An evaluation of bariatric surgery in all military treatment facilities.

BACKGROUND: Multiple bariatric databases have been formed, but there have been no comprehensive assessments of military treatment facilities (MTFs). MTFs have unique patients and coverage policies by Tricare insurance. METHODS: MHS Mart (M2) was used to review the outpatient medical record, AHLTA, from October 2013 to December 2018 for type of bariatric procedure, demographics, military-specific data, comorbidities, and complications, which were identified by ICD code and CPT code, including a robotic modifier. MTFs were classified by volume as high (HV) with > 50 cases annually, moderate (MV) with 25 to 50 cases, and low (LV) with < 25 cases, as well as by the presence of surgical residencies. RESULTS: Patients at MTFs were slightly younger and more female than by other database studies. The Army was the most common branch of service, and dependents of retirees were the most common beneficiary population. MTFs with residencies had slightly older patients and fewer Army patients. HV, MV, and LV MTFs had similar patients except for branch of service. Over time, the proportion of open gastric bypasses increased, biliopancreatic diversions with duodenal switches decreased, and robotic assistance increased 744%. MTFs with residencies performed more procedures than those without residencies, and with the exception of procedures utilizing robotic assistance, procedures were overall similar to those without residencies. HV MTFs performed most of the procedures annually, and their procedures were proportionately similar to MV and LV MTFs, with the exception of HV MTFs having a higher proportion of laparoscopic bypasses and robotic assistance. CONCLUSION: MTFs largely perform similar procedures on similar patients relative to MBSAQIP and NSQIP studies. Robotic assistance increased significantly over time. Except for laparoscopic bypasses and procedures with robotic assistance, HV MTFs performed similar proportions of procedures to MV and LV MTFs. MTFs with residencies performed similar procedures to those without residencies.

Utilization of combination bowel preparation (CBP) is protective against the development of post-operative Clostridium difficile infection (CDI), decreases septic complications, and provides a survival benefit.

BACKGROUND: The current standard recommended by the American Society of Colon and Rectal Surgeons (ASCRS) is to utilize a combined bowel preparation (CBP) that involves both mechanical (MBP) and oral antibiotic (ABP) components. The current literature is equivocal on whether ABP predisposes to post-operative Clostridium difficile infection (CDI). CDI following colorectal surgery is a significant complication leading to increase in significant morbidity and mortality. Objective was to further delineate the association between CBP and CDI. METHODS: Retrospective review of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) registry was performed. Specifically the main and targeted colectomy/proctectomy databases for 2015 and 2016 were analyzed. 64,449 colorectal surgeries were contained. Exclusion of non-elective cases and cases that did not utilize a bowel preparation or used ABP alone resulted in 24,000 cases for final analysis. Primary endpoint was post-operative CDI development. Secondary analysis involved surgical site infections (SSIs), anastomotic leaks, and sepsis development. 30-day mortality rates, rapidity of return of bowel function, and length of stay were also evaluated. RESULTS: Approximately two-thirds of the cases analyzed involved CBP and the remaining third used MBP alone. Cases that utilized CBP had statistically significant lower rates of all infectious complications evaluated. CBP was found to be protective in regard to the development of CDI with an odds ratio (OR) of 0.58. Our results collaborate the current literature that CBP decreases SSIs and anastomotic leaks with ORs of 0.58 and 0.79, respectively. CBP had its most profound effect on lowering septic shock and mortality rates halving the incidence of both. CONCLUSION: Our findings support the ASCRS guidelines for routine utilization of CBP to optimize post-operative outcomes. CBP does not increase the risk of CDI and in fact is significantly protective. CBP potentially also provides decreased risk of sepsis and mortality.

"Who is watching the watchdog?": ethical perspectives of sharing health-related data for precision medicine in Singapore.

