Association between preoperative gonioscopic status and postoperative glaucoma after phacoemulsification in dogs: A retrospective cohort study of 505 eyes.

OBJECTIVE: To assess whether preoperative gonioscopy status is associated with the development of postoperative glaucoma after phacoemulsification. PROCEDURE: Eligible dogs and eyes were selected from medical records (2007-2017), and each eye was classified as having normal or abnormal gonioscopy status. Records were examined for postoperative glaucoma, and data were collected for baseline variables including patient signalment, surgical factors, and pre, intra, and postoperative medications. RESULTS: Of 305 dogs (505 eyes) selected for review in this study, 111 dogs (163 eyes) had abnormal gonioscopy findings, and 194 dogs (342 eyes) had normal gonioscopy findings. Postoperative glaucoma occurred in 24% (39/163) of eyes with abnormal gonioscopy and in 14% (49/342) eyes with normal gonioscopy. Eyes with abnormal gonioscopy status were at higher risk of postoperative glaucoma compared to normal eyes (P = .025). There was no important confounding due to the numerous baseline variables summarised above. Regardless of gonioscopy status, the risk of glaucoma was highest during the first 2 months after surgery. CONCLUSIONS: Eyes with abnormal gonioscopy findings are at increased risk of postoperative glaucoma compared with eyes with normal gonioscopy findings. Gonioscopy is recommended as a part of presurgical assessment in all dogs prior to phacoemulsification. Further study is needed to assess whether the incidence of postoperative glaucoma can be reduced by increased monitoring or altered treatment protocols in cases that are known to have abnormal gonioscopy findings prior to cataract surgery.

Development and Evaluation of a Novel Instrument to Measure Severity of Intraoperative Events Using Video Data.

OBJECTIVE: To develop and evaluate a novel instrument to measure SEVERE processes using video data. BACKGROUND: Surgical video data can serve an important role in understanding the relationship between intraoperative events and postoperative outcomes. However, a standard tool to measure severity of intraoperative events is not yet available. METHODS: Items to be included in the instrument were identified through literature and video reviews. A committee of experts guided item reduction, including pilot tests and revisions, and determined weighted scores. Content validity was evaluated using a validated sensibility questionnaire. Inter-rater reliability was assessed by calculating intraclass correlation coefficient. Construct validity was evaluated on a sample of 120 patients who underwent laparoscopic Roux-en-Y gastric bypass procedure, in which comprehensive video data was obtained. RESULTS: SEVERE index measures severity of 5 event types using ordinal scales. Each intraoperative event is given a weighted score out of 10. Inter-rater reliability was excellent [0.87 (95%-confidence interval, 0.77-0.92)]. In a sample of consecutive 120 patients undergoing gastric bypass procedures, a median of 12 events [interquartile range (IQR) 9-18] occurred per patient and bleeding was the most frequent type (median 10, IQR 7-14). The median SEVERE score per case was 11.3 (IQR 8.3-16.9). In risk-adjusted multivariable regression models, history of previous abdominal surgery (P = 0.02) and body mass index (P = 0.005) were associated with SEVERE scores, demonstrating construct validity evidence. CONCLUSION: The SEVERE index may prove to be a useful instrument in identifying patients with high risk of developing postoperative complications.

Results of COVID-minimal Surgical Pathway During Surge-phase of COVID-19 Pandemic.

