Predictors of Length of Hospital Stay After Reduction of Internal Hernia in Patients With a History of Roux-en-Y Gastric Bypass.

BACKGROUND: Postoperative internal hernias after Roux-en-Y gastric bypass (RYGB) have an incidence of 2%-9% and are a surgical emergency. Evidence on factors associated with length of stay (LOS) after emergent internal hernia reduction in RYGB patients is limited. METHODS: This is a retrospective review of patients who underwent internal hernia reduction after RYGB at our tertiary care center over a 5 year period from 2015 to 2020. Demographics, comorbidities, and intra- and postoperative hospital course were collected. Univariate and multivariate linear regressions were used to investigate factors associated with LOS. RESULTS: We identified 38 patients with internal hernia after RYGB. These patients with mean age 44.1 years were majority female (71.1%) and white race (60.5%). Of the 24 patients where the RYGB was done at our institution, the mean RYGB to IH interval was 43 months. Petersen's defect (57.8%) followed by jejuno-jejunal mesenteric defect (31.6%) were the most common locations for IH. Both Petersen's and jejuno-jejunal mesenteric hernias were found in 4 cases (10.5%). Revision of bypass and small bowel resection were required in 13.2% and 5.3% of cases, respectively. The median (interquartile range) length of stay (LOS) was 2 days. On the multivariate analysis, male sex (P = .019), conversion to exploratory laparotomy (P = .005), and resection of small bowel (P < .001) were independent risk factors for increased LOS. CONCLUSION: The most common location of IH after RYGB is Petersen's defect, followed by jejuno-jejunal mesenteric defect. LOS was significantly associated with male sex, exploratory laparotomy, and resection of small bowel.

The African Goat Improvement Network: a scientific group empowering smallholder farmers.

The African Goat Improvement Network (AGIN) is a collaborative group of scientists focused on genetic improvement of goats in small holder communities across the African continent. The group emerged from a series of workshops focused on enhancing goat productivity and sustainability. Discussions began in 2011 at the inaugural workshop held in Nairobi, Kenya. The goals of this diverse group were to: improve indigenous goat production in Africa; characterize existing goat populations and to facilitate germplasm preservation where appropriate; and to genomic approaches to better understand adaptation. The long-term goal was to develop cost-effective strategies to apply genomics to improve productivity of small holder farmers without sacrificing adaptation. Genome-wide information on genetic variation enabled genetic diversity studies, facilitated improved germplasm preservation decisions, and provided information necessary to initiate large scale genetic improvement programs. These improvements were partially implemented through a series of community-based breeding programs that engaged and empowered local small farmers, especially women, to promote sustainability of the production system. As with many international collaborative efforts, the AGIN work serves as a platform for human capacity development. This paper chronicles the evolution of the collaborative approach leading to the current AGIN organization and describes how it builds capacity for sustained research and development long after the initial program funds are gone. It is unique in its effectiveness for simultaneous, multi-level capacity building for researchers, students, farmers and communities, and local and regional government officials. The positive impact of AGIN capacity building has been felt by participants from developing, as well as developed country partners.

Impact of Enhanced Recovery After Surgery (ERAS) Combined with Bariatric Surgery Targeting Opioid Prescriptions (BSTOP) Protocol on Patient Outcomes, Length of Stay and Opioid Prescription After Bariatric Surgery.

