Endoluminal Vacuum Therapy as Effective Treatment for Patients with Postoperative Leakage After Metabolic Bariatric Surgery-A Single-Center Experience.

BACKGROUND: Metabolic bariatric surgery (MBS) is standardized and safe. Nevertheless, complications such as anastomotic leakage (AL) or staple-line leakage (SLL) can occur. In upper GI or colorectal surgery, endoluminal vacuum therapy (EVT) offers a therapeutic alternative to revisional surgery. Data on EVT in patients with leakage after MBS remain scarce. The aim of this study is to evaluate the efficacy of EVT and its potential as endoscopic alternative to revisional surgery. MATERIAL AND METHODS: All patients treated for AL or SLL with EVT after MBS between 01/2016 and 08/2023 at the Department for General Surgery, Medical University Vienna, were included in this retrospective, single-center study. Therapeutic value of EVT as management option for acute postoperative leakage after MBS in daily practice was evaluated. Statistical analyses were performed descriptively. RESULTS: Twenty-one patients were treated with EVT within the observational period of 7 years. In 11 cases (52.4%), the index surgery was a primary bariatric intervention; in 10 cases (47.6%), a secondary surgery after initial MBS was performed. Favored approach was a combination of revisional surgery and EVT (n = 18; 85.7%), intermediate self-expanding metal stent (SEMS) in 16 (76.2%) cases. EVT was changed six times (0-33) every 3-4 days. Mean EVT time was 25.1 days (3-97). No severe associated complications were detected and EVT showed an efficacy of 95.2%. CONCLUSION: This small case series supports the trend to establish EVT in daily clinical practice when revisional surgery after MBS is needed, thus preventing further reoperation and reducing associated morbidity and mortality in critically ill patients.

Determination of strontium radioisotopes in routine and emergency samples.

We present the radioanalytical strategies used for the determination of strontium radioisotopes in routine and emergency samples. While in routine monitoring, the main goal is to achieve limits of detection as low as possible. In emergency, priority is given to the rapid procurement of data about a contamination. The parameters accuracy, precision and detection limit of the radiochemical methods are shown. We present the results obtained over the past 22 years in proficiency tests and in the analysis of reference materials.

Persistent Mercury Contamination in Shooting Range Soils: The Legacy from Former Primers.

Mercury (Hg) compounds were used in the past in primers for rifle and handgun ammunition. Despite its toxicity, little is known about the contamination of shooting-range soils with this metal. We present new data about the Hg contamination of surface soils from numerous shooting ranges of Switzerland. Our study demonstrates that Hg is measurable at high levels in surface soils from the shooting ranges. In three of the investigated ranges, concentrations above the maximum Swiss guidance value of Hg in soil of 500 µg kg-1 were measured. Since the use of mercury-containing ammunition was stopped in the 1960s, our results demonstrate the high persistence of Hg in soils and their slow recovery by natural mechanisms.

State selective charge transfer cross sections for Na+ with excited rubidium: a unique diagnostic of the population dynamics of a magneto-optical trap.

It is shown how the newly developed technique of magneto-optical-trap recoil-ion momentum spectroscopy can be used to measure the temporal evolution of excited state fraction in such a trap. In this case, the fraction of atoms in a 5p state is measured. The technique can be generalized to allow the measurement of more complicated systems, e.g., a Rb sample having a mixture of 5s, 5p, 4d, and Rydberg states.

Chemical shift mapping of shikimate-3-phosphate binding to the isolated N-terminal domain of 5-enolpyruvylshikimate-3-phosphate synthase.

To facilitate evaluation of enzyme-ligand complexes in solution, we have isolated the 26-kDa N-terminal domain of 5-enolpyruvylshikimate-3-phosphate (EPSP) synthase for analysis by NMR spectroscopy. The isolated domain is capable of binding the substrate shikimate-3-phosphate (S3P), and this letter reports the localization of the S3P binding site using chemical shift mapping. Based on the NMR data, we propose that Ser23, Arg27, Ser197, and Tyr200 are directly involved in S3P binding. We also describe changes in the observed nuclear Overhauser effects (NOEs) that are consistent with a partial conformational change in the N-terminal domain upon S3P binding.

Shikimate-3-phosphate binds to the isolated N-terminal domain of 5-enolpyruvylshikimate-3-phosphate synthase.

