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A growing body of evidence supports the efficacy and safety of bariatric surgery for clinically severe obesity. Despite this empirical support, bariatric surgery remains profoundly underutilized. The reasons for underutilization are likely multifactorial, including health insurance coverage and benefits design, lack of awareness about bariatric surgery by patients, and anecdotal concerns about safety. We believe that there are two other factors-the occurrence of weight stigma and bias and suboptimal communication between patients and providers-that also serve as barriers to greater utilization. The article reviews the existing literature related to these two factors. The review also highlights the science of shared medical decision-making as a potential strategy to promote appropriate conversations between patients and providers, both surgical and nonsurgical, about the efficacy and safety of bariatric surgery. Shared medical decision-making is used in other areas where complex medical decisions are required. We believe that it has great potential to contribute to the increased utilization for the millions of individuals who could benefit from bariatric surgery.

Background The public health impact of the coronavirus disease 2019 (COVID-19) pandemic has motivated a rapid search for potential therapeutics, with some key successes. However, the potential impact of different treatments, and consequently research and procurement priorities, have not been clear. Methods Using a mathematical model of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, COVID-19 disease and clinical care, we explore the public-health impact of different potential therapeutics, under a range of scenarios varying healthcare capacity, epidemic trajectories; and drug efficacy in the absence of supportive care. Results The impact of drugs like dexamethasone (delivered to the most critically-ill in hospital and whose therapeutic benefit is expected to depend on the availability of supportive care such as oxygen and mechanical ventilation) is likely to be limited in settings where healthcare capacity is lowest or where uncontrolled epidemics result in hospitals being overwhelmed. As such, it may avert 22% of deaths in high-income countries but only 8% in low-income countries (assuming R = 1.35). Therapeutics for different patient populations (those not in hospital, early in the course of infection) and types of benefit (reducing disease severity or infectiousness, preventing hospitalization) could have much greater benefits, particularly in resource-poor settings facing large epidemics. Conclusions Advances in the treatment of COVID-19 to date have been focused on hospitalized-patients and predicated on an assumption of adequate access to supportive care. Therapeutics delivered earlier in the course of infection that reduce the need for healthcare or reduce infectiousness could have significant impact, and research into their efficacy and means of delivery should be a priority.

Coronavirus disease 2019 (COVID-19) is associated with cardiovascular (CV) complications including myocardial injury, myocarditis, arrhythmias, and venous thromboembolism. The infection is more severe in patients with pre-existing cardiovascular disease (CVD), where systemic inflammation due to cytokine storm, hypercoagulation, as well as high hematocrit and platelet (PLT) count may contribute to an increased CV risk. The authors hypothesize that anticoagulants and antiplatelets prevent miocardial infarction (MI) in patients with pre-existing CVD.A cohort study enrolled patients with a confirmed diagnosis of COVID-19. Clinical and laboratory data, total and CV mortality, as well as MI incidence and treatment regimens were compared according to the time of hospitalization: 40-day period in April-May (Group 1) and in October-November (Group 2).A total of 195 patients were enrolled: 93 in Group 1, with 36.5%, and 102 in Group 2 with 38.2% pre-existing CVD. Group 1 was managed with infusion therapy; only 10.7% received anticoagulation. Group 2 received preventive anticoagulants, antiplatelets, and infusion therapy. In Group 1, seven cases of MI were recorded compared to only three in Group 2. No significant difference in overall mortality (4.3% vs 6.86%, p = 0.441) and MI incidence (7.5% vs 2.9%, p = 0.149) was found, but significant differences were seen in the incidence of severe and critically ill cases between the groups (69.9% and 7.5% vs 75.5% and 20.6%, p 0.001).Poorer outcomes in the early COVID-19 wave were associated with inadequate anticoagulation due to lack of knowledge about the new virus. Despite significantly more severe cases, there was no significant difference in overall mortality and MI incidence in patients with anticoagulation.HINTERGRUND: „Coronavirus disease 2019“ (COVID-19) ist mit kardiovaskulären (KV) Komplikationen, einschließlich Myokardinfarkt (MI), Myokarditis, Arrhythmien und venösen Thrombembolien, assoziiert. Die Infektion verläuft bei Menschen mit vorbestehenden KV-Erkrankungen schwerer, bei denen systemische Inflammation aufgrund der Hyperzytokinämie, Hyperkoagulation sowie erhöhte Hämatokrit- und Thrombozytenwerte zu einem erhöhten KV-Risiko beitragen könnten. Die Autoren stellen die Hypothese auf, dass ein Herzinfarkt bei Menschen mit präexistenten KV-Erkrankungen durch Antikoagulanzien und Thrombozytenaggregationshemmer verhindert werden kann.In die Kohortenstudie wurden Patienten mit bestätigter COVID-19-Diagnose aufgenommen. Deren klinische Parameter und Labordaten, Gesamtsterblichkeit und kardiovaskuläre Mortalität, MI-Inzidenz und die Behandlungsmodalitäten wurden, abhängig vom Zeitraum des Krankenhausaufenthalts (40-Tages-Zeitraum im April/Mai [Gruppe 1] bzw. Oktober/November [Gruppe 2]), verglichen.Insgesamt wurden 195 Patienten in die Studie aufgenommen: 93 in Gruppe 1 und 102 in Gruppe 2, davon 36,5 % (Gruppe 1) bzw. 38,2 % (Gruppe 2) mit vorbestehender KV-Erkrankung. Die Patienten in Gruppe 1 erhielten eine Infusionstherapie, nur 10,7 % wurden mit Antikoagulanzien behandelt. Bei Gruppe 2 kamen präventiv Antikoagulanzien und Thrombozytenaggregationshemmer zusätzlich zur Infusionstherapie zum Einsatz. In Gruppe 1 erlitten 7 Patienten einen MI, in Gruppe 2 nur 3. Keine signifikanten Unterschiede zwischen beiden Gruppen wurden bezüglich der Gesamtsterblichkeit (4,3 % vs. 6,86 %, p = 0,441) und MI-Inzidenz (7,5 % vs. 2,9 %, p = 0,149) festgestellt, jedoch hinsichtlich der Inzidenz schwerer und kritisch kranker Fälle (69,9 % und 7,5 % vs. 75,5 % und 20,6 %, p 0,001).Schlechtere Behandlungsresultate in der frühen COVID-19-Phase waren mit inadäquater Antikoagulation aufgrund fehlender Kenntnisse über das neue Virus assoziiert. Trotz der signifikant schwereren Verläufe ergaben sich keine signifikanten Unterschiede bezüglich der Gesamtsterblichkeit und der Herzinfarktinzidenz bei Patienten unter Antikoagulation.

The aim of the study is to demonstrate, using a clinical example, the possibility of treating a patient with a severe acetabular defect by performing a one-stage revision arthroplasty using an individual design. Materials and methods. A 45-year-old female patient was admitted with complaints of pain, limitation of movement in the right hip joint, and gait disturbance. From anamnesis at the age of 5 years, reconstructive operations of the hip joints were performed. In 1991, CITO performed primary total arthroplasty of the right hip joint with an endoprosthesis from ESKA Implants. In 1998, due to the instability of the acetabular component of the total endoprosthesis of the right hip joint, revision arthroplasty was performed, and the cup was placed with a cement fixation. In 2001, for left-sided dysplastic coxarthrosis, primary total arthroplasty of the left hip joint was performed. In 2012, due to the instability of the total endoprosthesis of the left hip joint, revision arthroplasty was performed using an ESI anti-protrusion ring (ENDOSERVICE) with a cement cup and a Zweimller-type femoral component; the femur defect was repaired using a fresh frozen cortical graft. In October 2019, instability of the total endoprosthesis of the right hip joint was revealed, for which revision endoprosthetics was performed using an individual acetabular component. Results. The HHS index before revision arthroplasty was 21 points, after 1 month after surgery 44 points, after 3 months after surgery 65, after 6 months 82. Quality of life was assessed according to the WOMAC scale: before surgery 73 points, after 1 month after surgery 54 points, after 3 months 31, after 6 months 15 points. At the time of the last consultation, the patient moves with a cane, lameness persists, associated with scar reconstruction and atrophy of the gluteal muscles. Conclusion. The use of individual structures allows to restore the support ability of the lower limb and the function of the hip joint in the case of an extensive defect of the pelvic bones of the pelvic discontinuity type.

Purpose: The aim of this study was to improve patient oral hygiene outcomes in a rehabilitation unit by implementing a nursing education package and oral hygiene assessment tool. Design: A case–control design with 50 rehabilitation patients was performed. Methods: Nursing staff received education and training in applying the Modified Oral Health Assessment Tool. Clinician assessment of patient oral hygiene occurred on admission and at days 5–7. Each patient reported their perceptions of oral hygiene and comfort prior to hospitalization, while in the hospital, and after transfer to the rehabilitation unit. Findings: Oral hygiene rating scores improved significantly from admission to the rehabilitation unit to days 5–7 (p = .00). The mean score of patient perceived cleanliness improved from hospital admission to admission to the rehabilitation unit. Conclusion: Oral hygiene was improved following admission to a rehabilitation unit with a consistent and individualized approach to oral hygiene. Clinical Relevance: The introduction of a consistent and individualized approach to oral hygiene demonstrates positive patient outcomes and high patient acceptance.

