A stochastic framework for evaluating CAR T cell therapy efficacy and variability.

Based on a deterministic and stochastic process hybrid model, we use white noises to account for patient variabilities in treatment outcomes, use a hyperparameter to represent patient heterogeneity in a cohort, and construct a stochastic model in terms of Ito stochastic differential equations for testing the efficacy of three different treatment protocols in CAR T cell therapy. The stochastic model has three ergodic invariant measures which correspond to three unstable equilibrium solutions of the deterministic system, while the ergodic invariant measures are attractors under some conditions for tumor growth. As the stable dynamics of the stochastic system reflects long-term outcomes of the therapy, the transient dynamics provide chances of cure in short-term. Two stopping times, the time to cure and time to progress, allow us to conduct numerical simulations with three different protocols of CAR T cell treatment through the transient dynamics of the stochastic model. The probability distributions of the time to cure and time to progress present outcome details of different protocols, which are significant for current clinical study of CAR T cell therapy.

Emerging Enterovirus A71 Subgenogroup B5 Causing Severe Hand, Foot, and Mouth Disease, Vietnam, 2023.

We report on a 2023 outbreak of severe hand, foot, and mouth disease in southern Vietnam caused by an emerging lineage of enterovirus A71 subgenogroup B5. Affected children were significantly older than those reported during previous outbreaks. The virus should be closely monitored to assess its potential for global dispersal.

Assessing cognitive decline in Vietnamese older adults using the Montreal Cognitive Assessment-Basic (MoCA-B) and Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) during the COVID-19 pandemic: A feasibility study.

Objectives: The lack of cognitive assessment tools suitable for people with minimal formal education is a barrier to identify cognitive impairment in Vietnam. Our aims were to (i) evaluate the feasibility of conducting the Montreal Cognitive Assessment-Basic (MoCA-B) and Informant Questionnaire On Cognitive Decline in the Elderly (IQCODE) remotely on the Vietnamese older adults, (ii) examine the association between the two tests, (iii) identify demographic factors correlated with these tools. Methods: The MoCA-B was adapted from the original English version, and a remote testing procedure was conducted. One hundred seventy-three participants aged 60 and above living in the Vietnamese southern provinces were recruited via an online platform during the COVID-19 pandemic. Results: IQCODE results showed that the proportions of rural participants classified as having mild cognitive impairment and dementia were substantially higher than those in urban areas. Levels of education and living areas were associated with IQCODE scores. Education attainment was also the main predictor of MoCA-B scores (30% of variance explained), with an average of 10.5 points difference between those with no formal education and those who attended university. Conclusions: It is feasible to administer the IQCODE and MoCA-B remotely in the Vietnamese older population. Education attainment played a stronger role in predicting MoCA-B scores than IQCODE, suggesting the influence of this factor on MoCA-B scores. Further study is needed to develop socio-culturally appropriate cognitive screening tests for the Vietnamese population.

The avoidable delay in weight loss surgery for those with BMI over 50.

BACKGROUND: Many insurance companies mandate medically supervised weight loss programs (MSWLPs) prior to bariatric surgery. This retrospective study aims to elucidate whether the average 6-month preoperative medical-management period decreases preoperative BMI for those with BMI ≥ 50. METHODS: All adult patients with bariatric consultation at any time at the New York University Langone Health campuses during the period 2015 to 2021 were evaluated via electronic medical records. Only patients with ≥ BMI 50, without previous bariatric surgeries, and those with 6-month insurance-mandated medical visits were included. A paired t-test was performed on the difference in BMI and percent-weight loss among the subjects at least 6 months before surgery and on the day of surgery. RESULTS: Of the 130 patients with BMI ≥ 50, undergoing preoperative 6-month office weigh-ins, the mean difference in BMI was - 1.51 (P < 0.01). The mean total body weight loss was 4.8% (P < 0.01). There were no intraoperative complications nor 30-day complications or mortality in the group. CONCLUSIONS: We found that there was weight loss during the 6-month insurance-mandated medical management prior to surgery, but the amount (4.8%) did not reach the goal target of 10% of body weight. We found that there were no complications and question the need for prolonged delay to surgery.

Personalized Medicine and Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is a common disease that is often under-diagnosed and under-treated in all ages. This is due to differences in morphology, diversity in clinical phenotypes, and differences in diagnosis and treatment of OSA in children and adults, even among individuals of the same age. Therefore, a personalized medicine approach to diagnosis and treatment of OSA is necessary for physicians in clinical practice. In children and adults without serious underlying medical conditions, polysomnography at sleep labs may be an inappropriate and inconvenient testing modality compared to home sleep apnea testing. In addition, the apnea-hypopnea index should not be considered as a single parameter for making treatment decisions. Thus, the treatment of OSA should be personalized and based on individual tolerance to sleep-quality-related parameters measured by the microarousal index, harmful effects of OSA on the cardiovascular system related to severe hypoxia, and patients' comorbidities. The current treatment options for OSA include lifestyle modification, continuous positive airway pressure (CPAP) therapy, oral appliance, surgery, and other alternative treatments. CPAP therapy has been recommended as a cornerstone treatment for moderate-to-severe OSA in adults. However, not all patients can afford or tolerate CPAP therapy. This narrative review seeks to describe the current concepts and relevant approaches towards personalized management of patients with OSA, according to pathophysiology, cluster analysis of clinical characteristics, adequate combined therapy, and the consideration of patients' expectations.

