Single Versus Double Anastomosis Duodenal Switch in the Management of Obesity: A Meta-analysis and Systematic Review.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective yet technically challenging bariatric surgery with many complications. Alternatively, single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) was recently introduced as a simplified bariatric procedure. This meta-analysis aimed to assess the safety and efficacy of SADI-S compared with BPD-DS in the management of patients with obesity. METHODS: Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to May 2022 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022333521). RESULTS: From 123 studies screened, 6 studies met the eligibility criteria, with a total of 1847 patients with obesity undergoing either SADI-S (n=818) or BPD-DS (n=1029). Preoperative body mass index was similar between the 2 groups, and the BPD-DS group had a greater % excess body mass index loss (EBMIL) (MD=-10.16%, 95% confidence interval: -11.80, -8.51, I 2 =0%) at 2 years compared with the SADI-S group. There was no difference observed in preoperative comorbidities and remission, including diabetes, hypertension, and dyslipidemia between SADI-S and BPD-DS cohorts. Compared with BPD-DS, SADI-S had shorter hospital stays (MD=-1.36 d, 95% CI: -2.39, -0.33, I 2 =86%), and fewer long-term (>30 d) complications (OR=0.56, 95% CI: 0.42, 0.74, I 2 =20%). Conversely, among nutritional deficiency outcomes, the SADI-S group had few patients with abnormal vitamin D (OR=0.51, 95% CI: 0.36, 0.72, I 2 =0%) values than the BPD-DS group. CONCLUSIONS: SADI-S has shown to be a possible alternative treatment option to BPD-DS in managing patients with obesity. Despite the promising results, further randomized controlled studies with more extended follow-up periods are necessary to ascertain the safety and efficacy of the treatment.

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

BackgroundTreatment of COVID-19 patients with plasma containing anti-SARS-CoV-2 antibodies may have a beneficial effect on clinical outcomes. We aimed to evaluate the safety and efficacy of convalescent plasma in patients admitted to hospital with COVID-19. MethodsIn this randomised, controlled, open-label, platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]) several possible treatments are being compared with usual care in patients hospitalised with COVID-19 in the UK. Eligible and consenting patients were randomly allocated to receive either usual care plus high titre convalescent plasma or usual care alone. The primary outcome was 28-day mortality. FindingsBetween 28 May 2020 and 15 January 2021, 5795 patients were randomly allocated to receive convalescent plasma and 5763 to usual care alone. There was no significant difference in 28-day mortality between the two groups: 1398 (24%) of 5795 patients allocated convalescent plasma and 1408 (24%) of 5763 patients allocated usual care died within 28 days (rate ratio [RR] 1{middle dot}00; 95% confidence interval [CI] 0{middle dot}93 to 1{middle dot}07; p=0{middle dot}93). The 28-day mortality rate ratio was similar in all prespecified subgroups of patients, including in those patients without detectable SARS-CoV-2 antibodies at randomisation. Allocation to convalescent plasma had no significant effect on the proportion of patients discharged from hospital within 28 days (66% vs. 67%; rate ratio 0{middle dot}98; 95% CI 0{middle dot}94-1{middle dot}03, p=0{middle dot}50). Among those not on invasive mechanical ventilation at baseline, there was no significant difference in the proportion meeting the composite endpoint of progression to invasive mechanical ventilation or death (28% vs. 29%; rate ratio 0{middle dot}99; 95% CI 0{middle dot}93-1{middle dot}05, p=0{middle dot}79). InterpretationAmong patients hospitalised with COVID-19, high-titre convalescent plasma did not improve survival or other prespecified clinical outcomes. FundingUK Research and Innovation (Medical Research Council) and National Institute of Health Research (Grant refs: MC_PC_19056; COV19-RECPLA).

Optimal Management of the Hyperkinetic Gallbladder: A Comparison of Outcomes Between Operative and Nonoperative Approaches.

