomass production were not affected by mycorrhizal treatment. Both species grew faster and accumulated greater biomass in the more degraded forest zones. Nitrogen and phosphorus content reduced for both tree species in the more degraded forest zones, however, inoculated D. polyphylla seedlings had higher nutrient content across all forest zones, as did S. balangeran though less uniformly. Both these tree species are therefore suitable for reforesting degraded TPSF and mycorrhizal inoculation is recommended given a) inoculated seedlings in the degraded area permitted a higher mycorrhizal colonization level, and b) mycorrhizae increased nutrient uptake in the transplanted seedlings, although in this short-term study survival or growth improvement in the inoculated seedlings was not apparent.

Management of antiplatelet therapy in patients with cardiac stents who need subsequent surgery is complex. Current guidelines recommend delaying elective surgery or, if surgery is emergent, proceeding without aspirin cessation. This study assessed provider knowledge, attitudes, and practices for patients with cardiac stents needing subsequent surgery. A national survey was administered to Veterans Administration surgeons, anesthesiologists, and cardiologists. Questions examined guideline awareness and agreement, perceptions of bleeding risk and stent thrombosis, practice patterns for antiplatelet therapy management, and experience with perioperative stent thrombosis. Chi-square tests and generalized estimating equations were used to examine differences in reported practices. Among 295 respondents, guideline awareness (92%) and agreement (93%) were high but higher among cardiologists and anesthesiologists than surgeons. Guideline agreement and personal experience with stent thrombosis were also associated with reported practice patterns. In adjusted models for early surgeries, cardiologists and anesthesiologists were more likely to report continuation of dual therapy as compared with surgeons regardless of stent type (drug-eluting P = 0.03; bare metal P < 0.01). Despite successful guideline adoption, significant variations in practice patterns by provider type were found. Understanding reasons behind the variation and outcomes of various antiplatelet management strategies are important steps in optimizing care of patients with coronary stents undergoing noncardiac surgery.

Background and Purpose— The modified Rankin Scale (mRS) is the recommended functional outcome assessment in stroke trials. Utility of mRS may be limited by interobserver variability. prestroke function, described using mRS, is often used as trial entry criterion. We assessed the reliability and validity of prestroke mRS in acute stroke. Methods— We present two complementary analyses of the properties of prestroke mRS: (1) Paired interviewers (trained in mRS) performed independently a blinded assessment of mRS and prestroke mRS. Interobserver variability was described using percentage agreement and weighted (kw) κ statistics with 95% confidence interval (95% CI). Validity was assessed by comparing prestroke mRS with other markers of function (comorbidity; medication count; need for carers). (2) We further assessed validity using a larger retrospective dataset. We compared prestroke mRS with Charlson comorbidity index (CCI) and the Rockwood frailty index. Rank correlation coefficient or Fisher exact test were used as appropriate. Results— Paired interviewers assessed 74 stroke survivors. Median standard mRS was 4 (interquartile range [IQR], 2–4), median prestroke mRS was 1 (IQR, 0–3; range, 0–4). Reliability for standard mRS interview was 56% agreement, kw=0.55 (95% CI, 0.39–0.71). Reliability for prestroke mRS was 70%, kw=0.70 (95% CI, 0.53–0.87). The retrospective dataset described 231 subjects. In this data set, Spearman Rho for prestroke mRS and frailty index was J. 0.82 (95% CI, 0.78–0.86); CCI 0.50 (95% CI, 0.40–0.59); patient age 0.45 (95% CI, 0.34–0.54); medication count 0.28 (95% CI, 0.15–0.40). There was no association between need for carers and prestroke mRS (p=0.10). Conclusions— Interobserver reliability of prestroke mRS is limited but comparable with standard mRS. Poor correlation of prestroke mRS with certain markers of function suggests limited validity. Our data would suggest that relying on mRS alone may be a suboptimal measure of prestroke function and could potentially bias trial samples.

Background Echocardiography is not recommended for routine pre-surgical evaluation but may have value for patients at high risk of major adverse cardiovascular events (MACE). The objective of this study was to evaluate whether pre-operative echocardiography is associated with lower risk of post-operative MACE among patients with coronary artery disease. Methods Using administrative and registry data, we examined associations of echocardiography within 3 months prior to surgery with postoperative MACE (myocardial infarction, revascularization, or death within 30 days) among patients with coronary artery disease undergoing elective, non-cardiac surgeries in the United States Veterans Affairs healthcare system in 2000–2012. Results Echocardiography preceded 4,378 (16.4 %) of 26,641 surgeries. MACE occurred within 30 days following 944 (3.5 %) surgeries. A 10 % higher case-mix adjusted rate of pre-operative echocardiography assessed at the hospital level was associated with a hospital-level risk of MACE that was 1.0 % (95 % confidence interval [CI] 0.1 %, 2.0 %) higher overall and 1.7 % (95 % CI 0.2 %, 3.2 %) higher among patients with recent myocardial infarction, valvular heart disease, or heart failure. At the patient level, pre-operative echocardiography was associated with an odds ratio for MACE of 1.9 (95 % CI 1.7, 2.2) overall and 1.8 (95 % CI 1.5, 2.2) among patients with recent myocardial infarction, valvular heart disease, or heart failure adjusting for MACE risk factors. Conclusions Pre-operative echocardiography was not associated with lower risk of post-operative MACE, even in a high risk population. Future guidelines should encourage pre-operative echocardiography only in specific patients with cardiovascular disease among whom findings can be translated into effective changes in care. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0357-5) contains supplementary material, which is available to authorized users.

