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Background Bariatric surgery can influence the presentation, diagnosis, and management of gastrointestinal cancers. Oesophago-Gastric (OG) malignancies in patients who have had a prior bariatric procedure have not been fully characterised. Objective To characterise OG malignancies after bariatric procedures. Setting University Hospital, United Kingdom. Methods We performed a retrospective, multi-centre observational study of patients with OG malignancies after bariatric surgery to characterise this condition. Results This study includes 170 patients from 75 centres in 25 countries who underwent bariatric procedures between 1985 and 2020. At the time of the bariatric procedure, the mean age was 50.2 ± 10 years and the mean weight 128.8 ± 28.9 kg. Females comprised 57.3% (n=98) of the population. Most (n=64) patients underwent a Roux-en-Y Gastric Bypass (RYGB) followed by Adjustable Gastric Band (AGB) (n = 46) and Sleeve Gastrectomy (SG) (n = 43). Time to cancer diagnosis after bariatric surgery was 9.5 ± 7.4 years and mean weight at diagnosis was 87.4 ± 21.9 kg. The time lag was 5.9 ± 4.1 years after SG compared to 9.4 ± 7.1 years after RYGB and 10.5 ± 5.7 years after AGB. One-third of patients presented with metastatic disease. The majority of tumours were adenocarcinoma (82.9%). Approximately 1 in 5 patients underwent palliative treatment from the outset. Time from diagnosis to mortality was under one year for most patients who died over the intervening period. Conclusions The OGMOS (Oesophago-Gastric Malignancies after Obesity/ Bariatric Surgery) study presents the largest series to date of patients developing OG malignancies after bariatric surgery and attempts to characterise this condition.

BACKGROUND: Development and prioritization of quality measures typically relies on experts in clinical medicine, but patients and their caregivers may have different perspectives on quality measurement priorities. OBJECTIVE: To inform priorities for health system implementation of palliative cancer and end-of-life care quality measures by eliciting perspectives of patients and caregivers. DESIGN: Using modified RAND-UCLA Appropriateness Panel methods and materials tailored for knowledgeable lay participants, we convened a panel to rate cancer palliative care process quality measure concepts before and after a 1-day, in-person meeting. PARTICIPANTS: Nine patients and caregivers with experience living with or caring for patients with cancer. MAIN MEASURES: Panelists rated each concept on importance for providing patient- and family-centered care on a nine-point scale and each panelist nominated five highest priority measure concepts (“top 5”). KEY RESULTS: Cancer patient and caregiver panelists rated all measure concepts presented as highly important to patient- and family- centered care (median rating ≥ 7) in pre-panel (mean rating range, 6.9–8.8) and post-panel ratings (mean rating range, 7.2–8.9). Forced choice nominations of the “top 5” helped distinguish similarly rated measure concepts. Measure concepts nominated into the “top 5” by three or more panelists included two measure concepts of communication (goals of care discussions and discussion of prognosis), one measure concept on providing comprehensive assessments of patients, and three on symptoms including pain management plans, improvement in pain, and depression management plans. Patients and caregivers nominated one additional measure concept (pain screening) back into consideration, bringing the total number of measure concepts under consideration to 21. CONCLUSIONS: Input from cancer patients and caregivers helped identify quality measurement priorities for health system implementation. Forced choice nominations were useful to discriminate concepts with the highest perceived importance. Our approach serves as a model for incorporating patient and caregiver priorities in quality measure development and implementation. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-07041-8.

BACKGROUND AND PURPOSE Falls are a major health concern after stroke. Spatial and temporal gait asymmetry and variability can contribute to instability and increased fall risk in persons with stroke (PwS). We aimed to quantify gait spatiotemporal symmetry and variability parameters in PwS undergoing rehabilitation in the subacute stage of the disease, by comparison to healthy participants, and to examine the associations between these parameters and patients' reactive and proactive balance capacity. METHODS Twenty-two PwS and 12 healthy adults walked over a computerized treadmill system at their self-selected walking speed. Symmetry and variability of gait parameters (step length, swing time, and stance time) as well as upper extremity and lower extremity angular range of motion in the sagittal plane were extracted. In addition, the Berg Balance Scale (BBS) and the fall threshold in response to sudden surface translations at increasing intensities were assessed. RESULTS PwS demonstrated significantly higher asymmetry in all gait parameters in comparison to controls. Also, PwS demonstrated increased stance time variability in comparison to healthy controls and increased swing time variability in the paretic lower extremity. Significant negative associations were found between fall threshold and stance time asymmetry in PwS (r = -0.48, P = 0.022), between the BBS and swing time asymmetry (r = -0.50, P = 0.018), and between the BBS and stance time variability of the paretic lower extremity (r = -0.56, P = 0.006). DISCUSSION AND CONCLUSIONS Findings highlight the importance of gait temporal symmetry and variability measures for dynamic balance control after stroke. These parameters should be considered when assessing gait recovery and safety in PwS.Video Abstract available for more insight from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A355).

BACKGROUND: Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers. OBJECTIVES: To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer–related pain in a large integrated healthcare system. DESIGN: Qualitative research. PARTICIPANTS: We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs). APPROACH: We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus. RESULTS: Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines. CONCLUSIONS: Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06747-z.

Objective To assess the correlation between in vitro fertilization (IVF) and complications of the third stage of labor. Design Retrospective cohort of vaginal deliveries from November 2008 to January 2020. Maternal and obstetric outcomes of singleton deliveries were compared between IVF and non-IVF pregnancies. Setting University hospital. Patient(s) Women with live singleton vaginal deliveries at >24 weeks of gestation. Intervention(s) In vitro fertilization–attained pregnancies (compared with spontaneous ones). Main Outcome Measure(s) Complications of the third stage of labor, defined as manual placental removal (either entire removal due to nonseparation or exploration of the uterine cavity due to suspected retained products of conception). Result(s) Overall, 1,264 IVF pregnancies and 34,166 non-IVF pregnancies were included. Deliveries in the IVF group were characterized by an older maternal age, lower parity, higher rate of diabetes and hypertensive disorders, higher rate of placental abnormalities, earlier gestational age, higher rate of labor induction, chorioamnionitis, and instrumental delivery. Complications of the third stage of labor occurred in 5.9% of IVF deliveries and in 2.8% of controls, and blood transfusion was more prevalent in IVF deliveries. The rate of complications of the third stage were higher in both fresh and frozen transfer cycles as compared with spontaneous pregnancies (5.8%, 8.8%, and 2.8%, respectively), although no difference was noted between fresh and frozen transfers. In vitro fertilization was associated independently with complications of the third stage of labor after adjustment for potential confounders. Conclusion(s) In vitro fertilization is associated independently with an increased risk of complications of the third stage of labor.

PURPOSE: Monitoring and improving the quality of palliative and end-of-life cancer care remain pressing needs in the United States. Among existing measures that assess the quality of palliative and end-of-life care, many operationalize similar concepts. We identified existing palliative care process measures and synthesized these measures to aid stakeholder prioritization that will facilitate health system implementation in patients with advanced cancer. METHODS: We reviewed MEDLINE/PubMed-indexed articles for process quality measures related to palliative and end-of-life care for patients with advanced cancer, supplemented by expert input. Measures were inductively grouped into “measure concepts” and higher-level groups. RESULTS: Literature review identified 226 unique measures from 23 measure sources, which we grouped into 64 measure concepts within 12 groups. Groups were advance care planning (11 measure concepts), pain (7), dyspnea (9), palliative care–specific issues (6), other specific symptoms (17), comprehensive assessment (2), symptom assessment (1), hospice/palliative care referral (1), spiritual care (2), mental health (5), information provision (2), and culturally appropriate care (1). CONCLUSION: Measure concepts covered the spectrum of care from acute symptom management to advance care planning and psychosocial needs, with variability in the number of measure concepts per group. This taxonomy of process quality measure concepts can be used by health systems seeking stakeholder input to prioritize targets for improving palliative and end-of-life care quality in patients with advanced cancer.

