Factors Associated with Non-Completion of a Pediatric Metabolic and Bariatric Surgery Program.

BACKGROUND: Childhood obesity is a devastating disease process disproportionately affecting minority and low-income populations. Though bariatric surgery leads to durable weight loss and reversal of multiple obesity-related comorbidities, only a small fraction of pediatric patients undergoes the procedure. We sought to identify factors associated with non-completion in a pediatric bariatric surgery program. METHODS: Retrospective review of consecutive patients ≤18-years-old referred to an academic adolescent bariatric surgery program between 2017 and 2022 (n = 20 completers, 40 non-completers) was completed. Demographics and medical and psychosocial histories were summarized by completion status. RESULTS: Of the 33% (20/60; 85% female, 30% racial minorities) who successfully completed the program, the median age was 16 years [IQR 16, 17]. The median age of non-completers was 16 years [IQR 15, 17] (55% female, 56% racial minorities). Non-completion was associated with male gender (15% of completers vs 45% of non-completers, p = 0.022), neighborhood income <150% poverty level (0 completers vs 17.5% of non-completers, p = 0.047), and presence of environmental or family stressors (22% of completers vs 65% of non-completers, p = 0.008). Though not statistically significant, non-completers tended to be racial minorities (p = 0.054). CONCLUSIONS: Non-completion of the bariatric surgery pathway was more prevalent among male patients from lower-income neighborhoods with significant environmental or family stressors. These patients also tended to be racial and ethnic minorities. The findings underscore the need for further investigation into barriers to pediatric bariatric surgery. LEVEL OF EVIDENCE: Level III.

Improvements in Sleep After Shoulder Arthroscopy Are Correlated With Improvements in Various Patient-Reported Outcomes: A Systematic Review.

Purpose: To determine the prevalence of sleep disturbances in patients before and after arthroscopic surgery of the shoulder and to evaluate the association between patient-reported outcomes and standardized sleep disturbance tools after shoulder arthroscopy. Methods: A systematic review, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, was conducted by searching the PubMed, Embase, and Scopus databases using the terms "arthroscopic surgery" and "sleep." Two independent reviewers evaluated the studies based on the inclusion criteria focused on the effects of shoulder arthroscopy on sleep disturbance and the use of outcome measures related to sleep. Data on sleep quality and functional outcomes were collected and analyzed using various assessment tools, including the Pittsburgh Sleep Quality Index and American Shoulder and Elbow Surgeons score. The methodologic quality of included studies was assessed using the Methodological Index for Non-randomized Studies (MINORS) criteria. Results: The review included 15 studies (9 Level IV, 5 Level III, and 1 Level II) comprising 1,818 arthroscopic patients (average age, 57.4 ± 8.86 years; follow-up range, 6 months to 75.7 months). The prevalence rates of sleep disturbances before and after shoulder arthroscopy ranged from 75.8% to 100% and from 19% to 62%, respectively. Every study included in this analysis reported an improvement in rates of sleep disturbances postoperatively compared with preoperatively. Improvements in standardized sleep disturbance scores were associated with functional outcomes. Conclusions: Sleep disturbances are commonly observed before and after arthroscopic surgery of the shoulder. Arthroscopic surgery of the shoulder appears to improve sleep quality, and surgeons can expect functional outcomes, specifically the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, numeric rating scale or visual analog scale score, and Constant-Murley score, to improve in line with sleep quality. Level of Evidence: Level IV, systematic review of Level II to IV studies.

Recreational and Commercial Catfishing Injuries: A Review of the Literature.

Catfish injuries are increasingly common from the recreational activities of hobbyists, fishermen, and "noodling" enthusiasts as well as in the commercial catfish industry, most commonly in Brazil. Injuries can range from mild skin abrasions to life-threatening infections and tissue damage requiring urgent treatment. Most injuries and subsequent morbidity associated with catfish encounters involve the dorsal and pectoral fins. These injuries are most often lacerations involving the upper extremities. Deep, penetrating catfish spine injuries can lead to serious injuries, including arterial and nerve lacerations. Catfish venom is released when a spine is torn. The venom may cause reactions that include erythema, edema, local hemorrhage, tissue necrosis, and muscle contractions. When "finned" by a catfish, the fish's spine may separate from the fish, which can cause a foreign body embedment. Some injuries are not thought to be severe enough at the time of injury to require medical care, although symptoms may arise years later. In this literature review of catfishing injuries, references were obtained through a PubMed search of the following terms: catfish injuries, fishing, envenomation, spine, and aquatic infection. Articles were chosen for citation based on pertinence to the topic of catfishing.

