A conserved viral amphipathic helix governs the replication site-specific membrane association.

Positive-strand RNA viruses assemble their viral replication complexes (VRCs) on specific host organelle membranes, yet it is unclear how viral replication proteins recognize and what motifs or domains in viral replication proteins determine their destinations. We show here that an amphipathic helix, helix B in replication protein 1a of brome mosaic virus (BMV), is necessary for 1a's localization to the nuclear endoplasmic reticulum (ER) membrane where BMV assembles its VRCs. Helix B is also sufficient to target soluble proteins to the nuclear ER membrane in yeast and plant cells. We further show that an equivalent helix in several plant- and human-infecting viruses of the Alsuviricetes class targets fluorescent proteins to the organelle membranes where they form their VRCs, including ER, vacuole, and Golgi membranes. Our work reveals a conserved helix that governs the localization of VRCs among a group of viruses and points to a possible target for developing broad-spectrum antiviral strategies.

Primary anastomosis with diverting loop ileostomy vs. Hartmann's procedure for acute diverticulitis: what happens after discharge? Results of a nationwide analysis.

BACKGROUND: Current guidelines recommend resection with primary anastomosis with diverting loop ileostomy over Hartmann's procedure if deemed safe for acute diverticulitis. The primary objective of the current study was to compare the utilization of these strategies and describe nationwide ostomy closure patterns and readmission outcomes within 1 year of discharge. METHODS: This was a retrospective, population-based, cohort study of United States Hospitals reporting to the Nationwide Readmissions Database from January 2011 to December 2019. There were 35,774 patients identified undergoing non-elective primary anastomosis with diverting loop ileostomy or Hartmann's procedure for acute diverticulitis. Rates of ostomy closure, unplanned readmissions, and complications were compared. Cox proportional hazards and logistic regression models were used to control for patient and hospital-level confounders as well as severity of disease. RESULTS: Of the 35,774 patients identified, 93.5% underwent Hartmann's procedure. Half (47.2%) were aged 46-65 years, 50.8% female, 41.2% publicly insured, and 91.7% underwent open surgery. Primary anastomosis was associated with higher rates of 1-year ostomy closure (83.6% vs. 53.4%, p < 0.001) and shorter time-to-closure [median 72 days (Interquartile range 49-103) vs. 115 (86-160); p < 0.001]. Primary anastomosis was associated with increased unplanned readmissions [Hazard Ratio = 2.83 (95% Confidence Interval 2.83-3.37); p < 0.001], but fewer complications upon stoma closure [Odds Ratio 0.51 (95% 0.42-0.63); p < 0.001]. There were no differences in complications between primary anastomosis and Hartmann's procedure during index admission [Odds Ratio = 1.13 (95% Confidence Interval 0.96-1.33); p = 0.137]. CONCLUSION: Patients who undergo primary anastomosis for acute diverticulitis are more likely to undergo ostomy reversal and experience fewer postoperative complications upon stoma reversal. These data support the current national guidelines that recommend primary anastomosis in appropriate cases of acute diverticulitis requiring operative treatment.

How Does Reduction Mammaplasty Surgical Technique Impact Clinical, Aesthetic, and Patient-Reported Outcomes?: A Comparison of the Superomedial and Inferior Pedicle Techniques.

BACKGROUND: A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes. METHODS: Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed. RESULTS: Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03). CONCLUSIONS: The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.

Incidence and Epidemiology of Traumatic Tympanic Membrane Rupture: A National Trauma Data Bank Analysis.

