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Abstract Background Acute pancreatitis (AP) is an inflammatory disorder that causes a considerable economic health burden. While the overall mortality is low, around 20% of patients have a complicated course of disease resulting in increased morbidity and mortality. There is an emerging body of evidence that the microbiome exerts a crucial impact on the pathophysiology and course of AP. For several decades multiple clinical and laboratory parameters have been evaluated, and complex scoring systems were developed to predict the clinical course of AP upon admission. However, the majority of scoring systems are determined after several days and achieve a sensitivity around 70% for early prediction of severe AP. Thus, continued efforts are required to investigate reliable biomarkers for the early prediction of severity in order to guide early clinical management of AP patients. Methods We designed a multi-center, prospective clinical-translational study to test whether the orointestinal microbiome may serve as novel early predictor of the course, severity and outcome of patients with AP. We will recruit 400 AP patients and obtain buccal and rectal swabs within 72 h of admission to the hospital. Following DNA extraction, microbiome analysis will be performed using 3rd generation sequencing Oxford Nanopore Technologies (ONT) for 16S rRNA and metagenomic sequencing. Alpha- and beta-diversity will be determined and correlated to the revised Atlanta classification and additional clinical outcome parameters such as the length of hospital stay, number and type of complications, number of interventions and 30-day mortality. Discussion If AP patients show a distinct orointestinal microbiome dependent on the severity and course of the disease, microbiome sequencing could rapidly be implemented in the early clinical management of AP patients in the future. Trial registration: ClinicalTrials.gov Identifier: NCT04777812

Importance: Persistent hypothermia after cardiopulmonary bypass (CPB) in neonates with congenital heart defects (CHD) has been historically considered benign despite lack of evidence on its prognostic significance., Objectives: Examine associations between the magnitude and pattern of unintentional postoperative hypothermia and odds of complications in neonates with CHD undergoing CPB., Design: Retrospective cohort study., Setting: Single northeastern U.S., urban pediatric quaternary care center with an established cardiac surgery program., Participants: Population-based sample of neonates greater than or equal to 34 weeks gestation undergoing their first CPB between 2015 and 2019., Interventions: None., Main Outcomes and Measurements: Hourly temperature measurements for the first 48 postoperative hours were extracted from inpatient medical records, and clinical characteristics and outcomes were accessed through the local patient registry. Group-based trajectory modeling (GBTM) identified latent temporal temperature trajectories. Associations of trajectories with outcomes were assessed using multivariable binary logistic regression. Outcomes (postoperative complications) were manually adjudicated by experts or were predefined by the patient registry., Results: Four hundred fifty neonates met inclusion criteria. Their mean (sd) gestational age was 38 weeks (1.3), mean (sd) birth weight was 3.19 kilograms (0.55), median (interquartile range) surgical age was 4.7 days (3.3-7.0), 284 of 450 (63%) were male, and 272 of 450 (60%) were White. GBTM identified three distinct curvilinear temperature trajectories: persistent hypothermia (n = 38, 9%), resolving hypothermia (n = 233, 52%), and normothermia (n = 179, 40%). Compared with the normothermic group, those with persistent hypothermia had significantly higher odds of cardiac arrest, actionable arrhythmia, delayed first successful extubation, prolonged cardiac ICU length of stay, very poor weight gain, and 30-day hospital mortality. The persistent hypothermia group was characterized by greater odds of having a lower gestational age, more prevalent neurologic abnormalities, more unplanned reoperations, and a low surgical mortality risk assessment., Conclusions: Persistent postoperative hypothermia in neonates after CPB is independently associated with having greater odds of complications. Recovery patterns from postoperative hypothermia may be a clinically useful marker to identify patient instability in neonates. Additional research is needed for causal modeling and prospective validation before clinical adoption., Competing Interests: Dr. Henker is a member of the Critical Care Explorations editorial board. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

This continuing medical education article highlights the central role of transcutaneous sonography in diagnosing parenchymal pancreatic diseases. It emphasizes the importance of in-depth knowledge of sonographic imaging of organ anatomy and a structured examination methodology, particularly for identifying acute and chronic pancreatitis and related complications. The article provides detailed guidance for optimized examination techniques and equipment settings, even under challenging conditions, and discusses the application of ultrasound in various scenarios of pancreatic diseases. Moreover, the relevance of advanced sonographic techniques such as high-frequency sonography, elastography, and contrast-enhanced sonography is illuminated in the context of expanded diagnostic workup., Competing Interests: Declaration of financial interestsReceipt of research funding: yes, from another institution (pharmaceutical or medical technology company, etc.); receipt of payment/financial advantage for providing services as a lecturer: yes, from another institution (pharmaceutical or medical technology company, etc.); paid consultant/internal trainer/salaried employee: no; patent/business interest/shares (author/partner, spouse, children) in company: no; patent/business interest/shares (author/partner, spouse, children) in sponsor of this CME article or in company whose interests are affected by the CME article: no.Declaration of non-financial interestsVB and TK are actively involved in leading the Internal Medicine Section of the German Society for Ultrasound in Medicine (DEGUM)., (Thieme. All rights reserved.)

