Outcomes and Decision-Making in Older Adults Needing Thyroidectomy

Over 150,000 thyroidectomies are performed annually in the US, of which 25% are performed in older adults (over 65) (1). Older adults pose unique challenges to surgical decision-making as the benefits of surgery must be weighed against surgical risks, co-existing comorbidities, and postoperative quality of life. While single institution studies demonstrate the safety of thyroidectomy in older adults, population based studies cite increased length of stay and complication rates (2-5). Additionally, prior studies demonstrate that older adults tend to undergo less surgery for thyroid cancer and have worse disease-specific survival (6, 7). While the dreaded, classic complication of recurrent or superior laryngeal nerve injury is rare, 30-40% of younger adults with intact nerve function still report clinical sequelae of laryngeal dysfunction such as a change in their voice or dysphagia (8-13). It is not well understood why this occurs or who is at risk for developing these changes. Even less is understood about the impact of thyroidectomy on voice, swallowing, and quality of life (QOL) in older adults, despite the likelihood that older adults are at even greater risk than the younger adults who suffer these sequelae. While, there are no tools to objectively measure laryngeal muscle mass and strength, frailty, in part a sarcopenia phenotype validated in older adults, might serve as a surrogate marker to predict voice and swallowing impairments following thyroidectomy. This thesis attempts to advance our understanding of the outcomes and surgical decision-making in older patients undergoing thyroidectomy. The first contribution of this thesis is to evaluate the impact of thyroidectomy on voice and swallowing in older adults using a prospective longitudinal cohort study. The second contribution is to assess the association between frailty and adverse voice and swallowing outcomes post-thyroidectomy. Identifying at-risk older adults for these sequelae is critical for the development of prophylactic and therapeutic interventions to reduce surgical disability in the many older adults who undergo thyroidectomy. The final contribution of this thesis is to understand surgical decision-making regarding thyroidectomy in older adults utilizing a discrete-choice experiment administered to high-volume endocrine surgeons

Effect of Music Interventions on Sedation in Children Undergoing Magnetic Resonance Imaging: Clinical Trial

Background: Although parenteral sedation is often required in MRI studies in children, it is stressful and increases the cost of healthcare. Objectives: We evaluated the impact of music interventions in children receiving parenteral sedation for MRI studies on total number of doses of sedation medications, sedation time, levels of cortisol and cytokines, sedation success, adverse events, parental satisfaction, and cost savings. Methods: We conducted a prospective open unblinded four-arm clinical evaluation of interventions on 471 children 1-12 years of age undergoing MRI and receiving parenteral sedation. Children were assigned to active music therapy (AMT), facilitated music listening (FML), and as comparison another intervention (child life intervention or CLI), or no intervention (NI); measures included number of doses of sedation medications, time of sedation, sedation success, adverse events, parental satisfaction, and salivary levels of the stress hormone cortisol and pro-inflammatory cytokines, before and after intervention. Results: The total number of sedation doses, total sedation time, and levels of salivary cortisol and cytokines did not differ between the four groups. One FMLA choice, Wee Sing Animal Songs, resulted in significant decrease in total sedation time and reduction of associated costs. Conclusions: The use of one type of FML led to decreased total sedation time in children. This is an important finding since FML is an inexpensive non-invasive intervention which could be of significant time and cost saving benefits

Anesthetic Management of Pheochromocytoma Resection in Adults with Single Ventricle Physiology

Survival rates for patients with palliated congenital heart disease are increasing, and an increasing number of adults with cyanotic congenital heart disease (CCHD) might require surgical resection of pheochromocytoma-paraganglioma (PHEO-PGL). A recent study supports the idea that patients with a history of CCHD and current or historical cyanosis might be at increased risk for developing PHEO-PGL. We review the anesthetic management of two adults with single-ventricle physiology following Fontan palliation presenting for PHEO-PGL resection and review prior published case reports. We found the use of epidural analgesia to be safe and effective in the operative and postoperative management of our patients

How a thrombectomy service can reduce hospital deficit:a cost-effectiveness study

