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We report a survey (August 2017 to March 2018) and risk factor analysis of faecal carriage of antibacterial-resistant (ABR)

Complex abdominal wall reconstruction for ventral and incisional hernias can be quite painful with prolonged length of stay (LOS). There are a variety of options to manage post-operative pain after a ventral hernia repair, including epidural catheters, transversus abdominis plane (TAP) blocks, and intravenous narcotic pain medications (IVPM). We hypothesized that TAP blocks with liposomal bupivacaine decrease the LOS compared to epidurals and IVPM.A retrospective review of all patients who underwent an open ventral hernia repair with retromuscular mesh between 2016 and 2020 was conducted. LOS was used as the primary outcome. Secondary outcomes included post-operative pain and 90-day post-operative complications.An epidural was used in 66 patients, a TAP block with liposomal bupivacaine in 18 patients, and IVPM in 11 patients. The epidural group was noted to have a significantly longer duration of surgery (251.11 vs. 207.94 min; P 0.05) and larger area of mesh (461.85 vs. 338.17 cmPatients who received a TAP block for post-operative pain management had a significantly shorter length of stay compared to those patients who received an epidural. While the TAP block group reported higher POD1 pain scores, they did not have a significant difference in post-operative complications. TAP blocks with liposomal bupivacaine should be considered for post-operative pain control in complex ventral hernia repairs.

Robotic-assisted general surgery procedures are becoming commonplace, requiring more residency programs to establish training curricula for residents. Concerns exist regarding the impact this will have on surgical residents' operative case distribution in laparoscopic and open surgery. This study aimed to analyze the impact of a growing robotic operative case volume and established robotic surgery training curriculum on the general surgery resident operative experience.The robotic surgery training curriculum at the Medical College of Wisconsin was established in 2017. ACGME operative case logs of residents from 2014 to 2020 were analyzed to determine resident participation in open, laparoscopic, and robotic cases. Case categories included alimentary tract, abdomen, endocrine, thoracic, pediatric, and trauma. A one-way analysis of variance (ANOVA) was used to analyze overall cases, as well as participation by case type, post-graduate year (PGY) level, resident role, and institution type. Statistical significance was defined as a p value 0.05.Operative case logs from 77 residents were analyzed with a total of 34,757 cases: 59.3% open, 39.6% laparoscopic, and 1.1% robotic. There was no significant change in open or laparoscopic case volumes. However, there was a 3.4% increase in robotic cases, from 2014 to 2020 (p = 0.01), specifically in foregut (4.0%, p = 0.01), intestinal (1.6%, p = 0.03), and hernia (8.3%, p = 0.003) procedures. Academic (2.8%, p = 0.01) and veterans' hospital (2.0%, p = 0.01) institutions saw a significant increase in their residents' robotic cases. The only resident role with a significant increase in robotic cases was first assistant (8.0%, p = 0.004). There was no significant difference across PGY levels by surgical approach.This study highlights that the growth of robotic cases has not had a detrimental effect on the resident experience with open and laparoscopic cases. As robotic cases continually increase, the impact on laparoscopic and open case volumes must be monitored to ensure a well-balanced training experience.

Hiatal hernia recurrence following surgical repair is common. We sought to define the most common anatomic location and mechanism for hiatal failure to inform technical strategies to decrease recurrence rates.Retrospective chart review and video analysis were performed for all recurrent hiatal hernia operations performed by a single surgeon between January 2013 and April 2020. Hiatal recurrences were defined by anatomic quadrants. Recurrences on both left and right on either the anterior or posterior portion of the hiatus were simply classified as 'anterior' or 'posterior', respectively. Three or more quadrants were defined as circumferential. Mechanism of recurrence was defined as disruption of the previous repair or dilation of the hiatus.There were 130 patients to meet criteria. Median time to reoperation from previous hiatal repair was 60 months (IQR19.5-132). First-time recurrent repairs accounted for 74%, second time 18%, and three or more previous repairs for 8% of analyzed procedures. Mesh had been placed at the hiatus in a previous operation in 16%. All reoperative cases were completed laparoscopically. Video analysis revealed anterior recurrences were most common (67%), followed by circumferential (29%). There were two with left-anterior recurrence (1.5%), two posterior recurrence (1.5%), and one right-sided recurrence. The mechanism of recurrence was dilation in 74% and disruption in 26%. Disruption as a mechanism was most common in circumferential hiatal failures. Neither the prior number of hiatal surgeries nor the presence of mesh at the time of reoperation correlated with anatomic recurrence location or mechanism. Reoperations in patients with hiatal disruption occurred after a shorter interval when compared to hiatal dilation.The most common location and mechanism for hiatal hernia recurrence is anterior dilation of the hiatus. Outcomes following techniques designed to reinforce the anterior hiatus and perhaps to prevent hiatal dilation should be explored.

The bottom-up assembly of nanoelectronic devices from molecular building blocks is a target of widespread interest. Herein we demonstrate an in situ seeded growth approach to produce a nanowire-based electrical device. This exploits the chemisorption of block terpolymer-based seed fibres with a thiophene-functionalised corona onto metal electrodes as the initial step. We then use these surface-bound seeds to initiate the growth of well-defined one-dimensional fibre-like micelles via the seeded growth method known as “Living crystallisation-driven self-assembly’’ and demonstrate that they are capable of spanning an interelectrode gap. Finally, a chemical oxidation step was used to transform the nanofibres into nanowires to generate a two-terminal device. This seeded growth approach of growing well-defined circuit elements provides a useful new design tool for bottom-up device fabrication.

