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Aerodynamic models of bird flight, assuming power minimization, predict a quadratic relationship (i.e. U-shaped curve) between flapping frequency and airspeed. This relationship is supported by experimental bird flight data from wind tunnels, but the degree to which it characterizes natural flight, and the extent to which birds might modify it to accommodate other behaviors, is less known. We hypothesized that the U-shaped relationship would vary or vanish when minimizing power is not a primary consideration. We analyzed videos of wild cliff swallows (Petrochelidon pyrrhonota) engaged in solo and tandem (i.e. following or being followed by a conspecific) flights to collect bird flapping frequencies and airspeeds. Solo birds had a U-shaped flapping frequency to speed relationship. Birds engaged in tandem flights had the opposite pattern; their flapping frequencies varied with speed as an inverse U-shaped curve and were up to 2.1 times higher than solo birds at the same speed., Competing Interests: Competing interests The authors declare no competing or financial interests., (© 2025. Published by The Company of Biologists.)

Background: There has been tremendous effort to improve quality following colorectal surgery, including the proliferation of minimally invasive techniques, enhanced recovery protocols, and surgical site infection prevention bundles. While these programs have demonstrated improved postoperative outcomes at the institutional level, it is unclear whether similar benefits are present on a national scale., Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Targeted Colectomy data from 2012 to 2020 were used to identify patients undergoing minimally invasive surgery (MIS) or open partial colectomy (CPT 44140, 44204) or low anterior resection (CPT 44145, 44207). Chronological cohorts as well as annual trends in 30-day postoperative outcomes including surgical site infection, venous thromboembolism, and length of stay were assessed using both univariable and multivariable regression analyses., Results: 261,301 patients, 135,876 (52 ​%) female, with a median age of 62 (IQR 53-72) were included. Across all years, MIS partial colectomy was the most common procedure (37 ​%), followed by MIS low anterior resection (27 ​%), open partial colectomy (24 ​%), and open low anterior resection (12 ​%). MIS increased from 59 ​% in 2012-2014 to 66 ​% in 2018-2020 (p ​< ​0.001). During this same period, postoperative length of stay decreased from a median of 5 days (IQR 4-7) in 2012-2014 to 4 days (IQR 3-6) in 2018-2020 (p ​< ​0.001). Superficial surgical site infections decreased from 5.5 ​% in 2012-2014 to 2.9 ​% in 2018-2020 (p ​< ​0.001). Deep surgical site infections similarly decreased from 1.1 ​% to 0.4 ​% between these periods (p ​< ​0.001). Pulmonary embolism also decreased from 0.6 ​% to 0.5 ​% between periods (p ​= ​0.02). 30-day mortality was unchanged at 1.7 ​% between 2012-2014 and 2018-2020 (p ​= ​0.40). After adjustment for ACS NSQIP estimated probability of morbidity and mortality, undergoing a colectomy in 2020 compared to 2012 was associated with a 14 ​% decrease in postoperative length of stay (p ​< ​0.001)., Conclusions: Between 2012 and 2020, significant improvements in postoperative outcomes after colectomy were observed in the United States. These results support the positive impact that the widespread adoption of quality improvement initiatives is having on colorectal patient care nationally., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Insects must fly in highly variable natural environments filled with gusts, vortices, and other transient aerodynamic phenomena that challenge flight stability. Furthermore, the aerodynamic forces that support insect flight are produced from rapidly oscillating wings of time-varying orientation and configuration. The instantaneous flight forces produced by these wings are large relative to the average forces supporting body weight. The magnitude of these forces and their time-varying direction add another challenge to flight stability, because even proportionally small asymmetries in timing or magnitude between the left and right wings may be sufficient to produce large changes in body orientation. However, these same large-magnitude oscillating forces also offer an opportunity for unexpected flight stability through nonlinear interactions between body orientation, body oscillation in response to time-varying inertial and aerodynamic forces, and the oscillating wings themselves. Understanding the emergent stability properties of flying insects is a crucial step toward understanding the requirements for evolution of flapping flight and decoding the role of sensory feedback in flight control. Here, we provide a brief review of insect flight stability, with some emphasis on stability effects brought about by oscillating wings, and present some preliminary experimental data probing some aspects of flight stability in free-flying insects., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Integrative and Comparative Biology.)

Birds commonly exploit environmental features such as columns of rising air and vertical windspeed gradients to lower the cost of flight. These environmental subsidies may be especially important for birds that forage via continuous flight, as seen in black skimmers. These birds forage through a unique behavior, called skimming, where they fly above the water surface with their mandible lowered into the water, catching fish on contact. Thus, their foraging flight incurs costs of moving through both air and water. Prior studies of black skimmer flight behavior have focused on reductions in flight cost due to ground effect, but ignored potential beneficial interactions with the surrounding air. We hypothesized a halfpipe skimming strategy for skimmers to reduce the foraging cost by taking advantage of the wind gradient, where the skimmers perform a wind gradient energy extraction maneuver at the end of a skimming bout through a foraging patch. Using video recordings, wind speed and wind direction measurements, we recorded 70 bird tracks over 4 days at two field sites on the North Carolina coast. We found that while ascending, the skimmers flew more upwind and then flew more downwind when descending, a pattern consistent with harvesting energy from the wind gradient. The strength of the wind gradient and flight behavior of the skimmers indicate that the halfpipe skimming strategy could reduce foraging cost by up to 2.5%., Competing Interests: Competing interests The authors declare no competing or financial interests., (© 2024. Published by The Company of Biologists Ltd.)

Animals must tune their physical performance to changing environmental conditions, and the breadth of environmental tolerance may contribute to delineating the geographic range of a species. A common environmental challenge that flying animals face is the reduction of air density at high elevation and the reduction in the effectiveness of lift production that accompanies it. As a species, turkey vultures (Cathartes aura) inhabit a >3000 m elevation range, and fly considerably higher, necessitating that they accommodate for a 27% change in air density (0.890 to 1.227 kg m-3) through behavior, physiology or biomechanics. We predicted that birds flying at high elevation would maintain aerodynamic lift performance behaviorally via higher flight speeds, rather than increases in power output or local phenotypic adaptation. We used three-dimensional videography to track turkey vultures flying at three elevations, and data supported the hypothesized negative relationship between median airspeed and air density. Additionally, neither the ratio of horizontal speed to sinking speed nor flapping behavior varied with air density., Competing Interests: Competing interests The authors declare no competing or financial interests., (© 2024. Published by The Company of Biologists Ltd.)

