Laparoscopic sleeve gastrectomy for obesity treatment in adolescents and young adults: a systematic review and meta-analysis.

BACKGROUND: The incidence of obesity has been increasing in younger population, posing a significant impact on adolescents' life and health care system worldwide. METHODS: We critically analyzed the existing literature on the use of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity. We performed an in-depth evaluation of 37 studies and analyzed the effect of LSG in 2300 patients, aged ≤ 22 years. RESULTS: Mean body mass index (BMI) loss after LSG was 17.81 kg/m2. Gastroesophageal reflux was the most common complication. Most of the patients showed remission of comorbidities including hypertension, diabetes, and obstructive sleep apnea after LSG. CONCLUSIONS: These findings suggest that surgical intervention is highly beneficial for reducing BMI in appropriately selected adolescents and young adults suffering from obesity and comorbidities such as life-threatening obstructive sleep apnea.

Pain management trend of vaso-occulsive crisis (VOC) at a community hospital emergency department (ED) for patients with sickle cell disease.

Pain management at the emergency department (ED) for vaso-occulsive crisis (VOC) for patients with sickle cell disease has not been optimum, with a long delay in giving the initial analgesic. We conducted a retrospective survey over a 7-year period to determine our ED's timing in giving pain medication to patients with VOC as a quality improvement project. We compared different periods, children vs adults, and the influence of gender in the analgesic administration timing. This is a retrospective chart review of three different periods: (1) years 2007-2008, (2) years 2011-2012, and (3) year 2013. We extracted relevant information from ED records. Data were analyzed using Student t test, chi-square analysis, and the Kruskal-Wallis test. There was a progressive improvement in the time interval to the 1st analgesic over these three periods. Children received analgesics more quickly than adults in all periods. Male adult patients received pain medication faster than female adult patients, although initial pain scores were higher in female than in male patients. Progressively fewer pediatric patients utilized ED over these three periods, but no difference for adult patients was observed. The proportion of pediatric patients admitted to the hospital increased with each period. The progressive decrease in both the number of patients and the number of visits to the ED by children suggested that the collective number of VOC in children has decreased, possibly secondary to the dissemination of hydroxyurea use. We failed to observe the same trend in adult patients. The need for IV access, and ordering laboratory tests or imaging studies tends to delay analgesic administration. Delay in administration of the first analgesic was more pronounced for female adult patients than male adult patients in spite of their higher pain score. Health care providers working in ED should make conscious efforts to respect pain in women as well as pain in men. Though not proven from this study, we believe that a significantly wider use of hydroxyurea by adult patients most likely would reduce their utilization of ED for the purpose of relief of pain, and further pediatric hematologists may be better positioned to increase hydroxyurea adherence by young adult patients, since they have had established rapport with them before transitioning to adult care.

Intestinal Intussusception Due to Entrapped Ascaris lumbricoides in a 13-Year-Old Male Patient.

Ascaris lumbricoides is a fairly common intestinal nematode affecting children worldwide, leading to major medical and surgical complications. Although most of the cases are asymptomatic, heavy infestation causes various acute abdominal complications. Ascaris-induced intestinal intussusception is one of the rare presentations. We report a case of a 13-year-old boy with Ascaris lumbricoides infestation presenting with ileocolic intussusception. The patient presented to the emergency unit with colicky abdominal pain, vomiting, and constipation for two days. He was sick-looking and dehydrated. Further examination revealed diffuse abdominal distension with tenderness, guarding, and palpable mass in the right lower quadrant. Ultrasonography showed long-segment ileocolic intussusception with several worms in the intestinal lumen and adjacent mesenteric lymphadenopathy. An exploratory laparotomy was performed, which revealed ileocolic intussusception. The telescopic loop of the ileum was found to be gangrenous and was resected, and a loop ileostomy was performed. The patient was discharged on the seventh day postoperatively without any complications. Physicians in tropical and subtropical countries should consider this condition in the differential diagnosis when they encounter similar presentations in their clinical practice. Sonography is a non-invasive, easy-to-use, and widely available imaging modality that can be employed to diagnose entrapped Ascaris in cases presenting with acute gastrointestinal complications. Early diagnosis and prompt surgical intervention can prevent bowel ischemia/gangrene and significantly reduce morbidity and mortality associated with such cases.

