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BackgroundVenous thromboembolism (VTE) is a major source of morbidity and mortality after ventral hernia surgery, but the risk of VTE after discharge has not been reported.Study designData from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) were used to investigate the risk of post-discharge VTE. Current procedural terminology (CPT) codes identified all reported patients who underwent ventral hernia repair from 2011 to 2017. We created a multivariable regression model for post-discharge VTE, using the 2011-2016 dataset to develop the model and 2017 as a validation set. The prediction model was used to create a risk calculator as a mobile application.ResultsThe rate of VTE after surgery was 0.62% (878 of 141,065) with 48% occurring after discharge from the hospital. The final predictor model consisted of eight variables: age > 60 years, male sex, body mass index (BMI) ≥ 35 kg/m2), operative time > 2 h, concurrent panniculectomy, post-operative hospitalization > 1 day, presence of bleeding disorder, and emergency operation. The model had good calibration and discrimination (Hosmer-Lemeshow goodness-of-fit test, p = 0.71; c-statistic = 0.71). Threshold analysis showed a strategy of extended-duration thromboprophylaxis was optimized when the risk of post-discharge VTE was > 0.3%.ConclusionForty-eight percent of VTEs after ventral hernia repair occur after discharge, particularly in older, male, obese patients undergoing longer and complex operations that require hospitalization > 1 day. Post-discharge thromboprophylaxis should be considered in these patients, particularly when risk of VTE exceeds 0.3%.

This paper will discuss the entire process of acquiring and deploying Hopper from the first vendor market surveys to providing 3.8 million hours of production cycles per day for NERSC users. Installing the latest system at NERSC has been both a logistical and technical adventure. Balancing compute requirements with power, cooling, and space limitations drove the initial choice and configuration of the XE6, and a number of first-of- a-kind features implemented in collaboration with Cray have resulted in a high performance, usable, and reliable system.

Bone marrow fat may serve a metabolic role distinct from other fat depots, and it may be altered by metabolic conditions including diabetes. Caloric restriction paradoxically increases marrow fat in mice, and women with anorexia nervosa have high marrow fat. The longitudinal effect of weight loss on marrow fat in humans is unknown. We hypothesized that marrow fat increases after Roux-en-Y gastric bypass (RYGB) surgery, as total body fat decreases. In a pilot study of 11 morbidly obese women (6 diabetic, 5 nondiabetic), we measured vertebral marrow fat content (percentage fat fraction) before and 6 months after RYGB using magnetic resonance spectroscopy. Total body fat mass declined in all participants (mean ± SD decline 19.1 ± 6.1 kg or 36.5% ± 10.9%, p

This paper will discuss the entire process of acquiring and deploying Hopper from the first vendor market surveys to providing 3.8 million hours of production cycles per day for NERSC users. Installing the latest system at NERSC has been both a logistical and technical adventure. Balancing compute requirements with power, cooling, and space limitations drove the initial choice and configuration of the XE6, and a number of first-of- a-kind features implemented in collaboration with Cray have resulted in a high performance, usable, and reliable system.

Context: Roux-en-Y gastric bypass (RYGB) has deleterious effects on bone mass, microarchitecture, and strength. Data are lacking on the skeletal effects of sleeve gastrectomy (SG), now the most commonly performed bariatric surgical procedure., Objective: We examined changes in bone turnover, areal and volumetric bone mineral density (aBMD, vBMD), and appendicular bone microarchitecture and estimated strength after SG. We compared the results to those previously reported after RYGB, hypothesizing lesser effects after SG than RYGB., Design Setting Participants: Prospective observational cohort study of 54 adults with obesity undergoing SG at an academic center., Main Outcome Measures: Skeletal characterization with biochemical markers of bone turnover, dual-energy X-ray absorptiometry (DXA), quantitative computed tomography (QCT), and high-resolution peripheral QCT (HR-pQCT) was performed preoperatively and 6- and 12-months postoperatively., Results: Over 12 months, mean percentage weight loss was 28.8%. Bone turnover marker levels increased, and total hip aBMD decreased -8.0% (95% CI -9.1%, -6.7%, p<0.01). Spinal aBMD and vBMD declines were larger in postmenopausal women than men. Tibial and radial trabecular and cortical microstructure worsened, as did tibial estimated strength, particularly in postmenopausal women. When compared to data from a RYGB cohort with identical design and measurements, some SG biochemical, vBMD, and radial microstructural parameters were smaller, while other changes were not., Conclusions: Bone mass, microstructure, and strength decrease after SG. Some skeletal parameters change less after SG than after RYGB, while for others, we find no evidence for smaller effects after SG. Postmenopausal women may be at highest risk of skeletal consequences after SG.

Laparoscopic sleeve gastrectomy (LSG), the most common bariatric surgical procedure, leads to durable weight loss and improves obesity-related comorbidities. However, it induces abnormalities in bone metabolism. One unexplored potential contributor is the gut microbiome, which influences bone metabolism and is altered after surgery. We characterized the relationship between the gut microbiome and skeletal health in severe obesity and after LSG. In a prospective cohort study, 23 adults with severe obesity underwent skeletal health assessment and stool collection preoperatively and 6 mo after LSG. Gut microbial diversity and composition were characterized using 16S rRNA gene sequencing, and fecal concentrations of short-chain fatty acids (SCFA) were measured with LC-MS/MS. Spearman's correlations and PERMANOVA analyses were applied to assess relationships between the gut microbiome and bone health measures including serum bone turnover markers (C-terminal telopeptide of type 1 collagen [CTx] and procollagen type 1 N-terminal propeptide [P1NP]), areal BMD, intestinal calcium absorption, and calciotropic hormones. Six months after LSG, CTx and P1NP increased (by median 188% and 61%, P < .01) and femoral neck BMD decreased (mean -3.3%, P < .01). Concurrently, there was a decrease in relative abundance of the phylum Firmicutes. Although there were no change in overall microbial diversity or fecal SCFA concentrations after LSG, those with greater within-subject change in gut community microbial composition (β-diversity) postoperatively had greater increases in P1NP level (ρ = 0.48, P = .02) and greater bone loss at the femoral neck (ρ = -0.43, P = .04). In addition, within-participant shifts in microbial richness/evenness (α-diversity) were associated with changes in IGF-1 levels (ρ = 0.56, P < .01). The lower the postoperative fecal butyrate concentration, the lower the IGF-1 level (ρ = 0.43, P = .04). Meanwhile, the larger the decrease in butyrate concentration, the higher the postoperative CTx (ρ = -0.43, P = .04). These findings suggest that LSG-induced gut microbiome alteration may influence skeletal outcomes postoperatively, and microbial influences on butyrate formation and IGF-1 are possible mechanisms., (© Published by Oxford University Press on behalf of the American Society for Bone and Mineral Research 2024.)