The evolution of flight in an early winged insect ancestral lineage is recognized as a key adaptation explaining the unparalleled success and diversification of insects. Subsequent transitions and modifications to flight machinery, including secondary reductions and losses, also play a central role in shaping the impacts of insects on broadscale geographic and ecological processes and patterns in the present and future. Given the importance of insect flight, there has been a centuries-long history of research and debate on the evolutionary origins and biological mechanisms of flight. Here, we revisit this history from an interdisciplinary perspective, discussing recent discoveries regarding the developmental origins, physiology, biomechanics, and neurobiology and sensory control of flight in a diverse set of insect models. We also identify major outstanding questions yet to be addressed and provide recommendations for overcoming current methodological challenges faced when studying insect flight, which will allow the field to continue to move forward in new and exciting directions. By integrating mechanistic work into ecological and evolutionary contexts, we hope that this synthesis promotes and stimulates new interdisciplinary research efforts necessary to close the many existing gaps about the causes and consequences of insect flight evolution., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Integrative and Comparative Biology.)

Many bird species commonly aggregate in flocks for reasons ranging from predator defense to navigation. Available evidence suggests that certain types of flocks-the V and echelon formations of large birds-may provide a benefit that reduces the aerodynamic cost of flight, whereas cluster flocks typical of smaller birds may increase flight costs. However, metabolic flight costs have not been directly measured in any of these group flight contexts [Zhang and Lauder, J. Exp. Biol. 226 , jeb245617 (2023)]. Here, we measured the energetic benefits of flight in small groups of two or three birds and the requirements for realizing those benefits, using metabolic energy expenditure and flight position measurements from European Starlings flying in a wind tunnel. The starlings continuously varied their relative position during flights but adopted a V formation motif on average, with a modal spanwise and streamwise spacing of [0.81, 0.91] wingspans. As measured via CO 2 production, flight costs for follower birds were significantly reduced compared to their individual solo flight benchmarks. However, followers with more positional variability with respect to leaders did less well, even increasing their costs above solo flight. Thus, we directly demonstrate energetic costs and benefits for group flight followers in an experimental context amenable to further investigation of the underlying aerodynamics, wake interactions, and bird characteristics that produce these metabolic effects., Competing Interests: Competing interests statement:The authors declare no competing interest.

Much has been written about the energetic effects of animals moving in schools or flocks, but experimental results are few and often ambiguous. A new study in PLOS Biology shows that schooling greatly reduces the cost of transport for fish in turbulent flow., Competing Interests: The author has declared that no competing interests exist., (Copyright: © 2024 Tyson L. Hedrick. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Adult moths from framily Spingidae (i.e. hawkmoths or sphinx moths) commonly feed on flower nectar through an extended proboscis, often several centimeters in length and longer than the body of the moth. Feeding on a viscous liquid (nectar) through a long and narrow tube is a challenging fluid dynamic problem and the subject of long-running scientific investigation. Here we characterized the relationship between proboscis submergence depth and nectar drinking rate in Manduca sexta hawkmoths. Video recordings of moth feeding bouts were collected and neural networks were used to extract data by object localization, tracking the location of the nectar meniscus and moths' proboscis tips. We found that although feeding rates vary among bouts, the variation was not associated with proboscis submergence depth. These results show that despite the theoretical possibility of fluid uptake through the walls of the proboscis, such effects do not have a substantial effect on nectar uptake rate, and suggest that nectar must traverse the full length of the proboscis., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Pierce, Hedrick. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

A limiting factor in the design of smaller size uncrewed aerial vehicles is their inability to navigate through gust-laden environments. As a result, engineers have turned towards bio-inspired engineering approaches for gust mitigation techniques. In this study, the aerodynamics of a red-tailed hawk's response to variable-magnitude discrete transverse gusts was investigated. The hawk was flown in an indoor flight arena instrumented by multiple high-speed cameras to quantify the 3D motion of the bird as it navigated through the gust. The hawk maintained its flapping motion across the gust in all runs; however, it encountered the gust at different points in the flapping pattern depending on the run and gust magnitude. The hawk responded with a downwards pitching motion of the wing, decreasing the wing pitch angle to between -20 ∘ and -5 ∘ , and remained in this configuration until gust exit. The wing pitch data was then applied to a lower-order aerodynamic model that estimated lift coefficients across the wing. In gusts slower than the forward flight velocity (low gust ratio), the lift coefficient increases at a low-rate, to a maximum of around 2-2.5. In gusts faster than the forward flight velocity (high gust ratio), the lift coefficient initially increased rapidly, before increasing at a low-rate to a value around 4-5. In both regimes, the hawk's observed height change due to gust interaction was similar (and small), despite larger estimated lift coefficients over the high gust regime. This suggests another mitigation factor apart from the wing response is present. One potential factor is the tail pitching response observed here, which prior work has shown serves to mitigate pitch disturbances from gusts., (Creative Commons Attribution license.)

The physical principles that govern the function of biological structures also mediate their evolution, but the evolutionary drivers of morphological traits within complex structures can be difficult to predict. Here, we use morphological traits measured from 1096 3-dimensional bird wing scans from 178 species to test the interaction of two frameworks for relating morphology to evolution. We examine whether the evolutionary rate (σ 2 ) and mode is dominated by the modular organization of the wing into handwing and armwing regions, and/or the relationship between trait morphology and functional output (i.e. mechanical sensitivity, driven here by flapping flight aerodynamics). Our results support discretization of the armwing and handwing as morphological modules, but morphological disparity and σ 2 varied continuously with the mechanical sensitivity gradient and were not modular. Thus, mechanical sensitivity should be considered an independent and fundamental driver of evolutionary dynamics in biomechanical traits, distinct from morphological modularity., (© 2023. The Author(s).)