Be inFLUential: Evaluation of a multifaceted intervention to increase influenza vaccination rates among pediatric inpatients.

BACKGROUND AND OBJECTIVE: Annual influenza vaccination is recommended for individual ≥6 months of age, yet vaccination rates remain below national targets in the US. Hospitalization provides another medical setting for influenza vaccination, but the effectiveness of inpatient interventions has not been well studied. Our objective was to evaluate the effectiveness of a multifaceted intervention to increase influenza vaccination rates among pediatric inpatients. METHODS: We conducted a pre-post interventional study on medical inpatient units at Children's Hospital Colorado from September 2016-April 2017 (pre-intervention) and September 2017-April 2018 (intervention). The intervention targeted nurses (web-based education modules, huddles and reminders) and providers (vaccination lists in the electronic health record, reminders, vaccination reports and financial incentives for residents). Outcomes were influenza vaccine ordering rates, and influenza vaccination rates at discharge. We analyzed data using descriptive statistics, bivariate and logistic regression. RESULTS: Among 4,050 inpatients in 2016-2017 and 4,523 inpatients in 2017 aged ≥ 6 months, vaccination status was documented for 2,902/4,050 (71.7%) and 3,431/4,523 (75.9%) children aged > 6 months of age hospitalized during the study period. The vaccine ordering rate among eligible children was 28.8% in the pre-intervention season versus 50.2% in the intervention season (p < 0.001). The intervention was associated with 1.23 (95% CI 1.11-1.35) times higher odds of appropriate vaccination screening on admission, 2.27 (95% CI 2.01-2.56) times higher odds of a vaccination being ordered, and 1.39 (95% CI 1.27-1.53) times higher odds of a child being vaccinated against influenza at discharge (all p < 0.001). Residents (56%) and medical providers (39%) were more likely to order vaccines compared with nurses (5%), p = 0.014). CONCLUSION: A multifaceted intervention targeting nurses, residents and providers comprising education, visual reminders, vaccination reports and financial incentives is an effective way of improving influenza vaccine ordering, resulting in higher inpatient influenza vaccination rates.

Skin Graft Techniques.

Management of extensive lower extremity soft tissue and skin loss can be a very difficult to achieve by any surgeon. There can be several associated comorbidities that need to be considered and addressed with these patients. The approach is multifactorial and requires commitment from both the surgeon as well as the patient. There are several protocols that have been formulated throughout the literature addressing soft tissue and skin coverage of the limbs. This article provides a review of the literature and describes the evaluation, harvesting, transplantation, and management of skin grafting techniques to the lower extremities.

Immunohistochemistry of IL-1ß, IL-6 and TNF-α in spleens of mice treated with gold nanoparticles.

Gold nanoparticles (AuNPs) possess considerable biocompatibility and therefore gaining more attention for their biomedical applications. Previous studies have shown the transient increase in pro-inflammatory cytokines expression in different organs of rats and mice exposed to AuNPs. Structural changes in the spleen of mice treated with AuNPs have also been reported. This investigation was aimed to study the immunostaining of IL-1ß, IL-6 and TNF-α in mice treated with different sizes of AuNPs. The animals were divided into 7 groups of 4 animals in each group. One group received saline and served as control. Two sets of three groups were treated with 5 nm, 20 nm and 50 nm diameter AuNPs. One set was sacrificed on day 1 and the other on day 7 following the AuNPs injections. Spleens were dissected out and promptly fixed in formalin for 3 days and then processed for IL-1ß, IL-6 and TNF-α immunostaining using target-specific antibodies. The immunoreactivities of IL-1ß and IL-6 were increased with the increase of AuNP size. The immunostaining of IL-1ß in spleen of 20 nm AuNP treated mice was subsequently decreased on day 7 whereas it persisted in 50 nm AuNP group. The increase in the immunoreactivity of IL-6 on day 1 was decreased on day 7 in the spleens of mice treated with 20 nm or 50 nm AuNPs. The immunostaining of TNF-α was found to be negative in all the treatment groups. In conclusion, the size of AuNPs plays an important role in the expression of proinflammatory cytokines in mouse spleen; small size (5 nm) AuNPs caused minimal effect, whereas larger (50 nm) AuNPs produced intense immunostaining.

