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Background: Decreasing readmissions is an important quality improvement strategy. Targeted interventions that effectively decrease readmissions have not been fully investigated and standardized., Objective: The purpose of this study was to assess the effectiveness of interventions designed to decrease readmissions after colorectal surgery., Design: This was a retrospective comparison of patients before and after the implementation of interventions., Setting: This study was conducted at a single institution dedicated enhanced recovery pathway colorectal surgery service., Patients: The study group received quality review interventions that were designed to decrease readmissions: preadmission class upgrades, a mobile phone app, a pharmacist-led pain management strategy, and an early postdischarge clinic. The control group was composed of enhanced recovery patients before the interventions. Propensity score weighting was used to adjust patient characteristics and predictors for imbalances., Main Outcome Measure: The primary outcome was 30-day readmissions. Secondary outcomes included emergency department visits., Results: There were 1052 patients in the preintervention group and 668 patients in the postintervention group. After propensity score weighting, the postintervention cohort had a significantly lower readmission rate (9.98% vs 17.82%, p < 0.001) and emergency department visit rate (14.58% vs 23.15%, p < 0.001) than the preintervention group, and surgical site infection type I/II was significantly decreased as a readmission diagnosis (9.46% vs 2.43%, p = 0.043). Median time to readmission was 6 (interquartile 3-11) days in the preintervention group and 8 (3-17) days in the postintervention group (p = 0.21). Ileus, acute kidney injury, and surgical site infection type III were common reasons for readmissions and emergency department visits., Limitations: A single-institution study may not be generalizable., Conclusion: Readmission bundles composed of targeted interventions are associated with a decrease in readmissions and emergency department visits after enhanced recovery colorectal surgery. Bundle composition may be institution dependent. Further study and refinement of bundle components are required as next-step quality metric improvements. See Video Abstract at http://links.lww.com/DCR/B849., Anlisis En Una Sola Institucin De Las Cirugas Colorectales Con Vas De Recuperacin Dirigida Aumentada Que Reducen Los Reingresos: ANTECEDENTES:La reducción de los reingresos es una importante estrategia de mejora de la calidad. Las intervenciones dirigidas que reducen eficazmente los reingresos no se han investigado ni estandarizado por completo.OBJETIVO:El propósito de este estudio fue evaluar la efectividad de las intervenciones diseñadas para disminuir los reingresos después de la cirugía colorrectal.DISEÑO:Comparación retrospectiva de pacientes antes y después de la implementación de las intervenciones.ESCENARIO:Una sola institución dedicada al Servicio de cirugía colorrectal con vías de recuperación dirigida aumentadaPACIENTES:El grupo de estudio recibió intervenciones de revisión de calidad que fueron diseñadas para disminuir los reingresos: actualizaciones de clases previas a la admisión, una aplicación para teléfono móvil, una estrategia de manejo del dolor dirigida por farmacéuticos y alta temprana de la clínica. El grupo de control estaba compuesto por pacientes con recuperación mejorada antes de las intervenciones. Se utilizó la ponderación del puntaje de propensión para ajustar las características del paciente y los predictores de los desequilibrios.PARÁMETRO DE RESULTADO PRINCIPAL:El resultado primario fueron los reingresos a los 30 días. Los resultados secundarios incluyeron visitas al servicio de urgencias.RESULTADOS:Hubo 1052 pacientes en el grupo de preintervención y 668 pacientes en el grupo de posintervención. Después de la ponderación del puntaje de propensión, la cohorte posterior a la intervención tuvo una tasa de reingreso significativamente menor (9,98% frente a 17,82%, p <0,001) y una tasa de visitas al servicio de urgencias (14,58% frente a 23,15%, p <0,001) que el grupo de preintervención y la infección del sitio quirúrgico tipo I / II se redujo significativamente como diagnóstico de reingreso (9,46% frente a 2,43%, p = 0,043). La mediana de tiempo hasta la readmisión fue de 6 [IQR 3, 11] días en el grupo de preintervención y de 8 [3, 17] días en el grupo de posintervención (p = 0,21). El íleo, la lesión renal aguda y la infección del sitio quirúrgico tipo III fueron motivos frecuentes de reingresos y visitas al servicio de urgencias.LIMITACIONES:El estudio de una sola institución puede no ser generalizable.CONCLUSIÓNES:Los paquetes de readmisión compuestos por intervenciones dirigidas se asocian con una disminución en las readmisiones y las visitas al departamento de emergencias después de una cirugía colorrectal con vías de recuperación dirigida aumentada. La composición del paquete puede depender de la institución. Se requieren más estudios y refinamientos de los componentes del paquete como siguiente paso de mejora de la métrica de calidad. Consulte Video Resumen en http://links.lww.com/DCR/B849. (Traducción-Dr Yolanda Colorado)., (Copyright © The ASCRS 2021.)

