Impact of bariatric surgery on serum urate targets in people with morbid obesity and diabetes: a prospective longitudinal study.

OBJECTIVES: Weight loss leads to reduced serum urate (SU) in people with obesity. However, the clinical relevance of such reductions in SU is unknown. This study examined the impact of non-surgical weight loss and bariatric surgery on SU targets in people with morbid obesity and diabetes. METHODS: The study was a single-centre, prospective study of 60 people with type 2 diabetes and body mass index ≥35 kg/m(2). Following 6 months of non-surgical weight loss, all participants had laparoscopic sleeve gastrectomy, with a further 1 year of follow-up. Serial SUs were measured throughout the study. RESULTS: Participants experienced mean (SD) weight loss of 5.5 (4.1) kg prior to surgery and 34.3 (11.1) kg following surgery. SU did not change following non-surgical weight loss (0.38 (0.09) mmol/L at baseline and 0.38 (0.10) mmol/L at follow-up), but increased to 0.44 (0.15) mmol/L in the immediate postoperative period and reduced to 0.30 (0.08) mmol/L 1 year after surgery (p<0.05 for both compared with baseline). Baseline SU, cessation of diuretics, female sex and change in creatinine independently predicted change in SU at the final visit. In participants without gout, SU above saturation levels (≥0.41 mmol/L) were present in 19/48 (40%) at baseline and 1/48 (2%) 1 year after surgery (p<0.0001). In participants with gout, SU above therapeutic target levels (≥0.36 mmol/L) were present in 10/12 (83%) at baseline and 4/12 (33%) 1 year after surgery (p=0.031). CONCLUSIONS: Clinically relevant reductions in SU occur following bariatric surgery in people with diabetes and WHO class II or higher obesity.

Persistent hip pain despite normal radiographs.

Acetabular fractures are frequently missed on plain view radiographs of the hip and pelvis. A high degree of clinical suspicion for an acetabular fracture should be maintained in any patient with persistent traumatic hip, pelvic, or buttock pain, and inability to ambulate.

mRNA or ChAd0x1 COVID-19 Vaccination of Adolescents Induces Robust Antibody and Cellular Responses With Continued Recognition of Omicron Following mRNA-1273.

Children and adolescents generally experience mild COVID-19. However, those with underlying physical health conditions are at a significantly increased risk of severe disease. Here, we present a comprehensive analysis of antibody and cellular responses in adolescents with severe neuro-disabilities who received COVID-19 vaccination with either ChAdOx1 (n=6) or an mRNA vaccine (mRNA-1273, n=8, BNT162b2, n=1). Strong immune responses were observed after vaccination and antibody levels and neutralisation titres were both higher after two doses. Both measures were also higher after mRNA vaccination and were further enhanced by prior natural infection where one vaccine dose was sufficient to generate peak antibody response. Robust T-cell responses were generated after dual vaccination and were also higher following mRNA vaccination. Early T-cells were characterised by a dominant effector-memory CD4+ T-cell population with a type-1 cytokine signature with additional production of IL-10. Antibody levels were well-maintained for at least 3 months after vaccination and 3 of 4 donors showed measurable neutralisation titres against the Omicron variant. T-cell responses also remained robust, with generation of a central/stem cell memory pool and showed strong reactivity against Omicron spike. These data demonstrate that COVID-19 vaccines display strong immunogenicity in adolescents and that dual vaccination, or single vaccination following prior infection, generate higher immune responses than seen after natural infection and develop activity against Omicron. Initial evidence suggests that mRNA vaccination elicits stronger immune responses than adenoviral delivery, although the latter is also higher than seen in adult populations. COVID-19 vaccines are therefore highly immunogenic in high-risk adolescents and dual vaccination might be able to provide relative protection against the Omicron variant that is currently globally dominant.

Paving the way for invasive species: road type and the spread of common ragweed (Ambrosia artemisiifolia).

