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Background: Laparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed., Study Design: PubMed, EMBASE, and SCOPUS databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions tool. Assessed outcomes included intra- and postoperative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random-effects model to report odds ratio (OR) and 95% CIs and continuous data to report mean difference and 95% CIs., Results: Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic and 168,335 laparoscopic patients) studies assessed HHR outcomes, whereas 9 (2,384 robotic and 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a nonsignificantly shorter length of hospital stay (LOS) (mean difference -0.41, 95% CI -0.87 to -0.05), fewer conversions to open (OR 0.22, 95% CI 0.03 to 1.49), and lower morbidity rates (OR 0.76, 95% CI 0.47 to 1.23). Robotic HM led to significantly fewer esophageal perforations (OR 0.36, 95% CI 0.15 to 0.83), reinterventions (OR 0.18, 95% CI 0.07 to 0.47) a nonsignificantly shorter LOS (mean difference -0.31, 95% CI -0.62 to 0.00). Both robotic HM and HHR had significantly longer operative times., Conclusions: Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the 2 methods, given the low-to-moderate quality of included studies., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Integrating artificial intelligence (AI) into healthcare prompts the need to measure its proficiency relative to human experts. This study evaluates the proficiency of ChatGPT, an OpenAI language model, in offering guidance concerning bariatric surgery compared to bariatric surgeons. Five clinical scenarios representative of diverse bariatric surgery situations were given to ASMBS-accredited bariatric surgeons and ChatGPT. Both groups proposed medical or surgical management for the patients depicted in each scenario. The outcomes from both the surgeons and ChatGPT were examined and matched with the clinical benchmarks set by the American Society for Metabolic and Bariatric Surgery (ASMBS). There was a high degree of agreement between ChatGPT and physicians on the three simpler clinical scenarios. There was a positive correlation between physicians' and ChatGPT answers for not recommending surgery. ChatGPT's advice aligned with ASMBS guidelines 60% of the time, in contrast to bariatric surgeons, who consistently aligned with the guidelines 100% of the time. ChatGPT showcases potential in offering guidance on bariatric surgery, but it does not have the comprehensive and personalized perspective that doctors exhibit consistently. Enhancing AI's training on intricate patient situations will bolster its role in the medical field.

Achalasia is a neurodegenerative disorder affecting esophageal sphincter function. Treatment options include non-surgical and surgical approaches, such as Heller myotomy (HM). Combining Dor fundoplication with HM is controversial but may prevent gastroesophageal reflux disease (GERD). This retrospective cohort study aimed to assess whether HM with Dor fundoplication reduces GERD rates and increases dysphagia rates. Eighty patients who underwent HM between January 2018 and August 2023 were included. Sixty-four patients had Dor fundoplication and were matched 4:1 to 16 patients without fundoplication. Records were reviewed for GERD and achalasia symptoms at various postoperative time points. No significant differences in GERD or dysphagia symptoms were found between the two groups at any time point. Similarly, there were no significant differences in chest pain or dysphagia treatment. In conclusion, this study suggests that the addition of Dor fundoplication to HM does not significantly impact postoperative GERD or achalasia-related symptoms., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Dermatology remains highly competitive, with strong USMLE Step 1 scores traditionally crucial for securing residency positions. The 2023-2024 cycle introduced significant changes, including pass/fail USMLE Step 1 score reports and an expanded program signaling system. This study explores dermatology residency applicant profiles within this new context. A survey of 2023-2024 dermatology applicants was conducted via social media to gather demographic and application data. A total of 63 survey responses were collected: 74.6% matched and 25.4% unmatched. The racial distribution was 54% White/Caucasian, 25.4% Asian/Pacific Islander, 9.5% Black/African American, 4.8% Hispanic/Latino, and 6.3% other. The median USMLE Step 2 score was 257 (215-277). Racial differences in USMLE Step 2 scores were significant (P = 0.031), but did not affect match rates (P = 0.116). Letters of recommendation from dermatology program directors were linked to lower match rates (P = 0.036). A positive correlation was found between the number of audition rotations completed and matching at such programs (r²=0.817). Of all matched respondents, 46.8% matched to a program they did not signal; of these, 50.0% matched to a program at which they completed an audition rotation and 40.9% to their home dermatology program affiliation. The mean number of interviews was 8.02, with matched applicants receiving more invitations than unmatched applicants (9.02 vs. 5.06, P = 0.002). The shift to pass/fail USMLE Step 1 scores and expanded program signaling did not notably affect the median USMLE Step 2 score from prior years or match rates among underrepresented minorities. Success in matching continues to depend on a holistic evaluation., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Objectives: Artificial intelligence (AI), such as ChatGPT and Bard, has gained popularity as a tool in medical education. The use of AI in family medicine has not yet been assessed. The objective of this study is to compare the performance of three large language models (LLMs; ChatGPT 3.5, ChatGPT 4.0, and Google Bard) on the family medicine in-training exam (ITE)., Methods: The 193 multiple-choice questions of the 2022 ITE, written by the American Board of Family Medicine, were inputted in ChatGPT 3.5, ChatGPT 4.0, and Bard. The LLMs' performance was then scored and scaled., Results: ChatGPT 4.0 scored 167/193 (86.5%) with a scaled score of 730 out of 800. According to the Bayesian score predictor, ChatGPT 4.0 has a 100% chance of passing the family medicine board exam. ChatGPT 3.5 scored 66.3%, translating to a scaled score of 400 and an 88% chance of passing the family medicine board exam. Bard scored 64.2%, with a scaled score of 380 and an 85% chance of passing the boards. Compared to the national average of postgraduate year 3 residents, only ChatGPT 4.0 surpassed the residents' mean of 68.4%., Conclusions: ChatGPT 4.0 was the only LLM that outperformed the family medicine postgraduate year 3 residents' national averages on the 2022 ITE, providing robust explanations and demonstrating its potential use in delivering background information on common medical concepts that appear on board exams.

Background: Hepatitis C (HCV) infection affects more than 2.2 million people in the United States and is associated with liver cirrhosis and gallstone formation. However, cholecystectomy outcomes of patients with and without HCV infection are not well studied. This study aimed to examine the differences in cholecystectomy outcomes among patients with untreated, treated, and no HCV infection history., Methods: A retrospective cohort study was conducted at a single institution that included data of more than 12 years. Patients were excluded if they had a previous chronic hepatitis B or HIV diagnosis. Patients without HCV infection were matched to patients with HCV infection based on age, sex (male or female), and race/ethnicity., Results: This study identified 66 patients with untreated HCV infection and 33 patients with treated HCV infection. Furthermore, 324 patients without HCV infection were matched to the cohort HCV infection. The overall postoperative complication rate was 10.9%. There was no statistically significant difference in postoperative complication rates between the groups (P = .71). There was no significant difference in the level of intervention required to treat these complications according to the Clavien-Dindo classification (P = .97), postoperative intensive care unit admission (P = .43), or reoperation rate (P = .45)., Conclusion: Despite having a longer mean length of stay and increased risk of intraoperative blood product transfusion, both patients with untreated HCV infection and those with treated HCV infection had similar rates of postoperative complications and complication severity compared with controls. Our findings suggest that patients with HCV infection tolerate cholecystectomy at a comparable level to patients without HCV infection. The lack of difference in postoperative complication rates between patients with untreated and treated HCV infection indicates that lack of antiviral treatment should not delay cholecystectomy., (Published by Elsevier Inc.)