The aim of this study is to understand the relative contribution of preoperative patient factors, operative characteristics, and postoperative hospital course on 30-day postoperative readmissions.Determining the risk of readmission after surgery is difficult. Understanding the most important contributing factors is important to improving prediction of and reducing postoperative readmission risk.National Veterans Affairs Surgical Quality Improvement Program data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital signs, prior healthcare utilization, and postoperative complications data. Variables were categorized as preoperative, operative, postoperative/predischarge, and postdischarge. Logistic models predicting 30-day readmission were compared using adjusted R and c-statistics with cross-validation to estimate predictive discrimination.Our study sample included 237,441 surgeries: 43% orthopedic, 39% general, and 18% vascular. Overall 30-day unplanned readmission rate was 11.1%, differing by surgical specialty (vascular 15.4%, general 12.9%, and orthopedic 7.6%, P0.001). Most common readmission reasons were wound complications (30.7%), gastrointestinal (16.1%), bleeding (4.9%), and fluid/electrolyte (7.5%) complications. Models using information available at the time of discharge explained 10.4% of the variability in readmissions. Of these, preoperative patient-level factors contributed the most to predictive models (R 7.0% [c-statistic 0.67]); prediction was improved by inclusion of intraoperative (R 9.0%, c-statistic 0.69) and postoperative variables (R 10.4%, c-statistic 0.71). Including postdischarge complications improved predictive ability, explaining 19.6% of the variation (R 19.6%, c-statistic 0.76).Postoperative readmissions are difficult to predict at the time of discharge, and of information available at that time, preoperative factors are the most important.

α-Synuclein plays a central role in Parkinson's disease, where it contributes to the vulnerability of synapses to degeneration. However, the downstream mechanisms through which α-synuclein controls synaptic stability and degeneration are not fully understood. Here, comparative proteomics on synapses isolated from α-synuclein−/− mouse brain identified mitochondrial proteins as primary targets of α-synuclein, revealing 37 mitochondrial proteins not previously linked to α-synuclein or neurodegeneration pathways. Of these, sideroflexin 3 (SFXN3) was found to be a mitochondrial protein localized to the inner mitochondrial membrane. Loss of SFXN3 did not disturb mitochondrial electron transport chain function in mouse synapses, suggesting that its function in mitochondria is likely to be independent of canonical bioenergetic pathways. In contrast, experimental manipulation of SFXN3 levels disrupted synaptic morphology at the Drosophila neuromuscular junction. These results provide novel insights into α-synuclein-dependent pathways, highlighting an important influence on mitochondrial proteins at the synapse, including SFXN3. We also identify SFXN3 as a new mitochondrial protein capable of regulating synaptic morphology in vivo., Summary: Comparative proteomics revealed that mitochondrial proteins are a major target for α-synuclein. Sideroflexin 3 (SFXN3) was identified as one α-synuclein-dependent mitochondrial protein capable of altering synaptic morphology in vivo.

Objective To compare mitral valve repair (MVRepair) and mitral valve replacement (MVReplace) trends in the Veterans Affairs (VA) Surgical Quality Improvement Program. Methods Trends were compared by bivariate analyses, followed by backward stepwise selection and multivariable logistic modeling to determine the effect of preoperative comorbidities and facility-level factors on MVRepair (vs MVReplace) rate. A subgroup analysis focused on patients who underwent elective surgery for isolated primary degenerative mitral regurgitation. Propensity matching was done in the overall and primary degenerative cohorts. Results From October 2000 to October 2013, 4165 veterans underwent MVRepair (n = 2408) or MVReplace (n = 1757) for MV disease of any cause at 40 VA medical centers (procedural volume, 0-29/y; median 7/y). The MVRepair percentage increased from 48% in 2001 to 63% in 2013 ( P 2 = 0.19, P = .005). Unadjusted 30-day and 1-year mortality rates were lower after MVRepair than after MVReplace (3.5% vs 4.8%, P = .04; 9.8% vs 12.1%, P = .02). Among the propensity-matched patients (n = 2520), 30-day and 1-year mortality were similar after MVRepair and MVReplace. In the propensity-matched primary degenerative subgroup (n = 664), unadjusted long-term mortality for up to 10 years postoperatively was lower after MVRepair (28% vs 37%, P = .003), as was risk-adjusted long-term mortality (hazard ratio, 0.78; 95% confidence interval, 0.61-1.01). Conclusions In the VA Health System, mortality after MV operations is low. Despite the survival advantage associated with MV repair in primary mitral regurgitation, repair is infrequent at some centers, representing an opportunity for quality improvement.

Current guidelines for delaying surgery after coronary stent placement are based on stent type. However, the indication for the stent may be an important risk factor for postoperative major adverse cardiac events (MACE).To determine whether the clinical indication for a coronary stent is associated with postoperative MACE.Retrospective cohort study in patients at US Veterans Affairs hospitals who had a coronary stent placed between January 1, 2000, and December 31, 2010, and underwent noncardiac surgery within the following 24 months. The association between the indication for stent and postoperative MACE rates was examined using logistic regression to control for patient and procedure factors.Three subgroups of stent indication were examined: (1) myocardial infarction (MI); (2) unstable angina; and (3) revascularization not associated with acute coronary syndrome (non-ACS).Composite 30-day postoperative MACE rates including all-cause mortality, MI, or revascularization.Among 26 661 patients (median [IQR] age, 68 [61.0-76.0] years; 98.4% male; 88.1% white) who underwent 41 815 surgical procedures within 24 months following coronary stent placement, the stent indication was MI in 32.8% of the procedures, unstable angina in 33.8%, and non-ACS in 33.4%. Postoperative MACE rates were significantly higher in the MI group (7.5%) compared with the unstable angina (2.7%) and non-ACS (2.6%) groups (P .001). When surgery was performed within 3 months of percutaneous coronary intervention, adjusted odds of MACE were significantly higher in the MI group compared with the non-ACS group (odds ratio [OR] = 5.25; 95% CI, 4.08-6.75). This risk decreased over time, although it remained significantly higher at 12 to 24 months from percutaneous coronary intervention (OR = 1.95; 95% CI, 1.58-2.40). The adjusted odds of MACE for the unstable angina group were similar to those for the non-ACS group when surgery was performed within 3 months (OR = 1.11; 95% CI, 0.80-1.53) or between 12 and 24 months (OR = 1.08; 95% CI, 0.86-1.37) from stent placement. Stent type was not significantly associated with MACE regardless of indication.Surgery in patients with a coronary stent placed for MI was associated with increased postoperative MACE rates compared with other stent indications. The risk declined over time from PCI, and delaying surgery up to 6 months in this cohort of patients with stents may be important regardless of stent type.

