40-year-old Male with a Headache and Altered Mental Status.

A 40-year-old man presents to the emergency department with headache, nausea and paresthesias, with subsequent fever and mental status change. Magnetic resonance imaging showed increased fluid-attenuation inversion recovery signal involving multiple areas of the brain, including the pons. This case takes the reader through the differential diagnosis of rhombencephalitis (inflammation of the hindbrain) with discussion of the unanticipated ultimate diagnosis and its treatment.

Single Anastomosis Duodeno-Ileal Switch (SADIS): A Systematic Review of Efficacy and Safety.

BACKGROUND: Owing to the possibility of weight regain after the long-term follow-up of gastric bypass patients and because of the high morbidity of biliopancreatic diversion with duodenal switch, single-anastomosis duodeno-ileal switch (SADIS) has emerged as a rescue procedure in bariatric surgery. OBJECTIVE: The purpose of this review is to summarize the literature data on SADIS. SETTING: University Hospital, NY. METHODS: A comprehensive literature review was performed through October 2016 to identify English studies on SADIS performed in human subjects. Outcomes of interest were technical considerations, postoperative complications, weight loss outcome, comorbidity resolution rate, and nutritional deficiency after SADIS. RESULTS: A total of 12 studies including 581 SADIS patients (217 males and 364 females) were included. SADIS was a primary procedure in 508 patients (87.4%) and a conversion procedure in 73 patients (12.6%). The length of common limb was 300 cm in 54.2%, 250 cm in 23%, and 200 cm in 13.4% of patients. Anastomosis technique was a linear stapler in 26.7% and a hand sewn suture technique in 73.3% of patients. Diarrhea was the most common complication (1.2%). The average %EWL was 30% at 3 months, 55% at 6 months, 70% at 1 year, and 85% at 2 years. Co-morbidity resolution rate was 74.1% for type 2 diabetes mellitus, 96.3% for hypertension, 68.3% for dyslipidemia, 63.3% for obstructive sleep apnea, and 87.5% for GERD. Overall, vitamin A, selenium, and iron deficiency were the most common nutritional deficiencies with the possibility of the protein malnutrition in up to 34% of the patients when measured. CONCLUSION: As a modified bariatric procedure, SADIS has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients. When measured, there was a high prevalence of macro-nutrient deficiencies following SADIS. There is a high technical variability, and long-term data are required before any meaningful conclusion can be made.

Portomesentric and splenic vein thrombosis (PMSVT) after bariatric surgery: a systematic review of 110 patients.

BACKGROUND: Portomesenteric and splenic vein thrombosis (PMSVT) is a rare but potentially serious complication after bariatric surgery. No study has systematically analyzed its incidence and risk factors. OBJECTIVES: To pool the data regarding PMSVT after bariatric surgery and determine its incidence and risk factors. METHODS: A meta-analysis and systematic review was conducted to retrieve studies on PMSVT after bariatric surgery. RESULTS: A total of 41 eligible studies including 110 patients with postbariatric PMSVT were enrolled; the estimated incidence rate based on 13 studies was .4%. The use of oral contraception was reported in 35.4% of patients, previous surgery in 61.1%, smoking in 37.2%, and history of coagulopathy in 43%. PMSVT mostly occurred after sleeve gastrectomy (78.9%) and within the first postoperative month (88.9%). Pneumoperitoneum pressure was>15 mm Hg in 6% of patients. The portal vein was the most commonly affected vessel (41.5%). Prothrombin 20210 mutation and protein C/S deficiency were the most common thrombophilic conditions. Unfractionated heparin (59.1%), vitamin K antagonists (50.9%), and low molecular weight heparin (39.1%) were the most common treatments for PMSVT. The morbidity and mortality rates for postbariatric PMSVT were 8.2% and 3.6%, respectively. CONCLUSION: PMSVT usually occurs within the first postoperative month and is mostly reported after sleeve gastrectomy. The portal vein is the most commonly involved vessel. A previous hypercoagulable state can be an important risk factor. Most patients can be treated with anticoagulation therapy. Further studies with comprehensive data review of patient information are required.

