Marquette General Hospital

CONTEXT: Despite the growing popularity of bariatric surgery, there remain concerns about perioperative safety and variation in outcomes across hospitals. OBJECTIVE: To assess complication rates of different bariatric procedures and variability in rates of serious complications across hospitals and according to procedure volume and center of excellence (COE) status. DESIGN, SETTING, AND PATIENTS: Involving 25 hospitals and 62 surgeons statewide, the Michigan Bariatric Surgery Collaborative (MBSC) administers an externally audited, prospective clinical registry. We evaluated short-term morbidity in 15,275 Michigan patients undergoing 1 of 3 common bariatric procedures between 2006 and 2009. We used multilevel regression models to assess variation in risk-adjusted complication rates across hospitals and the effects of procedure volume and COE designation (by the American College of Surgeons or American Society for Metabolic and Bariatric Surgery) status. MAIN OUTCOME MEASURE: Complications occurring within 30 days of surgery. RESULTS: Overall, 7.3% of patients experienced perioperative complications, most of which were wound problems and other minor complications. Serious complications were most common after gastric bypass (3.6%; 95% confidence interval [CI], 3.2%-4.0%), followed by sleeve gastrectomy (2.2%; 95% CI, 1.2%-3.2%), and laparoscopic adjustable gastric band (0.9%; 95% CI, 0.6%-1.1%) procedures (P < .001). Mortality occurred in 0.04% (95% CI, 0.001%-0.13%) of laparoscopic adjustable gastric band, 0 sleeve gastrectomy, and 0.14% (95% CI, 0.08%-0.25%) of the gastric bypass patients. After adjustment for patient characteristics and procedure mix, rates of serious complications varied from 1.6% (95% CI, 1.3-2.0) to 3.5% (95% CI, 2.4-5.0) (risk difference, 1.9; 95% CI, 0.08-3.7) across hospitals. Average annual procedure volume was inversely associated with rates of serious complications at both the hospital level (< 150 cases, 4.1%; 95% CI, 3.0%-5.1%; 150-299 cases, 2.7%; 95% CI, 2.2-3.2; and > or = 300 cases, 2.3%; 95% CI, 2.0%-2.6%; P = .003) and surgeon level (< 100 cases, 3.8%; 95% CI, 3.2%-4.5%; 100-249 cases, 2.4%; 95% CI, 2.1%-2.8%; > or = 250 cases, 1.9%; 95% CI, 1.4%-2.3%; P = .001). Adjusted rates of serious complications were similar in COE and non-COE hospitals (COE, 2.7%; 95% CI, 2.5%-3.1%; non-COE, 2.0%; 95% CI, 1.5%-2.4%; P = .41). CONCLUSIONS: The frequency of serious complications among patients undergoing bariatric surgery in Michigan was relatively low. Rates of serious complications are inversely associated with hospital and surgeon procedure volume, but unrelated to COE accreditation by professional organizations.

BACKGROUND: A number of surgical approaches are utilized in total hip arthroplasty. It has been hypothesized that the anterior approach results in less muscle damage than the posterior approach. We prospectively analyzed biochemical markers of muscle damage and inflammation in patients treated with minimally invasive total hip arthroplasty with an anterior or posterior approach to provide objective evidence of the local soft-tissue injury at the time of arthroplasty. METHODS: Twenty-nine patients treated with minimally invasive total hip arthroplasty through a direct anterior approach and twenty-eight patients treated with the same procedure through a posterior approach were prospectively analyzed. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum creatine kinase (CK), C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-1 beta (IL-1ß), and tumor necrosis factor-alpha (TNF-a) levels were measured preoperatively, in the post-anesthesia-care unit (except for the CRP level), and on postoperative days 1 and 2. The Student t test and Fisher exact test were used to make comparisons between the two groups. Independent predictors of elevation in levels of markers of inflammation and muscle damage were determined with use of multivariate logistic regression analysis. RESULTS: The levels of the markers of inflammation were slightly decreased in the direct-anterior-approach group as compared with those in the posterior-approach group. The rise in the CK level in the posterior-approach group was 5.5 times higher than that in the anterior-approach group in the post-anesthesia-care unit (mean difference, 150.3 units/L [95% CI, 70.4 to 230.2]; p < 0.05) and nearly twice as high cumulatively (mean difference, 305.0 units/L [95% CI, -46.7 to 656.8]; p < 0.05). CONCLUSIONS: We believe that the anterior total hip arthroplasty approach used in this study caused significantly less muscle damage than did the posterior surgical approach, as indicated by serum CK levels. The clinical importance of the rise in the CK level needs to be delineated by additional clinical studies. The overall physiologic burden, as demonstrated by measurement of inflammation marker levels, appears to be similar between the anterior and posterior approaches. Objective measurement of muscle damage and inflammation markers provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.