This position statement is issued by the American Society for Metabolic and Bariatric. Surgery in response to inquiries made to the Society by patients, physicians, Society members, hospitals, health insurance payors, the media, and others regarding the access and outcomes of metabolic and bariatric surgery for beneficiaries of Centers for Medicare and Medicaid Services. This position statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement is not intended to be and should not be construed as stating or establishing a local, regional, or national standard of care. This statement will be revised in the future as additional evidence becomes available., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Proximal ulnar nerve lacerations are challenging to treat because of the complex integration of sensory and motor function in the hand. The purpose of this study was to compare primary repair and primary repair plus anterior interosseous nerve (AIN) reverse end-to-side (RETS) coaptation in the setting of proximal ulnar nerve injuries., Methods: A prospective cohort study was performed of all patients at a single, academic, level I trauma center from 2014 to 2018 presenting with isolated complete ulnar nerve lacerations. Patients underwent either primary repair (PR) only or primary repair and AIN RETS (PR + RETS). Data collected included demographic information; quick Disabilities of the Arm, Shoulder and Hand questionnaire score; Medical Research Council score; grip and pinch strength; and visual analogue scale pain scores at 6 and 12 months postoperatively., Results: Sixty patients were included in the study: 28 in the PR group and 32 in the RETS + PR group. There was no difference in demographic variables or location of injury between the two groups. Average quick Disabilities of the Arm, Shoulder and Hand questionnaire scores for the PR and PR + RETS groups were 65 ± 6 and 36 ± 4 at 6 months and 46 ± 4 and 24 ± 3 at 12 months postoperatively, respectively, and were significantly lower in the PR + RETS group at both points. Average grip and pinch strength were significantly greater for the PR + RETS group at 6 and 12 months., Conclusion: This study demonstrated that primary repair of proximal ulnar nerve injuries plus AIN RETS coaptation yielded superior strength and improved upper extremity function when compared with PR alone., Clinical Question/level of Evidence: Therapeutic, II., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Objective: The purpose of this study was to describe the different strategies used to supplement North American Pharmacist Licensure Examination (NAPLEX) and Multistate Pharmacy Jurisprudence Examination (MPJE) preparation in the US pharmacy programs., Methods: An online survey was developed to gather information from 141 accredited schools/colleges of pharmacy about the preparation methods used during the 2021-22 academic year. The questionnaire contained 19 NAPLEX- and 10 MPJE-specific questions related to timing, content, use of commercial products and programs, faculty involvement, and whether these activities were required or recommended. Characteristics of schools/colleges were compared based on the presence or absence of preparation programs; preparation programs were descriptively reported., Results: The response rate was 71%. Most schools (87/100 respondents) provided NAPLEX preparation programs starting in the advanced pharmacy practice experiential year, required students to participate, and focused on reviewing the content instead of assessing students' examination readiness. Similar elements were reported among 61 schools providing MPJE preparation programs. Schools used a variety of resources including access to vendor-based question banks or review materials, and completing live, proctored, NAPLEX-like examinations. Characteristics of schools or colleges did not differ significantly based on presence or absence of a preparation program., Conclusion: Schools/colleges of pharmacy use a variety of strategies to prepare students for licensing examinations. Many require student participation in vendor-based preparation programs for NAPLEX, and homegrown programs for MPJE preparation. The next step will be to determine the effectiveness of various approaches used by the schools/colleges on first-time licensure examination attempts., Competing Interests: Declaration of Competing Interests None declared., (Copyright © 2023 American Association of Colleges of Pharmacy. Published by Elsevier Inc. All rights reserved.)

Context: Laparoscopic sleeve gastrectomy (LSG), now the most commonly performed bariatric operation, is a highly effective treatment for obesity. While Roux-en-Y gastric bypass is known to impair intestinal fractional calcium absorption (FCA) and negatively affect bone metabolism, LSG's effects on calcium homeostasis and bone health have not been well characterized., Objective: We determined the effect of LSG on FCA, while maintaining robust 25-hydroxyvitamin D (25OHD) levels and recommended calcium intake., Design, Setting, Participants: Prospective pre-post observational cohort study of 35 women and men with severe obesity undergoing LSG., Main Outcomes: FCA was measured preoperatively and 6 months postoperatively with a gold-standard dual stable isotope method. Other measures included calciotropic hormones, bone turnover markers, and bone mineral density (BMD) by dual-energy X-ray absorptiometry and quantitative computed tomography., Results: Mean ± SD FCA decreased from 31.4 ± 15.4% preoperatively to 16.1 ± 12.3% postoperatively (P < 0.01), while median (interquartile range) 25OHD levels were 39 (32-46) ng/mL and 36 (30-46) ng/mL, respectively. Concurrently, median 1,25-dihydroxyvitamin D level increased from 60 (50-82) pg/mL to 86 (72-107) pg/mL (P < 0.01), without significant changes in parathyroid hormone or 24-hour urinary calcium levels. Bone turnover marker levels increased substantially, and areal BMD decreased at the proximal femur. Those with lower postoperative FCA had greater areal BMD loss at the total hip (ρ = 0.45, P < 0.01)., Conclusions: FCA decreases after LSG, with a concurrent rise in bone turnover marker levels and decline in BMD, despite robust 25OHD levels and with recommended calcium intake. Decline in FCA could contribute to negative skeletal effects following LSG., (Published by Oxford University Press on behalf of the Endocrine Society 2022.)

This study aims to evaluate the research productivity trends in orthopaedic residents who were selected for shoulder and elbow fellowships from 2010 to 2019. We hypothesize that residents matching into orthopaedic shoulder and elbow fellowships are increasing both their publication number and publication quality from 2010 to 2019. Fellows of orthopaedic shoulder and elbow programs from 2010 to 2019 were identified through publicly accessible information on fellowship programs. Each fellow's publication data during their residency was collected via publicly available search engines, and analyzed to include: fellowship year, residency years, fellowship program and location, total publications, number of publications in high-impact general orthopaedic and shoulder and elbow journals, and authorship position. A total of 176 orthopaedic shoulder and elbow fellows from 17 different programs were identified and included in the study. The fellows produced a total of 668 publications, published 172 articles in high impact journals, and had first authorship on 49% of the studies. On average, there were 3.8 publications per fellow per year from 2010 to 2019. There were 5.7 publications produced per fellow in 2018-2019, compared to just 2.92 publications per fellow in 2010-2011. Overall, there was an increasing trend in publications, publications in high impact journals, and first authorship publications per applicant matching into shoulder and elbow fellowship from 2010 to 2019. (Journal of Surgical Orthopaedic Advances 31(4):205-208, 2022).