OBJECTIVE: The outcomes of patients treated on the COVID-minimal pathway were evaluated during a period of surging COVID-19 hospital admissions, to determine the safety of continuing to perform urgent operations during the pandemic. SUMMARY OF BACKGROUND DATA: Crucial treatments were delayed for many patients during the COVID-19 pandemic, over concerns for hospital-acquired COVID-19 infections. To protect cancer patients whose survival depended on timely surgery, a "COVID-minimal pathway" was created. METHODS: Patients who underwent a surgical procedure on the pathway between April and May 2020 were evaluated. The "COVID-minimal surgical pathway" consisted of: (A) evolving best-practices in COVID-19 transmission-reduction, (B) screening patients and staff, (C) preoperative COVID-19 patient testing, (D) isolating pathway patients from COVID-19 patients. Patient status through 2 weeks from discharge was determined as a reflection of hospital-acquired COVID-19 infections. RESULTS: After implementation, pathway screening processes excluded 7 COVID-19-positive people from interacting with pathway (4 staff and 3 patients). Overall, 122 patients underwent 125 procedures on pathway, yielding 83 admissions (42 outpatient procedures). The median age was 64 (56-79) and 57% of patients were female. The most common surgical indications were cancer affecting the uterus, genitourinary tract, colon, lung or head and neck. The median length of admission was 3 days (1-6). Repeat COVID-19 testing performed on 27 patients (all negative), including 9 patients evaluated in an emergency room and 8 readmitted patients. In the postoperative period, no patient developed a COVID-19 infection. CONCLUSIONS: A COVID-minimal pathway comprised of physical space modifications and operational changes may allow urgent cancer treatment to safely continue during the COVID-19 pandemic, even during the surge-phase.

Using Machine Learning Applied to Real-World Healthcare Data for Predictive Analytics: An Applied Example in Bariatric Surgery.

OBJECTIVES: Laparoscopic metabolic surgery (MxS) can lead to remission of type 2 diabetes (T2D); however, treatment response to MxS can be heterogeneous. Here, we demonstrate an open-source predictive analytics platform that applies machine-learning techniques to a common data model; we develop and validate a predictive model of antihyperglycemic medication cessation (validated proxy for A1c control) in patients with treated T2D who underwent MxS. METHODS: We selected patients meeting the following criteria in 2 large US healthcare claims databases (Truven Health MarketScan Commercial [CCAE]; Optum Clinformatics [Optum]): underwent MxS between January 1, 2007, to October 1, 2013 (first = index); aged ≥18 years; continuous enrollment 180 days pre-index (baseline) to 730 days postindex; baseline T2D diagnosis and treatment. The outcome was no antihyperglycemic medication treatment from 365 to 730 days after MxS. A regularized logistic regression model was trained using the following candidate predictor categories measured at baseline: demographics, conditions, medications, measurements, and procedures. A 75% to 25% split of the CCAE group was used for model training and testing; the Optum group was used for external validation. RESULTS: 13 050 (CCAE) and 3477 (Optum) patients met the study inclusion criteria. Antihyperglycemic medication cessation rates were 72.9% (CCAE) and 70.8% (Optum). The model possessed good internal discriminative accuracy (area under the curve [AUC] = 0.778 [95% CI = 0.761-0.795] in CCAE test set N = 3527) and transportability (external AUC = 0.759 [95% CI = 0.741-0.777] in Optum N = 3477). CONCLUSION: The application of machine learning techniques to real-world healthcare data can yield useful predictive models to assist patient selection. In future practice, establishment of prerequisite technological infrastructure will be needed to implement such models for real-world decision support.

Bariatric Surgery: Safety, Efficacy, Disease State, Collaboration, Future.

Obesity provides an opportunity for bariatric and orthopedic surgeons to collaborate through emphasis on safety, effectiveness and patient experience. A value equation can be offered for combining weight loss for the patient with obesity and joint disease.

Prevalence and Risk Factors for Bariatric Surgery Readmissions: Findings From 130,007 Admissions in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

