To wean or not to wean: proton pump inhibitor management after anti-reflux surgery amongst foregut experts.

BACKGROUND: Most patients undergoing anti-reflux surgery (ARS) have a history of preoperative proton pump inhibitor (PPI) use. It is well-established that ARS is effective in restoring the anti-reflux barrier, eliminating the ongoing need for costly PPIs. Current literature lacks objective evidence supporting an optimal postoperative PPI cessation or weaning strategy, leading to wide practice variations. We sought to objectively gauge current practice and opinion surrounding the postoperative management of PPIs among expert foregut surgeons and gastroenterologists in the United States. METHODS: We created a survey of postoperative PPI management protocols, with an emphasis on discontinuation and timing of PPI cessation, and aimed to determine what factors played a role in the decision-making. An electronic survey tool (Qualtrics XM, Qualtrics, Provo, UT) was used to distribute the survey and to record the responses anonymously for a period of three months. RESULTS: The survey was viewed 2658 times by 373 institutions and shared with 644 members. In total, 121 respondents participated in the survey and 111 were surgeons (92%). Fifty respondents (42%) always discontinue PPIs immediately after ARS. Of the remaining 70 respondents (58%), 46% always wean or taper PPIs postoperatively and 47% wean or taper them selectively. The majority (92%) of practitioners taper within a 3-month period postoperatively. Five respondents never discontinue PPIs after ARS. Overall, only 23 respondents (19%) stated their protocol is based on medical literature or evidence-based medicine. Instead, decision-making is primarily based on anecdotal evidence/personal preference (42%, n = 50) or prior training/mentors (39%, n = 47). CONCLUSIONS: There are two major protocols used for PPI discontinuation after ARS: Nearly half of providers abruptly stop PPIs, while just over half gradually tapers them, most often in the early postoperative period. These decisions are primarily driven by institutional practices and personal preferences, underscoring the need for evidence-based recommendations.

High Resolution Manometry in a Functioning Fundoplication - Establishing a Standard Profile: Retrospective Chart Review.

OBJECTIVE: The aim of this study was to provide a full HRM data set in patients with a normal functioning fundoplication. BACKGROUND: The Chicago classification was devised to correlate HRM values to the clinical status of patients with swallowing disorder. However, it is unclear whether those values are applicable after fundoplication as the literature is sparse. METHODS: We identified patients with pre- and postoperative HRM who had a normal functioning primary fundoplication as defined by (1) resolution of preoperative symptoms without significant postoperative side effects, (2) no dysphagia reported on a standardized questionnaire given on the day of the postoperative HRM and (3) normal acid exposure determined objectively by esophageal pH-testing. RESULTS: Fifty patients met inclusion criteria for the study. Thirty-three patients (66%) underwent complete fundoplication and 17 patients (34%) underwent posterior partial fundoplication. Postoperative HRM was performed at a median of 12 months after primary surgery. Lower esophageal sphincter (LES) values significantly increased with the addition of a fundoplication. Median integrated relaxation pressure (IRP) was 14 mm Hg ( P = 0.0001), median resting pressure 19.5 mm Hg ( P = 0.0263), and median total length LES was 3.95 cm ( P = 0.0098). The 95th percentile for IRP in a complete fundoplication was 29 versus 23 mm Hg in a partial fundoplication ( P = 0.3667). CONCLUSION: We offer a new standard manometric profile for a normally functioning fundoplication which provides a necessary benchmark for analyzing postoperative problems with a fundoplication. The previously acceptedupper limit defining esophageal outflow obstruction (IRP >20 mm Hg) is not clinically applicable after fundoplication as the majority of patients in this dysphagia-free cohort exceeded this value. Interestingly, there does not seem to be a significant difference in HRM LES values between complete and partial fundoplication.

POEM: clinical outcomes beyond 5 years.

BACKGROUND: The short-term success of peroral endoscopic myotomy (POEM) is well documented but the durability of the operation is questioned. The aim of this study was to evaluate the clinical outcomes of the POEM procedure for esophageal motility disorders in a large cohort in which all patients had at least 5 years of follow-up. METHODS: All patients from a single center who underwent a POEM between October 2010 and September 2014 were followed for long-term clinical outcomes. Postoperative Eckardt symptom scores of short term and ≥ 5 years were collected through phone interview. Clinical success was defined as an Eckardt score < 3. Overall success was defined as Eckardt score < 3 and freedom from additional interventions. RESULTS: Of 138 patients, 100 patients were available for follow-up (mean age 56, 52% male). The indication for operation was achalasia in 94. The mean follow-up duration was 75 months (range: 60-106 months). Dysphagia was improved in 91% of patients. Long-term overall success was achieved in 79% of patients (80% of achalasia patients, 67% of DES patients). Preoperative mean Eckardt score was 6. At 6 months, it was 1, and at 75 months, it was 2 (p = 0.204). Five-year freedom from intervention was 96%. Overall, 7 patients had additional treatments: 1 balloon dilation (35 mm), 4 laparoscopic Heller myotomy, and 2 redo POEM at a mean of 51 months post-POEM. Ninety-three percent expressed complete satisfaction with POEM. CONCLUSION: A multitude of studies has shown the early benefits of POEM. Here, we show that nearly 80% of patients report clinical success with no significant decrement in symptom scores between their short- and long-term follow-up. Clearly POEM is an effective option for achalasia with durable long-term treatment efficacy.