BACKGROUND: Evidence shows that 14.2% of opioid-naive patients have long-term opioid dependence after bariatric surgery. Enhanced recovery after surgery (ERAS) protocols are widely used in bariatric surgery, while bariatric surgery targeting opioid prescriptions (BSTOP) protocols were recently introduced. We will investigate the combined impact of ERAS and BSTOP protocols after bariatric surgery. METHODS: We conducted a retrospective review for patients who underwent either a sleeve gastrectomy or Roux-en-Y gastric bypass at a tertiary care center. Pre-intervention and post-intervention data were compared. Primary outcomes were length of stay (LOS), 30-day readmission, 30-day complications, and discharge on opioids. Multivariate Poisson regression with robust standard error was used to analyze LOS. RESULTS: There was no significant difference in 30-day emergency room visits (3.3% vs. 4.0%; p value = 0.631), 30-day readmission (4.4% vs. 5.4%; p value = 0.577) or 30-day complication rate (4.2% vs. 6.4%; p value = 0.199). LOS was significantly lower in the post-intervention group; mean (interquartile range) 2 (1-2) days vs. 1 (1-2) day, p value < 0.001. On multivariate analysis, the post-intervention group had 0.74 (95% confidence interval 0.65-0.85; p value < 0.001) times lower LOS as compared to pre-intervention group. Patients with DM had a significantly longer LOS (relative risk: 1.22; p = 0.018). No other covariates were associated with LOS (p value < 0.05 for all). BSTOP analysis found a significant difference between the two groups. Discharge on opioids decreased from 40.6% pre-intervention to 7.1% post-intervention. CONCLUSION: ERAS and BSTOP protocols reduced length of stay and opioid need at discharge without an increase in complication or readmission rates.

Single-Incision Laparoscopic Cholecystectomy Using the Marionette Transumbilical Approach Is Safe and Efficient with Careful Patient Selection: A Comparative Analysis with Conventional Multiport Laparoscopic Cholecystectomy.

Objectives The "marionette technique" for transumbilical laparoscopic cholecystectomy (m-TLC) offers improved cosmesis and possibly shorter postoperative recovery for patient undergoing laparoscopic cholecystectomy versus the four-port conventional laparoscopic cholecystectomy (CLC). We compared the outcomes of m-TLC and CLC at a tertiary care facility in New York. Methods A retrospective chart review was conducted and data on patients who underwent m-TLC and CLC were retrieved. Hospital length of stay (LOS), operative time, and complications were compared between the two groups using linear and logistic regression, as appropriate. Results M-TLC group patients were significantly younger, predominantly females with lower body mass index. They were less likely to have previous abdominal surgery and more likely to have noninflammatory pathology ( p < 0.05 for all). Nonadjusted LOS (1 vs. 3 days, p -value < 0.0001) and operative time (50 vs. 56 minutes, p -value = 0.007) were significantly lower among patients who underwent m-TLC; however, there was no significant difference on multivariate analysis. In multivariate analysis, there was no difference in the overall complication rate (odds ratio: 1.63; 95% confidence interval 0.02-2.39). Conclusion With careful patient selection, m-TLC offers better cosmesis with comparable safety outcomes. Level of evidence Level III.

Gastric Banding with Previous Roux-en-Y Gastric Bypass (Band over Pouch): Not Worth the Weight.

Background and Objectives: Revisional bariatric surgery continues to increase. Laparoscopic adjustable gastric banding (LAGB) after previous Roux-en-Y gastric bypass (RYGB), known colloquially as "band-overpouch" has become an option despite a dearth of critically analyzed long-term data. Methods: Our prospectively maintained database was retrospectively reviewed for patients who underwent band-overpouch at our Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence in a 18-year period ending October 31, 2021. We evaluated: demographics, comorbidities, operative procedures, and outcomes (30-day and > 30-day). Results: During the study period, of 4,614 bariatric procedures performed, 42 were band-overpouch with 39 (93%) being women. Overall, mean age was 49.8 years (range 26-75), a mean weight 251 pounds (range 141-447), and mean body mass index 42.4 (range 26-62). Comorbidities included: hypertension (n = 31; 74%), diabetes (n = 27; 64%), obstructive sleep apnea (n = 26; 62%), gastroesophageal reflux disease (n = 26; 62%), and osteoarthritis (n = 25; 60%). All procedures were performed laparoscopically with no conversions to open. Mean length of stay was 1.2 days (range 1-3). Mean follow-up time was 4.2 years (range 0.5-11). Mean excess weight loss was 14.9%, 24.3%, and 28.2% at 6 months, 1 year and ≥ 3 years, respectively. There was one 30-day trocar-site hematoma requiring transfusion. Long-term events included: 1-year (1 endoscopy for retained food; 1 internal hernia), 3-year (1 LAGB erosion; 1 LAGB explant), 4-year (1 anastomotic ulcer), 6-year (1 LAGB explant and Roux-en-Y revision), and 8-year (1 LAGB erosion). One 5-year mortality occurred (2.4%), in association with hospitalization for chronic illness and malnutrition. Band erosions were successfully treated surgically without replacement. Conclusion: Band-overpouch is associated with moderate excess weight loss and has good short-term safety outcomes.