Objective: Early disease prediction is challenging in acute pancreatitis (AP). Here, we prospectively investigate whether the microbiome predicts severity of AP (Pancreatitis-Microbiome As Predictor of Severity; P-MAPS) early at hospital admission., Design: Buccal and rectal microbial swabs were collected from 424 patients with AP within 72 hours of hospital admission in 15 European centres. All samples were sequenced by full-length 16S rRNA and metagenomic sequencing using Oxford Nanopore Technologies. Primary endpoint was the association of the orointestinal microbiome with the revised Atlanta classification (RAC). Secondary endpoints were mortality, length of hospital stay and severity (organ failure >48 hours and/or occurrence of pancreatic collections requiring intervention) as post hoc analysis. Multivariate analysis was conducted from normalised microbial and corresponding clinical data to build classifiers for predicting severity. For functional profiling, gene set enrichment analysis (GSEA) was performed and normalised enrichment scores calculated., Results: After data processing, 411 buccal and 391 rectal samples were analysed. The intestinal microbiome significantly differed for the RAC (Bray-Curtis, p value=0.009), mortality (Bray-Curtis, p value 0.006), length of hospital stay (Bray-Curtis, p=0.009) and severity (Bray-Curtis, p value=0.008). A classifier for severity with 16 different species and systemic inflammatory response syndrome achieved an area under the receiving operating characteristic (AUROC) of 85%, a positive predictive value of 67% and a negative predictive value of 94% outperforming established severity scores. GSEA revealed functional pathway units suggesting elevated short-chain fatty acid (SCFA) production in severe AP., Conclusions: The orointestinal microbiome predicts clinical hallmark features of AP, and SCFAs may be used for future diagnostic and therapeutic concepts., Trial Registration Number: NCT04777812., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Investing in clinical education is important for adult urgent and emergency surgery and traumatology as it promotes registered nurses' competencies by providing professional development training to respond to urgent or emergency surgeries., Objective: To examine registered nurses' self-assessment of the effects of virtual video simulation with an immediate debriefing approach on nursing process competencies, nursing care quality, incomplete care, and patient safety in surgical units., Methods: This study used a quasi-experimental two-group pre- and post-test design. The study was conducted at two provincial hospitals in Cambodia. Participants included registered nurses employed in surgical units. The experimental group ( n  = 46) completed a virtual video simulation and immediate debriefing. The control group ( n  = 35) completed virtual training on the nursing process. Data were collected two months after a successful second-week follow-up using Competency of Nursing Process, Cambodian Nursing Care Quality, Care Left Undone, and Patient Safety scales. Wilcoxon signed-rank test and Mann-Whitney U test were used to evaluate the differences before and after the sessions. Generalized linear model was used to compare the differences between the two groups., Results: The results showed statistically significant improvements in the experimental group on competency, nursing care quality, patient safety, and reducing care left undone after the intervention. However, the control group revealed statistically insignificant differences. In addition, the experimental group provided positive feedback, such as experiencing a real patient scenario, developing critical-thinking, improving communication skills, and having an opportunity to ask questions., Conclusion: Our study showed that VVS and immediate debriefing have the potential to support in-service training of RNs from diverse backgrounds. Particularly, integrating virtual video simulation and immediate debriefing may to promote competency in the nursing process and improve care outcomes., Competing Interests: National Ethics Committee for Health Research (no. 017 NECHR). The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 Published by Elsevier Ltd.)