Significance Stem cells can be conceptualized as computational processors capable of sensing, processing, and converting environmental information (input) to yield a specific differentiation pathway (output). In this study, we employ a temperature-controlled polymer sheet actuator to interpret and transfer information, controlled by the material’s programming, to mesenchymal stem cells. The cell’s interpretation of mechanical, thermal, and biochemical signaling is shown to be dependent on the actuator’s activity, utilized to accelerate differentiation toward bone cells, further elucidating the role of microenvironmental parameters on mammalian cells. Our method provides a unique approach to processing two discrete stimuli into one biochemical signal, calcium ions, providing a basis for the logical control of the flow of biological signals and the design of cellular functions., Stem cells are capable of sensing and processing environmental inputs, converting this information to output a specific cell lineage through signaling cascades. Despite the combinatorial nature of mechanical, thermal, and biochemical signals, these stimuli have typically been decoupled and applied independently, requiring continuous regulation by controlling units. We employ a programmable polymer actuator sheet to autonomously synchronize thermal and mechanical signals applied to mesenchymal stem cells (MSCs). Using a grid on its underside, the shape change of polymer sheet, as well as cell morphology, calcium (Ca2+) influx, and focal adhesion assembly, could be visualized and quantified. This paper gives compelling evidence that the temperature sensing and mechanosensing of MSCs are interconnected via intracellular Ca2+. Up-regulated Ca2+ levels lead to a remarkable alteration of histone H3K9 acetylation and activation of osteogenic related genes. The interplay of physical, thermal, and biochemical signaling was utilized to accelerate the cell differentiation toward osteogenic lineage. The approach of programmable bioinstructivity provides a fundamental principle for functional biomaterials exhibiting multifaceted stimuli on differentiation programs. Technological impact is expected in the tissue engineering of periosteum for treating bone defects.

Within the field of shape-changing materials, synthetic chemical modification has been widely used to introduce key structural units and subsequently expand the mechanical functionality of actuator devices. The introduction of architectural elements that facilitate

The mechanical properties of electrospun fiber meshes typically are measured by tensile testing at the macro-scale without precisely addressing the spatial scale of living cells and their submicron architecture. Atomic force microscopy (AFM) enables the examination of the nano- and micro-mechanical properties of the fibers with potential to correlate the structural mechanical properties across length scales with composition and functional behavior. In this study, a polyesteretherurethane (PEEU) polymer containing poly(p-dioxanone) (PPDO) and poly(ɛ-caprolactone) (PCL) segments was electrospun into fiber meshes or suspended single fibers. We employed AFM three point bending testing and AFM force mapping to measure the elastic modulus and stiffness of individual micro/nanofibers and the fiber mesh. The local stiffness of the fiber mesh including the randomized, intersecting structure was also examined for each individual fiber. Force mapping results with a set point of 50 nN demonstrated the dependence of the elasticity of a single fiber on the fiber mesh architecture. The non-homogeneous stiffness along the same fiber was attributed to the intersecting structure of the supporting mesh morphology. The same fiber measured at a point with and without axial fiber support showed a remarkable difference in stiffness, ranging from 0.2 to 10 nN/nm respectively. For the region, where supporting fibers densely intersected, the stiffness was found to be considerably higher. In the region where the degrees of freedom of the fibers was not restricted, allowing greater displacement, the stiffness were observed to be lower. This study elucidates the relationship between architecture and the mechanical properties of a micro/nanofiber mesh. By providing a greater understanding of the role of spatial arrangement and organization on the surface mechanical properties of such materials, we hope to provide insight into the design of microenvironments capable of regulating cell functionality.

Background Postoperative urinary retention (POUR) can impact quality outcomes, leading to urinary tract infections, longer lengths of stay, and increased healthcare costs. The incidence of POUR in bariatric patients is unknown. Our primary objective was to determine the incidence and risk factors contributing to POUR in primary bariatric surgery. Methods A retrospective review was conducted on patients who underwent a laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2017. POUR was defined as the inability to urinate postoperatively, requiring urinary catheterization. Univariate and multivariate analyses were performed on perioperative variables and their correlation with POUR. Results During the study period, 603 patients underwent surgery: 317 (52.6%) LSG and 286 (47.4%) LRYGB. Overall, 49 (8.1%) patients developed POUR. There were no significant differences in preoperative demographics between patients with and without POUR. Patients who underwent an LSG had an increased incidence of POUR compared with LRYGB (P = 0.002). In both procedures, POUR was associated with decreased neostigmine, isolated nondepolarizing muscle relaxant, and reduced intraoperative fluid. LSG and congestive heart failure, as well as LSG and body weight, were independently associated with POUR. Female patients who experienced POUR had significantly increased length of stay. Conclusions Risk factors associated with POUR after primary bariatric surgery include LSG, less intraoperative neostigmine and intravenous fluids, and isolated nondepolarizing muscle relaxants. These risk factors can help educate patients and providers, as well as identify quality initiatives that focus on perioperative and anesthetic management to reduce POUR and length of hospital stay.