Information on the effects of agricultural practices such as seeding rate (S), row spacing (RS), herbicide apical treatment (T), and nitrogen application (N) on soybean seed nutrition (protein, oil, fatty acids, sugars, and amino acids) is limited. Although seed composition (nutrition) constituents are genetically controlled, agricultural practices and environmental conditions significantly influence the amount and quality of seed nutrition. Therefore, the objective of this research was to understand the responses of these seed composition constituents to these practices, the environment, and cultivar differences. Two-field experiments were conducted, in 2015 and 2016, in Milan, TN, USA. The experiments were irrigated with four replications and included: two soybean cultivars, two seeding rates, three different row spacings, two N rates, and Cobra herbicide apical treatment. The results showed significant effects of S, RS, N, and T on some seed composition constituents, including protein; oleic, linolenic, and stearic acids; sugars; and some amino acids. The current research demonstrated that single or twin row with a seeding rate of 40,000 seeds ha -1 resulted in higher protein, oleic, some sugars, and some amino acids. However, a high seeding rate of 56,000 seeds ha -1 resulted in lower protein, oleic acid, some sugars, and some amino acids due to plant competition for soil nutrients. Herbicide apical application of Cobra1X resulted in higher linolenic acid and some amino acids. Application of nitrogen resulted in higher protein, linolenic, and some amino acids. This research is beneficial to the scientific communities, including breeders and physiologists through advancing knowledge on the interactions between cultivars and environment for seed nutritional quality selection, and to soybean producers through consideration of best agricultural management to maintain high seed nutritional qualities.

Intracorporeal options for sigmoid resection have been recently developed but not extensively evaluated. This study was designed to assess outcomes comparing intracorporeal and extracorporeal techniques for robotic-assisted sigmoid resection in an established enhanced recovery pathway. This is a retrospective comparison of intracorporeal and extracorporeal techniques for robotic-assisted sigmoid resection for benign and malignant disease. Operative technique for the newer intracorporeal innovation is described in detail. Propensity score matching was performed using patient characteristics as predictors in the propensity score model. 169 cases met inclusion criteria. After propensity score matching, 114 cases were available for analysis (intracorporeal 57, extracorporeal 57). Almost 90% were for diverticulitis in each group. There were significantly fewer conversions in the intracorporeal group when compared to the extracorporeal group (5.26% vs. 19.3%, P = 0.029). Operative time was significantly longer in the intracorporeal group (193.33 vs. 159.89 min, P < 0.001). There was no significant difference between groups for time to flatus and bowel movements, hospital length of stay, postoperative 30-day complications, and readmission rates. There were significantly fewer extraction site hernias in the intracorporeal group (0 vs. 6 (10.53%), P = 0.027) likely because there were fewer midline extraction sites (8.77% vs. 38.6%, P < 0.001). When compared to extracorporeal techniques for robotic sigmoid resection in an enhanced recovery pathway, the intracorporeal approach is safe and associated with fewer conversions, fewer extraction site hernias, and longer operating times. As adoption of the intracorporeal approach continues to increase, further analysis of this technique in larger studies may be warranted.

