Post-Anesthesia Evaluation: Using a Systems Based Team Approach to Achieve Compliance with CMS Interpretive Guidelines

Introduction: In December of 2009 the Center for Medicare and Medicaid Services (CMS) issued Revised Anesthesia Services Interpretive Guidelines. The revised post-anesthesia evaluation rules require assessment and documentation within 48 hours from the time the patient is moved into the recovery area for patients (includes outpatients prior to discharge as well as all inpatients). It applies to all patients who have had monitored anesthesia services, regional or general anesthesia. It must be performed and documented by a practitioner who is qualified to administer anesthesia and can be completed at any time and location as long as the patient has recovered sufficiently from anesthesia to answer the key questions related to the evaluation. Required key elements include assessment of mental status, pain, nausea and vomiting, temperature, hydration, respiratory and cardiovascular status. We describe the systems based team approach we used to achieve compliance with the 93% or higher post-anesthesia evaluation set by CMS and The Joint Commission. Background: UMass Memorial is a multi-campus medical center (A: Ambulatory Surgery Center (ASC), C: Tertiary University site, B: Memorial).Annually we provide anesthesia coverage for approximately 37,000 patients at 43 anesthetizing locations (44% inpatients and 56% outpatient procedures). The spread of Anesthesiology resources over three sites and the resident work hour restrictions posed a challenge to ensure compliance with CMS requirements for post-anesthesia evaluation and documentation. Methods: With input from the Anesthesiologists at all three sites we designed a template form that captured the required elements of the post-anesthesia evaluation and became part of the patient medical record (figure 1). We also modified the discharge process from the Post Anesthesia Care Unit (PACU). Previously our patients were discharged when the Alderete criteria were met using a standardized post-anesthesia order set. We modified this post-anesthesia order set to add post-anesthesia evaluation and documentation to the discharge criteria (figure 2). The Peri-anesthesia staff (PACU and Surgical Admission unit) was educated about these changes. We implemented a visual clue by the patient stretcher in the PACU when the patient was discharge ready. A member of the Anesthesia team completed the evaluation and documentation prior to patient discharge from the PACU. Patients who were admitted directly to the ICU or were not seen in the PACU were seen the following day by a member of the group. We used a systems based team approach with the help of the Anesthesiology staff and Peri-anesthesia nursing to implement this process across all three campuses. Random monthly chart audits were performed by our Quality department to assess our compliance with these CMS revised guidelines (20 charts at each site per month). Conclusion: We were able to achieve an average compliance rate of 82 to 93% across the medical center (figure 3)

The adult perceptual limen of syllable segregation in typically developing paediatric speech

Inappropriate gaps between syllables are one of the core diagnostic features of both childhood apraxia of speech and acquired apraxia of speech. However, little is known about how listeners perceive and identify inappropriate pauses between syllables (gap detection). Only one previous study has investigated the perception of inappropriate pauses between syllables in typical adult speakers and no investigations of gap detection in children's speech have been undertaken. The purpose of this research was to explore the boundaries of listener gap detection to determine at which gap length (duration) a listener can perceive that an inappropriate pause is present in child speech. Listener perception of between-syllable gaps was explored in an experimental design study using the online survey platform Qualtrics. Speech samples were collected from two typically developing children and digitally manipulated to insert gaps between syllables. Adult listeners (n = 84) were recruited and could accurately detect segregation on 80% of presentations at a duration between 100 and 125 ms and could accurately detect segregation on 90% of presentations at a duration between 125 and 150 ms. Listener musical training, gender and age were not correlated with accuracy of detection, but speech pathology training was, albeit weakly. Male speaker gender, and strong onset syllable stress were correlated with increased accuracy compared to female speaker gender and weak onset syllable stress in some gap conditions. The results contribute to our understanding of speech acceptability in CAS and other prosodic disorders and moves towards developing standardised criteria for rating syllable segregation. There may also be implications for computer and artificial intelligence understanding of child speech and automatic detection of disordered speech based on between syllable segregation

