Correlation between pre-operative endoscopic findings with reflux symptom score for gastro-oesophageal reflux disease in bariatric patients.

INTRODUCTION: There is a strong association between gastro-oesophageal reflux disease and morbid obesity. METHODS: Two hundred and eleven morbidly obese patients operated between September 2007 and June 2017 were retrospectively reviewed. All patients underwent pre-operative upper gastrointestinal endoscopy and assessment by reflux symptomatic score questionnaire. RESULTS: Of the total 211 patients, 156 (73.94%) were females; mean body mass index of the cohort was 46.23 ± 3.1 kg/m2. There was no evidence of Barrett's oesophagus or malignancy on pre-operative endoscopy. 63.04% of the patients (n = 133) in the study cohort had normal endoscopy. Pre-operative evaluation by reflux symptom score (RSS) questionnaire revealed no evidence of gastro-oesophageal reflux disease in 61.13% of patients (n = 129). The total number of patients with symptoms was 82 (38.86%). They were further divided into two categories based on severity of symptoms, namely, mild + moderate 60 (73.17%) and severe + very severe 22 (26.83%). From the cohort of symptomatic patients, the sub-cohort of 60 mild + moderate symptomatic patients had equal number of patients with normal 30 (50%) and abnormal endoscopy 30 (50%). In the sub-cohort of patients with severe + very severe symptoms (n = 22; 26.83%), endoscopy was abnormal in 6 (27.7%) patients. Whereas, out of 129 (61.13%) asymptomatic patients, one-third (n = 42) had abnormal endoscopy. The weighted kappa score was used between pre-operative endoscopic findings and RSS was statistically not significant (k - 0.0986). CONCLUSION: Pre-operative endoscopy is a must in all bariatric patients as significant percentage of asymptomatic patients can have abnormal endoscopy and vice versa.

Impact of bariatric surgery on type 2 diabetes in morbidly obese patients and its correlation with pre-operative prediction scores.

BACKGROUND: Bariatric surgery, besides causing significant weight reduction, leads to improvement in type 2 diabetes mellitus (T2DM). However, there is a scarcity of data on the prediction of diabetes resolution in non-Western population. OBJECTIVE: To evaluate the impact of bariatric surgery on T2DM and to assess the accuracy of pre-operative scoring systems in predicting remission. STUDY SETTING: A tertiary care academic centre, India. METHODOLOGY: We used a retrospective cohort of all diabetic patients (n = 244) who underwent bariatric surgery at our centre in the past 10 years. The cohort was followed up for diabetes remission, and pre-operative scoring systems were analysed against the observed results. RESULTS: Of 244 patients, we were able to contact 156 patients. The median period of follow-up was 38 months. The mean body mass index (BMI) of the study group decreased from 45.4 to 33.4 kg/m2 (%excess BMI loss = 61.2%). The number of patients dependent on oral anti-diabetic pharmacotherapy and on insulin decreased from 133 (85.3%) to 40 (25.6%) and from 31 (19.9%) to 7 (4.5%), respectively. Remission was analysed for 96 patients, who submitted complete biochemical investigations. The median follow-up period for this sub-cohort was 36 months. 38 (39.6%) patients were in complete remission, 15 (15.6%) patients in partial remission and 34 (38.5%) patients showed an improved glycaemic control. The three pre-operative scores, Advanced-DiaRem, DiaRem and ABCD, showed predictive accuracies of 81.1%, 75.6% and 77.8%, respectively. CONCLUSIONS: Besides leading to excess BMI loss of 61.2%, bariatric surgery also resulted in diabetes remission in 55.2% of the patients. Amongst various pre-operative scores, Advanced-DiaRem has the highest predictive accuracy for T2DM remission.

Adenocarcinoma of oesophagus involving gastro-oesophageal junction following mini-gastric bypass/one anastomosis gastric bypass.

