Bariatric or weight-loss surgery is a popular option for weight reduction. Depending on the surgical procedure, gastric changes like decreased transit time and volume and increased pH, decreased absorption surface in the small intestine, decreased exposure to bile acids and enterohepatic circulation, and decreased gastrointestinal transit time may be expected. In the years after bariatric surgery, patients will also substantially lose weight. As a result of these changes, the absorption, distribution, metabolism, and/or elimination of drugs may be altered. The purpose of this article is to report the general influence of bariatric surgery on oral drug absorption, and to provide guidance for dosing of commonly used or high-risk drugs in this special population. Upon oral drug administration, the time to maximum concentration is often earlier and this concentration may be higher with less consistent effects on trough concentrations and exposure. Additionally, prescription of liquid formulations to bariatric patients is supported by some reports, even though the high sugar load of these suspensions may be of concern. Studies on extended release medications result in an unaltered exposure for a substantial number of drugs. Also, studies evaluating the influence of timing after surgery show dynamic absorption profiles. Although for this group a specific advice can be proposed for many drugs, we conclude that there is insufficient evidence for general advices for oral drug therapy after bariatric surgery implying that a risk assessment on a case-by-case basis is required for each drug.
The impact of treatment on the risk of lymphoma in patients with rheumatoid arthritis (RA) is unclear. Here, we aimed to assess if the risk of lymphoma differs according to the type of Tumor Necrosis factor inhibitor (TNFi), comparing monoclonal anti-TNF antibodies (Ab) to the soluble TNF receptor. We used BAFF-transgenic (Tg) mice as a model of autoimmunity-associated lymphoma. Six-month aged BAFF-Tg mice were treated with TNFi for 12 months. Histological examination of the spleen, assessment of the cellular composition of the spleen by flow cytometry and assessment of B cell clonality were performed at sacrifice. Crude mortality and incidence of lymphoma were significantly higher in mice treated with monoclonal anti-TNF Ab compared to both controls and mice treated with the soluble TNF receptor, even at high dose. Flow cytometry analysis revealed decreased splenic macrophage infiltration in mice treated with monoclonal anti-TNF Ab. Overall, this study demonstrates, for the first time, that a very prolonged treatment with monoclonal anti-TNF Ab increase the risk of lymphoma in B cell-driven autoimmunity. This data suggests a closer monitoring for lymphoma development in patients suffering from B cell-driven autoimmune disease with long-term exposure to monoclonal anti-TNF Ab.
The Fontan operation has improved the survival of children born with single ventricle physiology. Selecting candidates for the Fontan operation may be difficult on borderline cases. No clear criterion has been established on the risk for staged Fontan palliation. Another aspect that remains controversial is the indications for fenestration. Intraoperative pulmonary flow study may identify high-risk patients for the procedure. In this report, the authors describe their results with Fontan procedures in children with pulmonary pressure >15 mmHg.
Closure of muscular ventricular septal defects remains a challenge for cardiac surgeons and interventional cardiologists. Different techniques, approaches, and devices are available to increase the success of these procedures. Changwe et al, in this issue of the Journal, describe a novel approach with the usage of a probe-guided system, with encouraging results.
The consideration of realistic load assumptions is important for the fatigue design of highly stressed nodular cast iron components for wind energy application. Especially in case of overloads causing elastic-plastic deformation, residual stresses may have a strong impact on fatigue life. In strain-controlled fatigue tests with constant and variable amplitudes, the influence of overloads on the lifetime was investigated. The overload was applied with the objective to create high tensile residual stresses. During fatigue testing the transient material behavior, cyclic hardening, cyclic relaxation of the residual stresses as well as quasi static creep effects, of the EN-GJS-400-18-LT was recorded and evaluated. To quantify the influence of the transient material behavior on the calculated lifetime, fatigue analyses are carried out with the strain-life approach, both with and without consideration of the transient material behavior. The results show that conservative damage sums are derived if the transient material behavior, especially the relaxation of tensile residual stresses, is neglected.
