Exocrine pancreatic insufficiency after bariatric surgery: a bariatric surgery center of excellence experience.

INTRODUCTION: Gastrointestinal symptoms such as diarrhea, bloating, abdominal pain, and nausea are common after bariatric surgery (BS) and can lead to significant morbidity. While many diagnoses can explain these symptoms, post-bariatric exocrine pancreatic insufficiency (EPI) is becoming increasingly recognized as contributor to gastrointestinal symptoms. The frequency and outcomes of EPI after BS are not well understood. We investigated the prevalence and outcomes of EPI over 18 years at a tertiary bariatric referral center. METHODS: A retrospective review of patients who underwent primary or revisional BS from 2002 to 2020 was performed. Patients were included if they were suspected of having EPI or underwent fecal elastase testing (FE-1). EPI diagnosis was defined as positive FE-1 testing or improvement with empiric pancreatic enzyme replacement therapy (PERT). RESULTS: EPI was suspected in 261 patients, and 190 were tested via FE-1 (89.5%) or empirically treated (10.5%). EPI was diagnosed in 79 (41.6%) patients and was associated with older age and lower BMI. Therapeutic PERT was given to 65 patients diagnosed with EPI, and 56 (86.2%) patients reported improved symptoms. Patients who underwent RYGB and BPD-DS were more likely to have EPI than those after SG (47.9% and 70.0% vs 17.4%, p < 0.01). EPI diagnosis was associated with a history chronic pancreatitis. While diarrhea and abdominal pain were the most common symptoms prompting FE-1 testing, no symptoms were significantly associated with EPI. EPI was also associated with abnormal fecal fat results and treatment with bile acid sequestrants, but not small intestinal bacterial overgrowth. CONCLUSION: This study highlights that exocrine pancreatic insufficiency can account to for previously unexplained GI complaints after bariatric surgery. Therefore, bariatric surgery programs should consider this diagnosis in symptomatic patients, especially following RYGB and BPD-DS. Further work to define patient factors that should prompt evaluation, optimal treatment, and prevention is necessary.

Quality of Nutrition Environments, Menus and Foods Served, and Food Program Achievement in Oklahoma Family Child Care Homes.

Child care environments foster children's healthy eating habits by providing exposure to healthy foods and feeding practices. We assessed the healthfulness of nutrition environments, menu/meal quality, and the achievement of Child and Adult Care Food Program (CACFP) guidelines and best practices in Oklahoma CACFP-enrolled family child care homes (FCCHs) (n = 51). Two-day classroom observations were conducted. Healthfulness of classroom nutrition environments was assessed using the Environment and Policy Assessment and Observation (EPAO). Foods served to and consumed by children were quantified using the Dietary Observations in Child Care (DOCC) tool. Nutrient analysis was performed to determine total energy for foods listed on menus, served to, and consumed by children. Menu and meal food variety and CACFP Guideline Achievement Scores were determined. Average nutrition environment score was 11.7 ± 1.2 (61.5% of maximum possible score). Energy (kcals) from menus and consumed by children was insufficient to meet two-thirds of their daily reference intake. Children were exposed to 1.7 vegetables and 1.3 fruits per meal. CACFP Guideline Achievement Scores were 66.3% ± 7.8 for menus and 59.3% ± 7.6 for mealtimes. Similar to previous research, our findings indicate a need for improved FCCH nutrition practices. Tailored interventions for FCCHs are needed.

Nasal Trauma: Who Nose what happens to the non-manipulated?

BACKGROUND: Nasal trauma is the most common facial injury worldwide. Prompt assessment allows for recognition of injuries requiring surgical intervention in the form of nasal bone manipulation. The literature is unclear to what extent patients undergoing conservative management subsequently require surgical intervention. METHODS: A retrospective chart review of all patients presenting with nasal injury between July 2017 and July 2018 who underwent conservative and surgical management was undertaken. Re-referral and subsequent surgical intervention were documented. RESULTS: In a cohort of 390 patients with nasal injury 229 patients underwent conservative management. Average age was 29 years. Males comprised 60% of our conservative cohort and 81% of the manipulated cohort. 8.3% of patients managed conservatively and 12% of those undergoing manipulation were re-referred. CONCLUSION: Nasal trauma assessment is a significant workload for an ENT unit. Conservative management is appropriate following clinical assessment and does not lead to increased intervention compared with those who are surgically manipulated.

