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Roux-en-Y gastric bypass (RYGB) is a mainstay of management of morbid obesity, particularly in individuals with significant weight-related medical comorbidities, but it also represents an effective therapeutic option for select patients with gastroesophageal reflux disease (GERD). The purpose of this chapter is to describe the appropriate population that may benefit from RYGB as management of GERD, specific surgical techniques for the performance of REYGB, perioperative management, and management of special situations and postoperative complications.

Throughout its history, surgery has been a field of continuous innovation, but the last few decades have seen a particularly rapid pace of new technologies and applications. The widespread use of laparoscopy and minimal access surgery has demonstrated benefits in reductions in patient pain, wound complications, and in some instances, an improvement in the technical performance of certain procedures.

The physical and chemical properties of nanocrystals can be modified by changing the ligands attached at their surfaces. A ligand exchange procedure with ammonium polysulfides has been developed to replace the native ligands on cubic zinc sulfide nanocrystals. Several mixtures of polysulfides in formamide and other solvents were prepared with different average chain lengths and used to achieve high yield ligand exchange, as confirmed by UV–vis spectroscopy, infrared spectroscopy and X-ray photoelectron spectroscopy. The results show that polysulfide content can be increased with longer surface ligands and that the exchange process yields compositionally pure surfaces before and after high temperature anneals. X-ray diffraction and scanning electron microscopy show that, when annealed in nitrogen at 525 °C, polysulfide ligands lead to average crystal sizes 2–3 times larger than in the un-exchanged control sample. The ligand exchange procedure itself does not alter nanocrystal size. Nanocrystal inks prepared from the exchanged samples form thin films that exhibit superior grain growth, morphology, mass retention, and composition compared to the un-exchanged material. Overall, polysulfide species are demonstrated as alternative ligands for the surfaces of metal chalcogenide nanocrystals which, when incorporated in an efficient ligand-exchange procedure, can improve the quality of ZnS nanocrystal inks.

Methods for predicting mineralogy from logging tool measurements have been an active area of research for several decades. In spite of these efforts, methods for predicting quantitative mineralogy including clay types from well logging data were not fully achieved. The introduction of geochemical logging tools in the 1980s offered promise; however, early versions of geochemical logging tools did not measure elemental chemistry with enough accuracy and precision to enable reliable and quantitative determination of mineralogy. Recent advances in geochemical logging tool technology now enable accurate and robust measurements of the chemical elemental concentrations that are needed to determine continuous quantitative and detailed logs of mineralogy. This paper presents a novel approach for determining more accurate, detailed mineralogy from an elemental spectroscopy logging tool. This work was made possible by three recent developments: the introduction of a new high-performance neutron-induced gamma ray spectroscopy logging tool, a new high-quality research database consisting of chemistry and mineralogy measured on cores acquired worldwide from conventional and unconventional reservoirs, and a new model-independent inversion method that overcomes the limitations of previous model-dependent methods. The model-independent inversion makes use of the database which includes clean sands, shaly sands, shales, carbonates, and complex mixed lithologies. The database contains laboratory measurements of dry-weight elemental chemistry and mineralogy measured by transmission Fourier transform infrared spectroscopy. The database is used to derive a model-independent mapping function that accurately represents the complex functional relationship between the elemental concentrations and the mineral concentrations. Once the mapping function is determined from the database, it can be used to predict quantitative mineralogy from elemental concentrations derived from the logging tool measurements. Unlike previous inversion methods, the model-independent mapping function does not have any adjustable parameters or require any user inputs such as mineral properties or endpoints. The mapping function is used to predict continuous logs of matrix densities plus concentrations of 14 minerals (i.e., illite, smectite, kaolinite, chlorite, quartz, calcite, dolomite, ankerite, plagioclase, orthoclase, mica, pyrite, siderite, and anhydrite) from eight dry-weight elemental concentrations derived from the logging tool. The new method has been applied to well log data acquired worldwide in numerous conventional and unconventional reservoirs having a wide variety of complex mineralogies. The predicted mineralogies and matrix densities are generally found to be in good quantitative agreement with core-derived mineralogies and matrix densities.

The power conversion efficiency of quantum-dot-sensitized solar cells (QDSSCs) hinges on interfacial charge transfer. Increasing quantum dot (QD) loading on the TiO2 anode has been proposed as a means to block recombination of electrons in the TiO2 to the hole transport material; however, it is not known whether a corresponding increase in QD-mediated recombination processes might lead to an overall higher rate of recombination. In this work, a 3-fold increase in PbS QD loading was achieved by the addition of an aqueous base to negatively charge the TiO2 surface during Pb cation deposition. Increased QD loading improved QDSSC device efficiencies through both increased light absorption and an overall reduction in recombination. Unexpectedly, we also found increased QD size had the detrimental effect of increasing recombination. Kinetic modeling of the effect of QD size on interfacial charge transfer processes provided qualitative agreement with the observed variation in recombination lifetimes. These results demonstrate a robust method of improving QD loading, identify the specific mechanisms by which increased QD deposition impacts device performance, and provide a framework for future efforts optimizing the device architecture of QDSSCs.

The abundance of dawsonite in an exploration well in the Green River Formation oil shale has been characterized by well logging, FTIR, DSC, and wet chemistry. The four methods agree qualitatively but not quantitatively. Thermal analysis was then used to characterize changes in the dawsonite decomposition endotherm as a function of pressure. The peak temperature of the endotherm increased with pressure and the size decreased with pressure. The total endotherm at high temperature that includes dolomite and calcite reactions decreased with increased pressure, presumably due to formation of more stable silicates.