Telerehabilitation refers to the delivery of rehabilitation services via information and communication technologies. Clinically, this term encompasses a range of rehabilitation and habilitation services that include assessment, monitoring, prevention, intervention, supervision, education, consultation, and counseling. Telerehabilitation has the capacity to provide service across the lifespan and across a continuum of care. Just as the services and providers of telerehabilitation are broad, so are the points of service, which may include health care settings, clinics, homes, schools, or community-based worksites. This document was developed collaboratively by members of the Telerehabilitation SIG of the American Telemedicine Association, with input and guidance from other practitioners in the field, strategic stakeholders, and ATA staff. Its purpose is to inform and assist practitioners in providing effective and safe services that are based on client needs, current empirical evidence, and available technologies. Telerehabilitation professionals, in conjunction with professional associations and other organizations are encouraged to use this document as a template for developing discipline-specific standards, guidelines, and practice requirements.

In Brief Objective: To evaluate the comparative effectiveness of sleeve gastrectomy (SG), laparoscopic gastric bypass (RYGB), and laparoscopic adjustable gastric banding (LAGB) procedures. Background: Citing limitations of published studies, payers have been reluctant to provide routine coverage for SG for the treatment of morbid obesity. Methods: Using data from an externally audited, statewide clinical registry, we matched 2949 SG patients with equal numbers of RYGB and LAGB patients on 23 baseline characteristics. Outcomes assessed included complications occurring within 30 days, and weight loss, quality of life, and comorbidity remission at 1, 2, and 3 years after bariatric surgery. Results: Matching resulted in cohorts of SG, RYGB, and LAGB patients that were well balanced on baseline characteristics. Overall complication rates among patients undergoing SG (6.3%) were significantly lower than for RYGB (10.0%, P < 0.0001) but higher than for LAGB (2.4%, P < 0.0001). Serious complication rates were similar for SG (2.4%) and RYGB (2.5%, P = 0.736) but higher than for LAGB (1.0%, P < 0.0001). Excess body weight loss at 1 year was 13% lower for SG (60%) than for RYGB (69%, P < 0.0001), but was 77% higher for SG than for LAGB (34%, P < 0.0001). SG was similarly closer to RYGB than LAGB with regard to remission of obesity-related comorbidities. Conclusions: With better weight loss than LAGB and lower complication rates than RYGB, SG is a reasonable choice for the treatment of morbid obesity and should be covered by both public and private payers. Citing limitations of published studies, payers have been reluctant to provide routine coverage for sleeve gastrectomy for the treatment of morbid obesity. Using data from a statewide, externally audited clinical registry, our study compares rates of complications, and weight loss, comorbidity remission, quality of life, and satisfaction for 3 years after bariatric surgery among nearly 9000 morbidly obese patients. We find that with better weight loss than adjustable gastric band and lower complication rates than gastric bypass, sleeve gastrectomy is a reasonable choice for the treatment of morbid obesity and should be covered by both public and private payers.

