Cost-savings of short stay sleeve gastrectomy and walk-in hydration clinic versus conventional inpatient care.

OBJECTIVE: We aim to evaluate the cost-saving of the short stay ward (SSW) versus conventional inpatient care following sleeve gastrectomy (LSG). We also compared the readmission rates pre- and post-inception of the intravenous hydration clinic and analyzed the cost-savings. METHODS: Patients who underwent LSG between December 2021 to March 2022 with SSW care were compared with standard inpatient care. Total costs were analyzed using univariate analysis. With a separate cohort of patients, 30-day readmission rates in the 12-months preceding and following implementation of the IV hydration clinic and associated cost-savings were evaluated. RESULTS: After matching on the propensity score to within ± 0.1, 20-subjects pairs were retained. The total cost per SSW-subject was significantly lower at $13,647.81 compared to $15,565.27 for conventional inpatient care (p = 0.0302). Lower average ward charges ($667.76 vs $1371.34, p < 0.0001), lower average daily treatment fee per case ($235.68 vs $836.54, p < 0.0001), and lower average laboratory investigation fee ($612.31 vs $797.21, p < 0.0001) accounted for the difference in costs between the groups. Thirty-day readmission rate reduced from 8.9 to 1.8% after implementation of the hydration clinic (p < 0.01) with decreased 30-day readmission cost (S$96,955.57 vs. S$5910.27, p < 0.01). CONCLUSION: SSW for LSG is cost-effective and should be preferred to inpatient management. Walk-in hydration clinics significantly reduced readmission rates and result in tremendous cost-savings.

Folding Double-Stranded DNA into Designed Shapes with Triplex-Forming Oligonucleotides.

The compaction and organization of genomic DNA is a central mechanism in eukaryotic cells, but engineered architectural control over double-stranded DNA (dsDNA) is notably challenging. Here, long dsDNA templates are folded into designed shapes via triplex-mediated self-assembly. Triplex-forming oligonucleotides (TFOs) bind purines in dsDNA via normal or reverse Hoogsteen interactions. In the triplex origami methodology, these non-canonical interactions are programmed to compact dsDNA (linear or plasmid) into well-defined objects, which demonstrate a variety of structural features: hollow and raster-filled, single- and multi-layered, with custom curvatures and geometries, and featuring lattice-free, square-, or honeycomb-pleated internal arrangements. Surprisingly, the length of integrated and free-standing dsDNA loops can be modulated with near-perfect efficiency; from hundreds down to only six bp (2 nm). The inherent rigidity of dsDNA promotes structural robustness and non-periodic structures of almost 25.000 nt are therefore formed with fewer unique starting materials, compared to other DNA-based self-assembly methods. Densely triplexed structures also resist degradation by DNase I. Triplex-mediated dsDNA folding is methodologically straightforward and orthogonal to Watson-Crick-based methods. Moreover, it enables unprecedented spatial control over dsDNA templates.

Ultrapotent human antibodies protect against SARS-CoV-2 challenge via multiple mechanisms.

Efficient therapeutic options are needed to control the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that has caused more than 922,000 fatalities as of 13 September 2020. We report the isolation and characterization of two ultrapotent SARS-CoV-2 human neutralizing antibodies (S2E12 and S2M11) that protect hamsters against SARS-CoV-2 challenge. Cryo-electron microscopy structures show that S2E12 and S2M11 competitively block angiotensin-converting enzyme 2 (ACE2) attachment and that S2M11 also locks the spike in a closed conformation by recognition of a quaternary epitope spanning two adjacent receptor-binding domains. Antibody cocktails that include S2M11, S2E12, or the previously identified S309 antibody broadly neutralize a panel of circulating SARS-CoV-2 isolates and activate effector functions. Our results pave the way to implement antibody cocktails for prophylaxis or therapy, circumventing or limiting the emergence of viral escape mutants.

The postcholecystectomy syndrome in morbid obesity.

