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Surgery Morbidity and Mortality (MM) presentations include a thorough literature review. This requires a significant amount of time expenditure frequently incompatible with the current surgical resident work hours. Additionally, literature reviews can be redundant for commonly encountered adverse events. The goal of this study was to explore (a) how surgery residents perform literature reviews, and (b) how repetitive presented adverse events are.A survey was sent out during the academic year 2019-2020. The Morbidity and Mortality repository for that academic year was indexed, and the proportion of adverse events having occurred more than once calculated. The amount of time spent on literature reviews, proportion of repetitive adverse events as well as degree of thoroughness of reviews was evaluated on a 1 to 5 Likert scale.Tulane University General Surgery program, New Orleans, LA, USA.All clinically active residents.All residents, filled out the survey. Seventeen out of 29 (58.6%) residents reported dedicating approximately one hour performing literature reviews. Median studying time was 1 hour (interquartile range: 1-1.5 hours). Seventeen out of 29 (58.6%) residents employed 2 resources. The most common combination of resources was PubMed and Google (11/29, 37.9%). Most residents (21/29, 72.4%) believed that their thoroughness was at most average (≤3/5 on a Likert scale) and 27/29 (93.1%) believed that their literature review could have been more thorough. More than half of the adverse events presented were found to be redundant during that academic year.Time spent reviewing the literature does not allow for a thorough review, and a significant portion of adverse events presented are redundant. A central repository for literature reviews of adverse events would improve the quality of reviews and avoid duplicating efforts.

Bariatric surgery has demonstrated sustained improvements in quality. Malpractice closed claims have been offered as a means of assessing quality. Few studies have investigated malpractice closed claims and opportunities for improvement in bariatric surgery.To examine the prevalence and causes of malpractice claims with examination of prospects for quality improvement.University hospital, United States; private practice.Four national malpractice insurers participated in the closed-claims registry. Data regarding patients, staff, procedures, and hospital status were gathered from closed-claims files. Following data collection, a clinical summary of each closed claim was collected and later assessed by an expert panel on the basis of the following: contributing diagnosis and treatment events; whether complications were potentially preventable by the surgeon; the role of language, fatigue, distraction, workload, or teaching hospital/trainee supervision; communication concerns; and final care determination.A total of 175 closed claims were collected from index bariatric surgeries within the period from 2006-2014. Of these, 75.9% of surgeons were board certified and 43.3% of the hospitals were accredited for bariatric surgery. Most clinical complications after bariatric surgery that led to malpractice lawsuits were mortality (35.1%) and leaks (17.5%). While they were not the common cause for malpractice suits, bleeding (5.3%), retained foreign body (5.3%), and vascular injury (4.4%) occurred at higher rates than national averages.Prevalence of malpractice claims regarding bariatric surgery is low. Failure to diagnose, delay in treatment, postoperative care, and communication domain responses indicate future opportunities for improvement.

Circulating micronutrient levels of both serum copper and zinc have been studied to varying degrees in both the general public and patients having undergone bariatric surgery. According to the 2019 ASMBS clinical guidelines, copper supplementation is recommended for patients undergoing metabolic surgery, especially after Roux-en-Y gastric bypass and duodenal switch. Copper excess has not been previously reported to any significant degree in any population. In this study, we investigate an elevated serum copper level in the pre-surgical intervention population of the Bariatric Center of the University Medical Center–New Orleans, a primary safety net hospital for the state of Louisiana. Five hundred five consecutive patients from the bariatric surgery undergoing a workup for surgical intervention were assessed. Patients were included regardless of whether they proceeded to surgery. The study was conducted as a retrospective review of deidentified data that was collected as part of our routine workup for bariatric surgery. The study population of the clinic consisted of a mean BMI of approximately 50 kg/m2, with 91% of the population reporting female and 69% recording an African American race. It was discovered in this population that 26% of the patients had an elevated copper level of > 155 mcg/dl. Additional analysis was performed attempting to elucidate an environmental role in the elevation by qualitative analysis of patient’s location of residence using reported home address. Additional variables were studied as well including serum zinc concentration, age, BMI, and race to address any correlative variables with our findings. This study identifies an elevated serum copper concentration in a pre-intervention underserved bariatric center population positively associated with BMI, female gender, and African American race. Additional studies will be necessary to see if these trends are also apparent in normal weight controls, or if weight loss influences copper levels. Pre-existing serum copper deficiencies may be more prevalent in the bariatric populations than previously believed. Increased serum copper in this population was positively associated with increased BMI, age, and female gender compared to that of the male group. Increased serum copper was also associated more closely with African American ethnicity compared to Caucasian patients.