Superior mesenteric artery thrombosis in a patient with COVID-19 pneumonia and Clostridium Difficle.

COVID-19, a novel respiratory viral illness, has spread globally and led to over 111 million cases worldwide. Most commonly, patients present with respiratory symptoms, and those with increased severity progress to acute hypoxic respiratory failure. Additionally, a portion of patients are noted to have coagulopathy and are considered to be at an increased risk for thromboembolic events. In this article, we present a unique case of a patient with severe abdominal pain in the setting of COVID-19 pneumonia and community acquired Clostridium difficile, found to have superior mesenteric artery thrombosis requiring exploratory laparotomy, thrombectomy and small bowel resection.

Plasmablastic Lymphoma Causing Adult Intussusception After Cardiac Transplantation.

Intussusception in adults is a rare occurrence at approximately 5% and malignancy as the cause comprises half that number. The most common malignancies found are primary adenocarcinoma, metastatic carcinoma, lymphoma, and gastrointestinal stromal tumors. Lymphoma is the second most common. The management of adult intussusception is generally surgical, which is due to the higher likelihood of malignancy being the underlying cause. The patient's history helps to direct management and the most likely underlying diagnosis. This is especially important in patients who are immunosuppressed and with a history of lymphoproliferative disease. Early management and proper surgical intervention allow for the best survival rate. Here we present a case of adult intussusception caused by a rare and aggressive type of non-Hodgkin lymphoma.

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial.

OBJECTIVES: To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture. DESIGN: Multisite randomized controlled trial from April 2009 to March 2013. SETTING: Three New York hospitals. PARTICIPANTS: Individuals with hip fracture (N = 161). INTERVENTION: Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82). MEASUREMENTS: Pain (0-10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects. RESULTS: Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3-232 vs 100.0 feet, 95% CI = 65.1-134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6-11.0) vs 9.1 (95% CI = 8.2-10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents. CONCLUSION: Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.

Can Intraoperative Processed EEG Predict Postoperative Cognitive Dysfunction in the Elderly?

PURPOSE: Postoperative cognitive dysfunction (POCD) is a serious and costly complication of the elderly; even mild impairment has the potential to impact overall well being. Anesthesiologists continue to search for ways to manipulate intraoperative technique to optimize postoperative cognition in the elderly. Depth of anesthesia during surgery is an area that has shown some promise for short-term outcomes, such as delirium. However, excessive depth has both positive and negative associations with longer-term POCD. We hypothesize that this uncertainty is due to the inability of median depth to capture the amount of burst suppression or electrical silence. In this study, our purpose was to identify the intraoperative processed EEG parameters that are most closely correlated with POCD. METHODS: To explore the association of several processed EEG parameters with POCD, we performed a retrospective analysis of a cohort of 105 patients aged >68 years scheduled for major surgery under general anesthesia. Intraoperative medications, hemodynamics, processed EEG and cerebral oxygen saturation were recorded. All patients had a cognitive battery before surgery and repeated at 3 months afterward. FINDINGS: One hundred and five patients enrolled and 77 (73.3%) patients completed the 3-month cognitive testing. The incidence of POCD was 27%; the median Bispectral Index value for patients who developed POCD was similar to patients who did not (46 vs 42 minutes). However, patients who developed POCD spent less time with Bispectral Index <45 minutes (82.8 vs 122.5 minutes, P = 0.01) and burst suppression (35 vs 96 minutes, P = 0.04). Hypotension, cerebral desaturation, and use of total intravenous anesthesia were similar between patients with and without POCD. IMPLICATIONS: Patients who developed POCD spent less time in EEG burst suppression and less time in deep states. Burst suppression may be protective for POCD. Further work is needed to definitively identify the role of burst suppression in the context of other patient and intraoperative variables to prevent POCD.

