FIB-4 Reliability in Patients With Severe Obesity: Lower Cutoffs Needed?

BACKGROUND: Liver biopsy is the gold standard to evaluate hepatic fibrosis; however, it has many drawbacks, especially in patients with severe obesity. Noninvasive testing such as the FIB-4 score is increasingly being used as the initial screening tool to identify patients at risk for advanced fibrosis. The broader applicability of FIB-4 and the precision of its cutoff values remain uncertain in metabolic dysfunction-associated steatotic liver disease and patients with severe obesity. Our study explored the correlation between FIB-4 scores and intraoperative liver biopsy in patients with severe obesity undergoing bariatric surgery. METHODS: A total of 632 patients with severe obesity underwent preoperative vibration-controlled transient elastography and intraoperative liver biopsy during bariatric surgery from January 2020 to August 2021. Variables collected included patient demographics, laboratory values, abdominal ultrasound, vibration-controlled transient elastography, and liver biopsy results. ANOVA 1-way test, χ2 tests, and Fisher exact tests were used for quantitative and qualitative variables, respectively. The 95% CIs for the mean FIB-4 scores were used to generate surrogate cutoff values. The proposed FIB-4 cutoffs for F0-1, F2, F3, and F4 were 0.62 (CI: 0.59, 0.64), 0.88 (0.74, 1.01), 1.24 (0.94, 1.54), and 1.53 (0.82, 2.24), respectively. Area under the curve (AUC) methods were used to compare traditional to proposed cutoff values. RESULTS: Applying the traditional FIB-4 cutoffs to approximate advanced fibrosis yielded an AUC of 0.5748. Use of the proposed FIB-4 cutoffs increased the AUC to 0.6899. The proposed FIB-4 cutoffs correctly identified 40 patients with biopsy-proven advanced fibrosis (F3-F4), all of which would have been missed using traditional cutoffs. CONCLUSION: Our study revealed that the use of the currently accepted FIB-4 cutoffs as the screening modality for identifying patients with advanced fibrosis due to metabolic dysfunction-associated steatotic liver disease is insufficient and will result in missing patients with histologically confirmed advanced fibrosis. Use of the revised FIB-4 scores should be considered to diagnose patients with severe obesity at high risk of liver disease progression.

Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures.

OBJECTIVE: To define "best possible" outcomes for secondary bariatric surgery (BS). BACKGROUND: Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. METHODS: Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years. RESULTS: The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ±â€Š10 years, 8.4 ±â€Š5.3 years after primary BS, with a BMI 35.2 ±â€Š7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. CONCLUSION: Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

The Use of Frozen, Food-Grade Blood to Successfully Maintain Colonies of Four Species of Mosquitoes (Diptera: Culicidae).

An essential component of all mosquito-rearing activities is the act of blood-feeding the mosquitoes (Diptera: Culicidae). Many options exist for this purpose including live host animals and a diverse array of artificial-feeding methods. Most of the published artificial-feeding methods involve expensive materials, custom-built devices, or are labor-intensive. All of the previously published methods utilize blood sources, which are either expensive, or difficult to obtain. Additionally, much of the research into artificial blood-feeding methods for mosquitoes has focused on two species: Aedes aegypti (Linnaeus) and Aedes albopictus (Skuse). This article presents a modified artificial blood-feeding method that uses affordable and easily sourced materials, does not require any technical knowledge to assemble, and requires minimal time and effort. The combination of inexpensive aluminum plates, Parafilm and polytetrafluoroethylene tape membranes, an electric germination mat, and frozen, food-grade blood produces exceptional feeding rates and abundant egg production. The method has been used for 2 yr at the Lee County Mosquito Control District to successfully maintain laboratory colonies of four species of mosquito: Ae. aegypti, Ae. albopictus, Aedes taeniorhynchus (Wiedemann), and Culex quinquefasciatus (Say). Variations of this method are reported, which can be used for wild and laboratory colonies of multiple species. This modified method is highly accessible for any small-scale mosquito rearing facility with labor or budgetary constraints.

Reduction of opioid use after implementation of enhanced recovery after bariatric surgery (ERABS).