We describe our experiences with organizing pro bono medical genetics and neurology outreach programs on several different resource-limited islands in the West Indies. Due to geographic isolation, small population sizes, and socioeconomic disparities, most Caribbean islands lack medical services for managing, diagnosing, and counseling individuals with genetic disorders. From 2015 to 2019, we organized 2-3 clinics per year on various islands in the Caribbean. We also organized a week-long clinic to provide evaluations for children suspected of having autism spectrum disorder. Consultations for over 100 different individuals with suspected genetic disorders were performed in clinics or during home visits following referral by locally registered physicians. When possible, follow-up visits were attempted. When available and appropriate, clinical samples were shipped to collaborating laboratories for molecular analysis. Laboratory tests included karyotyping, cytogenomic microarray analysis, exome sequencing, triplet repeat expansion testing, blood amino acid level determination, biochemical assaying, and metabolomic profiling. We believe that significant contributions to healthcare by genetics professionals can be made even if availability is limited. Visiting geneticists may help by providing continuing medical education seminars. Clinical teaching rounds help to inform local physicians regarding the management of genetic disorders with the aim of generating awareness of genetic conditions. Even when only periodically available, a visiting geneticist may benefit affected individuals, their families, their local physicians, and the community at large.

EXECUTIVE SUMMARY This study examined whether usage of clinical data from the electronic health record (EHR) to create organizational- and unit-level performance dashboards and assess adherence to clinical practice guidelines is associated with hospital outcomes in risk-adjusted 30-day readmissions for patients with a principal diagnosis of heart failure (HF). It further assesses the association between the metrics of hospital financial health and the usage of those EHR-generated tools.A cross-sectional study design was used. The study used data from the 2016 American Hospital Association Annual Survey Information Technology Supplement, the Pennsylvania Health Care Cost Containment Council's (PHC4's) 2017 Hospital Performance Report, and the PHC4 General Acute Care Hospitals Financial Analysis Report for fiscal year 2017. Contingency tables, likelihood-ratio chi-square tests, and logistic regression were applied for data analysis.Usage of the EHR to assess adherence to clinical practice guidelines and create EHR-generated unit-level performance dashboards, rather than organizational performance dashboards, was more strongly associated with the hospitals' rating in risk-adjusted 30-day readmissions for HF patients. An increase in hospitals' operating margin was associated with greater odds of the usage of the discussed EHR tools, after controlling for hospital control/ownership and the total number of beds.Usage of some EHR-generated analytical tools may be more strongly associated with lower-than-expected 30-day hospital readmissions in HF patients than with other tools. Better hospital financial health is linked with greater uptake of the discussed analytical tools. Further research could help to determine which EHR-generated tools are more effective in improving hospital outcomes in HF.

Aims/Objectives: Understand the relationship between auditory input and balance motor control. Material and Methods: Twelve prelingual adolescent cochlear implant users (CIU) and 12 adult postlingu...

The ongoing coronavirus disease 2019 (COVID-19) pandemic poses a severe threat to public health worldwide. We combine data on demography, contact patterns, disease severity, and health care capacity and quality to understand its impact and inform strategies for its control. Younger populations in lower-income countries may reduce overall risk, but limited health system capacity coupled with closer intergenerational contact largely negates this benefit. Mitigation strategies that slow but do not interrupt transmission will still lead to COVID-19 epidemics rapidly overwhelming health systems, with substantial excess deaths in lower-income countries resulting from the poorer health care available. Of countries that have undertaken suppression to date, lower-income countries have acted earlier. However, this will need to be maintained or triggered more frequently in these settings to keep below available health capacity, with associated detrimental consequences for the wider health, well-being, and economies of these countries.

Moebius syndrome is a congenital neurological disorder that impacts facial expression, communication and appearance. In this article, the authors will discuss the psychological and social impacts of living with this rare form of facial palsy. Existing research suggests that patients may face challenges in developing psychological wellbeing, positive body image and in communicating effectively with others. Therefore, recommendations for nursing practitioners in how to best support this patient group are discussed.

OBJECTIVE: Due to the recent COVID-19 pandemic, the field of neuropsychology must rapidly evolve to incorporate assessments delivered via telehealth, or teleneuropsychology (TNP). Given the increasing demand to deliver services electronically due to public health concerns, it is important to review available TNP validity studies. This systematic review builds upon the work of Brearly and colleagues’ (2017) meta-analysis and provides an updated review of the literature, with special emphasis on test-level validity data. METHOD: Using similar methodology as Brearly and colleagues (2017) three internet databases (PubMed, EBSCOhost, PsycINFO) were searched for relevant articles published since 2016. Studies with older adults (aged 65+) who underwent face-to-face and TNP assessments in a counterbalanced cross-over design were included. After review, 10 articles were retained. Combined with 9 articles from Brearly’s (2017) analysis, a total of 19 studies were included in the systematic review. RESULTS: Retained studies included samples from 5 different countries, various ethnic/cultural backgrounds, and diverse diagnostic populations. Test-level analysis suggests there are cognitive screeners (MMSE, MoCA), language tests (BNT, Letter Fluency), attention/working memory tasks (Digit Span Total), and memory tests (HVLT-R) with strong support for TNP validity. Other measures are promising but lack sufficient support at this time. Few TNP studies have done in-home assessments and most studies rely on a PC or laptop. CONCLUSIONS: Overall, there appears to be good support for TNP assessments in older adults. Challenges to TNP in the current climate are discussed. Finally, a provisional outline of viable TNP procedures used in our clinic is provided.

Following the detection of the new coronavirus1 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its spread outside of China, Europe has experienced large epidemics of coronavirus disease 2019 (COVID-19). In response, many European countries have implemented non-pharmaceutical interventions, such as the closure of schools and national lockdowns. Here we study the effect of major interventions across 11 European countries for the period from the start of the COVID-19 epidemics in February 2020 until 4 May 2020, when lockdowns started to be lifted. Our model calculates backwards from observed deaths to estimate transmission that occurred several weeks previously, allowing for the time lag between infection and death. We use partial pooling of information between countries, with both individual and shared effects on the time-varying reproduction number (Rt). Pooling allows for more information to be used, helps to overcome idiosyncrasies in the data and enables more-timely estimates. Our model relies on fixed estimates of some epidemiological parameters (such as the infection fatality rate), does not include importation or subnational variation and assumes that changes in Rt are an immediate response to interventions rather than gradual changes in behaviour. Amidst the ongoing pandemic, we rely on death data that are incomplete, show systematic biases in reporting and are subject to future consolidation. We estimate that-for all of the countries we consider here-current interventions have been sufficient to drive Rt below 1 (probability Rt

Paradoxical adipose hyperplasia (PAH) following cryolipolysis is a rare but deforming complication. This likely underreported adverse event has been described as being refractory to both traditional tumescent liposuction and repeated cryolipolysis treatments. Here, we present 3 isolated cases with PAH deformity created by cryolipolysis. Management of PAH on the abdomen and flanks involved 2 key elements: ultrasound-assisted liposuction (UAL) technology and helium-activated radiofrequency (RF) energy subdermal coagulation. We observed complete resolution and definitive correction of PAH deformities at 2 weeks, 1 month, and 3 months postoperatively. UAL combined with helium-activated RF subdermal coagulation is a viable surgical modality to correct contour irregularities seen in PAH following cryolipolysis.

The anti-angiogenic effects of bisphosphonates have been hypothesized as one of the major etiologic factors in the development of medication-related osteonecrosis of the jaw (MRONJ), a severe debilitating condition with limited treatment options. This study evaluated the potential of a gelatine-hyaluronic acid hydrogel loaded with the angiogenic growth factor, vascular endothelial growth factor (VEGF), as a local delivery system to aid in maintaining vascularization in a bisphosphonate-treated (Zoledronic Acid) rodent maxillary extraction defect. Healing was assessed four weeks after implantation of the VEGF-hydrogel into extraction sockets. Gross examination and histological assessment showed that total osteonecrosis and inflammatory infiltrate was significantly reduced in the presence of VEGF. Also, total vascularity and specifically neovascularization, was significantly improved in animals that received VEGF hydrogel. Gene expression of vascular, inflammatory and bone specific markers within the defect area were also significantly altered in the presence of VEGF. Furthermore, plasma cytokine levels were assessed to determine the systemic effect of locally delivered VEGF and showed similar outcomes. In conclusion, the use of locally delivered VEGF within healing extraction sockets assists bone healing and prevents MRONJ via a pro-angiogenic and immunomodulatory mechanism.

