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To assess the effectiveness of a hospital physical therapy (PT) referral triggered by scores on a mobility assessment embedded in the electronic health record (EHR) and completed by nursing staff on hospital admission.EHR and billing data from 12 acute care hospitals in a western Pennsylvania health system (January 2017-February 2018) and 11 acute care hospitals in a northeastern Ohio health system (August 2019-July 2021).We utilized a regression discontinuity design to compare patients admitted to PA hospitals with stroke who reached the mobility score threshold for an EHR-PT referral (treatment) to those who did not (control). Outcomes were hospital length of stay (LOS) and 30-day readmission or mortality. Control variables included demographics, insurance, income, and comorbidities. Hospital systems with EHR-PT referrals were also compared to those without (OH hospitals as alternative control). Subgroup analyses based on age were also conducted.We identified adult patients with a primary or secondary diagnosis of stroke and mobility assessments completed by nursing (n = 4859 in PA hospitals, n = 1749 in OH hospitals) who completed their inpatient stay.In the PA hospitals, patients with EHR-PT referrals had an 11.4 percentage-point decrease in their 30-day readmission or mortality rates (95% CI -0.57, -0.01) relative to the control. This effect was not observed in the OH hospitals for 30-day readmission (β = 0.01; 95% CI -0.25, 0.26). Adults over 60 years old with EHR-PT referrals in PA had a 26.2 percentage-point (95% CI -0.88, -0.19) decreased risk of readmission or mortality compared to those without. Unclear relationships exist between EHR-PT referrals and hospital LOS in PA.Health systems should consider methodologies to facilitate early acute care hospital PT referrals informed by mobility assessments.

Despite many patients doing well after laparoscopic adjustable gastric band (LAGB) several studies caution offering this procedure for weight loss. The aim of our study was to review our long-term results over a decade.Following IRB approval, the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) Data Registry was used to identify LAGB placement between 2007 and 2013 by a single surgeon. We sought to determine complications of initial operation, weight loss and resolution of comorbidities over time, the indications for reoperation including removal, revision or conversion to another weight loss surgery. Chi-square test was used to analysis.From 403 LAGB performed between January 2007 and December 2013, 75 patients required reoperation with total 79 procedures, including band revision and/or conversion. Mean follow-up time was 5.78 years (73.67 months). The rate of reoperation was at least 18.61%. There were 60 band removals, 10 band revisions, 9 conversions to either sleeve or gastric bypass. Only 16 patients (20.25%) required reoperation due to inadequate weight loss. Band slippage/prolapse remained the most common non weight-related indication for reoperation (23, 29.11%). Reoperation associated with longer length of stay compared to index procedures (2.12 days vs 1.63 days, p lt; 0.0001) but no statistical difference in 30_days_complication. Of those who did not require reoperation, BMI at 10th year follow-up was 37.50 from initial BMI of 42.23 with EWL of 39.22%.Lap band is effective for most patients with long-term durability. Over time approximately one fifth will need additional surgery. Only one fifth of reoperation relates to inadequate weight loss.

This article discusses an intelligent immersive virtual operating room to enable teams to train in a distributed fashion wearing head-mounted displays.

Background Evidence suggests a rise in alcohol misuse after some bariatric procedures. Whether undergoing sleeve gastrectomy raises the risk of high-risk alcohol use is unclear. Objective To characterize the risk of high-risk alcohol use 1 year after sleeve gastrectomy and collect preliminary data on potential associations between disordered eating and high-risk drinking post-surgery. Methods We interviewed 97 patients before and 1 year after sleeve gastrectomy and assessed for high-risk alcohol use via a modified version of the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Eating behavior was assessed using the Three Factor Eating Questionnaire Revised-18 (TFEQ-R18). Results The prevalence of high-risk drinking increased from 13.4% prior to surgery to 22.7% 1 year after sleeve gastrectomy; 16.5% of our sample reported new high-risk drinking equivalent to an incidence of 19.0%. New high-risk drinkers appeared more likely to report lower cognitive restraint scores and higher scores for emotional and uncontrolled eating at baseline and had larger improvements in disordered eating scores post-surgery although these differences approached, but did not reach, statistical significance. Conclusion One in five non-high-risk drinkers developed new high-risk alcohol intake 1 year after sleeve gastrectomy. New high-risk drinkers appear to have greater disordered eating at baseline and reported greater improvement in eating behavior than those who did not develop new high-risk drinking. These results are consistent with the addiction transfer hypothesis postulating that some patients may replace disordered eating with alcohol misuse after sleeve gastrectomy. Graphical abstract Supplementary Information The online version contains supplementary material available at 10.1007/s11695-021-05847-3.

