Postoperative Length of Stay Following Enhanced Recovery After Surgery Protocol Implementation for Scheduled Cesarean Deliveries

Background Cesarean delivery is the most common major surgery worldwide. 1 In 2018, 1.2 million cesarean deliveries occurred in the United States, accounting for nearly 32% of all deliveries.2 Research has shown ERAS benefits include decreased length of stay, improved pain control, and improved patient satisfaction.2,3 Despite its use in numerous surgical specialties, ERAS implementation within obstetrics has been slow.2 The ERAS Society released a three-part guideline specific to cesarean deliveries in 2018 and 2019,4,5,6 yet few studies have assessed the impact of ERAS on cesarean postoperative outcomes.2 An improved perioperative course would be particularly beneficial for mothers undergoing cesarean delivery as they require a quick recovery in order to care for their newborn. The purpose of this retrospective, observational study was to determine how the recovery process following cesarean delivery may be improved by standardizing the perioperative care pathway, with the primary outcome of interest being postoperative length of stay. Methods • Design: Retrospective, observational cohort study at Providence Sacred Heart Medical Center (PSHMC) • This project was approved by the PSHMC Clinical Innovation and Research Council and deemed exempt from human subjects research by Providence Health Care Institutional Review Board. • Human subjects protection: Patient demographic and surgical data from electronic medical records were extracted, deidentified, and encrypted using a REDCap data collection tool • Inclusion Criteria: parturients 18 years of age or older who underwent scheduled cesarean delivery between June 1, 2017 to May 31, 2018 for pre-intervention group and June 1, 2019 to February 29, 2019 for postintervention group. • Exclusion Criteria: urgent or emergent cesarean deliveries, cesarean deliveries occurring in the run-in time period of June 1, 2018 through May 31, 2019, and mothers under the age of 18 years. • Outcome measurement: postoperative length of stay, defined as time of end of surgery to time of discharge • Exposure measurement: defined as post-ERAS protocol implementation following April 1, 2019. • Other variables considered included: age, weeks gestation, BMI, ASA, primary vs repeat cesarean, weeks gestation, and multiparty births. • Statistical analysis: a-prior power analysis, univariate analysis, bivariate analysis, and multivariate analysis Discussion In this retrospective observational study, this facility’s postoperative LOS following cesarean delivery was found to be low, with a median of 52.4 hours. Following ERAS implementation, the median postoperative LOS decreased to 51.2 hours but was not found to be statistically significant in an adjusted model. Cesarean deliveries comprised nearly 29% of all births at this facility, 58.5% of which were scheduled or elective cesarean deliveries. Characteristics of parturients were very similar among the pre- and post-ERAS patient groups; most patients were classified as ASA 2 and a mean age of 31 years. Repeated multivariate analysis using run-in periods of varying lengths and controlling for time consistently showed no significant difference in postoperative LOS between the pre-ERAS and post-ERAS groups. With the postoperative LOS at PSHMC being low prior to protocol implementation, it is likely that other facilities with longer postoperative LOS may see a greater benefit of ERAS implementation. Additional work is still required to further the understanding of ERAS for cesarean deliveries and its impact on postoperative recovery. Future studies of interest includes determining 30-day readmission rates and emergency room visits following discharge. In order to determine the true effect ERAS may have on postoperative length of stay and the recovery process following cesarean delivery, large prospective control trials are needed.https://digitalcommons.psjhealth.org/other_pubs/1110/thumbnail.jp

Translating Research into Action: A Framework for Research That Supports Advances In Population Health

The research community faces a growing need to deliver useful data and actionable evidence to support health systems and policymakers on ways to optimize the health of populations. Translating science into policy has not been the traditional strong suit of investigators, who typically view a journal publication as the endpoint of their work. They are less accustomed to seeing their data as an input to the work of communities and policymakers to improve population health. This article offers four suggestions as potential solutions: (1) shaping a research portfolio around user needs, (2) understanding the decision-making environment, (3) engaging stakeholders, and (4) strategic communication

A Video-based End-to-end Pipeline for Non-nutritive Sucking Action Recognition and Segmentation in Young Infants

We present an end-to-end computer vision pipeline to detect non-nutritive sucking (NNS) -- an infant sucking pattern with no nutrition delivered -- as a potential biomarker for developmental delays, using off-the-shelf baby monitor video footage. One barrier to clinical (or algorithmic) assessment of NNS stems from its sparsity, requiring experts to wade through hours of footage to find minutes of relevant activity. Our NNS activity segmentation algorithm solves this problem by identifying periods of NNS with high certainty -- up to 94.0\% average precision and 84.9\% average recall across 30 heterogeneous 60 s clips, drawn from our manually annotated NNS clinical in-crib dataset of 183 hours of overnight baby monitor footage from 19 infants. Our method is based on an underlying NNS action recognition algorithm, which uses spatiotemporal deep learning networks and infant-specific pose estimation, achieving 94.9\% accuracy in binary classification of 960 2.5 s balanced NNS vs. non-NNS clips. Tested on our second, independent, and public NNS in-the-wild dataset, NNS recognition classification reaches 92.3\% accuracy, and NNS segmentation achieves 90.8\% precision and 84.2\% recall

