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Direct carotid cavernous fistulas (dCCF) involve pathologic shunting from the internal carotid artery into the cavernous sinus. We systematically reviewed the methods and outcomes of endovascular therapy for dCCF.PubMed, Scopus, and EMBASE were used to identify studies that reported outcomes for patients undergoing embolization of dCCF. Outcomes included rates of occlusion, complications, symptom improvement, and recurrence. Pooled rates for each outcome were obtained with random effects models. The influence of embolization method on outcomes was assessed with meta-regressions.There were 16 studies comprising 270 patients. The mean age was 39.6 years, there were 36.3% females, and the mean follow-up was 19.7 months. Coils were the most common method of embolization (69.3%), followed by Onyx (31.1%), covered stent (22.2%), N-butyl cyanoacrylate (6.7%), and flow diversion (4.8%). The pooled overall occlusion rate was 92.1% (95% confidence interval [CI], 86.3-95.6; IEndovascular therapy for dCCF is associated with high occlusion and low complication rates. Recurrence is not uncommon, highlighting the need for close follow-up.

Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD.Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/mThe consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss.Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Objectives To compare faecal third-generation cephalosporin-resistant (3GC-R) Escherichia coli isolates from dogs living in a city and in a rural area ∼30 km away; to compare isolates from dogs, cattle and humans in these regions; and to determine risk factors associated with 3GC-R E. coli carriage in these two cohorts of dogs. Methods Six hundred dogs were included, with faecal samples processed to recover 3GC-R E. coli using 2 mg/L cefotaxime. WGS was by Illumina and risk factor analyses were by multivariable linear regression using the results of an owner-completed survey. Results 3GC-R E. coli were excreted by 20/303 rural and 31/297 urban dogs. The dominant canine 3GC-R ST was ST963 (blaCMY-2), which also accounted for 25% of CMY-2-producing E. coli in humans. Phylogenetic overlap between cattle and rural dog CTX-M-14-producing E. coli ST117 was observed as well as acquisition of pMOO-32-positive E. coli ST10 by a rural dog, a plasmid common on cattle farms in the area. Feeding raw meat was associated with carrying 3GC-R E. coli in rural dogs, but not in urban dogs, where swimming in rivers was a weak risk factor. Conclusions Given clear zoonotic potential for resistant canine E. coli, our work suggests interventions that may reduce this threat. In rural dogs, carriage of 3GC-R E. coli, particularly CTX-M producers, was phylogenetically associated with interaction with local cattle and epidemiologically associated with feeding raw meat. In urban dogs, sources of 3GC-R E. coli appear to be more varied and include environments such as rivers.

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

Background The objective of this study was to develop a multi-disciplinary care pathway to minimize perioperative complications in patients with advanced heart failure undergoing bariatric surgery. Patients with severe obesity and heart failure carry increased perioperative surgical risk compared to patients with no heart failure due to the severity of their cardiac disease state and associated comorbidities. Our bariatric program routinely excluded patients with advanced heart failure from undergoing bariatric surgery due to the high reported perioperative risk. However, knowing the potential beneficial impact of bariatric surgery for advanced heart failure, our program hoped that the thoughtful development of a perioperative pathway before inclusion of patients with advanced heart failure in the bariatric surgery program could minimize the morbidity of these high-risk patients in comparison to prior publications in the literature. Methods Two multi-disciplinary care pathways were developed, including advanced heart failure, anticoagulation specialists, and transplant cardiologists, to optimize bariatric care for severely obese patients with advanced heart failure with or without mechanical circulatory support and implementation was evaluated for short-term 30-day complications and 6 month cardiac and weight-loss outcomes. Results Two multi-disciplinary care pathways were developed and implemented on 5 patients with heart failure with reduced ejection fraction (pathway 1) and 3 patients requiring mechanical circulatory support (pathway 2). There were no in-hospital complications or mortality following either pathway, and there was only 1 emergency room visit and 1 re-admission. The average length of stay for patients with heart failure with reduced ejection fraction without mechanical circulatory support was 2.4 days and for heart failure with reduced ejection fraction with mechanical circulatory support was 4.3 days. Three patients met body mass index criteria for transplant listing at 6 months. Ejection fraction increased an average of 9% at 6 months postoperatively for patients with heart failure with reduced ejection fraction not requiring mechanical circulatory support. Conclusion With multi-disciplinary care pathway development designed to maximize safety by intensely supporting preoperative cardiac optimization and medication titration postoperatively, bariatric surgery can be performed in patients with advanced heart failure with or without mechanical circulatory support, allowing patients the opportunity for weight loss as a bridge to transplant or potentially meaningful cardiac recovery.

