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Bariatric surgery continues to be the most effective long-term treatment for obesity and its associated co-morbidities. Despite the benefits, not all patients may repeat the decision to undergo bariatric surgery based on their postoperative experience (postdecision dissonance).In this study, we explore the predictors of postdecision dissonance following bariatric surgery.Accredited bariatric center at an academic medical center.Patients at an accredited Bariatric Center who underwent bariatric surgery between 2011 and 2017 were surveyed to determine factors predictive of postdecision dissonance, as well as expectations, well-being, and overall satisfaction.A total of 591 patients were sent surveys, of whom 184 (31.1%) responded. Of the 184 responders, 20 (10.9%) patients would not choose to undergo bariatric surgery if they had it do to over again (postdecision dissonance). There was no difference in the time since surgery, age, sex, or type of bariatric surgery among groups. Dissonant patients were less likely to be married and privately insured. Dissonant patients were more likely to feel they had inadequate preoperative education on postoperative expectations (P.001). These patients also had significantly greater postoperative weight regain, failed weight loss expectations, depression, and dissatisfied body image.Postdecision dissonance is driven in part by a patient's perceived inadequacy of preoperative preparation for postoperative outcomes coupled with postoperative weight regain, depression, dissatisfied body image, and failed weight loss expectations. This highlights the importance of preoperative counseling on managing expectations and outcomes after surgery, as well as the need for continued postoperative engagement with a bariatric program to address weight regain and provide mental health support.

Shape memory is the capability of a material to be deformed and fixed into a temporary shape. Recovery of the original shape can then be triggered only by an external stimulus. Shape-memory polymers are highly deformable materials that can be programmed to recover a memorized shape in response to a variety of environmental and spatially localized stimuli as a one-way effect. The shape-memory function can also be generated as a reversible effect enabling actuation behaviour through macroscale deformation and processing, specifically by dictating the macromolecular orientation of actuation units and of the skeleton structure of geometry-determining units in the polymers. Shape-memory polymers can be programmed and reprogrammed into arbitrary shapes. Both recovery and actuation behaviour are reprogrammable. In this Review, we outline the common basis and key differences between the two shape-memory behaviours of polymers in terms of mechanism, fabrication schemes and characterization methods. We discuss which combination of macromolecular architecture and macroscale processing is necessary for coordinated, decentralized and responsive physical behaviour. The extraction of relevant thermomechanical information is described, and design criteria are shown for microscale and macroscale morphologies to gain high levels of recovered or actuation strains as well as on-demand 2D-to-3D shape transformations. Finally, real-world applications and key future challenges are highlighted. Shape-memory materials can generate programmable movements triggered by an external stimulus, such as an environmental change. In this Review, the authors discuss mechanisms, fabrication schemes, characterization methods and applications of the one-way shape-memory effect enabling shape recovery and of reversible shape-memory effects exhibiting actuation behaviour.

Acute gastric volvulus is a relatively rare, but serious, surgical emergency defined as rotation of the stomach greater than 180 °. This leads to foregut luminal obstruction and compromised blood flow to the stomach with ischemia and potentially necrosis. Treatment is initiated with gastric decompression via a nasogastric tube or endoscopic decompression. Definitive surgical management includes reduction of the volvulized stomach, resection of gastric necrosis if present, and gastropexy. A high index of suspicion is necessary to ensure a prompt work-up and intervention. If diagnosis and treatment are significantly delayed, morbidity and mortality rates can be high. This is related to the fact that the cohort of patients likely to be affected by this phenomenon is typically the elderly and often frail with decreased physiologic reserve to tolerate such an insult.

The Institute of Medicine (IOM) was established as the health arm of the National Academy of Sciences in 1970. The IOM published two seminal reports that are largely credited with shining the spotlight on patient harm related to medical errors. The IOM’s report, To Err is Human: Building a Safer Health System, was released in 1999 and highlighted how tens of thousands of patients in the United States die each year from medical errors that could have been prevented. In the report, medical errors were defined as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” This report was followed in 2001 by the IOM’s Crossing the Quality Chasm: A New Health System for the 21st Century, which described broader quality issues and defined six aims for healthcare. These six aims include the goals for healthcare to be safe, effective, timely, patient-centered, efficient, and equitable. With these two reports, the IOM Committee on Quality of Health Care in America laid out a vision for how the healthcare system and related policy must be transformed in order to close the gap between what we know to be good quality care and the care that is actually delivered in practice.

Laparoscopic surgery has gained popularity in recent time. An essential aspect of this technique is production of a pneumoperitoneum with insufflation for adequate visualization and manipulation of abdominal contents. Various techniques have been developed over the years for optimal access with minimization of complications. Some of these complications include vascular injury, visceral injury, and incisional hernia. Furthermore, considerations with regards to the patient’s physical morphology, and the cardiovascular/respiratory effects of increased abdominal pressure and anesthesia must be accounted for. The guidelines to optimize patient care in these regards are discussed in this review. This review contains 2 videos, 5 figures, 2 tables, and 79 references. Keywords: trocar insertion, port site hernia, Veress needle, optical trocar, trocar related injuries, Hassan cannula, pneumoperitoneum, air embolism, pneumoperitoneum physiology

Paraesophageal hernias have among the highest recurrence rates of all hernias and represent a technically challenging problem for the surgeon. There is broad heterogeneity in both the type of paraesophageal hernia as well as the options for repair. This chapter will review the evaluation of a patient with a recurrent paraesophageal hernia as well the factors involved in patient selection. We will detail our preferred operative technique in recurrent paraesophageal hernia repair as well as technical considerations. Finally the results of repair are reviewed.