A total of 606 sows (PIC 1050) and their progeny (PIC 1050 × 280) were used to determine if feeding gestating and lactating sows a proprietary strain of Pichia guilliermondii as a whole-cell inactivated yeast product (WCY; CitriStim, ADM Animal Nutrition, Quincy, IL) improves sow and litter performance in a commercial production system. Once confirmed pregnant at d 35 post-breeding pregnancy check, sows were fed a basal gestation control (CON) diet (0.55% SID lysine) or the control diet fortified with 0.15% of the WCY replacing corn in the CON diet. Dietary treatments were also fed in lactation (1.05% SID lysine) once sows were moved into farrowing crates on approximately d 112 of gestation until weaning. Sows supplemented with WCY in gestation and lactation had increased total born piglets by 0.45 pigs (P < 0.04), piglets born alive (14.27 vs. 13.85; P < 0.04), and, therefore, heavier born alive litter weights (P < 0.001) compared to CON fed sows. A greater post cross-foster litter size (P < 0.001) meant that litter size at weaning was increased by 0.54 pigs when sows were fed WCY compared to CON (P < 0.001). However, litter weaning weights and 21-d adjusted litter weaning weights were similar (P > 0.158), although numerically greater, for WCY fed sows. Pigs from CON fed sows were 0.35 kg heavier at weaning compared to pigs from WCY fed sows (P < 0.001). This increase in weaning weight of pigs from CON fed sows is partially explained by their 0.93 d longer lactation (P < 0.001) and may also be due to the smaller litter size throughout lactation. The percent of litters treated for scours decreased from 38.3 to 14.2% when sows were fed WCY (P < 0.001). The distribution of birth and weaning weights was not impacted (P > 0.2461) by treatment. In conclusion, feeding gestating and lactating sows a proprietary strain of Pichia guilliermondii as a whole-cell inactivated yeast product increased the number of pigs born and weaned, and decreased the prevalence of scours during lactation.

Bariatric surgery produces weight loss in part by impacting appetite and eating behavior. Research suggests physical activity (PA) assists with regulation of appetite and eating during non-surgical weight loss, although whether PA carries similar benefits in the context of bariatric surgery is unknown.Evaluate associations of moderate-to-vigorous intensity PA (MVPA) and sedentary time (ST) with appetite sensations (hunger [homeostatic/hedonic], satiety) and eating regulation behaviors (restraint, disinhibition) before and during the initial year following bariatric surgery.Adult bariatric patients received an accelerometer to measure MVPA/ST and a smartphone to complete appetite/eating ratings at four semi-random times daily for 10 days at pre- and 3-, 6-, and 12-months post-surgery. Data were analyzed using generalized linear mixed models.Higher MVPA levels related to more satiety across time (This study is the first to show that MVPA and ST each associate with appetite and eating regulation in daily life before and during post-surgical weight loss. Results, while preliminary and requiring experimental confirmation, highlight potential for targeting bariatric patients' activity behaviors to enhance modulation of appetite, control of food intake, and resistance to overeating.

Operating room (OR) fires are rare but devastating events requiring immediate and effective response. Virtual Reality (VR) simulation training can provide a safe environment for practice of skills in such highly stressful situation. This study assessed interprofessional participants’ ability to respond to VR-simulated OR fire scenarios, attitudes, numbers of attempt of the VR simulation do participants need to successfully respond to OR fires and does prior experience, confidence level, or professional role predict the number of attempts needed to demonstrate safety and pass the simulation. 180 surgical team members volunteered to participate in this study at Beth Israel Deaconess Medical Center, Boston, MA. Each participant completed five VR OR simulation trials; the final two trials incorporated AI assistance. Primary outcomes were performance scores, number of attempts needed to pass, and pre- and post-survey results describing participant confidence and experiences. Differences across professional or training role were assessed using chi-square tests and analyses of variance. Differences in pass rates over time were assessed using repeated measures logistic regression. One hundred eighty participants completed simulation testing; 170 (94.4%) completed surveys. Participants included surgeons (17.2%), anesthesiologists (10.0%), allied health professionals (41.7%), and medical trainees (31.1%). Prior to training, 45.4% of participants reported feeling moderately or very confident in their ability to respond to an OR fire. Eight participants (4.4%) responded safely on the first simulation attempt. Forty-three participants (23.9%) passed by the third attempt (VR only); an additional 97 participants (53.9%) passed within the 4–5th attempt (VR with AI assistance). Providers are unprepared to respond to OR fires. VR-based simulation training provides a practical platform for individuals to improve their knowledge and performance in the management of OR fires with a 79% pass rate in our study. A VR AI approach to teaching this essential skill is innovative, feasible, and effective.

