Bariatric surgeons' views on pre-operative factors associated with improved health-related quality of life following surgery.

Bariatric surgery is an effective treatment for severe obesity, affording significant improvements in weight loss and health-related quality of life. However, bariatric surgeons' views on whether certain pre-operative factors predict improvements in post-operative health-related quality of life, and if so, which ones, are largely unknown. This cross-sectional survey study examined the views of 58 bariatric surgeons from Australia and New Zealand. A total of 18 factors were selected for exploration based on their mention in the literature. Participants rated the extent to which they thought these pre-operative factors would improve post-operative health-related quality of life. Responses showed that bariatric surgeons held diverse perspectives and revealed a lack of consensus regarding "predictive" factors. Generally, respondents agreed that better than average health literacy, higher socioeconomic status, good physical and psychological health, and positive social support were predictors of improved health-related quality of life following surgery. However, poor eating behaviours, smoking, and the use of alcohol or other substances were deemed negative predictors. Interestingly, aside from higher socioeconomic status, good psychological health, and positive social support, none of the aforementioned views aligned with existing literature. This study offers an initial insight into bariatric surgeons' views on the influence of different pre-operative factors on post-operative health-related quality of life. The array of views identified suggests that there may be an opportunity for medical education, but the findings warrant caution due to the sample size. Replication with a larger survey may be useful, especially as predicted health-related quality of life outcomes could guide decisions regarding surgical (non)progression.

Predicting time to asystole following withdrawal of life-sustaining treatment: a systematic review.

The planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life-sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria.

Pronounced Regional Variation in Esketamine and Ketamine Prescribing to US Medicaid Patients.

Ketamine and esketamine are efficacious for treatment-resistant depression. Unlike other antidepressants, ketamine lacks a therapeutic delay and decreases the risk for suicide. This cross-sectional study geographically characterized ketamine and esketamine prescribing to United States (US) Medicaid patients. Ketamine and esketamine prescription rates and spending per state were obtained. Between 2009 and 2020, ketamine prescribing rates peaked in 2013 followed by a general decline. For ketamine and esketamine in 2019, Montana (967/million enrollees) and Indiana (425) showed significantly higher prescription rates, respectively, relative to the national average. A total of 21 states prescribed neither ketamine nor esketamine in 2019. There was a 121.3% increase in esketamine prescriptions from 2019 to 2020. North Dakota (1,423) and North Carolina (1,094) were significantly elevated relative to the average state for esketamine in 2020. Ten states prescribed neither ketamine nor esketamine in 2020. Medicaid programs in 2020 spent 72.7-fold more for esketamine ($25.3 million) than on ketamine (0.3 million). Despite the effectiveness of ketamine and esketamine for treatment-resistant depression and anti-suicidal properties, their use among Medicaid patients was limited and highly variable in many areas of the US. Further research to better understand the origins of this state-level variation is needed.

Waiting in Pain II: An Updated Analysis of the Multidisciplinary Staffing Levels and Clinical Activity in Australian Specialist Persistent Pain Services.

This study provides an update on multidisciplinary staffing and clinical activity in Australian specialist persistent pain services. Of the 109 services identified, 57 responded, met inclusion criteria and completed a study-specific questionnaire detailing service characteristics, staff resources, and clinical activities. Where possible, data were compared between the 'Waiting in Pain' (WIP) investigations (WIP-I: Dec'08-Jan'10, WIP-II: Jul'16-Feb'18). WIP-II found more pain services (Level 1 centres, rural services) and more full-time equivalent (FTE) staffing (overall, psychiatry, psychology, occupational therapy) than WIP-I. Although Level 1 centres employed more FTE staff (overall, medical) than Level 2 clinics, staffing was comparable when considered relative to clinical activity and this was stable over time for most disciplines. Clinical activity in metropolitan and rural services also remained stable, as did rural service staffing (type, FTE), suggesting that newer clinics replicated existing models. WIP-II highlighted greater diversity in group structures than WIP-I and an associated mean .02FTE allied health staff/patient seen (WIP-I = .03 FTE). Staffing (amounts, types) did not change significantly over time when considered relative to clinical activity, supporting the conclusion that these are workable clinical structures. However, changes in group format (duration, staffing) suggest a shift towards lower-intensity programmes that require less allied health staffing to deliver. PERSPECTIVE: This article presents updated data regarding multidisciplinary staffing profiles, clinical activity, and group programme structures within Australian specialist persistent pain services and examines changes since the original investigation. As the only published staffing profile for multidisciplinary pain services, this project provides critical information to inform service (re)design and care delivery.