BACKGROUND: A hyperkinetic gallbladder is defined as a hepatobiliary iminodiacetic acid (HIDA) scan ejection fraction (EF) of >80%. This condition is poorly described, and there is no current consensus on optimal management. The intent of this study was to determine if cholecystectomy improves symptoms in patients with a hyperkinetic gallbladder when compared to those managed nonoperatively and if there were variables predictive of symptom improvement with or without cholecystectomy. MATERIALS AND METHODS: This retrospective study included patients from 3 academic hospitals in the Atlanta metro area between the years 2006 and 2018. All patients with an EF >80% were included. Following voluntary exclusion patients were contacted by phone. Each patient was administered a questionnaire regarding their surgical history, medical management, and current symptom profile via Otago score. Institutional Institutional Review Board approval was obtained. RESULTS: 4785 HIDA scans were performed, and 194 reported an EF >80% (incidence 15.7%). 96% of these scans were reported as normal by the radiologist. 68 patients were able to be contacted by phone and completed the questionnaire. 18 patients underwent cholecystectomy, and 89% reported that their symptoms attributed to gallbladder disease were no longer present. 50 patients did not undergo cholecystectomy, and alternate diagnoses, medication prescriptions, diet modification, emergency department visits, and Otago score were higher in this cohort. DISCUSSION: Patients who undergo cholecystectomy for a diagnosis of hyperkinetic gallbladder, on average, report improvement in symptoms when compared to patients managed nonoperatively. This study supports the practice of reporting and managing hyperkinetic gallbladders as a pathologic entity.

Evaluation of Technical Competency in Healthcare Simulation (E-TeCHS) tool: a modified Delphi study.

Background: Graduates of simulation fellowship programmes are expected to have the ability to perform a variety of simulation specific skills at the time of graduation. Currently, simulation fellowship directors have access to tools to assess the ability of a fellow to debrief learners. However, there is no tool to assess a simulation fellow's competency in technical skills. The purpose of our manuscript was to develop and obtain content validation of a novel instrument designed to assess a simulation fellow's ability to perform the five core simulation technical skills. Methods: The study protocol was based on a methodology for content validation of curriculum consensus guidelines. This approach involves a three-step process, which includes the initial delineation of the curricular content. This was then followed by the validation of the curricular content using survey methodology and lastly obtaining consensus on modifications using Delphi methodology. Results: Two rounds of modified Delphi methodology were performed. Seventy-four respondents provided feedback on the round 1 survey and 45 respondents provided feedback on round 2. The final assessment tool has five elements and 16 subitems with four optional subitems. Conclusion: The Evaluation of Technical Competency in Healthcare Simulation tool provides an instrument developed from a national consensus of content experts. This tool provides simulation fellowship directors a method to evaluate fellows' competency in technical skills.

Laparoscopic Paraesophageal Hernia Repair and Pulmonary Embolism.

OBJECTIVE: Pulmonary embolism (PE) following laparoscopic paraesophageal hernia repair (PEHR) is rare but occurs at a higher frequency than other laparoscopic procedures. We describe a series of patients who developed PEs after PEHR in hopes of capturing potential risk factors for further study. MATERIALS AND METHODS: Five cases of PE after PEHR were observed between 2017 and 2018. Individual and perioperative risk factors, and postoperative courses were reviewed. RESULTS: Patients had a mean age of 73 years (range, 59 to 86). All were female. Two patients presented acutely. Three patients underwent revisional surgery. The average procedure duration was 248 minutes (range, 162 to 324). All patients had gastrostomy tubes placed. The diagnosis of PE occurred within 3 to 19 days postoperatively. Four were treated with 3 months of oral anticoagulation; 1 was managed expectantly. CONCLUSIONS: Highly complex cases, marked by revisional status, need for mesh, large hernia size, and percutaneous endoscopic gastrostomy placement are likely at increased risk for PEs. Preoperative venous thromboembolism chemoprophylaxis should be considered in the majority of laparoscopic PEHR patients.

Physical Activity, Weight Control, and Biomarkers of Prognosis and Survival among Breast Cancer Survivors.

