Post Sleeve Reflux: indicators and impact on outcomes.

INTRODUCTION: Post-operative gastroesophageal reflux disease (GERD) remains a significant morbidity following sleeve gastrectomy (SG). We aim to evaluate the incidence and impact within a single center experience. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database was performed identifying laparoscopic or robotic SG patients. Primary outcomes included weight loss, rates of post-operative GERD (de-novo or aggravated), and re-intervention. Subgroup analysis was performed between patients with (Group 1) and without (Group 2) post-operative GERD. De-novo GERD and aggravated was defined as persistent GERD complaints or new/increased PPI usage in GERD naive or prior GERD patients, respectively. RESULTS: 392 patients were identified between 2014 and 2019. Average demographics: age 42.3 (18-84) years, Charlson Comorbidity Index (CCI) 1.12 (0-10), and body mass index (BMI) 47.7 (28-100). 98% were performed laparoscopically. Average excess weight loss (EWL) was 51.0% and 46.4% at 1 and 2 years post-operatively. Average follow up was 516 (6-2694) days. 69 (17%) patients developed post operative de-novo or aggravated GERD. Group 1 had significantly higher EWL at 9 months (57% vs 47%, p 0.003). 13 (3%) patients required operative re-intervention for GERD and other morbidities: 4 RYGB conversions, 4 diagnostic laparoscopies, 3 HHR, 1 MSA placement. Group 1 had higher rates of post-operative intervention (14% vs 1%, p 0.0001). Subanalysis demonstrated that Group 1 had elevated preoperative DeMeester scores on pH testing (34.8 vs 18.9, p 0.03). De-novo GERD had an elevated post-operative total acid exposure when compared to aggravated GERD (12.7% vs 7.0% p 0.03). No significant differences were found between preoperative endoscopy findings, pre and postoperative total acid exposure, post-operative DeMeester scores, and high-resolution manometry values regarding de-novo/aggravated GERD development. CONCLUSION: Preoperative DeMeester scores may serve as risk indicators regarding post-operative GERD. Outcomes such as reintervention remain elevated in post-operative GERD patients.

Weight loss outcomes are not compromised in bariatric patients using cannabis.

BACKGROUND: The legalization of cannabis in several states has led to increased documented use in the population. Bariatric surgery patients are no exception with estimates of anywhere from 6 to 8%. Cannabis is known to be associated with increased appetite, mood disorders, hyperphagia, and rarely, hyperemesis, which can potentially affect post-surgical weight loss. We aim to study the differences in bariatric surgery outcomes between cannabis users and non-users. METHODS: A retrospective review identified patients undergoing bariatric surgery. Patients were divided into two groups, cannabis users (CU) and non-cannabis users (non-CU). Cannabis users (defined as using at least once weekly) and a group of non-users were called to obtain additional information. Primary outcome was weight loss. Secondary outcomes included incidence of post-operative nausea and vomiting (PONV), length of stay (LOS), readmission, and need for additional intervention. RESULTS: A cohort of 364 sleeve gastrectomy patients met inclusion criteria, 31 (8.5%) CU and 333 (91.5%) non-CU. There was no difference in EWL between CU and non-CU at 1 week, 1 month, 3 months, 6 months, 9 months, 1 year, and 2 years. However, the CU group trended towards greater EWL at 3 years (52.9% vs. 38.1%, p = 0.094) and at 5 years (49.8% vs. 32.7%, p = 0.068). There were no significant differences between CU and non-CU with respect to either incidence or severity of PONV at one year after surgery or longer follow-up. CONCLUSION: Cannabis users did not experience inferior weight loss after bariatric surgery despite common assumptions that appetite stimulation can lead to suboptimal weight loss outcomes. Our findings add to other work challenging this dogma. Larger, long-term, multicenter studies are warranted.

Sustainability Initiatives in the Operating Room.

