International Medical Graduates Matching Into U.S. General Surgery Residency: 30-Year Match Trends.

INTRODUCTION: International medical graduates (IMGs) make up a small but important percentage of the U.S. surgical workforce. Detailed and contemporary studies on IMGs matching into U.S. general surgery residency positions are lacking. Our objective was to study these trends over a 30-y period. METHODS: We utilized the National Resident Matching Program reports from 1994 to 2023 to analyze the trends of U.S. M.D. seniors, D.O. seniors, and U.S. citizen and non-U.S. citizen IMGs matching into first-year categorical and preliminary general surgery residency positions. The percent of positions filled were calculated and trended over time using linear regression, where ß coefficient estimated the percentage of annual change in matched positions, and the R2 coefficient measured the amount of variance explained (perfect regression R2 = 1.0). RESULTS: Over the last 30 y, IMG match percentages have increased for both categorical (ß = 0.218%, R2 = 0.49, P < 0.001) and preliminary (ß = 0.705%, R2 = 0.76, P < 0.001) general surgery positions, with a greater increase in preliminary positions (ß = 0.705%). The percentage of positions filled by M.D. U.S. seniors in categorical positions has steadily decreased over the 30-y period (ß = -0.625%, R2 = 0.79, P < 0.001), and this decrease has largely occurred with a concurrent greater increase in U.S. D.O. seniors match percentage rates (ß = 0.430%, R2 = 0.64, P < 0.001), rather than IMGs (ß = 0.218%). Allopathic M.D. U.S. seniors preliminary match percentages have steadily decreased at the steepest rate (ß = -0.927%, R2 = 0.80, P < 0.001). In categorical positions, non-U.S. citizen IMGs' match percentages (ß = 0.069%, R2 = 0.204, P = 0.012) increased at a slightly slower rate than U.S. citizen IMGs (ß = 0.149%, R2 = 0.607, P < 0.001). In preliminary positions, non-U.S. citizen IMGs' match percentages (ß = 0.33%, R2 = 0.478, P < 0.001) increased at a similar rate as U.S. citizen IMGs (ß = 0.375%, R2 = 0.823, P < 0.0.001). In the 2023 National Resident Matching Program match, U.S. citizen and non-U.S. citizen IMGs together made up 10.3% of the categorical and 44.5% of the preliminary general surgery positions that were filled. For categorical positions in 2023, there was no major difference between positions matched by U.S. citizen IMGs (4.62%) and non-U.S. citizen IMGs (5.72%); on the other hand, for preliminary positions in 2023, non-U.S. citizen IMGs (31.96%) filled 2.5× times the number of positions as U.S. citizen IMGs (12.54%). CONCLUSIONS: Over the last 30 y, U.S. allopathic M.D. seniors matching into categorical general surgery positions have steadily decreased, while both U.S. osteopathic D.O. seniors and IMGs matching have increased. These data have important implications for the future U.S. surgical workforce.

Open Payments Data Analysis of General and Fellowship-trained Surgeons Receiving Industry General Payments From 2016 to 2020: Payment Disparities and COVID-19 Pandemic Impact.

