A clinical tip for conservative retrieval of fractured abutment screw

Fractures of the abutment screw are an extremely dreadful and taxing experience even for experienced clinicians. Retrieval of fractured screw segments due to excessive torque and improperly placed implants pose a great challenge to the clinician. The authors present a case wherein the fractured abutment screw was retrieved successfully with the help of an intraoral plastic mixing tip of light body putty material. The intraoral plastic mixing tips are a more readily available, cost-effective, and feasible alternative to other means of screw retrieval like ultrasonic scalers, endodontic files, and screw retrieval kits.

Telemedicine Use Decreases the Carbon Footprint of the Bariatric Surgery Preoperative Evaluation

BACKGROUND

Healthcare-associated activity accounts for 10% of the United States' carbon dioxide (CO2) emissions. Using telemedicine for bariatric surgery evaluations decreases emissions and reduces patient burden during the multiple required interdisciplinary visits. After adopting telemedicine during COVID, our clinic continues to utilize telemedicine for preoperative bariatric evaluations. We evaluated the reduced environmental impact associated with this practice.

METHODS

A retrospective review of all new evaluations for vertical sleeve gastrectomy (SG) or Roux-en Y gastric bypass (RYGB) from 2019 and 2021 was conducted. The 2019 year represents pre-pandemic, in-person evaluations and 2021 represents telemedicine evaluations during the COVID pandemic. Carbon emissions were calculated using the Environmental Protection Agency's (EPA's) validated formula of 404g CO2 per car-mile. Preoperative evaluation time was calculated from the initial clinic visit to the operation date.

RESULTS

There were 51 patients in the 2019 cohort and 55 patients in the 2021 cohort. In the 2019 in-person cohort, there was significantly more kg of estimated CO2 emitted (10,225 vs. 2011.4, p<.001) compared to the 2021 cohort. For time required to complete the preoperative workup, there was no statistically significant difference between the two groups (162 days vs. 193 days, p=.226). The attrition rate was lower in the 2021 cohort (22.22% v. 35.9%, p<.001).

CONCLUSIONS

Implementation of telemedicine for bariatric preoperative evaluations reduced patient travel, carbon emissions, and improved attrition rate. We encourage bariatric providers to use telemedicine as we believe this eases patient burdens and, with wider adoption, could significantly reduce our carbon footprint.

Preoperative esophageal testing predicts postoperative reflux status in sleeve gastrectomy patients

BACKGROUND

Patients who undergo vertical sleeve gastrectomy (VSG) are at risk of postoperative GERD. The reasons are multifactorial, but half of conversions to Roux-en Y gastric bypass are for intractable GERD. Our institution routinely performs preoperative pH and high-resolution manometry studies to aid in operative decision making. We hypothesize that abnormal pH studies in concert with ineffective esophageal motility would lead to higher rates of postoperative reflux after VSG.

METHODS

A single institution retrospective review was conducted of adult patients who underwent preoperative pH and manometry testing and VSG between 2015 and 2021. Patients filled out a symptom questionnaire at the time of testing. Postoperative reflux was defined by patient-reported symptoms at 1-year follow-up. Univariate logistic regression was used to examine the relationship between esophageal tests and postoperative reflux. The Lui method was used to determine the cutpoint for pH and manometric variables maximizing sensitivity and specificity for postoperative reflux.

RESULTS

Of 291 patients who underwent VSG, 66 (22.7%) had a named motility disorder and 67 (23%) had an abnormal DeMeester score. Preoperatively, reflux was reported by 122 patients (41.9%), of those, 69 (56.6%) had resolution. Preoperative pH and manometric abnormalities, and BMI reduction did not predict postoperative reflux status (p = ns). In a subgroup analysis of patients with an abnormal preoperative pH study, the Lui cutpoint to predict postoperative reflux was a DeMeester greater than 24.8. Postoperative reflux symptoms rates above and below this point were 41.9% versus 17.1%, respectively (p = 0.03).

CONCLUSION

While manometry abnormalities did not predict postoperative reflux symptoms, GERD burden did. Patients with a mildly elevated DeMeester score had a low risk of postoperative reflux compared to patients with a more abnormal DeMeester score. A preoperative pH study may help guide operative decision-making and lead to better counseling of patients of their risk for reflux after VSG.

Rehabilitation of Post-traumatic Anterior Maxillary Osseous Deficit Using Iliac Onlay Bone Graft Combined With Dental Implants

Fracture of the anterior maxilla usually causes a scooped-out defect in this region which leads to loss of lip support and a sub-optimal condition for placement of implants. The iliac crest is a frequently used donor location in oral and maxillofacial procedures for bone augmentation in order to restore jaw deformities brought on by trauma or pathological diseases prior to the placement of dental implants. Here we present the case of a patient who had undergone reconstruction of the maxillary osseous defect caused due to trauma by iliac crest grafting, followed by placement of dental implants after six months.

Efficacy of Sodium Bicarbonate-Buffered Local Anesthetic Solution in Cases Requiring Bilateral Maxillary Premolar Orthodontic Extraction: A Comparative Split-Mouth Study

Aims and objectives This study was carried out to evaluate the efficacy of 8.4% sodium bicarbonate-buffered local anesthetic solution and conventional local anesthetic in patients requiring bilateral maxillary orthodontic extractions in terms of pain on injection, onset of action, and duration of action. Methods 102 patients requiring bilateral maxillary orthodontic extractions were included in the study. Buffered local anesthetic was administered on one side while conventional local anesthesia (LA) was administered on the other side. Pain on injection was measured using a visual analogue scale, while onset of action was measured by probing the buccal mucosa after 30 seconds of administration and duration of action was measured by the time after which the patient experienced pain or took a rescue analgesic. The data was statistically analyzed to determine the significance. Results The pain during injection was found to be lesser at sites where buffered local anesthetic was administered (mean visual analogue scale (VAS) score = 2.4) as compared to conventional local anesthetic (mean VAS score = 3.9). The onset of action was faster with buffered local anesthetic (mean value = 62.3 seconds) as compared to conventional local anesthetic (mean value = 157.16 seconds). Lastly, the duration of action was found to be longer for buffered local anesthetic group (mean value = 225.65 minutes) as compared to conventional local anesthetic (mean value = 187 minutes). Conclusion 8.4% sodium bicarbonate-buffered local anesthetic was found to be more efficient than conventional local anesthetic in terms of reduction in pain on injection as well as faster onset and longer duration of action.

