Sutter Auburn Faith Hospital

Carbon ((13)C/(12)C) and nitrogen ((15)N/(14)N) stable isotope ratios were longitudinally measured in fingernail and hair samples from mother-infant pairs where infants were exclusively breastfed (n = 5), breast- and formula-fed (n = 2), or exclusively formula-fed (n = 1) from birth. All exclusively breastfed infants had a dual enrichment in carbon ( approximately 1 per thousand) and nitrogen ( approximately 2-3 per thousand) when compared to maternal values. In contrast, breast- and formula-fed subjects had reduced enrichments compared to exclusively breastfed subjects, and the exclusively formula-fed infant showed no increase in delta(13)C or delta(15)N values. This finding of a carbon trophic level effect in breastfeeding infants suggests that (13)C-enrichments of approximately 1 per thousand in archaeological populations are not necessarily the result of the consumption of C(4)-based weaning foods such as maize or millet. During the weaning process, the delta(13)C results for breastfed infants declined to maternal levels more rapidly than the delta(15)N results. This suggests that delta(13)C values have the potential to track the introduction of solid foods into the diet, whereas delta(15)N values monitor the length of time of breast milk consumption. These findings can be used to refine the isotopic analysis of breastfeeding and weaning patterns in past and modern populations.

While past experiments on animals, birds, fish, and insects have shown changes in stable isotope ratios due to nutritional stress, there has been little research on this topic in humans. To address this issue, a small pilot study was conducted. Hair samples from eight pregnant women who experienced nutritional stress associated with the nausea and vomiting of morning sickness (hyperemesis gravidarum) were measured for carbon (delta13C) and nitrogen (delta15N) stable isotope ratios. The delta13C results showed no change during morning sickness or pregnancy when compared with pre-pregnancy values. In contrast, the delta15N values generally increased during periods of weight loss and/or restricted weight gain associated with morning sickness. With weight gain and recovery from nutritional stress, the hair delta15N values displayed a decreasing trend over the course of gestation towards birth. This study illustrates how delta15N values are not only affected by diet, but also by the nitrogen balance of an individual. Potential applications of this research include the development of diagnostic techniques for tracking eating disorders, disease states, and nitrogen balance in archaeological, medical, and forensic cases.

Carbon (13C/12C) and nitrogen (15N/14N) stable isotope ratios were longitudinally measured in human hair that reflected the period from pre-conception to delivery in 10 pregnant women. There was no significant change in the delta13C results, but all subjects showed a decrease in delta15N values (-0.3 to -1.1 per thousand) during gestation. The mechanisms causing this decrease in hair delta15N have not been fully elucidated. However, since the delta15N values of dietary nitrogen and urea nitrogen are significantly lower compared to maternal tissues, it is hypothesized that the increased utilization of dietary and urea nitrogen for tissue synthesis during pregnancy resulted in a reduction of the steady state diet to a body trophic level effect by approximately 0.5-1 per thousand. An inverse correlation (R2 = 0.67) between hair delta15N and weight gain was also found, suggesting that positive nitrogen balance results in a reduction of delta15N values independent of diet. These results indicate that delta15N measurements have the ability to monitor not only dietary inputs, but also the nitrogen balance of an organism. A potential application of this technique is the detection of fertility patterns in modern and ancient species that have tissues that linearly record stable isotope ratios through time.

The development of stage III or IV pressure ulcers is currently considered a never event. Critical care patients are at high risk for development of pressure ulcers because of the increased use of devices, hemodynamic instability, and the use of vasoactive medications. This article addresses risk factors, risk scales such as the Norden, Braden, Waterlow, and Jackson-Cubbin scales used to determine the risk of pressure ulcers in critical care patients, and prevention of device-related pressure ulcers in patients in the critical care unit.

BACKGROUND: Large talar cartilage defects can be treated with either autologous chondrocyte implantation or matrix autologous chondrocyte implantation. Both techniques depend on successful harvesting of the chondrocytes. In the past, they have come from the ipsilateral knee, which has been associated with donor site morbidity. We hypothesized that damaged cartilage from the talus can be used as a reliable source for chondrocyte cell harvesting in preparation for possible matrix-induced autologous chondrocyte implantation (MACI). METHODS: Chondrocytes were harvested from the injured talar cartilage during ankle arthroscopy and sent to a cell laboratory, measured for initial biopsy weight, cultured for 4 to 6 weeks, and then analyzed for viability. A total of 151 patients were analyzed. RESULTS: The average biopsy initial weight was 187.1 mg. The average number of cells was 3.13 × 10(5). The viability of the chondrocytes provided by the manufacturer averaged 92.3% (range, 33%-100%). CONCLUSIONS: Chondrocytes harvested from the damaged talar articular cartilage were functional and proliferated with an average viability of 92%. CLINICAL RELEVANCE: This technique may provide a useful source of chondrocytes if needed for a future cell-based regenerative procedure such as MACI while eliminating the need to harvest chondrocytes from the knee or other intact areas of cartilage on the talus. LEVEL OF EVIDENCE: Level IV, case series.