Tiredness, depression, and sleep disorders in frontline healthcare workers during COVID-19 pandemic in Vietnam: A field hospital study.

Background: The COVID-19 outbreak witnessed in the autumn of 2021 led to unprecedented changes in healthcare systems in some emerging countries. Many field-hospitals, temporary sites of care for COVID-19 patients, were built around the country and followed by the healthcare workers who were mobilized. This study aimed to measure sleep disorders, depression, and fatigue in volunteers working at field hospitals during the COVID-19 outbreak. Methods: This was a cross-sectional study. The self-report questionnaire was used for each study subject. Sleep characters, including STOP's elements were questioned. Healthcare workers' burnout was detected by using Pichot's questionnaire. Results: One hundred front-line healthcare workers (FHWs), predominantly last year and graduated medical students, were included in the study (86% female subjects). The mean sleep-time of FHWs before, while working, and during the isolation period after working at COVID-19 field hospitals were: 7.78 ± 1.48, 5.71 ± 1.40, and 8.78 ± 2.31 h per day, respectively. Burnout was not a crucial issue for these volunteer subjects. The mean scores of Pichot's Fatigue Scale and Pichot's Depression Scale, measured after 4 weeks working at field hospitals, were 4.18 ± 5.42 and 2.54 ± 3.36, respectively. Thirteen participants were suspected of depression. The fatigue scores decreased significantly in the group who claimed short sleep latency. The factor that increased the depression score was "anxious feeling" (p = 0.001). Other significant factors were "short sleep latency," "observed sleep apnea," "tiredness, daily sleepiness" and "snoring." Conclusion: Appropriate work schedule, better sleep conditions, and mental health support could be helpful for FHWs. The mandatory 2 weeks of isolation after working in field hospitals provided opportunity for FHWs' recovery.

Stromal Vascular Fraction and Mesenchymal Stem Cells from Human Adipose Tissue: A Comparison of Immune Modulation and Angiogenic Potential.

INTRODUCTION: In recent years, both stromal vascular fraction (SVF) from adipose tissue and mesenchymal stem cells (MSC) from adipose tissues were extensively used in both preclinical and clinical treatment for various diseases. Some studies reported differences in treatment efficacy between SVFs and MSCs in animals as well as in humans. Therefore, this study is aimed to evaluate the immune modulation and angiogenic potential of SVFs and MSCs from the same SVF samples to support an explanation when SVFs or MSCs should be used. METHODS: The adipose tissue samples from ten female donors with consent forms were collected. SVFs from these samples were isolated according to the published protocols. The existence of mesenchymal cells that positive with CD44, CD73, CD90, and CD105 and endothelial progenitor cells that positive with CD31 and CD34 was determined using flow cytometry. Three samples of SVFs with similar percentages of mesenchymal cell portion and endothelial progenitor cell portion were used to isolate MSCs. Obtained MSCs were confirmed as MSCs using the ISCT minimal criteria. To compare the immune modulation of SVF and MSCs, the mixed lymphocyte assay was used. The lymphocyte proliferation, as well as IFN-gamma and TNF-alpha concentrations, were determined. To compare the angiogenic potential, the angiogenesis in quail embryo assay was used. The angiogenesis efficacy was measured based on the vessel areas formed in the embryos after 7 days. RESULTS: The results showed that all SVF samples contained the portions of mesenchymal cells and endothelial progenitor cells. MSCs from SVFs meet all minimal criteria of MSCs that suggested by ISCT. MSCs from SVFs efficiently suppressed the immune cell proliferation compared to the SVFs, especially at ratios of 1:4 (1 MSCs: 4 immune cells). MSCs also inhibited the IFN-gamma and TNF-alpha production more efficiently than SVFs (p < 0.05). However, in quail embryo models, SVFs triggered the angiogenesis and neovessel formation better than MSCs with more significant vessel areas after 7 days (p < 0.05). CONCLUSION: This study suggested that SVFs and MSCs have different potentials for immune modulation and angiogenesis. SVFs help the angiogenesis better than MSCs, while MSCs displayed the more significant immune modulation. These results can guide the usage of SVFs or MSCs in disease treatment.

Artemisinin resistance in the malaria parasite, Plasmodium falciparum, originates from its initial transcriptional response.

The emergence and spread of artemisinin-resistant Plasmodium falciparum, first in the Greater Mekong Subregion (GMS), and now in East Africa, is a major threat to global malaria elimination ambitions. To investigate the artemisinin resistance mechanism, transcriptome analysis was conducted of 577 P. falciparum isolates collected in the GMS between 2016-2018. A specific artemisinin resistance-associated transcriptional profile was identified that involves a broad but discrete set of biological functions related to proteotoxic stress, host cytoplasm remodelling, and REDOX metabolism. The artemisinin resistance-associated transcriptional profile evolved from initial transcriptional responses of susceptible parasites to artemisinin. The genetic basis for this adapted response is likely to be complex.

Evolution of Multidrug Resistance in Plasmodium falciparum: a Longitudinal Study of Genetic Resistance Markers in the Greater Mekong Subregion.