Resolution and penetration are primary criteria for clinical image quality. Conventionally, high bandwidth for resolution was achieved with a short pulse, which results in a tradeoff between resolution and penetration. Coded excitation extends the bounds of this tradeoff by increasing signal-to-noise ratio (SNR) through appropriate coding on transmit and decoding on receive. Although used for about 50 years in radar, coded excitation was successfully introduced into commercial ultrasound scanners only within the last 5 years. This delay is at least partly due to practical implementation issues particular to diagnostic ultrasound, which are the focus of this paper. After reviewing the basics of biphase and chirp coding, we present simulation results to quantify tradeoffs between penetration and resolution under frequency-dependent attenuation, dynamic focusing, and nonlinear propagation. Next we compare chirp and Golay code performance with respect to image quality and system requirements, then we show clinical images that illustrate the current applications of coded excitation in B-mode, harmonic, and flow imaging.

OBJECTIVES: To develop a risk prediction model for serious complications after bariatric surgery. BACKGROUND: Despite evidence for improved safety with bariatric surgery, serious complications remain a concern for patients, providers and payers. There is little population-level data on which risk factors can be used to identify patients at high risk for major morbidity. METHODS: The Michigan Bariatric Surgery Collaborative is a statewide consortium of hospitals and surgeons, which maintains an externally-audited prospective clinical registry. We analyzed data from 25,469 patients undergoing bariatric surgery between June 2006 and December 2010. Significant risk factors on univariable analysis were entered into a multivariable logistic regression model to identify factors associated with serious complications (life threatening and/or associated with lasting disability) within 30 days of surgery. Bootstrap resampling was performed to obtain bias-corrected confidence intervals and c-statistic. RESULTS: Overall, 644 patients (2.5%) experienced a serious complication. Significant risk factors (P < 0.05) included: prior VTE (odds ratio [OR] 1.90, confidence interval [CI] 1.41-2.54); mobility limitations (OR 1.61, CI 1.23-2.13); coronary artery disease (OR 1.53, CI 1.17-2.02); age over 50 (OR 1.38, CI 1.18-1.61); pulmonary disease (OR 1.37, CI 1.15-1.64); male gender (OR 1.26, CI 1.06-1.50); smoking history (OR 1.20, CI 1.02-1.40); and procedure type (reference lap band): duodenal switch (OR 9.68, CI 6.05-15.49); laparoscopic gastric bypass (OR 3.58, CI 2.79-4.64); open gastric bypass (OR 3.51, CI 2.38-5.22); sleeve gastrectomy (OR 2.46, CI 1.73-3.50). The c-statistic was 0.68 (bias-corrected to 0.66) and the model was well-calibrated across deciles of predicted risk. CONCLUSIONS: We have developed and validated a population-based risk scoring system for serious complications after bariatric surgery. We expect that this scoring system will improve the process of informed consent, facilitate the selection of procedures for high-risk patients, and allow for better risk stratification across studies of bariatric surgery.

Background: Numerous physical, psychological, and emotional benefits have been attributed to marijuana since its first reported use in 2,600 BC in a Chinese pharmacopoeia.The phytocannabinoids, cannabidiol (CBD), and delta-9-tetrahydrocannabinol (Δ9-THC) are the most studied extracts from cannabis sativa subspecies hemp and marijuana.CBD and Δ9-THC interact uniquely with the endocannabinoid system (ECS).Through direct and indirect actions, intrinsic endocannabinoids and plant-based phytocannabinoids modulate and influence a variety of physiological systems influenced by the ECS.Methods: In 1980, Cunha et al. reported anticonvulsant benefits in 7/8 subjects with medically uncontrolled epilepsy using marijuana extracts in a phase I clinical trial.Since then neurological applications have been the major focus of renewed research using medical marijuana and phytocannabinoid extracts.Results: Recent neurological uses include adjunctive treatment for malignant brain tumors, Parkinson's disease, Alzheimer's disease, multiple sclerosis, neuropathic pain, and the childhood seizure disorders Lennox-Gastaut and Dravet syndromes.In addition, psychiatric and mood disorders, such as schizophrenia, anxiety, depression, addiction, postconcussion syndrome, and posttraumatic stress disorders are being studied using phytocannabinoids.Conclusions: In this review we will provide animal and human research data on the current clinical neurological uses for CBD individually and in combination with Δ9-THC.We will emphasize the neuroprotective, antiinflammatory, and immunomodulatory benefits of phytocannabinoids and their applications in various clinical syndromes.