OBJECTIVE: To evaluate readmissions following laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB). BACKGROUND: Few studies have evaluated national readmission rates for primary bariatric surgery with national, bariatric-specific data. METHODS: Patients undergoing primary LAGB, LSG, or LRYGB from January 1, 2014 to December 31, 2014, at 698 centers were identified based upon Current Procedural Terminology codes. The primary outcome was 30-day readmission from date of initial operation. RESULTS: A total of 130,007 patients who underwent primary bariatric surgery were identified: 7378 LAGB (5.7%), 80,646 LSG (62.0%), and 41,983 LRYGB (32.3%). A total of 5663 (4.4%) patients were readmitted within 30 days for all causes. Patients undergoing LAGB had the lowest related readmission rate of 1.4%, followed by LSG (2.8%), and LRYGB (4.9%). Of patients who had a complication, 17.9% (n = 785) were readmitted, whereas those without readmission had a complication 1.9% of the time (P < 0.001). The most common cause of a related readmission was nausea, vomiting, fluid, electrolyte, and nutritional depletion (35.4%), followed by abdominal pain (13.5%), anastomotic leak (6.4%), and bleeding (5.8%), accounting for more than 61% of readmissions. When compared with LAGB, LSG, and LRYGB had significantly higher rates of readmission (LSG: odds ratio 1.89; 95% confidence interval 1.52-2.33; LRYGB: odds ratio 3.06; 95% confidence interval 2.46-3.81). CONCLUSIONS: National bariatric readmissions after primary procedures were closely associated with complications, varied based on the type of procedure, and were most commonly due to nausea, vomiting, electrolyte, and nutritional depletion.

Building a DNA barcode library of Alaska's non-marine arthropods.

Climate change may result in ecological futures with novel species assemblages, trophic mismatch, and mass extinction. Alaska has a limited taxonomic workforce to address these changes. We are building a DNA barcode library to facilitate a metabarcoding approach to monitoring non-marine arthropods. Working with the Canadian Centre for DNA Barcoding, we obtained DNA barcodes from recently collected and authoritatively identified specimens in the University of Alaska Museum (UAM) Insect Collection and the Kenai National Wildlife Refuge collection. We submitted tissues from 4776 specimens, of which 81% yielded DNA barcodes representing 1662 species and 1788 Barcode Index Numbers (BINs), of primarily terrestrial, large-bodied arthropods. This represents 84% of the species available for DNA barcoding in the UAM Insect Collection. There are now 4020 Alaskan arthropod species represented by DNA barcodes, after including all records in Barcode of Life Data Systems (BOLD) of species that occur in Alaska - i.e., 48.5% of the 8277 Alaskan, non-marine-arthropod, named species have associated DNA barcodes. An assessment of the identification power of the library in its current state yielded fewer species-level identifications than expected, but the results were not discouraging. We believe we are the first to deliberately begin development of a DNA barcode library of the entire arthropod fauna for a North American state or province. Although far from complete, this library will become increasingly valuable as more species are added and costs to obtain DNA sequences fall.

Milk protein concentration, estimated breeding value for fertility, and reproductive performance in lactating dairy cows.

Milk protein concentration in dairy cows has been positively associated with a range of measures of reproductive performance, and genetic factors affecting both milk protein concentration and reproductive performance may contribute to the observed phenotypic associations. It was of interest to assess whether these beneficial phenotypic associations are accounted for or interact with the effects of estimated breeding values for fertility. The effects of a multitrait estimated breeding value for fertility [the Australian breeding value for daughter fertility (ABV fertility)] on reproductive performance were also of interest. Interactions of milk protein concentration and ABV fertility with the interval from calving date to the start of the herd's seasonally concentrated breeding period were also assessed. A retrospective single cohort study was conducted using data collected from 74 Australian seasonally and split calving dairy herds. Associations between milk protein concentration, ABV fertility, and reproductive performance in Holstein cows were assessed using random effects logistic regression. Between 52,438 and 61,939 lactations were used for analyses of 4 reproductive performance measures. Milk protein concentration was strongly and positively associated with reproductive performance in dairy cows, and this effect was not accounted for by the effects of ABV fertility. Increases in ABV fertility had important additional beneficial effects on the probability of pregnancy by wk 6 and 21 of the herd's breeding period. For cows calved before the start of the breeding period, the effects of increases in both milk protein concentration and ABV fertility were beneficial regardless of their interval from calving to the start of the breeding period. These findings demonstrate the potential for increasing reproductive performance through identifying the causes of the association between milk protein concentration and reproductive performance and then devising management strategies to capitalize on them. Research should be conducted to understand the component of the relationship not captured by ABV fertility.