The Use of a Pediatric Migraine Practice Guideline in an Emergency Department Setting.

OBJECTIVE: The aim of the study was to evaluate the safety and efficacy of a standardized pediatric migraine practice guideline in the emergency department (ED). METHODS: Migraine Clinical Practice Guideline (MCPG) was created in collaboration with the Division of Pediatric Neurology and Pediatric Emergency Medicine. The MCPG was established on evidence-based data and best practice after a review of the literature. The MCPG was implemented for patients with a known diagnosis of migraine headaches and a verbal numeric pain score (VPS) greater than 6 on a 0 to 10 scale. Patients received intravenous saline, ketorolac, diphenhydramine, and either metoclopramide or prochlorperazine. After 40 minutes, another VPS was obtained, and if no improvement, a repeat dose of metoclopramide or prochlorperazine was administered. If after 40 minutes and minimal pain relief occurred, a consult to neurology was made. A chart review of patients enrolled in the MCPG from April 2004 to April 2013 was conducted. We recorded demographic data, vital signs, ED length of stay, initial VPS, last recorded VPS, adverse events, and admission rate. Nonparametric statistics were performed. RESULTS: A total of 533 charts were identified with a discharge diagnosis of migraine headache of which 266 were enrolled in the MCPG (179 females and 87 males). Mean (SD) age was 13.9 (3.1). Mean (SD) initial VPS was 7.8 (2.0). Mean (SD) discharge VPS was 2.1 (2.8), representing a 73% reduction of pain. Twenty patients (7.5%) were admitted for status migrainosus; mean (SD) age was 14.0 (3.5) years and mean (SD) VPS was 6.3 (2.8). Mean (SD) length of stay in ED was 283 (107) minutes. No adverse events were identified. CONCLUSIONS: Our MCPG was clinically safe and effective in treating children with acute migraine headaches. Our data add to the dearth of existing published literature on migraine treatment protocols in the ED setting. We recommend additional prospective and comparative studies to further evaluate the effectiveness of our protocol in this patient population.

Catfish noodling forearm injury requiring urgent surgical treatment: a case report and review of the literature.

"Noodling" is an ancient form of hand fishing recently gaining in popularity as a hobby and sport. We present one of the first case reports of a noodling injury in an adolescent male seeking to land a large catfish, and also review the literature on catfish-related injuries.

Current state of medical-advice-seeking behaviour for symptoms of colorectal cancer: determinants of failure and delay in medical consultation.

AIM: There are few data on the factors associated with healthcare-seeking behaviour for symptoms of colorectal cancer. This study describes the determinants of failure and delay in seeking medical advice for rectal bleeding and change in bowel habit. METHOD: In total, 1592 persons (56-88 years) were randomly selected from the Hunter Community Study and mailed a questionnaire. RESULTS: In all, 18% (60/332) of respondents experiencing rectal bleeding and 20% (39/195) reporting change in bowel habit had never consulted a doctor. The rate of delay (>1 month) for each symptom was 18% and 37%. The reasons for delay included the assumption that the symptoms were not serious or that they were benign. Triggers for seeking medical advice varied. Healthcare-seeking behaviour for rectal bleeding had not significantly improved compared with a previous community-based study. CONCLUSION: The seriousness of symptoms, importance of early detection and prompt medical consultation must be articulated in health messages to at-risk persons.

Intracellular trafficking of the UL11 tegument protein of herpes simplex virus type 1.