The incidence of traumatic tympanic membrane rupture (TTMR) has increased over recent decades. The association of certain external injury causes and bone fracture patterns with TTMR is anecdotal. It has been suggested that a diagnosis of TTMR may be missed during the acute trauma admission. The authors sought to evaluate the incidence of TTMR according to external injury cause and evaluate the association of skull fracture patterns with TTMR using a national trauma database. A cross-sectional analysis of trauma encounters was conducted using the National Trauma Data Bank (NTDB) from 2008 to 2015. Demographic and injury data were abstracted. Poisson regression was used to determine the incidence rate ratios of tympanic membrane rupture by external injury cause and logistic regression was used to estimate odds ratios (OR) of TTMR by skull fracture type. A total of 8214 patients were identified with TTMR during acute admission. The majority were on average 30 years old, 76% male, 71% White, had a mean Injury Severity Score of 14, and 42% were admitted to level I centers. The incidence rate ratio was only higher in lightning related injuries [5.262; 95% confidence interval (CI): 4.194-6.602] when using those caused by explosives as a reference. Basilar skull (OR: 12.95; 95% CI: 12.095-12.866) and cranial vault (OR: 2.938; 95% CI: 2.647-3.260) fractures were most associated with TTMR. The high incidence TTMR in association with certain external causes of injury and types of skull fractures should drive screening in the acute setting in order to increase detection and reduce morbidity from missed injuries.

Common beans as a source of food ingredients: Techno-functional and biological potential.

Common beans are an inexpensive source of high-quality food ingredients. They are rich in proteins, slowly digestible starch, fiber, phenolic compounds, and other bioactive molecules that could be separated and processed to obtain value-added ingredients with techno-functional and biological potential. The use of common beans in the food industry is a promising alternative to add nutritional and functional ingredients with a low impact on overall consumer acceptance. Researchers are evaluating traditional and novel technologies to develop functionally enhanced common bean ingredients, such as flours, proteins, starch powders, and phenolic extracts that could be introduced as functional ingredient alternatives in the food industry. This review compiles recent information on processing, techno-functional properties, food applications, and the biological potential of common bean ingredients. The evidence shows that incorporating an adequate proportion of common bean ingredients into regular foods such as pasta, bread, or nutritional bars improves their fiber, protein, phenolic compounds, and glycemic index profile without considerably affecting their organoleptic properties. Additionally, common bean consumption has shown health benefits in the gut microbiome, weight control, and the reduction of the risk of developing noncommunicable diseases. However, food matrix interaction studies and comprehensive clinical trials are needed to develop common bean ingredient applications and validate the health benefits over time.

Prospective Assessment of the Abdominal Hernia-Q (AHQ)-Patient Burden, Reliability, and Longitudinal Assessment of Quality of Life in Hernia Repair.

OBJECTIVE: This study assesses the user burden, reliability, and longitudinal validity of the AHQ, a novel VH patient-reported outcomes measure (PROM). BACKGROUND: We developed and psychometrically validated the AHQ as the first VH-specific, stakeholder-informed PROM. Yet, there remains a need to assess the AHQ's clinical applicability and further validate its psychometric properties. METHODS: To assess patient burden, pre- and postoperative patients were timed while completing the corresponding AHQ form. To measure test-retest reliability, a subset of patients completed the AHQ within a week of initial completion, and consecutive responses were correlated. Lastly, patients undergoing VH repair were prospectively administered the pre- and postoperative AHQ forms, the Hernia-Related Quality of Life Survey and the Short Form-12 both preoperatively and at postoperative intervals, up to over a year after surgery. Quality-of-Life scores were correlated from the 3 PROMs and effect sizes were compared using analysis of normal variance. RESULTS: Median response times for the pre- and postoperative AHQ were 1.1 and 2.7 minutes, respectively. The AHQ demonstrates high test-retest reliability coefficients for pre- and postoperative instruments ( r = 0.91, 0.89). The AHQ appropriately and proportionally measures expected changes following surgery and significantly correlates with all times points of theHernia-Related Quality of Life Survey and Short Form-12 MS and 4/5 (80%) SF12-PS. CONCLUSION: The AHQ is a patient-informed, psychometrically-validated, clinical instrument for measuring, quantifying, and tracking PROMs in VH patients. The AHQ exhibits low response burden, excellent reliability, and effectively measures hernia-specific changes in quality-of-Life following ventral hernia repair.

Evaluating Outcomes Related to Donor and Recipient Metabolic Environment: Macrosteatotic Allografts and Nonalcoholic Steatohepatitis.