Safety and efficacy of magnetic sphincter augmentation dilation.

BACKGROUND: The magnetic sphincter augmentation device (MSA) provides effective relief of gastroesophageal reflux symptoms. Dysphagia after MSA implantation sometimes prompts endoscopic dilation. The manufacturer's instructions are that it be performed 6 or more weeks after implantation under fluoroscopic guidance to not more than 15 mm keeping 3 or more beads closed. The purpose of this study was to assess adherence to these recommendations and explore the techniques used and outcomes after MSA dilation. METHODS AND PROCEDURES: We conducted a multicenter retrospective review of patients undergoing dilation for dysphagia after MSA placement from 2012 to 2018. RESULTS: A total of 144 patients underwent 245 dilations. The median size of MSA placed was 14 beads (range 12-17) and the median time to dilation was 175 days. A second dilation was performed in 67 patients, 22 patients had a third dilation and 7 patients underwent 4 or more dilations. In total, 17 devices (11.8%) were eventually explanted. The majority of dilations were performed with a balloon dilator (81%). The median dilator size was 18 mm and 73.4% were done with a dilator larger than 15 mm. There was no association between dilator size and need for subsequent dilation. Fluoroscopy was used in 28% of cases. There were no perforations or device erosions related to dilation. DISCUSSION: There is no clinical credence to the manufacturer's recommendation for the use of fluoroscopy and limitation to 15 mm when dilating a patient for dysphagia after MSA implantation. Use of a larger size dilator was not associated with perforation or device erosion, but also did not reduce the need for repeat dilation. Given this, we would recommend that the initial dilation for any size MSA device be done using a 15 mm through-the-scope balloon dilator. Dysphagia prompting dilation after MSA implantation is associated with nearly a 12% risk of device explantation.

Medical Applications of Drones for Disaster Relief: A Review of the Literature.

INTRODUCTION: Rapid progress has been made with unmanned aerial systems (UAS), which are now used in a wide variety of different fields, including media, agriculture, wildlife, and infrastructure. However, the application of UAS for medical purposes, and in particular disaster relief efforts, has been slower to develop. This paper will review and present pertinent studies in the literature. METHODOLOGY: Studies related to drones and medical applications for disaster relief were identified as part of a larger search regarding the civilian application of drones. A search for civilian drone applications was performed in the EBSCO (Elton B. Stephens Company) database. Non-civilian applications as well as redundant sources were excluded. RESULTS: The search identified 711 sources pertaining to civilian drone applications. Of these, 117 involved drone applications in disaster relief, and 28 articles specifically addressed medical uses. CONCLUSION: Drones can be useful during immediate and non-immediate medical disaster relief efforts. They can provide an instant telecommunications infrastructure, assist in telemedicine-enabled clinical services, perform equipment/drug/patient delivery, enhance search and rescue efforts, assess damage and map disaster zones. Rapid processing of permission for emergency operations, promotion of industry expansion, public awareness, and public participation must be emphasized for these to become routine applications. There is a major concern about the organizational umbrella that would promote this initiative. Creation of an organization such as a Drone Civil Air Patrol Wing (DCAPW) could improve our ability to provide post-disaster healthcare delivery services.

Detection of copy number variation by SNP-allelotyping.

Charcot-Marie-Tooth disease type 1A (CMT1A) is caused by an abnormal copy number variation (CNV) with a trisomy of chromosome 17p12. The increase of the DNA-segment copy number is expected to alter the allele frequency of single nucleotide polymorphism (SNP) within the duplicated region. We tested whether SNP allele frequency determined by a Sequenom MassArray can be used to detect the CMT1A mutation. Our results revealed distinct patterns of SNP allele frequency distribution, which reliably differentiated CMT1A patients from controls. This finding suggests that this technique may serve as an alternative approach to identifying CNV in certain diseases, including CMT1A.

Distinct or shared actions of peptide family isoforms: II. Multiple pyrokinins exert similar effects in the lobster stomatogastric nervous system.