Obstructive sleep apnea (OSA) is a serious obesity-associated disorder that causes significant short- and long-term medical consequences. The objective of this study is to compare the 6-month and 1-year postoperative symptomatic OSA remission rates of patients undergoing bariatric surgery based on their preoperative body mass index (BMI) stratification, type of bariatric operation—sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)—and OSA severity. We retrospectively analyzed 297 obese patients with a diagnosis of OSA who had undergone either SG or RYGB between 2011 and 2015. The overall 6-month symptomatic OSA remission rate for patients (n = 255) was 74.5%. At 6 months, patients with a preoperative BMI of 30–34.9 kg/m2 (class I), 35–39.9 kg/m2 (class II), and 40+ kg/m2 (class III) had 100, 70.0, and 75.0% (p = 0.2164) remission rates, respectively. The 6-month remission rates for SG and RYGB were 75.3 and 70.8% (p = 0.5165), respectively. The overall 1-year symptomatic OSA remission rate for patients (n = 162) was 87.1%. At 1 year, class I, II, and III patients had 100, 85.7, and 87.5% (p = 0.5740) remission rates, respectively. The 1-year remission rates for SG and RYGB were 89.2 and 81.2% (p = 0.2189), respectively. A sub-analysis (n = 69) based on preoperative OSA severity levels did not affect the remission outcome at either the 6-month (p = 0.3670) or 1-year (p = 0.3004) follow-up. Most obese patients experience symptomatic remission of their OSA after bariatric surgery, regardless of their preoperative BMI, choice of operation, or OSA severity.

Obesity not only increases the chances of developing diabetes-one of the top causes of death in the United States-but it also results in further medical complications.To compare the 6-month and 1-year postoperative remission rates of type 2 diabetic (T2D) patients after bariatric surgery based on preoperative glycosylated hemoglobin (A1C) stratification and pharmacologic therapy: insulin-dependent diabetic (IDD) versus noninsulin-dependent diabetic (NIDD).Academic hospital, United States.We retrospectively analyzed a prospectively maintained database of 186 obese patients with a diagnosis T2D who had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass surgery at our hospital.At 6 months (n = 180), patients who were stratified by preoperative A1C levels (6.5; ≥6.5 to8; ≥8) had 70.5%, 51.7%, and 30.0% remission rates (P.001) and at 1 year (n = 118) patients had 72.0%, 54.0%, and 42.8% remission rates (P = .053), respectively. When patients were substratified by preoperative pharmacologic therapy, IDD and NIDD patients had different remission rates within the same A1C level. At 6-months follow-up within A1C ≥6.5 to8 (IDD versus NIDD), the remission rate was 23.5% versus 64.1% (odds ratio [OR]: .173, confidence interval [CI]: .0471, .6308, P = .0079), and within A1C ≥8 the remission was 24.0% versus 37.5% (OR: .5263, CI: .2115, 1.3096, P = .1676), respectively. At 1-year follow-up within A1C ≥6.5 to8, the remission rate was 30.0% versus 62.9% (OR: .2521, CI: .0529, 1.2019, P = .0838), and within A1C ≥8 the remission was 31.4% versus 61.9% (OR: .2821, CI: .0908, .8762, P = .0286), respectively. Furthermore, when IDD patients were compared between A1C ≥6.5 to8 and A1C ≥8 the remission rates were nearly identical, and for NIDD patients A1C was not significantly associated with remission regardless of the level, except at 6 months.While a difference was observed between overall A1C levels-the lower the A1C level, the higher the remission rate-IDD patients had lower remission rates than NIDD patients irrespective of A1C levels; further, IDD patients performed similarly across A1C levels.

Apheresis technology to collect platelet (PLT) components differs among devices. We evaluated the relationship of the plateletpheresis device with bacterial contamination and reported septic transfusion reactions.Plateletpheresis was performed using Amicus (Fenwal, a Fresenius Kabi Company) or Trima (Trima Accel, TerumoBCT) from 2010 to 2014. All donations used inlet-line sample diversion and were tested by quality control (QC; Day 1) aerobic culture. Rates of bacterial contamination and septic reactions to PLTs were calculated for both devices.During the 5-year study period, plateletpheresis collections using Amicus and Trima devices totaled 1,486,888 and 671,955 donations, respectively. The rate of confirmed-positive bacterial cultures of apheresis PLT donations was significantly higher with Amicus than with Trima (252 vs. 112 per 10Apheresis technology affects bacterial contamination of plateletpheresis collections. The device-specific, higher rate of confirmed-positive bacterial culture results also correlated with a significantly higher rate of reported septic transfusion reactions to apheresis PLTs.

In 2015, thirteen per- and polyfluoroalkyl substances (PFAS), including perfluorohexanesulfonate (PFHxS), perfluorooctanesulfonate (PFOS), perfluorooctanoate (PFOA), perfluorononanoate (PFNA), and perfluorodecanoate (PFDA) were analyzed in human plasma that were collected from a total of 616 American Red Cross male and female blood donors (ages 20-69) at 6 regional blood collection centers. Plasma samples were analyzed using a validated solvent precipitation-isotope dilution direction-liquid chromatography tandem mass spectrometry method. The data were analyzed in conjunction with prior cross-sectional investigations [2000-2001 (n =645), 2006 (n =600), and 2010 (n =600)] to determine PFAS trends. Age- and sex-adjusted geometric mean serum (2000-2001) and plasma (2006, 2010, 2015) concentrations (ng/mL) were, respectively: PFHxS (2.3, 1.5, 1.3, 0.9); PFOS (35.1, 14.5, 8.4, 4.3); PFOA (4.7, 3.4, 2.4, 1.1); PFNA (0.6, 1.0, 0.8, 0.4); and PFDA (0.2, 0.3, 0.3, 0.1). The percentage decline in these geometric mean concentrations from 2000-2001 to 2015 were: PFHxS (61%); PFOS (88%); PFOA (77%); PFNA (33%); and PFDA (50%). The results indicate a continued decline of PFHxS, PFOS, and PFOA concentrations in American Red Cross blood donors. For the remaining PFAS measured in 2015, including the shorter chain perfluoroalkyls perfluorobutanesulfonate (PFBS) and perfluorohexanoate (PFHxA), the majority of samples were below the lower limit of quantitation.