Physical inactivity and obesity may increase risk of poor prognosis in breast cancer through effects on insulin or insulin-like growth factors or their binding proteins, insulin resistance, glucose metabolism, sex hormones, leptin and other adipokines, immunologic or inflammatory factors, oxidative stress, and Deoxyribonucleic acid (DNA) damage or repair capacity. The present review is based upon bibliographic searches in PubMed and relevant search terms. Articles published in English from January 1, 1980 through October 1, 2018 were identified using the following MeSH search terms and Boolean algebra commands: breast cancer survivors AND (insulin-like growth factor OR insulin resistance OR glucose metabolism OR sex hormones OR leptin OR adipokines OR immunologic OR inflammatory factors OR oxidative stress OR DNA repair capacity). After screening the abstracts or full texts of these articles and reviewing the references of previous review articles, a total of 66 studies met the eligibility criteria. Based upon published studies, it is difficult to determine the type or dose of exercise that affects inflammatory markers among breast cancer survivors. The optimal type of exercise, dose, and timing of physical activity needed to improve the inflammatory profile following a breast cancer diagnosis is unknown. Studies have used a range of physical activity types including aerobic, resistance training, yoga, and Tai Chi. A further issue is that existing studies of physical activity and biomarkers have included a range of disease stages. There is a need for a better understanding of the biological pathways through which physical activity and weight management increase survival in order to design targeted weight loss and exercise interventions for breast cancer survivors.

Healthy lifestyle intervention for African American uterine cancer survivors: Study protocol.

BACKGROUND: Cancer of the uterine corpus is the most common gynecologic malignancy and the fourth most common cancer in U.S. women. There is a racial disparity in the survival from endometrial cancer and this may be addressed by culturally-tailored lifestyle interventions to help African American (AA) endometrial cancer survivors lose weight or maintain a healthy weight. OBJECTIVE: The overall purpose of this pilot study is to develop and evaluate a culturally-tailored lifestyle intervention to help AA uterine cancer survivors reduce their risk of cancer recurrence and improve their quality of life through healthy eating, physical activity, and weight management. While many interventions have been evaluated to assist cancer survivors through diet and physical activity, few have focused on AA women with a uterine cancer diagnosis. METHODS: Community-engaged research principles are being followed. This study was developed with input from the Augusta University (AU) College of Nursing Community Advisory Board (CAB) and the Division of Gynecologic Oncology at the Georgia Cancer Center at AU. Weekly sessions throughout a 12-week intervention will include physical activity and lectures on improving nutritional status. The pre/post-test design includes baseline and 6-month follow-up, where participants will complete a questionnaire that assesses knowledge and attitudes about physical activity, nutrition, uterine cancer, social support, and quality of life. CONCLUSIONS: From this pilot study, we will learn more about the feasibility and integration of healthy lifestyle interventions in this patient population, and the results can provide an opportunity for a larger-scale, multi-center study with a randomized controlled design.

Medical judgement analogue studies with applications to spaceflight crew medical officer.

BACKGROUND: The National Aeronautics and Space Administration (NASA) developed plans for potential emergency conditions from the Exploration Medical Conditions List. In an effort to mitigate conditions on the Exploration Medical Conditions List, NASA implemented a crew medical officer (CMO) designation for eligible astronauts. This pilot study aims to add knowledge that could be used in the Integrated Medical Model. METHODS: An analogue population was recruited for two categories: administrative physicians (AP) representing the physician CMOs and technical professionals (TP) representing the non-physician CMOs. Participants completed four medical simulations focused on abdominal pain: cholecystitis (CH) and renal colic (RC) and chest pain: cardiac ischaemia (STEMI; ST-segment elevation myocardial infarction) and pneumothorax (PX). The Medical Judgment Metric (MJM) was used to evaluate medical decision making. RESULTS: There were no significant differences between the AP and TP groups in age, gender, race, ethnicity, education and baseline heart rate. Significant differences were noted in MJM average rater scores in AP versus TP in CH: 13.0 (±2.25), 4.5 (±0.48), p=<0.001; RC: 12.3 (±2.66), 4.8 (±0.94); STEMI: 12.1 (±3.33), 4.9 (±0.56); and PX: 13.5 (±2.53), 5.3 (±1.01), respectively. DISCUSSION: There could be a positive effect on crew health risk by having a physician CMO. The MJM demonstrated the ability to quantify medical judgement between the two analogue groups of spaceflight CMOs. Future studies should incorporate the MJM in a larger analogue population study to assess the medical risk for spaceflight crewmembers.

Coaching From the Sidelines: Examining the Impact of Teledebriefing in Simulation-Based Training.

