Can technical factors explain the volume-outcome relationship in gastric bypass surgery?

BackgroundThe existence of a relationship between surgeon volume and patient outcome has been reported for different complex surgical operations. This relationship has also been confirmed for patients undergoing Roux-en-Y gastric bypass (RYGB) in the Longitudinal Assessment of Bariatric Surgery (LABS) study. Despite multiple studies demonstrating volume-outcome relationships, fewer studies investigate the causes of this relationship.ObjectiveThe purpose of the present study is to understand possible explanations for the volume-outcome relationship in LABS.MethodsLABS includes a 10-center, prospective study examining 30-day outcomes after bariatric surgery. The relationship between surgeon annual RYGB volume and incidence of a composite endpoint (CE) has been published previously. Technical aspects of RYGB surgery were compared between high and low volume surgeons. The previously published model was adjusted for select technical factors.ResultsHigh-volume surgeons (>100 RYGBs/yr) were more likely to perform a linear stapled gastrojejunostomy, use fibrin sealant, and place a drain at the gastrojejunostomy compared with low-volume surgeons (<25 RYGBs/yr), and less likely to perform an intraoperative leak test. After adjusting for the newly identified technical factors, the relative risk of CE was .93 per 10 RYGB/yr increase in volume, compared with .90 for clinical risk adjustment alone.ConclusionHigh-volume surgeons exhibited certain differences in technique compared with low-volume surgeons. After adjusting for these differences, the strength of the volume-outcome relationship previously found was reduced only slightly, suggesting that other factors are also involved.     

Protein Energy Wasting in a Cohort of Maintenance Hemodialysis Patients in Dhaka,Bangladesh

Malnutrition is associated with high rates of mortality among patients with end stage kidney disease (ESKD). There is a paucity of data from Bangladesh, where around 35,000–40,000 people reach ESKD annually. We assessed protein-energy wasting (PEW) amongst 133 patients at a single hemodialysis setting in Dhaka. Patients were 49% male, age 50 ± 13 years, 62% were on twice-weekly hemodialysis. Anthropometric, biochemical, and laboratory evaluations revealed: BMI 24.1 ± 5.2 kg/m², mid-arm muscle circumference (MAMC) 21.6 ± 3.6 cm, and serum albumin 3.7 ± 0.6 g/dL. Based on published criteria, 18% patients had PEW and for these patients, BMI (19.8 ± 2.4 vs. 25.2 ± 5.2 kg/m²), MAMC (19.4 ± 2.4 vs. 22.2 ± 3.8 cm), serum albumin (3.5 ± 0.7 vs. 3.8 ± 0.5 g/dL), and total cholesterol (135 ± 34 vs. 159 ± 40 mg/dL), were significantly lower as compared to non-PEW patients, while hand grip strength was similar (19.5 ± 7.6 vs. 19.7 ± 7.3 kg). Inflammatory C-reactive protein levels tended to be higher in the PEW group (20.0 ± 34.8 vs. 10.0 ± 13.9 p = 0.065). Lipoprotein analyses revealed PEW patients had significantly lower low density lipoprotein cholesterol (71 ± 29 vs. 88 ± 31 mg/dL, p < 0.05) and plasma triglyceride (132 ± 51 vs. 189 ± 103 mg/dL, p < 0.05), while high density lipoprotein cholesterol was similar. Nutritional assessments using a single 24 h recall were possible from 115 of the patients, but only 66 of these were acceptable reporters. Amongst these, while no major differences were noted between PEW and non-PEW patients, the majority of patients did not meet dietary recommendations for energy, protein, fiber, and several micronutrients (in some cases intakes were 60–90% below recommendations). Malnutrition Inflammation Scores were significantly higher in PEW patients (7.6 ± 3.1 vs. 5.3 ± 2.7 p < 0.004). No discernible differences were apparent in measured parameters between patients on twice- vs. thrice-weekly dialysis. Data from a larger cohort are needed prior to establishing patient-management guidelines for PEW in this population.     