Biomarker potential of C-peptide for screening of insulin resistance in diabetic and non-diabetic individuals.

Insulin resistance is a hallmark feature of type-2 diabetes mellitus (T2DM). We determined the homeostatic model assessment insulin resistance (HOMA-IR) and evaluated its association with C-peptide, insulin, fasting blood glucose (FBG) and glycated hemoglobin (HbA1c) in T2DM patients and non-diabetic subjects. This study comprised a total of 47 T2DM patients and 38 non-diabetic controls. Venous blood samples from all the subjects were collected and sera were analyzed for FBG, HbA1c, insulin and C-peptide using an autoanalyzer. HOMA-IR was calculated using the following equation: HOMA-IR = fasting insulin (µU/ml) × fasting glucose (mmol/L)/22.5. There was a significant increase in the levels of FBG and HbA1c in diabetic patients. Although the levels of C-peptide and insulin did not differ significantly between the two groups, a significant increase in HOMA-IR was observed in T2DM patients. Both insulin and C-peptide were significantly correlated with HOMA-IR. In conclusion, C-peptide may serve as a simple and convenient predictor of HOMA-IR.

Potential of lipoproteins as biomarkers in acute myocardial infarction.

Acute myocardial infarction (AMI), commonly known as heart attack, is a medical emergency that is potentially fatal if not promptly and properly managed. The early diagnosis of AMI is critically important for the timely institution of pharmacotherapy to prevent myocardial damage and preserve cardiac function. Ischemic insults during AMI cause myocardial tissue damage, releasing the cardiac muscle protein troponin T into the blood stream. Therefore, serum troponin T levels are used as a sensitive and specific indicator of myocardial injury for diagnosing AMI. However, there remains a requirement for developing technologies for more accurate biomarkers or signatures for AMI diagnosis or prognosis. Previous studies have implicated impaired lipid metabolism as a causative factor in AMI development. Lipoproteins are important constituents of lipid metabolism; their levels in the blood stream are a convenient biomarker tool for monitoring lipid metabolism. This review summarizes recent findings (data of studies from 2001 to 2016) regarding the biomarker potentials of various lipoproteins, including low-density lipoprotein, oxidized low-density lipoprotein, high-density lipoprotein, lipoprotein-a, and remnant lipoprotein, for the risk stratification of AMI.

Postinduction Supportive Care of Pediatric Acute Myelocytic Leukemia: Should Patients be Kept in the Hospital?

Children with AML become profoundly neutropenic while they undergo remission induction chemotherapy. It is unknown whether these children should be kept in the hospital while they are severely neutropenic to prevent life-threatening complications associated with neutropenia and reduce fatality. We at our institution routinely discharge patients after completing remission induction chemotherapy in the presence of profound neutropenia, unless it is clinically contraindicated. We reviewed all AML patients who were consecutively treated at our hospital from 1989 to 2011. Thirteen patients were electively discharged after completion of induction I chemotherapy. Of the 13, 4 died due to relapse or complications of stem cell transplants (not due to neutropenia related complications). Another eight are long term survivors. In this very small series, discharge from the hospital even though patients were severely neutropenic did not adversely affect the survival.