Pattern and Coloration of Periclimenes rathbunae from the Turks and Caicos Islands, with Comments on Host Associations in Other Anemone Shrimps of the West Indies and Bermuda

The commensal shrimp Periclimenes rathbunae Schmitt, 1924, lives in association with the sea anemones Condylactis gigantea Weinland, 1860, and Stichodactyla (= Stoichactis) helianthus Ellis, 1767, in the Turks and Caicos Islands, British West Indies. We describe its pattem and coloration in life. Published reports of distribution and host acceptance by P. rathbunae and three of its congeners (P. anthophilus Holthuis and Eibl-Eibesfeldt, 1964; P. pedersoni Chace, 1958; and P. yucatanicus Ives, 1891) are reviewed. The last two species are recorded for the first time from the Turks and Caicos, and the association of P. yucatanicus with Stichodactyla helianthus on the Caicos Bank is a new host record. Finally, we offer the first direct evidence that P. yucatanicus leaves the host anemone temporarily to clean fishes, discounting a previous suggestion of its role as a noncleaning mimic of P. pedersoni

Pattern and Coloration of Periclimenes rathbunae from the Turks and Caicos Islands, with Comments on Host Associations in Other Anemone Shrimps of the West Indies and Bermuda

The commensal shrimp Periclimenes rathbunae Schmitt, 1924, lives in association with the sea anemones Condylactis gigantea Weinland, 1860, and Stichodactyla (= Stoichactis) helianthus Ellis, 1767, in the Turks and Caicos Islands, British West Indies. We describe its pattem and coloration in life. Published reports of distribution and host acceptance by P. rathbunae and three of its congeners (P. anthophilus Holthuis and Eibl-Eibesfeldt, 1964; P. pedersoni Chace, 1958; and P. yucatanicus Ives, 1891) are reviewed. The last two species are recorded for the first time from the Turks and Caicos, and the association of P. yucatanicus with Stichodactyla helianthus on the Caicos Bank is a new host record. Finally, we offer the first direct evidence that P. yucatanicus leaves the host anemone temporarily to clean fishes, discounting a previous suggestion of its role as a noncleaning mimic of P. pedersoni

Abdominal Wound Problems After Hysterectomy With Electrocautery vs. Scalpel Subcutaneous Incision

The purpose of this study was to evaluate the relationship between postoperative abdominal incision problems and opening subcutaneous tissues with electrocautery or scalpel. Women scheduled for elective abdominal hysterectomy who gave informed consent were randomly assigned to subcutaneous abdominal wall tissue incision by electrocautery or scalpel. Postoperative abdominal wound problem diagnoses included seroma, hematoma, infection, or dehiscence without identifiable etiology. Fifteen of 380 women (3.9%) developed a wound problem; six had scalpel and nine had electrosurgical subcutaneous incisions (P = 0.4). Thicker subcutaneous tissues (P = 0.04) and concurrent pelvic infection (P < 0.001) were significant risk factors for postoperative wound problems. Only two women (0.5%) developed an infection. We conclude that the method of subcutaneous tissue incision was unrelated to the development of postoperative abdominal incision problems in 380 women undergoing elective abdominal hysterectomy

Prophylactic Antibiotics for Suction Curettage in Incomplete Abortion

Objective: The purpose of this study was to investigate the efficacy of 200 mg of prophylactic doxycycline in preventing pelvic infection after curettage for spontaneous (incomplete) abortion

Live-Cell Chromosome Dynamics and Outcome of X Chromosome Pairing Events during ES Cell Differentiation

SummaryRandom X inactivation represents a paradigm for monoallelic gene regulation during early ES cell differentiation. In mice, the choice of X chromosome to inactivate in XX cells is ensured by monoallelic regulation of Xist RNA via its antisense transcription unit Tsix/Xite. Homologous pairing events have been proposed to underlie asymmetric Tsix expression, but direct evidence has been lacking owing to their dynamic and transient nature. Here we investigate the live-cell dynamics and outcome of Tsix pairing in differentiating mouse ES cells. We find an overall increase in genome dynamics including the Xics during early differentiation. During pairing, however, Xic loci show markedly reduced movements. Upon separation, Tsix expression becomes transiently monoallelic, providing a window of opportunity for monoallelic Xist upregulation. Our findings reveal the spatiotemporal choreography of the X chromosomes during early differentiation and indicate a direct role for pairing in facilitating symmetry-breaking and monoallelic regulation of Xist during random X inactivation

Contribution of epigenetic landscapes and transcription factors to X-chromosome reactivation in the inner cell mass.