Background: Artificial intelligence (AI)-generated explanations about medical topics may be clearer and more accessible than traditional evidence-based sources, enhancing patient understanding and autonomy. We evaluated different AI explanations for patients about common diagnoses to aid in patient care., Methods: We prompted ChatGPT 3.5, Google Bard, HuggingChat, and Claude 2 separately to generate a short patient education paragraph about seven common diagnoses. We used the Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) to evaluate the readability and grade level of the responses. We used the Agency for Healthcare Research and Quality's Patient Education Materials Assessment Tool (PEMAT) grading rubric to evaluate the understandability and actionability of responses., Results: Claude 2 demonstrated scores of FRE (67.0), FKGL (7.4), and PEMAT, 69% for understandability, and 34% for actionability. ChatGPT scores were FRE (58.5), FKGL (9.3), PEMAT (69% and 31%, respectively). Google Bard scores were FRE (50.1), FKGL (9.9), PEMAT (52% and 23%). HuggingChat scores were FRE (48.7) and FKGL (11.6), PEMAT (57% and 29%)., Conclusion: Claude 2 and ChatGPT demonstrated superior readability and understandability, but practical application and patient outcomes need further exploration. This study is limited by the rapid development of these tools with newer improved models replacing the older ones. Additionally, the accuracy and clarity of AI responses is based on that of the user-generated response. The PEMAT grading rubric is also mainly used for patient information leaflets that include visual aids and may contain subjective evaluations., (© 2024 by the Society of Teachers of Family Medicine.)

Background: A common postoperative challenge following implant-based breast reconstruction surgery is lateral or inferior displacement of the implant, which ultimately requires surgical intervention to shape the pocket for improved symmetry. Capsulorrhaphy is traditionally performed with smooth sutures, but the use of barbed sutures has proven to be more efficient and effective in other plastic surgery procedures. This study aimed to demonstrate the safety and efficacy of barbed sutures for breast reconstruction implant capsulorrhaphy., Methods: A retrospective cohort study was performed including all consecutive patients who underwent capsulorrhaphy by the senior author utilizing barbed sutures and, for comparison, another colleague utilizing smooth sutures from the years 2018-2021., Results: Twenty-eight patients were identified who underwent barbed suture capsulorrhaphy (a total of 36 breasts operated on), which was compared with 20 patients who had smooth suture capsulorrhaphy (a total of 34 breasts operated on). The average ages of the barbed and smooth suture cohorts were 55 and 53 years old ( P = 1.00), respectively. The average BMI of the barbed and smooth suture cohorts were 26.7 and 25.0 kg/m 2 ( P = .15), respectively. The reoperation rates for both groups were similar at 5%. Overall complication rate was 13.9% in the barbed suture group and 8.8% in the smooth suture group, which was not statistically significant ( P = .71). Patients with barbed sutures did not have an increased risk of complications compared with those who received smooth sutures (OR 1.67 (0.37-7.59), P = .51)., Conclusions: In conclusion, performing implant-based breast reconstruction capsulorrhaphy with barbed sutures is a safe and effective procedure as compared with smooth sutures., (© 2024 HMP Global. All Rights Reserved. Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.)

Background: American football is the most popular sport in the United States, with over 5.6 million people >6 years old playing the sport. Fractures in American football athletes are significant, as they compromise an athlete's performance and can also lead to prolonged recovery periods, affecting team dynamics and player careers. Analyzing these injuries is critical to evaluate preventive measures and tailor rehabilitation strategies to ensure the well-being and sustained peak performance of football athletes on and off the field., Purpose: To analyze the trend of American football fractures by body site, sex, and age in amateur athletes over a 20-year period between 2002 and 2021., Study Design: Descriptive epidemiology study., Methods: The National Electronic Injury Surveillance System (NEISS) database was queried to characterize football-related fractures and injuries from 2002 to 2021 in patients aged 0-99 years old. National injury estimates were calculated using sample weights. Chi-square analysis and one-way ANOVA were performed to compare categorical variables., Results: Of 56,809 cases of American football-related fractures over 20 years, patients aged 10 to 14 years had the highest incidence of fractures, composing 41.2% of all fractures (n = 23,389), and patients aged <18 years represented 88.8% of all fractures (n = 50,457). The median age of players when fractures occurred was 13 years. Upper extremity fractures (n = 41,863 [73.7%]) were the most common fracture reported compared with lower extremity and head, neck, and trunk fractures. Among upper extremity fractures, finger fractures had the highest prevalence (35.6%), followed by lower arm fractures (19.9%) and wrist fractures (13%). While most cases resulted in release after treatment (93.1%), 5.9% resulted in treatment and hospitalization. When analyzing trends in American football-related fractures over time, we observed the largest number of fractures in 2006 (n = 3664), while the smallest number of fractures occurred in 2020 (n = 1313). Also, a downward trend was found in American football-related fractures since 2006, with a mean of 101 fewer fractures each year., Conclusion: Our analysis showed that American football-related fractures diagnosed in the emergency department in the United States were most likely to occur in pediatric patients (10-18 years old). In addition, patients experiencing American football-related fractures were most likely to have an upper extremity fracture and not require hospitalization. The trend in American football-related fractures has been decreasing since 2006., Competing Interests: The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval was not sought for the present study., (© The Author(s) 2024.)

Background: The body mass index (BMI) is an imperfect clinical measure of obesity that should be used in conjunction with other valid measures of weight-related risk. We studied whether there is a superior measure of obesity-related comorbidities., Methods: Records of bariatric clinic patients who had an abdominal computed tomography (CT) within 1 year of visit were reviewed. The presence of obesity-related comorbidities was determined at the time of the scan. BMI and ponderal index (PI) were calculated, and CT scans were reviewed to determine the visceral cross-sectional area (VCSA), subcutaneous fat cross-sectional area (SFCSA), and liver volume (LV). Data were analyzed using the Kruskal-Wallis test and Mann-Whitney U test., Results: A higher number of comorbidities were found to be associated with a larger BMI (P = .011), VCSA (P = .014), SFCSA (P = .007), and LV (P = .014), but not a larger PI (P = .11). Of the 16 comorbidities assessed, VCSA and LV were associated with more than BMI and SFCSA. However, each measure could be associated with different comorbidities. A higher BMI was associated with increased insulin use (P = .034), hypertension (P = .007), and history of obstructive sleep apnea (P = .015), none of which were associated with PI. BMI and PI were the only measures associated with a history of deep vein thrombosis/pulmonary embolism (both P < .01). Only SFCSA was found to be associated with gastroesophageal reflux disease (P = .029). VCSA (P = .038) and LV (P = .001) were associated with nonalcoholic fatty liver disease., Conclusion: No measure could account for all obesity-related comorbidities, implying the need for targeted measurements. However, PI was the least effective measure., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Teaching and learning of clinical reasoning are core principles of medical education. However, little guidance exists for faculty leaders to navigate curricular transitions between pre-clerkship and clerkship curricular phases. This study compares how educational leaders in these two phases understand clinical reasoning instruction. Previously reported cross-sectional surveys of pre-clerkship clinical skills course directors, and clerkship leaders were compared. Comparisons focused on perceived importance of a number of core clinical reasoning concepts, barriers to clinical reasoning instruction, level of familiarity across the undergraduate medical curriculum, and inclusion of clinical reasoning instruction in each area of the curriculum. Analyses were performed using the Mann Whitney U test. Both sets of leaders rated lack of curricular time as the largest barrier to teaching clinical reasoning. Clerkship leaders also noted a lack of faculty with skills to teach clinical reasoning concepts as a significant barrier ( p  < 0.02), while pre-clerkship leaders were more likely to perceive that these concepts were too advanced for their students ( p  < 0.001). Pre-clerkship leaders reported a higher level of familiarity with the clerkship curriculum than clerkship leaders reported of the pre-clerkship curriculum ( p  < 0.001). As faculty transition students from the pre-clerkship to the clerkship phase, a shared understanding of what is taught and when, accompanied by successful faculty development, may aid the development of longitudinal, milestone-based clinical reasoning instruction.

