Background Hepatic resection is associated with substantial morbidity and resource use. To contain costs and improve outcomes, recent health care regulations focus on reducing hospital readmissions ...while using readmission rates as a quality measure. The goal of this investigation was to characterize the incidence, patterns, and risk factors for readmission after resection for hepatocellular carcinoma. Study design Patient demographics, operative factors, and perioperative outcomes of 245 patients undergoing hepatic resection at an academic center from 2000 to 2012 were reviewed retrospectively. Factors associated for readmission within 90 days of operation were identified through univariate and multivariate logistic regression analysis. Results Forty-six patients (18.7%) required hospital readmission. Univariate analysis identified American Society of Anesthesiologists class, preoperative Model for End-stage Liver Disease score and total bilirubin, preexisting vascular disease, acute renal failure, bile leak, peak postoperative total bilirubin, and intraabdominal infection as factors associated with readmission. Intraabdominal infection, postoperative renal failure, and a history of vascular disease were found to be significant on multivariate analysis. Overall, intraabdominal infection was the strongest predictor for readmission. Conclusion Early readmission after hepatectomy remains relatively common. Postoperative complications and patient comorbidities are the dominant factors in readmission, and we must be mindful of those patients at increased risk for readmission.
Multidrug-resistant tuberculosis (MDR-TB) unit in KwaZulu-Natal, South Africa.
To develop and evaluate a nurse case management model and intervention using the tenets of the Chronic Care Model to ...manage treatment for MDR-TB patients with a high prevalence of human immunodeficiency virus (HIV) co-infection.
A quasi-experimental pilot programme utilizing a nurse case manager to manage care for 40 hospitalized MDR-TB patients, 70% HIV co-infected, during the intensive phase of MDR-TB treatment. Patients were followed for six months to compare proximal outcomes identified in the model between the pre- and post-intervention period.
The greatest percent differences between baseline and six-month MDR-TB proximal outcomes were seen in the following three areas: baseline symptom evaluation on treatment initiation (95% improvement), baseline and monthly laboratory evaluations completed per guidelines (75% improvement), and adverse drug reactions acted upon by medical and/or nursing intervention (75% improvement).
Improvements were identified in guideline-based treatment and monitoring of adverse drug reactions following implementation of the nurse case management intervention. Further study is required to determine if the intervention introduced in this model will ultimately result in improvements in final MDR-TB treatment outcomes.
Standard pharmacotherapy approaches to treat tobacco use may be ineffective in people with high nicotine dependence. Individuals with high nicotine dependence may be good candidates for a new ...treatment approach—combination of varenicline and nicotine patch.
Standard pharmacotherapy approaches to treat tobacco use may be ineffective in people with high nicotine dependence. Individuals with high nicotine dependence may be good candidates for a new treatment approach—combination of varenicline and nicotine patch.
Objectives To characterize parental attitudes regarding board certification and other factors that influence selection of physicians to care for children. Study design A web-based survey administered ...in 2008 to a random sample of 3621 adults ≥18 years of age stratified by parents and non-parents. Proportion of respondents who view board certification and other measures of quality as important factors in selecting a physician to care for children. Results Survey completion rate was 62%. Almost all (95%) believe it is important or very important for doctors who care for children to be assessed on their quality of care, receive high ratings from patients (91%), and pass a written test at regular intervals (88%). Most reported that recommendations from friends or family (84%) and board certification (82%) were important or very important factors in choosing a physician for their child. Seventy-seven percent of parents stated that they would be likely to change their child's physician if he/she did not maintain board certification Conclusion Parents report a preference for board-certified physicians and expect them to participate in Maintenance of Certification. Greater understanding of quality measures and the board certification process would empower consumers to make more informed decisions in selecting a physician for their children.
Patients thought to be at greater risk of liver waitlist dropout than their laboratory Model for End-Stage Liver Disease (lMELD) score reflects are commonly given MELD exceptions, where a higher ...allocation MELD (aMELD) score is assigned that is thought to reflect the patient’s risk. This study was undertaken to determine whether exceptions for reasons other than hepatocellular carcinoma (HCC) are justified, and whether exception aMELD scores appropriately estimate risk.
Adult primary liver transplantation candidates listed in the current era of liver allocation in the United Network for Organ Sharing database were analyzed. Patients granted non-HCC-related MELD exceptions and those without MELD exceptions were compared. Rates of waitlist dropout and liver transplantation were analyzed using cause-specific hazards regression, with separate models fitted to adjust for lMELD and aMELD.