Research question Does long-term reproductive outcome after early pregnancy loss (EPL) differ between women who are treated with misoprostol and surgical aspiration. Design A historic cohort study of all women who were diagnosed with early pregnancy loss (≤12 weeks), in a single medical centre, between September 2016 and August 2017, was conducted. The women were treated with either misoprostol or surgical aspiration according to their own preferences. Women who were lost to follow-up or did not attempt to conceive again were excluded. The primary outcome measure was the cumulative pregnancy rate within 12 months from intervention. Results Baseline characteristics were comparable between women who received misoprostol (n = 163) and women who underwent surgical aspiration (n = 122). Women who received misoprostol had a higher rate of interventions for retained products of conception (11.0% versus 3.3%, respectively; P = 0.015). The misoprostol and the surgical aspiration groups did not differ in rate of repeated miscarriages (17.8% versus 21.3%, respectively; P = 0.45), or pregnancy rate within 6 months (58.3% versus 50.0%, respectively; P = 0.16), 12 months (78.5% versus 78.7%, respectively; P = 0.97) and 24 months (92.0% versus 91.8%, respectively; P = 0.94). Live birth rate within 24 months was comparable (62.0% versus 58.2%, respectively; P = 0.52), as well as gestational age at birth (38.5 versus 38.6 weeks, respectively; P = 0.81) and birthweight (3295 versus 3161 g, respectively; P = 0.07). Conclusions Long-term reproductive outcomes are comparable in women with EPL who are treated with either misoprostol or surgical aspiration. Our findings may help counselling patients facing EPL who have concerns about their future reproduction.

What are the clinical characteristics of pregnancies complicated by fetal growth restriction (FGR) and preeclampsia in patients who have undergone IVF, and what is the correlation between these complications and histopathological placental findings in such pregnancies.A retrospective cohort of patients who had delivered their babies at our institution who had been diagnosed with preeclampsia, whose babies had been diagnosed with FGR, or both. Deliveries in which the placenta was sent for histopathological examination were included. Computerized files and pathological reports were reviewed, and maternal, obstetric, neonatal outcomes and placental histopathological reports were compared between pregnancies conceived by IVF and controls. Placental lesions were classified according to the Amsterdam criteria.Between December 2008 and December 2018, the placentas of 1114 singleton babies who had received a diagnosis of FGR, whose mothers had received a diagnosis of preeclampisa, or both, were examined. A total of 105 patients conceived with IVF and 1009 were conceived spontaneously. The IVF group was older, of lower parity and had a higher rate of diabetes and chronic hypertension. Deliveries occurred at an earlier gestational age, although birth weight was not significantly different between the groups. The rate of neonatal adverse composite outcome among IVF deliveries was significantly lower (59.0% versus 76.7%; P0.001). On placental examination, placental weight, maternal and fetal vascular malperfusion lesions were similar between the groups, whereas villitis of unknown etiology was significantly more common among the IVF group (16.2% versus 8.3%; P = 0.007).Neonatal outcome is relatively favourable in IVF patients with placental-related diseases. Placental chronic villitis is more common in IVF patients, pointing to an additive immunological cause.

Objective: To determine the factors that influence bleeding during the course of bariatric surgeries. Background: Bariatric surgery is safe with a low percentage of complications compared with other abdominal surgeries. Bleeding is one of the most common complications in surgery for obesity that has the risk of being catastrophic. Methods: The study includes 8,544 cases that underwent bariatric surgery from January 2013 to March 2016 retrospectively, in 4 private institutions. Multiple demographic data were collected: patient characteristics, diseases, medications, surgery type, operative technique, devices, surgeon’s skill, and volume. Results: Bleeding was the most frequent complication that occurred in 122 (1.3%) patients. The Gastric bypass had the highest rate of bleeding (3.05%) of which, 20% were intraoperative bleeding and 80% postoperatively (intra-abdominal in 75%, and intra-luminal in 5%). Simultaneous surgeries, revisional surgeries, stratification of body mass index, stapler line reinforcement, and hospital volume did not affect bleeding occurrence. The determining factors for bleeding were hypertension, chronic lung disease, age >45 years, arrhythmia, and surgeon’s skills. Conclusion: Bleeding after bariatric surgery has a low occurrence. The factors that influence the occurrence of perioperative bleeding in bariatric surgery are: hypertension, chronic lung disease, age >45 years, arrhythmia, and surgeon’s skills.

Circadian and circannual cycles trigger physiological changes whose reflection on human transcriptomes remains largely uncharted. We used the time and season of death of 932 individuals from GTEx to jointly investigate transcriptomic changes associated with those cycles across multiple tissues. Overall, most variation across tissues during day-night and among seasons was unique to each cycle. Although all tissues remodeled their transcriptomes, brain and gonadal tissues exhibited the highest seasonality, whereas those in the thoracic cavity showed stronger day-night regulation. Core clock genes displayed marked day-night differences across multiple tissues, which were largely conserved in baboon and mouse, but adapted to their nocturnal or diurnal habits. Seasonal variation of expression affected multiple pathways, and it was enriched among genes associated with the immune response, consistent with the seasonality of viral infections. Furthermore, they unveiled cytoarchitectural changes in brain regions. Altogether, our results provide the first combined atlas of how transcriptomes from human tissues adapt to major cycling environmental conditions. This atlas may have multiple applications; for example, drug targets with day-night or seasonal variation in gene expression may benefit from temporally adjusted doses. The research reported in this publication was supported by the National Human Genome Research Institute of the National Institutes of Health (R01MH101814 and 5U24HG009446 to R.G.), by the Spanish Ministry of Science and Innovation (PGC2018-094017-B-I00 to R.G. and BFU2017-89201-P to M.I.), and by the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation program (ERC-StG-LS2-637591 and ERC-CoG-LS2-101002275 to M.I.). A.R. was a predoctoral fellow of the CONACYT “Becas al Extranjero” Program of Mexico. We acknowledge the support of the Spanish Ministry of Science and Innovation to the EMBL partnership, Centro de Excelencia Severo Ochoa and CERCA Programme / Generalitat de Catalunya. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Background: Metabolic and bariatric surgery (MBS) is an effective treatment for adolescents with severe obesity. Objectives: This study examined the safety of MBS in adolescents during the coronavirus disease 2019 (COVID-19) pandemic. Methods: This was a global, multicentre and observational cohort study of MBS performed between May 01, 2020, and October 10,2020, in 68 centres from 24 countries. Data collection included in-hospital and 30-day COVID-19 and surgery-specific morbidity/mortality. Results: One hundred and seventy adolescent patients (mean age: 17.75 ± 1.30 years), mostly females (n=122, 71.8%), underwent MBS during the study period. The mean pre-operative weight and body mass index were 122.16 ± 15.92 kg and 43.7± 7.11 kg/m2, respectively. Although majority of patients had pre-operative testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (n=146; 85.9%), only 42.4% (n=72) of the patients were asked to self-isolate pre-operatively. Two patients developed symptomatic SARS-CoV-2 infection post-operatively (1.2%). The overall complication rate was 5.3% (n=9). There was no mortality in this cohort. Conclusions: MBS in adolescents with obesity is safe during the COVID-19 pandemic when performed within the context of local precautionary procedures (such as pre-operative testing). The 30-day morbidity rates were similar to those reported pre-pandemic. These data will help facilitate the safe re-introduction of MBS services for this group of patients.