Increasing resistance in Plasmodium falciparum to artemisinins and their artemisinin combination therapy (ACT) partner drugs jeopardizes effective antimalarial treatment. Resistance is worst in the Greater Mekong subregion. Monitoring genetic markers of resistance can help to guide antimalarial therapy. Markers of resistance to artemisinins (PfKelch mutations), mefloquine (amplification of P. falciparum multidrug resistance-1 [PfMDR1]), and piperaquine (PfPlasmepsin2/3 amplification and specific P. falciparum chloroquine resistance transporter [PfCRT] mutations) were assessed in 6,722 P. falciparum samples from Vietnam, Lao People's Democratic Republic (PDR), Cambodia, Thailand, and Myanmar between 2007 and 2019. Against a high background prevalence of PfKelch mutations, PfMDR1 and PfPlasmepsin2/3 amplification closely followed regional drug pressures over time. PfPlasmepsin2/3 amplification preceded piperaquine resistance-associated PfCRT mutations in Cambodia and reached a peak prevalence of 23/28 (82%) in 2015. This declined to 57/156 (38%) after first-line treatment was changed from dihydroartemisinin-piperaquine to artesunate-mefloquine (ASMQ) between 2014 and 2017. The frequency of PfMDR1 amplification increased from 0/293 (0%) between 2012 and 2017 to 12/156 (8%) in 2019. Amplification of PfMDR1 and PfPlasmepsin2/3 in the same parasites was extremely rare (4/6,722 [0.06%]) and was dispersed over time. The mechanisms conferring mefloquine and piperaquine resistance may be counterbalancing. This supports the development of ASMQ plus piperaquine as a triple artemisinin combination therapy.

Not All Discharge Settings Are Created Equal: Thirty-Day Readmission Risk after Elective Colorectal Surgery.

BACKGROUND: Discharge to nonhome settings after colorectal resection may increase risk of hospital readmission. OBJECTIVE: The purpose of this study was to determine the impact of various discharge dispositions on 30-day readmission after adjusting for confounding demographic and clinical factors. DESIGN: This was a retrospective cohort study. SETTINGS: Data were obtained from the University HealthSystem Consortium (2011-2015). PATIENTS: Adults who underwent elective colorectal resection were included. MAIN OUTCOME MEASURES: Thirty-day hospital readmission risk was measured. RESULTS: The mean age of the study population (n = 97,455) was 58 years; half were men and 78% were white. Seventy percent were discharged home routinely (home without service), 24% to home with organized health services, 5% to skilled nursing facility, 1% to rehabilitation facility, and <1% to long-term care hospital. Overall rate of readmission was 12%; 9% from home without service, 16% from home with organized home health services, 19% from skilled nursing facility, 34% from rehabilitation facility, and 22% from long-term care hospital (p < 0.001). Patients with an intensive care unit stay, more postoperative complications, and longer hospitalization stay were more likely to be discharged to home with organized home health services or to a facility (p < 0.001). Discharge to home with organized home health services, skilled nursing facility, or rehabilitation facility increased multivariable-adjusted readmission risk by 30% (OR = 1.3 (95% CI, 1.3-1.6)), 60% (OR = 1.6 (95% CI, 1.5-1.8)), or 200% (OR = 3.0 (95% CI, 2.5-3.6)). Discharge to long-term care hospital was not associated with higher adjusted readmission risk (OR = 1.2 (95% CI, 0.9-1.6)), despite this group having the highest comorbidity and postoperative complications. Among patients readmitted within 30 days, median time to readmission was significantly different among home without service (n = 7), home with organized home health services (n = 8), skilled nursing facility (n = 8), rehabilitation facility (n = 9), and long-term care hospital (n = 12; p < 0.001). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Discharge to home with organized home health services, skilled nursing facility, or rehabilitation facility, but not long-term care hospital, is associated with increased adjusted risk of readmission compared with routine home discharge. Potential targets to decrease readmission include improving transition of care at discharge, improving quality of care after discharge, and improving facility resources. See Video Abstract at http://links.lww.com/DCR/B272. NO TODAS LAS CONFIGURACIONES DE ALTA SON IGUALES: RIESGOS DE READMISIÓN A 30 DÍAS DESPUÉS DE CIRUGÍA COLORRECTAL ELECTIVA: El alta hospitalaria hacia el domicilio luego de una resección colorrectal puede aumentar el riesgo de readmisión.Determinar el impacto de varias configuraciones diferentes de alta en la readmisión a 30 días luego de ajustar factores demográficos y clínicos.Estudio de cohortes retrospectivo.Los datos se obtuvieron del Consorcio del Sistema de Salud Universitaria (2011-2015).Todos aquellos adultos que se sometieron a una resección colorrectal electiva.Los riesgos de readmisión hospitalaria a 30 días.La edad media de la población estudiada (n = 97,455) fué de 58 años; la mitad eran hombres y un 78% eran blancos. El 70% fueron dados de alta de manera rutinaria (a domicilio sin servicios complementarios), 24% alta a domicilio con servicios de salud organizados, 5% alta hacia un centro con cuidados de enfermería especializada, 1% alta hacia un centro de rehabilitación y <1% alta hacia un hospital con atención a largo plazo. La tasa global de readmisión fué del 12%; nueve por ciento desde domicilios sin servicios complementarios, 16% desde domicilios con servicios de salud organizados, 19% desde un centro de enfermería especializada, 34% desde el centro de rehabilitación y 22% desde un hospital con atención a largo plazo (p <0.001). Los pacientes con estadías en Unidad de Cuidados Intensivos, con más complicaciones postoperatorias y con una hospitalización prolongada tenían más probabilidades de ser dados de alta hacia un domicilio con servicios de salud organizados o hacia un centro de rehabilitación (p <0,001). El alta hospitalaria con servicios organizados de atención médica domiciliaria, centros de enfermería especializada o centros de rehabilitación aumentaron el riesgo de readmisión ajustada de múltiples variables en un 30% (OR 1.3, IC 95% 1.3-1.6), 60% (OR 1.6, IC 95% 1.5-1.8), o 200% (OR 3.0, IC 95% 2.5-3.6), respectivamente. El alta hospitalaria a largo plazo no fué asociada con un mayor riesgo de readmisión ajustada (OR 1.2, IC 95% 0.9-1.6), no obstante que este grupo fué el que tuvo las mayores comorbilidades y complicaciones postoperatorias. Entre los pacientes readmitidos dentro de los 30 días, la mediana del tiempo hasta el reingreso fue significativamente diferente entre el domicilio sin servicios complementarios (7), domicilio con servicios de salud organizados (8), el centro de cuidados de enfermería especializada (8), centros de rehabilitación (9) y hospitales con atención a largo plazo (12) (p <0,001).Naturaleza retrospectiva del presente estudio.El alta hospitalaria con servicios de salud domiciliarios organizados, hacia centros de enfermería especializada o hacia centros de rehabilitación se asocian con un mayor riesgo ajustado de readmisión en comparación con el alta domiciliaria de rutina y los hospitales con atención a largo plazo. Los objetivos potenciales para disminuir la readmisión incluyen mejorar la transición de la atención al momento del alta, mejorar la calidad de la atención después del alta y mejorar las diferentes facilidades para los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B272.