Background Preoperative carbohydrate loading is a component of Enhanced Recovery After Surgery (ERAS) protocols, but there is limited literature in bariatric surgery patients. Objectives The objective of this study was to characterize the impact of preoperative carbohydrate loading on postoperative bariatric surgery outcomes. Setting University Hospital. Methods Patients undergoing a primary minimally invasive Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2018 and 2020 were randomized to standard management or intervention. Standard management patients were nothing by mouth (NPO) after midnight prior to surgery. Intervention patients consumed 2 carbohydrate drinks: 1 the night before and another 3 hours prior to surgery. Primary outcomes analyzed included postoperative nausea and vomiting (PONV), length of stay, and overall complications. Results In total, 134 patients were analyzed: 64 intervention (47.8%) and 70 (52.2%) standard. In the end, 7% and 15% of patients were lost to follow-up at 6-weeks and 3-months, respectively. There was no statistically significant difference in length of stay (2.0 ± 1.2 vs 2.1 ± .9 d; P = .65) or postoperative outcomes between the 2 groups. There were no episodes of aspiration among the intervention group. Among RYGB patients, intervention patients had a shorter duration of nausea compared with standard patients. There was no significant difference in glycemic control among patients with and without diabetes. Conclusions Preoperative carbohydrate drinks can be administered to bariatric surgery patients without significant risks. Carbohydrate loading preoperatively can decrease the duration of PONV in RYGB patients. Carbohydrate drinks can be safely included in bariatric ERAS protocols for patients with and without diabetes, although the benefits remain unknown.

Evidence-based guidelines on the appropriate amount of opioid medications to prescribe following bariatric surgery are lacking. We sought to determine our current opioid-prescribing practices, patient utilization, and satisfaction with pain control following elective bariatric surgery. A retrospective chart review and phone survey were conducted on patients who underwent laparoscopic or robotic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from April 2018 to March 2019 at a single academic medical center. Opioid medications were converted to morphine milligram equivalents provided (MMEs). In total, 192 patients met inclusion criteria. The median amount of opioid medication prescribed on discharge was 300 oral MMEs, although there was a significant difference between the MMEs prescribed to patients with and without chronic opioid therapy (median 300 MMEs opioid naive vs. 375 MMEs chronic opioid therapy, p = 0.01). Significantly fewer SG patients required a refill of their opioid medication compared to RYGB (8.3% vs. 23.9%, p = 0.003). Of the 192 patients, 87 (45.3%) completed the phone survey. Fifty-six patients (64%) reported that they took half or less of the initially prescribed opioids. Of the patients with leftover medication, 36% reported that they did not dispose of the medication. Overall understanding of pain control options after surgery was significantly lower in patients who felt they were prescribed “too little” opioids (p = 0.01), patients requiring refills (p = 0.02), and patients who were not satisfied with their pain control (p = 0.02). There is a gap between the amount of opioid medication prescribed and taken by patients following bariatric surgery in our practice. Patients who were least satisfied with their pain control reported knowledge gaps about pain control options that were more significant than patients who were more satisfied. Future initiatives should focus on the reduction of opioids prescribed to bariatric surgery patients post-operatively and on opioid education for patients.

Background The purpose of this study was to report the impact of a pilot robotic general surgery resident training curriculum. Materials and methods A single institution pilot robotic general surgery training curriculum was instituted in 2016. Accreditation Council for Graduate Medical Education operative case log trends, resident simulation performance, and surveys were analyzed. Results Forty-three general surgery residents participated in the robotic surgery training curriculum, 2016 to 2019. In total, 161 robotic cases were logged, increasing each academic year. Residents acted as bedside assistant in 42.9% (n=69) and as console surgeon in 57.1% (n=92). Fifteen first-year residents were surveyed on the training curriculum. On the postcurriculum survey, 100% found the curriculum to be very helpful, notably the hands-on in-service and skills simulator. Conclusions Since the curriculum onset, residents participated in an increasing number of robotic operative cases and were actively engaged in simulation exercises. The establishment of this curriculum has facilitated the integration of resident education into the utilization of robotic technology. This study highlights the value of a formal robotic surgery curriculum for general surgery residency training.