Background Surgical site infection (SSI) is an important marker of postoperative morbidity and overall quality of care. Transfusion-related immunomodulation can lead to weakened immunity in response to blood transfusion and predispose patients to SSIs. Objectives The aim of this study was to determine the impact of perioperative blood transfusions on SSIs in bariatric surgery patients. Setting National data set. Methods The American College of Surgeons National Surgical Quality Improvement Program data sets were queried for laparoscopic and open bariatric operations between 2012 and 2014. Univariate analyses identified perioperative variables associated with postoperative SSIs. Multivariate regression analyses determined the effect of perioperative blood transfusions on postoperative SSI. Results The study cohort included 59,424 patients: 480 (8.1%) biliopancreatic diversions, 28,268 (44.2%) gastric bypasses, 30,258 (50.9%) sleeve gastrectomies, and 418 (7.0%) bariatric revisions. Of the patients, 1107 (1.9%) developed a SSI: 662 (1.1%) superficial, 89 (0.1%) deep, and 356 (.6%) organ space. Patients receiving a perioperative blood transfusion were more likely to develop any type of SSI, organ space being most prevalent (Fig. 1). Among organ space SSIs, 198 (55.6%) were gastric bypasses and 125 (35.1%) were sleeve gastrectomies. Conclusions Bariatric surgery patients who receive a perioperative blood transfusion are at higher risk of developing SSIs, particularly organ space. The majority of organ space SSIs occur after gastric bypass, likely secondary to infected intra-abdominal hematomas. Close monitoring of postoperative signs of infection in these patients is important to determine if additional interventions are warranted.

Recent studies have suggested that potential aberrant alterations in the gastrointestinal microbiome contribute to the development of cardiovascular disease, specifically hypertension. Bariatric surgery produces significant sustained weight loss and hypertension resolution likely through multiple mechanisms which includes beneficial changes in the gut microbiome. We hypothesized that the type of prophylactic antibiotic given for bariatric surgery could impact the resolution rate of hypertension by altering the post-operative gastrointestinal microflora. A retrospective analysis of adult bariatric patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2012 and 2016 was conducted. The standard antibiotic prophylaxis was cefazolin, or clindamycin in patients with a penicillin allergy. Univariate analyses were performed comparing the differing peri-operative antibiotic treatments with resolution of hypertension at 2-week (± 1 week), 6-week (± 2 weeks), 3-month (± 2 weeks), 6-month (± 6 weeks), and 1-year (± 2 months) follow-up appointments. The criterion for resolution of hypertension was no longer requiring medication at time of follow-up. In total, 123 RYGB and 88 SG patients were included. No significant differences were found between cefazolin and clindamycin regarding hypertension resolution rates after SG. However, patients who underwent RYGB and received clindamycin had a significantly higher rate of hypertension resolution compared to cefazolin. This effect started at 2 weeks post-operatively (52.4% vs. 23.5% respectively, p = 0.008) and persisted up to the 1-year (57.9% vs. 44.0% respectively, p = 0.05). Prophylactic peri-operative, intravenous clindamycin was associated with significantly increased resolution of post-operative hypertension compared to cefazolin. This finding was not observed in SG patients. Future studies are needed to confirm the mechanism of action for this novel finding is due to the differing modifications of the gastrointestinal microflora after RYGB resulting from the specific peri-operative antibiotic administered.

Interoception is the body-to-brain axis of sensation concerning the state of the internal body. Interoceptive signals from the heart can modulate emotional processing. Moreover, the degree to which people accurately detect their own heart beating at rest can predict their emotional responsivity. Here we determine how interoceptive signals can modulate the perception of faces by exploiting phasic cardiac activity within a binocular onset rivalry paradigm. We demonstrate that afferent cardiac signals facilitate the early processing of fearful face images in individuals with high interoceptive (heartbeat detection) accuracy: The contraction of heart at cardiac systole enhanced the detection of fearful faces (during initial image selection in rivalrous presentations), and shortened reaction times for subsequent emotional judgements. However, cardiac systole does not lead to an overall bias in increased fear categorisation. Our findings highlight interactive contributions of interoception in shaping perceptual and behavioural aspects of emotional processing. Our results thereby add to empirical data regarding mechanisms of body-brain integration underpinning emotional experience. (Preprint of manuscript under review)

Polymeric materials possessing specific features like programmability, high deformability, and easy processability are highly desirable for creating modern actuating systems. In this study, thermoplastic shape-memory polymer actuators obtained by combining crystallizable poly(epsilon-caprolactone) (PCL) and poly(3S-isobutylmorpholin-2,5-dione) (PIBMD) segments in multiblock copolymers are described. We designed these materials according to our hypothesis that the confinement of glassy PIBMD domains present at the upper actuation temperature contribute to the stability of the actuator skeleton, especially at large programming strains. The copolymers have a phase-segregated morphology, indicated by the well-separated melting and glass transition temperatures for PIBMD and PCL, but possess a partially overlapping T-m of PCL and T-g of PIBMD in the temperature interval from 40 to 60 degrees C. Crystalline PIBMD hard domains act as strong physical netpoints in the PIBMD-PCL bulk material enabling high deformability (up to 2000%) and good elastic recoverability (up to 80% at 50 degrees C above T-m,T-PCL). In the programmed thermoplastic actuators a high content of crystallizable PCL actuation domains ensures pronounced thermoreversible shape changes upon repetitive cooling and heating. The programmed actuator skeleton, composed of PCL crystals present at the upper actuation temperature T-high and the remaining glassy PIBMD domains, enabled oriented crystallization upon cooling. The actuation performance of PIBMD-PCL could be tailored by balancing the interplay between actuation and skeleton, but also by varying the quantity of crystalline PIBMD hard domains via the copolymer composition, the applied programming strain, and the choice of T-high. The actuator with 17 mol% PIBMD showed the highest reversible elongation of 11.4% when programmed to a strain of 900% at 50 degrees C. It is anticipated that the presented thermoplastic actuator materials can be applied as modern compression textiles.