The cellular and synaptic architecture of the mechanosensory dorsal horn

The deep dorsal horn is a poorly characterized spinal cord region implicated in processing low-threshold mechanoreceptor (LTMR) information. We report an array of mouse genetic tools for defining neuronal components and functions of the dorsal horn LTMR-recipient zone (LTMR-RZ), a role for LTMR-RZ processing in tactile perception, and the basic logic of LTMR-RZ organization. We found an unexpectedly high degree of neuronal diversity in the LTMR-RZ: seven excitatory and four inhibitory subtypes of interneurons exhibiting unique morphological, physiological, and synaptic properties. Remarkably, LTMRs form synapses on between four and 11 LTMR-RZ interneuron subtypes, while each LTMR-RZ interneuron subtype samples inputs from at least one to three LTMR classes, as well as spinal cord interneurons and corticospinal neurons. Thus, the LTMR-RZ is a somatosensory processing region endowed with a neuronal complexity that rivals the retina and functions to pattern the activity of ascending touch pathways that underlie tactile perception

Germline Mutations in NFKB2 Implicate the Noncanonical NF-κB Pathway in the Pathogenesis of Common Variable Immunodeficiency

Common variable immunodeficiency (CVID) is a heterogeneous disorder characterized by antibody deficiency, poor humoral response to antigens, and recurrent infections. To investigate the molecular cause of CVID, we carried out exome sequence analysis of a family diagnosed with CVID and identified a heterozygous frameshift mutation, c.2564delA (p.Lys855Serfs∗7), in NFKB2 affecting the C terminus of NF-κB2 (also known as p100/p52 or p100/p49). Subsequent screening of NFKB2 in 33 unrelated CVID-affected individuals uncovered a second heterozygous nonsense mutation, c.2557C>T (p.Arg853∗), in one simplex case. Affected individuals in both families presented with an unusual combination of childhood-onset hypogammaglobulinemia with recurrent infections, autoimmune features, and adrenal insufficiency. NF-κB2 is the principal protein involved in the noncanonical NF-κB pathway, is evolutionarily conserved, and functions in peripheral lymphoid organ development, B cell development, and antibody production. In addition, Nfkb2 mouse models demonstrate a CVID-like phenotype with hypogammaglobulinemia and poor humoral response to antigens. Immunoblot analysis and immunofluorescence microscopy of transformed B cells from affected individuals show that the NFKB2 mutations affect phosphorylation and proteasomal processing of p100 and, ultimately, p52 nuclear translocation. These findings describe germline mutations in NFKB2 and establish the noncanonical NF-κB signaling pathway as a genetic etiology for this primary immunodeficiency syndrome

Prediction of peptide and protein propensity for amyloid formation

Understanding which peptides and proteins have the potential to undergo amyloid formation and what driving forces are responsible for amyloid-like fiber formation and stabilization remains limited. This is mainly because proteins that can undergo structural changes, which lead to amyloid formation, are quite diverse and share no obvious sequence or structural homology, despite the structural similarity found in the fibrils. To address these issues, a novel approach based on recursive feature selection and feed-forward neural networks was undertaken to identify key features highly correlated with the self-assembly problem. This approach allowed the identification of seven physicochemical and biochemical properties of the amino acids highly associated with the self-assembly of peptides and proteins into amyloid-like fibrils (normalized frequency of β-sheet, normalized frequency of β-sheet from LG, weights for β-sheet at the window position of 1, isoelectric point, atom-based hydrophobic moment, helix termination parameter at position j+1 and ΔGº values for peptides extrapolated in 0 M urea). Moreover, these features enabled the development of a new predictor (available at http://cran.r-project.org/web/packages/appnn/index.html) capable of accurately and reliably predicting the amyloidogenic propensity from the polypeptide sequence alone with a prediction accuracy of 84.9 % against an external validation dataset of sequences with experimental in vitro, evidence of amyloid formation

Randomized Trial on the 5 a Day, the Rio Grande Way Website, A Web-based Program to Improve Fruit and Vegetable Consumption in Rural Communities