The increasing prevalence of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) affects both recipient and donor populations in liver transplantation. Presently, it is unclear whether transplantation of macrosteatotic allografts is affected by the metabolic milieu of liver transplant recipients. This study investigates fatty liver disease at the intersection of donor and recipient. A retrospective review of the Organ Procurement and Transplantation database identified 5167 NASH and 26,289 non-NASH transplant recipients who received transplants from January 1, 2004, to June 12, 2020. A total of 12,569 donors had allografts with no macrosteatosis (<5%), 16,140 had mild macrosteatosis (5%-29%), and 2747 had moderate to severe macrosteatosis (≥30%). Comparing recipients with NASH to propensity score-matched (PSM) recipients without NASH demonstrated noninferior graft and patient survival up to 10 years in patients with NASH. Similar trends were observed in subgroup analyses of transplants within each strata of allograft macrosteatosis. Assessing allograft macrosteatosis specifically in the NASH population demonstrated that allografts with ≥30% macrosteatosis were associated with reduced early graft survival (30 days, 93.32% versus 96.54% [P = 0.02]; 1 year, 84.53% versus 88.99% [P = 0.05]) compared with PSM grafts with <30% macrosteatosis. Long-term graft survival at 5 and 10 years, however, was similar. The use of carefully selected macrosteatotic allografts can be successful in both recipients with NASH and recipients without NASH. The metabolic environment of patients with NASH does not appear to adversely affect outcomes with regard to the allograft when controlled for numerous confounders. It is, however, important to remain cognizant of the potential for high-risk macrosteatotic allografts to negatively affect outcomes.

Pandemic Puppies: Man's Best Friend or Public Health Problem? A Multidatabase Study.

INTRODUCTION: The public health implications of the COVID-19 pandemic reach beyond those of the disease itself. Various centers have anecdotally reported increases in the incidence of dog bite injuries which predominate in pediatric populations. The reasons for this increase are likely multifactorial and include an increase in canine adoptions, remote learning, and psychosocial stressors induced by lockdowns. We hypothesized that there was a significant increase in the proportion of dog bite injuries at our institution and within a nationally representative cohort. METHODS: We queried our electronic health record and the National Electronic Injury Surveillance System (NEISS) for all records pertaining to dog bites between 2015 and 2020, and the annual incidence was calculated. Poisson regression was then used to estimate whether there was a significant difference in the adjusted risk ratio for each year. RESULTS: The institutional and national cohorts revealed relative increases in the incidence of dog bite injury of 243 and 147.9 per 100,000 over the study period, respectively. Both cohorts observed significant increases of 44% and 25% in the annual incidence relative to 2019, respectively. Poisson regression revealed a significantly elevated adjusted relative risk in the institutional cohort for 2020 (2.664, CI: 2.076-3.419, P < 0.001). The national cohort also revealed an increase (1.129, CI: 1.091-1.169, P < 0.001). CONCLUSIONS: A nationwide increase in the incidence of dog bite injuries among children was observed during COVID-19 in 2020. These findings suggest that dog bites remain a public health problem that must be addressed by public health agencies.

Assessing cross-laboratory performance for quantifying coliphage using EPA Method 1642.

AIMS: Widespread adoption of the new U.S. Environmental Protection Agency (USEPA) Method 1642 for enumeration of coliphage in recreational water requires demonstration that laboratories consistently meet internal method performance goals and yield results that are consistent across laboratories. METHODS AND RESULTS: Here we assess the performance of six laboratories processing a series of blind wastewater- and coliphage-spiked samples along with laboratory blanks. All laboratories met the method-defined recovery requirements when performance was averaged across samples, with the few failures on individual samples mostly occurring for less-experienced laboratories on the initial samples processed. Failures that occurred on later samples were generally attributed to easily correctable activities. Failure rates were higher for somatic vs. F+ coliphage, attributable to the more stringent performance criteria associated with somatic coliphage. There was no difference in failure rate between samples prepared in a marine water matrix compared to that in phosphate-buffered saline. CONCLUSIONS: Variation among laboratories was similar to that previously reported for enterococci, the current bacterial indicator used for evaluating beach water quality for public health protection. SIGNIFICANCE AND IMPACT OF THE STUDY: These findings suggest that laboratory performance is not an inhibitor to the adoption of coliphage as a new indicator for assessing recreational health risk.