The impact of socioeconomic status on telemedicine utilization during the COVID-19 pandemic among surgical clinics at an academic tertiary care center

BACKGROUND

The COVID-19 pandemic caused many surgical providers to conduct outpatient evaluations using remote audiovisual conferencing technology (i.e., telemedicine) for the first time in 2020. We describe our year-long institutional experience with telemedicine in several general surgery clinics at an academic tertiary care center and examine the relationship between area-based socioeconomic measures and the likelihood of telemedicine participation.

METHODS

We performed a retrospective review of our outpatient telemedicine utilization among four subspecialty clinics (including two acute care and two elective surgery clinics). Geocoding was used to link patient visit data to area-based socioeconomic measures and a multivariable analysis was performed to examine the relationship between socioeconomic indicators and patient participation in telemedicine.

RESULTS

While total outpatient visits per month reached a nadir in April 2020 (65% decrease in patient visits when compared to January 2020), there was a sharp increase in telemedicine utilization during the same month (38% of all visits compared to 0.8% of all visits in the month prior). Higher rates of telemedicine utilization were observed in the two elective surgery clinics (61% and 54%) compared to the two acute care surgery clinics (14% and 9%). A multivariable analysis demonstrated a borderline-significant linear trend (p = 0.07) between decreasing socioeconomic status and decreasing odds of telemedicine participation among elective surgery visits. A sensitivity analysis to examine the reliability of this trend showed similar results.

CONCLUSION

Telemedicine has many patient-centered benefits, and this study demonstrates that for certain elective subspecialty clinics, telemedicine may be utilized as the preferred method for surgical consultations. However, to ensure the equitable adoption and advancement of telemedicine services, healthcare providers will need to focus on mitigating the socioeconomic barriers to telemedicine participation.

Evidence of depot-specific regulation of all-trans-retinoic acid biosynthesis in human adipose tissue

The prevalence of obesity continues to rise, underscoring the need to better understand the pathways mediating adipose tissue (AT) expansion. All-trans-retinoic acid (atRA), a bioactive vitamin A metabolite, regulates adipogenesis and energy metabolism, and, in rodent studies, aberrant vitamin A metabolism appears a key facet of metabolic dysregulation. The relevance of these findings to human disease is unknown, as are the specific enzymes implicated in vitamin A metabolism within human AT. We hypothesized that in human AT, family 1A aldehyde dehydrogenase (ALDH1A) enzymes contribute to atRA biosynthesis in a depot-specific manner. To test this hypothesis, parallel samples of subcutaneous and omental AT from participants (n = 15) were collected during elective abdominal surgeries to quantify atRA biosynthesis and key atRA synthesizing enzymes. ALDH1A1 was the most abundant ALDH1A isoform in both AT depots with expression approximately twofold higher in omental than subcutaneous AT. ALDH1A2 was detected only in omental AT. Formation velocity of atRA was approximately threefold higher (p = 0.0001) in omental AT (9.8 [7.6, 11.2]) pmol/min/mg) than subcutaneous AT (3.2 [2.1, 4.0] pmol/min/mg) and correlated with ALDH1A2 expression in omental AT (β-coefficient = 3.07, p = 0.0007) and with ALDH1A1 expression in subcutaneous AT (β-coefficient = 0.13, p = 0.003). Despite a positive correlation between body mass index (BMI) and omental ALDH1A1 protein expression (Spearman r = 0.65, p = 0.01), BMI did not correlate with atRA formation. Our findings suggest that ALDH1A2 is the primary mediator of atRA formation in omental AT, whereas ALDH1A1 is the principal atRA-synthesizing enzyme in subcutaneous AT. These data highlight AT depot as a critical variable for defining the roles of retinoids in human AT biology.

Opioid Use Following Bariatric Surgery: Results of a Prospective Survey

BACKGROUND

Opioid use after bariatric surgery is not clearly understood. Few guidelines exist to inform opioid-prescribing practices after bariatric surgery.

OBJECTIVE

To understand opioid use following bariatric surgery.

SETTING

University hospital.

METHODS

Bariatric surgery patients at a single center were prospectively surveyed at the time of their post-operative visit (January-May 2018). Patients were asked about their opioid use following surgery, whether they received education about opioid use and what they did with leftover medications. Demographic and operative details were obtained from the medical record.

RESULTS

Among 33 patients, the majority (n = 29, 88%) were female with a median age of 40 (20-68) and body mass index of 44.8 (33-78.5). Most patients had leftover narcotics (n = 25, 73%). The median number of pills used was 15 (0-48). Only 12 patients (36%) thought that they had been prescribed "too much" pain medication. Most patients reported receiving education about expectations for post-operative pain (n = 22, 69%); few recalled education about reducing or stopping opioids (n = 13, 40%). More than half of patients (n = 17, 53%) kept their leftover opioids rather than disposing of them or bringing them to an approved turn in location.

CONCLUSIONS

Despite most patients having leftover opioids following surgery, few patients recognized possible overprescription. Education regarding opioid use following surgery is inconsistent, potentially contributing to the amount of retained opioids currently available. Future guidelines should focus on determining the appropriate amount of opioids to be prescribed following surgery and standardizing and improving education given to patients.