Accuracy and safety of pin placement during lateral versus dorsal stabilization of lumbar spinal fracture-luxation in dogs.

OBJECTIVE: To determine the accuracy and safety of pin placement for lateral vertebral stabilization to the reference dorsal stabilization. STUDY DESIGN: A randomized noninferiority trial. SAMPLE POPULATION: Twenty Greyhound cadaveric lumbar spines (L1-L6). METHODS: One hundred and fifty-nine lumbar vertebral pins placed in 80 vertebrae were assessed; these pins were distributed approximately equally between the dorsal and lateral approaches, and between 2 surgeons. Pin angle accuracy, bone purchase distance, and distances from pin to the spinal canal and the aorta were measured for each pin. RESULTS: The lateral approach was superior for pin angle accuracy and bone purchase. The mean angle of deviation was 15.3° with the dorsal approach and 7.0° with the lateral approach. The mean bone purchase was 16.7 mm with the dorsal approach and 22.2 mm with the lateral approach. Pins were placed at a mean of 2.3 mm from the spinal canal with the dorsal approach and 1.7 mm with the lateral approach. Pins were placed at a mean of 3.8 mm from the aorta with the dorsal approach and 8.0 mm with the lateral approach. The percentage of pins breaching the spinal canal was 14% with the dorsal approach and 19% with the lateral approach. Fourteen percent of pins placed via the dorsal approach breached the aorta, whereas no pins placed via the lateral approach breached the aorta. CONCLUSION: Relative to the dorsal approach, the lateral approach improves angle accuracy, bone purchase, and distance between pins, and the aorta and is noninferior with regards to the distance between pins and the spinal canal.

The Impact of Different Surgical Techniques on Outcomes in Laparoscopic Sleeve Gastrectomies: The First Report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

OBJECTIVE: Questions remain regarding best surgical techniques to use for a laparoscopic sleeve gastrectomy (LSG) including the use of staple line reinforcement (SLR), bougie size (BS), and distance from the pylorus (DP) where the staple line is initiated. Our objectives were to assess the impact of these techniques on 30-day outcomes and to evaluate the impact of these techniques on weight loss and comorbidities at 1 year. METHODS: Using the MBSAQIP data registry, univariate analyses and hierarchical logistical regression models were developed to analyze outcomes for techniques of LSG at patient and surgeon-level. RESULTS: A total of 189,477 LSG operations were performed by 1634 surgeons at 720 centers from 2012 to 2014. Eighty percent of surgeons used SLR, 20% did not. SLR cases were associated with higher leak rates (0.96% vs 0.65%, odds ratio [OR] 1.20 95% confidence interval [CI] 1.00-1.43) and lower bleed rates (0.75% vs 1.00%, OR 0.74 95% CI 0.63-0.86) compared to no SLR at patient level. At the surgeon level, leak rates remained significant, but bleeding events became nonsignificant. BS ≥38 was associated with significantly lower leak rates compared to BS <38 at patient and surgeon level (patient level: 0.80% vs 0.96%, OR 0.72, 95% CI 0.62-0.94; surgeon level: 0.84% vs 0.95%, OR 0.90, 95% CI 0.80-0.99). BS ≥40 was associated with increased weight loss. DP had no impact on leaks or bleeds but showed an increase in weight loss with increasing DP. CONCLUSION: LSG is a safe procedure with a low morbidity rate. SLR is associated with increased leak rates. A surgeon should consider risks, benefits, and costs of these surgical techniques when performing a LSG and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.

Invited review: Recommendations for reporting intervention studies on reproductive performance in dairy cattle: Improving design, analysis, and interpretation of research on reproduction.