OBJECTIVE To report 1-year results from a 5-year mandated study. SUMMARY BACKGROUND DATA In 2012, the United States Food and Drug Administration approved magnetic sphincter augmentation (MSA) with the LINX Reflux Management System (Torax Medical, Shoreview, MN), a novel device for the surgical treatment of gastroesophageal reflux disease (GERD). Continued assessment of safety and effectiveness has been monitored in a Post Approval Study. METHODS Multicenter, prospective study of patients with pathologic acid reflux confirmed by esophageal pH testing undergoing MSA. Predefined clinical outcomes were assessed at the annual visit including a validated, disease-specific questionnaire, esophagogastricduodenoscopy and esophageal pH monitoring, and use of proton pump inhibitors. RESULTS A total of 200 patients (102 males, 98 females) with a mean age of 48.5 years (range 19.7-71.6) were treated with MSA between March 2013 and August 2015. At 1 year, the mean total acid exposure time decreased from 10.0% at baseline to 3.6%, and 74.4% of patients had normal esophageal acid exposure time (% time pH

Laparoscopic fundoplication is the treatment of choice for medically refractory gastroesophageal reflux disease (GERD). Surgeons seek to create a competent valve at the gastroesophageal junction (GEJ) but are careful to construct a ‘floppy’ fundoplication that is not too tight to minimize side effects. The endoscopic functional luminal-imaging probe (EndoFLIP®) uses impedance planimetry to assess the GEJ intraoperatively. We sought to determine if EndoFLIP variables are associated with symptomatic outcomes following fundoplication. We conducted a retrospective review of prospectively maintained data on subjects who underwent primary laparoscopic fundoplication at a single institution between 2014 and 2018. All patients met standard indications for antireflux surgery. Minimum diameter (Dmin), cross-sectional area (CSA), intra-bag pressure, and distensibility index of the GEJ were obtained at 30 mL volumes. GERD Health Related Quality of Life (GERD-HRQL) surveys were administered pre- and postoperatively. Patients were excluded if they underwent fundoplication without EndoFLIP assessment or if they did not complete a postop GERD-HRQL survey. Receiver operating characteristic curves were used to determine if EndoFLIP measurements were correlated with symptomatic outcomes. Forty-three patients met inclusion criteria. The change in Dmin and CSA measures during fundoplication were associated with daily or more frequent heartburn at 6 or more months postop. A decrease in Dmin of 0.15 mm or less (AUC = 0.718, sensitivity: 71%, specificity: 69%) and a decrease in CSA of 1.5 mm2 or less (AUC = 0.728, sensitivity: 71%, specificity: 70%) were associated with severe heartburn. GEJ opening dynamics attained by EndoFLIP appear to be associated with symptomatic outcomes. When the Dmin and CSA do not decrease by a defined threshold, heartburn is more likely to be severe at 6 or more months postoperatively. This suggests that the fundoplication may not be tight enough to prevent persistent or recurrent GERD.

The majority of patients who undergo a laparoscopic fundoplication for gastroesophageal reflux disease (GERD) have a structural (hiatal hernia, shortened lower esophageal sphincter [LES]) or functional (weak LES) defect of the gastroesophageal junction (GEJ). We hypothesized that the symptomatic outcomes of fundoplication in patients with a competent GEJ prior to surgery are inferior to those with an incompetent GEJ. This is a retrospective review of prospectively maintained data on subjects who underwent primary laparoscopic fundoplication (Nissen or Toupet) for medically refractory and confirmed GERD. Three esophageal manometry variables were used to determine GEJ competency: (1) hiatal hernia (normal = no hernia), (2) total lower esophageal sphincter length (normal ≥ 2.43 cm), and (3) lower esophageal sphincter pressure (normal = 15.0–43.7 mmHg). Patients in the competent group had normal values for all 3 variables. Symptomatic outcomes were assessed with the GERD Health-Related Quality of Life (HRQL) survey administered pre- and postoperatively, and then compared both intragroup, intergroup, and by procedure. A total of 78 patients met inclusion criteria—17 competent GEJ and 61 incompetent GEJ patients. GERD-HRQL scores improved in the incompetent cohort at all intervals out to 2 years postoperatively. GERD-HRQL improved in the competent cohort at 2 months, with no difference at 6 months or 2 years postoperatively compared to preoperative scores. Competent GEJ patients receiving a Nissen fundoplication had a higher rate of additional procedures (endoscopy with or without dilation, pH studies) following surgery to address recurrent or persistent GERD symptoms compared to Toupet. GERD patients with a competent GEJ report a lower GERD-HRQL with more frequent and severe reflux symptoms up to 2 years post-fundoplication. Competent GEJ patients receiving a Nissen fundoplication are more likely to have additional procedures to address symptoms following surgery. Surgeons should approach patients with a competent GEJ and medically refractory GERD with caution.

The prevalence of super obesity (SO, BMI > 50.0 kg/m2) and super-super obesity (SSO, BMI > 60 kg/m2) is increasing. Current data are limited and discrepant on the relationship between SSO and post-bariatric surgery complication risk. We hypothesized there would be increased complications for both laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) in SSO compared to SO, but the relative risk (RR) would support the use of LSG in SSO patients. Metabolic and Bariatric Surgery Accreditation and Quality Improvement 2016 data were queried for SO and SSO patients undergoing LRYGB or LSG. Thirty-day post-operative complications were calculated. Univariate analyses were performed with a χ2 or Student’s t test. Comparisons between multiple groups were performed using a one-way ANOVA. Statistical significance was defined as p

OBJECTIVES/HYPOTHESIS Gastroesophageal reflux disease and associated metaplasia of the esophagus (Barrett's esophagus [BE]) are primary risk factors for esophageal adenocarcinoma (EAC). Widespread use of acid suppression medications has failed to stem the rise of EAC, suggesting that nonacid reflux may underlie its pathophysiology. Pepsin is a tumor promoter in the larynx and has been implicated in esophageal carcinogenesis. Herein, specimens from the esophageal cancer spectrum were tested for pepsin presence. Pepsin-induced carcinogenic changes were assayed in an esophageal cell culture model. STUDY DESIGN Laboratory analysis. METHODS Pepsin was assayed in reflux and cancer free esophagi, BE, EAC, and esophageal cancer lacking association with reflux (squamous cell carcinoma [SCC]). Refluxed or locally synthesized pepsin was assayed by Western blot. Local synthesis of pepsin and proton pumps was assayed via reverse transcription-polymerase chain reaction. The effect of pepsin on BE and EAC markers was investigated via enzyme-linked immunosorbent assay and quantitative polymerase chain reaction in human esophageal epithelial cells treated with pepsin or control diluent. RESULTS Pepsinogen and proton pump mRNA were observed in BE (3/5) and EAC (4/4) samples, but not in normal adjacent specimens, SCC (0/2), or reflux and cancer-free esophagi. Chronic pepsin treatment (0.1-1 mg/mL, 4 weeks) of human esophageal cells in vitro induced BE and EAC markers interleukin 8 and KRT8 and depleted normal esophageal marker KRT10 (P < .05) expression. CONCLUSIONS Local synthesis of pepsin and proton pumps in BE and EAC is not uncommon. Absence of these molecules in normal (noncancer) esophagi, SCC, and in vitro data support a role for pepsin in reflux-attributed carcinogenic changes in the esophagus. LEVEL OF EVIDENCE NA Laryngoscope, 129:2687-2695, 2019.