Introduction: Specialists in poison information are responsible for following-up with exposure cases managed at healthcare facilities. However, the amount of time, call components, and barriers met when completing an initial healthcare facility follow-up call in which a large amount of data and clinical recommendations are shared is not well described., Methods: A retrospective observational study was conducted by randomizing healthcare facility initial follow-up calls from January to April 2022. One hundred and thirty calls that met the inclusion criteria were randomly selected. We recorded seven unique time intervals within each call. Day of the week, time of day, and variability amongst specialists in poison information were also assessed., Results: Initial follow-up calls took a median of 7.2 min. Most (67%) follow-up calls were directed to emergency departments. Barriers to completion of calls were most commonly due to the healthcare reporter being busy (37%) and specialists in poison information being placed on terminal hold (30%). There was variability between specialists in poison information in the time for healthcare reporter to share data ( P  < 0.0001), time for specialists in poison information recommendations ( P  = 0.0076), and total time ( P  = 0.0003)., Discussion: Variability exists amongst specialists in poison information during periods of information exchange, particularly when the healthcare reporter is providing information and subsequently when the specialist in poison information is providing recommendations. Barriers to completing calls centered around healthcare reporter being busy or the specialist in poison information being placed on a terminal hold. There was no correlation with the time or day of the week., Conclusions: With notable variability in these calls during periods of intense communication of data and treatment recommendations, there are likely opportunities for specialists in poison information and poison center directors to work together to address variability and overcome barriers to completing initial hospital follow-up calls. Further studies to evaluate variability amongst specialists in poison information are the next steps in understanding this complex topic.

Introduction: Various factors impact outcomes following bariatric surgery. Lack of access to healthy food options (food insecurity [FI]) is another potential factor affecting outcomes. No prior studies have directly explored the relationship between residing in a high FI zip code and patient outcomes relating to weight loss after bariatric surgery. We hypothesized that living in a high FI zip code would be associated with decreased weight loss postsurgery., Methods: We conducted a retrospective study with 210 bariatric surgery patients at a tertiary referral center from January to December 2020. Patient weight and body mass index (BMI) were recorded at three time points: surgery date, 1 mo, and 12 mo postoperative. Residential addresses were collected, and FI rates for the corresponding Zip Code Tabulation Areas were obtained from the 2022 Feeding America Map the Meal Gap study (2020 data)., Results: The FI rate showed a negative correlation of -18.3% (95% confidence interval: -35% to -0.5%; P = 0.039) with the percentage of excess weight loss (%EWL) at 1 y. In multivariate analysis, preoperative BMI (P = 0.001), presence of diabetes mellitus (P = 0.008), and bariatric procedure type (P = 0.000) were significant predictors of %EWL at 1 y. After adjusting for confounding factors, including sex, preoperative BMI, insurance status, primary bariatric procedure, and emergency department visits, the increased FI rate (P = 0.047) remained significantly associated with a decreased %EWL at 1 y., Conclusions: Residing in a high FI, Zip Code Tabulation Areas correlated with a decreased %EWL at 1 y after bariatric surgery. These findings highlight the importance of assessing FI status in pre-bariatric surgery patients and providing additional support to individuals facing FI., (Published by Elsevier Inc.)

Background: Shivering is often encountered in patients undergoing targeted temperature management (TTM) after cardiac arrest. The most efficient, safe way to prevent shivering during TTM is not clearly defined. Objective: The purpose of this study was to evaluate the impact of shivering management using a stepwise shivering protocol on time to target temperature (TT), medication utilization and nursing confidence. Methods: Single-center, retrospective chart review of all post-cardiac arrest patients who underwent TTM between 2016 and 2021. The primary outcome is a comparison of time to TT pre- and post-protocol implementation. Secondary objectives compared nursing confidence and medication utilization pre- and post-shivering protocol implementation. Results: Fifty-seven patients were included in the pre-protocol group and thirty-seven were in the post-protocol group. The median (IQR) time to TT was 195 (250) minutes and 165 (170), respectively (p = 0.190). The average doses of acetaminophen was 285 mg pre- vs 1994 mg post- (p <0.001, buspirone 47 mg pre- vs 127 mg post- (p < 0.001), magnesium 0.9 g pre-vs 2.8 g post- (p < 0.001), and fentanyl 1564 mcg pre- vs 2286 mcg post- (p=0.023). No difference was seen for midazolam and cisatracurium. Nurses reported feeling confident with his/her ability to manage shivering during TTM 38.5% of the time pre-protocol compared to 60% post-protocol (p = 0.306). Conclusion: Implementation of a stepwise approach to prevent and treat shivering improved time to TT in our institution, although this finding was not statistically significant. The stepwise protocol supported a reduced amount of high-risk medication use and increased nursing confidence in shivering management., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) facilitate weight loss. Weight regain off therapy is concerning. We reported the case of a 35-year-old male prescribed oral semaglutide with 22.7 kg weight loss over 120 days. Herein, we describe the clinical course when discontinuing GLP-1 RA therapy, one approach to maintaining weight loss after discontinuation, and a possible new side effect. At day 120, we continued oral semaglutide 7 mg daily, down from 14 mg, for weight maintenance with subsequent weight regain. We re-increased semaglutide to 14 mg/day with weight re-loss within 1 month and weight maintance for a year. We then discontinued semaglutide; weight loss was maintained for 6 months. The patient reported lactose intolerance ∼13 months before starting semaglutide. During semaglutide therapy, the patient reported worsened lactose intolerance and new gluten intolerance. Food allergy/celiac testing were negative. Intolerances did not improve with semaglutide discontinuation. Six months after semaglutide discontinuation, the patient was diagnosed with small intestinal bacterial overgrowth, possibly worsened by semaglutide. Factors potentially supporting weight maintenance were early drug treatment for new-onset obesity, non-geriatric age, strength training, and diet modification. The case highlights tailoring approaches to maintain weight loss without GLP-1 RAs. Trials are needed to optimize weight maintenance strategies., Competing Interests: Dr. Carris has received research funding (institution receives and manages funds) from Sanofi Winthrop Industries. Dr. DuCoin declares consulting for Johnson & Johnson, Medtronic, and Intuitive. The remaining authors have no conflicts of interest, or other interests, that might be perceived to influence the results and/or discussion reported in this paper.

