Post-Pancreatoduodenectomy Outcomes and Epidural Analgesia: A 5-Year Single Institution Experience

Introduction Optimal pain control post-pancreatoduodenectomy is a challenge. Epidural analgesia (EDA) is increasingly utilized despite inherent risks and unclear effects on outcomes. Methods All pancreatoduodenectomies (PD) performed from 1/2013-12/2017 were included. Clinical parameters were obtained from retrospective review of a prospective clinical database, the ACS NSQIP prospective institutional database and medical record review. Chi-Square/Fisher’s Exact and Independent-Samples t-Tests were used for univariable analyses; multivariable regression (MVR) was performed. Results 671 consecutive PD from a single institution were included (429 EDA, 242 non-EDA). On univariable analysis, EDA patients experienced significantly less wound disruption (0.2% vs. 2.1%), unplanned intubation (3.0% vs. 7.9%), pulmonary embolism (0.5% vs. 2.5%), mechanical-ventilation >48hrs (2.1% vs. 7.9%), septic shock (2.6% vs. 5.8%), and lower pain scores. On MVR accounting for baseline group differences (gender, hypertension, pre-operative transfusion, labs, approach, pancreatic duct size), EDA was associated with less superficial wound infections (OR 0.34; CI 0.14-0.83; P=0.017), unplanned intubations (OR 0.36; CI 0.14-0.88; P=0.024), mechanical ventilation >48 hrs (OR 0.22; CI 0.08-0.62; P=0.004), and septic shock (OR 0.39; CI 0.15-1.00; P=0.050). EDA improved pain scores post-PD days 1-3 (P<0.001). No differences were seen in cardiac or renal complications; pancreatic fistula (B+C) or delayed gastric emptying; 30/90-day mortality; length of stay, readmission, discharge destination, or unplanned reoperation. Conclusion Based on the largest single institution series published to date, our data support the use of EDA for optimization of pain control. More importantly, our data document that EDA significantly improved infectious and pulmonary complications

Smoking as a risk factor for lung cancer in women and men: A systematic review and meta-analysis

Published by BMJ. Objectives To investigate the sex-specific association between smoking and lung cancer. Design Systematic review and meta-analysis. Data sources We searched PubMed and EMBASE from 1 January 1999 to 15 April 2016 for cohort studies. Cohort studies before 1 January 1999 were retrieved from a previous meta-analysis. Individual participant data from three sources were also available to supplement analyses of published literature. Eligibility criteria for selecting studies Cohort studies reporting the sex-specific relative risk (RR) of lung cancer associated with smoking. Results Data from 29 studies representing 99 cohort studies, 7 million individuals and &gt;50 000 incident lung cancer cases were included. The sex-specific RRs and their ratio comparing women with men were pooled using random-effects meta-analysis with inverse-variance weighting. The pooled multiple-adjusted lung cancer RR was 6.99 (95% Confidence Interval (CI) 5.09 to 9.59) in women and 7.33 (95% CI 4.90 to 10.96) in men. The pooled ratio of the RRs was 0.92 (95% CI 0.72 to 1.16; I 2 =89%; p&lt;0.001), with no evidence of publication bias or differences across major pre-defined participant and study subtypes. The women-to-men ratio of RRs was 0.99 (95% CI 0.65 to 1.52), 1.11 (95% CI 0.75 to 1.64) and 0.94 (95% CI 0.69 to 1.30), for light, moderate and heavy smoking, respectively. Conclusions Smoking yields similar risks of lung cancer in women compared with men. However, these data may underestimate the true risks of lung cancer among women, as the smoking epidemic has not yet reached full maturity in women. Continued efforts to measure the sex-specific association of smoking and lung cancer are required

Believing in the American Dream Sustains Negative Attitudes toward Those in Poverty

A critical lever in the fight against poverty is to improve attitudes toward those living in poverty. Attempting to understand the factors that impact these attitudes, we ask: Does believing that meritocracy exists (descriptive meritocracy) sustain negative attitudes? Using cross-sectional (N = 301) and experimental (N = 439) methods, we found that belief in the United States as a meritocracy is associated with blaming people living in poverty and predicts negative attitudes toward them. Replicating and extending these findings, we experimentally manipulated beliefs in meritocracy and blame. Weakening American Dream beliefs predicted improved attitudes toward those in poverty. Understanding the nuanced role of belief systems in attitudes toward those in poverty provides strategies for promoting more positive thoughts and feelings

Intestinal parasites at the Late Bronze Age settlement of Must Farm, in the fens of East Anglia, UK (9th century B.C.E.).