Objective: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities. Background: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers. Methods: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting. Results: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements. Conclusions: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.

Teacher performance pay is often introduced with the goal of reducing gaps in test scores across groups, yet little is known about how well they achieve this aim. We ask, “Do test score-based teacher incentives impact the Black–White test score gap?” Using student–teacher matched data and a difference-in-differences approach in which the performance of a teacher’s students before and after the policy is compared, we find that performance pay increases the conditional Black–White gap. The effect is particularly evident when bonuses are large, consistent with a causal response to performance pay.

STUDY OBJECTIVE To compare the Fundamentals of Laparoscopic Surgery (FLS) exam scores between obstetrics and gynecology (OBGYN) and general surgery (GS) providers. DESIGN This is a retrospective cohort study at a single institution from July 2007 to May 2018. Categorical and continuous variables were analyzed with χ2 test, t test, and Wilcoxon rank sum test. SETTING Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, a tertiary care academic medical center. PATIENTS All providers who took the FLS exam at the Carl J. Shapiro Simulation and Skills Center at BIDMC. INTERVENTIONS FLS certification. MEASUREMENTS AND MAIN RESULTS A total of 205 BIDMC trainees and faculty took the FLS exam between July 2007 and May 2018, of which 176 were identified to be OBGYN or GS providers. The FLS certification pass rate was high for both specialties (97.0% OBGYN vs 96.1% sGS, p = .76). When comparing all providers, no significant difference was found in the mean manual skill test scores between surgical specialties (594.9 OBGYN vs 601.0 GS, p = .59); whereas, a significant difference was noted in the mean cognitive scores, with GS providers scoring higher than OBGYN providers (533.8 OBGYN vs 583.4 GS, p

BACKGROUND: Gastrointestinal symptoms (GIS) are common after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). However, little is known about frequencies of GIS and their co-occurrence with risky eating behaviors. OBJECTIVES: Compare RYGB and SG on GIS and risky eating behaviors, and test associations between GIS and behaviors. SETTING: Two university hospitals in Northeastern United States. METHODS: RYGB (n = 18) and SG (n = 53) patients completed smartphone-based ecological momentary assessment of GIS and risky eating behaviors at 4 semi-random times daily for 10 days preoperatively and at 3, 6, and 12 months postoperatively. Study objectives were evaluated using generalized linear mixed-effects models. RESULTS: All available data from each assessment were included in the analysis: participant attrition was 18%, 30%, and 38% at 3, 6, and 12 months. All GIS were reduced at 12 months postoperative. Bloating decreased consistently whereas cramping, dehydration, and dumping first increased at 3 to 6 months then decreased to 12 months. Diarrhea, nausea, reflux, and vomiting decreased to 12 months for RYGB, but first increased at 3 to 6 months then decreased to 12 months for SG. Consumption of carbonated and sugar-sweetened beverages, fatty meats, and sweets decreased to 6 months then rebounded at 12 months. Eating past the first sign of fullness, drinking liquids with meals, not starting meals with protein, and fried foods consumption decreased to 6 months and then rebounded for RYGB only at 12 months. Alcohol consumption did not change. Sweets consumption and eating past the first sign of fullness were most consistently associated with GIS for both RYGB and SG patients. CONCLUSION: GIS and risky eating behaviors improved postoperatively, although patterns of change were variable and occasionally differed between RYGB and SG. Pending replication, patients may benefit from intervention to limit risky behaviors that are tailored to their surgery type. (Surg Obes Relat Dis 2021;17:475–483.) 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Background Enhancing cognitive load while performing a bimanual surgical task affects performance. Whether repeated training under this condition could benefit performance in an operating room was tested using a virtual reality simulator with cognitive load applied through two-digit math multiplication questions. Method 11 subjects were randomized to Control, VR and VR + CL groups. After a pre-test, VR and VR + CL groups repeated the peg transfer task 150 times over 15 sessions with cognitive load applied only for the last 100 trials. After training, all groups took a post-test and two weeks later the retention test with and without cognitive load and the transfer task on a pig intestine of 150 cm long under cognitive load. Results and conclusion Mixed ANOVA analysis showed significant differences between the control and VR and VR + CL groups (p = 0.013, p = 0.009) but no differences between the VR + CL and the VR groups (p = 1.0). GOALS bimanual dexterity score on transfer test show that VR + CL group outperformed both Control and VR groups (p = 0.016, p = 0.03). Training under cognitive load benefitted performance on an actual surgical task under similar conditions.

How does ethnic diversity within a jurisdiction impact residents’ demand for local public goods? This question is central to the literature on diversity and local spending but remains relatively untested. To fill this gap, we study outcomes from California school district ballot measures to increase school funding. We use an instrumental variable approach to account for endogeneity in diversity. We find no evidence that diversity impacts willingness to be taxed to fund local schools. Our findings suggest that the negative effects of diversity on spending may be occurring through other channels, such as the decision-making of local officials.

