Persistent Quadriceps Weakness with Femoral Nerve Block

Purpose: Femoral nerve blocks (FNB) for anterior cruciate ligament reconstruction (ACLR) can effectively reduce post-operative pain, though this is tempered with the potential for quadriceps weakness, and subsequent concerns regarding impeded rehabilitation. The purpose of this retrospective study was to assess post-ACLR differences in International Knee Documentation Committee Subjective Knee Form (IKDC) scores in patients who did not (NB) and did (FB) receive perioperative FNB. Methods: A retrospective review was performed to identify all adults undergoing ACLR at Tripler Army Medical Center between January 2013 and August 2016, with International Knee Documentation Committee (IKDC) outcome scores from pre-surgery to 6-12 months post-surgery. Patients were then divided into two groups, with the FB group being patients who received femoral nerve blocks (FNBs), and NB group patients not receiving a block. Demographics included age, sex, BMI, and ASA category. IKDC scores were converted to normative values. Variables were analyzed using Mann-Whitney-U, ANCOVA, and Chi-square tests. Results: A total of 123 ACLR patients were identified with complete IKDC scores, of which 41 did not receive a femoral nerve block. Preoperatively, IKDC scores were statistically similar between NB (Mean=40.82,SD=15.82) and FB groups (Mean=40.03,SD=15.36), (p=.79). There were no significant group differences in time-to-follow-up (p=.30), age (p=.74), or BMI (p=.11), gender (p=.27) or ASA category (p=.26). A repeated measures ANCOVA examined whether the treatment groups differed in IKDC score changes from pre-surgery to follow-up. Both groups had a significant increase in IKDC score from pre-surgery to follow-up (p<0.008). However, there was no significant difference between groups (p<0.8) (Figure 2). Conclusion: This retrospective review of outcomes after ACLR surgery indicate knee functioning improvements after ACLR did not differ between patients who did and did not receive FNB. Future rigorous studies are needed to fully examine FNB effects on other patient-reported and clinical outcomes after ACLR. Data Sources: PubMED, Cochrane Library, CINAHL, and Google Search. Keywords: International Knee Documentation Committee, IKDC, anterior cruciate ligament, ACL, reconstruction, repair, surgery, femoral nerve block, nerve block, quadricepsDoctor of Anesthesia PracticeAnesthesia ProgramUniversity of Michigan-Flinthttps://deepblue.lib.umich.edu/bitstream/2027.42/143501/1/Scott2017.pd

Guide to Stakeholder Groups for Great Basin Sagebrush Steppe Restoration

This guide is intended to provide information on active stakeholder interest groups focused on restoration of sagebrush ecosystems in the Great Basin region. It is based on a comprehensive search of internet websites, recently filed litigation records, previous interviews, and discussions with land managers in the region. The information contained in the guide is representative of the general environment in which restoration activities are conducted in the six states comprising the SageSTEP project, and is not meant to be an all-inclusive listing of groups. All efforts were made to identify groups most active and thus most pertinent to land managers and researchers in the region. There undoubtedly exist additional groups active on a more local level, which are equally as significant to restoration activities as those identified here. The guide, as developed, is intended to be particularly useful for those working in fuels treatments and NEPA issues

Diagnostic Performance of Receptor-Specific Surgical Specimen Staining Correlates with Receptor Expression Level

Intraoperative margin assessment is imperative to cancer cure but is a continued challenge to successful surgery. Breast conserving surgery is a relevant example, where a cosmetically improved outcome is gained over mastectomy, but re-excision is required in \u3e25  %   of cases due to positive or closely involved margins. Clinical translation of margin assessment modalities that must directly contact the patient or required administered contrast agents are time consuming and costly to move from bench to bedside. Tumor resections provide a unique surgical opportunity to deploy margin assessment technologies including contrast agents on the resected tissues, substantially shortening the path to the clinic. However, staining of resected tissues is plagued by nonspecific uptake. A ratiometric imaging approach where matched targeted and untargeted probes are used for staining has demonstrated substantially improved biomarker quantification over staining with conventional targeted contrast agents alone. Our group has developed an antibody-based ratiometric imaging technology using fluorescently labeled, spectrally distinct targeted and untargeted antibody probes termed dual-stain difference specimen imaging (DDSI). Herein, the targeted biomarker expression level and pattern are evaluated for their effects on DDSI diagnostic potential. Epidermal growth factor receptor expression level was correlated to DDSI diagnostic potential, which was found to be robust to spatial pattern expression variation. These results highlight the utility of DDSI for accurate margin assessment of freshly resected tumor specimens