Growing evidence indicates that herpes simplex virus type 1 (HSV-1) acquires its final envelope in the trans-Golgi network (TGN). During the envelopment process, the viral nucleocapsid as well as the envelope and tegument proteins must arrive at this site in order to be incorporated into assembling virions. To gain a better understanding of how these proteins associate with cellular membranes and target to the correct compartment, we have been studying the intracellular trafficking properties of the small tegument protein encoded by the U(L)11 gene of HSV-1. This 96-amino-acid, myristylated protein accumulates on the cytoplasmic face of internal membranes, where it is thought to play a role in nucleocapsid envelopment and egress. When expressed in the absence of other HSV-1 proteins, the UL11 protein localizes to the Golgi apparatus, and previous deletion analyses have revealed that the membrane-trafficking information is contained within the first 49 amino acids. The goal of this study was to map the functional domains required for proper Golgi membrane localization. In addition to N-terminal myristylation, which allows for weak membrane binding, UL11 appears to be palmitylated on one or more of three consecutive N-terminal cysteines. Using membrane-pelleting experiments and confocal microscopy, we show that palmitylation of UL11 is required for both Golgi targeting specificity and strong membrane binding. Furthermore, we found that a conserved acidic cluster within the first half of UL11 is required for the recycling of this tegument protein from the plasma membrane to the Golgi apparatus. Taken together, our results demonstrate that UL11 has highly dynamic membrane-trafficking properties, which suggests that it may play multiple roles on the plasma membrane as well as on the nuclear and TGN membranes.

Membrane targeting properties of a herpesvirus tegument protein-retrovirus Gag chimera.

The retroviral Gag protein is capable of directing the production and release of virus-like particles in the absence of all other viral components. Budding normally occurs after Gag is transported to the plasma membrane by its membrane-targeting and -binding (M) domain. In the Rous sarcoma virus (RSV) Gag protein, the M domain is contained within the first 86 amino acids. When M is deleted, membrane association and budding fail to occur. Budding is restored when M is replaced with foreign membrane-binding sequences, such as that of the Src oncoprotein. Moreover, the RSV M domain is capable of targeting heterologous proteins to the plasma membrane. Although the solution structure of the RSV M domain has been determined, the mechanism by which M specifically targets Gag to the plasma membrane rather than to one or more of the large number of internal membrane surfaces (e.g., the Golgi apparatus, endoplasmic reticulum, and nuclear, mitochondrial, or lysosomal membranes) is unknown. To further investigate the requirements for targeting proteins to discrete cellular locations, we have replaced the M domain of RSV with the product of the unique long region 11 (U(L)11) gene of herpes simplex virus type 1. This 96-amino-acid myristylated protein is thought to be involved in virion transport and envelopment at internal membrane sites. When the first 100 amino acids of RSV Gag (including the M domain) were replaced by the entire UL11 sequence, the chimeric protein localized at and budded into the Golgi apparatus rather than being targeted to the plasma membrane. Myristate was found to be required for this specific targeting, as were the first 49 amino acids of UL11, which contain an acidic cluster motif. In addition to shedding new light on UL11, these experiments demonstrate that RSV Gag can be directed to internal cellular membranes and suggest that regions outside of the M domain do not contain a dominant plasma membrane-targeting motif.

Infection and replication of herpes simplex virus type 1 in an organotypic epithelial culture system.

We have used the organotypic culture system as a model to study the initial infectious process and spread of herpes simplex virus type 1 (HSV-1) in fully stratified and differentiated human epithelial tissue. The growth kinetics of HSV-1 were determined in organotypic tissues of human epidermal or ectocervical origin. Concurrently, we followed the spread of HSV-1 by immunostaining thin sections of infected organotypic tissue. After HSV-1 was applied to the top cornified epithelial layer, virus penetrated to the basal layer of replicating epithelium and grew to high titers. The virus was limited in its spread in that not all cells within the tissue had demonstrable infection. A ribonucleotide reductase mutant, ICP6 delta, could infect and replicate in basal layers of the organotypic tissues. However, we found that spread was limited in, and to, the basal cell layer. Peak ICP6 delta titers were 100-fold less than in cultures infected with wild-type HSV-1. Studies of HSV mutants should allow us to further define the role of specific viral genes which are associated with infection and spread in a tissue culture system that mimics the initial portal of entry for certain HSV infections.