An Analysis of Essential Pediatric Surgical Cases Encountered During a Decade of Large-Scale Military Humanitarian Aid Missions.

INTRODUCTION: Disease Control Priorities, 3rd Edition (DCP3) is an evidence-based, published resource that outlines essential procedures recommended for developing health care systems. These systems must consider various populations and the incidence of certain surgical conditions that require treatment. In relation to pediatric patients, the prevalence of certain surgical conditions encountered remains unclear in several low- and middle-income countries. Over the past 15 years, the USNS Mercy, one of the U.S. Navy's large hospital ships, has led the Pacific Partnership missions, which provide large-scale humanitarian aid throughout Southeast Asia. The data collected during these missions provide an opportunity to analyze the scope of pediatric operations performed in resource-limited countries. This analysis may assist in future planning for specific needs during military humanitarian missions. MATERIALS AND METHODS: Surgical case data were prospectively collected during the six Pacific Partnership missions from 2006 to 2018. Demographic data were analyzed for all patients ≤8 years of age who underwent an operation. These data were retrospectively reviewed and all case logs were categorized by mission year, procedure-type, and host nation. Operations were classified based on 44 essential operations delineated in DCP3. Primary outcome was incidence of DCP3 essential operations. Secondary outcomes were perioperative complications. Standard statistical methods were performed for descriptive analysis. RESULTS: A total of 3,209 major and minor operations were performed during 24 port visits in nine countries. Pediatric cases represented 1,117 (38%) of these procedures. Pediatric surgeons performed 291 (26%) of these cases. Based on DCP3 criteria, 789 pediatric operations (71%) were considered essential procedures. The most common DCP3-aligned procedures were cleft lip repair (432, 57%), hernia repair (207, 27%), and hydrocelectomy (60, 8%). Operative volume for pediatric surgery was highest during the 2008 mission (522 cases), when two pediatric surgeons were deployed, and lowest during the 2018 mission (five cases), when the mission focus was on education rather than surgical procedures and lack of pediatric cases referred by the host nation. Overall complication rate for pediatric cases was 1%. CONCLUSIONS: This study represents the largest known analysis of military humanitarian assistance. Pediatric operations represented over one-third of the surgical volume during Pacific Partnership missions from 2006 to 2018. The majority of cases were DCP3-aligned and associated with a low complication rate. Future humanitarian aid missions and host nations should allocate appropriate medical and educational resources to treat DCP3 pediatric surgical diseases in low- and middle-income countries to support long-term capacity building while maintaining optimal surgical outcomes.

Publisher correction: Young inversion with multiple linked QTLs under selection in a hybrid zone.

In Fig. 5 of the version of this Article originally published, the final number on the x axes of each panel was incorrectly written as 1.5; it should have read 7.5. This has now been corrected in all versions of the Article.

Insights into Land Plant Evolution Garnered from the Marchantia polymorpha Genome.

The evolution of land flora transformed the terrestrial environment. Land plants evolved from an ancestral charophycean alga from which they inherited developmental, biochemical, and cell biological attributes. Additional biochemical and physiological adaptations to land, and a life cycle with an alternation between multicellular haploid and diploid generations that facilitated efficient dispersal of desiccation tolerant spores, evolved in the ancestral land plant. We analyzed the genome of the liverwort Marchantia polymorpha, a member of a basal land plant lineage. Relative to charophycean algae, land plant genomes are characterized by genes encoding novel biochemical pathways, new phytohormone signaling pathways (notably auxin), expanded repertoires of signaling pathways, and increased diversity in some transcription factor families. Compared with other sequenced land plants, M. polymorpha exhibits low genetic redundancy in most regulatory pathways, with this portion of its genome resembling that predicted for the ancestral land plant. PAPERCLIP.

Young inversion with multiple linked QTLs under selection in a hybrid zone.