Patients with a paraesophageal hernia may experience gastroesophageal reflux symptoms and/or obstructive symptoms such as dysphagia. Some patients with large and complex paraesophageal hernias unintentionally lose a significant amount of weight secondary to difficulty eating. A subset of patients will develop Cameron’s erosions in the hernia, which contribute to anemia. Given the heterogeneous nature of patients who ultimately undergo paraesophageal hernia repair, we sought to determine if patients with anemia or malnutrition suffered from increased morbidity or mortality. The American College of Surgeons National Surgical Quality Improvement Program datasets from 2011 to 2015 were queried to identify patients undergoing paraesophageal hernia repair. Malnutrition was defined as preoperative albumin

The primary objective of this study was to evaluate the utility of CRP in early identification of post-operative complications after bariatric surgery. The ability of this marker to acutely predict post-operative complications in bariatric surgery patients has not been determined. A retrospective chart review was conducted of adult patients who underwent a primary and revisional laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) between 2013 and 2017 at a single institution. Patients were identified using the prospective Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. CRP levels were drawn on post-operative day one per standard protocol. Univariate analyses were performed to determine the predictive impact of CRP levels on post-operative complications, readmissions, and reoperations. There were 275 patients who underwent bariatric surgery, 222 primary and 53 revisional. Of the 275 patients, 36 (13.1%) had a complication. Bariatric surgery patients with a post-operative complication had higher CRP levels compared to those who did not (4.8 ± 4.6 vs. 2.9 ± 2.0; p = 0.02). A CRP ≥ 5 mg/dL had a sensitivity for a complication of 27% and a specificity of 88%. There was no difference in CRP levels for patients with a 30-day reoperation or readmission. There were no mortalities. Bariatric surgery patients with elevated post-operative CRP levels are at increased risk for 30-day complications. The low sensitivity of a CRP ≥ 5 mg/dL suggests that a normal CRP level alone does not rule out the possibility of a post-operative complication. However, with its high specificity, there should be an elevated clinical suspicion of a post-operative complication in patients with a CRP ≥ 5 mg/dL.

Is it feasible to democratize the powerful institutions of global governance that currently work to advance globalization processes, making them more responsive to the needs and interests of the people affected by their policies? This chapter discusses the motivation for addressing this “democratic deficit” at the transnational level, in the context of the inequalities in power and resources engendered by globalization and its institutional framework. It critically analyses two main lines of argument put forward for democratization of global governance—the “all subjected” and the “all affected” principles—and then proposes a reformulation of them for this new context. It concludes by considering some concrete directions for fulfilling democratic norms transnationally, including ways of introducing greater transparency and accountability in transnational institutions, as well as more extensive changes that would enable people to gain substantial control over the forces and structures that currently profoundly affect them.

Background Hospital readmission rates are an important quality metric. A readmission very soon after discharge may be related to a different cause than readmissions that occur later in the first 30 d. Materials and Methods The National Surgical Quality Improvement Program data sets from 2014 to 2015 were used to identify patients undergoing general surgery procedures. Demographics, comorbidities, and morbidity were analyzed. Stepwise regression was used to determine statistical predictors for any readmission. The final model variables were a combination of selected clinical variables and statistically significant variables. Multinomial logistic regression was then used with these variables to develop models for “very early” (days 0-3 after discharge) and “early” (days 4-30) readmissions. Results A total of 744,492 patients were included with 5.9% readmitted within 30 d and 1.5% readmitted within 3 d of discharge (26.1% of all readmissions). Significant risk factors for any readmission included ≥3 comorbidities, major surgery (operative time >1 h, length of stay greater >2 d), and American Society of Anesthesiologists class ≥3. When examining “very early” readmissions, the greatest risk factor was experiencing a severe complication (≥Grade III) before discharge. Conclusions Readmissions within 3 d of discharge constitute a large portion of all 30 d readmissions. The greatest risk factor for “very early” readmission was a severe complication before discharge. Better understanding of the reason for this association is needed to develop effective prevention strategies.

Approximately 15 % of older women on oral medications for osteoporosis could be considered for alternatives including parenteral therapies. Collection of data on socio-demographic/clinical variables is unlikely to be helpful in predicting low/non-adherence. Alternative approaches are needed to identify individuals at risk of low/non-adherence. This study aims to identify individual patient reasons for stopping medications for osteoporosis, and to investigate whether this can be predicted from knowledge about socio-demographic/clinical data, or whether alternative approaches need to be used. The Cohort for Skeletal Health in Bristol and Avon (COSHIBA) recruited 3200 older women from South West UK, of whom a proportion were on medications for osteoporosis at baseline. Information on self-reported adherence and reasons for low/non-adherence were collected at 6-monthly intervals over a 2-year period. Data was also collected on potential predictors of and impact of low/non-adherence. Two hundred thirty-three of 3200 (7.3 %) women were on medications for osteoporosis at baseline. Mean length of time on treatment prior to enrolment was 46 months. Of those on osteoporosis medications, 94.9 % were on bisphosphonates; 8.5 % reported low adherence and 21.6 % stopped their medication completely over the 2-year follow-up period. Length of time on medication at baseline did not influence rates of low/non-adherence. Reasons for low/non-adherence to bisphosphonates included side effects (53.9 %), practical reasons such as forgetting to take them (18.0 %) and beliefs about medications (20.5 %). No convincing predictors of low/non-adherence were identified. Approximately 15 % of older women on oral medications for osteoporosis could be considered for alternatives including parenteral therapies. This has important implications for healthcare provision. Collection of data on socio-demographic/clinical variables is unlikely to be helpful in predicting low/non-adherence. Alternative approaches are needed to identify individuals at risk of low/non-adherence to osteoporosis medications.