Background: The rate of anal squamous cell cancer (aSCC) is increasing among women living with HIV. Treatment of precursor high grade squamous intraepithelial lesions (HSIL) may reduce the risk of progression to aSCC. The objective of this study was to examine effects of a dedicated high-resolution anoscopy (HRA) clinic on management of HSIL in women with HIV., Methods: Women living with HIV who underwent anal dysplasia screening at a single institution between 2006 and 2020 were reviewed. Those who underwent screening before (Group A) and after (Group B) the implementation of an HRA program in 2017 were compared. The primary outcome of interest was the successful detection and treatment of HSIL., Results: A total of 201 women living with HIV underwent anal dysplasia screening between 2006 and 2020. Seventy-seven patients were found to have abnormal anal cytology requiring further treatment: 43 (55.8%) in Group A and 34 (44.2%) patients in Group B. Of the patients with abnormal anal cytology, 76.7% of patients in Group A received further biopsy and treatment, whereas 79.4% of Group B patients underwent subsequent biopsy and treatment. In propensity score weighting logistic regression analysis, the Group B was 4.6 times as likely to diagnosis HSIL on biopsy compared to Group A (OR = 4.60, 95% CI: 1.15 to 18.38, P = .03)., Conclusions: Anal dysplasia is common among women living with HIV. The establishment of a HRA program was associated with increased identification and treatment of HSIL among women living with HIV, which may prevent the progression to aSCC., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Racial and ethnic disparities in receipt of recommended colorectal cancer screening exist; however, the impact of social determinants of health on such disparities has not been recently studied in a national cohort., Objective: This study aimed to determine whether social determinants of health attenuate racial disparities in receipt of colorectal cancer screening., Design: This was a cross-sectional telephone survey of self-reported race and ethnicity and up-to-date colorectal cancer screening. Associations between race/ethnicity and colorectal cancer screening were tested before and after adjustment for demographics, behavioral factors, and social determinants of health., Setting: This was a nationally representative telephone survey of US residents in 2018., Patients: The patients included were US residents aged 50 to 75 years., Main Outcome Measures: The primary outcome was up-to-date colorectal cancer screening status, according to 2008 US Preventive Services Task Force recommendations., Results: This study included 226,106 respondents aged 50 to 75 years. Before adjustment, all minority racial and ethnic groups demonstrated a significantly lower odds of screening than those of non-Hispanic white respondents. After adjustment for demographics, behavioral factors, and social determinants of health, compared to non-Hispanic white respondents, odds of screening were found to be increased among non-Hispanic black respondents (OR, 1.10; p = 0.02); lower but attenuated among Hispanic respondents (OR, 0.73; p < 0.001), non-Hispanic American Indian/Alaskan Native respondents (OR, 0.85; p = 0.048), and non-Hispanic respondents of other races (OR, 0.82; p = 0.01); and lower but not attenuated among non-Hispanic Asian respondents (OR, 0.68; p < 0.001)., Limitations: Recall bias, participant bias, and residual confounding., Conclusions: Adjustment for social determinants of health reduced racial and ethnic disparities in colorectal cancer screening among all minority racial and ethnic groups except non-Hispanic Asian individuals; however, other unmeasured confounders likely exist. See Video Abstract at http://links.lww.com/DCR/B977 ., Asociacin De Raza, Etnicidad Y Determinantes Sociales De La Salud Con La Deteccin Del Cncer Colorrectal: ANTECEDENTES: Existen disparidades raciales y étnicas en la recepción de las pruebas recomendadas de detección de cáncer colorrectal; sin embargo, el impacto de los determinantes sociales de la salud en dichas disparidades no se ha estudiado recientemente en una cohorte nacional.OBJETIVO: El objetivo de este estudio fue determinar si los determinantes sociales de la salud atenúan las disparidades raciales en la recepción de pruebas de detección del cáncer colorrectal.DISEÑO: Encuesta telefónica transversal de raza y etnia autoinformada y detección actualizada de cáncer colorrectal. Las asociaciones entre la raza/etnicidad y la detección del cáncer colorrectal se probaron antes y después del ajuste por demografía, factores conductuales y determinantes sociales de la salud.ESCENARIO: Esta fue una encuesta telefónica representativa a nivel nacional de los residentes de EE. UU. en 2018.PACIENTES: Los pacientes eran residentes de EE. UU. de 50 a 75 años.PRINCIPALES MEDIDAS DE RESULTADO: Estado actualizado de detección de cáncer colorrectal, según las recomendaciones del Grupo de Trabajo de Servicios Preventivos de EE. UU. de 2008.RESULTADOS: Este estudio incluyó a 226.106 encuestados de 50 a 75 años. Antes del ajuste, todos los grupos étnicos y raciales minoritarios demostraron probabilidades significativamente más bajas de detección en comparación con los encuestados blancos no hispanos. Después del ajuste por demografía, factores conductuales y determinantes sociales de la salud, en comparación con los encuestados blancos no hispanos, las probabilidades de detección aumentaron entre los encuestados negros no hispanos (OR 1,10, p = 0,02); más bajo pero atenuado entre los encuestados hispanos (OR 0,73, p < 0,001), los encuestados indios americanos/nativos de Alaska no hispanos (OR 0,85, p = 0,048) y los encuestados no hispanos de otras razas (OR 0,82, p = 0,01); y menor pero no atenuado entre los encuestados asiáticos no hispanos (OR 0,68, p < 0,001).LIMITACIONES: Sesgo de recuerdo y sesgo de participante, así como confusión residual.CONCLUSIONES: El ajuste para los determinantes sociales de la salud redujo las disparidades raciales y étnicas en la detección del cáncer colorrectal entre todos los grupos étnicos y raciales minoritarios, excepto las personas asiáticas no hispanas; sin embargo, es probable que existan otros factores de confusión no medidos. Consulte Video Resumen en http://links.lww.com/DCR/B977 . (Traducción-Dr. Felipe Bellolio )., (Copyright © The ASCRS 2022.)

Description: The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding the management of patients with an enteral stoma., Methods: This CPU was commissioned and approved by the AGA Institute Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of a multidisciplinary group of authors composed of gastroenterologists, a colorectal surgeon, a wound ostomy and continence nurse, and ostomate., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Flight is an efficient way of transport over a unit of distance, but it can be very costly over each unit of time, and reducing flight energy expenditure is a major selective pressure in birds. The common swift (Apus apus) is one of the most aerial bird species, performing most behaviours in flight: foraging, sleeping and also drinking by regularly descending to various waterbodies and skimming over the surface. An energy-saving way to perform such touch-and-go drinking would be to strive to conserve mechanical energy, by transforming potential energy to kinetic energy during the gliding descent, touching water at high speed, and regaining height with minimal muscular work. Using 3D optical tracking, we recorded 163 swift drinking trajectories, over three waterbodies near Rennes, France. Contrary to the energy conservation hypothesis, we show that swifts approaching a waterbody with a higher mechanical energy (higher height and/or speed 5 s before contact) do not reach the water at higher speeds, but do brake, i.e. dissipate mechanical energy to lose both height and speed. Braking seems to be linked with sharp turns and the use of headwind to some extent, but finer turns and postural adjustments, beyond the resolving power of our tracking data, could also be involved. We hypothesize that this surprisingly costly behaviour results from a trade-off between energy expenditure and safety, because approaching a water surface requires fine motor control, and high speed increases the risk of falling into the water, which would have serious energetic and survival costs for a swift., Competing Interests: Competing interests The authors declare no competing or financial interests., (© 2023. Published by The Company of Biologists Ltd.)