Creation and Institutional Validation of a Readmission Risk Calculator for Elective Colorectal Surgery.

BACKGROUND: Readmissions reflect adverse patient outcomes, and clinicians currently lack accurate models to predict readmission risk. OBJECTIVE: We sought to create a readmission risk calculator for use in the postoperative setting after elective colon and rectal surgery. DESIGN: Patients were identified from 2012-2014 American College of Surgery-National Surgical Quality Improvement Program data. A model was created with 60% of the National Surgical Quality Improvement Program sample using multivariable logistic regression to stratify patients into low/medium- and high-risk categories. The model was validated with the remaining 40% of the National Surgical Quality Improvement Program sample and 2016-2018 institutional data. SETTINGS: The study included both national and institutional data. PATIENTS: Patients who underwent elective abdominal colon or rectal resection were included. MAIN OUTCOME MEASURES: The primary outcome was readmission within 30 days of surgery. Secondary outcomes included reasons for and time interval to readmission. RESULTS: The model discrimination (c-statistic) was 0.76 ((95% CI, 0.75-0.76); p < 0.0001) in the National Surgical Quality Improvement Program model creation cohort (n = 50,508), 0.70 ((95% CI, 0.69-0.70); p < 0.0001) in the National Surgical Quality Improvement Program validation cohort (n = 33,714), and 0.62 ((95% CI, 0.54-0.70); p = 0.04) in the institutional cohort (n = 400). High risk was designated as ≥8.7% readmission risk. Readmission rates in National Surgical Quality Improvement Program and institutional data were 10.7% and 8.8% overall; of patients predicted to be high risk, observed readmission rate was 22.1% in the National Surgical Quality Improvement Program and 12.4% in the institutional cohorts. Overall median interval from surgery to readmission was 14 days in the National Surgical Quality Improvement Program and 11 days institutionally. The most common reasons for readmission were organ space infection, bowel obstruction/paralytic ileus, and dehydration in both the National Surgical Quality Improvement Program and institutional data. LIMITATIONS: This was a retrospective observational review. CONCLUSIONS: For patients who undergo elective colon and rectal surgery, use of a readmission risk calculator developed for postoperative use can identify high-risk patients for potential amelioration of modifiable risk factors, more intensive outpatient follow-up, or planned readmission. See Video Abstract at http://links.lww.com/DCR/B284. CREACIÓN Y VALIDACIÓN INSTITUCIONAL DE UNA CALCULADORA DE RIESGO DE REINGRESO PARA CIRUGÍA COLORRECTAL ELECTIVE: Los reingresos reflejan resultados adversos de los pacientes y los médicos actualmente carecen de modelos precisos para predecir el riesgo de reingreso.Intentamos crear una calculadora de riesgo de readmisión para su uso en el entorno postoperatorio después de una cirugía electiva de colon y recto.Los pacientes que se sometieron a una resección electiva del colon abdominal o rectal se identificaron a partir de los datos del Programa Nacional de Mejora de la Calidad Quirúrgica (ACS-NSQIP) del Colegio Americano de Cirugia Nacional 2012-2014. Se creó un modelo con el 60% de la muestra NSQIP utilizando regresión logística multivariable para estratificar a los pacientes en categorías de riesgo bajo / medio y alto. El modelo fue validado con el 40% restante de la muestra NSQIP y datos institucionales 2016-2018.El estudio incluyó datos tanto nacionales como institucionales.El resultado primario fue el reingreso dentro de los 30 días de la cirugía. Los resultados secundarios incluyeron razones e intervalo de tiempo para el reingreso.La discriminación del modelo (estadística c) fue de 0,76 (IC del 95%: 0,75-0,76, p < 0,0001) en la cohorte de creación del modelo NSQIP (n = 50,508), 0,70 (IC del 95%: 0,69-0,70, p < 0,0001) en la cohorte de validación NSQIP (n = 33,714), y 0,62 (IC del 95%: 0,54-0,70, p = 0,04) en la cohorte institucional (n = 400). Alto riesgo se designó como > 8,7% de riesgo de readmisión. Las tasas de readmisión en NSQIP y los datos institucionales fueron del 10,7% y del 8,8% en general; de pacientes con riesgo alto, la tasa de reingreso observada fue del 22.1% en el NSQIP y del 12.4% en las cohortes institucionales. El intervalo medio general desde la cirugía hasta el reingreso fue de 14 días en NSQIP y 11 días institucionalmente. Las razones más comunes para el reingreso fueron infección del espacio orgánico, obstrucción intestinal / íleo paralítico y deshidratación tanto en NSQIP como en datos institucionales.Esta fue una revisión observacional retrospectiva.Para los pacientes que se someten a cirugía electiva de colon y recto, el uso de una calculadora de riesgo de reingreso desarrollada para el uso postoperatorio puede identificar a los pacientes de alto riesgo para una posible mejora de los factores de riesgo modificables, un seguimiento ambulatorio más intensivo o un reingreso planificado. Consulte Video Resumen en http://links.lww.com/DCR/B284. (Traducción-Dr Yesenia Rojas-Khalil).