Oil recovery through deemulsification research : separation of water from emulsified oil

In an effort to improve the environment, there is a need to recover and reuse the oil and water components of lubricating emulsions used in copper drawing and rolling processes. The Freeport-McMoRan Copper and Gold Inc. copper rod mill located in El Paso, TX was chosen as the site location for this project. It is one of the largest rolling and drawing operation facilities in the world, and it meets the established criteria set by Project ORDER. A large facility generates an average of 8,400 gallons of spent lubricant per day. The WERC emulsion sample contains 98 v% water and 2 v% lubricating oil and contains metal debris that would negatively impact water quality if it were discharged into surface waters. Oil and water are valuable resources and their maximum recoveries are desired. Project ORDER successfully recovers more than 90 v% of the water and essentially all of the oil. The recovered water could be recycled for fresh lubricant production within the facility, eliminating almost all water discharge and reducing water intake. The recovered oil will be sent to oil recyclers, lowering discharge expenses. Project ORDER has carefully evaluated several water recovery, oil recovery, and metal recovery technologies to design the commercial process. The first processing step of Project ORDER is an ultrafiltration (UF) membrane that recovers 90 v% of the water in the spent emulsion sample. As water permeates the membrane, the concentration of oil in the emulsion increases from about 2 v% to 30 v%. The second processing step removes essentially all of the water from the UF concentrate using an evaporator, which operates by passing low pressure steam through a jacketed, agitated vessel. The third processing step removes metal debris from the oil using a depth filter. The fourth processing step utilizes a reverse osmosis (RO) membrane to purify the UF permeate water for recycle. The fifth processing step reduces the amount of waste from the RO reject using an evaporator, which also operates by passing low pressure steam through a jacketed, agitated vessel. The evaporator removes essentially all of the water in the RO reject and the remaining waste is sent for disposal. The evaporated water from both evaporation units is condensed and combined with the RO permeate to be recycled. Based on a spent emulsion production rate of 8,400 gal/day, it costs $793, 000 per year for current disposal by incineration. For Project ORDER the fixed capital investment is$899,000, the yearly operating cost is $528,000, and the net present worth is$413,000 with a 24% discounted rate of return. After the initial investment is recovered, Project ORDER results in a net savings of $265,000 per year. This project is a promising process to achieve all the goals of Task 5. It produces oil with less than 3% water content, produces maximum water yield, minimizes waste solution, avoids the use of harmful materials and is cost and energy efficient. The health and safety of all individuals involved and the environmental impact of Project ORDER is of utmost importance throughout the construction and life of the project. The facility will ensure that all processes will comply with regulations outlined by the Environmental Protection Agency (EPA), Occupational Safety and Health Administration (OSHA), the Resource Conservation and Recovery Act (RCRA), and Texas State and El Paso County regulations. All operations and company procedures will comply with The Emergency Planning and Community Right-to-Know Act of 1986. The following report provides a detailed proposal for an oil and water recovery system, including experimental research results, process optimization, full-scale design, economic analysis, and environmental, health and safety considerations

Optimizing Fresh Specimen Staining for Rapid Identification of Tumor Biomarkers During Surgery.

