Nonlocal topological insulators: Deterministic aperiodic arrays supporting localized topological states protected by nonlocal symmetries.

The properties of topological systems are inherently tied to their dimensionality. Indeed, higher-dimensional periodic systems exhibit topological phases not shared by their lower-dimensional counterparts. On the other hand, aperiodic arrays in lower-dimensional systems (e.g., the Harper model) have been successfully employed to emulate higher-dimensional physics. This raises a general question on the possibility of extended topological classification in lower dimensions, and whether the topological invariants of higher-dimensional periodic systems may assume a different meaning in their lower-dimensional aperiodic counterparts. Here, we demonstrate that, indeed, for a topological system in higher dimensions one can construct a one-dimensional (1D) deterministic aperiodic counterpart which retains its spectrum and topological characteristics. We consider a four-dimensional (4D) quantized hexadecapole higher-order topological insulator (HOTI) which supports topological corner modes. We apply the Lanczos transformation and map it onto an equivalent deterministic aperiodic 1D array (DAA) emulating 4D HOTI in 1D. We observe topological zero-energy zero-dimensional (0D) states of the DAA-the direct counterparts of corner states in 4D HOTI and the hallmark of the multipole topological phase, which is meaningless in lower dimensions. To explain this paradox, we show that higher-dimension invariant, the multipole polarization, retains its quantization in the DAA, yet changes its meaning by becoming a nonlocal correlator in the 1D system. By introducing nonlocal topological phases of DAAs, our discovery opens a direction in topological physics. It also unveils opportunities to engineer topological states in aperiodic systems and paves the path to application of resonances associates with such states protected by nonlocal symmetries.

Observation of higher-order topological acoustic states protected by generalized chiral symmetry.

Topological systems are inherently robust to disorder and continuous perturbations, resulting in dissipation-free edge transport of electrons in quantum solids, or reflectionless guiding of photons and phonons in classical wave systems characterized by topological invariants. Recently, a new class of topological materials characterized by bulk polarization has been introduced, and was shown to host higher-order topological corner states. Here, we demonstrate theoretically and experimentally that 3D-printed two-dimensional acoustic meta-structures can possess nontrivial bulk topological polarization and host one-dimensional edge and Wannier-type second-order zero-dimensional corner states with unique acoustic properties. We observe second-order topological states protected by a generalized chiral symmetry of the meta-structure, which are localized at the corners and are pinned to 'zero energy'. Interestingly, unlike the 'zero energy' states protected by conventional chiral symmetry, the generalized chiral symmetry of our three-atom sublattice enables their spectral overlap with the continuum of bulk states without leakage. Our findings offer possibilities for advanced control of the propagation and manipulation of sound, including within the radiative continuum.

Use of high-frequency electrical stimulation in gastrocutaneous fistula closure: a case report.

BACKGROUND: Gastrocutaneous fistula is a rare complication following Roux-en-Y gastric bypass, a commonly performed bariatric surgery. While most ECFs respond to conservative management, some do not close despite adequate nutritional support, infection source control, and drainage management. As such, the chronicity of these difficult-to-treat wounds can be physically and economically costly to patients. CASE REPORT: A 53-year-old female with a history of Roux-en-Y gastric bypass developed a gastrocutaneous fistula secondary to a perforated gastrojejunal ulcer, requiring immediate surgical intervention. After being discharged from the hospital, 37 days of conservative management and NPWT did not reduce the size of the fistula tract. To help control the patient's chronic abdominal pain and increase the rate of wound healing, the patient underwent treatment with HFES (20 kHz) delivered using a handheld transcutaneous electrical nerve stimulator. This electrotherapy was found to reduce the majority of the patient's pain within the first treatment session. The patient's fistula also began to decrease in size within 1 week of initiating treatment. CONCLUSION: This case report details the successful closure of a gastrocutaneous fistula after administration of HFES 3 times a week over the course of 25 days. The mechanism of action of HFES and its role in the wound healing process are also discussed.