Little is known about the types of intestinal parasites that infected people living in prehistoric Britain. The Late Bronze Age archaeological site of Must Farm was a pile-dwelling settlement located in a wetland, consisting of stilted timber structures constructed over a slow-moving freshwater channel. At excavation, sediment samples were collected from occupation deposits around the timber structures. Fifteen coprolites were also hand-recovered from the occupation deposits; four were identified as human and seven as canine, using fecal lipid biomarkers. Digital light microscopy was used to identify preserved helminth eggs in the sediment and coprolites. Eggs of fish tapeworm (Diphyllobothrium latum and Diphyllobothrium dendriticum), Echinostoma sp., giant kidney worm (Dioctophyma renale), probable pig whipworm (Trichuris suis) and Capillaria sp. were found. This is the earliest evidence for fish tapeworm, Echinostoma worm, Capillaria worm and the giant kidney worm so far identified in Britain. It appears that the wetland environment of the settlement contributed to establishing parasite diversity and put the inhabitants at risk of infection by helminth species spread by eating raw fish, frogs or molluscs that flourish in freshwater aquatic environments, conversely the wetland may also have protected them from infection by certain geohelminths

Defining boat wake impacts on shoreline stability toward management and policy solutions

Coastal economies are often supported by activities that rely on commercial or recreational vessels to move people or goods, such as shipping, transportation, cruising, and fishing. Unintentionally, frequent or intense vessel traffic can contribute to erosion of coastlines; this can be particularly evident in sheltered systems where shoreline erosion should be minimal in the absence of boat waves. We reviewed the state of the science of known effects of boat waves on shoreline stability, examined data on erosion, turbidity, and shoreline armoring patterns for evidence of a response to boat waves in Chesapeake Bay, and reviewed existing management and policy actions in Chesapeake Bay and nearby states to make recommendations for actions to minimize boat wake impacts. In the literature, as well as in our analyses, boat wake energy may be linked to elevated turbidity and shoreline erosion, particularly in narrow waterways. In Chesapeake Bay, three lines of evidence suggest boat waves are contributing to shoreline erosion and poor water clarity in some Bay creeks and tributaries: 1) nearshore turbidity was elevated in many waterways during periods of expected high boating activity, 2) armoring was placed along about a quarter of the low energy shorelines of three examined tidal creeks that are exposed to relatively high boating pressure, and 3) 15% of the shorelines we examined throughout the Bay (9000 km) are low energy shorelines that are experiencing high erosion (≥0.3 m/yr) that cannot be attributed to wind wave energy. Still, there remain significant data gaps that preclude the determination of the overall contribution of boat waves to shoreline erosion throughout the Bay, notably, shoreline erosion data in low energy waterways, recreational boating traffic patterns, and nearshore bathymetry. Interim protective measures can be (and have been) applied in high risk waterways, such as small, low energy waterways that have high recreational boating activity, to help reduce shoreline erosion. Policy options used in Bay states and elsewhere include setbacks from the shore, wake restrictions, and speed restrictions; other more restrictive policies may include prohibition on boats of a certain size or limiting the number of passages. Finally, a systems-approach to boat wake impact management using uniform boat wake policies is likely to be the most effective for consistent shoreline protection

A Survey of Microbial Communities on Dry-Aged Beef in Commercial Meat Processing Facilities