Aim: To assess the effects of the nursing workforce and advanced nursing practice on the outcomes of patients and life expectancy, including mortality rates of under-five children in Cambodia, and to develop policy recommendations to increase the influence of the nursing workforce., Background: In low-middle-income nations, life expectancy and under-five mortality are important measures of public health. However, there is still a dearth of literature related to the nursing workforce in Southeast Asia., Method: The authors retrieved the data from the World Nursing Report produced by the World Health Organization 2020 for 10 member states. The transparent reporting of a multivariable prediction model for individual prognosis or diagnosis checklist has guided this study. The univariate linear regression model was applied to categorize the potential predictors for each outcome assessment. In addition, the Spearman rank correlation test was selected to assess the potential predictors, and a multivariate statistical analysis was carried out for each of the five outcomes., Results: According to the study's findings, nurse density and advanced practice nursing improve both female and male life expectancy. The existence of advanced nursing roles is associated with decreased under-five mortality., Conclusions: There are great opportunities to improve the nursing workforce within Cambodia and other Association of Southeast Asian Nations member states to increase patient outcomes. Investment in nursing is essential for improved patient outcomes., Implications for Nursing and Health Policy: Health policy investments in these projects and future initiatives intended to advance nurse density, education, and practice are based on this study's results. Policy initiatives should focus on increasing density because nursing appears to impact life expectancy and other outcomes., (© 2023 International Council of Nurses.)

Background: An increasing number of international patients continue to visit emergency departments (EDs) in Japanese hospitals. However, nurses in Japan perceive challenges when caring for patients from other countries. This study explored ED nurses' perceptions of barriers when caring for walk-in international patients., Methods: Five semi-structured online focus group interviews involving 15 registered nurses with experience in caring for patients in an ED at a university referral hospital located in the center of Tokyo were conducted. Thematic analysis was used to identify patterns from the interviews., Results: The themes that emerged were as follows: (1) hesitation to engage with patients due to ambiguity, (2) loss of harmony in the ED, (3) difficulty with mutual goal settings, and (4) decreased professional self-efficacy., Conclusion: The findings provide an understanding of the challenges faced when caring for walk-in international patients. Educational interventions for ED nurses and other strategies, such as the use of interpreters, can enhance nurses' abilities to improve patient safety and maintain equality., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Aim: To test a modified team-based learning approach on undergraduate learning outcomes in an acute-care nursing course in Japan., Design: Mixed-methods., Methods: Students worked on three simulated cases, engaged in pre-class preparation, completed a quiz and engaged in group work. We collected data on team approach, critical-thinking disposition and time spent in self-learning at four time-points: before the intervention and after each simulated case. Data were analysed using a linear mixed model, a Kruskal-Wallis test and a content analysis., Data Sources: We recruited nursing students attending a mandatory course in acute-care nursing at University A. Data were collected at four time-points between April and July 2018. Data from 73 of 93 respondents were analysed., Results: Team approach, critical thinking and self-learning all increased significantly across the time-points. Four categories emerged from students' comments: 'achievement of teamwork', 'sense of learning efficacy', 'satisfaction with course approach' and 'issues related to course approach'. The modified team-based learning approach led to improvements in team approach and critical-thinking disposition across the course., Conclusion: Incorporating team-based learning into the curriculum not only contributes to team building but is also effective as a teaching method to improve student learning., Implications for the Profession And/or Patient Care: The intervention led to improvements in team approach and critical-thinking disposition across the course. The educational intervention also led to more time for self-learning. Future studies should include participants from various universities and evaluate the outcomes over a longer period., (© 2023 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Objectives: This study aimed to develop and evaluate a competency of nursing process questionnaire (CNPQ) for registered nurses in Cambodia., Methods: Guided by the nursing process, an initial questionnaire was generated through focus group discussion, literature review, and the expert consultation. Finally, the validity and reliability of the questionnaire were validated through a questionnaire survey online of 260 registered nurses selected from Complimentary Package Activities 1, 2, 3, and national hospitals from January to February 2022 in five geographic areas of Cambodia., Results: The content validity index was 1.00. The Cronbach's α coefficient for the whole questionnaire was 0.963, and the range for the five dimensions was 0.963-0.964, which shows that the questions were consistent. The test-retest reliability was 0.769. The exploratory factor analysis led to a list of 24 items that were grouped into five dimensions: assessment, diagnosis, planning, implementation, and evaluation. The cumulative variance contribution rate was 70.08%., Conclusions: The CNPQ developed in this study showed good reliability and validity and can be used to assess the competency of registered nurses by themselves and help nursing managers to develop the relevant policies., Competing Interests: The authors have declared no conflict of interest., (© 2023 The Authors.)

Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed., (Published by Elsevier Ltd.)