INTRODUCTION: Although simulation facilities are available at most teaching institutions, the number of qualified instructors and/or content experts that facilitate postsimulation debriefing is inadequate at many institutions. There remains a paucity of evidence-based data regarding several aspects of debriefing, including debriefing with a facilitator present versus teledebriefing, in which participants undergo debriefing with a facilitator providing instruction and direction from an off-site location while they observe the simulation in real-time. We conducted this study to identify the effectiveness and feasibility of teledebriefing as an alternative form of instruction. METHODS: This study was conducted with emergency medicine residents randomized into either a teledebriefing or on-site debriefing group during 11 simulation training sessions implemented for a 9-month period. The primary outcome of interest was resident perception of debriefing effectiveness, as measured by the Debriefing Assessment for Simulation in Healthcare-Student Version (See Appendix, Supplemental Digital Content 1, http://links.lww.com/SIH/A282) completed at the end of every simulation session. RESULTS: A total of 44 debriefings occurred during the study period with a total number of 246 Debriefing Assessment for Simulation in Healthcare-Student Version completed. The data revealed a statistically significant difference between the effectiveness of on-site debriefing [6.64 (0.45)] and teledebriefing [6.08 (0.57), P < 0.001]. Residents regularly evaluated both traditional debriefing and teledebriefing as "consistently effective/very good." CONCLUSIONS: Teledebriefing was found to be rated lower than in-person debriefing but was still consistently effective. Further research is necessary to evaluate the effectiveness of teledebriefing in comparison with other alternatives. Teledebriefing potentially provides an alternative form of instruction within simulation environments for programs lacking access to expert faculty.

A Novel Simulation Technician Laboratory Design: Results of a Survey-Based Study.

UNLABELLED: OBJECTIVE : The purpose of this study was to elicit feedback from simulation technicians prior to developing the first simulation technician-specific simulation laboratory in Akron, OH. BACKGROUND: Simulation technicians serve a vital role in simulation centers within hospitals/health centers around the world. The first simulation technician degree program in the US has been approved in Akron, OH. To satisfy the requirements of this program and to meet the needs of this special audience of learners, a customized simulation lab is essential. METHOD: A web-based survey was circulated to simulation technicians prior to completion of the lab for the new program. The survey consisted of questions aimed at identifying structural and functional design elements of a novel simulation center for the training of simulation technicians. Quantitative methods were utilized to analyze data. RESULTS: Over 90% of technicians (n=65) think that a lab designed explicitly for the training of technicians is novel and beneficial. Approximately 75% of respondents think that the space provided appropriate audiovisual (AV) infrastructure and space to evaluate the ability of technicians to be independent. The respondents think that the lab needed more storage space, visualization space for a large number of students, and more space in the technical/repair area. CONCLUSIONS : A space designed for the training of simulation technicians was considered to be beneficial. This laboratory requires distinct space for technical repair, adequate bench space for the maintenance and repair of simulators, an appropriate AV infrastructure, and space to evaluate the ability of technicians to be independent.

A Community-Engaged Approach to Developing a Mobile Cancer Prevention App: The mCPA Study Protocol.

BACKGROUND: Rapid growth of mobile technologies has resulted in a proliferation of lifestyle-oriented mobile phone apps. However, most do not have a theoretical framework and few have been developed using a community-based participatory research approach. A community academic team will develop a theory-based, culturally tailored, mobile-enabled, Web-based app-the Mobile Cancer Prevention App (mCPA)-to promote adherence to dietary and physical activity guidelines. OBJECTIVE: The aim of this study is to develop mCPA content with input from breast cancer survivors. METHODS: Members of SISTAAH (Survivors Involving Supporters to Take Action in Advancing Health) Talk (N=12), treated for Stages I-IIIc breast cancer for less than 1 year, 75 years of age or younger, and English-speaking and writing, will be recruited to participate in the study. To develop the app content, breast cancer survivors will engage with researchers in videotaped and audiotaped sessions, including (1) didactic instructions with goals for, benefits of, and strategies to enhance dietary intake and physical activity, (2) guided discussions for setting individualized goals, monitoring progress, and providing or receiving feedback, (3) experiential nutrition education through cooking demonstrations, and (4) interactive physical activity focused on walking, yoga, and strength training. Qualitative (focus group discussions and key informant interviews) and quantitative (sensory evaluation) methods will be used to evaluate the participatory process and outcomes. RESULTS: Investigators and participants anticipate development of an acceptable (frequency and duration of usage) feasible (structure, ease of use, features), and accessible mobile app available for intervention testing in early 2017. CONCLUSIONS: Depending on the availability of research funding, mCPA testing, which will be initiated in Miami, will be extended to Chicago, Houston, Philadelphia, and Los Angeles.