BACKGROUND: There is level 1 evidence for cerebral thrombectomy with thrombolysis in acute large vessel occlusion. Many hospitals are now contemplating setting up this life-saving service. For the hospital, however, the first treatment is associated with an initial high cost to cover the procedure. Whilst the health economic benefit of treating stroke is documented, this is the only study to date performing matched-pair, patient-level costing to determine treatment cost within the first hospital episode and up to 90 days post-event. METHODS: We conducted a retrospective coarsened exact matched-pair analysis of 50 acute stroke patients eligible for thrombectomy. RESULTS: Thrombectomy resulted in significantly more good outcomes (mRS 0–2) compared to matched controls (56% vs 8%, p = 0.001). More patients in the thrombectomy group could be discharged home (60% vs 28%), fewer were discharged to nursing homes (4% vs 16%), residential homes (0% vs 12%) or rehabilitation centres (8% vs 20%). Thrombectomy patients had fewer serious adverse events (n = 30 vs 86) and were, on average, discharged 36 days earlier. They required significantly fewer physiotherapy sessions (18.72 vs 46.49, p = 0.0009) resulting in a median reduction in total rehabilitation cost of £4982 (p = 0.0002) per patient. The total cost of additional investigations was £227 lower (p = 0.0369). Overall, the median cost without thrombectomy was £39,664 per case vs £22,444, resulting in median savings of £17,221 (p = 0.0489). CONCLUSIONS: Mechanical thrombectomy improved patient outcome, reduced length of hospitalisation and, even without procedural reimbursement, significantly reduced cost to the thrombectomy providing hospital

Use of recycled linear low-density polyethylene carbon in Li-ion anodes

Lithium-ion batteries are commonly used in many small electronics around the world. Efforts to make components of Li-ion batteries more sustainable have ranged from use of a brown algae extract in Li-ion anodes to efforts to recycle lithium. Linear-low density polyethylene (LLDPE) has been shown to exhibit the strong conductive properties required of a conductive agent in a Li-ion anode and can be made from recycled waste plastics such as cling wrap and poly-gloves. Electrodes were fabricated using polyethylene glycol (PEG) coated magnetite as the active material, PPBT polymeric binder, and LLDPE Carbon. Electrodes made with 14.3 wt.% LLDPE did not cycle well and exhibited a poor morphology with a cracked surface and large aggregates. Simple conductivity testing using a 4-point probe and profilometry measurements showed that Super-P was orders of magnitude more conductive than LLDPE. Increasing the carbon loading to 33.3 wt.% LLDPE in the electrode drastically improved rate capabilities and capacity retention. SEM analysis showed that a higher carbon loading of LLDPE had a better morphology overall and demonstrated less cracking. However, when compared to Super-P, the electrode had larger aggregates and a higher density of clumping. EDX SEM imaging and elemental (Fe, O, C) image mapping confirmed the presence of Fe3O4 nanoparticles, carbon additives, and PPBT binder. XPS analysis after 100 cycles confirmed the presence of an SEI layer in the LLDPE electrode. XPS on electrode slurries showed the presence of satellite peaks which confirm interactions between the polymeric binder and active material surface, regardless of carbon used. EIS testing provided information on the charge transfer resistances of Super-P and LLDPE which was consistent with the cycling trends. Overall, use of LLDPE in Li-ion batteries has been shown to work in a half-cell assembly. The performance of LLDPE does not beat the current industry standard, Super-P, but demonstrates promise for use after further optimization and analysis.Undergraduat

<span style="font-size:14.0pt;font-family:"Times New Roman","serif";mso-bidi-language: HI" lang="EN-IN">Evaluation of radioprotective effects of <i>Opuntia elatior </i>extract on catalase and <span style="font-size:14.0pt;font-family:"Times New Roman","serif";mso-bidi-language: HI" lang="EN-IN">superoxide dismutase activity in mouse liver </span></span>

31-35Ionizing radiations affect the living systems by damaging the vital macromolecules and structures of the target cell. A number of chemical and synthetic compounds have radioprotective potential but their high toxicity limits clinical application. Therefore, development of less toxic and potential drug of plant origin for the modification of radiation effects is required. Adult male Swiss albino mice were selected and divided into four groups. Group I was sham irradiated. Group II was fed with OE only (10 mg/kg body weight). Group III was irradiated with 8Gy Co60 gamma irradiation and Group IV was given OE one hour before irradiation. Mice were sacrificed at various post irradiation intervals to analyse the Catalase and Superoxide dismutase (SOD) activity in the liver. Results were subjected to students 't' test. The activity of both SOD and Catalase were found to be decreased till 7th day post irradiation in control group while a significant increase was observed in the OE pretreated irradiated group as compared to the control groups at all the intervals. Opuntia elatior extract pretreatment provides protection against radiation induced changes in the Catalase and SOD activity in the mouse liver. </span

Anticipatory governance of solar geoengineering: conflicting visions of the future and their links to governance proposals

This article identifies diverse rationales to call for anticipatory governance of solar geoengineering, in light of a climate crisis. In focusing on governance rationales, we step back from proliferating debates in the literature on ‘how, when, whom, and where’ to govern, to address the important prior question of why govern solar geoengineering in the first place: to restrict or enable its further consideration? We link these opposing rationales to contrasting underlying visions of a future impacted by climate change. These visions see the future as either more or less threatening, depending upon whether it includes the possible future use of solar geoengineering. Our analysis links these contrasting visions and governance rationales to existing governance proposals in the literature. In doing so, we illustrate why some proposals differ so significantly, while also showing that similar-sounding proposals may emanate from quite distinct rationales and thus advance different ends, depending upon how they are designed in practice