BACKGROUND: Bariatric surgery patients spend much of their waking time sedentary. Yet, little is known about their patterns of accumulation of sedentary time (ST) and whether more prolonged ST is associated with lower physical activity (PA), independent of total ST, or obesity severity. OBJECTIVES: To characterize variability in prolonged ST among bariatric patients preoperatively and assess the importance of a “prolonger” pattern in relation to PA and weight status. SETTING: Two university hospital clinics, United States. METHODS: Adult patients (n = 76) wore a wrist-based accelerometer for 10 days preoperatively. ST and time spent in light and moderate-to-vigorous PA was determined using validated thresholds. Percent of total ST accumulated in ≥30-consecutive ST minute bouts was calculated, and participants were trichotomized into low, medium, and high “prolongers” based on this value. The associations of prolonged ST with PA and obesity were examined. RESULTS: On average, participants accumulated a mean ± standard deviation of 10.5 ± 2.1 hours of ST per day, 30% of which was prolonged (prolonger groups: low = 7.2%–24.5%, medium = 24.5%–33.0%, and high = 34.0%–52.6% of ST in ≥30-min bouts). Adjusting for covariates including total ST, high prolongers had fewer light PA minutes per day (P < .01), and a greater percentage of prolonged ST related to lower likelihood of meeting the national guideline of ≥150 moderate-to-vigorous PA minutes per week (P = .012). High (versus low) prolongers had more severe obesity (P < .05). CONCLUSIONS: Accumulating a greater percentage of ST in prolonged bouts appears to be adversely related to PA and obesity severity among bariatric patients. Future research should determine whether interrupting prolonged ST with brief breaks can favorably modify PA and weight in this population. (Surg Obes Relat Dis 2020;16:562–567.) © 2020 American Society for Bariatric Surgery.

Despite an increase in percentage of women entering the surgical field, women tend to favor certain surgical subspecialties. The purpose of this study was to investigate how surgeons advise trainees in pursuit of a surgical career. An 18-question survey was administered to members of the American College of Surgeons through their monthly newsletter NewScope. Respondents were asked to identify subspecialties that they would consider to be most receptive to men or women and how they would advise men and women pursuing a surgical specialty. There were 663 respondents, of which the majority (n = 465, 70.99%) were male. When asked if participants had a role model in medical school, 61.10 per cent had male role models/mentors, whereas only 7.96 per cent had female role models/mentors. Among the 23 surgical subspecialties listed, the top five specialties viewed as receptive for women were breast surgery, obstetrics and gynecology, plastic surgery, ophthalmology, and GS. Surgical specialty and gender of the respondent played a role in how surgeons advised men and women trainees, especially in specialties that traditionally have less female representation. There is inherent gender-based bias in advisement of trainees that may affect surgical specialty choice. Surgeon gender, age, and surgical specialty could be predictors as to how trainees are advised.

Laparoscopic sleeve gastrectomy (LSG) may be complicated by postoperative pain, nausea, and vomiting, with consequent increases in length of stay (LOS), decreased patient satisfaction, and higher costs. While enhanced recovery after surgery (ERAS) protocols have been in circulation for many years, there is no standard ERAS protocol for bariatric surgery. Data were collected prospectively and compared to a historical control. All patients undergoing LSG, ages 18 to 75, were included in the pathway; those with preoperative chronic opioid use were excluded from our results. Statistical analysis was performed using t-statistics and chi-squared test. Ninety patients undergoing LSG, performed by a single surgeon, were included in our ERAS group from November 26, 2018, to April 30, 2019, and were compared to a historical control of 570 patients who underwent LSG over the previous 5 years (pre-ERAS). Measured outcomes included discharge opioid prescriptions issued, hospital length of stay, 30-day readmissions, reoperations, morbidity, and mortality. Ten (11%) ERAS patients vs 100% of pre-ERAS patients received opioid prescriptions upon, or after, discharge (p