Propofol Use in the Elderly Population: Prevalence of Overdose and Association With 30-Day Mortality.

PURPOSE: Geriatric patients are more sensitive to the anesthetic effects of propofol and its adverse effects, such as hypotension, than is the general population; thus, a reduced dose (1-1.5 mg/kg) is recommended for the induction of anesthesia. The extent to which clinicians follow established dosing guidelines has not been well described. Therefore, we investigated the prevalence of propofol overdose in the elderly population to determine whether propofol overdose occurs and is associated with increased hypotension and 30-day mortality. METHODS: In this retrospective study in patients who received propofol for the induction of general anesthesia, data on demographic characteristics, preoperative medications, intraoperative management, and 30-day mortality were collected. The dose of propofol used for the induction of anesthesia and the median blood pressure in the pre- and immediate postinduction periods were determined. Hypotension was defined as either: (1) a decrease in mean arterial pressure (MAP) of >40% concurrent with a MAP of <70 mm Hg; or (2) a MAP of <60 mm Hg. FINDINGS: A total of 17,540 patients were included in the analysis; 4033 (23.0%) were aged >65 years. The median (interquartile range) propofol dose in the group aged >65 years was 1.8 (1.4-2.2) mg/kg, above the recommended dose, in comparison to 2.2 (1.9-2.5) mg/kg in younger patients. On multivariate analysis, increased propofol dose was associated with increased postinduction hypotension, especially in patients over 70 years of age, but not 30-day mortality. IMPLICATIONS: Older patients received greater-than-recommended doses of propofol for induction, which may have led to significant dose-dependent hypotension. Despite this finding, the dose of propofol for induction was not independently associated with a greater 30-day mortality rate. More education regarding geriatric concerns is needed for encouraging anesthesiologists to tailor the plan for anesthesia in geriatric patients. However, overall postsurgical mortality is a function of preoperative risk and type surgical procedure.

Coordinated international action to accelerate genome-to-phenome with FAANG, the Functional Annotation of Animal Genomes project.

We describe the organization of a nascent international effort, the Functional Annotation of Animal Genomes (FAANG) project, whose aim is to produce comprehensive maps of functional elements in the genomes of domesticated animal species.

Biomechanical Comparison of Perpendicular Versus Oblique In Situ Screw Fixation of Slipped Capital Femoral Epiphysis.

BACKGROUND: Percutaneous in situ single screw fixation is the preferred treatment for stable and unstable slipped capital femoral epiphysis (SCFE). The recommended screw placement is in the center of the epiphysis and perpendicular to the physis, which necessitates an anterior starting point for most SCFEs. A recent clinical study has shown good clinical results with a laterally based screw for SCFE, which is oblique to the physis. We sought to biomechanically compare these 2 techniques for load to failure and hypothesized that the laterally based oblique screw is equivalent or superior to an anteriorly based perpendicular screw. METHODS: Twenty-two paired immature porcine femurs were used to compare the techniques. A SCFE model was created in all femurs using a previously published technique by performing a 30-degree posterior closing wedge osteotomy through the proximal physis. In the control group, a screw was placed perpendicular to the slip with an anterior starting point. In the experimental group, the screw was started as close to the mid-lateral cortex of the proximal femur as possible while maintaining the screw anterior to the posterior cortex of the femoral neck and ending at the apex of the epiphysis ignoring the resultant angle to the physis for the experimental group. The specimens were then potted and loaded in a physiologically relevant posteroinferior direction (30 degrees posterior from vertical) to determine load to failure (N) and stiffness (N/mm). RESULTS: No statistical difference was found between the 2 groups in maximum load to failure or stiffness (P>0.05). CONCLUSIONS: A laterally based screw oblique to the physis for in situ fixation in mild SCFE is not significantly different than an anteriorly based screw perpendicular to the physis in load to failure and stiffness in our study model. CLINICAL RELEVANCE: In light of no difference in load to failure of these 2 constructs, surgeons may be more comfortable with the traditional lateral entry point while still aiming for screw placement in the center of head.

