Outcomes of peroral endoscopic myotomy in patients with achalasia and prior bariatric surgery: A multicenter experience.

Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was <3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.

Surgical management of gastroesophageal reflux disease in the obese patient.

BACKGROUND: Gastroesophageal reflux disease (GERD) affects two thirds of the American population. Obesity is also a disease that affects two thirds of the population. The pathophysiology of reflux disease is reasonably understood, however, the degree to which obesity affects this disease remains poorly defined. Therefore the approach to GERD in the obese patient requires special attention and its own algorithm. METHODS: A literature search was conducted to consolidate the current available literature on GERD and its management in the obese. In addition, the authors reviewed the literature and present expert opinion on controversial topics. RESULTS: It is well established that GERD is increased in obesity and the pathophysiology is reviewed. Management options for GERD are discussed, with a focus on the obese population. Management strategies including fundoplication and gastric bypass are discussed. In addition, bariatric surgery in the setting of GERD is also reviewed. CONCLUSIONS: Currently this is an extremely controversial topic and this white paper presents a strong review of the literature to help guide the management of this challenging disease in this population. Expert recommendations are given throughout the paper based upon the current available data.

Putative behavioral history effects and aggression maintained by escape from therapists.

Differentially higher rates of aggression in treatment sessions occurred in the presence of two staff members who had previously worked with the participant at another facility. Adding an edible reinforcer for compliance and the absence of aggression in sessions conducted by these two staff members decreased aggression to rates similar to those obtained with less familiar therapists. Results suggest that embedding positive reinforcement within a demand context may reduce the aversiveness of therapists correlated with a history of demand situations.

Formation of the epidermal calcium gradient coincides with key milestones of barrier ontogenesis in the rodent.

The epidermal permeability barrier forms late in gestation, coincident with decreased lipid synthesis, increased lipid processing, and development of a mature, multi-layered stratum corneum. Prior studies have shown that changes in the epidermal Ca++ gradient in vivo regulate lamellar body secretion and lipid synthesis, and modulations in extracellular Ca++ in vitro also regulate keratinocyte differentiation. We asked here whether a Ca++ gradient forms in fetal epidermis in utero, and whether its emergence correlates with key developmental milestones of barrier formation and stratum corneum development. Using either ion precipitation or proton induced X-ray emission analysis of fetal mouse and rat skin, we showed that a Ca++ gradient is not present at gestational days 16-18, prior to barrier formation, and that a gradient forms coincident with the emergence of barrier competence (day 19, mouse; day 20, rat) prior to birth. These results are consistent with a role for Ca++ in the regulation of key metabolic events leading to barrier formation. Whether the calcium gradient is formed actively or passively remains to be determined.

Microwave incubation improves lipolytic enzyme preservation for ultrastructural cytochemistry.

Standard methods for the ultrastructural detection of lipase and sphingomyelinase activities in the skin result in considerable loss of structural preservation, often interfering with accurate delineation of enzyme localization in association with specific organelles. Moreover, poor preservation occurs, even after extensive aldehyde prefixation, owing to the prolonged incubation times needed to detect residual enzyme activity, which often require non-physiological conditions. A modified incubation protocol is described here, which uses microwave irradiation in conjunction with drastically shortened incubation times, resulting in both superior ultrastructural preservation and excellent localization in mammalian epidermis. This method should be useful generally not only for the study of lipase localization in skin, but also in conjunction with the cytochemical detection of a variety of enzymes in various types of tissue.

Techniques in immuno-electron microscopy. I. Cryosubstitution.