BACKGROUND: We aimed to examine the ethical concerns Singaporeans have about sharing health-data for precision medicine (PM) and identify suggestions for governance strategies. Just as Asian genomes are under-represented in PM, the views of Asian populations about the risks and benefits of data sharing are under-represented in prior attitudinal research. METHODS: We conducted seven focus groups with 62 participants in Singapore from May to July 2019. They were conducted in three languages (English, Mandarin and Malay) and analysed with qualitative content and thematic analysis. RESULTS: Four key themes emerged: nuanced understandings of data security and data sensitivity; trade-offs between data protection and research benefits; trust (and distrust) in the public and private sectors; and governance and control options. Participants were aware of the inherent risks associated with data sharing for research. Participants expressed conditional support for data sharing, including genomic sequence data and information contained within electronic medical records. This support included sharing data with researchers from universities and healthcare institutions, both in Singapore and overseas. Support was conditional on the perceived social value of the research and appropriate de-identification and data security processes. Participants suggested that a data sharing oversight body would help strengthen public trust and comfort in data research for PM in Singapore. CONCLUSION: Maintenance of public trust in data security systems and governance regimes can enhance participation in PM and data sharing for research. Contrary to themes in much prior research, participants demonstrated a sophisticated understanding of the inherent risks of data sharing, analysed trade-offs between risks and potential benefits of PM, and often adopted an international perspective.

A plantar closing wedge osteotomy of the medial cuneiform for residual forefoot supination in flatfoot reconstruction.

BACKGROUND: Residual forefoot supination is commonly encountered during a flatfoot reconstruction, and a new technique for its treatment is described. Contrary to the standard Cotton osteotomy, a plantar closing wedge osteotomy of the medial cuneiform (PCWOMC) was performed, which has a number of advantages. METHODS: We followed 10 feet in 9 patients who had a PCWOMC performed as the last step of a standard flatfoot reconstruction for the correction of residual forefoot supination. These patients were evaluated pre- and postoperatively by standardized radiographic parameters, Short Form-12 (SF-12), and Foot and Ankle Outcome Score (FAOS). RESULTS: Patients were followed for an average of 25.8 months with final radiographic analysis performed at an average of 9.9 months. A significant difference (P < .001) between pre- and postoperative parameters was demonstrated for both lateral talus-first metatarsal angle and medial-cuneiform-to-ground distance. Likewise, there was a statistically significant improvement in the SF-12 score and 4 out of 5 components of the FAOS. One patient developed internal hardware-related symptoms, which were relieved following implant removal. All osteotomies healed uneventfully. CONCLUSION: A PCWOMC can be considered an alternative to the Cotton osteotomy for the treatment of forefoot supination deformity in adult flatfoot reconstruction. The main advantage of this technique over the Cotton osteotomy was simplicity, as an additional dorsal incision and bone graft were not required. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Perceptions of 'Precision' and 'Personalised' Medicine in Singapore and Associated Ethical Issues.

Governments are investing in precision medicine (PM) with the aim of improving healthcare through the use of genomic analyses and data analytics to develop tailored treatment approaches for individual patients. The success of PM is contingent upon clear public communications that engender trust and secure the social licence to collect and share large population-wide data sets because specific consent for each data re-use is impractical. Variation in the terminology used by different programmes used to describe PM may hinder clear communication and threaten trust. Language is used to create common understanding and expectations regarding precision medicine between researchers, clinicians and the volunteers. There is a need to better understand public interpretations of PM-related terminology. This paper reports on a qualitative study involving 24 focus group participants in the multi-lingual context of Singapore. The study explored how Singaporeans interpret and understand the terms 'precision medicine' and 'personalised medicine', and which term they felt more aptly communicates the concept and goals of PM. Results suggest that participants were unable to readily link the terms with this area of medicine and initially displayed preferences for the more familiar term of 'personalised'. The use of visual aids to convey key concepts resonated with participants, some of whom then indicated preferences for the term 'precision' as being a more accurate description of PM research. These aids helped to facilitate dialogue around the ethical and social value, as well as the risks, of PM. Implications for programme developers and policy makers are discussed.

Fixation Techniques: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle is based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Fixation Techniques" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%. RESULTS: A total of 15 statements on fixation techniques reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 15 statements achieved strong consensus, with at least 82% agreement. CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians with using fixation techniques in the treatment of osteochondral lesions of the talus.

Investigating the relationship between ankle arthrodesis and adjacent-joint arthritis in the hindfoot: a systematic review.

