Effects of Modification of Pain Protocol on Incidence of Post Operative Nausea and Vomiting.

BackgroundA Perioperative Surgical Home (PSH) care model applies a standardized multidisciplinary approach to patient care using evidence-based medicine to modify and improve protocols. Analysis of patient outcome measures, such as postoperative nausea and vomiting (PONV), allows for refinement of existing protocols to improve patient care. We aim to compare the incidence of PONV in patients who underwent primary total joint arthroplasty before and after modification of our PSH pain protocol.MethodsAll total joint replacement PSH (TJR-PSH) patients who underwent primary THA (n=149) or TKA (n=212) in the study period were included. The modified protocol added a single dose of intravenous (IV) ketorolac given in the operating room and oxycodone immediate release orally instead of IV Hydromorphone in the Post Anesthesia Care Unit (PACU). The outcomes were (1) incidence of PONV and (2) average pain score in the PACU. We also examined the effect of primary anesthetic (spinal vs. GA) on these outcomes. The groups were compared using chi-square tests of proportions.ResultsThe incidence of post-operative nausea in the PACU decreased significantly with the modified protocol (27.4% vs. 38.1%, p=0.0442). There was no difference in PONV based on choice of anesthetic or procedure. Average PACU pain scores did not differ significantly between the two protocols.ConclusionSimple modifications to TJR-PSH multimodal pain management protocol, with decrease in IV narcotic use, resulted in a lower incidence of postoperative nausea, without compromising average PACU pain scores. This report demonstrates the need for continuous monitoring of PSH pathways and implementation of revisions as needed

Banning Commercial Foresting: What are the Costs?

The Philippines' forest cover has suffered from massive denudation through the years due to uncontrolled and indiscriminate commercial logging. Because of this, calls for a total logging ban had been raised in various fora, including in the legislature where bills that consider the possibility of a ban are being studied. However, the possible economic costs of such ban as espoused in some studies has delayed the passage of these bills. This Policy Notes provides some economic costing based on computations that may help in firming up decisions regarding the proposed ban.forestry sector, environmental issues, environmental management

Mobile/Modular BSL-4 Containment Facilities Integrated into a Curation Receiving Laboratory for Restricted Earth Return Missions

NASA robotic sample return missions designated Category V Restricted Earth Return by the NASA Planetary Protection (PP) Office require sample containment and biohazard testing upon return to Earth. Since the 1960s, sample containment from an unknown extraterrestrial biohazard have been related to the highest containment standards and protocols known to modern science. Today, this is Biosafety Level (BSL) 4 containment. In the U.S., the Biosafety in Microbiological and Biomedical Laboratories publication authored by the U.S. Department of Health and Human Services (HHS): Public Health Service, Centers for Disease Control and Prevention, and the National Institutes of Health houses the primary recommendations, standards, and design requirements for all BSL labs. Past mission concept studies for constructing a NASA Curation Receiving Laboratory with an integrated BSL-4 quarantine and biohazard testing facility have been estimated in the hundreds of millions of dollars (USD). As an alternative option, we have conducted a trade study for constructing a mobile and/or modular sample containment laboratory that would meet all BSL-4 and planetary protection standards and protocols at a fraction of the cost. Mobile and modular BSL-2 and 3 facilities have been successfully constructed and deployed world-wide for government testing of pathogens and pharmaceutical production. Our study showed that a modular BSL-4 construction could result in ~ 90% cost reduction when compared to traditional BSL-4 construction methods without compromising the preservation of the samples or Earth. For the design/construction requirements of a mobile/modular BSL-4 containment, we used the established HHS document standards and protocols for manipulation of agents in Class III Biosafety Cabinets (BSC; i.e., negative pressure gloveboxes) that are currently followed in operational BSL-4 facilities in the U.S

Economic Growth and Agricultural Trade of Less-Developed Countries: Technical Report

The United States has an extensive assistance program for less developed countries (LDCs), although its contribution is the lowest among the developed market economies in percent of allocated GNP (OECD 1988). On average for 1985/86, about 11.2 percent or $1.05 billion (1985 prices and exchange rates) of U.S. official development assistance was related directly to agricultural production (OECD 1988). The impact of agricultural development assistance on U.S. agricultural export markets is a concern of the U.S. government and agricultural producers, especially in periods of excess supplies of agricultural commodities. Specifically, U.S. policy makers and producers ask whether development assistance emphasizing agriculture in LDCs is consistent with policies to promote or enhance exports of U.S. agricultural commodities and increase income to the domestic agricultural sector

Patient Navigators Connecting Patients to Community Resources to Improve Diabetes Outcomes