Patients who have been sensitized to leukocytes by transfusions and pregnancy are subject to “pyrogenic” reactions of varying severity following the administration of whole blood. Present methods for preparing buffy coat‐poor blood utilize differential centrifugation or sedimentation in the presence of dextran. They are time consuming and not uniformly dependable. The procedure described removes the granulocytes from heparinized whole blood by passing it over a column of Nylon fibers in ten to 15 minutes. Only 5 per cent of the donation is retained in the column and the white blood counts of the final product are 500‐3,100/cu. mm. with 95 to 100 per cent lymphocytes. Cr51 survival studies suggest that these preparations withstand storage satisfactorily for 14 to 21 days. Our experience with the transfusion of 82 units of this product and the relative importance of lymphocytes and granulocytes in leukoagglutination are discussed.

Advances in all aspects of science and discovery continue to occur at an exponential rate, leading to a wealth of new knowledge and technologies that have the potential to transform dental practice. This "new science" within the areas of cell/ molecular biology, genetics, tissue engineering, nanotechnology, and informatics has been available for several years; however, the assimilation of this information into the dental curriculum has been slow. For the profession and the patients it serves to benefit fully from modern science, new knowledge and technologies must be incorporated into the mainstream of dental education. The continued evolution of the dental curriculum presents a major challenge to faculty, administrators, and external constituencies because of the high cost, overcrowded schedule, unique demands of clinical training, changing nature of teaching/assessment methods, and large scope of new material impacting all areas of the educational program. Additionally, there is a lack of personnel with adequate training/experience in both foundational and clinical sciences to support the effective application and/or integration of new science information into curriculum planning, implementation, and assessment processes. Nonetheless, the speed of this evolution must be increased if dentistry is to maintain its standing as a respected health care profession. The influence of new science on dental education and the dental curriculum is already evident in some dental schools. For example, the Marquette University School of Dentistry has developed a comprehensive model of curriculum revision that integrates foundational and clinical sciences and also provides a dedicated research/scholarly track and faculty development programming to support such a curriculum. Educational reforms at other dental schools are based on addition of new curricular elements and include innovative approaches that introduce concepts regarding new advances in science, evidence-based foundations, and translational research. To illustrate these reforms, the Marquette curriculum and initiatives at the University of Connecticut and the University of Texas Health Science Center at San Antonio dental schools are described in this article, with recognition that other dental schools may also be developing strategies to infuse new science and evidence-based critical appraisal skills into their students' educational experiences. Discussion of the rationale, goals/objectives, and outcomes within the context of dissemination of these models should help other dental schools to design approaches for integrating this new material that are appropriate to their particular circumstances and mission. For the profession to advance, every dental school must play a role in establishing a culture that attaches value to research/discovery, evidence-based practice, and the application of new knowledge/technologies to patient care.

OBJECTIVE: We sought to identify risk factors for venous thromboembolism (VTE) among patients undergoing bariatric surgery in Michigan. BACKGROUND: VTE remains a major source of morbidity and mortality after bariatric surgery. It is unclear which factors should be used to identify patients at high risk for VTE. METHODS: The Michigan Bariatric Surgery Collaborative maintains a prospective clinical registry of bariatric surgery patients. For this study, we identified all patients undergoing primary bariatric surgery between June 2006 and April 2011 and determined rates of VTE. Potential risk factors for VTE were analyzed using a hierarchical logistic regression model, accounting for clustering of patients within hospitals. Significant risk factors were used to develop a risk calculator for development of VTE after bariatric surgery. RESULTS: Among 27,818 patients who underwent bariatric surgery during the study period, 93 patients (0.33%) experienced a VTE complication, including 51 patents with pulmonary embolism. There were 8 associated deaths. Significant risk factors included previous history of VTE (OR 4.15, CI 2.42-7.08); male gender (OR 2.08, CI 1.36-3.19); operative time more than 3 hours (OR 1.86, CI 1.07-3.24); BMI category (per 10 units) (OR 1.37, CI 1.06-1.75); age category (per 10 years) (OR 1.25, CI 1.03-1.51); and procedure type (reference adjustable gastric band): duodenal switch (OR 9.45, CI 2.50-35.97); open gastric bypass (OR 6.48, CI 2.17-19.41); laparoscopic gastric bypass (OR 3.97, CI 1.77-8.91); and sleeve gastrectomy (OR 3.50, CI 1.30-9.34). Nearly 97% of patients had a predicted VTE risk less than 1%. CONCLUSIONS: In this population-based study, overall VTE rates were low among patients undergoing bariatric surgery. The use of an empirically based risk calculator will allow for the development of a risk-stratified approach to VTE prophylaxis.