Normal skin was cryoprotected by submerging it in a mixture of 30% dimethylformamide (DMF) in PBS or RPMI. Subsequently it was frozen in liquid propane gas. Cryosubstitution was carried out at -90 degrees C by using methanol to which uranyl acetate or osmium tetroxide were added. The tissue was embedded in either Lowicryl K4M at -40 degrees C or in Epon at +60 degrees C. The tissue was evaluated by its overall preservation of ultrastructural details and by its labeling intensity after incubation with either anti-desmoglein or anti-type VII collagen monoclonal antibodies. The mixture of DMF and PBS caused an electron-dense precipitate within the cell. The overall morphology was better in Epon-embedded material than in K4M-embedded material. However, the labeling was best in K4M material. Regardless of whether the tissue was embedded in Epon or K4M, the addition of osmium tetroxide markedly reduced the degree of labeling.

Congenital self-healing reticulohistiocytosis--a benign Langerhans cell disease.

An-11-day old girl was seen with brownish nodular lesions scattered over the body with emphasis on the face and scalp. Several lesions had started to involute. Tissue was studied by histopathology, immunohistopathology, routine electron microscopy, and immuno-electron microscopy using cryosubstitution and embedding in K4M. Immunohistopathology revealed that the cells of the dermal infiltrate were Langerhans cells. They expressed Leu 6 and HLA-DR. On routine electron microscopy no Birbeck granules were found in the dermal cells. Birbeck granules in epidermal Langerhans cells were deformed and often situated next to laminated dense bodies. The latter expressed Leu 6 and lysozyme on immuno-electron microscopy. It was concluded that congenital self-healing reticulohistiocytosis is a benign Langerhans cell disease in which Birbeck granules are transformed to laminated dense bodies and possibly degraded by lysosomal enzymes.

The failure of feedback on alcohol impairment to reduce impaired driving.

We examined the effects of rules to govern drinking, individual feedback on blood alcohol concentration (BAC), and public posting of group data on impaired driving on the incidence of impaired driving. Level of impairment was determined from breath samples taken from tavern patrons. Following baseline, an intervention package consisting of (a) cards to guide patrons in pacing their drinking to stay under the legal limit, (b) individual feedback on BAC, and (c) posted group feedback on the percentage of patrons driving while impaired the preceding week was introduced in two taverns. Results indicated that the intervention package did not reduce the percentage of impaired drivers departing either tavern. The addition of a brief intensive police enforcement program directed at impaired driving produced a short-term reduction in impaired driving.

Behavior of injured and uninjured children and their parents in a simulated hazardous setting.

Compared the behavior of parents and their previously injured children with parents and their uninjured children in unstructured play and distracted parent conditions. Injured children were more disruptive, more active, and had more contacts with hazards, whereas uninjured children had more appropriate behavior. Parents of injured children had lower rates of play activities. Observable classes of parent and child behaviors amenable to change were associated with a history of child injury. Further study is needed to assess the use of safe and unsafe behavior as proxy measures for injuries and to identify functional classes of safe and unsafe behavior for which active strategies can be developed to prevent children's injuries.

The Self-Injury Trauma (SIT) Scale: a method for quantifying surface tissue damage caused by self-injurious behavior.

A method is described for classifying and quantifying surface tissue damage caused by self-injurious behavior. The Self-Injury Trauma Scale permits differentiation of self-injurious behavior according to topography, location of the injury on the body, type of injury, number of injuries, and estimate of severity. Fifty pairs of independently scored records were subjected to interrater reliability analyses, and the following mean (median) percentage agreement scores were obtained: overall agreement, 97% (98%); location of injury, 99% (100%); type of injury, 96% (100%); number of injuries, 89% (100%); and severity of injury, 94% (100%). Percentage agreement also was calculated for three summary scores: Number Index, 90%; Severity Index, 92%; and Estimate of Current Risk, 100%. Potential applications and limitations of the scale are discussed.

Ultrastructural localization of lectin binding sites in human melanocytes.