Introduction The Eliminate Yellow fever Epidemics (EYE) strategy was launched in 2017 in response to the resurgence of yellow fever in Africa and the Americas. The strategy relies on several vaccination activities, including preventive mass vaccination campaigns (PMVCs). However, by how much PMVCs are associated with a decreased risk of outbreak to occur has not yet been quantified. Methods and Findings We used the self-controlled case series (SCCS) method to assess the association between the occurrence of yellow fever outbreaks and the implementation of PMVCs at the province level in the African endemic region. As all time-invariant confounders are implicitly controlled for, the SCCS method is an alternative to classical cohort or case-control study designs when the risk of residual confounding is high, in particular confounding by indication. The location and dates of outbreaks were identified from international epidemiological records, and information on PMVCs was provided by coordinators of vaccination activities and international funders. The study sample consisted of provinces that were both affected by an outbreak and targeted for a PMVC between 2005 and 2018. We compared the relative incidence of outbreaks before and after the implementation of a PMVC. The sensitivity of our estimates to a range of assumptions was explored, and the results of the SCCS method were compared to those obtained through a retrospective cohort study design. We further derived the number of yellow fever outbreaks that have been prevented by PMVCs. The study sample consisted of 33 provinces from 11 African countries. Among these, outbreaks occurred during the pre-PMVC period in 26 (79%) provinces versus 7 (21%) occurring in the post-PMVC period. At the province level, the post-PMVC period was associated with a 86% reduction (95% Confidence interval 66% to 94%, p-value A limitation of our study is the fact that it does not account for potential time-varying confounders, such as changing environmental drivers of yellow fever or possibly improved disease surveillance. Conclusion In this study, we provide new empirical evidence of the high preventive impact of PMVCs on yellow fever outbreaks. This study illustrates that the SCCS method can be advantageously applied at the population level in order to evaluate a public health intervention. AUTHOR SUMMARY Why Was This Study Done? Yellow fever is a mosquito-borne vaccine-preventable disease that may cause large urban outbreaks, especially in tropical African regions. Since 2006, Preventive Mass Vaccination Campaigns (PMVCs) have been implemented in many African provinces. These are large scale vaccination campaigns targeting all or most age group in a specific area. The preventive impact PMVCs may have on the risk of yellow fever outbreak has not been quantified yet. What Did the Researchers Do and Find? We used the self-controlled case series (SCCS) method to assess the association between PMVCs and outbreak risk at the province level over 34 African countries between 2005 and 2018. Using this method, we compared pre- and post-PMVC period are compared within each province individually, thus controlling for all possible confounders that do not vary in time, especially the fact that provinces indicated for PMVCs are generally those considered at highest baseline risk of yellow fever (ie confounding by indication). At the province level, we estimated that implementation of PMVCs was associated with an 86% reduction (66% to 94%) in the risk of yellow fever outbreak. Results from a complete cohort analysis provided less reliable results than the SCCS method, likely because of confounding by indication that was not entirely controlled for by adjusting on known drivers of yellow fever. We further estimated that all PMVCs conducted between 2006 and 2018 in Africa may have reduced the total number of yellow fever outbreaks by 34% (22% to 45%). What Do These Findings Mean? These results provide new empirical evidence of the high preventive impact of PMVCs on yellow fever outbreaks. These results may encourage rapid re-scheduling of yellow fever PMVCs that have been postponed due to the COVID-19 pandemic. The SCCS design may be advantageously applied at the population level to assess the impact of public health interventions.

BackgroundThe unprecedented public health impact of the COVID-19 pandemic has motivated a rapid search for potential therapeutics, with some key successes. However, the potential impact of different treatments, and consequently research and procurement priorities, have not been clear.Methods and FindingsWe develop a mathematical model of SARS-CoV-2 transmission, COVID-19 disease and clinical care to explore the potential public-health impact of a range of different potential therapeutics, under a range of different scenarios varying: i) healthcare capacity, ii) epidemic trajectories; and iii) drug efficacy in the absence of supportive care. In each case, the outcome of interest was the number of COVID-19 deaths averted in scenarios with the therapeutic compared to scenarios without. We find the impact of drugs like dexamethasone (which are delivered to the most critically-ill in hospital and whose therapeutic benefit is expected to depend on the availability of supportive care such as oxygen and mechanical ventilation) is likely to be limited in settings where healthcare capacity is lowest or where uncontrolled epidemics result in hospitals being overwhelmed. As such, it may avert 22% of deaths in high-income countries but only 8% in low-income countries (assuming R=1.35). Therapeutics for different patient populations (those not in hospital, early in the course of infection) and types of benefit (reducing disease severity or infectiousness, preventing hospitalisation) could have much greater benefits, particularly in resource-poor settings facing large epidemics.ConclusionsThere is a global asymmetry in who is likely to benefit from advances in the treatment of COVID-19 to date, which have been focussed on hospitalised-patients and predicated on an assumption of adequate access to supportive care. Therapeutics that can feasibly be delivered to those earlier in the course of infection that reduce the need for healthcare or reduce infectiousness could have significant impact, and research into their efficacy and means of delivery should be a priority.

Background Insurance-mandated precertification requirements are barriers to bariatric surgery. The value of their prescription, based on insurance type rather that the clinical necessity, is unclear. Objectives To determine whether there is an association between insurance-mandated precertification criteria for bariatric surgery and short-term inpatient healthcare utilization. Setting Pennsylvania Health Care Cost Containment Council's inpatient care databases for the years 2016-2017. Methods The study included 2717 adults who underwent bariatric surgery in Southeastern Pennsylvania in 2016. Postoperative length of stay and rehospitalizations for these individuals were followed using clinical and claims data during the first year after bariatric surgery. Results The requirements for 3- to 6-month preoperative medical weight management, as well as pulmonology and cardiology examinations, were not associated with the patient length of stay, number of all-cause rehospitalizations, or number of all-cause rehospitalization days after adjusting for patient age, sex, race, ethnicity, the Elixhauser comorbidity score, type of the surgery, facility where the surgery was performed, primary payer type, and the estimated median household income. Among commercially insured individuals (n = 1499), the mean number of all-cause rehospitalizations during the study period was lower in patients with no medical weight management requirement by a factor of .57 (lower by 43.1%; 95% confidence interval, .35-.94, P = .03) and higher in patients with no requirement for preoperative cardiology and pulmonology evaluations by a factor of 2.09 (95% confidence interval 1.09-4.02, P = .03). Conclusion The findings suggest that the precertification requirement for preoperative medical weight management is not associated with a reduction in inpatient healthcare utilization in the first postoperative year.

Background Long-term durability of weight loss is a prerequisite for a greater acceptance of bariatric surgery. Objective To examine long-term weight trajectory in patients undergoing Roux-en-Y gastric bypass (RYGB) and determine factors predicting long-term follow-up and weight outcomes. Setting University Hospital. Methods A retrospective cohort of adults who underwent RYGB during 1997-2010 were identified and followed until 2017. Predictors for attendance at periodic follow-up visits, reduction in body mass index (BMI), and percent excess BMI lost were determined using multivariable logistic regression and linear mixed-effects models. The latter was used to predict long-term weight outcomes for a typical patient. Results The study included 1,104 patients with a mean age of 45.5 (standard deviation, SD, 9.9) years and a pre-operative BMI of 54.7 (SD 10.9) kg/m2. Follow-up data were available for 92.8% of the patients after 1 year, 50.0% after 5 years, and 35.2% after 10 years post-surgery. Black patients, compared to White individuals, were less likely to attend follow-up visits. Attendance at follow-up visits at least every other year was not associated with larger weight loss, but higher pre-operative BMI, being White (vs. Black), and female sex were. Predicted BMI reduction for a typical patient, a 45-year-old White female with a pre-operative BMI of 54.7 kg/m2 and private health insurance, undergoing laparoscopic RYGB in 2004, was 18.3 (standard error, SE, 0.36) kg/m2 at year 5 and 17.6 (SE 0.49) kg/m2 at year 10, respectively. Conclusions RYGB results in clinically significant and durable weight loss. Attendance at periodic follow-up visits does not appear to be associated with long-term weight loss outcomes. Future work should focus on strategies to remove barriers to post-operative care.

BackgroundSub-Saharan Africa has seen substantial reductions in cases and deaths due to malaria over the past two decades. While this reduction is primarily due to an increasing expansion of interventions, urbanisation has played its part as urban areas typically experience substantially less malaria transmission than rural areas. However, this may be partially lost with the invasion and establishment of Anopheles stephensi. An. stephensi, the primary urban malaria vector in Asia, was first detected in Africa during 2012 in Djibouti and was subsequently identified in Ethiopia in 2016, and later in Sudan and Somalia. In Djibouti, malaria cases have increased 30-fold from 2012 to 2019 though the impact in the wider region remains unclear.MethodsHere we have adapted an existing model of mechanistic malaria transmission to estimate the increase in vector density required to explain the trends in malaria cases seen in Djibouti. To account for the observed plasticity in An. stephensi behaviour, and the unknowns of how it will establish in a novel environment, we sample behavioural parameters in order to account for a wide range of uncertainty. This quantification is then applied to Ethiopia, considering temperature-dependent extrinsic incubation periods, pre-existing vector-control interventions and Plasmodium falciparum prevalence in order to assess the potential impact of An. stephensi establishment on P. falciparum transmission. Following this, we estimate the potential impact of scaling up ITN (insecticide treated nets)/IRS (indoor residual spraying) and implementing piperonyl butoxide (PBO) ITNs and larval source management,, as well as their economic costs.ResultsWe estimate that annual P. falciparum malaria cases could increase by 50% (95% CI 14-90) if no additional interventions are implemented. The implementation of sufficient control measures to reduce malaria transmission to pre-stephensi levels will cost hundreds of millions of USD.ConclusionsSubstantial heterogeneity across the country is predicted and large increases in vector control interventions could be needed to prevent a major public health emergency.