A new silicon detector has been developed to provide the PHENIX experiment with precise charged particle tracking at forward and backward rapidity. The Forward Silicon Vertex Tracker (FVTX) was installed in PHENIX prior to the 2012 run period of the Relativistic Heavy Ion Collider (RHIC). The FVTX is composed of two annular endcaps, each with four stations of silicon mini-strip sensors, covering a rapidity range of $1.2, Comment: version submitted to NIM

Plant roots serve as conduits for water flow not only from soil to leaves but also from wetter to drier soil. This hydraulic redistribution through root systems occurs in soils worldwide and can enhance stomatal opening, transpiration, and plant carbon gain. For decades, upward hydraulic lift (HL) of deep water through roots into dry, litter-rich, surface soil also has been hypothesized to enhance nutrient availability to plants by stimulating microbially controlled nutrient cycling. This link has not been demonstrated in the field. Working in sagebrush-steppe, where water and nitrogen limit plant growth and reproduction and where HL occurs naturally during summer drought, we slightly augmented deep soil water availability to 14 HL+ treatment plants throughout the summer growing season. The HL+ sagebrush lifted greater amounts of water than control plants and had slightly less negative predawn and midday leaf water potentials. Soil respiration was also augmented under HL+ plants. At summer’s end, application of a gas-based 15 N isotopic labeling technique revealed increased rates of nitrogen cycling in surface soil layers around HL+ plants and increased uptake of nitrogen into HL+ plants’ inflorescences as sagebrush set seed. These treatment effects persisted even though unexpected monsoon rainstorms arrived during assays and increased surface soil moisture around all plants. Simulation models from ecosystem to global scales have just begun to include effects of hydraulic redistribution on water and surface energy fluxes. Results from this field study indicate that plants carrying out HL can also substantially enhance decomposition and nitrogen cycling in surface soils.

Transfusion-transmitted West Nile virus (WNV) infection is infrequent as a result of minipool (MP) and individual-donation (ID) nucleic acid testing (NAT) of blood donations. ID-NAT is triggered on the basis of local WNV activity identified by MP-NAT.A 78-year-old male patient who was treated for cardiac disease received 14 blood components from 30 donors in August 2016. He was discharged 7 days after aortic valve replacement and coronary bypass surgery, but was re-admitted on Day 12 with symptoms of viral infection, and eventually was diagnosed with aseptic meningitis. The patent died on Day 51.The patient was positive for WNV-immunoglobulin M (IgM) antibodies in his cerebrospinal fluid on Day 14 and was positive for WNV-IgM (on Days 14 and 16) and WNV-IgG antibodies (on Day 16) in his serum. All associated donations were nonreactive by MP-NAT or ID-NAT. However, one MP-NAT was noted to have an elevated (but negative) signal-to-cutoff ratio, and one donor from that MP was subsequently found positive for WNV-IgM and IgG antibodies; the donor was diagnosed with a WNV-like viral syndrome that had an onset 3 to 5 days postdonation. The donor's plasma was transfused 12 days before the patient's onset of WNV-meningoencephalitis. Conversion to ID-NAT was triggered for the region 7 days after the implicated donation, which was associated with the region's first human WNV case.Despite the possibility of mosquito-borne transmission, this was considered to be a case of transfusion-transmitted WNV infection from an MP-NAT-nonreactive donation collected just before triggering conversion to ID-NAT; a rare event recognized once in 84 million donations.

Eleven perfluorinated alkyl acids (PFAAs) were analyzed in plasma from a total of 600 American Red Cross adult blood donors from six locations in 2010. The samples were extracted by protein precipitation and quantified by using liquid chromatography tandem mass spectrometry (HPLC/MS/MS). The anions of the three perfluorosulfonic acids measured were perfluorobutane sulfonate (PFBS), perfluorohexane sulfonate (PFHxS), and perfluorooctane sulfonate (PFOS). The anions of the eight perfluorocarboxylic acids were perfluoropentanoate (PFPeA), perfluorohexanoate (PFHxA), perfluoroheptanoate (PFHpA), perfluorooctanoate (PFOA), perfluorononanoate (PFNA), perfluorodecanoate (PFDA), perfluoroundecanoate (PFUnA), and perfluorododecanoate (PFDoA). Findings were compared to results from different donor samples analyzed at the same locations collected in 2000-2001 (N = 645 serum samples) and 2006 (N = 600 plasma samples). Most measurements in 2010 were less than the lower limit of quantitation for PFBS, PFPeA, PFHxA, and PFDoA. For the remaining analytes, the geometric mean concentrations (ng/mL) in 2000-2001, 2006, and 2010 were, respectively, PFHxS: (2.25, 1.52, 1.34); PFOS (34.9, 14.5, 8.3); PFHpA (0.13, 0.09, 0.05); PFOA (4.70, 3.44, 2.44); PFNA (0.57, 0.97, 0.83); PFDA (0.16, 0.34, 0.27), and PFUnA (0.10, 0.18, 0.14). The percentage decline (parentheses) in geometric mean concentrations from 2000-2001 to 2010 were PFHxS (40%), PFOS (76%), and PFOA (48%). The decline in PFOS suggested a population halving time of 4.3 years. This estimate is comparable to the geometric mean serum elimination half-life of 4.8 years reported in individuals. This similarity supports the conclusion that the dominant PFOS-related exposures to humans in the United States were greatly mitigated during the phase-out period.

BACKGROUND: Almost all of the reported US tick-borne and transfusion-associated Babesia cases have been caused by Babesia microti, which is endemic in the Northeast and upper Midwest. We investigated a case caused by B. duncani (formerly, the WA1-type parasite), in a 59-year-old California resident with sickle cell disease (HbSS) whose only risk factor for infection was receipt of red blood cell transfusions. CASE REPORT: The patient's case was diagnosed in September 2008: intraerythrocytic parasites were noted on a blood smear, after a several-month history of increasing transfusion requirements. Molecular and indirect fluorescent antibody (IFA) analyses were negative for B. microti but were positive for B. duncani (IFA titer, 1:1024). The complete 18S ribosomal RNA gene of the parasite was amplified from a blood specimen; the DNA sequence was identical to the sequence for the index WA1 parasite isolated in 1991. The patient's case prompted a transfusion investigation: 34 of 38 pertinent blood donors were evaluated, none of whom tested positive by B. microti IFA. The implicated donora 67-year-old California residenthad a B. duncani titer of 1:4096; B. duncani also was isolated by inoculating jirds (Mongolian gerbils) with a blood specimen from March 2009, more than 10 months after his index donation in April 2008. The patient's case was diagnosed more than 4 months after the implicated transfusion in May 2008. CONCLUSIONS: This patient had the third documented transfusion case caused by B. duncani. His case underscores the fact that babesiosis can be caused by agents not detected by molecular or serologic analyses for B. microti.