Urban green space has particular importance for both the ecology and residents of cities. They have been shown to provide a range of ecosystem services including supporting biodiversity, regulating urban climates, limiting pollution and improving human health (e.g. Gaston 2010). The main anthropogenic use of such areas is for recreation, and local governments often maintain public green spaces primarily for that purpose (Gaston 2010). Therefore, the urban social environment shows a high degree of reciprocal interaction with the biological, social and built environment, though this still remains a poorly studied topic (Pickett et al. 2011). Since the aim of many European cities is to increase the biodiversity of their green spaces and thereby make them more resilient over time, more studies on the ecological characteristics and functions of green space are recommended (Forman 2008; Grimm et al. 2008; Pickett et al. 2011; Francis and Chadwick 2011).

Castration-resistant prostate cancer (CRPC), the invariably lethal phenotype of advanced prostate cancer, represents a clinical state defined by disease progression despite reduction of testosterone to castrate levels (i.e., ≤50 ng/dL). Although resistant to androgen-deprivation therapy (i.e., LHRH agonists/antagonists), CRPC continues to depend on the androgen receptor (AR)-signaling pathway. Supporting the importance of AR-signaling in a castration-resistant state, the next-generation AR-signaling inhibitors enzalutamide and abiraterone have been shown to afford a survival benefit in men with metastatic CRPC. However, primary and secondary resistance mechanisms to these agents inevitably drive continued disease progression—often as a result of re-activation of AR-signaling. With increased understanding of the mechanisms underlying how continued AR-signaling occurs in spite of drugs like abiraterone and enzalutamide, a new wave of therapies is emerging designed to more effectively target AR-signaling. This review will focus on the more clinically relevant mechanisms of CRPC drug resistance and our ongoing efforts to develop drugs to target these mechanisms.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective treatment for achieving and maintaining weight loss and for improving obesity-related comorbidities. As part of the approval process for bariatric surgery, many insurance companies require patients to have documented recent participation in a supervised weight loss program. The goal of this study was to evaluate the relationship of preoperative weight changes with outcomes following LRYGB. A retrospective review was conducted of adult patients undergoing LRYGB between 2008 and 2012 at a single institution. Patients were stratified into quartiles based on % excess weight gain (0–4.99 % and ≥5 % EWG) and % excess weight loss (0–4.99 % and ≥5 % EWL). Generalized linear models were used to examine differences in postoperative weight outcomes at 6, 12, and 24 months. Covariates included in the final adjusted models were determined using backwards stepwise selection. Of the 300 patients included in the study, there were no significant demographic differences among the quartiles. However, there was an increased time to operation for patients who gained or lost ≥5 % excess body weight (p

Purpose: To measure test–retest and interrater reliability of the Berg Balance Scale (BBS) in community-dwelling adults with mild to moderate Alzheimer disease (AD). Method: A sample of 15 adults (mean age 80.20 [SD 5.03] years) with AD performed three balance tests: the BBS, timed up-and-go test (TUG), and Functional Reach Test (FRT). Both relative reliability, using the intra-class correlation coefficient (ICC), and absolute reliability, using standard error of measurement (SEM) and minimal detectable change (MDC95) values, were calculated; Bland–Altman plots were constructed to evaluate inter-tester agreement. The test–retest interval was 1 week. Results: For the BBS, relative reliability values were 0.95 (95% CI, 0.85–0.98) for test–retest reliability and 0.72 (95% CI, 0.31–0.91) for interrater reliability; SEM was 6.01 points and MDC95was 16.66 points; and interrater agreement was 16.62 points. The BBS performed better in test–retest reliability than the TUG and FRT, tests with established reliability in AD. Between 33% and 50% of participants required cueing beyond standardized instructions because they were unable to remember test instructions. Conclusions: The BBS achieved relative reliability values that support its clinical utility, but MDC95and agreement values indicate the scale has performance limitations in AD. Further research to optimize balance assessment for people with AD is required.

Background Hospital readmissions are associated with higher resource utilization and worse patient outcomes. Causes of unplanned readmission to the hospital are multiple with some being better targets for intervention than others. To understand risk factors for surgical readmission and their incremental contribution to current Veterans Health Administration (VA) surgical quality assessment, the study, Improving Surgical Quality: Readmission (ISQ-R), is being conducted to develop a readmission risk prediction tool, explore predisposing and enabling factors, and identify and rank reasons for readmission in terms of salience and mutability. Methods Harnessing the rich VA enterprise data, predictive readmission models are being developed in data from patients who underwent surgical procedures within the VA 2007–2012. Prospective assessment of psychosocial determinants of readmission including patient self-efficacy, cognitive, affective and caregiver status are being obtained from a cohort having colorectal, thoracic or vascular procedures at four VA hospitals in 2015–2017. Using these two data sources, ISQ-R will develop readmission categories and validate the readmission risk prediction model. A modified Delphi process will convene surgeons, non-surgeon clinicians and quality improvement nurses to rank proposed readmission categories vis-à-vis potential preventability. Discussion ISQ-R will identify promising avenues for interventions to facilitate improvements in surgical quality, informing specifications for surgical workflow managers seeking to improve care and reduce cost. ISQ-R will work with Veterans Affairs Surgical Quality Improvement Program (VASQIP) to recommend potential new elements VASQIP might collect to monitor surgical complications and readmissions which might be preventable and ultimately improve surgical care.

Social capital is an immensely popular topic in the social sciences. The merits and limitations of its theoretical conceptualization have been debated by scholars for over two decades. These debates tend to problematize social capital theory’s conceptualization, its application to social phenomena and policy prescription, as well as its peculiar relationship to the uncivil tendencies that describe the “dark side of social capital” (Putnam 2000). To date, few of social capital theory’s problems have been adequately resolved, leaving ample room for further discussion and conceptualization by its exponents.

Given the nature of government policy and funding for victim support groups, combined with the types of leaders identified in Chap. 4, it should come as no surprise that victim groups were predominantly engaged in bonding, rather than bridging social capital. While around 80 % of groups were engaged in either functional or dysfunctional bonding, only around 20 % built bridging forms of social capital. In this chapter, I will reveal the ways in which victim support groups bonded, bridged, and constricted. Significantly, leadership and trust were crucial determinants of whether bonding, bridging, or constriction occurred. However, government policy, as I have already argued, also played an important role in shaping social capital in victim support groups. Thus, I begin with an investigation of Northern Ireland’s social capital policy.