Choledocholithiasis has been found in about 5% to 20% of the approximately 20 million Americans with cholelithiasis who have undergone cholecystectomy. We report a case of a 64-year-old woman who developed gallstones after undergoing a cholecystectomy >40 years earlier. The potential of retained gallstones, incomplete gallbladder removal, or regeneration of gallstones in the gallbladder remnant or cystic duct remnant after a long time following cholecystectomy is discussed.

The minimal detectable difference for endurance shuttle walk test performance in people with COPD on completion of a program of high-intensity ground-based walking.

BACKGROUND: In people with moderate-to-severe chronic obstructive pulmonary disease (COPD), the minimal detectable difference (MDD) in endurance shuttle walk test (ESWT) performance following exercise training is unclear. We sought to determine the MDD for ESWT performance following supervised ground-based walking training using anchor- and distribution-based approaches and report whether these values exceeded random variation in test performance. METHODS: Participants with COPD trained for 30-45 min, 2-3 times weekly for 8-10 weeks. The ESWT was performed before and after the training period. Immediately after training, participants rated their change in walking ability using a Global Rating of Change scale. Receiver Operating Characteristic curves were used to derive the value that best separated those who perceived their improvement in walking ability to be at least 'a little' better from 'almost the same, hardly any change'. These values were compared with those calculated using a distribution-based method. Random variation in test performance was defined as the minimal detectable change (MDC), calculated using the standard error of measurement. RESULTS: 78 participants (aged 70 ±â€¯8 yr and FEV1 43 ±â€¯15% predicted) completed the ESWT before and after training. The value that best separated those who perceived their walking ability as 'a little' better was 70 s. The 95% confidence intervals around this estimate traversed zero. The distribution-based estimate was 156 s. The MDC was 227 s. CONCLUSIONS: The MDD established using the anchor- and distribution-based approaches differed considerably. Large variation in test performance cautions against using the MDD to interpret changes in an individual. CLINICAL TRIALS REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12609000472279).

Effect on health-related quality of life of ongoing feedback during a 12-month maintenance walking programme in patients with COPD: a randomized controlled trial.

BACKGROUND AND OBJECTIVE: In patients with COPD, this study evaluated the effect on health-related quality of life (HRQoL) of adding ongoing feedback to a 12-month unsupervised maintenance walking programme. METHODS: Participants were randomized to either an intervention group (IG) or control group (CG). Both groups completed the same 2-month supervised, walking training programme followed by a 12-month unsupervised maintenance walking programme. During the maintenance programme, the IG received ongoing feedback (telephone calls, biofeedback and progressive goal setting) and the CG received no feedback. RESULTS: A total of 75 participants completed the study (mean (SD): age 69 (8) years; forced expiratory volume in 1 s (FEV1 ) 43 (15) % predicted). There was no between-group differences in the magnitude of change in HRQoL when data collected on completion of the 12-month maintenance programme were compared with that collected either before the 2-month supervised programme (mean between-group difference (MD) in total St George's Respiratory Questionnaire change scores: 1 point, 95% CI: -9 to 7) or on completion of the 2-month supervised programme (MD: 4 points, 95% CI -2 to 10). CONCLUSION: Following a 2-month supervised walking training programme, ongoing feedback was no more effective than no feedback in maintaining HRQoL during a 12-month unsupervised walking programme.

Estimating endurance shuttle walk test speed using the six-minute walk test in people with chronic obstructive pulmonary disease.

The objective of this study was to derive and validate an equation to estimate the speed for the endurance shuttle walk test (ESWT) using results from the six-minute walk test (6MWT) in patients with chronic obstructive pulmonary disease (COPD). Participants with diagnosed COPD (n = 84) performed two incremental shuttle walk tests (ISWTs) and two 6MWTs. ESWT speed was calculated from the ISWT results using the original published method. An equation was derived, which directly related six-minute walk distance (6MWD) to ESWT speed. The derived equation was validated in a different group of people with COPD (n = 52). There was a strong correlation between average 6MWD and the calculated ESWT speed (r = 0.88, p < 0.001). The ESWT speed (kilometre per hour) was estimated using the following equation: 0.4889 + (0.0083 × 6MWD). The mean difference (±limits of agreement) between ESWT speeds was calculated using the original published method and found to be 0.03 (±0.77) km/hour. When the ISWT is not the test of choice for clinicians, the 6MWT can be used to accurately estimate the speed for the ESWT.