Obesity in midlife: lifestyle and dietary strategies

As the rate of obesity increases globally, so does the incidence of other non-communicable diseases such as diabetes, cardiovascular disease, cancer, osteoporosis, osteoarthritis, and dementia, which have been referred to as 'adiposity-based chronic disease'. With timely lifestyle modification such as behavioral changes, implementation of a healthy diet, and proper physical activity, many of these diseases can be prevented. Weight gain is one of the major health concerns of midlife. Midlife body changes are the result of aging, menopause, and other influences unique to menopausal women which interfere with adoption of a healthy lifestyle. Reduced metabolism levels lead to low energy levels, which discourage physical activity. In addition, with the onset of bone loss, menopausal women begin to lose muscle mass and gain more fat, resulting in osteopenic sarco-obesity. Adoption of a healthy lifestyle is a first-line option in the treatment for these midlife changes. Lifestyle medicine offers a broad set of network-based interventions, which need to be brought to the forefront in preventing and managing obesity at all stages. This review article focuses on evidence-based lifestyle changes and their benefits for reducing morbidity and mortality related to obesity and its complications prevalent at midlife and beyond.

The impact of bariatric surgery on asthma control differs among obese individuals with reported prior or current asthma, with or without metabolic syndrome

BACKGROUND

Both obesity and the metabolic syndrome have been independently associated with increased asthma morbidity. However, it is unclear whether metabolic syndrome limits the beneficial effects of weight loss on asthma.

OBJECTIVES

To evaluate whether bariatric weight loss is associated with improved asthma control, and whether this association varies by metabolic syndrome status.

METHODS

We determined the changes in asthma control, defined by the Asthma Control Test (ACT), before and after bariatric surgery among participants with asthma in the multi-center Longitudinal Assessment of Bariatric Surgery (LABS) study, stratifying our analysis by the presence or absence of metabolic syndrome.

RESULTS

Among 2,458 LABS participants, 555 participants had an asthma diagnosis and were included in our analysis. Of these, 78% (n = 433) met criteria for metabolic syndrome (MetSyn) at baseline. In patients without MetSyn, mean ACT increased from 20.4 at baseline to 22.1 by 12-24 months, ending at 21.3 at 60 months. In contrast, among those with MetSyn there was no significant improvement in ACT scores. The proportion of patients without MetSyn with adequate asthma control (ACT >19) increased from 58% at baseline to 78% and 82% at 12 and 60 months, respectively, whereas among those with MetSyn, it was 73.8% at baseline, 77.1% at 12 months, dropping to 47.1% at 60 months (p = 0.004 for interaction between metabolic syndrome and time). Having MetSyn also increased the likelihood of losing asthma control during follow-up (HR = 1.92, 95% confidence interval [CI] 1.24-2.97, p = 0.003).

CONCLUSIONS

Metabolic syndrome may negatively modify the effect of bariatric surgery-induced weight loss on asthma control.

Abstract P1-08-07: Withdrawn

This abstract was withdrawn by the authors.

Bariatric Surgery in Women of Childbearing Age, Timing Between an Operation and Birth, and Associated Perinatal Complications

Importance

Metabolic changes after maternal bariatric surgery may affect subsequent fetal development. Many relevant perinatal outcomes have not been studied in this postoperative population, and the risks associated with short operation-to-birth (OTB) intervals have not been well examined.

Objective

To examine the risk for perinatal complications in women with a history of bariatric surgery (postoperative mothers [POMs]) by comparing them with mothers without operations (nonoperative mothers [NOMs]) and examining the association of the OTB interval with perinatal outcomes.

Design, Setting, and Participants

This investigation was a population-based retrospective cohort study (January 1, 1980, to May 30, 2013) at hospitals in Washington State. Data were collected from birth certificates and maternally linked hospital discharge data. Participants were all POMs and their infants (n = 1859) and a population-based random sample of NOMs and their infants frequency matched by delivery year (n = 8437).

Exposures

Bariatric operation before birth or categories of OTB intervals.

Main Outcomes and Measures

The primary outcomes were prematurity, neonatal intensive care unit (NICU) admission, congenital malformation, small for gestational age (SGA), birth injury, low Apgar score (≤8), and neonatal mortality. Poisson regression was used to compute relative risks (RRs) and 95% CIs, with adjustments for maternal body mass index, delivery year, socioeconomic status, age, parity, and comorbid conditions.

Results

A total of 10 296 individuals were included in the analyses for this study. In the overall cohort, the median age was 29 years (interquartile range, 24-33 years). Compared with infants from NOMS, infants from POMs had a higher risk for prematurity (14.0% vs 8.6%; RR, 1.57; 95% CI, 1.33-1.85), NICU admission (15.2% vs 11.3%; RR, 1.25; 95% CI, 1.08-1.44), SGA status (13.0% vs 8.9%; RR, 1.93; 95% CI, 1.65-2.26), and low Apgar score (17.5% vs 14.8%; RR, 1.21; 95% CI, 1.06-1.37). Compared with infants from mothers with greater than a 4-year OTB interval, infants from mothers with less than a 2-year interval had higher risks for prematurity (11.8% vs 17.2%; RR, 1.48; 95% CI, 1.00-2.19), NICU admission (12.1% vs 17.7%; RR, 1.54; 95% CI, 1.05-2.25), and SGA status (9.2% vs 12.7%; RR, 1.51; 95% CI, 0.94-2.42).

Conclusions and Relevance

Infants of mothers with a previous bariatric operation had a greater likelihood of perinatal complications compared with infants of NOMs. Operation-to-birth intervals of less than 2 years were associated with higher risks for prematurity, NICU admission, and SGA status compared with longer intervals. These findings are relevant to women with a history of bariatric surgery and could inform decisions regarding the optimal timing between an operation and conception.