Initial validation of a modified suction task training system.

BACKGROUND: Trainees rarely have the opportunity to practice suctioning copious or bloody secretions from the airways of patients in respiratory distress. The act of suctioning is frequently overlooked during the training of personnel in airway management and, thus, there is a dearth of simulated suction devices that can reproduce the fidelity of this process. OBJECTIVE: The authors describe their experience developing and obtaining initial validation of a modified suction task training system. METHODS: Senior-level students and faculty participated in the validation of this simulator. All participants used the modified Yankauer suction device in a simulated 'mini' scenario that required the use of suction. The panel of experts consisted of faculty from respiratory therapy, nursing and emergency medical services. After completion of the scenario, participants were asked to anonymously complete a survey. RESULTS: More than 94% (n=36) of students agreed or strongly agreed that the simulated oropharyngeal suction was an important component in their learning experience. The expert panel (n=11) strongly agreed that the modified Yankauer suctioning of oral secretions was an important component of student training and also strongly agreed that this apparatus would improve their students' suctioning skills (82% for both questions). Similar to the students, 90% of the faculty believed strongly that the simulator worked well. DISCUSSION: The authors describe their experience developing and obtaining initial validation of a modified suction task training system that has both structural and functional fidelity, offering learners an opportunity to practice appropriate and effective suctioning in patients.

HISTORIQUE: Les stagiaires ont rarement l'occasion de s'exercer à l'aspiration de sécrétions copieuses ou sanguinolentes dans les voies aériennes de patients en détresse respiratoire. On néglige souvent l'aspiration dans le cadre de la formation du personnel sur la prise en charge des voies aériennes. Il existe donc peu d'appareils de simulation de l'aspiration pour reproduire ce processus fidèlement. OBJECTIF: Les auteurs décrivent leur expérience dans la mise au point d'un système modifié de formation sur l'aspiration et dans sa validation initiale. MÉTHODOLOGIE: Des étudiants avancés et des professeurs ont participé à la validation de ce simulateur. Tous les participants ont utilisé l'appareil d'aspiration modifié Yankauer dans un mini-scénario d'aspiration. Le groupe d'experts était composé de professeurs en inhalothérapie, en soins infirmiers et en services médicaux d'urgence. Une fois le scénario terminé, les participants ont été invités à remplir un sondage anonyme. RÉSULTATS: Plus de 94 % des étudiants (n=36) étaient d'accord ou fortement d'accord avec le fait que la simulation de l'aspiration oropharyngée était un élément important de leur expérience d'apprentissage. Le groupe d'experts (n=11) était fortement d'accord avec le fait que l'appareil d'aspiration modifié Yankauer des sécrétions orales constituait un élément important de la formation des étudiants et que cet appareil pouvait améliorer les habiletés d'aspiration des étudiants (82 % aux deux questions). À l'instar des étudiants, 90 % des professeurs étaient fortement convaincus que le simulateur fonctionnait bien. EXPOSÉ: Les auteurs décrivent leur expérience à mettre au point et à obtenir la validation initiale d'un système de formation modifié sur l'aspiration, fidèle à la fois sur le plan structurel et fonctionnel, qui permet aux apprenants de s'exercer à une aspiration pertinente et efficace chez les patients.

In vivo MRI detection of carotid atherosclerotic lesions and kidney inflammation in ApoE-deficient mice by using LOX-1 targeted iron nanoparticles.