Comorbidities and medication burden in patients with chronic obstructive pulmonary disease attending pulmonary rehabilitation.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is characterized by concomitant systemic manifestations and comorbidities such as cardiovascular disease. Little data exist on the prevalence of comorbidities and medication burden in people with COPD attending pulmonary rehabilitation (PR) programs in Australia. This study aimed to determine the prevalence of comorbidities and describe the type and number of medications reported in a sample of patients with COPD referred to PR. METHODS: A retrospective audit was conducted on patients referred to PR over a 1-year period. Data were collected on patient demographics, disease severity, comorbidities, and medications by review of patient notes, physician referral, and self-reported medication use. RESULTS: Data were available on 70 patients (forced expiratory volume in 1 second = 37.5 [26.0] % predicted). Ninety-six percent of patients had at least 1 comorbidity, and 29% had 5 or more. The most common comorbidities were associated with cardiovascular disease (64% of patients). Almost half of the sample was overweight or obese (49%). Prescription medication use was high, with 57% using between 4 and 7 medications, and 29% using 8 or more. CONCLUSIONS: Patients with COPD attending PR in Australia have high rates of comorbidity. The number of medications prescribed for these individuals is similar to that seen in other chronic disease states such as chronic heart failure. Pulmonary rehabilitation presents opportunities for clinicians to educate patients on self-management strategies for multiple comorbidities, review medication usage, and discuss strategies aimed at optimizing adherence with medication regimes.

Relationships between cholesterol efflux and high-density lipoprotein particles in patients with type 2 diabetes mellitus.

BACKGROUND: High-density lipoprotein (HDL) encompasses a heterogeneous population of lipoproteins with differences in functionality. The impact of HDL heterogeneity on its ability to support HDL-mediated cholesterol efflux has not been previously studied in patients with type 2 diabetes mellitus (T2DM). OBJECTIVES: To examine the relationships between various HDL subtypes and cholesterol efflux from macrophages in patients with T2DM. METHODS: Lipoprotein molecular profiles of 44 patients were studied by NMR spectroscopy. Cholesterol efflux was expressed as percentage efflux of radioactivity from lipid-laden THP-1 macrophages preincubated with (3)H-cholesterol and then incubated with serum depleted of apolipoprotein B to provide an HDL-enriched acceptor medium. RESULTS: There was a predominance of small HDL particles (59%) and small putatively atherogenic low-density lipoprotein particles (56%). Neither HDL-C nor ApoA-I concentrations showed statistically significant correlations with percentage cholesterol efflux, but a significant positive relationship was found with the total HDL particle concentration (r = 0.41, P = .005) contributed to largely by medium HDL particles (r = 0.41, P = .006). The correlation between medium-sized HDL particle concentration remained significantly associated with cholesterol efflux when assessed with the use of a linear regression model that included all the HDL lipoprotein subclass concentrations as well as apolipoprotein A-I. Importantly, no statistically significant association was observed between the number of small HDL particles and cholesterol efflux. Hemoglobin A1c showed a significant inverse correlation with cholesterol efflux (r = -0.31, P = .04). CONCLUSION: In patients with moderately controlled type 2 diabetes mellitus, cholesterol efflux from macrophages incubated with apolipoprotein B-depleted plasmas correlated significantly and positively with the concentration of total and medium-sized HDL and not with that of the smallest particles.

Health status of older adults with Type 2 diabetes mellitus after aerobic or resistance training: a randomised trial.