Roads function as prime habitats and corridors for invasive plant species. Yet despite the diversity of road types, there is little research on the influence of these types on the spread of invaders. Common ragweed (Ambrosia artemisiifolia), a plant producing large amounts of allergenic pollen, was selected as a species model for examining the impact of road type on the spread of invasive plants. We examined this relationship in an agricultural region of Quebec, Canada. We mapped plant distribution along different road types, and constructed a model of species presence. Common ragweed was found in almost all sampling sites located along regional (97%) and local paved (81%) roads. However, verges of unpaved local roads were rarely (13%) colonized by the plant. A model (53% of variance explained), constructed with only four variables (paved regional roads, paved local roads, recently mown road verges, forest cover), correctly predicted (success rate: 89%) the spatial distribution of common ragweed. Results support the hypothesis that attributes associated with paved roads strongly favour the spread of an opportunistic invasive plant species. Specifically, larger verges and greater disturbance associated with higher traffic volume create propitious conditions for common ragweed. To date, emphasis has been placed on controlling the plant in agricultural fields, even though roadsides are probably a much larger seed source. Strategies for controlling the weed along roads have only focused on major highways, even though the considerable populations along local roads also contribute to the production of pollen. Management prioritizations developed to control common ragweed are thus questionable.

Clinical practice guideline for the prevention of oral and oropharyngeal mucositis in pediatric cancer and hematopoietic stem cell transplant patients: 2021 update.

PURPOSE: To update the 2015 clinical practice guideline for the prevention of oral mucositis in pediatric cancer or hematopoietic stem cell transplant (HSCT) patients. METHODS: We performed seven systematic reviews of mucositis prevention. Three reviews included randomized controlled trials (RCTs) conducted in pediatric and adult patients evaluating cryotherapy, keratinocyte growth factor (KGF) or photobiomodulation therapy with a focus on efficacy. Three reviews included studies of any design conducted in pediatric patients evaluating these same interventions with a focus on adverse events and feasibility. One review included all RCTs of any intervention for mucositis prevention in pediatric patients. Primary outcome was severe oral mucositis. RESULTS: We included 107 unique studies of cryotherapy (22 RCTs and 4 pediatric studies); KGF (15 RCTs and 12 pediatric studies); photobiomodulation therapy (29 RCTs and 8 pediatric studies) and any intervention (31 pediatric RCTs). Effects on severe mucositis reduction from RCTs were cryotherapy risk ratio (RR) 0.49 and 95% confidence interval (CI) 0.31-0.76; palifermin RR 0.81 and 95% CI 0.69-0.95 and photobiomodulation therapy RR 0.40 and 95% CI 0.27-0.60. Cryotherapy was not feasible in young children while photobiomodulation therapy was feasible across age groups. Palifermin was associated with adverse effects. CONCLUSIONS: Cryotherapy should be used for older cooperative pediatric patients who will receive short infusions of melphalan or 5-fluorouracil. Intraoral photobiomodulation therapy (620-750 nm spectrum) should be used in pediatric patients undergoing autologous or allogeneic HSCT and for pediatric head and neck carcinoma patients undergoing radiotherapy. Palifermin should not be used routinely in pediatric cancer or HSCT patients.

Systemic Inflammation Is Associated With Neurologic Involvement in Pediatric Inflammatory Multisystem Syndrome Associated With SARS-CoV-2.