BACKGROUND: Operating rooms (ORs) contribute up to 30% of a hospital's waste, are very resource-intensive, and thus provide an opportunity for improvement. METHODS: A narrative review was conducted, searching MEDLINE, EMBASE, and ProQuest databases. The study included 78 of the 108 published articles. RESULTS: The researchers identified and categorized articles according to the following major themes: Committee and Leadership; Waste Reduction; Segregating OR waste; Minimizing unnecessary devices and packaging; Reducing energy consumption; Choosing anesthetic gases; Education; Reducing water consumption; Different surgical venues; Donating medical supplies. Formation of an OR committee or a hospital Green Team dedicated to environmentally sustainable initiatives can significantly improve health care's impact on the environment while saving money. Changes in supply chain with preferences for reusable devices, effective recycling, repurposing instruments, and donating items can all be effective means of diverting waste away from landfills. Reducing unnecessary packaging and instruments would eliminate excess in the waste stream. Curtailing energy and water usage results in cost and environmental savings. Surgical venue (inpatient vs. outpatient surgical center) can also contribute to waste. Transitioning away from certain inhaled anesthetics can minimize greenhouse gas impact. Education to all levels in the health care system is important to drive change and maintain change. CONCLUSION: Optimizing efficiency and decreasing waste generation can have a positive impact on the environment and can be accompanied by cost reduction. Because the field of sustainability in health care is young but burgeoning, increased research is needed to support evidence-based approaches.

A Case of Spontaneous Coronary Artery Dissection in a Patient with Severe Anorexia Nervosa.

There are a variety of cardiac complications of anorexia nervosa including arrythmias, valvopathies, and myopathies. Spontaneous coronary artery dissection (SCAD) has not been widely reported among this patient population. This case report describes a middle-aged female with severe anorexia nervosa, who presented after being found unconscious, and was later diagnosed with SCAD. A literature review revealed one previous case of SCAD in a patient with anorexia nervosa and prompted a discussion of a series of possible predisposing factors for SCAD in this patient population. Patients with anorexia nervosa may be at increased risk for SCAD due to their complex nutritional and endocrine imbalances. This case highlights a possible underdiagnosed cardiac complication of anorexia nervosa.

Effect of Daily Dosage of Morphine Milligram Equivalents on Free Flap Complications: A Single-Institution Retrospective Study.

INTRODUCTION: There appears to be an association between preoperative opioid use and postoperative complications. We sought to determine whether patients with a history of chronic opiate use (defined as 3 months or more of sustained use) prior to undergoing free flap surgery have higher rates of 30-day complications. METHODS: A retrospective review of patients undergoing free flaps from 2015 to 2020 was performed. Patient characteristics were analyzed, including daily preoperative dose of opiates, which were then converted to morphine milligram equivalents; intra-operative variables such as estimated blood loss and operating room time; and 30-day outcomes, including wound and flap complications, return to the operating room, and readmissions. RESULTS: One hundred fifty-five patients received 160 free flaps. Of these flaps, 50/160 (31%) were performed on patients with an opiate prescription for at least three months prior to surgery. Using multivariable analysis, morphine milligram equivalents, a surrogate for opioid dose, were significantly associated with flap complications (odds ratio (OR) 1.011, 95% confidence interval (CI) 1.003-1.020, p<0.01), partial flap loss (OR 1.010, 95% CI 1.003-1.019, p<0.01), and surgical site infections (OR 1.017, 95% CI 1.007-1.027, p<0.01). Additionally, estimated blood loss was associated with partial flap loss (OR 4.838, 95% CI 1.589-14.728, p<0.006), and operating room time was also associated with flap complications (OR 1.337, 95% CI 1.152-1.150, p<0.01). CONCLUSION: Chronic preoperative opioid use is common for free flap surgery, and according to our single-center experience, higher daily doses are a risk factor for flap complications and surgical site infections. These findings add to the growing body of evidence that opioid use is a modifiable risk factor that may increase surgical morbidity.

Impact of Correcting Nutritional Deficiency Anemias in the Elderly on Hospitalizations, Falls, and Mortalities.