Initial characterization of the membrane-associated form of ICP4 of herpes simplex virus type 1.

The immediate-early gene product, ICP4, of herpes simplex virus type 1 (HSV-1) is one of the major transcriptional regulatory proteins in the virus replicative process and is localized primarily within the nucleus soon after its synthesis. Earlier studies have shown that detectable amounts of ICP4 are also associated with the plasma membranes of infected cells (F. Yao and R. J. Courtney, J. Virol. 65:1516-1524, 1991). To extend our understanding of the properties of the membrane-associated ICP4, we have used various electrophoretic techniques, including sodium dodecyl sulfate-polyacrylamide gel electrophoresis, two-dimensional gel electrophoresis, and isoelectric focusing, to compare the membrane- and nuclear-associated forms of ICP4. The data from all of these methods revealed that a single unique form of ICP4 associates with plasma membranes of HSV-1-infected cells. While multiple forms of ICP4 were detected in infected cell nuclei, the membrane-associated form of ICP4 appeared to have a lower apparent molecular weight and a more acidic pI than the various forms of ICP4 found in infected cell nuclei. These results suggest that a novel form of ICP4 may associate with plasma membranes of HSV-1-infected cells. A recombinant adenovirus, AdICP4 (encoding an ICP4 protein), was used to determine the role that other herpesvirus proteins may play in the membrane association of ICP4. The results suggest that the expression of other HSV-1 proteins is not required for the membrane association of ICP4.

Influence of the host cell on the association of ICP4 and ICP0 with herpes simplex virus type 1.

ICP4 and ICP0 are two immediate-early proteins of herpes simplex virus type 1 associated with the transcriptional activation of viral genes within infected cells. Previous studies in our laboratory have shown that approximately 100-200 molecules each of ICP4 and ICP0 are associated with the tegument region of virions purified from Vero and HEp-2 cells (F. Yao and R. J. Courtney, 1989, J. Virol. 63, 3338-3344 and 1992, J. Virol. 66, 2709-2716). However, other studies have shown that ICP4 molecules are primarily associated with non-capsid-containing light (L) particles obtained from BHK-21 cells and purified by 5-15% continuous Ficoll gradients (J. McLauchlan and F. J. Rixon, 1992, J. Gen. Virol. 73, 269-276). To reconcile these findings with regard to the association of immediate-early protein with virions obtained from different cell lines, our studies have focused on determining if the host cell type influences the amounts of ICP4 and ICP0 associated with the capsid-containing heavy (H) virus particles (purified virions) compared to the amounts associated with L particles. Virus particles were purified from three different cell lines, Vero, HEp-2, and BHK-21 cells. The H and L virus particles were resolved on 5-15% Ficoll gradients. The results presented indicate that although ICP4 and ICP0 are readily detectable in H particles obtained from Vero and HEp-2 cells, minimal amounts of ICP4 and ICP0 are associated with H particles obtained from BHK-21 cells. The data suggest that the host cell may influence the relative amounts of ICP4 and ICP0 associated with the tegument region of virus particles. Finally, physical particle counts of the H and L particles also suggest that the host cell influences the relative number of L particles produced within the cell.

Chemical cross-linking of virion envelope and tegument proteins of herpes simplex virus type 1.

The virion of herpes simplex virus type 1 (HSV-1) consists of three structural components which include the envelope, tegument, and capsid. Little is known about the organization and potential interaction of proteins of the tegument and envelope. In this report, studies with chemical cross-linking reagents were initiated to determine the arrangement of the HSV-1 glycoprotein B (gB) on the viral envelope and its interactions with other virion proteins. With use of four homobifunctional N-hydroxysuccinimide ester reagents, gB was cross-linked to dimers and eventually high molecular weight complexes. In addition, four virion structural proteins were detected to be associated with gB as well as gD and gH but not with gC when cross-linked with dithiobis(succinimidyl propionate). Experimental results indicated that these four proteins are likely to represent viral tegument proteins and one of these proteins was immunologically identified as the known tegument protein, VP16.

