Perceptions of dengue risk and acceptability of a dengue vaccine in residents of Puerto Rico.

Dengvaxia is the first dengue vaccine recommended in the United States (U.S.). It is recommended for children aged 9-16 y with laboratory-confirmed previous dengue infection and living in areas where dengue is endemic. We conducted focus groups with parents and in-depth interviews with key informants (i.e. practicing pediatricians, physicians from immunization clinics, university researchers, and school officials) in Puerto Rico (P.R.) to examine acceptability, barriers, and motivators to vaccinate with Dengvaxia. We also carried out informal meetings and semi-structured interviews to evaluate key messages and educational materials with pediatricians and parents. Barriers to vaccination included lack of information, distrust toward new vaccines, vaccine side effects and risks, and high cost of/lack of insurance coverage for laboratory tests and vaccines. Motivators included clear information about the vaccine, a desire to prevent future dengue infections, the experience of a previous dengue infection or awareness of dengue fatality, vaccine and laboratory tests covered by health insurance, availability of rapid test results and vaccine appointments. School officials and parents agreed parents would pay a deductible of $5-20 for Dengvaxia. For vaccine information dissemination, parents preferred an educational campaign through traditional media and social media, and one-on-one counseling of parents by healthcare providers. Education about this vaccine to healthcare providers will help them answer parents' questions. Dengvaxia acceptability in P.R. will increase by addressing motivators and barriers to vaccination and by disseminating vaccine information in plain language through spokespersons from health institutions in P.R.

A narrative review of imaging for pancreas adenocarcinoma: staging, surgical considerations, and surveillance.

Background and Objective: Pancreas adenocarcinoma is a disease with dire prognosis. Imaging is pivotal to the diagnosis, staging, reassessment, surgical planning, and surveillance of pancreas cancer. The purpose of this paper is to provide the reader an overview of current imaging practices for pancreas adenocarcinoma. Methods: A literature search of original papers and reviews through 2022 was performed using the PubMed database. The most current American College of Radiology Appropriateness Criteria and National Comprehensive Cancer Network guidelines on pancreas cancer imaging were also included. Key Content and Findings: Multidisciplinary team care at a high-volume institution is instrumental to optimal patient management and outcomes. It is therefore important for all team members to be aware of imaging modality options, strengths, and challenges. Additionally, a high-level understanding of imaging findings is useful clinically. This manuscript provides a current overview of imaging modalities used in the identification and assessment of pancreas adenocarcinoma, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. Imaging findings, including the expected and unexpected, are reviewed to give the novice imager a better understanding. Conclusions: This review provides a current overview of imaging for pancreas adenocarcinoma, including strengths and weakness of various imaging modalities; therefore, providing the reader with a robust resource when considering imaging in the management of this disease.

Management of Body Condition Score between Pregnancy Scanning and Lamb Marking Impacts the Survival of Triplet-Bearing Ewes and Their Lambs.

This study evaluated the impacts of management of body condition score (BCS) between pregnancy scanning and lamb marking on the mortality of triplet-bearing ewes and their lambs at 19 research sites across Southern Australia. Triplet-bearing ewes of Maternal (crossbred or composite) or Merino breed were randomly allocated to treatment at pregnancy scanning at an average of 97 days from the start of joining: High or Low BCS. The BCS of individual ewes was assessed at pregnancy scanning, pre-lambing (average of 137 days from the start of joining) and marking (average of 165 days from the end of joining), and ewe and lamb mortality to marking, recorded for each mob. The average BCS at pregnancy scanning was 3.4 for Maternal ewes and 3.3 for Merino ewes. There were no breed by BCS treatment effects on the BCS of ewes at pregnancy scanning or lamb marking or on the change in BCS between pregnancy scanning and pre-lambing or between pre-lambing and marking. The change in BCS differed between the High and Low BCS treatments, between pregnancy scanning and pre-lambing (0.12 vs. -0.33; p < 0.001) and between pre-lambing and marking (-0.39 vs. 0.07; p < 0.001) but did not differ between breeds. The average BCS at marking for ewes managed at the High and Low BCS treatments was 3.1 and 3.0 for Maternals and 3.0 and 2.8 for Merinos. Survival of triplet-bearing Merino ewes (p < 0.01) and their lambs (p < 0.001) was greater when ewes were managed at the High BCS compared to the Low BCS. The BCS treatment did not impact the survival of Maternal ewes or their lambs. The survival of Merino but not Maternal lambs was higher when ewes were in greater BCS pre-lambing (p < 0.01) and when ewes gained BCS between pregnancy scanning and pre-lambing (p < 0.01). Ewe mortality was lower when ewes gained BCS between pregnancy scanning and pre-lambing (p < 0.05). Merino ewes were more likely to die than Maternal ewes for a given change in BCS between pregnancy scanning and pre-lambing (p = 0.065). Overall, our findings demonstrate that producers should manage the nutrition of triplet-bearing Merino ewes so that ewes are in greater BCS at lambing and/or to gain BCS between pregnancy scanning and lambing to improve ewe and lamb survival. Triplet-bearing Maternal ewes should be managed to gain BCS between pregnancy scanning and lambing to improve ewe survival.

