Safety of overlapping inpatient orthopaedic surgery: A multicenter study

BackgroundAlthough overlapping surgery is used to maximize efficiency, more empirical data are needed to guide patient safety. We conducted a retrospective cohort study to evaluate the safety of overlapping inpatient orthopaedic surgery, as judged by the occurrence of perioperative complications.MethodsAll inpatient orthopaedic surgical procedures performed at 5 academic institutions from January 1, 2015, to December 31, 2015, were included. Overlapping surgery was defined as 2 skin incisions open simultaneously for 1 surgeon. In comparing patients who underwent overlapping surgery with those who underwent non-overlapping surgery, the primary outcome was the occurrence of a perioperative complication within 30 days of the surgical procedure, and secondary outcomes included all-cause 30-day readmission, length of stay, and mortality. To determine if there was an association between overlapping surgery and a perioperative complication, we tested for non-inferiority of overlapping surgery, assuming a null hypothesis of an increased risk of 50%. We used an inverse probability of treatment weighted regression model adjusted for institution, procedure type, demographic characteristics (age, sex, race, comorbidities), admission type, admission severity of illness, and clustering by surgeon.ResultsAmong 14,135 cases, the frequency of overlapping surgery was 40%. The frequencies of perioperative complications were 1% in the overlapping surgery group and 2% in the non-overlapping surgery group. The overlapping surgery group was non-inferior to the non-overlapping surgery group (odds ratio [OR], 0.61 [90% confidence interval (CI), 0.45 to 0.83]; p < 0.001), with reduced odds of perioperative complications (OR, 0.61 [95% CI, 0.43 to 0.88]; p = 0.009). For secondary outcomes, there was a significantly lower chance of all-cause 30-day readmission in the overlapping surgery group (OR, 0.67 [95% CI, 0.52 to 0.87]; p = 0.003) and shorter length of stay (e, 0.94 [95% CI, 0.89 to 0.99]; p = 0.012). There was no difference in mortality.ConclusionsOur results suggest that overlapping inpatient orthopaedic surgery does not introduce additional perioperative risk for the complications that we evaluated. The suitability of this practice should be determined by individual surgeons on a case-by-case basis with appropriate informed consent.Level of evidenceTherapeutic Level III. See Instructions for Authors for a complete description of levels of evidence

Development and Validation of a Global Competency Framework for Preparing New Graduates for Early Career Professional Roles

Objectives: The current objectives include the development of a global competency model applicable across a wide range of jobs, industries, and geographies for university graduates entering the workplace. Method: The competency model was developed utilizing a global panel of subject matter experts and a validation survey of over 25,000 students, faculty, staff, and employers across more than 30 countries. Results: The results showed substantial consistency for the importance and criticality ratings of the competencies, with Achieving Objectives, Analyzing and Solving Problems, Adapting to Change, Communicating Orally, Learning and Self-Development, Making Decisions, Planning and Organizing, and Working Well with Others as the highest-rated competencies across regions, roles, and industries. Conclusions: The most important competencies for students entering the workforce were consistent across different jobs, different industries, and different countries. The diversity and varied experience levels of the sample provide greater generalizability than most competency modeling projects that are often idiosyncratic to specific roles, industries, subjects, or levels. Implication for Theory and/or Practice: University faculty and staff can use the results of the validation study to develop curricula and programs that will be better able to foster important competencies to ensure that their students are better prepared to enter the workplace. Although some organizations emphasize leadership as important for all professional employees, Managing the Work of Others, Leading Others, and Influencing Others were consistently rated lower in importance by employers across all roles and regions and may not be appropriate as the primary focus of skill development for new graduates

Acute Exercise Activates Pulmonary eNOS and Lowers Pulmonary Pressure in Rats with Pulmonary Arterial Hypertension

poster abstractNO-dependent arterial relaxation is impaired in pulmonary arterial hypertension (PAH). Exercise may be beneficial in PAH, just as it is for systemic vascular disease, via upregulation of endothelial nitric oxide synthase (eNOS) expression and activity. However, exercise-induced cardiac stress in PAH could also promote detrimental RV inflammation. We investigated pulmonary pressure and eNOS, as well inflammatory indicators in the RV, following a single 45 min run bout at moderate intensity in a rat model of PAH. Male Sprague-Dawley rats received either monocrotaline to induce PAH, or saline, for healthy controls. A subset of PAH and healthy controls performed 4 wks of progressive TM familiarization (15-30min, 8-20 m/min) in preparation for their final 45 min run @ 75% of VO2max. Immediately following the run, RV systolic pressure was measured and RV and lung tissues were harvested and cryofixed. eNOS and phosphorylated (at Ser1177) eNOS (p-eNOS) was measured via immunoblotting in lung homogenates and expressed normalized to vinculin. Immunofluorescence for inflammatory markers CD45/68 in cryofixed RV sections evaluated the acute inflammatory response to exercise. MCT reduced VO2max and caused RV hypertrophy (expressed as RV/LV+septum) as consistent with this model. RVSP (normalized by systemic BP) was lower in PAH-Ex vs. unexercised PAH with no difference between exercised and unexercised controls. Greater p-eNOS was measured in PAH-Ex lung compared to unexercised PAH, with no difference between exercised and unexercised controls. PAH-Ex also tended to have greater pulmonary eNOS than their unexercised counterparts. No greater exercise-induced CD45/68 infiltration was observed in RV of PAH compared to that of controls. In rats with moderate MCT-induced PAH, a single exercise bout does not increase acute RV inflammation but lowers pulmonary pressure, possibly mediated in part via pulmonary eNOS activation