There is no consensus regarding the optimal venous thromboembolism (VTE) prevention strategy following bariatric surgery. Post-discharge chemoprophylaxis is frequently recommended for high-risk patients with little supporting data.To define practices related to post-discharge chemoprophylaxis in the United States.United States.From the Truven Health MarketScan Research database we identified patients age 18 to 64 years undergoing laparoscopic sleeve gastrectomy and gastric bypass (2009-2015). Use of post-discharge low-molecular-weight or unfractionated heparin, vitamin K antagonists, Factor Xa inhibitors, or direct thrombin inhibitors was determined, as was the occurrence of VTE events from discharge to 90 days. Patients with VTE during the index admission were excluded to focus on chemoprophylaxis after discharge (versus treatment). Multivariate logistic regression was used to evaluate the association between VTE and anticoagulant usage.Of 105,246 patients, .8% with VTE prior to discharge were excluded. The study cohort was 78.1% female, with a median age of 44 years. Hypercoagulable disorder was present in .9%. Post-discharge chemoprophylaxis rates were 11.3% and varied from state to state (.5%-37.4%). VTE rates varied from state to state (.4%-2.6%). VTE after discharge occurred in 1.3%. On multivariate analysis, hypercoagulable disorder (odds ratio [OR] 14.0; 95% confidence interval [CI] 11.6-16.9, P.001), age ≥60 years (OR 2.3; 95% CI 1.0-5.3; P = .047), and male sex (female OR .8; 95% CI .7-.9, P.001) increased the risk for VTE. Post-discharge chemoprophylaxis was associated with increased VTE risk (OR 2.1; 95% CI 1.8-2.4; P.001).Post-discharge chemoprophylaxis following laparoscopic bariatric surgery is employed in 11.3% of patients. Variation in VTE rates and prophylaxis strategies exist nationally.

Functional health status (FHS) is the ability to perform activities of daily living without caregiver assistance.The primary aim of this study was to determine the impact of impaired preoperative FHS on morbidity and mortality within 30 days of bariatric surgery.Academic medical center in the United States.The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 data set was queried for primary minimally invasive bariatric procedures. The demographic characteristics and perioperative details of patients who were functionally independent were compared with patients with impaired FHS. Multivariable logistic regression analysis was performed to determine the odds of developing a perioperative complication or death for patients with impaired functional health.Of patients, 1515 (1.0%) were reported as having impaired FHS and 147,195 patients (99.0%) were independent before surgery. Patients with impaired FHS experienced significantly longer length of hospital stays (2.4 versus 1.8 d; P.0001), a higher morbidity (adjusted odds ratio 1.5; P0.0001), and higher mortality (adjusted odds ratio 2.1; P.0001). Impaired FHS resulted in significantly increased rate of unplanned admissions to the intensive care unit, interventions, reoperations, and readmissions within 30 days of surgery.Patients with impaired FHS preoperatively have a significantly increased risk of short-term morbidity and mortality after bariatric surgery. The results of this study highlight the importance of establishing quality initiatives focused on improving short-term outcomes for patients with impaired functional health status.

Blood transfusions can affect the clotting cascade, leading to a hypercoagulable state. The association of a venous thromboembolic (VTE) event and perioperative blood transfusion has been identified previously in surgical patients, but not after ventral hernia repair (VHR). The aim of this study was to evaluate the risk of VTE in VHR patients who receive a perioperative blood transfusion. The American College of Surgeons National Surgery Quality Improvement Program was queried for open (n = 34,687) and laparoscopic (n = 11,544) VHRs that occurred from 2013 to 2015. Regression analyses were used to determine factors predictive of VTE within 30-day post-operatively, the impact of bleeding requiring blood transfusion, and the influence of surgical approach on VTE. Post-operative VTE occurred in 246 (0.5%) VHR patients. Among those patients, 53.0% occurred after discharge. Increased age, operative time, and comorbidities increased the risk of VTE (p

BACKGROUND Various surgical techniques exist to create the gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (LRYGB). Linear-stapled anastomosis (LSA) and circular-stapled anastomosis (CSA) are two commonly employed techniques. We hypothesized that CSA is associated with an increased rate of surgical site infection (SSI) and gastrojejunostomy stenosis when compared to LSA. METHODS This study is a retrospective review of patients who underwent LRYGB for morbid obesity at a single institution between 2012 and 2016. Three bariatric surgeons contributed patients to this series. Clinical information and perioperative outcomes were collected through 90 days after surgery. RESULTS 171 patients met the inclusion criteria. Two patients did not complete 90-day follow-up and were excluded from the analysis (88 patients CSA, 81 LSA; 99% 90-day follow-up). Patient demographics did not differ between groups. The LSA technique was associated with a significantly reduced rate of SSI (0 (0%) vs. 6 (6.8%), p = 0.02) and stenosis (2 (2.5%) vs. 17 (19.3%), p