Decreasing Mob Size at Lambing Increases the Survival of Triplet Lambs Born on Farms across Southern Australia.

Industry consultation in Australia revealed that the potential impact of the mob size of ewes during lambing on the survival of triplet-born lambs was an important research priority. Previous research has demonstrated that smaller mob sizes at lambing improve the survival of single- and especially twin-born lambs, regardless of ewe stocking rate. Therefore, we hypothesised that lambing triplet-bearing ewes in smaller mobs, regardless of stocking rate, will increase the survival of their lambs. Research sites were established on 12 commercial sheep farms across southern Australia between 2019 and 2021. One farm used Merinos whilst the remainder of the farms used non-Merino breeds, consisting of composite ewes joined to composite or terminal sires. Three of the farms were used in two years of the experiment. Adult, triplet-bearing ewes were randomly allocated into one of two treatments, 'High' or 'Low' mob size, at an average of 135 days from the start of joining. Ewe and lamb survival were assessed between allocation to treatments and lamb marking. Lamb survival was significantly greater for lambs born in the Low (65.6%) compared with the High (56.6%) mob size treatments (p < 0.001). There was no effect of mob size at lambing on the mortality of triplet-bearing ewes. Analysis of the effect of the actual mob sizes showed that reducing the mob size at lambing by 10 triplet-bearing ewes increased the survival of their lambs to marking by 1.5% (p < 0.001). This study has shown that the survival of triplet-born lambs can be improved by lambing triplet-bearing ewes in smaller mobs regardless of stocking rate when ranging from 0.7-13 ewes/ha.

Reproductive Performance of Triplet-Bearing Ewes on Commercial Farms and Research Priorities Identified by Sheep Producers to Improve the Survival of Triplet-Bearing Ewes and Their Lambs.

Consultation with sheep producers was used to quantify the mortality of triplet-bearing ewes and their lambs, identify management practices adopted by producers to reduce these losses and prioritise future research needs to improve the survival of triplet-bearing ewes and their lambs. Surveys were completed by 64 producers across Australia who identified and separated triplet-bearing ewes from twin-bearing ewes in 2017 and/or 2018. On average, 5.9% of all ewes mated were identified as carrying triplets (6.6% of non-Merino ewes and 2.9% of Merino ewes). The average mortality of triplet-bearing ewes was 6.4%, and ewe mortality did not differ significantly between ewe breeds. The average survival of triplet-born lambs was 59%, and survival was significantly higher for lambs from non-Merino compared to Merino ewes (60.1 vs. 52.9%, p < 0.05). The key strategies adopted to reduce the mortality of triplet-bearing ewes and their lambs included management of condition score, feed-on-offer, mob size at lambing and use of shelter. There were no differences (p > 0.05) in the average mortality of triplet-bearing ewes or their lambs between producers that prioritised the adoption of certain management practices. However, significant variation existed between producers in their targets at lambing for ewe condition score (2.8 to 3.5), mob size (10 to 150 ewes) and feed-on-offer (800 to 2500 kg dry matter/ha). Overwhelmingly, the highest priorities for further research identified by producers from surveys, workshops and a webinar were ewe condition score, mob size, feed-on-offer at lambing and mineral supplementation. This study informs benchmarks for mortality of triplet-bearing ewes and their lambs under extensive grazing conditions in Australia, and the priorities for future research to reduce these losses.

Novel Use of Time-Resolved Magnetic Resonance Angiography to Evaluate Retrograde Lumbar Vein Flow and Epidural Venous Plexus Enhancement in Chronic Headache Patients With and Without Nutcracker Physiology.