Rationale: Positive margin status due to incomplete removal of tumor tissue during breast conserving surgery (BCS) is a prevalent diagnosis usually requiring a second surgical procedure. These follow-up procedures increase the risk of morbidity and delay the use of adjuvant therapy; thus, significant efforts are underway to develop new intraoperative strategies for margin assessment to eliminate re-excision procedures. One strategy under development uses topical application of dual probe staining and a fluorescence imaging strategy termed dual probe difference specimen imaging (DDSI). DDSI uses a receptor-targeted fluorescent probe and an untargeted, spectrally-distinct fluorescent companion imaging agent topically applied to fresh resected specimens, where the fluorescence from each probe is imaged and a normalized difference image is computed to identify tumor-target distribution in the specimen margins. While previous reports suggested this approach is a promising new tool for surgical guidance, advancing the approach into the clinic requires methodical protocol optimization and further validation. Methods: In the present study, we used breast cancer xenografts and receiver operator characteristic (ROC) curve analysis to evaluate a wide range of staining and imaging parameters, and completed a prospective validation study on multiple tumor phenotypes with different target expression. Imaging fluorophore-probe pair, concentration, and incubation times were systematically optimized using n=6 tissue specimen replicates per staining condition. Resulting tumor vs. normal adipose tissue diagnostic performance were reported and staining patterns were validated via receptor specific immunohistochemistry colocalization. Optimal staining conditions were tested in receptor positive and receptor negative cohorts to confirm specificity. Results: The optimal staining conditions were found to be a one minute stain in a 200 nM probe solution (area under the curve (AUC) = 0.97), where the choice of fluorescent label combination did not significantly affect the diagnostic performance. Using an optimal threshold value determined from ROC curve analysis on a training data set, a prospective study on xenografts resulted in an AUC=0.95 for receptor positive tumors and an AUC = 0.50 for receptor negative (control) tumors, confirming the diagnostic performance of this novel imaging technique. Conclusions: DDSI provides a robust, molecularly specific imaging methodology for identifying tumor tissue over benign mammary adipose tissue. Using a dual probe imaging strategy, nonspecific accumulation of targeted probe was corrected for and tumor vs. normal tissue diagnostic potential was improved, circumventing difficulties with ex vivotissue specimen staining and allowing for rapid clinical translation of this promising technology for tumor margin detection during BCS procedures

Simple guide to starting a research group

Conducting cutting-edge research and scholarship becomes more complicated with each passing year; forming a collaborative research group offers a way to navigate this increasing complexity. Yet many individuals whose work might benefit from the formation of a collaborative team may feel overwhelmed by the prospect of attempting to build and maintain a research group. We propose this simple guide for starting and maintaining such an enterprise

Clinically relevant dual probe difference specimen imaging (DDSI) protocol for freshly resected breast cancer specimen staining

Background: Re-excision rates following breast conserving surgery (BCS) remain as high as ~ 35%, with positive margins detected during follow-up histopathology. Additional breast cancer resection surgery is not only taxing on the patient and health care system, but also delays adjuvant therapies, increasing morbidity and reducing the likelihood of a positive outcome. The ability to precisely resect and visualize tumor margins in real time within the surgical theater would greatly benefit patients, surgeons and the health care system. Current tumor margin assessment technologies utilized during BCS involve relatively lengthy and labor-intensive protocols, which impede the surgical work flow. Methods: In previous work, we have developed and validated a fluorescence imaging method termed dual probe difference specimen imaging (DDSI) to accurately detect benign and malignant tissue with direct correlation to the targeted biomarker expression levels intraoperatively. The DDSI method is currently on par with touch prep cytology in execution time (~ 15-min). In this study, the main goal was to shorten the DDSI protocol by decreasing tissue blocking and washing times to optimize the DDSI protocol to \u3c 10-min whilst maintaining robust benign and malignant tissue differentiation. Results: We evaluated the utility of the shortened DDSI staining methodology using xenografts grown from cell lines with varied epidermal growth factor receptor (EGFR) expression levels, comparing accuracy through receiver operator characteristic (ROC) curve analyses across varied tissue blocking and washing times. An optimized 8-min DDSI methodology was developed for future clinical translation. Conclusions: Successful completion of this work resulted in substantial shortening of the DDSI methodology for use in the operating room, that provided robust, highly receptor specific, sensitive diagnostic capabilities between benign and malignant tissues