Background/Objectives: The allocation of attention can alter the perception of magnitude. When performing line bisections, young adults deviate leftward (pseudoneglect), a bias thought to be induced by right hemisphere dominance for allocating spatial attention. However, when performing body bisections young adults deviate rightward, suggesting left hemisphere dominance for allocating body-centered attention. With aging, there is a reduction of pseudoneglect thought to result from either an age-related decrease in right hemispheric functions (right hemi-aging) or from hemispheric asymmetry reduction in older adults (HAROLD). The goal of this study was to learn if there are tactile body-centered perceptual-attentional right-left asymmetries in that change with aging. Methods: The participants were younger and older healthy adults. Semmes-Weinstein Monofilaments were used to test for differences in the perceived magnitude of pressure differences between a reference stimulus and test stimuli applied to the right and left palmar thenar eminence. Results: Young adults perceived the magnitude of difference in the lightest pressure stimuli applied to the right hand as being greater than the older adults. Young adults perceived the magnitude of difference between the lightest pressure and reference applied to the right hand to be greater than the left hand, but older adults perceived a lighter stimulus greater on the left compared to the right. Conclusions: Whereas the right hemisphere appears to be dominant in mediating spatial attention, the left hemisphere may play a dominant role in the allocation of body-centered attention. Like the aging-related reduction of the visual perception of the magnitude (length) of the left side of a line, this tactile reduction in magnitude (pressure) perception in older adults suggests that with aging, there is a reduction of left-hemispheric mediated allocation of tactile attention, and this result is not fully consistent with either the HAROLD or hemi-aging models.

Objective In the 50 years since a premature partial physeal arrest (a physeal bar) was first excised from an epiphysis there have been no large in-depth studies reporting the results in patients followed to skeletal maturity. This paper reports the results of physeal bar resection surgery in a group of patients followed to skeletal maturity, documenting the restored growth of the affected physis, the affected bone, and the final limb-length discrepancy. Methods Forty-eight patients underwent physeal bar resection of the distal femur (21), proximal tibia (9), and distal tibia (18) by 1 surgeon (H.A.P.) from 1968 through 1996, and were followed prospectively to skeletal maturity with clinical and radiologic examinations. Factors such as sex, age at time of injury, etiology of the bar, physeal bar location and size, age at time of bar excision, interposition material, and additional surgical procedures were analyzed with respect to physis, bone, and limb growth following bar resection. Results The mean growth for the entire bone following physeal bar excision was 7.6 cm for the distal femur, 4.7 cm for the proximal tibia, and 7.5 cm for the distal tibia, compared with growth in the contralateral control bone of 6.8 cm in the femur, 5.0 cm in the proximal tibia, and 7.8 cm in the distal tibia. The maximum bone growth following bar excision in a single patient was 21.3 cm for the distal femur, 10.3 cm for the proximal tibia, and 18.6 cm for the distal tibia. The mean limb-length discrepancy at maturity was -1.7 cm for the distal femur, -1.3 cm for the proximal tibia, and -1.1 cm for the distal tibia (all sites combined -1.4 cm). Fourteen patients (29%) had only the 1 bar excision with no other accompanying or subsequent surgery. Thirty-four patients (71%) had 1 to 4 accompanying or subsequent leg length or angular correcting procedures. Conclusions Physeal bar excision to restore growth when applied to the appropriate patient is a useful, rewarding procedure, reducing the number of surgical limb length equalizing procedures. It is a demanding surgical procedure and requires diligent and careful follow-up until maturity. Additional limb length equalizing surgery is frequently needed. Level of evidence Case series, level IV.

Background Information about the role of auditory input and motor control is limited. Objectives Assessment the relationship between auditory and vestibular information with specific motor and cognitive functions. Methods Posturography in 17 Pre-lingual Cochlear Implant Adolescents, (PCIA) age 14.06 ± 3.05 in four sensory conditions was analyzed: (A) eyes open, cochlear implant (CI) on, (B) eyes open, CI off, (C) eyes closed standing on a foam over a platform (ECFP) with CI on, and (D) ECFP, CI off. Gait velocity (GV) was registered by inertial sensors using a 10-meter test. Vestibulo-ocular reflex (VOR) was evaluated with the video head impulse test (VHIT) and visual spatial skill (VS) assessed with the WISC-V test. Results SV had no significant difference between conditions A and B (p = .2461). Comparing C and D, SV values decreased when CI was turned on (p = .0036). A significant linear relationship between VOR and GV (p = .0064) generating the VOR gain loss lower gait. Relationship between VOR and VS scores was no significant (p = .685). Conclusions and significance Auditory information is a relevant cue when somatosensory and visual inputs are modified and range of vestibular function influence in a dynamic motor activity as gait, facts which must be considered in the neurodevelopment control.

Despite the effectiveness of bariatric surgery, both with respect to weight loss and improvements in obesity-related co-morbidities, it remains underused. Only 1% of the currently eligible population undergoes surgical treatment for obesity, with roughly 228,000 individuals receiving bariatric surgery in the United States each year. Several barriers to bariatric surgery have been identified, including limited patient and referring physician knowledge and attitudes regarding the effectiveness and safety of bariatric surgery. However, the role of insurance coverage and benefit design as a barrier to access to care has received less attention to date. Bariatric surgery is cost-effective compared with nonsurgical treatments among individuals with extreme obesity and type 2 diabetes. While it may not result in cost savings among all bariatric surgery eligible patients, for certain patient subgroups, bariatric surgery may be cost neutral compared with traditional treatment options. In addition, longer-term outcomes of bariatric surgery suggest decreased or stable costs in the long run. The purpose of this review paper was to synthesize the existing knowledge on why bariatric surgery remains largely underused in the United States with a focus on health insurance benefits and design. In addition, the review discusses the applicability of value-based insurance design to bariatric surgery. Value-based insurance design has been previously applied to bariatric surgery coverage with use of incentive-based cost-sharing adjustments. Its application could be further extended because the postoperative clinical outcomes and costs vary among the different subgroups of bariatric surgery eligible patients.

Despite the potential negative impact of facial palsy, major gaps in understanding persist surrounding the treatment and care of those affected. This collaborative three-round Delphi process aimed to identify priorities for future facial palsy research, from the perspective of clinicians, researchers, patients and carers. It also determined whether the research priorities of patients and carers aligned with those of health professionals and researchers. In Round 1, participants (n = 85) were asked to generate research questions by focus groups or an online or postal survey. In Rounds 2 (n = 72) and 3 (n = 78), participants were asked to rate the priorities identified on a 5-point ordinal scale. Thirty-six questions reached the definition of 'high priority' consensus. Seven of each groups' top ten research priorities were shared. Prioritised questions included the provision and pathways of care, the psychosocial impact of living with facial palsy and the effective management of side effects. Establishing the research priorities in the field of facial palsy is a significant first step in ensuring that the future research agenda is focussed on topics that are considered important by both patients and health professionals.

The COVID-19 pandemic has resulted in substantial mortality worldwide. However, to date, countries in the Middle East and Africa have reported considerably lower mortality rates than in Europe and the Americas. Motivated by reports of an overwhelmed health system, we estimate the likely under-ascertainment of COVID-19 mortality in Damascus, Syria. Using all-cause mortality data, we fit a mathematical model of COVID-19 transmission to reported mortality, estimating that 1.25% of COVID-19 deaths (sensitivity range 1.00% – 3.00%) have been reported as of 2 September 2020. By 2 September, we estimate that 4,380 (95% CI: 3,250 – 5,550) COVID-19 deaths in Damascus may have been missed, with 39.0% (95% CI: 32.5% – 45.0%) of the population in Damascus estimated to have been infected. Accounting for under-ascertainment corroborates reports of exceeded hospital bed capacity and is validated by community-uploaded obituary notifications, which confirm extensive unreported mortality in Damascus., Reported COVID-19 mortality rates have been relatively low in Syria, but there has been concern about overwhelmed health systems. Here, the authors use community mortality indicators and estimate that

High-speed running density (HSRd) is the ratio of high-speed efforts and distance covered. This study aimed to evaluate differences in HSRd between training, games, and among positions in collegiate women's lacrosse, and correlate HSRd with other training metrics. Data were collected during a collegiate training year (practices n = 162, games n = 14) through players (n = 25) wearing microtechnology. HSRd differed between training sessions and games (p .001