Distractions during surgical procedures are associated with team inefficiency and medical error. Little is published about the healthcare provider's perception of distraction and its adverse impact in the operating room. We aim to explore the perception of the operating room team on multiple distractions during surgical procedures.A 26-question survey was administered to surgeons, anesthesia team members, nurses, and scrub technicians at our institution. Respondents were asked to identify and rank multiple distractions and indicate how each distraction might affect the flow of surgery.There was 160 responders for a response rate of 19.18% (160/834), of which 71 (44.1%) male and 82 (50.9%) female, 48 (29.8%) surgeons, 59 (36.6%) anesthesiologists, Certified Registered Nurse Anesthetists (CRNA), and 53 (32.9%) OR nurses and scrub technicians. Responders were classified into a junior group ( 10 years of experience) and a senior group (≥ 10 years). Auditory distraction followed by equipment were the most distracting factors in the operating room. All potential auditory distractions in this survey were associated with higher percentage of certain level of negative impact on the flow of surgery except for music. The top 5 distractors belonged to equipment and environment categories. Phone calls/ pagers/ beepers and case relevant communications were consistently among the top 5 most common distractors. Case relevant communications, music, teaching, and consultation were the top 4 most perceived positive impact on the flow of surgery. Distractors with higher levels of "bothersome" rating appeared to associate with a higher level of perceived negative impact on the flow of surgery. Vision was the least distracting factor and appeared to cause minimal positive impact on the flow of surgery.To our knowledge, this is the first survey studying perception of surgery, anesthesia, and OR staff on various distractions in the operating room. Fewer unnecessary distractions might improve the flow of surgery, improve OR teamwork, and potentially improve patient outcomes.

To examine whether depression status before metabolic and bariatric surgery (MBS) influenced 5-year weight loss, diabetes, and safety/utilization outcomes in the PCORnet Bariatric Study.Research on the impact of depression on MBS outcomes is inconsistent with few large, long-term studies.Data were extracted from 23 health systems on 36,871 patients who underwent sleeve gastrectomy (SG; n=16,158) or gastric bypass (RYGB; n=20,713) from 2005-2015. Patients with and without a depression diagnosis in the year prior to MBS were evaluated for % total weight loss (%TWL), diabetes outcomes, and postsurgical safety/utilization (reoperations, revisions, endoscopy, hospitalizations, mortality) at 1, 3 and 5 years after MBS.27.1% of SG and 33.0% of RYGB patients had preoperative depression, and they had more medical and psychiatric comorbidities than those without depression. At 5 years of follow-up, those with depression, versus those without depression, had slightly less %TWL after RYGB, but not after SG (between group difference = 0.42%TWL, p=0.04). However, patients with depression had slightly larger HbA1c improvements after RYGB but not after SG (between group difference = -0.19, p=0.04). Baseline depression did not moderate diabetes remission or relapse, reoperations, revision, or mortality across operations; however, baseline depression did moderate the risk of endoscopy and repeat hospitalization across RYGB versus SG.Patients with depression undergoing RYGB and SG had similar weight loss, diabetes, and safety/utilization outcomes to those without depression. The effects of depression were clinically small compared to the choice of operation.

The Fundamental Use of Surgical Energy (FUSE) program was developed by The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to promote the safe use of surgical energy. A curriculum that could be used in hospital educational programs was needed to expand access. The goal of this project was to develop a short, inexpensive, online module that emphasizes key FUSE learning objectives. The accompanying survey assessed perceived relevancy.The SAGES FUSE Committee developed the Hospital Compliance Module. The target audience included all OR personnel. The Module was piloted at Beth Israel Deaconess Medical Center. The data were analyzed using Chi-square with Yates' correction two-tailed test.Three-hundred-eighty individuals completed the survey: 198 (52%) surgeons, 139 (37%) nurses, 28 (7%) surgical technicians, and 15 (4%) house staff. For "…the Module taught me valuable information" 155 (41%) responded extremely and 350 (92%) responded at least somewhat. For "As a result of [the Module] how likely are you to change how you set up or use energy devices…?" 103 (27%) responded extremely and 305 (80%) responded at least somewhat. For "How likely are you to recommend this compliance module…?" 143 (38%) responded extremely and 333 (88%) responded at least somewhat.The FUSE Hospital Compliance Module is effective and efficient. It should be considered for widespread distribution by hospitals to enhance staff education.