Data Accuracy and Predictors of High Ratings of Colon and Rectal Surgeons on an Online Physician Rating Website.

BACKGROUND: Online physician rating Web sites are used by over half of consumers to select doctors. No studies have examined physician rating Web sites for colon and rectal surgeons. OBJECTIVE: The purpose of this study was to evaluate the accuracy and rating patterns of colon and rectal surgeons on the largest physician rating Web site. DESIGN: Physician characteristics and ratings were collected from a randomly selected sample of 500 from 3043 Healthgrades "colon and rectal surgery specialists." Board certifications were verified with the American Board of Surgery and American Board of Colon and Rectal Surgery Web sites. SETTINGS: Data acquisition was completed on July 18, 2018. PATIENTS: Patients were not directly studied. MAIN OUTCOME MEASURES: The primary outcome was to assess the accuracy of Healthgrades in reporting American Board of Surgery and American Board of Colon and Rectal Surgery certification. The secondary outcome was to identify factors associated with high star ratings. RESULTS: A total of 48 (9.6%) of the 500 sampled were incorrectly identified as practicing US surgeons and excluded from subsequent analysis. Healthgrades showed 80.1% agreement with verified board certifications for American Board of Surgery and 85.4% for American Board of Colon and Rectal Surgery. The mean star rating was 4.2 of 5.0 (SD = 0.9), and 77 (21.6%) had 5-star ratings. In a multivariable logistic model (p < 0.001), 5-star rating was associated with 1 to 9 years (OR = 2.76; p = 0.04) or >40 years in practice (OR = 3.35; p = 0.04) and fewer reviews (OR = 0.88; p < 0.001). There were no significant associations with surgeon sex, age, geographic region, or board certification. LIMITATIONS: Data were limited to a single physician rating Web site. CONCLUSIONS: In the modern age of healthcare consumerism, physician rating Web sites should be used with caution given inaccuracies. More accurate online resources are needed to inform patient decisions in the selection of specialized colon and rectal surgical care. See Video Abstract at http://links.lww.com/DCR/B91. PRECISIÓN DE DATOS Y PREDICTORES DE ALTAS CALIFICACIONES DE CIRUJANOS DE COLON Y RECTO EN UN SITIO WEB DE CALIFICACIÓN MÉDICA EN LÍNEA: Más de la mitad de los consumidores utilizan los sitios web de calificación de médicos en línea para seleccionar médicos. Ningún estudio ha examinado los sitios web de calificación de médicos para cirujanos de colon y recto.Evaluar la precisión y los patrones de calificación de los cirujanos de colon y recto en el sitio web más grande de calificación de médicos.Las características y calificaciones de los médicos se obtuvieron de una muestra seleccionada al azar de 500 de 3,043 "especialistas en cirugía de colon y recto" de Healthgrades. Las certificaciones del Consejo se verificaron en los sitios web del Consejo Americano de Cirugía y del Consejo Americano de Cirugía de Colon y Recto.La adquisición de datos se completó el 18 de julio de 2018.Los pacientes no fueron estudiados directamente.El resultado primario fue evaluar la precisión de Healthgrades al informar la certificación por el Consejo Americano de Cirugía y por el Consejo Americano de Cirugía de Colon y Recto. El resultado secundario fue identificar factores asociados con altas calificaciones en estrellas.Un total de 48 (9.6%) de la muestra de 500 fueron identificados incorrectamente como cirujanos practicantes de EE. UU. y excluidos del análisis subsecuente. Healthgrades mostró un 80.1% de concordancia con las certificaciones verificadas del Consejo Americano de Cirugía y el 85.4% con el Consejo Americano de Cirugía de Colon y Recto. La calificación promedio de estrellas fue 4.2 / 5 (SD 0.9), y 77 (21.6%) tuvieron calificaciones de 5 estrellas. En un modelo logístico multivariable (p <0.001), la calificación de 5 estrellas se asoció con 1-9 años (OR 2.76, p = 0.04) o más de 40 años en la práctica (OR 3.35, p = 0.04) y menos evaluaciones (OR 0.88, p <0.001). No hubo asociaciones significativas con el género, edad, región geográfica o certificación por los Consejos del cirujano.Los datos se limitaron a un solo sitio web de calificación de médicos.En la era moderna del consumismo en atención médica, los sitios web de calificación de los médicos deben usarse con precaución debido a imprecisiones. Se necesitan recursos en línea más precisos para que las decisiones de los pacientes sean informadas en la selección de atención quirúrgica especializada de colon y recto. Consulte Video Resumen en http://links.lww.com/DCR/B91. (Traducción-Dr. Jorge Silva-Velazco).