National recurrence of pancreatitis and readmissions after biliary pancreatitis.

BACKGROUND: National and international guidelines support early cholecystectomy after mild gallstone pancreatitis but a recent nationwide study suggested these recommendations are not universally followed. Our study sought to quantify the national utilization of same hospitalization cholecystectomy versus non-operative management (NOM) and its association with pancreatitis recurrence, readmissions, and costs after mild gallstone pancreatitis (GP). METHODS: Adult patients admitted with mild GP were identified from the Nationwide Readmission Database 2010-2015. Primary outcomes included the rate of cholecystectomy during the index admission as well as pancreatitis recurrence and readmission at 30 and 180 days (30d, 180d) comparing NOM to same hospitalization cholecystectomy. Mortality upon readmission, total length of stay (LOS), and total costs (combined index-readmission hospital costs) were also explored. Cox proportional hazards regression and generalized linear models controlled for patient/hospital confounders. RESULTS: Among the 65,067 patients identified, 30% underwent cholecystectomy. The NOM cohort was older (58 vs. 50 years), had more comorbidities (Charlson index > 2, 23.5% vs. 11.5%), fewer female patients (56.7% vs. 67%) and less discharge-to-home (84.9% vs. 94.4%) (all p < 0.001). NOM was associated with increase in recurrence and unplanned readmissions at 30d [Hazard Ratio 3.53 (95% CI 2.92-4.27), 2.41 (2.11-2.74), respectively], and 180d [4.27 (3.65-4.98), 2.78 (2.54-3.04), respectively], as well as increased mortality during 180d readmission 1.88 (1.06-3.35). This approach was also associated with significant increase in LOS [predicted mean difference 2.79 days (95% CI 2.46-3.12)] and total costs [$2507.89 ($1714.4-$3301.4)]. CONCLUSIONS: In the USA, most patients presenting with mild GP do not undergo same hospitalization cholecystectomy. This strategy results in higher recurrent pancreatitis, mortality during readmission, and an additional $4.85 M/year in hospital costs nationwide. These data support same hospitalization cholecystectomy as the gold standard for mild GP.

Direct-to-Implant Versus 2-Stage Breast Reconstruction: Which Technique Is Better? An Analysis of 104 Patients at a Single Institution.

BACKGROUND: Two-stage (TS) implant-based reconstruction is the most commonly performed method of reconstruction after mastectomy. A growing number of surgeons are offering patients direct-to-implant (DTI) reconstruction, which has the potential to minimize the number of surgeries needed and time to complete reconstruction, as well as improve health care utilization. However, there are conflicting data regarding the outcomes and complications of DTI, and studies comparing the 2 methods exclusively are lacking. METHODS: Patients undergoing implant-based reconstruction after mastectomy within a large interstate health system between 2015 and 2019 were retrospectively identified and grouped by reconstruction technique (TS and DTI). The primary outcomes were a composite of complications (surgical site occurrences), health care utilization (reoperations, unplanned emergency department visits, and readmissions), and time to reconstruction completion. Risk-adjusted logistic and generalized linear models were used to compare outcomes between TS and DTI. RESULTS: Of 104 patients, 42 underwent DTI (40.4%) and 62 underwent TS (59.6%) reconstruction. Most demographic characteristics, and oncologic and surgical details were comparable between groups ( P > 0.05). However, patients undergoing TS reconstruction were more likely to be publicly insured, have a smoking history, and undergo skin-sparing instead of nipple-sparing mastectomy. The composite outcome of complications, reoperations, and health care utilization was higher for DTI reconstruction within univariate (81.0% vs 59.7%, P = 0.03) and risk-adjusted analyses (odds ratio, 3.78 [95% confidence interval [CI], 1.09-13.9]; P < 0.04). Individual outcome assessment showed increased mastectomy flap necrosis (16.7% vs 1.6%, P < 0.01) and reoperations due to a complication (33.3% vs 16.1%; P = 0.04) in the DTI cohort. Although DTI patients completed their aesthetic revisions sooner than TS patients (median, 256 days vs 479 [ P < 0.01]; predicted mean difference for TS [reference DTI], 298 days [95% CI, 71-525 days]; P < 0.01), the time to complete reconstruction (first to last surgery) did not differ between groups (median days, DTI vs TS, 173 vs 146 [ P = 0.25]; predicted mean difference [reference, DTI], -98 days [95% CI, -222 to 25.14 days]; P = 0.11). CONCLUSIONS: In this cohort of patients, DTI reconstruction was associated with higher complications, reoperations, and health care utilization with no difference in time to complete reconstruction compared with TS reconstruction. Further studies are warranted to investigate patient-reported outcomes and cost analysis between TS and DTI reconstruction.