Adipose tissue (AT) is used extensively in reconstructive and regenerative therapies, but transplanted fat often undergoes cell death, leading to inflammation, calcification, and requirement for further revision surgery. Previously, we have found that mesenchymal progenitor cells within human AT can proliferate in three-dimensional culture under proangiogenic conditions. These cells (primed ADipose progenitor cells, PADS) robustly differentiate into adipocytes in vitro (ad-PADS). The goal of this study is to determine whether ad-PADS can form structured AT in vivo, with potential for use in surgical applications. Grafts formed from ad-PADS were compared to grafts formed from AT obtained by liposuction after implantation into nude mice. Graft volume was measured by microcomputed tomography scanning, and the functionality of cells within the graft was assessed by quantifying circulating human adiponectin. The degree of graft vascularization by donor or host vessels and the content of human or mouse adipocytes within the graft were measured using species-specific endothelial and adipocyte-specific quantitative real time polymerase chain reaction probes, and histochemistry with mouse and human-specific lectins. Our results show that ad-PADS grafted subcutaneously into nude mice induce robust vascularization from the host, continue to increase in volume over time, express the human adipocyte marker PLIN1 at levels comparable to human AT, and secrete increasing amounts of human adiponectin into the mouse circulation. In contrast, grafts composed of AT fragments obtained by liposuction become less vascularized, develop regions of calcification and decreased content of PLIN1, and secrete lower amounts of adiponectin per unit volume. Enrichment of liposuction tissue with ad-PADS improves vascularization, indicating that ad-PADS may be proangiogenic. Mechanistically, ad-PADS express an extracellular matrix gene signature that includes elements previously associated with small vessel development (COL4A1). Thus, through the formation of a proangiogenic environment, ad-PADS can form functional AT with capacity for long-term survival, and can potentially be used to improve outcomes in reconstructive and regenerative medicine. Impact Statement This research describes the use of human mesenchymal progenitor cells for generating functional adipose tissue in vivo in a nude mouse model. Further preclinical development of the methods and insights described in this article can lead to therapeutic use of these cells in regenerative and reconstructive medicine.

Screening for blood born viruses is routinely performed before fertility treatment in assisted reproduction technology (ART) clinics worldwide. It involves testing for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), among others. Identifying patients with positive viral screening allows to refer them and their partners for appropriate counseling and treatment. The need for repeat viral screening and its required frequency have never been clearly established. In Israel, viral screening is mandatory and is repeated annually. Our aim was to determine the prevalence of HBV, HCV, and HIV seroconversion in patients with negative screening upon initiation of ART treatment. A retrospective analysis of viral screening tests of all fertility patients in a single assisted conception unit between 1997 and 2015. During the study period, 2844 patients were treated at our clinic, out of whom 1945 patients met the inclusion criteria. The average length of treatment was 1.61 ± 0.81 years, during which female patients underwent screening tests 2.6 ± 0.9 times, and male patients 2.3 ± 1.2 times. No case of seroconversion to any of the three viruses was noted during the entire study period, resulting a seroconversion rate of 0%. Primary infection with HBV, HCV, or HIV is an extremely rare event among Israeli infertile patients, and the risk for seroconversion in this population is practically nil. Annual screening of both partners leads to substantial costs and appears to be futile. Our results question the current practice and support increasing the interval between screening tests in low-risk populations.

Backgroud In order to maximize In vitro fertilization (IVF) success rates in advanced- age patients, it has been suggested to favor the use of intracytoplasmic sperm injection (ICSI) over conventional insemination (CI), with the notion that ICSI would serve as a tool to overcome interference in sperm oocyte interaction and sperm oocyte penetration issues that can be related to maternal age and are not due to sperm abnormalities. We therefore aim to evaluate the role of ICSI in the treatment of non-male factor infertile patients aged ≥35 in terms of fertilization and top-quality embryo rates. Methods In this retrospective cohort study, data were collected and analyzed for all patients with non-male factor infertility, aged ≥35 treated, undergoing their first IVF cycle attempt with 6 or more oocytes yield, in whom a 50% ICSI-CI division was performed. Results Five hundreds and four oocytes were collected from 52 eligible patients. Overall, 245 oocytes underwent ICSI and 259 oocytes underwent CI. The fertilization rate was 71.0% following ICSI, compared to 50.1% in the CI treated oocytes (P

Background: Extreme obesity leads to increased health risks and perioperative complications. The results of bariatric surgery in patients with super-super obesity (SSO) are presented in this study. Methods: From April 2008 to August 2019, 60 patients with super-super obesity underwent bariatric surgery. Their weight loss and outcome were analyzed. The mean follow-up time was 72.25 months. Results: At baseline, the mean age was 41.5 years old, the mean BMI was 63.81 kg/m2, 80% of the patients suffered from co-morbidities, and 23.33% were revisional surgeries. Weight loss continued for up to two years after surgery. The percentage of excess weight lost at two years was 62.27%, from two to five years: 61.48%, from five to 10 years: 36.82% and after ten years it was 31.89% (P

Research question What is the global variability in misoprostol treatment for the management of early pregnancy loss (EPL)? Design An international web-based survey of fertility specialists and obstetrics and gynaecology clinicians was conducted between August and November 2020. The survey consisted of 16 questions addressing several aspects of misoprostol treatment for EPL. Results Overall, 309 clinicians from 80 countries participated in the survey, of whom 67.3% were fertility specialists. Nearly one-half (47.9%) of the respondents let the patient choose the first line of treatment (expectant management, misoprostol treatment or surgical aspiration) according to her own preference. The 248 respondents who administer misoprostol in their daily practice were asked further questions; 59.7% of them advise patients to take the medication at home. The most common dose and route of administration is 800 µg administered vaginally. Only 28.6% of participants use mifepristone pretreatment. Variation in the timing of the first follow-up visit after misoprostol administration was wide, ranging from 24 h to 1 week in most clinics. In case of incomplete expulsion, only 42.3% of the respondents routinely administer a second dose. The timing of the final visit and the definition of successful treatment also differed greatly among respondents. Conclusions There is large variability in the use of misoprostol for the management of EPL. High-quality research is necessary to examine several aspects of the treatment. Particularly, the timing and effectiveness of a second dose administration and the criteria to decide on treatment failure or success deserve more research in the future.

Pregnancy is a physiological state of continuous adaptation to changing maternal and fetal nutritional needs, including a reduction of maternal insulin sensitivity allowing for appropriately enhanced glucose availability to the fetus. However, excessive insulin resistance in conjunction with insufficient insulin secretion results in gestational diabetes mellitus (GDM), greatly increasing the risk for pregnancy complications and predisposing both mothers and offspring to future metabolic disease. Here, we report a signaling pathway connecting pregnancy-associated plasma protein A (PAPPA) with adipose tissue expansion in pregnancy. Adipose tissue plays a central role in the regulation of insulin sensitivity, and we show that, in both mice and humans, pregnancy caused remodeling of adipose tissue evidenced by altered adipocyte size, vascularization, and in vitro expansion capacity. PAPPA is known to be a metalloprotease secreted by human placenta that modulates insulin-like growth factor (IGF) bioavailability through prolteolysis of IGF binding proteins (IGFBPs) 2, 4, and 5. We demonstrate that recombinant PAPPA can stimulate ex vivo human adipose tissue expansion in an IGFBP-5– and IGF-1–dependent manner. Moreover, mice lacking PAPPA displayed impaired adipose tissue remodeling, pregnancy-induced insulin resistance, and hepatic steatosis, recapitulating multiple aspects of human GDM. In a cohort of 6361 pregnant women, concentrations of circulating PAPPA are inversely correlated with glycemia and odds of developing GDM. These data identify PAPPA and the IGF signaling pathway as necessary for the regulation of maternal adipose tissue physiology and systemic glucose homeostasis, with consequences for long-term metabolic risk and potential for therapeutic use.

Research question: We aimed to assess whether the incidence of placental disorders of pregnancy decreases with increasing parity in repeat in vitro fertilization (IVF) pregnancies, in similar to spontaneous pregnancies. Design: This was a retrospective cohort of deliveries between November 2008 and January 2020, in a single university-affiliated medical center. We included women with only IVF attained singleton pregnancies (no spontaneous conception) with at least two deliveries, and compared the obstetric and perinatal outcomes between first, second and third deliveries. Each woman served as her own control. The primary outcome was the incidence of placental related disorders of pregnancy, defined as small for gestational age (SGA) neonates and/or preeclampsia (PE). Results: A total of 307 first deliveries, 307 second deliveries and 49 third deliveries by the same women were compared. A trend for a decreased rate of PE was noted with increased parity (p=0.06) and a significant decrease in the rate of small for gestational age (SGA) – 11.7% for first delivery, 7.8% for second delivery and 2.0% for third (p=0.04). This difference in SGA incidence was maintained in a matched sub-analysis of the 49 women with three deliveries (p=0.04), and after adjustment for fresh/frozen embryo transfer (p=0.03). Although SGA and PE were generally more common in IVF than spontaneous pregnancies, their decrease with increasing parity, mimicked that in spontaneous pregnancies. Conclusion: IVF pregnancies are associated with an increased risk of placental disorders of pregnancy. However, they exhibit a decrease in incidence with increasing parity.