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been extensively proven in lower gastrointestinal surgery to decrease postoperative physiologic stress and length of stay (LOS). ERAS in bariatric surgery (ERABS) varies immensely from each program with inconsistent results with a predominant goal of reducing LOS. Our focus in implementing enhanced recovery after bariatric surgery (ERABS) protocols is aimed at reducing postoperative pain and opioid use. METHODS: This is a retrospective review of patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (VSG) at a single high-volume center from June 2016 to October 2017. Patients on previous standard protocol were categorized into "Pre-Liposomal Bupivacaine (LB) group." After routine use of Exparel™, patients were grouped into "LB group." After ERABS protocol was initiated, patients were categorized into "ERABS/LB group." Postoperative opioids were converted to morphine equivalents units (MEU); pain scores, LOS, and 30-day outcomes were analyzed using combination of t test and Mann-Whitney U. RESULTS: A total of 1340 patients were included in the study: 304 patients in pre-LB group; 754 patients in LB group, and 282 patients in ERABS/LB group. Total hospital opioid use was 58.6 MEU in pre-LB, 40.8 MEU in LB, and 23.8 MEU in ERABS/LB (p = 0.01). ERABS/LB group found a 59.5% decline in MEU requirements compared to pre-LB (p < 0.001) and 44.9% of patients did not require any additional narcotics on the floor compared to 0% in pre-LB group (p < 0.001). ERABS/LB LOS was an average of 1.48 days compared to 1.54 days in pre-LB group (p = 0.03) with an overall decrease of 3.74% in readmission rates (p = 0.03). CONCLUSIONS: Implementation of ERABS significantly reduced postoperative opioid use, LOS, and readmissions. With ERABS, a more profound effect was observed than simply adding Exparel™ to preexisting protocols. Almost half of these patients did not require narcotics while recovering on the surgical floor. More studies are required to assess the true effect of ERABS without use of Exparel™.

Defining Global Benchmarks in Bariatric Surgery: A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

OBJECTIVE: To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]). BACKGROUND: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix. METHODS: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI>50 kg/m and age>65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators. RESULTS: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8 ±â€Š5.8 kg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication. CONCLUSION: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.

Evaluation of Pyriproxyfen Dissemination via Aedes albopictus From a Point-Source Larvicide Application in Northeast Florida.

The Asian tiger mosquito, Aedes albopictus , ranks among the most important vectors of dengue fever, Zika virus, and chikungunya virus. With no specific medications or vaccines available, vector control is the only way to combat these diseases. Autodissemination of the insect growth regulator pyriproxyfen (NyGuard®) from a point-source treatment was evaluated in field settings in northeast Florida. The objective of this study was to investigate the possibility of pyriproxyfen dissemination from a treatment site to nontreated oviposition sites via the skip oviposition behavior of Ae. albopictus. A spray application was made to a tire pile using a Stihl® SR 420 backpack sprayer. Autodissemination oviposition vases containing oak infusion water were positioned in groups of five at 25 to 400 m in 4 transects surrounding the tire pile. Two sets of 5 control vases containing oak infusion water were placed 1,500 m from the tire pile and oak infusion water samples were collected directly from the tire pile. Fifty milliliter samples were extracted from each vase weekly and preserved for pyriproxyfen residue analysis. All vases were analyzed at week 0 (4 h post-treatment), 1, 2, 4, and 6. Overall, there were no differences in pupal mortality between the control and autodissemination vases. The tire pile samples had significantly more mortality (P < 0.0001) out to 4 wk when compared to autodissemination and control vases.

Isolation of a Novel Pythium Species, P. thermoculicivorax, and Trichoderma sp. from Natural Enzootic Mosquito Larval Infections.

Only a handful of microbial mosquito larval pathogens have been described to date. Sampling several natural enzootic infections of mosquito larvae in southwestern Florida indicated the presence of microbial pathogens capable of extensive larval mortality. A microscopic analysis of one sample site revealed extensive apparent growth of a Pythium-like microbe on mosquito larvae, with the highest degree of infection observed in the siphon and head regions. Structures consistent with sporangia were seen on infected insects after lactophenol blue staining, and higher-resolution scanning electron microscopy (SEM) micrographs showed sporangia and encysted zoospores targeting the head and siphon regions. The isolate was single-colony purified, and molecular identification targeting the ITS and COX1 loci coupled to phylogenetic reconstruction indicated that the isolate belonged to the Pythium genus but was distinct from its closest characterized species, P. inflatum. Morphological features were characterized, with the isolate showing rapid growth on all mycological media tested and relatively high thermotolerance, capable of robust growth at 37 °C; hence, it was designated P. thermoculicivorax. Sampling from a second series of natural infections of mosquito larvae resulted in the molecular identification of three Trichoderma isolates, one with high similarity to T. strigosum and the other two clustering closely with T. asperellum. These data highlight the occurrence of natural enzootic infections of mosquito larvae, potentially as a resource for the identification of new mosquito pathogens.

