Heterogeneity of weight loss after gastric bypass,sleeve gastrectomy,and adjustable gastric banding

Background

Laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding all lead to substantial weight loss in obese patients. Long-term weight loss can be highly variable beyond 1-year postsurgery. This study examines and compares the frequency distribution of weight loss and lack of treatment effect rates after laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding.

Implementation of Recommendations for Long-Acting Contraception Among Women Aged 13 to 18 Years in Primary Care

ObjectiveClinical specialty societies recommend long-acting reversible contraceptives (LARCs) as first-line contraception for adolescent women. We evaluated whether a combined educational and process improvement intervention enhanced LARC placement in primary care within an integrated health care system.MethodsThe intervention included journal clubs, live continuing education, point-of-care guidelines, and new patient materials. We conducted a retrospective cohort study across 3 time periods: baseline (January 2013?September 2015), early implementation (October 2015–March 2016), and full implementation (April 2016–June 2017). The primary outcome was the proportion of LARCs placed by primary care clinicians among women aged 13 to 18 years compared with gynecology clinicians.ResultsKaiser Foundation Health Plan of Colorado cared for approximately 20,000 women aged 13 to 18 years in each calendar quarter between 2013 and 2017. Overall, LARC placement increased from 7.0 per 1000 members per quarter at baseline to 13.0 per 1000 during the full intervention. Primary care clinicians placed 6.2% of all LARCs in 2013, increasing to 32.1% by 2017 (P < .001), including 45.5% of contraceptive implants. Clinicians who attended educational sessions were more likely to adopt LARCs than those who did not (17.9% vs 6.4% respectively, P = .009). Neither overall LARC placement rates (relative risk, 1.9; 95% confidence interval, 0.7?5.6) nor contraceptive implant rates (relative risk, 3.0; 95% confidence interval, 0.9?9.8) increased significantly in clinicians who attended educational activities.ConclusionsThis multimodal intervention was associated with increased LARC placement for adolescent women in primary care. The combination of education and process improvement is a promising strategy to promote clinician behavior change.     

Crediting his critics' concerns: Remaking John Snow's map of Broad Street cholera, 1854

Few cases in the history of epidemiology and public health are more famous than John Snow's investigation of a neighborhood cholera outbreak in the St. James, Westminster, area of London in 1854. In this study Snow is assumed to have proven that cholera was water rather than airborne through a methodology that became, and to a great extent remains, central to the science and social science of disease studies. And yet, Snow's work did not satisfy most of his contemporaries who considered his proof of a solely waterborne cholera interesting but unconvincing. Uniquely, this paper asks whether the caution of Snow's contemporaries was reasonable, and secondly, whether Snow might have been more convincing within the science of the day. The answers significantly alter our understanding of this paradigmatic case. It does so in a manner offering insights both into the origins of nineteenth century disease analysis and more generally, the relation of mapping in the investigation of an outbreak of uncertain origin. The result has general relevance—pedagogically and practically—in epidemiology, medical geography, and public health.     

BENEFICENCE,TEMPERANCE AND MEDICAL SCIENCE

John Coakley Lettsom (1744–1815) founded the Medical Society of London and played a key role in the development of the Royal Humane Society. His Quaker background underpinned his interest in social reform. He established dispensaries and soup kitchens for the poor, recognized the need for public health measures in the control of disease, and advocated prison reform and education of the poor.     

Epilepsy and Recursive Consciousness with Special Attention to Jackson's Theory of Consciousness

Summary: John Hughlings Jackson's theory of consciousness has been reconsidered. The author stressed that his uniqueness as a neuroscientist lay in his keen interest in the recursive nature of human consciousness. Two clinical symptoms of interest to Jackson were discussed: recurrent utterances and mental diplopia. Recurrent utterances were believed to represent an exceptional state, in which the unconscious process in speech production, otherwise destined to be swept away automatically, became manifest and observable. Jackson regarded mental diplopia as a revelation of otherwise inaccessible duality of all healthy mental actions. Therefore, he supposed that the essence of recursive consciousness resided in a transformation of multiple, multidirectional, unconscious processes into a linear, unidirectional process     

Cross-reactive antigens and immunity to diseases caused by encapsulated bacteria.

Antigenic structures may be shared among naturally occurring polymers, including proteins and polysaccharides. Proteins are polymers of amino acids. Cross-reactions between proteins are due to similarities in their overall shape rather than their individual amino acid components. Cross-reactions have been demonstrated among proteins with similar evolutionary development and structure, such as serum albumins or immunoglobulins. Polysaccharides are polymers of monosaccharides. In contrast to proteins, antigenic specificities may be conferred by mono-, di-, and trisaccharides. Since there are about 150 known naturally occurring monosaccharides, it is not unexpected that cross-reactions are demonstrable between polysaccharides from widely divergent sources.     

Translocation X;10 in a case of congenital acute monocytic leukemia

Unusual cytogenetic findings were noted in the leukemic cells from a patient with congenital acute monocytic leukemia (AMol or M5, according to the FAB classification), whereas, the chromosomes of cultured skin fibroblasts were normal. G-banded karyotypes of leukemic cells showed an X-autosome translocation, 46,X,t(X;10)(Xpter----q13::10q11.2----qter)(10pter---- q11.2::Xq28----q13:: Xq28----qter). Review of reported cases of acute nonlymphocytic leukemia (ANLL) with rearrangements involving chromosomes #10 or X showed a high frequency of abnormalities of the short arm of #10 in myelomonocytic (M4) and monocytic (M5) leukemias, particularly in patients less than 2-yr-of-age. Although previously reported cases of ANLL in infants are predominantly of these types, the translocation observed in this case is unique. Fragile sites known to exist on chromosomes #10 and X are not associated with neoplasia and, except for Xq27-28, were not at the breakpoints of the case presented. The precise location of a human cellular oncogene recently identified on the X chromosome remains unknown.     

The discovery of neuronopathy and neuropathy as a cause of progressive paralysis in childhood. The historical origins of modern differential diagnosis in neuromuscular disease

The concept of the differential diagnosis has a central place in all clinical medicine. In neurology and paediatrics, evolution of thought concerning the differential diagnosis of the child presenting with symptoms of neuromuscular disease was far in advance of similar diagnostic approaches to problems of infectious, infective and neoplastic disease; and as such forms a significant historical model for the development of modern clinical approaches to the sick or disabled child. The account presented in this paper provides a detailed historical review of the development of thought relating to the causes of neuromuscular disease. Nosological developments concerning diseases of the motor unit can be conveniently classified into three periods: (a) a "state of the art" period to 1850; (b) 1850-1890 - a period of parallel and interdependent advances in both normal neuro-anatomy and neurophysiology, and diseases recognized as variations from such norms. In this era Duchenne was the first to write about the differential diagnosis of the progressive muscular paralysis in childhood; and Gowers was the first to write specifically on the hereditary transmission of this group of diseases; (c) in 1891 was described the first case of childhood neuronopathy recognized as such, and with this development was ushered in the modern era of clinical differential diagnosis of childhood neuromuscular disease. The "splitters" have won the great debate concerning the clinical approach to neurological diseases. The continual further refining of an exact diagnosis is the only way in which a realistic prognosis can be forecast, correct genetic counseling can be offered, and (if the condition is treatable) optimal therapy can be introduced.