Effect of Picroliv on cadmium-induced hepatic and renal damage in the rat

The therapeutic efficacy of Picroliv-a standardized-was investigated in male rats exposed to CdCl2 (0.5 mg/kg, sc), 5 days/week for 18 weeks. Picroliv at two doses (6 and 12 mg/kg, po) was given to the cadmium (Cd)-administered group for the last 4 weeks (ie, weeks 15 -18). The Cd altered oxidative stress indices, such as increased lipid peroxidation and membrane fluidity, reduced levels of non-protein sulphydryls (NPSHs), and Na-K-ATPase activity in the liver and kidney were found close to the control values by Picroliv treatment, suggesting its antioxidant potential. The hepatoprotective action of Picroliv was evident by its ability to lower the Cd-induced liver function parameters-the serum enzymes, such as alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), g-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH). Bile flow and biliary Cd also increased as a result of Picroliv's choleretic property. The Cd-induced serum urea and urinary excretion of proteins, calcium (Ca), Cd and enzymes, such as Nacetyl-b-D-glucosaminidase (NAG) and LDH, were less marked on Picroliv treatment, indicating recovery from nephrotoxicity. Organ uptake of Cd and essential metals by Cd exposure was reduced on Picroliv treatment. Cdinduced hepatic metallothionein (MT) was lowered by Picroliv, whereas renal MT was unaltered. Cd-induced hepatic damage was also minimized. However, the renal morphological changes were marginally protected by Picroliv. The 12-mg Picroliv dose was more effective than the 6-mg dose in causing amelioration of the above parameters. This study has provided clear evidence for the hepato-and renal protective efficacy of Picroliv against experimental Cd toxicity.

Prevention of acute cadmium toxicity by Picroliv

The potential of Picroliv, a herbal extract against acute cadmium (Cd) intoxication, was evaluated in male rats. Biochemical and histopathological profile in rats pretreated with Picroliv (12 mg/kg, oral) followed by a single dose of Cd as cadmium chloride (CdCl2) (3 mg/kg, ip) revealed marked suppression of oxidative stress in liver and testes. The Cd-induced enhanced levels of lipid peroxidation, membrane fluidity and reduced levels of nonprotein sulphydryls and Na+K+ATPase were significantly restored to near normal by Picroliv pretreatment. In addition, the Cd-induced serum levels of glutamate oxaloacetate transaminase, glutamate pyruvate transaminase, gamma glutamyl transpeptidase and lactate dehydrogenase were restored to near basal levels. Hepatic and testicular histopathological damage was also minimized. The results strongly suggest definite hepatoand testicular protection by Picroliv. The antioxidant potential of the herbal extract in the major part, and not its chelating property, seems to be responsible for its ameliorative action.

Changing Pattern of Clinical Profile of First Contact Patients Attending Outpatient Services At the General Hospital Psychiatric Units In India Over the Last 50 Years

Introduction

Over the last eight decades, general hospital psychiatric units (GHPUs) have become important mental health service set-ups in India. This period has seen a large number of radical changes in the Indian society. In this background, it is important to know if it had any effects on the patients attending the GHPUs.

Methodology

A total of five hundred subjects, attending a GHPU were recruited prospectively for the study. The subjects were assessed using a semi-structured proforma. A comparison was made with similar studies conducted in GHPU settings over the last 5 decades.

Results

Neurotic, stress related and somatoform disorders was the commonest diagnostic group (33%) followed by psychotic disorders (17%) and mood disorders (15%). The finding is broadly similar to the studies done at different times in the last 5 decades. However, there were lesser number of patients with mental retardation, organic brain syndrome and seizure disorder.

Conclusion

The study highlights the strengths of GHPU set-ups like inter-speciality referrals, fewer stigmas, patients travelling from far off places to seek treatment and involvement of family in the care of mentally ill.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Task performance in standard laparoscopy in comparison with single-incision laparoscopy in a modified skills trainer

BACKGROUND

Single-incision laparoscopy (SIL) is similar to conventional laparoscopic surgery (LAP), but carries specific technical challenges due to lack of triangulation, reduced dexterity, conflicts due to inline instrumentation, and impaired visualization. This study was designed to evaluate technical skill performance of SIL versus LAP surgery in a simulated environment.

METHODS

We developed a modified laparoscopic skills trainer for SIL based upon the fundamentals of laparoscopic surgery (FLS) model. This includes a standard laparoscopic tower for visualization, allowing replication of the conflicts between scope and instruments. It also has a modified trainer box allowing use of different access devices and instruments for SIL. Sixteen subjects at different levels of training (novice through expert) completed four FLS tasks with standard LAP techniques. They then practiced the same tasks using SIL technique until they reached a steady state of performance. The first and last SIL trials were recorded.

RESULTS

Baseline SIL peg transfer was worse than FLS (254 ± 157 s vs 99 ± 27, p < 0.0002). Final SIL time was still significantly worse than FLS (173 ± 130, p < 0.02). FLS, baseline SIL, and final SIL circle cutting were not significantly different (p = 0.058). Final SIL loop ligation was significantly faster than FLS (48 ± 19 vs 70 ± 42, p < 0.05). FLS suturing was faster than SIL suturing (281 ± 188 vs. 526 ± 105, p < 0.01). There was substantial dropout due to frustration with SIL, and only two surgeons were able to successfully complete SIL suturing.

CONCLUSIONS

There are technical challenges with SIL that vary depending on task. Peg transfer and suturing were significantly impaired in SIL, while circle cutting was not significantly affected, and ligating loop was faster with SIL than LAP. These challenges may impact clinical outcomes of SIL and should influence training in SIL as well as future product development.

