Comparing remission and recurrence of hypertension after bariatric surgery: vertical sleeve gastrectomy versus Roux-en-Y gastric bypass.

BACKGROUND: Bariatric surgery results in rapid weight loss and resolution of many co-morbidities including hypertension. OBJECTIVES: To investigate the association of the 2 most common bariatric surgical procedures, vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB), with sustained remission from hypertension, and evaluate other independent predictors of sustained remission. SETTING: Privately insured patients with hypertension in the United States undergoing bariatric surgery. METHODS: A cohort of hypertensive bariatric patients was created using detailed inclusion and exclusion criteria. Remission was defined as no refill of antihypertensive medication for 30 days after patients' medication was expected to run out, and recurrence as medication refill after at least 90 days of remission. RESULTS: Of 7006 patients in our cohort, 5874 experienced remission of their hypertension (83.8%). 745 of the 5874 (12.7%) patients later experienced recurrence. The adjusted hazard ratio of remission for VSG compared with RYGB was 1.06 (95% confidence interval [CI]; 1.0, 1.11). The adjusted hazard ratio of recurrence for VSG compared with RYGB was .84 (95% CI; .71, .97). A higher number of medications at the time of surgery was associated with a decreased likelihood of remission and an increased risk of recurrence of hypertension. CONCLUSION: There was no difference in the likelihood of remission of hypertension between VSG and RYGB. The number of medications at the time of surgery was the most important predictor of remission and recurrence of hypertension after surgery.

Impact of type 2 diabetes on hospitalization and mortality in people with malignancy.

AIM: To compare the characteristics of and outcomes for people with malignancies with and without a co-diagnosis of diabetes. METHODS: Emergency department and hospital discharge data from a single centre for the period between 1 January 2015 and 31 December 2017 were used to identify people with a diagnosis of a malignancy and diabetes. Multivariate Cox regression models were used to estimate the effect of diabetes on all-cause mortality. A truncated negative binomial regression model was used to assess the impact of diabetes on length of hospital inpatient stay. Prentice-Williams-Peterson total time models were used to assess the effect of diabetes on number of emergency department re-presentations and inpatient re-admissions. RESULTS: Of 7004 people identified with malignancies, 1195 (17.1%) were also diagnosed with diabetes. A diagnosis of diabetes was associated with a greater number of inpatient re-admissions [adjusted hazard ratio 1.13 (95% CI 1.03, 1.24)], a greater number of emergency department re-presentations [adjusted hazard ratio 1.13 (95% CI 1.05, 1.22)] and longer length of stay [adjusted incidence rate ratio 1.14 (95% CI 1.04, 1.25)]. A co-diagnosis of diabetes was also associated with a 48% increased risk of all-cause mortality [adjusted hazard ratio 1.48 (95% CI 1.22-1.76)]. CONCLUSIONS: People with malignancies and diabetes had significantly more emergency department presentations, more inpatient admissions, longer length of hospital stay and higher rates of all-cause mortality compared to people with a malignancy without diabetes.

Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study.

BACKGROUND: The Duke Activity Status Index (DASI) questionnaire might help incorporate self-reported functional capacity into preoperative risk assessment. Nonetheless, prognostically important thresholds in DASI scores remain unclear. We conducted a nested cohort analysis of the Measurement of Exercise Tolerance before Surgery (METS) study to characterise the association of preoperative DASI scores with postoperative death or complications. METHODS: The analysis included 1546 participants (≥40 yr of age) at an elevated cardiac risk who had inpatient noncardiac surgery. The primary outcome was 30-day death or myocardial injury. The secondary outcomes were 30-day death or myocardial infarction, in-hospital moderate-to-severe complications, and 1 yr death or new disability. Multivariable logistic regression modelling was used to characterise the adjusted association of preoperative DASI scores with outcomes. RESULTS: The DASI score had non-linear associations with outcomes. Self-reported functional capacity better than a DASI score of 34 was associated with reduced odds of 30-day death or myocardial injury (odds ratio: 0.97 per 1 point increase above 34; 95% confidence interval [CI]: 0.96-0.99) and 1 yr death or new disability (odds ratio: 0.96 per 1 point increase above 34; 95% CI: 0.92-0.99). Self-reported functional capacity worse than a DASI score of 34 was associated with increased odds of 30-day death or myocardial infarction (odds ratio: 1.05 per 1 point decrease below 34; 95% CI: 1.00-1.09), and moderate-to-severe complications (odds ratio: 1.03 per 1 point decrease below 34; 95% CI: 1.01-1.05). CONCLUSIONS: A DASI score of 34 represents a threshold for identifying patients at risk for myocardial injury, myocardial infarction, moderate-to-severe complications, and new disability.