Item does not contain fulltext CONTEXT: Illicit drug use is associated with risky sexual behaviors in adolescents and young adults. However, few studies have examined these associations among drug users of all reproductive ages, using a control group of nonusers. METHODS: Associations between marijuana and cocaine use, and outcomes related to sexual behaviors and reproductive health, were assessed using data from the 2002 National Survey of Family Growth. Overall, 4,928 men and 7,643 women aged 15-44 were interviewed. Chi-square tests, t tests and multivariable logistic regression analyses were used; in supplementary analyses, men and women were stratified by age-group (25 or younger, and older than 25), to capture the understudied older adults who use drugs. RESULTS: Twenty-seven percent of men and 16% of women reported use of marijuana or cocaine in the last year. Drug users were younger than nonusers at first vaginal sex (mean, 15.2-16.1 vs. 17.3-17.5 years) and were more likely to have engaged in risky sexual behaviors in the last year, including having had sex with a nonmonogamous partner (odds ratios, 3.3-5.2 for men and 2.9-6.5 for women), while high on alcohol or drugs (10.1-18.0 and 8.1-24.2), or in exchange for money or drugs (2.7-2.8 and 2.3-9.2). They also were more likely to have undergone STD testing or treatment. Drug use was associated with risky sexual behaviors in both age-groups. CONCLUSION: Programs aimed at reducing sexual risks among drug users should address the behaviors of men and women of all reproductive ages.

The purpose of this study was to determine the concentration trends of a nine-target-analyte homologous series of perfluorocarboxylates from six American Red Cross adult blood donor centers. A total of 645 serum and 600 plasma samples were obtained in 2000-2001 and 2006, respectively, with samples stratified for each 10-year (20-69) age- and sex-group per each location. Samples were extracted by protein precipitation and quantified by using tandem mass spectrometry. The nine perfluorocarboxylates were perfluorobutanoate (PFBA, C(3)F(7)CO(2)(-)), perfluoropentanoate (PFPeA, C(4)F(9)CO(2)(-)), perfluorohexanoate (PFHxA, C(5)F(11)CO(2)(-)), perfluoroheptanoate (PFHpA, C(6)F(13)CO(2)(-)), perfluorooctanoate (PFOA, C(7)F(15)CO(2)(-)), perfluorononanoate (PFNA, C(8)F(17)CO(2)(-)), perfluorodecanoate (PFDA, C(9)F(19)CO(2)(-)), perfluoroundecanoate (PFUnA,C(10)F(21)CO(2)(-)), and perfluorododecanoate (PFDoA, C(11)F(23)CO(2)(-)). The majority of measurements were less than the lower limit of quantitation for PFPeA, PFHxA, and PFDoA. For the remaining targeted analytes, the geometric mean serum and plasma concentrations (ng/mL) for 2000-2001 and 2006 were, respectively, as follows: PFBA 2.61 vs 0.33, PFHpA 0.13 vs 0.09, PFOA 4.70 vs 3.44, PFNA 0.57 vs 0.97, PFDA 0.16 vs 0.34, and PFUnA 0.10 vs 0.18. Estimates of the 95th percent tolerance limits (ng/mL) were as follows: PFBA 5.3 vs 1.4, PFHpA 0.4 vs 0.4, PFOA 12.3 vs 7.7, PFNA 1.4 vs 2.2, PFDA 0.4 vs 0.8, and PFUnA 0.3 vs 0.5. Important observations were the decline in PFBA and increase in PFNA, PFDA, and PFUnA concentrations between 2000-2001 and 2006. The longer chain length perfluorocarboxylates were also highly correlated with each other.

Because bariatric surgery is becoming increasingly common, gastroenterologists need to be familiar with the surgical and endoscopic anatomy of the operations in use today. This review focuses on the 4 most commonly performed bariatric operations in the United States: Roux-en-Y gastric bypass, adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. The anatomy and mechanism of action of each procedure is discussed and illustrated. Emphasis is placed on the endoscopic anatomy, with review of the commonly encountered complications. Emerging techniques and devices are reviewed.

We describe a family with a novel, inherited AXIN2 mutation (c.1989G>A) segregating in an autosomal dominant pattern with oligodontia and variable other findings including colonic polyposis, gastric polyps, a mild ectodermal dysplasia phenotype with sparse hair and eyebrows, and early onset colorectal and breast cancers. This novel mutation predicts p.Tyr663X, which is a truncated protein that is missing the last three exons, including the DIX (Disheveled and AXIN interacting) domain. This nonsense mutation is predicted to destroy the inhibitory action of AXIN2 on WNT signaling. Previous authors have described an unrelated family with autosomal dominant oligodontia and a variable colorectal phenotype segregating with a nonsense mutation of AXIN2, as well as a frameshift AXIN2 mutation in an unrelated individual with oligodontia. Our report provides additional evidence supporting an autosomal dominant AXIN2-associated ectodermal dysplasia and neoplastic syndrome.

Chemical bath deposition and ion exchange were used to incorporate copper, zinc, tin and sulfur into a thin film precursor stack. The stack was then sulfurized to form the photovoltaic absorber material Cu 2 ZnSnS 4 (CZTS). The morphology and elemental composition of the films at each process stage were analyzed by Auger electron spectroscopy and scanning electron microscopy, and the structural and optical properties of the sulfurized film were determined by a combination of X-ray diffraction, Raman scattering, and diffuse reflectance UV–Vis spectroscopy. Compositionally uniform microcrystalline CZTS with kesterite structure and a bandgap of 1.45 eV were observed. A preliminary solar cell device was produced exhibiting photovoltaic and rectifying behavior.

This paper documents the evaluation of a Field Portable X-Ray Fluorescence spectrometer (FP-XRF) as a bench top laboratory unit with regard to quantitative elemental analysis of siliciclastic soils and sediments. With the end-user in mind, we outline a calibration scheme that offers significant improvement in data quality over the manufacturer's calibration. Our calibration approach is based on Standard Reference Materials (SRMs) as calibration standards, the use of least-squares regression techniques that allow for uncertainty in both x and y data (i.e., type II linear regression), propagation of error with respect to predicted concentrations, and goodness of fit evaluation. Data presented include the repeated analysis of numerous standard reference sediments and soils, which are used to evaluate the instrument response to changes in concentration, signal stability over the course of ∼1 year, and calibration model suitability. We present Hudson River estuary sediment data along with independent confirmatory analyses as a demonstration. Our results for the estuarine sediments are in very good agreement with independent laboratory analyses, indicating that the FP-XRF is comparable to traditional laboratory instrument/analytical techniques, and capable of providing high quality data for numerous elements.