Multi-Threshold Voltage CMOS Design for Low-Power Half Adder Circuit

The new era of portable electronic devices demands lesser power dissipation for longer battery life and design compactability. Leakage current and leakage power are dominating factors which greatly affect the power consumption in low voltage and low power applications. For many numerical representations of binary numbers, combinational circuits like adder, encoder, multiplexer, etc. are useful circuits for arithmetic operation. A novel high speed and low power half adder cell is introduced here which consists of AND gate and OR gate. This cell shows high speed, lower power consumption than conventional half adder. In CMOS technology, transistors used have small area and low power consumption. It is used in various applications like adder, subtract or, multiplexer, ALU and microprocessors digital VLSI systems. As the scaling technology reduces, the leakage power increases. In this paper, multi threshold complementary metal oxide semiconductor (MTCMOS) technique is proposed to reduce the leakage current and leakage power. MTCMOS is an effective circuit level technique that increases the performance of a cell by using both low- and high-threshold voltage transistors. Leakage current is reduced by 85.37% and leakage power is reduced by 87.45% using MTCMOS technique as compared to standard CMOS technique. The half adder design simulation work was performed by cadence simulation tool at 45-nm technology.

Urinary Incontinence Before and After Bariatric Surgery

IMPORTANCE

Among women and men with severe obesity, evidence for improvement in urinary incontinence beyond the first year after bariatric surgery-induced weight loss is lacking.

OBJECTIVES

To examine change in urinary incontinence before and after bariatric surgery and to identify factors associated with improvement and remission among women and men in the first 3 years after bariatric surgery.

DESIGN, SETTING, AND PARTICIPANTS

The Longitudinal Assessment of Bariatric Surgery 2 is an observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Participants were recruited between February 21, 2005, and February 17, 2009. Adults undergoing first-time bariatric surgical procedures as part of clinical care by participating surgeons between March 14, 2006, and April 24, 2009, were followed up for 3 years (through October 24, 2012).

INTERVENTION

Participants undergoing bariatric surgery completed research assessments before the procedure and annually thereafter.

MAIN OUTCOMES AND MEASURES

The frequency and type of urinary incontinence episodes in the past 3 months were assessed using a validated questionnaire. Prevalent urinary incontinence was defined as at least weekly urinary incontinence episodes, and remission was defined as change from prevalent urinary incontinence at baseline to less than weekly urinary incontinence episodes at follow-up.

RESULTS

Of 2458 participants, 1987 (80.8%) completed baseline and follow-up assessments. At baseline, the median age was 47 years (age range, 18-78 years), the median body mass index was 46 kg/m2 (range, 34-94 kg/m2), and 1565 of 1987 (78.8%) were women. Urinary incontinence was more prevalent among women (49.3%; 95% CI, 46.9%-51.9%) than men (21.8%; 95% CI, 18.2%-26.1%) (P < .001). After a mean 1-year weight loss of 29.5% (95% CI, 29.0%-30.1%) in women and 27.0% (95% CI, 25.9%-28.6%) in men, year 1 urinary incontinence prevalence was significantly lower among women (18.3%; 95% CI, 16.4%-20.4%) and men (9.8%; 95% CI, 7.2%-13.4%) (P < .001 for all). The 3-year prevalence was higher than the 1-year prevalence for both sexes (24.8%; 95% CI, 21.8%-26.5% among women and 12.2%; 95% CI, 9.0%-16.4% among men) but was substantially lower than baseline (P < .001 for all). Weight loss was independently related to urinary incontinence remission (relative risk, 1.08; 95% CI, 1.06-1.10 in women and 1.07; 95% CI, 1.02-1.13 in men) per 5% weight loss, as were younger age and the absence of a severe walking limitation.

CONCLUSIONS AND RELEVANCE

Among women and men with severe obesity, bariatric surgery was associated with substantially reduced urinary incontinence over 3 years. Improvement in urinary incontinence may be an important benefit of bariatric surgery.

Heparin enhances uptake of platelet factor 4/heparin complexes by monocytes and macrophages

BACKGROUND

Heparin-induced thrombocytopenia (HIT) is an iatrogenic complication of heparin therapy caused by antibodies to a self-antigen, platelet factor (4) and heparin. The reasons why antibodies form to PF4/heparin, but not to PF4 bound to other cellular glycosaminoglycans are poorly understood.

OBJECTIVE

To investigate differences in cellular responses to cell-bound PF4 and PF4/heparin complexes, we studied the internalization of each by peripheral blood-derived monocytes, dendritic cells and neutrophils.

METHODS AND RESULTS

Using unlabeled and fluorescently-labeled antigen and/or labeled monoclonal antibody to PF4/heparin complexes (KKO), we show that PF4/heparin complexes are taken up by monocytes in a heparin-dependent manner and are internalized by human monocytes and dendritic cells, but not by neutrophils. Complexes of PF4/low-molecular-weight heparin and complexes composed of heparin and murine PF4, protamine or lysozyme are internalized similarly, suggesting a common endocytic pathway. Uptake of complexes is mediated by macropinocytosis, as shown by inhibition using cytochalasin D and amiloride. Internalized complexes are transported intact to late endosomes, as indicated by co-staining of vesicles with KKO and lysosomal associated membrane protein-2 (LAMP-2). Lastly, we show that cellular uptake is accompanied by expression of MHCII and CD83 co-stimulatory molecules.

CONCLUSIONS

Taken together, these studies establish a distinct role for heparin in enhancing antigen uptake and activation of the initial steps in the cellular immune response to PF4-containing complexes.

A national review of the frequency of minimally invasive surgery among general surgery residents: assessment of ACGME case logs during 2 decades of general surgery resident training

IMPORTANCE

Minimally invasive surgery (MIS) has created a shift in how many surgical diseases are treated. Examining the effect on resident operative experience provides valuable insight into trends that may be useful for restructuring the requirements of resident training.