Background In view of reported associations between high adiposity, particularly in midlife and late-life dementia risk, we aimed to determine associations between body mass index (BMI), and BMI changes across adulthood and brain structure and pathology at age 69–71 years. Methods Four hundred sixty-five dementia-free participants from Insight 46, a sub-study of the British 1946 birth cohort, who had cross-sectional T1/FLAIR volumetric MRI, and florbetapir amyloid-PET imaging at age 69–71 years, were included in analyses. We quantified white matter hyperintensity volume (WMHV) using T1 and FLAIR 3D-MRI; β-amyloid (Aβ) positivity/negativity using a SUVR approach; and whole brain (WBV) and hippocampal volumes (HV) using 3D T1-MRI. We investigated the influence of BMI, and BMI changes at and between 36, 43, 53, 60–64, 69 and 71 years, on late-life WMHV, Aβ-status, WBV and mean HV. Analyses were repeated using overweight and obese status. Results At no time-point was BMI, change in BMI or overweight/obese status associated with WMHV or WBV at age 69–71 years. Decreasing BMI in the 1–2 years before imaging was associated with an increased odds of being β-amyloid positive (OR 1.45, 95% confidence interval 1.09, 1.92). There were associations between being overweight and larger mean HV at ages 60–64 (β = 0.073 ml, 95% CI 0.009, 0.137), 69 (β = 0.076 ml, 95% CI 0.012, 0.140) and 71 years (β = 0.101 ml, 95% CI 0.037, 0.165). A similar, albeit weaker, trend was seen with obese status. Conclusions Using WMHV, β-amyloid status and brain volumes as indicators of brain health, we do not find evidence to explain reported associations between midlife obesity and late-life dementia risk. Declining BMI in later life may reflect preclinical Alzheimer’s disease.

Circulating micronutrient levels of both serum copper and zinc have been studied to varying degrees in both the general public and patients having undergone bariatric surgery. According to the 2019 ASMBS clinical guidelines, copper supplementation is recommended for patients undergoing metabolic surgery, especially after Roux-en-Y gastric bypass and duodenal switch. Copper excess has not been previously reported to any significant degree in any population.In this study, we investigate an elevated serum copper level in the pre-surgical intervention population of the Bariatric Center of the University Medical Center-New Orleans, a primary safety net hospital for the state of Louisiana.Five hundred five consecutive patients from the bariatric surgery undergoing a workup for surgical intervention were assessed. Patients were included regardless of whether they proceeded to surgery. The study was conducted as a retrospective review of deidentified data that was collected as part of our routine workup for bariatric surgery.The study population of the clinic consisted of a mean BMI of approximately 50 kg/mThis study identifies an elevated serum copper concentration in a pre-intervention underserved bariatric center population positively associated with BMI, female gender, and African American race. Additional studies will be necessary to see if these trends are also apparent in normal weight controls, or if weight loss influences copper levels. Pre-existing serum copper deficiencies may be more prevalent in the bariatric populations than previously believed. Increased serum copper in this population was positively associated with increased BMI, age, and female gender compared to that of the male group. Increased serum copper was also associated more closely with African American ethnicity compared to Caucasian patients.