To analyze in-hospital complications in patients with acute ST-elevation myocardial infarction (STEMI) depending on renal function.Observational study in patients with STEMI.The study included 169 patients undergoing primary percutaneous coronary intervention. In all patients glomerular filtration rate (GRF) was calculated using the Modification of Diet in Renal Disease Study (MDRD) equation. Of these patients, 84 had a GFR ≥ 90 ml/min/1.73 m2 (Group 1) and 85 90 ml/min/1.73 m2 (Group 2). Other parameters in both groups were comparable. Study groups were followed to compare Killip class 2 acute heart failure, in-hospital pneumonia, pulseless ventricular tachycardia or ventricular fibrillation, new onset atrial fibrillation, and high grade atrioventricular block. All patients were treated according to European Society of Cardiology (ESC) guidelines for the management of acute myocardial infarction in patients presenting with ST elevation.Mean GFR in Group 1 was 107.6 [Formula: see text] and in Group 2 75.3 [Formula: see text] 11.2 (p 0.0001). The incidence of atrial fibrillation was higher in Group 2: in Group 1 and Group 2 the atrial fibrillation rate was 1.12% (one of 84) vs 8.24% (seven of 85) (p = 0.031), respectively. Group 1 revealed significantly lower rates of acute heart failure (Killip class 2): in Group 1 and Group 2 0% (0 of 84 patients) vs 5.88% (five of 85 patients) (p = 0.024), respectively. The authors found no significant differences for other complications: in Group 1 and Group 2 ventricular tachycardia or ventricular fibrillation was 4.76% (four of 84 patients) vs 5.89% (five of 85 patients) (p = 0.75), high grade atrioventricular block was 2.38% (two of 84 patients) vs 4.71% (four of 85 patients) (p = 0.41), and the in-hospital pneumonia rate was 2.38% (two of 84 patients) vs 4.71% (four of 85 patients) (p = 0.41), respectively.Patients with lower GFR were more likely to suffer from in-hospital acute heart failure (Killip class 2) and atrial fibrillation in STEMI despite primary percutaneous coronary intervention. Renal function did not affect in-hospital pneumonia, pulseless ventricular tachycardia or ventricular fibrillation rates. The evaluation of kidney function through GFR in STEMI patients may make in-hospital complications more predictable.HINTERGRUND: Die sich stationär bei Patienten mit akutem ST-Hebungsinfarkt (STEMI [„ST-elevation myocardial infarction“]) ereignenden Komplikationen wurden bezüglich ihrer Abhängigkeit von der Nierenfunktion analysiert.Es handelte sich um eine Beobachtungsstudie bei STEMI-Patienten.In die Studie wurden 169 Patienten, die einer primären perkutanen koronaren Intervention unterzogen worden waren, eingeschlossen. Bei allen Probanden wurde die glomeruläre Filtrationsrate (GFR) mittels der Gleichung der MRDR-Studie (MDRD: „modification of diet in renal disease“) ermittelt. Von ihnen hatten 84 eine GFR ≥ 90 ml/min/1,73 m2 (Gruppe 1) und 85 eine GFR 90 ml/min/1,73 m2 (Gruppe 2). Andere Parameter beider Gruppen waren vergleichbar. Die Studiengruppen wurden bezüglich der Häufigkeit des Auftretens von akuter Herzinsuffizienz (Killip-Klasse 2), im Krankenhaus auftretender Pneumonie, pulsloser ventrikulärer Tachykardie oder Kammerflimmern, neu auftretendem Vorhofflimmern und hochgradigem atrioventrikulärem (AV) Block verglichen. Alle Patienten wurden nach den ESC-Leitlinien (ESC: „European Society of Cardiology“) zum Management des akuten Myokardinfarkts bei ST-Hebung behandelt.Die mittlere GFR in Gruppe 1 bzw. 2 war 107,6 [Formula: see text] bzw. 75,3 [Formula: see text]11,2 (p 0,0001). Die Inzidenz von Vorhofflimmern war in Gruppe 2 höher: In Gruppe 1 betrug diese 1,12 % (1 von 84), in Gruppe 2 8,24 % (7 von 85; p = 0,031). Bei den Probanden von Gruppe 1 kam es signifikant seltener zur akuten Herzinsuffizienz (Killip-Klasse 2): In Gruppe 1 trat diese bei 0 % (0 von 84 Patienten) auf vs. 5,88 % (5 von 85 Patienten) in Gruppe 2 (p = 0,024). Für die anderen Komplikationen wurden keine signifikanten Unterschiede festgestellt: Ventrikuläre Tachykardie oder Kammerflimmern traten in Gruppe 1 bei 4,76 % (4 von 84 Patienten), in Gruppe 2 bei 5,89 % (5 von 85 Patienten) auf (p = 0,75), ein hochgradiger AV-Block bei 2,38 % (2 von 84 Patienten) vs. 4,71 % (4 von 85 Patienten; p = 0,41), und stationär eine Pneumonie wurde bei 2,38 % (2 von 84 Patienten) bzw. 4,71 % (4 von 85 Patienten) beobachtet (p = 0,41).Bei Patienten mit STEMI und niedriger GFR kam es trotz primärer perkutaner koronarer Intervention eher zur akuten Herzinsuffizienz (Killip-Klasse 2) im Krankenhaus und Vorhofflimmern. Die Häufigkeiten des Auftretens von Pneumonie im Krankenhaus, pulsloser ventrikulärer Tachykardie oder Kammerflimmern waren nicht mit der Nierenfunktion assoziiert. Die Beurteilung der Nierenfunktion mittels GFR-Bestimmung bei STEMI-Patienten kann das Auftreten von Komplikationen im Krankenhaus vorhersehbarer machen.

The worldwide endeavour to develop safe and effective COVID-19 vaccines has been extraordinary, and vaccination is now underway in many countries. However, the doses available in 2021 are likely to be limited. We extended a mathematical model of SARS-CoV-2 transmission across different country settings to evaluate the public health impact of potential vaccines using WHO-developed target product profiles. We identified optimal vaccine allocation strategies within- and between-countries to maximise averted deaths under constraints on dose supply. We found that the health impact of SARS-CoV-2 vaccination depends on the cumulative population-level infection incidence when vaccination begins, the duration of natural immunity, the trajectory of the epidemic prior to vaccination, and the level of healthcare available to effectively treat those with disease. Within a country we find that for a limited supply (doses for

Child protection and mental health during conflict intersects with a variety of adverse conflict-related factors, and intervention outcomes in the field are often difficult to predict. Using the casefiles of 376 school children registered in a Mental Health and Psychosocial Support (MHPSS) project in the Northwest governorate of Idleb in Syria, this study aimed to determine (i) the rates of various protection concerns (potential mental health conditions, psychosocial deprivation issues, and social, behavioural and emotional issues) for students enrolled in this project, (ii) whether the rates of any of the protection concerns varied between children and adolescents, or between boys and girls, and (iii) which of the identified demographic and protection sector factors predicted the presence of potential mental health conditions and MHPSS intervention outcomes. MHPSS interventions (including individual MHPSS sessions tailored for children in conflict, resilience building activities, tutoring, peer building activities, community awareness, and other tailored services) were implemented at schools operated by the UK-based organization, Syria Relief. The variables tested included demographic variables of age group (208 children, aged 4–9 years; 168 adolescents, aged 10–14 years) and gender (211 males, 165 females), and 23 protection sector variables including 11 potential mental health problems (anxiety, attention deficit hyperactivity disorder, conduct disorder, autism, epilepsy, motor tics, depression, post-traumatic-stress disorder, social phobia, specific phobia, learning disability), 7 psychosocial deprivation (PSD) variables (war injury, child labour, loss of caregiver, neglect, domestic abuse, displacement, poverty), and 5 social, behavioural and emotional (SBE) variables (low/abnormal socialization, emotional issue, peer issues/being bullied, peer issues/being aggressive, educational decline). Within the sample, 73.7% were found with a probable mental health problem, with 30.6% showing signs of anxiety, 36.2% of depression and 26.6% showing signs of post-traumatic-stress disorder. Additionally, 74.5% of the sample had at least one form of PSD present (42.6% were displaced, 39.6% suffered from abject poverty), and 64.9% had a reported SBE concern. Children were more likely to have a potential mental health concern, especially autism and PTSD, and poor socialization; while adolescents were more likely to engage in child labour, experience abject poverty, exhibit aggressive behaviour, and educational decline. Male gender was associated with child labour and aggressive behaviour while female gender was associated with the presence of potential mental health problems, especially depression, and loss of caregiver, and poor socialisation. Odds ratios (ORs) indicated significant negative impact of the presence of SBE concerns (any), 4.45 (95% CI: 1.68–12.7), emotional issue, 11.02 (95% CI: 2.76–74.49), low/abnormal socialization, 8.37 (95% CI, 2–57.71), and displacement, 2.91 (95% CI, 1.21–7.48) on the child’s mental health. MHPSS intervention outcomes were categorized as case improvement, decline, or incomplete/limited information available; with case improvement noted for 63.6% of the sample, decline noted for 14.4%, and incomplete treatment/limited follow-up noted for 22.1% of the sample. Additional analysis of predictors of treatment success found that child labour was significantly associated with a lack of treatment success, OR 0.24 (95% CI, 0.07–0.92). These findings provide important insights into the complex tailoring needs that protection and MHPSS field projects require.