Insulinomas are the most common functioning pancreatic neuroendocrine tumors (NET), which can lead to hyperinsulinemic hypoglycemia. In advanced metastatic stages of the disease, the prognosis is poor. Patients with hormonally active insulinomas primarily present with features of neuroglycopenia. Transformation from a nonfunctional to a functional NET is rare. Here, we present a case of a 59-year-old male adult with a metastatic insulinoma and late onset of endocrine activity. Besides medical treatment with Diazoxide and small frequent feedings, continuous intravenous glucose application was eventually required to avoid hypoglycemia. Furthermore, we show that selective internal radiation therapy (SIRT) can be an effective therapeutic approach for symptom reduction in advanced metastatic disease., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Intravenous dantrolene is the first-line treatment of malignant hyperthermia (MH), however, it is not always accessible in lower-middle income countries (LMICs). Facilities in the United States are in a transition period where dantrolene is being replaced with Ryanodex, therefore, there is an opportunity for excess dantrolene to be utilized in LMICs where neither dantrolene nor Ryanodex exist. Thirty-six vials of recently expired, unused dantrolene were obtained for a hospital in a LMIC and an MH program was developed in conjunction with the Lao Friends Hospital for Children (LFHC) anesthesia providers, LFHC liaison, LFHC leadership team, and an expert in the field of MH. Components of the MH program included developing a facility-specific protocol, treatment guidelines, supply list, and educational tools. A designated MH drawer was also created in preparation for an MH event. By procuring dantrolene and implementing an MH program in a facility where no MH protocol, treatment guidelines, supply list, or educational tools existed, LFHC is better equipped to handle a potentially lethal scenario., Competing Interests: Name: Alyssa Smith, DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Barbara Brandom, MD Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Laurel Miner, PhD, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Richard Henker, PhD, CRNA, FAANA, FAAN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. The authors did not discuss off-label use within the article. Disclosure statements are available upon request., (Copyright © by the American Association of Nurse Anesthetists.)

Many outpatient gastrointestinal procedures are completed with propofol anesthesia. A side effect of propofol is airway obstruction and subsequent hypoxia. This study was designed to determine whether the use of a high-flow nasal cannula is associated with a decreased incidence of hypoxia or airway obstruction in patients undergoing propofol sedation in the gastrointestinal laboratory with a STOP-BANG score ≥5. High-flow nasal cannula was administered at 70 L/min on 27 patients with a STOP-BANG score ≥5 receiving monitored anesthesia care sedation for an esophagogastroduodenoscopy, endoscopic ultrasound, or colonoscopy procedure. Patients were compared to a group from a previous project without the use of high-flow nasal cannula assessing whether hypoxia, apnea, or the need for airway maneuvers occurred. The non-high-flow nasal cannula group required an airway maneuver 53.3% (n = 8) whereas the high-flow nasal cannula group required an airway maneuver 18.5% (n = 5) (p = .021). High-flow nasal cannula was associated with a reduced need for airway maneuvers in patients with a high risk of obstructive sleep apnea undergoing propofol-assisted procedures., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Society of Gastroenterology Nurses and Associates.)

Acute pancreatitis is a primary sterile inflammation of the pancreas, which is characterized by an unphysiological enzyme activation. This leads to an inflammatory reaction with edema, vascular damage and cell decay. The first German interdisciplinary S3 guidelines on chronic pancreatitis were published in 2012. Under the auspices of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) and with the participation of various societies and patient representatives, the guidelines were recently revised and extended, Comprehensive S3 guidelines on acute and chronic pancreatitis were compiled and agreed by consensus. This article presents the important clinical aspects on acute pancreatitis from these guidelines in a compact form and the recommendations are justified., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

This descriptive exploratory study sought to gain insight about where caregivers of children with Down syndrome find information regarding anesthesia and the experiences of these caregivers when their child had to receive an anesthetic. We hypothesized that the Internet and social media were major sources of information. We recruited parents/caregivers via Down syndrome organizational websites and social media. A total of 515 participants completed a 24-question survey. Descriptive analysis and content analysis were used to analyze the data. Nearly all participants (96%) indicated their child had received an anesthetic. Reportedly, 41.2% had never searched the Internet about anesthesia. Responses indicated that caregivers obtained information mostly from Facebook groups and local websites and groups. Respondents believed the information was helpful (88.2%) but considered it to be only somewhat trustworthy (73.3%). Most (82%) indicated they would prefer a face-to-face conversation with the anesthesia provider. Among participants, 45% reported having a positive experience with anesthesia, 25% reported a negative experience, and 30% responded neither. Negative experiences involved children who had symptoms of emergence delirium and regression or when the caregiver perceived there were unexpected complications. These results are intended to be used to develop a checklist for caregivers when speaking to anesthesia providers., Competing Interests: Name: Kathleen Piotrowski, DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Christine M. DeSilva, MS, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Melissa Dominick, DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Richard Henker, PhD, CRNA, FAAN, FAANA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Laurel Kinsey, DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Joshua Dunn, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. The authors did not discuss off-label use within the article. Disclosure statements are available for viewing upon request., (Copyright © by the American Association of Nurse Anesthetists.)