Orientation of the cleavage site of the herpes simplex virus glycoprotein G-2.

During the synthesis of glycoprotein G-2 (gG-2) of herpes simplex virus type 2, the 104,000-Da gG-2 precursor (104K precursor) is cleaved to generate the 72K and the 31K intermediates. The 72K product is processed to generate the mature gG-2 (molecular mass, 108,000 Da), while the 31K product is additionally processed and secreted into the extracellular medium as the 34K component (H. K. Su, R. Eberle, and R. J. Courtney, J. Virol. 61:1735-1737, 1987). In this study, the orientations of the 31K and 72K products on the 104K precursor were determined by using two antipeptide sera produced in rabbits and a monoclonal antibody, 13 alpha C6, directed against gG-2. The sera prepared against synthetic peptides corresponding to the terminal amino acid residues 67 to 78 and an internal peptide at amino acids 247 to 260 of gG-2 recognized the 104K precursor and the 31K cleavage product but not the 72K intermediate. In contrast, 13 alpha C6 detected the 72K cleavage product and the uncleaved precursor but not the 31K cleavage component. The epitope recognized by 13 alpha C6 was mapped within amino acids 486 to 566. These results suggest that the 31K cleavage product is derived from the amino-terminal portion of the 104K precursor molecule and that the 72K intermediate is derived from the carboxyl terminus. In support of our model described above for the synthesis of gG-2, antibodies recognizing either of the cleavage products reacted with the uncleaved precursor but not with the other cleavage product. By using partial endo-beta-N-acetylglucosaminidase H analysis, two N-linked glycosylation sites were found on each of the cleavage products. The distribution of the N-linked glycosylation sites and the reactivities of the antipeptide sera allowed the cleavage region on the precursor to be mapped to within amino acids 260 to 437.

Analysis of the UL36 open reading frame encoding the large tegument protein (ICP1/2) of herpes simplex virus type 1.

Using peptide antisera specific for regions within the N terminus and C terminus of the predicted UL36 gene product, immunoblotting experiments were performed to demonstrate definitively that ICP1/2 is encoded by the UL36 gene. These data also suggest that both the cell- and the virion-associated forms of ICP1/2 are colinear with the complete predicted amino acid sequence of the UL36 gene. Computer-assisted analyses of the predicted amino acid sequence of the UL36 gene revealed the presence of two putative leucine zipper-type motifs and a potential ATP-binding domain. The possible functions of these consensus domains will also be discussed.

Characterization of the large tegument protein (ICP1/2) of herpes simplex virus type 1.

ICP1/2 (also designated VP1/2) is a 270-kDa structural protein of herpes simplex virus type 1 (HSV-1) which is located in the tegument region of the virion. In this report we describe the production of a polyclonal antiserum specific for ICP1/2 and the use of this antiserum to examine the synthesis, processing, and intracellular localization of the viral polypeptide. Pulse-labeling studies indicated that ICP1/2 is synthesized late during infection, being initially detectable between 8 and 9 hr postinfection with the rate of synthesis continuing to increase until 11 to 12 hr postinfection. Further studies on the expression of ICP1/2 in the presence or absence of viral DNA replication indicated that the synthesis of the polypeptide is absolutely dependent on viral DNA replication. These results suggest that ICP1/2 represents a gamma 2 (true late) gene product. Additionally, we have performed experiments to determine if ICP1/2 is post-translationally modified in HSV-infected cells. These studies indicated that ICP1/2 is phosphorylated on serine residues; however, we found no evidence to suggest that the protein is glycosylated. Using subcellular fractionation and indirect immunofluorescence techniques, we have determined that ICP1/2 is diffusely distributed throughout the nucleus and cytoplasm of HSV-infected cells with no specific compartmentalization of the polypeptide.

Posttranslational modification and subcellular localization of the p12 capsid protein of herpes simplex virus type 1.