X-chromosome inactivation is established during early development. In mice, transcriptional repression of the paternal X-chromosome (Xp) and enrichment in epigenetic marks such as H3K27me3 is achieved by the early blastocyst stage. X-chromosome inactivation is then reversed in the inner cell mass. The mechanisms underlying Xp reactivation remain enigmatic. Using in vivo single-cell approaches (allele-specific RNAseq, nascent RNA-fluorescent in situ hybridization and immunofluorescence), we show here that different genes are reactivated at different stages, with more slowly reactivated genes tending to be enriched in H3meK27. We further show that in UTX H3K27 histone demethylase mutant embryos, these genes are even more slowly reactivated, suggesting that these genes carry an epigenetic memory that may be actively lost. On the other hand, expression of rapidly reactivated genes may be driven by transcription factors. Thus, some X-linked genes have minimal epigenetic memory in the inner cell mass, whereas others may require active erasure of chromatin marks

A Conserved Noncoding Locus Regulates Random Monoallelic Xist Expression across a Topological Boundary

cis-Regulatory communication is crucial in mammalian development and is thought to be restricted by the spatial partitioning of the genome in topologically associating domains (TADs). Here, we discovered that the Xist locus is regulated by sequences in the neighboring TAD. In particular, the promoter of the noncoding RNA Linx (LinxP) acts as a long-range silencer and influences the choice of X chromosome to be inactivated. This is independent of Linx transcription and independent of any effect on Tsix, the antisense regulator of Xist that shares the same TAD as Linx. Unlike Tsix, LinxP is well conserved across mammals, suggesting an ancestral mechanism for random monoallelic Xist regulation. When introduced in the same TAD as Xist, LinxP switches from a silencer to an enhancer. Our study uncovers an unsuspected regulatory axis for X chromosome inactivation and a class of cis-regulatory effects that may exploit TAD partitioning to modulate developmental decisions.Galupa et al. uncover elements important for Xist regulation in its neighboring TAD and reveal that these elements can influence gene regulation both within and between topological domains. These findings, in a context where dynamic, developmental expression is necessary, challenge current models for TAD-based gene-regulatory landscapes

Genetic risk and a primary role for cell-mediated immune mechanisms in multiple sclerosis.

Multiple sclerosis is a common disease of the central nervous system in which the interplay between inflammatory and neurodegenerative processes typically results in intermittent neurological disturbance followed by progressive accumulation of disability. Epidemiological studies have shown that genetic factors are primarily responsible for the substantially increased frequency of the disease seen in the relatives of affected individuals, and systematic attempts to identify linkage in multiplex families have confirmed that variation within the major histocompatibility complex (MHC) exerts the greatest individual effect on risk. Modestly powered genome-wide association studies (GWAS) have enabled more than 20 additional risk loci to be identified and have shown that multiple variants exerting modest individual effects have a key role in disease susceptibility. Most of the genetic architecture underlying susceptibility to the disease remains to be defined and is anticipated to require the analysis of sample sizes that are beyond the numbers currently available to individual research groups. In a collaborative GWAS involving 9,772 cases of European descent collected by 23 research groups working in 15 different countries, we have replicated almost all of the previously suggested associations and identified at least a further 29 novel susceptibility loci. Within the MHC we have refined the identity of the HLA-DRB1 risk alleles and confirmed that variation in the HLA-A gene underlies the independent protective effect attributable to the class I region. Immunologically relevant genes are significantly overrepresented among those mapping close to the identified loci and particularly implicate T-helper-cell differentiation in the pathogenesis of multiple sclerosis