Background Hospital readmissions are a quality indicator in bariatric surgery. In recent years, duration of stay after bariatric surgery has trended down greatly. We hypothesized that a shorter postoperative hospitalization does not increase the likelihood of readmission. Methods The University HealthSystem Consortium (UHC) is an alliance of academic medical centers and affiliated hospitals. The UHC's clinical database contains information on inpatient stay and returns (readmissions) up to 30 days after discharge. A multicenter analysis of outcomes was performed by the use of data from the January 2009 to December 2013 for patients 18 years and older. Patients were identified by bariatric procedure International Classification of Diseases, Ninth Revision, codes and restricted by diagnosis codes for morbid obesity. Results A total of 95,294 patients met inclusion criteria. The mean patient age was 45.4 (±0.11) years, and 73,941 (77.6%) subjects were female. There were 5,423 (5.7%) readmissions within the study period. Patients with hospitalizations of 3 days and more than 3 days were twice and four times as likely to be readmitted than those with hospitalizations of one day, respectively ( P Conclusion Patients with longer postoperative hospitalizations were more likely to be readmitted after bariatric surgery. Early discharge does not appear to be associated with increased readmission rates.

Various surgical techniques exist to create the gastrojejunostomy during laparoscopic Roux-en-Y gastric bypasses (LRYGB). A hand-sewn anastomosis (HSA) and circular-stapled anastomosis (CSA) are both common techniques. We hypothesized that the CSA was associated with a greater incidence of anastomotic complications. As a secondary aim, we sought to determine if weight loss varied by technique.This study is a retrospective review of patients who underwent primary LRYGB at the Medical College of Wisconsin from January 2010 to December 2011. Procedures were performed by one of 2 surgeons, each with a preferred gastrojejunostomy technique. Clinical information and patient outcomes were followed up to one year.A total of 190 patients underwent LRYGB during the study interval. The majority of patients underwent HSA. Forty-one of 190 (21.6%) patients experienced one or more complications. Most complications were Clavien Classification Grade III and were experienced within 30 days of surgery in 3 (2.2%) HSA patients and 6 (10.9%) CSA patients (P = .02). Anastomotic complications occurred more frequently with the CSA technique (marginal ulcer 5.5% CSA versus .7% HSA; P = .04 and stenosis 16.4% CSA versus 3% HSA; P = .01). There were no gastrojejunostomy leaks in this series. Operative time was significantly longer in HSA patients (204 minutes HSA versus 166 minutes CSA; P.01), but length of hospital stay did not differ. Weight loss at 12 months was similar between techniques (69.4% percent excess BMI lost (EBMIL) HSA versus 76.6% EBMIL CSA; P = .11). No patients were lost to follow-up at 30 days. Thirty-five patients (19%) were lost to follow-up by one year.The CSA technique of gastrojejunostomy in gastric bypass is associated with a higher rate of nonlife threatening anastomotic complications than the HSA technique. Operative times are significantly longer for HSA, but length of hospital stay (LOS) and long-term weight loss are equivalent.

Objective: Despite widespread use of proton pump inhibitors (PPIs), the incidence of esophageal adenocarcinoma (EAC) continues to rise. PPIs reduce reflux acidity, but only transiently inactivate gastric enzymes. Nonacid reflux, specifically nonacid pepsin, contributes to carcinogenesis in the larynx. Given the carcinogenic potential of pepsin and inefficacy of PPIs to prevent EAC, the presence and effect of pepsin in the esophagus should be investigated. Methods: Normal and Barrett’s biopsies from 8 Barrett’s esophagus patients were collected for pepsin analysis via Western blot and reverse transcriptase-polymerase chain reaction (RT-PCR). Human esophageal cells cultured from healthy patients were treated with pepsin (0.01-1 mg/mL; 1-20 hours), acid (pH 4) ± pepsin (5 minutes); real-time RT-PCR, ELISA, and cell migration were assayed. Results: Pepsin was detected in all 8 Barrett’s and 4 of 8 adjacent normal specimens. Pepsinogen mRNA was observed in 22 Barrett’s, but not in normal adjacent samples. Pepsin induced PTSG2 (COX-2) and IL-1β expression and cell migration in vitro. Conclusions: Pepsin is synthesized by metaplastic, Barrett’s esophageal mucosa. Nonacid pepsin increases metrics of tumorigenicity in esophageal epithelial cells in vitro. These findings implicate refluxed and locally synthesized pepsin in development and progression of EAC and, in part, explain the inefficacy of PPIs in the prevention of EAC.