Shrub encroachment (SE) has been occurring and studied worldwide over the last century. What remains to be investigated is how soil and vegetation characteristics vary under canopy of different species of shrubs for restoration goals. Thus, this study aimed to compare the effect of three shrub species (Amygdalus scoparia, Ebenus stellata, and Daphne mezereum) on soil and vegetation characteristics under their canopies in semiarid rangelands in Iran for restoration purposes of degraded areas. Fifteen sites were randomly selected in such three shrub species which were found close to each other in each site. Soil and vegetation characteristics were measured under the three shrubs, comparing with outside the shrub canopies (control). One-way ANOVA and non-metric dimensional scaling were used to clarify the differences of the effects of different shrub species on sub-canopy soil and plants. The results indicated that the effect of different species of shrubs on soil properties was not equal, more pronounced by A. scoparia. Similarly, the highest value of herbaceous Shannon-Wiener diversity index was recorded under A. scoparia (2.07) as compared with D. mezerum (1.76), E. stellata (1.41). The highest and lowest values of Menhinick richness index were observed under A. scoparia (3.43) and E. stellata (1.46), respectively. Compared with two other shrubs, a taller canopy in A. scoparia (3.50m vs. 2.60m and 1.83m) probably led to greater litter input by the shrub. Different effects of different species of shrubs on sub-canopy soil and vegetation should be considered in the restoration projects of degraded semiarid rangelands.
Soil degradation restricts the development of agriculture and the degree of soil degradation is related to land use type. Quick and efficient evaluation of the degree of soil degradation is needed for the timeous implementation of remedial measures to ensure soil sustainability. Earthworm community characteristics are closely related to soil management practices and soil quality and could be used for evaluation purposes. In this Loess Plateau study, the degree of soil degradation under nine different land use types (natural and planted woodland, shrubbery, and grassland, plus cropland, orchard, and abandoned land) was related to the earthworm community characteristics (density, biomass, and the Shannon-Wiener, Species richness, and Pielou’s evenness indices) using a soil degradation index calculated from soil physicochemical properties determined for each land use type. The earthworm community characteristics associated with a low degree of degradation were significantly higher than those associated with a high degradation degree. Compared to the artificially managed land use types, earthworms in the natural ones showed higher biomass, density, and diversity. The earthworm density, biomass, and Shannon-Weiner index were significantly correlated with soil organic matter and total nitrogen content. These findings indicate that earthworm community characteristics can comprehensively characterise the physicochemical properties and biological characteristics of soils under different land use types. Linear correlations showed a significant relationship between the soil degradation index and the earthworm community characteristics, indicating that the latter could be used effectively to evaluate and represent the degree of degradation of soils on the Loess Plateau over a certain degradation range.
Introduction: The complex electrophysiological phenomena related to the atrioventricular node (AVN) are due to its complex anatomical structures. Aside from the inferior nodal extension (INE), other node-like tissues, such as the retroaortic node (RN), have been less described and may also share the mechanism of normal conduction and abnormal conduction in AVN re-entrant tachycardia (AVNRT). Methods: High-density sections of the entire AVN were obtained from rats and rabbits. Fibrosis was analyzed by Masson’s trichrome staining. Connexin (Cx43, Cx40, and Cx45) and ion channel (Nav1.5, Cav3.1, and HCN4) proteins were immunohistochemically labeled for the analysis of tissue features. Three-dimensional (3D) reconstruction of the AV junction was performed to clarify the relationships among different structures. Results: The RN expressed the same connexin isoforms as the compact node (CN) and INE. Nav1.5 labeling was present at a low level in the CN, RN and INE, where Cav3.1 and HCN4 were expressed. The CN connected with the RN in a narrow strip pattern at the level of the start of the CN. The RN presented as a shuttle shape and was the only tissue directly connected with the atrium in the anterior septum. Conclusion: The RN connects with the AVN anatomically, suggesting that there is direct electrical conduction between them. The entrance of the atria into the AVN is the distal part of the RN, which may form the fast pathway of the AVN.
Background: Although the burden of influenza is well characterized, the burden of community-onset non-influenza respiratory viruses has not been systematically assessed. Understanding the severity and seasonality of non-influenza viruses, including human coronaviruses, will provide a better understanding of the overall disease burden from respiratory viruses that could better inform resource utilization for hospitals and highlight the value of preventative strategies, including vaccines. Methods: From October 2017 to September 2019, a retrospective study was performed in a pre-defined catchment area to estimate the population-based incidence of community-onset respiratory viruses associated with hospitalization. Included patients were >18 years old, resided in New York City, were hospitalized for >24 hours, and had a respiratory virus detected within 3 calendar-days of admission. Disease burden was measured by hospital length of stay (LOS), intensive care unit (ICU) admissions, and in-hospital mortality and compared among those with laboratory-confirmed influenza versus those with laboratory-confirmed non-influenza viruses (human coronaviruses, parainfluenza viruses, respiratory syncytial virus, human metapneumovirus, and adenovirus). Results: During the study period, 4,232 eligible patients were identified of whom 50.9% were >65 years of age. For each virus, the population-based incidence was highest for those >80 years of age. When compared to those with influenza viruses detected, those with non-influenza respiratory viruses detected (combined) had higher population-based incidence, significantly more ICU admissions, and higher in-house mortality. Conclusions: The burden of non-influenza respiratory viruses for hospitalized adults is substantial. Prevention and treatment strategies are needed for non-influenza respiratory viruses, particularly for older adults.