Mini-gastric bypass/one anastomosis gastric bypass (MGB/OAGB) is an emerging weight loss surgical procedure. There are serious concerns not only regarding the symptomatic biliary reflux into the stomach and the oesophagus but also the increased risk of malignancy after MGB/OAGB. A 54-year-old male, with a body mass index (BMI) of 46.1 kg/m2, underwent Robotic MGB at another centre on 22nd June 2016. His pre-operative upper gastrointestinal endoscopy was not done. He lost 58 kg within 18 months after the surgery and attained a BMI of 25.1 kg/m2. However, 2-year post-MGB, the patient had rapid weight loss of 19 kg with a decrease in BMI to 18.3 kg/m2 within a span of 2 months. He also developed progressive dysphagia and had recurrent episodes of non-bilious vomiting. His endoscopy showed eccentric ulcerated growth in lower oesophagus extending up to the gastro-oesophageal junction and biopsy reported adenocarcinoma of oesophagus. MGB/OAGB has a potential for bile reflux with increased chances of malignancy. Surveillance by endoscopy at regular intervals for all patients who have undergone MGB/OAGB might help in early detection of Barrett's oesophagus or carcinoma of oesophagus or stomach.

Acute Chest Syndrome.

Audience: Emergency medicine residents and medical students on emergency medicine rotations. Introduction: Acute chest syndrome is a life-threatening, potentially catastrophic complication of sickle cell disease.1,2 It occurs in approximately 50% of patients with sickle cell disease, with up to 13% all-cause mortality.1 Most common in children aged 2-4, up to 80% of patients with a prior diagnosis of acute chest syndrome will have recurrence of this syndrome.4 Diagnostic criteria include a new infiltrate on pulmonary imaging combined with any of the following: fever > 38.5°C (101.3°F), cough, wheezing, hypoxemia (PaO2 < 60 mm Hg), tachypnea, or chest pain.4,5 The pathophysiology of acute chest syndrome involves vaso-occlusion in pulmonary vessels resulting in hypoxia, release of inflammatory mediators, acidosis, and infarction of lung tissue. The most common precipitants are infections (viral or bacterial), rib infarction, and fat emboli.1,2,4 Patients commonly present with fever, dyspnea, cough, chills, chest pain, or hemoptysis. Diagnosis is made through physical exam, blood work, and chest imaging.1,2 Chest radiograph is considered the gold standard for imaging modality.3 Management of acute chest syndrome includes hydration with IV crystalloid solutions, antibiotics, judicious analgesia, oxygen, and, in severe cases, transfusion.6 Emergency medicine practitioners should keep acute chest syndrome as a cannot miss, high consequence differential diagnosis for all patients with sickle cell disease presenting to the Emergency Department. Educational Objectives: At the end of this oral board session, examinees will: 1) demonstrate the ability to obtain a complete medical history; 2) demonstrate the ability to perform a detailed physical examination in a patient with respiratory distress; 3) identify a patient with respiratory distress and hypoxia and manage appropriately (administer oxygen, place patient on monitor); 4) investigate the broad differential diagnoses which include acute chest syndrome, pneumonia, acute coronary syndrome, acute congestive heart failure, acute aortic dissection and acute pulmonary embolism; 5) list the appropriate laboratory and imaging studies to differentiate acute chest syndrome from other diagnoses (complete blood count, comprehensive metabolic panel, brain natriuretic peptide (BNP), lactic acid, procalcitonin, EKG, troponin level, d-dimer, chest radiograph); 6) identify a patient with acute chest syndrome and manage appropriately (administer intravenous pain medications, administer antibiotics after obtaining blood cultures, emergent consultation with hematology) and 7) provide appropriate disposition to the intensive care unit after consultation with hematology. Educational Methods: This case is used as a method to assess learners' ability to rapidly assess a patient in respiratory distress. The learner needs to address a limited differential diagnosis list while simultaneously stabilizing and treating the patient. The "patient" becomes an active participant in the case, with repeated requests for pain medication, and appropriate analgesic administration is required as a critical action. For faculty, this case is used to assist with periodic assessment of resident performance while in the emergency department (ED).We use oral board testing as one additional tool to assess residents' critical thinking, while still applying the pressure that is needed to pass the oral certification examination. Large groups of residents can be assessed in short periods of time without needing to "wait" for this particular patient presentation to be seen in the ED.In this case, learners were assessed using a free online evaluation tool, Google forms. Multiple questions were written for each critical action, and the Google form served as the online evaluation and repository of this information. The critical actions of the case were then tied to Emergency Medicine Milestones, and the results were compiled for use during resident clinical competency evaluations. Residents were provided with immediate feedback of their performance and were also given their electronic evaluations when requested. Research Methods: To assess the strengths and weaknesses of the case, learners and instructors were given the opportunity to provide electronic feedback after the case was completed. Subsequent modifications were made based on the feedback provided. Additionally, learners answered written multiple-choice questions after the case to assess for retention of the material. Results: Senior and junior residents alike enjoyed the process of an oral board simulation as an alternative to a more formal lecture. Seniors also stated that they felt more confident with their ability to pass the oral certification examination after having gone through oral board testing while in residency. Overall, the case was rated relatively highly, with residents scoring the case as 4.3 ± 0.186, 95% confidence interval (1-5 Likert scale, 5 being excellent, n=53) after their assessment was completed. Discussion: Students and residents who participated in the oral board exam formatting found this to be preferable to a traditional lecture and enjoyed the learning environment. Faculty also found this type of participation to be more engaging and were pleased with the ability to perform high-stress assessments with low stakes. The content contained in the case is relevant to all emergency medicine trainees, and this formatting forces the learner to be an active participant in the learning session. The case is a good model for the high-stakes testing of the oral certification exam and is an effective way to test a resident's ability to rapidly assess and manage a life-threatening condition in the ED. Topics: Sickle cell anemia, vaso-occlusive pain crisis, acute chest syndrome, hypoxia, pneumonia, sepsis.