Antoinette C Spoto-Cannons,1 Deanna M Isom,2 Max Feldman,3 Kira K Zwygart,3 Rahul Mhaskar,4 Marna Rayl Greenberg5 1Department of Pediatrics, Morsani College of Medicine, University of Florida, Tampa, FL, USA; 2Department of Education, Morsani College of Medicine, University of Florida, Tampa, FL, USA; 3Department of Internal Medicine, Morsani College of Medicine, Unibversity of Florida, Tampa, FL, USA; 4Department of Family Medicine, Morsani College of Medicine, University of Florida, Tampa, FL, USA; 5Department of Emergency and Hospital Medicine, Lehigh Valley Campus, Morsani College of Medicine, University of South Florida, Bethlehem, PA, USACorrespondence: Marna Rayl GreenbergDepartment of Emergency and Hospital Medicine, Lehigh Valley Hospital, Morsani College of Medicine, University of South Florida, LVH-M-5th Floor EM Residency Suite, 2545 Schoenersville Road, Bethlehem, PA 2545, USAEmail mrgdo@ptd.netBackground: The skill of self-assessment is critical to medical students. We sought to determine whether there were differences between student self-assessments and their faculty assessments and if they were modified by gender. Additionally, we sought to determine the differences in these assessments between students in a traditional (core) versus an enhanced (SELECT) medical school curriculum.Methods: In this retrospective study, mid-term and final assessment and feedback forms from the first-year Doctoring 1 course were analyzed from three academic years: 2014–2015 through 2016–2017. Data were abstracted from the forms and de-identified for analysis. Class year, student gender, and class type were also abstracted from this “on the shelf” data from program assessment. The level of agreement between faculty and student assessments was investigated using Wilcoxon signed ranks test. The gender differences (male versus female students) between student assessments and their assessment by their faculty were investigated by using the Kruskal Wallis test.Results: Five hundred and thirty-five student self-assessments were analyzed. Fifty-six percent (301/535) were male while 44% (234/535) were female. Faculty assessments (P-value

Background/Objectives: The hypercoagulable state associated with COVID-19 infection is associated with adverse outcomes and mortality. Studies have also demonstrated high rates of venous thromboembolism (VTE) events among patients with sepsis. We aimed to evaluate how the increase in thrombotic events in critically ill patients with COVID-19 infection compares to that of critically ill patients with non-COVID-19 sepsis. Methods: A chart review was performed of patients 18 years or older admitted to the intensive care unit (ICU) at Tampa General Hospital between 1 January 2020 and 31 December 2020 diagnosed with COVID-19 or sepsis secondary to other pathogens. Non-COVID-19 sepsis patients and COVID-19 patients were propensity-matched 3:1 on the Charlson Comorbidity Index. Multivariate analyses adjusting for confounding were conducted to report odds ratio (OR) and 95% confidence intervals (95% CIs) of predictors for thrombotic events and overall mortality. Results: After propensity score matching, 492 sepsis patients and 164 COVID-19 patients were included in the analysis. COVID-19 patients were significantly older ( p = 0.021) and showed higher BMI ( p < 0.001) than sepsis patients. COVID-19 patients did not show significantly higher odds of thrombosis after adjustment for confounders (OR 0.85, 95% CI 0.42-1.72), but had significantly lower odds of mortality than sepsis patients (OR 0.33, 95% CI 0.16-0.66). Conclusions: Our results suggest that further study is required to lower the rate of VTE in COVID-19 and non-COVID-19 sepsis patients admitted to the ICU; it is also reasonable to consider similar thromboembolism practices between these two patient groups.

Background: Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure., Methods: A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines., Results: Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I 2  = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I 2  = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I 2  = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%., Conclusion: Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: The purpose of this study is to investigate the impact of preoperative comorbidities, including depression, anxiety, type 2 diabetes mellitus, obstructive sleep apnea, hypothyroidism, and the type of surgery on %EBWL (percent estimated body weight loss) in patients 1 year after bariatric surgery. Patients who choose to undergo bariatric surgery often have other comorbidities that can affect both the outcomes of their procedures and the postoperative period. We predict that patients who have depression, anxiety, diabetes mellitus, obstructive sleep apnea, or hypothyroidism will have a smaller change in %EBWL when compared to patients without any of these comorbidities., Methods and Procedures: Data points were retrospectively collected from the charts of 440 patients from March 2012-December 2019 who underwent a sleeve gastrectomy or gastric bypass surgery. Data collected included patient demographics, select comorbidities, including diabetes mellitus, obstructive sleep apnea, hypothyroidism, depression, and anxiety, and body weight at baseline and 1 year postoperatively. Ideal body weight was calculated using the formula 50 + (2.3 × height in inches over 5 feet) for males and 45.5 + (2.3 × height in inches over 5 feet) for females. Excess body weight was then calculated by subtracting ideal body weight from actual weight at the above forementioned time points. Finally, %EBWL was calculated using the formula (change in weight over 1 year/excess weight) × 100., Results: Patients who had a higher baseline BMI (p < 0.001), diabetes mellitus (p = 0.026), hypothyroidism (p = 0.046), and who had a laparoscopic sleeve gastrectomy rather than Roux-en-Y gastric bypass (p < 0.001) had a smaller %EBWL in the first year after bariatric surgery as compared to patients without these comorbidities at the time of surgery. Controversially, patients with anxiety or depression (p = 0.73) or obstructive sleep apnea (p = 0.075) did not have a statistically significant difference in %EBWL., Conclusion: A higher baseline BMI, diabetes mellitus, hypothyroidism, and undergoing laparoscopic sleeve gastrectomy may lead to lower %EBWL in the postoperative period after bariatric surgery. At the same time, patients' mental health status and sleep apnea status were not related to %EBWL. This study provides new insight into which comorbidities may need tighter control in order to optimize weight loss outcomes after bariatric surgery., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Anti-B-cell maturation antigen (BCMA) chimeric antigen receptor T-cell (CAR-T) therapy is transforming the care of patients with relapsed/refractory multiple myeloma (MM). Unfortunately, despite being a disease of older adults these patients remain under-represented in most pivotal clinical trials. We performed a systematic review and proportion meta-analysis of prospective clinical trials and observational studies of anti-BCMA CAR-T therapy in patients with MM with the aim to determine the efficacy and safety of this therapy in older adults (≥65 years)., Materials and Methods: We searched the Pubmed, Scopus, Web of Science (WOS), Ovid, Embase, CENTRAL, and CINAHL databases through September 9, 2022 and abstracts from the American Society of Hematology (ASH) Annual Meeting 2022. Primary outcome measures included overall response rate (ORR), rates of cytokine release syndrome (CRS), and immune cell-effector-associated neurotoxicity syndrome (ICANS). study was registered with PROSPERO (study number: CRD42022334287)., Results: After screening 2218 references, 14 studies were included for data extraction, with a total of 558 patients, 26.2% (n = 146) of whom were older adults. The pooled ORR amongst this population was 93%, which was comparable to the ORR of 86% amongst younger patients. In older adults, the rates of CRS (any grade) and grade ≥ 3 were 95% and 21%, respectively. For younger patients, the pooled rate of CRS (any grade) and grade ≥ 3 CRS was 91% and 20%, respectively. The rate of ICANS (any grade) in older adults was 15%, which was higher than that observed in those <65 years., Conclusion: Older adults experience comparable outcomes to younger patients with anti-BCMA CAR-T therapy, albeit with numerically higher rates of neurotoxicity., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Some dietary patterns are associated with inflammation, while others lower inflammation and improve health. However, many people cannot follow a complete, healthy diet. Therefore, this study's aim was to identify specific foods associated chronic inflammation and mortality. The study used Multi-Ethnic Study of Atherosclerosis (MESA) research materials from the NHLBI Biologic Specimen and Data Repository Information Coordinating Center. Three plant-based and three animal-based MESA food categories were chosen based on perceived availability in the western diet. The assessed food categories were avocado, ham, sausage, eggs, greens, and broccoli. Inflammatory markers assessed were interleukin-6 (IL-6), fibrinogen antigen, C-reactive protein, D-Dimer, interleukin-2, matrix metalloproteinase 3, necrosis factor-a soluble receptors, oxidized LDL (oxLDL), and total homocysteine. The primary outcome was the multivariable association of foods and inflammatory markers with all-cause mortality. All inflammatory makers, except oxLDL, were associated with mortality in univariate analysis. The effect was largest with IL-6 and D-dimer. The category of broccoli had the most consistent association in univariate analyses with lower inflammation and lower mortality odds. Low and high broccoli consumption versus no consumption were associated with lower mortality odds in the multivariable models with IL-6 and D-dimer. Consumption of the MESA - defined food category "broccoli" ( i.e. , broccoli, cabbage, cauliflower, brussels sprouts, sauerkraut, and kimchee) was associated with lower inflammation and lower mortality odds. These findings should be validated in randomized controlled trials testing a "food is medicine" approach to identify which, if any, of these foods may have potential as an herbal therapeutic for chronic inflammation.