Background Pulmonary embolism (PE) is an uncommon, life-threatening complication after living donor nephrectomy (LDN), and is considered among the most common causes for donor mortality. Most cases of postoperative PEs are thought to originate in deep venous thrombosis (DVT) of the lower extremities. Case Report A 56-year-old, healthy woman underwent laparoscopic left LDN. Her postoperative course was complicated by PE, presenting at postoperative day 7. Doppler ultrasonography of her lower extremities did not demonstrate DVT. Both transthoracic echocardiogram and contrast-enhanced computed tomography demonstrated a floating thrombus within the inferior vena cava (IVC) originating from a thrombus in the left renal vein stump. Symptoms resolved with systemic anticoagulation. Repeat transesophageal echocardiography demonstrated resolution of the IVC thrombus. Conclusions Thrombus originating in left renal vein stump should be considered in patients who develop PE after LDN, especially when lower extremity DVT is not demonstrated.

Type 2 diabetes mellitus affects more than 170 million people worldwide. Because this disease is strongly linked to obesity, the term "diabesity" has been coined to describe the confluence of the 2 disease processes. Bariatric surgery has been performed for many years to achieve sustained weight loss in the morbidly obese population. As a secondary effect, a remarkable improvement in glycemic control is commonly achieved postoperatively. This has led to substantial interest in the use of bariatric procedures to treat type 2 diabetes mellitus. Surgical procedures in common use include the adjustable gastric band, the Roux-en-Y gastric bypass, the biliopancreatic diversion with duodenal switch, and the sleeve gastrectomy. Additionally, several investigational procedures including the ileal interposition and duodenal-jejunal bypass have been proposed as primary interventions for type 2 diabetes mellitus. These operations achieve their metabolic effects through a combination of volume restriction, intestinal bypass, and hormonal changes. As more data become available on the positive effect of bariatric procedures on type 2 diabetes mellitus, the use of such operations may grow. Bariatric surgery may ultimately become a major tool in the long-term treatment of type 2 diabetes mellitus. This manuscript presents an extensive review of the literature supporting these concepts.

Natural orifice transluminal endoscopic surgery (NOTES) is an experimental surgical approach. Several intra-abdominal procedures have been successfully performed in animals and humans although the long-term safety is still unknown. Potential advantages are reduction of wound-related complications, reduced postoperative pain, improved cosmesis, and short recovery time. This study aimed to measure the overall perception among health care workers and medical students. Materials: A brief 9-item survey was created to measure the perception among health care workers and medical students. A total of 120 surveys were completed. Results: Overall, 15% had a favorable perception, 29% had an unfavorable perception, and 55% were undecided. A total of 40% considered the possibility of avoiding wound-related complications the most appealing advantage, whereas 54% cited unknown safety as the most concerning possible disadvantage. Current occupation, previous knowledge, and affiliation to the surgical department influenced the overall perception. Conclusion: Most health care workers and medical students in our sample were undecided in their perception of NOTES.

BACKGROUND: Plasma components from female donors were responsible for most cases of transfusion-related acute lung injury (TRALI) reported to the American Red Cross (ARC) between 2003 and 2005. Consequently, we began preferentially distributing plasma from male donors for transfusion in 2006 and evaluated the effect on reported TRALI cases in the ensuing 2 years. STUDY DESIGN AND METHODS: Suspected TRALI cases reported to the ARC Hemovigilance Program in calendar years (CY) 2006, 2007, and 2008 are described. Any case involving a fatality was also independently reviewed by three ARC physicians and classified as probable TRALI or not TRALI. RESULTS: The percentage of plasma collected from male donors and distributed for transfusion increased each year from 55% in CY2006 to 79% in CY2007 and 95% in CY2008. Independent medical review of the 77 reported TRALI cases involving a fatality identified 38 cases as probable TRALI. Plasma was the only component transfused in six of these cases in 2006, five in 2007, and zero in 2008. Overall, the analysis of reported fatalities and nonfatal cases demonstrates that TRALI involving only plasma transfusion was significantly reduced in 2008 compared to 2006 (32 vs. 7 cases; odds ratio [OR] = 0.21; 95% confidence interval [CI] = 0.08-0.45), to a level that was no longer different from the rate of TRALI observed for RBC transfusion (4.0 vs. 2.3 per 106 distributed components; OR = 1.78; 95% CI = 0.67-4.36). CONCLUSIONS: Reported TRALI cases from plasma transfusion decreased in 2008 compared to the prior 2 years simultaneously with the conversion to male-predominant plasma for transfusion.

Gastrojejunal anastomotic stricture is the most commonly occurring short-term complication after Roux-en-Y gastric bypass. Endoscopic balloon dilation is the first-line treatment for stricture. However, an optimal dilation protocol has not been identified. This study aimed to document routine management of stricture after laparoscopic gastric bypass and its impact on postoperative weight loss.Charts of patients who underwent gastric bypass from 2000 to 2006 were reviewed using a standardized abstraction form. Patients with stricture were matched with control subjects based on age +/-5 years, gender, and preoperative body mass index (BMI +/- 5). Patients with at least 6 months of follow-up assessment were included in the study.Of the 113 patients included in the study, 20% were male, 26% black, 19% Hispanic, and 51% white. Their mean age was 42 +/- 10 years (range, 22-66 years). The mean preoperative BMI was 47.0 +/- 5.4 kg/m(2) for the case group and 46.6 +/- 5.5 kg/m(2) for the control group (p = 0.3). After adjustment for patient characteristics, using a larger balloon was associated with reduced odds of stricture recurrence (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.12-0.85; p = 0.02). All the patients were without signs or symptoms of stricture at the last follow-up visit (20 +/- 17 months). Weight loss was similar between the two groups. The percentage of estimated weight loss (%EWL) at 12 months postoperatively was 66% for the study participants and 67% for the control subjects (p = 0.5). Baseline alcohol use and higher preoperative BMI were associated with a higher BMI 6 months postoperatively (p = 0.004 and p0.001, respectively).Initial dilation with a larger balloon is safe and may prevent stricture recurrence. Further study of modifiable risk factors for reduced weight loss after surgery, such as alcohol use, may improve patient outcomes.