Lectin-like Oxidized Low-Density Lipoprotein Receptor 1 (LOX-1) plays a key role in atherosclerotic plaque initiation, formation and rupture, as well as in hyperlipidemia-induced glomerular disease. Here we report a sensitive, specific and biocompatible LOX-1-targeted-USPIO for the noninvasive MR imaging of LOX-1 within carotid atherosclerotic lesions and glomerular disease in apoE-deficient mice. In vitro analysis showed the highest uptake of targeted USPIOs in only activated RAW264.7 macrophages, and in vivo MRI studies showed signal loss in carotid atherosclerotic lesions after administration of targeted USPIOs at 8h and 24h. These areas of signal loss were correlated with the presence of nanoparticles in the atherosclerotic lesions, and immunohistochemistry and Perl's staining confirmed the co-localization of the LOX-1/macrophages/MMP-9 and targeted nanoparticles. Finally, additional studies suggest that this targeted probe may have potential to noninvasively image early glomerular disease. This finding may provide important methods for characterizing vulnerable atherosclerotic plaques and hyperlipidemia-induced glomerular diseases. FROM THE CLINICAL EDITOR: A functionalized USPIO-based negative contrast material was used in this study, demonstrating feasibility of sensitive MRI-based detection of atherosclerotic plaque formation in the carotid arteries and in the renal cortex, paving the way to potential future clinical applications.

Iatrogenic combined bile duct and right hepatic artery injury during single incision laparoscopic cholecystectomy.

BACKGROUND: Numerous recent reports describe the performance of laparoscopic procedures through a single incision. Although the feasibility of this approach for a variety of procedures is currently being established, little data are available regarding safety. CASE REPORT: A 65-year-old female patient who was transferred from an outside institution had undergone a single incision laparoscopic cholecystectomy that resulted in biliary tract and vascular injuries. METHODS: The patient was transferred with a known bile duct injury on the first postoperative day following single incision laparoscopic cholecystectomy. Review of her magnetic resonance imaging and percutaneous transhepatic cholangiogram studies showed a Bismuth type 3 bile duct injury. Hepatic angiogram demonstrated an occlusion of the right hepatic artery with collateralization from the left hepatic artery. She was initially managed conservatively with a right-sided external biliary drain, followed 6 weeks later by a Hepp-Couinaud procedure to reconstruct the biliary tract. CONCLUSION: As new techniques evolve, it is imperative that safety, or potential side effects, or both safety and side effects, be monitored, because no learning curve is established for these new techniques. In these initial stages, surgeons should have a low threshold to add additional ports when necessary to ensure that procedures are completed safely.

A novel subpopulation of B-1 cells is enriched with autoreactivity in normal and lupus-prone mice.

OBJECTIVE: B-1 cells have long been suggested to play an important role in lupus. However, reports to date have been controversial regarding their pathogenic or protective roles in different animal models. We undertook this study to investigate a novel subpopulation of B-1 cells and its roles in murine lupus. METHODS: Lymphocyte phenotypes were assessed by flow cytometry. Autoantibody secretion was analyzed by enzyme-linked immunosorbent assay, autoantigen proteome array, and antinuclear antibody assay. Cell proliferation was measured by thymidine incorporation and 5,6-carboxyfluorescein succinimidyl ester dilution. B cell Ig isotype switching was measured by enzyme-linked immunospot assay. RESULTS: Anti-double-stranded DNA (anti-dsDNA) autoantibodies were preferentially secreted by a subpopulation of CD5+ B-1 cells that expressed programmed death ligand 2 (termed L2pB1 cells). A substantial proportion of hybridoma clones generated from L2pB1 cells reacted to dsDNA. Moreover, these clones were highly cross-reactive with other lupus-related autoantigens. L2pB1 cells were potent antigen-presenting cells and promoted Th17 cell differentiation in vitro. A dramatic increase of circulating L2pB1 cells in lupus-prone BXSB mice was correlated with elevated serum titers of anti-dsDNA antibodies. A significant number of L2pB1 cells preferentially switched to IgG1 and IgG2b when stimulated with interleukin-21. CONCLUSION: Our findings identify a novel subpopulation of B-1 cells that is enriched for autoreactive specificities, undergoes isotype switch, manifests enhanced antigen presentation, promotes Th17 cell differentiation, and is preferentially associated with the development of lupus in a murine model. Together, these findings suggest that L2pB1 cells have the potential to initiate autoimmunity through serologic and T cell-mediated mechanisms.