Fixed chromosomal inversions can reduce gene flow and promote speciation in two ways: by suppressing recombination and by carrying locally favoured alleles at multiple loci. However, it is unknown whether favoured mutations slowly accumulate on older inversions or if young inversions spread because they capture pre-existing adaptive quantitative trait loci (QTLs). By genetic mapping, chromosome painting and genome sequencing, we have identified a major inversion controlling ecologically important traits in Boechera stricta. The inversion arose since the last glaciation and subsequently reached local high frequency in a hybrid speciation zone. Furthermore, the inversion shows signs of positive directional selection. To test whether the inversion could have captured existing, linked QTLs, we crossed standard, collinear haplotypes from the hybrid zone and found multiple linked phenology QTLs within the inversion region. These findings provide the first direct evidence that linked, locally adapted QTLs may be captured by young inversions during incipient speciation.

Synoecnema watinagii (Drilonematoidea: Ungellidae: Synoecneminae), a new nematode species parasitic in earthworms from the Philippines with the first molecular and SEM data for the genus.

A new species of the genus Synoecnema-S. watinagii sp. n.-is described and illustrated. The species is characterized by its small size, lack of sexual dimorphism apart from sexual characters, males with pericloacal disk, females with anterior vulva position and lacking an anus, and similar caudal organs in both sexes in the shape of long, deep slits on the surface of the posterior half of body. Sequences of D2-D3 LSU and SSU rDNA and SEM images were obtained for the first time for the genus Synoecnema. Phylogenetic analysis of these sequences supported the validity of the genus and elucidated its relationships within Synoecneminae and Drilonematoidea. The earthworm host was characterized by its CoxI mt DNA sequence.

Live birth rates after combined adjuvant therapy in IVF-ICSI cycles: a matched case-control study.

The effectiveness of combined co-treatment with aspirin, doxycycline, prednisolone, with or without oestradiol patches, was investigated on live birth (LBR) rates after fresh and frozen embryo transfers (FET) in IVF and intracytoplasmic sperm injection cycles. Cases (n = 485) and controls (n = 485) were extensively matched in a one-to-one ratio on nine physical and clinical parameters: maternal age, body mass index, smoking status, stimulation cycle number, cumulative dose of FSH, stimulation protocol, insemination method, day of embryo transfer and number of embryos transferred. No significant differences were found in fresh cycles between cases and controls for the pregnancy outcomes analysed, but fewer surplus embryos were available for freezing in the combined adjuvant group. In FET cycles, LBR was lower in the treatment group (OR: 0.49, 95% CI 0.25 to 0.95). The lower LBR in FET cycles seemed to be clustered in patients receiving combined adjuvant treatment without luteal oestradiol (OR 0.37, 95% CI 0.17 to 0.80). No difference was found in LBR between cases and controls when stratified according to the number of previous cycles (<3 or ≥3). There is no benefit of this combined adjuvant strategy in fresh IVF cycles, and possible harm when used in frozen cycles.

Complications after laparoscopic and open subtotal colectomy for inflammatory colitis: a case-matched comparison.

AIM: The aim of this study was to compare the early postoperative outcome of patients undergoing laparoscopic subtotal colectomy with those undergoing open subtotal colectomy for colitis refractory to medical treatment. METHOD: A retrospective observational study was carried out of patients who underwent subtotal colectomy for refractory colitis, at a single centre, between 2006 and 2012. Patients were matched for age, gender, American Society of Anesthesiology (ASA) grade, urgency of operation and immunosuppressant/modulator treatment. The primary outcome measure was the number of postoperative complications, classified using the Clavien-Dindo scale. Secondary end-points included procedure duration, laparoscopic conversion rates, blood loss, 30-day readmission rates and length of hospital stay. RESULTS: Ninety-six patients were included, 39 of whom had laparoscopic surgery. Thirty-two of these were matched to similar patients who underwent an open procedure. The overall duration of the procedure was longer for laparoscopic surgery than for open surgery (median: 240 vs 150 min, P < 0.005) but estimated blood loss was less (median: 75 vs 400 ml, P < 0.005). In the laparoscopic group, 23 patients experienced 27 complications, and in the open surgery group, 23 patients experienced 30 complications. Most complications were minor (Grade I/II), and the distribution of complications, by grade, was similar between the two groups. There was no statistically significant difference in 30-day readmission rates between the laparoscopic and open groups (five readmissions vs eight readmissions, P = 0.536). Length of hospital stay was 4 days shorter for laparoscopic surgery, but this difference was not statistically significant (median: 7 vs 11 days, P = 0.159). CONCLUSION: In patients requiring colectomy for acute severe colitis, laparoscopic surgery reduced blood loss but increased operating time and was not associated with a reduction in early postoperative complications, length of hospital stay or readmission rates.