OBJECTIVE

To evaluate changes in general surgery resident operative experience regarding MIS.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of the frequency of MIS relative to open operations among general surgery residents using the Accreditation Council for Graduate Medical Education case logs for academic years 1993-1994 through 2011-2012.

EXPOSURES

General surgery residency training among accredited programs in the United States.

MAIN OUTCOMES AND MEASURES

We analyzed the difference in the mean number of MIS techniques and corresponding open procedures across training periods using 2-tailed t tests with statistical significance set at P < .05.

RESULTS

Of 6,467,708 operations with the option of MIS, 2,393,030 (37.0%) were performed with the MIS approach. Of all MIS operations performed, the 5 most common were cholecystectomy (48.5%), appendectomy (16.2%), groin hernia repair (10.0%), abdominal exploration (nontrauma) (4.4%), and antireflux procedures (3.6%). During the study period, there was a transition from a predominantly open to MIS approach for appendectomy, antireflux procedures, thoracic wedge resection, and partial gastric resection. Cholecystectomy is the only procedure for which MIS was more common than the open technique throughout the study period (P < .001). The open approach is more common for all other procedures, including splenectomy (0.7% MIS), common bile duct exploration (24.9% MIS), gastrostomy (25.9% MIS), abdominal exploration (33.1% MIS), hernia (20.3% MIS), lung resection (22.3% MIS), partial or total colectomy (39.1%), enterolysis (19.0% MIS), ileostomy (9.0% MIS), enterectomy (5.2% MIS), vagotomy (1.8% MIS), and pediatric antireflux procedures (35.9% MIS); P < .001.

CONCLUSIONS AND RELEVANCE

Minimally invasive surgery has an increasingly prominent role in contemporary surgical therapy for many common diseases. The open approach, however, still predominates in all but 5 procedures. Residents today must become efficient at performing multiple techniques for a single procedure, which demands a broader skill set than in the past.

Eating behavior and eating disorders in adults before bariatric surgery

OBJECTIVE

To describe eating patterns, prevalence of problematic eating behaviors, and determine factors associated with binge eating disorder (BED), before bariatric surgery.

METHOD

Before surgery, 2,266 participants (median age 46 years; 78.6% female; 86.9% white; median body mass index 45.9 kg/m(2) ) of the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study completed eating behavior survey items in the self-administered LABS-2 Behavior form. Other measures included the Alcohol Use Disorder Identification Test, the LABS-2 Psychiatric and Emotional Test Survey, the Beck Depression Inventory, the Interpersonal Support Evaluation List-12, the Short Form-36 Health Survey, and Impact of Weight Quality of Life-Lite Survey.

RESULTS

The majority (92.1%) of participants reported eating dinner regularly, whereas just over half (54.0%) reported eating breakfast regularly. Half of the participants reported eating at least four meals/week at restaurants; two meals/week were fast food. Loss of control eating was reported by 43.4%, night eating syndrome by 17.7%; 15.7% satisfied criteria for binge eating disorder (BED), 2% for bulimia nervosa. Factors that independently increased the odds of BED were being a college graduate, eating more times per day, taking medication for psychiatric or emotional problems, and having symptoms of alcohol use disorder, lower self-esteem and greater depressive symptoms.

DISCUSSION

Before undergoing bariatric surgery a substantial proportion of patients report problematic eating behaviors. Several factors associated with BED were identified, most suggesting other mental health problems, including higher levels of depressive symptomotology. The strengths of this study include the large sample size, the multi-center design and use of standardized assessment practices.

Course of depressive symptoms and treatment in the longitudinal assessment of bariatric surgery (LABS-2) study

OBJECTIVE

To examine changes in depressive symptoms and treatment in the first 3 years following bariatric surgery.

METHODS

The longitudinal assessment of bariatric surgery-2 (LABS-2) is an observational cohort study of adults (n = 2,458) who underwent a bariatric surgical procedure at 1 of 10 US hospitals between 2006 and 2009. This study includes 2,148 participants who completed the Beck depression inventory (BDI) at baseline and ≥ one follow-up visit in years 1-3.

RESULTS

At baseline, 40.4% self-reported treatment for depression. At least mild depressive symptoms (BDI score ≥ 10) were reported by 28.3%; moderate (BDI score 19-29) and severe (BDI score ≥30) symptoms were uncommon (4.2 and 0.5%, respectively). Mild-to-severe depressive symptoms independently increased the odds (OR = 1.75; P = 0.03) of a major adverse event within 30 days of surgery. Compared with baseline, symptom severity was significantly lower at all follow-up time points (e.g., mild-to-severe symptomatology was 8.9%, 6 months; 8.4%, 1year; 12.2%, 2 years; 15.6%, 3 years; ps < 0.001), but increased between 1 and 3 years postoperatively (P < 0.01). Change in depressive symptoms was significantly related to change in body mass index (r = 0.42; P < 0001).

CONCLUSION

Bariatric surgery has a positive impact on depressive features. However, data suggest some deterioration in improvement after the first postoperative year. LABS-2, #NCT00465829, http://www.clinicaltrials.gov/ct2/show/NCT00465829.