Temporal and storage effects on ultra-low volume droplets of insecticides collected on Teflon-coated slides.

Use of microscope slides is the most commonly used method to field-assess the droplet spectrum of ultra-low volume (ULV) sprays. Due to absence of analysis facilities during military deployments, slides must be stored and shipped, and the impact of delays in processing and storage conditions on droplets is unknown. This study was designed to evaluate the effect of storage temperatures and duration on droplets on Teflon-coated slides. Treatments included BVA-13 mineral oil, Kontrol 30-30 (30% permethrin), and Fyfanon (96.5% malathion), 2 slide wrapping techniques (proper and improper), and 2 storage temperatures (23 and 45 degrees C), replicated 6 times. The same areas of a slide were measured at different times for 56-58 days using the DropVision droplet measurement system. Regardless of the wrapping technique, droplets of BVA-13, Fyfanon, and Kontrol 30-30 on slides stored at 45 degrees C reduced significantly after 1, 2, and 1 day, respectively, but droplets on slides stored at 23 degrees C were not significantly affected. The results of this study may assist vector control professionals to accurately interpret the droplet size and help in the effective dispersal of ULV-applied insecticides.

Detection of Aedes Scapularis In Southwestern Florida.

Aedes scapularis has recently been detected for the first time in southwestern Florida. During the course of research and surveillance activities by local mosquito control districts in 2020 and 2021, a total of 190 adult females were collected from 14 separate locations in Collier and Lee Counties. To date, Ae. scapularis has been found in 5 counties since its rediscovery in Florida in 2006. Its detection and likely northward expansion into Collier and Lee Counties from the southern Florida Peninsula is in line with ecological niche model predictions that found the environment of the Gulf Coast of southwestern Florida to be highly suitable for the species. Due to its potential ability to transmit both exotic and endemic pathogens such as Everglades virus and Dirofilaria immitis, understanding the range and distribution of Ae. scapularis should be a priority for Florida mosquito control and public health agencies.

Developing methods for chilling, compacting, and sterilizing adult Aedes aegypti (Diptera: Culicidae) and comparing mating competitiveness between males sterilized as adults versus pupae for sterile male release.

The yellow fever mosquito, Aedes aegypti L., can transmit several pathogens responsible for human diseases. With insecticide resistance development becoming a concern, alternative control strategies are needed for Ae. aegypti. Sterile insect technique (SIT) is an increasingly popular option being explored. However, logistical issues in mass production and sterilization make it difficult to maintain a SIT program. Male mosquitoes are typically irradiated as pupae because this is the earliest developmental point at which females can be separated from males, but asynchrony in pupation and high variability in pupal responses to irradiation based on pupal age make it difficult to sterilize mass quantities of pupae on a regular schedule in a rearing facility. Young adult mosquitoes have wider windows for irradiation sterilization than pupae, which can allow facilities to have fixed schedules for irradiation. We produced a workflow for adult Ae. aegypti irradiation in a mosquito control district with an operational SIT program that currently irradiates pupae. The impacts of chilling, compaction, and radiation dose on survival were all assessed before combining them into a complete adult irradiation protocol. Males chilled up to 16 h prior to compaction and compacted to 100 males/cm3 during radiation resulted in low mortality. Males irradiated as adults had increased longevity and similar sterility compared to males irradiated as pupae. Additionally, males sterilized as adults were more sexually competitive than males sterilized as pupae. Thus, we have shown that irradiating adult males can be a viable option to increase the efficiency of this operational mosquito SIT program.

Monkeypox virus-infected individuals mount comparable humoral immune responses as Smallpox-vaccinated individuals.