Objective. To assess how curriculum committees at US schools and colleges of pharmacy have evolved since 2011 regarding their responsibilities, structures, functions, charges, and activities. Methods. A total of 133 fully accredited schools and colleges of pharmacy were included in the survey. Data collection occurred between March and September 2020, and survey questions pertained to academic year 2019-2020. Data were collected on committee membership, leadership, functions, and charges. New questions explored ties to assessments and Standards 2016. Analysis included descriptive statistics and comparisons to the 2011 survey results. Results. The response rate was 80%; one partial response was excluded from analysis. Most schools and colleges (93%) rely on a curriculum committee to provide curriculum oversight. Faculty and students remain the most frequent types of members, but increases have occurred in the number of committees with members from other areas, including experiential programs, staff, directors, librarians, and pharmacy residents. Committee charges have increased beyond the traditional activities of curriculum planning, mapping, and review to include newer tasks. In one-third of the institutions, the primary responsibility for various assessment activities is shared by both committees. Conclusion. Curriculum committees remain a key part of pharmacy education but continue to evolve to meet their responsibilities related to new and increasing numbers of charges and to find ways to communicate and share duties with their assessment counterparts. Based on these findings, recommendations include having clear guidance for curriculum committees and reducing the frequency of their scheduled work to ensure they will be able to address new challenges as they emerge., (© 2022 American Association of Colleges of Pharmacy.)

Background: The scratch collapse test is a provocative test that has been successfully used for peripheral neuropathies. The elbow is the main testing site, but there may be times when use of the upper extremities is contraindicated. This study sought to determine the sensitivity of using the scratch collapse test on the lower extremity for upper extremity neuropathies., Methods: One hundred patients with an electromyographically confirmed diagnosis of carpal tunnel or cubital tunnel syndrome were prospectively enrolled. As a control, the scratch collapse test was conducted normally using the elbow as a testing site. After a baseline was established, the test was repeated using eversion of the foot and ankle against an inversion force., Results: Of the 100 study patients, 89 had a positive scratch collapse test on the upper extremity and 84 had a positive test on the lower extremity. In the 51 patients with carpal tunnel syndrome, 45 had a positive test on the upper extremity (sensitivity, 88.2 percent; 95 percent CI, 76.13 to 95.56 percent), and 42 had a positive test of the lower extremity (sensitivity, 82.35 percent; 95 percent CI, 69.13 to 91.60 percent). In the 49 patients with cubital tunnel syndrome, 44 had a positive test on the upper extremity (sensitivity, 89.8 percent; 95 percent CI, 77.77 to 96.6 percent), and 42 had a positive test on the lower extremity (sensitivity, 85.7 percent; 95 percent CI, 72.76 to 94.06 percent)., Conclusion: There were no statistically significant differences in the sensitivities of the scratch collapse test on the upper or lower extremities, suggesting that the lower extremity could serve as an alternative site for the scratch collapse test., Clinical Question/level of Evidence: Diagnostic, II., Competing Interests: Disclosure : All authors have no potential conflicts of interest and no financial interests to disclose. No funding was received for this article ., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Context: The adverse skeletal effects of Roux-en-Y gastric bypass (RYGB) are partly caused by intestinal calcium absorption decline. Prebiotics, such as soluble corn fiber (SCF), augment colonic calcium absorption in healthy individuals., Objective: We tested the effects of SCF on fractional calcium absorption (FCA), biochemical parameters, and the fecal microbiome in a post-RYGB population., Methods: Randomized, double-blind, placebo-controlled trial of 20 postmenopausal women with history of RYGB a mean 5 years prior; a 2-month course of 20 g/day SCF or maltodextrin placebo was taken orally. The main outcome measure was between-group difference in absolute change in FCA (primary outcome) and was measured with a gold standard dual stable isotope method. Other measures included tolerability, adherence, serum calciotropic hormones and bone turnover markers, and fecal microbial composition via 16S rRNA gene sequencing., Results: Mean FCA ± SD at baseline was low at 5.5 ± 5.1%. Comparing SCF to placebo, there was no between-group difference in mean (95% CI) change in FCA (+3.4 [-6.7, +13.6]%), nor in calciotropic hormones or bone turnover markers. The SCF group had a wider variation in FCA change than placebo (SD 13.4% vs 7.0%). Those with greater change in microbial composition following SCF treatment had greater increase in FCA (r2 = 0.72, P = 0.05). SCF adherence was high, and gastrointestinal symptoms were similar between groups., Conclusion: No between-group differences were observed in changes in FCA or calciotropic hormones, but wide CIs suggest a variable impact of SCF that may be due to the degree of gut microbiome alteration. Daily SCF consumption was well tolerated. Larger and longer-term studies are warranted., (Published by Oxford University Press on behalf of the Endocrine Society 2021.)

Management of unstable injuries was revolutionized by the Internal Joint Stabilizer (IJS). When compared to long-term immobilization, transarticular pinning, and hinge external fixation, the IJS results in decreased complications and improved clinical outcomes. Historically, the IJS was applied via a lateral approach; however, this limited intraoperative visualization and, in some cases, resulted in increased operative times. This technical report describes a posterior approach, for IJS application. The posterior approach involves an 8- to 10-cm incision over the posterior elbow through the deep fascia before identifying the olecranon and lateral capitellum, then proceeding with IJS application through manufacturer instructions. The ulnar and radial nerves must be identified as they could be damaged in this approach. Using the posterior approach at our institution, we have noticed a possible decrease in operative times and an increase in intraoperative visualization of the elbow without a subsequent increase in complications.

History can inconspicuously repeat itself through words and language. We explored the association between the "Black" and "African American" racial labels and the ideologies of the historical movements within which they gained prominence (Civil Rights and Black Power, respectively). Two content analyses and two preregistered experimental studies ( N = 1,204 White American adults) show that the associations between "Black" and "bias and discrimination" and between "African American" and "civil rights and equality" are evident in images, op-eds, and perceptions of organizations. Google Images search results for "Black people" evoke more racially victimized imagery than search results for "African American people" (Study 1), and op-eds that use the Black label contain more bias and discrimination content than those that use the African American label (Study 2). Finally, White Americans infer the ideologies of organizations by the racial label within the organization's name (Studies 3 and 4). Consequently, these inferences guide the degree to which Whites support the organization financially.