Intake of seafood in the US varies by age, income, and education level but not by race-ethnicity.

Current US federal dietary guidance recommends regular consumption of seafood (fish + shellfish) to promote health; however, little is known about how well Americans meet the guideline, particularly population subgroups that may be at risk for inadequate intake. The purposes of this study were to describe the prevalence of seafood consumption and, among consumers, the amounts of seafood eaten by sex, age group, income and education level, and race-ethnicity. Data from 15,407 adults aged 19+ participating in the 2005-2010 National Health and Nutrition Examination Surveys were analyzed using methods to account for sporadic intake of seafood. Over 80% of Americans reported consuming any seafood over the past 30 days, 74% reported consuming fish, and 54% reported eating shellfish. The percentages varied by socio-demographic group. Younger age and lower income and education levels were associated with lower odds of being a seafood consumer (p < 0.0001). Among those who reported eating seafood, the average amount eaten of any seafood was 158.2 ± 5.6 g/week. Among seafood consumers, women and individuals of lower age and education levels consumed less seafood. Approximately 80%-90% of seafood consumers did not meet seafood recommendations when needs were estimated by energy requirements. A great deal of work remains to move Americans toward seafood consumption at current recommended levels.

Prone position is associated with mild cerebral oxygen desaturation in elderly surgical patients.

PURPOSE: A variety of hemodynamic and respiratory alterations accompany patients in the prone position; however the effect of the prone position on intraoperative cerebral saturation has not been studied. We sought to examine whether the incidence of cerebral oxygen desaturation in elderly patients (≥68 years of age) undergoing spine surgery in the prone position was more common than patients undergoing major surgery in the supine position. METHODS: We performed a retrospective cohort study of 205 patients; 63 patients underwent surgery in the prone position and 142 in the supine position. Patients were evaluated for cerebral desaturation with bilateral cerebral oximetry. The primary predictor was position, secondary were: length of the surgery, incidence and duration of cerebral desaturation episodes at several thresholds, average time of Bispectral index below threshold of 45 in minutes, average electroencephalogram suppression ratio >0, amount of blood transfused, and the incidence of hypotension and hypertension. RESULTS: Elderly spine surgery patients in the prone position were more than twice as likely to experience mild cerebral desaturation as patients in the supine position. Patients in the prone position had longer surgeries; however cerebral desaturation in the prone position was significantly more common even when adjusted for surgery time and the occurrence of intraoperative hypotension. CONCLUSION: Cerebral desaturation is related to the prone position in elderly surgery patients. Future studies are necessary to determine whether this translates to a higher incidence of postoperative cognitive dysfunction and delirium.

Do stress markers and anesthetic technique predict delirium in the elderly?