OBJECTIVE: To characterize industry nonresearch payments made to general and fellowship-trained surgeons between 2016 and 2020. BACKGROUND: The Centers for Medicare & Medicaid Services Open Payments Data (OPD) reports industry payments made to physicians related to drugs and medical devices. General payments are those not associated with research. METHODS: OPD data were queried for general and fellowship-trained surgeons who received general payments from 2016 to 2020. Payments' nature, amount, company, covered product, and location were collected. Surgeons' demographics, subspecialty, and leadership roles in hospitals, societies, and editorial boards were evaluated. RESULTS: From 2016 to 2020, 44,700 general and fellowship-trained surgeons were paid $535,425,543 in 1,440,850 general payments. The median payment was $29.18. The most frequent payments were for food and beverage (76.6%) and travel and lodging (15.6%); however, the highest dollar payments were for consulting fees ($93,128,401; 17.4%), education ($88,404,531; 16.5%), royalty or license ($87,471,238; 16.3%), and travel and lodging ($66,333,149; 12.4%). Five companies made half of all payments ($265,654,522; 49.6%): Intuitive Surgical ($128,517,411; 24%), Boston Scientific ($48,094,570; 9%), Edwards Lifesciences ($41,835,544, 7.8%), Medtronic Vascular ($33,607,136; 6.3%), and W. L. Gore & Associates ($16,626,371; 3.1%). Medical devices comprised 74.7% of payments ($399,897,217), followed by drugs and biologicals ($33,945,300; 6.3%). Texas, California, Florida, New York, and Pennsylvania received the most payments; however, the top dollar payments were in California ($65,702,579; 12.3%), Michigan ($52,990,904, 9.9%), Texas ($39,362,131; 7.4%), Maryland ($37,611,959; 7%), and Florida ($33,417,093, 6.2%). General surgery received the highest total payments ($245,031,174; 45.8%), followed by thoracic surgery ($167,806,514; 31.3%) and vascular surgery ($60,781,266; 11.4%). A total of 10,361 surgeons were paid >$5000, of which 1614 were women (15.6%); in this group, men received higher payments than women (means, $53,446 vs $22,571; P <0.001) and thoracic surgeons received highest payments (mean, $76,381; NS, P =0.14). A total of 120 surgeons were paid >$500,000 ($203,011,672; 38%)-5 non-Hispanic White (NHW) women (4.2%) and 82 NHW (68.3%), 24 Asian (20%), 7 Hispanic (5.8%), and 2 Black (1.7%) men; in this group, men received higher payments than women (means, $1,735,570 vs $684,224), and NHW men received payments double those of other men (means, $2,049,554 vs $955,368; NS, P =0.087). Among these 120 highly paid surgeons (>$500,000), 55 held hospital and departmental leadership roles, 30 were leaders in surgical societies, 27 authored clinical guidelines, and 16 served on journal editorial boards. During COVID-19, 2020 experienced half the number of payments than the preceding 3 years. CONCLUSIONS: General and fellowship-trained surgeons received substantial industry nonresearch payments. The highest-paid recipients were men. Further work is warranted in assessing how race, gender, and leadership roles influence the nature of industry payments and surgical practice. A significant decline in payments was observed early during the COVID-19 pandemic.

Peroral endoscopic myotomy: 10-year outcomes from a large, single-center U.S. series with high follow-up completion and comprehensive analysis of long-term efficacy, safety, objective GERD, and endoscopic functional luminal assessment.

BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) is becoming the treatment of choice for achalasia. Data beyond 3 years are emerging but are limited. We herein report our 10-year experience, focusing on long-term efficacy and safety including the prevalence, management, and sequelae of postoperative reflux. METHODS: This was a single-center prospective cohort study. RESULTS: Six hundred ten consecutive patients received POEM from October 2009 to October 2019, 160 for type 1 achalasia (26.2%), 307 for type II (50.3%), 93 for type III (15.6%), 25 for untyped achalasia (4.1%), and 23 for nonachalasia disorders (3.8%). Two hundred ninety-two patients (47.9%) had prior treatment(s). There was no aborted POEM. Median operation time was 54 minutes. Accidental mucosotomies occurred in 64 patients (10.5%) and clinically significant adverse events in 21 patients (3.4%). No adverse events led to death, surgery, interventional radiology interventions/drains, or altered functional status. At a median follow-up of 30 months, 29 failures occurred, defined as postoperative Eckardt score >3 or need for additional treatment. The Kaplan-Meier clinical success estimates at years 1, 2, 3, 4, 5, 6, and 7 were 98%, 96%, 96%, 94%, 92%, 91%, and 91%, respectively. These are highly accurate estimates because only 13 patients (2%) were missing follow-up assessments. One hundred twenty-five patients (20.5%) had reflux symptoms more than once per week. At a median of 4 months, the pH study was completed in 406 patients (66.6%) and was positive in 232 (57.1%), and endoscopy was completed in 438 patients (71.8%) and showed reflux esophagitis in 218 (49.8%), mostly mild. CONCLUSIONS: POEM is exceptionally safe and highly effective on long-term follow-up, with >90% clinical success at ≥5 years.

Epigenomics in an extraterrestrial environment: organ-specific alteration of DNA methylation and gene expression elicited by spaceflight in Arabidopsis thaliana.