Introduction: Hand surgery fellowships accept applicants from 3 different residencies: general surgery, orthopedic surgery, and plastic surgery. Although all of these specialties culminate into a board-certified hand surgeon, each specialty receives drastically different training in residency, which can have effects on which procedures these surgeons feel comfortable performing in their own practices. This study aims to compare practice patterns and complication rates among hand surgeons by residency training., Methods: The National Surgical Quality Improvement Program database was queried between the years of 2014 and 2018 for all Current Procedural Terminology codes pertaining to upper-extremity surgical procedures performed below the elbow. Procedures not performed by a general, orthopedic, or plastic surgeon were excluded, as well as polytraumas. Procedures were then stratified by anatomic region, tissue type, and primary specialty of the attending surgeon. Data collected included the number of each procedure, patient complexity, and complications. Statistical analysis consisted of a t test for continuous variables, χ2 analysis for categorical variables, and linear regression analysis to compare complications rates between specialties., Results: A total of 76,980 unique cases were included in our analysis: 4979 (6.4%) at the elbow, 43,680 (56.7%) at the forearm/wrist, 23,284 (30.2%) at the hand, 1421 (1.8%) flaps/grafts, 285 (0.4%) vascular, and 3331 (4.3%) neurological. Orthopedics performed most (79.5%) of the procedures, whereas plastic surgeons and general surgeons performed 17.3% and 3.1%, respectively. There were also significant differences by anatomic location/type of procedure, with orthopedic surgeons performing 99.2% of procedures at the elbow but only 67.7% of procedures at the hand. Linear regression analysis showed general surgeons had the lowest complication rates., Conclusions: Our data show significant differences in the number of upper-extremity surgeries performed by surgeons from each specialty at different anatomic locations.This could be due to differences in training during residency or proportionately more orthopedic surgeons being "full-time" hand surgeons. These data could affect hiring patterns in hospitals seeking hand surgeons depending on the variety of pathology encountered at that particular institution., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: A routine resting echocardiography has been suggested as a means to assess cardiac functioning and predict adverse cardiopulmonary events after bariatric surgery., Objectives: To describe the findings of routine resting echocardiographs in bariatric surgical candidates over a 3-year period and correlate them with observed adverse cardiopulmonary outcomes., Setting: Tertiary-care university-based referral hospital., Methods: We retrospectively reviewed 422 consecutive patients who underwent a laparoscopic sleeve gastrectomy or laparoscopic gastric bypass at our center over 3 years, of whom 321 (76%) received a routine resting preoperative echocardiogram. Abnormal preoperative echocardiogram findings and patient characteristics were recorded. The primary outcome measure was the number of adverse cardiopulmonary events within 30 days of surgery, a composite measure defined as any instance of myocardial infarction, sustained hypotension, stroke, new-onset arrhythmia, heart failure, intensive care admission for cardiopulmonary monitoring, or cardiac arrest., Results: Routine screening preoperative echocardiograms revealed left ventricular (LV) systolic dysfunction in 7 patients (2%), LV diastolic dysfunction in 71 patients (22%), LV hypertrophy in 73 patients (23%), wall motion abnormalities in 4 patients (1%), pulmonary hypertension in 47 patients (15%), left atrial enlargement in 45 patients (14%), and LV enlargement in 6 patients (1%). Adverse cardiopulmonary events occurred in only 4 patients, all of whom had a history of coronary revascularization, and 3 of whom had a prior myocardial infarction. No finding on the routine preoperative echocardiograms was associated with adverse cardiopulmonary events., Conclusion: A routine resting preoperative echocardiography added little to the cardiopulmonary risk stratification of patients who underwent bariatric surgery. High-risk patients were identifiable based on their medical history, particularly those with a known history of coronary artery disease and coronary revascularization., (Published by Elsevier Inc.)

Objective: The aim of this study was to evaluate which mesh type yields lower recurrence and complication rates after ventral hernia repair., Summary Background Data: More than 400,000 ventral hernia repairs are performed annually in the United States. Although the most effective method for repairing ventral hernias involves using mesh, whether to use biologic mesh versus synthetic mesh is controversial., Methods: Single-blind, randomized, controlled, pragmatic clinical trial conducted from March 2014 through October 2018; 165 patients enrolled with an average follow up of 26 months. Patients were randomized 1:1 to have their ventral hernias repaired using either a biologic (porcine) or synthetic (polypropylene) mesh. The primary study outcome measure was hernia recurrence at 2 years., Results: A total of 165 patients (68 men), mean age 55 years, were included in the study with a mean follow-up of 26 months. An intention-to-treat analysis noted that hernias recurred in 25 patients (39.7%) assigned to biologic mesh and in 14 patients (21.9%) assigned to synthetic mesh (P = 0.035) at 2 years. Subgroup analysis identified an increased rate of hernia recurrence in the biologic versus the synthetic mesh group under contaminated wound conditions (50.0% vs 5.9%; P for interaction = 0.041). Postoperative complication rates were similar for the 2 mesh types., Conclusions: The risk of hernia recurrence was significantly higher for patients undergoing ventral hernia repair with biologic mesh compared to synthetic mesh, with similar rates of postoperative complications. These data indicate that the use of synthetic mesh over biologic mesh to repair ventral hernias is effective and can be endorsed, including under contaminated wound conditions., Trial Registration: ClinicalTrials.gov Identifier: NCT02041494., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background. Esophagogastroduodenoscopy (EGD) is an important tool in the evolving specialty of acute care surgery (ACS). Understanding the types of nonelective EGDs performed by ACS groups is important for the development of ACS programs and the training of future general surgeons. Methods. We conducted a retrospective review of all EGDs performed by ACS surgeons at a single urban academic center over a 5-year period (January 2013-December 2018). Results. A total of 495 EGDs were performed, of which 129 (26%) were urgent, nonelective procedures. Patients who underwent urgent EGD were younger than those who underwent elective procedures (median 55 vs 60 years, P = .03), had higher American Society of Anesthesiologists (ASA) classes (median ASA 3 vs 2, P = .0002), and longer hospital stays (median 5 days vs 0 days, P < .0001). The most common indications for urgent endoscopies were the management of leak, dysphagia, or stenosis in patients with a history of foregut surgery, followed by the management of esophageal perforation. The success rate of endoscopic therapy was high (median 88%, interquartile range (IQR) 78-89%). However, some patients required multiple interventions (median 1, IQR 1-3), and patients treated for leaks were less likely to be successfully treated with endoscopic therapy alone than patients treated for other indications (success rate 65% vs 88%, P = .003). Conclusions. Our experience suggests that EGD has an important role in current ACS practice and that endoscopic management is safe and effective in a range of urgent surgical scenarios. Future ACS surgeons should be facile with endoscopic techniques.

Introduction  Pelvic ring fractures occur frequently among the elderly population, but some studies demonstrate a bimodal distribution where the incidence is elevated among younger age groups as well. The mechanisms of injury also vary based on age groups. Previous studies are specific to trauma registries and centers, but epidemiological data within the U.S. military are sparse. In the U.S. military population, pelvic ring fractures can be related to high-energy trauma including motor vehicle accidents and combat warfare. The purpose of this study was to determine the incidence of pelvic ring fractures among active duty U.S. military service members between 2006 and 2015, while also describing the demographics associated with the findings. Materials and Methods All data were collected from the U.S. Defense Medical Epidemiology Database (DMED). To calculate the incidence rates, only first-time occurrences for pelvic ring fractures among military members were used. Each point was identified using International Classification of Diseases, Ninth Revision (ICD-9), clinical modification code 808 for "fractures of the pelvis." A multivariate Poisson regression analysis was used to estimate the incidence rate per 1,000 person-years and 95% confidence intervals while controlling for sex, race, age, rank, and service. Rate ratios were calculated using different referent factors based on differences in sex, race, age, rank, and service branch. This study was IRB exempt as all the data used were de-identified patient data from the DMED system. Results Over the 10-year study period, a total of 4,802 incident cases of pelvic ring fractures, and a total of 13,748,429 person-years were documented. The overall incidence rate of pelvic ring fractures was 0.35 per 1,000 person-years. The incidence of pelvic ring fractures was highest among the youngest age group (<20 years) and among the lower-ranking service members. Additionally, other demographic groups such as the White race, female sex, and Army service members showed the highest incidence rates. Conclusion Our study determined baseline epidemiological data on incidence rates of pelvic ring fractures in the U.S. military. Patient demographics may be contributing factors, and the present analysis was able to elucidate associated underlying demographics. We demonstrated that the incidence was highest among the younger age groups, and that incidence rates may be specific to age cohorts. This study also found that lower-ranking service members had the highest incidence in all service branches, suggesting a form of occupational risk. Furthermore, our findings suggest that females, White race groups, and Army enlisted service members show a significantly higher incidence rate and may be at a greater risk. Our findings are important as they broaden the understanding of the patterns of pelvic ring fractures in the U.S. military population and occupational risks associated with this population., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Pisquiy et al.)

