Incidence of surgical site infection following mastectomy with and without immediate reconstruction using private insurer claims data

OBJECTIVE: The National Healthcare Safety Network classifies breast operations as clean procedures with an expected 1–2% surgical site infection (SSI) incidence. We assessed differences in SSI incidence following mastectomy with and without immediate reconstruction in a large, geographically diverse population. DESIGN: Retrospective cohort study. PATIENTS: Commercially-insured women aged 18–64 years with ICD-9-CM procedure or CPT-4 codes for mastectomy from 1/1/2004–12/31/2011. METHODS: Incident SSIs within 180 days after surgery were identified by ICD-9-CM diagnosis codes. The incidence of SSI after mastectomy +/− immediate reconstruction was compared by the chi-square test. RESULTS: From 2004–2011, 18,696 mastectomy procedures among 18,085 women were identified, with immediate reconstruction in 10,836 (58%) procedures. The 180-day incidence of SSI following mastectomy with or without reconstruction was 8.1% (1,520/18,696). Forty-nine percent of SSIs were identified within 30 days post-mastectomy, 24.5% between 31–60 days, 10.5% between 61–90 days, and 15.7% between 91–180 days. The incidence of SSI was 5.0% (395/7,860) after mastectomy-only, 10.3% (848/8,217) after mastectomy plus implant, 10.7% (207/1,942) after mastectomy plus flap, and 10.3% (70/677) after mastectomy plus flap and implant (p<0.001). The SSI risk was higher after bilateral compared with unilateral mastectomy with (11.4% vs. 9.4%, p=0.001) and without (6.1% vs. 4.7%, p=0.021) immediate reconstruction. CONCLUSIONS: SSI incidence was two-fold higher after mastectomy with immediate reconstruction than after mastectomy alone. Only 49% of SSIs were coded within 30 days after operation. Our results suggest stratification by procedure type will facilitate comparison of SSI rates after breast operations between facilities

Termites Create Spatial Structure And Govern Ecosystem Function By Affecting N-2 Fixation In An East African Savanna

The mechanisms by which even the clearest of keystone or dominant species exert community-wide effects are only partially understood in most ecosystems. This is especially true when a species or guild influences community-wide interactions via changes in the abiotic landscape. Using stable isotope analyses, we show that subterranean termites in an East African savanna strongly influence a key ecosystem process: atmospheric nitrogen fixation by a monodominant tree species and its bacterial symbionts. Specifically, we applied the N-15 natural abundance method in combination with other biogeochemical analyses to assess levels of nitrogen fixation by Acacia drepanolobium and its effects on co-occurring grasses and forbs in areas near and far from mounds and where ungulates were or were not excluded. We find that termites exert far stronger effects than do herbivores on nitrogen fixation. The percentage of nitrogen derived from fixation in Acacia drepanolobium trees is higher (55-80%) away from mounds vs. near mounds (40-50%). Mound soils have higher levels of plant available nitrogen, and Acacia drepanolobium may preferentially utilize soil-based nitrogen sources in lieu of fixed nitrogen when these sources are readily available near termite mounds. At the scale of the landscape, our models predict that termite/soil derived nitrogen sources influence \u3e50% of the Acacia drepanolobium trees in our system. Further, the spatial extent of these effects combine with the spacing of termite mounds to create highly regular patterning in nitrogen fixation rates, resulting in marked habitat heterogeneity in an otherwise uniform landscape. In summary, we show that termite-associated effects on nitrogen processes are not only stronger than those of more apparent large herbivores in the same system, but also occur in a highly regular spatial pattern, potentially adding to their importance as drivers of community and ecosystem structure

Using machining force feedback to quantify grain size in beta titanium

The fluctuating forces on the cutting tool generated during machining of β processed Ti-17 alloy are shown to contain sufficient information to enable measurement of β grain size to an equivalent accuracy of standard etching methods. Three orthogonal forces were gathered, cutting force tangential to the rotation, the force in the feed (radial) direction, and the normal force in the longitudinal axis. Each individual force produced a microstructure image with a high level of contrast but in some cases did not fully highlight all features as shown in the optical image of the equivalent area. By normalising and combining the three forces into a vector, followed by noise reduction, a high-resolution image with sufficient detail to undertake grain size measurements using the linear intercept was produced. The measured grain size differed by no more than 5% with respect the grain size measured in the etched micrograph. It is believed that the forces which have a higher proportion of elastic response in their total values, i.e., the feed and normal forces, produced the higher contrast images, indicating that elastic stresses produce the highest contrast between grains and plastic strains smear out the grain to grain variation

Inequities in treatments and outcomes among patients hospitalized with hypertrophic cardiomyopathy in the United States

Background Hypertrophic cardiomyopathy (HCM) is the most common heritable cardiac disease. In small studies, sociodemographic factors have been associated with disparities in septal reduction therapy, but little is known about the association of sociodemographic factors with HCM treatments and outcomes more broadly. Methods and Results Using the National Inpatient Survey from 2012 to 2018, HCM diagnoses and procedures were identified b