BACKGROUND: Plants adapted to diverse environments on Earth throughout their evolutionary history, and developed mechanisms to thrive in a variety of terrestrial habitats. When plants are grown in the novel environment of spaceflight aboard the International Space Station (ISS), an environment completely outside their evolutionary history, they respond with unique alterations to their gene expression profile. Identifying the genes important for physiological adaptation to spaceflight and dissecting the biological processes and pathways engaged by plants during spaceflight has helped reveal spaceflight adaptation, and has furthered understanding of terrestrial growth processes. However, the underlying regulatory mechanisms responsible for these changes in gene expression patterns are just beginning to be explored. Epigenetic modifications, such as DNA methylation at position five in cytosine, has been shown to play a role in the physiological adaptation to adverse terrestrial environments, and may play a role in spaceflight as well. RESULTS: Whole Genome Bisulfite Sequencing of DNA of Arabidopsis grown on the ISS from seed revealed organ-specific patterns of differential methylation compared to ground controls. The overall levels of methylation in CG, CHG, and CHH contexts were similar between flight and ground DNA, however, thousands of specifically differentially methylated cytosines were discovered, and there were clear organ-specific differences in methylation patterns. Spaceflight leaves had higher methylation levels in CHG and CHH contexts within protein-coding genes in spaceflight; about a fifth of the leaf genes were also differentially regulated in spaceflight, almost half of which were associated with reactive oxygen signaling. CONCLUSIONS: The physiological adaptation of plants to spaceflight is likely nuanced by epigenomic modification. This is the first examination of differential genomic methylation from plants grown completely in the spaceflight environment of the ISS in plant growth hardware developed for informing exploration life support strategies. Yet even in this optimized plant habitat, plants respond as if stressed. These data suggest that gene expression associated with physiological adaptation to spaceflight is regulated in part by methylation strategies similar to those engaged with familiar terrestrial stress responses. The differential methylation maps generated here provide a useful reference for elucidating the layers of regulation of spaceflight responses.

Surface-Induced Near-Field Scaling in the Knudsen Layer of a Rarefied Gas.

We report on experiments performed within the Knudsen boundary layer of a low-pressure gas. The noninvasive probe we use is a suspended nanoelectromechanical string, which interacts with ^{4}He gas at cryogenic temperatures. When the pressure P is decreased, a reduction of the damping force below molecular friction ∝P had been first reported in Phys. Rev. Lett. 113, 136101 (2014)PRLTAO0031-900710.1103/PhysRevLett.113.136101 and never reproduced since. We demonstrate that this effect is independent of geometry, but dependent on temperature. Within the framework of kinetic theory, this reduction is interpreted as a rarefaction phenomenon, carried through the boundary layer by a deviation from the usual Maxwell-Boltzmann equilibrium distribution induced by surface scattering. Adsorbed atoms are shown to play a key role in the process, which explains why room temperature data fail to reproduce it.

Spiral enteroscopy-assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video).

BACKGROUND: Deep enteroscopy-assisted ERCP (DEA-ERCP) in post-bariatric Roux-en-Y (RY) anatomy is challenging. Laparoscopy-assisted ERCP (LA-ERCP) and EUS-directed transgastric ERCP (EDGE) are technically easier and faster but are more invasive and morbid procedures. Therefore, we have used DEA-ERCP as our first-line approach, reserving EDGE and LA-ERCP for cases in which adjunctive techniques that cannot be performed through an enteroscope are required (eg, EUS-FNA, sleeve sphincter of Oddi manometry), or DEA-ERCP failures. The 2 main methods for DEA-ERCP are balloon- and spirus-assisted. Current literature on spiral enteroscopy ERCP (SE-ERCP) in bariatric RY anatomy is scant with low success rates reported. Our center has nearly exclusively used SE-ERCP for bariatric patients. Here, we report one of the largest such series to date. METHODS: This is a retrospective cohort study of consecutive patients with bariatric-length RY anatomy who had SE-ERCP from December 2009 to October 2016 at a tertiary care center, by one operator (S.N.S.). Primary outcomes included success at reaching the papilla, cannulation success, success of desired therapeutic intervention, and overall SE-ERCP success. RESULTS: Thirty-five SE-ERCPs were performed (28 in bariatric RY gastric bypass and 7 other long-limb RY surgical reconstructions). The papilla was reached in 86% (30/35) of cases. Cannulation success in patients in whom deep cannulation was indicated (28/30) was 100% (28/28 cases, including the 24 cases with native papilla). Therapeutic ERCP success was 100% (28/28). Overall SE-ERCP success was 86% (30/35). Median length of stay was 3 days. Median procedure time was 189 minutes. Reasons for SE-ERCP failures included RY anastomosis stricture, adhesions (2), long Roux limb, and redundant small bowel. Two of these patients underwent interventional radiology-guided percutaneous biliary drainage, 2 patients had laparoscopy-assisted ERCP, and 1 patient had EUS-guided antegrade cholangioscopy with sphincteroplasty and stone clearance. There were no adverse events. CONCLUSION: With sufficient allotted time (median procedure time ∼3 hours) and high operator experience (a single-operator volume that exceeds that of other published series), SE-ERCP is safe and effective in bariatric, long-limb RY patients with an overall success rate of 86%, which is higher than previously reported.