Predominance of Ehrlichia ewingii in Missouri dogs

To investigate the species distribution of Ehrlichia present in Missouri dogs, we tested 78 dogs suspected of having acute ehrlichiosis and 10 healthy dogs. Blood from each dog was screened with a broad-range 16S rRNA gene PCR assay that detects known pathogenic species of Ehrlichia and Anaplasma. The species was determined by using species-specific PCR assays and nucleotide sequencing. Ehrlichia antibody testing was performed by using an indirect immunofluorescence assay with Ehrlichia chaffeensis as the antigenic substrate. The broad-range assay detected Ehrlichia or Anaplasma DNA in 20 (26%) of the symptomatic dogs and 2 (20%) of the asymptomatic dogs. E. ewingii accounted for 20 (91%), and E. chaffeensis accounted for 1 (5%) of the positives. Anaplasma phagocytophilum DNA was detected in one dog, and the sequences of regions of the 16S rRNA gene and the groESL operon amplified from the blood of this dog matched the published sequences of this organism. Antibodies reactive with E. chaffeensis were detected in 14 (67%) of the 21 PCR-positive dogs and in 12 (19%) of the 64 PCR-negative dogs. Combining the results of PCR and serology indicated that 33 (39%) of 85 evaluable dogs had evidence of past or current Ehrlichia infection. We conclude that E. ewingii is the predominant etiologic agent of canine ehrlichiosis in the areas of Missouri included in this survey. E. canis, a widely recognized agent of canine ehrlichiosis, was not detected in any animal. The finding of E. ewingii in asymptomatic dogs suggests that dogs could be a reservoir for this Ehrlichia species

Support surfaces for pressure ulcer prevention.

BACKGROUND: Pressure ulcers (also known as bedsores, pressure sores, decubitus ulcers) are areas of localised damage to the skin and underlying tissue due to pressure, shear or friction. They are common in the elderly and immobile and costly in financial and human terms. Pressure-relieving beds, mattresses and seat cushions are widely used as aids to prevention in both institutional and non-institutional settings. OBJECTIVES: This systematic review seeks to answer the following questions: to what extent do pressure-relieving cushions, beds, mattress overlays and mattress replacements reduce the incidence of pressure ulcers compared with standard support surfaces? how effective are different pressure-relieving surfaces in preventing pressure ulcers, compared to one another? SEARCH STRATEGY: The Specialised Trials Register of the Cochrane Wounds Group (compiled from regular searches of many electronic databases including MEDLINE, CINAHL and EMBASE plus handsearching of specialist journals and conference proceedings) was searched up to January 2004, Issue 3, 2004 of the Cochrane Central Register of Controlled Trials was also searched. The reference sections of included studies were searched for further trials. SELECTION CRITERIA: Randomised controlled trials (RCTs), published or unpublished, which assessed the effectiveness of beds, mattresses, mattress overlays, and seating cushions for the prevention of pressure ulcers, in any patient group, in any setting. RCTs were eligible for inclusion if they reported an objective, clinical outcome measure such as incidence and severity of new of pressure ulcers developed. Studies which only reported proxy outcome measures such as interface pressure were excluded. DATA COLLECTION AND ANALYSIS: Trial data were extracted by one researcher and checked by a second. The results from each study are presented as relative risk for dichotomous variables. Where deemed appropriate, similar studies were pooled in a meta analysis. MAIN RESULTS: 41 RCTs were included in the review. Foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure ulcers in people at risk. The relative merits of alternating and constant low pressure devices, and of the different alternating pressure devices for pressure ulcer prevention are unclear.Pressure-relieving overlays on the operating table have been shown to reduce postoperative pressure ulcer incidence, although one study indicated that an overlay resulted in adverse skin changes. One trial indicated that Australian standard medical sheepskins prevented pressure ulcers. There is insufficient evidence to draw conclusions on the value of seat cushions, limb protectors and various constant low pressure devices as pressure ulcer prevention strategies.A study of Accident & Emergency trolley overlays did not identify a reduction in pressure ulcer incidence. There are tentative indications that foot waffle heel elevators, a particular low air loss hydrotherapy mattress and an operating theatre overlay are harmful. REVIEWERS' CONCLUSIONS: In people at high risk of pressure ulcer development, consideration should be given to the use of higher specification foam mattresses rather than standard hospital foam mattresses. The relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear. Organisations might consider the use of pressure relief for high risk patients in the operating theatre, as this is associated with a reduction in post-operative incidence of pressure ulcers. Seat cushions and overlays designed for use in Accident & Emergency settings have not been adequately evaluated