A precise approach to robotic intracorporeal rectal transection and hand-sewn purse-string anastomosis for low anterior resection.

This study presents a new technique for robotic-assisted intracorporeal rectal transection and hand-sewn anastomosis for low anterior resection that overcomes some limitations of conventional techniques. By integrating the advantages of the robotic platform, ensuring standardized exposure during rectal transection, and emphasizing the importance of avoiding complications associated with staple crossings, this innovation has the potential to significantly improve outcomes and reduce costs for patients with lower rectal tumors.

Robotic versus laparoscopic gastric bypass in bariatric surgery: a systematic review and meta-analysis on perioperative outcomes.

BACKGROUND: Robotic-assisted surgery has emerged as a compelling approach to bariatric surgery. However, current literature has not consistently demonstrated superior outcomes to laparoscopic bariatric surgery to justify its higher cost. With its mechanical advantages, the potential gains from the robotic surgical platform are likely to be apparent in more complex cases such as gastric bypass, especially revisional cases. OBJECTIVE: This systematic review and meta-analysis aimed to summarize the literature and evaluate the peri-operative outcomes of patients with obesity undergoing robotic gastric bypass versus laparoscopic gastric bypass surgery. SETTING: Systematic review. METHODS: A literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing outcomes of robotic and laparoscopic gastric bypass for obesity were included. RESULTS: Twenty-eight eligible studies comprised a total of 82,155 patients; 9051 robotic bypass surgery (RBS) versus 73,104 laparoscopic bypass surgery (LBS) were included. All included studies compared Roux-en-Y gastric bypass. RBS was noted to have higher reoperation rate within 30 days (4.4% versus 3.4%; odds ratio 1.31 [95% CI, 1.04-1.66]; P = .027; I2 = 43.5%) than LBS. All other endpoints measured (complication rate, anastomotic leak, anastomotic stricture, surgical site infections, hospital readmission, length of stay, operative time, conversion rate and mortality) did not show any difference between RBS and LBS. CONCLUSION: This systematic review and meta-analysis showed that there was no significant difference in key outcome measures in robotic versus laparoscopic gastric bypass. RBS was associated with a slightly higher reoperation rate and there was no reduction in overall complication rate with the use of robotic platform.

A resonant sextuplet of sub-Neptunes transiting the bright star HD 110067.

Planets with radii between that of the Earth and Neptune (hereafter referred to as 'sub-Neptunes') are found in close-in orbits around more than half of all Sun-like stars1,2. However, their composition, formation and evolution remain poorly understood3. The study of multiplanetary systems offers an opportunity to investigate the outcomes of planet formation and evolution while controlling for initial conditions and environment. Those in resonance (with their orbital periods related by a ratio of small integers) are particularly valuable because they imply a system architecture practically unchanged since its birth. Here we present the observations of six transiting planets around the bright nearby star HD 110067. We find that the planets follow a chain of resonant orbits. A dynamical study of the innermost planet triplet allowed the prediction and later confirmation of the orbits of the rest of the planets in the system. The six planets are found to be sub-Neptunes with radii ranging from 1.94R⊕ to 2.85R⊕. Three of the planets have measured masses, yielding low bulk densities that suggest the presence of large hydrogen-dominated atmospheres.

Effort and effort discounting as predictors of seeking psychotherapy among individuals with depression.

OBJECTIVES: Many individuals who experience depression do not seek psychotherapy, and past research has had limited success in predicting help-seeking in this population. Accounting for behavioral characteristics of depression that affect help-seeking decisions, such as effort discounting (devaluation of rewards as a function of effort), may address this gap. METHODS: Individuals with moderate-severe depression symptoms who were not in psychotherapy (N = 253) reported their depression symptom severity and the amount of effort they anticipated seeking psychotherapy would require; they also completed a behavioral measure of effort discounting. At a 3-month follow-up, they reported whether they initiated psychotherapy during the follow-up period. RESULTS: Depression symptom severity was associated with perceptions that seeking psychotherapy would be more effortful. In turn, perceptions that seeking psychotherapy would be more effortful prospectively predicted a lower likelihood of initiating psychotherapy. Effort discounting was unrelated to psychotherapy use. CONCLUSIONS: These results suggest that differences in the anticipated effort required to seek psychotherapy can increase depressed individuals' risk of going untreated. Future research may test whether reducing the effort of seeking psychotherapy increases psychotherapy use among those with depression. For instance, streamlining insurance enrollment procedures, implementing patient decision aids, or offering telehealth treatment options may be beneficial.