Abundant evidence from the medical, veterinary, and animal science literature demonstrates that there is substantial room for improvement of the clarity, completeness, and accuracy of reporting of intervention studies. More rigorous reporting guidelines are needed to improve the quality of data available for use in comparisons of outcomes (or meta-analyses) of multiple studies. Because of the diversity of factors that affect reproduction and the complexity of interactions between these, a systematic approach is required to design, conduct, and analyze basic and applied studies of dairy cattle reproduction. Greater consistency, clarity, completeness, and correctness of design and reporting will improve the value of each report and allow for greater depth of evaluation in meta-analyses. Each of these benefits will improve understanding and application of current knowledge and better identify questions that require additional modeling or primary research. The proposed guidelines and checklist will aid in the design, conduct, analysis, and reporting of intervention studies. We propose an adaptation of the REFLECT (Reporting Guidelines for Randomized Controlled Trials for Livestock and Food Safety) statement to provide guidelines and a checklist specific to reporting intervention studies in dairy cattle reproduction. Furthermore, we provide recommendations that will assist investigators to produce studies with greater internal and external validity that can more often be included in systematic reviews and global meta-analyses. Such studies will also assist the development of models to describe the physiology of reproduction.

Mesenteric defect closure in laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial.

INTRODUCTION: Internal herniation is a potential complication following laparoscopic Roux-en-Y gastric bypass (LRYGB). Previous studies have shown that closure of mesenteric defects after LRYGB may reduce the incidence of internal herniation. However, controversy remains as to whether mesenteric defect closure is necessary to decrease the incidence of internal hernias after LRYGB. This study aims to determine if jejeunal mesenteric defect closure reduces incidence of internal hernias and other complications in patients undergoing LRYGB. METHODS: 105 patients undergoing laparoscopic antecolic RYGB were randomized into two groups: closed mesenteric defect (n = 50) or open mesenteric defect (n = 55). Complication rates were obtained from the medical record. Patients were followed up to 3 years post-operatively. Patients also completed the gastrointestinal quality of life index (GI QoL) pre-operatively and 12 months post-operatively. Outcome measures included: incidence of internal hernias, complications, readmissions, reoperations, GI QoL scores, and percent excess weight loss (%EWL). RESULTS: Pre-operatively, there were no significant differences between the two groups. The closed group had a longer operative time (closed-153 min, open-138 min, p = 0.073). There was one internal hernia in the open group. There was no significant difference at 12 months for decrease in BMI (closed-15.9, open-16.3 kg/m(2), p = 0.288) or %EWL (closed-75.3%, open-69.0%, p = 0.134). There was no significant difference between the groups in incidence of internal hernias and general complications post-operatively. Both groups showed significantly improved GI QoL index scores from baseline to 12 months post-surgery, but there were no significant differences at 12 months between groups in total GI QoL (closed-108, open-112, p = 0.440). CONCLUSIONS: In this study, closure or non-closure of the jejeunal mesenteric defect following LRYGB appears to result in equivalent internal hernia and complication rates. High index of suspicion should be maintained whenever internal hernia is expected after LRYGB.

Bending strength and stiffness of canine cadaver spines after fixation of a lumbar spinal fracture-luxation using a novel unilateral stabilization technique compared to traditional dorsal stabilization.

OBJECTIVE: To 1) assess the bending strength and stiffness of canine cadaver spines after fixation of a lumbar spinal fracture-luxation using a novel unilateral stabilization technique with pins and polymethyl methacrylate (PMMA) and 2) compare the results to a reference standard dorsal pin and PMMA technique. STUDY DESIGN: A randomized non-inferiority trial. SAMPLE POPULATION: Cadaveric lumbar spines (L1-L6) from 20 Greyhounds. METHODS: Specimens were paired to match bodyweight and vertebral size. A standardized fracture/luxation was performed between L3 and L4. One spine within each pair was randomly assigned the unilateral fixation technique and the other received the reference standard dorsal fixation technique. Four-point bending of each specimen in flexion was performed by applying load to pins placed transversely into vertebrae L1, L2, L5, and L6. During testing, angular bending strength and stiffness were measured as a function of flexion angle. Margins for non-inferiority were defined a priori. Strength and stiffness of the specimens for each technique were compared statistically. RESULTS: Lower limits of 95% confidence intervals were above the defined margins for non-inferiority. Thus, based on these margins, for strength and stiffness, unilateral fixation was not inferior to dorsal fixation. CONCLUSIONS: This novel unilateral approach to lumbar spinal fixation yielded comparable strength and stiffness when tested for bending in flexion to that of reference standard dorsal approach. This approach is therefore a suitable alternative to the dorsal approach in appropriate lumbar spinal fracture configurations.