This study aimed to investigate the impact of preoperative psychological factors on postoperative pain. We included 300 postoperative patients who underwent open reduction and internal fixation surgery. Pain Scale, Pain Catastrophizing Scale, and Depression, Anxiety, and Stress Scale were completed by patients preoperatively and at 24 hours after surgery. Clinical characteristics were obtained from medical records. Data were analyzed using multiple linear regression. Postoperative pain was predicted by pain catastrophizing and anxiety symptoms. High preoperative catastrophizing and anxiety levels were associated with increased pain postoperatively. However, the relationships between preoperative depressive and stress symptoms and postoperative pain were not significant.

Aim: Severe pain in the immediate postoperative period can negatively affect patients' quality of recovery, prolong hospital stay, and increase the risk of developing persistent pain. This study aimed to examine the predictors of severe postoperative pain in the immediate postoperative period among orthopedic trauma patients., Methods: A prospective observational study design was used. Data were collected from 153 patients that underwent orthopedic surgery procedures. Pain scores were assessed by a numeric pain scale at 45 min in the Post Anesthesia Care Unit. Physical health status was measured by the American Society of Anesthesiologists Status Classification System, and total dose of opioids (converted to morphine equivalents) and other demographic and clinical characteristics were recorded from medical records., Results: Preoperative smoking and physical health status were statistically significant predictors of severe postoperative pain in the immediate postoperative period. The odds of severe postoperative pain for smokers were 2.42 times the odds of nonsmokers. Patients with severe systemic disease showed 4.27 times lower odds of severe pain than more healthy patients., Conclusion: Preoperative predictors of severe postoperative pain should be considered when assessing and treating orthopedic patients postoperatively to assure adequate pain relief., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

In Japan, a relative shortage of practicing anesthesiologists continues to be a national issue. To address this issue, some Japanese medical institutions have started developing curriculums to train non-physician perioperative anesthesia personnel, including nurse practitioners and perianesthesia nurses. We urgently need to establish a national standard for the education programs that train these extended non-physician anesthesia care providers. A certified registered nurse anesthetist educational program at a large academic medical center in the United States is described in detail as a reference. Highly systematic educational programs using simulation, didactics, and full clinical subspecialty rotations are ideal if not easily achievable in many current training institutions in Japan. Anesthesia assistant education programs in the United States can be used as an additional reference to create a national educational program in Japan., Competing Interests: None of the authors has any conflicts of interest to declare about this work.

Background: Acute pancreatitis (AP) is an inflammatory disorder that causes a considerable economic health burden. While the overall mortality is low, around 20% of patients have a complicated course of disease resulting in increased morbidity and mortality. There is an emerging body of evidence that the microbiome exerts a crucial impact on the pathophysiology and course of AP. For several decades multiple clinical and laboratory parameters have been evaluated, and complex scoring systems were developed to predict the clinical course of AP upon admission. However, the majority of scoring systems are determined after several days and achieve a sensitivity around 70% for early prediction of severe AP. Thus, continued efforts are required to investigate reliable biomarkers for the early prediction of severity in order to guide early clinical management of AP patients., Methods: We designed a multi-center, prospective clinical-translational study to test whether the orointestinal microbiome may serve as novel early predictor of the course, severity and outcome of patients with AP. We will recruit 400 AP patients and obtain buccal and rectal swabs within 72 h of admission to the hospital. Following DNA extraction, microbiome analysis will be performed using 3rd generation sequencing Oxford Nanopore Technologies (ONT) for 16S rRNA and metagenomic sequencing. Alpha- and beta-diversity will be determined and correlated to the revised Atlanta classification and additional clinical outcome parameters such as the length of hospital stay, number and type of complications, number of interventions and 30-day mortality., Discussion: If AP patients show a distinct orointestinal microbiome dependent on the severity and course of the disease, microbiome sequencing could rapidly be implemented in the early clinical management of AP patients in the future., Trial Registration: ClinicalTrials.gov Identifier: NCT04777812., (© 2021. The Author(s).)