Efficacy of Liming Forest Soil in the Context of African Swine Fever Virus

Since September 2020, Germany has experienced the first ever outbreak of African swine fever (ASF). The first known cases occurred exclusively in wild boar in forest areas in Brandenburg and Saxony; in July 2021, infected domestic pigs were also confirmed for the first time. As wild boar are considered the main reservoir for the virus in the European region, an effective interruption of this infection chain is essential. In particular, the removal and safe disposal of infected carcasses and the direct disinfection of contaminated, unpaved ground are priorities in this regard. For the disinfection, highly potent as well as environmentally compatible disinfectants must be used, which are neither influenced in their effectiveness by the soil condition nor by increased organic contamination. Thus, in this study, slaked lime, milk of lime and quicklime (1% to 10% solutions) were selected for efficacy testing against the test virus recommended by the German Veterinary Society (DVG), Modified Vaccinia Ankara virus (MVAV), and ASF virus (ASFV) in conjunction with six different forest soils from Saxony in two different soil layers (top soil and mineral soil) each. In summary, 10% of any tested lime type is able to inactivate both MVAV and ASFV under conditions of high organic load and independent of the water content of the soil. At least a 4 log reduction of the virus titer in all tested forest soil types and layers and by all applied lime types was observed. In conclusion, the high efficacy and suitability of all tested lime products against both viruses and in the presence of high organic load in forest soil can be confirmed and will help to control ASF spread.     

Persistent protein losing enteropathy in post measles diarrhoea.

Faecal alpha 1 antitrypsin was measured in two groups of children with diarrhoea aged 6 months to 6 years during the acute and recovery stages of the illness. Group 1 comprised 19 children with a history of measles in the two weeks preceding admission to hospital. In this group there were six cases of Shigella species, six enterotoxigenic Escherichia coli, and five rotavirus, and two did not yield an aetiologic agent. Group 2 comprised 15 children with diarrhoea only. In this group there were five cases of Shigella species, five enterotoxigenic Escherichia coli, and five rotavirus. Children with rotavirus diarrhoea belonging to both groups showed a transient high faecal clearance of alpha 1 antitrypsin during the acute stage. Post measles cases of diarrhoea showed significantly higher faecal clearance of alpha 1 antitrypsin than group 2 subjects in both the acute and recovery stages. The faecal clearance of alpha 1 antitrypsin in both groups was significantly higher during the acute stage compared with the recovery stage. Highest faecal clearances of alpha 1 antitrypsin were observed in children with post measles shigellosis in the acute stage and they also had persistently raised concentrations, thus suggesting prolonged protein losing enteropathy.     

Zinc supplementation as adjunct therapy in children with measles accompanied by pneumonia: a double-blind,randomized controlled trial

BACKGROUND: Zinc deficiency, common in developing countries, is associated with decreased immunocompetence. Zinc supplementation benefits children with acute and persistent diarrhea and prevents pneumonia. Most deaths from vaccine-preventable diseases are from measles and whooping cough; pneumonia is the most common complication of measles and often the proximate cause of related deaths. OBJECTIVE: We evaluated the effect of zinc supplementation on episodes of illness in children with measles accompanied by pneumonia. DESIGN: In a double-blind, randomized controlled trial, children aged 9 mo-15 y who were admitted to the Infectious Diseases Hospital in Calcutta with clinically severe measles accompanied by pneumonia and who had been ill for 相似文献   