A detailed study of the influence of molecular beam epitaxial growth conditions on the structural and magnetic characteristics of CuMnSb films on lattice matched GaSb is presented. For a set of nine 40~nm thick layers, the Mn and Sb fluxes are varied to produce material with different elemental compositions. It is found that the layers grown under a relative Mn to Sb flux ratio of $\Phi_{\text{Mn}}$/$\Phi_{\text{Sb}}=1.24\pm0.02$ are closest to the stoichiometric composition, for which the N\'{e}el temperature ($T_\text{N}$) attains its maximum values. Mn-related structural defects are believed to be the driving contribution to changes in the vertical lattice parameter. Having established the optimum growth conditions, a second set of samples with CuMnSb layer thickness varied from 5 to 510 nm is fabricated. We show that for sufficiently large thicknesses, the magnetic characteristics ($T_\text{N}\simeq62$ K, Curie-Weiss temperature $\Theta_\text{CW} = -100$ K) of the stoichiometric layers do correspond to the parameters reported for bulk samples. On the other hand, we observe a reduction of $T_\text{N}$ as a function of the CuMnSb thickness for our thinnest layers. All findings reported here are of particular relevance for studies aiming at the demonstration of N\'{e}el vector switching and detection in this noncentrosymmetric antiferromagnet, which have been recently proposed., Comment: The following article has been accepted by Applied Physics Letters. After it is published, it will be found at https://doi.org/10.1063/5.0092828

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

Despite the increasing prevalence and severity of childhood obesity, the national utilization of adolescent bariatric surgery has plateaued. Concern about the perioperative safety of adolescent bariatric surgery has limited referrals and insurance coverage. The purpose of this study was to compare the 30-d complication rate of minimally invasive bariatric surgery in adolescents and adults.The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 data set was queried for primary minimally invasive bariatric procedures in adolescents and adults. Adolescents were defined as age 19 y or younger. Univariate analyses were performed to determine if there was an increased incidence of the adolescent 30-d complication rate as compared with adults.Of the cases who met inclusion criteria, 1076 (0.8%) were adolescents and 142,704 (99.2%) were adults. Laparoscopic sleeve gastrectomy was the most commonly performed procedure for both patient populations, although at a higher rate in adolescents (73.9% versus 68.8% in adults, P = 0 0.0001). The overall 30-d complication rate was comparable in adolescents and adults (6.3% versus 7.3%; P = 0.21) with similar rates of intervention, reoperation, readmission, and mortality. There was no significant difference in any specific perioperative complication class reported between adolescents and adults, except wound disruption (0.2% versus 0.0%, P 0.0001) and postlaparoscopic sleeve gastrectomy coma24 h (0.1% versus 0.0%, P 0.0001).Bariatric surgery in adolescents shares a similar perioperative safety profile as found in adults. This data support the utilization and extension of adult criteria for bariatric surgery to adolescents with morbid obesity.

The Endoluminal Functional Lumen Imaging Probe (Endoflip™) is a balloon-based catheter that provides real-time, objective feedback regarding the distensibility of any sphincter in the gastrointestinal tract. Usage of the Functional Lumen Imaging Probe (FLIP) has not been standardized, which has limited the interpretation and generalizability of published data. The purpose of this consensus statement is to provide a standardized protocol for obtaining FLIP measurements in order to create a more uniform approach to data collection. Five expert foregut surgeons, all of whom utilize the FLIP system in their daily practice, convened on March 19, 2019, to create a standardized protocol for obtaining FLIP measurements during hiatal hernia repair and fundoplication, magnetic sphincter augmentation, laparoscopic Heller myotomy, and peroral endoscopic myotomy. Existing literature was presented and reviewed. Each step of the protocol was discussed in detail until a unanimous consensus was reached. A standardized protocol was developed for obtaining FLIP measurements during hiatal hernia repair and fundoplication, magnetic sphincter augmentation, laparoscopic Heller myotomy, and peroral endoscopic myotomy. The FLIP impedance planimetry system is the only technology available that provides surgeons an objective way to assess the tightness of a fundoplication or adequacy of a myotomy during an operation. While considerable research remains to correlate FLIP measurements to patient outcomes, this consensus statement will provide standardization of data collection among FLIP users that will enhance the understanding of future study results.