BACKGROUND: Despite the recognized importance of lifestyle modification in reducing risk of developing type 2 diabetes and in diabetes management, the use of available community resources by both patients and their primary care providers (PCPs) remains low. The patient navigator model, widely used in cancer care, may have the potential to link PCPs and community resources for reduction of risk and control of type 2 diabetes. In this study we tested the feasibility and acceptability of telephone-based nonprofessional patient navigation to promote linkages between the PCP office and community programs for patients with or at risk for diabetes. METHODS: This was a mixed-methods interventional prospective cohort study conducted between November 2012 and August 2013. We included adult patients with and at risk for type 2 diabetes from six primary care practices. Patient-level measures of glycemic control, diabetes care, and self-efficacy from medical records, and qualitative interview data on acceptability and feasibility, were used. RESULTS: A total of 179 patients participated in the study. Two patient navigators provided services over the phone, using motivational interviewing techniques. Patient navigators provided regular feedback to PCPs and followed up with the patients through phone calls. The patient navigators made 1028 calls, with an average of 6 calls per patient. At follow-up, reduction in HbA1c (7.8 ± 1.9% vs 7.2 ± 1.3%; P = .001) and improvement in patient self-efficacy (3.1 ± 0.8 vs 3.6 ± 0.7; P < .001) were observed. Qualitative analysis revealed uniformly positive feedback from providers and patients. CONCLUSIONS: The patient navigator model is a promising and acceptable strategy to link patient, PCP, and community resources for promoting lifestyle modification in people living with or at risk for type 2 diabetes

No First-Order Phase Transition in the Gross-Neveu Model?

Within a variational calculation we investigate the role of baryons for the structure of dense matter in the Gross-Neveu model. We construct a trial ground state at finite baryon density which breaks translational invariance. Its scalar potential interpolates between widely spaced kinks and antikinks at low density and the value zero at infinite density. Its energy is lower than the one of the standard Fermi gas at all densities considered. This suggests that the discrete gamma_5 symmetry of the Gross-Neveu model does not get restored in a first order phase transition at finite density, at variance with common wisdom.Comment: 16 pages, 7 figures, LaTe

Cellular automaton decoders of topological quantum memories in the fault tolerant setting

Active error decoding and correction of topological quantum codes—in particular the toric code—remains one of the most viable routes to large scale quantum information processing. In contrast, passive error correction relies on the natural physical dynamics of a system to protect encoded quantum information. However, the search is ongoing for a completely satisfactory passive scheme applicable to locally interacting two-dimensional systems. Here, we investigate dynamical decoders that provide passive error correction by embedding the decoding process into local dynamics. We propose a specific discrete time cellular-automaton decoder in the fault tolerant setting and provide numerical evidence showing that the logical qubit has a survival time extended by several orders of magnitude over that of a bare unencoded qubit. We stress that (asynchronous) dynamical decoding gives rise to a Markovian dissipative process. We hence equate cellular-automaton decoding to a fully dissipative topological quantum memory, which removes errors continuously. In this sense, uncontrolled and unwanted local noise can be corrected for by a controlled local dissipative process. We analyze the required resources, commenting on additional polylogarithmic factors beyond those incurred by an ideal constant resource dynamical decoder

Association Between Angiographic Complications and Clinical Outcomes Among Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention An EARLY ACS (Early Glycoprotein IIb/IIIa Inhibition in Non–ST-Segment Elevation Acute Coronary Syndrome) Angiographic Substudy

ObjectivesThe goal of this analysis was to determine the association between intraprocedural complications and clinical outcomes among patients with high-risk non–ST-segment elevation acute coronary syndrome (NSTEACS) undergoing percutaneous coronary intervention (PCI).BackgroundAmong patients undergoing PCI for NSTEACS, the relationship between intraprocedural complications and clinical outcomes, independent of epicardial and myocardial perfusion, has not been well characterized.MethodsThe EARLY ACS (Early Glycoprotein IIb/IIIa Inhibition in Non–ST-Segment Elevation Acute Coronary Syndrome) trial enrolled 9,406 patients with high-risk NSTEACS undergoing an early invasive strategy. Of these, 1,452 underwent angiographic assessment in an independent core laboratory and did not have a myocardial infarction (MI) between enrollment and angiography. We assessed the relationship between abrupt closure, loss of side branch(es), distal embolization, and no-reflow phenomenon and 30-day clinical outcomes in these patients.ResultsOf the patients, 166 (11.4%) experienced an intraprocedural complication. Baseline clinical characteristics were similar between patients who did and did not have complications. The 30-day composite of death or MI was significantly higher among patients with an intraprocedural complication (28.3% vs. 7.8%, odds ratio [OR]: 4.68, 95% confidence interval [CI]: 3.2 to 7.0, p < 0.001). Individually, both mortality (3.0% vs. 0.9%, OR: 3.60, 95% CI: 1.2 to 10.5, p = 0.019) and MI (27.1% vs. 7.4%, OR: 4.66, 95% CI: 3.1 to 7.0, p < 0.001) were significantly increased. After adjusting for differences in post-PCI epicardial and myocardial perfusion, the association with 30-day death or MI remained significant.ConclusionsAmong high-risk NSTEACS patients undergoing an invasive strategy, the incidence of intraprocedural complications is high, and the occurrence of these complications is associated with worse clinical outcomes independent of epicardial and myocardial perfusion.(Early Glycoprotein IIb/IIIa Inhibition in Patients With Non–ST-segment Elevation Acute Coronary Syndrome [EARLY ACS]; NCT00089895