Introduction: Reduction mammaplasties are routinely performed on women of child-bearing age, yet there still exists some uncertainty regarding a patient's ability to breastfeed following the procedure. This is due to inconsistent definitions of "successful" breastfeeding, a variety of pedicles implemented, and inadequate follow-up in the published literature. Our aim was to summarize the current data and provide clear recommendations for counseling patients on expected breastfeeding outcomes following reduction mammaplasty., Methods: A systematic review and meta-analysis in accordance with the PRISMA guidelines was conducted. We included papers that reported proportion of breastfeeding ability following reduction mammaplasty., Results: We identified 33 papers that met our inclusion criteria. We found that women who undergo reduction mammaplasty are at a 3.5 times increased odds of not being able to breastfeed compared to controls. Overall, reduction mammaplasty patients have a breastfeeding success rate of 62%. The breastfeeding success rate for patients with inferior pedicles was 64%, superior pedicles was 59%, and lateral pedicles was 55%. No conclusions could be drawn regarding medial, central, vertical, and horizontal pedicles on breastfeeding ability., Conclusion: Current data suggest that women undergoing reduction mammaplasty have an increased odds of unsuccessful breastfeeding when compared to similar women who have not undergone the procedure. Based on the current literature, pedicle type does play a role in rate of breastfeeding success, although there is a need for further research on the aforementioned pedicles. Physicians should be aware of the likelihood of successful breastfeeding following reduction mammaplasty so that patients can be more thoroughly counseled prior to a decision for surgery., Level of Evidence I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Zachary Pruitt,1 Rahul Mhaskar,2 Bryan G Kane,3 Robert D Barraco,4 Deborah J DeWaay,2 Alex M Rosenau,3 Kristin A Bresnan,5 Marna Rayl Greenberg3 1Department of Health Policy and Management, College of Public Health, Morsani College of Medicine, University of South Florida, Tampa, FL, 2Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 3Department of Emergency Medicine, Morsani College of Medicine, University of South Florida, Lehigh Valley Campus, Allentown, PA, 4Department of Surgery, Morsani College of Medicine, University of South Florida, Lehigh Valley Campus, Allentown, PA, 5Department of Family Medicine, Morsani College of Medicine, University of South Florida, Lehigh Valley Campus, Allentown, PA, USA Background: There is currently no gold standard for delivery of systems-based practice in medical education, and it is challenging to incorporate into medical education. Health systems competence requires physicians to understand patient care within the broader health care system and is vital to improving the quality of care clinicians provide. We describe a health systems curriculum that utilizes problem-based learning across 4 years of systems-based practice medical education at a single institution.Methods: This case study describes the application of a problem-based learning approach to system-based practice medical education. A series of behavioral statements, called entrustable professional activities, was created to assess student health system competence. Student evaluation of course curriculum design, delivery, and assessment was provided through web-based surveys.Results: To meet competency standards for system-based practice, a health systems curriculum was developed and delivered across 4 years of medical school training. Each of the health system lectures and problem-based learning activities are described herein. The majority of first and second year medical students stated they gained working knowledge of health systems by engaging in these sessions. The majority of the 2016 graduating students (88.24%) felt that the course content, overall, prepared them for their career.Conclusion: A health systems curriculum in undergraduate medical education using a problem-based learning approach is feasible. The majority of students learning health systems curriculum through this format reported being prepared to improve individual patient care and optimize the health system’s value (better care and health for lower cost). Keywords: health systems, undergraduate medical, education