Objective To compare obstetric and perinatal outcomes between pregnancies conceived using in vitro fertilization (IVF) and natural pregnancies of the same women. Design This was a case-control study of deliveries between November 2008 and January 2020 in which each IVF pregnancy was matched to a natural pregnancy of the same woman (1:1 ratio). Setting University hospital. Patient(s) We included women with consecutive live singleton deliveries (>24 weeks of gestation) at the Edith Wolfson Medical Center. We excluded IVF pregnancies attained using egg donation. Intervention(s) In vitro fertilization–attained pregnancies (as compared with natural ones). Main Outcome Measure(s) Primary outcome: preterm birth (PTB). Secondary outcomes: small for gestational age (SGA) neonates and pregnancy-induced hypertension (PIH; gestational hypertension or pre-eclampsia). Result(s) A total of 544 IVF pregnancies were matched to 544 natural pregnancies, each in the same woman. In 292 women (53.7%), the natural pregnancy preceded the IVF pregnancy. Maternal age was significantly higher in IVF deliveries. Gestational age at delivery and the rates of PTB, PIH, instrumental delivery, cesarean delivery, and SGA neonates were comparable between IVF and natural pregnancies. Birth weight was slightly lower in IVF pregnancies. On multivariate analysis, IVF was not independently associated with PTB, SGA, or PIH after adjustment for confounders. Conclusion(s) When compared in a cohort of the same women, natural and IVF-attained pregnancies did not differ with regard to obstetric and perinatal outcomes.

PURPOSE: To study whether placentas of singleton pregnancies conceived after fresh embryo transfer (ET) contain more histopathological lesions compared with placentas of singleton pregnancies conceived after frozen-thawed embryo transfer (FET). METHODS: A prospective cohort study of placental histopathology in 131 women with singleton IVF pregnancies who delivered at a single medical center, between December 2017 and May 2019. The prevalence of different placental histopathology lesions was compared between women who conceived after fresh ET and FET. RESULTS: Women who conceived after fresh ET (n = 74) did not differ from women who conceived after FET (n = 57) with regard to maternal age, BMI, nulliparity, or infertility diagnosis. Gestational week at delivery was lower in pregnancies conceived after fresh ET (38.5 vs. 39.2 weeks, respectively, p = 0.04), and a trend for a lower birthweight following fresh ET was noted (3040 vs. 3216 g, respectively, p = 0.053). However, placental histopathology analysis from pregnancies conceived after fresh ET was comparable to pregnancies conceived after FET, with regard to the prevalence of maternal vascular malperfusion lesions (45.9% vs. 50.9%, respectively, p = 0.57), fetal vascular malperfusion lesions (17.6% vs. 21.1, p = 0.61), acute inflammatory response lesions (28.4% vs. 28.1%, respectively, p = 0.96), and chronic inflammatory response lesions (13.5% vs. 8.8%, respectively, p = 0.48). CONCLUSION: Placental histopathology did not differ between IVF pregnancies conceived after fresh and frozen ET. These results are reassuring for clinicians and patients who wish to pursue with transferring fresh embryos.

To examine associations of patients' attendance to follow-up meetings with a registered dietitian (RD) and physical exercise practices with weight loss during the 1 year following laparoscopic sleeve gastrectomy (SG).Of 241 patients with obesity who underwent SG during 2012, 184 (76.3%) participated in a 1-year follow-up telephone interview and had information on number of RD follow-up meetings. Clinical information was available from computerized patient files. Multiple logistic regression analysis, adjusting for propensity score, was computed to reveal factors associated with greater weight loss.The mean %TWL was 31.4 ± 6.1 and the mean number of reported RD meetings during the year following SG was 4.6. The proportion of physically active patients increased by 15% (from 23 to 42) among those who attended at least 3 RD follow-up meetings (n = 123), and by 5% (from 18 to 23) among those who attended fewer than 3 meetings (n = 61) (p = 0.05). Patients conducting physical exercise reported a lower level of pain/discomfort on the EQ5D quality-of-life questionnaire (p = 0.03). The adjusted regression model revealed no association between the number of RD follow-up meetings and weight-reduction success, but physical exercise during the year following SG conferred a 2.6 times greater odds of belonging to the upper two tertiles of the % excess body weight loss ( 95% CI 1.2-5.3).Patients with better adherence to RD follow-up meetings were also more physically active. Patients on physical exercise also achieved greater weight reduction following SG, and reported less pain or discomfort. Nutritional counselling and physical exercise are necessary to ensure maximal and sustainable benefits from SG. LEVEL OF EVIDENCE: Level III, Cohort study.

Impaired sympathetic/parasympathetic response, expressed by elevated Acetylcholinesterase (AChE) is associated with obesity, metabolic syndrome and inflammation. However, the association between morbid obesity and AChE and the changes in cholinergic tone following bariatric laparoscopic sleeve gastrectomy (LSG) surgery-induced weight reduction were never analyzed. Two studies are presented; the first (the “apparently healthy cohort”) was a cross-sectional study and the second (the “LSG cohort”) was a prospective-cohort study with 12 months of follow-up. The “apparently healthy cohort” included 1450 apparently healthy participants who volunteered to the Tel-Aviv Medical Center Inflammation Survey (TAMCIS) during a routine annual checkup visit. The “LSG cohort” included 77 morbid obese patients before and at 3, 6, and 12 months following LSG surgery. Main outcomes included anthropometric measurements, Hemoglobin A1c (HbA1C), serum AChE, insulin test and Homeostasis Model Assessment (HOMA). Among the TAMCIS participants, serum AChE activity increased with BMI in a dose-dependent manner until it reached a peak level at BMI of 30–35 kg/m², followed by a plateau. Following LSG, a significant decrease in AChE activity between baseline and 12 months post-surgery was found for men, but not for women (−122.2 ± 135.3, P

PURPOSE: The purpose of the study is to calculate the cumulative pregnancy rate and cumulative live birth rate in women undergoing in vitro fertilization (IVF) at ages 44–45. METHODS: The study calculated cumulative live pregnancy rate and cumulative live birth rate of 124 women aged 44 to 45 years old who commenced IVF treatment. MAIN OUTCOME MEASURES: The main outcome measures are cumulative live pregnancy rate and cumulative live birth rate. RESULTS: Cumulative live pregnancy rates following 1, 2, 3, and 4 cycles were 5.6, 11, 17, and 20%, respectively, with no additional pregnancies in further cycles. Cumulative live birth rates following 1, 2, and 3 cycles were 1.6, 3, and 7%, respectively, with no additional live births in further cycles. CONCLUSIONS: The cumulative pregnancy rate rises during the first 4 cycles and cumulative live birth rate rises during the first 3 cycles, with no additional rise in pregnancies or deliveries thereafter, suggesting that it is futile to offer more than 3 cycles of treatment to 44–45-year-old women.