Is ambulatory laparoscopic Roux-en-Y gastric bypass associated with higher adverse events?

OBJECTIVE: To determine the impact of length of stay upon 30-day outcomes. BACKGROUND: It has been recommended the goal length of stay (LOS) after laparoscopic Roux-en-Y gastric bypass (LRYGB) should be 1 day to improve resource utilization. This study's aim was to assess LRYGB outcomes by LOS. METHODS: Data were obtained from the BOLD (Bariatric Outcomes Longitudinal Database) for 51,788 laparoscopic gastric bypass (LRYGB) procedures performed between 2007 and 2010. Logistic regression models were used to evaluate age, sex, race, body mass index, insurance status, comorbidities, and LOS as predictors for 30-day mortality, serious complications, and readmissions. RESULTS: Overall patient demographics were as follows: median age, 45 years; median body mass index, 46.3 kg/m; % female, 78.6; % white, 77.8; % private insurance, 86.2; and % comorbidities more than 5 (39.1%). Overall, 30-day outcomes included mortality, 0.1%; serious complications, 0.5%; and readmissions, 3.8%. median LOS was 2 days, and the distribution of LOS was as follows [n (%)]: 0 (1.0), 1 (18.4), 2 (59.0), 3 (17.5), and 4 (4.1). Using the median LOS 2 days as reference, the logistic regression analysis revealed that ambulatory LOS of was significantly associated with increased risk of 30-day mortality (odds ratio: 13.02; P < 0.0001) as was LOS 1 day (odds ratio: 2.02; P < 0.0552). For LOS of 0 day, there was a trend toward an increase in the rate of 30-day serious complications (odds ratio: 1.9; P < 0.16). There was no significant trend between LOS status and 30-day readmission rates. CONCLUSIONS: In this large, prospective, clinical database, LOS of 1 day or less for LRYGB patients was significantly associated with an increased risk of 30-day mortality and a trend toward increased risk of 30-day serious complications.

Increasing access to specialty surgical care: application of a new resource allocation model to bariatric surgery.

OBJECTIVES: To calculate the public health impact and economic benefit of using ancillary health care professionals for routine postoperative care. BACKGROUND: The need for specialty surgical care far exceeds its supply, particularly in weight loss surgery. Bariatric surgery is cost-effective and the only effective long-term weight loss strategy for morbidly obese patients. Without clinically appropriate task shifting, surgeons, hospitals, and untreated patients incur a high opportunity cost. METHODS: Visit schedules, time per visit, and revenues were obtained from bariatric centers of excellence. Case-specific surgeon fees were derived from published Current Procedural Terminology data. The novel Microsoft Excel model was allowed to run until a steady state was evident (status quo). This model was compared with one in which the surgeon participates in follow-up visits beyond 3 months only if there is a complication (task shifting). Changes in operative capacity and national quality-adjusted life years (QALYs) were calculated. RESULTS: In the status quo model, per capita surgical volume capacity equilibrates at 7 surgical procedures per week, with 27% of the surgeon's time dedicated to routine long-term follow-up visits. Task shifting increases operative capacity by 38%, resulting in 143,000 to 882,000 QALYs gained annually. Per surgeon, task shifting achieves an annual increase of 95 to 588 QALYs, $5 million in facility revenue, 48 cases of cure of obstructive sleep apnea, 44 cases of remission of type 2 diabetes mellitus, and 35 cases of cure of hypertension. CONCLUSIONS: Optimal resource allocation through task shifting is economically appealing and can achieve dramatic public health benefit by increasing access to specialty surgery.