5-Enolpyruvylshikimate-3-phosphate (EPSP) synthase catalyzes the transfer of the enolpyruvyl moiety from phosphoenolpyruvate (PEP) to shikimate-3-phosphate (S3P). Mutagenesis and X-ray crystallography data suggest that the active site of the enzyme is in the cleft between its two globular domains; however, they have not defined which residues are responsible for substrate binding and catalysis. Here we attempt to establish the binding of the substrate S3P to the isolated N-terminal domain of EPSP synthase using a combination of NMR spectroscopy and isothermal titration calorimetry. Our experimental results indicate that there is a saturable and stable conformational change in the isolated N-terminal domain upon S3P binding and that the chemical environment of the S3P phosphorus when bound to the isolated domain is very similar to that of S3P bound to EPSP synthase. We also conclude that most of the free energy of S3P binding to EPSP synthase is contributed by the N-terminal domain.

Finance issue brief: bans on financial incentives.

Following efforts to ban the use of gag clauses, state lawmakers now are turning their attention to prohibiting managed care plans from using financial incentives. Twenty-seven states have enacted laws banning the use of such incentives.

Finance, providers issue brief: HMO medical directors.

Medical directors of managed care organizations have the ultimate responsibility of deciding the treatments for which a health plan will pay. Cognizant of consumer concerns over the power inherent in the position, states are seeking to inject more accountability into the decision-making process. Among the issues with which they have begun to grapple: whether medical directors should be required to hold a medical license from the state in which they work and, by extension, whether they should be under the jurisdiction of the state medical board.

Finance, providers issue brief: insurer liability.

When a health plan denies payment for a procedure on grounds that it is not medically necessary or when it refuses a physician-ordered referral to a specialist, has it crossed the line from making an insurance judgment to practicing medicine? If the patient suffers harm as a result of the decision, is the plan liable for medical malpractice? Those were questions 35 states considered in 1999, and at least 32 states are grappling with this year as they seek to respond to physician and patient pressure to curb the power of the managed care industry. Traditionally, health insurers have been protected by state laws banning "the corporate practice of medicine," which means the patient's only recourse is to sue under a "vicarious liability" theory. Now, however, lawmakers are debating legislation to extend the scope of malpractice liability beyond individual practitioners to insurance carriers and plans themselves.

Finance issue brief: continuity of care.

When a health care provider disenrolls or is terminated by a managed care plan, how long can that provider's patients continue to receive covered treatment for a life-threatening condition, pregnancy, disability or other circumstance that requires continuous medical care? Lawmakers in twenty-seven states have answered that question.

Finance issue brief: freedom of choice.

Should managed care plans have the ability to limit an individual's "freedom of choice" when it comes to selecting a provider? As part of the anti-managed care movement of the early 1990s, 22 states enacted freedom of choice laws; the majority apply only to pharmacies.

Finance issue brief: any willing provider.

Today, almost half the states have laws obligating managed care organizations (MCOs) such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) to contract with any willing health care provider. Although most provisions are limited to pharmacies or pharmacists, several states have adopted broad provisions applying to hospitals, physicians, chiropractors, pharmacists, podiatrists, therapists and nurses.

Finance issue brief: bans on gag clauses.

Forty-eight states prohibit managed care organizations (MCOs) from limiting a provider's ability to discuss potential treatment options with patients.

Providers issue brief: provider protections.

While national efforts are aimed at strengthening consumer protections under managed care, a number of states are increasing efforts to improve protections for providers as well. Written notification of contract termination, ensuring the existence of a due process, and disclosure of credentialing criteria are three options states are pursuing.

Finance issue brief: women's health: a legislative overview of selected mandates.

From pregnancy to breast cancer screening and osteoporosis prevention, women have a need for a gender-specific set of health services. Dialogue that once occurred only between women and their physicians has evolved into debate between representatives from the insurance industry and state legislators. Therefore, women's health issues have risen on the legislative agenda, illustrated by the increased volume of bills introduced and enacted during the past five years.

Finance issue brief: prompt payment.

Although under standard business laws withholding prompt payment is considered an unfair trade practice, a number of states are enacting new laws or clarifying existing language to ensure that health plans are paying providers in a timely fashion.

Finance issue brief: point of service.

A point-of-service (POS) option is a type of plan offered by managed care organizations (MCOs), including health maintenance organizations (HMOs), that allows people who are willing to pay higher out-of-pocket costs to see out-of-plan providers. Mandating a point-of-service option essentially eliminates the use of closed-panel HMOs. This issue brief addresses only bills that mandate managed care plans to offer a point-of-service option.

Finance issue brief: medical necessity.

The information in this Issue Brief is based on a 50-state survey and a recent literature review. The Health Policy Tracking Service recognizes the complexity of this issue and discourages anyone from using this as their sole resource on the issue.

Finance issue brief: emergency care.

Under what circumstances is an enrollee in a managed care plan eligible to exercise judgment as a "prudent layperson" in determining that an emergency medical condition exists? Does his or her condition justify immediate attention without prior authorization, even if it means an emergency room visit or dialing 911?