Context: The gut hormones peptide YY (PYY) and ghrelin mediate in part the metabolic benefits of Roux-en-Y gastric bypass (RYGB) surgery. However, preclinical data suggest these hormones also affect the skeleton and could contribute to postoperative bone loss., Objective: We investigated whether changes in fasting serum total PYY and ghrelin were associated with bone turnover marker levels and loss of bone mineral density (BMD) after RYGB., Design, Setting, Participants: Prospective cohort of adults undergoing RYGB (n=44) at San Francisco academic hospitals., Main Outcome Measures: We analyzed 6-month changes in PYY, ghrelin, bone turnover markers, and BMD by dual-energy x-ray absorptiometry (DXA) and quantitative computed tomography (QCT). We calculated the uncoupling index (UI), reflecting the relative balance of bone resorption and formation., Results: Postoperatively, there was a trend for an increase in PYY (+25pg/mL, p=0.07) and a significant increase in ghrelin (+192pg/mL, p<0.01). PYY changes negatively correlated with changes in spine BMD by QCT (r=-0.36, p=0.02) and bone formation marker P1NP (r=-0.30, p=0.05). Relationships were significant after adjustments for age, sex, and weight loss. No consistent relationships were found between ghrelin and skeletal outcomes. Mean 6-month UI was -3.3; UI correlated with spine BMD loss by QCT (r=0.40, p=0.01)., Conclusions: Postoperative PYY increases were associated with attenuated increases in P1NP and greater declines in spine BMD by QCT. Uncoupling of bone turnover correlated with BMD loss. These findings suggest a role for PYY in loss of bone mass after RYGB and highlight the relationship between intestinal and skeletal metabolism., (Published by Elsevier Inc.)

Background: Gallstone disease occurs more commonly in the obese population and is often diagnosed during the preoperative evaluation for bariatric surgery., Objectives: This study analyzed outcomes of laparoscopic gastric bypass (LGB) and laparoscopic sleeve gastrectomy (SG), with and without cholecystectomy (LC), using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program., Setting: Patients reported to Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participating centers in the United States and Canada in 2015., Methods: All cases of LGB and SG, with and without LC, were analyzed. A 1:1 propensity-matched cohort was created for both SG and LGB, with and without concomitant LC. Multivariate logistic regression stratified by procedure was used to identify predictors of major complications after SG and LGB, using concomitant LC as a predictor. We also constructed a model for surgical site infections (SSIs) for SG group., Results: Of 98,292 sleeve operations, 2046 (2%) had concomitant LC. Of 44,427 bypass operations, 1426 (3%) had concomitant LC. For the sleeve group, concomitant LC increased operative time by an average of 27 minutes but did not affect length of stay, mortality, or major complications. Concomitant LC was associated with increased SSI (1% versus .4%) and need for reoperation (1.6% versus .7%) in univariate models. After adjusting for other predictors, concomitant LC was associated with increased risk for SSI (odds ratio 2.5, confidence interval 1.0-5.9, P = .04). For the bypass group, concomitant LC increased operative time by an average of 28 minutes to the operation, and postoperative length of stay averaged ∼5 hours longer (2.4 versus 2.2 d, P = .03). Thirty-day complications were similar between the groups. On multivariate analysis, concomitant LC was not a significant risk factor for major complications. Only operative time was an independent factor for major complications., Conclusions: Concomitant LC with laparoscopic sleeve gastrectomy or gastric bypass did not affect mortality or risk of major complication. For sleeve patients, concomitant LC was associated with a .6% increased risk (.4% to 1.0%) of SSI. Concomitant LC with laparoscopic sleeve gastrectomy or gastric bypass is safe when indicated for gallstone disease., (Copyright © 2019. Published by Elsevier Inc.)

Context: Bariatric surgery results in reduced muscle mass as weight is lost, but postoperative changes in muscle strength and performance are incompletely understood., Objective: To examine changes in body composition, strength, physical activity, and physical performance following Roux-en-Y gastric bypass (RYGB)., Design, Participants, Outcomes: In a prospective cohort of 47 adults (37 women, 10 men) aged 45 ± 12 years (mean ± SD) with body mass index (BMI) 44 ± 8 kg/m2, we measured body composition by dual-energy X-ray absorptiometry, handgrip strength, physical activity, and physical performance (chair stand time, gait speed, 400-m walk time) before and 6 and 12 months after RYGB. Relative strength was calculated as absolute handgrip strength/BMI and as absolute strength/appendicular lean mass (ALM)., Results: Participants experienced substantial 12-month decreases in weight (-37 ± 10 kg or 30% ± 7%), fat mass (-48% ± 12%), and total lean mass (-13% ± 6%). Mean absolute strength declined by 9% ± 17% (P < 0.01). In contrast, relative strength increased by 32% ± 25% (strength/BMI) and 9% ± 20% (strength/ALM) (P < 0.01 for both). There were clinically significant postoperative improvements in all physical performance measures, including mean improvement in gait speed of >0.1 m/s (P < 0.01) and decrease in 400-m walk time of nearly a full minute., Conclusions: In the setting of dramatic weight loss, lean mass and absolute grip strength declined after RYGB. However, relative muscle strength and physical function improved meaningfully and are thus noteworthy positive outcomes of gastric bypass.

Background: Reproductive-aged women represent about half of those undergoing bariatric surgery in the United States. Obstetric and bariatric professional societies recommend that women avoid pregnancy for 12-18 months postoperatively due to concern for increased pregnancy risks, and that providers should counsel women about these recommendations and their contraceptive options. However, knowledge about women's experience with perioperative counseling and postoperative contraceptive use is limited., Objective: We sought to: (1) determine prevalence of perioperative contraceptive and pregnancy interval discussions among women who have recently undergone bariatric surgery; and (2) describe postoperative contraceptive use within the first year of surgery in this population., Study Design: We performed a cross-sectional study of US women, aged 18-45 years and recruited through Facebook, who underwent bariatric surgery within the last 24 months., Results: We enrolled 363 geographically diverse women. Three-quarters recalled perioperative pregnancy or contraceptive discussions, the majority with a bariatric provider. Half felt it was "very important" to discuss these issues perioperatively, and 41% of those who reported discussions wished they had had more. Of the 66% of women who reported using contraception in the first 12 months postoperatively, 27% used oral contraceptives and 26% used an intrauterine device. One third of contraceptive users who had undergone Roux-en-Y gastric bypass, a combined restrictive-malabsorptive procedure, were using oral contraceptives. Perioperative contraceptive or pregnancy discussions were independently associated with increased postoperative contraceptive use (odds ratios, 2.5; 95% confidence interval, 1.5-4.3, P < .001)., Conclusion: A substantial proportion of women who had undergone bariatric surgery reported having had no perioperative pregnancy or contraception counseling, and many women who had felt the discussions were insufficient. Those who had had perioperative discussions were more likely to use contraception postoperatively. Reproductive-aged women should be routinely counseled perioperatively about pregnancy and contraception in the context of their reproductive desires, so they can make informed decisions about perioperative pregnancy prevention and contraceptive method use., (Published by Elsevier Inc.)