One integrative measurement of microbial activity in soils is the efficiency by which microbes convert assimilated carbon (C) into biomass C. This efficiency, called the microbial growth efficiency ( Y ), is a key physiological characteristic that regulates soil carbon sequestration, nutrient immobilization, and greenhouse gas emissions. Changes in rainfall patterns and soil water content as the result of global climate change have the potential to influence microbial activity and lead to changes in Y and thus, nutrient cycling at the ecosystem level. Unfortunately, little information is available on how environmental variables such as soil moisture influence Y . We have developed a new method for injecting 13 C-labeled carbon as acetic acid vapor into soil that will allow measurement of microbial growth efficiency (as Y C ) without increasing soil moisture content. We compare Y determined with this new approach with an alternate method where injected 15 N-labeled ammonia gas is used to quantify microbial N immobilization, and microbial growth efficiency is calculated based on microbial C:N and respiration rate (as Y N ). We also include injections of a solution containing labeled ammonium and acetate in our experiment to compare the results of our vapor methods with more commonly employed liquid-based methods. The 13 C-acetic acid vapor, which was supplied to soils with soil moisture content ranging from 0.05 to 0.21 g H 2 O g −1 soil, was readily assimilated and respired by microbes. Between 0.10 and 0.21 g H 2 O g −1 soil (−0.60 to −0.04 MPa), values of Y C averaged 0.46, and were significantly lower than values of Y N , with average values of 0.58. Over this range, soil moisture content had no significant effect on either Y C or Y N . However, at the lowest soil moisture content (0.05 g H 2 O g −1 soil; Y C and Y N diverged substantially, suggesting that in very dry soils, constraints on microbial growth cause differential uptake of C and N resources.

Diabetes is one of the most common diseases in the United States, with 1.5 million new cases reported in 2005 and a projected 48.3 million diabetics in the year 2050. Despite the disease's remarkably high prevalence and the substantial efforts focused on pharmacological treatment of the disease, current dietary, behavioral, and medical therapies have achieved only limited success. For over 2 decades, bariatric surgeons have recognized that gastric bypass surgery causes a remarkable, durable improvement in type 2 diabetes mellitus. Remarkably, this normalization of glucose metabolism occurs within several weeks of surgery, long before substantial weight loss takes place. As early as in 1987, data have been available demonstrating that 83% of patients with diabetes and 99% of those with impaired glucose tolerance become euglycemic after gastric bypass surgery. Despite the availability of this effective treatment for diabetes, the primary therapy for type 2 diabetes mellitus has remained medical. In this article, we review some of the hypotheses about how bariatric operations affect glucose metabolism and diabetes as well as the research that has been done to elucidate these mechanisms. Additionally, we discuss how surgery may one day represent an important management option for type 2 diabetes mellitus. Mt Sinai J Med 76:281–293, 2009. © 2009 Mount Sinai School of Medicine

Identification of microsatellite unstable (MSI-H) colorectal cancers (CRCs) is important not only for the identification of hereditary nonpolyposis colorectal cancer syndrome but also because MSI-H CRCs have a better prognosis and may respond differently to 5-fluorouracil-based chemotherapy. We present 2 nearly equivalent logistic regression models for clinical use that predict microsatellite instability based on the review of 1649 CRCs from patients of all ages collected in a population-based case control study in northern Israel. One hundred ninety-eight of these 1649 tumors demonstrated a high degree of microsatellite instability (12%). Multivariate analysis found that2 tumor-infiltrating lymphocyte (TIL) cells per high-powered field, the lack of dirty necrosis, the presence of a Crohn-like reaction, right-sided location, any mucinous differentiation (mucinous or focally mucinous) and well or poor differentiation, and age less than 50 were all independent predictors of MSI-H. We developed 2 logistic regression models that differ only by the statistical approach used to analyze the number of TIL cells per high-powered field, where the slightly more accurate (and complex) model uses the log of the total number of TIL cells. The simpler clinical model uses a cut-off of 2TIL cells per high-powered field. The accuracy of both models is high, with an 85.4% versus 85.0% probability of correctly classifying tumors as MSI-H. By employing the simpler model, pathologists can predict the likelihood of microsatellite instability by compiling the MSI probability score (Table 4 and Fig. 1) from simple histologic and clinical data available during sign-out. Our model shows that approximately 43% of CRCs have a MSI probability score of 1 or less and hence have little likelihood (3%) of being MSI-H. Although this model is not perfect in predicting microsatellite instability, its use could improve the efficiency of expensive diagnostic testing.

Summary 1. Linking microbial activity with ecosystem function is a continuing goal among ecologists focusing their efforts below ground in terrestrial ecosystems. 2. Genomic approaches, using DNA and RNA extracted from soil to characterize types of microbes present and genes expressed in soil, are promising, but, the required destructive harvest confounds spatial and temporal information. 3. Microbiosensors offer a gene-based way to examine microbial perception of, and response to, the soil environment non-destructively, with high spatial and temporal resolution. 4. In this mini-review, we explore the promise, challenges and tradeoffs associated with the design and deployment of microbiosensors in soil, as well as the interpretation of information derived from them live from the soil grain'. Both the promises and challenges are caused by the facts that: microbiosensors are living organisms with specific traits; they come from a phylogenetically diverse but restricted subsample of enormous soil microbial diversity; they are responsive to internal and external influences on multiple cellular processes (not just promoter induction); and they become part of food chains in non-sterile soils. We examine each of these characteristics, and associated blessings and curses, in the context of using microbiosensors to explore microbial soil ecology.

Substance abuse poses significant health risks to childbearing-aged women in the United States and, for those who become pregnant, to their children. Alcohol is the most prevalent substance consumed by childbearing-aged women, followed by tobacco, and a variety of illicit drugs. Substance use in the preconception period predicts substance use during the prenatal period. Evidence-based methods for screening and intervening on harmful consumption patterns of these substances have been developed and are recommended for use in primary care settings for women who are pregnant, planning a pregnancy, or at risk for becoming pregnant. This report describes the scope of substance abuse in the target population and provides recommendations from the Clinical Working Group of the Select Panel on Preconception Care, Centers for Disease Control and Prevention, for addressing alcohol, tobacco, and illicit drug use among childbearing-aged women.