Hepatic pathology among patients without known liver disease undergoing bariatric surgery: observations and a perspective from the longitudinal assessment of bariatric surgery (LABS) study

Liver biopsy is not routine during bariatric surgery. Alanine aminotransferase (ALT) is widely used to screen for liver disease. We assessed the relationship between ALT and pathology in biopsies from Longitudinal Assessment of Bariatric Surgery (LABS) patients with normal preoperative ALTs. Biopsies from the LABS-1 and LABS-2 studies were scored using the NASH CRN and Ishak systems. Diagnosis and histology were examined in relation to alanine aminotransferase (ALT) values. Six-hundred ninety-three suitable biopsies were evaluated. Biopsied patients had a median age of 45 years; 78.6% were female and 35.1% diabetic; median body mass index was 46 kg/m(2). Six-hundred thirty-five biopsied patients had preoperative ALTs. Median ALT was 25 IU/L (interquartile range [IQR] 19-36 IU/L); 26.6% had an ALT > 35 IU/L and 29.9% exceeded the more restrictive Prati criteria for normal. Using the Prati criteria, 7.9% of participants with normal ALT had steatohepatitis and 5.3% had ≥ stage 2 fibrosis. Logistic regression models were used to predict the probabilities of having bridging fibrosis/cirrhosis or a diagnosis of borderline/definite steatohepatitis in the unbiopsied LABS-2 sample. The proportion of biopsied participants with these findings was very similar to the modeled results from the unbiopsied cohorts. We estimated that 86.0% of participants with advanced fibrosis and 88.1% of participants with borderline/definite steatohepatitis were not biopsied and went undiagnosed. As ALT did not reliably exclude significant obesity-related liver disease in bariatric surgery patients, consideration should be given to routine liver biopsy during bariatric surgery and medical follow-up of significant hepatic pathology.

Pigmented villonodular synovitis great toe

A young boy of 14 years. presented with swelling over dorsal aspect of right great toe, which was slightly tender, non fluctuant. It was excised under subarachnoid block. The mass was golden brown in colour encircling the extensor tendon (Extensor Hallucis Longus Tendon). Histopathology reported to be Pigmented Villonodular Synovitis.

The effect of obesity in adolescence on adult health status

OBJECTIVE

To test the hypothesis that adolescent obesity would be associated with greater risks of adverse health in severely obese adults.

METHODS

Before weight loss surgery, adult participants in the Longitudinal Assessment of Bariatric Surgery-2 underwent detailed anthropometric and comorbidity assessment. Weight status at age 18 was retrospectively determined. Participants who were ≥80% certain of recalled height and weight at age 18 (1502 of 2308) were included. Log binomial regression was used to evaluate whether weight status at age 18 was independently associated with risk of comorbid conditions at time of surgery controlling for potential confounders.

RESULTS

Median age and adult body mass index (BMI) were 47 years and 46, respectively. At age 18, 42% of subjects were healthy weight, 29% overweight, 16% class 1 obese, and 13% class ≥2 obese. Compared with healthy weight at age 18, class ≥2 obesity at age 18 independently increased the risk of lower-extremity venous edema with skin manifestations by 435% (P < .0001), severe walking limitation by 321% (P < .0001), abnormal kidney function by 302% (P < .0001), polycystic ovary syndrome by 74% (P = .03), asthma by 48% (P = .01), diabetes by 42% (P < .01), obstructive sleep apnea by 25% (P < .01), and hypertension (by varying degrees based on age and gender). Conversely, the associated risk of hyperlipidemia was reduced by 61% (P < .01).

CONCLUSIONS

Severe obesity at age 18 was independently associated with increased risk of several comorbid conditions in adults undergoing bariatric surgery.

Eliciting a policy response for the rising epidemic of overweight-obesity in India

India is experiencing multiple transitions with respect to nutrition patterns, epidemiology and demography. Along with staggering childhood undernutrition, a rapid rise in chronic diseases and their risk factors including overweight-obesity (O-O), among all sections of society, is compounding India's health challenges. We present an overview of the O-O scenario (prevalence, determinants) and profile existing initiatives to address this modifiable risk factor in India. Urgent attention from all sectors, committed resources, policy support and targeted actions are warranted to combat the dual burden of malnutrition. The health systems should be reoriented and strengthened, in addition to enabling actions in other sectors, to address prevention and control of non-communicable diseases and associated risk factors like O-O.

Reporting weight change: standardized reporting accounting for baseline weight

BACKGROUND

Although it is recognized that a standardized approach to reporting weight change is essential to meaningful comparisons among cohorts and across studies, consensus is lacking. This study aimed to propose a method of reporting weight change that would allow meaningful comparisons among studies of patients who underwent bariatric surgery and to demonstrate its utility using an example from the Longitudinal Assessment of Bariatric Surgery (LABS).

METHODS

Relationships among several measures of weight change are described. Results from an observational, longitudinal cohort study of adults undergoing bariatric surgery and from simulation studies are used to illustrate the proposed method.

RESULTS

Baseline weight is a critical parameter when assessing weight change. Men undergoing a bariatric procedure other than gastric bypass or adjustable band tended to have greater weight loss 12 months after surgery than men undergoing gastric bypass when not accounting for baseline weight, but the opposite was found when results were adjusted for baseline weight. Simulation results show that with relatively modest sample sizes, the adjusted weight loss was significantly different between the 2 groups of men.

CONCLUSION

A consistent metric for reporting weight loss after bariatric surgery is essential to interpret outcomes across studies and among subgroups. The baseline weight adjusted percent of weight loss (A%WL) uses a standard population (e.g., the LABS cohort) to account for differences between cohorts with respect to baseline weight, and its use can change the interpretation of results compared with an unadjusted measure.

Can technical factors explain the volume-outcome relationship in gastric bypass surgery?

BACKGROUND

The existence of a relationship between surgeon volume and patient outcome has been reported for different complex surgical operations. This relationship has also been confirmed for patients undergoing Roux-en-Y gastric bypass (RYGB) in the Longitudinal Assessment of Bariatric Surgery (LABS) study. Despite multiple studies demonstrating volume-outcome relationships, fewer studies investigate the causes of this relationship.

OBJECTIVE

The purpose of the present study is to understand possible explanations for the volume-outcome relationship in LABS.