A Case Report of Spontaneous Pneumomediastinum From an Unusual Cause: Baritone Practice.

Spontaneous pneumomediastinum (SPM) is a rare but potentially life-threatening clinical entity in which free air is introduced into the mediastinum. It most commonly presents in young males and has an incidence of approximately 0.002% of the general population. Symptoms include sudden onset chest pain, dyspnea, neck pain, vomiting, and odynophagia. Physical examination usually reveals subcutaneous emphysema, hoarse voice, tachycardia, tachypnea, and occasionally a Hamman's sign, which is a mediastinal "crunch" sound heard on cardiac auscultation. We present a case of an 18-year-old male baritone player who presented to the ED with chest pain and odynophagia shortly after waking up one morning. The patient's chest radiograph (CXR) revealed free air in the mediastinum with subcutaneous air tracking into the soft tissues of the neck and supraclavicular region. CT of the chest with contrast esophagram confirmed the diagnosis of primary SPM. The cause of his condition was likely due to barotrauma secondary to playing the baritone in his marching band. He had no evidence of esophageal injury or infectious process which further supports the diagnosis of primary SPM. After an extensive workup, the patient was discharged from the ED with instructions on rest, analgesia, and antitussives as needed. Evaluation of chest pain patients in the ED should include a CXR, in addition to other indicated tests, to rule out this potentially debilitating condition. Fortunately, though SPM is potentially life-threatening, most cases resolve spontaneously without surgical intervention.

3rd-Degree Atrioventricular Block.