[Image: see text] Block copolymer self-assembly has enabled the creation of a range of solution-phase nanostructures with applications from optoelectronics and biomedicine to catalysis. However, to incorporate such materials into devices a method that facilitates their precise manipulation and deposition is desirable. Herein we describe how optical tweezers can be used to trap, manipulate, and pattern individual cylindrical micelles and larger hybrid micellar materials. Through the combination of TIRF imaging and optical trapping we can precisely control the three-dimensional motion of individual cylindrical block copolymer micelles in solution, enabling the creation of customizable arrays. We also demonstrate that dynamic holographic assembly enables the creation of ordered customizable arrays of complex hybrid block copolymer structures. By creating a program which automatically identifies, traps, and then deposits multiple assemblies simultaneously we have been able to dramatically speed up this normally slow process, enabling the fabrication of arrays of hybrid structures containing hundreds of assemblies in minutes rather than hours.

SynopsisBackgroundOur primary aim was to test whether cattle-associated fluoroquinolone-resistant (FQ-R) Escherichia coli found on dairy farms were a significant cause of bacteriuria in humans living in the same 50 × 50 km geographical region located in South West England. Another aim was to identify risk factors for the presence of FQ-R E. coli on dairy farms.MethodsFQ-R E. coli were isolated during 2017-18 from 42 dairy farms and from community urine samples. Forty-two cattle and 489 human urinary isolates were subjected to WGS, allowing phylogenetic comparisons. Risk factors were identified using a Bayesian regularisation approach.ResultsOf 489 FQ-R human isolates, 255 were also 3rd generation cephalosporin-resistant (3GC-R), with strong genetic linkage between aac(6’)Ib-cr and blaCTX-M-15. We identified possible farm-to-human sharing for pairs of ST744 and ST162 isolates, but core genome SNP distances (71 and 63, respectively) were smaller in pairs of ST744 and ST162 isolates from different farms (7 and 3 SNPs, respectively). Total farm fluoroquinolone use showed a positive association with the odds of isolating FQ-R E. coli while total dry cow therapy use showed a negative association.ConclusionsThis work suggests that FQ-R E. coli found on dairy farms have a limited impact on community bacteriuria within the local human population, however, this appears greater than observed for 3GC-R E. coli when studied in parallel. Reducing fluoroquinolone use may reduce the on-farm prevalence of FQ-R E. coli, and this reduction may be greater when dry cow therapy is targeted to the ecology of resistant E. coli on the farm.

Little is known about the drivers of critically important antibacterial resistance in species with zoonotic potential present on farms (e.g., CTX-M β-lactamase-positive Escherichia coli). We collected samples monthly between January 2017 and December 2018 on 53 dairy farms in South West England, along with data for 610 variables concerning antibacterial usage, management practices, and meteorological factors. We detected E. coli resistant to amoxicillin, ciprofloxacin, streptomycin, and tetracycline in 2,754/4,145 (66%), 263/4,145 (6%), 1,475/4,145 (36%), and 2,874/4,145 (69%), respectively, of samples from fecally contaminated on-farm and near-farm sites. E. coli positive for blaCTX-M were detected in 224/4,145 (5.4%) of samples. Multilevel, multivariable logistic regression showed antibacterial dry cow therapeutic choice (including use of cefquinome or framycetin) to be associated with higher odds of blaCTX-M positivity. Low average monthly ambient temperature was associated with lower odds of blaCTX-ME. coli positivity in samples and with lower odds of finding E. coli resistant to each of the four test antibacterials. This was in addition to the effect of temperature on total E. coli density. Furthermore, samples collected close to calves had higher odds of having E. coli resistant to each antibacterial, as well as E. coli positive for blaCTX-M. Samples collected on pastureland had lower odds of having E. coli resistant to amoxicillin or tetracycline, as well as lower odds of being positive for blaCTX-M. IMPORTANCE Antibacterial resistance poses a significant threat to human and animal health and global food security. Surveillance for resistance on farms is important for many reasons, including tracking impacts of interventions aimed at reducing the prevalence of resistance. In this longitudinal survey of dairy farm antibacterial resistance, we showed that local temperature—as it changes over the course of a year—was associated with the prevalence of antibacterial-resistant E. coli. We also showed that prevalence of resistant E. coli was lower on pastureland and higher in environments inhabited by young animals. These findings have profound implications for routine surveillance and for surveys carried out for research. They provide important evidence that sampling at a single time point and/or single location on a farm is unlikely to be adequate to accurately determine the status of the farm regarding the presence of samples containing resistant E. coli.

INTRODUCTION Pre-operative hemoglobin (Hb) A1c levels ≥ 8% can lead to increased post-operative complications. In bariatric surgery patients, attaining a pre-operative HbA1c < 8% can be a challenge. The purpose of this study was to identify the association of pre-operative HbA1c on post-operative outcomes in bariatric surgery patients. MATERIAL AND METHODS A retrospective chart review was conducted on diabetic patients (HbA1c ≥ 6.5%) who underwent primary bariatric surgery at a single institution between the years 2013 and 2019. Patients were divided into two groups based on their pre-operative HbA1c levels of < 8% and ≥ 8%. Univariate analyses were performed to determine an association between pre-operative HbA1c levels and post-operative outcomes. RESULTS There were 351 primary diabetic bariatric surgery patients, 270 HbA1c

High levels of reactive oxygen species (ROS) during stem cell expansion often lead to replicative senescence. Here, a polydopamine (PDA)-coated substrate was used to scavenge extracellular ROS for mesenchymal stem cell (MSC) expansion. The PDA-coated substrate could reduce the oxidative stress and mitochondrial damage in replicative senescent MSCs. The expression of senescence-associated β-galactosidase of MSCs from three human donors (both bone marrow- and adipose tissue-derived) was suppressed on PDA. The MSCs on the PDA-coated substrate showed a lower level of interleukin 6 (IL-6), one of the senescence-associated inflammatory components. Cellular senescence-specific genes, such as p53 and p21, were downregulated on the PDA-coated substrate, while the stemness-related gene, OCT4, was upregulated. The PDA-coated substrate strongly promoted the proliferation rate of MSCs, while the stem cell character and differentiation potential were retained. Large-scale expansion of stem cells would greatly benefit from the PDA-coated substrate.

