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

Evolutionary innovation and diversification of carotenoid-based pigmentation in finches

© 2016 The Author(s). Evolution © 2016 The Society for the Study of Evolution. The ornaments used by animals to mediate social interactions are diverse, and by reconstructing their evolutionary pathways we can gain new insights into the mechanisms underlying ornamental innovation and variability. Here, we examine variation in plumage carotenoids among the true finches (Aves: Fringillidae) using biochemical and comparative phylogenetic analyses to reconstruct the evolutionary history of carotenoid states and evaluate competing models of carotenoid evolution. Our comparative analyses reveal that the most likely ancestor of finches used dietary carotenoids as yellow plumage colorants, and that the ability to metabolically modify dietary carotenoids into more complex pigments arose secondarily once finches began to use modified carotenoids to create red plumage. Following the evolutionary “innovation” that enabled modified red carotenoid pigments to be deposited as plumage colorants, many finch species subsequently modified carotenoid biochemical pathways to create yellow plumage. However, no reversions to dietary carotenoids were observed. The finding that ornaments and their underlying mechanisms may be operating under different selection regimes—where ornamental trait colors undergo frequent reversions (e.g., between red and yellow plumage) while carotenoid metabolization mechanisms are more conserved—supports a growing empirical framework suggesting different evolutionary patterns for ornaments and the mechanistic innovations that facilitate their diversification

Hydrodynamic modeling of tidal-fluvial flows in a large river estuary

This is the author accepted manuscript. The final version is available from Elsevier via the DOI in this recordThe transition between riverine and estuarine environments is characterised by a change from unidirectional to bidirectional flows, in a region referred to herein as the Tidally-Influenced Fluvial Zone (TIFZ). In order to improve our understanding of the hydrodynamics and morphodynamics of this zone, we present a combined field and numerical modelling study of the Columbia River Estuary (CRE), USA, tidally-influenced fluvial zone. The CRE is large measuring 40 km in length and between 5 and 10 km wide. A shallow water model (Delft3D) was applied in both 2D and 3D configurations and model sensitivity to the key process parameterizations was investigated. Our results indicate that a 2D model constrained within the estuary can sufficiently reproduce depth-averaged flow within the TIFZ of a stratified estuary. Model results highlight the interactions between tidal-, fluvial- and topographic-forcing that result in depth dependent tidal rectification, and thus zones of residual sediment transport that: i) may be flood-directed along shallow channel margins and in the lee of bars, and simultaneously ii) is ebb-directed within deeper channel thalwegs. This condition is enhanced at lower discharges, but increased fluvial discharge reduces the number and size of regions with net flood-directed sediment transport and flow. These sediment transport patterns provide a mechanism to extend the bar/island topography downstream, and generate flood-directed, ebb-directed, and symmetrical bedforms, all within the same channel. Analysis of the model data reveals flood-directed sediment transport is due to both tidal variability and mean flow. These results highlight the need to include the mean flow component (M0) when considering the long-term morphodynamic evolution in a TIFZ. Model results highlight the interactions between tidal-, fluvial- and topographic-forcing that result in depth dependent tidal rectification, and thus zones of residual sediment transport that: i) may be flood-directed along shallow channel margins and in the lee of bars, and simultaneously ii) is ebb-directed within deeper channel thalwegs. This condition is enhanced at lower discharges, but increased fluvial discharge reduces the number and size of regions with net flood-directed sediment transport and flow. These sediment transport patterns provide a mechanism to extend the bar/island topography downstream, and generate flood-directed, ebb-directed, and symmetrical bedforms, all within the same channel. Analysis of the model data reveals flood-directed sediment transport is due to both tidal variability and mean flow. These results highlight the need to include the mean flow component (M0) when considering the long-term morphodynamic evolution in a TIFZ

Prospectus, March 4, 1998

https://spark.parkland.edu/prospectus_1998/1007/thumbnail.jp

Prospectus, February 25, 1998

https://spark.parkland.edu/prospectus_1998/1006/thumbnail.jp

Novel nonadride, heptadride and maleic acid metabolites from the byssochlamic acid producer <i>Byssochlamys fulva </i>IMI 40021 – an insight into the biosynthesis of maleidrides