The archaeological potential of the northern Luangwa Valley, Zambia: The Luwumbu basin.

The Luangwa Basin, Zambia, which forms part of the Zambezi drainage, is strategically located between the Central African plateau and the East African Rift system. The Luangwa River and major tributaries, such as the Luwumbu River, are perennial water sources supporting essential resources that sustain human communities and a rich and diverse fauna and flora. The archaeological record of Luangwa is relatively unknown, despite early archaeological exploration hinting at its potential. Recent research in the southern Luangwa valley, however, suggests that it preserves a long record of hominin occupation spanning the Early to Late Stone Age. The research described here details fieldwork carried out in northeastern Luangwa, in the Luwumbu Basin, that confirms that a relatively deep package of Quaternary deposits, containing evidence of the Stone Age occupation of the region persists in the upper piedmont zone.

Improving management of needle distress during the journey to dialysis through psychological education and training-the INJECT study feasibility pilot protocol.

BACKGROUND: Needle-related distress is a common yet poorly recognised and managed problem among haemodialysis (HD) patients. The aim of this pilot study is to test the feasibility and acceptability of the INJECT Intervention-an innovative psychology-based intervention to empower patients to self-manage needle distress with the support of dialysis nurses. METHODS: This investigator-initiated, single-arm, non-randomised feasibility study will take place in a large dialysis service in Adelaide, Australia. Participants will include patients aged ≥ 18 years, commencing or already receiving maintenance HD, recruited through dialysis physicians and nursing staff as individuals believed to be at risk of needle distress. They will be screened for inclusion using the Dialysis Fear of Injection Questionnaire (DFIQ) and enrolled into the study if the score is ≥ 2. The multi-pronged intervention encompasses (i) psychologist review, (ii) patient self-management program and (iii) nursing education program. The primary aim is to evaluate feasibility and acceptability of the intervention from patient and dialysis nurse perspectives, including recruitment, retention, engagement with the intervention and completion. Secondary exploratory outcomes will assess suitability of various tools for measuring needle distress, evaluate acceptability of the nursing education program and measure cannulation-related trauma and vascular access outcomes. CONCLUSION: The results will inform the protocol for larger trials addressing needle distress in HD patients. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000229875, approved 4 April 2021, https://www.anzctr.org.au/ .

Promoting resilience in healthcare workers during the COVID-19 pandemic with a brief online intervention.

INTRODUCTION: The psychological wellbeing of healthcare workers has been impacted by the high levels of stress many have experienced during the Coronavirus Disease 2019 (COVID-19) pandemic. This study aimed to examine the feasibility and acceptability of a brief online course focused on introducing evidence-based skills that could increase resilience and decreases emotional distress in healthcare workers during the pandemic. MATERIALS AND METHODS: Employees of a large healthcare system completed a mental health survey at baseline, and then one month and two months after some employees participated in an online resilience-enhancement course consisting of three 12-19 min videos focused on mindfulness, mentalization, and self-compassion. RESULTS: A total of 554 participants completed the baseline survey, endorsing moderate to high levels of emotional distress. Of those who completed all three assessments and participated in the course (n = 38), significant improvements in resilience and reductions in emotional distress were found one and two months later, in comparison to those who did not participate in the course (n = 110). DISCUSSION: These findings suggest that a brief, online intervention can improve the mental health of healthcare workers during a crisis such as the COVID-19 pandemic.