The Wide-Field Infrared Transient Explorer (WINTER) is a new infrared time-domain survey instrument which will be deployed on a dedicated 1 meter robotic telescope at Palomar Observatory. WINTER will perform a seeing-limited time domain survey of the infrared (IR) sky, with a particular emphasis on identifying r-process material in binary neutron star (BNS) merger remnants detected by LIGO. We describe the scientific goals and survey design of the WINTER instrument. With a dedicated trigger and the ability to map the full LIGO O4 positional error contour in the IR to a distance of 190 Mpc within four hours, WINTER will be a powerful kilonova discovery engine and tool for multi-messenger astrophysics investigations. In addition to follow-up observations of merging binaries, WINTER will facilitate a wide range of time-domain astronomical observations, all the while building up a deep coadded image of the static infrared sky suitable for survey science. WINTER's custom camera features six commercial large-format Indium Gallium Arsenide (InGaAs) sensors and a tiled optical system which covers a $>$1-square-degree field of view with 90% fill factor. The instrument observes in Y, J and a short-H (Hs) band tuned to the long-wave cutoff of the InGaAs sensors, covering a wavelength range from 0.9 - 1.7 microns. We present the design of the WINTER instrument and current progress towards final integration at Palomar Observatory and commissioning planned for mid-2021., Published in SPIE Astronomical Telescopes + Instrumentation 2020, Ground-based and Airborne Instrumentation for Astronomy VIII 14 pages, 7 figures

The Wide-field Infrared Transient Explorer (WINTER) is a 1x1 degree infrared survey telescope under development at MIT and Caltech, and slated for commissioning at Palomar Observatory in 2021. WINTER is a seeing-limited infrared time-domain survey and has two main science goals: (1) the discovery of IR kilonovae and r-process materials from binary neutron star mergers and (2) the study of general IR transients, including supernovae, tidal disruption events, and transiting exoplanets around low mass stars. We plan to meet these science goals with technologies that are relatively new to astrophysical research: hybridized InGaAs sensors as an alternative to traditional, but expensive, HgCdTe arrays and an IR-optimized 1-meter COTS telescope. To mitigate risk, optimize development efforts, and ensure that WINTER meets its science objectives, we use model-based systems engineering (MBSE) techniques commonly featured in aerospace engineering projects. Even as ground-based instrumentation projects grow in complexity, they do not often have the budget for a full-time systems engineer. We present one example of systems engineering for the ground-based WINTER project, featuring software tools that allow students or staff to learn the fundamentals of MBSE and capture the results in a formalized software interface. We focus on the top-level science requirements with a detailed example of how the goal of detecting kilonovae flows down to WINTER's optical design. In particular, we discuss new methods for tolerance simulations, eliminating stray light, and maximizing image quality of a fly's-eye design that slices the telescope's focus onto 6 non-buttable, IR detectors. We also include a discussion of safety constraints for a robotic telescope., Comment: Published in SPIE Astronomical Telescopes + Instrumentation 2020, Ground-based and Airborne Instrumentation for Astronomy VIII. 12 pages, 9 figures

Study purpose: Little information exists on the cause of injury for patients who are treated and discharged from emergency departments; these patients comprise approximately 90% of all injured patients requiring medical care. A method is described to assign external cause of injury codes (E codes) prospectively to all injured patients seen in a large-volume ED. Methods: E code assignment was performed by the ED triage nurses on entrance to the ED. A checklist was used that contained frequently occurring codes as identified in a pilot study. E codes were entered into the patients' records on the hospital mainframe computer by a medical records technician. These were acquired for a nine-month period to determine feasibility, accuracy, and ease of use. Accuracy was verified retrospectively. Results: During the nine-month period, 67,495 patients were treated. Acute injury accounted for 16,186 of the visits, and 2,085 were return visits for a previously treated injury. The majority of patients with any injury type were treated and discharged and would not have been included in traditional data sets of injured patients. Overall admission rate for injury was 13%. Accuracy of prospectively assigned E codes was 98%, and this method of assigning E codes resulted in no additional effort by the triage nurse. Conclusion: E coding is a valuable method for injury surveillance, easily performed in EDs with high volume. Its value is essential for injury prevention research on injuries from any cause.