Calf strains are common injuries seen in primary care and sports medicine clinics. Differentiating strains of the gastrocnemius or soleus is important for treatment and prognosis. Simple clinical testing can assist in diagnosis and is aided by knowledge of the anatomy and common clinical presentation.

Is the emergence of social marketing a Pandora's Box for the discipline of marketing? A survey of four disparate groups with special knowledge and interest in the issue reports on the possible ethical ramifications of social marketing.

Committee Members Co-Chairs David Brennan, M.B.E., Senior Research Engineer, National Rehabilitation Hospital, Washington, District of Columbia. Lyn Tindall, Ph.D., Speech-Language Pathologist, Department of Veterans Affairs Medical Center, Lexington, Kentucky. Writing Committee Janet Brown, M.A., CCC-SLP, Director, Health Care Services, American Speech-Language-Hearing Association, Rockville, Maryland. Mike Campbell, M.S., M.B.A., CCC-SLP, Director of the Speech and Hearing Program, The University of North Carolina at Greensboro, Browns Summit, North Carolina. Jana Cason, D.H.S., OTR/L, Assistant Professor, Auerbach School of Occupational Therapy, Louisville, Kentucky. Diana Christiana, M.A.T., CCC-SLP, President/CEO, Clinical Communications, Sugar Land, TX. Alan Lee, Ph.D., P.T., D.P.T., C.W.S., G.C.S., Associate Professor, Mount St. Mary's College, Doctor of Physical Therapy Program, Los Angeles, California. David R. Smith, Director, Telehealth Resource Center, Marquette General Hospital, Marquette, Michigan. Deborah Theodoros, Ph.D., Associate Professor and Head, Division of Speech Pathology, School of Health and Rehabilitative Sciences, The University of Queensland, Queensland, Australia. Contributors Working Group Members [WG], Consultants [C], Reviewers [R], Telerehabilitation Special Interest Group Chair [TR], ATA Standards and Guidelines Committee Member [SG], and ATA Staff [S] Nina Antoniotti, R.N., M.B.A., Ph.D., Chair of SG, Director of Telehealth, Marshfield Clinic, Marshfield, Wisconsin. Jordana Bernard, M.B.A., S, Senior Director, Program Services, American Telemedicine Association, Washington, District of Columbia. Anne Burdick, M.D., M.P.H., SG, Associate Dean for Telemedicine and Clinical Outreach, Professor of Dermatology, Director, Leprosy Program, University of Miami Miller School of Medicine, Miami, Florida. Jerry Cavallerano, Ph.D., OD, SG, Staff Optometrist, Assistant to the Director, Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts. Ellen Cohn, Ph.D., CCC-SLP, TR, WG, Associate Dean for Instructional Development, School of Health and Rehabilitative Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania. Paul Cox, MSEE, WG, President, PERL Research, Huntsville, Alabama. Mary Fran Delaune, P.T., MPT, R, Director, Practice Department, American Physical Therapy Association, Alexandria, Virginia. Matt Elrod, P.T., D.P.T., M.Ed., N.S.C., R, Associate Director, Practice Department, American Physical Therapy Association, Alexandria, Virginia. Brian Grady, M.D., [SG], VISN5 TMH Lead and Director, TeleMental Health, School of Medicine, University of Maryland, Baltimore, Maryland. Elizabeth Krupinski, Ph.D., Vice Chair of SG, Associate Director, Program Evaluation, University of Arizona, Arizona Telemedicine Program, Department of Radiology, Research Professor, Department of Radiology Research, Tucson, Arizona. Jonathan D. Linkous, MPA, S, Chief Executive Director, American Telemedicine Association, Washington, District of Columbia. Michael Pramuka, Ph.D., CRC, WG, Rehabilitation Counselor, Walter Reed Medical Center, Washington, District of Columbia. Richard Schein, Ph.D., WG, Postdoctoral Associate, Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, Pennsylvania. Lou Theurer, SG, Grant Administrator, Burn Telemedicine Program, University of Utah Health Sciences Center, Salt Lake City, Utah. Jill Winters, Ph.D., R.N., WG, SG, Dean and Professor, Columbia College of Nursing, Milwaukee, Wisconsin.