Background Postoperative urinary retention (POUR) after laparoscopic inguinal hernia repair has an incidence of 2%-30%. POUR can lead to increased length of stay, decreased patient satisfaction, and increased health-care costs. The objective of this study was to determine the patient risk factors at our institution contributing to POUR after laparoscopic total extraperitoneal (TEP) inguinal hernia repair. Methods A retrospective chart review of patients who underwent a laparoscopic TEP inguinal hernia repair at our institution from 2009 to 2016. POUR is defined as the inability to urinate requiring urinary straight or indwelling catheterization in the postoperative period. Univariate analyses were performed on perioperative variables and their correlation with POUR. Results In total, 578 laparoscopic TEP inguinal hernia repair patients were included in the study: 277 (48%) indirect, 144 (25%) direct, 6 (1%) femoral, and 151 (26%) combination of direct, indirect, and/or femoral hernias. Of these, 292 (51%) were bilateral, and 286 (49%) were unilateral. Overall, 64 (11.1%) of the 578 patients developed POUR. POUR was significantly associated with benign prostatic hyperplasia, age 60 y or older, urinary tract infection within 30 d, and decreased body mass index. Conclusions Patients aged greater than 60 y, with benign prostatic hyperplasia, and a decreased body mass index (≤25.8 kg/m2) were more likely to develop POUR after laparoscopic TEP inguinal hernia repair. In addition, these patients were more likely to develop a urinary tract infection within 30 d. Future quality initiatives can be explored to minimize the incidence of POUR in high-risk patient populations.

In bariatric surgery patients, urinary tract infections (UTIs) are one of the most common postoperative infections. In this study, we sought to determine if preoperative patient factors and perioperative processes contribute to an increased risk of UTI. A retrospective analysis was performed of patients who underwent bariatric surgery at a single institution between March 2012 and May 2016. Standard protocol was antibiotic prophylaxis with cefazolin. Patients with a penicillin allergy received clindamycin. Urinary catheters were placed selectively. A univariate and multivariate analyses were performed to determine risk factors for patients who developed a UTI within 30 days postoperatively. Six hundred ninety-four patients (82.7% female) underwent bariatric surgery in the study interval. UTIs were more common in females (4.9 vs. 1.7%, p = 0.12). On univariate analysis age, operative time, length of stay, urinary catheter placement, clindamycin prophylaxis, and revisional surgery were significantly correlated with UTI. A multivariate logistic regression model revealed the risk of UTI increased 5.38-fold [95% confidence interval (CI) 2.41–12.05] with clindamycin use, 6.37-fold [95% CI 2.22–18.18] with revision surgery, and 1.25-fold [95% CI 1.05–1.49] for every 5 years gained in age. Older age, clindamycin prophylaxis, and revisional procedures are significantly associated with an increased rate of UTI following bariatric surgery. Several identified variables are modifiable risk factors and targets for a quality improvement initiative to decrease the rate of UTI in bariatric surgery patients.

Preoperative immobility in general surgery patients has been associated with an increased risk of postoperative complications. It is unknown if immobility affects bariatric surgery outcomes.The aim of this study was to determine the impact of immobility on 30-day postoperative bariatric surgery outcomes.This study took place at a university hospital 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. Preoperative immobility was defined as limited ambulation most or all the time. Logistic regression analysis was performed to determine if immobile patients are at increased risk (odds ratio [OR]) for 30-day complications.There were 148,710 primary minimally invasive bariatric procedures in 2015. Immobile patients had an increased risk of mortality (OR 4.59, P.001) and greater operative times, length of stay, reoperation rates, and readmissions. Immobile patients had a greater risk of multiple complications, including acute renal failure (OR 6.42, P.001), pulmonary embolism (OR 2.44, P = .01), cardiac arrest (OR 2.81, P = .05), and septic shock (OR 2.78, P = .02). Regardless of procedure type, immobile patients had a higher incidence of perioperative morbidity compared with ambulatory patients.This study is the first to specifically assess the impact of immobility on 30-day bariatric surgery outcomes. Immobile patients have a significantly increased risk of morbidity and mortality. This study provides an opportunity for the development of multiple quality initiatives to improve the safety and perioperative complication profile for immobile patients undergoing bariatric surgery.

Approximately 5–10% of patients who have antireflux surgery will undergo reoperative surgery. Failure can be due to persistent or recurrence of original symptoms or development of new symptoms after the antireflux surgery. Risk factors include inadequate response to acid suppression medical therapy, atypical symptoms, and patients with normal preoperative pH study. The etiology for failure of an antireflux procedure ranges from misdiagnosis to functional problems and anatomic failure. Reoperative antireflux surgery is a complex procedure and is best performed at high-volume centers and by surgeons with significant experience to obtain an optimal outcome. Reoperative surgery can have success rates as high as 81%.

Soft robots and devices with the advanced capability to perform adaptive motions similar to that of human beings often have stimuli-sensitive polymeric materials as the key actuating component. The external signals triggering the smart polymers’ actuations can be transmitted either via a direct physical connection between actuator and controlling unit (tethered) or remotely without a connecting wire. However, the vast majority of such polymeric actuator materials are limited to one specific type of motion as their geometrical information is chemically fixed. Here, we present magnetically driven nanocomposite actuators, which can be reversibly reprogrammed to different actuation geometries by a solely physical procedure. Our approach is based on nanocomposite materials comprising spatially segregated crystallizable actuation and geometry determining units. Upon exposure to a specific magnetic field strength the actuators’ geometric memory is erased by the melting of the geometry determining units allowing the implementation of a new actuator shape. The actuation performance of the nanocomposites can be tuned and the technical significance was demonstrated in a multi-cyclic experiment with several hundreds of repetitive free-standing shape shifts without losing performance.