Does hospital accreditation impact bariatric surgery safety?

OBJECTIVE: To evaluate the impact of hospital accreditation upon bariatric surgery outcomes. BACKGROUND: Since 2004, the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery have accredited bariatric hospitals. Few studies have evaluated the impact of hospital accreditation on all bariatric surgery outcomes. METHODS: Bariatric surgery hospitalizations were identified using International Classification of Diseases, Ninth Revision (ICD9) codes in the 2010 Nationwide Inpatient Sample (NIS). Hospital names and American Hospital Association (AHA) codes were used to identify accredited bariatric centers. Relevant ICD9 codes were used for identifying demographics, length of stay (LOS), total charges, mortality, complications, and failure to rescue (FTR) events. RESULTS: There were 117,478 weighted bariatric patient discharges corresponding to 235 unique hospitals in the 2010 NIS data set. A total of 72,615 (61.8%) weighted discharges, corresponding to 145 (61.7%) named or AHA-identifiable hospitals were included. Among the 145 hospitals, 66 (45.5%) were unaccredited and 79 (54.5%) accredited. Compared with accredited centers, unaccredited centers had a higher mean LOS (2.25 vs 1.99 days, P < 0.0001), as well as total charges ($51,189 vs $42,212, P < 0.0001). Incidence of any complication was higher at unaccredited centers than at accredited centers (12.3% vs 11.3%, P = 0.001), as was mortality (0.13% vs 0.07%, P = 0.019) and FTR (0.97% vs 0.55%, P = 0.046). Multivariable logistic regression analysis identified unaccredited status as a positive predictor of incidence of complication [odds ratio (OR) = 1.08, P < 0.0001], as well as mortality (OR = 2.13, P = 0.013). CONCLUSIONS AND RELEVANCE: Hospital accreditation status is associated with safer outcomes, shorter LOS, and lower total charges after bariatric surgery.

Premilking teat disinfection: is it worthwhile in pasture-grazed dairy herds?

A controlled trial was conducted in 5 pasture-grazed commercial dairy herds in Australia in 2012 to determine whether premilking teat disinfection and drying of teats reduces clinical mastitis incidence during early lactation by at least 50%. A 50% reduction was estimated to be the minimum required to justify additional costs of labor, disinfectants, and other resources if premilking teat disinfection was implemented in a 500-cow herd averaging 8 clinical cases per 100 cow-months. A secondary aim was to determine whether this premilking teat disinfection routine reduces incidence of new udder infections. Treatment was applied in each herd for approximately 60 d (range of 59.5 to 61 d), commencing in each herd soon after the start of the herd's main or only calving period. Within each herd, cows were allocated to either the treatment (premilking disinfection) or the control (no premilking disinfection) group based on their herd identity number. During the trial period, any cow having a new case of clinical mastitis or an individual cow cell count greater than 250,000 cells/mL of milk (when preceded by individual cow cell counts of 250,000 cells/mL of milk or below) was deemed to have had a new infection. Overall, neither clinical mastitis incidence nor new infection rate differed significantly between treatment and control groups. Over the whole study period, 98 of the 1,029 cows in the premilking disinfection group and 97 of the 1,025 cows in the control group had clinical mastitis. Total cow-days at risk of clinical mastitis were similar in each group. However, clinical incidence rates were markedly lower in treatment cows in one herd (herd 3; incidence rate ratio=0.34) and there was some evidence that new infection incidence rates were lower in treated cows in this herd (incidence rate ratio=0.42). Rainfall during the study period was below long-term district average in all 5 study herds. Cows' teats were less dirty than in previous, wetter years for the 4 herds where no significant clinical mastitis response was detected but some teat soiling was observed in herd 3 during the study period. Routine application of premilking teat disinfection in pasture-grazed herds is unlikely to produce a worthwhile (economic) reduction in the number of clinical mastitis cases when teats are relatively clean and dry and the clinical mastitis incidence is low. However, premilking disinfection might be worthwhile during periods when teats are heavily soiled and the incidence of clinical mastitis due to environmental pathogens is high.