Audience: This oral boards case is appropriate for emergency medicine residents and medical students on emergency medicine rotations. Introduction/Background: Third-degree heart block (also known as complete heart block) is a cardiovascular emergency that requires prompt recognition. Complete heart block is a type of atrioventricular (AV) block whereby no atrial impulses reach the ventricular conduction system. The most common etiology of AV block is ischemic heart disease, with up to 1 in 5 patients developing some type of conduction disturbance after an MI.1 Complete heart block is seen in 8% of patients post-MI.2 Other causes include myocarditis, infectious endocarditis, infiltrative cardiac disease, congenital AV blocks, non-ischemic cardiomyopathy, electrolyte disturbances, and drug side effects.3 In complete heart block, the heart rate is dependent on the location of the block and a functioning secondary pacemaker within the conduction system. Analysis of the EKG will determine the location of this escape rhythm. For escape rhythms originating at the AV node or high in the His-Purkinje system, the QRS complex will typically be narrow, and the ventricular rate typically in the 40-60 bpm range. For blocks with ventricular escape rhythms, the QRS will appear wide, with rates of 20-40 bpm. Patients presenting with 3rd-degree AVB with ventricular escape rhythms can destabilize. If no escape rhythm generates, patients develop asystole and cardiac arrest. Since 1 in 600 adults over the age of 65 will develop a form of supraventricular conduction abnormality each year, this disease process is important to identify and treat.4 Effective management includes accurate interpretation of a 12-lead EKG, assessment of hemodynamic stability and systemic perfusion, and time-sensitive pharmacologic or procedural intervention. Educational Objectives: At the end of this oral board session, examinees will: 1) demonstrate ability to obtain a complete medical history including detailed cardiac history, 2) demonstrate the ability to perform a detailed physical examination in a patient with cardiac complaints, 3) investigate the broad differential diagnoses which include acute coronary syndrome (ACS), electrolyte imbalances, pulmonary embolism, cerebrovascular accident, aortic dissection and arrhythmias, 4) obtain and interpret the cardiac monitor rhythm strip to identify complete heart block, 5) list the appropriate laboratory and imaging studies to differentiate arrhythmia from other diagnoses (complete blood count, comprehensive metabolic panel, magnesium level, EKG, troponin level, chest radiograph), 6) identify a patient with complete heart block and manage appropriately (administer IV atropine, attempt transcutaneous pacing, place a transvenous pacemaker, emergent consultation with interventional cardiology), 7) provide appropriate disposition to intensive care after consultation with interventional cardiologist. Educational Methods: This is a straight-forward case which was written to assess learners' ability to rapidly recognize an unstable cardiac rhythm and to subsequently treat and stabilize the patient. Oral board testing is used as a proxy for the emergency department (ED) and can assist with periodic assessment of resident performance while in the ED.We have found that oral board testing is a useful tool to assess residents' critical thinking while still applying pressure that is needed to pass the examination itself. Large groups of residents can be assessed in a short time period without needing to "wait" for a particular clinical condition to present to the ED.In this case, learners were assessed using a free online evaluation tool, ie, Google forms. Multiple questions were written for each critical action, and the Google form served as the online evaluation and repository. The critical actions of the case were then tied to Emergency Medicine Milestones, and the results were compiled for use during residency clinical competency evaluations. Residents were provided with immediate verbal feedback of their performance and were also given their electronic evaluations when requested. Research Methods: Learners and instructors were given the opportunity to provide electronic feedback after the case was completed to assess strengths and weaknesses, and subsequent modifications were made. Additionally, learners answered written multiple-choice questions after the case to assess for retention of the material. Results: Senior learners found this to be a more enjoyable way to refresh their skills than direct lecture. Junior residents and students who encountered this clinical entity first in the oral board rather than in the ED, stated that they enjoyed the ability to "trial run" the case before being faced with an emergent and uncontrolled setting of the ED. Overall, the learners rated the case as 4.7 (1-5 Likert scale, 5 being excellent) after the mock oral board examination was completed. Discussion: Students and residents who were assessed with a mock oral board session found this to be an improvement over traditional "lecture" and were pleased to have participated. The content is highly relevant to emergency medicine and the format forces learners to be actively engaged in review of the material. The case is a good model for the high stakes testing of written and oral board examinations, and is an effective way to assess a resident's ability to rapidly assess and manage a life-threatening condition in the ED. Topics: Third-degree AV block, complete heart block, 3rd-degree block, hypotension, syncope, bradycardia, cardiovascular emergency.

Surgical management of super-super obesity with grade III esophageal varices and liver cirrhosis: The ultimate challenge.