Does the Geographical Distribution of Facial Trauma Surgeons Correspond to Facial Trauma Burden? A Nationwide Population-Level Analysis.

ABSTRACT: It is unknown if craniofacial trauma services are inequitably distributed throughout the US. The authors aimed to describe the geographical distribution of craniofacial trauma, surgeons, and training positions nationwide. State-level data were obtained on craniofacial trauma admissions, surgeons, training positions, population, and income for 2016 to 2017. Normalized densities (per million population [PMP]) were ascertained. State/ regional-level densities were compared between highest/lowest. Risk-adjusted generalized linear models were used to determine independent associations. There were 790,415 craniofacial trauma admissions (x? = 2330.6 PMP), 28,004 surgeons (x? = 83.5 PMP), and 746 training positions (x? = 1.9 PMP) nationwide. There was significant state-level variation in the density PMP of trauma (median 1999.5 versus 2983.5, P   <  0.01), surgeon (70.8 versus 98.8, P  < 0.01), training positions (0 versus 3.4, P  < 0.01) between lowest/highest quartiles. Surgeon distribution was positively associated with income and training positions density ( P  < 0.01). Subanalysis revealed that there was an increase of 6.7 plastic and reconstructive surgeons/PMP for every increase of 1000 trauma admissions/PMP ( P  < 0.01). There is an uneven state-level distribution of facial trauma surgeons across the US associated with income. Plastic surgeon distribution corresponded closer to craniofacial trauma care need than that of ENT and OMF surgeons. Further work to close the gap between workforce availability and clinical need is necessary.

Characterization of Phages YuuY, KaiHaiDragon, and OneinaGillian Isolated from Microbacterium foliorum.

Microbacterium foliorum is a Gram-positive bacteria found in organic matter. Three lytic bacteriophages, KaiHaiDragon, OneinaGillian, and YuuY, were isolated from M. foliorum strain NRRL B-24224. Phage YuuY in particular expresses a broad host range as it possesses the ability to infect closely related bacterial species Microbacterium aerolatum at a high plating efficiency. Characterization tests were performed on all three Microbacterium phage to assess morphology, genomic characteristics, pH and thermal stabilities, life cycle, and the type of receptor used for infection. All three phages showed similar pH stability, ranging from pH 5-11, except for KaiHaiDragon, which had a reduced infection effectiveness at a pH of 11. YuuY possessed a significantly higher temperature tolerance compared to the other Microbacterium phages as some phage particles remained viable after incubation temperatures of up to 80 °C. Based on the one-step growth curve assay, all three Microbacterium phages possessed a relatively short latent period of 90 min and an approximately two-fold burst size factor. Moreover, all three phages utilize a carbohydrate receptor to initiate infection. Based on bioinformatics analysis, YuuY, KaiHaiDragon and OneinaGillian were assigned to clusters EA10, EC, and EG, respectively.

Dual Tack Mesh Fixation System on a Cadaveric Porcine Model-Creation of a Mesh Fixation System for Hernia Treatment and Prevention.