Distribution of Elective Ileal Pouch-Anal Anastomosis Cases for Ulcerative Colitis: a Study Utilizing the University Health System Consortium Database.

BACKGROUND: Trends and distribution of ileal pouch-anal anastomosis (IPAA) procedures for patients with ulcerative colitis (UC) are unknown. We examined the frequency, distribution, and volume-outcome relationship for this relatively infrequent procedure using a large national data source. METHODS: Data were obtained from the University HealthSystem Consortium (UHC) for patients with a primary diagnosis of UC admitted electively and who underwent surgical intervention between 2012 and 2015. RESULTS: The mean age of the study population (n = 6875) was 43 years and 57% were men. Among these, one-third (n = 2307) underwent an IPAA, while 24% (n = 1160) underwent total abdominal colectomy, 16% (n = 1134) underwent proctectomy, and 2% (n = 108) underwent total proctocolectomy with end ileostomy. The frequency of IPAA cases among all elective surgical cases was relatively stable at 33-35% over the study period. A total of 131 hospitals, out of 279 hospitals participating in the UHC (47%), performed IPAA. UHC contains all inpatient data on more than 140 (> 90%) academic medical centers in the US and their affiliates. Most hospitals (101) performed < 5 cases annually. The median number of IPAA cases performed annually was 1.8 [IQR 0.8 - 4.3]. The top 10 hospitals performed one-half (48%) of IPAA cases, but only 18% of another type of complex pelvic dissection cases such as low anterior resection. Short-term postoperative complications after IPAA, however, were similar regardless of IPAA volume. CONCLUSIONS: Nearly one-half of IPAA cases were performed at only 10 hospitals out of the 131 hospitals performing IPAA in the study. IPAA procedures are infrequently performed by most academic medical centers in the US. The redistribution of IPAA procedures, likely a result of previously established referral patterns and centralization, has a potential impact on the training of future colorectal fellows as well as access to care.

Fully Integrated and Foldable Microdevice Encapsulated with Agarose for Long-Term Storage Potential for Point-of-Care Testing of Multiplex Foodborne Pathogens.

In this study, we fabricated a fully integrated and foldable microdevice encapsulated with 2-hydroxyethyl agarose for long-term storage of reagents for the integration of isothermal amplification and subsequent colorimetric detection for the monitoring of multiplex foodborne pathogens. The microdevice comprises a reaction zone and a detection zone. Both zones were made of a thin polycarbonate film and sealed by an adhesive film to make the microdevice foldable. The 2-hydroxyethyl agarose with loop-mediated isothermal amplification (LAMP) reagents and silver nitrate were deposited in the reaction and detection chambers, respectively, for long-term maintenance of reagent activity. A thin graphene-based heater associated with a handheld battery was employed to supply a constant temperature for on-chip amplification for 30 min. To simplify the sample manipulation process, a folding motion was adopted to allow the loading of LAMP amplicons from the reaction to the detection chambers and a colorimetric strategy was used for simple visual read-out of the results on-site. Using the agarose, the reagents were successfully stored and the reagent activity was maintained for at least 45 days. Prior to performing multiplex detections, the spiked juice was thermally lysed and purified with polydopamine-coated paper. The amplifications of Salmonella spp. and Escherichia coli O157:H7 (E. coli O157:H7) were successfully demonstrated based on the stable isothermal condition attained by the heater. The microdevice can detect the low concentration of E. coli O157:H7 at 2.5 × 102 copies per mL. The introduced microdevice acts as a simple and user-friendly platform for the identification of foodborne pathogens, paving the way for the construction of a truly portable, read-out microdevice for use as a public healthcare monitoring device.

Fabrication of a polycarbonate microdevice and boronic acid-mediated surface modification for on-chip sample purification and amplification of foodborne pathogens.