Sinus pericranii is a rare vascular anomaly involving a venous sinus that drains into a subgaleal collection of veins through an emissary vein. Data regarding presentation, management, and outcomes are limited to case reports and small case series. There are no technical videos detailing the technique for percutaneous embolization. We present the case of a child with an enlarging, symptomatic accessory type sinus pericranii with connection to the torcula, who underwent percutaneous embolization after unsuccessful transvenous embolization. Embolization was performed with 3.4 cc Onyx-34 under live fluoroscopy and serial control superior sagittal sinus venograms . Significant reduction of flow into the sinus pericranii was achieved and the lesion had nearly completely resolved at the 3-week follow-up. Percutaneous embolization of the sinus pericranii is a reasonable alternative to transvenous embolization, but additional data are needed to determine the optimal treatment. The technical details and practical considerations discussed here may help neurointerventionalists adopt this treatment. The video also includes references 1–4 which are relevant to this topic.Video 1Case presentation and technique for percutaneous embolization of sinus pericranii­

A 1.5 kg, male, wild-caught tiger rat snake (Spilotes pullatus) presented with an externally visible distension of the body wall at the level of the heart. Ultrasound examination showed marked pericardial effusion. Pericardial fluid showed no bacterial or fungal growth, few leukocytes, and few suspected reactive mesothelial or neoplastic cells. Therapeutic pericardiocentesis was successfully performed, removing most of the fluid from the pericardial sac. The snake had mild lethargy and weakness immediately after the procedure but returned to normal behavior within 2 wk. Repeat pericardiocentesis was performed 6 mo after the initial presentation when moderate refilling of the pericardial sac was seen. The snake died 4 days after the second procedure with acute hemorrhage. Pericardial mesothelioma was diagnosed by histopathology after postmortem examination. This report provides the first documented case of mesothelioma in a tiger rat snake and the first description of the disease in colubrids.

Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disease in the United States. Nonsurgical management with acid-reducing medications is a common first-line therapy for most patients. Despite appropriate medical therapy, many patients continue to suffer from refractory GERD-related symptoms, experience complications, or desire to stop medical therapy due to cost or side effects. Laparoscopic Nissen fundoplication is the most common intervention but is performed in a very small portion of patients who would otherwise qualify. Concerns about side effects and long-term efficacy of fundoplication play a major role in the underutilization of surgical therapy for GERD. Lower esophageal sphincter (LES) augmentation with a magnetic implantable device is a novel therapy that has recently been introduced as an alternative to fundoplication. Magnetic sphincter augmentation has so far been demonstrated to be a safe and effective procedure with certain advantages when compared to traditional antireflux surgery with a fundoplication.

Introduction. Bariatric surgery performed at high volume centers decreases length of stay, cost, and morbidity and mortality. The effect of a high volume of bariatric surgery procedures on outcomes may extend not just to bariatric surgery but to any general surgical procedure in morbidly obese patients. We hypothesized that patients with morbid obesity (body mass index >40 kg/m2) undergoing common, nonbariatric general surgery would have decreased morbidity and mortality at centers performing high volumes of bariatric surgery. Methods. The 2016 National Inpatient Sample (NIS) was used to identify the number of laparoscopic gastric bypass and sleeve gastrectomy performed at each hospital. Hospitals were classified as high volume bariatric hospitals (HVBH) ≥10 reported cases (50 actual)/year or low volume bariatric hospitals (LVBH) p value of p = 0.03 ) with higher rates of COPD ( p = 0.04 ). Patients at LVBH had higher rates of nicotine dependence ( p = 0.0001 ) and obstructive sleep apnea ( p < 0.001 ). On propensity-weighted analysis adjusting for preoperative comorbidities and hospital procedure volume, there were significantly higher rates of multiple postprocedure complications at LVBH, specifically, postprocedure respiratory failure for patients undergoing elective laparoscopic cholecystectomy, elective ventral hernia repair with mesh and appendectomy. Conclusion. Patients with morbid obesity may have an advantage in having general surgery procedures at HVBH. HVBH may have a volume-outcomes relationship where the hospital and staff familiarity with the management principles required to minimize the postoperative risk associated with morbid obesity and improve patient outcomes.

