Analysis of the learning process for laparoscopic sleeve gastrectomy: CUSUM-curve of 110 consecutive patients with 1-year follow-up.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure worldwide. A tremendous recent increase in the number of LSGs has not been driven by an accurate learning process, especially in low volume bariatric centers. The cumulative-sum (CUSUM) method is an effective analysis of the learning process, taking intraoperative and postoperative variables into account. This study was aimed at establishing a CUSUM learning curve for LSG in order to define the number of procedures needed to achieve sufficient surgical skill. METHODS: All LSGs performed by a single general surgeon between September 2014 and November 2017 were considered. We hypothesized that the key t variables related to the LSG learning process (LP) are: operative time (OT), intraoperative complications or difficulties, need for expert assistance, length of hospital stay (LOS), and 3-month postoperative morbidity. All of these parameters are binary variables analyzed with the risk-adjusted CUSUM method. Two groups, learning group (LG) and experienced group (EG), were identified and compared by univariate analysis. Multivariate analysis was performed to identify the variables most closely associated with operative time and surgical success. One-year weight loss outcomes were likewise analyzed. RESULTS: One hundred and ten (110) consecutive LSGs were considered. CUSUM-LSG showed that the mean number of consecutive interventions necessary to reach proficiency in LSG was 58. In multivariate analysis, surgical success was negatively correlated with longer operative time and need for expert assistance. Body mass index was not correlated with surgical success. CONCLUSION: Fifty-eight LSG procedures were required to achieve surgical skill. Operative time and the need for expert assistance were variables most closely associated with surgical success. ACGME COMPETENCY: Practice-based learning and improvement.

Combined circular external fixation and flexible intramedullary nailing for pediatric bilateral open tibia fractures in blast injury.

Management of blast injuries with open fractures and extensive soft tissue damage in pediatric patients is a challenging task even in experienced hands. This article reports the case of an 8-year-old boy with bilateral open tibia fractures and soft tissue loss due to the accidental explosion of a skyrocket. After the emergency procedures with lavage, debridement and temporary bone stabilization, we performed the definitive reconstruction surgery using a combined circular external fixation and flexible intramedullary nailing technique on both legs. This technique allowed easy access to the wounds for plastic surgery procedures and early bilateral weight bearing. All implants were removed within 6 months, the fractures healed with good axial alignment and the patient returned to his preinjury activities one year after the trauma. In this case, the combined use of circular external fixation and flexible intramedullary nailing ensured optimal fractures stabilization, minimizing the damage to the soft tissues and the obstruction for plastic surgeons. We believe that this technique should be considered in pediatric patients with open fractures of the lower limbs and extensive soft tissue injuries.

Self-expandable metal stent placement for treatment of severe sphincterotomy bleeding.

One of the most frequent complications of endoscopic sphincterotomy (ES) is bleeding. When post-ES bleeding does not respond to the use of typical endoscopic therapy, the only alternative is angiography or surgery. A 82-year-old female was admitted for jaundice. A RMN-cholangiography revealed multiple stones in the common bile duct (CBD). She underwent endoscopic retrograde cholangiopancreatography (ERCP). The papilla major was located between two large periampullary diverticula. During the ES, a severe bleeding was observed from the upper part of the biliary cut. Several methods of hemostasis (injection of adrenaline, thermal methods and balloon tamponate) were performed without efficacy. A partially covered metallic stent was placed across the biliary orifice, in order to compress mechanically the bleeding site archiving the hemostasis.

Ictero-haemorraghic leptospirosis with pulmonary involvement and acute renal failure: case report.

Leptospirosis is a spirochetal zoonosis with a worldwide distribution affecting both animals and humans. These are infected only occasionally by direct contact with infected animals or through contaminated water and soil. Generally, this disease is commonly found in tropical regions. Infected patients usually present with non-specific features. In fact, the clinical manifestations of leptospirosis are variable, ranging from occult infection to Weil's disease with fatal complications. Often the disease remains underdiagnosed due to the broad spectrum of signs and symptoms. Here we are reporting a case of a woman with an ictero-haemorraghic leptospirosis complicated by acute renal failure and pulmonary involvement that received intensive care unit support including intubation and ventilation and promptly resolved with appropriate therapy.

Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients

Objective: To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. Methods: Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear. Recommendations: The article is focused on a suggested glycemic control end point such that a blood glucose ≥150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤70 mg/dL) and to minimize glycemic variability. Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients. Conclusions: While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.

Management of distal tibial intra-articular fractures with circular external fixation.

The treatment of tibial plafond fractures requires careful management of the soft tissue envelope, reconstruction of the articular surface and stable fixation with minimal additional damage. Thirty cases of AO type 43 C tibial fractures were treated by transosseous osteosynthesis (Ilizarov technique). The external fixator constructs used were Ilizarov (Transosseous osteosynthesis: theoretical and clinical aspects of the regeneration and growth of tissue, Springer, Berlin, 1992) and Sheffield (Classification AO des fractures, Springer, Berlin, 1987) circular fixator systems. All tibial plafond fractures healed. Using radiological criteria for assessment of reduction of the articular fragments and the clinical scoring system described by Teeny and Wiss, there were excellent and good restoration of articular structure in 27 cases and good clinical results in 14. This treatment method compares well with previous published series and is to be recommended for this group of difficult fractures.

An integrated environment for stereoscopic acquisition, off-line 3D elaboration, and visual presentation of biological actions.

We present an integrated environment for stereoscopic acquisition, off-line 3D elaboration, and visual presentation of biological hand actions. The system is used in neurophysiological experiments aimed at the investigation of the parameters of the external stimuli that mirror neurons visually extract and match on their movement related activity.

Cardiovascular actions of magnesium.

Intracellular magnesium is an important modulator of calcium and potassium channels in cardiac myocytes. Hypomagnesemia is common in hospitalized patients and may contribute significantly to cardiac morbidity and mortality, particularly in states associated with myocardial ischemia. Therefore, it is important to maintain the plasma magnesium concentration within the normal range in asymptomatic patients and in patients with cardiac disease as prophylaxis against the occurrence of significant arrhythmias.

Dietary composition and physiologic adaptations to energy restriction.

BACKGROUND: The concept of a body weight set point, determined predominantly by genetic mechanisms, has been proposed to explain the poor long-term results of conventional energy-restricted diets in the treatment of obesity. OBJECTIVE: The objective of this study was to examine whether dietary composition affects hormonal and metabolic adaptations to energy restriction. DESIGN: A randomized, crossover design was used to compare the effects of a high-glycemic-index (high-GI) and a low-glycemic-index (low-GI) energy-restricted diet. The macronutrient composition of the high-GI diet was (as percent of energy) 67% carbohydrate, 15% protein, and 18% fat and that of the low-GI diet was 43% carbohydrate, 27% protein, and 30% fat; the diets had similar total energy, energy density, and fiber contents. The subjects, 10 moderately overweight young men, were studied for 9 d on 2 separate occasions. On days -1 to 0, they consumed self-selected foods ad libitum. On days 1-6, they received an energy-restricted high- or low-GI diet. On days 7-8, the high- or low-GI diets were consumed ad libitum. RESULTS: Serum leptin decreased to a lesser extent from day 0 to day 6 with the high-GI diet than with the low-GI diet. Resting energy expenditure declined by 10.5% during the high-GI diet but by only 4.6% during the low-GI diet (7.38 +/- 0.39 and 7.78 +/- 0.36 MJ/d, respectively, on days 5-6; P = 0.04). Nitrogen balance tended to be more negative, and energy intake from snacks on days 7-8 was greater, with the high-GI than the low-GI diet. CONCLUSION: Diets with identical energy contents can have different effects on leptin concentrations, energy expenditure, voluntary food intake, and nitrogen balance, suggesting that the physiologic adaptations to energy restriction can be modified by dietary composition.

The effect of growth hormone treatment on the insulin-like growth factor axis in a child with nonislet cell tumor hypoglycemia.