Introduction: The prevalence of tobacco use in the Veteran population and among Veterans Health Administration patients remains high, resulting in significant health and economic consequences. This problem has generated many tobacco research studies and clinical interventions, which often rely upon tobacco use status data previously recorded in electronic health records (EHR). Therefore, the consistency and reliability of these data are critical. The Veterans Health Administration uses an extensive EHR system where tobacco use status can be documented either as free text (FT) or as health factors (HF). The current literature assessing the reliability of HF and FT data is limited. This analysis evaluated the agreement between HF and FT tobacco use status data., Materials and Methods: This retrospective study included Veterans who underwent coronary revascularization and had tobacco use statuses recorded as both HF and FT. These statuses were categorized as "Current," "Former," or "Never." The closest recorded status to the index date (date of revascularization procedure) for each subject in both datasets was chosen, and Cohen's kappa statistic was calculated to measure the agreement between HF and FT. Implausible tobacco use status changes within each dataset were quantified to assess trustworthiness. Agreement between HF and FT data was first measured for all subjects (n = 1,095), which included those who had implausible status changes in either dataset and then measured again for subjects (n = 770) without any implausible status changes in either dataset. This study was exempt from institutional review board review., Results: Overall, 14.3% and 17.7% of all subjects had implausible tobacco use status changes in HF and FT data, respectively. For all subjects (n = 1,095), including those with implausible data, there was "moderate" agreement between HF and FT data (kappa = 0.49; 95% CI, 0.44-0.53). For subjects without implausible data (n = 770), the strength of agreement between HF and FT data was "good" (kappa = 0.64; 95% CI, 0.59-0.69)., Conclusions: Agreement between HF and FT data that document the tobacco use statuses of Veterans varied because of implausible data. HF data had fewer implausible tobacco use statuses, but FT data were recorded more frequently. Although HF and FT data can be reasonably relied upon to determine the tobacco use statuses of Veterans, researchers and clinicians must be aware of implausible data and consider methods to overcome this limitation. Future studies should investigate the ways of improving the consistency of EHR documentation by health care providers and benchmark HF and FT data against a gold standard like biochemical verification to determine accuracy., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Social media is increasingly being used by the public as a medium for health information. Unfortunately, misinformation has become widely available on these sites, often being provided using content that is designed to be more popular and engaging, and it is difficult for the public to differentiate between what is true and what is false. TikTok is one of these platforms and has been rapidly growing over the last few years. As an increasing number of people look to TikTok for their health information, it is important that quality information is accessible and popular on the platform. We conducted a review of TikTok videos using the top 10 videos to show when searching for 13 common conditions. Characteristics of both the creator and video were recorded and analyzed. Videos on conditions commonly diagnosed younger were commonly produced by younger creators with the condition, often based on their own experiences. Conversely, videos on conditions commonly diagnosed older were commonly produced by healthcare professionals providing educational information. Though for conditions affecting older individuals healthcare professionals may be able to create didactic, educational videos, for those affecting younger individuals, it may be beneficial to partner with younger creators, or "influencers," to produce more viral content. Further studies may expand on these ideas to encompass more facets of healthcare. As this study did not analyze the quality of the information in the videos, future research should also focus on determining the quality of popular content on TikTok and other social media platforms., (© The Author(s) 2024. Published by Oxford University Press on behalf of Fellowship of Postgraduate Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Repair options for ventral hernias in bariatric patients include performing a staged approach in which bariatric surgery is performed before definitive hernia repair (BS-first), a staged approach in which hernia repair is performed before bariatric surgery (HR-first), or a concomitant approach., Objectives: This meta-analysis aims to determine which surgical approach is best for bariatric patients with hernias., Setting: PubMed, CENTRAL, and Embase databases., Methods: A comprehensive search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to screen for all studies that focused on outcomes of patients who underwent both hernia repair and bariatric surgery, either simultaneously or separately. Exclusion criteria included hiatal and inguinal hernia studies, case reports, and case series., Results: 27 studies fit our inclusion criteria after identifying 1584 studies initially. Seven comparative studies were included, enrolling 8548 staged patients (6458 BS-first) and 3528 concomitant patients. A total of 7 single-arm staged studies and 13 single-arm concomitant studies were also included. Data on hernia recurrence, mesh infection, reoperation, surgical site infections, seroma, bowel complications, and mortality were abstracted. The concomitant approach was associated with decreased odds of experiencing surgical site infections, reoperation, and seromas. The staged approach (BS-first) was associated with decreased odds of mesh infection. The single-arm studies suggest a lower incidence of hernia recurrence in a staged BS-first approach than in a concomitant approach., Conclusions: The data suggest a concomitant approach is appropriate for hernias that the surgeon feels do not require mesh, while the staged (BS-first) approach is more appropriate if the hernia requires mesh placement., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Rhabdomyolysis is a clinical syndrome with the potential to cause cardiac arrhythmias, renal failure, and even death. Currently, there are no studies regarding risk factors for developing post-operative rhabdomyolysis (POR) after spinal fusion surgeries. Our objective was to study risk factors associated with, and to develop a decision-making framework for post-operative rhabdomyolysis after spinal fusion surgery., Methods: We performed a retrospective cohort study of all spinal fusions of three or more levels over 2.25 years by a single surgeon at two centers. POR was defined as a creatine phosphokinase (CPK) greater than 2000 IU/L., Results: 76 surgical procedures on 72 patients were identified. Rate of POR in our cohort was 22% (17/76). Male sex was associated with POR ( p  < 0.05). Previously validated risk factors: younger age, lower ASA score, elevated BMI, higher pre-operative creatinine, increased intraoperative blood loss, specific surgical positions, and length of surgery, were not associated with POR. In a logistic regression model, male gender increases the odds of POR in all patients 5.82-fold ( p  = 0.047). In patients without a second surgery within seven days, a logistic regression model suggests each additional level fused via transpsoas approach, and male gender, increases the risk of POR 1.81-times ( p  = 0.015), and 6.26-times ( p  = 0.047), respectively. In patients with posterior fusions, a logistic regression model suggests increasing the number of lateral levels fused via transpsoas approach in the same surgery, and male gender, increases the risk of POR 1.68-times and 6.34-times, respectively. In these same subgroups, increased thickness of the psoas major in lateral transpsoas fusions increased risk of POR ( p  = 0.023, p  = 0.046, respectively)., Conclusions: In spinal fusions, increasing the number of lateral levels fused via transpsoas approach, and male gender, predispose patients to increased risk of POR in those without a second surgery within seven days, and in those with a simultaneous posterior fusion.

Objective: To identify variables that may contribute to the development of proximal junctional failure (PJF) in patients with long lumbo-sacral and thoraco-lumbo-pelvic constructs undergoing anterior column realignment (ACR) with anterior longitudinal ligament release (ALLR)., Methods: Data of patients with adult spinal deformity who underwent ACR with ALLR at L3-4 were collected retrospectively from medical records and a prospectively maintained spine research database between 2016 and 2022., Results: Eleven (41%) developed PJF at a mean of 24 ± 21 months from the index surgery. The cohort was then divided into 2 groups for analysis, 13 subjects in the high pelvic incidence (PI) group (defined as PI ≥ 55°) and 14 subjects in the low PI group (defined as PI < 55°). Visual Analog Scale for back pain and Oswestry Disability Index decreased from 9.5 to 2.1 and 61 to 10 in the high PI group, and from 8.9 to 2.4 and 60.9 to 10.3 in the low PI group, respectively. PI (P = 0.004), sacral slope (P = 0.005), and postoperative PI-lumbar lordosis mismatch (P = 0.02) were found to be significant predictors of PJF. The receiver operator curve revealed a cutoff PI value ≤ 53° (95% confidence interval: 52°-64°), below which the risk of PJF becomes significantly higher in patients undergoing ACR with ALLR at L3-4., Conclusions: PI may be a predictor of PJF and highly correlates with ACR-ALLR levels. In patients undergoing L3-4 ACR-ALLR, a PI value of ≤53° is associated with a significantly elevated risk of PJF. Preoperative planning of ACR-ALLR level based on normal sagittal alignment in otherwise healthy individuals may mitigate the risk of PJF development in patients with adult spinal deformity treated with ACR-ALLR., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Objective: Optimizing the extent of resection (EOR) and facial nerve outcomes (FNO) remain a challenge in medium to large vestibular schwannomas (VS). Currently, tumor size has been the only consistently reported factor predicting FNO and EOR. Here, we sought to evaluate whether the degree of the tumor's compression on the middle cerebellar peduncle (PC) influences FNO and EOR in medium to large VS., Methods: This retrospective case series included 99 patients who underwent surgical resection of their VSs from 2014 to 2022. Preoperative MR imaging was used to measure the degree of PC. Patient medical records were queried to determine the EOR and FNO., Results: Patients with unfavorable FNO (HB 3 +) immediately post-op had significantly greater PC than those with favorable FNO (19.9 vs. 15.4 mm, P = .047). This significance was not observed at the last follow-up but there was a trend. When medium-sized tumors (15-30 mm) were analyzed separately, patients with unfavorable FNO immediate post-op and at last follow-up had significantly greater PC than their favorable counterparts (14.1 vs 8.7 mm). Significantly greater PC was also observed in patients who underwent subtotal resection (20.7 mm) compared to near (14.3 mm) and gross total resection (10.8 mm). Multivariate analyses confirmed these findings in medium-sized tumors, but not large-sized tumors., Conclusion: The degree of PC as measured on preoperative imaging can predict FNO and EOR in medium-sized vestibular schwannomas. Medium-sized tumors with > 15 mm of PC likely will have worse FNO and lower EOR., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Endobronchial forceps are commonly used for complex IVC filter removal and after initial attempts at IVC filter retrieval with a snare have failed. Currently, there are no clear guidelines to help distinguish cases where primary removal should be attempted with standard snare technique or whether attempts at removal should directly be started with forceps. This study is aimed to identify clinical and imaging predictors of snare failure which necessitate conversion to endobronchial forceps., Methods: Retrospective analysis of 543 patients who underwent IVC filter retrievals were performed at three large quaternary care centers from Jan 2015 to Jan 2022. Patient demographics and IVC filter characteristics on cross-sectional images (degree of tilt, hook embedment, and strut penetration, etc.) were reviewed. Binary multivariate logistic regression was used to identify predictors of IVC filter retrieval where snare retrieval would fail., Results: Thirty seven percent of the patients (n = 203) necessitated utilization of endobronchial forceps. IVC filter hook embedment (OR:4.55; 95%CI: 1.74-11.87; p = 0.002) and strut penetration (OR: 56.46; 95% CI 20.2-157.7; p = 0.001) were predictors of snare failure. In contrast, total dwell time, BMI, and degree of filter tilt were not associated with snare failure. Intraprocedural conversion from snare to endobronchial forceps was significantly associated with increased contrast volume, radiation dose, and total procedure times (p < 0.05)., Conclusion: IVC filter hook embedment and strut penetration were predictors of snare retrieval failure. Intraprocedural conversion from snare to endobronchial forceps increased contrast volume, radiation dose, and total procedure time. When either hook embedment or strut penetration is present on pre-procedural cross-sectional images, IVC filter retrieval should be initiated using endobronchial forceps., Level of Evidence: Level 3, large multicenter retrospective cohort., (© 2023. The Author(s).)