Synthetic Pseudo-Spin-Hall effect in acoustic metamaterials.

While vector fields naturally offer additional degrees of freedom for emulating spin, acoustic pressure field is scalar in nature, and it requires engineering of synthetic degrees of freedom by material design. Here we experimentally demonstrate the control of sound waves by using two types of engineered acoustic systems, where synthetic pseudo-spin emerges either as a consequence of the evanescent nature of the field or due to lattice symmetry. First, we show that evanescent sound waves in perforated films possess transverse angular momentum locked to their propagation direction which enables their directional excitation. Second, we demonstrate that lattice symmetries of an acoustic kagome lattice also enable a synthetic transverse pseudo-spin locked to the linear momentum, enabling control of the propagation of modes both in the bulk and along the edges. Our results open a new degree of control of radiation and propagation of acoustic waves thus offering new design approaches for acoustic devices.

Discovery and phylogenetic analysis of novel members of class b enterotoxigenic Escherichia coli adhesive fimbriae.

Enterotoxigenic Escherichia coli (ETEC) is recognized to be a common cause of acute watery diarrhea in children from developing countries. Colonization factors (CFAs) have been identified predominantly in ETEC isolates secreting heat-stable enterotoxin (ST) or cosecreting ST with a heat-labile toxin (LT). We hypothesized that LT-only-secreting ETEC produces unique colonization factors not previously described in ST and LTST-secreting ETEC. A set of degenerate primers based on nucleotide sequence similarities between the major structural genes of CS20 (csnA), CS18 (fotA), CS12 (cswA), and porcine antigen 987 (fasA) was developed and used to screen a collection of 266 LT-secreting ETEC isolates in which no known CFA was detected. PCR-amplified products of different molecular masses were obtained from 49 (18.4%) isolates. Nucleotide sequence analysis of the PCR amplicons followed by GenBank nucleotide BLASTn analysis revealed five novel DNA sequences; translated amino acid BLASTx analysis confirmed sequence similarity to class 1b major structural proteins encoded by csnA, fotA, and fasA. Strains expressing the novel CFAs were phylotyped and analyzed using multilocus sequence typing (MLST; Achtman scheme), and the types detected were compared to those of a collection of archived global E. coli strains. In conclusion, application of the degenerate primer sets to ETEC isolates from surveillance studies increased the total number of ETEC isolates with detectable CFAs by almost 20%. Additionally, MLST analysis suggests that for many CFAs, there may be a requirement for certain genetic backgrounds to acquire and maintain plasmids carrying genes encoding CFAs.

Demonstration of a third-order hierarchy of topological states in a three-dimensional acoustic metamaterial.

Classical wave systems have constituted an excellent platform for emulating complex quantum phenomena, such as demonstrating topological phenomena in photonics and acoustics. Recently, a new class of topological states localized in more than one dimension of a D-dimensional system, referred to as higher-order topological (HOT) states, has been reported, offering an even more versatile platform to confine and control classical radiation and mechanical motion. Here, we design and experimentally study a 3D topological acoustic metamaterial supporting third-order (0D) topological corner states along with second-order (1D) edge states and first-order (2D) surface states within the same topological bandgap, thus establishing a full hierarchy of nontrivial bulk polarization-induced states in three dimensions. The assembled 3D topological metamaterial represents the acoustic analog of a pyrochlore lattice made of interconnected molecules, and is shown to exhibit topological bulk polarization, leading to the emergence of boundary states.

Demonstration of a quantized acoustic octupole topological insulator.