Introduction: There may be short-term outcomes advantages for the intracorporeal approach to minimally invasive right colectomy., Methods: This is a retrospective propensity score-matched comparison of intracorporeal and extracorporeal techniques for robotic-assisted right colectomy in an Enhanced Recovery colorectal surgery service., Results: 55 intracorporeal and 55 extracorporeal cases were compared. Operative time was significantly longer (p < 0.001) and incision length shorter in the intracorporeal group (p = 0.007). Outcomes significantly favorable for the intracorporeal group included conversion-to-open (p = 0.013), time to first flatus (p < 0.001), time to first bowel movement (p = 0.006), and dehydration (p = 0.03). There were more extraction site hernias in the midline compared to off-midline locations, though this difference did not reach statistical significance (p = 0.06)., Conclusion: There are outcomes advantages for the intracorporeal technique for robotic-assisted right colectomy when compared to the extracorporeal approach for patients in an Enhanced Recovery Pathway. Training efforts should continue to advocate the intracorporeal option., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Multimodal pain management is an integral part of enhanced recovery pathways. The most effective pain management strategies have not been determined., Objective: The purpose of this study was to compare liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing colorectal surgery., Design: This is a single-institution, open-label randomized (1:1) trial., Setting: This study compared liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing elective open and minimally invasive colorectal surgery in an enhanced recovery pathway., Patients: Two hundred were enrolled. Following randomization, allocation, and follow-up, there were 92 patients with transversus abdominis plane block and 87 patients with epidural analgesia available for analysis., Interventions: The interventions comprised liposomal bupivacaine transversus abdominis plane block versus epidural analgesia., Main Outcome Measures: The primary outcomes measured were numeric pain scores and the overall benefit of analgesia scores., Results: There were no significant differences in the Numeric Pain Scale and Overall Benefit of Analgesia Score between groups. Time trend analysis revealed that patients with transversus abdominis plane block had higher numeric pain scores on the day of surgery, but that the relationship was reversed later in the postoperative period. Opioid use was significantly less in the transversus abdominis plane block group (206.84 mg vs 98.29 mg, p < 0.001). There were no significant differences in time to GI recovery, hospital length of stay, and postoperative complications. Cost was considerably more for the epidural analgesia group., Limitations: This study was conducted at a single institution., Conclusions: This randomized trial shows that perioperative pain management with liposomal bupivacaine transversus abdominis plane block is as effective as epidural analgesia and is associated with less opioid use and less cost. These data and the more favorable risk profile suggest that liposomal bupivacaine transversus abdominis plane block is a viable multimodal perioperative pain management option for this patient population in an established enhanced recovery pathway., Clinical Trial Registration: http://www.clinicaltrials.gov (NCT02591407). See Video Abstract at http://links.lww.com/DCR/A737.

Mosquitoes are intensely studied as vectors of disease-causing pathogens, but we know relatively less about microbes that naturally reside in mosquitoes. Profiling resident bacteria in mosquitoes can help identify bacterial groups that can be exploited as a strategy of controlling mosquito populations. High-throughput 16S rRNA gene sequencing and traditional culture-based methods were used to identify bacterial assemblages in Culex quinquefasciatus Say (Diptera: Culicidae) in a tissue- and stage-specific design. In parallel, wild host Cx. quinquefasciatus was compared with our domestic strain. 16S rRNA genes survey finds that Cx. quinquefasciatus has taxonomically restricted bacterial communities, with 90% of its bacterial microbiota composed of eight distinctive bacterial groups: Nocardioidaceae (Actinomycetales), Microbacteriaceae (Actinomycetales), Flavobacteriaceae, Rhizobiales, Acetobacteraceae, Rickettsiaceae, Comamondaceae (Burkholderiales), and Enterobacteriaceae. Taking into account both metagenome- and culture-based methods, we suggest three bacterial groups, Acetobacteraceae, Flavobacteriaceae, and Enterobacteriaceae, as candidates for mutualists in Cx. quinquefasciatus. Members of these three bacterial families have been studied as mutualists, or even as symbionts, in other insect groups, so it is quite possible they play similar roles in mosquitoes.