Stevens-Johnson syndrome is a rare, potentially fatal drug reaction that causes necrosis of epidermal cells. Early recognition of the syndrome is essential to prevent complications. This article discusses identification, complications, and treatment of Stevens-Johnson syndrome.

Drought is one of the most complex and destructive natural hazards for rangeland managers to cope with given its inherently variable spatial and temporal impacts. California's devastating 2012–2016 drought highlights a critical need to develop adaptive strategies for coping with an increasingly variable climate. During the 2012–2016 drought, we interviewed 48 California ranchers to assess both on-ranch drought impacts and the effectiveness of implemented drought management practices. Three themes were identified based on the Adaptive Decision-Making Framework: 1) management capacity (i.e., operator demographics and operation structure), 2) drought planning and flexibility, and 3) adaptive learning (i.e., impacts experienced and effectiveness of drought management practices). Ranchers underscored the significance of drought planning, flexible management strategies, and prior experience as key factors that enabled them to navigate the 2012–2016 drought. In addition, ranchers described how explicit, proactive planning informed drought management decisions that prioritized long-term economic and ecological resilience. Although multispecies grazing was the least used proactive practice, it was identified as the most effective proactive practice by interviewed ranchers who had adopted it as a drought management tool (4.38 out of five effectiveness ranking; eight operators). Multispecies grazers (MSGs) significantly differed from single-species grazers (SSGs) in adoption of several reactive drought management practices, suggesting MSGs potentially have greater flexibility in coping with and adapting to drought. Resurgent strategies that prioritize management flexibility to mitigate drought impacts, such as multispecies grazing, may offer promise in helping ranchers adapt to future droughts. Interviewed ranchers emphasized that forward planning, including a range of proactive and reactive management strategies, were key in building flexibility and, ultimately, their resilience to drought.

Patients with heart failure may benefit from implantation of a biventricular pacemaker. This article discusses the indications for biventricular pacemaker implantation and the assessment of patients with biventricular pacemakers. Biventricular pacemakers require more assessments than do traditional single- or dual-chamber pacemakers.

Development of a coordinated, comprehensive “care and cost” monitoring system could function much like air traffic control systems.

<h2>Abstract</h2> Modern advancements in total ankle arthroplasty techniques and implants have increased their popularity as treatment for ankle osteoarthritis. The preeminent approach for ankle replacement involves an anterior incision. However, wound complications with this approach provide a persistent challenge to surgeons. The present study was conducted to synthesize current data on ankle replacement wound complications via an anterior approach. A systematic review was completed including studies published from 1993 to present that employed an anterior approach and had precise criteria for wound healing and revisions. Twenty-nine studies, with level 3 to 4 evidence and moderate to serious bias, were included for a total of 6,986 ankle arthroplasties. The rate of wound healing without any complication was 90.38 %. Minor dehiscence occurred in 6.00 % of cases, while major wounds or infections occurred in 3.62 %. Across 2,966 implants, the rate of major wounds or infections decreased from 7.03 % before 2013 to 4.75 % after 2013 (<i>p</i> = 0.034). Limited comparisons involving simple suture closure to various adjunct wound management techniques including negative pressure wound therapy, 2-octyl cyanoacrylate, platelet-rich plasma, dehydrated human amniotic membrane allograft, non-invasive skin expansion strips, compression wound dressings, tranexamic acid, surgical helmets, tourniquets, ankle arthrodesis, and lateral approach ankle arthroplasty, yielded non-significant differences (<i>p</i> > 0.18). Therefore, contemporary techniques, patient selection, and current implants may be leading to better soft tissue healing. As ankle replacement continues to surge in popularity, further research is needed to evaluate causative factors in successful anterior incision healing. <h3>Level of Clinical Evidence</h3> 3