Recently introduced quantized multipole topological insulators (QMTIs) reveal new types of gapped boundary states, which themselves represent lower-dimensional topological phases and host symmetry protected zero-dimensional corner states. Inspired by these predictions, tremendous efforts have been devoted to the experimental observation of quantized quadrupole topological phase. However, due to stringent requirements of anti-commuting reflection symmetries, it is challenging to achieve higher-order quantized multipole moments, such as octupole moments, in a three-dimensional structure. Here, we overcome this challenge, and experimentally realize the acoustic analogue of a quantized octupole topological insulator using negatively coupled resonators. We confirm by first-principle studies that our design possesses a quantized octupole topological phase, and experimentally demonstrate spectroscopic evidence of a hierarchy of boundary modes, observing 3rd order topological corner states. Furthermore, we reveal topological phase transitions from higher- to lower-order multipole moments. Our work offers a pathway to explore higher-order topological states in 3D classical platforms.

Using a field quantitative real-time PCR test to rapidly identify highly viremic rift valley fever cases.

Approximately 8% of Rift Valley fever (RVF) cases develop severe disease, leading to hemorrhage, hepatitis, and/or encephalitis and resulting in up to 50% of deaths. A major obstacle in the management of RVF and other viral hemorrhagic fever cases in outbreaks that occur in rural settings is the inability to rapidly identify such cases, with poor prognosis early enough to allow for more-aggressive therapies. During an RVF outbreak in Kenya in 2006 to 2007, we evaluated whether quantitative real-time reverse transcription-PCR (qRT-PCR) could be used in the field to rapidly identify viremic RVF cases with risk of death. In 52 of 430 RVF cases analyzed by qRT-PCR and virus culture, 18 died (case fatality rate [CFR] = 34.6%). Levels of viremia in fatal cases were significantly higher than those in nonfatal cases (mean of 10(5.2) versus 10(2.9) per ml; P < 0.005). A negative correlation between the levels of infectious virus particles and the qRT-PCR crossover threshold (C(T)) values allowed the use of qRT-PCR to assess prognosis. The CFR was 50.0% among cases with C(T) values of <27.0 (corresponding to 2.1 x 10(4) viral RNA particles/ml of serum) and 4.5% among cases with C(T) values of >or=27.0. This cutoff yielded 93.8% sensitivity and a 95.5% negative predictive value; the specificity and positive predictive value were 58% and 50%, respectively. This study shows a correlation between high viremia and fatality and indicates that qRT-PCR testing can identify nearly all fatal RVF cases.

Hospital variation in perioperative complications for laparoscopic sleeve gastrectomy in Michigan.

BACKGROUND: Laparoscopic sleeve gastrectomy has surpassed gastric bypass and laparoscopic adjustable gastric banding recently as the most common weight-loss procedure. Previously, substantial concerns existed regarding variation in perioperative safety with bariatric surgery. This study aimed to assess rates of perioperative complications for laparoscopic sleeve gastrectomy across hospitals and in relation to procedure volume within the Michigan Bariatric Surgery Collaborative. STUDY DESIGN: We analyzed 8,693 patients who underwent laparoscopic sleeve gastrectomy from 2013 through 2014 across 40 hospitals in the Michigan Bariatric Surgery Collaborative. Mixed-effects logistic regression was used to assess hospital variation in risk- and reliability-adjusted rates of overall and serious 30-day complications and their relationship with hospital annual volume of stapling procedures (gastric bypass and sleeve gastrectomy). RESULTS: Overall, 5.4% of patients experienced perioperative complications. Adjusted rates of overall complications varied three-fold across hospitals, ranging from 3.6% (95% confidence interval 1.9-6.8%) to 11.0% (95% confidence interval 7.7-15.5%). Serious complications occurred in just 1.2% of patients and varied minimally. In this analysis, hospital volume was not associated with overall or serious complications. The 1 hospital with significantly less overall complication rates was high-volume (≥ 125 procedures/year); however, of the 4 hospitals with significantly greater complication rates, 3 were medium-volume (50-124 procedures/year), and 1 was high-volume. The remaining hospitals were not significantly different than the cohort mean. CONCLUSION: Serious complications among patients undergoing laparoscopic sleeve gastrectomy were relatively infrequent in this cohort of patients in the Michigan Bariatric Surgery Collaborative. Rates of overall complications varied widely across the hospitals enrolled in this statewide quality collaborative, although this variation was unrelated to volume standards required for accreditation as a comprehensive bariatric surgery center.