BACKGROUND: Ankle arthrodesis traditionally has been regarded as the treatment of choice for many patients with end-stage ankle arthritis. However, a major reported risk of ankle arthrodesis is adjacent-joint degeneration. There are conflicting views in the literature as to the causative link between ankle arthrodesis and progression to adjacent-joint arthritis. Recent studies have challenged the causative link between arthrodesis and adjacent-joint arthritis, purporting that preexisting adjacent-joint arthritis is present in many patients. The aim of the present study was to systematically review the available literature to determine if there is sufficient evidence to support either hypothesis. METHODS: A literature search of the EMBASE and PubMed/MEDLINE databases (1974 to present) was performed. A total of twenty-four studies were included for review. The studies were reviewed, and the relevant information was extracted, including research methodology, postoperative outcomes in the adjacent joints of the foot, and whether pre-arthrodesis radiographs and medical records were available for analysis. RESULTS: The twenty-four manuscripts included eighteen clinical studies, five biomechanical studies, and one gait-analysis study. The majority of biomechanical studies showed altered biomechanics in the fused ankle; however, there was no clear consensus as to whether these findings were causes of adjacent-joint arthritis. In studies assessing clinical outcomes, the reported prevalence of subtalar joint arthritis ranged from 24% to 100% and the prevalence of talonavicular and calcaneocuboid arthritis ranged from 18% to 77%. Correlation between imaging findings of arthritis in adjacent joints and patient symptoms was not established in a number of the clinical studies reviewed. CONCLUSIONS: There is no true consensus in the literature as to the effects of ankle arthrodesis on biomechanics or whether ankle arthrodesis leads to adjacent-joint arthritis. Similarly, a correlation between postoperative imaging findings and clinical presentation in this cohort of patients has not been conclusively demonstrated.

Talonavicular arthroscopy for osteochondral lesions: technique and case series.

BACKGROUND: Traditional treatment of talonavicular osteochondral lesions (OCLs) requires an open procedure. Arthroscopic microfracture of talonavicular OCLs may provide a viable, minimally invasive approach. The purpose of this study was to describe an arthroscopic approach for treatment of talonavicular OCLs, describe the proximity of arthroscopic portals to important structures in cadaver specimens, and report magnetic resonance imaging (MRI) findings and clinical outcomes of this technique. METHODS: Five cadaver specimens were dissected so proximity of portals to adjacent tendons and neurovascular structures could be assessed. Subsequently, 3 athletic patients with OCLs of the talonavicular joint were treated with arthroscopic debridement and microfracture. Patient records and imaging studies were retrospectively reviewed. RESULTS: In the cadaver specimens, the mean distance between the neurovascular bundle and the medial border of the extensor hallucis longus (EHL) was 9.0 (range, 8 to 10) mm. The saphenous nerve was located a mean of 6.8 (range, 6 to 7) mm from the medial border of the tibialis anterior tendon. Therefore, portals were placed just medial to the EHL and tibialis anterior tendon to avoid the neurovascular bundle and saphenous nerve, respectively. In all patients, access, identification of the OCL, debridement, and microfracture were successfully performed. All patients demonstrated improvements in Foot and Ankle Outcome Scores and Short Form-12 scores and began gradual return to activity within 12 weeks following the operation. No significant complications occurred. MRI indicated signal consistent with reparative fibrocartilage in all patients. CONCLUSION: Talonavicular arthroscopy allowed visualization, curettage, synovectomy, loose body removal, and microfracture of OCLs that would have otherwise required an open approach. At early follow-up, all patients had returned to their previous activity levels. Arthroscopy of the talonavicular joint was a viable approach for microfracture of OCLs. LEVEL OF EVIDENCE: Level IV, case series.

Cloud-based solution to identify statistically significant MS peaks differentiating sample categories.

BACKGROUND: Mass spectrometry (MS) has evolved to become the primary high throughput tool for proteomics based biomarker discovery. Until now, multiple challenges in protein MS data analysis remain: large-scale and complex data set management; MS peak identification, indexing; and high dimensional peak differential analysis with the concurrent statistical tests based false discovery rate (FDR). "Turnkey" solutions are needed for biomarker investigations to rapidly process MS data sets to identify statistically significant peaks for subsequent validation. FINDINGS: Here we present an efficient and effective solution, which provides experimental biologists easy access to "cloud" computing capabilities to analyze MS data. The web portal can be accessed at http://transmed.stanford.edu/ssa/. CONCLUSIONS: Presented web application supplies large scale MS data online uploading and analysis with a simple user interface. This bioinformatic tool will facilitate the discovery of the potential protein biomarkers using MS.