Background Similar to gastric bypass patients, a regimen of ursodeoxycholic acid in the immediate postoperative period might obviate the need for routine cholecystectomy. Routine cholecystectomy has been recommended for patients who undergo biliopancreatic diversion (BPD), because of the high prevalence of gallstones in the obese patient and presumed development of gallstones postoperatively. We have considered elective cholecystectomy only if gallbladder disease were present. The aim of this study was to assess the need for cholecystectomy in the postoperative period in such patients. Methods In this retrospective study, the data from 219 patients who had undergone BPD with duodenal switch (BPD/DS), from January 1999 to January 2003, were analyzed. We performed a 150-cm alimentary limb and 100-cm common channel BPD/DS. The patients received 600 mg ursodeoxycholic acid orally daily for 6 months. The following data were recorded: demographics, medical history, medication, weight loss, diagnostic evaluation, and operative and pathologic data. Results Of the 219 patients who underwent surgery, 59 were men (26.9%) and 160 women were (73.1%) (mean age 41.7 years, mean body mass index 55.7 kg/m 2 ). The mean follow-up was 30 months (range 12–48). Of the 219 patients, 57 (19.6%) underwent cholecystectomy: 28 (12.7%) preoperatively, 10 (4.5%) simultaneously, and 19 (8.7%) postoperatively. Simultaneous cholecystectomy was performed when the patient had a history of colic episodes with gallbladder disease (disclosed by preoperative ultrasonography). The postoperative cholecystectomy pathology reports showed cholecystitis in only 7 patients. Conclusion The results of our study have shown that the incidence of postoperative cholecystectomy in BPD/DS patients is low, and cholecystitis is rare. Routine cholecystectomy in BPD/DS patients is no longer recommended.

Pulmonary embolism is the leading cause of death after bariatric surgery and represents one of the many potential life-threatening conditions after bariatric surgery. The Advanced Bariatric Life Support (ABLS) initiative was developed to teach practising bariatric surgeons, emergency physicians, and allied health professionals the need for accurate and timely diagnosis and management of life-threatening bariatric surgery complications. This case study was derived from the ABLS file and discusses the difficulty in differentiating between two major complications after gastric bypass — pulmonary embolism vs leak. Accurate diagnosis and expeditious treatment are of utmost importance to prevent death associated with these serious bariatric surgical complications.

Effective management of introduced species requires the early identification of species that pose a significant threat of becoming invasive. To better understand the invasive ecology of species in New England, USA, we compiled a character data set with which to compare non-native species that are known invaders to non-native species that are not currently known to be invasive. In contrast to previous biological trait-based models, we employed a Bayesian hierarchical analysis to identify sets of plant traits associated with invasiveness for each of three growth forms (vines, shrubs, and trees). The resulting models identify a suite of ‘invasive traits’ highlighting the ecology associated with invasiveness for each of three growth forms. The most effective predictors of invasiveness that emerged from our model were ‘invasive elsewhere’, ‘fast growth rate’, ‘native latitudinal range’, and ‘growth form’. The contrast among growth forms was pronounced. For example, ‘wind dispersal’ was positively correlated with invasiveness in trees, but negatively correlated in shrubs and vines. The predictive model was able to correctly classify invasive plants 67% of the time (22/33), and non-invasive plants 95% of the time (204/215). A number of potential future invasive species in New England that deserve management consideration were identified.

BACKGROUND: American Red Cross surveillance data on transfusion-related acute lung injury (TRALI) fatalities were analyzed to evaluate the association with components from donors with white blood cell (WBC) antibodies and to examine the potential impact of the selective transfusion of plasma from male donors. STUDY DESIGN AND METHODS: Suspected TRALI reports in 2003 through 2005 were identified and all fatalities were reviewed and classified by three physicians as “probable TRALI” or of “unrelated etiology,” with independent review of the associated serologic investigation. Hospital investigational and reporting biases could not be fully controlled in this retrospective study. RESULTS: A total of 550 reports of suspected TRALI, including 72 fatalities, were investigated. The number of reports increased each year and the rate varied by geographic region. Retrospective review of fatalities revealed 38 cases of probable TRALI, the majority (24 of 38 [63%]) after plasma transfusion. A female, WBC antibody–positive donor was involved in 71 percent (27 of 38) of cases and in 75 percent (18 of 24) of cases involving plasma transfusion. Female antibody-positive donors were more likely to be associated with probable TRALI than with unrelated cases (p = 0.0001; odds ratio [OR], 9.5; 95% confidence interval [CI], 2.9-31.1]. The rate of probable TRALI among recipient fatalities was higher for plasma components (1:202,673; OR, 12.5; 95% CI, 5.4-28.9) and apheresis platelets (PLTs; 1:320,572; OR, 7.9; 95% CI, 2.5-24.8) compared to red cells (1:2,527,437). Male donors contributed 64.5 and 52.0 percent of distributed apheresis PLTs and plasma components, respectively, in 2005. CONCLUSION: Plasma components linked to female donors with WBC antibodies were responsible for the majority of probable TRALI fatalities. Prudent measures to limit transfusion of WBC antibody–containing plasma components may prevent as many as six fatalities per year in the Red Cross system.

Several large series of laparoscopic donor nephrectomy (LDN) have been published, largely focusing on immediate results and short-term complications. The aim of this study was to examine the results of LDN and collect medium-term and long-term donor followup. We examined the results of two surgeons who performed 500 consecutive LDNs from 1996 to 2005. Prospective databases were reviewed for both donors and recipients to record demographics, medical history, intraoperative events, and complications. Patients were followed between 1 month and 9 years after surgery to assess for delayed complications, especially hypertension, renal insufficiency, incisional hernia, bowel obstruction, and chronic pain. Left kidneys were procured in 86.2% of cases. Mean operative time was 3.5 h, and warm ischemia time averaged 3.4 min. Hand-assistance was used in 13.8%, and conversion rate was 1.8%. Intraoperative complication rate was 5.8% and was predominantly bleeding (93.1%). Most (86.2%) of the operative complications occurred during the initial 150 cases of a surgeon, compared with 10.3% in the subsequent 150 cases (p = 0.003). Operative time decreased by 87 min after the initial 150 cases (p < 0.001). Immediate graft survival was 97.5%. Delayed graft function occurred in 3.0% of recipients, and acute tubular necrosis occurred in 7.0%. Thirty-day donor complication rate was 9.8%. Mean donor creatinine was 1.24 on the first postoperative day, 1.27 at 2 weeks, and 1.24 at 1 year. At a mean followup of 32.8 months, long-term donor complications consisted of 11 cases of hypertension, 9 cases of prolonged pain or paresthesia, 2 incisional hernias, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, and 1 hydrocele requiring repair. LDN can be performed with acceptable immediate morbidity and excellent graft function. Operative time and complications decreased significantly after a surgeon performed 150 cases. Long-term complications were uncommon but included a likely underestimated incidence of hypertension.