Comment on ``Creating Metastable Schroedinger Cat States''

After a careful analysis of the feedback model recently proposed by Slosser and Milburn [Phys. Rev. Lett. 75, 418 (1995)], we are led to the conclusion that---under realistic conditions---their scheme is not significantly more effective in the production of linear superpositions of macroscopically distinguishable quantum states than the usual quantum-optical Kerr effect.Comment: 1 page, RevTeX, 1 eps figure (fig_1.eps), accepted for publication in Physical Review Letters [Phys. Rev. Lett. 77 (9) (1996)

Stage-dependent transient storage of phosphorus in alluvial floodplains

Models for contaminant transport in streams commonly idealize transient storage as a well-mixed but immobile system. These transient storage models capture rapid (near-stream) hyporheic storage and transport, but do not account for large-scale, stage-dependent interaction with the alluvial aquifer. The objective of this research was to document transient storage of phosphorus (P) in coarse gravel alluvium potentially influenced by large-scale, stage-dependent preferential flow pathways (PFPs). Long-term monitoring was performed at floodplain sites adjacent to the Barren Fork Creek and Honey Creek in northeastern Oklahoma. Based on results from subsurface electrical resistivity mapping which was correlated to hydraulic conductivity data, observation wells were installed both in higher hydraulic conductivity and lower hydraulic conductivity subsoils. Water levels in the wells were monitored over time, and water samples were obtained from the observation wells and the stream to document P concentrations at multiple times during high flow events. Contour plots indicating direction of flow were developed using water table elevation data. Contour plots of total P concentrations showed the alluvial aquifer acting as a transient storage zone, with P-laden stream water heterogeneously entering the aquifer during the passage of a storm pulse, and subsequently re-entering the stream during baseflow conditions. Some groundwater in the alluvial floodplains had total P concentrations that mirrored the streams’ total P concentrations. A detailed analysis of P forms indicated that particulate P (i.e. P attached to particulates greater than 0·45 μm) was a significant portion of the P transport. This research suggests the need for more controlled studies on stage-dependent transient storage in alluvial systems

Stage-dependent transient storage of phosphorus in alluvial floodplains

Models for contaminant transport in streams commonly idealize transient storage as a well-mixed but immobile system. These transient storage models capture rapid (near-stream) hyporheic storage and transport, but do not account for large-scale, stage-dependent interaction with the alluvial aquifer. The objective of this research was to document transient storage of phosphorus (P) in coarse gravel alluvium potentially influenced by large-scale, stage-dependent preferential flow pathways (PFPs). Long-term monitoring was performed at floodplain sites adjacent to the Barren Fork Creek and Honey Creek in northeastern Oklahoma. Based on results from subsurface electrical resistivity mapping which was correlated to hydraulic conductivity data, observation wells were installed both in higher hydraulic conductivity and lower hydraulic conductivity subsoils. Water levels in the wells were monitored over time, and water samples were obtained from the observation wells and the stream to document P concentrations at multiple times during high flow events. Contour plots indicating direction of flow were developed using water table elevation data. Contour plots of total P concentrations showed the alluvial aquifer acting as a transient storage zone, with P-laden stream water heterogeneously entering the aquifer during the passage of a storm pulse, and subsequently re-entering the stream during baseflow conditions. Some groundwater in the alluvial floodplains had total P concentrations that mirrored the streams’ total P concentrations. A detailed analysis of P forms indicated that particulate P (i.e. P attached to particulates greater than 0·45 μm) was a significant portion of the P transport. This research suggests the need for more controlled studies on stage-dependent transient storage in alluvial systems

Bringing high-grade arteriovenous malformations under control: clinical outcomes following multimodality treatment in children.