Roux-en-Y gastric bypass (RYGB) surgery is a highly effective treatment for obesity but negatively affects the skeleton. Studies of skeletal effects have generally examined areal bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), but DXA may be inaccurate in the setting of marked weight loss. Further, as a result of modestly sized samples of mostly premenopausal women and very few men, effects of RYGB by sex and menopausal status are unknown. We prospectively studied the effects of RYGB on skeletal health, including axial and appendicular volumetric BMD and appendicular bone microarchitecture and estimated strength. Obese adults (N = 48; 27 premenopausal and 11 postmenopausal women, 10 men) with mean ± SD body mass index (BMI) 44 ± 7 kg/m 2 were assessed before and 6 and 12 months after RYGB. Participants underwent spine and hip DXA, spine QCT, radius and tibia HR-pQCT, and laboratory evaluation. Mean 12-month weight loss was 37 kg (30% of preoperative weight). Overall median 12-month increase in serum collagen type I C-telopeptide (CTx) was 278% (p < 0.0001), with greater increases in postmenopausal than premenopausal women (p = 0.049). Femoral neck BMD by DXA decreased by mean 5.0% and 8.0% over 6 and 12 months (p < 0.0001). Spinal BMD by QCT decreased by mean 6.6% and 8.1% (p < 0.0001); declines were larger among postmenopausal than premenopausal women (11.6% versus 6.0% at 12 months, p = 0.02). Radial and tibial BMD and estimated strength by HR-pQCT declined. At the tibia, detrimental changes in trabecular microarchitecture were apparent at 6 and 12 months. Cortical porosity increased at the radius and tibia, with more dramatic 12-month increases among postmenopausal than premenopausal women or men at the tibia (51.4% versus 18.3% versus 3.0%, p < 0.01 between groups). In conclusion, detrimental effects of RYGB on axial and appendicular bone mass and microarchitecture are detectable as early as 6 months postoperatively. Postmenopausal women are at highest risk for skeletal consequences and may warrant targeted screening or interventions. © 2017 American Society for Bone and Mineral Research., (© 2017 American Society for Bone and Mineral Research.)

Background: Laparoscopic sleeve gastrectomy (LSG) has become popular due to its technical ease and excellent short-term results. Understanding the risk profile of LSG compared with the gold standard laparoscopic Roux-en-Y gastric bypass (LRYGB) is critical for patient selection., Objectives: To use traditional regression techniques and random forest classification algorithms to compare LSG with LRYGB using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Data Registry., Setting: United States., Methods: Outcomes were leak, morbidity, and mortality within 30 days. Variable importance was assessed using random forest algorithms. Multivariate models were created in a training set and evaluated on the testing set with receiver operating characteristic curves. The adjusted odds of each outcome were compared., Results: Of 134,142 patients, 93,062 (69%) underwent LSG and 41,080 (31%) underwent LRYGB. One hundred seventy-eight deaths occurred in 96 (.1%) of LSG patients compared with 82 (.2%) of LRYGB patients (P<.001). Morbidity occurred in 8% (5.8% in LSG versus 11.7% in LRYGB, P<.001). Leaks occurred in 1% (.8% in LSG versus 1.6% in LRYGB, P<.001). The most important predictors of all outcomes were body mass index, albumin, and age. In the adjusted multivariate models, LRYGB had higher odds of all complications (leak: odds ratio 2.10, P<.001; morbidity: odds ratio 2.02, P<.001; death: odds ratio 1.64, P<.01)., Conclusion: In the Metabolic and Bariatric Surgery Accreditation and Quality Improvements data registry for 2015, LSG had half the risk-adjusted odds of death, serious morbidity, and leak in the first 30 days compared with LRYGB., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The Joint Commission's SCIP Inf-9 mandated early removal of indwelling urinary catheters (IUCs), but the impact of compliance on catheter-associated urinary tract infection (CAUTI) and postoperative urinary retention (POUR) are unknown., Methods: Retrospective pre- and post-intervention study at a single tertiary academic medical center of all patients undergoing general surgery procedures with an IUC placed at the time of surgery who were admitted for at least two days before and after a Best Practice Advisory was put in place to improve compliance with SCIP Inf-9., Results: A total of 1036 patients were included (468 pre-intervention; 568 post-intervention). POUR occurred in 13% of patients and CAUTI in 0.8%. There was no change in POUR, CAUTI, or catheter utilization after the Best Practice Advisory was initiated. Both POUR and CAUTI predicted longer lengths of stay., Conclusions: Near-perfect SCIP Inf-9 compliance had no effect on the CAUTI rate at our institution., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Bone marrow fat is a unique fat depot that may regulate bone metabolism. Marrow fat is increased in states of low bone mass, severe underweight, and diabetes. However, longitudinal effects of weight loss and improved glucose homeostasis on marrow fat are unclear, as is the relationship between marrow fat and bone mineral density (BMD) changes. We hypothesized that after Roux-en-Y gastric bypass (RYGB) surgery, marrow fat changes are associated with BMD loss. We enrolled 30 obese women, stratified by diabetes status. Before and 6 months after RYGB, we measured BMD by dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) and vertebral marrow fat content by magnetic resonance spectroscopy. At baseline, those with higher marrow fat had lower BMD. Postoperatively, total body fat declined dramatically in all participants. Effects of RYGB on marrow fat differed by diabetes status (p = 0.03). Nondiabetic women showed no significant mean change in marrow fat (+1.8%, 95% confidence interval [CI] -1.8% to +5.4%, p = 0.29), although those who lost more total body fat were more likely to have marrow fat increases (r = -0.70, p = 0.01). In contrast, diabetic women demonstrated a mean marrow fat change of -6.5% (95% CI -13.1% to 0%, p = 0.05). Overall, those with greater improvements in hemoglobin A1c had decreases in marrow fat (r = 0.50, p = 0.01). Increases in IGF-1, a potential mediator of the marrow fat-bone relationship, were associated with marrow fat declines (r = -0.40, p = 0.05). Spinal volumetric BMD decreased by 6.4% ± 5.9% (p < 0.01), and femoral neck areal BMD decreased by 4.3% ± 4.1% (p < 0.01). Marrow fat and BMD changes were negatively associated, such that those with marrow fat increases had more BMD loss at both spine (r = -0.58, p < 0.01) and femoral neck (r = -0.49, p = 0.01), independent of age and menopause. Our findings suggest that glucose metabolism and weight loss may influence marrow fat behavior, and marrow fat may be a determinant of bone metabolism. © 2017 American Society for Bone and Mineral Research., (© 2017 American Society for Bone and Mineral Research.)