OBJECTIVE: Compression of the left renal vein by the superior mesenteric artery, known as nutcracker phenomenon (NCP), can cause retrograde flow and congestion in communicating venous systems. It has recently been speculated that NCP can result in retrograde flow and congestion of the lumbar veins and epidural venous plexus (EVP), thereby affecting the central nervous system. This study describes the novel use of time-resolved magnetic resonance angiography (trMRA) to evaluate for retrograde left second lumbar vein (L2LV) flow and early EVP enhancement in patients with chronic daily headache (CDH) with and without NCP. METHODS: A retrospective analysis was performed of 31 patients with CDH (27 females and 4 males; median age, 38 years [range, 18-63 years]) who underwent trMRA centered over the L2LV to evaluate the direction of blood flow and presence of early EVP enhancement from May 2020 to March 2022. Descriptive statistics were performed, and anatomic associations were analyzed in patients with and without retrograde L2LV flow and early EVP enhancement. The accuracy of magnetic resonance imaging findings in detecting these flow patterns was also assessed. RESULTS: Patients with NCP who demonstrated narrowing of the left renal vein, a positive beak sign ( P = 0.052), decreased aortomesenteric distance ( P = 0.038), and decreased SMA angle demonstrated increased rates of retrograde L2LV flow and early EVP enhancement. A positive beak sign was 83% specific, and an aortomesenteric distance of ≤6.5 mm was 61% sensitive and 83% specific for identifying retrograde L2LV flow with early regional EVP enhancement in patients with CDH. CONCLUSIONS: Retrograde L2LV flow with early EVP enhancement in CDH patients can be effectively evaluated using trMRA and was seen with greater propensity in those patients with NCP.

Predicting Early Weight Loss Failure Using a Bariatric Surgery Outcomes Calculator and Weight Loss Curves.

CONTEXT: Weight loss after bariatric surgery can be accurately predicted using an outcomes calculator; however, outliers exist that do not meet the 1 year post-surgery weight projections. OBJECTIVE: Our goal was to determine how soon after surgery these outliers can be identified. DESIGN: We conducted a retrospective cohort study. SETTING, PATIENTS, AND INTERVENTION: Using a bariatric surgery outcomes calculator formulated by the Michigan Bariatric Surgery Collaborative (MBSC), predicted weight loss at 1 year post-surgery was calculated on all patients who underwent primary bariatric surgery at a single-center academic institution between 2006 and 2015 who also had a documented 1-year follow-up weight (n = 1050). MAIN OUTCOME MEASURES: Weight loss curves were compared between high, low, and non-outliers as defined by their observed-to-expected (O:E) weight loss ratio based on total body weight loss (TBWL) %. RESULTS: Mean predicted weight loss for the study group was 39.1 ± 9.9 kg, while mean actual weight loss was 39.7 ± 17.1 kg resulting in a mean O:E 1.01 (± 0.35). Based on analysis of the O:E ratios at 1 year post-surgery, the study group was sub-classified. Low outliers (n = 188, O:E 0.51) had significantly lower weight loss at 2 months (13.1% vs 15.6% and 16.5% TBWL, p < 0. 001) and at 6 months (19% vs 26% and 30% TBWL, p < 0.001) when compared to non-outliers (n = 638, O:E 1.00) and high outliers (n = 224, O:E 1.46), respectively. CONCLUSIONS: Weight loss curves based on individually calculated outcomes can help identify low outliers for additional interventions as early as 2 months after bariatric surgery.

An accelerated hospital observation pathway to reduce length of stay for patients with COVID-19.