Many neuropeptides are members of peptide families, with multiple structurally similar isoforms frequently found even within a single species. This raises the question of whether the individual peptides serve common or distinct functions. In the accompanying paper, we found high isoform specificity in the responses of the lobster (Homarus americanus) cardiac neuromuscular system to members of the pyrokinin peptide family: only one of five crustacean isoforms showed any bioactivity in the cardiac system. Because previous studies in other species had found little isoform specificity in pyrokinin actions, we examined the effects of the same five crustacean pyrokinins on the lobster stomatogastric nervous system (STNS). In contrast to our findings in the cardiac system, the effects of the five pyrokinin isoforms on the STNS were indistinguishable: they all activated or enhanced the gastric mill motor pattern, but did not alter the pyloric pattern. These results, in combination with those from the cardiac ganglion, suggest that members of a peptide family in the same species can be both isoform specific and highly promiscuous in their modulatory capacity. The mechanisms that underlie these differences in specificity have not yet been elucidated; one possible explanation, which has yet to be tested, is the presence and differential distribution of multiple receptors for members of this peptide family.

Can We Identify Patients Appropriate for Same-Day Discharge After Laparoscopic Fundoplication?

Background: Patients, surgeons, and payers are interested in reducing hospital length of stay. Outpatient laparoscopic fundoplication (LF) can be done safely and cost effectively. There is low acceptance of this practice due to fear of readmission and patient dissatisfaction. Our aim was to identify factors predicting failure of same-day discharge after LF. Methods and Procedures: We simulated an outpatient setting for patients who underwent LF from 2017 to 2018 and collected the data prospectively. A perioperative pain and nausea protocol was utilized. Postoperatively, patients were given a liquid diet and oral medications, observed overnight, and then discharged after standard criteria were met. Failure was defined by the need for physician intervention after 3 hours or failure to discharge. Univariate and multivariable logistic regression analyses were performed assessing factors associated with failure. Two-sample t-test and chi-squared tests were used for significance. Results: Ninety-eight patients were included. Twenty patients failed, primarily due to the need for intravenous medications. Seven were discharged on postoperative day 1 but required physician intervention after 3 hours. Thirteen patients stayed >23 hours. Two patients were readmitted within 1 week of discharge. There was one acute recurrence, requiring reoperation, and one conversion to laparotomy. We found no statistically significant patient risk factor, comorbidity, or perioperative variable that could reliably predict failure of same-day discharge. Conclusion: This study suggests that same-day discharge after LF is safe and feasible. However, 20% of patients will unpredictably fail to meet discharge criteria.

Singing streams: Describing freshwater soundscapes with the help of acoustic indices.

Understanding soundscapes, that is, the totality of sounds within a location, helps to assess nature in a more holistic way, providing a novel approach to investigating ecosystems. To date, very few studies have investigated freshwater soundscapes in their entirety and none across a broad spatial scale.In this study, we recorded 12 freshwater streams in South East Queensland continuously for three days and calculated three acoustic indices for each minute in each stream. We then used principal component analysis of summary statistics for all three acoustic indices to investigate acoustic properties of each stream and spatial variation in their soundscapes.All streams had a unique soundscape with most exhibiting diurnal variation in acoustic patterns. Across these sites, we identified five distinct groups with similar acoustic characteristics. We found that we could use summary statistics of AIs to describe daytimes across streams as well. Most difference in stream soundscapes was observed during the daytime with significant variation in soundscapes both between hours and among sites. Synthesis and Application. We demonstrate how to characterize stream soundscapes by using simple summary statistics of complex acoustic indices. This technique allows simple and rapid investigation of streams with similar acoustic properties and the capacity to characterize them in a holistic and universal way. While we developed this technique for freshwater streams, it is also applicable to terrestrial and marine soundscapes.

Salmon abundance and patterns of forest greenness as measured by satellite imagery.

Linkages across ecosystems can shape productivity. Salmon carcasses are exemplary of cross-system linkages, because they can fertilize riparian vegetation and shape patterns of terrestrial biodiversity. Detection of salmon fertilization effects has been confined to field-based studies that are limited in scale. Here we use satellite images to quantify the effects of salmon on greenness of riparian vegetation. We measure tree greenness across spatial and temporal gradients of salmon fertilization effects in two regions. In the first case study, we find that deciduous trees are greener in years following large salmon spawning events, and that the magnitude of this effect was related to the specific abundance of spawning salmon. In the second case study we compare greenness of mixed evergreen and deciduous forests across different watersheds that have different salmon spawning densities. We found greenness was related positively to salmon spawning density near streams with high evergreen cover and flat stream banks. These findings suggest that the effect of salmon carcasses on riparian vegetation may be detectable from space. Further work on this approach, especially with high spatial, temporal and spectral data, may allow estimation of the spatial extent of nutrient enrichment from salmon carcasses and aid ecosystem-based management to protect important ecosystem linkages.