A perpetual switching system in pulmonary capillaries

Of the 300 billion capillaries in the human lung, a small fraction meet normal oxygen requirements at rest, with the remainder forming a large reserve. The maximum oxygen demands of the acute stress response require that the reserve capillaries are rapidly recruited. To remain primed for emergencies, the normal cardiac output must be parceled throughout the capillary bed to maintain low opening pressures. The flow-distributing system requires complex switching. Because the pulmonary microcirculation contains contractile machinery, one hypothesis posits an active switching system. The opposing hypothesis is based on passive switching that requires no regulation. Both hypotheses were tested ex vivo in canine lung lobes. The lobes were perfused first with autologous blood, and capillary switching patterns were recorded by videomicroscopy. Next, the vasculature of the lobes was saline flushed, fixed by glutaraldehyde perfusion, flushed again, and then reperfused with the original, unfixed blood. Flow patterns through the same capillaries were recorded again. The 16-min-long videos were divided into 4-s increments. Each capillary segment was recorded as being perfused if at least one red blood cell crossed the entire segment. Otherwise it was recorded as unperfused. These binary measurements were made manually for each segment during every 4 s throughout the 16-min recordings of the fresh and fixed capillaries (>60,000 measurements). Unexpectedly, the switching patterns did not change after fixation. We conclude that the pulmonary capillaries can remain primed for emergencies without requiring regulation: no detectors, no feedback loops, and no effectors-a rare system in biology. NEW & NOTEWORTHY The fluctuating flow patterns of red blood cells within the pulmonary capillary networks have been assumed to be actively controlled within the pulmonary microcirculation. Here we show that the capillary flow switching patterns in the same network are the same whether the lungs are fresh or fixed. This unexpected observation can be successfully explained by a new model of pulmonary capillary flow based on chaos theory and fractal mathematics

Microvascular inflammatory responses to ceramide and cigarette smoke in the intact rat assessed with intravital two-photon microscopy

poster abstractsmoke, characterized by alterations of the alveolar barrier function. We investigated this hypothesis by utilizing a novel application of intravital two-photon excitation microscopy (TPM) of the lung in a living, breathing animal. Methods: We first developed a technique of TPM to permit imaging of the lung maintained within the thoracic cavity of an intact rat. To accomplish this, we optimized the lung-microscope interface with an imaging window uniquely designed to minimize cardiac and respiratory motion during TPM acquisitions. To investigate alveolar barrier disruption in real time, we utilized intravenous (i.v.) fluorescent probes to examine changes in alveolar leukocyte trafficking and microvascular barrier function in response to i.v. ceramide (C16:0 PEG, 10 mg/kg), and to cigarette smoke extract (CSE) delivered i.v. (1ml/kg) or intratracheally via a nebulizer (2mL/kg). Results: We performed intravital TPM monitoring of the lung microcirculation of a living rat with maintained physiological cardio-pulmonary parameters for up to 3h. Time-lapse and 3-D reconstruction images revealed heterogeneous extravasation of FITC-labeled serum albumin from the alveolar microcirculation into the alveolar airspaces in response to ceramide, in a dose-dependent manner. Further, we noted that in response to both ceramide and to CSE, leukocytes accumulated in the lung parenchyma and demonstrated reduced mobility through the microcirculation, suggesting increased adhesion to the endothelium. Intratracheal administration of CSE caused increased extravasation of leukocytes into alveolar spaces within 10 minutes. Conclusions: We developed approaches that permit the application of intravital TPM to lung with no motion artifacts from the breathing and cardiac cycles. This approach permits visualization of the lung subpleural parenchyma with a high resolution. Both gross and subtle inflammatory changes that reflect alveolar epithelial and/or endothelial barrier dysfunction can be assessed with this methodology

Exercise Training Improves Cardiac and Skeletal Muscle Metabolism in Rats with Pulmonary Arterial Hypertension