Denosumab for craniofacial fibrous dysplasia: duration of efficacy and post-treatment effects.

Denosumab has been advocated as a potential treatment for the rare skeletal disorder fibrous dysplasia (FD); however, there is limited data to support safety and efficacy, particularly after drug discontinuation. We report a case of successful treatment of aggressive craniofacial FD with denosumab, highlighting novel insights into the duration of efficacy, surrogate treatment markers, and discontinuation effects. A 13-year-old girl presented with persistent pain and expansion of a maxillary FD lesion, which was not responsive to repeated surgical procedures or bisphosphonates. Pre-treatment biopsy showed high RANKL expression and localization with proliferation markers. Denosumab therapy was associated with improved pain, decreased bone turnover markers, and increased lesion density on computed tomography scan. During 3.5 years of treatment, the patient developed increased non-lesional bone density, and after denosumab discontinuation, she developed hypercalcemia managed with bisphosphonates. Pain relief and lesion stability continued for 2 years following treatment, and symptom recurrence coincided with increased bone turnover markers and decreased lesion density back to pre-treatment levels. This case highlights the importance of considering the duration of efficacy when treating patients with FD and other nonresectable skeletal neoplasms that require long-term management.

Overturning circulation, nutrient limitation, and warming in the Glacial North Pacific.

Although the Pacific Ocean is a major reservoir of heat and CO2, and thus an important component of the global climate system, its circulation under different climatic conditions is poorly understood. Here, we present evidence that during the Last Glacial Maximum (LGM), the North Pacific was better ventilated at intermediate depths and had surface waters with lower nutrients, higher salinity, and warmer temperatures compared to today. Modeling shows that this pattern is well explained by enhanced Pacific meridional overturning circulation (PMOC), which brings warm, salty, and nutrient-poor subtropical waters to high latitudes. Enhanced PMOC at the LGM would have lowered atmospheric CO2-in part through synergy with the Southern Ocean-and supported an equable regional climate, which may have aided human habitability in Beringia, and migration from Asia to North America.

The effect of probiotics on the incidence of Clostridioides difficile: Retrospective cohort analysis.

BACKGROUND: Conflicting evidence exists regarding probiotics and the incidence of Clostridioides difficile infection (CDI). This study evaluates whether probiotics are efficacious for CDI prophylaxis in patients receiving antibiotics. METHODS: A retrospective cohort analysis of patients admitted to NYU Winthrop Hospital who received at least 1 dose of antibiotics considered high risk of inducing CDI. Patients were grouped according to probiotic use; association between probiotic use and incident CDI was examined. A model for incident CDI adjusting for known CDI risk factors was estimated. RESULTS: Of 3,267 patients, 4.6% had CDI within 12 weeks of antibiotics initiation. A total of 5.1% received probiotics within 24 hours of initiation, and 6.6% initiated probiotics during the 12-week follow-up. Of those taking probiotics within 24 hours of antibiotics, 9.6% had CDI, and of those not taking probiotics 4.2% had CDI (relative risk, 2.3; 95% confidence interval, 1.4, 3.7). In time-dependent Cox models accounting for probiotic initiation and adjusting for potential confounders, a positive association between probiotics and CDI remained significant (hazard ratio, 2.7; P < .001). DISCUSSION: Patients who received antibiotics with concurrent probiotics were more likely to have an incident of CDI compared with those who did not receive probiotics. Additional risk factors were histamine 2 receptor antagonists, proton pump inhibitors, and administration of multiple antibiotics simultaneously. CONCLUSIONS: The present study, because of its large population and inclusion of multiple variables playing a role in CDI, serves as a valuable resource when considering efficacy of probiotics as CDI prophylaxis.

Improving North Atlantic Marine Core Chronologies Using 230Th Normalization.