Efficacy and Safety of the Over-the-Scope Clip (OTSC) System in the Management of Leak and Fistula After Laparoscopic Sleeve Gastrectomy: a Systematic Review.

BACKGROUND: Endoscopic management of leaks/fistulas after laparoscopic sleeve gastrectomy (LSG) is gaining popularity in the bariatric surgery. OBJECTIVES: This study aimed to review the efficacy and safety of over-the-scope-clip (OTSC) system in endoscopic closure of post-LSG leak/fistula. METHODS: PubMed/Medline and major journals of the field were systematically reviewed for studies on endoscopic closure of post-LSG leaks/fistula by means of the OTSC system. RESULTS: A total of ten eligible studies including 195 patients with post-LSG leaks/fistula were identified. The time between LSG and leak/fistula ranged from 1 day to 803 days. Most of the leaks/fistula were located at the proximal staple line, and they sized from 3 to 20 mm. Time between leak diagnosis and OTSC clipping ranged from 0 to 271 days. Thirty-three out of 53 patients (63.5%) required one clip for closure of the lesion. Regarding the OTSC-related complications, a leak occurred in five patients (9.3%) and OTSC migration, stenosis, and tear each in one patient (1.8%). Of the 73 patients with post-LSG leak treated with OTSC, 63 patients had an overall successful closure (86.3%). CONCLUSION: OTSC system is a promising endoscopic approach for management of post-LSG leaks in appropriately selected patients. Unfortunately, most studies are series with a small sample size, short-term follow-up, and mixed data of concomitant procedures with OTSC. Further studies should distinguish the net efficacy of the OTSC system from other concomitant procedures in treatment of post-LSG leak.

Assessing the Impact of an Interactive Mobile Game on Tobacco-Related Attitudes and Beliefs: The Truth Campaign's "Flavor Monsters".

Given that over 97 percent of American teens play videogames, it is not surprising that many "games for health" target youth. Although tobacco use is the leading cause of preventable death in the United States, few digital games focus on preventing this behavior. The aims of this study were twofold: (1) to determine if youth will play a game with tobacco-related information and themes and (2) to explain the relationship between the truth(®) (Legacy, Washington, DC) campaign's "Flavor Monsters" gameplay and shifts in game-related tobacco knowledge, attitudes, and beliefs. First, two versions of the game, with different amounts of tobacco-related content, were developed to examine the influence of tobacco-related content on player engagement, length of play, awareness of the truth brand, and receptivity to the game. No statistically significant differences were found for engagement (P=0.81), length of play (P=0.10), or awareness of the truth brand (P=0.67). Using an online survey through a preexisting online panel of 13-24 year olds, a longitudinal (n=693) design was used whereby exposure to messages varied naturally over time. Because of the large number of anti-tobacco industry attitude questions, we created an Anti-Tobacco Industry (ATI) Index based on the results of a factor analysis. Although gameplay was not a predictor of lower levels of intention to smoke, level mastered was a significant positive predictor of ATI Index attitudes score at 3 months, controlling for baseline ATI Index score, age, gender, and ever cigarette use (P=0.002). Longitudinal findings indicate a cumulative and enduring effect, suggesting that anti-tobacco content can be successfully integrated within a mobile game to help increase anti-tobacco attitudes.

Impact of tobacco control policy on quitting and nicotine dependence among women in five European countries.