In this study, we integrated sample purification and genetic amplification in a seamless polycarbonate microdevice to facilitate foodborne pathogen detection. The sample purification process was realized based on the increased affinity of the boronic acid-modified surface toward the cis-diol group present on the bacterial outer membrane. The modification procedure was conducted at room temperature using disposable syringe. The visible color and fluorescence signals of alizarin red sodium were used to confirm the success of the surface modification process. Escherichia coli O157:H7 containing green fluorescence protein (GFP) and Staphylococcus aureus were chosen as the microbial models to demonstrate the nonspecific immobilization using the microdevice. Bacterial solutions of various concentrations were injected into the microdevice at three flow rates to optimize the operation conditions. This microdevice successfully amplified the 384-bp fragment of the eaeA gene of the captured E. coli O157:H7 within 1 h. Its detection limit for E. coli O157:H7 was determined to be 1 × 103 colony-forming units per milliliter (CFU mL-1). The proposed microdevice serves as a monolithic platform for facile and on-site identification of major foodborne pathogens.

Female Representation and Implicit Gender Bias at the 2017 American Society of Colon and Rectal Surgeons' Annual Scientific and Tripartite Meeting.

BACKGROUND: Women surgeons are underrepresented in academic surgery and may be subject to implicit gender bias. In colorectal surgery, women comprise 42% of new graduates, but only 19% of Diplomates in the United States. OBJECTIVE: We evaluated the representation of women at the 2017 American Society of Colon and Rectal Surgeons Scientific and Tripartite Meeting and assessed for implicit gender bias. DESIGN: This was a prospective observational study. SETTING: The study occurred at the 2017 Tripartite Meeting. MAIN OUTCOME MEASURES: The primary outcome measured was the percentage of women in the formal program relative to conference attendees and forms of address. METHODS: Female program representation was quantified by role (moderator or speaker), session type, and topic. Introductions of speakers by moderators were classified as formal (using a professional title) or informal (using name only), and further stratified by gender. RESULTS: Overall, 31% of meeting attendees who are ASCRS members were women, with higher percentages of women as Candidates (44%) and Members (35%) compared with Fellows (24%). Women comprised 28% of moderators (n = 26) and 28% of speakers (n = 80). The highest percentage of women moderators and speakers was in education (48%) and the lowest was in techniques and technology (17%). In the 41 of 47 sessions evaluated, female moderators were more likely than male moderators to use formal introductions (68.7% vs 54.0%, p = 0.02). There was no difference when female moderators formally introduced female versus male speakers (73.9% vs 66.7%, p = 0.52); however, male moderators were significantly less likely to formally introduce a female versus male speaker (36.4% vs 59.2%, p = 0.003). LIMITATIONS: Yearly program gender composition may fluctuate. Low numbers in certain areas limit interpretability. Other factors potentially influenced speaker introductions. CONCLUSIONS: Overall, program representation of women was similar to meeting demographics, although with low numbers in some topics. An imbalance in the formality of speaker introductions between genders was observed. Awareness of implicit gender bias may improve gender equity and inclusiveness in our specialty. See Video Abstract at http://links.lww.com/DCR/A802.

Impact of the "Weekend Effect" for Hospital Discharges on Readmissions After Elective Colectomy.

BACKGROUND: Hospital readmissions after elective colectomy are costly and potentially preventable. It is unknown whether hospital discharge on a weekend impacts readmission risk. OBJECTIVE: This study aimed to use a national database to determine whether discharge on a weekend versus weekday impacts the risk of readmission, and to determine what discharge-related factors impact this risk. DESIGN: This investigation is a retrospective cohort study. SETTINGS: Data were derived from the University HealthSystem Consortium, PATIENTS:: Adults who underwent elective colectomy from 2011 to 2015 were included. MAIN OUTCOME MEASURES: The primary outcome measured was the 30-day hospital readmission rate. RESULTS: Of the 76,031 patients who survived the index hospitalization, the mean age of the study population was 58 years; half were men and more than 75% were white. Overall, 20,829 (27%) were discharged on the weekend, and the remaining 55,202 (73%) were discharged on weekdays. The overall 30-day readmission rate was 10.5%; 8.9% for those discharged on the weekend vs 11.1% for those discharged during the weekday (unadjusted OR, 0.78; 95% CI, 0.74-0.83). The adjusted readmission risk was lower for patients discharged home without services (routine, without organized home health service) on a weekend compared with on a weekday (adjusted OR, 0.87; 95% CI, 0.81-0.93; readmission rates, 7.4% vs 8.9%, p < 0.001); however, the combination of weekend discharge and the need for home services increased readmission risk (adjusted OR, 1.39; 95% CI, 1.25-1.55; readmission rate, 16.2% vs 8.9%, p < 0.001). Although patients discharged to rehabilitation and skilled nursing facilities were at an increased risk of readmission compared with those discharged to home, there was no additive increase in risk of readmission for weekend discharge. LIMITATIONS: Data did not capture readmission beyond 30 days or to nonindex hospitals. CONCLUSIONS: Patients discharged on a weekend following elective colectomy were at increased risk of readmission compared with patients discharged on a weekday if they required organized home health services. Further prospective studies are needed to identify areas of intervention to improve the discharge infrastructure. See Video Abstract at http://links.lww.com/DCR/A799.