In early 2022, a cluster of monkeypox virus (MPXV) infection (mpox) cases were identified within the UK with no prior travel history to MPXV-endemic regions. Subsequently, case numbers exceeding 80,000 were reported worldwide, primarily affecting gay, bisexual, and other men who have sex with men (GBMSM). Public health agencies worldwide have offered the IMVANEX Smallpox vaccination to these individuals at high-risk to provide protection and limit the spread of MPXV. We have developed a comprehensive array of ELISAs to study poxvirus-induced antibodies, utilising 24 MPXV and 3 Vaccinia virus (VACV) recombinant antigens. Panels of serum samples from individuals with differing Smallpox-vaccine doses and those with prior MPXV infection were tested on these assays, where we observed that one dose of Smallpox vaccination induces a low number of antibodies to a limited number of MPXV antigens but increasing with further vaccination doses. MPXV infection induced similar antibody responses to diverse poxvirus antigens observed in Smallpox-vaccinated individuals. We identify MPXV A27 as a serological marker of MPXV-infection, whilst MPXV M1 (VACV L1) is likely IMVANEX-specific. Here, we demonstrate analogous humoral antigen recognition between both MPXV-infected or Smallpox-vaccinated individuals, with binding to diverse yet core set of poxvirus antigens, providing opportunities for future vaccine (e.g., mRNA) and therapeutic (e.g., mAbs) design.

Site-saturation mutagenesis of position V117 in OXA-1 ß-lactamase: effect of side chain polarity on enzyme carboxylation and substrate turnover.

Class D ß-lactamases pose an emerging threat to the efficacy of ß-lactam therapy for bacterial infections. Class D enzymes differ mechanistically from other ß-lactamases by the presence of an active-site N-carboxylated lysine that serves as a general base to activate the serine nucleophile for attack. We have used site-saturation mutagenesis at position V117 in the class D ß-lactamase OXA-1 to investigate how alterations in the environment around N-carboxylated K70 affect the ability of that modified residue to carry out its normal function. Minimum inhibitory concentration analysis of the 20 position 117 variants demonstrates a clear pattern of charge and polarity effects on the level of ampicillin resistance imparted on Escherichia coli (E. coli). Substitutions that introduce a negative charge (D, E) at position 117 reduce resistance to near background levels, while the positively charged K and R residues maintain the highest resistance levels of all mutants. Treatment of the acidic variants with the fluorescent penicillin BOCILLIN FL followed by SDS-PAGE shows that they are active for acylation by substrate but deacylation-deficient. We used a novel fluorescence anisotropy assay to show that the specific charge and hydrogen-bonding potential of the residue at position 117 affect CO(2) binding to K70, which in turn correlates to deacylation activity. These conclusions are discussed in light of the mechanisms proposed for both class D ß-lactamases and BlaR ß-lactam sensor proteins and suggest a reason for the preponderance of asparagine at the V117-homologous position in the sensors.

A sterile insect technique pilot trial on Captiva Island: defining mosquito population parameters for sterile male releases using mark-release-recapture.

BACKGROUND: The sterile insect technique (SIT), which involves area-wide inundative releases of sterile insects to suppress the reproduction of a target species, has proven to be an effective pest control method. The technique demands the continuous release of sterilized insects in quantities that ensure a high sterile male:wild male ratio for the suppression of the wild population over succeeding generations. METHODS: For these releases, it is important to determine several ecological and biological population parameters, including the longevity of the released males in the field, the dispersal of the released males and the wild pest population size. The Lee County Mosquito Control District initiated a study in a 47-ha portion of Captiva Island (Florida, USA), an island with a total area of 230 ha, to define biological SIT parameters for Aedes aegypti (L.), an invasive disease-vectoring mosquito known to be difficult to control due to a combination of daytime biting activity, use of cryptic breeding habitats that are difficult to target with conventional night-time ultra-low volume methods, and emerging resistance to commonly used insecticides. Another goal was to assess patterns of dispersal and survival for laboratory-reared sterile Ae. aegypti males released over time in the pilot site. These parameters will be used to evaluate the efficacy of a SIT suppression program for Ae. aegypti on Captiva Island. RESULTS: Over the course of seven mark-release-recapture studies using single- and multiple-point releases, 190,504 sterile marked males were released, for which the recapture rate was 1.5% over a mean period of 12 days. The mean distance traveled by sterile males of the local strain of Ae. aegypti that has colonized Captiva Island was 201.7 m from the release point, with an observed maximum traveled distance of 404.5 m. The released sterile mosquitoes had a probability of daily survival of 0.67 and an average life expectancy of ~ 2.46 days. CONCLUSIONS: These data together with the population size estimate and sterile:wild ratio provide a solid basis for planning the SIT operational phase which is aimed at mosquito population suppression.