Mine Safety Appliances Company (MSA) designs hermetically sealed, lithium-ion cells designed specifically for applications where high quality, high reliability and long cycle life are essential. The primary market for MSA's cells is aerospace, although other equally demanding applications are envisioned. The lithium- ion system has excellent charge retention to maximize readiness, zero memory effect to extend cycle life, and a three-to- one voltage advantage over nickel- hydrogen and nickel-cadmium battery technologies. Such benefits for the lithium-ion system outweigh initial higher costs and the need for more stringent

In response to the Navy's requirement for a lighter, higher capacity, secondary battery, Mine Safety Appliances (MSA) Company designed and built an experimental lithium-ion "drop-in" replacement battery for demonstration of its performance in the Pioneer aircraft. Lithium ion technology using a lithiated cobalt dioxide positive electrode, graphitized carbon negative electrode and liquid organic electrolyte has demonstrated a significant enhancement in performance over other rechargeable systems such as nickel-cadmium and nickel-metal hydride in comparable applications. Key features of the lithium ion system include higher gravimetric and volumetric energy densities, good charge retention (to maximize readiness), and zero memory effect. Such benefits outweigh a higher unit cost and the need for more stringent charge/discharge control. Design of the cells and battery, and preliminary battery test results are described.

This article examines a recently implemented strategy to transfer responsibility for local public health service delivery from a county health department to a hospital-based integrated delivery system. Innovative quality management efforts at both local and state levels offer opportunities for sustained improvement in the availability and adequacy of public health services under this arrangement.

OBJECTIVE: The authors studied the results of laparoscopic colectomies performed by a surgical team on 80 consecutive patients and compared these results with standard open colectomies. METHODS: Eight consecutive laparoscopic-assisted colectomies were performed by Norfolk Surgical Group in a 14-month period and compared to 53 patients who had a conventional open colectomies. Analysis included indications for surgery, types of procedure, complications, incidence and causes for conversion, length of procedure, duration of postoperative ileus, hospital stay, operating room and total hospital charges, and examination of the pathologic specimens. RESULTS: Many different types of colectomies were performed successfully and safely for a variety of surgical indications. The conversion rate was 22.5%, which decreased to 15% in the second half of the series. Complications in patients who underwent laparoscopic operations were not severe in number of type. The length of the operative procedure, operating room charge, and the total hospital charge were greater for patients undergoing laparoscopic-assisted colectomies. Patients who underwent laparoscopic operations had a shorter period of postoperative ileus and less pain, resumed a regular diet sooner, and were discharged from the hospital sooner than patients who underwent open colectomies. There was no significant difference in the pathology specimens obtained by laparoscopic-assisted colectomies compared with conventional open colectomies for length of specimen, surgical margins, and number of lymph nodes retrieved. CONCLUSIONS: This study indicated that laparoscopic techniques can be applied safely and effectively to a broad range of colonic operations. Laparoscopic-assisted colectomies take longer to perform and are more costly, but are associated with less paralytic ileus, less pain, and reduced hospital stay. Laparoscopic colectomies for the treatment of malignancy are achievable technically, but will require careful long-term study.

Social responsibility is a concept often used to describe how large corporations, or even small businesses, should “give back” something to the communities that they serve. We feel the same is true when it comes to faculty members. Oftentimes, the greatest expertise in a given subject area in a community is housed within the confines of the faculty members of the local college or university and such knowledge and expertise can be shared in a plethora of venues as part of the “service” component of their annual evaluation. Our paper sets forth an example of such faculty involvement in an attempt to improve the decision-making of our incoming students and, as a result, the overall community by providing a presentation to our Freshman Seminar courses on the legal ramifications of poor decision-making as they begin to manage their newfound freedom of choices. In our paper, we point out the pedagological system that we use to emphasize the importance of making the right choices for now, which will clearly have a direct effect upon their future.