IMPORTANCE: The optimal approach for profiling hospital performance with bariatric surgery is unclear. OBJECTIVE: To develop a novel composite measure for profiling hospital performance with bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS: Using clinical registry data from the Michigan Bariatric Surgery Collaborative, we studied all patients undergoing bariatric surgery from January 1, 2008, through December 31, 2010. For laparoscopic gastric bypass surgery, we used empirical Bayes techniques to create a composite measure by combining several measures, including serious complications, reoperations, and readmissions; hospital and surgeon volume; and outcomes with other related procedures. Hospitals were ranked for 2008 through 2009 and placed in 1 of 3 groups: 3-star (top 20%), 2-star (middle 60%), and 1-star (bottom 20%). We assessed how well these ratings predicted outcomes in the next year (2010) compared with other widely used measures. MAIN OUTCOMES AND MEASURES: Risk-adjusted serious complications. RESULTS: Composite measures explained a larger proportion of hospital-level variation in serious complication rates with laparoscopic gastric bypass than other measures. For example, the composite measure explained 89% of the variation compared with only 28% for risk-adjusted complication rates alone. Composite measures also appeared better at predicting future performance compared with individual measures. When ranked on the composite measure, 1-star hospitals had 2-fold higher serious complication rates (4.6% vs 2.4%; odds ratio, 2.0; 95% CI, 1.1-3.5) compared with 3-star hospitals. Differences in serious complication rates between 1- and 3-star hospitals were much smaller when hospitals were ranked using serious complications (4.0% vs 2.7%; odds ratio, 1.6; 95% CI, 0.8-2.9) and hospital volume (3.3% vs 3.2%; odds ratio, 0.85; 95% CI, 0.4-1.7). CONCLUSIONS AND RELEVANCE: Composite measures are much better at explaining hospital-level variation in serious complications and predicting future performance than other approaches. In this preliminary study, it appears that such composite measures may be better than existing alternatives for profiling hospital performance with bariatric surgery.

The concentrations of contaminants generated from discrete source areas are critical to urban nonpoint Source Load and Management Model (SLAMM) loading calculations to Lake Superior.This study summarizes data-collection efforts during 12 storms in October 1993 and from May through August 1994, in which stormwater data were collected concurrently at 33 sites representing the eight major source areas in a 117-hectare urban basin in Marquette, Mich.For the 12 storms, commercial rooftops produced the highest geometric mean concentrations of dissolved metals such as lead (20 mg/L), zinc (263 mg/L), cadmium (0.71 mg/L), and copper (17.8 mg/L).Parking lots produced the highest concentration for all of the individual polycyclic aromatic hydrocarbon (PAH) compounds (summation equal to 64 mg/L).Residential lawns generated the highest concentrations of total kjeldahl nitrogen (9.3 mg/L) and total phosphorus (2.3 mg/L).A mass-budget approach, in which summed source area loads are compared to those measured at the basin outlet for individual storms, provided the basis for an error analysis to identify unreliable concentration data.Of the 611 concentration samples used in the mass budgets, 59 were identified as unreliable.Seventy-six percent of the unreliable samples came from collection bottles that were filled prior to the end of runoff.These full bottles may have captured a first-flush effect or acted as a sediment trap.The relative importance of an individual source-area load to the overall basin-outlet load varied according to the individual constituent.Parking lots were a major contributor of total zinc (30 percent), total cadmium (25 percent), total copper (22 percent), and all the PAH compounds (=64 percent); whereas low-traffic streets were a major producer of total suspended solids (27 percent), nitrate plus nitrite (21 percent), and total cadmium (25 percent).Grass areas were a major producer of total kjeldahl nitrogen (31 percent) and total phosphorus (26 percent), even though the water volume generated from grass areas was low (5.8 percent of the total water volume generated).