Background The Eliminate Yellow fever Epidemics (EYE) strategy was launched in 2017 in response to the resurgence of yellow fever in Africa and the Americas. The strategy relies on several vaccination activities, including preventive mass vaccination campaigns (PMVCs). However, to what extent PMVCs are associated with a decreased risk of outbreak has not yet been quantified. Methods and findings We used the self-controlled case series (SCCS) method to assess the association between the occurrence of yellow fever outbreaks and the implementation of PMVCs at the province level in the African endemic region. As all time-invariant confounders are implicitly controlled for in the SCCS method, this method is an alternative to classical cohort or case–control study designs when the risk of residual confounding is high, in particular confounding by indication. The locations and dates of outbreaks were identified from international epidemiological records, and information on PMVCs was provided by coordinators of vaccination activities and international funders. The study sample consisted of provinces that were both affected by an outbreak and targeted for a PMVC between 2005 and 2018. We compared the incidence of outbreaks before and after the implementation of a PMVC. The sensitivity of our estimates to a range of assumptions was explored, and the results of the SCCS method were compared to those obtained through a retrospective cohort study design. We further derived the number of yellow fever outbreaks that have been prevented by PMVCs. The study sample consisted of 33 provinces from 11 African countries. Among these, the first outbreak occurred during the pre-PMVC period in 26 (79%) provinces, and during the post-PMVC period in 7 (21%) provinces. At the province level, the post-PMVC period was associated with an 86% reduction (95% CI 66% to 94%, p < 0.001) in the risk of outbreak as compared to the pre-PMVC period. This negative association between exposure to PMVCs and outbreak was robustly observed across a range of sensitivity analyses, especially when using quantitative estimates of vaccination coverage as an alternative exposure measure, or when varying the observation period. In contrast, the results of the cohort-style analyses were highly sensitive to the choice of covariates included in the model. Based on the SCCS results, we estimated that PMVCs were associated with a 34% (95% CI 22% to 45%) reduction in the number of outbreaks in Africa from 2005 to 2018. A limitation of our study is the fact that it does not account for potential time-varying confounders, such as changing environmental drivers of yellow fever and possibly improved disease surveillance. Conclusions In this study, we provide new empirical evidence of the high preventive impact of PMVCs on yellow fever outbreaks. This study illustrates that the SCCS method can be advantageously applied at the population level in order to evaluate a public health intervention., In this cohort study, Kévin Jean and colleagues correlate lower risk of disease outbreaks with mass vaccination against yellow fever., Author summary Why was this study done? Yellow fever is a mosquito-borne, vaccine-preventable disease that may cause large urban outbreaks, especially in tropical African regions. Since 2006, preventive mass vaccination campaigns (PMVCs) have been implemented in many African provinces. These are large-scale vaccination campaigns targeting all or most age groups in a specific area. The preventive impact PMVCs may have on the risk of yellow fever outbreak has not been quantified yet. What did the researchers do and find? We used the self-controlled case series (SCCS) method to assess the association between PMVCs and outbreak risk at the province level in 34 African countries between 2005 and 2018. We compared pre- and post-PMVC periods within each province individually, thus implicitly controlling for all possible confounders that do not vary in time, especially the fact that provinces indicated for PMVCs are generally those considered at highest baseline risk of yellow fever (confounding by indication). At the province level, we estimated that implementation of PMVCs was associated with an 86% reduction (95% CI 66% to 94%) in the risk of yellow fever outbreak. A complete cohort analysis provided less reliable results than the SCCS method, likely because of confounding by indication that was not entirely controlled for by adjusting for known drivers of yellow fever. We further estimated that all PMVCs conducted between 2006 and 2018 in Africa may have reduced the total number of yellow fever outbreaks by 34% (95% CI 22% to 45%). What do these findings mean? These results provide new empirical evidence of the high preventive impact of PMVCs on yellow fever outbreaks. These results may encourage rapid rescheduling of yellow fever PMVCs that have been postponed due to the COVID-19 pandemic. The SCCS design may be advantageously applied at the population level to assess the impact of public health interventions.

Introduction: This study aimed to assess changes in the fluorescence characteristics of Enterococcus faecalis in human dentine over a period of 24 h following treatment with endodontic irrigants. Method: Sterilised, non-functional extracted third molars were embedded in acrylic resin and uniformly sectioned into 2 mm thick dentine sections. After the removal of smear layer, the dentine sections were inoculated with E. faecalis and cultured for 7 days. The infected dentine sections were subsequently treated with different concentrations of sodium hypochlorite (NaOCl) and hydrogen peroxide (HO). Bacterial fluorescence readings were assessed at different time points using a calibrated laser device. All data were assessed for normality (Kolmogorov Smirnoff test) and analysed using ANOVA with Bonferroni post-hoc tests. Results: Fluorescence readings were quenched when E. faecalis infected human dentine sections were treated with oxidizing irrigants in vitro. Throughout a 24-hour period, fluorescence recovered in part but did not return to baseline level. Conclusion: The fluorescence quenching effect of these oxidizing agents needs to be considered when using laser fluorescence in assessing the quality of root canal debridement or disinfection.

Background Bariatric surgery is underutilized in the United States. Objective To examine temporal changes in patient characteristics and insurer type mix among adult bariatric surgery patients in southeastern Pennsylvania and to investigate the associations between payor type, insurance plan type, cost-sharing arrangements (among traditional Medicare beneficiaries), and bariatric surgery utilization. Setting Pennsylvania Health Care Cost Containment Council's databases in southeastern Pennsylvania during 2014-2018. Methods All adult patients who underwent the most common types of bariatric surgery and a 1:1 matched sample of surgery patients and those who were eligible for surgery but did not undergo surgery were identified. Contingency tables, Pearson χ2 tests, and logistic regression were used for statistical analysis. Results Over the 5 years, there was an increase in the proportion of Black individuals (37.1% in 2014 versus 43.0% in 2018), Hispanics (5.4% versus 8.0%), and Medicaid beneficiaries (19.2% in 2014 versus 28.5% in 2018) who underwent surgery. The odds of undergoing bariatric surgery based on payor type only between Medicare beneficiaries were statistically different (22% smaller odds) compared with privately insured individuals. There were significantly different odds of undergoing surgery based on insurance plan type within Medicare and private insurance payor categories. Individuals with traditional Medicare plans with no supplementary insurance and those with dual eligibility had smaller odds of undergoing surgery (42% and 32%, respectively) compared with those with private secondary insurance. Conclusions Insurance plan design may be as important in determining the utilization of bariatric surgery as the general payor type after controlling for confounding socio-demographic factors.

Postoperative delirium is associated with accelerated cognitive decline, mortality and high healthcare costs. The importance of perioperative risk identification is increasingly recognized but optimal prevention strategies are still evolving. We review the case of an at-risk 79-year-old who had three lumbar spine surgeries within a year, two of which were complicated by postoperative delirium and one which was not. We discuss how a comprehensive preoperative cognitive assessment successfully informed perioperative decision making, including anesthetic management and postoperative multimodal delirium prevention strategies by geriatric medicine. The case exemplifies how coordinated interdisciplinary team management may reduce postoperative delirium in high risk individuals.

BackgroundYellow fever (YF) is a viral haemorrhagic fever endemic in tropical regions of Africa and South America. Current intervention policies, namely the Eliminate Yellow fever Epidemics (EYE) strategy are actioned through vaccination. However, the stockpiles and production mean that vaccination can be in short supply. As such, intervention strategies need to be optimised; one of the tools for doing this is mathematical modelling.MethodsWe fit a generalised linear model of YF reports to occurrence data available from 1987 to 2019 in Africa and South America and available serology survey data to estimate the force of infection across the continents. Then, using demographic and vaccination data, we examine the impact of interventions.FindingsWe estimate that in 2018 there were approximately 51,000 (95%CrI [31,000 - 82,000]) deaths due to YF in Africa and South America. When we examine the impact of mass vaccination campaigns in Africa, these amount to approximately 10,000 (95%CrI [6,000 - 17,000]) deaths averted in 2018 due to mass vaccination activities in Africa; this corresponds to a 47% reduction (95%CrI [10% - 77%]).InterpretationWe find that the majority, 92% (95%CrI [89% - 95%]), of global burden occurs in Africa and that mass vaccination activities have significantly reduced the current deaths per year due to YF. This methodology allows us to evaluate the effectiveness of vaccination campaigns past, present and future and illustrates the need for continued vigilance and surveillance of YF.FundingBMGF and MRC

Mayaro virus (MAYV) is an arbovirus that is endemic to tropical forests in Central and South America, particularly within the Amazon basin. In recent years, concern has increased regarding MAYV’s ability to invade urban areas and cause epidemics across the region. We conducted a systematic literature review to characterise the evolutionary history of MAYV, its transmission potential, and exposure patterns to the virus. We analysed data from the literature on MAYV infection to produce estimates of key epidemiological parameters, including the generation time and the basic reproduction number, R0. We also estimated the force-of-infection (FOI) in epidemic and endemic settings. Seventy-six publications met our inclusion criteria. Evidence of MAYV infection in humans, animals, or vectors was reported in 14 Latin American countries. Nine countries reported evidence of acute infection in humans confirmed by viral isolation or reverse transcription-PCR (RT-PCR). We identified at least five MAYV outbreaks. Seroprevalence from population based cross-sectional studies ranged from 21% to 72%. The estimated mean generation time of MAYV was 15.2 days (95% CrI: 11.7–19.8) with a standard deviation of 6.3 days (95% CrI: 4.2–9.5). The per-capita risk of MAYV infection (FOI) ranged between 0.01 and 0.05 per year. The mean R0 estimates ranged between 2.1 and 2.9 in the Amazon basin areas and between 1.1 and 1.3 in the regions outside of the Amazon basin. Although MAYV has been identified in urban vectors, there is not yet evidence of sustained urban transmission. MAYV’s enzootic cycle could become established in forested areas within cities similar to yellow fever virus., Author summary Each year, diseases that are transmitted by mosquitoes cause substantial deaths and disability across the world. We performed a systematic literature review of Mayaro virus (MAYV) and estimated key epidemiological parameters that can be used to improve future outbreak response. We estimated the generation time and basic reproduction number for a historical outbreak. Our results suggest that the force-of-infection of MAYV in endemic settings is low. We did not find evidence of substantial urban transmission of MAYV. Nevertheless, similarities between MAYV and yellow fever virus epidemiology suggest that MAYV could emerge in urban areas. Local transmission of MAYV has never been reported outside of Central and South America. Our results highlight the need to continue monitoring emerging arboviruses in the Americas.