OBJECTIVES: Strategies to maintain hospital capacity during the COVID-19 pandemic included reducing hospital length of stay (LOS) for infected patients. We sought to evaluate the association between LOS and enrollment in the COVID Accelerated Care Pathway, which consisted of a hospital observation protocol and postdischarge automated text message-based monitoring. STUDY DESIGN: Retrospective matched cohort study of patients hospitalized from December 14, 2020, to January 31, 2021. METHODS: Participants were patients who presented to the emergency department with acute infection due to COVID-19, required hospitalization, and met pathway inclusion criteria. Participants were compared with a propensity score-matched cohort of patients with COVID-19 admitted to the same hospital during the 7 weeks preceding and following pathway implementation. RESULTS: There were 44 patients in the intervention group and 83 patients in the propensity score-matched cohort. The mean (SD) hospital LOS for patients in the intervention group was 1.7 (2.6) days compared with 3.9 (2.3) days for patients in the matched cohort (difference, -2.2 days; 95% CI, -3.3 to -1.1). In the intervention group, 2 patients (5%; 95% CI, 0%-15%) were rehospitalized within 14 days compared with 8 (10%; 95% CI, 4%-17%) in the matched cohort. CONCLUSIONS: Patients with COVID-19 who were managed through an accelerated hospital observation protocol and postdischarge monitoring service had reduced hospital LOS compared with patients receiving standard care. Hospital preparedness for future public health emergencies may involve the design of pathways that reduce the time that patients spend in the hospital, lower cost, and ensure continued recovery upon discharge.

Toxoplasma gondii is not an important contributor to poor reproductive performance of primiparous ewes from southern Australia: a prospective cohort study.

BACKGROUND: Toxoplasma gondii causes reproductive losses in sheep worldwide, including Australia. The reproductive performance of primiparous ewes is typically lower than for mature, multiparous ewes, and younger ewes are more likely to be immunologically naïve and therefore more susceptible to reproductive disease if T. gondii infection occurs during pregnancy. The aim of this study was to assess the impact of infection with T. gondii on the reproductive performance of primiparous ewes in southern Australia using a prospective cohort study. This will inform the need for targeted control strategies for T. gondii in Australian sheep. RESULTS: Toxoplasma gondii seropositivity using indirect ELISA was detected at 16/28 farms located across southern Australia. Apparent seropositivity to T. gondii was lower in primiparous ewes (1.1, 95% confidence interval (CI) 0.6, 1.8) compared to mature, multiparous ewes (8.1, 95% CI 6.0, 10.5; P < 0.001). Toxoplasma gondii seroconversion during the gestation and lambing period was confirmed for 11/1097 (1.0, 95% CI 0.5, 1.7) of pregnant primiparous ewes that failed to raise a lamb, and 1/161 (0.6, 95% CI 0.1, 2.9) primiparous ewes with confirmed mid-pregnancy abortion. CONCLUSIONS: Low frequency of detection of T. gondii seroconversion during gestation and low frequency of seropositivity to T. gondii suggests that toxoplasmosis was not an important contributor to reproductive losses in primiparous ewes on farms located over a wide geographical area in southern Australia.

Seropositivity to Coxiella burnetii in primiparous and multiparous ewes from southern Australia: A cross-sectional study.

The role of infectious diseases including coxiellosis in causing poorer reproductive performance of primiparous ewes are not well studied. The aims of this study were to determine if natural exposure to Coxiella burnetii is widespread in breeding ewes and whether seropositivity is associated with poor reproductive performance of primiparous ewes. Seropositivity to Coxiella burnetii was 0.08% (CI95% 0.01, 0.36) in primiparous ewes and 0.36% (CI95% 0.07, 1.14) in mature ewes. Coxiella burnetii was not detected in aborted or stillborn lambs using qPCR. These findings suggest C. burnetii infection was unlikely to be an important contributor to abortion and perinatal mortalities observed for primiparous ewe flocks, and exposure to C. burnetii was not widespread in ewes on farms located over wide geographical region of southern Australia. Whilst ewes on these farms were not an important reservoir for C. burnetii, sporadic zoonotic transmission from sheep is reported and has public health implications.

Neospora caninum is not an important contributor to poor reproductive performance of primiparous ewes from southern Australia: evidence from a cross-sectional study.

Neospora caninum has been implicated as a sporadic cause of abortion and perinatal deaths in sheep flocks globally. However, its significance as a reproductive pathogen for sheep in Australia remains unknown. The aims of this study were to (i) determine the seroprevalence of N. caninum in Australian breeding ewes and (ii) examine if natural exposure to N. caninum is associated with poor reproductive performance of primiparous ewes in southern Australia. Thirty flocks of primiparous ewes (aged 1-2 years old at lambing) from 28 farms in three states (Western Australia, South Australia and Victoria) were monitored between mating and lamb marking. Blood samples were also collected from multiparous mature ewes (aged 3 years or older) at each farm. Seroprevalence for anti-N. caninum IgG using indirect ELISA was determined for a subset of primiparous ewes that were predominantly determined to be pregnant and subsequently failed to rear a lamb (n = 1279) and randomly selected mature multiparous ewes with unknown reproductive status (n = 558). Neopsora caninum apparent seroprevalence was 0.16% (95% confidence interval 0.03%, 0.5%) in primiparous ewes, with seropositivity identified in two ewes from farms located in South Australia and Victoria. There was no evidence of seropositivity in mature ewes with apparent seroprevalence 0% (0%, 0.45%). These findings suggest that N. caninum infection was not widespread in primiparous ewes or mature multiparous ewes on these farms, and exposure to N. caninum infection was unlikely to explain abortion and perinatal mortalities observed for primiparous ewes.