After more than three decades of conflict in Northern Ireland, the country is mourning the loss of around 3,700 lives (McKittrick et al. 2007:13; Fay et al. 1999a, b) and has been left with tens of thousands of physically and psychologically affected surviving victims. These numbers constitute a significant portion of the 1.8 million population. The devastating human impact of the Troubles has led to a situation where the needs of surviving victims must be addressed; a challenging task due to the nature of political and social cleavages in Northern Ireland. While numerous government policies have aimed to address the needs of victims, the bulk of victim support has been left to civil society. In this chapter, I will examine the roles and functions of victim support groups. To do so, I must first address the evolution of social policy as it pertains to victims and the needs of victims and survivors.

Background When patients with drug-eluting stents (DES) present for surgery, current guidelines recommend delaying elective surgeries until 1 year of dual antiplatelet therapy has been completed. Methods We performed a systematic literature review of the major adverse cardiac events (MACE) associated with noncardiac surgery in patients with DES. Results Twenty-eight of 358 studies met inclusion criteria. Overall, MACE rates decreased as time to surgery increased and varied from 0% to 18% for surgeries within 1 year as compared with 0% to 12% for surgery more than 1 year after a stent. In addition, the current literature showed limited evidence for a protective effect of continuing perioperative dual antiplatelet therapy on MACE rates. Conclusions The current literature supports a significant decrease in MACE when surgery is performed 1 year after DES placement; however, the level of evidence is weak. Larger studies are needed to determine the safe interval for surgery after stent placement.

The safety and efficacy of performing concomitant surgical procedures with an incisional hernia repair (IHR) is not well understood. There are conflicting reports on the outcomes for permanent mesh implantation in the setting of clean-contaminated procedures. The purpose of this study was to review the effect of concomitant surgical procedures on IHR outcomes. This is a retrospective multisite cohort of patients undergoing elective IHR at 16 Veterans Affairs hospitals from 1998 to 2002. Concomitant procedure status, hernia characteristics, and operative details were determined using physician-abstracted operative notes. Hernia outcomes of recurrence and mesh explantation were determined from the medical chart. χ2 tests, Kaplan-Meier curves, and Cox regression were used to evaluate the effects of concomitant status on hernia outcomes. Of the 1495 elective IHRs, 75 (4.8%) were same site and 56 (3.8%) different site concomitant procedures. At median follow-up of 69.3 months (range 19.1–98.3), 33.6 per cent of patients had a recurrence, mesh explantation, or both. Permanent mesh placement was less likely among concomitant procedures as compared with nonconcomitant procedures ( P < 0.0001). Adjusted Cox proportional hazards models of hernia outcomes resulted in an increased hazard for recurrence among same site clean procedures (Hazard Ratio (HR) = 1.8, P = 0.03) and an increased hazard for mesh explantation among same site clean-contaminated procedures (HR = 8.4, P = 0.002). Concomitant same site procedures are significantly associated with adverse hernia outcomes as compared with isolated IHR or IHR with other site concomitant procedures. The high failure rate of hernia repairs among same site concomitant procedures should be taken into account during the surgical decision-making process.

This study examines the effect of emergent repair on incisional hernia repair outcomes at 16 Veteran's Affairs Medical Centers between 1998 and 2002. Of the 1452 cases reviewed, 63 (4.3%) were repaired emergently. Patients undergoing emergent repair were older ( P = 0.02), more likely to be black ( P = 0.02), and have congestive heart failure ( P = 0.001) or chronic obstructive pulmonary disease ( P = 0.001). Of emergent repairs, 76.2 per cent involved intestinal incarceration versus 7.2 per cent of elective repairs ( P < 0.0001), and 17.5 per cent had concomitant bowel resection compared with 3.9 per cent of elective cases ( P < 0.0001). Patients undergoing emergent repair were also more likely to receive primary suture repair (49.2 vs 31.1%, P = 0.003), develop a postoperative complication (26.0 vs 11.3%, P = 0.002), and have increased postoperative length of stay (7 vs 4 days, P < 0.0001). There were nine (14.3%) deaths at 30 days for the emergent group compared with 10 (0.7%) in the elective group ( P < 0.001). However, there was no significant difference between emergent and elective repairs in long-term complications. Emergent hernia repair is associated with increased mortality rates, early complications, and longer length of stay; however, long-term outcomes are equivalent to elective cases. These data suggest that technical outcomes for emergent repairs approach those of elective operations.

Forest rehabilitation activities have been initiated on degraded peatland at several sites in Southeast Asia. In order to achieve rehabilitation efficiently and on the largest possible scale, cost-effective, transferable methods need to be established. One potential method, which has previously proven successful in both temperate and neotropical forest ecosystems, is the construction of artificial bird perches outside the forest edge. These provide resting perches for frugivorous birds, encouraging them to fly out of the forest, thus increasing seed dispersal and subsequent seedling recruitment into the degraded area. This method was trialled for the first time in degraded tropical peat swamp forest in Indonesia. The results show that the perches were used by frugivorous birds, leading to a significant increase in seed dispersal; however, seedling recruitment was not increased. The frugivorous birds using the perches were degraded zone species and dispersed mainly tree species from the degraded area. Furthermore, while some seeds of forest-area tree species were dispersed, largely only the degraded area tree species survived to seedling stage. Neither seasonality nor distance from forest edge proved to be significant factors influencing seed dispersal or seedling recruitment, the latter highlighting that seeds were principally being dispersed from within the degraded area rather than from the forest. Although artificial perches did increase seed dispersal, their use as an actual restoration tool in the process of forest regeneration on degraded tropical peatland is limited. Furthermore, when the cost- and effort-to-area factors are considered, this method is shown to be inefficient.

People exhibit an immediacy bias when making judgments and decisions about humanitarian aid, perceiving as more deserving and donating disproportionately to humanitarian crises that happen to arouse immediate emotion. The immediacy bias produced different serial position effects, contingent on decision timing (Experiment 1). When making allocation decisions directly after viewing to four emotionally evocative films about four different humanitarian crises, participants donated disproportionately more to the final, immediate crisis, in contrast, when making donation decisions sequentially, after viewing each of the four crises, participants donated disproportionately to the immediate crisis. The immediacy bias was associated with ‘‘scope neglect,’’ causing people to take action against relatively less deadly crises (Experiments 2 and 3). The immediacy bias emerged even when participants were warned about emotional manipulation (Experiment 3). The immediacy bias diminished over time, as immediate emotions presumably subsided (Experiment 2). Implications for charitable giving, serial position effects, and the influence of emotion on choice are discussed.