Revised sequence and annotation of the Rhodobacter sphaeroides 2.4.1 genome.

The DNA sequences of chromosomes I and II of Rhodobacter sphaeroides strain 2.4.1 have been revised, and the annotation of the entire genomic sequence, including both chromosomes and the five plasmids, has been updated. Errors in the originally published sequence have been corrected, and ~11% of the coding regions in the original sequence have been affected by the revised annotation.

Genome Sequence of the ethene- and vinyl chloride-oxidizing actinomycete Nocardioides sp. strain JS614.

Nocardioides sp. strain JS614 grows on ethene and vinyl chloride (VC) as sole carbon and energy sources and is of interest for bioremediation and biocatalysis. Sequencing of the complete genome of JS614 provides insight into the genetic basis of alkene oxidation, supports ongoing research into the physiology and biochemistry of growth on ethene and VC, and provides biomarkers to facilitate detection of VC/ethene oxidizers in the environment. This is the first genome sequence from the genus Nocardioides and the first genome of a VC/ethene-oxidizing bacterium.

Sequential mechanisms underlying concentration invariance in biological olfaction.

Concentration invariance-the capacity to recognize a given odorant (analyte) across a range of concentrations-is an unusually difficult problem in the olfactory modality. Nevertheless, humans and other animals are able to recognize known odors across substantial concentration ranges, and this concentration invariance is a highly desirable property for artificial systems as well. Several properties of olfactory systems have been proposed to contribute to concentration invariance, but none of these alone can plausibly achieve full concentration invariance. We here propose that the mammalian olfactory system uses at least six computational mechanisms in series to reduce the concentration-dependent variance in odor representations to a level at which different concentrations of odors evoke reasonably similar representations, while preserving variance arising from differences in odor quality. We suggest that the residual variance then is treated like any other source of stimulus variance, and categorized appropriately into "odors" via perceptual learning. We further show that naïve mice respond to different concentrations of an odorant just as if they were differences in quality, suggesting that, prior to odor categorization, the learning-independent compensatory mechanisms are limited in their capacity to achieve concentration invariance.

The meaning of health in rural children: a mixed methods approach.

Gaining an understanding of the meaning of health in children may provide insight into factors that contribute to effective programs aimed at preventing diseases such as childhood obesity. A mixed methods design was used to explore the meaning of health of rural Saskatchewan children. A health questionnaire and Body Mass Index scores were collected from 99 children (Grades 1 to 7). A focused ethnographic approach was used to explore the meaning of health in a subset of 20 children (9 to 12 years old). Regardless of weight status, children described their meaning of health as Knowing Stuff, Having a Working Body, and Feeling Happy and suggested that Feeling Happy was most meaningful. The rural environment appeared to provide a sense of safety, security, and freedom. The researcher discovered the value children placed on the psychosocial dimension of health and provided insights into aspects that may foster healthy behaviors in this population.

Qualitative Evaluation of Medical Information Processing Needs of 60 Women Choosing Ovarian Cancer Surveillance or Prophylactic Oophorectomy.

Thirty women who had prophylactic oophorectomy (PO) and thirty women undergoing ovarian cancer surveillance (OCS) completed a one-time in-depth telephone interview exploring information gathering and decision-making processes. There were close similarities between groups, including age, race, marital status, education, menopausal status, number undergoing genetic testing for BRCA mutations, and number of prophylactic mastectomies. The majority of participants indicated overall satisfaction with their final decision. However, many described the information gathering process as frustrating and anxiety provoking. Participants in both groups expressed a need to process medical information within the context of individual psychosocial needs and personal perceptions and experiences. There were recurrent themes with regard to informational and psychosocial needs and personal perceptions and experiences that impacted decision-making process for these women. The present paper is a companion paper to Swisher et al. (J Repr Med 2001, 46:87-94) with the focus of this paper to illustrate the medical informational processing needs identified by this group of women.