Adolescent bariatric surgery: a qualitative exploratory study of US patient perspectives.

Bariatric surgery is a safe and effective intervention to treat severe obesity and related comorbidities in adolescents. No qualitative studies have explored the perspectives of US adolescent weight-loss patients on their bariatric surgery motivations, decision-making or experiences. The purpose of this qualitative exploratory study was to explore the perspectives of adolescent patients seeking bariatric surgery while enrolled in a medical weight management programme. Eligible participants 13-21 years old were recruited through a weight management programme at a tertiary care children's hospital in the US Midwest. Interviews were conducted remotely using a video chat medium. An initial 60-min semi-structured interview was conducted with seven participants who were 16-21 years old: one deciding on bariatric surgery, one pre-operative and five post-operative. A brief follow-up interview was conducted 1 month later with four participants. Interviews were transcribed and coded using Atlas.ti software. Three broad themes emerged from participants' reflections: the long journey to surgery, time scarcity and be ready for change. The decision to pursue bariatric surgery takes place after struggling with obesity and failed weight-loss attempts since early childhood. Post-operative participants described bariatric surgery as life-changing, but determining when to schedule surgery is a challenge for adolescents.

Epidural extension failure in obese women is comparable to that of non-obese women.

BACKGROUND: Management of labor epidurals in obese women is difficult and extension to surgical anesthesia is not always successful. Our previous retrospective pilot study found epidural extension was more likely to fail in obese women. This study used a prospective cohort to compare the failure rate of epidural extension in obese and non-obese women and to identify risk factors for extension failure. METHODS: One hundred obese participants (Group O, body mass index ≥ 40 kg/m2 ) were prospectively identified and allocated two sequential controls (Group C, body mass index ≤ 30 kg/m2 ). All subjects utilized epidural labor analgesia and subsequently required anesthesia for cesarean section. The primary outcome measure was failure of the labor epidural to be used as the primary anesthetic technique. Risk factors for extension failure were identified using Chi-squared and logistic regression. RESULTS: The odds ratio (OR) of extension failure was 1.69 in Group O (20% vs. 13%; 95% CI: 0.88-3.21, P = 0.11). Risk factors for failure in obese women included ineffective labor analgesia requiring anesthesiologist intervention, (OR 3.94, 95% CI: 1.16-13.45, P = 0.028) and BMI > 50 kg/m2 (OR 3.42, 95% CI: 1.07-10.96, P = 0.038). CONCLUSION: The failure rate of epidural extension did not differ significantly between the groups. Further research is needed to determine the influence of body mass index > 50 kg/m2 on epidural extension for cesarean section.

Widening Participation To The Medical Course At Queens University Belfast.