Background Cardiovascular disease had a global prevalence of 523 million cases and 18.6 million deaths in 2019. The current standard for diagnosing coronary artery disease (CAD) is coronary angiography. Surprisingly, despite well-established clinical indications, up to 40% of the one million invasive cardiac catheterizations return a result of ‘no blockage’. The present studies employed RNA sequencing of whole blood to identify an RNA signature in patients with angiographically confirmed CAD. Methods Whole blood RNA was depleted of ribosomal RNA (rRNA) and analyzed by single-molecule sequencing of RNA (RNAseq) to identify transcripts associated with CAD (TRACs) in a discovery group of 96 patients presenting for elective coronary catheterization. The resulting transcript counts were compared between groups to identify differentially expressed genes (DEGs). Results Surprisingly, 98% of DEGs/TRACs were down-regulated ~ 1.7-fold in patients with mild to severe CAD (> 20% stenosis). The TRACs were independent of comorbid risk factors for CAD, such as sex, hypertension, and smoking. Bioinformatic analysis identified an enrichment in transcripts such as FoxP1, ICOSLG, IKZF4/Eos, SMYD3, TRIM28, and TCF3/E2A that are likely markers of regulatory T cells (Treg), consistent with known reductions in Tregs in CAD. A validation cohort of 80 patients confirmed the overall pattern (92% down-regulation) and supported many of the Treg-related changes. TRACs were enriched for transcripts associated with stress granules, which sequester RNAs, and ciliary and synaptic transcripts, possibly consistent with changes in the immune synapse of developing T cells. Conclusions These studies identify a novel mRNA signature of a Treg-like defect in CAD patients and provides a blueprint for a diagnostic test for CAD. The pattern of changes is consistent with stress-related changes in the maturation of T and Treg cells, possibly due to changes in the immune synapse.

A developmental Bacillus based direct-fed microbial (DFM) was added to nursery pig diets to evaluate the effect on growth and health in two 35-d randomized complete block design experiments blocked on initial BW and sex. Experiment 1 used 315 weaned pigs (20.1 d of age; 6.11 kg initial BW) allotted to one of three diets: 1) Negative Control (NC; no antibiotics but with pharmacological Zn or Cu), 2) NC+DFM 0.55x109CFU, 3) NC+DFM 1.1x109CFU. Experiment 2 used 376 weaned pigs (17.8 d of age; 5.99 kg initial BW) allotted to one of four diets, the same 3 diets from Experiment 1 plus a lower inclusion rate: 4) NC+DFM 0.275x109CFU. Both studies had 15 replicates/treatment, 6–7 pigs/pen. Pigs were budget fed phase 1–3 diets (1.13 kg/pig; 2.72 kg/pig; and 6.35 kg/pig, respectively) and ad libitum fed Phase 4 diet to d35. For Experiment 1, during week 1 pigs fed the DFM tended to linearly decrease ADFI (P = 0.086) and linearly increase G:F (P = 0.085). During day 21–35 of Experiment 1 pigs fed DFM linearly increased ADG (P = 0.035) and quadratically increased ADFI (P = 0.027). Overall for experiment 1, ADG (P = 0.114) and ADFI (P = 0.104) tended to quadratically increase and G:F linearly increased (P = 0.012) with increasing concentrations of DFM. Experiment 2; during week 1 and 3 ADFI (P = 0.084, P = 0.050, respectively) quadratically increased and G:F (P = 0.081; P = 0.022, respectively) quadratically decreased as DFM increased in the diet. During d21–35 of experiment 2, ADG (P = 0.064) quadratically increased and G:F (P = 0.012) quadratically decreased as DFM increased. Overall for Experiment 2 ADFI numerically increased (4.3%) with no increase in ADG, resulting in a quadratic decrease in G:F (P = 0.010) as the DFM increased in the diet. Summarizing these two studies, the DFM product had its greatest effect increasing ADFI while inconsistently impacting gain and efficiency.

Weight loss surgery (WLS) is neither risk-free nor universally effective. Few studies have examined what proportion of patients regret having undergone WLS.We interviewed patients at two WLS centers before and after WLS about weight loss, quality of life/QOL (Impact of Weight on QOL-lite), and decision regret (modified Brehaut Regret scale, range 0-100). We conducted separate multivariable logistic regression models to examine the association between weight loss and ∆QOL scores and having decision regret (score 50).Of 205 RYGB patients, only 2.2% (year 1) to 5.1% (year 4, n = 134) reported regret scores 50 over 4 years; 2.0-4.5% did not think they made the right decision; 2.0-4.5% would not undergo WLS again. In contrast, of 188 gastric banding patients (n = 123 at year 4), 8.2-20.3% had regret scores 50; 5.9-19.5% did not think they made the right decision; 7.1-19.5% would not undergo WLS again. Weight loss and ∆QOL scores were significant correlates of decision regret after banding although weight loss was a stronger correlate with lower model quasi-likelihood under the independence model criterion score. Four years after banding, mean weight loss for patients with regret scores 50 was 7.4% vs. 21.1% for those with scores 50; the AOR for regret score 50 was 0.90 (95% CI 0.87-0.94) for every 1% greater weight loss. Poor sexual function, but not weight loss or other QOL factors, was significantly correlated with decision regret after RYGB.Few patients regret undergoing RYGB but 20% regret undergoing gastric banding with weight loss being a major driver.