Purpose: Results of a study to formalize an antimicrobial stewardship program (ASP) in a small community hospital are presented., Methods: The formalization process began with a gap analysis of the hospital's antimicrobial services, followed by the development of a fully integrated, multipharmacist ASP. The impact was studied with an institutional review board-approved study design. Retrospective pre-ASP data were pulled from March 1 to June 30, 2012 and 2013 patient records; prospective post-ASP data were collected for March 1 to June 30, 2015. Analyses included descriptive and inferential statistics., Results: No significant differences in age, percent of patients on antimicrobials, or length of stay were found between the 2 groups. The post-ASP period showed a 30.2% decrease in defined daily dose (DDD) per 1,000 patient-days for the 18 most frequently used parenteral antimicrobial agents ( p < 0.001). For all nursing units except nursery, the vancomycin and piperacillin-tazobactam DDD per 1,000 patient-days decreased by 63% ( p < 0.001) and 36% ( p < 0.001), respectively. Mean antibiotic charges per patient-day decreased from $10.44 to $3.09 ( p < 0.001) and from $18.04 to $11.29 ( p < 0.001) for vancomycin and piperacillin-tazobactam, respectively. Pharmacist interventions increased from 19.3 per 1,000 patients to 104.3 per 1,000 patients. Deescalation of therapy was the most common intervention (46% and 29%) in both time periods., Conclusion: In a small community hospital, a new formalized ASP with pharmacists showed a decrease in the DDD per 1,000 patient-days and average antibiotic charges per patient-day for vancomycin and piperacillin-tazobactam within 4 months of implementation. The approach used to develop a formalized ASP could be used as an example for development in small community hospitals with similar resources., Competing Interests: DisclosuresThis project was funded by the ASHP Research and Education Foundation through the 2015 Pharmacy Resident Practice Based Research Grant program. All authors were investigators or consultants on the project. The authors have declared no other potential conflicts of interest., (Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Obesity accelerates the development of osteoarthritis of the knee and hip by exerting deleterious effects on joints through both biomechanical and also systemic inflammatory changes. The objective of this review was to evaluate the impact of obesity on lower limb biomechanics and total joint arthroplasty outcomes, as well as weight changes after joint arthroplasty and the role of bariatric surgery among patients requiring joint arthroplasty. The currently published data indicate that weight loss increases swing time, stride length, gait speed, and lower extremity range of motion. Total joint arthroplasty improves pain and joint function, but does not induce significant weight loss in the majority of patients. Bariatric surgery improves gait biomechanics, and in the severely obese patient with osteoarthritis improves pain and joint function. The evidence for supporting bariatric surgery before total joint arthroplasty is limited to retrospective reports with conflicting results. Fundamental clinical questions remain regarding the optimal management of morbid obesity and lower extremity arthritis, which should be the focus of future collaborations across disciplines providing care to patients with both conditions., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Patients who take chronic corticosteroids are increasingly referred for bariatric surgery. Little is known about their clinical outcomes., Objective: Determine whether chronic steroid use is associated with increased morbidity and mortality after stapled bariatric procedures., Setting: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database., Methods: All patients who underwent laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass and were reported to the ACS-NSQIP from 2011 to 2013 were reviewed. Patients were grouped based on type of surgery and history of chronic steroid use. Primary outcome measures were mortality and serious morbidity in the first 30 days. Regression analyses were used to determine predictors of outcome., Results: Of 23,798 patients who underwent laparoscopic sleeve gastrectomy and 38,184 who underwent Roux-en-Y gastric bypass, 385 (1.6%) and 430 (1.1%), respectively, were on chronic steroids. Patients on chronic steroids had a 3.4 times increased likelihood of dying within 30 days (95% confidence interval 1.4-8.1, P = .007), and 2-fold increased odds of serious complications (95% confidence interval 1.2-2.3, P = .008), regardless of surgery type. In multivariate regression, steroid usage remained an independent predictor of mortality and serious complications., Conclusion: In a large, nationally representative patient database, steroid use independently predicted mortality and serious postoperative complications after stapled bariatric procedures. Surgeons should be cautious about offering stapled bariatric procedures to patients on chronic steroids., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Total knee arthroplasty (TKA) has been shown to restore mobility, return an individual to activities of daily living, and improve quality of life. Nearly 80% of patients undergoing TKA report moderate to severe pain in the first 2 weeks following surgery., Methods: A retrospective study was conducted in 103 patients who underwent TKA between October 12, 2014 and May 30, 2015 by a single surgeon at a small community hospital. During this period, data were analyzed for differences in outcomes with a change from intraoperative periarticular (IOPA) injections containing an anesthetic/analgesic mixture of ropivacaine, epinephrine, ketorolac, and clonidine to liposomal bupivacaine. Patient records were reviewed to extract study data including postoperative opioid use, length of stay (LOS), opioid-associated adverse events, and non-opioid analgesic use., Results: No statistical differences were determined between groups for mean postoperative opiate usage in morphine equivalences during any time frame or for total opiate usage (79.4 vs 89.2 mg; P = .259) during the first 72 postoperative hours. Patients who received a liposomal bupivacaine injection did have a statistically significant increase in hospital LOS (70.0 vs 75.5 hours; P = .013) when compared to patients who received an IOPA injection. The incidence of nausea or vomiting, pruritus, or oversedation did not differ between groups., Conclusion: Pain control in TKA with a multimodal pain management protocol was not improved with the addition of liposomal bupivacaine compared to the IOPA injection at a community hospital.