The risk of complications after bariatric surgery is high in morbidly obese patients suffering from liver cirrhosis along with moderate to severe portal hypertension. Esophageal varices are even considered as a contraindication for bariatric surgery by many surgeons. We report the case of a 40-year-old gentleman with a body mass index of 65.3 kg/m2 , with multiple comorbidities including type 2 diabetes mellitus, severe obstructive sleep apnea. On evaluation, he had Child-Pugh A liver cirrhosis with portal hypertension along with grade III esophageal varices and splenomegaly. After adequate optimization, laparoscopic sleeve gastrectomy was performed. The patient is doing well at a follow up of 12 months with an adequate weight loss and resolution of comorbidities. Sleeve gastrectomy can be performed in a morbidly obese Child-Pugh A cirrhotic patient with portal hypertension and esophageal varices with proper counseling regarding more than usual risk for morbidity and mortality.

Esophageal Rupture Associated With COVID-19: A Novel Case Report.

Emergency departments (EDs) are the primary driver for hospital admissions in the United States (US), and that trend is likely to continue through the ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. As the US continues to experience rampant community spread, coronavirus disease 2019 (COVID-19) will likely present in increasingly variable ways to the EDs. We present a case of Mallory-Weiss tear and esophageal perforation, which was likely caused by COVID-19 pneumonia. This case is notably the first of its kind that we have seen reported in the COVID-19-related literature. Clinicians should be vigilant about the various complications of COVID-19 and continue to exercise caution when seeing and treating these patients.

Eclampsia.

Audience: Emergency medicine residents and medical students on emergency medicine rotations. Introduction: Eclampsia is an uncommon but important life-threatening obstetrical emergency, complicating 1.5-10 deliveries per 10,000 pregnancies in resource-rich countries.1 If not recognized and treated promptly, there is risk of significant morbidity or death to both mother and baby. Clinically, eclampsia is defined by new-onset seizures or coma in women with preeclampsia.2 Preeclampsia is defined by maternal hypertension after 20 weeks gestation with or without signs of end organ dysfunction, and, like eclampsia, can develop in the postpartum period.1 Eclampsia manifests as new onset generalized tonicclonic seizures. Eclamptic seizures are usually preceded by neurologic symptoms such as severe or atypical headache, visual disturbances, and non-neurologic symptoms such as severe abdominal pain or proteinuria.1 Emergent treatment involves prompt administration of (intravenous) IV magnesium sulfate.2,3,4 Adjuncts include securing the airway if necessary and administration of IV antihypertensive medications. Like preeclampsia, definitive management is by prompt delivery of the fetus if the mother is still pregnant.1 If untreated, maternal mortality is as high as 14%.1 Women who develop eclampsia are at increased risk of obstetric complications in subsequent pregnancies and at higher risk for cardiovascular disease and metabolic disease later in life. Educational Objectives: At the end of this oral boards session, examinees will: 1) Demonstrate ability to obtain a complete medical history including a detailed obstetric history. 2) Demonstrate the ability to perform a detailed physical examination in a postpartum female patient who presents with a seizure. 3) Investigate the broad differential diagnoses which include electrolyte imbalances, brain tumor, meningitis or encephalitis, hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and eclampsia. 4) List the appropriate laboratory and imaging studies to differentiate eclampsia from other diagnoses (complete blood count, comprehensive metabolic panel, magnesium level, pregnancy testing, urinalysis, and computed tomography [CT] scan of the head). 5) Identify a postpartum eclampsia patient and manage appropriately (administer IV magnesium therapy, administer IV antihypertensive therapy, emergent consultation with an obstetrician). 6) Provide appropriate disposition to the intensive care unit after consulting with an obstetrician. Educational Methods: This was envisioned as an oral board testing case due to the multiple aspects which require emergency care. Residents are expected to assess the seriousness of the patient's condition, elicit critical details from her recent medical history, and synthesize that data in order to treat a medically complex patient. Oral board testing is able to incorporate each of these aspects together and provide the resident with a dynamic learning environment.Oral board testing is a way to assess the resident's ability to rapidly obtain and interpret multiple sources of information simultaneously. By utilizing a case that requires pharmaceutical therapy, the clinical competency committee is able to obtain additional milestones which are sometimes difficult to test in the emergency department itself.Learners were assessed using online evaluation tools available, ie, Google forms. Critical actions were subsequently tied to Emergency Medicine Milestones and the results were compiled and used for resident evaluations and clinical competency. Residents were given verbal feedback immediately after the examination, and they were provided with the scores of their online evaluation after all results were compiled. Research Methods: Learners and instructors provided written feedback after the case was administered to assess for strengths and weaknesses of the case, and modifications were then made to better address concerns. Learners answered written multiple-choice questions on high-level concepts, ie, critical actions, at least one month after this exam was completed. Results: Learners found this a challenging, but enjoyable, way to refresh their knowledge and skills regarding preeclampsia, and this was a highly rated part of their mock oral board examination. Overall, residents rated the session 4.3 (1-5 Likert scale, 5 being Excellent) after the oral board review session was completed. Comments from residents included "haven't seen post-partum preeclampsia in residency" and "challenging to remember magnesium dosing." Discussion: Residents and medical students were evaluated using this method and both enjoyed the activity as a novel way to study as well as exercise their medical knowledge. The content was both highly relevant to the practice of emergency medicine and the format was an effective way to deliver the information to the learners. The case is a good model to evaluate for the high stakes testing of both the written and oral board examinations, but also a way to assess residents' abilities to treat preeclamptic and eclamptic patients in the emergency department. Topics: Eclampsia, preeclampsia, seizures, end-organ damage, hypertensive emergency, altered mental status, neurologic emergency, obstetric emergency.

