Evaluating bowel enterotomy closures in simulated deep body cavities using the reversing half-hitch alternating post and square knots: a randomized controlled trial

BackgroundSquare knots can be difficult to construct in deep body cavities. The reversing half-hitch alternating post (RHAP) surgical knot has noninferior tensile strength and performance characteristics in deep body cavities. We compared the enterotomy repairs of novice learners in simulated deep body cavities using RHAP versus square knots after proficiency-based training.MethodsUndergraduate students were randomized to RHAP (n = 10) or square knot (n = 10) groups and trained to defined proficiency. They then performed hand-sewn enterotomy repairs of cadaveric porcine small bowels on flat surfaces and in simulated deep body cavities. We recorded time to knot-tying proficiency and to enterotomy repair, and burst pressures for the repair.ResultsMean time-to-proficiency in knot tying was equivalent between the RHAP and square knot groups (23 [standard deviation (SD) 3] v. 21 [SD 2] min, p = 0.33). Mean time for enterotomy repair in deep cavities was shorter for the RHAP group (16 [SD 2] min v. 21 [SD 1] min, p = 0.02). Mean burst pressures for enterotomy repair were equivalent on flat surfaces (128 [SD 41] v. 101 [SD 36] mm Hg, p = 0.31), and were significantly higher for the RHAP group in simulated deep body cavities (32 [SD 13] v. 105 [SD 37] mm Hg, p = 0.05).ConclusionThe RHAP knots appear to have superior performance versus square knots when tied in a deep body cavity by novice learners. Future work should focus on demonstrating the clinical relevance and broad utility of the RHAP knot in abdominal surgery. Both knot types should be taught to novice learners.     

Placental Insulin/IGF-1 Signaling,PGC-1α, and Inflammatory Pathways Are Associated With Metabolic Outcomes at 4–6 Years of Age: The ECHO Healthy Start Cohort

An adverse intrauterine environment is associated with the future risk of obesity and type 2 diabetes. Changes in placental function may underpin the intrauterine origins of adult disease, but longitudinal studies linking placental function with childhood outcomes are rare. Here, we determined the abundance and phosphorylation of protein intermediates involved in insulin signaling, inflammation, cortisol metabolism, protein glycosylation, and mitochondrial biogenesis in placental villus samples from healthy mothers from the Healthy Start cohort. Using MANOVA, we tested the association between placental proteins and offspring adiposity (fat mass percentage) at birth (n = 109) and infancy (4–6 months, n = 104), and adiposity, skinfold thickness, triglycerides, and insulin in children (4–6 years, n = 66). Placental IGF-1 receptor protein was positively associated with serum triglycerides in children. GSK3β phosphorylation at serine 9, a readout of insulin and growth factor signaling, and the ratio of phosphorylated to total JNK2 were both positively associated with midthigh skinfold thickness in children. Moreover, peroxisome proliferator–activated receptor γ coactivator (PGC)-1α abundance was positively associated with insulin in children. In conclusion, placental insulin/IGF-1 signaling, PGC-1α, and inflammation pathways were positively associated with metabolic outcomes in 4- to 6-year-old children, identifying a novel link between placental function and long-term metabolic outcomes.     

Bipolar disorders and narcissism: Diagnostic concerns,conceptual commonalities and potential antecedents

Narcissistic personality disorder (NPD) and the manic and hypomanic episodes found in the bipolar disorders are characterized by grandiosity. It is possible that this shared grandiosity is a ‘homologous structure’ or reflects a superficial similarity between two disparate conditions. It is, however, possible that NPD and the bipolar disorders are more closely related than implied by their segregation into the separate superordinate categories of personality disorders and mood disorders. Whereas narcissism is considered to be a life-course, stable trait and the bipolar disorders are characterized by episodes of mania and depression, there is considerable research indicating that narcissism may be linked to mood instability (including depression) and bipolar disorder may have a pervasive personality component (i.e., hypomanic personality). Utilizing dimensional models of psychopathology, the current review examined the evidence linking narcissism and the bipolar disorders and suggests that considerable overlap may exist in the domains associated with reward-seeking, harm avoidance and social functioning.     