BACKGROUND: Onlay mesh repair (OMR) has proven to be a widely used, simple, and effective technique for treatment and prevention of hernia occurrence. Despite established benefits, there is still a lack of widespread adoption. In this study, we present the Dual Tacker Device (DTD), an enabling technology that directly addresses the limitations to the adoption of OMR, saving surgical time and effort and making OMR more reproducible across a wide range of patients. METHODS: The DTD mesh fixation system is a semiautomated, hand-held, disposable, multipoint onlay mechanical mesh fixation system that is able to rapidly and uniformly tension and fixate mesh for both hernia treatment and prevention. A cadaveric porcine model was used as a pilot test conducted during a 2 day session to assess the usability of the device and to show that the DTD provided equivalent or superior biomechanical support compared with the standard of care (hand-sewn, OptiFix). RESULTS: Our study included 37 cadaveric porcine incisional closure abdominal wall models. These were divided into four groups: DTD-mediated OMR (n = 14), hand-sewn OMR (n = 7), OptiFix OMR (n = 9), and suture-only repair (no mesh) (n = 7). Eight surgical residents performed device-mediated and hand-sewn OMR. Average time to completion was fastest in the DTD cohort (45.6s) with a statistically significant difference compared with the hand-sewn cohort (343.1s, P < 0.01). No difference in tensile strength was noted between DTD (195.32N), hand-sewn (200.48N), and OptiFix (163.23N). Discreet hand movements were smallest in the DTD (29N) and significant (P < 0.01) when compared with hand-sewn (202N) and OptiFix (35N). CONCLUSIONS: The use of the DTD is not only feasible, but demonstrated improvement in time to completion and economy of movement over current standard of care. While more testing is needed and planned, compared with conventional approaches, the DTD represents a robust proof of principle with promising implications for clinical feasibility and adoptability.

Early Clinical and Patient-Reported Outcomes of a New Hybrid Mesh for Incisional Hernia Repair.

INTRODUCTION: Consensus on the safety and efficacy of various types of mesh in reconstructing the abdomen has yet to be reached. Hybrid mesh products have been designed to address the need for a cost-effective mesh leveraging the tensile strength of a synthetic mesh while minimizing the prosthetic footprint within the abdominal wall through resorbable materials. In this study we evaluate early clinical outcomes and health related quality of life (HR-QOL) of a new Hybrid mesh, SynecorTM, for Ventral Hernia Repair (VHR). METHODS: Adult (>18 y old) patients undergoing VHR with SynecorTM mesh by a single surgeon between 2017-2019 with ≥1-y follow-up were identified. We analyzed a composite of postoperative outcomes as well as the incidence of hernia recurrence, readmissions, mortality, and HR-QOL. RESULTS: Thirty-five patients were included in our analysis with a median follow up of 2.1 y. The median age and BMI were 54.1 y and 33.2 kg/m2, respectively. The rate of surgical site occurrences was 37.1%, with only one patient (2.9%) requiring surgical intervention. No patients developed a hernia recurrence. Overall HR-QOL improved significantly (preoperative mean 2.5 [SD 0.7] versus postoperative 3.4 [0.4]; P< 0.01), particularly in regards to pain, functional status, self-esteem and body image (all P < 0.05). CONCLUSIONS: Abdominal reinforcement with SynecorTM mesh at the time of VHR results in promising early recurrence rates, an acceptable safety risk profile, and an improvement in overall HR-QOL.

Post-mastectomy breast reconstruction: reducing the disparity through educational outreach to the underserved.

PURPOSE: Poor health literacy and awareness are thought to be some of the major contributors to existing racial/ethnic disparities in access to breast reconstruction after mastectomy. This study aimed to determine whether physician led, community-based educational symposium improves understanding of breast cancer care and breast reconstruction in underserved populations. METHODS: Annual educational symposiums were held between 2017 and 2019 in underserved communities in the greater Philadelphia area. The symposium consisted of a series of short lectures on breast health, cancer screening, surgical management and reconstruction, patient testimonials, a Q&A panel, and an exhibitor fair. Attendees were given pre- and post-symposium surveys that evaluated knowledge of breast cancer care and reconstruction on a 0-100 scale based on percentage of correct answers. RESULTS: Of 169 individuals, 92%, 91%, and 83% completed pre-symposium, post-symposium, and both surveys, respectively. Median age was 60 years, and 92% were Black. Knowledge/understanding survey scores significantly improved after the symposium (50 vs. 87, p < 0.01). Of all respondents, 92% found the symposium to be useful, 89% were introduced to resources that they were not previously aware of, 90% would recommend the symposium to others, and 91% would pass along the information they learned. CONCLUSION: This study presents an effective and reproducible strategy to increase community awareness and understanding of general breast cancer concepts and breast reconstruction options. Through community outreach and education, physicians can help underserved populations have a better understanding of their potential options for breast reconstruction and ultimately reduce this well documented but inadequately addressed disparity in cancer care.