Technique or technology? Evaluating leaks after gastric bypass.

OBJECTIVE: To assess the relationship between technique and surgical devices on anastomotic and staple-line leaks after laparoscopic Roux-en-Y gastric bypass. BACKGROUND: Leaks after bariatric surgery remain a major source of morbidity and mortality. The association of surgical technique and devices with leaks after gastric bypass is poorly understood. SETTING: Multi-centered study that included teaching and non-teaching hospitals that participate in a statewide consortium for quality improvement using a payer-funded outcome registry. METHODS: We analyzed data from the Michigan Bariatric Surgery Collaborative and performed a case-control study comparing patients who sustained a leak with those who did not after primary laparoscopic Roux-en-Y gastric bypass. A total of 71 (.44%) patients with leaks were identified between January 2007 and December 2011. The leak group was matched 1:2 to a control group (nonleak) based on procedure type, age, body mass index, sex, and the year in which the procedure was performed. Technique-specific case characteristics and device-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. RESULTS: The rate of leak decreased during the study period, and there was a significant downward trend (slope estimate: -.19961%, P = .0372). After performing multivariate analysis, the type of anastomosis (circular stapler, hand-sewn, or linear stapler) and stapler manufacturer were not associated with leaks. The use of buttressing material was associated with a higher rate of leaks (odds ratio: 8.79 [95% confidence interval: 2.49-31.01], P = .0007), whereas the use of fibrin sealant was associated with a lower rate of leaks (odds ratio .11 [95% confidence interval: .03-.41], P = .0013). These findings could not be explained by differences in measures of surgeon performance. CONCLUSION: Leak rates after laparoscopic gastric bypass have fallen in Michigan despite variations in technique and device utilization. Although the type of anastomosis and stapler manufacturer do not appear to be significantly associated with leaks, it appears that the use of buttressing material was more common in cases in which leaks occurred, whereas the use of fibrin sealant was not. Given the complex interplay of multiple variables that affect surgical outcomes, future studies justifying the benefits of operative devices should be evaluated prospectively in the context of surgeon technique and skill.

Conversion of intestinal bypass to Roux-en-Y gastric bypass: a case report and brief review.

Intestinal bypass procedures for the treatment of morbid obesity have been largely replaced by Roux-en-Y gastric bypass procedures. The main reason for this change over the past 40 years stems from the myriad of negative nutritional and physiologic repercussions of intestinal bypass procedures. We present a case of a patient with severely atrophied small bowel and the novel method used for the conversion of the intestinal bypass procedure to Roux-en-Y gastric bypass. Additionally, we present a brief review of jejunoileal bypass.

A randomized, double-blind, placebo-controlled study evaluating the efficacy and safety of rifaximin for the prevention of travelers' diarrhea in US military personnel deployed to Incirlik Air Base, Incirlik, Turkey.

BACKGROUND: Infectious diarrhea is an important problem among travelers and deployed US military overseas causing substantial morbidity due to acute illness and may result in burdensome postinfectious sequelae. METHODS: The nonsystemic antibiotic rifaximin was evaluated for prevention of travelers' diarrhea (TD) in a US military and civilian adult beneficiary population in a randomized, double-blind, placebo-controlled clinical trial. In all, 100 volunteers deployed to Incirlik Air Base, Turkey, received rifaximin 1,100 mg once daily or placebo for 2 weeks, and participants were followed daily for 2 weeks. RESULTS: In an intention to treat analysis (n = 95), TD (based on subjects meeting case definition or early treatment) developed in 6.3% (3 of 48) of the rifaximin group compared with 19.2% (9 of 47) in the placebo group (Fisher's exact test p = 0.07). Rifaximin provided 67% (95% confidence interval, -13% to 91%, p = 0.07) protection against TD. Rifaximin 1,100 mg once daily was well tolerated with no observed differences in adverse events, whether solicited or unsolicited among the two treatment groups. CONCLUSIONS: Rifaximin may represent an option among military personnel on deployment for prevention of TD with supportive future studies that consider deployment length, settings, and operational situations where widespread use of chemoprophylaxis may increase force health protection without undue risk during critical deployments.