In this protocol, we discuss general techniques for tracking the three-dimensional (3D) locations of the mosquito body, wings, legs, or other features of interest using videos. Tracking data must be acquired to produce detailed kinematics of moving mosquitoes. The software of focus for this protocol, DLTdv, was chosen for its widespread use and excellent support and because it is open-source. In addition, DLTdv allows both manual and automatic tracking. The automatic tracking can be done using a classic machine vision or machine-learning algorithm. The software supports both single-camera analysis and multicamera systems and can take advantage of sophisticated calibration algorithms, both for intrinsic lens distortion correction and for 3D DLT-based reconstruction. For this protocol, we assume all kinematic data is acquired post hoc through video analysis., (© 2023 Cold Spring Harbor Laboratory Press.)

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies., (© 2022. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and American Society of Colon and Rectal Surgeons (ASCRS).)

Kinematic measurements have been essential to the study of comparative biomechanics and offer insight into relationships between technological development and scientific progress. Here, we review the 100 year history of kinematic measurements in Journal of Experimental Biology (JEB) through eras that used film, analog video and digital video, and approaches that have circumvented the use of image capture. This history originated with the career of Sir James Gray and has since evolved over the generations of investigators that have followed. Although some JEB studies have featured technological developments that were ahead of their time, the vast majority of research adopted equipment that was broadly available through the consumer or industrial markets. We found that across eras, an emphasis on high-speed phenomena outpaced the growth of the number of articles published by JEB and the size of datasets increased significantly. Despite these advances, the number of species studied within individual reports has not differed significantly over time. Therefore, we find that advances in technology have helped to enable a growth in the number of JEB studies that have included kinematic measurements, contributed to an emphasis on high-speed phenomena, and yielded biomechanical studies that are more data rich, but are no more comparative now than in previous decades., Competing Interests: Competing interests The authors declare no competing or financial interests., (© 2023. Published by The Company of Biologists Ltd.)

Hummingbirds have evolved to hover and manoeuvre with exceptional flight control. This is enabled by their musculoskeletal system that successfully exploits the agile motion of flapping wings. Here, we synthesize existing empirical and modelling data to generate novel hypotheses for principles of hummingbird wing actuation. These may help guide future experimental work and provide insights into the evolution and robotic emulation of hummingbird flight. We develop a functional model of the hummingbird musculoskeletal system, which predicts instantaneous, three-dimensional torque produced by primary (pectoralis and supracoracoideus) and combined secondary muscles. The model also predicts primary muscle contractile behaviour, including stress, strain, elasticity and work. Results suggest that the primary muscles (i.e. the flight 'engine') function as diverse effectors, as they do not simply power the stroke, but also actively deviate and pitch the wing with comparable actuation torque. The results also suggest that the secondary muscles produce controlled-tightening effects by acting against primary muscles in deviation and pitching. The diverse effects of the pectoralis are associated with the evolution of a comparatively enormous bicipital crest on the humerus.

Background: High airway driving pressure is associated with adverse outcomes in critically ill patients receiving mechanical ventilation, but large multicentre studies investigating airway driving pressure during major surgery are lacking. We hypothesised that increased driving pressure is associated with postoperative pulmonary complications in patients undergoing major abdominal surgery., Methods: In this preregistered multicentre retrospective observational cohort study, the authors reviewed major abdominal surgical procedures in 11 hospitals from 2004 to 2018. The primary outcome was a composite of postoperative pulmonary complications, defined as postoperative pneumonia, unplanned tracheal intubation, or prolonged mechanical ventilation for more than 48 h. Associations between intraoperative dynamic driving pressure and outcomes, adjusted for patient and procedural factors, were evaluated., Results: Among 14 218 qualifying cases, 389 (2.7%) experienced postoperative pulmonary complications. After adjustment, the mean dynamic driving pressure was associated with postoperative pulmonary complications (adjusted odds ratio for every 1 cm H 2 O increase: 1.04; 95% confidence interval [CI], 1.02-1.06; P <0.001). Neither tidal volume nor PEEP was associated with postoperative pulmonary complications. Increased BMI, shorter height, and female sex were predictors for higher dynamic driving pressure (β=0.35, 95% CI 0.32-0.39, P <0.001; β=-0.01, 95% CI -0.02 to 0.00, P =0.005; and β=0.74, 95% CI 0.63-0.86, P <0.001, respectively)., Conclusions: Dynamic airway driving pressure, but not tidal volume or PEEP, is associated with postoperative pulmonary complications in models controlling for a large number of risk predictors and covariates. Such models are capable of risk prediction applicable to individual patients., Competing Interests: Declarations of interest DAC reports research funding (paid to institution) unrelated to the presented work from Merck & Co. Inc. (Rahway, NJ, USA). All other authors declare that they have no conflicts of interest.

Background: As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay., Methods: Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes., Results: Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing., Conclusions: The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: While total sleep duration and rapid eye movement (REM) sleep duration have been associated with long-term mortality in non-surgical cohorts, the impact of preoperative sleep on postoperative outcomes has not been well studied., Methods: In this secondary analysis of a prospective observational cohort study, patients who recorded at least 1 sleep episode using a consumer wearable device in the 7 days before elective colorectal surgery were included. 30-day postoperative outcomes among those who did and did not receive at least 6 h of total sleep, as well as those who did and did not receive at least 1 h of rapid eye movement (REM) sleep, were compared., Results: 34 out of 95 (35.8%) patients averaged at least 6 h of sleep per night, while 44 out of 82 (53.7%) averaged 1 h or more of REM sleep. Patients who slept less than 6 h had similar postoperative outcomes compared to those who slept 6 h or more. Patients who averaged less than 1 h of REM sleep, compared to those who achieved 1 h or more of REM sleep, had significantly higher rates of complication development (29.0% vs. 9.1%, P = 0.02), and return to the OR (10.5% vs. 0%, P = 0.04). After adjustment for confounding factors, increased REM sleep duration remained significantly associated with decreased complication development (increase in REM sleep from 50 to 60 min: OR 0.72, P = 0.009; REM sleep ≥ 1 h: OR 0.22, P = 0.03)., Conclusion: In this cohort of patients undergoing elective colorectal surgery, those who developed a complication within 30 days were less likely to average at least 1 h of REM sleep in the week before surgery than those who did not develop a complication. Preoperative REM sleep duration may represent a risk factor for surgical complications; however additional research is necessary to confirm this relationship., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The management of patients with metastatic colorectal cancer (CRC) has evolved significantly over the last decade owing to advances in aggressive multimodality chemotherapy options, targeted therapy, development of sophisticated operative techniques, and adjunct radiotherapy options. Patients with synchronous CRC require complex decision-making with multidisciplinary collaboration to develop individualized treatment strategies taking into account tumor biology and patients' individual goals and objectives. We will outline important considerations with regard to treatment options for patients with synchronous metastatic CRC to facilitate contemporary evidence-based management decisions and optimize oncologic outcomes., Competing Interests: Disclosure T.L. Hedrick – consultant with Johnson and Johnson, V.M. Zaydfudim – none., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Women surgeons face numerous barriers to career advancement. Inequitable citation of surgical literature may represent a contributing factor to gender disparities in academic surgery., Study Design: This was a cross-sectional analysis of publications from 50 top-ranking surgery journals in 2017 and 2018, as defined by the 2019 InCites Journal Citation Reports. The citation rate of publications by women vs men first authors was compared. Similarly, the citation rate of publications by men vs women last authors was also compared. Adjusted regression analyses of citation rates accounted for the time interval since publication as well as the journal within which the article was published, among other potential confounding factors., Results: A total of 19,084 publications from 48 surgery journals with a median (interquartile range) of 8 (4 to 15) citations contributing to a median (interquartile range) Journal Impact Factor of 4.0 (3.4 to 4.6) were analyzed. Compared with man-first author publications, woman-first author publications demonstrated a 9% lower citation rate (incidence rate ratio 0.91, p < 0.001). Similarly, compared with publications by man-last authors, woman-last author publications demonstrated a 4% lower citation rate (incidence rate ratio 0.96, p = 0.03). These associations persisted after multivariable adjustment for additional confounding factors, however, not on sensitivity analysis of 24 of the highest-ranking journals., Conclusions: Among top-tier surgical journals, publications by women-first and -last authors were less cited compared with publications by men-first and -last authors, but not among the highest-tier surgical journals. Gender bias may exist in the citation of surgical research, contributing to gender disparities in academic surgery., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