How to Develop a Risk Prediction Smartphone App.

Purpose. Powered by big data, predictive models provide individualized risk stratification to inform clinical decision-making and mitigate long-term morbidity. We describe how to transform a large institutional dataset into a real-time, interactive clinical decision support mobile user interface for risk prediction. Methods. A clinical decision point ideal for risk stratification and modification was identified. Demographics, medical comorbidities, and operative characteristics were abstracted from the electronic medical record (EMR) using ICD-9 codes. Surgery-specific predictive models were generated using regression modeling and corroborated with internal validation. A clinical support interface was designed in partnership with an app developer, followed by subsequent beta testing and clinical implementation of the final tool. Results. Individual, specialty-specific, and preoperatively actionable models incorporating clustered procedural codes were created. Using longitudinal inpatient, outpatient, and office-based data from a large multicenter health system, all patient and operative variables were weighted according to ß-coefficients. The individual risk model parameters were incorporated into specialty-specific modules and implemented into an accessible iOS/Android compatible mobile application. Conclusions. As proof of concept, we provide a framework for developing a clinical decision support mobile user interface, through the use of clinical and administrative longitudinal data. Point-of-care applications, particularly ones designed with implementation and actionability in mind, have the potential to aid clinicians in identifying and optimizing risk factors that impact the outcome of interest's occurrence, thereby enabling clinicians to take targeted risk-reduction actions. In addition, such applications may help facilitate counseling, informed consent, and shared decision-making, leading to improved patient-centered care.

Is It Safe to Manage Acute Cholecystitis Nonoperatively During Pregnancy?: A Nationwide Analysis of Morbidity According to Management Strategy.

OBJECTIVES: To compare cholecystectomy (CCY) and nonoperative treatment (no-CCY) for acute cholecystitis in pregnancy. SUMMARY OF BACKGROUND DATA: Current Society of Gastrointestinal and Endoscopic Surgery guidelines recommend CCY over nonoperative management of acute cholecystitis during pregnancy, and the American College of Obstetricians and Gynecologists recommend medically necessary surgery regardless of trimester. This approach has been recently questioned. METHODS: Pregnant women admitted with acute cholecystitis were identified using the Nationwide Readmission Database 2010-2015. Propensity-score adjusted logistic regression models were used to compare CCY and no-CCY. The primary outcome was a composite measure of adverse maternal-fetal outcomes (intrauterine death/stillbirth, poor fetal growth, abortion, preterm delivery, C-section, obstetric bleeding, infection of the amniotic fluid, venous thromboembolism). RESULTS: There were 6390 pregnant women with acute cholecystitis: 38.2% underwent CCY, of which 5.1% were open. Patients were more likely to be managed operatively in their second trimester (First 43.9%, Second 59.1%, Third 34.2%; P < 0.01). Patients managed with CCY did not differ in age, insurance, income, Charlson Comorbidity Index, diabetes or obesity when compared to no-CCY (all P > 0.05), but were less likely to have a previous C-section, gestational diabetes, preeclampsia/eclampsia or be in the third trimester (P ≤ 0.01). Risk-adjusted analyses showed that no-CCY was associated with significantly increased maternal-fetal complications during the index admission [odds ratio 3.0 (95% confidence interval 2.08-4.34), P < 0.01] and 30-day readmissions [odds ratio 1.61 (confidence interval % CI 1.12-2.32), P < 0.01]. CONCLUSIONS: Contrary to current guidelines, most pregnant women admitted in the US with acute cholecystitis are managed nonoperatively. This is associated with over twice the odds of maternal-fetal complications in addition to increased readmissions.