Effect of reversible intermittent intra-abdominal vagal nerve blockade on morbid obesity: the ReCharge randomized clinical trial.

IMPORTANCE: Although conventional bariatric surgery results in weight loss, it does so with potential short-term and long-term morbidity. OBJECTIVE: To evaluate the effectiveness and safety of intermittent, reversible vagal nerve blockade therapy for obesity treatment. DESIGN, SETTING, AND PARTICIPANTS: A randomized, double-blind, sham-controlled clinical trial involving 239 participants who had a body mass index of 40 to 45 or 35 to 40 and 1 or more obesity-related condition was conducted at 10 sites in the United States and Australia between May and December 2011. The 12-month blinded portion of the 5-year study was completed in January 2013. INTERVENTIONS: One hundred sixty-two patients received an active vagal nerve block device and 77 received a sham device. All participants received weight management education. MAIN OUTCOMES AND MEASURES: The coprimary efficacy objectives were to determine whether the vagal nerve block was superior in mean percentage excess weight loss to sham by a 10-point margin with at least 55% of patients in the vagal block group achieving a 20% loss and 45% achieving a 25% loss. The primary safety objective was to determine whether the rate of serious adverse events related to device, procedure, or therapy in the vagal block group was less than 15%. RESULTS: In the intent-to-treat analysis, the vagal nerve block group had a mean 24.4% excess weight loss (9.2% of their initial body weight loss) vs 15.9% excess weight loss (6.0% initial body weight loss) in the sham group. The mean difference in the percentage of the excess weight loss between groups was 8.5 percentage points (95% CI, 3.1-13.9), which did not meet the 10-point target (P = .71), although weight loss was statistically greater in the vagal nerve block group (P = .002 for treatment difference in a post hoc analysis). At 12 months, 52% of patients in the vagal nerve block group achieved 20% or more excess weight loss and 38% achieved 25% or more excess weight loss vs 32% in the sham group who achieved 20% or more loss and 23% who achieved 25% or more loss. The device, procedure, or therapy-related serious adverse event rate in the vagal nerve block group was 3.7% (95% CI, 1.4%-7.9%), significantly lower than the 15% goal. The adverse events more frequent in the vagal nerve block group were heartburn or dyspepsia and abdominal pain attributed to therapy; all were reported as mild or moderate in severity. CONCLUSION AND RELEVANCE: Among patients with morbid obesity, the use of vagal nerve block therapy compared with a sham control device did not meet either of the prespecified coprimary efficacy objectives, although weight loss in the vagal block group was statistically greater than in the sham device group. The treatment was well tolerated, having met the primary safety objective. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01327976.

Lessons learned from the metabolic and bariatric surgery accreditation and quality improvement program site surveys: common deficiencies and corrective actions.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is a joint program between the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS). On-site surveys of the applicant programs to determine adherence to the MBSAQIP standards are a hallmark of the accreditation process. OBJECTIVES: A retrospective review of 619 site surveys completed over 2 years was performed to include analysis of reviewer decisions, tabulation and cross-reference of identified deficiencies to the MBSAQIP standards and determine final disposition of corrective actions and overall accreditation rates. SETTING: Accredited Hospitals (Community and Academic) within MBSAQIP. METHODS: This is a retrospective review of site surveys by expert panel. RESULTS: ≥1 MBSAQIP Standards deficiencies were present at 149 of the 619 program site surveys (24.07%). The 3 leading Standards in Deficiency were in order: Commitment to Quality Care, Continuous Quality Improvement Process, and Data Collection. Within a year following initial site survey of the149 programs with Standards deficiencies, 59 programs demonstrated compliance, 83 programs were placed on probation (with a specific time-frame to demonstrate compliance) and 7 programs were denied accreditation. Ultimately, 98.9% of programs were able to gain or maintain MBSAQIP accreditation. CONCLUSIONS: The MBSAQIP accreditation through on-site surveys can identify and improve program adherence to MBSAQIP standards.