Scapular fractures are uncommon, and the spine of the scapula is a particularly rare site of injury. As a result, our knowledge of these injuries, the management options and the functional outcome is limited. We report a rare case of a scapular spine fracture in a patient with rotator cuff arthropathy with no obvious history of trauma. The pathophysiology behind this is unclear; however, we suggest that a combination of cuff arthropathy, steroid use and chronic cough contributed to it. Reverse total shoulder arthroplasty is commonly used to treat rotator cuff arthropathy, and the effect of scapular spine fractures on surgical outcomes is unknown. It is possible that the deltoid function provides a better indicator of post-operative outcomes.

Tenodesis and tenotomy are the main surgical options to treat different pathologies of the long head of the biceps tendon. Maintaining the functionality of the tendon during tenodesis makes it more preferable surgical option. The consensus on the most advanced tenodesis technique has not been reached. The article presents the arthroscopic all-inside technique of suprapectoral tenodesis of the biceps tendon using the technique of “zone marking” with 2 spinal needles or pins., Technique Video Video 1 The video describes a technique of arthroscopic suprapectoral tenodesis of the long head of the biceps with interference screw. After diagnostic arthroscopy, the intra-articular part of the biceps is marked by passing the first spinal needle through the tendon. The next step is tenotomy of LHBT, which is performed close to superior labrum using an arthroscopic scissor. LHBT stump treatment is performed with a radiofrequency device. The anterolateral portal visualizes the marking needle in the projection of the bicipital groove. Here bursectomy, subacromial decompression, and LHBT fixation with the second spinal needle or pin are performed. The transverse ligament is dissected with the radiofrequency device. The second spinal needle is used to fix the tendon to the humerus. The biceps tendon is removed from the opened groove into the subdeltoid space. Then, a hole is drilled in the middle third of the groove along the guide pin. In the last stage of the operation, the biceps tendon is inserted into the canal using a grasper. Along the nitinol guidewire in the canal, the tendon is fixed with an interference screw. After the reliability of fixation is confirmed with the hook probe, the second spinal needle is removed. (LHBT, long head of the biceps tendon.)

BACKGROUND: Access to bariatric surgery is restricted by insurers in numerous ways, including by precertification criteria such as 3-6 months preoperative supervised medical weight management and documented 2-year weight history. OBJECTIVES: To investigate if there is an association between the aforementioned precertification criteria, insurance plan type, and the likelihood of undergoing bariatric surgery, after controlling for potential sociodemographic confounders. RESEARCH DESIGN: The study was conducted using the Pennsylvania Health Care Cost Containment Council’s data in 5 counties of Pennsylvania in 2016 and records of preoperative insurance requirements maintained by the Temple University Bariatric Surgery Program. Privately insured bariatric surgery patients and individuals who met the eligibility criteria but did not undergo surgery were identified and 1:1 matched by sex, race, age group, and zip code (n = 1,054). Univariate tests and logistic regression analysis were utilized for data analysis. RESULTS: The insurance requirement for 3-6 months preoperative supervised medical weight management was associated with smaller odds of undergoing surgery (odds ratio [OR] = 0.459, 95% confidence interval [CI] 0.253-0.832, P = 0.010), after controlling for insurance plan type and the requirement for documented weight history. Preferred provider organization (OR = 1.422, 95% CI 1.063-1.902, P = 0.018) and fee-for-service (OR = 1.447, 95% CI 1.021-2.050, P = 0.038) plans were associated with greater odds of undergoing surgery, compared with health maintenance organization plans, after controlling for the studied precertification requirements. The documented weight history requirement was not a significant predictor of the odds of undergoing surgery (P = 0.132). CONCLUSIONS: There is a need for consideration of insurance benefits design as a determinant of access to bariatric surgery.

Highlight We estimated SARS-CoV-2 infection prevalence in cohorts of repatriated citizens from Wuhan to be 0.44% (95% CI: 0.19%–1.03%). Although not representative of the wider population we believe these estimates are helpful in providing a conservative estimate of infection prevalence in Wuhan City, China, in the absence of large-scale population testing early in the epidemic.

The burden of malaria is heavily concentrated in sub-Saharan Africa (SSA) where cases and deaths associated with COVID-19 are rising1. In response, countries are implementing societal measures aimed at curtailing transmission of SARS-CoV-22,3. Despite these measures, the COVID-19 epidemic could still result in millions of deaths as local health facilities become overwhelmed4. Advances in malaria control this century have been largely due to distribution of long-lasting insecticidal nets (LLINs)5, with many SSA countries having planned campaigns for 2020. In the present study, we use COVID-19 and malaria transmission models to estimate the impact of disruption of malaria prevention activities and other core health services under four different COVID-19 epidemic scenarios. If activities are halted, the malaria burden in 2020 could be more than double that of 2019. In Nigeria alone, reducing case management for 6 months and delaying LLIN campaigns could result in 81,000 (44,000–119,000) additional deaths. Mitigating these negative impacts is achievable, and LLIN distributions in particular should be prioritized alongside access to antimalarial treatments to prevent substantial malaria epidemics. Transmission dynamics models of COVID-19 and malaria reveal how different scenarios of COVID-19 spread and varying levels of interruption to antimalarial programs could result in increased deaths in sub-Saharan Africa.

Summary Background WHO has called for increased testing in response to the COVID-19 pandemic, but countries have taken different approaches and the effectiveness of alternative strategies is unknown. We aimed to investigate the potential impact of different testing and isolation strategies on transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods We developed a mathematical model of SARS-CoV-2 transmission based on infectiousness and PCR test sensitivity over time since infection. We estimated the reduction in the effective reproduction number (R) achieved by testing and isolating symptomatic individuals, regular screening of high-risk groups irrespective of symptoms, and quarantine of contacts of laboratory-confirmed cases identified through test-and-trace protocols. The expected effectiveness of different testing strategies was defined as the percentage reduction in R. We reviewed data on the performance of antibody tests reported by the Foundation for Innovative New Diagnostics and examined their implications for the use of so-called immunity passports. Findings If all individuals with symptoms compatible with COVID-19 self-isolated and self-isolation was 100% effective in reducing onwards transmission, self-isolation of symptomatic individuals would result in a reduction in R of 47% (95% uncertainty interval [UI] 32–55). PCR testing to identify SARS-CoV-2 infection soon after symptom onset could reduce the number of individuals needing to self-isolate, but would also reduce the effectiveness of self-isolation (around 10% would be false negatives). Weekly screening of health-care workers and other high-risk groups irrespective of symptoms by use of PCR testing is estimated to reduce their contribution to SARS-CoV-2 transmission by 23% (95% UI 16–40), on top of reductions achieved by self-isolation following symptoms, assuming results are available at 24 h. The effectiveness of test and trace depends strongly on coverage and the timeliness of contact tracing, potentially reducing R by 26% (95% UI 14–35) on top of reductions achieved by self-isolation following symptoms, if 80% of cases and contacts are identified and there is immediate testing following symptom onset and quarantine of contacts within 24 h. Among currently available antibody tests, performance has been highly variable, with specificity around 90% or lower for rapid diagnostic tests and 95–99% for laboratory-based ELISA and chemiluminescent assays. Interpretation Molecular testing can play an important role in prevention of SARS-CoV-2 transmission, especially among health-care workers and other high-risk groups, but no single strategy will reduce R below 1 at current levels of population immunity. Immunity passports based on antibody tests or tests for infection face substantial technical, legal, and ethical challenges. Funding UK Medical Research Council.

Objective: Microtia is a medically complex condition, with the option of surgery to address hearing and reconstruct the ear. The current study explored adults’ experiences of microtia, with a particular focus on the psychosocial impact and experiences of ear reconstruction. The ultimate aim was to identify areas for support and future research that could improve patient care. Design: Fifteen adults (12 females) aged between 20 and 62 years took part in semi-structured interviews. Interviews were audio-recorded, transcribed verbatim, and analyzed using inductive thematic analysis. Results: Three main themes were identified in the data: microtia as an invisible difference, surgery as a welcome opportunity, and living well with microtia. Participants had incorporated microtia into their self-concept and did not report a lasting negative impact on their lives. However, some psychosocial challenges were reported, including anxiety about showing their ears (even after reconstruction), disclosing their diagnosis to romantic partners, surgical decision-making, and feeling unsupported in the work environment. Conclusion: Individuals with microtia may benefit from psychosocial interventions to increase confidence, access to support for treatment decision-making, and guidance around disclosing microtia to employers.

On 21 February 2020, a resident of the municipality of Vo', a small town near Padua (Italy), died of pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection1. This was the first coronavirus disease 19 (COVID-19)-related death detected in Italy since the detection of SARS-CoV-2 in the Chinese city of Wuhan, Hubei province2. In response, the regional authorities imposed the lockdown of the whole municipality for 14 days3. Here we collected information on the demography, clinical presentation, hospitalization, contact network and the presence of SARS-CoV-2 infection in nasopharyngeal swabs for 85.9% and 71.5% of the population of Vo' at two consecutive time points. From the first survey, which was conducted around the time the town lockdown started, we found a prevalence of infection of 2.6% (95% confidence interval (CI): 2.1-3.3%). From the second survey, which was conducted at the end of the lockdown, we found a prevalence of 1.2% (95% CI: 0.8-1.8%). Notably, 42.5% (95% CI: 31.5-54.6%) of the confirmed SARS-CoV-2 infections detected across the two surveys were asymptomatic (that is, did not have symptoms at the time of swab testing and did not develop symptoms afterwards). The mean serial interval was 7.2 days (95% CI: 5.9-9.6). We found no statistically significant difference in the viral load of symptomatic versus asymptomatic infections (P = 0.62 and 0.74 for E and RdRp genes, respectively, exact Wilcoxon-Mann-Whitney test). This study sheds light on the frequency of asymptomatic SARS-CoV-2 infection, their infectivity (as measured by the viral load) and provides insights into its transmission dynamics and the efficacy of the implemented control measures.