Producing independent and accurate chronologies for marine sediments is a prerequisite to understand the sequence of millennial-scale events and reveal potential temporal offsets between marine and continental records, or between different marine records, possibly from different regions. The last 40 ky is a generally well-constrained period since radiocarbon (14C) can be used as an absolute dating tool. However, in the northern North Atlantic, calendar ages cannot be directly derived from 14C ages, due to temporal and spatial variations of surface reservoir ages. Alternatively, chronologies can be derived by aligning Greenland ice-core time series with marine surface records. Yet this approach suffers from the lack of clearly defined climatic events between 14.7 and 23.3 cal ky BP (hereafter ka), a crucial period encompassing Heinrich Stadial 1 and the onset of the last deglaciation. In this study, (i) we assess the benefits of 230Th normalization to refine the sedimentation history between surface temperature alignment tie points and (ii) revisit the chronologies of three North Atlantic marine records. Our study supports the contention that the marked increase in the Greenland Ca2+ record at 17.48 ka ± 0.21 ky (1σ) occurred within dating uncertainty of sea surface temperature cooling in the North Atlantic at the onset of Heinrich Stadial 1. This sharp feature might be useful for future chronostratigraphic alignments to remedy the lack of chronological constraint between 14.7 and 23.3 ka for North Atlantic marine records that are subject to large changes in 14C surface reservoir age.

Legionnaire's disease presenting with encephalitis, myoclonus, and seizures: Successful treatment with doxycycline.

Legionnaire's disease (LD) is a non-zoonotic atypical community acquired pneumonia (CAP) with several characteristic extra-pulmonary findings. Pending diagnostic test results, selected characteristic findings when considered together are the basis of clinical syndromic diagnosis and the basis of empiric antimicrobial therapy. Of the extra-pulmonary manifestation of LD, neurologic findings are among the most common, e.g., headache, mental confusion. In LD, encephalitis is rare as are myoclonus and seizures. This is a most interesting case of LD that presented with encephalitis, myoclonus and seizures. Pulmonary infiltrates developed early after admission. LD was suspected on the basis of otherwise unexplained characteristic findings, e.g., hypophosphatemia, elevated serum transaminases, microscopic hematuria, elevated ferritin, and empiric doxycycline therapy was started. The diagnosis of LD was further supported by prominent and persistent myoclonus and seizures, rare but characteristic neurologic findings in LD. On week 12 of hospitalization, he finally seroconverted with negative urinary antigen tests indicating his LD was due to a non-L. pneumophilia (serotype 01) strain. On doxycycline, he made a slow but complete recovery. We believe this is the first reported case of LD presenting with encephalitis, myoclonus, and seizures successfully treated with doxycycline.

HIV adult with fever and shortness of breath: Influenza B misdiagnosed as Pneumocystis (carinii) jiroveci pneumonia (PCP).

Clinical correlation is essential in assessing the relevance of the patient's history and physical findings in making a clinical presumptive diagnosis. False diagnostic associations may result in misdiagnosis. We present a case of an elderly female with HIV on HAART who presented with shortness of breath assumed to have Pneumocystis (carinii) jiroveci pneumonia (PCP) even though she had a clinical diagnosis of influenza B. She was thought to have PCP only because she had HIV. Tests for PCP were negative including BAL staining. Influenza B present in her respiratory secretions by PCR and was also cultured from BAL fluid. Diagnostic associations are helpful in suggesting diagnostic possibilities but must be supported by clinical correlation of characteristic clinical features.

Lack of Pharmacokinetic Basis of Weight-Based Dosing and Intra-Operative Re-Dosing with Cefazolin Surgical Prophylaxis in Obese Patients: Implications for Antibiotic Stewardship.