The impact of lamb and ewe mortality associated with dystocia on Australian and New Zealand sheep farms: A systematic review, meta-analysis and bio-economic model.

Dystocia contributes to lamb and ewe mortality in the periparturient period but impacts for extensive sheep production systems remain poorly understood. Here we show that lamb and ewe mortality associated with dystocia has important impacts on sheep production in Australia and New Zealand, and quantify financial impacts for the Australian sheep industry. A systematic review of the literature identified 11 publications published since 1990 that reported sheep mortality due to dystocia in Australia or New Zealand. Assumptions for ewe breeding flock structure and reproductive performance were based on Australian sheep industry data. The proportion of lamb mortality attributable to dystocia (including stillbirths and perinatal deaths with evidence of hypoxic injury) pooled across all studies (pooled proportional mortality ratio) was 47 % (95 % Confidence Interval (CI): 38, 55). Pooled proportional mortality ratio for Australian studies was 53 % (95 %CI: 47, 60), and for New Zealand studies was 35 % (95 %CI: 19, 51). Pooled proportional mortality ratio was similar for lambs born to Merino and non-Merino ewes, although more data are needed to determine effects of ewe breed independent of other factors. Pooled proportional mortality ratio was higher for single lambs (59 %; 95 % CI: 55, 63) than twin (47 %; 41, 54) or triplet (49 %; 46, 52) lambs. However, the number of dystocia-associated mortalities is higher for twin-born lambs than for singles because total mortality is higher for twin-born lambs. It is estimated that approximately 7.7 million lamb deaths and 297,500 ewe deaths per year are attributable to dystocia in Australia for the national flock of 38 million breeding ewes. The whole-farm bio-economic Model of an Integrated Dryland Agricultural System (MIDAS) was used to determine the impacts of dystocia-associated ewe and lamb mortality on Australian farm profit. Dystocia is estimated to reduce Australian national farm profit by AU$780 million or $23.00 per ewe mated based on an assumed lamb sale price of AU$6.50 per kg carcass weight. These estimates do not include the costs of reduced productivity for surviving ewes and lambs, intervention, post-farmgate impacts, delayed genetic progress, or impacts on animal welfare and access into sheep meat and wool markets. Reducing dystocia through improved genetics and sheep management will improve animal welfare and farm profit.

The SARS-CoV-2 pandemic: the race to trace: contact tracing scale-up in San Francisco-early lessons learned.

In order to effectively control spread of coronavirus 2019 (COVID-19), it is essential that jurisdictions have the capacity to rapidly trace close contacts of each and every case. Best practice guidance on how to implement such programs is urgently needed. We describe the early experience in the City and County of San Francisco (CCSF), where the City's Department of Health expanded contact tracing capability in anticipation of changes in San Francisco's 'shelter in place' order between April and June 2020. Important prerequisites to successful scale-up included a rapid expansion of the COVID-19 response workforce, expansion of testing capability, and other containment resources. San Francisco's scale-up offers a model for how other jurisdictions can rapidly mobilize a workforce. We underscore the importance of an efficient digital case management system, effective training, and expansion of supportive service programs for those in quarantine or isolation, and metrics to ensure continuous performance improvement.

Chlamydia pecorum detection in aborted and stillborn lambs from Western Australia.