Surgical and Medical Applications of Drones: A Comprehensive Review.

BACKGROUND: Drones have the ability to gather real time data cost effectively, to deliver payloads and have initiated the rapid evolution of many industrial, commercial, and recreational applications. Unfortunately, there has been a slower expansion in the field of medicine. This article provides a comprehensive review of current and future drone applications in medicine, in hopes of empowering and inspiring more aggressive investigation. DATABASE: A literature search was performed by EBSCO (Elton B. Stephens Company) Discovery Service, searching the phrases "drones," "UAV," "unmanned aerial vehicles," "UAS," and "unmanned aerial systems." A second search was used to identify sources that contained "drone" in the subject or title and "medicine" in any of the text, yielding 60,260 results. After screening for irrelevant material, 1296 sources remained applicable. Major themes and number of sources were as follows: 116 public health and medical surveillance, 8 telemedicine, and 78 medical transport systems. CONCLUSION: Drones are used for surveillance of disaster sites and areas with biological hazards, as well as in epidemiology for research and tracking disease spread. Telecommunication drones are being used for diagnosis and treatment, perioperative evaluation, and telementoring in remote areas. Drones have the potential to be reliable medical delivery platforms for microbiological and laboratory samples, pharmaceuticals, vaccines, emergency medical equipment, and patient transport. Government agencies have placed drone use on the national agenda. The next steps include aggressive research initiatives in the areas of safety, industry expansion, increased public awareness, and participation.

Differences in nitrate and phosphorus export between wooded and grassed riparian zones from farmland to receiving waterways under varying rainfall conditions.

Agricultural activities in catchments can cause excessive nutrient loads in waterways. Catchment nitrogen (N) and phosphorus (P) flows may be intercepted and assimilated by riparian vegetation. While prior studies suggest that woody vegetation is preferable for reducing P loads, the question remains: is woody vegetation or grass cover more effective at reducing catchment N and P exports to waterways. To address this we investigated the relative importance of vegetation type, hydrologic and soil microbial processes on N and P losses from soil to a stream. The study involved the analysis of data from two soil microcosm experiments, and a field case study. We found P leaching loss from riparian zones depended significantly on vegetation type (woody vs. grass cover), with lower P exported from wooded riparian zones, irrespective of the scale of rainfall. For N leaching losses, the scale of rainfall had an effect. During high rainfall, vegetation type had a major effect on N leaching loss, with lower N exported from grassed verses wooded riparian zones. However, under low rainfall conditions, soil type and soil C and N stores, potential indicators of soil microbial activity, rather than vegetation cover, affected N leaching. It is hypothesized that soil microbes were reducing N removal under these conditions. We reason that nitrifiers may have played an important role in soil N cycling, as increased soil ammonium had a strong positive effect on nitrate leaching loads, mediated through soil nitrate stores. Whereas, N immobilization, via incorporation into microbial biomass, and denitrification processes appeared to be limited by C availability, with increased C associated with reduced N leaching. Overall, this study identified that N leaching losses from riparian zones appeared to be affected by two different processes, vegetative uptake and soil microbial processes, the relative importance of which was driven by hydrological conditions.

The PMP22 gene and its related diseases.

Peripheral myelin protein-22 (PMP22) is primarily expressed in the compact myelin of the peripheral nervous system. Levels of PMP22 have to be tightly regulated since alterations of PMP22 levels by mutations of the PMP22 gene are responsible for >50 % of all patients with inherited peripheral neuropathies, including Charcot-Marie-Tooth type-1A (CMT1A) with trisomy of PMP22, hereditary neuropathy with liability to pressure palsies (HNPP) with heterozygous deletion of PMP22, and CMT1E with point mutations of PMP22. While overexpression and point-mutations of the PMP22 gene may produce gain-of-function phenotypes, deletion of PMP22 results in a loss-of-function phenotype that reveals the normal physiological functions of the PMP22 protein. In this article, we will review the basic genetics, biochemistry and molecular structure of PMP22, followed by discussion of the current understanding of pathogenic mechanisms involving in the inherited neuropathies with mutations in PMP22 gene.

Zn(tbip) (H2tbip= 5-tert-butyl isophthalic acid): a highly stable guest-free microporous metal organic framework with unique gas separation capability.

A novel guest-free metal organic framework (GFMMOF) is synthesized and structurally characterized. It contains one-dimensional close-packed open channels with a pore diameter of 4.5 A. It demonstrates a remarkable thermal stability, a unique ability to separate methanol from dimethyl ether or water, and is among the microporous MOFs having the highest adsorbed hydrogen density (0.054 g/cm3 at 77 K and 1 atm).