BACKGROUND: Transfer RNAs are synthesized as a primary transcript that is processed to produce a mature tRNA. As part of the maturation process, a subset of the nucleosides are modified. Modifications in the anticodon region often modulate the decoding ability of the tRNA. At position 34, the majority of yeast cytosolic tRNA species that have a uridine are modified to 5-carbamoylmethyluridine (ncm(5)U), 5-carbamoylmethyl-2'-O-methyluridine (ncm(5)Um), 5-methoxycarbonylmethyl-uridine (mcm(5)U) or 5-methoxycarbonylmethyl-2-thiouridine (mcm(5)s(2)U). The formation of mcm(5) and ncm(5) side chains involves a complex pathway, where the last step in formation of mcm(5) is a methyl esterification of cm(5) dependent on the Trm9 and Trm112 proteins. METHODOLOGY AND PRINCIPAL FINDINGS: Both Trm9 and Trm112 are required for the last step in formation of mcm(5) side chains at wobble uridines. By co-expressing a histidine-tagged Trm9p together with a native Trm112p in E. coli, these two proteins purified as a complex. The presence of Trm112p dramatically improves the methyltransferase activity of Trm9p in vitro. Single tRNA species that normally contain mcm(5)U or mcm(5)s(2)U nucleosides were isolated from trm9Δ or trm112Δ mutants and the presence of modified nucleosides was analyzed by HPLC. In both mutants, mcm(5)U and mcm(5)s(2)U nucleosides are absent in tRNAs and the major intermediates accumulating were ncm(5)U and ncm(5)s(2)U, not the expected cm(5)U and cm(5)s(2)U. CONCLUSIONS: Trm9p and Trm112p function together at the final step in formation of mcm(5)U in tRNA by using the intermediate cm(5)U as a substrate. In tRNA isolated from trm9Δ and trm112Δ strains, ncm(5)U and ncm(5)s(2)U nucleosides accumulate, questioning the order of nucleoside intermediate formation of the mcm(5) side chain. We propose two alternative explanations for this observation. One is that the intermediate cm(5)U is generated from ncm(5)U by a yet unknown mechanism and the other is that cm(5)U is formed before ncm(5)U and mcm(5)U.

OBJECTIVE: To assess relationships between safety culture and complications within 30 days of bariatric surgery. BACKGROUND: Safety culture refers to the quality of teamwork, coordination, and communication, as well as responses to error in health care settings. Although safety culture is thought to be an important determinant of surgical outcomes, few studies have examined this empirically. METHODS: We surveyed staff from 22 Michigan hospitals participating in a statewide bariatric surgery collaborative. Each safety culture survey item was rated on a 1 to 5 Likert scale with lower scores representing better patient safety culture. These data were linked to clinical registry data for 24,117 bariatric surgery patients between 2007 and 2010. We used negative binomial regression to calculate incidence rates and incidence rate ratios measuring the increase in hospitals' rate of complications per unit increase in safety culture (individual items as well as hospital and operating room-specific subscales), controlling for patient risk factors, procedure mix, and bariatric procedure volume. RESULTS: All 22 hospitals participated in this study, submitting safety culture ratings from 53 surgeons, 102 nurses, and 29 operating room administrators. Rates of serious complications were significantly lower among hospitals receiving an overall safety rating of excellent from nurses (1.5%), compared with those receiving a very good (2.6%) or acceptable (4.6%) rating (P = <0.0001). Surgeons' overall safety ratings were also associated with rates of serious complications (2.1% excellent, 2.6% very good, 4.7% acceptable, P = 0.011). Nurses' ratings of the hospital-specific subscale (P = 0.002) and surgeons' ratings of the operating room-specific subscale (P = 0.045) were also associated with rates of serious complications. Of the individual items, those related to coordination and communication between hospital units were the most strongly associated with rates of complications. Operating room administrator ratings of safety culture were not related to rates of complications for any of the domains of safety culture studied. CONCLUSIONS: Safety culture is associated with rates of serious surgical complications in bariatric surgery. Although nurses provide better information about hospital safety culture, surgeons are better judges of safety culture in the operating room. Interventions targeting safety culture, particularly coordination and communication, seem to be important for quality improvement.