Inclusion of vagotomy and pyloroplasty in the surgical treatment of gastroesophageal reflux associated with hiatal hernia has long been controversial. To evaluate the morbidity of vagotomy in the treatment of reflux esophagitis, a retrospective study of 311 patients treated by the Hill posterior gastropexy technique of hiatal hernia repair was tabulated. Vagotomy with the anti-reflux operation was performed upon 159 patients (51%). Vagotomy was not included for 152 patients (49%). The incidence of postoperative symptoms with or without vagotomy was almost equally divided--41% without vagotomy and 47% with vagotomy. However, the major postoperative symptoms that occurred in both groups were abdominal cramps and bloating which usually disappeared in the early postoperative period and were attributed to the anti-reflux procedure and not to vagotomy. When vagotomy was included with the anti-reflux operation, the incidence and duration of long term, disabling postoperative symptoms were significantly increased. Diarrhea occurred two times more frequently. Nausea and vomiting occurred ten times more frequently and dumping was present only in vagotomized patients. Long term postoperative symptoms, judged on a basis of symptoms lasting longer than three months duration, occurred in 1% of patients without vagotomy and 26% when vagotomy was included. This study revealed that no additional protection against recurrent symptoms of gastroesophageal reflux or radiographic evidence of recurrent hiatal hernia was provided by inclusion of vagotomy. In conclusion, vagotomy is contraindicated in the treatment of gastroesophageal reflux except in the presence of peptic ulcer disease.

Conditions are given which imply the convergence to zero of solutions of the second order damped nonlinear ordinary differential equation \[ \left( r(t)u'\right) ' + \phi \left( t,u,u'\right) u' + p(t)f(u) = h\left( t,u,u'\right) \]. In the case when $h = 0$, the uniform stability and uniqueness of the zero solution on the ray $[ 0,\infty )$ are also established. The proofs are based on the construction of Lyapunov functions.

• This work represents a 12-year experience from the Eastern Virginia Medical School, Norfolk, with 115 patients who had pharyngoesophageal resections for cancer treatment. Each patient received reconstruction by one of four major techniques: deltopectoral flaps (n = 43), pectoralis myocutaneous flaps (n = 36), gastric pull-ups (n = 19), and free jejunal autografts (n = 17). An analysis of the procedures with emphasis on the functional results indicates that each technique has advantages in specific circumstances. Guidelines for the application of these techniques are presented. ( Arch Otolaryngol Head Neck Surg 1987;113:40-44)

The latissimus dorsi myocutaneous flap is a remarkably durable and versatile flap. Flap necrosis did not occur in any of our patients. One can safely carry with it skin segments as narrow as 3 cm, or as wide as 30 cm. In addition to the 5 cases presented, we have used the flap to repair axillary burn contractures, for breast reconstruction after a transverse incision, and for coverage of the upper arm and shoulder. The applications of this flap challenge the creative imagination of the surgeon and allow a simplified reconstruction, compared to other good methods. The newly described posterior advancement of a latissimus dorsi myocutaneous flap is suggested as the preferred method to repair meningomyelocele defects.

Conditions are given on the functions p, q, $\phi $, and g which imply that all continuable solutions of \[ u'' + q( t )\phi ( {u,u'} ) + p( t )u^\alpha g( {u'} ) = 0 \] are oscillatory on the ray $[ {0,\infty } )$ when $\alpha > 0$ is the quotient of odd integers and $\alpha \ne 1$. When $q = 0$ and $g = 1$, these theorems reduce to the well-known sufficiency theorems of Atkinson and Belohorec.

Thirty-eight delinquency-prone adolescent males (school drop outs) were compared with 45 in-school adolescent males on 10 personality variables as measured by the Jesness Inventory. Age, IQ, and geographical location were controlled. Data was col lected in a specific metropolitan area showing a significantly high delinquency rate. Analysis of variance shows a significant interaction between these groups and the personality variables. Results show the delinguency-prone group to be significantly (p < .01) more Immature and Repressive, less Affective and Socially Anxious than the controls. An additional comparison with an institutionalized population permits some speculation as to patterning effects of personality variables over the three groups.