We have previously described a case of tumor-associated hypoglycemia secondary to the production of high molecular weight insulin-line growth factor (IGF)-II in a child with congenital neuroblastoma. The child's hypoglycemia resolved with GH therapy and has continued to be well controlled for 1 yr. This represents one of the first cases of nonislet cell tumor hypoglycemia (NICTH) treated successfully with long-term exogenous GH. We now present an in-depth analysis of the IGF axis in this patient, before and after GH treatment. Although IGF-II levels at presentation were in the normal range, they were inappropriate for the patient's low GH state. Furthermore, the percentage of "big" IGF-II was elevated, as was the level of the IGF-IIE peptide, which is normally cleaved in the processing of the mature peptide. On the initial evaluation, GH levels failed to rise in response to hypoglycemia, IGF-I levels were low, IGF binding protein-3 (IGFBP-3) levels were suppressed, and IGFBP-2 levels were elevated. We have shown that baseline IGFBP-3 levels were low by RIA and immunoblotting and have demonstrated that this decrease was not associated with IGFBP protease activity. We have also demonstrated the baseline suppression of the acid labile subunit (ALS) of the 150K ternary complex by a novel immunoblot assay. The ratio of IGFs to IGFBP-3 was dramatically elevated, presumably leading to hypoglycemia. Furthermore, the percentage of serum IGF-I and IGF-II present as part of a binary (50K) complex with IGFBPs was also increased. GH therapy resulted in a normalization of the levels of blood sugars, IGFBP-3, ALS, IGFBP-2, and IGF-I, as well as the IGF/IGFBP-3 ratio. In summary, we have presented evidence that the hypoglycemia in this patient resulted from tumor production of high molecular weight IGF-II, which suppressed GH secretion, leading to the described derangements in the IGF binding proteins. We speculate that as a result of the decreased IGFBP-3 and ALS levels, the IGF population was shifted from the stable 150K complex to lower molecular weight complexes with IGF binding proteins, increasing IGF availability to tissues due to rapid turnover of these low molecular weight complexes. We demonstrated the reversal of the abnormalities in the IGFBP levels with GH treatment, corresponding to the clinical response of euglycemia.

Non-islet-cell tumor associated with hypoglycemia in a child: successful long-term therapy with growth hormone.

Hypoglycemia occurred in a 2-year-old girl with neuroblastoma. Initially, growth hormone secretion was suppressed, and she had low levels of insulin-like growth factor (IGF)-I and IGF binding protein-3, but elevated levels of large molecular weight IGF-II. We postulated that the pathogenesis of her hypoglycemia involved production of IGF-II by her neuroblastoma, leading to GH suppression and an abnormally elevated ratio of IGF to IGF binding protein. She was successfully treated with growth hormone; treatment was associated with normalization of the growth hormone-dependent growth factor levels and with euglycemia.

Social problems and health in urbanization.

One of the main characteristics of urbanization in Asia is the very rapid increase in population movement from rural to urban centers. This phenomenon has led to changing population structure, its composition and lifestyles in the cities and its fringes. As a consequent of population pressure on urban system and infrastructure, compounded by the nature of the composition of the in-migrant population, the urban concentrates are faced with several social and socio-economic problems. Although there has been a lot of interests among researchers to study the causes and effects or urbanization, there is a vacuum in the area of health implications. Planners and administrators usually give priority to the physical aspects of the urban and urbanities. Social problems and health implications thereof receives very little attention either at the level of administration or research. This paper therefore is a brave attempt to focus and draw some attention to this neglected area by looking at selected social problems and the health consequences.

Urbanization and low-income housing in Malaysia: impact on the urban Malays.

The focus of this study is on urbanization in Malaysia. "This paper is divided into three parts. The first part examines the trend of uneven urban development in West Malaysia. The second part discusses the change [in] ethnic composition of urban population between 1970 and 1980 intercensal period. The third part analyses the impact of the urbanization process on the Malays in the context of housing problems of the lower income groups." (SUMMARY IN THA)