Background Prosthetic mesh used for incisional hernia repair (IHR) reduces hernia recurrence. Mesh infection results in significant morbidity and challenges for subsequent abdominal wall reconstruction. The risk factors that lead to mesh explantation are not well known. Methods This is a multisite cohort study of patients undergoing IHR at 16 Veterans Affairs hospitals from 1998 to 2002. Results Of the 1,071 mesh repairs, 55 (5.1%) had subsequent mesh explantation at a median of 7.3 months (interquartile range 1.4–22.2) after IHR with permanent mesh prosthesis. Infection was the most common reason for explantation (69%). No differences were observed by the type of repair. Adjusting for covariates, same-site concomitant surgery (hazard ratio [HR] = 6.3) and postoperative surgical site infection (HR = 6.5) were associated with mesh explantation. Conclusions Patients undergoing IHR with concomitant intra-abdominal procedures have a greater than 6-fold increased hazard of subsequent mesh explantation. Permanent prosthetic mesh should be used with caution in this setting.

Background The frequency of subsequent abdominal operations (SAO) and complications attributable to earlier ventral incisional hernia repair (VIHR) are unknown. We examined the effect of repair type and technique on the difficulty and complications of subsequent surgery. Study Design A cohort of VIHRs at 16 Veterans Affairs hospitals between 1998 and 2002 was examined for postrepair abdominal operation by chart review. The primary independent variable was type and technique of the index VIHR: suture or mesh repair stratified by mesh type and position in relation to abdominal wall musculature. Subsequent surgery characteristics including operative time, inadvertent enterotomy, mesh removal, and length of postoperative stay were determined by chart review. Regression modeling was used to adjust for potential confounding variables. Results At a median of 80 months after VIHR in 1,444 patients, 366 (25.3%) experienced SAO. Nearly two-thirds of these involved rerepair of the VIHR with or without a concomitant procedure. Mesh removal was significantly more likely in expanded polytetrafluoroethylene repairs as compared with polypropylene repairs, regardless of technique (odds ratio=3.6; p=0.01). On multivariable regression modeling, polypropylene underlay (p = 0.03) and inlay (p = 0.001) and absorbable/biologic mesh (p = 0.05) significantly increased operative time for SAO. Repair type, mesh type, or position had no significant effect on risk of inadvertent enterotomy during the SAO (p≥0.27). Conclusions Subsequent abdominal operations after VIHR are common. Underlay or inlay polypropylene mesh increases SAO operative time, but there was no increased risk of intestinal injury. Earlier repair with expanded polytetrafluoroethylene did not increase operative time, but there was equivalent risk for intestinal injury and increased risk for mesh removal.

The Vancouver Island marmot (Marmota vancouverensis; VIM) is one of North America's most endangered species with fewer than 150 individuals remaining in the wild. A captive breeding program was established across four facilities in Canada as an insurance population and source of animals for reintroduction to the wild. The purpose of this study was to gather information about the basic reproductive biology and behavior of this species, which is essential to improve captive breeding programs. Regular fecal samples were obtained from adult female (n = 14) and male (n = 10) marmots, 2 years of age and older, over 1-3 breeding seasons (2-3 months duration posthibernation) for steroid hormone analysis. Enzyme immunoassays were validated for quantifying fecal testosterone metabolite concentrations for males, and fecal estrogen and progesterone metabolite concentrations for females. Results indicated that fecal progesterone metabolite concentrations can be used to monitor ovulation and pregnancy. Behavioral monitoring through infrared video surveillance was conducted in four breeding pairs over a 2-year period (n = 7 behavioral profiles). Breeding behaviors correlated strongly with changes in reproductive endocrine profiles. A high frequency of play behavior or "wrestling" was observed in conjunction with breeding activity before an elevation in progesterone metabolite concentrations. Impending parturition was associated with increased aggression and exclusion of the male from the maternal nestbox as well as an increase in nesting activity. Observational data combined with hormonal analysis suggest that female VIMs are induced ovulators and that multiple breeding attempts may be required for ovulation and conception. Gestation appears to be approximately 34 days from peak breeding activity (32 days from estimated ovulation). Fecal testosterone concentrations suggest that testicular activity is seasonal with the reproductive activity occurring immediately posthibernation. Monitoring breeding behavior is a useful means of indicating estrus, conception and pregnancy, which can also be supported by the hormonal analysis of daily fecal samples of individual animals.

In this article, I reveal the textual mechanisms that influential news editors employed to manipulate popular understandings of Mario Juruna, a Xavante leader who played an important role in advancing democracy during Brazil's military dictatorship and became the first Indian elected to national office. I argue that editors used the implicit messages of represented language to initiate shifts in the public's perception of the Xavante leader and thereby to change its opinion of him. Juruna's case illustrates that linguistic resources are powerful tools that hegemonic institutions, such as the press, and other dominant parties may employ to advance their own interests and influence public opinion on matters of political and social import.

Peat fires have been a severe recurrent problem for Indonesia, but droughts due to prolonged dry season aggravate burning conditions. To get a better understanding of this issue, we studied fire conditions in a portion of the ex-Mega Rice Project (MRP) area, Central Kalimantan. To examine fire season and hydrology factors affecting peat fires we analyzed daily TRMM data, Nino 3.4 SST Anomalies, and changing groundwater levels (GWL) from 300 dipwells. Our results quantify time-lags between the period of lowest precipitation and the lowest GWL; providing some ability to predict fire risk in advance of the lowest GWL. The rise of Nino 3.4 SST anomalies is significant risk factors for peat fire as they signify dry months which may yield large fire occurrences. GWL in 2011 was lower than in 2012, but fires were more frequent in 2012, indicating that low precipitation amounts in the wet season of 2011/2012 left the peat in a dry condition early in 2012. Most of the fires occurred in areas with GWL less than -30 cm, powerfully illustrating the importance of maintaining GWL at more than -10 cm, to prevent degraded peatlands from experiencing surface and deep peat fires.