Third-generation cephalosporin resistance (3GC-R) in Escherichia coli is a rising problem in human and farmed-animal populations. We conducted whole-genome sequencing analysis of 138 representative 3GC-R isolates previously collected from dairy farms in southwest England and confirmed by PCR to carry acquired 3GC-R genes. This analysis identified bla(CTX-M) (131 isolates encoding CTX-M-1, -14, -15, -and 32 and the novel variant CTX-M-214), bla(CMY-2) (6 isolates), and bla(DHA-1) (1 isolate). A highly conserved plasmid was identified in 73 isolates, representing 27 E. coli sequence types. This novel ∼220-kb IncHI2 plasmid carrying bla(CTX-M-32) was sequenced to closure and designated pMOO-32. It was found experimentally to be stable in cattle and human transconjugant E. coli even in the absence of selective pressure and was found by multiplex PCR to be present on 26 study farms representing a remarkable range of transmission over 1,500 square kilometers. However, the plasmid was not found among human urinary E. coli isolates we recently characterized from people living in the same geographical location, collected in parallel with farm sampling. There were close relatives of two bla(CTX-M) plasmids circulating among eight human and two cattle isolates, and a closely related bla(CMY-2) plasmid was found in one cattle and one human isolate. However, phylogenetic evidence of recent sharing of 3GC-R strains between farms and humans in the same region was not found. IMPORTANCE Third-generation cephalosporins (3GCs) are critically important antibacterials, and 3GC resistance (3GC-R) threatens human health, particularly in the context of opportunistic pathogens such as Escherichia coli. There is some evidence for zoonotic transmission of 3GC-R E. coli through food, but little work has been done examining possible transmission via interaction of people with the local near-farm environment. We characterized acquired 3GC-R E. coli found on dairy farms in a geographically restricted region of the United Kingdom and compared these with E. coli from people living in the same region, collected in parallel. While there is strong evidence for recent farm-to-farm transmission of 3GC-R strains and plasmids—including one epidemic plasmid that has a remarkable capacity to be transmitted—there was no evidence that 3GC-R E. coli found on study farms had a significant impact on circulating 3GC-R E. coli strains or plasmids in the local human population.

Advances in the fabrication and characterization of polymeric nanomaterials has greatly advanced the miniaturization of soft actuators, creating materials capable of replicating the functional physical behavior previously limited to the macroscale. Here, we demonstrate how a reversible shape-memory polymer actuation can be generated in a single micro/nano object, where the shape change during actuation of an individual fiber can be dictated by programming using an AFM-based method. Electrospinning was used to prepare poly(epsilon-caprolactone) micro-/nanofibers, which were fixed and crosslinked on a structured silicon wafer. The programming as well as the observation of recovery and reversible displacement of the fiber were performed by vertical three point bending, using an AFM testing platform introduced here. A plateau tip was utilized to improve the stability of the fiber contact and working distance, enabling larger deformations and greater rbSMPA performance. Values for the reversible elongation of epsilon(rev)= 3.4 +/- 0.1% and 10.5 +/- 0.1% were obtained for a single micro (d = 1.0 +/- 0.2 mu m) and nanofiber (d = 300 +/- 100 nm) in cyclic testing between the temperatures 10 and 60 degrees C. The reversible actuation of the nanofiber was successfully characterized for 10 cycles. The demonstration and characterization of individual shape-memory nano and microfiber actuators represents an important step in the creation of miniaturized robotic devices capable of performing complex physical functions at the length scale of cells and structural component of the extracellular matrix.

Hypertension is a common comorbid condition associated with obesity and is a significant risk factor for cardiovascular disease and the related morbidity and mortality. Improvement in hypertension is directly associated with weight loss. Bariatric surgery is correlated with durable weight loss as compared to life-style and medical treatment with associated improvement in hypertension. Bariatric surgery is a recommended treatment for patients with uncontrolled hypertension and obesity to prevent long-term cardiovascular morbidity and mortality.

Objectives Antibacterial resistance (ABR) is a major global health security threat, with a disproportionate burden on lower-and middle-income countries (LMICs). It is not understood how ‘One Health’, where human health is co-dependent on animal health and the environment, might impact the burden of ABR in LMICs. Thailand's 2017 “National Strategic Plan on Antimicrobial Resistance” (NSP-AMR) aims to reduce AMR morbidity by 50% through 20% reductions in human and 30% in animal antibacterial use (ABU). There is a need to understand the implications of such a plan within a One Health perspective. Methods A model of ABU, gut colonisation with extended-spectrum beta-lactamase (ESBL)-producing bacteria and transmission was calibrated using estimates of the prevalence of ESBL-producing bacteria in Thailand. This model was used to project the reduction in human ABR over 20 years (2020–2040) for each One Health driver, including individual transmission rates between humans, animals and the environment, and to estimate the long-term impact of the NSP-AMR intervention. Results The model predicts that human ABU was the most important factor in reducing the colonisation of humans with resistant bacteria (maximum 65.7–99.7% reduction). The NSP-AMR is projected to reduce human colonisation by 6.0–18.8%, with more ambitious targets (30% reductions in human ABU) increasing this to 8.5–24.9%. Conclusions Our model provides a simple framework to explain the mechanisms underpinning ABR, suggesting that future interventions targeting the simultaneous reduction of transmission and ABU would help to control ABR more effectively in Thailand., Highlights • We present a novel mathematical model of human, animal and environment ABR transmission and ABU. • Human ABU was identified as the main driver of human ABR. • Resistance within humans was primarily driven by human activity rather than animal or environmental usage or transmission. • One Health interventions which consider human, animal and environmental transmission and usage can yield the highest impact.

Utilization of minimally invasive techniques for ventral and inguinal hernia repairs continues to rise. The purpose of this study was to provide updates on national utilization trends and wound complications of minimally invasive versus open ventral and inguinal hernia repairs.Data were accessed from the 2006 to 2017 National Surgical Quality Improvement Program database. All CPT codes that correlated to laparoscopic and open inguinal and ventral hernia repairs were queried. The total number of cases and wound complications, including superficial surgical site infection (SSI), deep SSI, organ space SSI, and wound dehiscence, was collected for each respective CPT code and compared for each year. IBM SPSS Statistics Software and Microsoft Excel were used to collect and analyze the data.Between 2009 and 2017, the percentage of minimally invasive inguinal hernia repairs increased from 23.1 to 37.8%, whereas the percentage of minimally invasive ventral hernias only increased from 31.5 to 36.6%. Open inguinal hernia repairs had a wound complication rate ranging from 0.60 to 0.74%, which was double the rate of minimally invasive repairs (0.24 to 0.49%) for nearly each respective year. Minimally invasive ventral hernia repairs had total wound complication rates ranging from 0.91 to 1.37%, whereas open ventral hernias had the highest total wound complication rates ranging from 5.07 to 6.26%.Over the last ten years, the utilization of minimally invasive inguinal and ventral hernia repair has increased by nearly two-fold. A larger proportion of this increase has been secondary to minimally invasive inguinal compared to ventral hernia repairs. Wound complications across all techniques remained stable or improved, and remained significantly less in the minimally invasive compared to open approaches. This study highlights the continued growth of minimally invasive techniques in hernia repair over the last decade.