Design and validation of a multiplex polymerase chain reaction for the identification of enterotoxigenic Escherichia coli and associated colonization factor antigens.

Development of a genetic tool for the detection of genes encoding enterotoxins and colonization factors would greatly enhance enterotoxigenic Escherichia coli (ETEC) surveillance. Oligonucleotide primers were designed to amplify genes encoding human ST, porcine ST, LT and the structural genes of colonization factor antigen (CFA)/I, CS1 to CS8, CS12 to CS15, CS17 to CS22, and PCFO71. Screening 89 ETEC isolates phenotypically expressing a known CFA showed that, without exception, the multiplex polymerase chain reaction (mPCR) detected the structural gene of the expressed CFA, in addition to CS21 in 22.5% of isolates. Silent genes such as cssB (CS6) were also detected in 9.0%. Additionally, we screened 71 CFA phenotypically negative isolates and detected a CFA in more than 50% of tested isolates. In conclusion, we have designed a simple 4-step mPCR for the rapid detection of ETEC virulence factors. The assay is rapid, reproducible, relatively inexpensive, and has the potential to be field applicable.

Murine macrophages kill the vegetative form of Bacillus anthracis.

Anti-protective antigen antibody was reported to enhance macrophage killing of ingested Bacillus anthracis spores, but it was unclear whether the antibody-mediated macrophage killing mechanism was directed against the spore itself or the vegetative form emerging from the ingested and germinating spore. To address this question, we compared the killing of germination-proficient (gp) and germination-deficient (DeltagerH) Sterne 34F2 strain spores by murine peritoneal macrophages. While macrophages similarly ingested both spores, only gp Sterne was killed at 5 h (0.37 log kill). Pretreatment of macrophages with gamma interferon (IFN-gamma) or opsonization with immunoglobulin G (IgG) isolated from a subject immunized with an anthrax vaccine enhanced the killing of Sterne to 0.49 and 0.73 log, respectively, but the combination of IFN-gamma and IgG was no better than either treatment alone. Under no condition was there killing of DeltagerH spores. To examine the ability of the exosporium to protect spores from macrophages, we compared the macrophage-mediated killing of nonsonicated (exosporium+) and sonicated (exosporium-) Sterne 34F2 spores. More sonicated spores than nonsonicated spores were killed at 5 h (0.98 versus 0.37 log kill, respectively). Pretreatment with IFN-gamma increased the sonicated spore killing to 1.39 log. However, the opsonization with IgG was no better than no treatment or pretreatment with IFN-gamma. We conclude that macrophages appear unable to kill the spore form of B. anthracis and that the exosporium may play a role in the protection of spores from macrophages.

Macrophage-mediated germination of Bacillus anthracis endospores requires the gerH operon.

The gerHABC operon of Bacillus anthracis, encoding a gerA-like family member of germinant sensors, was shown to be required for endospore germination in the presence of macrophages and in macrophage-conditioned media. The loss of the germination phenotype in macrophage cultures of B. anthracis gerH-null endospores was restored by complementation in trans with a wild-type copy of gerH expressed under the control of its own promoter. Using endospores from both the parental strain B. anthracis Sterne and an isogenic gerH-null strain, we partially characterized germinants secreted by macrophages into the extracellular medium.

Identification and characterization of the gerH operon of Bacillus anthracis endospores: a differential role for purine nucleosides in germination.

We identified a tri-cistronic operon, gerH, in Bacillus anthracis that is important for endospore germination triggered by two distinct germination response pathways termed inosine-His and purine-Ala. Together, the two pathways allow B. anthracis endospores a broader recognition of purines and amino acids that may be important for host-mediated germination.