Alzheimer's disease (AD) is a multifactorial neurodegenerative disease characterized by cognitive and behavioral changes in older adults. Emerging evidence suggests poor oral health is associated with AD, but there is a lack of large-scale clinical studies demonstrating this link. Herein, we used the TriNetX database to generate clinical cohorts and assess the risk of AD and survival among >30 million de-identified subjects with normal oral health ( n = 31,418,814) and poor oral health ( n = 1,232,751). There was a greater than two-fold increase in AD risk in the poor oral health cohort compared to the normal oral health group (risk ratio (RR): 2.363, (95% confidence interval: 2.326, 2.401)). To reduce potential bias, we performed retrospective propensity score matching for age, gender, and multiple laboratory measures. After matching, the cohorts had no significant differences in survival probability. Furthermore, when comparing multiple oral conditions, diseases related to tooth loss were the most significant risk factor for AD (RR: 3.186, (95% CI: 3.007, 3.376)). Our results suggest that oral health may be important in AD risk, regardless of age, gender, or laboratory measures. However, more large-scale cohort studies are necessary to validate these findings and further evaluate links between oral health and AD.

Introduction: Peroral endoscopic myotomy (POEM) is a novel endoscopic procedure used to treat achalasia and other spastic esophageal disorders that is an alternative to Heller myotomy. We seek to define the learning curve of POEM for a foregut surgeon with no formal endoscopic or POEM training by analyzing different intraoperative factors in a single series., Methods and Procedures: The first 38 consecutive patients undergoing POEM by a single foregut surgeon were included in this retrospective study. Inverse curve regression models were used to analyze total operative time (TOT) and total operative time per centimeter of myotomy (TOT-CM), in addition to other intraoperative variables. Clinical outcomes were reported as pre- and post-operative Eckardt Scores., Results: All patients had type II achalasia with no post-operative complications observed. Eckardt scores improved postoperatively (median (range): 1 (0-4)) compared with the preoperative scores (10 (8-12)) (P < .001). The total operative time (median 76 minutes, range 51-129) decreased significantly over the course of the series (R 2 = .38, P < .001), with a learning plateau at 70 minutes and a learning rate of 12 cases. Total operative time per centimeter of myotomy (median 7.08 min/cm, range 4.25 to 15.38) decreased over time (R 2 = .45, P < .001), with a learning plateau at 7 minutes/cm and a learning rate of 12 cases., Conclusion: The number of cases for a foregut surgeon to become proficient in a POEM procedure was found to be 12-14 cases. The learning curve for a POEM in a formally trained foregut surgeon may be comparable to an endoscopically trained interventionist., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Acute basilar artery occlusion (BAO) is a devastating neurologic event. As endovascular thrombectomy (EVT) became more prevalent for anterior circulation strokes, investigations were conducted in the posterior circulation. Its success in improving outcomes compared to standard medical therapy (SMT) after BAO has been debated., Methods: We conducted a systematic review and meta-analysis of all randomized controlled trials (RCTs) and observational cohort studies evaluating EVT compared to SMT in acute BAO. We queried PubMed, Embase, and Cochrane for studies. Primary outcome was good functional outcome at 90 days (modified Rankin scale (mRS) ≤ 3). We analyzed studies for risk of bias (ROB) and calculated pooled risk ratios (RRs), odds ratios (ORs), and mean differences (MDs) with 95% confidence intervals (95%CI) using the random effects model for our primary outcome and secondary positive outcomes and harms., Results: We identified four RCTs (991 patients randomized) and three cohort studies (1030 patients treated in-trial) that fit inclusion criteria. Three RCTs had low ROB, one had serious ROB. One cohort study had high ROB, one had moderate ROB, and one had low ROB. EVT was statistically significantly more associated with good functional outcome than SMT in RCTs (RR=1.54, 95%CI=1.16-2.04, p = 0.003) and trended towards significance in cohort studies (RR=2.64, 95%CI=0.87-8.00, p = 0.09). Mean mRS at 90 days was lower in EVT patients in RCTs (MD= - 0.65, 95%CI= - 1.07- - 0.22, p = 0.003) though not cohort studies (MD = - 0.84, 95%CI= - 2.48-0.79, p = 0.31). Symptomatic intracerebral hemorrhage (sICH) was statistically significantly associated with EVT in RCTs (OR=6.36, 95%CI=2.24-18.07, p < 0.001) and statistically non-significantly in cohort studies (OR=4.51, 95CI=1.00-20.33, p = 0.05). Mortality at 90 days was statistically lower with EVT than with SMT in both RCTs (OR=0.76, 95%CI=0.65-0.88, p < 0.001) cohort studies (OR=0.36, 95%CI=0.26-0.50, p < 0.001) CONCLUSION: EVT is associated with greater rates of good functional outcomes and lower rates of death and disability despite higher rates of periprocedural sICH., Competing Interests: Declaration of Competing Interest MM: Consultant-Medtronic, Cerenovus. Stock -Serenity Medical, Synchron, VICIS, Endostream. Other authors: None., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Coronaviruses, known for their crown-like appearance, cause mild gastrointestinal and respiratory diseases. Some cause outbreaks of respiratory diseases, most recently, SARS-CoV-2, the coronavirus disease 2019 (COVID-19). Individuals with COVID-19 are reported to be in both arterial and venous prothrombotic states. In addition to a lipid-lowering effect, statin also has an anti-inflammatory effect, which addresses one of the underlying causes of thrombosis. An in-silico study revealed that statins could directly interact with the main protease enzyme of SARS-CoV-2 and prevent infectivity. Due to these pleiotropic properties, statins may positively impact the outcome of hospitalized patients with COVID-19 infections., Methods: A total of 26 445 acute COVID-19-infected patients were included in this study. Patients were stratified based on home statin use status: no statins, high-intensity statins (atorvastatin 40-80 mg daily and rosuvastatin 20-40 mg daily), and low-to-moderate intensity statins (all other statins). A multivariate generalized linear model and logistic regression were used to predict the hospital length of stay and inpatient mortality, respectively., Results: The hospital length of stay was compared between low-intensity and high-intensity statin use against no statin therapy. The length of stay was 3.88 days (95% CI, 3.56-4.20; P < .0001) longer among patients with low-dose statin therapy compared to patients without. The length of stay was 4.77 days (95% CI, 4.42-5.13; P <.0001) longer among patients with high-intensity statin therapy than those without. The odds of in-hospital mortality decreased by 24% (OR, 0.76; 95% CI, 0.76-0.97) among those with high-dose statin therapy compared to patients without ( P = .02). There was no statistical significance between the low-dose statin group and the no statin group for inpatient mortality., Conclusion: Hospitalized COVID-19 patients on statin therapy, regardless of intensity, are more likely to have a longer length of stay. There may be a mortality benefit in using high-intensity statin in acute COVID-19-infected patients. The results of this study are insufficient to recommend statin therapy for inpatient COVID-19 treatment. However, patients with significant cardiovascular comorbidities, where statins are indicated, should be on these medications, especially amidst the COVID-19 pandemic. Randomized controlled trials are needed to assess the potential in-hospital benefit of statin therapy on COVID-19 patients., Competing Interests: Conflicts of Interest The authors declare they have no conflicts of interest., (© 2023 HCA Physician Services, Inc. d/b/a Emerald Medical Education.)