BACKGROUND: The incidence and prevalence of anemia increase with age, particularly in adults older than 65 years, and it is associated with a number of adverse health outcomes (AHO), particularly hospitalizations, falls and mortalities. Given that approximately one-third of these anemias are due to reversible causes, we studied whether the treatment of nutritional deficiency anemia (NDA), namely iron deficiency anemia (IDA), cobalamin deficiency anemia (CDA), and folate deficiency anemia (FDA), improves AHO; and explored whether each NDA had different AHO. METHODS: We reviewed electronic medical records of our internal medicine office patients aged 65 years or older, who had a diagnosis of anemia in a non-acute setting. RESULTS: Total 600 patients were included. Mean age was 75.2 years. Thirty-one point three percent had NDA (CDA 15.3%, IDA 12.3%, FDA 3.7%); and 68.7% had other anemias whom we categorized as non-nutritional deficiency anemias (NNDA), which included anemia of chronic disease (11.2%), myelodysplastic syndrome (6.2%), renal insufficiency anemia (5.7%) and unexplained anemia (45.6%). Even after adequate treatment, IDA group had significantly more hospitalizations (median, 25th - 75th: 2 (0 - 4) vs. 0 (0 - 1), P < 0.001), falls (median, 25th - 75th: 1 (0 - 3) vs. 0 (0 - 1), P < 0.001) and mortalities (10.8% vs. 3.4%, P = 0.011); CDA group had significantly more hospitalizations (median, 25th - 75th: 1 (0 - 2) vs. 0 (0 - 1), P = 0.007), but no difference in falls (median, 25th - 75th: 0 (0 - 1) vs. 0 (0 - 1), P = 0.171) and mortalities (7.6% vs. 3.4%, P = 0.083); and FDA group had significantly more hospitalizations (median, 25th - 75th: 1 (0 - 2) vs. 0 (0 - 1), P = 0.001), but no difference in falls (median, 25th - 75th: 0 (0 - 1) vs. 0 (0 - 1), P = 0.615) and mortalities (4.5% vs. 3.4%, P = 0.550), compared to the NNDA group. Age, Black race, higher number of comorbidities, presence of malignancy and use of direct oral anticoagulants were associated with increased odds of AHO in patients with NDA. CONCLUSIONS: Compared to the patients with NNDA, patients with IDA had more hospitalizations, falls and mortalities even after adequate treatment; while patients with CDA and FDA had only more hospitalizations. Adequate treatment mitigated falls and mortalities in elderly patients with CDA and FDA.

COVID-19 and Systemic Lupus Erythematosus: Focus on Immune Response and Therapeutics.

The SARS-CoV-2 novel coronavirus has caused the COVID-19 pandemic with over 35 million cases and over a million deaths worldwide as of early October 2020. The populations most affected are the elderly and especially those with underlying comorbidities. In terms of race and ethnicity, black and hispanic populations are affected at disproportionately higher rates. Individuals with underlying conditions that cause an immune-compromised state are considered vulnerable to this infection. The immune response is an important determinant in viral infections including coronaviruses, not only in the antiviral defense but also in the disease progression, severity, and clinical outcomes of COVID-19. Systemic lupus erythematosus is a chronic autoimmune disease which also disproportionately afflicts black and hispanic populations. In lupus patients, an aberrant immune response is characterized by the presence of circulating autoantibodies, lymphopenia, aberrant T cells, and proinflammatory cytokines along with defective regulatory mechanisms, leading to immune-mediated damage to tissues. Lupus patients are often treated with immune-suppressants and therefore are immune-compromised and more susceptible to infections and may be vulnerable to coronavirus infection. While the anti-viral immune response is important to protect from coronavirus infection, an uncontrolled proinflammatory cytokine response can lead to cytokine storm which causes damage to the lungs and other organs, causing significant morbidity and mortality. Better understanding of the underlying immune response and therapeutic strategies in lupus and COVID-19 is important to guide management of this deadly infectious disease in the context of lupus and vice-versa.

What's Sex Got to Do With COVID-19? Gender-Based Differences in the Host Immune Response to Coronaviruses.