Roux-en-Y gastric bypass (RYGB) surgery has negative effects on bone, mediated in part by effects on nutrient absorption. Not only can RYGB result in vitamin D malabsorption, but the bypassed duodenum and proximal jejunum are also the predominant sites of active, transcellular, 1,25(OH)2 D-mediated calcium (Ca) uptake. However, Ca absorption occurs throughout the intestine, and those who undergo RYGB might maintain sufficient Ca absorption, particularly if vitamin D status and Ca intake are robust. We determined the effects of RYGB on intestinal fractional Ca absorption (FCA) while maintaining ample 25OHD levels (goal ≥30 ng/mL) and Ca intake (1200 mg daily) in a prospective cohort of 33 obese adults (BMI 44.7 ± 7.4 kg/m(2)). FCA was measured preoperatively and 6 months postoperatively with a dual stable isotope method. Other measures included calciotropic hormones, bone turnover markers, and BMD by DXA and QCT. Mean 6-month weight loss was 32.5 ± 8.4 kg (25.8% ± 5.2% of preoperative weight). FCA decreased from 32.7% ± 14.0% preoperatively to 6.9% ± 3.8% postoperatively (p < 0.0001), despite median (interquartile range) 25OHD levels of 41.0 (33.1 to 48.5) and 36.5 (28.8 to 40.4) ng/mL, respectively. Consistent with the FCA decline, 24-hour urinary Ca decreased, PTH increased, and 1,25(OH)2 D increased (p ≤ 0.02). Bone turnover markers increased markedly, areal BMD decreased at the proximal femur, and volumetric BMD decreased at the spine (p < 0.001). Those with lower postoperative FCA had greater increases in serum CTx (ρ = -0.43, p = 0.01). Declines in FCA and BMD were not correlated over the 6 months. In conclusion, FCA decreased dramatically after RYGB, even with most 25OHD levels ≥30 ng/mL and with recommended Ca intake. RYGB patients may need high Ca intake to prevent perturbations in Ca homeostasis, although the approach to Ca supplementation needs further study. Decline in FCA could contribute to the decline in BMD after RYGB, and strategies to avoid long-term skeletal consequences should be investigated., (© 2015 American Society for Bone and Mineral Research.)

Mycobacteriophage ShedlockHolmes is a newly isolated phage infecting Mycobacterium smegmatis mc(2)155. It has a 61,081-bp genome containing 99 predicted protein-coding genes and one tRNA gene. ShedlockHolmes is closely related to mycobacteriophages Pixie, Keshu, and MacnCheese and is a new member of subcluster K3., (Copyright © 2015 Pope et al.)

Bone marrow fat may serve a metabolic role distinct from other fat depots, and it may be altered by metabolic conditions including diabetes. Caloric restriction paradoxically increases marrow fat in mice, and women with anorexia nervosa have high marrow fat. The longitudinal effect of weight loss on marrow fat in humans is unknown. We hypothesized that marrow fat increases after Roux-en-Y gastric bypass (RYGB) surgery, as total body fat decreases. In a pilot study of 11 morbidly obese women (6 diabetic, 5 nondiabetic), we measured vertebral marrow fat content (percentage fat fraction) before and 6 months after RYGB using magnetic resonance spectroscopy. Total body fat mass declined in all participants (mean ± SD decline 19.1 ± 6.1 kg or 36.5% ± 10.9%, p<0.001). Areal bone mineral density (BMD) decreased by 5.2% ± 3.5% and 4.1% ± 2.6% at the femoral neck and total hip, respectively, and volumetric BMD decreased at the spine by 7.4% ± 2.8% (p<0.001 for all). Effects of RYGB on marrow fat differed by diabetes status (adjusted p=0.04). There was little mean change in marrow fat in nondiabetic women (mean +0.9%, 95% CI -10.0 to +11.7%, p=0.84). In contrast, marrow fat decreased in diabetic women (-7.5%, 95% CI -15.2 to +0.1%, p=0.05). Changes in total body fat mass and marrow fat were inversely correlated among nondiabetic (r=-0.96, p=0.01) but not diabetic (r=0.52, p=0.29) participants. In conclusion, among those without diabetes, marrow fat is maintained on average after RYGB, despite dramatic declines in overall fat mass. Among those with diabetes, RYGB may reduce marrow fat. Thus, future studies of marrow fat should take diabetes status into account. Marrow fat may have unique metabolic behavior compared with other fat depots., (Published by Elsevier Inc.)

Widespread adoption of electronic medical records (EMRs) in the United States is transforming the practice of medicine from a paper-based cottage industry into an integrated health care delivery system. Most physicians and institutions view the widespread use of EMRs to be inevitable. But the transformation has not been painless. Many have questioned whether the substantial investment in electronic health records has really been justified by improved patient outcomes or quality of care. This article describes historical and recent efforts to use EMRs to improve the quality of patient care, and provides a roadmap of EMR uses for the foreseeable future., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The constitutive response of a commercial magnesium alloy rolled sheet (AZ31B-O) is studied based on room temperature tensile and compressive tests at strain rates ranging from 10(-3) to 10(3) s(-1). Because of its strong basal texture, this alloy exhibits a significant tension-compression asymmetry (strength differential) that is manifest further in terms of rather different strain rate sensitivity under tensile versus compressive loading. Under tensile loading, this alloy exhibits conventional positive strain rate sensitivity. Under compressive loading, the flow stress is initially rate insensitive until twinning is exhausted after which slip processes are activated, and conventional rate sensitivity is recovered. The material exhibits rather mild in-plane anisotropy in terms of strength, but strong transverse anisotropy (r-value), and a high degree of variation in the measured r-values along the different sheet orientations which is indicative of a higher degree of anisotropy than that observed based solely upon the variation in stresses. This rather complex behaviour is attributed to the strong basal texture, and the different deformation mechanisms being activated as the orientation and sign of applied loading are varied. A new constitutive equation is proposed to model the measured compressive behaviour that captures the rate sensitivity of the sigmoidal stress-strain response. The measured tensile stress-strain response is fit to the Zerilli-Armstrong hcp material model.

Background: Proponents of single-incision laparoscopic surgery (SILS) claim patients have less pain, faster recovery, and better long-term cosmetic results than patients who undergo multiport laparoscopy. However, randomized comparisons are lacking. This study presents the results of a prospective randomized trial of SILS or 3-port laparoscopic appendectomy., Study Design: Adults with uncomplicated acute appendicitis were randomized 1:1 to either SILS or 3-port laparoscopic appendectomy. The primary end point was early postoperative pain (measured by opiate usage and pain score in the first 12 hours). Secondary end points were operative time, complication rate (including conversions), and recovery time (days of oral opiate usage and return to work). After 6 months, body image and cosmetic appearance were assessed using a validated survey., Results: The trial was planned for 150 patients, but was halted after 75 patients when planned interim analysis showed that SILS patients had more postoperative pain (pain score: 4.4 ± 1.6 vs 3.5 ± 1.5; p = 0.01) and higher inpatient opiate usage (hydromorphone use: 3.9 ± 1.9 mg vs 2.8 ± 1.7 mg; p = 0.01) than 3-port laparoscopy. Operative time for SILS averaged 40% longer (54 ± 17 minutes vs 38 ± 11 minutes; p < 0.01). Only 1 SILS case was converted to 3-port. There were no significant differences in length of stay, complications, oral pain medication usage after discharge, or return to work. After 6 months, body image and cosmetic appearance were excellent for both groups and indistinguishable by most measures. However, 3-port patients reported better physical attractiveness (4.0 ± 0.4 vs 3.8 ± 0.4; p = 0.04) and SILS patients reported better scars (score 18.4 ± 2.7 vs 16.4 ± 3.0; p < 0.01). Results are reported as mean ± SD., Conclusions: Single-incision laparoscopic surgery appendectomy resulted in more pain and longer operative times without improving short-term recovery or complications. Long-term body image and cosmetic appearance were excellent in both groups., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)