PTSD and Comorbid Psychotic Disorder: Comparison with Veterans Diagnosed with PTSD or Psychotic Disorder

Symptoms of posttraumatic stress disorder (PTSD), psychosis, general psychopathology, role functioning, violence potential, and cognitive and emotional aspects of psychotic states were compared in three groups of veterans. Groups were defined on the basis of their DSM-IV diagnoses: Psychotic disorder and war-related PTSD, war-related PTSD without psychotic symptoms, and psychotic disorder without PTSD. Veterans with PTSD and a comorbid psychotic disorder showed significantly higher levels of positive symptoms of psychosis, general psychopathology, paranoia, and violent thoughts, feelings, and behaviors than the other two groups. These data show that patients with comorbid PTSD and psychotic disorder show levels of cognitive, emotional, and behavioral disturbance that far exceed the levels of disturbance seen in patients with PTSD without psychosis or in patients with psychotic disorder.     

Quality of Life Among Food Allergic Patients and Their Caregivers

Food allergy is increasing in prevalence worldwide. This review summarizes progress made studying relationships between food allergy and quality of life (QOL), with an emphasis on recent work in the field. Early work examining QOL among food allergy patients established that stress and anxiety associated with continuous allergen avoidance and the looming threat of anaphylaxis were associated with significantly impaired food allergy quality of life (FAQOL) for children with food allergy and their caregivers. Recent clinical studies suggest that undergoing oral food challenge to confirm food allergy and oral immunotherapy to treat food allergy may each improve FAQOL among both patients and their caregivers. Other intervention modalities, such as nurse-facilitated counseling and educational workshops, also hold promise, but additional work is needed. Future work must strive to recruit more representative, population-based samples, including adult patients, in order to improve the generalizability and clinical relevance of findings.     

Addressing Oncofertility Needs: Views of Female Cancer Patients in Fertility Preservation

A total of 41 questionnaires were returned from 64 respondents who consented to receive a questionnaire through the mail. Almost all valued the opportunity to receive consultation to address their fertility concerns and discuss fertility preservation options. Psychological stress, time pressure, and costs were identified as main factors affecting respondents’ decision to proceed with in-vitro fertilization to cryopreserve oocytes or embryos. About one third indicated that the discussion of fertility matters was initiated by themselves, their friends, and families rather than their health care providers. The findings have identified several major barriers encountered by female cancer patients when seeking fertility preservation services.     

The role of patient–provider sexual health communication in understanding the uptake of HIV prevention services among Black men who have sex with men

We examined factors that may be associated with whether Black men who have sex with men a) disclose their sexual orientation to healthcare providers, and b) discuss their sexual health with healthcare providers to inform interventions to improve HIV prevention efforts and reduce HIV incidence rates among Black men who have sex with men. During 2011–2012, we conducted semi-structured individual in-depth interviews with Black men who have sex with men in New York City. Interviews were audio recorded. We examined transcribed responses for main themes using a qualitative exploratory approach followed by computer-assisted thematic analyses. Twenty-nine men participated. The median age was 25.3 years; 41% (n = 12) earned an annual income of < US$10,000; 72% (n = 21) had a college degree; 86% (n = 25) reported being single; 69% (n = 20) self-identified as gay or homosexual. We identified three main themes affecting whether the men discussed their sexual orientation and sexual health with healthcare providers: 1) comfort discussing sexual health needs; 2) health literacy; and 3) trust. Identifying strategies for improved comfort, health literacy and trust between Black men who have sex with men and healthcare providers may be an important strategy for increasing sexual health patient–provider communications, increasing opportunities for HIV prevention including testing and reducing HIV-related health disparities.