The ultrastructural localization of carbohydrate residues in human melanocytes of normal epidermis and of one compound naevus was studied. The following lectins were used in a post-embedding technique: 1. peanut agglutinin (PNA), which reacts specifically with N-acetylgalactosamine; 2. Concanavalia ensiformis (Con A) indicating alpha-D-glucose and alpha-D-mannose binding sites; 3. Ulex europaeus agglutinin (UEA I) specific for alpha-L-fucose; 4. Wheat germ agglutinin (WGA), reacting specifically with N-acetyl-glucosamine and neuraminic acid (sialic acid); and 5. Limax flavus agglutinin (LFA), also specific for sialic acid (Neu5Ac-alpha-2,3-Gal and Neu5Ac-alpha-2,6-Gal). When incubated with WGA, Con A and LFA strong labelling was seen within the cytoplasm and in the plasma membrane of melanocytes, whereas incubations with PNA and UEA I revealed an occasional gold particle only. The determination of the distribution of carbohydrate residues in normal melanocytes is a prerequisite for future studies of abnormal melanocytes.

Human peripheral blood accessory cell: isolation by hypotonic density gradient, functional, and phenotypical characterization.

In order to purify the human peripheral blood-derived accessory cell that cooperate with T lymphocytes in the process of mitogenic stimulation, we developed a new density gradient separation. This was based on the principle of hypotonic swelling of the cells to obtain a differential change of the buoyant densities of cells. By this method, we have obtained a highly accessory cell-depleted lymphocyte fraction whose proliferative response to sodium periodate stimulation was almost aborted. Another fraction containing high accessory cell activity was further divided into Fc-receptor-positive and -negative cells. The latter revealed the highest accessory activity for T lymphocyte periodate stimulation. The cells were characterized according to a number of markers and appeared to resemble lymphoid dendritic cells. Compared with the monocyte/macrophage fraction, they showed veils and dendritiform elongations and expressed reduced values of monocyte/macrophage specific markers. Compared with the high accessory activity of these cells, monocytes/macrophages expressed a low accessory activity.

Large-scale reductions in speeding and accidents in Canada and Israel: a behavioral ecological perspective.

We assessed the effects of posted feedback and warning ticket programs on speeding and accidents in two cities. In Experiment 1, speeding feedback signs were effective even when 10 were used in Dartmouth, Nova Scotia, and reductions in speeding were associated with reductions in accidents. The effectiveness of the signs was correlated with the number of intersections and residences within 0.5 km beyond them, and the signs had no effect on untreated streets. In Experiment 2, posted feedback and a warning program reduced speeding and accidents on 14 streets in Haifa, Israel.

Feedback interventions and driving speed: A parametric and comparative analysis.

Five experiments were conducted to assess the effects of several variables on the efficacy of feedback in reducing driving speed. Experiment 1 systematically varied the criterion used to define speeding, and results showed that the use of a lenient criterion (20 km/hr over the speed limit), which allowed for the posting of high percentages of drivers not speeding, was more effective in reducing speeding than the use of a stringent criterion (10 km/hr over the speed limit). In Experiment 2 an analysis revealed that posting feedback reduced speeding on a limited access highway and the effects persisted to some degree up to 6 km. Experiments 3 and 4 compared the effectiveness of an unmanned parked police vehicle (Experiment 3) and a police air patrol speeding program (Experiment 4) with the feedback sign and determined whether the presence of either of these enforcement variables could potentiate the efficacy of the sign. The results of both experiments demonstrated that although the two enforcement programs initially produced larger effects than the feedback sign, the magnitude of their effect attenuated over time. Experiment 5 compared the effectiveness of a traditional enforcement program with a warning program which included handing out a flier providing feedback on the number and types of accidents occuring on the road during the past year. This experiment demonstrated that the warning program produced a marked reduction in speeding and the traditional enforcement program did not. Furthermore, the warning program and a feedback sign together produced an even greater reduction in speeding than either alone.

An analysis of some variables influencing the effectiveness of reprimands.

