Avian Influenza A Virus Associations in Wild, Terrestrial Mammals: A Review of Potential Synanthropic Vectors to Poultry Facilities.

The potential role of wild mammals in the epidemiology of influenza A viruses (IAVs) at the farm-side level has gained increasing consideration over the past two decades. In some instances, select mammals may be more likely to visit riparian areas (both close and distant to farms) as well as poultry farms, as compared to traditional reservoir hosts, such as waterfowl. Of significance, many mammalian species can successfully replicate and shed multiple avian IAVs to high titers without prior virus adaptation and often can shed virus in greater quantities than synanthropic avian species. Within this review, we summarize and discuss the potential risks that synanthropic mammals could pose by trafficking IAVs to poultry operations based on current and historic literature.

Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery.

HYPOTHESIS: An increase in national utilization of bariatric surgery correlates with the dissemination of laparoscopic bariatric surgery. DESIGN: Evaluation of Nationwide Inpatient Sample data from 1998 through 2002. SETTING: National database. PATIENTS: A total of 188,599 patients underwent bariatric surgery for the treatment of morbid obesity. MAIN OUTCOME MEASURES: Annual total number of bariatric operations, the proportion of Roux-en-Y gastric bypass vs gastroplasty, the proportion of laparoscopic cases, postoperative length of stay, crude in-hospital mortality, and the number of institutions that perform bariatric surgery. RESULTS: Between 1998 and 2002, the number of bariatric operations increased from 12,775 cases to 70,256 cases. The rate of bariatric surgery increased from 6.3 to 32.7 procedures per 100,000 adults. Laparoscopic bariatric surgery increased from 2.1% to 17.9%. The number of bariatric surgeons with membership in the American Society for Bariatric Surgery increased from 258 to 631, and the number of institutions that perform bariatric surgery increased from 131 to 323. During this 5-year period, the annual rate of laparoscopic bariatric surgery increased exponentially (by 44-fold) compared with a linear growth in open bariatric surgery (by 3-fold). CONCLUSIONS: Between 1998 and 2002, there was a 450% increase in the number of bariatric operations performed in the United States, a 144% increase in the number of American Society for Bariatric Surgery bariatric surgeons, and a 146% increase in the number of bariatric centers. The growth of laparoscopic bariatric surgery during this 5-year period greatly exceeds that of open bariatric surgery.

Trends in utilization and outcomes of laparoscopic versus open appendectomy.

BACKGROUND: Although a number of trials have analyzed the outcomes of laparoscopic versus open appendectomy, the clinical advantages, and cost-effectiveness of laparoscopic appendectomy in the management of acute and perforated appendicitis are still not clearly defined. The aim of this study was to examine utilization and outcomes of laparoscopic versus open appendectomy using a national administrative database of academic medical centers and teaching hospitals. METHODS: Using ICD-9 diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent appendectomy for acute and perforated appendicitis between 1999 and 2003 (n = 60,236). Trends in utilization of laparoscopic appendectomy were examined over the 5-year period. The outcomes of laparoscopic and open appendectomy were compared including length of hospital stay, 30-day readmission, complications, observed and expected (risk-adjusted) in-hospital mortality, and costs. RESULTS: Overall, 41,085 patients underwent open appendectomy and 19,151 patients underwent laparoscopic appendectomy. The percentage of appendectomy performed by laparoscopy increased from 20% in 1999 to 43% in 2003 (P <0.01). Compared with patients who underwent open appendectomy, patients who underwent laparoscopic appendectomy were more likely female, more likely white, had a lower severity of illness, and were less likely to have perforated appendicitis. Laparoscopic appendectomy was associated with a shorter length of hospital stay (2.5 days vs 3.4 days), lower rate of 30-day readmission (1.0% vs 1.3%), and lower rate of overall complications (6.1% vs 9.6%). There was no significant difference in the observed to expected mortality ratio between laparoscopic and open appendectomy (0.5 vs 0.6, respectively). The mean cost per case was similar between the two groups (US$ 6,242 vs US$ 6,260). CONCLUSIONS: Utilization of laparoscopic appendectomy at academic centers has increased more than two-fold between 1999 and 2003. Patients selected for laparoscopic appendectomy have less advanced appendicitis and have a shorter length of stay and fewer complications without increasing the inpatient care cost.

Endorectal flap advancement repair is an effective treatment for selected patients with anorectal fistulas.

Although the majority of anorectal fistulas may be treated with fistulotomy, patients with higher-lying fistulas or women with anterior fistulas in whom simple fistulotomy may threaten continence present a management dilemma. Endorectal flap advancement repair is one potential solution. Chart review was performed of consecutive patients receiving endorectal advancement flaps during a 5-year period (1999-2003). Twenty-nine patients received endorectal advancement flap repair. In 21 (72%) patients, an etiology of the fistula could not be clearly identified, and they were considered to be cryptoglandular in origin. Eight (24%) patients had pathology presumed to be related to prior obstetrical injury. There were 18 (62%) women, and the majority (72%) had anterior fistulas and flaps. Primary success was defined as resolution of symptoms for at least a 3-month period without an additional surgical procedure. If resolution of symptoms after flap placement was achieved after an additional surgical procedure, it was considered a secondary success. Primary success was achieved in 20 (69%) patients, and a secondary success in four (44%) of the remaining nine patients, for a total success of 83 per cent. Anal advancement flaps demonstrate a reasonable success rate when utilized in this group of patients with challenging anorectal fistulas.