The variation of the molecular architecture of multiblock copolymers has enabled the introduction of functional behaviour and the control of key mechanical properties. In the current study, we explore the synergistic relationship of two structural components in a shape-memory material formed of a multiblock copolymer with crystallizable poly(epsilon-caprolactone) and crystallizable polyfoligo(3S-iso-butylmorpholine-2,5-dione) segments (PCL-PIBMD). The thermal and structural properties of PCL-PIBMD films were compared with PCI.-PU and PMMD-PU investigated by means of DSC, SAXS and WARS measurements. The shape-memory properties were quantified by cyclic, thermomechanical tensile tests, where deformation strains up to 900% were applied for programming PCL-PIBMD films at 50 degrees C. Toluene vapor treatment experiments demonstrated that the temporary shape was fixed mainly by glassy PIBMD domains at strains lower than 600% with the PCL contribution to fixation increasing to 42 +/- 2% at programming strains of 900% This study into the shape-memory mechanism of PCL-PIBMD provides insight into the structure function relation in multiblock copolymers with both crystallizable and glassy switching segments.

Inguinal hernia repair, laparoscopic or open, is one of the most frequently performed operations in general surgery. Postoperative urinary retention (POUR) can occur in 0.2-35 % of patients after inguinal hernia repair. The primary objective of this study was to determine the incidence of POUR after inguinal hernia repair. As a secondary goal, we sought to determine whether perioperative and patient factors predicted urinary retention.This study is a retrospective review of patients who underwent inguinal hernia repair with synthetic mesh at the Medical College of Wisconsin from January 2007 to June 2012. Procedures were performed by four surgeons. Clinical information and perioperative outcomes were collected up to hospital discharge. Urinary retention was defined as need for urinary catheterization postoperatively.A total of 192 patients were included in the study (88 bilateral, 46 %) and (104 unilateral, 54 %). The majority of subjects (76 %) underwent laparoscopic repair. The overall POUR rate was 13 %, with 25 of 192 patients requiring a Foley catheter prior to discharge. POUR was significantly associated with bilateral hernia repairs (p = 0.04), BMI ≥ 35 kg/m(2) (p = 0.05) and longer operative times (p = 0.03). Based on odds ratio (OR) estimates, for every 10-min increase in operative time, an 11 % increase in the odds of urinary retention is expected (OR 1.11, CI 1.004-1.223; p = 0.04). For every 10-min increase in operative time, an 11 % increase in POUR is expected.Bilateral hernia repairs, BMI ≥ 35 kg/m(2), and operative time are significant predictors of POUR. These factors are important to determine potential risk to patients and interventions such as strict fluid administration, use of catheters, and potential premedication.

The crystallization-driven self-assembly (CDSA) of crystalline-coil polyselenophene diblock copolymers represents a facile approach to nanofibers with distinct optoelectronic properties relative to those of their polythiophene analogs. The synthesis of an asymmetric diblock copolymer with a crystallizable, π-conjugated poly(3-heptylselenophene) (P3C7Se) block and an amorphous polystyrene (PS) coblock is described. CDSA was performed in solvents selective for the PS block. Based on transmission electron microscopy (TEM) analysis, P3C7Se18-b-PS125 formed very long (up to 5 μm), highly aggregated nanofibers in n-butyl acetate (nBuOAc) whereas shorter (ca. 500 nm) micelles of low polydispersity were obtained in cyclohexane. The micelle core widths in both solvents determined from TEM analysis (≈ 8 nm) were commensurate with fully-extended P3C7Se18 chains (estimated length = 7.1 nm). Atomic force microscopy (AFM) analysis provided characterization of the micelle cross-section including the PS corona (overall micelle width ≈ 60 nm). The crystallinity of the micelle cores was probed by UV–vis and photoluminescence (PL) spectroscopy and wide-angle X-ray scattering (WAXS).

Spawning was induced in both male and female Pismo clams by injecting 0.4 ml of 5 mM serotonin into the gonad. Spawned oocytes had already matured to metaphase I of meiosis or were undergoing germinal vesicle breakdown at the time of release. Prophase-arrested oocytes scraped from the ovaries of uninjected clams were induced to undergo germinal vesicle breakdown in vitro by incubating them with 0.22--0 μM serotonin in seawater; the former concentration was optimal. In vitro matured oocytes were fertilizable and developed to larvae, whereas sperm penetrated prophase-arrested oocytes without activating them. Fertilization was more successful in slightly alkaline seawater (pH 8.5). The electrical response of oocytes to serotonin was studied by means of intracellular microelectrode recording. Resting potentials of prophase-arrested oocytes were between -60 and -80 mV and there was no immediate electrical response to perfusion with serotonin. However, about 10-15 min later (before germinal vesicle breakdown), membrane potentials usually began to drift slowly in the positive direction (net change by 40 min + 9 +/- 6.6 mV (SD; n = 8), whereas resting potentials of oocytes perfused with seawater alone usually drifted in the negative direction (-3 +/- 6.1 mV; n = 7). A dramatic increase in input resistance was consistently observed in oocytes induced to mature with serotonin, probably due to the inactivation of K+ channels, although this was not tested. Action potentials were always (7 out of 7 cases) present in maturing oocytes, but were detected only sometimes (7 of 14 cases) in prophase-arrested oocytes, presumably due to their lower input resistances.

Hiatal hernia repair and fundoplication provide excellent long-term results. However, even with the application of the time-tested surgical principles, recurrence rates in postoperatively-unscreened and screened patient groups may be as high as 14% and 25% respectively [1–3]. Also, recurrent hiatal hernia is recognized as the most common cause of the failure of an antireflux procedure with an incidence of approximately 50% of all cases [4, 5]. Failed fundoplication and recurrent hiatal hernia may be associated with a myriad of symptoms that may necessitate urgent surgical care and present a challenging clinical problem that requires in depth understanding of the condition.