Size matters: a survey of how urinary-tract stones are measured in the UK

BACKGROUND AND PURPOSE: Stone size forms the basis of management pathways in patients with urolithiasis. We carried out a questionnaire-based audit to find out how stone size is routinely measured by radiologists in the UK. MATERIALS AND METHODS: A series of 831 anonymous questionnaires concerning how stone size is assessed using four imaging modalities--plain abdominal radiograph (KUB film), intravenous urogram (IVU), ultrasound, and CT--were sent to 277 radiology departments. Following the survey, a substudy at our institution compared urologists (N = 10) and radiologists (N = 5) in estimating the size of a large (26-mm) and small (11- mm) calculus on KUB films. RESULTS: Of the questionnaires, 425 were returned, and 421 were analyzed. Of these, 85% were from consultants, 14% from trainees/middle grades, and 1% "unspecified." In total, 92% of the respondents were radiologists (10% uroradiologists) and 8% urologists. Estimation of stone size ("guestimation") from KUB films and IVUs was used by 40% and 36% of radiologists, respectively, whereas graded rulers were used by 57% and 59%, respectively. For ultrasound scans and CT, electronic measurement was the favored method (81% and 73%), but guestimation was still used by 10% and 15%, respectively. When assessing the KUB films and IVU, 59% and 61% of urologists, respectively, also used guestimation. The substudy revealed a significant difference among radiologists in the accuracy of size estimation for the 11-mm stone (mean estimated size 9.6 mm; P = 0.02, one-sample t-test). CONCLUSION: A large proportion of radiologists use guestimation for assessing stone size on KUB films and IVU. Even when electronic measuring aids were available for CT and ultrasonography, guestimates remained prevalent. Our substudy showed that radiologists significantly underestimated the smaller stone.     

Suppressive effect of zinc on antibody response to cholera toxin in children given the killed, B subunit-whole cell, oral cholera vaccine

In a previous study, children aged 2-5 years old in Bangladesh were supplemented orally with a single dose of Vitamin A (200,000 IU) and a placebo for zinc (zinc equivalent to 20 mg of elemental zinc) everyday for 42 days (group A), zinc and a placebo for Vitamin A (group Z), zinc and Vitamin A (group AZ) or both placebos (group P). All children were orally immunised with two doses of the killed cholera vaccine containing whole cells and a recombinant B subunit of cholera toxin (CT). The number of children who responded with > or = 4-fold vibriocidal antibody (a proxy indicator of protection against cholera) was significantly greater among the zinc-supplemented groups than among the non-zinc-supplemented groups, while Vitamin A supplementation did not appear to have any effect. The sera from these children were assayed for antibody to CT. Antibody to CT is known to exert a synergistic protective effect against cholera in animal studies, and offer significantly higher short-term protection against cholera and significant short-term protection against enterotoxigenic Escherichia coli diarrhoea in humans on oral immunisation with the cholera vaccine. Children who received zinc had significantly reduced levels of serum antibodies to CT than children who received placebos only. Factorial analysis showed a trend for zinc showing a reduction in the number of children responding with CT-antibody, while Vitamin A did not appear to have any effect. Thus, zinc enhanced vibriocidal antibody response, but suppressed CT-antibody response, suggesting that zinc supplementation has different modulating effects on vibriocidal antibody response and CT-antibody response.     

Thromboprophylaxis in laparoscopic abdominal surgery

Background: Since the introduction of laparoscopic cholecystectomy, there has been a great concern regarding the increased risk of thromboembolism following laparoscopic surgery. However, in the absence of clear guidelines, the use of thromboprophylaxis in laparoscopic abdominal surgery is controversial. Methods: The evidence for and against routine and selective thromboprophylaxis in patients undergoing laparoscopic abdominal procedures was reviewed based mainly on published British and Danish surveys, together with the author's own survey. An attempt was made to come up with a generally‐accepted protocol for thromboprophylaxis in laparoscopic surgery. Results: Less thromboembolic events were encountered by laparoscopic surgeons who adopt routine thromboprophylaxis. More thromboembolic events following laparoscopic abdominal surgery were encountered by surgeons adopting selective thromboprophylaxis policy. Conclusion: Routine thromboprophylaxis seems to be more effective in protection against thromboembolism. However, this warrants further confirmation by prospective randomized trials.