Reversal of Roux en Y gastric bypass: largest single institution experience.

BACKGROUND: There is a paucity of literature on patients who have undergone reversal of Roux-en-Y gastric bypass (RYGB) to normal anatomy. We present the largest single institution experience with reversal of RYGB for serious chronic complications. OBJECTIVE: To describe our experience including indications, outcomes, and complications of RYGB reversal. SETTING: Academic-affiliated private practice. METHODS: Retrospective review of 48 patients who underwent laparoscopic reversal of RYGB between 2012 and 2016. RESULTS: Ninety-six percent (n = 46) of patients were female, and the mean age was 48.6 (range, 23-72). Indications for reversal of RYGB included marginal ulcer (n = 25, 12 of whom were malnourished and 17 had coexisting substance abuse), malnutrition alone (n = 11), chronic pain and nausea (n = 7), and postprandial hyperinsulinemic hypoglycemia (n = 5). Overall 30-day complication rate was 29% (n = 14), including gastrogastric anastomotic leak (n = 5), sepsis (n = 5), and bleeding requiring transfusion (n = 3). Weight gain after surgery increased in all patients, especially those patients deemed severely malnourished. All patients reported resolution of symptoms leading to reversal of RYGB, although 58% of patients were lost to follow-up at 1 year after surgery. CONCLUSIONS: Laparoscopic reversal of Roux-en-Y gastric bypass is a complex revisional operation that can be safely performed in a select group of patients with serious complications. The main indications for reversal of RYGB included malnutrition with and without recalcitrant marginal ulcers. Weight gain and resolution of malnutrition occurred soon after reversal of gastric bypass. Because the complication rates are high, reversal should be considered only after all salvage attempts have failed. Reversal to normal anatomy carries high morbidity, including sepsis, leaks and bleeding, high reoperative rates, and readmission. Although reversal of RYGB has a role in the treatment of a select group of patients, it should be undertaken by surgeons with considerable experience in RYGB revision.

Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery program: a randomized clinical trial.

BACKGROUND: Use of liposomal bupivacaine (LB) in surgery is reported with decreased postoperative opioid requirements. The efficacy of LB versus standard bupivacaine injections at laparoscopic port sites during bariatric surgery is unknown. OBJECTIVES: To determine whether there was a difference in postoperative hospital opioid requirements after port site injections of LB versus standard bupivacaine during laparoscopic bariatric surgeries. Primary endpoint was total in hospital opioid use expressed as morphine-equivalent use. Secondary endpoints included home opioid use, pain scores, hospital length of stay, and adverse events. SETTING: Academic-affiliated private practice. METHODS: A 2-group randomized, double-blinded trial from November 2017 to August 2018 with patients randomly assigned to receive either LB or bupivacaine alone at trocar site injections during laparoscopic Roux-en-Y gastric bypass (LRYGB) or vertical sleeve gastrectomy (VSG). All patients underwent enhanced recovery after bariatric surgery protocols. RESULTS: All patients undergoing LRYGB or VSG assessed for eligibility. Of 682 patients undergoing LRYGB or VSG, 231 met inclusion criteria, 52 patients excluded intraoperatively. Among 231 patients (mean age, 39.2 years; 79% women; mean body mass index 45.0), 179 patients (77%) completed the trial. Patients randomly assigned to receive either LB (n = 89) or bupivacaine alone (n = 90) at trocar site injection during LRYGB or VSG. Postoperative morphine-equivalent use were similar (LB 8.3 [standard deviation 4.0-13.9] versus bupivacaine group 7.5 [standard deviation 3.6-13.1] P = .94) with highest requirement in first 4 hours after surgery. There was no significant difference in length of stay, pain scores, or complications. There were more patients in the bupivacaine group that did not take pain medications on postoperative days 2 to 4 (P = .032, P = .23, P = .005, respectively). There were more patients in the bupivacaine group 48.1% (n = 39) compared with the LB group 34.2% (n = 27) that did not consume any narcotic tablets at home but this not found to be statistically significant (P value = .07). CONCLUSIONS: Among patients undergoing primary bariatric surgery under enhanced recovery after bariatric surgery protocol, there was no significant difference in postoperative hospital opioid use in those receiving LB compared with standard bupivacaine. A greater percentage of patients in the standard bupivacaine group did not require any narcotics at home, which was significant on postoperative days 2 to 4. To become completely opioid free after bariatric surgery, resources should be focused on multimodal approaches instead of reliance on type of anesthetic medication used.