poster abstractIn patients with pulmonary arterial hypertension (PAH), a shift from oxidative to glycolytic metabolism promotes right ventricular (RV) and skeletal muscle dysfunction that contributes to reduced exercise tolerance. As seen for other cardiopulmonary diseases, exercise training (ExT) may ameliorate this glycolytic switch in PAH and improve exercise capacity. The purpose of this research is to investigate ExT in a rat model of PAH on markers of glycolytic and oxidative metabolism in RV and skeletal muscle. Male Sprague-Dawley rats received monocrotaline (MCT, 40 mg/kg, s.q.) to induce PAH (n= 13), or saline, for healthy controls (n=5). After 2 wks, with MCT-induced PAH established, 6 wks of treadmill (TM) ExT was initiated for a subset of PAH animals (PAH-ExT, n= 6) and healthy controls (CON-ExT, n=3). ExT runs progressed up to 60 min at mild relative intensity, 50% of maximal aerobic capacity (VO2max). VO2max was assessed at baseline, in pre-training and post-training TM testing via analysis of expired gases. Abundance of Glut-1, a marker of glycolytic metabolism, was evaluated in cryosections of RV and soleus with immunofluorescent (IF) staining and quantification. Data are presented as mean±SE. MCT-ExT rats maintained aerobic capacity over 6 wks better than sedentary counterparts (MCT-SED)(VO2max= -134±109 vs. -521±129 ml/kg/hr, p=0.04) and was not different than CON-ExT (-201±31 ml/kg/hr, p=0.82). A lower abundance of Glut-1 was observed in both RV and soleus myocytes of PAH-ExT rats (MPI= 10.9 ±0.9 for RV; 13.7±0.8 for soleus) compared to PAH-SED rats (15.7±2.4, p=0.05, for RV; 17.4±1.4, p=0.04, for soleus) and was similar to CON-ExT rats (13.0±2.2, p=0.33, for RV; 9.0±2.3, p=0.26, for soleus), indicative of a shift toward greater dependency on oxidative metabolism. Exercise training attenuates functional decline following MCT administration in rats. Preservation of aerobic capacity may be explained by promotion of more efficient RV and skeletal muscle mitochondrial substrate utilization

Integrated Weighted Gene Co-expression Network Analysis with an Application to Chronic Fatigue Syndrome

<p>Abstract</p> <p>Background</p> <p>Systems biologic approaches such as Weighted Gene Co-expression Network Analysis (WGCNA) can effectively integrate gene expression and trait data to identify pathways and candidate biomarkers. Here we show that the additional inclusion of genetic marker data allows one to characterize network relationships as causal or reactive in a chronic fatigue syndrome (CFS) data set.</p> <p>Results</p> <p>We combine WGCNA with genetic marker data to identify a disease-related pathway and its causal drivers, an analysis which we refer to as "Integrated WGCNA" or IWGCNA. Specifically, we present the following IWGCNA approach: 1) construct a co-expression network, 2) identify trait-related modules within the network, 3) use a trait-related genetic marker to prioritize genes within the module, 4) apply an integrated gene screening strategy to identify candidate genes and 5) carry out causality testing to verify and/or prioritize results. By applying this strategy to a CFS data set consisting of microarray, SNP and clinical trait data, we identify a module of 299 highly correlated genes that is associated with CFS severity. Our integrated gene screening strategy results in 20 candidate genes. We show that our approach yields biologically interesting genes that function in the same pathway and are causal drivers for their parent module. We use a separate data set to replicate findings and use Ingenuity Pathways Analysis software to functionally annotate the candidate gene pathways.</p> <p>Conclusion</p> <p>We show how WGCNA can be combined with genetic marker data to identify disease-related pathways and the causal drivers within them. The systems genetics approach described here can easily be used to generate testable genetic hypotheses in other complex disease studies.</p

NEXUS/Physics: An interdisciplinary repurposing of physics for biologists

In response to increasing calls for the reform of the undergraduate science curriculum for life science majors and pre-medical students (Bio2010, Scientific Foundations for Future Physicians, Vision & Change), an interdisciplinary team has created NEXUS/Physics: a repurposing of an introductory physics curriculum for the life sciences. The curriculum interacts strongly and supportively with introductory biology and chemistry courses taken by life sciences students, with the goal of helping students build general, multi-discipline scientific competencies. In order to do this, our two-semester NEXUS/Physics course sequence is positioned as a second year course so students will have had some exposure to basic concepts in biology and chemistry. NEXUS/Physics stresses interdisciplinary examples and the content differs markedly from traditional introductory physics to facilitate this. It extends the discussion of energy to include interatomic potentials and chemical reactions, the discussion of thermodynamics to include enthalpy and Gibbs free energy, and includes a serious discussion of random vs. coherent motion including diffusion. The development of instructional materials is coordinated with careful education research. Both the new content and the results of the research are described in a series of papers for which this paper serves as an overview and context.Comment: 12 page

The development of path integration: combining estimations of distance and heading

Efficient daily navigation is underpinned by path integration, the mechanism by which we use self-movement information to update our position in space. This process is well-understood in adulthood, but there has been relatively little study of path integration in childhood, leading to an underrepresentation in accounts of navigational development. Previous research has shown that calculation of distance and heading both tend to be less accurate in children as they are in adults, although there have been no studies of the combined calculation of distance and heading that typifies naturalistic path integration. In the present study 5-year-olds and 7-year-olds took part in a triangle-completion task, where they were required to return to the startpoint of a multi-element path using only idiothetic information. Performance was compared to a sample of adult participants, who were found to be more accurate than children on measures of landing error, heading error, and distance error. 7-year-olds were significantly more accurate than 5-year-olds on measures of landing error and heading error, although the difference between groups was much smaller for distance error. All measures were reliably correlated with age, demonstrating a clear development of path integration abilities within the age range tested. Taken together, these data make a strong case for the inclusion of path integration within developmental models of spatial navigational processing