OBJECTIVE:Brain arteriovenous malformations (AVMs) consist of dysplastic blood vessels with direct arteriovenous shunts that can hemorrhage spontaneously. In children, a higher lifetime hemorrhage risk must be balanced with treatment-related morbidity. The authors describe a collaborative, multimodal strategy resulting in effective and safe treatment of pediatric AVMs. METHODS:A retrospective analysis of a prospectively maintained database was performed in children with treated and nontreated pediatric AVMs at the University of California, San Francisco, from 1998 to 2017. Inclusion criteria were age ≤ 18 years at time of diagnosis and an AVM confirmed by a catheter angiogram. RESULTS:The authors evaluated 189 pediatric patients with AVMs over the study period, including 119 ruptured (63%) and 70 unruptured (37%) AVMs. The mean age at diagnosis was 11.6 ± 4.3 years. With respect to Spetzler-Martin (SM) grade, there were 38 (20.1%) grade I, 40 (21.2%) grade II, 62 (32.8%) grade III, 40 (21.2%) grade IV, and 9 (4.8%) grade V lesions. Six patients were managed conservatively, and 183 patients underwent treatment, including 120 resections, 82 stereotactic radiosurgery (SRS), and 37 endovascular embolizations. Forty-four of 49 (89.8%) high-grade AVMs (SM grade IV or V) were treated. Multiple treatment modalities were used in 29.5% of low-grade and 27.3% of high-grade AVMs. Complete angiographic obliteration was obtained in 73.4% of low-grade lesions (SM grade I-III) and in 45.2% of high-grade lesions. A periprocedural stroke occurred in a single patient (0.5%), and there was 1 treatment-related death. The mean clinical follow-up for the cohort was 4.1 ± 4.6 years, and 96.6% and 84.3% of patients neurologically improved or remained unchanged in the ruptured and unruptured AVM groups following treatment, respectively. There were 16 bleeding events following initiation of AVM treatment (annual rate: 0.02 events per person-year). CONCLUSIONS:Coordinated multidisciplinary evaluation and individualized planning can result in safe and effective treatment of children with AVMs. In particular, it is possible to treat the majority of high-grade AVMs with an acceptable safety profile. Judicious use of multimodality therapy should be limited to appropriately selected patients after thorough team-based discussions to avoid additive morbidity. Future multicenter studies are required to better design predictive models to aid with patient selection for multimodal pediatric care, especially with high-grade AVMs

The relation of C - reactive protein to chronic kidney disease in African Americans: the Jackson Heart Study

<p>Abstract</p> <p>Background</p> <p>African Americans have an increased incidence and worse prognosis with chronic kidney disease (CKD - estimated glomerular filtration rate [eGFR] <60 ml/min/1.73 m²) than their counterparts of European-descent. Inflammation has been related to renal disease in non-Hispanic whites, but there are limited data on the role of inflammation in renal dysfunction in African Americans in the community.</p> <p>Methods</p> <p>We examined the cross-sectional relation of log transformed C-reactive protein (CRP) to renal function (eGFR by Modification of Diet and Renal Disease equation) in African American participants of the community-based Jackson Heart Study's first examination (2000 to 2004). We conducted multivariable linear regression relating CRP to eGFR adjusting for age, sex, body mass index, systolic and diastolic blood pressure, diabetes, total/HDL cholesterol, triglycerides, smoking, antihypertensive therapy, lipid lowering therapy, hormone replacement therapy, and prevalent cardiovascular disease events. In a secondary analysis we assessed the association of CRP with albuminuria (defined as albumin-to-creatinine ratio > 30 mg/g).</p> <p>Results</p> <p>Participants (n = 4320, 63.2% women) had a mean age ± SD of 54.0 ± 12.8 years. The prevalence of CKD was 5.2% (n = 228 cases). In multivariable regression, CRP concentrations were higher in those with CKD compared to those without CKD (mean CRP 3.2 ± 1.1 mg/L vs. 2.4 ± 1.0 mg/L, respectively p < 0.0001). CRP was significantly associated with albuminuria in sex and age adjusted model however not in the multivariable adjusted model (p > 0.05).</p> <p>Conclusion</p> <p>CRP was associated with CKD however not albuminuria in multivariable-adjusted analyses. The study of inflammation in the progression of renal disease in African Americans merits further investigation.</p

C-Reactive Protein Gene Variants Are Associated with Postoperative C-reactive Protein Levels After Coronary Artery Bypass Surgery

Background: Elevated baseline C-reactive protein (CRP) levels are associated with increased risk for developing cardiovascular disease. Several CRP gene variants have been associated with altered baseline CRP levels in ambulatory populations. However, the influence of CRP gene variants on CRP levels during inflammatory states, such as surgery, is largely unexplored. We describe the association between candidate CRP gene variants and postoperative plasma CRP levels in patients undergoing primary, elective coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). Methods: Using a multicenter candidate gene association study design, we examined the association between seventeen candidate CRP single nucleotide polymorphisms (SNPs) and inferred haplotypes, and altered postoperative CRP levels in 604 patients undergoing CABG surgery with CPB. Perioperative CRP levels were measured immediately prior to surgery, post-CPB and on postoperative days (POD) 1–4. Results: CRP levels were significantly elevated at all postoperative time points when compared with preoperative levels (P < 0.0001). After adjusting for clinical covariates, the minor allele of the synonymous coding SNP, rs1800947 was associated with lower peak postoperative CRP levels ($P = 2.4 × 10^{-4}$) and lower CRP levels across all postoperative time points ($P = 4.8 × 10^{-5}$). rs1800947 remained highly significant after Bonferroni adjustment for multiple comparisons. Conclusion: We identified a CRP gene SNP associated with lower postoperative CRP levels in patients undergoing CABG surgery with CPB. Further investigation is needed to clarify the significance of this association between CRP gene variants and the acute-phase rise in postoperative CRP levels with regard to the risk of adverse postoperative outcomes