Importance Preoperative hyperglycemia is associated with adverse postoperative outcomes among patients who undergo surgery. Whether preoperative hemoglobin A 1c (HbA 1c ) or postoperative glucose levels are more useful in predicting adverse events following surgery is uncertain in the current literature. Objective To examine the use of preoperative HbA 1c and early postoperative glucose levels for predicting postoperative complications and readmission. Design, Setting, and Participants In this observational cohort study, inpatient gastrointestinal surgical procedures performed at 117 Veterans Affairs hospitals from 2007 to 2014 were identified, and cases of known infection within 3 days before surgery were excluded. Preoperative HbA 1c levels were examined as a continuous and categorical variable ( 6.5%). A logistic regression modeled postoperative complications and readmissions with the closest preoperative HbA 1c within 90 days and the highest postoperative glucose levels within 48 hours of undergoing surgery. Main Outcomes and Measures Postoperative complications and 30-day unplanned readmission following discharge. Results Of 21 541 participants, 1193 (5.5%) were women, and the mean (SD) age was 63.7 (10.6) years. The cohort included 23 094 operations with measurements of preoperative HbA 1c levels and postoperative glucose levels. The complication and 30-day readmission rates were 27.2% and 14.7%, respectively. In logistic regression models adjusting for HbA 1c , postoperative glucose levels, postoperative insulin use, diabetes, body mass index (calculated as weight in kilograms divided by height in meters squared), and other patient and procedural factors, peak postoperative glucose levels of more than 250 mg/dL were associated with increased 30-day readmissions (odds ratio, 1.18; 95% CI, 0.99-1.41; P = .07). By contrast, a preoperative HbA 1c of more than 6.5% was associated with decreased 30-day readmissions (odds ratio, 0.85; 95% CI, 0.74-0.96; P = .01). As preoperative HbA 1c increased, the frequency of 48-hour postoperative glucose checks increased (4.92, 6.89, and 9.71 for an HbA 1c 6.5%, respectively; P 1c of more than 6.5% had lower thresholds for postoperative insulin use. Conclusions and Relevance Early postoperative hyperglycemia was associated with increased readmission, but elevated preoperative HbA 1c was not. A higher preoperative HbA 1c was associated with increased postoperative glucose level checks and insulin use, suggesting that heightened postoperative vigilance and a lower threshold to treat hyperglycemia may explain this finding.

Over the past decade in Brazil, the convergence between international environmentalism and indigenous cultural survival concerns led to an unprecedented internationalization of local A native struggles. The Indian-environmentalist alliance has benefited both parties, but recent events suggest that it may be unstable and may pose political risks for native people. The limitations of transnational symbolic politics as a vehicle for indigenous activism reflect tensions and contradictions in outsiders' symbolic constructions of Indian identity.

Sternal closure with rigid titanium plates (primary sternal plating) may reduce sternal wound complications in high-risk patients. We began performing primary sternal plating for the following indications: obesity, manual laborer, osteoporotic sternum, or intraoperative transverse sternal fracture. Patients receiving plate closure were compared to a risk-matched control group receiving wire closure. Outcomes of interest were postoperative length of stay and sternal wound complications [sterile dehiscence or deep sternal wound infection (DSWI)]. Wound complications were classified by time of occurrence as early (or=30 days postoperation) or late (30 days postoperation). Of 445 total cardiac cases during the 5-year study period, 129 (29%) met inclusion criteria. The plate group (n=30) and wire group (n=99) were generally well-matched in terms of risk factors. Postoperative length of stay was significantly shorter in the plate group (median 7 vs. 8 days, P=0.023). No early sternal wound complications occurred in the plate group, compared to 12 (12%) in the wire group (P=0.067). The incidence of late sternal wound complications was 10% in both groups (P=1.0). Primary sternal plating appears to provide benefits over wire closure during the early postoperative period, but may not prevent late wound complications in patients with osteoporosis or extreme obesity.

Studies of restoration ecology are well established for northern peatlands, but at an early stage for tropical peatlands. Extensive peatland areas in Southeast Asia have been degraded through deforestation, drainage and fire, leading to on- and off-site environmental and socio-economic impacts of local to global significance. To address these problems, landscape-scale restoration measures are urgently required. This paper reviews and illustrates, using information from on-going trials in Kalimantan, Indonesia, the current state of knowledge pertaining to (i) land-cover dynamics of degraded peatlands, (ii) vegetation rehabilitation, (iii) restoration of hydrology, (iv) rehabilitation of carbon sequestration and storage, and (v) promotion of sustainable livelihoods for local communities. For a 4500 km2 study site in Central Kalimantan, Indonesia, we show a 78% reduction in forest cover between 1973 and 2003 and demonstrate that fire, exacerbated by drainage, is the principal driver of land-use change. Progressive vegetation succession follows infrequent, low-intensity fires, but repeated and high-intensity fires result in retrogressive succession towards non-forest communities. Re-wetting the peat is an important key to vegetation restoration and protection of remaining peat carbon stocks. The effectiveness of hydrological restoration is discussed and likely impacts on greenhouse gas emissions evaluated. Initial results indicate that raised water levels have limited short-term impact on reducing CO2 emissions, but could be critical in reducing fire risk. We conclude that successful restoration of degraded peatlands must be grounded in scientific knowledge, relevant to socio-economic circumstances, and should not proceed without the consent and co-operation of local communities.

Background Incisional hernia repair (IHR) with mesh has been associated with decreased hernia recurrence. We analyzed variation in mesh use for IHR. Methods A cohort undergoing IHR from 16 Veterans' Administration (VA) Hospitals was identified. Patient-specific variables were obtained from National Surgical Quality Improvement Program (NSQIP) data. Operative variables were obtained from physician-abstracted operative notes. Univariate and multivariable logistic regression analyses were used to model mesh implantation predictors. Results A total of 1,123 IHR cases were analyzed; Mesh was implanted in 69.6% (n = 781). Regression models demonstrated repair at a high performing facility was associated with a nearly 4-fold increase in mesh utilization. Other significant predictors include repair of recurrent hernia, chronic steroid use, and multiple fascial defects. Conclusions There is variation in the rate of mesh placement for IHR by VA facility, even after accounting for key explanatory variables. Patterns of mesh placement in IHR appear to be based on practice style.