Molecular genotyping of duck hepatitis A viruses (DHAV) in Vietnam.

INTRODUCTION: The aim of this study was to identify the genetic characteristics and molecular genotyping of duck hepatitis A virus (DHAV) isolated in Vietnam during 2009-2013. METHODOLOGY: Thirty duckling livers from outbreaks between 2009 and 2013 in seven provinces were collected and identified by polymerase chain reaction (PCR). Then, VP1 genes of eleven positive samples and two attenuated vaccine strains were sequenced and analyzed. RESULTS: Genotypic and phylogenetic analyses indicated that the 13 Vietnamese isolates were classified into two genotypes, DHAV-1 and DHAV-3. The rate of identity and homology was 91%-100% between the 10 Vietnamese and 26 global strains of DHAV-3, and 92%-100% between 3 Vietnamese and 16 strains of DHAV-1. Between the DHAV-3 and DHAV-1 strains, the divergence reached 30%. At the C-terminal of VP1 for the different strains, a hypervariable region was observed, and notably, six of the Vietnamese DHAV-3 strains in this study showed four consistent differences (at positions T184M, Q200H, K207N, and K214R) within this group that were distinct from all other DHAV-3 strains. CONCLUSIONS: This is the first report of molecular characterization of DHAVs in Vietnam. At least two genotypes were identified, DHAV-1 and DHAV-3, with diversified clades within and between genotypes. DHAV-3 seemed to be dominant in Vietnam.

Development and evaluation of a single-step duplex PCR for simultaneous detection of Fasciola hepatica and Fasciola gigantica (family Fasciolidae, class Trematoda, phylum Platyhelminthes).

A single-step multiplex PCR (here referred to as a duplex PCR) has been developed for simultaneous detection and diagnosis of Fasciola hepatica and F. gigantica. These species overlap in distribution in many countries of North and East Africa and Central and Southeast Asia and are similar in egg morphology, making identification from fecal samples difficult. Based on a comparative alignment of mitochondrial DNA (mtDNA) spanning the region of cox1-trnT-rrnL, two species-specific forward primers were designed, FHF (for F. hepatica) and FGF (for F. gigantica), and a single reverse primer, FHGR (common for both species). Conventional PCR followed by sequencing was applied using species-specific primer pairs to verify the specificity of primers and the identity of Fasciola DNA templates. Duplex PCR (using three primers) was used for testing with the DNA extracted from adult worms, miracidia, and eggs, producing amplicons of 1,031 bp for F. hepatica and 615 bp for F. gigantica. The duplex PCR failed to amplify from DNA of other common liver and intestinal trematodes, including two opisthorchiids, three heterophyids, an echinostomid, another fasciolid, and a taeniid cestode. The sensitivity assay showed that the duplex PCR limit of detection for each Fasciola species was between 0.012 ng and 0.006 ng DNA. Evaluation using DNA templates from 32 Fasciola samples (28 adults and 4 eggs) and from 25 field-collected stools of ruminants and humans revealed specific bands of the correct size and the presence of Fasciola species. This novel mtDNA duplex PCR is a sensitive and fast tool for accurate identification of Fasciola species in areas of distributional and zonal overlap.

Mycobacterium tuberculosis lineage influences innate immune response and virulence and is associated with distinct cell envelope lipid profiles.

The six major genetic lineages of Mycobacterium tuberculosis are strongly associated with specific geographical regions, but their relevance to bacterial virulence and the clinical consequences of infection are unclear. Previously, we found that in Vietnam, East Asian/Beijing and Indo-Oceanic strains were significantly more likely to cause disseminated tuberculosis with meningitis than those from the Euro-American lineage. To investigate this observation we characterised 7 East Asian/Beijing, 5 Indo-Oceanic and 6 Euro-American Vietnamese strains in bone-marrow-derived macrophages, dendritic cells and mice. East Asian/Beijing and Indo-Oceanic strains induced significantly more TNF-α and IL-1ß from macrophages than the Euro-American strains, and East Asian/Beijing strains were detectable earlier in the blood of infected mice and grew faster in the lungs. We hypothesised that these differences were induced by lineage-specific variation in cell envelope lipids. Whole lipid extracts from East Asian/Beijing and Indo-Oceanic strains induced higher concentrations of TNF-α from macrophages than Euro-American lipids. The lipid extracts were fractionated and compared by thin layer chromatography to reveal a distinct pattern of lineage-associated profiles. A phthiotriol dimycocerosate was exclusively produced by East Asian/Beijing strains, but not the phenolic glycolipid previously associated with the hyper-virulent phenotype of some isolates of this lineage. All Indo-Oceanic strains produced a unique unidentified lipid, shown to be a phenolphthiocerol dimycocerosate dependent upon an intact pks15/1 for its production. This was described by Goren as the 'attenuation indictor lipid' more than 40 years ago, due to its association with less virulent strains from southern India. Mutation of pks15/1 in a representative Indo-Oceanic strain prevented phenolphthiocerol dimycocerosate synthesis, but did not alter macrophage cytokine induction. Our findings suggest that the early interactions between M. tuberculosis and host are determined by the lineage of the infecting strain; but we were unable to show these differences are driven by lineage-specific cell-surface expressed lipids.