The novel severe acute respiratory syndrome coronavirus 2, the cause of the coronavirus disease 2019 (COVID-19) pandemic, has ravaged the world, with over 22 million total cases and over 770,000 deaths worldwide as of August 18, 2020. While the elderly are most severely affected, implicating an age bias, a striking factor in the demographics of this deadly disease is the gender bias, with higher numbers of cases, greater disease severity, and higher death rates among men than women across the lifespan. While pre-existing comorbidities and social, behavioral, and lifestyle factors contribute to this bias, biological factors underlying the host immune response may be crucial contributors. Women mount stronger immune responses to infections and vaccinations and outlive men. Sex-based biological factors underlying the immune response are therefore important determinants of susceptibility to infections, disease outcomes, and mortality. Despite this, gender is a profoundly understudied and often overlooked variable in research related to the immune response and infectious diseases, and it is largely ignored in drug and vaccine clinical trials. Understanding these factors will not only help better understand the pathogenesis of COVID-19, but it will also guide the design of effective therapies and vaccine strategies for gender-based personalized medicine. This review focuses on sex-based differences in genes, sex hormones, and the microbiome underlying the host immune response and their relevance to infections with a focus on coronaviruses.

Early dynamics of photosynthetic Lhcf2 and Lhcf15 transcription and mRNA stabilities in response to herbivory-related decadienal in Phaeodactylum tricornutum.

Abiotic and biotic stresses widely reduce light harvesting complex (LHC) gene expression in higher plants and algae. However, control mechanisms and functions of these changes are not well understood. During herbivory, marine diatom species release oxylipins that impair grazer reproduction and serve as signaling molecules to nearby undamaged diatoms. To examine LHC mRNA regulation by oxylipin exposure, the diatom Phaeodactylum tricornutum was treated with a sublethal concentration of trans,trans-2,4-decadienal (DD) during the light cycle. Transcriptome analyses revealed extensive suppression of LHC mRNAs and a smaller set of up-regulated LHC mRNAs at 3 h. For two divergently regulated LHCF antennae family mRNAs, in vivo 4-thiouracil metabolic labeling was used to distinguish synthesis and degradation rates. Within 3 h of DD exposure, Lhcf2 mRNA levels and transcription were strongly suppressed and its mRNA half-life decreased. In contrast, Lhcf15 mRNA mainly accumulated between 3-9 h, its transcription increased and its mRNA was highly stabilized. Hence, DD-treated cells utilized transcriptional and mRNA stability control mechanisms which were likely major factors in the differing Lhcf2 and Lhcf15 expression patterns. Widespread LHC mRNA regulation and possible effects on photosynthesis may contribute to enhanced fitness in cells impacted by herbivory and other stresses.

Aging, Immunity, and COVID-19: How Age Influences the Host Immune Response to Coronavirus Infections?

The novel coronavirus severe acute respiratory syndrome coronavirus 2 causing the Coronavirus disease (COVID-19) pandemic has ravaged the world with over 72 million total cases and over 1.6 million deaths worldwide as of early December 2020. An overwhelming preponderance of cases and deaths is observed within the elderly population, and especially in those with pre-existing conditions and comorbidities. Aging causes numerous biological changes in the immune system, which are linked to age-related illnesses and susceptibility to infectious diseases. Age-related changes influence the host immune response and therefore not only weaken the ability to fight respiratory infections but also to mount effective responses to vaccines. Immunosenescence and inflamm-aging are considered key features of the aging immune system wherein accumulation of senescent immune cells contribute to its decline and simultaneously increased inflammatory phenotypes cause immune dysfunction. Age-related quantitative and qualitative changes in the immune system affect cells and soluble mediators of both the innate and adaptive immune responses within lymphoid and non-lymphoid peripheral tissues. These changes determine not only the susceptibility to infections, but also disease progression and clinical outcomes thereafter. Furthermore, the response to therapeutics and the immune response to vaccines are influenced by age-related changes within the immune system. Therefore, better understanding of the pathophysiology of aging and the immune response will not only help understand age-related diseases but also guide targeted management strategies for deadly infectious diseases like COVID-19.

On the Viability and Potential Value of Stem Cells for Repair and Treatment of Central Neurotrauma: Overview and Speculations.