Lamb survival is an important welfare and productivity issue for sheep industries worldwide. Lower lamb survival has been reported for primiparous ewes, but the causes of this are not well studied. The aim of this study was to determine causes of perinatal deaths for lambs born to primiparous ewes in Western Australia, and identify if infectious diseases are implicated. Lamb mortality from birth to marking were determined for 11 primiparous ewe flocks on 10 farms in Western Australia. Lamb mortality from birth to marking averaged 14% for single-born and 26% for multiple-born lambs. Lamb necropsies (n = 298) identified starvation-mismosthering-exposure (34%), dystocia (24%) and stillbirth (15%) as the most common causes of perinatal lamb death. There was no evidence of exotic abortigenic pathogens in aborted and stillborn lambs (n = 35). Chlamydia pecorum was detected by qPCR in 15/35 aborted and stillborn lambs on 5/6 farms. Preliminary molecular characterisation of C. pecorum detected in samples from aborted and stillborn lambs (n = 8) using both Multilocus Sequence Typing and ompA genotyping indicated all strains were genetically identical to previously described pathogenic livestock strains, denoted ST23, and dissimilar to gastrointestinal strains. High frequency of detection of a pathogenic C. pecorum strains ST23 associated with ovine abortion and stillbirth on multiple farms located across a wide geographic area has not been previously reported. Chlamydia pecorum may contribute to reproductive wastage for primiparous sheep in Western Australia. Further investigation to understand C. pecorum epidemiology and impact on sheep reproduction is warranted.

Abortion and Lamb Mortality between Pregnancy Scanning and Lamb Marking for Maiden Ewes in Southern Australia.

The contribution of abortions to the overall mortality of lambs born to maiden (primiparous) ewes in Australia remains unclear. This cohort study aimed to quantify abortion and lamb mortality for ewe lambs and maiden Merino two-tooth ewes. Lamb mortality from pregnancy scanning to marking were determined for 19 ewe lamb and 11 Merino two-tooth ewe flocks across southern Australia. Average lamb mortality from scanning to marking was 35.8% (range 14.3-71.1%) for the ewe lambs and 29.4% (range 19.7-52.7%) for the two-tooth ewes. Mid-pregnancy abortion was detected in 5.7% of ewes (range 0-50%) in the ewe lamb flocks and 0.9% of ewes (range 0-4.4%) in the two-tooth ewe flocks. Mid-pregnancy abortion affecting ≥2% of ewes was observed in 6/19 ewe lamb flocks and 2/11 two-tooth ewe flocks. Lamb mortality from birth to marking represented the greatest contributor to foetal and lamb mortality after scanning, but mid-pregnancy abortion was an important contributor to lamb mortality in some ewe lamb flocks. Variability between the flocks indicates scope to improve the overall reproductive performance for maiden ewes by reducing foetal and lamb losses. Addressing mid-pregnancy abortion may improve the reproductive performance in some flocks.

Metabolic Parameters, Weight Loss, and Comorbidities 4 Years After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

BACKGROUND: Sleeve gastrectomy (LSG) is now the predominant bariatric surgery performed, yet there is limited long-term data comparing important outcomes between LSG and Roux-en-Y gastric bypass (RYGB). This study compares weight loss and impact on comorbidities of the two procedures. METHODS: We retrospectively evaluated weight, blood pressure, hemoglobin A1c, cholesterol, and medication use for hypertension, diabetes, and hyperlipidemia at 1-4 years post-operatively in 380 patients who underwent RYGB and 334 patients who underwent LSG at the University of Michigan from January 2008 to November 2013. Follow-up rates from 714 patients initially were 657 (92%), 556 (78%), 507 (71%), and 498 (70%) at 1-4 years post-operatively. RESULTS: Baseline characteristics were similar except for higher weight and BMI in LSG. There was greater weight loss with RYGB vs. LSG at all points. Hemoglobin A1c and total cholesterol improved more in RYGB vs. LSG at 4 years. There was greater remission of hypertension and discontinuation of all medications for hypertension and diabetes with RYGB at 4 years. CONCLUSIONS: Weight loss, reduction in medications for hypertension and diabetes, improvements in markers of diabetes and hyperlipidemia, and remission rates of hypertension were superior with RYGB vs. LSG 4 years post-operatively. Choice of bariatric procedures should be tailored to surgical risk, comorbidities, and weight loss goals.

Milestone Weight Loss Goals (Weight Normalization and Remission of Obesity) after Gastric Bypass Surgery: Long-Term Results from the University of Michigan.