OBJECTIVE: Pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a severe immune-mediated disorder. We aim to report the neurologic features of children with PIMS-TS. METHODS: We identified children presenting to a large children's hospital with PIMS-TS from March to June 2020 and performed a retrospective medical note review, identifying clinical and investigative features alongside short-term outcome of children presenting with neurologic symptoms. RESULTS: Seventy-five patients with PIMS-TS were identified, 9 (12%) had neurologic involvement: altered conciseness (3), behavioral changes (3), focal neurology deficits (2), persistent headaches (2), hallucinations (2), excessive sleepiness (1), and new-onset focal seizures (1). Four patients had cranial images abnormalities. At 3-month follow-up, 1 child had died, 1 had hemiparesis, 3 had behavioral changes, and 4 completely recovered. Systemic inflammatory and prothrombotic markers were higher in patients with neurologic involvement (mean highest CRP 267 vs 202 mg/L, p = 0.05; procalcitonin 30.65 vs 13.11 µg/L, p = 0.04; fibrinogen 7.04 vs 6.17 g/L, p = 0.07; d-dimers 19.68 vs 7.35 mg/L, p = 0.005). Among patients with neurologic involvement, these markers were higher in those without full recovery at 3 months (ferritin 2284 vs 283 µg/L, p = 0.05; d-dimers 30.34 vs 6.37 mg/L, p = 0.04). Patients with and without neurologic involvement shared similar risk factors for PIMS-TS (Black, Asian and Minority Ethnic ethnicity 78% vs 70%, obese/overweight 56% vs 42%). CONCLUSIONS: Broad neurologic features were found in 12% patients with PIMS-TS. By 3-month follow-up, half of these surviving children had recovered fully without neurologic impairment. Significantly higher systemic inflammatory markers were identified in children with neurologic involvement and in those who had not recovered fully.

Neonatal Chylothoraces: A 10-Year Experience in a Tertiary Neonatal Referral Centre.

BACKGROUND: Neonatal chylothorax is a rare condition, but has a high mortality. STUDY OBJECTIVES: To analyse the outcomes of a series of neonates with chylothorax and review the literature to determine best practice. DESIGN: A case series review and a literature review using electronic databases including the key words neonates and chylothorax. RESULTS: Six cases of neonatal chylothorax were identified during a ten-year period, two had congenital chylothoraces and four iatrogenic chylothoraces after thoracic surgery or chest instrumentation. The neonates were ventilated for a median of 30 (range 13-125) days with a median maximum daily pleural fluid output of 218 (range 86-310) ml/kg/day. All the neonates were given medium-chain triglyceride (MCT) feeds which stabilised pleural fluid output in four and reduced it in another. Octreotide was used in three neonates, but the dosage used had no significant effect on pleural output. Two neonates required surgical intervention. The literature review demonstrated MCT feeds can reduce or stabilise pleural fluid output, but highlighted variable use of octreotide and inconsistent dosing regimens and outcomes. No consensus regarding indications for surgical intervention was identified. SUMMARY AND CONCLUSION: Neonatal chylothorax is uncommon, but affected neonates require high healthcare utilisation.

Sustained inflations during delivery suite stabilisation in prematurely-born infants - A randomised trial.

BACKGROUND: Sustained inflations at initial stabilisation in the delivery suite may reduce the need for intubation and result in a shorter duration of initial ventilation, but have not been compared to routine UK practice. AIMS: To compare the early efficacy of sustained inflation during stabilisation after delivery to UK practice. STUDY DESIGN: A randomised trial was performed of a fifteen second sustained inflation compared to five inflations lasting 2 to 3 s, each intervention could be repeated once if no chest rise was apparent. Respiratory function monitoring was undertaken. SUBJECTS: Infants born prior to 34 weeks of gestation. OUTCOME MEASURES: The minute volume and maximum end-tidal carbon dioxide level in the first minute after the interventions, the time to the first spontaneous breath after the beginning of stabilisation and the duration of ventilation in the first 48 h. RESULTS: There were no significant differences in the minute volume or maximum end tidal carbon dioxide level between the groups. Infants in the sustained inflation group made a respiratory effort sooner (median 3.5 (range 0.2-59) versus median 12.8 (range 0.4-119) s, p = 0.001). The sustained inflation group were ventilated for a shorter duration in the first 48 h (median 17 (range 0-48) versus median 32.5 (range 0-48) h, p = 0.025). CONCLUSIONS: A sustained inflation of 15 s compared to five two to three second inflations during initial stabilisation was associated with a shorter duration of mechanical ventilation in the first 48 h after birth.

Dysuria: An Uncommon Presentation in Emergency Department Following Bladder Neck Disruption.

Prostate cancer is the most common life-threatening cancer diagnosed in men. Complications of prostatectomies vary and often include urinary incontinence, erectile dysfunction and pain, while other complications go unreported. While emergency physicians are already familiar with the more common post-operative complications presenting to their departments, including urinary retention, ileus, surgical site infections, venous thromboembolisms and urinary tract infections, they must have a high index of suspicion for rarer complications. We report a case of posterior bladder neck disruption as a complication of a robotic assisted laparoscopic prostatectomy that presented to the emergency department as dysuria and abdominal pain following urination.