The United Kingdom Clinical Aptitude Test (UKCAT) was introduced to assist in identification of applicants from all levels of society with the appropriate characteristics to become good doctors. Evidence that the UKCAT has achieved such widened participation (WP) in applicants to medical school remains elusive. One of the limitations to WP investigation has been that data on socioeconomic status of applicants to medical schools has been obtained through voluntary submission on application to UKCAT and up to 30% of applications offered either none or only limited information. In this study of local applicants (451 from Northern Ireland) to Queens University Belfast (QUB) for 2012, socioeconomic data was ascertained through post code analysis. These data were utilized to investigate the relationship between affluence, application to the medical school and UKCAT score. Our study has shown that for NI applicants to QUB medical school, postcode /socioeconomic back ground accounts for only 3 percent of UK CAT score variation. We have also shown that our admissions process is largely independent of socioeconomic background. However we have demonstrated that the socioeconomic profile of applicants from Northern Ireland to QUB medical school is such that even if every applicant to QUB in 2012 were offered a place in the medical school the number of applicants from least affluent areas would increase by only 9. In conclusion efforts to achieve meaningful WP must be directed at raising aspirations for a career in Medicine within the community.

Shelf life of fresh meat products under LED or fluorescent lighting.

Enhanced pork loin chops, beef longissimus lumborum steaks, semimembranosus steaks (superficial and deep portions), ground beef, and ground turkey were displayed under light emitting diode (LED) and fluorescent (FLS) lighting in two multi-shelf, retail display cases with identical operating parameters. Visual and instrumental color, internal product temperature, case temperature, case cycling, thiobarbituric acid reactive substances (TBARS), and Enterobacteriaceae and aerobic plate counts were evaluated. Under LED, beef products (except the deep portion of beef semimembranosus steaks) showed less (P<0.05) visual discoloration. Pork loin chops had higher (P<0.05) L* values for LED lighting. Other than beef longissimus lumborum steaks, products displayed under LED lights had colder internal temperatures than products under FLS lights (P<0.05). Under LED, pork loin chops, ground turkey, and beef semimembranosus steaks had higher (P<0.05) values for TBARS. LED provides colder case and product temperatures, more case efficiency, and extended color life by at least 0.5d for longissimus and semimembranosus steaks; however, some LED cuts showed increased lipid oxidation.

The diagnostic accuracy of magnetic resonance venography in the detection of deep venous thrombosis: a systematic review and meta-analysis.

AIM: To search the literature for further evidence for the use of magnetic resonance venography (MRV) in the detection of suspected DVT and to re-evaluate the accuracy of MRV in the detection of suspected deep vein thrombosis (DVT). MATERIALS AND METHODS: PubMed, EMBASE, Scopus, Cochrane, and Web of Science were searched. Study quality and the risk of bias were evaluated using the QUADAS 2. A random effects meta-analysis including subgroup and sensitivity analyses were performed. RESULTS: The search resulted in 23 observational studies all from academic centres. Sixteen articles were included in the meta-analysis. The summary estimates for MRV as a diagnostic non-invasive tool revealed a sensitivity of 93% (95% confidence interval [CI]: 89% to 95%) and specificity of 96% (95% CI: 94% to 97%). The heterogeneity of the studies was high. Inconsistency (I2) for sensitivity and specificity was 80.7% and 77.9%, respectively. CONCLUSION: Further studies investigating the use of MRV in the detection of suspected DVT did not offer further evidence to support the replacement of ultrasound with MRV as the first-line investigation. However, MRV may offer an alternative tool in the detection/diagnosis of DVT for whom ultrasound is inadequate or not feasible (such as in the obese patient).

Proxy measures of vitamin D status - season and latitude - correlate with adverse outcomes after bariatric surgery in the Nationwide Inpatient Sample, 2001-2010: a retrospective cohort study.