BACKGROUND: Rates of weight normalization and obesity remission after Roux-en-Y gastric bypass (GB) are unknown. This study evaluated weight loss, rates of achieving body mass index (BMI) <25 or 30 kg/m2, recidivism, and predictors of success following GB. METHODS: We retrospectively studied weight and BMI at baseline, 2 and 6 months, and annually at 1-7 years in 219 patients undergoing GB at the University of Michigan from January 2008 to November 2010. RESULTS: Follow-up was excellent for a population traditionally associated with high attrition rates with data availability of 157/219, 145/219, 144/219, 134/219, 123/219, 82/161, and 29/64 patients at 1-7 years, respectively. Mean baseline BMI was 47.0 kg/m2. Weight normalization (BMI <25 kg/m2) occurred in 2.3-6.8% of patients. More importantly, 47% of patients achieved remission of obesity (BMI <30 kg/m2) at some time point and 24% (52/219) at the last observed time point. BMI <30 kg/m2 was associated with a lower initial BMI and follow-up for more than 2 years. CONCLUSIONS: Rates of weight normalization are low after GB; however, a large number of patients achieved BMI <30 kg/m2. While the percent total weight loss and excess weight loss are both quite high in the entire cohort and this is likely associated with significant health benefits, our results still underscore the need to address obesity with intensive clinical attention earlier in its course.

Supporting Better Evidence Generation and Use within Social Innovation in Health in Low- and Middle-Income Countries: A Qualitative Study.

BACKGROUND: While several papers have highlighted a lack of evidence to scale social innovations in health, fewer have explored decision-maker understandings of the relative merit of different types of evidence, how such data are interpreted and applied, and what practical support is required to improve evidence generation. The objectives of this paper are to understand (1) beliefs and attitudes towards the value of and types of evidence in scaling social innovations for health, (2) approaches to evidence generation and evaluation used in systems and policy change, and (3) how better evidence-generation can be undertaken and supported within social innovation in health. METHODS: Thirty-two one-on-one interviews were conducted between July and November 2015 with purposively selected practitioners, policymakers, and funders from low- and middle- income countries (LMICs). Data were analysed using a Framework Analysis Approach. RESULTS: While practitioners, funders, and policymakers said they held outcome evidence in high regard, their practices only bear out this assertion to varying degrees. Few have given systematic consideration to potential unintended consequences, in particular harm, of the programs they implement, fund, or adopt. Stakeholders suggest that better evidence-generation can be undertaken and supported within social innovation in health by supporting the research efforts of emerging community organizations; creating links between practitioners and academia; altering the funding landscape for evidence-generation; providing responsive technical education; and creating accountability for funders, practitioners, and policymakers. CONCLUSION: How better evidence-generation can be undertaken and supported within social innovation in health is a previously under-operationalised aspect of the policy-making process that remains essential in order to refrain from causing harm, enable the optimization of existing interventions, and ultimately, to scale and fund what works.

Roux-En-Y Gastric Bypass Vs. Sleeve Gastrectomy: Balancing the Risks of Surgery with the Benefits of Weight Loss.

BACKGROUND: The purpose of the study was to compare weight loss, metabolic parameters, and postoperative complications in patients undergoing Roux-en-Y gastric bypass (GB) and sleeve gastrectomy (SG). METHODS: We retrospectively studied 30-day postoperative complications as well as change in weight, blood pressure, cholesterol, hemoglobin, hemoglobin A1C, and creatinine from baseline to 2, 6, 12, and 24 months postoperatively in 383 patients undergoing GB and 336 patients undergoing SG at the University of Michigan from January 2008 to November 2013. For a study population which typically has high attrition rates, there were excellent follow-up rates (706/719 at 2 months, 566/719 at 6 months, 519/719 at 12 months, and 382/719 at 24 months). RESULTS: Baseline characteristics were similar in both groups except for higher weight and BMI in the SG group. The GB group experienced greater total body weight loss at 6, 12, and 24 months (41.9 vs. 34.6 kg at 24 months, p < 0.0001). Excess weight loss was 69.7 and 51.7 % following GB and SG respectively at 24 months (p < 0.0001). BP improved significantly in both groups. Surgical complication rates were greater after GB (10.1 vs. 3.5 %, p = 0.0007) with no significant difference in life-threatening or potentially life-threatening complications. CONCLUSIONS: Weight loss was greater following GB compared to SG at 2 years. The risk for surgical complications was greater following GB. Surgical intervention should be tailored to surgical risk, comorbidities, and desired weight loss.