First metatarsophalangeal joint arthrodesis is a common surgical intervention for end-stage hallux rigidus and valgus. Such cases can be complicated by disruptions in the metatarsal parabola, particularly an elongated second metatarsal. Some experts advocate for a shortening osteotomy of long metatarsals to restore forefoot balance. However, the present investigators question the benefit of second metatarsal shortening procedures when the first metatarsal is effectively lengthened with arthrodesis. Thus, the current study sought to compare first metatarsophalangeal joint arthrodesis with and without second metatarsal shortening osteotomy. After study criteria, 24 patients undergoing first MTPJ arthrodesis with adjacent Weil osteotomy were matched to 48 patients who underwent first MTPJ arthrodesis alone. Patients were matched for age, sex, indication (hallux rigidus or hallux valgus), metatarsal parabola, body-mass index (BMI), laterality, bone supplementation, fixation type (interfragmentary screw and dorsal locking plate), diabetes, tobacco use, and inflammatory arthropathies. No significant demographic differences were found between the groups (P &gt; .1). At the mean follow-up of 25.5 months, the Weil osteotomy group had twice as many reoperations compared with the control group, at a rate of 25 and 6.3%, respectively (P = .053; OR: 4.9; CI: 1.1-21.7). There were 4 nonunions in each group, with nonunion rates of 16% in the Weil osteotomy group versus 8.3% in the arthrodesis-alone group (P = .43; OR: 2.15; CI: 0.49-9.5). Subsecond metatarsal pain was observed in 16.7% of the Weil osteotomy group (n = 4) and 6.3% of the control group (p= 0.23, OR: 2.8; CI: 0.57-13.6). In this first metatarsophalangeal joint arthrodesis series, no benefit was found when an adjacent second metatarsal shortening osteotomy was completed for preoperative metatarsalgia. Further research is needed to determine if such osteotomies benefit patients undergoing first metatarsophalangeal joint arthrodesis. Levels of Evidence: III

Obesity and malnutrition are modifiable risk factors associated with increased postoperative complications following total knee arthroplasty (TKA). Obesity is paradoxically associated with malnutrition. Previous studies have only evaluated the impact of body mass index (BMI) and hypoalbuminemia separately in relation to postoperative TKA outcomes and have attempted to compare the impact of these modifiable risk factors. Our study seeks to establish if increased BMI and decreased albumin levels have a compounding effect on postoperative outcomes. A retrospective analysis was conducted using the 2011-2014 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) dataset. This study reaffirmed that increased BMI and low albumin levels are associated with increased postoperative complications following TKA. Moreover, this study demonstrated that they do not have a compounding effect, but rather only help predict outcomes when analyzed individually. (Journal of Surgical Orthopaedic Advances 32(2) 114-117, 2023).

Introduction: Diet and the prep medication affect the quality of colonoscopy examinations. The most widely accepted clear liquid diet does not leave patients with many options, and can be especially difficult for the diabetic population. This study compares prep quality between full liquid diet (FLD) and a clear liquid diet (CLD) in the setting of a split dosing sodium sulfate solution. Methods: This was a single-blinded, prospective, randomized study in a single community setting that included 160 patients who underwent elective outpatient colonoscopy for colon cancer screening or surveillance. Patients were randomized to either the standard of care CLD or the FLD which allowed patients to consume milk, ice cream, pudding, sorbet and sherbet but avoided red or purple coloring. Both groups received sodium sulfate as the prep solution. A sample size of 80 patients per group was needed to have approximately 80% power to detect a 15% difference between the two groups. The X2 Test of Independence was used to compare differences between the groups on the categorical variables and analysis of variance was used to compare differences between continuous variables. The primary outcome was the mean difference on the Ottawa Bowel Preparation scale between the two groups. Results: Of the 160 patients enrolled, 159 were randomized. 58% of the patients were female. The most common indication for the exam was average risk screening (72.5%), followed by personal history of polyp (21.3%), family history of colon cancer (5%), and family history of colon polyp (0.6%). 81 patients were enrolled in the CLD group and 78 patients in the FLD group. There was no difference in the mean Ottawa score between the CLD and FLD, 2.68 and 2.53, respectively (P = 0.653). Overall, the prep process was well-tolerated with the exception of more headache complaints in the FLD group. The overall cecal intubation rate, adenoma detection rate and average withdraw time were 99.4%, 49.6% and 10.2 minutes, respectively. Conclusion: This non-inferior result adds to the increase in literature demonstrating a strict CLD may not be necessary for a colonoscopy exam. Endoscopists should be more confident in having greater latitude in the prep diet. This, in return, may also improve the willingness of the patients to complete such an exam.