There were 29,243 patients, with 2,555 in the exception group. Nationally, exception patients were more likely to dropout (hazard ratio HR 1.60; 95% CI, 1.45 to 1.76; p < 0.001) or undergo liver transplantation (HR 3.49; 95% CI, 3.32 to 3.67; p < 0.001) than their lMELD-adjusted counterparts. Adjusting for aMELD, exception patients were less likely to dropout (HR 0.77; 95% CI, 0.70 to 0.85; p < 0.001) and less likely to undergo liver transplantation (HR 0.76; 95% CI, 0.72 to 0.80; p < 0.001). Exception patients were not at significantly increased risk of waitlist dropout when adjusted for lMELD in 4 of 11 United Network for Organ Sharing regions.
Despite appropriate use of non-HCC MELD exceptions on a national level, patients with non-HCC MELD exceptions were awarded inappropriately high priority for transplantation in many regions. This highlights the need to consider local conditions faced by transplantation candidates when estimating waitlist mortality and determining priority for transplantation.
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OBJECTIVES/GOALS: Supported by the State of Alabama, the Alabama Genomic Health Initiative (AGHI) is aimed at preventing and treating common conditions with a genetic basis. This joint UAB ...Medicine-HudsonAlpha Institute for Biotechnology effort provides genomic testing, interpretation, and counseling free of charge to residents in each of Alabama’s 67 counties. METHODS/STUDY POPULATION: Launched in 2017, as a state-wide population cohort, AGHI (1.0) enrolled 6,331 Alabamians and returned individual risk of disease(s) related to the ACMG SF v2.0 medically actionable genes. In 2021, the cohort was expanded to include a primary care cohort. AGHI (2.0) has enrolled 750 primary care patients, returning individual risk of disease(s) related to the ACMG SF v3.1 gene list and pre-emptive pharmacogenetics (PGx) to guide medication therapy. Genotyping is done on the Illumina Global Diversity Array with Sanger sequencing to confirm likely pathogenic / pathogenic variants in medically actionable genes and CYP2D6 copy number variants using Taqman assays, resulting in a CLIA-grade report. Disease risk results are returned by genetic counselors and Pharmacogenetics results are returned by Pharmacists. RESULTS/ANTICIPATED RESULTS: We have engaged a statewide community (>7000 participants), returning 94 disease risk genetic reports and 500 PGx reports. Disease risk reports include increased predisposition to cancers (n=38), cardiac diseases (n=33), metabolic (n=12), other (n=11). 100% of participants harbor an actionable PGx variant, 70% are on medication with PGx guidance, 48% harbor PGx variants and are taking medications affected. In 10% of participants, pharmacists sent an active alert to the provider to consider/ recommend alternative medication. Most commonly impacted medications included antidepressants, NSAIDS, proton-pump inhibitors and tramadol. To enable the EMR integration of genomic information, we have developed an automated transfer of reports into the EMR with Genetics Reports and PGx reports viewable in Cerner. DISCUSSION/SIGNIFICANCE: We share our experience on pre-emptive implementation of genetic risk and pharmacogenetic actionability at a population and clinic level. Both patients and providers are actively engaged, providing feedback to refine the return of results. Real time alerts with guidance at the time of prescription are needed to ensure future actionability and value.
Abstract NCBE (SLC4A10) is a member of the SLC4 family of bicarbonate transporters, several of which play important roles in intracellular-pH regulation and transepithelial HCO3− transport. Here we ...characterize a new antibody that was generated in rabbit against a fusion protein consisting of maltose-binding protein and the first 135 amino acids (aa) of the N-terminus of human NCBE. Western blotting—both of purified peptides representing the initial ∼120 aa of the transporters and of full-length transporters expressed in Xenopus oocytes—demonstrated that the antibody is specific for NCBE versus the two most closely related proteins, NDCBE (SLC4A8) and NBCn1 (SLC4A7). Western blotting of tissue in four regions of adult mouse brain indicates that NCBE is expressed most abundantly in cerebral cortex (CX), cerebellum (CB) and hippocampus (HC), and less so in subcortex (SCX). NCBE protein was present in CX, CB, and HC microdissected to avoid choroid plexus. Immunocytochemistry shows that NCBE is present at the basolateral membrane of embryonic day 18 (E18) fetal and adult choroid plexus. NCBE protein is present by Western blot and immunocytochemistry in cultured and freshly dissociated HC neurons but not astrocytes. By Western blot, nearly all NCBE in mouse and rat brain is highly N-glycosylated (∼150 kDa). PNGase F reduces the molecular weight (MW) of natural NCBE in mouse brain or human NCBE expressed in oocytes to approximately the predicted MW of the unglycosylated protein. In oocytes, mutating any one of the three consensus N-glycosylation sites reduces glycosylation of the other two, and the triple mutant exhibits negligible functional expression.