Per-oral endoscopic myotomy in patients with or without prior Heller's myotomy: comparing long-term outcomes in a large U.S. single-center cohort (with videos).

BACKGROUND AND AIMS: Heller's myotomy (HM) is one of the most effective treatments for esophageal achalasia. However, failures do exist, and the success rate tends to decrease with time. The efficacy of rescue treatments for patients with failed HM is limited. A few small-scale studies have reported outcomes of per-oral endoscopic myotomy (POEM) in these patients. We conducted this study to systematically assess feasibility, safety, and efficacy of POEM on patients who have had HM. METHODS: Patients at least 3 months out from POEM were selected from our prospective database: 318 consecutive POEMs performed from October 2009 to October 2016. The efficacy and safety of POEM were compared between the 46 patients with prior HM and the remaining 272 patients. RESULTS: Patients with prior HM had longer disease history, more advanced disease, more type I and less type II achalasia, lower before-POEM Eckardt scores, and lower before-POEM lower esophageal sphincter (LES) pressure (all P < .01). Procedure parameters and follow-up results (clinical success rate, Eckardt score, LES pressure, GERD score, esophagitis, and pH testing) showed no significant difference between the 2 groups. For the 46 HM-POEM patients, no clinically significant perioperative adverse events occurred. Their overall clinical success rate (Eckardt score ≤3 and no other treatment needed) was 95.7% at a median follow-up of 28 months. CONCLUSION: POEM as a rescue treatment for patients with achalasia who failed HM is feasible, safe, and highly effective. It should be the treatment of choice in managing these challenging cases at centers with a high level of experience with POEM.

Prevalence of Delirium and Coma In Mechanically Ventilated Patients Sedated With Dexmedetomidine or Propofol.

OBJECTIVE: To assess the prevalence of delirium and coma in mechanically ventilated patients sedated with dexmedetomidine or propofol alone; to evaluate the hospital length of stay for both treatment groups; and to evaluate the level of sedation, adverse effects, and hospital outcomes. METHODS: Medical records were reviewed retrospectively for patients who were admitted to the medical or surgical intensive care units (ICUs) in a 591-bed teaching hospital and who received either dexmedetomidine or propofol alone for 24 hours or more for sedation. RESULTS: A total of 111 patients were included in the study, with 56 patients in the dexmedetomidine group and 55 patients in the propofol group. Results of the analysis showed that the propofol group had a higher prevalence of coma (43.6% versus 12.5%; P < 0.001). Dexmedetomidine patients had a longer median hospital length of stay of 23.5 days (interquartile range [IQR], 11.5-39.5 days) versus 15.0 days (IQR, 7.0-24.0 days; P = 0.01). The rates of delirium were similar in both groups, with 16% in dexmedetomidine-treated patients versus 20% in propofol-treated patients (P = 0.63). CONCLUSION: No difference in the prevalence of delirium was found when comparing the dexmedetomidine- and propofol-treated groups. Propofol was associated with more coma and oversedation; dexmedetomidine was associated with longer time to extubation, longer length of stay in the ICU, and longer hospital length of stay.

The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy.