Chemical functionalization of poly(epsilon-caprolactone) (PCL) enables a molecular integration of additional function. Here, we report an approach to incorporate reactive alkynyl side-groups by synthesizing a chain-extended PCL, where the reactive site is introduced through the covalently functionalizable chain extender 3 (prop-2-yn-1-yloxy)propane-1,2-diol (YPD). Chain-extended PCL with M-w of 101 to 385 kg.mol(-1) were successfully synthesized in a one-pot reaction from PCL-diols with various molar masses, L-lysine ethyl ester diisocyanate (LDI) or trimethyl(hexamethylene)diisocyanate (TMDI), and YPD, in which the density of functionalizable groups and spacing between them can be controlled by the composition of the polymer. The employed diisocyanate compounds and YPD possess an asymmetric structure and form a non-crystallizable segment leaving the PCL crystallites to dominate the material's mechanical properties. The mixed glass transition temperature T-g = - 60 to - 46 degrees C of the PCL/polyurethane amorphous phase maintains the synthesized materials in a highly elastic state at ambient and physiological conditions. Reaction conditions for covalent attachment in copper(I)-catalyzed azide-alkyne-cycloaddition reactions (CuAAC) in solution were optimized in a series of model reactions between the alkyne moieties of the chain-extended PCL and benzyl azide, reaching conversions over 95% of the alkyne moieties and with yields of up to 94% for the purified functionalized PCL. This methodology was applied for reaction with the azide-functionalized cell adhesion peptide GRGDS. The required modification of the peptide provides selectivity in the coupling reactions. The obtained results suggest that YPD could potentially be employed as versatile molecular unit for the creation of a variety of functionalizable polyesters as well as polyurethanes and polycarbonates offering efficient and selective click-reactions.

A 1.5 kg, male, wild-caught tiger rat snake (

Little is known about the drivers of critically important antibacterial resistance in species with zoonotic potential present on farms (e.g., CTX-M β-lactamase-positive Escherichia coli). We collected samples monthly between January 2017 and December 2018 on 53 dairy farms in South West England, along with data for 610 variables concerning antibacterial usage, management practices, and meteorological factors. We detected E. coli resistant to amoxicillin, ciprofloxacin, streptomycin, and tetracycline in 2,754/4,145 (66%), 263/4,145 (6%), 1,475/4,145 (36%), and 2,874/4,145 (69%), respectively, of samples from fecally contaminated on-farm and near-farm sites. E. coli positive for bla(CTX-M) were detected in 224/4,145 (5.4%) of samples. Multilevel, multivariable logistic regression showed antibacterial dry cow therapeutic choice (including use of cefquinome or framycetin) to be associated with higher odds of bla(CTX-M) positivity. Low average monthly ambient temperature was associated with lower odds of bla(CTX-M) E. coli positivity in samples and with lower odds of finding E. coli resistant to each of the four test antibacterials. This was in addition to the effect of temperature on total E. coli density. Furthermore, samples collected close to calves had higher odds of having E. coli resistant to each antibacterial, as well as E. coli positive for bla(CTX-M). Samples collected on pastureland had lower odds of having E. coli resistant to amoxicillin or tetracycline, as well as lower odds of being positive for bla(CTX-M). IMPORTANCE Antibacterial resistance poses a significant threat to human and animal health and global food security. Surveillance for resistance on farms is important for many reasons, including tracking impacts of interventions aimed at reducing the prevalence of resistance. In this longitudinal survey of dairy farm antibacterial resistance, we showed that local temperature—as it changes over the course of a year—was associated with the prevalence of antibacterial-resistant E. coli. We also showed that prevalence of resistant E. coli was lower on pastureland and higher in environments inhabited by young animals. These findings have profound implications for routine surveillance and for surveys carried out for research. They provide important evidence that sampling at a single time point and/or single location on a farm is unlikely to be adequate to accurately determine the status of the farm regarding the presence of samples containing resistant E. coli.

It is widely acknowledged that although people show considerable concern about the well-being of family, friends, and others close to them, perhaps extending to their own national group, they most often show much less concern for the needs and rights of distant others, for example, those working in sweatshop conditions, or suffering from extreme poverty, or experiencing severe impacts from climate change. This chapter considers the motivation people might have (or might come to have) for taking the needs and rights of these distant others seriously and for standing in solidarity with them. Does this motivation arise from rational reflection on their rights and their equal moral status, as traditionally conceived, or does it require beyond this a disposition to empathy or to care? Drawing on recent philosophical analyses of empathy and on the feminist ethics of care, as well as on the author’s own previous account of transnational solidarities, the chapter analyzes some of the epistemic and motivational aspects of empathy, while also taking note of its potential dangers. It goes on to argue that rational respect can usefully be supplemented with an understanding of the perspective of the other and “feeling with” them and explores some specific ways in which empathizing can transform critical reasoning in global contexts. The chapter’s conclusion suggests some implications of this account for the current issue of how to conceive of the responsibility for fulfilling the requirements of global justice.