OBJECTIVE: To investigate the association between adverse surgical outcomes following bariatric surgery and proxy measures of vitamin D (VitD) status (season and latitude) in the Nationwide Inpatient Sample (NIS). BACKGROUND: Obesity is an independent risk factor for VitD deficiency (25(OH)D < 20 ng ml-1). VitD deficiency compounds the chronic inflammation of obesity, increasing the risk of adverse outcomes following bariatric surgery. Epidemiology has long used season and latitude as proxies for group VitD, as VitD status is largely determined by sun exposure, which is greatest during summer and at the Equator. METHODS: We assessed proxy measures of group VitD status. We compared surgeries in VitD Summer (July to September), Winter (January to March), and Fall/Spring (October to December and April to June) and in the North (≥37°N) vs. the South (<37°N). RESULTS: We identified 932,091 bariatric surgeries; 81.2% were women and 74.4% were white. Sex was unequally distributed by season (p = 0.005). Median age was 43.0 years (all groups). Most surgeries occurred in the North (64.8%). Adverse outcome rates ranged from 0.01% (wound infections) to 39.4% [prolonged length of stay {LOS}]. Season was inversely associated with wound infection (p = 0.018) and dehiscence (p = 0.001). Extended LOS was inversely correlated with season (p < 0.001). These relationships held after adjustment. Prolonged LOS (p < 0.001) and any complication (p = 0.108) were more common in the North. CONCLUSIONS: We have demonstrated a graded relationship between seasonality and adverse outcomes following bariatric surgery. The association was strongest for dehiscence and prolonged LOS. These relationships held when using latitude. A prospective study measuring pre-operative 25(OH)D concentration would strengthen the case for causality in adverse surgical outcomes.

Effects of meal composition on postprandial incretin, glucose and insulin responses after surgical and medical weight loss.

BACKGROUND: Meal tolerance tests are frequently used to study dynamic incretin and insulin responses in the postprandial state; however, the optimal meal that is best tolerated and suited for hormonal response following surgical and medical weight loss has yet to be determined. OBJECTIVE: To evaluate the tolerability and effectiveness of different test meals in inducing detectable changes in markers of glucose metabolism in individuals who have undergone a weight loss intervention. METHODS: Six individuals who underwent surgical or medical weight loss (two Roux-en-Y gastric bypass, two sleeve gastrectomy and two medical weight loss) each completed three meal tolerance tests using liquid-mixed, solid-mixed and high-fat test meals. The tolerability of each test meal, as determined by the total amount consumed and palatability, as well as fasting and meal-stimulated glucagon-like peptide, glucose-dependent insulinotropic polypeptide, insulin and glucose were measured. RESULTS: Among the six individuals, the liquid-mixed meal was better and more uniformly tolerated with a median meal completion rate of 99%. Among the four bariatric surgical patients, liquid-mixed meal stimulated on average a higher glucagon-like peptide (percent difference: 83.7, 89), insulin secretion (percent difference: 155.1, 158.7) and glucose-dependent insulinotropic polypeptide (percent difference: 113.5, 34.3) compared with solid-mixed and high-fat meals. CONCLUSIONS: The liquid-mixed meal was better tolerated with higher incretin and insulin response compared with the high-fat and solid-mixed meals and is best suited for the evaluation of stimulated glucose homeostasis.

Patients' perspective of wide-awake hand surgery--100 consecutive cases.

The wide-awake hand surgery (WAHS) technique involves injecting lidocaine with adrenaline for hand surgical procedures that are done without the use of tourniquets, sedation, regional or general anaesthetic. This is a retrospective review of the first 100 consecutive patients who underwent operations using this technique at our centre. The operations included carpal and cubital tunnel decompression, trapeziectomy, tendon transfer, and tenolysis. A questionnaire adapted from Lalonde's previous work on wide-awake surgery was used to assess patients' experiences. Sixty-five percent of the patients responded to the postal questionnaire, the majority reporting a high satisfaction level. Ninety-one percent of responders reported that the operation was less painful or comparable with a procedure at the dentist; 86% would prefer to be wide-awake if they needed to have hand surgery again, and 90% stated they would recommend WAHS to a friend.

QTLs associated with root traits increase yield in upland rice when transferred through marker-assisted selection.