BACKGROUND: A prior study showed positive effects of resistance training on health status in individuals with diabetes compared to aerobic or no exercise, the exercise regimens were either different in volume, duration or rate of progression. We aimed to compare the effects of progressive resistance training (PRT) or aerobic training (AT) of similar volume over an 8-week period on health status (measured using the Short-form 36 Questionnaire) in middle aged adults with type 2 diabetes mellitus (T2DM). FINDINGS: Sixty subjects aged 58 (7) years were randomised to PRT (n = 30) or AT (n = 30). General health and vitality were significantly improved in both groups (mean (SD) change scores for PRT were 12.2(11.5) and 10.5(18.2), and for AT, 13.3(19.6) and 10.0(13.1), respectively) and exceeded the minimally important difference of 5 points. The PRT group also had improved physical function and mental health status (mean (SD) change scores: 9.0(22.6), p < 0.05 and 5.3(12.3), p < 0.05, respectively), which was not observed in the AT group. However, the between group differences were not statistically significant. CONCLUSIONS: Both exercise regimens have positive impact on health status that correlated well with clinical improvement in patients with T2DM. PRT may have some additional benefits as there were significant changes in more domains of the SF-36 than that observed for the AT group.

Minimal difference between aerobic and progressive resistance exercise on metabolic profile and fitness in older adults with diabetes mellitus: a randomised trial.

QUESTION: Is progressive resistance training as effective as aerobic training of similar duration in sedentary older adults with diabetes mellitus? DESIGN: A randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis. PARTICIPANTS: Sixty people with Type 2 diabetes mellitus with glycosylated haemoglobin (HbA1c) between 8% and 10% in the past month. INTERVENTION: One group undertook progressive resistance exercise and the other group undertook aerobic exercise. Both groups completed 18 sessions over 8 weeks. In each session, the progressive resistance exercise group did nine resistive exercises while the aerobic exercise group did 50 minutes of aerobic exercise. OUTCOME MEASURES: HbA1c, blood glucose, lipid profile (total, high- and low-density cholesterol and triglycerides), weight, body mass index, body fat, waist circumference, waist:hip ratio, blood pressure, and peak oxygen consumption. RESULTS: Forty-nine (82%) participants completed the intervention. HbA1c reduced by a similar amount in both groups (MD 0.1%, 95% CI -0.3 to 0.5). However, significant between-group differences occurred in change in waist circumference in favour of progressive resistance exercise (MD -1.8 cm, 95% CI -0.5 to -3.1), and in change in peak oxygen consumption in favour of aerobic exercise (MD 5.2 ml/kg, 95% CI 0.0 to 10.4). CONCLUSIONS: Progressive resistance exercise has similar effects to aerobic exercise and therefore offers a useful alternative for patients unable to participate in aerobic exercise. TRIAL REGISTRATION: NCT01000519.

SMS text message healthcare appointment reminders in England.

Missed appointments place a costly and disruptive strain on National Health Service resources in England. One major source of missed appointments appears to be insufficient communication between patients and providers. SMS text messaging shows promise as a simple, cost-effective means of bridging this communications gap. SMS provides an instant and asynchronous means of communication that protects patient privacy. The potential for this technology is balanced, however, by the lack of high-quality evidence to support its use. There is an urgent need for robust evaluation of critical quality, safety, cost implications, and acceptability before the large-scale rollout of SMS-based systems.

A patient with autism and severe depression: medical and ethical challenges for an adolescent medicine unit.

An adolescent with autism and intellectual disability presented with severe depression related to menstruation. Because of the complex medical, psychiatric and ethical issues involved, her care was coordinated by a hospital-based adolescent medicine unit. After trials of other therapies over an extended period and interdisciplinary and intersectoral case conferencing, it was decided that hysterectomy was the most appropriate management. This case highlights the complexity of adolescent health care in a tertiary hospital, the importance of intersectoral cooperation between hospital and community, and the integral role of interdisciplinary care of adolescent patients with chronic conditions.