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Harini Bejjanki,1 Lazarus K Mramba,2 Stacy G Beal,3 Nila Radhakrishnan,1 Rohit Bishnoi,1 Chintan Shah,1 Nikhil Agrawal,4 Neil Harris,3 Robert Leverence,1 Kenneth Rand3 1Division of Hospital Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA; 2Statistics, Department of Internal Medicine, University of Florida, Gainesville, FL, USA; 3Department of Pathology, Immunology, & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA; 4Department of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA Background: The recommendations of the American Board of Internal Medicine Foundation’s “Choosing Wisely®” initiative recognize the importance of improving the appropriateness of testing behavior and reducing the number of duplicate laboratory tests.Objective: To assess the effectiveness of an electronic medical record Best Practice Alert (BPA or “pop up”) intervention aimed at reducing duplicate laboratory tests and hospital costs.Design: Comparison of the number of duplicated laboratory tests performed on inpatients before and after the intervention.Setting: University of Florida Health Shands Hospital, Gainesville, FL, USA, during 2014–2017.Intervention: The electronic medical record intervention was a BPA pop-up alert that informed the ordering physician if a recent identical order already existed along with the “ordering time”, “collecting time”, “resulting time”, and the result itself.Main outcome measures: Percentage change in the number of inpatient duplicate orders of selected clinical biochemistry tests and cost savings from reduction of the duplicates. Student’s t-test and beta-binomial models were used to analyze the data.Results: Results from the beta-binomial model indicated that the intervention reduced the overall duplicates by 18% (OR=0.82, standard error=0.016, P-value

BACKGROUND AND PURPOSE: The Systolic Blood Pressure Intervention (SPRINT) randomized trial demonstrated that intensive blood pressure management resulted in slower progression of cerebral white matter hyperintensities, compared with standard therapy. We assessed longitudinal changes in brain functional connectivity to determine whether intensive treatment results in less decline in functional connectivity and how changes in brain functional connectivity relate to changes in brain structure. MATERIALS AND METHODS: Five hundred forty-eight participants completed longitudinal brain MR imaging, including resting-state fMRI, during a median follow-up of 3.84 years. Functional brain networks were identified using independent component analysis, and a mean connectivity score was calculated for each network. Longitudinal changes in mean connectivity score were compared between treatment groups using a 2-sample t test, followed by a voxelwise t test. In the full cohort, adjusted linear regression analysis was performed between changes in the mean connectivity score and changes in structural MR imaging metrics. RESULTS: Four hundred six participants had longitudinal imaging that passed quality control. The auditory-salience-language network demonstrated a significantly larger decline in the mean connectivity score in the standard treatment group relative to the intensive treatment group (P = .014), with regions of significant difference between treatment groups in the cingulate and right temporal/insular regions. There was no treatment group difference in other networks. Longitudinal changes in mean connectivity score of the default mode network but not the auditory-salience-language network demonstrated a significant correlation with longitudinal changes in white matter hyperintensities (P = .013). CONCLUSIONS: Intensive treatment was associated with preservation of functional connectivity of the auditory-salience-language network, while mean network connectivity in other networks was not significantly different between intensive and standard therapy. A longitudinal increase in the white matter hyperintensity burden is associated with a decline in mean connectivity of the default mode network.

Background :Laparoscopic fundoplication (LF) has become the operation of choice for patients who need surgery for gastro esophageal reflux disease (GERD). Several studies have shown that the long-term results with surgery for GERD are better than medical therapy. In this retrospective study, we outline our experience with LF over an 8 year period. We analyzed factors that would affect the results of surgery and help in a better selection of patients for the operation. Materials and Methods :From 1999 to 2007, 107 patients underwent a LF. Eighty five patients had surgery for GERD and form the basis of this article. The other 22 patients had paraesophageal hernias and were excluded from the study. Pre-operative evaluation consisted of endoscopy, a barium study, esophageal manometry and 24h pH monitoring. Patients were followed up every 3rd month for the 1st year, twice in the 2nd year and then annually. Follow up was by personal interview or telephonic conversation. At the last follow up the results of surgery were graded as good or poor as per a scoring system. Those with a poor result were evaluated and re-operation advised when an anatomical problem caused the poor result. Subjective, objective and technical variables were analyzed which could affect the outcome of surgery. Results :In 84 patients, the operation was completed by laparoscopic access. One patient with bleeding was converted to open surgery. There were 5 intra-operative complications; 3 pnemothoracis, 1 esophageal perforation and 1 gastric fundus perforation. There was no mortality. Two patients underwent re-operation, 1 for delayed gastric emptying and 1 for dysphagia. Seventy four patients have been followed up from 7 months to 8 years. Eleven have been lost to follow up. Fifty seven patients (77%) have had a good result from surgery. Seventeen (23%) had a poor result; of these there were 4 wrap failures, 1 delayed gastric emptying and 1 excessive gas bloat as the cause. In 11 patients, there was no apparent cause of a poor result. Individual variables which predicted a good response to surgery ( P < 0.5); were a good response to proton pump inhibitors (PPis), volume reflux and a pH score of more than 14. Conclusion :LF gives good long-term relief of symptoms in patients with GERD. Strict selection criteria are necessary to optimize the results of surgery. Poor selection will result in a patient who is no better, or often worse than before surgery.

Background: Surgeons are more interested in the techniques available, in recurrence rates, and in short term complications of hernia surgery. The present study was conducted with an objective to compare inguinal hernioplasty with the prolene hernia system verses Linchenstein repair. Methodology: The present comparative study was conducted on the patient admitted with the diagnosis of primary unilateral inguinal hernia. These patients were randomly placed in two groups, one group was subjected to open tension free Prolene hernia system mesh hernioplasty & other group Linchenstein repair. The patients were assessed for the severity of post operative pain using visual analogue scale, duration of surgery, technical difficulty and post-operative complications like wound infection, wound seroma. Results: Duration of surgery in case of Linchenstein mesh repair ranged from 40 -50 minutes and in PHS ranged from 60 - 80 minutes with mean of 70.4 minutes. For Linchenstein repair at the end of 7th day 24% cases have no pain, 60% cases have minimal pain, while 16% cases have moderate pain. For PHS at the end of 7th day 44% cases have no pain, 48% cases have minimal pain, while 8% cases have moderate pain. No patient has severe pain at the end of 7th and 15th day. Conclusion: There is no significant difference found in hospital stay, Complications, chronic pain and recurrence rate in either group. PHS is bit difficult for new surgeon, it requires expertise.

We demonstrate a widely applicable technique to absolutely calibrate the energy scale of x-ray spectra with experimentally well-known and accurately calculable transitions of highly charged ions, allowing us to measure the K-shell Rydberg spectrum of molecular O_{2} with 8 meV uncertainty. We reveal a systematic ∼450  meV shift from previous literature values, and settle an extraordinary discrepancy between astrophysical and laboratory measurements of neutral atomic oxygen, the latter being calibrated against the aforementioned O_{2} literature values. Because of the widespread use of such, now deprecated, references, our method impacts on many branches of x-ray absorption spectroscopy. Moreover, it potentially reduces absolute uncertainties there to below the meV level.