A high prevalence of undiagnosed obstructive sleep apnea (OSA) exists in patients receiving sedation for gastrointestinal laboratory (GI lab) procedures, with potentially serious adverse events associated with untreated OSA. This quality improvement project aimed to identify patients at high risk of OSA and evaluate their risk of intraprocedure airway maneuvers and adverse events in a GI lab. In the GI lab, nurses administered and documented the STOP-BANG questionnaire as part of their pre-procedure assessment of 80 patients presenting for elective procedures. The occurrence of airway maneuvers and adverse events during the procedures was measured using a checklist given to nurse anesthetists as they brought patients to the postprocedure area. Patients with STOP-BANG scores below 5 and with scores of 5 and above were compared. Descriptive and inferential statistics were used to analyze differences in patient outcomes. Patients with high STOP-BANG scores had an increased need for airway maneuvers and higher occurrence of adverse events (P=.05). These results support the use of STOP-BANG as a pre-procedure risk assessment tool. Anesthesia professionals can anticipate intraprocedure airway interventions, consider preemptive interventions in a GI lab, and be more vigilant when caring for patients with high STOP-BANG scores at high risk of undiagnosed OSA., Competing Interests: The authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did not discuss off-label use within the article. Disclosure statements are available for viewing upon request., (Copyright © by the American Association of Nurse Anesthetists.)

Purpose: To evaluate the agreement of temporal artery temperature (Tat) with esophageal temperature (Tes) and oral temperature (Tor), and explore potential factors associated with the level of agreement between the thermometry methods in different clinical settings., Design: A prospective repeated measures (induction, emergence, and postanesthesia care unit) design was used., Methods: Temperature data were collected for 54 patients receiving general anesthesia. Analyses included descriptive statistics, paired t tests for the within-patient comparison of temperature methods, Bland-Altman plots to examine agreement between methods, and multiple linear regression to identify factors associated with the agreement between methods., Findings: Tat was significantly higher compared with Tes and Tor (P < .05) and was poor at detecting hypothermia. The use of a muscle relaxant and surgical site were suggested to be associated with the difference between Tat and Tes at emergence., Conclusions: Tat is more convenient, but less accurate, than other thermometry methods. These inaccuracies are exacerbated by common anesthetic medications., (Copyright © 2018 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Aims: The purpose of this study was to determine the reliability and validity of the Japanese version of the Richards-Campbell Sleep Questionnaire as a measure of sleep among intensive care unit patients in a Japanese hospital., Design: Cross-sectional survey., Methods: The Richards-Campbell Sleep Questionnaire was initially translated into Japanese using the back-translation method. Validity was evaluated by determining the association between sleep efficiency, measured using simplified polysomnography, and the total score on the Japanese version of the Richards-Campbell Sleep Questionnaire. Adult non-intubated intensive care unit patients who completed the five-item visual analogue scale underwent polysomnography for one night. Reliability was tested using Cronbach's alpha coefficient., Results: Thirty-three patients were included in the analysis. After excluding four patients with subsyndromal delirium, the Pearson correlation coefficient was 0.602 ( p  = 0.001). Cronbach's alpha coefficient was 0.911., Conclusion: The Japanese version of the Richards-Campbell Sleep Questionnaire could be used as an alternative to polysomnography when assessing sleep quality in lucid intensive care unit patients., Competing Interests: The authors declare no conflict of interest.