A case is presented of an intraspinal extradural ganglion cyst at the L4-5 level. The clinical picture suggested a herniated nucleus pulposus at this level. A myelogram revealed a round lesion almost completely obstructing the flow of Pantopaque at the L4-5 level. A ganglion cyst with a haemorrhage into it and the surrounding tissue was removed, and surgery was followed by complete recovery.

STUDY DESIGN: To report on the preliminary results of preparing and reconstructing the pars interarticularis with a cable-screw construct. The success of previous techniques to repair the pars defect has been variable. OBJECTIVES: To assess the results of a new technique for stabilizing the pars interarticularis, using the strongest materials, pedicle screws, and cables in the strongest bony elements--the pedicle and lamina. SUMMARY OF BACKGROUND DATA: Previous techniques have been inadequate structurally to stabilize the pars interarticularis effectively, or the techniques were difficult to perform. Placing a screw across the defect was technically difficult and took away from the surface area of the fusion. The Scott technique used wiring between the transverse process and spinous process; and in the Morscher Technique, a hook screw was used to repair the pars defect--a technically difficult procedure, using bulky hardware. METHODS: Patients with pars interarticularis defects were carefully selected for this technique if they had primarily low back pain that did not respond to conservative treatment. The eligible patient had Grade I or less spondylolisthesis, little or no desiccation detectable on magnetic resonance imaging, and pain reproduced with injection of the pars defect. Surgical technique involved placing a special pedicle cable-screw into the pedicle of the involved vertebra. A double cable was passed underneath the lamina, threaded through the hole of the pedicle screw, and wrapped around the spinous process. The cables were simultaneously tensioned and crimped. A tricortical bone graft was compressed between the pedicle and lamina. RESULTS: Seven patients had this technique with a follow-up of 25.5 months (range, 19-37 months). The mean age was 20.5 years (range, 12-32 years), and the mean duration of symptoms was 31 months. All patients had severe pain before surgery that prevented participation in sports and normal daily activities. After surgery, results in five were rated as excellent and in two as good, according to the Prolo score. There were no failures of the cable-screw constructs, and all of the defects appear to have united solidly. CONCLUSION: The cable-screw construct uses the strongest anchors (the pedicle and the lamina) and uses compression obtained with cables to stabilize the pars interarticularis. Early results indicate that this is a safe and effective technique for this difficult problem.

This study compared the Biomic automated well reader results to the MicroScan WalkAway results for reading MicroScan antimicrobial susceptibility and identification panels at four different sites. Routine fresh clinical isolates and quality control (QC) organisms were tested at each study site. A total of 46,176 MicroScan panel drug-organism combinations were read. The Biomic category agreement for 3,117 Gram-negative bacteria was 98.4%, with 1.4% minor and 0.2% major discrepancies. The Biomic category agreement for 5,233 Gram-positive bacteria was 98.7%, with 0.9% minor, 0.3% major, and 0.1% very major errors. Essential agreement, defined as Biomic results that were within ±1 2-fold dilution of the MicroScan results, was 99.3% for Gram-negative bacteria and 98.3% for Gram-positive bacteria. Biomic reading of MicroScan identification panels provided an overall agreement (first- and second-choice organism match) of 99.5% with 846 Gram-negative isolates and 99.5% with 430 Gram-positive isolates. These results suggest that the Biomic automated reader can provide accurate reading of MicroScan panels and has the capability of a visual panel read for manual adjustment of results.