Patient: Male, 81 Final Diagnosis: Bochdalex hernia Symptoms: Chest pain • vomiting Medication: — Clinical Procedure: Laparoscopic repair of both diaphragmatic hernias Specialty: Surgery Objective: Rare co-existance of disease or pathology Background: A Bochdalek hernia (BH) is a rare congenital condition consisting of a posterolateral defect in the diaphragm. A para-esophageal hernia (PEH) is a rare variant of hiatus hernia. BH and PEH may present with gastric volvulus or incarceration, requiring emergency treatment. Minimally invasive surgery is the preferred treatment, particularly for elderly patients and patients with comorbidities. The occurrence of BH with concomitant PEH is a very rare event. We describe a case of an octogenarian patient with BH and concomitant PEH treated laparoscopically. Case Report: An 81-year-old male patient, without significant comorbidities, presented with a two-month history of severe chest pain and vomiting after eating. Cardiological investigations ruled out cardiac ischemia, infarction, or other cardiovascular abnormalities. Chest and abdominal computed tomography (CT) imaging demonstrated a large diaphragmatic hernia, with the entire stomach in the left thorax. Laboratory results showed mild anemia and a low iron level. The patient underwent simultaneous laparoscopic repair of a BH and a PEH with mesh reinforcement without antireflux fundoplication. The patient’s postoperative recovery was uneventful. Conclusions: We have presented a rare case of BH with concomitant PEH in an octogenarian that was successfully treated with laparoscopic surgery. Although these two forms of hernia are a very rare association, this case report illustrates that the surgical approach should be individualized in each patient’s case to ensure a successful surgical outcome. In this case, the decision was made to suture the diaphragmatic crura and reinforce the diaphragm repair with mesh, rather than by fundoplication.

Various definitions for bariatric surgery (BS) success exist, with weight loss and comorbidity resolution outcomes being the most prominent. The study’s aim was to compare how various healthcare professionals perceive success in BS. A 29-item, 10-point Likert scale online survey was distributed via email to Israeli healthcare professionals involved in the different BS aspects using common national professional organizations. These included bariatric surgeons, dietitians, social workers, psychologists, psychiatrists, primary care physicians, gastroenterologists, and nurses. Statement relevancy to BS success was rated. An item was classed as “very important” for BS success if at least 70% of participants rated it 8 or higher in each subgroup. Inter-observer agreement was calculated using kappa statistics. Data on specific occupation, years-in-practice, and major workplace were collected as well. A total of 155 responses was obtained. The majority of respondents were dietitians (34.8%, n = 54), followed by bariatric surgeons (31.0%, n = 48) and nurses (14.8%, n = 23). Most respondents work mainly at public hospitals (32.9%, n = 51), followed by private hospitals (26.5%, n = 41). The mean years-in-practice among all healthcare professionals was 8.5 ± 8.5 years. Overall inter-observer agreement for prioritized items in accordance to BS success among all health professional subgroups was fair (Fleiss kappa = 0.278, P

Background Hiatal hernia (HH) is common in the bariatric population. Its presence imposes various degrees of difficulty in performing laparoscopic sleeve gastrectomy (LSG). Preoperative upper gastrointestinal evaluation consists of fluoroscopic and or endoscopic studies Objectives To evaluate the efficacy of routine, preoperative barium swallow in identifying HH in patients undergoing LSG, and determine if such foreknowledge changes operative and immediate postoperative course regarding operative time, intraoperative adverse events, and length of hospital stay (LOS). In addition, to quantify HH prevalence in these patients and correlate preoperative patient characteristics with its presence. Setting High-volume bariatric practice in a private hospital in Israel Methods Retrospective analysis of prospectively collected data between October 2010 and March 2015: anthropometrics, co-morbidities, previous barium swallow, preoperative HH workup (type and result), operative and immediate postoperative course. Results Primary LSG was performed in 2417 patients. The overall prevalence of HH was 7.3%. Preoperative diagnosis of gastroesophageal reflux disease and female gender were independent risk factors for HH presence. Operative times were significantly longer when HH was concomitantly repaired but "foreknowledge" thereof did not assist in shortening this time. Looking for an HH that was suggested in preoperative upper gastrointestinal evaluation slightly prolonged surgery. LOS was not changed in a significant fashion by HH presence and repair, whether suspected or incidentally found. Conclusion Routine, pre-LSG barium swallow does not seem to offer an advantage over selective intraoperative hiatal exploration, in the discovery and management of HH. Conversely, when preoperative workup yields a false-positive result, surgery is slightly prolonged.

Background Low postoperative protein intake may represent a modifiable risk factor that leads to fat free mass (FFM) loss postlaparoscopic sleeve gastrectomy (LSG), but data concerning this phenomenon is scarce. Objectives To evaluate the association between daily protein intake and relative FFM loss at 6 (M6) and 12 (M12) months after LSG surgery. Settings Private hospital and university hospital. Methods A prospective cohort study with 12 months follow-up of 77 patients who underwent LSG surgery. Anthropometrics including body composition analysis measured by multifrequency bioelectrical impedance analysis, 3-day food diaries, food intolerance, and habitual physical activity were evaluated at baseline and at M3, M6, and M12. Results Repeated body composition measurements and food diary were available for 77 patients (45 women) at M6 and for 68 patients at M12. Mean age was 42.7±9.4 years and mean preoperative body mass index was 42.2±4.8 kg/m 2 . A protein intake of≥60 g/d was achieved in 13.3%, 32.5% and 39.7% of the study participants at M3, M6 and M12, respectively. FFM significantly decreased at M6 and stabilized at M12. Protein intake of≥60 g/d was associated with a significantly lower relative FFM loss at M6 among women (8.9±6.5% versus 12.4±4.1%; P = .039) and this trend was also reported among men (9.5±5.5% versus 13.4±6.0%; P = .068). A logistic regression for the prediction of FFM loss of≥10% at M6, indicated that protein intake≥60 g/d is a strong protective factor (odds ratio=0.29, 95% confidence interval .09–.96, P = .043). Conclusion Our study supports the currently recommended protein intake goal of≥60 g/d as an efficient strategy for better preservation of FFM post-LSG.

Background CD40 is a transmembrane protein mainly expressed on the antigen‐presenting cells surface. CD40 plays a crucial role in immunoglobulin class switching and antibodies production. Genetic polymorphisms in the CD40 gene have been associated with increased risk of systemic lupus erythematosus (SLE) in several populations. This study aimed to evaluate the association of CD40 polymorphisms (−1 C > T, rs1883832 and 6,048 G > T, rs4810485) with SLE susceptibility, as well as with mRNA expression and soluble CD40 (sCD40) levels. Methods The study included 293 patients with SLE and 294 control subjects (CS). Genotyping was performed by PCR‐RFLP method. CD40 mRNA expression was determined by quantitative real‐time PCR, and ELISA quantified sCD40 levels. Results The CD40 polymorphisms −1 C > T and 6,048 G > T were associated with SLE susceptibility. There was no difference between CD40 mRNA expression and CD40 polymorphisms. The sCD40 levels were lower in SLE patients with TT haplotype, whereas higher sCD40 levels were associated with damage and impaired renal function according to SLICC and KDIGO. The sCD40 levels were negatively correlated with eGFR. Conclusion The CD40 gene polymorphisms increase the risk of SLE in the western Mexican population. The sCD40 levels are associated with −1 C > T polymorphism and chronic kidney disease., The CD40 gene polymorphisms increase the risk of SLE in the western Mexican population. The sCD40 levels are associated with −1 C > T polymorphism and chronic kidney disease.