The relevance of gastrointestinal manifestations of cystic fibrosis (CF) is increasing due to an improved life expectancy. We report on 2 adult patients with prior lung transplantation who presented with a severe inflammatory disorder of the ileocecal region. One patient underwent ileocecal resection; the second patient died after emergency surgery for intestinal perforation. Both cases did not show typical signs of CF-related distal intestinal obstruction syndrome or extensive fibrosing colonopathy. However, the clinical and histopathological findings revealed CF-induced inflammatory alterations of the intestinal mucosa. Thus, these cases illustrate a further CF-related bowel disorder, which can be especially relevant in long-term CF survivors., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: This purpose of this case study and review was to understand perianesthesia care of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy surgery (CRS+HIPEC)., Design: Case study., Methods: The perianesthesiaa medical record of a patient under CRS+HIPEC was analyzed to study the characteristics of perianestheia care for CRS+HIPEC. The literature of perianestheisa care for CRS+HIPEC was reviewed., Findings: The challenges that perianesthesia care for CRS+HIPEC include-but are not limited to-electrolyte abnormalities, hemodynamic instabilities, and temperature fluctuation. Optimal perianesthesia management of a patient treated with CRS+HIPEC requires control of a complex interplay of physiologic mechanisms., Conclusions: Besides maintenance of clinical and laboratory parameters, and recognition and treatment of any changes, evidenced-based guidelines are needed, not only for the optimal perianesthesia management of these patients, but also to avoid potential life threatening intraoperative and postoperative complications. The standardization of perianesthesia management for CRS+HIPEC is a necessary step in meeting these goals., (Copyright © 2018 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Background: Mixed adenoneuroendocrine carcinomas (MANECs) are rare malignancies with both neuroendocrine and non-neuroendocrine components. To date, the prognosis of gastroenteropancreatic MANECs remains dismal, and treatment options are mainly based on guidelines for the treatment of pure neuroendocrine carcinomas or small cell lung cancer. Established first-line therapy in the metastatic situation is cisplatin and etoposide. Platinum derivatives are known to cause a variety of side effects also involving the visual system. Severe orbital and optic nerve toxicities have been described mainly after intracarotid infusion of cisplatin., Case Report: Herein we report a rare case of a 60-year-old male patient suffering from MANEC of the gastroesophageal junction with HER2/neu overexpression who developed severe orbital and ocular neurotoxicity (grade 3 according to CTCAE v4.03) after intravenous cisplatin., Conclusion: We discuss diagnostic approaches and differential diagnoses in this clinical situation. Before starting treatment with intravenous and topical steroids, it is crucial to rule out meningeal and cerebral spread as well as paraneoplastic and endocrine syndromes., (© 2019 S. Karger AG, Basel.)

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.

Because of a critical shortage of anesthesia providers in Belize, the Belize Ministry of Health initiated support for the creation of a nurse anesthesia education program. Developed in collaboration with Health Volunteers Overseas and the University of Belize, the nurse anesthesia education program graduated 10 nurse anesthetists. This article describes the 24-month nurse anesthesia education program’s design, implementation, and evaluation. Challenges and opportunities experienced during the program are outlined as lessons learned for planning similar programs.

Background: mu-opioid receptor ( OPRM1) and catechol-O-methyltransferase ( COMT) contribute to the neurotransmission pathway of pain. COMT affects mu receptor expression and density in the brain. The aim of this study was to explore the OPRM1 and COMT interaction effects on postoperative pain and opioid consumption., Methods: This cross-sectional exploratory study used genotype and clinical data from 153 postoperative patients. Using multiple regression analyses, four single-nucleotide polymorphisms of COMT (rs6269, rs4633, rs4818, and rs4680), their haplotypes, and diplotypes were considered for their interactions with A118G of OPRM1 regarding postoperative pain and opioid consumption., Results: For opioid consumption, significant interactions were found between OPRM1 A118G and COMT rs4680 ( p = .037) and between OPRM1 and COMT rs4633 ( p = .037). Patients having Met158Met of COMT rs4680 and AG/GG of OPRM1 or TT of COMT rs4633 and AG/GG of OPRM1 consumed the largest amount of opioid compared to those having other combinations. For postoperative pain, a significant interaction was found between OPRM1 and the low pain sensitivity (LPS; GCGG) haplotype of COMT ( p = .017). For patients with no copies of the LPS haplotype, AA of OPRM1 A118G was significantly associated with higher pain scores compared to the variant AG/GG. However, the opposite direction was observed for patients with at least one copy of the LPS haplotype., Conclusions: The interaction of OPRM1 with COMT may contribute to variability in postoperative pain and opioid consumption. Additional larger studies are needed to confirm findings.

Purpose/objectives: An efficient but comprehensive documentation system is essential for reducing nursing workload and ensuring adequate time for direct patient care. A "focus" is a nursing diagnosis or patient problem. The purpose of this project is to review and revise the focuses in the electronic charting system and to develop new focuses for documentation of clinical pathways. In addition, this project evaluated the impact of these changes on time required for documentation and nurse satisfaction., Background/rationale: In 2012, a large hospital in Taiwan implemented a self-developed electronic charting system that had 217 focuses in the database. Staff reported low job satisfaction and too much time on documentation. Three major issues were identified, including repetitious and redundant documentation, incorrect templates, and an incomprehensive database., Description: A clinical nurse specialist devised quality improvement project was implemented on one 50-bed surgical unit. Forty-one focuses were revised and 13 new focuses were developed for clinical pathways. The implementation of new focus templates enhanced evidence-based practice and prevented redundant documentation. Focus templates also incorporated nursing policies and/or patient education materials. Two outcome indicators, time spent documenting and nurse satisfaction, were evaluated 3 months after implementation., Outcomes: Documentation time decreased by 60% (from 138.5 to 55.8 hours) per week. The median documentation time per patient per day decreased from 18.4 minutes to 9.3 minutes. Average scores for satisfaction in usability, content, functionality, and effectiveness were increased., Conclusion: Evidence-based focus templates used for documentation can reduce documentation time and increase nurse satisfaction. Clinical nurse specialists play an important role in leading the development of quality improvement projects while improving work efficiency.