A total of 606 sows (PIC 1050) and their progeny (PIC 1050×280) were used to determine if feeding gestating and lactating sows a proprietary strain of Pichia guilliermondi as a whole-cell inactivated yeast product (WCY; CitriStim, ADM Animal Nutrition, Quincy, IL) improves sow and litter performance in a commercial production system. Once confirmed pregnant at d 35 post-breeding pregnancy check, sows were fed either a basal gestation control (CON) diet (0.55% SID Lysine) or the control diet fortified with 0.15% (1.36 kg/ton) of the WCY replacing corn in the CON diet. Dietary treatments were also fed in lactation (1.05% SID Lysine) once sows were moved into farrowing crates on approximately d 112 of gestation until weaning. Sows supplemented with WCY in gestation and lactation had a greater number of total born piglets by 0.45 pigs (P=0.040), born alive (P< 0.04), heavier born alive litter weight (P< 0.001), and greater post cross-foster litter size (P< 0.001) compared to CON fed sows. Litter size at weaning was increased by 0.54 pigs when sows were fed WCY compared to CON (P< 0.001). However, the average piglet weaning weights from CON fed sows were heavier by 0.35 kg compared to WCY (P< 0.001). This increase in body weight of piglets from CON fed sows is partially explained by their 0.93 days longer lactation (P< 0.001), and may also be due to the smaller litter size nursed throughout lactation. The percent of litters treated for scours decreased from 38.3% to 14.2% when sows were fed WCY (P< 0.001). The distribution of birth weights by body weight range was not different (P=0.2461) between treatments. In conclusion, feeding gestating and lactating sows a proprietary strain of Pichia guilliermondi as a whole-cell inactivated yeast product increased the number of piglets born and number weaned as well as decreased the prevalence of scours during lactation.

Forty-seven sows and their progeny were used to determine if feeding gestating and lactating sows a Bacillus licheniformis direct-fed microbial (DFM), an organic acid blend of medium chain and short chain fatty acids (OA), or in combination improves sow lactation feed and water intake, litter growth, and subsequent reproductive performance. On approximately d80 of gestation, sows were fed one of four diets in a 2 x 2 factorial design: 1) gestation control (CON; 0.55% SID Lysine), 2) CON with DFM (1.6x109 CFU/kg of complete feed), 3) CON with 0.4% OA, 4) CON with both DFM and OA. Dietary treatments were also fed throughout lactation (1.00% SID Lysine) starting on approximately d112 of gestation when sows entered farrowing facility. There was a tendency (P = 0.079) for DFM to decrease the amount of sow body weight loss in lactation by approximately 6% compared to sows not consuming the DFM, likely related to DFM sows numerically (P = 0.124) consuming 8.4% more feed during d7-14 of lactation. Sows fed the OA diets had fewer mummies/litter (P = 0.038) compared to diets not containing OA. Sows fed diets with the DFM gave birth to lighter pigs born alive (P = 0.003) compared to non-DFM fed sows, and a tendency for an interaction (P = 0.092) existed where feeding OA+DFM lessened the decrease in born alive BW. There was an interaction tendency (P = 0.133) where sows fed DFM returned to estrus 22 hours sooner than CON, but only 8 hours sooner when sows were fed the OA+DFM diet. In conclusion, feeding a Bacillus licheniformis DFM to sows may decrease pig born alive weight but reduce sow BW loss through 6.4% more lactation feed intake, quickening the return to estrus. Feeding the OA alone or in combination did not improve sow reproductive and litter growth performance in this study, and may require a larger sample size.

Purpose Over the past decade, an increasing number of bariatric surgeons are trained in fellowships annually despite only a modest increase in nationwide bariatric surgery volume. The study surveys the bariatric surgery job market trend in order to inform better career-choice decisions for trainees interested in this field. Materials and Methods A national retrospective cohort survey over an 11-year period was conducted. Bariatric surgery fellowship graduates from 2008 to 2019 and program directors (PDs) were surveyed electronically. Univariate analysis was performed comparing responses between earlier (2008–2016) and recent graduates (2017–2019). Results We identified a total of 996 graduates and 143 PDs. Response rates were 9% and 20% respectively (n = 88, 29). Sixty-eight percent of graduates felt there are not enough bariatric jobs for new graduates. Seventy-nine percent of PDs felt that it is more difficult to find a bariatric job for their fellows now than 5–10 years ago. Forty-eight percent of PDs felt that we are training too many bariatric fellows. Seventy-seven percent of all graduates want the majority of their practice to be comprised bariatric cases; however, only 42% of them reported achieving this. In the univariate analysis, recent graduates were less likely to be currently employed as a bariatric surgeon (64% vs. 86%, p = 0.02) and were less satisfied with their current case volume (42% vs. 66%, p = 0.01). Conclusions The temporal increase in bariatric fellowship graduates over the past decade has resulted in a significant decline in the likelihood of employment in a full-time bariatric surgical practice and a decline in surgeons’ bariatric case volumes.