Central neurotrauma, such as spinal cord injury or traumatic brain injury, can damage critical axonal pathways and neurons and lead to partial to complete loss of neural function that is difficult to address in the mature central nervous system. Improvement and innovation in the development, manufacture, and delivery of stem-cell based therapies, as well as the continued exploration of newer forms of stem cells, have allowed the professional and public spheres to resolve technical and ethical questions that previously hindered stem cell research for central nervous system injury. Recent in vitro and in vivo models have demonstrated the potential that reprogrammed autologous stem cells, in particular, have to restore functionality and induce regeneration-while potentially mitigating technical issues of immunogenicity, rejection, and ethical issues of embryonic derivation. These newer stem-cell based approaches are not, however, without concerns and problems of safety, efficacy, use and distribution. This review is an assessment of the current state of the science, the potential solutions that have been and are currently being explored, and the problems and questions that arise from what appears to be a promising way forward (i.e., autologous stem cell-based therapies)-for the purpose of advancing the research for much-needed therapeutic interventions for central neurotrauma.

Efficacy of WHO recommendation for continued breastfeeding and maternal cART for prevention of perinatal and postnatal HIV transmission in Zambia.

INTRODUCTION: To prevent mother-to-child transmission (MTCT) of HIV in developing countries, new World Health Organization (WHO) guidelines recommend maternal combination antiretroviral therapy (cART) during pregnancy, throughout breastfeeding for 1 year and then cessation of breastfeeding (COB). The efficacy of this approach during the first six months of exclusive breastfeeding has been demonstrated, but the efficacy of this approach beyond six months is not well documented. METHODS: A prospective observational cohort study of 279 HIV-positive mothers was started on zidovudine/3TC and lopinavir/ritonavir tablets between 14 and 30 weeks gestation and continued indefinitely thereafter. Women were encouraged to exclusively breastfeed for six months, complementary feed for the next six months and then cease breastfeeding between 12 and 13 months. Infants were followed for transmission to 18 months and for survival to 24 months. Text message reminders and stipends for food and transport were utilized to encourage adherence and follow-up. RESULTS: Total MTCT was 9 of 219 live born infants (4.1%; confidence interval (CI) 2.2-7.6%). All breastfeeding transmissions that could be timed (5/5) occurred after six months of age. All mothers who transmitted after six months had a six-month plasma viral load >1,000 copies/ml (p<0.001). Poor adherence to cART as noted by missed dispensary visits was associated with transmission (p=0.04). Infant mortality was lower after six months of age than during the first six months of life (p=0.02). The cumulative rate of infant HIV infection or death at 18 months was 29/226 (12.8% 95 CI: 7.5-20.8%). CONCLUSIONS: Maternal cART may limit MTCT of HIV to the UNAIDS target of <5% for eradication of paediatric HIV within the context of a clinical study, but poor adherence to cART and follow-up can limit the benefit. Continued breastfeeding can prevent the rise in infant mortality after six months seen in previous studies, which encouraged early COB.

Value of occupational medicine board certification.

OBJECTIVE: To assess the impact of occupational medicine board certification and career stage on practice characteristics. METHODS: Two hundred sixty occupational medicine physicians completed a questionnaire and 25 activity log descriptions about 72 items in 9 major domains. For each item, the percentage of activities involving the item and the percentage of physicians conducting the item at least once were calculated. Results were analyzed by board certification status and career stage. RESULTS: Board-certified physicians had more-diverse practice activities and skills. They were more involved in management and public health-oriented activities, with greater emphasis on toxicology and less on musculoskeletal disorders. The noncertified physicians received more payment from workers' compensation. Early-career physicians spent more time in direct injury/illness treatment, being paid by workers' compensation, and addressing musculoskeletal problems. CONCLUSIONS: Formal training confers advantages in practice diversity and population medicine orientation.

Career paths in occupational medicine.

OBJECTIVE: To describe career path patterns for occupational medicine (OM) physicians. METHODS: A convenience sample of 129 occupational physicians described work activities and locations at several career points up to 20 years ago, first OM position, and 10 years after expectations. RESULTS: Clinical activities were important throughout (eg, 41% and 46% of occupational physicians reported frequently treating patients 20 years ago and currently). Practice locations changed more markedly, with increased multisite clinics and hospital/medical center-based practices. Performing mainly clinical activities in a first job increased from 82% to 97% over the past 20 years. Career transitions between clinical and nonclinical roles were common (40% of participants). Many anticipate transition to nonclinical work over 10 years. CONCLUSIONS: Activities have not fundamentally changed, but practice locations have evolved. Both clinical and management activities remain important, and path to managerial positions increasingly begins in clinical practice.

Anxiety during respirator use: comparison of two respirator types.