Traumatic Vertebral Artery Stenosis Inflicted by Stray Arrow.

A 17-year-old female presented to the emergency room with an arrow sticking out the right aspect of her neck. Her vital signs were stable with systolic blood pressure of 117 mmHg, without either tachycardia, dyspnea, or signs of active bleeding. She was fully conscious with intact sensory and motor function on all extremities. Computed Tomography (CT) showed that the tip of the arrowhead lodged at the transverse foramen of the third cervical vertebra. Digital subtraction angiography revealed that the arrowhead lies posterior to the right vertebral artery, narrowly missing it by about two millimeters. Emergency surgery was arranged in hybrid operating suite. An occlusion balloon catheter was introduced to right vertebral artery but not inflated prior to extracting the arrowhead. After extraction, oozing from the wound was noted. We then inflated the balloon while the neurosurgeon performed hemostasis with gauze compression and electrocoagulation probe. The right vertebral angiography after releasing of the balloon showed focal narrowing of the artery without contrast extravasation. The patient was discharged on the fifth hospital day, and no anticoagulant was prescribed due to lack of neurological deficit. Pre-surgical planning and partnership with the neurosurgeon lead to the optimal outcome for this case.

Kinetics of Metastable Argon Optical Excitation and Gain in Ar/He Microplasmas.

The optically pumped rare-gas metastable laser is capable of high-intensity lasing on a broad range of near-infrared transitions for excited-state rare gas atoms (Ar*, Kr*, Ne*, Xe*) diluted in flowing He. The lasing action is generated by photoexcitation of the metastable atom to an upper state, followed by collisional energy transfer with He to a neighboring state and lasing back to the metastable state. The metastables are generated in a high-efficiency electric discharge at pressures of ∼0.4 to 1 atm. The diode-pumped rare-gas laser (DPRGL) is a chemically inert analogue to diode-pumped alkali laser (DPAL) systems, with similar optical and power scaling characteristics for high-energy laser applications. We used a continuous-wave linear microplasma array in Ar/He mixtures to produce Ar(1s5) (Paschen notation) metastables at number densities exceeding 1013 cm-3. The gain medium was optically pumped by both a narrow-line 1 W titanium-sapphire laser and a 30 W diode laser. Tunable diode laser absorption and gain spectroscopy determined Ar(1s5) number densities and small-signal gains up to ∼2.5 cm-1. Continuous-wave lasing was observed using the diode pump laser. The results were analyzed with a steady-state kinetics model relating the gain and the Ar(1s5) number density.

A dense ring of the trans-Neptunian object Quaoar outside its Roche limit.

Planetary rings are observed not only around giant planets1, but also around small bodies such as the Centaur Chariklo2 and the dwarf planet Haumea3. Up to now, all known dense rings were located close enough to their parent bodies, being inside the Roche limit, where tidal forces prevent material with reasonable densities from aggregating into a satellite. Here we report observations of an inhomogeneous ring around the trans-Neptunian body (50000) Quaoar. This trans-Neptunian object has an estimated radius4 of 555 km and possesses a roughly 80-km satellite5 (Weywot) that orbits at 24 Quaoar radii6,7. The detected ring orbits at 7.4 radii from the central body, which is well outside Quaoar's classical Roche limit, thus indicating that this limit does not always determine where ring material can survive. Our local collisional simulations show that elastic collisions, based on laboratory experiments8, can maintain a ring far away from the body. Moreover, Quaoar's ring orbits close to the 1/3 spin-orbit resonance9 with Quaoar, a property shared by Chariklo's2,10,11 and Haumea's3 rings, suggesting that this resonance plays a key role in ring confinement for small bodies.

Screening for malnutrition in emergency laparotomy patients: a comparison of three tools.