Safety and Efficacy of Bariatric Surgery in Advanced Liver Fibrosis.

BACKGROUND: There is limited data on the safety and efficacy of metabolic and bariatric (MBS) surgery in patients with advanced liver fibrosis. METHODS: This is a retrospective analysis of data of patients with advanced liver fibrosis undergoing MBS at a tertiary care centre. Weight loss and complications were analysed. Transient elastography and liver biopsy findings 1 year after surgery were compared with baseline. RESULTS: Twenty-two patients had cirrhosis and 16 had stage 3 fibrosis; all were Child Pugh A. Majority (76%) underwent sleeve gastrectomy. Mean excess BMI loss was 65.8 ± 18.9%. There were no leaks or 30-day mortality. One patient with cirrhosis had late mortality due to liver decompensation. Preoperative and postoperative median LSM were 15.5 kPa (interquartile range IQR = 24.4-11.6) and 10.9 kPa (IQR 19.3-7.6), respectively. Preoperative and postoperative median CAP were 352.5 dB/m (IQR = 372-315.5) and 303 dB/m (IQR 331-269.5), respectively. On follow-up biopsy, nine of twelve patients had improvement in fibrosis, while three had no change. Four out of five patients in the cirrhotic cohort had improvement in fibrosis stage and LSM improved in all of them. Five out of seven patients with stage 3 fibrosis had an improvement in fibrosis stage and none progressed to cirrhosis. LSM improved in three of these five patients. CONCLUSION: MBS has the potential to ameliorate advanced liver fibrosis, including cirrhosis. Transient elastography can be used as an effective tool for screening and follow-up of liver disease in patients undergoing MBS.

Evaluation of Epworth Sleepiness Scale to Predict Obstructive Sleep Apnea in Morbidly Obese Patients and Increasing Its Utility.