Altering root morphology of rice (Oryza sativa L.) cultivars could improve yields in drought-prone upland ecosystems. Marker-assisted backcross breeding was used to introgress four QTLs for root traits into an upland rice cultivar. The QTLs had previously been identified under experimental conditions in a different genetic background. The introgressed lines and the recurrent parent were grown for 6 years by resource-poor farmers in upland sites in Eastern India and yields recorded. In combination the QTLs significantly increased yield by 1 t ha(-1) under relatively favourable field conditions. In less favourable trials, the QTL effects were not detected due to greater heterogeneity in soil-water availability in very low yielding environments and consequent yield variability. Root studies under controlled conditions showed that lines with the introgressions had longer roots throughout tillering than the recurrent parent (14 cm longer 2 weeks after sowing). Therefore, both improved roots and increased yield can be attributed to the introgression of QTLs. This is the first demonstration that marker-assisted backcross breeding (MABC) to introgress multiple root QTLs identified under controlled conditions is an effective strategy to improve farmers' yields of upland rice. The strategy was used to breed a novel upland rice cultivar that has been released in India as Birsa Vikas Dhan 111.

Characteristics associated with improved knee extension after strength training for individuals with cerebral palsy and crouch gait.

Muscle weakness may contribute to crouch gait in individuals with cerebral palsy, and some individuals participate in strength training programs to improve crouch gait. Unfortunately, improvements in muscle strength and gait are inconsistent after completing strength training programs. The purpose of this study was to examine changes in knee extensor strength and knee extension angle during walking after strength training in individuals with cerebral palsy who walk in crouch gait and to determine subject characteristics associated with these changes. A literature review was performed of studies published since January 2000 that included strength training, three-dimensional motion analysis, and knee extensor strength measurements for individuals with cerebral palsy. Three studies met these criteria and individual subject data was obtained from the authors for thirty crouch gait subjects. Univariate regression analyses were performed to determine which of ten physical examination and motor performance variables were associated with changes in strength and knee extension during gait. Change in knee extensor strength ranged from a 25% decrease to a 215% increase, and change in minimum knee flexion angle during gait ranged from an improvement of 9° more knee extension to 15° more knee flexion. Individuals without hamstring spasticity had greater improvement in knee extension after strength training. Hamstring spasticity was associated with an undesired increase in knee flexion during walking. Subject-specific factors such as hamstring spasticity may be useful for predicting which subjects will benefit from strength training to improve crouch gait.

Aerosol exposure to the angola strain of marburg virus causes lethal viral hemorrhagic Fever in cynomolgus macaques.

Cynomolgus macaques were exposed to the Angola strain of Lake Victoria Marburg virus (MARV) by aerosol to examine disease course and lethality. Macaques became febrile 4 to 7 days postexposure; the peak febrile response was delayed 1 to 2 days in animals that received a lower dose; viremia coincided with the onset of fever. All 6 macaques succumbed to the infection, with the 3 macaques in the low-dose group becoming moribund on day 9, a day later than the macaques in the high-dose group. Gross pathologic lesions included maculopapular cutaneous rash; pulmonary congestion and edema; pericardial effusion; enlarged, congested, and/or hemorrhagic lymphoid tissues; enlarged friable fatty liver; and pyloric and duodenal congestion and/or hemorrhage. Fibrinous interstitial pneumonia was the most consistent pulmonary change. Lymphocytolysis and lymphoid depletion, as confirmed by TUNEL (terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling), were observed in the mediastinal lymph nodes and spleen. MARV antigen was detected in the lungs, mediastinal lymph nodes, spleen, and liver of all animals examined. In infected macaques, nuclear expression of interleukin-33 was lost in pulmonary arteriolar and mediastinal lymph node high endothelial venule endothelial cells; interleukin-33-positive fibroblastic reticular cells in the mediastinal lymph node were consistently negative for MARV antigen. These macaques exhibited a number of features similar to those of human filovirus infections; as such, this model of aerosolized MARV-Angola might be useful in developing medical countermeasures under the Animal Rule.