BACKGROUND: Postoperative delirium (PD) is a prevalent complication of elderly surgical patients, which predisposes to worsened cognitive recovery and dementia. Risk of PD has been associated with increasing magnitude of the hypothalamic-pituitary-adrenal stress response (serum cortisol, epinephrine and norepinephrine) to surgery. Anesthetics suppress this response; however, some (total intravenous anesthesia, TIVA) more than others (anesthetic gases). Prior comparisons of anesthetics have been equivocal but have not included stress markers. We hypothesized that TIVA would decrease serum stress markers and the incidence of PD. METHODS: We performed a prospective cohort study of 76 elderly major surgical patients. Patients received TIVA or sevoflurane gas, and blood was drawn for serum markers pre-, intra-, and postoperatively. PD was assessed with the Confusion Assessment Method. We compared stress markers and PD between patients who received TIVA versus sevoflurane, and then modeled PD including stress and anesthetic. RESULTS: The group that received TIVA during surgery demonstrated lower levels of all stress markers compared to the gas group, but no difference in PD. However, across groups, the postoperative norepinephrine level was much higher in patients who developed PD. Other markers and other times had no effect. CONCLUSION: The development of PD depends more on postoperative stress than intraoperative stress or anesthetic.

Influence of anesthetics on Alzheimer's disease: biophysical, animal model, and clinical reports.

Since the finding in the 1880 s that elderly patients may experience cognitive decline following surgery, the search for an understanding of this phenomenon has been underway. In the last decade, evidence from biophysical (light scattering and nuclear magnetic resonance), in vitro, in vivo animal studies, retrospective evaluations of human registries, and recently prospective randomized trials have explored the idea that various anesthetic agents play a role in this phenomenon by interacting with the biochemical mechanisms that are also responsible for the development of Alzheimer's disease. In the current review, we examine the evidence available and conclude that there is significant evidence to suggest an important role for this mechanism.

Pharmacological treatments of non-substance-withdrawal delirium: a systematic review of prospective trials.

OBJECTIVE: Most reviews of pharmacological strategies for delirium treatment evaluate the effectiveness of these interventions for delirium prevention, reduction in duration and severity of ongoing delirium, and other outcomes that extend beyond the recommendations of expert treatment guidelines. However, little if any attention is given to substantiating the potential benefits of such treatment or addressing the methodological weaknesses that, in part, limit the pharmacological recommendations made by expert treatment guidelines. Therefore, the authors conducted a systematic review to provide the most up-to-date and inclusive review of published prospective trials of potential pharmacological interventions for the prevention and treatment of delirium, and they discuss potential benefits of pharmacological prevention of delirium and/or reduction of ongoing delirium episode duration and severity. METHOD: The analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including prospective randomized and nonrandomized double-blind, single-blind, and open-label clinical trials of any pharmacological agent for the prevention or treatment of delirium and reviewing them systematically for effectiveness on several predefined outcomes. RESULTS: The pharmacological strategies reviewed showed greater success in preventing delirium than in treating it. Significant delirium prevention effects are associated with haloperidol, second-generation antipsychotics, iliac fascia block, gabapentin, melatonin, lower levels of intraoperative propofol sedation, and a single dose of ketamine during anesthetic induction and with dexmedetomidine compared with other sedation strategies for mechanically ventilated patients. CONCLUSIONS: These promising results warrant further study with consideration of the methodological weaknesses and inconsistencies of studies to date.

Issues of fish consumption for cardiovascular disease risk reduction.

Increasing fish consumption is recommended for intake of omega-3 (n-3) fatty acids and to confer benefits for the risk reduction of cardiovascular disease (CVD). Most Americans are not achieving intake levels that comply with current recommendations. It is the goal of this review to provide an overview of the issues affecting this shortfall of intake. Herein we describe the relationship between fish intake and CVD risk reduction as well as the other nutritional contributions of fish to the diet. Currently recommended intake levels are described and estimates of fish consumption at a food disappearance and individual level are reported. Risk and benefit factors influencing the choice to consume fish are outlined. The multiple factors influencing fish availability from global capture and aquaculture are described as are other pertinent issues of fish nutrition, production, sustainability, and consumption patterns. This review highlights some of the work that needs to be carried out to meet the demand for fish and to positively affect intake levels to meet fish intake recommendations for CVD risk reduction.