INTRODUCTION: Studies have shown that Epworth sleepiness scale (ESS) is not a good tool to predict obstructive sleep apnea (OSA). However, data regarding the accuracy of ESS in the prediction of OSA among morbidly obese patients are scarce. METHODS: The study involved a retrospective review of the charts of the consecutive patients who underwent bariatric surgery at a tertiary care teaching hospital. All the patients underwent polysomnography (PSG) and undertook the ESS questionnaire. The sensitivity and specificity of ESS were calculated based on its correlation with the PSG findings. Furthermore, a new score was devised to improve the utility of ESS to predict OSA. RESULTS: A total of 232 consecutive patients from January 2014 to July 2017 were included in the study. The mean age and body mass index (BMI) were 40.5 ± 11.8 years and 47.6 ± 7.3 kg/m2, respectively. Among the 162 patients who had an ESS <10, 57.4% had moderate-to-severe OSA. The sensitivity of ESS to predict moderate-to-severe OSA was found to be 38.8% and the positive predictive value was 84.2% (positive likelihood ratio 2.82, 95% confidence interval = 1.57-5.06). A predictive score was identified as 0.031Age (years) +0.039BMI (kg/m2) + 0.038ESS + Gender (1 for male, 0 for female). The score had a sensitivity of 80% at a cutoff of 3.3. CONCLUSIONS: Among the morbidly obese, ESS is a poor predictor of OSA. Its utility as a tool for prediction of moderate-to-severe OSA can be improved by use of a new formula incorporating age, gender, and BMI beside ESS.

Outcomes in Super Obese Patients Undergoing One Anastomosis Gastric Bypass or Laparoscopic Sleeve Gastrectomy.

INTRODUCTION: The data on the role of OAGB in super obese patients and its direct comparison with LSG in super obese patients is scarce. OBJECTIVES: To compare weight loss, impact on comorbidities and nutritional parameters between LSG and OAGB in super obese patients. METHODS: Prospectively collected data of 75 matched patients with BMI > 50, who underwent either laparoscopic sleeve gastrectomy (LSG) or one anastomosis gastric bypass (OAGB), was analyzed retrospectively. Percentage excess weight loss at 1 year and impact on comorbidities were compared in both the groups. RESULTS: Both the groups were comparable for age, sex, BMI, and presence or absence of diabetes mellitus. Mean TWL% ± 2SD at 1 year was 30.09% ± 19.76 in patients undergoing LSG, while it was 39.9% ± 12.78 in patients undergoing OAGB (p < 0.001). In the LSG group, 85.7% and 66.67% of patients had remission of diabetes mellitus and hypertension, respectively, as compared to 77.77% and 78.5%, respectively, in the OAGB group. All the patients with OSA had a resolution of their symptoms in both the groups. Patients in the OAGB group became more folate deficient despite regular supplementation. CONCLUSION: Weight loss following OAGB was found to be better than LSG in the super obese patients in our study. There was a similar resolution of comorbidities and a lesser rate of major complications in the OAGB group.

Alpha5GABAA receptors mediate the amnestic but not sedative-hypnotic effects of the general anesthetic etomidate.

A fundamental objective of anesthesia research is to identify the receptors and brain regions that mediate the various behavioral components of the anesthetic state, including amnesia, immobility, and unconsciousness. Using complementary in vivo and in vitro approaches, we found that GABAA receptors that contain the alpha5 subunit (alpha5GABAARs) play a critical role in amnesia caused by the prototypic intravenous anesthetic etomidate. Whole-cell recordings from hippocampal pyramidal neurons showed that etomidate markedly increased a tonic inhibitory conductance generated by alpha5GABAARs, whereas synaptic transmission was only slightly enhanced. Long-term potentiation (LTP) of field EPSPs recorded in CA1 stratum radiatum was reduced by etomidate in wild-type (WT) but not alpha5 null mutant (alpha5-/-) mice. In addition, etomidate impaired memory performance of WT but not alpha5-/- mice for spatial and nonspatial hippocampal-dependent learning tasks. The brain concentration of etomidate associated with memory impairment in vivo was comparable with that which increased the tonic inhibitory conductance and blocked LTP in vitro. The alpha5-/- mice did not exhibit a generalized resistance to etomidate, in that the sedative-hypnotic effects measured with the rotarod, loss of righting reflex, and spontaneous motor activity were similar in WT and alpha5-/- mice. Deletion of the alpha5 subunit of the GABAARs reduced the amnestic but not the sedative-hypnotic properties of etomidate. Thus, the amnestic and sedative-hypnotic properties of etomidate can be dissociated on the basis of GABAAR subtype pharmacology.