Although several studies have shown that social reprimands can function as punishers, no study reported to data has isolated any of the factors influencing reprimand efficacy. Three experiments were conducted to investigate several factors. Experiment 1 used an alternating treatments design and was conducted on two elementary school boys, one of whom was in a special education class. Results showed that verbal reprimands delivered with eye contact and firm grasp of the student's shoulders reduced disruptive behavior to a greater extent than did verbal reprimands delivered without eye contact and grasp. Both types of reprimand were more effective than a baseline condition during which disruptive behavior was ignored. Experiment 2 also used an alternating treatments design and was conducted on one elementary school boy. Results demonstrated that reprimands delivered from one meter away were considerably more effective than reprimands delivered from seven meters away. Experiment 3 used a reversal design and was conducted on two pairs of elementary school children, one a pair of boys and the other a pair of girls. Results demonstrated that reprimands delivered to just one member of the pair reduced the disruptive behavior of both members of the pair. Thus, the effects of reprimands "spilled" over to nonreprimanded students.

A comparison of the effects of posted feedback and increased police surveillance on highway speeding.

A counterbalanced, reversal design was used to compare the effectiveness of posted feedback and increased police surveillance in reducing speeding on two urban highways. Drivers' speeds were measured using a concealed radar unit. During public posting, a large highway sign, which listed the percentage of drivers not speeding during the preceding week and the best record to date, was erected on each street. Use of the feedback sign alternated with periods of baseline and periods of increased police surveillance and ticketing. During increased police surveillance, highly visible, stationary police radar patrols were established along the highways for either 30 min or 60 min per day, 5 days per week. Results indicated that although public posting was highly effective in reducing the percentage of speeding drivers, increased police surveillance was not. Thus, since the feedback sign required only 30 min per week to maintain, public posting was at least 10 times more efficient in controlling speeding than was police surveillance and ticketing.

Reducing elevator energy use: A comparison of posted feedback and reduced elevator convenience.

The effects of two different procedures for reducing elevator energy use were assessed using a multiple-baseline design. In the first procedure, feedback about the amount of energy consumed by the elevators each week was posted on each elevator door. Later, signs advocating the use of stairs to save energy and improve health were posted next to the feedback signs. In the second procedure, the time required to travel between floors was increased by adding a delay to the elevator door closing mechanisms. Results indicated that neither feedback alone nor feedback plus educational signs reduced the amount of energy consumed by the elevators. However, use of the door delay reduced consumption by one-third in all elevators.A second experiment replicated the effect of the door delay on energy consumption and, in addition, demonstrated that the door delay also produced a reduction in the number of persons using the elevator. The second experiment also showed that, following an initial period during which a full delay was in effect, a gradual reduction of the delay interval resulted in continued energy conservation. Reduced convenience as a general strategy for energy conservation is discussed.

An analysis of public posting in reducing speeding behavior on an urban highway.

The effects of public posting on speeding behavior on an urban highway were assessed using a reversal design. During baseline the percentage of drivers speeding was measured with a concealed radar unit. During the daily posting condition a highway sign was installed which provided feedback on the percentage of drivers not speeding yesterday and the best record to date. This sign was then covered and reintroduced. Results indicated that the sign was effective in reducing speeding behavior. Furthermore, the effects were most pronounced in reducing the speeds of the faster drivers. Next, daily and weekly postings were compared with the sign alone without numerical feedback: results revealed that the weekly posting condition was as effective as the daily posting condition, but that the sign had no influence when numbers were not posted. Finally, the weekly posting procedure remained effective during a 6-month follow-up condition.

A comparison of the effects of fixed and variable ratio schedules of reinforcement on the behavior of deaf children.

The performance of all five students in an adjustment class for deaf children was compared under fixed and variable ratio schedules of reinforcement. During the fixed ratio (FR) condition, students earned checks if they were attentive and did not engage in disruptive behavior. These checks could be exchanged for the opportunity to draw a prize from a grab bag. During the variable ratio (VR) condition, they earned a draw from the grab bag according to a variable ratio schedule with a mean ratio equal to the value of the preceding FR schedule. During the VR condition, students visually attended more and engaged in disruptive behavior less often than during the FR condition. The number of math problems completed per minute was also higher during the VR condition although no specific consequences were applied to math performance.