METHODS

LABS includes a 10-center, prospective study examining 30-day outcomes after bariatric surgery. The relationship between surgeon annual RYGB volume and incidence of a composite endpoint (CE) has been published previously. Technical aspects of RYGB surgery were compared between high and low volume surgeons. The previously published model was adjusted for select technical factors.

RESULTS

High-volume surgeons (>100 RYGBs/yr) were more likely to perform a linear stapled gastrojejunostomy, use fibrin sealant, and place a drain at the gastrojejunostomy compared with low-volume surgeons (<25 RYGBs/yr), and less likely to perform an intraoperative leak test. After adjusting for the newly identified technical factors, the relative risk of CE was .93 per 10 RYGB/yr increase in volume, compared with .90 for clinical risk adjustment alone.

CONCLUSION

High-volume surgeons exhibited certain differences in technique compared with low-volume surgeons. After adjusting for these differences, the strength of the volume-outcome relationship previously found was reduced only slightly, suggesting that other factors are also involved.

Oral mucoceles - review of the literature

Oral mucoceles are mucin filled cavities and lined by ductal epithelium or covered by granulation tissue in retention or extravasation type respectively. The extra-vasation type is very common in the minor salivary glands (particularly in the labial glands), but very infrequent in the major salivary glands, whilst most of the retention cyst affect the major salivary glands. Partial obstruction of duct and spillage of mucin following trauma are the chief etiological factors. Though the two lesions are clinically indistinguishable, the patients are typically older than in the case of extra-vasation type. The case history along with heedful clinical examination of the lesion is crucial for diagnosing mucoceles correctly, but to avoid recurrences histopathological examination is mandatory. The surgical approach to mucoceles is the most common mode of treatment amongst various other techniques including cryosurgery, laser and so on.

Single-incision laparoscopy: training, techniques, and safe introduction to clinical practice

BACKGROUND

Single-incision laparoscopy is an emerging technique that brings new challenges to laparoscopy and introduces new skills that a surgeon must learn. The learning needs for single-incision skills acquisition are unknown and no current guidelines exist for training or for its safe adoption.

METHODS

We developed an approach to adoption of new surgical techniques and applied it to single-incision laparoscopy. It is based on the following principles: a defined training algorithm, dry and wet-laboratory practice, a graded clinical introduction, and careful review of early outcomes. We analyzed its impact in our initial 40 patients.

RESULTS

Our training paradigm consisted of the following: attending a formal course, developing a simulation model, and animal laboratory training, followed by graduated clinical adoption. A 20% conversion rate to standard laparoscopy or open surgery occurred.

CONCLUSION

Introducing a new surgical technique may not only offer potential advantages but also present significant risks. We developed a thoughtful approach to adoption that includes simulation-based training, progressive clinical adoption, and early review of outcomes. This approach may be applied to various new clinical applications.

Improvement of respiratory symptoms following Heller myotomy for achalasia

INTRODUCTION

Although patients with achalasia complain mainly of dysphagia, we have observed that they also have a high rate of respiratory problems. We hypothesized that the latter may be due to poor esophageal clearance leading to aspiration. This study examines the effect of Heller myotomy on these symptoms.

METHODS

We studied the course of 111 patients with achalasia who underwent Heller myotomy between 1994 and 2008 and who agreed to participate in this study. All patients completed a questionnaire postoperatively assessing the preoperative and postoperative prevalence and severity of symptoms using visual analog scales. Patients were divided into two groups: one that included all those with respiratory symptoms (dyspnea, hoarseness, cough, wheezing, sore throat, and/or a history of asthma or pneumonia) prior to myotomy and one that included those without those symptoms.

RESULTS

All patients presented with dysphagia as their primary complaint, and 63 (57%) reported respiratory symptoms or disease prior to surgery. There were no significant differences in preoperative characteristics between those with and without respiratory manifestations. After a median follow-up of 71 months (range 9-186 months), 55 (87%) patients reported durable improvement of dysphagia. The frequency and severity of all respiratory symptoms decreased significantly. Twenty-four of the 29 patients (82%) who reported a history of pneumonia prior to surgery did not experience recurrent episodes after Heller myotomy.

CONCLUSIONS

A Heller myotomy is effective in improving esophageal emptying in patients with achalasia. This results in sustained improvement of dysphagia and associated respiratory symptoms/diseases. This suggests that respiratory symptoms/diseases in these patients are likely caused by esophageal retention of food and secretions, and then aspiration.

MRSA screening in the vascular day-case population

INTRODUCTION

The UK Government has prioritised methicillin-resistant Staphylococcus aureus (MRSA) screening and new operational guidance has instructed that all day-case surgical patients should be screened from April 2009. We sought to identify the number of MRSA-positive patients in the vascular day-case population over a 1-year period and to profile this cohort in terms of risk-factors for MRSA. We also sought to identify whether the new guidance from the Department of Health (DH) had resulted in increased screening rates.

PATIENTS AND METHODS

Electronic records and laboratory culture results were prospectively consulted to identify whether patients had been screened and if MRSA had been isolated. Consideration was given to whether any patients had a delayed discharge or subsequent admission with an MRSA-related complication.

RESULTS

Six patients (2.1%) screened MRSA-positive (DH estimate 7%); five were previously known to be MRSA-positive, therefore only 0.36% patients were newly-identified as MRSA-positive. The proportion of patients screened increased from 35% to 72.5% after April 2009, in accordance with DH guidance. Successful decolonisation was proved in two patients (33.3%).

CONCLUSIONS

There is dispute with several of the key assumptions behind the DH's impact assessment justifying an expanded MRSA-screening policy. It is not cost-effective to screen all vascular day-case admissions. We recommend selective screening for patients previously identified as MRSA-positive, or considered high risk.