Multiple Origins of Virus Persistence during Natural Control of HIV Infection.

Targeted HIV cure strategies require definition of the mechanisms that maintain the virus. Here, we tracked HIV replication and the persistence of infected CD4 T cells in individuals with natural virologic control by sequencing viruses, T cell receptor genes, HIV integration sites, and cellular transcriptomes. Our results revealed three mechanisms of HIV persistence operating within distinct anatomic and functional compartments. In lymph node, we detected viruses with genetic and transcriptional attributes of active replication in both T follicular helper (TFH) cells and non-TFH memory cells. In blood, we detected inducible proviruses of archival origin among highly differentiated, clonally expanded cells. Linking the lymph node and blood was a small population of circulating cells harboring inducible proviruses of recent origin. Thus, HIV replication in lymphoid tissue, clonal expansion of infected cells, and recirculation of recently infected cells act together to maintain the virus in HIV controllers despite effective antiviral immunity.

Increased incidence of marginal ulceration following conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: a multi-institutional experience.

BACKGROUND: Marginal ulcer (MU) formation is a serious complication following Roux-en-Y Gastric Bypass (RYGB). Incidental data suggested a higher incidence of MU following conversion of Sleeve Gastrectomy to RYGB (S-RYGB). Herein, we evaluate the incidence of MU after primary versus secondary RYGB. METHODS: After IRB approval, each institution's electronic medical record and MBSAQIP database were queried to retrospectively identify adult patients who underwent primary RYGB (P-RYGB), Gastric Banding to RYGB (B-RYGB), or S-RYGB between 2014 and 2019, with minimum 1 year follow-up. Patient demographics, operative data, and post-operative outcomes were compared. Numeric variables were compared via two-sample t test, Wilcoxon test or Kruskal Wallis rank sum test. Two-sample proportion test or Fisher's exact test was employed for categorical and binary variables. p < 0.05 marked statistical significance. RESULTS: 748 patients underwent RYGB: P-RYGB n = 584 [78.1%]; B-RYGB n = 98 [13.1%]; S-RYGB n = 66 [8.8%]. Most patients were female (83.2%). Mean age was 45.7 years. Forty-six (n = 6.1%) patients developed MU, a median of 14 ± 32.2 months (range 0.5-82) post-operatively. Incidence of MU was significantly higher for patients undergoing S-RYGB (n = 9 [13.6%]), compared to P-RYGB (n = 34 [5.8%]) and B-RYGB (n = 3 [3.1%]) (p = 0.023). Median time (months) to MU was significantly shorter for patients who underwent S-RYGB (5 ± 6) compared to P-RYGB or B-RYGB (19 ± 37.5) (p = 0.035). Among those who developed MU, there was no significant difference in H. pylori status, NSAID, steroid, or tobacco use, irrespective of operation performed. CONCLUSION: In this multi-institutional cohort, patients who underwent S-RYGB had a significantly higher incidence of MU than those with P-RYGB or B-RYGB. Further research is needed to elucidate its pathophysiology and prevention strategies.

Weight loss and clinical outcomes following primary versus secondary Roux-en-Y gastric bypass: a multi-institutional experience.

BACKGROUND: Revisional bariatric surgeries are increasing for weight recurrence and return of co-morbidities. Herein, we compare weight loss and clinical outcomes following primary Roux-en-Y Gastric Bypass (P-RYGB), adjustable gastric banding to RYGB (B-RYGB), and sleeve gastrectomy to RYGB (S-RYGB) to determine if primary versus secondary RYGB offer comparable benefits. METHODS: Participating institutions' EMRs and MBSAQIP databases were used to identify adult patients who underwent P-/B-/S-RYGB from 2013 to 2019 with a minimum one-year follow-up. Weight loss and clinical outcomes were assessed at 30 days, 1 year, and 5 years. Our multivariable model controlled for year, institution, patient and procedure characteristics, and excess body weight (EBW). RESULTS: 768 patients underwent RYGB: P-RYGB n = 581 [75.7%]; B-RYGB n = 106 [13.7%]; S-RYGB n = 81 [10.5%]. The number of secondary RYGB procedures increased in recent years. The most common indications for B-RYGB and S-RYGB were weight recurrence/nonresponse (59.8%) and GERD (65.4%), respectively. Mean time from index operation to B-RYGB or S-RYGB was 8.9 and 3.9 years, respectively. After adjusting for EBW, 1 year %TWL (total weight loss) and %EWL (excess weight loss) were greater after P-RYGB (30.4%, 56.7%) versus B-RYGB (26.2%, 49.4%) or S-RYGB (15.6%, 37%). Overall comorbidity resolution was comparable. Secondary RYGB patients had a longer adjusted mean length of stay (OR 1.17, p = 0.071) and a higher risk of pre-discharge complications or 30-day reoperation. CONCLUSION: Primary RYGB offers superior short-term weight loss outcomes compared to secondary RYGB, with decreased risk of 30-day reoperation.