BACKGROUND Freeze-all IVF cycles are becoming increasingly prevalent for a variety of clinical indications. However, the actual treatment objectives and preferred treatment regimens for freeze-all cycles have not been clearly established. OBJECTIVE AND RATIONALE We aimed to conduct a systematic review of all aspects of ovarian stimulation for freeze-all cycles. SEARCH METHODS A comprehensive search in Medline, Embase and The Cochrane Library was performed. The search strategy included keywords related to freeze-all, cycle segmentation, cumulative live birth rate, preimplantation genetic diagnosis, preimplantation genetic testing for aneuploidy, fertility preservation, oocyte donation and frozen-thawed embryo transfer. We included relevant studies published in English from 2000 to 2018. OUTCOMES Our search generated 3292 records. Overall, 69 articles were included in the final review. Good-quality evidence indicates that in freeze-all cycles the cumulative live birth rate increases as the number of oocytes retrieved increases. Although the risk of severe ovarian hyperstimulation syndrome (OHSS) is virtually eliminated in freeze-all cycles, there are certain risks associated with retrieval of large oocyte cohorts. Therefore, ovarian stimulation should be planned to yield between 15 and 20 oocytes. The early follicular phase is currently the preferred starting point for ovarian stimulation, although luteal phase stimulation can be used if necessary. The improved safety associated with the GnRH antagonist regimen makes it the regimen of choice for ovarian stimulation in freeze-all cycles. Ovulation triggering with a GnRH agonist almost completely eliminates the risk of OHSS without affecting oocyte and embryo quality and is therefore the trigger of choice. The addition of low-dose hCG in a dual trigger has been suggested to improve oocyte and embryo quality, but further research in freeze-all cycles is required. Moderate-quality evidence indicates that in freeze-all cycles, a moderate delay of 2–3 days in ovulation triggering may result in the retrieval of an increased number of mature oocytes without impairing the pregnancy rate. There are no high-quality studies evaluating the effects of sustained supraphysiological estradiol (E2) levels on the safety and efficacy of freeze-all cycles. However, no significant adverse effects have been described. There is conflicting evidence regarding the effect of late follicular progesterone elevation in freeze-all cycles. WIDER IMPLICATIONS Ovarian stimulation for freeze-all cycles is different in many aspects from conventional stimulation for fresh IVF cycles. Optimisation of ovarian stimulation for freeze-all cycles should result in enhanced treatment safety along with improved cumulative live birth rates and should become the focus of future studies.

Exercise mitigates chronic diseases such as diabetes, cardiovascular diseases, and obesity; however, the molecular mechanisms governing protection from these diseases are not completely understood. Here we demonstrate that exercise rescues metabolically compromised high fat diet (HFD) fed mice, and reprograms subcutaneous white adipose tissue (scWAT). Using transcriptomic profiling, scWAT was analyzed for HFD gene expression changes that were rescued by exercise. Gene networks involved in vascularization were identified as prominent targets of exercise, which led us to investigate the vasculature architecture and endothelial phenotype. Vascular density in scWAT was found to be compromised in HFD, and exercise rescued this defect. Similarly, angiogenic capacity as measured by ex vivo capillary sprouting was significantly promoted with exercise. Together, these data demonstrate that exercise enhances scWAT vascularization and functional capacity for angiogenesis, and can prevent the detrimental effects of HFD. The improvement in these indices correlates with improvement of whole-body metabolism, suggesting that scWAT vascularization may be a potential therapeutic target for metabolic disease. Published version

Objective: We examined short and long-term outcomes of bariatric surgery in patients with obesity and type 1 diabetes mellitus (T1DM). Methods: We reviewed the records of all adults insured by Maccabi Healthcare Services during 2010 -2015, with body mass index (BMI) ⩾30 kg/m2 and T1DM; and compared weight reduction and glucose control according to the performance of bariatric surgery. BMI and glycated hemoglobin (HbA1c) levels were extracted for baseline and every 6 months, for a mean 3.5 years. Results: Of 52 patients, 26(50%) underwent bariatric surgery. Those who underwent surgery were more often female and with a longer duration of diabetes. Immediately postoperative, 4(15%) developed diabetic ketoacidosis, while 6(23%) experienced severe hypoglycemic episodes. The mean BMI decreased among surgery patients: from 39.5±4.4 to 30.1±5.0 kg/m2 ( p < 0.0001); and increased among those who did not undergo surgery: from 33.6±3.9 to 35.1±4.4 kg/m2 ( p = 0.49). The mean HbA1c level decreased during the first 6 months postoperative: from 8.5±0.9% to 7.9±0.9%; however, at the end of follow-up, was similar to baseline, 8.6±2.0% (p = 0.87). For patients who did not undergo surgery, the mean HbA1c increased from 7.9±1.9% to 8.6±1.5% ( p = 0.09). Conclusions: Among individuals with obesity and T1DM, weight loss was successful after bariatric surgery, but glucose control did not improve. The postoperative risks of diabetic ketoacidosis and severe hypoglycemic episodes should be considering when performing bariatric surgery in this population.

Obesity is a chronic condition significantly associated with health disorders, including type-II diabetes, cardiovascular diseases and inflammation. Its prevalence has been on the rise for the last few decades, contributing to the World Health Organization’s statement touting obesity as the pandemic of the millennium. In parallel, its incidence in patients with inflammatory bowel disease (IBD) is rising, with the prevalence of obesity among patients with IBD is similar to that of the general population ~20%?30%. The main common pathophysiological pathways which might link obesity to IBD include: disproportional accumulation of visceral fat, impaired release of adipokines, chronic inflammation, and disturbances in the gut microbiome. Large retrospective studies have shown that obesity is associated with an increased risk of Crohn’s Disease (CD), a chronic, progressive, destructive condition whose incidence has been increasing as well (3-20 cases per 100,000). Bariatric surgery is a well-accepted, effective and safe option for significant and durable weight loss in individuals with morbidly obesity. Even though obesity is associated with higher rates of surgical complexities and postoperative complications (possibly further exacerbated in patients with IBD), data from case studies and multiple data analyses have demonstrated that bariatric surgery in patients with both morbid obesity and CD is safe and effective. Bariatric surgery infers marked improvement in weight-associated comorbidities, massive weight loss, as well as better quality of life, in this special patient population.

Labour is the single largest cost contributor and main limiting factor to development of the agricultural industry. Manual labour remains a major, essential factor for greenhouse-grown specialty crops. Furthermore, musculoskeletal injuries are prevalent during manual work processes performed in agricultural environments. This study aims to improve work efficiency and productivity and to identify tasks that can cause musculoskeletal injury. Working procedures were characterised using a work-study method, environmental conditions were recorded and a biomechanical analysis of the inspected task was conducted. An innovative measuring system was developed that enables synchronisation and analysis of the manufacturing, biomechanics, workload and environmental data. The study focused on the trellising and harvesting stages of pepper and tomato in greenhouses on two farms located in southwest Israel. We further conducted several experiments in which we changed the working method and assessed the effect on productivity. Another experiment was conducted to test the effect of three different trellising angles (30°, 60°, 90°) on labour and yield in tomato. The results revealed that in tomato, in comparison to current methods, picking 4 fruit per cycle will increase production rate by 17%, leaf removal from the fruit area will increase production rate by 14.4%—up to 40.2%—and the best trellising angle with respect to yield and labour will be 30°. Analysis of biomechanical risk showed that the maximum weight of lifted boxes should not exceed 12 kg, and when picking fruit growing low to the ground, the workers are exposed to medium to high risk of injury.

Introduction: Battered child syndrome is defi ned as all forms of violence, prejudice or physical and mental abuse, carelessness or neglect infl icted on the child while under the care of his parents, tutors or any other person exerting physical and/or intellectual superiority. In over 50% of all cases lesions are found in the head and neck area. For that reason, dentists, especially pediatric dentists, must be aware to recognize all sorts of battering or neglect based on a suitably-taken clinical history, and focused exploration when suspicion of battered child syndrome is established. Objective: To be knowledgeable with BCS intra- and extra-oral indicators which might allow the pediatric dentist to recognize signs and contribute in the diagnosis as part of a multi-disciplinary team in charge of providing care to this type of patients. Clinical case: A two year, fi ve month old male patient was brought to the National Pediatrics Institute affl icted with peri-orbital edema, multiple limb fractures and oral-facial indicators which suggested battered child syndrome diagnosis. Conclusion: Taking into consideration the frequency with which oral and facial structures are involved in battered child syndrome cases there is a medical, ethical and legal commitment for all dentists and specifi cally pediatric dentists, to intervene in prevention, detection, diagnosis and treatment of this medical and social problem.