The filamentous fungus Byssochlamys fulva strain IMI 40021 produces (+)-byssochlamic acid 1, its novel dihydroanalogue 2 and four related secondarymetabolites. Agnestadrides A, 17 and B, 18 constitute a novel class of seven-membered ring, maleic anhydride-containing (hence termed heptadride) natural products. The putative maleic anhydride precursor 5 for both nonadride and heptadride biosynthesis was isolated as a fermentation product for the first time and its structure confirmed by synthesis. Acid 5 undergoes facile decarboxylation to anhydride 6. The generic term maleidrides is proposed to encompass biosynthetically-related compounds containing maleic anhydride moieties fused to an alicyclic ring, varying in size and substituents

Internet-based psychoeducation for bipolar disorder: a qualitative analysis of feasibility, acceptability and impact

&lt;p&gt;Background: In a recent exploratory randomised trial we found that a novel, internet-based psychoeducation programme for bipolar disorder (Beating Bipolar) was relatively easy to deliver and had a modest effect on psychological quality of life. We sought to explore the experiences of participants with respect to feasibility, acceptability and impact of Beating Bipolar.&lt;/p&gt; &lt;p&gt;Methods: Participants were invited to take part in a semi-structured interview. Thematic analysis techniques were employed; to explore and describe participants’ experiences, the data were analysed for emerging themes which were identified and coded.&lt;/p&gt; &lt;p&gt;Results: The programme was feasible to deliver and acceptable to participants where they felt comfortable using a computer. It was found to impact upon insight into illness, health behaviour, personal routines and positive attitudes towards medication. Many participants regarded the programme as likely to be most beneficial for those recently diagnosed.&lt;/p&gt; &lt;p&gt;Conclusions: An online psychoeducation package for bipolar disorder, such as Beating Bipolar, is feasible and acceptable to patients, has a positive impact on self-management behaviours and may be particularly suited to early intervention. Alternative (non-internet) formats should also be made available to patients.&lt;/p&gt

DNA profile components predict malignant outcomes in select cases of intraductal papillary mucinous neoplasm with negative cytology

Predicting malignancy in intraductal papillary mucinous neoplasm remains challenging. Integrated molecular pathology combines pancreatic fluid DNA and clinical factors into a malignant potential score. We sought to determine the utility of DNA components alone in predicting high-grade dysplasia/invasive disease. Methods We reviewed prospectively the records from 1,106 patients with intraductal papillary mucinous neoplasm. We excluded non-intraductal papillary mucinous neoplasm cases and cases with definitive malignant cytology. A total 225 patients had 283 DNA profiles (98 followed by surgery, 185 followed by ≥23-month surveillance). High-grade dysplasia/invasive outcomes were high-grade dysplasia, intraductal papillary mucinous neoplasm-invasive, and adenocarcinoma on surgical pathology or mesenteric or vascular invasion, metastases, or biopsy with high-grade dysplasia or adenocarcinoma during surveillance. Results High-quantity DNA predicted (P = .004) high-grade dysplasia/invasive disease outcomes with sensitivity of 78.3%, but 52.7% specificity, indicating benign cases may exhibit high-quantity DNA. High clonality loss of heterozygosity of tumor suppressor genes was 98.0% specific, strongly predicted high-grade dysplasia/invasive disease but lacked sensitivity (20.0%). High-quantity DNA + high clonality loss of heterozygosity had 99.0% specificity for high-grade dysplasia/invasive disease. KRAS mutation alone did not predict high-grade dysplasia/invasive disease, but, when combined with high-quantity DNA (specificity 84.7%) and high clonality loss of heterozygosity (specificity 99.0%) strongly predicted high-grade dysplasia/invasive outcomes. Conclusion Certain DNA components are highly specific for high-grade dysplasia/invasive disease and may indicate aggressive lesions, requiring resection when cytology fails

HAC-ER: a disaster response system based on human-agent collectives

This paper proposes a novel disaster management system called HAC-ER that addresses some of the challenges faced by emergency responders by enabling humans and agents, using state-of-the-art algorithms, to collaboratively plan and carry out tasks in teams referred to as human-agent collectives. In particular, HAC-ER utilises crowdsourcing combined with machine learning to extract situational awareness information from large streams of reports posted by members of the public and trusted organisations. We then show how this information can inform human-agent teams in coordinating multi-UAV deployments as well as task planning for responders on the ground. Finally, HAC-ER incorporates a tool for tracking and analysing the provenance of information shared across the entire system. In summary, this paper describes a prototype system, validated by real-world emergency responders, that combines several state-of-the-art techniques for integrating humans and agents, and illustrates, for the first time, how such an approach can enable more effective disaster response operations