Pulmonary Resection for Metastatic Adrenocortical Carcinoma: The National Cancer Institute Experience

Adrenocortical carcinoma (ACC) is a rare neoplasm with a high propensity for locoregional recurrences and distant metastases for which there are no effective systemic therapies. This study was undertaken to determine outcomes of patients undergoing pulmonary metastasectomy for ACC. A single-institution retrospective review was performed of patients undergoing pulmonary metastasectomy for ACC from 1979 to 2010. Twenty-six patients underwent 60 pulmonary metastasectomies. Fifteen patients (58%) underwent unilateral thoracotomy, 6 (23%) had staged thoracotomies, and 5 (19%) underwent median sternotomy as the initial thoracic procedure. Median number and size of lesions were 6 and 2 cm, respectively. Twenty-three patients (88%) were rendered free of disease in the lung, and 14 (54%) were rendered completely free of disease. Median overall and 5-year actuarial survivals from initial pulmonary metastasectomy were 40 months and 41%, respectively, with a median potential follow-up of 120 months. Median recurrence-free survival (RFS) and 5-year RFS for ipsilateral thoracic recurrences were 6 months, and 25%, respectively. The median RFS in the contralateral thorax was 5 months. Time to first recurrence after adrenalectomy and T stage of the primary tumor, but not adjuvant or neoadjuvant chemotherapy, were associated with increased overall survival after pulmonary metastasectomy. This study represents the most comprehensive review of outcomes of patients undergoing pulmonary metastasectomy for ACC. Given the lack of effective systemic therapies, pulmonary metastasectomy may be beneficial in properly selected patients

Anticipatory governance of solar geoengineering: conflicting visions of the future and their links to governance proposals

This article identifies diverse rationales to call for anticipatory governance of solar geoengineering, in light of a climate crisis. In focusing on governance rationales, we step back from proliferating debates in the literature on ‘how, when, whom, and where’ to govern, to address the important prior question of why govern solar geoengineering in the first place: to restrict or enable its further consideration? We link these opposing rationales to contrasting underlying visions of a future impacted by climate change. These visions see the future as either more or less threatening, depending upon whether it includes the possible future use of solar geoengineering. Our analysis links these contrasting visions and governance rationales to existing governance proposals in the literature. In doing so, we illustratewhy some proposals differ so significantly, while also showing that similar-sounding proposals may emanate from quite distinct rationales and thus advance different ends, depending upon how they are designed in practice.</p

Cognitive impairment burden in older and younger adults across the kidney transplant care continuum

BackgroundYounger kidney transplant (KT) candidates and recipients may have cognitive impairment due to chronic diseases and reliance on dialysis.MethodsTo quantify cognitive impairment burden by age across the KT care continuum, we leveraged a two- center cohort study of 3854 KT candidates at evaluation, 1114 recipients at admission, and 405 recipients at 1- year post- KT with measured global cognitive performance (3MS) or executive function (Trail Making Test). We also estimated burden of severe cognitive impairment that affects functional dependence (activities of daily living [ADL] < 6 or instrumental activities of daily living [IADL] < 8).ResultsAmong KT candidates, global cognitive impairment (18- 34 years: 11.1%; 35- 49 years: 14.0%; 50- 64 years: 19.5%; - ¥65 years: 22.0%) and severe cognitive impairment burden (18- 34 years: 1.1%; 35- 49 years: 3.0%; 50- 64 years: 6.2%; - ¥65 years: 7.7%) increased linearly with age. Among KT recipients at admission, global cognitive impairment (18- 34 years: 9.1%; 35- 49 years: 6.1%; 50- 64 years: 9.3%; - ¥65 years: 15.7%) and severe cognitive impairment burden (18- 34 years: 1.4%; 35- 49 years: 1.4%; 50- 64 years: 2.2%; - ¥65 years: 4.6%) was lower. Despite lowest burden of cognitive impairment among KT recipients at 1- year post- KT across all ages (18- 34 years: 1.7%; 35- 49 years: 3.4%; 50- 64 years: 4.3%; - ¥65 years: 6.5%), many still exhibited severe cognitive impairment (18- 34 years: .0%; 35- 49 years: 1.9%; 50- 64 years: 2.4%; - ¥65 years: 3.5%).ConclusionFindings were consistent for executive function impairment. While cognitive impairment increases with age, younger KT candidates have a high burden comparable to community- dwelling older adults, with some potentially suffering from severe forms. Transplant centers should consider routinely screening patients during clinical care encounters regardless of age.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/171037/1/ctr14425.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/171037/2/ctr14425_am.pd