Two main causes for nutrient deficiencies following bariatric surgery (BS) are pre-operative deficiencies and favoring foods with high-energy density and poor micronutrient content. The aims of this study were to evaluate nutritional status and gender differences and the prevalence of nutritional deficiencies among candidates for laparoscopic sleeve gastrectomy (LSG) surgery. A cross-sectional analysis of pre-surgery data collected as part of a randomized clinical trial on 100 morbidly obese patients with non-alcoholic fatty liver disease (NAFLD) admitted to LSG surgery at Assuta Medical Center between February 2014 and January 2015. Anthropometrics, food intake, and fasting blood tests were evaluated during the baseline visit. One-hundred patients completed the pre-operative measurements (60 % female) with a mean age of 41.9 ± 9.8 years and a mean BMI of 42.3 ± 4.7 kg/m2. Pre-operatively, deficiencies for iron, ferritin, folic acid, vitamin B1, vitamin B12, vitamin D, and hemoglobin were 6, 1, 1, 6, 0, 22, and 6 %, respectively. Pre-surgery, mean energy, protein, fat, and carbohydrate intake were 2710.7 ± 1275.7 kcal/day, 114.2 ± 48.5, 110.6 ± 54.5, and 321.6 ± 176.1 gr/day, respectively. The intakes for iron, calcium, folic acid, vitamin B12, and vitamin B1 were below the Dietary Reference Intake (DRI) recommendations for 46, 48, 58, 14, and 34 % of the study population, respectively. We found a low prevalence of nutritional deficiencies pre-operatively except for vitamin D. Most micronutrient intake did not reach the DRI recommendations, despite high-caloric and macronutrient intake indicating a poor dietary quality.

Laparoscopic sleeve gastrectomy (LSG) is gaining wide acceptance as a single surgical treatment for obesity. The reported morbidity and mortality rates are low. We herein report the results of LSG performed in a high-volume center by an experienced team. Retrospective analysis of a prospectively maintained database of all bariatric surgery (BS) was performed between May 2006 and December 2014. Data inspected included operative time, length of hospital stay (LOS), comorbidity resolution, re-operation, percent excess weight loss (%EWL), and 30-day morbidity and mortality. In the study period, 3003 patients underwent BS (1901 (63 %) female). Mean age and body mass index (BMI) were 43 years (range 14–73) and 42.8 kg/m2 (range 35–73), respectively. %EWL at 1 year was 72 % (n = 937; 57 % follow-up rate). There was 1 perioperative mortality due to bleeding (0.03 %). Comorbidity improvement and resolution were 98 % for obstructive sleep apnea, 79 % for diabetes mellitus, 87 % for dyslipidemia, and 85 % for hypertension. Mean operative time and LOS were 50 min (range 32–94) and 2.2 days (range 1–38), respectively. Of the patients, 132 had complications (4.4 %), 25 leaks (0.83 %), 63 bleeding (2.1 %), 1 intra-abdominal abscesses (0.03 %), 3 sleeve strictures (0.1 %), 2 mesenteric vein thromboses (0.06 %), 10 trocar site hernias (0.3 %), and 78 symptomatic cholelithiasis (2.6 %). Re-operation was needed in 13 patients (0.43 %). In a high-volume center with an experienced team, LSG can be performed with low morbidity and mortality.

Patient: Female, 52-year-old Final Diagnosis: Epithelial ovarian cancer with central nervous system involvement Symptoms: Abdominal pain • convulsions • dyspnea • weigh loss Medication: — Clinical Procedure: — Specialty: Oncology Objective: Unusual or unexpected effect of treatment Background: Despite advances in diagnosis and treatment, epithelial ovarian cancer (EOC) continues to be highly lethal. Undoubtedly, the introduction of poly(adenosine diphosphate-ribose) polymerase inhibitors such as olaparib will alter this clinical picture. Phase III studies have already documented clinically relevant outcomes, particularly among patients with BRCA mutations and homologous recombination deficiency. Case Report: Here we present a case report that documents the evolution of refractory multidrug-resistant, BRCA1-mutated EOC in a patient who had advanced clinical deterioration, carcinomatosis, and central nervous system (CNS) involvement that responded favorably to olaparib, resulting in a tripling of her progression-free survival. Conclusions: Olaparib proved to be a safe and effective option for the treatment of a patient with multidrug-resistant, BRCA1-mutated EOC with CNS metastases. This suggests that early initiation of the drug in similar cases can be very useful.

This study investigates how the positions of paramedic equipment bags affect paramedic performance and biomechanical loads during out-of-hospital Cardiopulmonary Resuscitation (CPR). An experiment was conducted in which 12 paramedic teams (each including two paramedics) performed in-situ simulations of a cardiac-arrest scenario. CPR quality was evaluated using five standard resuscitation measures (i.e., pre- and post-shock pauses, and compression rate, depth and fraction). The spinal loads while lifting, pulling and pushing the equipment bags were assessed using digital human modeling software (Jack) and prediction equation from previous studies. The results highlight where paramedics are currently choosing to position their equipment. They also demonstrate that the positions of the equipment bags affect CPR quality as well as the paramedics' work efficiency, physiological effort and biomechanical loads. The spinal loads ranged from 1901 to 4030N; furthermore, every occasion on which an equipment bag was lifted resulted in spinal forces higher than 3400N, thus exceeding the maximum threshold stipulated by the National Institute for Occupational Safety and Health. 72% of paramedics' postures were categorized as high or very high risk for musculoskeletal disorders by the Rapid Entire Body Assessment. Guidelines related to bag positioning and equipment handling might improve CPR quality and patient outcomes, and reduce paramedics' risk of injury.

The endocannabinoid (eCB) system plays a key role in the development of obesity and its comorbidities. Limited information exists on the changes in circulating eCBs following bariatric surgery. This study aims to (i) assess the circulating levels of eCBs and related molecules and (ii) examine the association between their levels and numerous clinical/metabolic features pre- and post-operatively. Sixty-five morbidly obese patients (age 42.78 ± 9.27 years; BMI 42.00 ± 5.01 kg/m2) underwent laparoscopic sleeve gastrectomy (LSG) surgery, and were followed up for 12 months. Data collected included anthropometrics and metabolic parameters. The serum levels of the eCBs, 2-arachidonoylglycerol (2-AG), anandamide (AEA); and their related molecules, arachidonic acid (AA) and oleoylethanolamine (OEA) were measured by liquid chromatography-mass spectrometry. Levels of 2-AG, AEA, and AA were reduced post operatively with no differences in serum OEA levels. The delta changes in eCB levels between pre- and post-operation were correlated with the delta of different metabolic parameters. Positive correlations were found between delta AA and waist circumference (WC) (r = 0.28, P

Failure or complications following laparoscopic adjustable gastric banding (LAGB) may necessitate band removal and conversional surgery. Band position and band-induced chronic vomiting create ideal conditions for de novo hiatal hernia (HH) formation. HH presence impedes and complicates conversional surgery by obscuring crucial anatomical landmarks and hindering precise gastric sleeve or pouch formation. The aim of this study was to evaluate the incidence of a HH in patients with an LAGB undergoing conversion compared to patients undergoing primary bariatric surgery (BS). Retrospective review of consecutive BS performed between 2010 and 2015. Data collected included demographics, anthropometrics, comorbidities, previous BS, preoperative and intra-operative HH detection, operation time, perioperative complications and length of hospital stay. During the study period, 2843 patients (36% males) underwent BS. Of these, 2615 patients (92%) were “primary” (no previous BS—control group), 197 (7%) had a previous LAGB (study group), and 31 (1%) had a different previous BS and were excluded. Reasons for conversion included weight regain, band intolerance and band-related complications. Mean age and body mass index were similar between the study and the control groups. HH was preoperatively diagnosed by upper gastrointestinal (UGI) fluoroscopy in 9.1% and 9.0% of the LAGB and control groups (p = NS), respectively. However, HH was detected intra-operatively in 20.3% and 7.3%, respectively (p