This study was undertaken to examine the effect of cirrhosis on elective and emergent umbilical herniorrhapy outcomes.Procedures were identified from the Veterans' Affairs National Surgical Quality Improvement Program at 16 hospitals. Medical records and operative reports were physician abstracted to obtain preoperative and intraoperative variables.Of the 1,421 cases reviewed, 127 (8.9%) had cirrhosis. Cirrhotics were more likely to undergo emergent repair (26.0% vs. 4.8%, p0.0001), concomitant bowel resection (8.7% vs. 0.8%, p0.0001), return to operating room (7.9% vs. 2.5%, p = 0.0006), and increased postoperative length of stay (4.0 vs. 2.0 days, p = 0.01). Best-fit regression models found cirrhosis was not a significant predictor of postoperative complications. Significant predictors of complications were emergent case (OR 5.4; 95% CI 3.1-9.4), diabetes (OR 2.1; 95% CI 1.2-3.8), congestive heart failure (OR 4.0; 95% CI 1.4-11.4), and chronic obstructive pulmonary disease (OR 2.0; 95% CI 1.1-3.6). Among emergent repairs, cirrhosis (OR 4.4; 95% CI 1.3-14.3) was strongly associated with postoperative complications.Elective repair in cirrhotics is associated with similar outcomes as in patients without cirrhosis. Emergent repair in cirrhotics is associated with worse outcomes. Early elective repair may improve the overall outcomes for patients with cirrhosis.

Although liberal blood transfusion thresholds have not been beneficial following noncardiac surgery, it is unclear whether higher thresholds are appropriate for patients who develop postoperative myocardial infarction (MI).To evaluate the association between postoperative blood transfusion and mortality in patients with coronary artery disease and postoperative MI following noncardiac surgery.Retrospective cohort study involving Veterans Affairs facilities from January 1, 2000, to December 31, 2012. A total of 7361 patients with coronary artery disease who underwent inpatient noncardiac surgery and had a nadir postoperative hematocrit between 20% and 30%. Patients with significant bleeding, including any preoperative blood transfusion or transfusion of greater than 4 units during the intraoperative or postoperative setting, were excluded. Mortality rates were compared using both logistic regression and propensity score matching. Patients were stratified by postoperative nadir hematocrit and the presence of postoperative MI.Initial postoperative blood transfusion.The 30-day postoperative mortality rate.Of the 7361 patients, 2027 patients (27.5%) received at least 1 postoperative blood transfusion. Postoperative mortality occurred in 267 (3.6%), and MI occurred in 271 (3.7%). Among the 5334 patients without postoperative blood transfusion, lower nadir hematocrit was associated with an increased risk for mortality (hematocrit of 20% to24%: 7.3%; 24% to27%: 3.7%; and 27% to 30%: 1.6%; P .01). In patients with postoperative MI, blood transfusion was associated with lower mortality, for those with hematocrit of 20% to 24% (odds ratio, 0.28; 95% CI, 0.13-0.64). In patients without postoperative MI, transfusion was associated with significantly higher mortality for those with hematocrit of 27% to 30% (odds ratio, 3.21; 95% CI, 1.85-5.60).These findings support a restrictive postoperative transfusion strategy in patients with stable coronary artery disease following noncardiac surgery. However, interventional studies are needed to evaluate the use of a more liberal transfusion strategy in patients who develop postoperative MI.

Equine grass sickness (EGS) is an acute, predominantly fatal, multiple system neuropathy of grazing horses with reported incidence rates of approximately 2%. An apparently identical disease occurs in multiple species including but not limited to cats, dogs, and rabbits. Although the precise aetiology remains unclear, ultrastructural findings have suggested that the primary lesion lies in the glycoprotein biosynthetic pathway of specific neuronal populations. The goal of this study was therefore to identify the molecular processes underpinning neurodegeneration in EGS. Here we use a bottom up approach beginning with the application of modern proteomic tools to the analysis of cranial (superior) cervical ganglion (CCG – a consistently affected tissue) from EGS affected patients and appropriate control cases postmortem. In what appears to be the first proteomic application of modern proteomic tools to equine neuronal tissues and/or to an inherent neurodegenerative disease oflarge animals (not a model of human disease), we identified 2311 proteins in CCG extracts, with 320 proteins increased and 186 decreased by greater than 20% relative to controls.Further examination of selected proteomic candidates by quantitative fluorescent western blotting (QFWB) and sub-cellular expression profiling by immunohistochemistry, highlighted a previously unreported dysregulation in proteins commonly associated with protein misfolding/aggregation responses seen in a myriad of human neurodegenerative conditions, including but not limited to amyloid precursor protein (APP), microtubule associated protein(Tau) and multiple components of the ubiquitin proteasome system (UPS). Differentially expressed proteins eligible for in silico pathway analysis clustered predominantly into the following biofunctions: 1. Diseases & disorders including; neurological disease, skeletal & muscular disorders; 2. Molecular and cellular functions: including cellular assembly & organisation, cell-to-cell signalling and interaction (including epinephrine, dopamine & adrenergic signalling and receptor function) and small molecule biochemistry. Interestingly,whilst the biofunctions identified in this study may represent pathways underpinning EGS induced neurodegeneration, this is also the first demonstration of potential molecular conservation (including previously unreported dysregulation of the UPS and APP) spanning the degenerative cascades from an apparently unrelated condition of large animals, to smallanimal models with altered neuronal vulnerability, and human neurological conditions.Importantly, this study highlights the feasibility and benefits of applying modern proteomic techniques to veterinary investigations of neurodegenerative processes in diseases of large animals.