REVIEW PAPER: pathology of animal models of alphavirus encephalitis.

The encephalitides caused by Venezuelan (VEEV), eastern (EEEV), and western (WEEV) equine encephalitis viruses are important natural diseases of horses and humans and potential agents of biowarfare or bioterrorism. No licensed vaccines or specific therapies exist to prevent or treat human infections with VEEV, EEEV, or WEEV. Well-characterized animal models are needed to support the development of such medical countermeasures under the United States Food and Drug Administration's "Animal Rule." This review focuses on the pathological features and pathogenetic mechanisms of these alphaviral encephalitides in animal models, with an emphasis on aerosol infections. Infection of mice, nonhuman primates, and other species with VEEV, EEEV, and WEEV causes encephalitis and often death. There is great variability in the specific manifestations of disease in the different models, however. Many aspects of the disease in animal models and in humans remain to be characterized using modern methods. Especially needed is a better understanding of the fundamental mechanisms involved in 3 key phases of the pathogenesis of alphavirus encephalitis. These are the early extraneural phase, the process of neuroinvasion itself, and virus and host factors related to neurovirulence. A greater understanding of these aspects could provide avenues for the development of medical countermeasures and better establish suitable animal models of alphavirus encephalitis for testing them under the Animal Rule.

Distribution and variability of redox zones controlling spatial variability of arsenic in the Mississippi River Valley alluvial aquifer, southeastern Arkansas.

Twenty one of 118 irrigation water wells in the shallow (25-30 m thick) Mississippi River Valley alluvial aquifer in the Bayou Bartholomew watershed, southeastern Arkansas had arsenic (As) concentrations (<0.5 to 77 microg/L) exceeding 10 microg/L. Sediment and groundwater samples were collected and analyzed from the sites of the highest, median, and lowest concentrations of As in groundwater in the alluvial aquifers located at Jefferson County, Arkansas. A traditional five-step sequential extraction was performed to differentiate the exchangeable, carbonate, amorphous Fe and Mn oxide, organic, and hot HNO(3)-leachable fraction of As and other compounds in sediments. The Chao reagent (0.25 M hydroxylamine hydrochloride in 0.25 M HCl) removes amorphous Fe and Mn oxides and oxyhydroxides (present as coatings on grains and amorphous minerals) by reductive dissolution and is a measure of reducible Fe and Mn in sediments. The hot HNO(3) extraction removes mostly crystalline metal oxides and all other labile forms of As. Significant total As (20%) is complexed with amorphous Fe and Mn oxides in sediments. Arsenic abundance is not significant in carbonates or organic matter. Significant (40-70 microg/kg) exchangeable As is only present at shallow depth (0-1 m below ground surface). Arsenic is positively correlated to Fe extracted by Chao reagent (r=0.83) and hot HNO(3) (r=0.85). Arsenic extracted by Chao reagent decreases significantly with depth as compared to As extracted by hot HNO(3). Fe (II)/Fe (the ratio of Fe concentration in the extracts of Chao reagent and hot HNO(3)) is positively correlated (r=0.76) to As extracted from Chao reagent. Although Fe (II)/Fe increases with depth, the relative abundance of reducible Fe decreases noticeably with depth. The amount of reducible Fe, as well as As complexed to amorphous Fe and Mn oxides and oxyhydroxides decreases with depth. Possible explanations for the decrease in reducible Fe and its complexed As with depth include historic flushing of As and Fe from hydrous ferric oxides (HFO) by microbially-mediated reductive dissolution and aging of HFO to crystalline phases. Hydrogeochemical data suggests that the groundwater in the area falls in the mildly reducing (suboxic) to relatively highly reducing (anoxic) zone, and points to reductive dissolution of HFO as the dominant As release mechanism. Spatial variability of gypsum solubility and simultaneous SO(4)(2-) reduction with co-precipitation of As and sulfide is an important limiting process controlling the concentration of As in groundwater in the area.