Patients presenting for inguinal hernia repair report a wide range of pain. We hypothesized that patients presenting with less preoperative pain would experience a greater improvement in long-term quality of life after an inguinal hernia repair.A total of 54 patients underwent either laparoscopic or open inguinal hernia repair and completed the Short Form 12 (SF-12) survey both preoperatively and 6 to 12 months after their repair. The physical and mental component scores (PCS and MCS) were calculated from the SF-12. Patients also completed an analog surgical pain scale. t Tests and analyses of covariance were used. A preoperative surgical pain scale score of12 was representative of moderate to severe pain.Regardless of preoperative pain, there was improvement in long-term PCS quality of life (45.4 ± 11.3 vs 50.1 ± 9.1; P .0001) that was not noted when assessing MCS quality of life (55.0 ± 8.3 vs 54.7 ± 9.4; P = .76). Patients who reported no or a low amount of preoperative pain experienced improved PCS quality of life compared with patients who reported moderate to severe preoperative pain (P = .048). This relationship was not noted with MCS (P = .16).This study suggests that patients presenting for inguinal hernia repair with no or low pain are more likely to experience improved physical function quality of life as a result of the herniorrhaphy.

Gastroesophageal reflux disease is an extremely common gastrointestinal condition. While first-line treatment is lifestyle modifications and medical therapy, this approach fails to completely control symptoms in many patients. In patients with persistent symptoms of GERD despite acid suppression, safe and effective surgical and endoscopic interventions are readily available and can lead to durable symptom control and minimal side effects when properly performed in appropriate patients. Unfortunately, antireflux surgical and endoscopic interventions are underutilized with an estimated 1% or less of candidates undergoing one of these procedures despite clear potential for benefit.

Understanding what proportion of the eligible population is undergoing bariatric surgery at the state level provides critical insight into characterizing bariatric surgery access. We sought to describe statewide trends in severe obesity demographics and report bariatric surgery volume in Wisconsin from 2011 to 2014.Self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to calculate prevalence rates of severe obesity (class II and III) in Wisconsin. Bariatric surgery volume data were analyzed from the Wisconsin Hospital Association. A survey was sent to all American Society for Metabolic and Bariatric Surgery member bariatric surgeons in Wisconsin to assess perspectives on bariatric surgery access, insurance coverage, and referral processes.The prevalence of severe obesity in Wisconsin increased by 30% from 2011 to 2014 (10.4%-13.2%; P = .035); the odds of severe obesity nearly doubled for adults age 20-39 (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.3-3.0). During this time, the volume of bariatric surgery declined by 4.2%; (1432 to 1372; P .001), whereas the rates of bariatric surgery per 1000 persons with severe obesity declined by 25.7% (3.5 to 2.6/1000). A majority (72%) of bariatric surgeon respondents felt bariatric surgery access either worsened or remained the same over the last 4 years.Severe obesity increased significantly in Wisconsin over a 4-year period, whereas bariatric surgery rates among severely obese persons have remained largely unchanged and are substantially below the national average. Combining the state-level obesity survey data and bariatric surgery administrative data may be a useful approach for tracking bariatric surgery access throughout the United States.

Background Average costs associated with common procedures can vary by surgeon without a corresponding variation in outcome or case complexity. Methods De-identified cost and equipment utilization data were collected from our hospital for elective laparoscopic cholecystectomy performed by 17 different surgeons over a 6-month period. A group of surgeons used this data to design a standardized equipment pick list that became optional (not mandated) for laparoscopic cholecystectomy. Cost and consumable surgical supply utilization data were collected for six months prior to and following the creation of the standardized pick-list. Results 280 elective laparoscopic cholecystectomies were performed during the study interval. In the 6 months after standardized pick list creation, the cost of disposable supplies utilized per case decreased by 32%. Conclusions Surgical cost savings can be achieved with standardized procedure pick lists and attention to the cost of consumable surgical supplies.

This study of Medicare beneficiaries who had a laparoscopic gastric band placed explores how common reoperations were among this population and what costs were involved for payers.

General Surgery is currently the fastest growing specialty with regards to robotic surgical system utilization. Contrary to the experience in laparoscopy, simulator training for robotic surgery is not widely employed partly because robotic surgical simulators are expensive. We sought to determine the effect of a robotic simulation curriculum and whether robotic surgical skills could be derived from those psychomotor skills attained in laparoscopic training. Twenty-seven trainees with no prior robotic experience and limited laparoscopy exposure were randomly assigned to one of three training groups: no simulator training, training on a fundamentals of laparoscopic surgery (FLS™) standard box trainer, and training on a robotic computer based simulator (da Vinci Skills Simulator™). Baseline robotic surgical skills were assessed on the clinical robot docked to a standard FLS trainer box on two tasks—intracorporeal knot tying and peg transfer. Subjects subsequently underwent four 1-h long training sessions in their assigned training environment over a course of several weeks. Robotic surgical skills were reassessed on the robot on the same two tasks used to assess skills prior to training. FLS training resulted in a greater score improvement than no training for both knot and peg scores. FLS training was also determined to result in greater score improvement than robotic simulator training for knot tying. There was no significant difference in peg transfer or knot tying scores when comparing robotic simulator training and no training. Robotic surgical skills can be in part derived from psychomotor skills developed in a laparoscopic trainer, especially for complex skills such as intracorporeal knot tying. Acquisition of robotic surgical skills may be enhanced by practice on a laparoscopic simulator using the FLS curriculum. This may be especially helpful when a robotic simulator is not available or is poorly accessible.