We have previously shown that the 12-kDa capsid protein (p12) of herpes simplex virus type 1 (HSV-1) is a gamma 2 (true late) gene product encoded by the UL35 open reading frame (D. S. McNabb and R. J. Courtney, J. Virol. 66:2653-2663, 1992). To extend the characterization of p12, we have investigated the posttranslational modifications and intracellular localization of the 12-kDa polypeptide. These studies have demonstrated that p12 is modified by phosphorylation at serine and threonine residues. In addition, analysis of p12 by acid-urea gel electrophoresis has indicated that the protein can be resolved into three components, designated p12a, p12b, and p12c. Using isotopic-labeling and alkaline phosphatase digestion experiments, we have determined that p12a and p12b are phosphorylated forms of the protein, and p12c is likely to represent the unphosphorylated polypeptide. The kinetics of phosphorylation was examined by pulse-chase radiolabeling, and these studies indicated that p12c can be completely converted into p12a and p12b following a 4-h chase. All three species of p12 were found to be associated with purified HSV-1 virions; however, p12b and p12c represented the most abundant forms of the protein within viral particles. We have also examined the intracellular localization of p12 by cell fractionation and indirect immunofluorescence techniques. These results indicated that p12 is predominantly localized in the nucleus of HSV-1-infected cells and appears to be restricted to specific regions within the nucleus.

Identification and characterization of the herpes simplex virus type 1 virion protein encoded by the UL35 open reading frame.

The UL35 open reading frame (ORF) of herpes simplex virus type 1 (HSV-1) has been predicted from DNA sequence analysis to encode a small polypeptide with a molecular weight of 12,095. We have investigated the protein product of the UL35 ORF by using a trpE-UL35 gene fusion to produce a corresponding fusion protein in Escherichia coli. The TrpE-UL35 chimeric protein was subsequently isolated and used as a source of immunogen for the production of rabbit polyclonal antiserum directed against the UL35 gene product. The TrpE-UL35 antiserum was found to recognize a 12-kDa protein which was specifically present in HSV-1-infected cells. By utilizing the TrpE-UL35 antiserum, the kinetics of synthesis of the UL35 gene product was examined, and these studies indicate that UL35 is expressed as a gamma 2 (true late) gene. The 12-kDa protein recognized by the TrpE-UL35 antiserum was associated with purified HSV-1 virions and type A and B capsids, suggesting that the UL35 ORF may encode the 12-kDa capsid protein variably designated p12, NC7, or VP26. To confirm this assignment, immunoprecipitation and immunoblotting studies were performed to demonstrate that the TrpE-UL35 antiserum reacts with the same polypeptide as an antiserum directed against the purified p12 capsid protein (anti-NC7) (G.H. Cohen, M. Ponce de Leon, H. Diggelmann, W.C. Lawrence, S.K. Vernon, and R.J. Eisenberg, J. Virol. 34:521-531, 1980). Furthermore, the anti-NC7 serum was also found to react with the TrpE-UL35 chimeric protein isolated from E. coli, providing additional evidence that the UL35 gene encodes p12. On the basis of these studies, we conclude that UL35 represents a true late gene which encodes the 12-kDa capsid protein of HSV-1.

Association of ICP0 but not ICP27 with purified virions of herpes simplex virus type 1.

Recent studies have shown that ICP4, one of the major immediate-early proteins of herpes simplex virus type 1 is present within the tegument region of the virion (F. Yao and R. J. Courtney, J. Virol. 63:3338-3344, 1989). With monoclonal antibodies to two additional immediate-early proteins, ICP0 and ICP27, and Western blot (immunoblot) analysis, ICP0, but not ICP27, was also found to be associated with purified virus particles. In an effort to localize the ICP0 within the virion, purified virions were treated with trypsin in the presence and absence of detergent. The data suggest that ICP0 is located within the tegument region of the virion and is not localized in the envelope or within the nucleocapsid. The number of molecules of ICP0 per virion was estimated to be approximately 150.

Membrane-associated antigens of herpes simplex virus.

A brief overview is presented concerning the membrane-associated antigens of herpes simplex viruses (HSV). Aspects discussed include certain properties and functional roles of the HSV-specific glycoproteins. In addition, recent findings of an association between certain immediate-early proteins of HSV-1 and the tegument of virions as well as the plasma membrane of virus-infected cells are discussed.