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Acute rises in glucocorticoid hormones allow individuals to adaptively respond to environmental challenges but may also have negative consequences, including oxidative stress. While the effects of chronic glucocorticoid exposure on oxidative stress have been well characterized, those of acute stress or glucocorticoid exposure have mostly been overlooked. We examined the relationship between acute stress exposure, glucocorticoids and oxidative stress in Japanese quail (Coturnix japonica). We (i) characterized the pattern of oxidative stress during an acute stressor in two phenotypically distinct breeds; (ii) determined whether corticosterone ingestion, in the absence of acute stress, increased oxidative stress, which we call glucocorticoid-induced oxidative stress (GiOS); and (iii) explored how prior experience to stressful events affected GiOS. Both breeds exhibited an increase in oxidative stress in response to an acute stressor. Importantly, in the absence of acute stress, ingesting corticosterone caused an acute rise in plasma corticosterone and oxidative stress. Lastly, birds exposed to no previous acute stress or numerous stressful events had high levels of GiOS in response to acute stress, while birds with moderate prior exposure did not. Together, these findings suggest that an acute stress response results in GiOS, but prior experience to stressors may modulate that oxidative cost.

This JAMA Performance Improvement article summarizes the AHRQ guideline on rapid response teams in its health care safety series, including whether rapid response teams decrease mortality or rates of cardiac arrest, if their use improves patient outcomes, and what barriers hinder their success in the hospital setting.

Enhanced recovery pathways (ERPs), initially developed more than 2 decades ago for colorectal operations, have been shown to improve patient outcomes for many elective procedures. 1-4 They apply standardized, evidencebased, and multidisciplinary approaches to reduce surgical stress and modify physiologic responses. 5-9 As these pathways evolve, it is evident that the key principles, including multimodal analgesia, early mobilization, patient and family engagement, and best practices for preventable harms, can benefit surgical patients broadly, including those undergoing emergency operations. Emergency general surgery (EGS) represents a growing public health burden in the US, with more than 3 million patients admitted annually for these conditions and nearly 30% requiring operation. 10 EGS patients are complex; 35% are older than 70 years and 50% have at least 1 medical comorbidity and are at higher risk for morbidity (15%) and mortality (1.2%). 10,11 Rates are even higher for complex emergency procedures, including 46.9% morbidity for bowel resections and 23.8% mortality for laparotomies. 11 Quality improvement work in EGS is challenging, limited by the urgent nature and heterogeneity in disease and patient characteristics. However, given that the success of ERPs lies in reducing perioperative stress through transdisciplinary teamwork and standardization, the benefits of ERPs might be even more pronounced in this high-risk population. The Safety Program for Improving Surgical Care and Recovery (ISCR) is a national ERP initiative implemented in 2017 through a collaboration among AHRQ (funder), American College of Surgeons, and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality. The ISCR program has been implemented across colorectal, orthopaedic, and gynecologic surgery services. Building on the lessons learned from earlier cohorts, the final cohort of the program will expand into EGS and include appendectomy; cholecystectomy; and emergency, nontrauma, and nonvascular major abdominal operations. The objective of this study was to evaluate the evidence for ERPs for emergency major abdominal operations and to provide a framework for developing and implementing ERPs in this patient population. METHODS Seven common EGS procedures, including appendectomy, cholecystectomy, perforated peptic ulcer repair, colectomy, CME questions for this article available at http://jacscme.facs.org

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Enhanced recovery pathways (ERPs) have emerged as one of the most effective strategies to improve clinical outcomes and reduce health care utilization in elective colorectal surgery. However, ERP implementation alone does not result in improvement without high pathway component compliance. 1,2 Hospital collaboratives have been used to accelerate quality improvement across clinical areas, including ERP adoption. [3][4][5] Despite collaborative participation, hospitals are frequently hindered by barriers related to local culture, agreement over ERP components, and resources.The question remains if patients can achieve equally efficacious outcomes regardless of local hospital culture. We sought to determine the association of high ERP compliance with patient outcomes in the setting of variation in hospitallevel performance in a national ERP collaborative.

INTRODUCTION: Social determinants of health (SDOH) have critical influence on access to care. The influence of SDOH on operative outcomes once access is gained is largely unknown. This study evaluates whether SDOH affects risk-adjusted surgical outcomes in a national sample of high vs low SDOH hospitals, and influence of high-variation of SDOH within hospitals.