BACKGROUND: Per oral endoscopic myotomy (POEM) represents a natural orifice transluminal endoscopic surgery approach to Heller myotomy. Our center was the first to offer POEM outside of Japan, allowing us to accumulate what is likely the highest single-operator POEM volume in the United States. OBJECTIVE: To define the POEM learning curve of a gastroenterologist by using a larger data set and more detailed statistical analysis than used in 2 other reports of POEM performed by surgeons. DESIGN: Prospective cohort study. SETTING: Tertiary-care academic medical center. PATIENTS: We analyzed the first 93 consecutive POEMs on patients with achalasia aged >18 years without contraindications to POEM performed by a single operator from October 2009 to November 2013. INTERVENTIONS: (1) Efficiency estimation via cumulative sum (CUSUM) analysis, (2) mastery estimation via penalized basis-spline regression and CUSUM analysis, (3) correlation of operator experience with clinical outcomes (Eckardt score improvement, lower esophageal sphincter pressure reduction) and technical errors (accidental mucosotomy rate), and (4) unadjusted and adjusted regression analysis to assess how patient characteristics affected procedure time by using a generalized linear model. MAIN OUTCOME MEASUREMENTS: Clinical outcomes, procedure time, technical errors. RESULTS: Efficiency was attained after 40 POEMs and mastery after 60 POEMs. When we used the adjusted regression analysis, only case number (operator experience) significantly affected procedure time (P < .0001). Improvements in clinical outcomes were excellent but not significantly affected by operator experience, as was the case with accidental mucosotomies. Procedure time was not significantly affected by age, sex, achalasia stage, baseline lower esophageal sphincter pressure, baseline Eckardt score, prior treatment of achalasia, prior botulinum toxin injection, incidence of accidental mucosotomies, length of myotomy, or type of knife used (all P > .05). LIMITATIONS: Our analysis may underestimate the number of POEMs required to achieve mastery for operators with limited or no endoscopic submucosal dissection experience. CONCLUSION: These results offer thresholds for efficiency and mastery of a single gastroenterologist operator that may guide the efforts of novice POEM operators.

Slippage and boundary layer probed in an almost ideal gas by a nanomechanical oscillator.

We measure the interaction between 4He gas at 4.2 K and a high-quality nanoelectromechanical string device for its first three symmetric modes (resonating at 2.2, 6.7, and 11 MHz with quality factor Q>0.1×106) over almost 6 orders of magnitude in pressure. This fluid can be viewed as the best experimental implementation of an almost ideal monoatomic and inert gas of which properties are tabulated. The experiment ranges from high pressure where the flow is of laminar Stokes-type presenting slippage down to very low pressures where the flow is molecular. In the molecular regime, when the mean-free path is of the order of the distance between the suspended nanomechanical probe and the bottom of the trench, we resolve for the first time the signature of the boundary (Knudsen) layer onto the measured dissipation. Our results are discussed in the framework of the most recent theories investigating boundary effects in fluids (both analytic approaches and direct simulation Monte Carlo methods).

Geometric data of commercially available tricuspid valve annuloplasty devices.

Tricuspid valve annuloplasty is the gold standard surgical treatment for functional tricuspid valve regurgitation. During this procedure, ring-like devices are implanted to reshape the diseased tricuspid valve annulus and to restore function. For the procedure, surgeons can choose from multiple available device options varying in shape and size. In this article, we provide the three-dimensional (3D) scanned geometry (*.stl) and reduced midline (*.vtk) of five different annuloplasty devices of all commercially available sizes. Three-dimensional images were captured using a 3D scanner. After extracting the surface geometry from these images, the images were converted to 3D point clouds and skeletonized to generate a 3D midline of each device. In total, we provide 30 data sets comprising the Edwards Classic, Edwards MC3, Edwards Physio, Medtronic TriAd, and Medtronic Contour 3D of sizes 26-36. This dataset can be used in computational models of tricuspid valve annuloplasty repair to inform accurate repair geometry and boundary conditions. Additionally, others can use these data to compare and inspire new device shapes and sizes.

Impact of tricuspid annuloplasty device shape and size on valve mechanics-a computational study.