INTRODUCTION: Malnourished patients undergoing emergency laparotomy are at risk of significant morbidity. The optimum screening tool to identify such patients in practice and research is yet to be determined. This study aims to compare the performance of three nutrition risk tools in predicting time without enteral nutrition in this population. METHODS: A prospective cohort study (NCT04696367) was conducted across two sites, recruiting patients undergoing National Emergency Laparotomy Audit eligible procedures. Data collected included demographics, diagnosis, procedure and outcomes. Nutrition risk was assessed using three tools: Malnutrition Universal Screening Tool (MUST) score, Nutritional Risk Index (NRI) and Nutritional Risk Score 2002 (NRS-2002). Complications were assessed with the Comprehensive Complication Index. Quality of life was measured at baseline and 5 days postsurgery using EQ-5D-5L. RESULTS: A total of 59 patients were recruited. Median age was 69 years. Of the 59 participants, 23 were judged high risk using MUST score, 13 using NRS and 8 using NRI. Median time to restart enteral intake was 7 days (interquartile range 7-14). Time without intake was correlated with increasing score using MUST (r=0.463, p<0.001) and NRS-2002 (r=0.296, p=0.03) but not NRI (r=-0.121, p=0.38). High-risk nutritional groups also had increased length of hospital stay, but not complication scores. CONCLUSIONS: Patients undergoing emergency laparotomy spend a prolonged time without enteral nutrition. Although all nutritional tools demonstrated some propensity to identify patients at higher risk of needing nutritional support, their performance was variable. Nevertheless, some may be useful in future clinical studies.

Stigma and Intentions to Seek Psychotherapy Among Primary Care Providers During the COVID-19 Pandemic: A Mediational Analysis.

BACKGROUND: Medical personnel have reported increases in psychological distress and depression during the COVID-19 pandemic. Additionally, many providers, including primary care providers (PCPs), face significant stigma related to personal mental healthcare. However, the process by which stigma affects help-seeking among PCPs is unclear. METHOD: Between January and May 2020, 112 PCPs completed a survey of perceived public stigma, self-stigma, attitudes, intentions to seek psychotherapy for depression, and a clinical vignette on patient referrals to psychotherapy. RESULTS: Self-stigma and attitudes toward psychotherapy sequentially mediated the relationship between perceived public stigma and intentions to seek psychotherapy. PCPs were more likely to refer a depressed patient to psychotherapy than seek personal psychotherapy, but lower personal help-seeking intentions were associated with lower referral intentions. CONCLUSION: These results clarify processes by which stigma hinders PCPs' psychotherapy use and highlight interventions to encourage their help-seeking. Addressing cultural and practical barriers in the medical field is needed to reduce stigma.

Appendiceal Mucinous Tumor Presenting as Recurrent Bowel Obstruction.

Appendiceal mucinous tumors are rare, with variable malignant potential, and they are usually found incidentally. Clinical symptoms are nonspecific. Rarely, appendiceal mucinous neoplasm causes bowel obstruction and makes diagnosis more difficult. We present a case of an 84-year-old female who came to our emergency department having had abdominal fullness and constipation for 5 days. Ileus, due to an affected adhesion band, was diagnosed initially, and symptoms improved gradually under conservative treatment. However, 3 months later she presented to the emergency department again with abdominal pain and distension; small bowel obstruction due to adhesion was again diagnosed. Recurrent bowel obstruction prompted emergent surgery. Operative findings showed a whitish appendiceal tumor adhering to and directly invading the adjacent ileum, with a segment of herniated small bowel wedged in between, causing the obstruction. Upon reviewing the initial computed tomography scan, the dilated tubular structure of appendiceal tumor was misrecognized as small bowel loop; there was no surrounding inflammatory sign, leading to diagnosis difficulty. Instead of a common cause of bowel obstruction, such as adhesion band, this case revealed bowel obstruction can be caused by the direct invasion of an appendiceal tumor. Awareness of this condition with careful image evaluation of small bowel obstruction is essential for diagnosis.

Real-time Ultrasound-Guided Manual Testicular Detorsion: A Case Report.

INTRODUCTION: Acute testicular torsion is a surgical emergency due to acute testicular ischemia. Manual testicular detorsion is a testis-saving, bedside therapeutic when performed correctly and in a timely fashion. This procedure is most commonly performed blindly with pain relief as the endpoint for detorsion. However, up to one-third of patients continued to show signs of residual torsion in the operating room even using pain relief as the stopping point for the procedure. CASE REPORT: We present a case demonstrating the utility of color Doppler ultrasound to confirm complete manual detorsion in a 14-year-old male with acute testicular torsion. The patient underwent 360-degree detorsion and had relief of pain; however, color Doppler demonstrated incomplete return of flow to the testis. After an additional 180-degree turn was made, color Doppler demonstrated complete return of normal vascular flow to the torsed testis. CONCLUSION: When it comes to testicular viability, timely restoration of blood flow to the testicle is of utmost importance. Manual detorsion is a non-invasive intervention that can be quickly and effectively performed at the bedside. Moreover, using color Doppler ultrasound guidance can ensure that physicians detorse in the proper direction and to completion, by providing instant visualization of restorative flow and ensuring reperfusion of the testis while awaiting definitive surgical management.