OBJECTIVE Laparoscopic Roux-en-Y gastric bypass (RYGB) modulates the low-grade inflammatory state associated with severe obesity. This study sought to investigate whether weight loss is causally implicated with changes in serum levels of inflammatory molecules. METHODS Using the largest genome-wide association study (n = 1,020 individuals), this study curated five genetic variants associated with weight loss following RYGB. Phenome-wide association studies (PheWAS) were performed to identify other phenotypes associated with these variants. Subsequently, two-sample Mendelian randomization was used to study the causal effects of weight loss on the serum levels of 382 inflammatory proteins (measured in 3,033 individuals). This is the first systematic quasi-experimental investigation of weight loss following RYGB and serum markers of inflammation. RESULTS The PheWAS analysis revealed that four of the five variants are associated with phenotypes relating to metabolism and inflammation, including insulin response and levels of C-reactive protein. Two-sample Mendelian randomization of the 382 serum inflammatory markers revealed that weight loss following RYGB increases serum levels of interleukin 22 (IL-22) (beta = 0.021, P

BACKGROUND: Valid methods for providing detailed formative feedback on direct laryngoscopy and endotracheal intubation (ETI) performance do not exist. We are developing an observation-based assessment tool for measuring performance and providing feedback during ETI. METHODS: Based on the literature and interviews of experts, we proposed an initial ETI metric with 22 items. Six anesthesiology experts used it to assess the quality of ETI performance in videotaped intubations. Following metric revisions, 2 expert groups assessed 2 collections of videos (27 total) using the revised metric. Two reference standards for comparison with metric scores were created with a third and fourth group of experts; (1) an average global rating (1–100) of each ETI performance and (2) average rank-ordered performance from best to worst. Rater agreement and correlations between the 2 methods were calculated. Regression analysis determined items that optimally discriminated quality. When calculating a score based on all clinically important terms, multiple weightings were evaluated. RESULTS: Metric items had high average rater agreement (80%) with intraclass correlation coefficients averaging 0.83. Correlations of the reference rank and score were high for both video collections (−0.96, P < .05, and −0.95, P < .05). Regression coefficients for different item weighting methods indicated strong relationships with global ratings (averaging r = 0.89, P < .05) and rankings averaging −0.85, P < .05). Prediction of global ratings using regression achieved high accuracy (R(2) = 0.8218). CONCLUSIONS: High observer agreement and strong correlations between metric and rank data support the validity of using this metric to assess ETI performance. Different weighting models yielded scores that correlated strongly with the ratings and ranks from global assessment. When using the metric to predict competency, a 3-item regression model is most accurate in predicting a global score.

School closings displace thousands of teachers in the U.S. every year. This paper explores how elementary school teachers in North Carolina respond to this labor market shock. After documenting that declining enrollment is a key driver of school closings in our study, we find that while most displaced teachers move to new schools in the same district, a considerable share leave public education altogether. We find that the increase in the propensity to leave teaching is largest for experienced teachers. It is also marginally larger for the highest and lowest value-added teachers compared to teachers in the middle of the value-added distribution, and, strikingly, twice as large for black teachers than white teachers even from the same closing school. Moving schools after a school closing has no impact on teacher effectiveness as measured by value-added. Although the primary goal of school closings is typically to move students out of declining or failing schools, school closings also affect the overall distributions of important teacher characteristics such as experience, race, and effectiveness in raising test scores. [The effect of school closings on teacher labor market outcomes and teacher effectiveness. Education Finance and Policy p1-55 (2020)]2020Education Finance and Policy10.1162/edfp_a_00317. Deposited by shareyourpaper.org and openaccessbutton.org. We've taken reasonable steps to ensure this content doesn't violate copyright. However, if you think it does you can request a takedown by emailing help@openaccessbutton.org.

Background This study sought to determine the long-term impact of multidisciplinary simulated operating room (OR) team training. Method Two-wave survey study (immediate post-training survey 2010–2017, follow-up 2018). Differences across time, specialty, and experience with adverse events were assessed using chi-square and t -tests. Results Immediately after training, more than 90% of respondents found simulation scenarios realistic and reported team training would provide safer patient care. However, follow-up participants reported less enthusiasm toward training, with 58% stating they would like to take similar training again. A majority of participants (77%) experienced adverse events after training; those reporting adverse events reported more positive long-term evaluations. Conclusions Simulated OR team training is initially highly valued by participants and is perceived as contributing to patient safety. Diminution of participant enthusiasm over time suggests that repeat training requirements be reconsidered, and less costly, alternative methods (such as asynchronous learning or virtual reality) should be explored.