A new study of flight control in Drosophila using neurogenetic methods and a virtual reality flight arena has revealed a group of descending neurons that fully activate the flight motor and steer the fly by independent regulation of the left and right wings., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Gliding animals change their body shape and posture while producing and modulating aerodynamic forces during flight. However, the combined effect of these different factors on aerodynamic force production, and ultimately the animal's gliding ability, remains uncertain. Here, we quantified the time-varying morphology and aerodynamics of complete, voluntary glides performed by a population of wild gliding lizards (Draco dussumieri) in a seven-camera motion capture arena constructed in their natural environment. Our findings, in conjunction with previous airfoil models, highlight how three-dimensional (3D) wing shape including camber, planform, and aspect ratio enables gliding flight and effective aerodynamic performance by the lizard up to and over an angle of attack (AoA) of 55° without catastrophic loss of lift. Furthermore, the lizards maintained a near maximal lift-to-drag ratio throughout their mid-glide by changing body pitch to control AoA, while simultaneously modulating airfoil camber to alter the magnitude of aerodynamic forces. This strategy allows an optimal aerodynamic configuration for horizontal transport while ensuring adaptability to real-world flight conditions and behavioral requirements. Overall, we empirically show that the aerodynamics of biological airfoils coupled with the animal's ability to control posture and their 3D wing shape enable efficient gliding and adaptive flight control in the natural habitat., (© 2022. The Author(s).)

Background: The proliferation of wearable technology presents a novel opportunity for perioperative activity monitoring; however, the association between perioperative activity level and readmission remains underexplored. This study sought to determine whether physical activity data captured by wearable technology before and after colorectal surgery can be used to predict 30-day readmission., Methods: In this prospective observational cohort study of adults undergoing elective major colorectal surgery (January 2018 to February 2019) at a single institution, participants wore an activity monitor 30 days before and after surgery. The primary outcome was return to baseline percentage, defined as step count on the day before discharge as a percentage of mean preoperative daily step count, among readmitted and non-readmitted patients., Results: 94 patients had sufficient data available for analysis, of which 16 patients (17.0%) were readmitted within 30 days following discharge. Readmitted patients achieved a lower return to baseline percentage compared to patients who were not readmitted (median 15.1% vs. 31.8%; P = 0.004). On multivariable analysis adjusting for readmission risk and hospital length of stay, an absolute increase of 10% in return to baseline percentage was associated with a 40% decreased risk of 30-day readmission (odds ratio 0.60; P = 0.02). Analysis of the receiver operating characteristic curve identified 28.9% as an optimal return to baseline percent threshold for predicting readmission., Conclusions: Achieving a higher percentage of an individual's preoperative baseline activity level on the day prior to discharge after major colorectal surgery is associated with decreased risk of 30-day hospital readmission., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Many residency programs struggle to meet the ACGME requirement for resident participation in quality improvement initiatives., Study Design: As part of an institutional quality improvement effort, trainees from the Departments of Surgery and Anesthesiology at a single academic medical center were teamed with institutional content experts in 7 key risk factor areas within preoperative patient optimization. A systematic review of each subject matter area was performed using the MEDLINE database. Institutional recommendations for the screening and management of each risk factor were developed and approved using modified Delphi consensus methodology. Upon project completion, an electronic survey was administered to all individuals who participated in the process to assess the perceived value of participation., Results: Fifty-one perioperative stakeholders participated in recommendation development: 26 trainees and 25 content experts. Residents led 6 out of 7 groups specific to a subject area within preoperative optimization. A total of 4,649 abstracts were identified, of which 456 full-text articles were selected for inclusion in recommendation development. Seventeen out of 26 (65.4%) trainees completed the survey. The vast majority of trainees reported increased understanding of their preoperative optimization subject area (15/17 [88.2%]) as well as the Delphi consensus method (14/17 [82.4%]) after participation in the project. Fourteen out of 17 (82.4%) trainees stated that they would participate in a similar quality improvement initiative again., Conclusions: We demonstrate a novel way to involve trainees in an institutional quality initiative that served to educate trainees in quality improvement, the systematic review process, Delphi methodology, and preoperative optimization. This study provides a framework that other residency programs can use to engage residents in institutional quality improvement efforts., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pre-operative administration of combined oral antibiotic agents and mechanical bowel preparation has been demonstrated to improve post-operative outcomes after elective colectomy, however, many patients do not receive combined preparation. Patient and procedural determinants of combined preparation receipt remain understudied. Patients and Methods: All patients undergoing elective colectomy within the 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use File and Targeted Colectomy datasets were included. Univariable and multivariable logistic regression analyses were performed to identify factors associated with receipt of combined preparation. Results: A total of 21,889 patients were included, of whom 13,848 (63.2%) received combined preparation pre-operatively. Patients who received combined preparation tended to be younger, male, of white race, and of non-Hispanic ethnicity (all p < 0.05). After multivariable adjustment, male gender, body mass index (BMI) 30-39 kg/m 2 , independent functional status, and laparoscopic and robotic surgical approaches were associated with receipt of combined preparation (all p < 0.05), whereas Asian race, hypertension, disseminated cancer, and inflammatory bowel disease were associated with omission of combined preparation (all p < 0.05). Conclusions: Patients with risk factors for infectious complications-including a poor functional status, comorbid conditions, and undergoing an open procedure-are less likely to receive combined preparation before elective colectomy. Similarly, female and Asian patients are less likely to receive combined preparation, emphasizing the need for equitable administration of combined preparation.