An ICA-based framework for joint analysis of cognitive scores and MEG event-related fields.

This paper proposes an independent component analysis (ICA)-based framework for exploring associations between neural signals measured with magnetoencephalography (MEG) and non-neuroimaging data of healthy subjects. Our proposed framework contains methods for subject group identification, latent source estimation of MEG, and discriminatory source visualization. Hierarchical clustering on principal components (HCPC) is used to cluster subject groups based on cognitive scores, and ICA is performed on MEG evoked responses such that not only higher-order statistics but also sample dependence within sources is taken into account. The clustered subject labels and estimated sources are jointly analyzed to determine discriminatory sources. Finally, discriminatory sources are used to calculate global difference maps (GDMs) for the summary. Results using a new data set reveal that estimated sources are significantly correlated with cognitive measures and subject demographics. Discriminatory sources have significant correlations with variables that have not been previously used for group identification, and GDMs can effectively identify group differences.

Minimally invasive cerebral revascularization in moyamoya disease in adult patients.

BACKGROUND: Moyamoya disease (MMD) affects young patients, is generally progressive, and results in strokes or cerebral hemorrhages for which medical management is not effective. OBJECTIVE: To determine the effectiveness of surgical management with minimally invasive cerebral revascularization in MMD. MATERIAL AND METHODS: We conducted a retrospective cohort study of patients undergoing extracranial-intracranial microsurgical revascularization surgery with mini-craniotomy, analyzing the epidemiological, clinical, neuroimaging, postoperative evolution, and complications. We describe the technique in detail. Key outcomes included graft patency, complications, and recurrence of ischemic or hemorrhagic stroke. RESULTS: From September 2017 to December 2020, 12 brain revascularization procedures for MMD were performed in eight patients (four bilateral), and all 12 grafts were classified as patent. The main complication was contralateral cerebral infarction identified by postoperative neuroimaging in a patient without clinical symptomatology. There was no case of scalp ischemia or necrosis when performing the minimally invasive approach with linear incision. CONCLUSIONS: The results of this study suggest that the minimally invasive extracranial-intracranial cerebral revascularization procedure for MMD in adults is effective, with graft patency in all cases and minimal morbidity.

Neighborhoods and functionality in metals.

The fundamental construct of organic chemistry involves understanding molecular behavior through functional groups. Much of computational chemistry focuses on this very principle, but metallic materials are rarely analyzed using these techniques owing to the assumption that they are delocalized and do not possess inherent functionality. In this paper, we propose a methodology that recovers functional groups in metallic materials from an energy perspective. We characterize neighborhoods associated with functional groups in metals by observing the evolution of Bader energy of the central cluster as a function of cluster size. This approach can be used to conceptually decompose metallic structure into meaningful chemical neighborhoods allowing for localization of energy-dependent properties. The generalizability of this approach is assessed by determining neighborhoods for crystalline materials of different structure types, and significant structural defects such as grain boundaries and dislocations. In all cases, we observe that the neighborhood size may be universal-around 2-3 atomic diameters. In its practical sense, this approach opens the door to the application of chemical concepts, e.g., orbital methods, to investigate a broad range of metallurgical phenomena, one neighborhood at a time.

Production and loss of O2(1Δ g ) at atmospheric pressure using microwave-driven microplasmas.

We have used arrays of microwave-generated microplasmas operating at atmospheric pressure to generate high concentrations of singlet molecular oxygen, O2(1Δ g ), which is of interest for biomedical applications. The discharge is sustained by a pair of microstrip-based microwave resonator arrays which force helium/oxygen gas mixtures through a narrow plasma channel. We have demonstrated the efficacy of both NO and less-hazardous N2O additives for suppression of ozone and associated enhancement of the O2(1Δ g ) yield. Quenching of O2(1Δ g ) by ozone is sufficiently suppressed such that quenching by ground state molecular oxygen becomes the dominant loss mechanism in the post-discharge outflow. We verified the absence of other significant gas-phase quenching mechanisms by measuring the O2(1Δ g ) decay along a quartz flow tube. These measurements indicated a first-order rate constant of (1.2 ± 0.3) × 10-24 m3 s-1, slightly slower than but consistent with prior measurements of singlet oxygen quenching on ground state oxygen. The discharge-initiated reaction mechanisms and data analysis are discussed in terms of a chemical kinetics model of the system.