Objective: This study aims to identify effective strategies related to recruitment and retention of immigrant survey participants., Methodology: The study used a multi-mode approach in, first, conducting a literature review of recent articles on surveys that either targeted immigrants or included large numbers of immigrants in their samples. Next, six surveys were reviewed that either targeted or included large numbers of immigrants. Finally, expert opinions on immigration were gathered regarding recruitment and retention of immigrant survey participants., Results: Although immigrants may be difficult to recruit due to limited English proficiency, mistrust of strangers, and/or high mobility, many of these challenges can be overcome by adopting the same strategies used when surveying ethnically diverse populations (e.g., snowballing versus advertisement, establishing a personal connection with data collectors). Nonetheless, a few practices were identified as most relevant for recruitment and retention of immigrant populations, including involving local community organizations relevant to immigrants, translation of materials tailored to the vernacular language of the various ethnicities, and customizing non-monetary incentives to the specific ethnicity., Conclusions: Based on the reviews and expert interviews, multiple strategies have been shown to be effective in recruiting and retaining immigrant participants.

Many techniques for laparoscopic appendectomy have been proposed with few comparative studies. We performed a retrospective review of all patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from 2006 to 2011. Techniques were: (1) transection of the mesoappendix and appendix with a single staple line (SSL); (2) transection of the mesoappendix and appendix with multiple staple lines (MSL); and (3) transection of the mesoappendix with ultrasonic shears and the appendix with a single staple line (USSL). A total of 565 cases were reviewed (149 SSL, 259 MSL, and 157 USSL). Patients treated with the SSL technique had decreased operative duration (P<0.001) and length of stay (P=0.003) despite equivalent disease presentations. Multivariate analysis demonstrated decreased operative duration with the SSL technique (P=0.001). Use of a SSL for transection of the mesoappendix and appendix is both a safe and efficient technique that results in reduced operative duration with excellent surgical outcomes.

The aim of the present study was to clarify the mechanisms underlying body understanding by examining the impact of visual experience (magnification and reduction) on perception of hand size and neutral external objects (squares). Independent groups of participants were asked to look through a 2× magnification lens, a ½-× reduction lens, or a control UV filter and to make visual size judgments about square stimuli and their hands. In Experiment 1, participants used a measuring device with unmarked wooden slats orientated in horizontal and radial/vertical space for their visual judgments. In Experiment 2, participants used an upright frontal slat for visual length judgments of their hands to eliminate any potential foreshortening in viewing the measurement apparatus. The results from the two experiments demonstrate that participants significantly underestimated both the square stimuli and their hands when they viewed them under a reduction lens. While overestimation and underestimation of squares was found for females in Experiment 2, males generally underestimated the squares. However, overestimation was not seen when the participants viewed their hands under a magnification lens. Implications of these findings are discussed.

An accurate measurement of BSA involved in patients injured by burns is critical in determining initial fluid requirements, nutritional needs, and criteria for tertiary center admissions. The rule of nines and the Lund-Browder chart are commonly used to calculate the BSA involved. However, their accuracy in all patient populations, namely obese patients, remains to be proven. Detailed BSA measurements were obtained from 163 adult patients according to linear formulas defined previously for individual body segments. Patients were then grouped based on body mass index (BMI). The contribution of individual body segments to the TBSA was determined based on BMI, and the validity of existing measurement tools was examined. Significant errors were found when comparing all groups with the rule of nines, which overestimated the contribution of the head and arms to the TBSA while underestimating the trunk and legs for all BMI groups. A new rule is proposed to minimize error, assigning 5% of the TBSA to the head and 15% of the TBSA to the arms across all BMI groups, while alternating the contribution of the trunk/legs as follows: normal-weight 35/45%, obese 40/40%, and morbidly obese 45/35%. Current modalities used to determine BSA burned are subject to significant errors, which are magnified as BMI increases. This new method provides increased accuracy in estimating the BSA involved in patients with burn injury regardless of BMI.

Three experiments examined gender differences in picture location memory in the sense of touch involving the change task. In Experiments 1 and 2, blindfolded sighted participants felt 15 tangible raised-line pictures and memorized their locations for 8 min. Subsequently, they felt another set of raised-line pictures that were identical to the original set, but locations were exchanged for 6 of them. The change task required participants to indicate which raised-line pictures were moved to new locations and which were not moved. It was expected that females would show superior picture location memory compared with males. The results showed that females had a significantly higher number of correct picture location judgments than males in Experiment 1. No differences appeared between males and females on the change task when the task was much more difficult and the raised-line pictures were irregularly arrayed in the second experiment. Task difficulty was too high in Experiment 2, and a third experiment reduced the number of pictures in the irregular array to 12. Females performed better than males in Experiment 3. Gender differences in the change task are small in magnitude in touch as well as in vision. The results of the present experiments using touch are consistent with the larger literature in vision.