Host Pah1p phosphatidate phosphatase limits viral replication by regulating phospholipid synthesis.

Replication of positive-strand RNA viruses [(+)RNA viruses] takes place in membrane-bound viral replication complexes (VRCs). Formation of VRCs requires virus-mediated manipulation of cellular lipid synthesis. Here, we report significantly enhanced brome mosaic virus (BMV) replication and much improved cell growth in yeast cells lacking PAH1 (pah1Δ), the sole yeast ortholog of human LIPIN genes. PAH1 encodes Pah1p (phosphatidic acid phosphohydrolase), which converts phosphatidate (PA) to diacylglycerol that is subsequently used for the synthesis of the storage lipid triacylglycerol. Inactivation of Pah1p leads to altered lipid composition, including high levels of PA, total phospholipids, ergosterol ester, and free fatty acids, as well as expansion of the nuclear membrane. In pah1Δ cells, BMV replication protein 1a and double-stranded RNA localized to the extended nuclear membrane, there was a significant increase in the number of VRCs formed, and BMV genomic replication increased by 2-fold compared to wild-type cells. In another yeast mutant that lacks both PAH1 and DGK1 (encodes diacylglycerol kinase converting diacylglycerol to PA), which has a normal nuclear membrane but maintains similar lipid compositional changes as in pah1Δ cells, BMV replicated as efficiently as in pah1Δ cells, suggesting that the altered lipid composition was responsible for the enhanced BMV replication. We further showed that increased levels of total phospholipids play an important role because the enhanced BMV replication required active synthesis of phosphatidylcholine, the major membrane phospholipid. Moreover, overexpression of a phosphatidylcholine synthesis gene (CHO2) promoted BMV replication. Conversely, overexpression of PAH1 or plant PAH1 orthologs inhibited BMV replication in yeast or Nicotiana benthamiana plants. Competing with its host for limited resources, BMV inhibited host growth, which was markedly alleviated in pah1Δ cells. Our work suggests that Pah1p promotes storage lipid synthesis and thus represses phospholipid synthesis, which in turn restricts both viral replication and cell growth during viral infection.

A 10-year ACS-NSQIP Analysis of Trends in Esophagectomy Practices.

BACKGROUND: Esophagectomy practices have evolved over time in response to new technologies and refinements in technique. Using the National Safety and Quality Improvement Program (NSQIP) database, we aimed to describe trends for esophagectomy in terms of approach, surgeon specialty, and associated outcomes. MATERIALS AND METHODS: Adult patients undergoing esophagectomy were identified within the 2007-2017 NSQIP database. The proportion of cases performed using different approaches was trended over time. Outcomes were compared with chi-squared and t-tests. Multivariate logistic regression was used to identify factors associated with outcomes and provide risk-adjusted measures. RESULTS: A total of 10,383 esophagectomies were included; 6347 (61.1%) were performed for cancer. The proportion of esophagectomies performed via the Ivor Lewis approach (ILE) increased between 2007 (37.0%) and 2017 (62.4%). Simultaneously, transhiatal esophagectomies (THEs) decreased from 41.1% to 21.5% (P < 0.001). THE was more frequently performed in patients with higher baseline probability of mortality (2.3% versus 2.0%, P < 0.001) and morbidity (32.2% versus. 28.7%, P < 0.001). The percentage performed with cardiothoracic surgeons increased from 0.8% in 2007 to 50.3% in 2017 (P < 0.001). The risk-adjusted complication rate was 45% for THE, 40% for ILE, and 50% for McKeown (MCK) esophagectomy (P < 0.001). The risk-adjusted rate of surgical site infection was 17.3% for THE, 13.1% for ILE, and 19% for MCK (P = 0.001). Within risk-adjusted analysis, surgical approach was not associated with complications. CONCLUSIONS: ILE has emerged as the predominant approach for esophagectomy nationwide among NSQIP-participating institutions and may be associated with lower complication rates than THE. The use of MCK esophagectomy has remained stable but is associated with increased complications.