Microfibers with a core-shell structure can be produced by co-axial electrospinning, allowing for the functionalization of the outer layer with bioactive molecules. In this study, a thermoplastic, degradable polyesteretherurethane (PEEU), consisting of poly(p-dioxanone) (PPDO) and poly(ɛ-caprolactone) (PCL) segments with different PPDO to PCL weight ratios, were processed into fiber meshes by co-axial electrospinning with gelatin. The prepared PEEU fibers have a diameter of 1.3±0.5 μm and an elastic modulus of around 5.1±1.0 MPa as measured by tensile testing in a dry state at 37°C, while the PEEU/Gelatin core-shell fibers with a gelatin content of 12±6 wt% and a diameter of 1.5±0.5 μm possess an elastic modulus of 15.0±1.1 MPa in a dry state at 37 °C but as low as 0.7±0.7 MPa when hydrated at 37 °C. Co-axial electrospinning allowed for the homogeneous distribution of the gelatin shell along the whole microfiber. Gelatin with conjugated Fluorescein (FITC) remained stable on the PEEU fibers after 7 days incubation in Phosphate-buffered saline (PBS) at 37 °C. The gelatin coating on PEEU fibers lead to enhanced human adipose tissue derived mesenchymal stem cell (hADSC) attachment and a proliferation rate 81.7±34.1 % higher in cell number in PEEU50/Gelatin fibers after 7 days of cell culture when compared to PEEU fibers without coating. In this work, we demonstrate that water-soluble gelatin can be incorporated as the outer shell of a polymer fiber via molecular entanglement, with a sustained presence and role in enhancing stem cell attachment and proliferation.

Laparoscopic fundoplication is the current gold standard for medically refractory gastroesophageal reflux disease. Over a 10-year period following surgery, 5–10% of primary laparoscopic fundoplication patients undergo reoperative surgery. Our objective was to compare the symptomatic outcomes and morbidity of primary and reoperative fundoplication procedures. This was a retrospective review of patients who underwent laparoscopic primary or reoperative fundoplication between 2011 and 2017. A single surgeon with a more than 10-year experience in reoperative foregut surgery performed all procedures. Patients in both groups completed the GERD health-related quality of life (GERD-HRQL) survey prior to surgery and postoperatively. Outcomes were reflected by the composite GERD-HRQL scores (0 to 50, with lower scores representing a better GERD-related quality of life), which were compared between groups postoperatively. Demographics, perioperative data, and complications were compared. Patient data were analyzed using Chi-Square tests and outcomes were analyzed using independent samples t tests and Mann–Whitney U tests. There were 136 primary and 82 reoperative fundoplications. Prior to surgery, GERD-HRQL scores were similar for primary and reoperative patients. Both groups experienced significant improvement in GERD-related quality of life at 2 years, although this improvement was greater in primary patients (8.7 ± 7.8 primary vs. 14.3 ± 13.6 reoperative, p = 0.02). Operative time and length of stay were longer following reoperative cases. The rate of moderate to severe 30-day complications requiring radiologic, endoscopic, or surgical intervention was similar (2.9% primary vs. 1.2% reoperative, p = 0.65). Patients who undergo reoperative fundoplication experience a significant improvement in their GERD-related symptoms, although not to the degree seen in primary antireflux surgery patients. Perioperative morbidity rates following reoperative and primary procedures can be similar in the hands of an experienced surgeon.

Laparoscopic Nissen fundoplication is currently the most commonly performed procedure for gastroesophageal reflux disease (GERD). In patients with inefficient esophageal motility, a partial fundoplication such as a Toupet 270-degree posterior fundoplication is often recommended. There is controversy as it relates to the necessity of this tailored approach to fundoplication. There is also debate when it comes to the suitability and even the superiority of a partial compared to a full fundoplication. There are numerous randomized controlled trials and meta-analyses of these trials to guide the debate. From the evidence, it would appear that a full and a partial fundoplication are associated with similar GERD-related outcomes and that a partial fundoplication is associated with fewer side effects such as bloating and dysphagia.

SynopsisObjectivesOur aims were to compare faecal third-generation cephalosporin-resistant (3GC-R) Escherichia coli isolates from dogs living in a city and in a rural area ~30 km away; to compare isolates from dogs, cattle, and humans in these regions; to determine risk factors associated with 3GC-R E. coli carriage in these two cohorts of dogs.Methods600 dogs were included, with faecal samples processed to recover 3GC-R E. coli using 2 mg/L cefotaxime. WGS was by Illumina; risk factor analyses were multivariable linear regression using the results of an owner-completed survey.Results3GC-R E. coli were excreted by 20/303 rural and 31/297 urban dogs. Dog/human sharing was evident for the dominant canine 3GC-R sequence type, ST963(blaCMY-2). Cattle/dog sharing was evident for CTX-M-14 and CTX-M-32-producing E. coli from rural dogs, including sharing of plasmid pMOO-32, which is common on cattle farms in the area. Feeding raw meat was associated with carrying 3GC-R E. coli in rural dogs, but not in urban dogs, where swimming in rivers was a weak risk factor.ConclusionsGiven clear zoonotic potential for resistant canine E. coli, our work suggests interventions that may reduce this threat. In rural dogs, carriage of 3GC-R E. coli, particularly CTX-M producers, was phylogenetically associated with interaction with local cattle and epidemiologically associated with feeding raw meat. In urban dogs, sources of 3GC-R E. coli appear to be more varied and include environments such as rivers.