The Internet is a new technology for health communication in communities. The 5 a Day, the Rio Grande Way website intended to increase fruits and vegetables (FV) consumption was evaluated in a rural region enrolling 755 adults (65% Hispanic, 9% Native American, 88% female) in a randomized pretest–posttest controlled trial in 2002–2004. A total of 473 (63%) adults completed a 4-month follow-up. The change in daily intake on a food frequency questionnaire (control: mean = − 0.26 servings; intervention: mean = 0.38; estimated difference = 0.64, SD = 0.52, t(df = 416) = 1.22, p = 0.223) and single item (13.9% eating 5+ servings at pretest, 19.8% posttest for intervention; 17.4%, 13.8% for controls; odds ratio (OR) = 1.84, 95% CI = 1.07, 3.17) was in the expected direction but significant only for the single item. Website use was low and variable (logins: M = 3.3, range = 1 to 39.0; total time: M = 22.2 minutes, range = 0 to 322.7), but it was associated positively with fruit and vegetable intake (total time: Spearman r = 0.14, p = 0.004 for food frequency; Spearman r = 0.135, p = 0.004 for single item). A nutrition website may improve FV intake. The comparison on the food frequency measure may have been undermined by its high variability. Websites may be successful in community settings only when they are used enough by adults to influence them

Impact of Obesity on Pediatric Acute Recurrent and Chronic Pancreatitis

OBJECTIVE: The aim of this study was to assess the impact of obesity on pediatric acute recurrent pancreatitis or chronic pancreatitis (CP). METHODS: We determined body mass index (BMI) status at enrollment in INSPPIRE (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) cohort using CDC criteria for pediatric-specific BMI percentiles. We used the Cochran-Armitage test to assess trends and the Jonckheere-Terpstra test to determine associations. RESULTS: Of 446 subjects (acute recurrent pancreatitis, n = 241; CP, n = 205), 22 were underweight, 258 normal weight, 75 overweight, and 91 were obese. The BMI groups were similar in sex, race, and age at presentation. Hypertriglyceridemia was more common in overweight or obese. Obese children were less likely to have CP and more likely to have acute inflammation on imaging. Compared with children with normal weight, obese or overweight children were older at first acute pancreatitis episode and diagnosed with CP at an older age. Obese or overweight children were less likely to undergo medical or endoscopic treatment, develop exocrine pancreatic insufficiency, and require total pancreatectomy with islet autotransplantation. Diabetes was similar among all groups. CONCLUSIONS: Obesity or overweight seems to delay the initial acute pancreatitis episode and diagnosis of CP compared with normal weight or underweight. The impact of obesity on pediatric CP progression and severity deserves further study

Citizen science in schools: engaging students in research on urban habitat for pollinators

Citizen science can play an important role in school science education. Citizen science is particularly relevant to addressing current societal environmental sustainability challenges, as it engages the students directly with environmental science and gives students an understanding of the scientific process. In addition, it allows students to observe local representations of global challenges. Here, we report a citizen science programme designed to engage school‐age children in real‐world scientific research. The programme used standardized methods deployed across multiple schools through scientist–school partnerships to engage students with an important conservation problem: habitat for pollinator insects in urban environments. Citizen science programmes such as the programme presented here can be used to enhance scientific literacy and skills. Provided key challenges to maintain data quality are met, this approach is a powerful way to contribute valuable citizen science data for understudied, but ecologically important study systems, particularly in urban environments across broad geographical areas

Chronic pancreatitis: Pediatric and adult cohorts show similarities in disease progress despite different risk factors

Objectives: To investigate the natural history of chronic pancreatitis (CP), patients in the North American Pancreatitis Study2 (NAPS2, adults) and INternational Study group of Pediatric Pancreatitis: In search for a cuRE (INSPPIRE, pediatric) were compared. Methods: Demographics, risk factors, disease duration, management and outcomes of 224 children and 1,063 adults were compared using appropriate statistical tests for categorical and continuous variables. Results: Alcohol was a risk in 53% of adults and 1% of children (p<0.0001); tobacco in 50% of adults and 7% of children (p<0.0001). Obstructive factors were more common in children (29% vs 19% in adults, p=0.001). Genetic risk factors were found more often in children. Exocrine pancreatic insufficiency was similar (children 26% vs adult 33%, p=0.107). Diabetes was more common in adults than children (36% vs 4% respectively, p<0.0001). Median emergency room visits, hospitalizations, and missed days of work/school were similar across the cohorts. As a secondary analysis, NAPS2 subjects with childhood onset (NAPS2-CO) were compared to INSPPIRE subjects. These two cohorts were more similar than the total INSPPIRE and NAPS2 cohorts, including for genetic risk factors. The only risk factor significantly more common in the NAPS2-CO cohort compared with the INSPPIRE cohort was alcohol (9% NAPS2-CO vs 1% INSPPIRE cohorts, p=0.011). Conclusions: Despite disparity in age of onset, children and adults with CP exhibit similarity in demographics, CP treatment, and pain. Differences between groups in radiographic findings and diabetes prevalence may be related to differences in risk factors associated with disease and length of time of CP