Traditionally, there have been uniform antibiotic dosing guidelines for prophylaxis for clean-clean-contaminated surgery in both non-obese and obese adults. All other factors predisposing to surgical site infections (SSIs) being equal, over time, the preferred drug is cefazolin. The usual dose, given immediately pre-procedure, has been 1 g intravenously (IV) in non-penicillin-allergic patients, which has been highly effective, Recently, it has become common practice to use high-dose cefazolin; i.e., 3 g IV, in obese patients. This article reviews the literature on high-dose cefazolin prophylactic regimens in the obese from a pharmacokinetic (PK) point of view. There are no comparative studies to support this approach, which is based largely on the theory "more must be better." Weight-based dosing of cefazolin in the obese is flawed, because it does not take into account PK factors, which are critical in the obese. Cefazolin is a water-soluble (hydrophilic) antibiotic that does not penetrate adipose tissue regardless of IV dose. Importantly, adipose tissue is not a valid target tissue in clean-clean-contaminated SSI prophylaxis, as it does not become infected. Higher doses result in proportionately higher serum/non-adipose tissue concentrations, but adipose tissue concentrations are unaffected. Cefazolin displays time-dependent killing kinetics so that as long as serum/tissue concentrations are above the minimum inhibitory concentration (MIC) of SSI pathogens, there is no enhanced killing with higher concentrations relative to concentration-dependent antibiotics. Taking into account PK principles, a cefazolin 1 g IV bolus results in peak serum concentrations of ∼185 mcg/mL, provides at least six hours of intra-operative protection, aside from any post-antibiotic effects, and eliminates any rationale for intra-operative re-dosing for procedures lasting six hours or less. Some have argued that a cefazolin 3 g IV dose in the obese does not matter, as more must necessarily be better. However, from an antibiotic stewardship program (ASP) perspective, unneeded antibiotics are unnecessary. Moreover, the costs of cefazolin 1 g (IV push) at $0.75 versus 2 g (IV piggyback) at $ 6.83 can be significant in large centers using cefazolin prophylaxis for cardiothoracic, orthopedic, obstetric/gynecology, and bariatric surgery. Excessive antibiotics also expose the patient to potential adverse effects; i.e., Clostridium difficile. There is no dose-dependent or duration of exposure effect on resistance with one or two pre-operative or intra-operative doses. Well-done PK-based studies in obese patients clearly demonstrate the lack of benefit of using a 3-g dose or intra-operative re-dosing and show no incremental increase in adipose tissue concentrations with high doses. From an ASP point of view, antibiotic dosing recommendations should be reviewed and revised on the basis of PK principles that indicate that weight-based dosing has no basis for pre-operative prophylaxis in obese patients.

Antidepressant medication exposure and 5-HT1A autoreceptor binding in major depressive disorder.

OBJECTIVE: We have previously reported higher brain serotonin 1A (5-HT1A ) autoreceptor binding in antidepressant-naïve patients with Major Depressive Disorder (MDD) compared with healthy volunteers, and a decrease in binding in MDD after selective serotonin reuptake inhibitor (SSRI) treatment. This SSRI effect is also present in rodents administered SSRIs chronically. We therefore sought to determine the duration of antidepressant medication effects on 5-HT1A receptor binding after medication discontinuation. METHODS: Positron emission tomography (PET) imaging with the 5-HT1A receptor radioligand [11 C]WAY-100635 was performed in 66 individuals with current DSM-IV MDD to examine relationships between 5-HT1A binding and time since most recent antidepressant treatment. All subjects were medication-free for at least 2 weeks prior to scanning. Thirty-two additional MDD comparison subjects were antidepressant naïve. RESULTS: No differences in [11 C]WAY-100635 binding were observed between antidepressant naïve and antidepressant exposed MDD groups in 13 a priori cortical and subcortical regions of interest, including raphe autoreceptors, assessed simultaneously in linear mixed effects models. Furthermore, [11 C]WAY-100635 binding did not correlate with time off antidepressants in the antidepressant exposed patients considering these ROIs. The same results were observed when effects of treatment discontinuation of any psychotropic medication used to treat their depression was examined. CONCLUSION: These results indicate that any antidepressant-associated downregulation of 5-HT1A autoreceptor binding reverses within 2 weeks of medication discontinuation. Since this effect is hypothesized to mediate the antidepressant action of SSRIs, and perhaps other antidepressants, it suggests that patients who need ongoing treatment may relapse rapidly when medication is discontinued. Moreover, 2 weeks appears to be a sufficiently long washout of antidepressant medications for a reliable measure of illness-related binding levels.