Free-living vertebrates tend to respond to environmental challenges by increasing circulating glucocorticoid levels. Changes in glucocorticoids can modulate various aspects of physiology and behavior, which can have fitness benefits in the short term but may be detrimental to fitness if elevated levels are frequent, prolonged, or both. The transfer of glucocorticoids from females to offspring might also have fitness consequences, but there is less known about the potential effects of transgenerational glucocorticoid transfer. Our study examined corticosterone levels in female Red-eared Sliders (Trachemys scripta) during the nesting season because of the potential fitness consequences for both females and offspring. Whether caught in aquatic traps or caught during the nesting process, females had similar circulating corticosterone levels that were relatively low. However, when females were subjected to a restraint protocol, corticosterone rose. Therefore, corticosterone levels may be elevated duri...

Laparoscopic ventral hernia repair (LVHR) is associated with shorter hospitalization and lower complication rates compared to open ventral hernia repair. We sought to determine if hernia-related factors, such as defect size and re-operative status correlate with postoperative complications, operative times and length of stay (LOS). The study is a retrospective review of 30-day perioperative outcomes following LVHR in 91 patients who underwent surgery at a single institution from August 2009 through June 2012. A single surgeon performed all procedures. Indications for surgery were recurrent incisional hernia in 33 % of patients and primary incisional or ventral abdominal hernias in the rest. Coated polyester mesh with an average size of 348 cm2 (±214; range 113–1,036) was used. Mean operative time was 132 min (±66.1; range 53–412). The mean LOS was 4.0 days (±3.5; range 1–22). Complications occurred in 13 patients for overall morbidity of 16.5 % and no mortality. There was one recurrence in 30 days (1.1 %). Patients who had a surgery >120 min or a LOS >1 day were statistically more likely to have multiple hernias, larger defect sizes (>40 cm2), larger mesh sizes (>300 cm2) or a history of recurrent hernia (P

Fibrous membranes capable of dynamically responding to external stimuli are highly desirable in textiles and biomedical materials, where adaptive behavior is required to accommodate complex environmental changes. For example, the creation of fabrics with temperature-dependent moisture permeability or self-regulating membranes for air filtration is dependent on the development of materials that exhibit a reversible stimuli-responsive pore size change. Here, by imbuing covalently crosslinked poly(ε-caprolactone) (cPCL) fibrous meshes with a reversible bidirectional shape-memory polymer actuation (rbSMPA) we create a material capable of temperature-controlled changes in porosity. Cyclic thermomechanical testing was used to characterize the mechanical properties of the meshes, which were composed of randomly arranged microfibers with diameters of 2.3 ± 0.6 μm giving an average pore size of approx. 10 μm. When subjected to programming strains of ε m = 300% and 100% reversible strain changes of εʹrev = 22% ± 1% and 6% ± 1% were measured, with switching temperature ranges of 10 °C–30 °C and 45 °C–60 °C for heating and cooling, respectively. The rbSMPA of cPCL fibrous meshes generated a microscale reversible pore size change of 11% ± 3% (an average of 1.5 ± 0.6 μm), as measured by scanning electron microscopy. The incorporation of a two-way shape-memory actuation capability into fibrous meshes is anticipated to advance the development and application of smart membrane materials, creating commercially viable textiles and devices with enhanced performance and novel functionality.

Obesity is a recognized risk factor for gastroesophageal reflux disease (GERD). Traditional antireflux surgery (fundoplication) may not be appropriate in the morbidly obese, especially when other effective alternatives exist (bariatric surgery). A 13-item survey was designed to elicit professional opinions regarding the treatment of medically refractory GERD in obese patients. Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) were randomly selected and emailed a link to an online survey. A total of 550 surgeons were contacted via email, and 92 (17 %) completed the survey. Of the respondents, 88 % perform laparoscopic antireflux surgery, 63 % perform bariatric surgery, and 59 % perform both. Overall, 77 % completed a minimally invasive surgery fellowship. In response to the question “Would you perform a laparoscopic fundoplication in a patient with medically refractory GERD and a BMI of ‘X’?” surgeons were less likely to offer fundoplication at a higher body mass index (BMI). The majority of respondents felt that laparoscopic Roux-en-Y gastric bypass was the best option (91 %), followed by laparoscopic sleeve gastrectomy (6 %). Many had a morbidly obese patient with a primary surgical indication of GERD denied a bariatric procedure by their insurance company (57 %), and 35 % of those surgeons chose to do nothing rather than subject the patient to a fundoplication. Respondents uniformly felt that bariatric surgery should be recognized as a standard surgical option for treating GERD in the obese (96 %). When surgical treatment of GERD is indicated in an obese patient, bariatric surgery is the optimal approach, in the opinion of surgeons responding to our survey. Unfortunately, third-party payers often decline to provide benefits for a bariatric procedure for this indication. Additional data is necessary to confirm our belief that the opinions elicited through this survey are consistent with the standard of care as defined by the medical community.

The authors discuss some of the unique aspects and lessons of the New Zealand post-earthquake building safety inspection program that was implemented following the Canterbury earthquake sequence of 2010–2011. The post-event safety assessment program was one of the largest and longest programs undertaken in recent times anywhere in the world. The effort engaged hundreds of engineering professionals throughout the country, and also sought expertise from outside, to perform post-earthquake structural safety inspections of more than 100,000 buildings in the city of Christchurch and the surrounding suburbs. While the building safety inspection procedure implemented was analogous to the ATC 20 program in the United States, many modifications were proposed and implemented in order to assess the large number of buildings that were subjected to strong and variable shaking during a period of two years. This note discusses some of the key aspects of the post-earthquake building safety inspection program and summarizes important lessons that can improve future earthquake response.