Background Previous reports have questioned the safety of bariatric surgery in older patients. The aim of this study was to quantify the perioperative morbidity and mortality of older patients undergoing laparoscopic bariatric procedures at our institution. Methods A retrospective chart review of all laparoscopic bariatric procedures performed from February 1999 to September 2005 was performed to identify patients at Mount Sinai Medical Center who were older than 60 years at surgery. Results We identified 55 patients (36 women and 19 men). The mean age was 61.5 years (range 60–70), and the mean body mass index was 46.2 kg/m2 (range 38.1–61.0). Of the 55 patients, 33 (60%) had undergone laparoscopic Roux-en- Y gastric bypass, 9 (16%) laparoscopic gastric banding, 7 (13%) laparoscopic biliopancreatic diversion with duodenal switch, 3 (5.5%) laparoscopic revisional surgery, and 3 (5.5%) laparoscopic sleeve gastrectomy. The mean operative time was 2.3 hours (range 1.1–5.5). No patients required conversion to open surgery, and no perioperative mortality occurred within 30 days. The morbidity rate was 7.3% (n = 4). One patient developed an anastomotic bleed that was treated conservatively, and another patient developed an empyema that was successfully drained with a chest tube. That patient also developed a urinary tract infection, and another patient had a wound infection. The mean length of stay was 2.8 days (range 1–14). Conclusions In a carefully selected patient population in a medical center with appropriate experience, laparoscopic bariatric surgery can be performed safely with low morbidity and mortality in the elderly population.

To test the hypothesis that an acute increase in O(2) tension increases cytosolic calcium ([Ca(2+)](i)) in fetal pulmonary artery endothelial cells (PAECs) via entry of extracellular calcium and subsequent calcium-induced calcium release (CICR) and nitric oxide release, low-passage PAECs (

At birth, the lung environment changes from low to relatively high O2tension. Pulmonary blood flow increases and pulmonary artery pressure decreases. Recent data suggest that pulmonary vascular calcium-sensitive K+channel (BKCa) activation mediates perinatal pulmonary vasodilation. Although BKCachannel expression is developmentally regulated, the molecular mechanisms responsible for BKCaexpression remain unknown. We tested the hypothesis that the low-O2tension environment of the normal fetus modulates BKCachannel expression. We analyzed BKCaexpression under conditions of hypoxia and normoxia both in vitro and in vivo. BKCaα-subunit mRNA expression increased twofold in ovine pulmonary artery smooth muscle cell (PASMC) primary cultures maintained in hypoxia. In vivo, BKCaexpression was similarly affected by hypoxia. When adult Sprague-Dawley rats were placed in hypobaric hypoxic chambers for 3 wk, hypoxic animals showed an increase of threefold in the expression of BKCaα- and more than twofold in the expression of BKCaβ1-subunit mRNA. Immunochemical staining was consistent with the genetic data. To assess transcriptional activation of the β-subunit of the BKCa, both BKCaβ1- and β2-subunit luciferase (KCaβ:luc+) reporter genes were constructed. Hypoxia increased PASMC KCaβ1:luc+reporter expression by threefold and KCaβ2:luc+expression by 35%. Fetal PASMC treated with the hypoxia-inducible factor-1 mimetic deferoxamine showed a 63 and 41% increase in BKCachannel α- and β1-subunit expression, respectively. Together, these results suggest that oxygen tension modulates BKCachannel subunit mRNA expression, and the regulation is, at least in part, at the transcriptional level.

Reports on the accuracy of magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) in evaluating living donor renovasculature employ few patients or omit the consequences of inaccurate scans. We retrospectively compared intraoperative findings to MRA/MRV scans in 146 donor-recipient pairs. For detecting accessory arteries and early branching, MRA sensitivity was 57.6%, specificity 96.5%, false positive rate 3.5%, false negative rate 42.4%, positive predictive value 82.6%, negative predictive value 88.6% and overall accuracy 87.7%. By excluding clinically inconsequential accessory arteries, MRA sensitivity rose to 73.1%, specificity to 96.7% and overall accuracy to 92.5%. For MRVs, sensitivity was 56.2%, specificity 99%, false positive rate 1%, false negative rate 43.8%, positive predictive value 90%, negative predictive value 94.8% and accuracy 94.5%. Inaccurate scans were associated with prolonged donor and recipient operations and more frequently reconstructed arteries, but did not affect clinical outcomes. Because most missed accessory arteries are inconsequential, MRA is a useful, less invasive method for defining donor renovascular anatomy.

Previous investigators have suggested that laparoscopic splenectomy should be the procedure of choice for the treatment of benign hematologic disorders unresponsive to medical therapy. To evaluate the safety and utility of laparoscopic splenectomy for a variety of splenic disorders, we reviewed our collective experience at 2 institutions. We studied our 8-year experience by retrospective chart review. Patient demographic data, splenic pathology, intraoperative events, concomitant procedures, and all adverse perioperative events were recorded. A total of 131 patients had laparoscopic splenectomy, and there were 8 conversions to open surgery. Pathology included 63 with idiopathic thrombocytopenic purpura (ITP), 23 malignancies, 12 thrombotic thrombocytopenic purpura (TTP), 10 autoimmune hemolytic anemia (AIHA), and 23 others. Accessory spleens were noted in 21 patients (16%). Concomitant surgical procedures included 12 hepatic biopsies, 4 distal pancreatectomies, 4 cholecystectomies, and 7 others. Mean operative time was 170 minutes. There were 16 major complications in 16 patients and 2 deaths. Median postoperative length of stay was 3 days. Conversions, due mostly to bleeding, are related to splenic pathology and medical comorbidity and are not temporally related to surgical experience (learning curve). The morbidity, mortality, and conversion rates were low. Laparoscopic splenectomy permits an appropriate abdominal exploration and is associated with a short hospital stay. It is the procedure of choice for most indications for splenectomy.