Is Bariatric Procedure Type Associated With Morbidity in Transplant Patients?

INTRODUCTION: Roux-en-Y Gastric Bypass (RYGB) has been associated with increased weight loss but more complications when compared with sleeve gastrectomy (SG). However, a direct comparison between RYGB and SG has never been performed in patients with a history of solid organ transplantation. The aim of this study was to determine the association between procedure type and surgical outcomes. MATERIALS AND METHODS: Patients with a history of solid organ transplantation were identified in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project Participant Use File database from 2017 to 2018. Procedure type (SG versus RYGB) was used to stratify patients. Propensity score matching and multivariable logistic regressions were used, and outcomes were compared. RESULTS: Of 678 cases identified, 80% (n = 542) underwent an SG and 20% (n = 136) had an RYGB. Patients differed significantly (P < 0.05) by multiple demographic variables. Multivariable regression revealed RYGB to be associated with higher overall morbidity (odds ratio [OR] 1.98; P = 0.012), morbidity related to surgery (OR 2.47; P = 0.002), unplanned readmissions (OR 2.48; P = 0.002), and readmissions related to surgery (OR 2.32; P = 0.016). After propensity score matching, RYGB, compared with SG, was also associated with higher morbidity (14% versus 7.4%; P = 0.077) and readmissions (13% versus 6.6%; P = 0.099) related to surgery, although this did not reach statistical significance. CONCLUSIONS: In patients with a history of solid organ transplant, RYGB was associated with increased morbidity and readmissions compared with SG.

Seatbelt Use in Females of Childbearing Age at an Urban Safety-Net Level 1 Trauma Center.

BACKGROUND: Safety restraint system (SRS) use is known to improve maternal and fetal outcomes in pregnant women. Factors associated with seatbelt use in females of childbearing age are largely unstudied despite global public health endeavors to increase use. We sought to define its use and uncover risk factors for not using a restraint system in this vulnerable patient cohort. MATERIALS AND METHODS: A retrospective chart review of all female patients aged 15-35 y presenting from 2007 to 2017 was performed using our institutional level 1 trauma database. Age, pregnancy, insurance status (commercial or private, Medicaid plan, and uninsured), race, and Injury Severity Score (ISS) were examined in unmatched data. A matched cohort was created to evaluate the impact of pregnancy on SRS use based on ISS, age, race, and insurance status with blinding to belt use during matching (two nonpregnant to one pregnant). Differences in restraint use were then examined using Mann-Whitney U and Chi-square tests. RESULTS: A total of 779 patients met inclusion criteria, of which 140 were pregnant. In unmatched data, there was no difference in belt use with regard to age, race, or insurance type. Overall belt use was 59%. Twenty-five percent of patients were uninsured, and 39% used a Medicaid plan. Pregnant patients were statistically more likely to wear belts (71% versus 57%, P = 0.003). In ISS-matched data, this difference was not upheld (63% pregnant belt use versus 58%, P = 0.615). CONCLUSIONS: Pregnancy did not induce improved safety behavior in our population. More study is needed to confirm our findings. Overall SRS use in our urban population is very poor, lags behind the national average, and requires additional public health attention.