Somatostatin enhances cAMP-dependent short-circuit current in human colon via somatostatin receptor subtype-2.

Somatostatin inhibits colonic ion secretion in animal models and cultured intestinal cell lines via somatostatin receptor subtype 2 and subtype 1, respectively. In a recent in vitro ion transport study of the human colon, somatostatin was shown to stimulate short-circuit current, a measure of electrogenic ion transport. In this study we have used the reverse-transcription polymerase chain reaction (RT-PCR) and measurements of changes in short-circuit current (Isc) in response to receptor subtype-specific analogs of somatostatin, to define the somatostatin receptor subtype responsible for the stimulation of short-circuit current in human colon. Somatostatin receptor subtypes 1, 2, and 5, but not 3 and 4, were detected in the human colonic epithelium. Measurements of short-circuit current showed somatostatin and octreotide (1 micromol/liter) increased the prostaglandin stimulated short-circuit current by 12.3+/-1 and 11.0+/-1 microA/cm2, respectively. Similarly, analogs selective for somatostatin receptor subtypes 2 and 5 (1 micromol/liter) produced an increase of short-circuit current of 11.7+/-1 and 13.2+/-1 microA/cm2, respectively. However, at a concentration (10 nmol/liter) near the EC50, the somatostatin receptor subtype 2 analog increased short-circuit current by 9+/-1 microA/cm2, whereas the receptor subtype 5 analog had no effect. There was no difference in receptor expression or effect of the peptides related to the anatomical site of tissue collection. In conclusion, human colonic mucosa expresses multiple somatostatin receptor subtypes, of which subtype 2 mediates the stimulatory effect of somatostatin on ion transport.

Clusterin is expressed in the anterior and intermediate lobes, but not in the posterior pituitary of sheep.

We have examined the expression of the ovine clusterin gene in the sheep pituitary gland, with the aim of determining its site of synthesis in this tissue. Northern blotting analysis of extracted polyadenylated RNA, using a (32)P-labelled rat clusterin cDNA probe, detected the greatest amounts of clusterin mRNA in the anterior part of dissected pituitary glands. In situ hybridisation studies showed clusterin mRNA in anterior and intermediate pituitary cells, with lower amounts in vascular endothelium and posterior pituicytes. Clusterin protein, detected by immunohistochemistry, was observed in some single secretory cells, within the capillary lumen and in cells around capillaries in the anterior and intermediate lobes, but no immunoreactivity was observed in posterior pituitary tissue. The pattern of clusterin expression in anterior and intermediate pituitary cells suggests possible roles for the protein in secretory cell turnover and/or hormone secretion or lipid uptake. Clusterin does not appear to be involved in ovine posterior pituitary hormone neurosecretion.

Effects of intraarticular hyaluronan on matrix changes induced in the lateral meniscus by total medial meniscectomy and exercise.

Total medial meniscectomy was performed in 12 adult merino sheep. Immediately after surgery, 8 animals received high-molecular-weight hyaluronan (HA) (1 mL, 10 mg/mL) and 4 were given sterile saline (1 mL) intraarticularly. Injections were given for 5 more weeks. In week 3 an exercise program, consisting of walking 24 km/wk, was initiated. This program was continued until the animals were killed at week 26 postmeniscectomy. At necropsy the lateral menisci were removed and divided into three concentric zones--inner, middle, and outer. Powdered aliquots of tissues from each zone were analyzed for collagen and hexuronate contents using colormetric methods. The glycosaminoglycans (GAGs)--chondroitin-O-sulfate (C-O-S), chondroitin-4-sulfate (C-4-S), chondroitin-6-sulfate (C-6-S), and dermatan sulfate (DS)--were determined using a high-performance liquid chromatography method. The lateral menisci from the joints of animals injected with HA showed higher hexuronate and GAG levels than those of controls. This increase was mainly due to C-6-S, which had highest levels in the inner and middle meniscal zones. In addition, dermatan sulfate levels increased significantly in the middle and outer zones of the lateral menisci compared with the same zones of the meniscus from the saline-treated group. Collagen and C-O-S levels were not statistically different from those of controls. These data suggest that intraarticular administration of high-molecular-weight HA immediately after open total medial meniscectomy may help preserve the proteoglycans in the lateral meniscus remaining in the joint.