Routine opioid use in surgical patients has received attention given the opioid epidemic and a renewed focus on the dangers and drawbacks of opioids in the postoperative setting. Little is known about opioid use in bariatric surgery, especially in the inpatient setting. We hypothesize that a standardized opioid-sparing protocol reduces postoperative inpatient opioid use in bariatric surgery patients.A retrospective cohort study was conducted of bariatric surgery patients at a single institution. From March to September 2019, a standardized intraoperative and postoperative opioid-sparing protocol was designed and implemented along with an educational program for patients regarding safe pain management. Inpatient opioid utilization in patients undergoing surgery in the preintervention phase between April and March 2019 was compared to patients from a postintervention phase of October 2019 to December 2020. Opioid utilization was measured in morphine milliequivalents (MME).A total of 359 patients were included; 192 preintervention and 167 postintervention. Patients were similar demographically. For all patients, mean age was 44.1 years, mean BMI 49.2 kg/m2, and 80% were female. Laparoscopic sleeve gastrectomy was performed in 48%, laparoscopic gastric bypass in 34%, robotic sleeve gastrectomy in 17%, and robotic gastric bypass in 1%. In the postintervention phase inpatient opioid utilization was significantly lower [median 134.8 [79.0-240.8] MME preintervention vs. 61.5 [35.5-150.0] MME postintervention (p 0.001)]. MME prescribed at discharge decreased from a median of 300 MME preintervention to 75 MME postintervention (p 0.001). In the postintervention phase, 16% of patients did not receive an opioid prescription at discharge compared to 0% preintervention (p 0.001). When examining by procedure, statistically significant reductions in opioid utilization were seen for each operation.Implementation of a standardized intraoperative and postoperative multimodal pain regimen and educational program significantly reduces inpatient opioid utilization in patients undergoing bariatric surgery.

Background Endovascular embolization (EE) is a treatment option for epistaxis refractory to first-line interventions. Data regarding embolization is limited to small case series and a meta-analysis has not been performed. Methods PubMed, Scopus, and EMBASE were used to identify studies that reported outcomes for at least 10 patients undergoing EE for epistaxis. Outcomes included procedural success, rebleeding, and complications. Pooled rates for each outcome were obtained with random effects models. Results A total of 44 studies comprising 1664 patients met the inclusion criteria. The mean age ranged from 28.1 to 67 years and there were 28.4% females. The pooled procedural success rate was 87% (95% CI 83.9–89.6, I 2 = 53%). Age (OR 0.95, 95% CI 0.91–1) and hereditary hemorrhagic telangiectasia ([HHT], OR 0.97, 95% CI 0.96–0.99) were associated with decreased odds of success. The pooled rebleeding rate was 16.4% (95% CI 13.6–19.6, I 2 = 48%), and HHT was associated with greater odds of rebleeding (OR 1.02, 95% CI 1–1.03). The pooled overall complication rate was 14.4% (95% CI 9.8–20.6, I 2 = 85.8%). The pooled rates of stroke and vision loss were 2.1% (95% CI 1.5–3.1, I 2 = 1.5%) and 1.8% (95% CI 1.2–2.6, I 2 = 0%), respectively. Conclusion EE for epistaxis has a high rate of procedural success. Interventionalists should be aware of the risk for rebleeding, especially among patients with HHT.

Outcomes following revisional fundoplication procedures are very good in the hands of experienced surgeons. Minimally invasive approaches with laparoscopy or robotic surgical systems are feasible with low conversion rates. Proper patient selection and evaluation are essential. Morbidity, length of stay, and operative time all tend to increase in revisions. This is especially true as the number of prior fundoplication attempts increases. GERD outcomes, quality of life, and patient satisfaction are excellent. Outcomes appear to be durable with recurrence rates slightly higher than recurrence rates following primary fundoplication.