Fish‐eating birds have been found to consume baitfish and sportfish raised on farms in the United States. Understanding the on‐farm economic effects of such wildlife conflicts is essential for ...wildlife management agencies to make informed decisions. Lesser scaup, while not widely considered a fish‐eating bird, will consume farmed fish. Baitfish and sportfish farms in Arkansas (the major baitfish and sportfish producing‐state in the U.S.) were surveyed to gather data on the cost of protecting farm crops from scaup. The values of lost sales revenue from the various species of baitfish and sportfish consumed by scaup were estimated based on a concomitant field study on the abundance, distribution, and dietary habits of scaup that visited Arkansas baitfish and sportfish farms during winters of 2016–2017 and 2017–2018. Economic effects were estimated for golden shiner, fathead minnow, sportfish, and goldfish farms. Total annual costs to scare birds from baitfish and sportfish farms were $622 ± 742 per ha. The greatest components of bird‐scaring costs were manpower (56%), truck usage (32%), levee upkeep for vehicle access to scare birds (9%), firearms and ammunition (2%), and pyrotechnic devices (1%). The combined annual economic losses, calculated as reduced revenue from fish losses to scaup plus expenditures to scare birds, averaged $683/ha for golden shiners, $695/ha for fathead minnows, $663/ha for sportfish, and $673/ha for goldfish across the two study years. The fish losses to scaup alone averaged $1.06 million per year ($0.09 million in Year 1 and $2.03 million in Year 2) for the Arkansas baitfish industry. Total direct negative economic effects on the Arkansas baitfish industry were estimated to be, on average, $5.5 million per year ($4.6 in Year 1 and $6.3 million in Year 2).
The genomes of sulfate-reducing bacteria remain poorly characterized, largely due to a paucity of experimental data and genetic tools. To meet this challenge, we generated an archived library of ...15,477 mapped transposon insertion mutants in the sulfate-reducing bacterium Desulfovibrio alaskensis G20. To demonstrate the utility of the individual mutants, we profiled gene expression in mutants of six regulatory genes and used these data, together with 1,313 high-confidence transcription start sites identified by tiling microarrays and transcriptome sequencing (5' RNA-Seq), to update the regulons of Fur and Rex and to confirm the predicted regulons of LysX, PhnF, PerR, and Dde_3000, a histidine kinase. In addition to enabling single mutant investigations, the D. alaskensis G20 transposon mutants also contain DNA bar codes, which enables the pooling and analysis of mutant fitness for thousands of strains simultaneously. Using two pools of mutants that represent insertions in 2,369 unique protein-coding genes, we demonstrate that the hypothetical gene Dde_3007 is required for methionine biosynthesis. Using comparative genomics, we propose that Dde_3007 performs a missing step in methionine biosynthesis by transferring a sulfur group to O-phosphohomoserine to form homocysteine. Additionally, we show that the entire choline utilization cluster is important for fitness in choline sulfate medium, which confirms that a functional microcompartment is required for choline oxidation. Finally, we demonstrate that Dde_3291, a MerR-like transcription factor, is a choline-dependent activator of the choline utilization cluster. Taken together, our data set and genetic resources provide a foundation for systems-level investigation of a poorly studied group of bacteria of environmental and industrial importance.
Sulfate-reducing bacteria contribute to global nutrient cycles and are a nuisance for the petroleum industry. Despite their environmental and industrial significance, the genomes of sulfate-reducing bacteria remain poorly characterized. Here, we describe a genetic approach to fill gaps in our knowledge of sulfate-reducing bacteria. We generated a large collection of archived, transposon mutants in Desulfovibrio alaskensis G20 and used the phenotypes of these mutant strains to infer the function of genes involved in gene regulation, methionine biosynthesis, and choline utilization. Our findings and mutant resources will enable systematic investigations into gene function, energy generation, stress response, and metabolism for this important group of bacteria.
Arkansas' bait‐ and sportfish facilities are commonly used by various piscivorous bird species, including lesser scaup (Aythya affinis) and greater scaup (A. marila) that consume substantial ...quantities of fish. To mediate this predation, farmers implement extensive bird harassment programs that create additional costs to fish loss, thus research investigating the distribution and abundance of scaup is needed to help farmers allocate their bird harassment efforts more efficiently. In winters 2016–2017 and 2017–2018 we conducted 1,368 pond surveys to investigate pond use by scaup on farms during birds' regular wintering period (i.e., November–March). We used intrinsic and extrinsic pond‐level and farm‐level characteristics as explanatory variables in generalized linear models to reveal characteristics associated with increased scaup use. Inter‐annual differences in scaup use were also considered in each model. Our pond‐level model showed that scaup occurred more frequently on larger golden shiner (Notemigonus crysoleucas) and fathead minnow (Pimephales promelas) ponds stocked at greater densities, particularly during our second study winter. Our farm‐level model suggested that farms further from major rivers and with an average pond size of approximately eight hectares had the greatest probability of scaup use. Producers can apply findings from our models to implement bird harassment efforts in times and locations where scaup predation is more likely to occur.
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