Duodenal switch in revisional bariatric surgery: conclusions from an expert consensus panel.

BACKGROUND: Duodenal switch (BPD/DS) is gaining popularity as a secondary procedure for inadequate weight loss after an initial operation. OBJECTIVES: We aimed to generate expert consensus points on the appropriate use of BPD/DS in the revisional bariatric surgical setting. SETTING: Data were gathered at an international conference with attendees from a variety of different institutions and settings. METHODS: Sixteen lines of questioning regarding revisional BPD/DS were presented to an expert panel of 29 bariatric surgeons. Current available literature was reviewed extensively for each topic and proposed to the panel before polling. Responses were collected and topics defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement). RESULTS: Consensus was present in 10 of 16 lines of questioning, with several key points most prominent. CONCLUSIONS: As a second-stage procedure, BPD/DS is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity (96.7% agree) or as a subsequent operation for a reliable patient with insufficient weight loss after SG (88.5%). In a patient with weight regain and reflux and/or enlarged fundus after SG, Roux-en-Y gastric bypass is preferable and BPD/DS should be avoided (90%). BPD/DS should not be used prophylactically in patients with a history of jejunoileal bypass who are otherwise doing well (80.8%). Applicability of BPD/DS is limited by technical difficulty; 86.2% of experts would routinely recommend or consider the procedure if it were more technically feasible after failed bypass. No consensus was found on approaches to revision of BPD/DS for protein malnutrition.

Conversion of standard Roux-en-Y gastric bypass to distal bypass for weight loss failure and metabolic syndrome: 3-year follow-up and evolution of technique to reduce nutritional complications.

BACKGROUND: Standard proximal Roux-en-Y gastric bypass (RYGB) fails to achieve long-term weight maintenance and/or control of metabolic syndrome in up to 35% of patients. OBJECTIVES: To improve the performance of the standard proximal gastric bypass by increasing the biliopancreatic limb length at the expense of the common channel. SETTINGS: Academic-affiliated private practice. METHODS: A retrospective review of all patients who underwent conversion to distal RYGB from 2010 to 2016 was performed. RYGB was modified by dividing the Roux limb at the jejunojejunostomy and transposing it distally to create a shortened total alimentary limb length (TALL) of 250 to 300 cm in the initial 11 patients. Of these, 7 developed protein calorie malnutrition and diarrhea requiring a second procedure to lengthen the common channel an additional 100 to 150 cm (TALL 400-450 cm), leading to resolution of all symptoms. The subsequent 85 patients were converted to distal RYGB with TALL 400 to 450 in a single-stage operation. RESULTS: Ninety-six RYGB patients underwent conversion to distal RYGB. The mean body mass index and mean excess weight loss at the time of distalization was 40.6 kg/m2 and 33.6%. At 1, 2, and 3 years after distalization, the mean body mass index was reduced to 34.4, 33.1, and 32.2 kg/m2, respectively, and excess weight loss improved to 41.9%, 53.7%, and 65.7%, respectively. Diabetes resolved in 66.7%, hypertension resolved in 28.6%, hyperlipidemia resolved in 40%, and sleep apnea resolved in 50% at 1 year. The 30-day complication rate and reoperation rates were 6.3% and 5.2%; an additional 7.3% (7/96) required reoperation for limb lengthening. Hypoalbuminemia developed in 21% at 3 years, but no increase in iron deficiency was observed. Calcium metabolism was affected by the distalization procedure to a greater degree as 21% of patients had low corrected calcium levels, 77% were deficient in vitamin D, and parathyroid hormone levels were above normal in 64% at 3 years. CONCLUSION: Revision of proximal RYGB to distal RYGB results in substantial improvement in weight loss and resolution of co-morbidities at 3 years. Diarrhea and protein calorie malnutrition were seen frequently in patients with TALL of 250 to 300 cm, whereas patients with TALL 400 to 450 cm demonstrated a lower incidence of nutritional issues, but the effect on calcium, parathyroid hormone, and the fat soluble vitamins A and D is still a major concern.

Quantification of permethrin resistance and kdr alleles in Florida strains of Aedes aegypti (L.) and Aedes albopictus (Skuse).