Background: Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS)., Study Design: In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement., Results: In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds., Conclusions: Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Surgeons.)

Background: Fecal management systems have become ubiquitous in hospitalized patients with fecal incontinence or severe diarrhea, especially in the setting of perianal wounds. Although fecal management system use has been shown to be safe and effective in initial series, case reports of rectal ulceration and severe bleeding have been reported, with a relative paucity of clinical safety data in the literature., Objective: The purpose of this study was to determine the rate of rectal complications attributable to fecal management systems, as well as to characterize possible risk factors and appropriate management strategies for such complications., Design: This was a retrospective cohort study., Settings: The study was conducted at a large academic medical center., Patients: All medical and surgical patients who underwent fecal management system placement from December 2014 to March 2017 were included., Main Outcome Measures: We measured any rectal complication associated with fecal management system use, defined as any rectal injury identified after fecal management system use confirmed by lower endoscopy., Results: A total of 629 patients were captured, with a median duration of fecal management system use of 4 days. Overall, 8 patients (1.3%) experienced a rectal injury associated with fecal management system use. All of the patients who experienced a rectal complication had severe underlying comorbidities, including 2 patients on dialysis, 1 patient with cirrhosis, and 3 patients with a recent history of emergent cardiac surgery. In 3 patients the bleeding resolved spontaneously, whereas the remaining 5 patients required intervention: transanal suture ligation (n = 2), endoscopic clip placement (n = 1), rectal packing (n = 1), and proctectomy in 1 patient with a history of pelvic radiotherapy., Limitations: The study was limited by its retrospective design and single institution., Conclusions: This is the largest study to date evaluating rectal complications from fecal management system use. Although rectal injury rates are low, they can lead to serious morbidity. Advanced age, severe comorbidities, pelvic radiotherapy, and anticoagulation status or coagulopathy are important factors to consider before fecal management system placement. See Video Abstract at http://links.lww.com/DCR/B698., Incidencia Y Caracterizacin De Las Complicaciones Rectales De Los Sistemas De Manejo Fecal: ANTECEDENTES:Los sistemas de manejo fecal se han vuelto omnipresentes en pacientes hospitalizados con incontinencia fecal o diarrea severa, especialmente en el contexto de heridas perianales. Aunque se ha demostrado que el uso del sistema de tratamiento fecal es seguro y eficaz en la serie inicial, se han notificado casos de ulceración rectal y hemorragia grave, con una relativa escasez de datos de seguridad clínica en la literatura.OBJETIVO:Determinar la tasa de complicaciones rectales atribuibles a los sistemas de manejo fecal. Caracterizar los posibles factores de riesgo y las estrategias de manejo adecuadas para tales complicaciones.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro médico académico de mayor volumen.PACIENTES:Todos los pacientes médicos y quirúrgicos que se sometieron a la colocación del sistema de manejo fecal desde diciembre de 2014 hasta marzo de 2017.PRINCIPALES MEDIDAS DE VALORACION:Cualquier complicación rectal asociada con el uso del sistema de manejo fecal, definida como cualquier lesión rectal identificada después del uso del sistema de manejo fecal confirmada por endoscopia baja.RESULTADOS:Se identificaron un total de 629 pacientes, con una duración media del uso del sistema de manejo fecal de 4,0 días. En general, 8 (1,3%) pacientes desarrollaron una lesión rectal asociada con el uso del sistema de manejo fecal. Todos los pacientes que mostraron una complicación rectal tenían comorbilidades subyacentes graves, incluidos dos pacientes en diálisis, un paciente con cirrosis y tres pacientes con antecedentes recientes de cirugía cardíaca emergente. En tres pacientes el sangrado se resolvió espontáneamente, mientras que los cinco pacientes restantes requirieron intervención: ligadura de sutura transanal (2), colocación de clip endoscópico (1), taponamiento rectal (1) y proctectomía en un paciente con antecedentes de radioterapia pélvica.LIMITACIONES:Diseño retrospectivo, institución única.CONCLUSIONES:Este es el estudio más grande hasta la fecha que evalúa las complicaciones rectales del uso del sistema de manejo fecal. Si bien las tasas de lesión rectal son bajas, pueden provocar una morbilidad grave. La edad avanzada, las comorbilidades graves, la radioterapia pélvica y el estado de anticoagulación o coagulopatía son factores importantes a considerar antes de la colocación del sistema de manejo fecal. Consulte Video Resumen en http://links.lww.com/DCR/B698., (Copyright © The ASCRS 2021.)

Background: Telemedicine has been rapidly adopted in the wake of the COVID-19 pandemic. There is limited work surrounding demographic and socioeconomic disparities that may exist in telemedicine utilization. This study aimed to examine demographic and socioeconomic differences in surgical patient telemedicine usage during the COVID-19 pandemic., Methods: Department of Surgery outpatients seen from July 1, 2019 to May 31, 2020 were stratified into three visit groups: pre-COVID-19 in-person, COVID-19 in-person, or COVID-19 telemedicine. Generalized linear models were used to examine associations of sex, race/ethnicity, Distressed Communities Index (DCI) scores, MyChart activation, and insurance status with telemedicine usage during the COVID-19 pandemic., Results: 14,792 patients (median age 60, female [57.0%], non-Hispanic White [76.4%]) contributed to 21,980 visits. Compared to visits before the pandemic, telemedicine visits during COVID-19 were more likely to be with patients from the least socioeconomically distressed communities (OR, 1.31; 95% CI, 1.08,1.58; P = 0.005), with an activated MyChart (OR, 1.38; 95% CI, 1.17-1.64; P < .001), and with non-government or commercial insurance (OR, 2.33; 95% CI, 1.84-2.94; P < .001). Adjusted comparison of telemedicine visits to in person visits during COVID-19 revealed telemedicine users were more likely to be female (OR, 1.38, 95% CI, 1.10-1.73; P = 0.005) and pay with non-government or commercial insurance (OR, 2.77; 95% CI, 1.85-4.16; P < .001)., Conclusions: During the first three months of the COVID-19 pandemic, telemedicine was more likely utilized by female patients and those without government or commercial insurance compared to patients who used in-person visits. Interventions using telemedicine to improve health care access might consider such differences in utilization., Competing Interests: The authors have declared that no competing interests exist.