Polymeric devices capable of releasing submicron particles (subMP) on demand are highly desirable for controlled release systems, sensors, and smart surfaces. Here, a temperature-memory polymer sheet with a programmable smooth surface served as matrix to embed and release polystyrene subMP controlled by particle size and temperature. subMPs embedding at 80 degrees C can be released sequentially according to their size (diameter D of 200 nm, 500 nm, 1 mu m) when heated. The differences in their embedding extent are determined by the various subMPs sizes and result in their distinct release temperatures. Microparticles of the same size (D approximate to 1 mu m) incorporated in films at different programming temperatures T-p (50, 65, and 80 degrees C) lead to a sequential release based on the temperature-memory effect. The change of apparent height over the film surface is quantified using atomic force microscopy and the realization of sequential release is proven by confocal laser scanning microscopy. The demonstration and quantification of on demand subMP release are of technological impact for assembly, particle sorting, and release technologies in microtechnology, catalysis, and controlled release.

Aims To investigate whether on-farm antibacterial usage (ABU), environmental antibacterial-resistant (ABR) Escherichia coli prevalence, sampling and sample handling methodologies are associated with ABR E. coli positivity in individual faecal samples from dairy heifers. Methods and Results Three hundred and sixty-four heifers from 37 farms were sampled via rectal or faecal pat sampling. Samples were stored at −80°C for variable periods before microbiological analysis. Data analysis was done through a multilevel, multivariable logistic regression approach. Individual rectal samples had increased odds of positivity for amoxicillin-, cefalexin- and tetracycline-resistant E. coli. Sample storage for 6–12 months was associated with decreased odds of finding amoxicillin- and tetracycline-resistant E. coli. On-farm ABU had little influence, and environmental ABR E. coli prevalence had no significant influence on the odds of sample-level positivity for ABR E. coli. Conclusions Sampling methodology and sample handling have a greater association than on-farm factors with the detection of ABR E. coli in individual faecal samples from dairy heifers. Significance and Impact of the Study Sampling and storage methodologies should be considered carefully at the point of designing ABR surveillance studies in livestock and their environments and, where possible, these methodologies should be standardized between and within future studies.

AimsTo investigate whether on-farm antibacterial usage (ABU), environmental antibacterial resistant (ABR) Escherichia coli prevalence, and sampling and sample handling methodologies are associated with ABR E. coli positivity in individual faecal samples from dairy heifers.Methods and ResultsThree hundred and sixty-four heifers from 37 farms were sampled via rectal or faecal pat sampling. Samples were stored at -80°C for variable periods before microbiological analysis. Data analysis was through a multilevel, multivariable logistic regression approach.Individual rectal samples had increased odds of positivity for amoxicillin, cefalexin and tetracycline-resistant E. coli. Sample storage for 6-12 month was associated with decreased odds of finding amoxicillin and tetracycline-resistant E. coli. On-farm ABU had little influence, and environmental ABR E. coli prevalence had no significant influence on on the odds of sample-level positivity for ABR E. coli.ConclusionsSampling methodology and sample handling have a greater association than on-farm factors with the detection of ABR E. coli in individual faecal samples from dairy heifers.Significance and Impact of the StudySampling and storage methodologies should be considered carefully at the point of designing ABR surveillance studies in livestock and their environments and, where possible, standardised between and within future studies.

Empathy-for-pain states are underpinned by interoception, i.e the central representation of internal states. Cardiac signals occur in a phasic manner; baroreceptor discharges at systole communicate the heartbeats’ strength. These signals modulate pain and emotion processing. We tested whether these phasic interoceptive signals modulate empathy-for-pain. As oxytocin (OT) enhances empathy and modulates interoceptive signals’ precision, we also tested if OT administration impacts empathy-for-pain via interoceptive mechanisms.Male subjects (N=32) attended three sessions to perform psychometric tests and an fMRI empathy-for-pain task, after intranasal administration of OT or placebo (40IU). Pictures of hands in painful or non-painful context were presented at systole or diastole. Effects of drug, emotion and cardiac timing on behaviour and brain activity was tested using general and mixed-effects linear models.Across conditions, activation was observed within regions implicated in pain and empathy-for-pain, with insula activation greater in the right than left hemisphere. OT administration, compared to placebo, attenuated the reactivity of some regions, including anterior cingulate cortex, but presentation of stimuli at systole blocked the OT attenuating effect.Our data suggest that OT alters the processing of motivationally-salient social cues, interacting with interoceptive signals. Our findings may inform targeted use of OT in psychiatric conditions linked to aberrant interoceptive processing.