How to Motivate Patients with Rheumatoid Arthritis to Quit Smoking.

OBJECTIVE: Seropositive rheumatoid arthritis (RA) is strongly linked to cigarette smoking, and smoking cessation is an essential step in RA management. Our objectives were to develop RA and smoking awareness materials and to evaluate the influence of the materials on awareness about the links between RA and smoking and on motivation to quit smoking. METHODS: A group of patients with seropositive RA in Fife, Scotland, were telephoned before the campaign, and the results of the precampaign questionnaire were used to develop the image for the campaign. After the campaign a second group of patients were questioned to ascertain the effect of the campaign. RESULTS: The 320 patient responses to the precampaign questionnaire revealed that many ex-smokers with RA had quit when they developed a known smoking-related disease such as emphysema. This concept was used to develop an image illustrating that RA is a smoking-related disease. The campaign was launched in Fife in 2011. The postcampaign questionnaire involving 380 patients revealed that there was 21% higher awareness of a link between RA and smoking and 45% higher awareness that smoking could interfere with treatment of RA. In total, 13/75 smokers who had cut down since the campaign had been influenced by the new information. CONCLUSION: The new materials have successfully increased patients' knowledge of the link between RA and smoking and the effect of smoking on RA therapy. RA smokers' attitudes to smoking may have been affected by the campaign.

Melanocortin-3 receptor gene variants in a Maori kindred with obesity and early onset type 2 diabetes.

Genetic studies suggest a diabetes susceptibility locus on human chromosome 20, near the melanocortin receptor-3 (MC3-R) gene. We examined the MC3-R as a candidate gene for type 2 diabetes in 12 members of a large Maori kindred with multiple affected members. The coding region of the MC3-R gene was sequenced for both diabetic and non-diabetic individuals. Two separate single base pair substitutions were found in the MC3-R coding sequence and these resulted in amino acid changes, Lysine6Threonine and Isoleucine81Valine. Neither of these MC3-R variants tracked with the presence of diabetes. Furthermore, the variant and wild type MC3-R showed similar functional coupling to adenylyl cyclase. A polymorphic marker (D20S32e) close to the human MC3-R (hMC3-R) coding sequence was investigated in a 60-member pedigree for association with diabetes and other metabolic parameters. There was an association between D20S32e genotype and fasting insulin (P=0.0085) and the insulin resistance index, HOMA-R (P=0.0042). An association was also found between genotype and HDL levels during oral glucose tolerance testing (P=0.0037). These associations were independent of BMI, age, gender and diabetes. Our data do not support a role for variations in the coding region of the hMC3-R in the development of type 2 diabetes in this Maori kindred, but suggest that a locus on chromosome 20 q, close to D20S32e, may contribute to both insulin secretion and action in the Maori kindred.

A polymorphism (D20S32e) close to the human melanocortin receptor 3 is associated with insulin resistance but not the metabolic syndrome.

Insulin resistance (IR) is postulated to underlie diabetes, the metabolic syndrome (MS) and cardiovascular disease (CVD). The D20S32e marker close to the melanocortin receptor-3 (hMC3-R) has been shown to be associated with IR in a large New Zealand Maori kindred, a population at high risk for MS and CVD. Here we examine the potential association of the D20S32e marker with the MS in this 60 member Maori kindred. There was a significant association between the D20S32e "B" allele and the fasting insulin component under both polygenic (beta=-5.3077; p=0.008) and common sibship effect (beta=-4.2161; p=0.03) models. No significant association between the same allele of D20S32e and the MS was observed after adjusting for age under a polygenic (p=0.103) or sibling (p=0.09) correlation model. We conclude that in this Maori kindred, the D20S32e polymorphism is significantly associated with insulin resistance but not with MS. Our data supports the hypothesis that multiple gene variants are necessary for the development of the MS.