Management of the acute anastomotic leak is complex and patient-specific. Clinically stable patients often benefit from a nonoperative approach utilizing antibiotics with or without percutaneous drainage. Clinically unstable patients or nonresponders to conservative management require operative intervention. Surgical management is dictated by the degree of contamination and inflammation but includes drainage with proximal diversion, anastomotic resection with end-stoma creation, or reanastomosis with proximal diversion. Newer therapies, including colorectal stenting, vacuum-assisted rectal drainage, and endoscopic clipping, have also been described., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Background: Childhood cancer survivors (CCS) are at elevated risk of secondary malignancies (SM). Enhanced screening for SM is recommended, but compliance is poor. We hypothesized that CCS with adult-onset SM (colorectal cancer [CRC], melanoma, or breast cancer [BC]) would present with more advanced disease and have decreased overall survival (OS)., Methods: The Surveillance, Epidemiology, and End Results Program was queried for patients diagnosed with cancer at age less than or equal to 18 also diagnosed with adult-onset CRC, melanoma, or BC. A cohort without a history of prior malignancy was likewise identified. Tumor features and clinical outcomes were compared., Results: CCS with a SM (n = 224) were compared with patients without a childhood cancer history (n = 1,392,670). CCS were diagnosed younger (BC = 37.6 vs. 61.3, p < 0.01, CRC = 35.0 vs. 67.1, p < 0.01, melanoma = 29.6 vs. 61.3 years old, p < 0.01). CCS with BC were more likely to have Stage III or IV disease (25.2% vs. 16.5%, p = 0.01). Hormone-receptor expression also differed; CCS were less likely to develop Luminal A-type tumors (48.6% vs. 66.9%, p = 0.01). After age-adjustment, CCS had worse OS (Hazard ratio: CRC = 2.449, p < 0.01, melanoma = 6.503, p < 0.01, BC = 3.383, p < 0.01)., Conclusion: CCS were younger when diagnosed with a SM. After age-adjustment, OS was diminished. Heightened surveillance may be necessary for CCS diagnosed with SM., (© 2021 Wiley Periodicals LLC.)

Crepuscular mosquitoes, which swarm in low light conditions, exhibit a range of adaptations including large aspect-ratio wings, high flapping frequencies and small stroke amplitudes that taken together, facilitate the generation of wing-tones that are well-suited for acoustic communication. In the current study, we employ computational aeroacoustic modeling to conduct a comparative study of wing-tone and flight efficiency in a mosquito (male Culex ) and a similar sized flying insect: a fruit fly ( Drosophila ). Based on this analysis, we show that pound-for-pound, a mosquito generates wing-tones that are a factor of about 3.4 times more intense than a fruit fly, and the mosquito is more efficient by a factor of about 3.7 in converting mechanical power into acoustic power. The wing-tones for the mosquito are also more tilted in the forward direction, a characteristic that would be more conducive for acoustic signaling during a mate chase. The simulation data also shows that the specific power (mechanical power over mean lift) of the mosquito is nearly equal to that of the fruit fly, indicating that the adaptations that facilitate wing-tone based communication in mosquitoes, do not seem to compromise their flight efficiency., (© 2021 IOP Publishing Ltd.)

Background/objective: Previous literature describes increased incidence of infusion-related reactions when administering thiamine doses greater than 100 mg as an intravenous (IV) push. The purpose of this evaluation was to assess the safety of administering higher doses of thiamine as IV push compared to infusion., Methods: A single-center, retrospective review was performed from June to October 2017. Included patients were aged 18 years or older and received 1 dose of IV thiamine 200 mg or greater. Patients were divided into 2 groups: group 1 included patients who received 200-mg IV push and, group 2 included patients who received any dose greater than 200 mg. The primary objective was to quantify and compare rate of adverse reactions between the 2 groups. Institutional thiamine prescribing practices were examined. Wilcoxon Rank Sum and Fischer exact tests were performed., Results: Sixty-six percent of patients were male, and the median age was 55 years (interquartile range [IQR]: 44-63). Fifty percent received 200-mg IV push, 20% received a combination of IV infusion and IV push, and 30% received IV infusion. Adverse reactions possibly due to thiamine administration occurred in 4 (2.0%) patients. One patient received 200 mg via IV infusion, while 3 received 200 mg via IV push. There was no significant difference in adverse reaction rate between IV push and IV infusion administrations ( P = .640)., Conclusion: Our results support administering thiamine doses of 200 mg or less as an IV push. Given lack of robust safety data, it is recommended to continue to dilute doses greater than 200 mg and infuse over 30 minutes.

Background: As the opioid epidemic escalates, preoperative opioid use has become increasingly common. Recent studies associated preoperative opioid use with postoperative morbidity. However, limited study of its impact on patients within enhanced recovery protocols (ERP) exists. We assessed the impact of preoperative opioid use on postoperative complications among colorectal surgery patients within an ERP, hypothesizing that opioid-exposed patients would be at increased risk of complications., Methods: Elective colorectal cases from August 2013 to June 2017 were reviewed in a retrospective cohort study comparing preoperative opioid-exposed patients to opioid-naïve patients. Postoperative complications were defined as a composite of complications captured by the American College of Surgeons National Surgical Quality Improvement Program. Logistic regression identified risk factors for postoperative complications., Results: 707 patients were identified, including 232 (32.8%) opioid-exposed patients. Opioid-exposed patients were younger (57.9 vs 61.9 years; p < 0.01) and more likely to smoke (27.6 vs 17.1%; p < 0.01). Laparoscopic procedures were less common among opioid-exposed patients (44.8 vs 58.1%; p < 0.01). Median morphine equivalents received were higher in opioid-exposed patients (65.0 vs 20.1 mg; p < 0.01), but compliance to ERP elements was otherwise equivalent. Postoperative complications were higher among opioid-exposed patients (28.5 vs 15.0%; p < 0.01), as was median length of stay (4.0 vs 3.0 days; p < 0.01). Logistic regression identified multiple patient- and procedure-related factors independently associated with postoperative complications, including preoperative opioid use (p = 0.001)., Conclusion: Preoperative opioid use is associated with increased risk of postoperative complications in elective colorectal surgery patients within an ERP. These results highlight the negative impact of opioid use, suggesting an opportunity to further reduce the risk of surgical complications through ERP expansion to include preoperative mitigation strategies for opioid-exposed patients.