To determine the relationship between oral antibiotic bowel preparation (OABP) and surgical site infection (SSI) rates in a national colectomy cohort.OABP for elective colorectal surgery has fallen out of favor. Large cohort studies show that OABP is associated with a 50% reduction in SSI after colectomy.A retrospective analysis of the National Surgical Quality Improvement Program colectomy cohort from 2011 to 2012 was performed to examine the association between use of OABP and outcomes of SSI, length of stay (LOS), and readmission after elective colectomy. Univariate and multivariable analyses for SSI were performed.The cohort included 8415 colorectal operations of which 5291 (62.9%) had a minimally invasive surgical (MIS) approach. Overall, 25.6% had no bowel preparation, 44.9% had mechanical bowel preparation (MBP) only, and 29.5% received OABP. The SSI rate was 11.1%, and it varied by preparation type: 14.9% no preparation, 12.0% MBP, and 6.5% OABP (P0.001). OABP group had significantly shorter hospital LOS: (median = 4, interquartile range: 3-6) versus other preparations (median LOS = 5) (P0.001). Readmission rates were lowest in OABP (8.1%) and highest in the no preparation group (11.8%). Multivariable logistic regressions found OABP associated with lower SSI [adjusted odds ratio (ORadj) = 0.46, 95% confidence interval (CI): 0.36-0.59]. Stratified models found OABP protective for SSI for both open procedures (ORadj = 0.40, 95% CI: 0.30-0.53) and MIS procedures (ORadj = 0.48, 95% CI: 0.36-0.65).OABP is associated with reduced SSI rates, shorter LOS, and fewer readmissions. Adoption of OABP before elective colectomy would reduce SSI without effecting LOS. The practice of MBP alone should be abandoned.

PubMedID: 25724123 Background Mutations in dedicator of cytokinesis 8 (DOCK8) cause a combined immunodeficiency (CID) also classified as autosomal recessive (AR) hyper-IgE syndrome (HIES). Recognizing patients with CID/HIES is of clinical importance because of the difference in prognosis and management. Objectives We sought to define the clinical features that distinguish DOCK8 deficiency from other forms of HIES and CIDs, study the mutational spectrum of DOCK8 deficiency, and report on the frequency of specific clinical findings. Methods Eighty-two patients from 60 families with CID and the phenotype of AR-HIES with (64 patients) and without (18 patients) DOCK8 mutations were studied. Support vector machines were used to compare clinical data from 35 patients with DOCK8 deficiency with those from 10 patients with AR-HIES without a DOCK8 mutation and 64 patients with signal transducer and activator of transcription 3 (STAT3) mutations. Results DOCK8-deficient patients had median IgE levels of 5201 IU, high eosinophil levels of usually at least 800/µL (92% of patients), and low IgM levels (62%). About 20% of patients were lymphopenic, mainly because of low CD4+ and CD8+ T-cell counts. Fewer than half of the patients tested produced normal specific antibody responses to recall antigens. Bacterial (84%), viral (78%), and fungal (70%) infections were frequently observed. Skin abscesses (60%) and allergies (73%) were common clinical problems. In contrast to STAT3 deficiency, there were few pneumatoceles, bone fractures, and teething problems. Mortality was high (34%). A combination of 5 clinical features was helpful in distinguishing patients with DOCK8 mutations from those with STAT3 mutations. Conclusions DOCK8 deficiency is likely in patients with severe viral infections, allergies, and/or low IgM levels who have a diagnosis of HIES plus hypereosinophilia and upper respiratory tract infections in the absence of parenchymal lung abnormalities, retained primary teeth, and minimal trauma fractures. © 2015 American Academy of Allergy, Asthma & Immunology. National Institutes of Health: R01AI065617 National Institutes of Health: R21AI087627

You made the grades. You took the LSAT. You accepted an invitation to the law school of your choice. Now, you have to do it all over again. This time you need to make the law school grades, in order to be invited to join the law firm of your choice. To make the grade, you need to employ the IRAC (Issue, Rule, Application, Conclusion) method of case briefing for the next three years of your life. IRAC enables readers to easily follow your legal writing.

Fecal samples were collected from female tigers (n = 17) to compare endocrine patterns associated with natural ovarian activity with those after chorionic gonadotropin ovulation induction and artificial insemination (AI). Baseline fecal estradiol concentrations were 65.77 +/- 3.61 ng/g with estrual peaks of 167.39 +/- 9.92 ng/g and an anovulatory cycle length of 17.96 +/- 0.70 days. Peak fecal estradiol was higher when females were housed with a male for breeding (262.30 +/- 41.43 vs. 165.30 +/- 3.67 ng/g; P < 0.05). The majority of animals showed some seasonal differences in fecal estradiol however, patterns were inconsistent. Fecal progestagens increased only after breeding confirming tigers are primarily induced ovulators. The non-pregnant luteal phase was 34.50 +/- 1.85 days in duration. In pregnant tigers, fecal progestagens remained elevated for 108 days until parturition and the diagnosis of pregnancy was possible based on the elevated fecal progestagens after 35 days of gestation. Tigers were administered equine chorionic gonadotropin (eCG) to stimulate follicular growth and human chorionic gonadotropin (hCG) to induce ovulation prior to AI [200 IU eCG/100 IU hCG (n = 5); 400 IU eCG/200 IU hCG (n = 2); 500 IU eCG/100 IU hCG (n = 2); 1000 IU eCG/750 IU hCG (n = 11); 1000 IU eCG/1000 IU hCG (n = 4)]. None of the tigers subjected to AI became pregnant (n = 9). Fecal endocrine patterns in gonadotropin-stimulated tigers were considerably different from those observed in naturally bred tigers. In particular, fecal estradiol concentrations were higher than those observed during natural estrus and remained elevated for longer periods of time in tigers administered the higher doses of gonadotropins typically used in conjunction with AI in this species. These abnormal endocrine patterns may help explain the poor success rate of AI in this species.

The late 1970s saw the first publicly reported use of the western blot, a technique for assessing the presence and relative abundance of specific proteins within complex biological samples. Since then, western blotting methodology has become a common component of the molecular biologists experimental repertoire. A cursory search of PubMed using the term “western blot” suggests that in excess of two hundred and twenty thousand published manuscripts have made use of this technique by the year 2014. Importantly, the last ten years have seen technical imaging advances coupled with the development of sensitive fluorescent labels which have improved sensitivity and yielded even greater ranges of linear detection. The result is a now truly Quantifiable Fluorescence based Western Blot (QFWB) that allows biologists to carry out comparative expression analysis with greater sensitivity and accuracy than ever before. Many “optimized” western blotting methodologies exist and are utilized in different laboratories. These often prove difficult to implement due to the requirement of subtle but undocumented procedural amendments. This protocol provides a comprehensive description of an established and robust QFWB method, complete with troubleshooting strategies.