Introduction: A community based hospital system introduced ICU Liberation (ABCDE bundle and PAD guidelines) in 1 target ICU at 6 diverse affiliates. Use of the Interprofessional Team (IPT) model combined with a dedicated RN Lead drove the implementation of this complex clinical initiative leading to rapid and successful cultural change. Methods: The region hosted an ICU Liberation Summit to build excitement and create a sense of urgency among ICU professionals. Respected clinically advanced RN Leads were promoted in each ICU to drive bundle implementation. These champions engaged staff through role modeling, extensive 1:1 mentoring, group education, and provided clinical assistance to the team. Audits validated staff performance of the RASS, CAM-ICU and CPOT assessments. RN Leads worked with the Affiliate Implementation Teams (AIT), comprised of a physician, RCP, RN, PT, and pharmacist, to develop and implement regional policies for all elements of the ABCDE bundle. AITs collaborated to change delivery of care by embracing evidence based practice using the IPT model. AITs participated in an interactive 12 week curriculum focused on role valuing, role clarity and role sharing. Training included partnership/team building, process improvement/PDSA and communication/cooperation. Results: The IPT combined with the RN Lead have improved communication and coordination of care that emphasizes patient/family participation. During daily bedside rounds, standardized assessment tools are used to monitor pain, sedation and delirium. Medication recommendations have lead to better pain control and lighter sedation. Coordination of daily awakening and spontaneous breathing trials have promoted earlier ventilator weaning and extubation. Earlier mobility has resulted in lower incidence of delirium and weakness. ABCDE Bundle policies were rapidly developed and approved for regional implementation. Conclusions: 6 ICUs in diverse hospitals implemented ICU Liberation in a 13 month period. The adoption of the IPT model addressed barriers and allowed rapid and successful change in patient care. RN Leads in each ICU drove cultural change, revision and implementation of new policies, and regional standardization of care.

Introduction: The American College of Critical Care Medicine (ACCM) has developed a clinical practice guideline for the management of pain, agitation, and delirium in adult patients in the Intensive Care Unit. This guideline was based on growing evidence that most critically ill patients are at risk for development of dangerous and potentially hospital induced conditions such as ICU delirium and weakness. The Respiratory Therapy departments in our hospital system embarked on an effort to collaborate and implement an interprofessional bundle approach to reduce these adverse events. Initially the Respiratory Therapists identified barriers to this project including workload and productivity concerns, fear of patient discomfort and asynchrony, and fear of inadvertent extubation during awakening and mobility. Methods: To overcome these barriers a variety of methods were used to engage staff. All Respiratory Therapy staff was invited to attend an educational symposium at which clinical experts presented data on the adverse events caused by current ICU care methods. Volunteers were solicited to be champions of the ABCDE bundle project and were trained on interprofessional team building and use of ‘UP to Date’ to gather evidence to promote evidence based, best practices. The team of volunteers worked with the interprofessional team to develop order sets and procedures to promote best practices such as daily rounds, delirium assessments, correct medication selection, daily awakening and spontaneous breathing trials and early mobility. Historically we tracked ventilator length of stay, we added re-intubation rate to our tracking as a balancing measure. To ensure workload neutrality we decreased routine ventilator monitoring from every 2 hours to every 4 hours. Results: Since implementation, daily interprofessional rounds are occurring, standardized scales are now being used to assess delirium and sedation levels, criteria for pain and sedation medication has been modified, daily awakening and SBT’s are being performed and patients who meet safety screening criteria are being mobilized. Patients are more awake and participating in ventilator weaning trials and mobilization. Ventilator length of stay has decreased with no increase in re-intubation rate. Conclusions: The ABCDE bundle was successfully implemented with high quality clinical outcomes. Management, clinical leaders and staff worked in tandem to remove barriers in conjunction with staff engagement which was critical to successful implementation. Further study is needed to evaluate participation and engagement in use of the bundle.

Kelly, Tamra1; Chaney, Chris2; Hampel, Leticia3; Sammons, Tim4; Switzler, Kelly5; Blankinship, Meg6; Cubre, Alan7; Reams, Heidi8 Author Information