We examined haptic viewpoint effects in blindfolded-sighted (BS) and visually impaired subjects: early blind (EB), late blind (LB), and very low vision (VLV). Participants felt complex objects and matched tangible pictures to them. In experiment 1, the EB and BS subjects had similar overall performance. Experiment 2 showed that the presence of a detail on the target object lowered performance in the BS subjects, and that matching accuracy was lower overall for top views for the blind subjects. In experiments 3-5, EB, LB, VLV, and BS subjects made judgments about perspective pictures of a model house with more salient object details. In experiment 3, performance was higher for side views than for corner views. Elevated side views were identified more readily than elevated corner views in experiment 4. Performance for top views was higher than for elevated side views in experiment 5, given the relative simplicity of the top-view depictions and salient details. The EB and BS participants had somewhat lower matching accuracy scores than the other groups. We suggest that visual experience is helpful, but not essential for picture perception. Viewpoint effects may vary with experience and object complexity, but the relevant experience need not be specifically visual in nature.

In acute care facilities, the orientation period for new graduates has been lengthened to ensure that the new nurse can confidently care for patients. The resulting extension of precepted time places preceptors at a high risk for burnout. To address this issue, team preceptorships during a nurse residency program were implemented as an alternative to a single-preceptor approach. The development, implementation, and evaluation of the team preceptorship model are discussed.

A series of experiments was carried out to examine the effect of curvature on haptic judgments of extent in sighted and blind individuals. Experiment 1 showed that diameters connecting the endpoints of semicircular lines were underestimated with respect to straight lines, but failed to show an effect of visual experience on length judgments. In experiment 2 we tested are lengths. The effects of curvature on perceived path length were weaker, but were still present in this experiment. Visual experience had no effect on path length judgments. Another experiment was performed to examine the effect of repeated tracing (1, 5, 9, or unlimited number of traces) on judgments of the lengths of straight lines and diameters of semicircles. Judgments of extent were more accurate when subjects engaged in larger numbers of traces. There was no effect of number of traces on curve-height judgments, suggesting that subjects were not using height estimates to judge diameters of semicircles. In a further experiment we tested the effect of number of traces on curves that varied in height. Restricting subjects to a single trace magnified the effect of path length on judgments of the distance between the endpoints of curves. Additional experiments showed that curvature effects on diameter judgments were not eliminated when stimuli were in the frontal plane or when the curves were explored with the use of two hands. Arm support had no effect on judged length in experiment 7. A final experiment showed a robust horizontal vertical illusion in haptic perception of convex curves, with overestimation of the heights of the curves compared with their widths. The practical and theoretical implications of the results are discussed.

The objective of this study was to test the hypothesis that the incidence and severity of clinical coliform mastitis could be decreased by Re-17 mutant Salmonella typhimurium bacterin toxoid. Holstein-Friesian cows from two Arizona dairies were selected for this study based on July through November projected calving dates; peak lactation occurred during the period of highest rainfall and peak environmental stress. The cows were randomly assigned to either a vaccinate or a control group, and 1292 cows were paired by herd, parity, calving date, and milk yield. The 646 vaccinates were injected twice during the third trimester of pregnancy with an Re-17 mutant S. typhimurium bacterin toxoid, and the 646 controls were not vaccinated. Vaccinated cows had significantly fewer clinical cases of coliform mastitis with positive coliform cultures and had lower culling rate from coliform mastitis than control cows during the first 5 mo of lactation. During the same period, the mortality rate from clinical coliform mastitis was 75% less in the vaccinated clinical coliform mastitic group than in the control group. Incidence of mastitis increased with advancing parity. The Re-17 mutant Salmonella typhimurium bacterin toxoid provided cross-protection against coliform mastitis; incidence and severity of clinical coliform mastitis were significantly lowered during the first 5 mo of lactation.