Anxiety may interfere with proper respirator use. This study directly compares the effect of two types of respirators--elastomeric half-face mask with dual-cartridges (HFM) and N95 filtering facepiece--on anxiety levels. Twelve volunteers with normal or mildly impaired respiratory conditions performed a series of simulated work tasks using the HFM and N95 on different days. The State-Trait Anxiety Inventory (STAI) measured state anxiety (SA) before and during respirator use. STAI also measured trait anxiety (TA), a stable personal characteristic. The effect of the respirator was measured as the difference between SA pre-use and during use. Work with HFM was associated with an increase in SA (2.92 units, p < .01), whereas work with the N95 had no observed effect. Anxiety should be considered in the selection of the best respirator for a user. Impact on anxiety should be considered for respirator design and certification purposes, particularly if the device is to be widely used in workplace and community settings.

Occupational medicine practice: activities and skills of a national sample.

OBJECTIVE: To characterize activities and skills of occupational physicians using work diaries. METHODS: A total of 260 occupational physicians from a national sample provided task/skill descriptions at approximately 25 specific times. The average percentage of activity samples using a skill and the interquartile range expressed results. RESULTS: Clinical activities, particularly musculoskeletal, were most frequent, followed by industry and health system management. Traditional public health approaches were infrequent. Injured patients, employers, and healthy workers were the most common beneficiaries. Communication about prevention and work restrictions was frequent. Interphysician variability was high for most measures. CONCLUSIONS: Results demonstrated a dichotomy-many frequent activities/skills are associated with other specialties as well (eg, treating injury); others, albeit less frequently used, demarcate the uniqueness of occupational medicine (eg, preventive examinations, toxicology, benefiting employers or worker groups, assessing work ability, payment by employers).

Occupational medicine practice: one specialty or three?

OBJECTIVE: To characterize education, practice, and skills of occupational physicians and to evaluate subgroups within the profession. METHODS: The data for the baseline surveys of the occupational medicine practice research project were collected for a national sample of occupational physicians using paper or on-line instruments. Three subgroups were defined a priori-injury care, clinical specialist, and management/population. RESULTS: Occupational medicine seems to include three distinct subgroups, which differ in characteristics such as patient volume, relevant clinical skills, and income source. Nevertheless, many commonalities were present across all three groups, such as emphasis on communication, OSHA, and workers compensation. Musculoskeletal and workers compensation care were most important, although there were highly significant differences among the three subgroups. CONCLUSIONS: Planning for education, certification, and organization of services should acknowledge the distinctions among the three subgroups.

Genetic determinants of mouse hepatitis virus strain 1 pneumovirulence.

We report here investigation into the genetic basis of mouse hepatitis virus strain 1 (MHV-1) pneumovirulence. Sequencing of the 3' one-third of the MHV-1 genome demonstrated that the genetic organization of MHV-1 was similar to that of other strains of MHV. The hemagglutinin esterase (HE) protein was truncated, and reverse transcription-PCR (RT-PCR) studies confirmed previous work that suggested that the MHV-1 HE is a pseudogene. Targeted recombination was used to select chimeric viruses containing either the MHV-1 S gene or genes encoding all of the MHV-1 structural proteins, on an MHV-A59 background. Challenge studies in mice demonstrated that expression of the MHV-1 S gene within the MHV-A59 background (rA59/S(MHV-1)) increased the pneumovirulence of MHV-A59, and mice infected with this recombinant virus developed pulmonary lesions that were similar to those observed with MHV-1, although rA59/S(MHV-1) was significantly less virulent. Chimeras containing all of the MHV-1 structural genes on an MHV-A59 background were able to reproduce the severe acute respiratory syndrome (SARS)-like pathology observed with MHV-1 and reproducibly increased pneumovirulence relative to rA59/S(MHV-1), but were still much less virulent than MHV-1. These data suggest that important determinants of pneumopathogenicity are contained within the 3' one-third of the MHV-1 genome, but additional important virulence factors must be encoded in the genome upstream of the S gene. The severity of the pulmonary lesions observed correlates better with elevated levels of inflammatory cytokines than with viral replication in the lungs, suggesting that pulmonary disease has an important immunological component.