Cornerstone, or guiding documents, for nursing and healthcare support the profession of nursing throughout the world. This article describes the impact of the civil war and instability in Cambodia that led to poverty and destruction of the healthcare system and provides a brief overview of nursing in Cambodia today. Since the 1990s, the Cambodian healthcare system has been recovering from war. Nurses have been transitioning from task oriented roles to more sophisticated roles that incorporate the nursing process. In addition to significant changes in nursing education and other advances in the healthcare system during the last five years, the Ministry of Health (MoH) has strongly encouraged the development of cornerstone documents to guide nursing practice for patient care provided in Cambodia. Standards and competencies have been developed based on the American Nurses Association (ANA) template for Scope and Standards of Practice. Cornerstone documents for nursing that have been implemented by the MoH, many at the Angkor Hospital for Children, include evidence based protocols, the nursing process framework, the Code of Ethics for Nurses and development of the Scope of Practice and Standards of Care for Cambodian Nurses.

This article discusses the glucose monitoring and treatment practices of a small community hospital and aims to determine how these practices relate to postoperative complications in patients undergoing vascular surgery. Previous studies in patients undergoing cardiovascular surgery have demonstrated that glucose control directly affects outcomes, including length of stay and incidence of infection, stroke, renal failure, myocardial infarction, and readmissions within 30 days of the initial surgery. A retrospective analysis of 101 patients who underwent vascular surgery was performed. After informed consent was obtained, patient charts were reviewed. Perioperative blood glucose levels, frequency of monitoring, treatment practices, and postoperative complications were collected by review of both electronic and paper medical records. Twenty-seven of the 101 patients had a blood glucose level greater than 140 mg/dL preoperatively. Intraoperative blood glucose levels were monitored for 8 patients. Nine patients had blood glucose levels treated during the perioperative period. The threshold for treatment of preoperative hyperglycemia was a blood glucose level of 236 mg/dL. Increased vigilance of perioperative blood glucose levels is needed so that appropriate interventions can be instituted and outcomes improved. Glucometers must be readily available to anesthesia providers so that intraoperative monitoring of blood glucose levels can occur.

Tetanus is a life-threatening disease that continues to have a high prevalence in developing countries. Severe muscle spasms often require patients to receive tracheostomy, high-dose sedatives, and sometimes prolonged neuromuscular blockade. Magnesium sulfate (MgSO4) infusion has great promise as an adjunct treatment for severe tetanus, as it may allow clinicians to decrease the dose of other sedative medications. Although the mechanism of action of MgSO4 is not well understood, it appears to attenuate both the muscle spasms and autonomic instability associated with severe tetanus infections. However, MgSO4 infusions are often managed based on serial measurements of serum magnesium levels and other laboratory tests such as arterial blood gases, which can be difficult to obtain in resource-poor settings. We describe a case of severe tetanus in Bhutan managed through the use of magnesium infusion titrated solely to physical examination findings., (Copyright © 2014 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

In this study, we present first data concerning the anatomical structure, blood supply and location of the lacrimal gland of the pig. Our data indicate that the porcine lacrimal gland may serve as a potential xenograft candidate in humans or as an animal model for engineering of a bioartificial lacrimal gland tissue construct for clinical application. For this purpose, we used different macroscopic preparation techniques and digital reconstruction of the histological gland morphology to gain new insights and important information concerning the feasibility of a lacrimal gland transplantation from pig to humans in general. Our results show that the lacrimal gland of the pig reveals a lot of morphological similarities to the analogous human lacrimal gland and thus might be regarded as a xenograft in the future. This is true for a similar anatomical location within the orbit as well as for the feeding artery supply to the organ. Functional differences concerning the composition of the tear fluid, due to a different secretory unit distribution within the gland tissue will, however, be a challenge in future investigations.