Use of a Research as Intervention Approach to Explore Telebehavioral Health Services During the COVID-19 Pandemic in Southeastern Idaho.

INTRODUCTION: Since the inception of the COVID-19 pandemic, telebehavioral health services have been a key contributor to continuation of care in rural and underserved areas of southeastern Idaho. Providers of telebehavioral health services faced numerous challenges as they navigated rapidly shifting regulations, variable access to internet and their own personal understandings of practice. OBJECTIVE: This study aimed to characterize provider experiences, generate policy- and practice-level recommendations, and raise awareness among community stakeholders regarding telebehavioral health in southeastern Idaho. METHODS: Using a newly developed conceptual/analytical framework, a research-as-intervention strategy was employed to conduct and analyze semi-structured interviews, short writings, and photographs from 7 primary care and behavioral health providers in the region. RESULTS: Providers shared examples from practice that addressed technology and training, access-to-care, safety, changing provider roles, payment for services, treatments that are not well suited to telehealth and the nuances of living and working in newly forged spaces of care. CONCLUSIONS: Providers found promise in telebehavioral health's utility as a hybrid model of care, but it must be supported by flexible legislation and policy. For example, it would help to make reimbursement expansions permanent and to simplify inter-jurisdictional practice options. Cross-sharing of information between licensing boards could help providers from various disciplines understand the parameters within which their colleagues must work.

Client preference accommodation for religious/spiritual integration and psychotherapy outcomes in naturalistic practice settings.

The purpose of this practice-research network study was to examine client preferences for religious/spiritual (R/S) integration and test whether preference accommodation in this area is linked to positive treatment outcomes (i.e., less dropout and greater client change). Thirteen independent practice psychotherapists and their 175 clients completed measures of R/S integration preferences and use of R/S techniques and approaches throughout treatment. Psychotherapists also completed an assessment of treatment dropout and change for each participating client. Overall, participating clients expressed moderate preferences for R/S integration, time spent on R/S topics, and an R/S match with their psychotherapists. Preferences in each of these 3 areas were stronger for R/S identifying clients (compared with non-R/S clients) and when clients believed that R/S integration was more essential to produce positive treatment outcomes. Both client R/S identification and client R/S integration preferences predicted psychotherapist's use of R/S techniques in treatment sessions. Importantly, clients' ratings of R/S preference accommodation significantly predicted psychotherapists' ratings of client treatment completion and client change. Specifically, with each unit increase on a 5-point measure of client perceptions of R/S preference accommodation, clients were 1.63 times more likely to be rated as treatment completers and 1.83 times more likely to be identified as having improved while in treatment. Implications for R/S integration in psychotherapy and future research directions are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Pancreas Cancer Incidence and Pancreas Cancer-Associated Mortality Are Low in National Cohort of 7211 Pancreas Cyst Patients.

BACKGROUND AND AIMS: Pancreatic cancer incidence and mortality among patients with pancreas cysts are unclear. The aims of this study are to evaluate incidence of pancreatic cancer and cause-specific mortality among patients with pancreatic cysts using a large national cohort over a long follow-up period. METHODS: We conducted a retrospective cohort study of US Veterans diagnosed with a pancreatic cyst 1999-2013, based on International Classification of Diseases, 9th edition (ICD9) coding within national Department of Veterans Affairs (VA) data. Pancreatic cancer incidence was ascertained using VA cancer registry data, ICD-9 codes, and the National Death Index, a national centralized database of death records, including cause-specific mortality. RESULTS: Among 7211 Veterans with pancreatic cysts contributing 31,501 person-years of follow-up (median follow-up 4.4 years), 79 (1.1%) developed pancreatic cancer. A total of 1982 patients (27.5%) died during the study follow-up period. Sixty-three patients (3.2% of deaths; 0.9% of pancreas cyst cohort) died from pancreatic cancer, but the leading causes of death in the cohort were non-pancreatic cancer (n = 498, 25% of deaths) and cardiovascular disease (n = 398, 20% of deaths). CONCLUSIONS: Pancreas cancer incidence and pancreatic cancer-associated mortality are very low in a large national cohort of VA pancreatic cyst patients with long-term follow-up. Most deaths were from non-pancreas cancers and cardiovascular causes, and only a minority (3.2%) were attributable to pancreas cancer. Given death from pancreas cancer is rare, future research should focus on identifying criteria for selecting individuals at high risk for death from pancreatic cancer for pancreatic cyst surveillance.