Background: Sutter Auburn Faith Hospital (SAFH) is a Primary and Rural Stroke Center that sees over 300 stroke patients a year.In 2024 SAFH saw a decrease in swallow screen compliance due to an increase of primary complaint presentation to the Emergency Department (ED) of confusion or dizziness who were later diagnosed with a stroke.This resulted in a decrease in our swallow screen compliance to 92.8%. Purpose: The purpose of this quality improvement project was to increase swallow screen compliance in stroke patients. Methods: SAFH completed a gap analysis of 2024 Q1-Q3 data, revealing that ED patients presenting with dizziness or increased confusion were most often missed for swallow screens.The gap analysis revealed that these patients received a head CT that did not result in an initial diagnosis of stroke but were admitted for other pathologies.The team identified the swallow screen as a nurse driven intervention that should be completed on all patients who are prescribed a head CT.In response the quality improvement project, “Swallow screen for head CT” was launched including RN Educationfor posterior stroke symptoms. The Swallow Screen inclusion criteria launched at the end of Q4 of 2024.The ED manager and Stroke Coordinator worked together throughout Q4, 2024 to identify nurses that needed an increased level of education to ensure there was clear understanding amongst the entire ED nurse group for compliance and buy in. Results: SAFH saw marked improvement of Swallow Screen Compliance, with 100% AHASTR306 Rural Stroke Dysphagia Screen compliance from January-June, 2025.Additionally, an increased performance of swallow screen completion for all patients with stroke, stroke-like symptoms and transient ischemic attack (TIA) to over 95%.Of the five patients that had a fall out in sallow screen prior to oral intake one was a TIA and two presented with mixed symptoms indicative of potential SEPSIS or infection, but MRI was positive for acute infarct days later.“Swallow Screen for head CT” increase compliance for those patients that were initially ruled to not have an infarct via CT scan but were diagnosed during hospitalization via MRI. Conclusion: Simple steps have helped embed the swallow screen process in nursing practice, achieving 100% compliance for TNK patients and improving safety for non-interventional stroke patients.Continued efforts are needed to include patients with mixed or unclear symptoms in the screening.

Objective: The primary objective of the study is to review the fusion rate associated with a single screw and staple construct in Lapidus bunionectomy, and to compare the complication rates, fusion outcomes, and radiographic results with those of other common fixation methods. Methods: Eighty-four bunionectomies met study criteria; in 24 cases, a single screw and staple construct was used, while 28 used a screw and locking plate, and 32 used two crossing screws. Although group matching was attempted, a greater body mass index was observed in the screw and locking plate group (p = 0.006). Results: The minimum follow-up was 12 months (mean, 31.4 months), and the primary outcome was fusion rate. Union rates were achieved in 95.8% for the single screw and staple fixation (23/24), 92.8% for the screw and locking plate (26/28), and 93.8% for crossing screws (30/32) without a statistically significant difference (p = 0.474). The single screw and staple group achieved significantly (p = 0.012) earlier radiographic and clinical union, at 11.7 (+ 1.86) weeks, compared to crossing screw (13.2 + 2.39 weeks) and screw and locking plate (13.5 + 1.69 weeks) groups. There were no significant differences in final first intermetatarsal angle (p = 0.403), hallux valgus angle (p = 0.153), or complication rates (p = 0.386) among the fixation methods. Conclusion: Our study shows that a single screw and staple construct is a viable option for Lapidus bunionectomy, demonstrating faster union time and maintained deformity correction with an acceptable complication rate. However, further research is required to validate the advantages and disadvantages of specific surgical implants. Level of evidence: III, retrospective case control study

Introduction: ICU delirium has been diagnosed in 60 to 85% of patients receiving mechanical ventilation and is undetected in many patients. Multiple studies document the need for detection and prevention of delirium. A key component to achieving recognition and treatment of delirium is daily interprofessional rounds in the ICU. Methods: The Sutter Auburn Faith Respiratory Therapy Department worked with a team including Physical Therapists, Registered Nurses, and Pharmacists to develop and implement collaborative, interprofessional rounds. The goal was to implement daily rounds to ensure patients are assessed with standardized tools to assess confusion and sedation levels as well as selection of appropriate medications for pain, agitation and delirium management, coordination of spontaneous awakening trials and spontaneous breathing trials and early mobility of patients. With the entire care team involved in rounds a focused care plan is formulated throughout the patients stay. Results: Our implementation plan included capitalizing on the existing nurse rounds, getting buy- in and participation from ancillary departments, conducting interprofessional team training, education of staff on the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Richmond Agitation Sedation Scale (RASS) tools, development of rounding worksheets, and articulating expectations of staff at rounds. The team quickly recognized the need to keep rounds short to ensure effective use of time. Goals of this project are: decrease hospital length of stay, decrease in ventilator length of stay, decrease incidence of delirium and decrease mortality rates. The team agreed to put the plan of care in the center of each discussion and give all team members an equal opportunity to contribute to the plan including the patient and the family. Initially physician participation was inconsistent, but as they began to see the synergy created, they have begun to accept this new culture. Conclusions: Implementation of collaborative, interprofessional rounds has been key to our effort to prevent and detect delirium in the ICU. In addition this program has improved relationships and collaboration between Respiratory Care Practitioners, nurses and other ancillary services team members. This program has been in place for about 8 months and is progressing well; we plan to monitor our measurable goals to ensure success.