Background Serological testing based on different antibody types are an alternative method being used to diagnose SARS-CoV-2 and has the potential of having higher diagnostic accuracy compared to the current gold standard rRT-PCR. Therefore, the objective of this review was to evaluate the diagnostic accuracy of IgG and IgM based point-of-care (POC) lateral flow immunoassay (LFIA), chemiluminescence enzyme immunoassay (CLIA), fluorescence enzyme-linked immunoassay (FIA) and ELISA systems that detect SARS-CoV-2 antigens. Method A systematic literature search was carried out in PubMed, Medline complete and MedRxiv. Studies evaluating the diagnostic accuracy of serological assays for SARS-CoV-2 were eligible. Study selection and data-extraction were performed by two authors independently. QUADAS-2 checklist tool was used to assess the quality of the studies. The bivariate model and the hierarchical summary receiver operating characteristic curve model were performed to evaluate the diagnostic accuracy of the serological tests. Subgroup meta-analysis was performed to explore the heterogeneity. Results The pooled sensitivity for IgG (n = 17), IgM (n = 16) and IgG-IgM (n = 24) based LFIA tests were 0.5856, 0.4637 and 0.6886, respectively compared to rRT-PCR method. The pooled sensitivity for IgG (n = 9) and IgM (n = 10) based CLIA tests were 0.9311 and 0.8516, respectively compared to rRT-PCR. The pooled sensitivity the IgG (n = 10), IgM (n = 11) and IgG-IgM (n = 5) based ELISA tests were 0.8292, 0.8388 and 0.8531 respectively compared to rRT-PCR. All tests displayed high specificities ranging from 0.9693 to 0.9991. Amongst the evaluated tests, IgG based CLIA expressed the highest sensitivity signifying its accurate detection of the largest proportion of infections identified by rRT-PCR. ELISA and CLIA tests performed better in terms of sensitivity compared to LFIA. IgG based tests performed better compared to IgM except for the ELISA. Conclusions We report that IgG-IgM based ELISA tests have the best overall diagnostic test accuracy. Moreover, irrespective of the method, a combined IgG/IgM test seems to be a better choice in terms of sensitivity than measuring either antibody type independently. Given the poor performances of the current LFIA devices, there is a need for more research on the development of highly sensitivity and specific POC LFIA that are adequate for most individual patient applications and attractive for large sero-prevalence studies. Systematic review registration PROSPERO CRD42020179112

Background: As of August 2021, every region of the world has been affected by the COVID-19 pandemic, with more than 196,000,000 cases worldwide. Methods: We analysed COVID-19 cases among travellers from mainland China to different regions and countries, comparing the region- and country-specific rates of detected and confirmed cases per flight volume to estimate the relative sensitivity of surveillance in different regions and countries. Results: Although travel restrictions from Wuhan City and other cities across China may have reduced the absolute number of travellers to and from China, we estimated that up to 70% (95% CI: 54% - 80%) of imported cases could remain undetected relative to the sensitivity of surveillance in Singapore. The percentage of undetected imported cases rises to 75% (95% CI 66% - 82%) when comparing to the surveillance sensitivity in multiple countries. Conclusions: Our analysis shows that a large number of COVID-19 cases remain undetected across the world. These undetected cases potentially resulted in multiple chains of human-to-human transmission outside mainland China.

Background To counter the increasing global risk of Yellow fever (YF), the World Health Organisation initiated the Eliminate Yellow fever Epidemics (EYE) strategy. Estimating YF burden, as well as vaccine impact, while accounting for the features of urban YF transmission such as indirect benefits of vaccination, is key to informing this strategy. Methods and findings We developed two model variants to estimate YF burden in sub-Saharan Africa, assuming all infections stem from either the sylvatic or the urban cycle of the disease. Both relied on an ecological niche model fitted to the local presence of any YF reported event in 34 African countries. We calibrated under-reporting using independent estimates of transmission intensity provided by 12 serological surveys performed in 11 countries. We calculated local numbers of YF infections, deaths and disability-adjusted life years (DALYs) lost based on estimated transmission intensity while accounting for time-varying vaccination coverage. We estimated vaccine demand and impact of future preventive mass vaccination campaigns (PMVCs) according to various vaccination scenarios. Vaccination activities conducted in Africa between 2005 and 2017 were estimated to prevent from 3.3 (95% CI 1.2–7.7) to 6.1 (95% CI 2.4–13.2) millions of deaths over the lifetime of vaccinees, representing extreme scenarios of none or maximal herd effects, respectively. By prioritizing provinces based on the risk of urban YF transmission in future PMVCs, an average of 37.7 million annual doses for PMVCs over eight years would avert an estimated 9,900,000 (95% CI 7,000,000–13,400,000) infections and 480,000 (180,000–1,140,000) deaths over the lifetime of vaccinees, corresponding to 1.7 (0.7–4.1) deaths averted per 1,000 vaccine doses. Conclusions By estimating YF burden and vaccine impact over a range of spatial and temporal scales, while accounting for the specificity of urban transmission, our model can be used to inform the current EYE strategy., Author summary As large-scale vaccination campaigns are begun or continued with the aim to eliminate yellow fever (YF) epidemics in several countries, estimating disease burden and vaccine impact is timely. We developed two model variants to estimate YF burden in sub-Saharan Africa, each either representing the sylvatic or urban cycle of the disease. Both relied on an ecological niche model fitted to known records of YF in 34 African countries and calibrated using serological survey data. Local numbers of YF infections and deaths were derived while accounting for time-varying vaccination coverage. We estimated vaccine demand and the impact of future preventive mass vaccination campaigns according to various vaccination scenarios. By providing burden and vaccine impact estimates over a range of spatial and temporal scales, and accounting for the specificity of urban transmission, our model can be used to inform the current international strategy to counter the increasing global risk of yellow fever.

Background: The application of Photobiomodulation (PBM), Piezoelectric Surgery (PES) and Concentrated Growth Factors (CGF) in dental implant sinus lift procedure has gained popularity. Aim: To detail a two cases report on the use of PMB, PES, and CGF as a means of enhanced angiogenesis in tissue regeneration in dental implant lateral wall sinus lift procedure. Materials and Methods: This paper presents two cases report on the multi-disciplined approach using PBM, PES, and CGF as a method of enriched angiogenesis in tissue regeneration in dental implant sinus lift technique. In both patients, the sinus lateral windows were created using PES and the sinus membrane was raised to make a new partition. Surface modified dental implants (average 8 mm long) were inserted concurrently, packed with autologous fibrin-rich CGF, and then lastly induced PBM using Multiwave Locked System (MLS) laser. Radiographic and clinical evaluation was implemented to validate the efficacy of this multi-disciplined approach. Results and discussion: Postoperative revival was ordinary with no noteworthy postoperative complications. Wound closure/angiogenesis occurred shortly after day one. New bone formation in all augmented maxillary sinuses was detected alongside the implants on plain radiographs and on cone-beam computed tomograms. The patients were very happy with the overall treatment (>80%) and the success rate of implant was 100% after a usual 10 months loading period. PBM, PES, and CGF enhance angiogenesis/wound healing by speeding up wound approximation/healing, lessening the followings: postoperative pain, swelling, bleeding, speech impairment, analgesic use, and trismus. Conclusion: Using PBM, PES, and CGF as a method to enrich angiogenesis/wound healing in sinus lift rendered initial phase of satisfaction, simplicity, effectiveness, minimal complication, enhanced angiogenesis/wound healing with no cross infection and allergic reaction. Keywords photobiomodulation - piezoelectric surgery - concentrated growth factors - sinus augmentation - angiogenesis/wound healing

BRONJ was considered to be due to direct suppression of bone remodelling and cytotoxic effects of zoledronic acid (ZA) on bone and oral mucosal cells. However, recent literature suggests that suppressed angiogenesis contributes significantly to the pathogenesis of this condition. This in vitro and in vivo study examined the effect of locally delivered VEGF-hydrogel and local gene expression in rat BRONJ model. In vitro release study with 200 ng of rat VEGF-165 (Biovision) loaded into 500 lL hydrogel (Hystem-HP) prior to cross-linking and incubated in release media that was sampled and quantified using ELISA, over 28-days. In vivo, a BRONJ model using Sprague-Dawley rats was established by weekly intraperitoneal injection of ZA (three weeks), followed by extraction of maxillary first two molars and creation of a 5 mm defect which received either VEGF-containing hydrogel, HA gel alone or no gel. ZA was continued for four weeks post-surgery, prior to sacrifice. Gross examination, micro-CT evaluation and histological assessment was conducted to evaluate the effect of VEGF local delivery. Histological assessment involved quantification of osteonecrotic areas, total vascularity (von Willebrand Factor, vWF immunostaining) and specifically, the microvessel density (CD105 immunostaining). Furthermore, to assess molecular level changes during bone and soft tissue healing, gene expression analysis was conducted on the bone and gingival tissue samples from defect area.