Recent outbreaks of locally transmitted dengue and Zika viruses in Florida have placed more emphasis on integrated vector management plans for Aedes aegypti (L.) and Aedes albopictus Skuse. Adulticiding, primarily with pyrethroids, is often employed for the immediate control of potentially arbovirus-infected mosquitoes during outbreak situations. While pyrethroid resistance is common in Ae. aegypti worldwide and testing is recommended by CDC and WHO, resistance to this class of products has not been widely examined or quantified in Florida. To address this information gap, we performed the first study to quantify both pyrethroid resistance and genetic markers of pyrethroid resistance in Ae. aegypti and Ae. albopictus strains in Florida. Using direct topical application to measure intrinsic toxicity, we examined 21 Ae. aegypti strains from 9 counties and found permethrin resistance (resistance ratio (RR) = 6-61-fold) in all strains when compared to the susceptible ORL1952 control strain. Permethrin resistance in five strains of Ae. albopictus was very low (RR<1.6) even when collected from the same containers producing resistant Ae. aegypti. Characterization of two sodium channel kdr alleles associated with pyrethroid-resistance showed widespread distribution in 62 strains of Ae. aegypti. The 1534 phenylalanine to cysteine (F1534C) single nucleotide polymorphism SNP was fixed or nearly fixed in all strains regardless of RR. We observed much more variation in the 1016 valine to isoleucine (V1016I) allele and observed that an increasing frequency of the homozygous V1016I allele correlates strongly with increased RR (Pearson corr = 0.905). In agreement with previous studies, we observed a very low frequency of three kdr genotypes, IIFF, VIFF, and IIFC. In this study, we provide a statewide examination of pyrethroid resistance, and demonstrate that permethrin resistance and the genetic markers for resistance are widely present in FL Ae. aegypti. Resistance testing should be included in an effective management program.

Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery.

OBJECTIVE Perception of perioperative pain is influenced by various psychological factors. The aim of this study was to determine the impact of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain scores, and quality of recovery in adults who underwent spine surgery. METHODS Patients undergoing spine surgery were enrolled in this study, and the preoperatively completed questionnaires included the verbal rating scale (VRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Opioid consumption and pain scores according to the VRS were recorded daily until discharge. RESULTS One hundred thirty-nine patients were recruited for the study, and 101 completed the QoR40 assessment postoperatively. Patients with higher catastrophizing scores were more likely to have higher maximum pain scores postoperatively (estimate: 0.03, SE: 0.01, p = 0.02), without increased opioid use (estimate: 0.44, SE: 0.27, p = 0.11). Preoperative anxiety (estimate: 1.18, SE: 0.65, p = 0.07) and depression scores (estimate: 1.06, SE: 0.71, p = 0.14) did not correlate with increased postoperative opioid use; however, patients with higher preoperative depression scores had lower quality of recovery after surgery (estimate: -1.9, SE: 0.56, p < 0.001). CONCLUSIONS Catastrophizing, anxiety, and depression play important roles in modulating postoperative pain. Preoperative evaluation of these factors, utilizing a validated tool, helps to identify patients at risk. This might allow for earlier psychological intervention that could reduce pain severity and improve the quality of recovery.

Accuracy of loop-mediated isothermal amplification for the diagnosis of Clostridium difficile infection: a systematic review.

Loop-mediated isothermal DNA amplification (LAMP) is currently used as standalone diagnostic test for C. difficile infection (CDI). We assessed the diagnostic accuracy of LAMP for the diagnosis of CDI. We searched 5 databases to identify studies that compared LAMP with culture cytotoxicity neutralization assay or anaerobic toxigenic culture (TC) of C. difficile. We used the random-effects model to calculate pooled sensitivities, specificities, diagnostic odds ratios, and their 95% confidence intervals (CIs). The search of the databases yielded 16 studies (6979 samples) that met inclusion criteria. When TC was used as the gold standard (6572 samples), bivariate analysis yielded a mean sensitivity of 0.95 (95% CI, 0.93-0.97; I(2)=67.4) and a mean specificity of 0.99 (95% CI, 0.96-1.00; I(2)=97.0). LAMP is a useful diagnostic tool with high sensitivity and specificity for detecting CDI. The results should, however, be interpreted only in the presence of clinical suspicion and symptoms of CDI.