Background: Tricuspid valve disease significantly affects 1.6 million Americans. The gold standard treatment for tricuspid disease is the implantation of annuloplasty devices. These ring-like devices come in various shapes and sizes. Choices for both shape and size are most often made by surgical intuition rather than scientific rationale. Methods: To understand the impact of shape and size on valve mechanics and to provide a rational basis for their selection, we used a subject-specific finite element model to conduct a virtual case study. That is, we implanted 4 different annuloplasty devices of 6 different sizes in our virtual patient. After each virtual surgery, we computed the coaptation area, leaflet end-systolic angles, leaflet stress, and chordal forces. Results: We found that contoured devices are better at normalizing end-systolic angles, whereas the one flat device, the Edwards Classic, maximized the coaptation area and minimized leaflet stress and chordal forces. We further found that reducing device size led to increased coaptation area but also negatively impacted end-systolic angles, stress, and chordal forces. Conclusions: Based on our analyses of the coaptation area, leaflet motion, leaflet stress, and chordal forces, we found that device shape and size have a significant impact on valve mechanics. Thereby, our study also demonstrates the value of simulation tools and device tests in "virtual patients." Expanding our study to many more valves may, in the future, allow for universal recommendations.

Comparison of Step-Based Metrics Under Laboratory and Free-Living Conditions in Femoroacetabular Impingement Syndrome.

CONTEXT: Femoroacetabular impingement syndrome (FAIS) causes pain and functional limitations. Little is known regarding walking characteristics, volume and intensity evaluated in laboratory and free-living conditions and whether these measures differ between those with FAIS and uninjured individuals. OBJECTIVE: To examine the differences in laboratory gait measures and free-living step-based metrics between individuals with FAIS and uninjured control participants. DESIGN: Comparative, cross-sectional study. PATIENTS OR OTHER PARTICIPANTS: We enrolled 25 participants with FAIS and 14 uninjured controls. MAIN OUTCOME MEASURES: We evaluated laboratory spatiotemporal gait measures (cadence, velocity, step length, stride length) during self-selected and fast walking speeds using an instrumented walkway. Participants then wore an accelerometer around the waist during waking hours for 7 consecutive days. Free-living step-based metrics included average daily steps, peak 1- and 30-minute cadence, and average daily time spent in walking cadence bands. We compared laboratory gait measures and step-based metrics between groups. RESULTS: The groups did not differ in laboratory spatiotemporal gait measures during both speeds (all p>0.05). The FAIS group took fewer daily steps (5,346±2,141 vs. 7,338±2,787 steps/day; p=0.030) and had a lower peak 1-minute (92.9±23.9 vs. 119.6±16.3 steps/min; p<0.001) and 30- minute cadences (60.9±27.1 vs. 86.8±22.4 steps/min; p=0.003) compared with uninjured controls, respectively. The FAIS group also spent less time in slow (6.0±3.6 vs. 10.3±3.4 min/day; p=0.001), medium (4.5 + 4.2 vs. 8.9±4.4 min/day; p=0.005), and brisk/moderate (4.5±6.2 vs. 12.2±10.3; p=0.020) cadence bands compared with uninjured controls. CONCLUSIONS: Considering only clinical/laboratory gait measures may not be representative of real- world walking-related PA behavior in individuals with FAIS.

Predictors of Length of Hospital Stay After Reduction of Internal Hernia in Patients With a History of Roux-en-Y Gastric Bypass.

BACKGROUND: Postoperative internal hernias after Roux-en-Y gastric bypass (RYGB) have an incidence of 2%-9% and are a surgical emergency. Evidence on factors associated with length of stay (LOS) after emergent internal hernia reduction in RYGB patients is limited. METHODS: This is a retrospective review of patients who underwent internal hernia reduction after RYGB at our tertiary care center over a 5 year period from 2015 to 2020. Demographics, comorbidities, and intra- and postoperative hospital course were collected. Univariate and multivariate linear regressions were used to investigate factors associated with LOS. RESULTS: We identified 38 patients with internal hernia after RYGB. These patients with mean age 44.1 years were majority female (71.1%) and white race (60.5%). Of the 24 patients where the RYGB was done at our institution, the mean RYGB to IH interval was 43 months. Petersen's defect (57.8%) followed by jejuno-jejunal mesenteric defect (31.6%) were the most common locations for IH. Both Petersen's and jejuno-jejunal mesenteric hernias were found in 4 cases (10.5%). Revision of bypass and small bowel resection were required in 13.2% and 5.3% of cases, respectively. The median (interquartile range) length of stay (LOS) was 2 days. On the multivariate analysis, male sex (P = .019), conversion to exploratory laparotomy (P = .005), and resection of small bowel (P < .001) were independent risk factors for increased LOS. CONCLUSION: The most common location of IH after RYGB is Petersen's defect, followed by jejuno-jejunal mesenteric defect. LOS was significantly associated with male sex, exploratory laparotomy, and resection of small bowel.