Many artisanal meat professionals believe that the microbial populations on the outer crust of dry-aged beef contribute to variation in sensory profiles; however, to date there is minimal information about the microbes themselves that grow on commercially produced dry-aged beef. The microbiome of dry-aged beef bone-in strip loins (Institutional Meat Purchase Specifications #175) from 5 commercial dry aging facilities, including one utilizing ultraviolet light treatment, were surveyed to assess the microbial populations residing on and within each subprimal. Each strip loin was sampled at multiple spatial locations and depths, and the microbial sequences present in the samples were identified using a nextgeneration sequencing approach. Insufficient microbial DNA was isolated from ultraviolet-light-treated strip loins, indicating that this treatment eliminates all or most microbial growth on the meat. Sequencing results indicated that each establishment was producing meat with different microbial communities, based on Permutational Multivariate Analysis of Variance (P &lt; 0.01) and clustering in the Principal Coordinates Analysis plot of Jaccard distances. The position on strip loins from which samples were taken had negligible influence on microbial community structure. Aging facility, and the relative unique environmental conditions within, was determined to be the only observed driver of community structure. Notable operational taxonomic units (OTUs) detected included the spoilage-associated bacterium Pseudomonas fragi and the fungal species Debaryomyces udenii and Penicillium polonicum. An OTU identified as Mucor sp. PG272 was found to be present in over 75% of all samples. This OTU may represent a species similar to Thamnidium, a mold that has been associated with product quality. This study established a general core microbiome for dry-aged beef observed in commercial facilities, variations of which may—as future research could indicate—contribute to distinct sensory properties

Retrospective analysis of factors influencing the implementation of a program to addressunprofessional behaviour and improve culture in Australian hospitals

Background: Unprofessional behaviour among hospital staff is common. Such behaviour negatively impacts on staff wellbeing and patient outcomes. Professional accountability programs collect information about unprofessional staff behaviour from colleagues or patients, providing this as informal feedback to raise awareness, promote reflection, and change behaviour. Despite increased adoption, studies have not assessed the implementation of these programs utilising implementation theory. This study aims to (1) identify factors influencing the implementation of a whole-of-hospital professional accountability and culture change program, Ethos, implemented in eight hospitals within a large healthcare provider group, and (2) examine whether expert recommended implementation strategies were intuitively used during implementation, and the degree to which they were operationalised to address identified barriers. Method: Data relating to implementation of Ethos from organisational documents, interviews with senior and middle management, and surveys of hospital staff and peer messengers were obtained and coded in NVivo using the Consolidated Framework for Implementation Research (CFIR). Implementation strategies to address identified barriers were generated using Expert Recommendations for Implementing Change (ERIC) strategies and used in a second round of targeted coding, then assessed for degree of alignment to contextual barriers. Results: Four enablers, seven barriers, and three mixed factors were found, including perceived limitations in the confidential nature of the online messaging tool (‘Design quality and packaging’), which had downstream challenges for the capacity to provide feedback about utilisation of Ethos (‘Goals and Feedback’, ‘Access to Knowledge and Information’). Fourteen recommended implementation strategies were used, however, only four of these were operationalised to completely address contextual barriers. Conclusion: Aspects of the inner setting (e.g., ‘Leadership Engagement’, ‘Tension for Change’) had the greatest influence on implementation and should be considered prior to the implementation of future professional accountability programs. Theory can improve understanding of factors affecting implementation, and support strategies to address them

Quantifying the impact of climate change on drought regimes using the Standardised Precipitation Index

The study presents a methodology to characterise short- or long-term drought events, designed to aid understanding of how climate change may affect future risk. An indicator of drought magnitude, combining parameters of duration, spatial extent and intensity, is presented based on the Standardised Precipitation Index (SPI). The SPI is applied to observed (1955–2003) and projected (2003–2050) precipitation data from the Community Integrated Assessment System (CIAS). Potential consequences of climate change on drought regimes in Australia, Brazil, China, Ethiopia, India, Spain, Portugal and the USA are quantified. Uncertainty is assessed by emulating a range of global circulation models to project climate change. Further uncertainty is addressed through the use of a high-emission scenario and a low stabilisation scenario representing a stringent mitigation policy. Climate change was shown to have a larger effect on the duration and magnitude of long-term droughts, and Australia, Brazil, Spain, Portugal and the USA were highlighted as being particularly vulnerable to multi-year drought events, with the potential for drought magnitude to exceed historical experience. The study highlights the characteristics of drought which may be more sensitive under climate change. For example, on average, short-term droughts in the USA do not become more intense but are projected to increase in duration. Importantly, the stringent mitigation scenario had limited effect on drought regimes in the first half of the twenty-first century, showing that adaptation to drought risk will be vital in these regions