Background: Fever is a common response to both infectious and non-infectious physiologic insults in the critically ill, and in certain populations it appears to be protective. Fever is particularly common in trauma patients, and even more so in those with infections. The relationship between fever, trauma status, and mortality in patients with an infection is unclear. Patients and Methods: A review of a prospectively maintained institutional database over a 17-year period was performed. Surgical and trauma intensive care unit (ICU) patients with a nosocomial infection were extracted to compare in-hospital mortality among trauma and non-trauma patients with and without fever. Univariable analyses compared patient and infection characteristics between trauma and non-trauma patients. A multivariable logistic regression model was created to identify predictors of in-hospital mortality, with a focus on fever and trauma status. Results: Nine hundred forty-one trauma patients and 1,449 non-trauma patients with ICU-acquired infections were identified. Trauma patients were younger (48 vs. 59, p < 0.001), more likely to be male (73% vs. 56%, p < 0.001), more likely to require blood transfusion (74% vs. 47%, p < 0.001), had lower Acute Physiology and Chronic Health Evaluation (APACHE) II scores (18 vs. 19, p = 0.02), and had lower rates of comorbidities. Trauma patients were more likely to develop a fever (72% vs. 43%, p < 0.001) and had lower in-hospital mortality (9.6% vs. 22.6%, p < 0.001). In multivariable analysis, non-trauma patients with fever had a lower odds of mortality compared with non-trauma patients without fever (odds ratio [OR] 0.63, p = 0.004). Trauma patients with fever had the lowest odds ratio for mortality when compared to non-trauma patients without fever (OR 0.25, p < 0.001). Conclusions: In this large cohort of trauma and surgical ICU patients with ICU-acquired infections, fever was associated with a lower odds of mortality in both trauma and non-trauma patients. Further investigation is needed to determine the mechanisms behind the interplay between trauma status, fever, and mortality.

Competing Interests: Conflicts of Interest: The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided. T. J. Gan: Honoraria from Acacia, Edwards, Masimo, Medtronic, Merck and Mallinckrodt. S. Bergese: Acacia (Funding for Clinical Trial to Ohio State University). F. Chung has received research support from the Ontario Ministry of Health and Long-Term Care, University Health Network Foundation, Acacia Pharma, Medtronics grants to institution outside of the submitted work, Up-to-date royalties, STOP-Bang proprietary to University Health Network. Speaker honorarium from Baxter Pharma. P. Diemunsch: Ambu: Member of an advisors panel on airway management, Fisher & Paykel: Research Grants, paid conferences, French Government: Expert at the Court of Appeal, Acacia Pharma: Research Grants, MSD: Member of an advisory panel on ERAS. A. S. Habib: Funded Research: Pacira Biosciences, Avanos Medical Inc., Advisory Board: Takeda. A. L. Kovac: Merck (speaker’s bureau), Helsinn (speaker’s bureau), Mundipharma (speaker’s bureau), Acacia (speaker’s bureau). T. A. Meyer: Acacia, Neumentum. R. D. Urman: Merck (research funding); Medtronic (consulting fees and research funding); Takeda (consulting fees); Acacia (consulting fees and research funding); Posimir (consulting fees). S. Ayad: Pacira, Medtronic and Acacia. K. Candiotti: Research support-Acacia, Pfizer, Takeda; Consulting-Acacia, Pfizer, Takeda. T. L. Hedrick: MedEdicus. P. Kranke acted as investigator in phase III trials on amisulpride during the last 3 years. He gave invited lectures for FreseniusKabi (propofol), Grünenthal, CSL-Behring, TevaRatiopharm. H. S. Minkowitz: Acacia, AcelRX, Adynxx, Concentric, Durect, Heron, Merck, Mallinckrodt, Innocoll, Pacira, Neumentum, Westward, Trevena, Takeda. J. Morton: Medtronic, Olympus, Novo Nordisk.

Background: Enhanced Recovery (ER) is a change management framework in which a multidisciplinary team of stakeholders utilizes evidence-based medicine to protocolize all aspects of a surgical care to allow more rapid return of function. While service-specific reports of ER adoption are common, institutional-wide adoption is complex, and reports of institution-wide ER adoption are lacking in the United States. We hypothesized that ER principles were generalizable across an institution and could be implemented across a multitude of surgical disciplines with improvements in length of stay, opioid consumption, and cost of care., Methods: Following the establishment of a formal institutional ER program, ER was adopted in 9 distinct surgical subspecialties over 5 years at an academic medical center. We compared length of stay, opioid consumption, and total cost of care in all surgical subspecialties as a function of time using a segmented regression/interrupted time series statistical model., Results: There were 7774 patients among 9 distinct surgical populations including 2155 patients in the pre-ER cohort and 5619 patients in the post-ER cohort. The introduction of an ER protocol was associated with several significant changes: a reduction in length of stay in 5 of 9 specialties; reduction in opioid consumption in 8 specialties; no change or reduction in maximum patient-reported pain scores; and reduction or no change in hospital costs in all specialties. The ER program was associated with an aggregate increase in profit over the study period., Conclusions: Institution-wide efforts to adopt ER can generate significant improvements in patient care, opioid consumption, hospital capacity, and profitability within a large academic medical center., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2020 International Anesthesia Research Society.)

Purpose: Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin administration. Management strategies are complex and include discontinuing heparin products, initiating alternative anticoagulants, interpreting laboratory test results, documenting heparin allergies, and providing patient education. Medication error reports and a retrospective review conducted at an academic medical center revealed an opportunity for a quality improvement initiative and led to the creation of a multidisciplinary workflow for the management of HIT. In a pre-post study, the impact of the multidisciplinary workflow on the safety and management of HIT was evaluated., Methods: The preimplementation group consisted of adult patients tested for suspected HIT from April 4, 2014, through May 31, 2016; the postimplementation group consisted of adult patients tested from November 1, 2016, through October 31, 2018. The primary outcome was the incidence of heparin product administration while HIT testing was ongoing. The secondary outcome was the rate of appropriate heparin allergy documentation., Results: The incidence of heparin product administration while HIT testing results were pending was significantly reduced, from 54.2% to 20.0% (P < 0.001), after workflow implementation. The rate of appropriate heparin allergy documentation significantly increased, from 95.0% to 100% (P < 0.001)., Conclusion: Implementation of a multidisciplinary workflow for the management of HIT significantly reduced the incidence of heparin administration while testing was ongoing and improved the rate of appropriate heparin allergy documentation., (© American Society of Health-System Pharmacists 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)