Evidence for the role of normal-state electrons in nanoelectromechanical damping mechanisms at very low temperatures.

We report on experiments performed at low temperatures on aluminum covered silicon nanoelectromechanical resonators. The substantial difference observed between the mechanical dissipation in the normal and superconducting states measured within the same device unambiguously demonstrates the importance of normal-state electrons in the damping mechanism. The dissipative component becomes vanishingly small at very low temperatures in the superconducting state, leading to exceptional values for the quality factor of such small silicon structures. A critical discussion is given within the framework of the standard tunneling model.

Veterinarians as practitioners and as key players in epidemiological surveillance: two tasks, two paradigms to be reconciled.

Veterinary practitioners are often involved in epidemiological surveillance systems, where their task is to detect animals suspected of suffering from diseases subject to surveillance and to include them in surveillance. However, these two tasks--practising veterinary medicine and taking part in surveillance--are based on different paradigms. Faced with a sick animal, a practitioner tries to maximise the probability of a correct diagnosis, whereas, when implementing surveillance, a veterinarian is required to maximise the inclusion of suspected cases in surveillance systems. Based on an analysis of the difficulties and problems posed by these coexisting tasks, the authors propose potential solutions through veterinary education and training. The implementers and coordinators of epidemiological surveillance systems must take these factors into account.

Perceptions of policy problems and solutions: Climate change and structural racism.

Public policy debates in the United States about how to respond to complex issues like climate change and structural racism are often portrayed in polarized terms. Progressives are seen as advocating for transformational responses to major problems, while conservatives are portrayed as denying these problems' existence. However, such depictions obscure the presence of a third bloc that acknowledges these problems' existence but does not support drastic approaches to solving them. Using survey experiments, we examine the relationships between problem belief and solution support in these two issues areas. We find overlap between those who acknowledge the existence of these problems and those who oppose large-scale policy solutions. Furthermore, we observe that the solution proposed may influence attitudes toward the problem. Our results suggest that political scientists and policy activists overestimate the extent of denial of these problems and mistarget persuasive efforts by focusing on problem belief over solution support.

Kwashiorkor after gastric bypass.

Gastric bypass has grown in popularity in recent years due to its high efficacy in achieving long-term weight loss in patients with morbid obesity. Gastric bypass has been described to further exacerbate baseline nutritional deficiencies due to reduced gastric capacity and malabsorption. In rare cases, when protein deficiency is severe, Kwashiorkor disease may arise. The incidence of Kwashiorkor specifically following gastric bypass is rare, with an incidence of 4.7%. We report a case of a female patient who underwent a gastric bypass and subsequently developed Kwashiorkor. Physicians' suspicion of index for Kwashiorkor should be high for patients presenting with signs or symptoms of severe malnutrition following weight-loss procedures.

Incidental aortocaval fistula in the setting of an unruptured abdominal aortic aneurysm.

An aortocaval fistula, a rare abnormal vascular communication between the aorta and inferior vena cava, is most commonly associated with abdominal aortic aneurysms (AAAs). Other factors leading to aortocaval fistula formation include atherosclerosis, collagen vascular diseases, vasculitis, hematogenous infections, prior spinal surgery, malignancy and radiation exposure. In rare instances, aortocaval fistulas may be discovered incidentally on abdominal imaging. We report an unusual case of an incidental aortocaval fistula in a 93-year-old male patient with an unruptured AAA, presenting with shortness of breath, malaise and lethargy. The patient had no other obvious risk factors for aortocaval fistula formation. Multidetector computed tomography angiography helped identify the fistula, and the patient was eventually transferred to hospice for comfort measures. This case highlights the importance of detailed imaging and preoperative planning in managing aortocaval fistulas and associated AAAs.