At least 70% of US adults have metabolic disease. However, less is done to address early disease (e.g., overweight, obesity, prediabetes) versus advanced disease (e.g., type 2 diabetes mellitus, coronary artery disease). Given the burden of advanced metabolic disease and the burgeoning pandemics of obesity and prediabetes a systematic response is required. To accomplish this, we offer several recommendations: (A) Patients with overweight, obesity, and/or prediabetes must be consistently diagnosed with these conditions in medical records to enable population health initiatives. (B) Patients with early metabolic disease should be offered in-person or virtual lifestyle interventions commensurate with the findings of the Diabetes Prevention Program. (C) Patients unable to participate in or otherwise failing lifestyle intervention must be screened to assess if they require pharmacotherapy. (D) Patients not indicated for, refusing, or failing pharmacotherapy must be screened to assess if they need bariatric surgery. (E) Regardless of treatment approach or lack of treatment, patients must be consistently screened for the progression of early metabolic disease to advanced disease to enable early control. Progression of metabolic disease from an overweight yet otherwise healthy person includes the development of prediabetes, obesity ± prediabetes, dyslipidemia, hypertension, type 2 diabetes, chronic kidney disease, coronary artery disease, and heart failure. Systematic approaches in health systems must be deployed with clear protocols and supported by streamlined technologies to manage their population's metabolic health from early through advanced metabolic disease. Additional research is needed to identify and validate optimal system-level interventions. Future research needs to identify strategies to roll out systematic interventions for the treatment of early metabolic disease and to improve the metabolic health among the progressively younger patients being impacted by obesity and diabetes., (© 2023. The Author(s).)

Introduction and Hypothesis: During the COVID-19 pandemic, many surgical societies released guidelines that included cancellation of elective cases. The aim of this study was to better understand our patients' perceptions of the severity of their pelvic floor disorders (PFDs) and to determine what factors influenced this perception. We also aimed to better understand who might be amenable to telemedicine visits and what factors influenced this decision., Methods: This is a cross-sectional quality improvement study that included women at least 18 years of age diagnosed with a pelvic floor disorder being evaluated within a university Female Pelvic Medicine and Reconstructive Surgery clinic during the COVID-19 pandemic. Patients whose appointments and procedures were being cancelled were queried on whether they would be willing to answer a telephone questionnaire developed by the clinical and research teams. We gathered descriptive data from 97 female patients with PFDs using a primary phone questionnaire. The data were analyzed using proportions and descriptive statistics., Results: Of the 97 patients, the majority (79%) viewed their conditions as non-urgent. Factors that influenced patients' perception of urgency included race (p=0.037), health status (p≤0.001), a history of diabetes (p=0.011), and willingness to attend an in-person appointment (p=0.010). Further, 52% of respondents were willing to attend a tele-health appointment. Statistically significant factors influencing this decision were ethnicity (p=0.019), marital status (p=0.019), and willingness to attend an in-person appointment (p=0.011)., Conclusion: The majority of women did not view their conditions as urgent during the COVID-19 pandemic and were amenable to a telehealth appointment., (© 2023. The International Urogynecological Association.)

Background: This retrospective cohort study aims to investigate emergency department (ED) visits and readmission after bariatric surgery among patients with a history of anxiety and/or depression. We predict that patients with a reported history of anxiety and/or depression will have more ED visits in the year following surgery than patients without a history of mental illness., Methods: Data were collected from the charts of all consecutive patients who underwent sleeve gastrectomy or gastric bypass surgery between March 2012 and December 2019. Data on baseline body mass index, mental health diagnosis and treatment and emergency department visits and hospital readmissions were retrospectively reviewed over the first year following surgery., Results: One thousand two hundred ninety-seven patients were originally included in this study and 1113 patients were included in the final analysis. Patients with a history of depression (OR 1.23; 95% CI 0.87-1.73), anxiety (OR 1.14; 95% CI 0.81-1.60), or both (OR 1.17; 95% CI 0.83-1.65) did not have a statistically significant increase in ED visits compared to patients without these disorders. Patients with a history of depression (OR 1.49; 95% CI 0.86-2.61), anxiety (OR 1.45; 95% CI 0.80-2.65) or both (OR 1.47; 95% CI 0.94-2.29) did not have a statistically significant increase in hospital readmissions in the first year after surgery compared to patients without these disorders. Patients treated with a sleeve gastrectomy were readmitted due to postoperative complications less frequently than those treated with other surgeries (OR 0.20; 95% CI 0.05-0.83)., Conclusion: Patients with a history of anxiety, depression or both did not have an increased rate of emergency department visits and hospital readmissions within the first year following bariatric surgery. This contradicts current literature and may be due to the multidisciplinary program patients undergo at this study's home institution., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background The objective of this study is to demonstrate the safety and feasibility of anti-reflux gastric bypass (ARGB) as a treatment for symptomatic massive paraesophageal hernias (PEH) in the obese population. Both gastroesophageal reflux disease (GERD) and PEH are particularly prevalent in the obese patient population, and obesity adversely affects the long-term outcomes of all anti-reflux procedures. Methods This is a single-center, retrospective review of 17 obese adults who underwent ARGB for the treatment of massive PEH between September 2019 and December 2021. Massive PEH was defined as >5 cm in a singular direction, and obesity as BMI ≥30 kg/m 2 . Patients without preoperative diagnostic testing were excluded. We reviewed and analyzed patient demographic data, postoperative symptom resolution, weight loss, and complications using descriptive statistics, change from baseline, and comparison of proportions. Results Sixteen of the 17 subjects were female. The median age was 48, and the median BMI was 39.10 kg/m 2  (30.0-49.3 kg/m 2 ). The average PEH size on imaging was 6.48 (H) x 6.25 (W) cm. The resolution of heartburn was 93.8% (p<0.001), and the resolution of nausea and vomiting was 80.0%. The mean postoperative length of follow-up was 9.12 months. Median excess body weight loss percentages at one, three, six, and 12 months were 16.43% (p<0.001), 35.92% (p<0.001), 40.64% (p=0.001), and 58.58% (p<0.01), respectively. Five patients experienced adverse events requiring additional intervention or hospitalization. There were no symptomatic hernia recurrences or mortality. Conclusion This study demonstrates that ARGB is feasible and potentially effective in treating symptomatic massive paraesophageal hernias in the obese patient population. Further investigation is needed to determine efficacy and long-term outcomes compared to standard surgical repair., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Kayastha et al.)