Background People are living longer than they were expected to 2 decades ago. Increased life expectancy and reduced mortality encompasses a simultaneous increase in the number of older adults with obesity that entails an increase of co-morbidities, such as diabetes, hypertension, cancer, and many other diseases. The aim of our study was to compare the outcomes of bariatric surgery in patients age ≥65 in comparison with younger patients. Methods This retrospective study compares bariatric surgeries performed in a private institution between the years 2013 and 2015. The study included 9044 patients divided into an older group (451 patients) and the younger group (8593 patients). Results In the younger group, bariatric surgery is distributed as follows: 77.68% sleeve gastrectomy, 12.72% gastric banding, 9.27% gastric bypass, and .33% duodenal switch or biliopancreatic diversion; in the older group: 70.51% sleeve gastrectomy, 15.08% gastric bypass, 13.97% gastric band, and .44% biliopancreatic diversion. In the control group 550 cases (6.4%) underwent revisional surgery; 64 cases (14.10%) underwent revision in the older group. Older patients lost less excess weight than younger patients (72.44% versus 86.11%, respectively). Older patients presented higher rates of complications (8.42% versus 5.59%), co-morbidities (77.60% versus 55.45%), and revisions (1.33% versus .77%). There was no statistical difference in hospital stay between older group and control group (2.27 versus 2.23, respectively). When performing a Clavien-Dindo classification, we demonstrated significant differences in class 3B and 4A and no differences in other classes. Two deaths occurred in the control group. Diabetes, fatty liver, and sleep apnea have been improved or remitted in >90% of patients in both groups, hypertension and hyperlipidemia by >80%, and hyperuricemia and ischemic heart disease were improved or resolved in >70% of the patients Conclusions Bariatric surgery in the elderly has more complications, but it can still be considered safe.

A local study was conducted to monitor the antibiotic susceptibility of N. gonorrhoeae in Bacolod City, Philippines. A total of 88 isolates were taken during the period of 1 January 2015 to 30 June 2017, from male patients ages 12 to 72 years. The highest incidence of gonorrhea infection was in the group aged 20–24 years (34.09%). The susceptibility pattern to antibiotics was as follows: ceftriaxone 100%, cefixime 82.6%, spectinomycin 92.1%, ciprofloxacin 4.9%, tetracycline 5.1%, and penicillin G with 0%. All isolates were noted to produce beta-lactamase, which can be attributed to plasmid-mediated penicillin resistance. These findings indicate that the resistance rates of N. gonorrhoeae to most commonly-used antibiotics are increasing, and that ceftriaxone remains an effective antibiotic in treating gonorrhea infections locally.

Data on vegetarianism and bariatric surgery (BS) are scarce. We herein describe the health and nutritional status of vegetarian patients who plan to undergo BS and propose combined recommendations for vegetarian patients who undergo BS, based on our clinical experience and current scientific literature in both nutrition fields. Cross-sectional analysis of a prospectively maintained database of all primary laparoscopic sleeve gastrectomies (LSG) performed at a bariatric center of excellence between January 2014 and November 2016 was carried out querying patients who declared a vegetarian or vegan lifestyle before surgery. Preoperative data collected included demographics, anthropometrics, dietary patterns, supplementation use, physical activity, smoking habits, co-morbidities, and blood tests. Each vegetarian was matched to five different omnivores based on age, gender, and BMI. During the study period, 1470 patients underwent primary LSG surgery (63.7% females). Twenty-one declared a vegetarian or vegan lifestyle (1.4%) pre-surgery. Most were classified as lacto-ovo (57.1%) and were driven from ethical reasons (85.7%). No differences were found between vegetarian and omnivore LSG candidates regarding co-morbidities and nutritional deficiencies, except for lower prevalence of impaired fasting glucose (14.3 vs. 47.1%;P = 0.007), lower ferritin levels (54.3 ± 50.5 vs. 96.8 ± 121.8 ng/ml; P = 0.052) and higher transferrin levels (313.9 ± 42.7 vs. 278.4 ± 40.4 mg/dl; P = 0.009) among the vegetarian cohort. Preoperative use of vitamin B12 and iron supplementation was higher among vegetarian LSG candidates than their omnivore counterparts (57.1 vs. 6.7%;P

Probiotics are commonly used after bariatric surgery; however, uncertainty remains regarding their efficacy. Our aim was to compare the effect of probiotics vs placebo on hepatic, inflammatory and clinical outcomes following laparoscopic sleeve gastrectomy (LSG). This randomized, double-blind, placebo-controlled, trial of 6-month treatment with probiotics (Bio-25; Supherb) vs placebo and 6 months of additional follow-up was conducted among 100 morbidly obese nonalcoholic fatty liver disease (NAFLD) patients who underwent LSG surgery. The primary outcome was a reduction in liver fat content, measured by abdominal ultrasound, and secondary outcomes were improvement of fibrosis, measured by shear-wave elastography, metabolic and inflammatory parameters, anthropometrics and quality of life (QOL). Fecal samples were collected and analyzed for microbial composition. One hundred patients (60% women, mean age of 41.9±9.8 years and body mass index of 42.3±4.7 kg m−2) were randomized, 80% attended the 6-month visit and 77% completed the 12-month follow-up. Fat content and NAFLD remission rate were similarly reduced in the probiotics and placebo groups at 6 months postsurgery (−0.9±0.5 vs −0.7±0.4 score; P=0.059 and 52.5 vs 40%; P=0.262, respectively) and at 12 months postsurgery. Fibrosis, liver-enzymes, C-reactive protein (CRP), leptin and cytokeratin-18 levels were significantly reduced and QOL significantly improved within groups (P⩽0.014 for all), but not between groups (P⩾0.173 for all) at 6 and 12 months postsurgery. Within-sample microbiota diversity (alpha-diversity) increased at 6-month postsurgery compared with baseline in both study arms (P⩽0.008) and decreased again at 12 months postsurgery compared with 6 months postsurgery (P⩽0.004) but did not reach baseline values. Probiotics administration does not improve hepatic, inflammatory and clinical outcomes 6- and 12 months post-LSG.

Upside-down stomach is a relatively rare type of a large paraesophageal hernia characterized by the migration of the stomach into the posterior mediastinum. Upside-down stomach is prone to severe complications and therefore surgery is recommended even in asymptomatic patients. A 62-year-old male presented with frequent abdominal pain with nausea and vomiting that persisted for one year. The patient was obese with fatty liver and was treated medically for gastroesophageal reflux disease (GERD) for 4 years. On upper gastrointestinal CT study a level-IV paraesophageal hernia was detected with upside-down stomach, and he was referred for elective surgery. Laparoscopic surgery included reduction of the stomach into the abdominal cavity followed by dissection of the paraesophageal membrane and hernia sac. The hiatal defect was closed using a wound closure device and nonabsorbable sutures. The defect closure was reinforced using Physiomesh tucked anteriorly and sutured posteriorly to the diaphragm. Follow-up was uneventful and the patient is free of complaints. The results of this surgical intervention support previous reports that laparoscopic repair with the use of biological mesh in the setting of large paraesophageal hernia should be favorably considered.

e17099 Background: Cytoreductive surgery is the most important prognostic factor in ovarian cancer. To identify in a timely manner the patients who are not candidates for optimal debulking, does not delay and optimize the treatment. Objetive: Identify the presurgical factors that characterize patients in whom optimal cytoreduction is not possible. Methods: Observational study in a retrospective cohort (n = 255) that compared pre-surgical factors between patients with optimal debulking (n = 65) and suboptimal (n = 190). Non-parametric tests were used, a Cox proportional hazards model was constructed and survival curves were drawn by method of Kaplan y Meier. Results: 255 patients were included. 75% achieved optimal debulking. 9 out of 10 evaluated tomography criteria showed association (p < 0.001) with suboptimal cytoreduction. The best cut-off value of Ca-125 to predict suboptimal surgery was 774 IU / mL. Only clinical ascites showed association with the result of the surgery (p < 0.001). There was no difference in complications between both groups (p = 0.267). The rate of optimal debulking has improved over time (p = 0.049). The turn of the surgeries has no impact on the overall survival of the patients (p = 0.792). Conclusions: Objective parameters (tomography and laboratory) should be used to select patients who are not candidates for surgery. The Clinical evaluation without objective parameters is not enough