OBJECTIVE: To describe differences in and factors associated with former smoking and nicotine dependence among women in Ireland, Sweden, France, Italy and the Czech Republic. METHODS: A cross-sectional, random digit dial telephone survey of 5000 women, aged 18 years and older, conducted in 2008. Analyses were conducted using logistic regression models. RESULTS: Respondents from Ireland and Sweden had statistically significantly higher odds of having quit smoking within the 5 years before survey administration compared with respondents from the Czech Republic. Current smokers from Ireland, Sweden, France and Italy are more nicotine dependent than those from the Czech Republic. CONCLUSIONS: Respondents from countries with stronger tobacco control policies were more likely to have quit smoking compared with those living in the Czech Republic. However, respondents in countries with some of the strongest policies (Ireland, Sweden, France and Italy) had higher odds of smoking within 30 min of waking, an established indicator of nicotine dependence. More research in this area is warranted, but this study suggests that now that the Czech Republic is beginning to implement strong tobacco control policy, they will probably achieve a rapid decline in population-level smoking. Ireland, Sweden, France, Italy and other countries with established, strong tobacco control policies would do well to consider what additional programmes they can put in place to help their highly nicotine-dependent population of smokers successfully quit.

Tobacco use by sexual identity among young adults in the United States.

INTRODUCTION: National surveillance data are needed for the lesbian, gay, bisexual, and transgender population, a group which has been shown to have unique health needs. METHODS: This study uses data from Legacy's Young Adult Cohort Study, a nationally representative sample collected in the summer of 2011 to examine patterns of tobacco use by sexual identity. RESULTS: Homosexual and bisexual past 30-day cigarette use (35% and 27%, respectively) was higher than heterosexual past 30-day cigarette use (18%; p = .004). The prevalence of any current tobacco use among heterosexuals was 22% compared with 35% in homosexuals and 31% in bisexuals (p = .04). Prevalence of dual use was 30% among heterosexuals, 43% among homosexuals, and 35% among bisexuals. High school education (OR = 4.27), current alcohol use (OR = 12.64), and current other drug use (OR = 9.67) were significant predictors of current cigarette use among lesbian, gay, and bisexual respondents. Strong predictors of other tobacco product use were Black race (OR = 6.95), current alcohol use (OR = 11.70), and current other drug use (OR = 7.42). CONCLUSIONS: Prevalence estimates for tobacco use were higher among young adults who self-identify as sexual minorities compared with those who identify as heterosexuals. Tobacco use is strongly associated with alcohol and other drug use in this population. This study highlights the significant disparities in tobacco use behaviors among sexual minority populations and the critical need to conduct surveillance among these groups.

Cigarette litter: smokers' attitudes and behaviors.

Cigarette butts are consistently the most collected items in litter clean-up efforts, which are a costly burden to local economies. In addition, tobacco waste may be detrimental to our natural environment. The tobacco industry has conducted or funded numerous studies on smokers' littering knowledge and behavior, however, non-industry sponsored research is rare. We sought to examine whether demographics and smokers' knowledge and beliefs toward cigarette waste as litter predicts littering behavior. Smokers aged 18 and older (n = 1,000) were interviewed about their knowledge and beliefs towards cigarette waste as litter. Respondents were members of the Research Now panel, an online panel of over three million respondents in the United States. Multivariate logistic regressions were conducted to determine factors significantly predictive of ever having littered cigarette butts or having littered cigarette butts within the past month (p-value < 0.05). The majority (74.1%) of smokers reported having littered cigarette butts at least once in their life, by disposing of them on the ground or throwing them out of a car window. Over half (55.7%) reported disposing of cigarette butts on the ground, in a sewer/gutter, or down a drain in the past month. Those who did not consider cigarette butts to be litter were over three and half times as likely to report having ever littered cigarette butts (OR = 3.68, 95%CI = 2.04, 6.66) and four times as likely to have littered cigarette butts in the past month (OR = 4.00, 95%CI = 2.53, 6.32). Males were significantly more likely to have littered cigarette butts in the past month compared to females (OR = 1.49, 95%CI = 1.14, 1.94). Holding the belief that cigarette butts are not litter was the only belief in this study that predicted ever or past-month littering of cigarette waste. Messages in anti-cigarette-litter campaigns should emphasize that cigarette butts are not just litter but are toxic waste and are harmful when disposed of improperly.