Case 1. An 82-year-old man with history of ischemic cardiomyopathy and multiple admissions due to acute decompensated heart failure was evaluated for moderate to severe secondary MR due to atrial dilation (atrial functional MR). TTE showed severe biatrial enlargement with a left atrial volume of 117mL and a left atrial volume index of 65.5ml/m2. It also showed LV of normal size, left ventricular LVIDd of 4.5cm and LVEF of 55%. En face view revealed two central jets arising from the coaptation gaps between posterior mitral leaflet indentations (P1/P2 and P2/P3) (Panel A). (Panel B) Transillumination rendering on 3D TEE, highlighted two distinct coaptation gaps between posterior mitral leaflet scallops. Case 2. A 63-years-old woman with medical history of ischemic cardiomyopathy and heart failure with reduced ejection fraction (35%) was evaluated for moderate to severe secondary MR. TTE showed the LV dilation with LVIDd of 5.7cm. TEE revealed severe eccentric MR. (Panel C) 3D color Doppler TEE imaging of the mitral valve showed a severe regurgitant jet, originated in-between P2 and P3 posterior scallops. (Panel D) Transillumination rendering on 3D TEE, view from left atrium, in systole highlighted the coaptation gap. (Panel E) 3D color Doppler TEE imaging showed residual mild MR after a mitral clip was deployed grasping the medial aspect of P2 and A2 scallops covering the coaptation defect. (Panel F) Transillumination rendering on 3D TEE, view from LV, showed complete resolution of the coaptation gap between posterior scallops after clip deployment.
Objective To develop a Core Outcome Set (COS) for treatment of perinatal depression Design Systematic overview of outcomes reported in the literature and consensus development study using a Delphi survey and modified nominal group technique. Setting International. Population Two hundred and twenty-two participants, representing thirteen countries. Methods A systematic overview of outcomes reported in recently published research, a two-round Delphi survey, a consensus meeting at which the final COS was decided. Main results In the literature search, 1772 abstracts were identified and evaluated, 284 papers/protocols were assessed in full and 165 studies were finally included in the review. In all, 106 outcomes were identified and thus included in the Delphi survey. 222 participants registered for the first round of the Delphi survey and 151 (68%) responded. In the second round, 123 (55%) participants responded. The following 9 outcomes were agreed upon for inclusion in the final COS: self-assessed symptoms of depression, diagnosis of depression by a clinician, parent to infant bonding, self-assessed symptoms of anxiety, quality of life, satisfaction with intervention, suicidal thoughts, attempted or committed suicide, thoughts of harming the baby, and adverse events. Conclusions The relevant stakeholders prioritised outcomes and reached consensus on a COS comprising nine outcomes. We hope that this COS will contribute to consistency and uniformity of outcome selection and reporting in future clinical trials involving treatment of perinatal depression Funding This article is adapted from a report by SBU, which provided funding for the study. Keywords: perinatal depression, postpartum depression, antenatal depression, COS
Background: Safely liberalizing the diet to include an allergenic food may accelerate resolution of food allergy. The outcome of liberalization, however, varies among patients. Methods: We conducted a prospective observational study to identify factors associated with outcome for egg allergy 1 year after oral food challenge (OFC). We enrolled children < 72 months-old who had egg allergy and underwent OFC for determination of the safe intake quantity of egg allergen. At enrollment, each child’s clinical background was recorded. The Food Allergy Quality of Life Questionnaire–Parent Form (FAQLQ–PF) was administered to the caregivers to assess their children’s QoL. Dietary advice based on the OFC result was then provided to support safe consumption of eggs. At 1 year after OFC, the quantity of egg each child safely consumed in daily life was surveyed. We classified the egg allergy outcome as Outgrowing (Group O) if the quantity increased during the 1 year, or as Non-outgrowing (Group N) if it did not. Factors associated with the outcome were investigated by multivariate logistic regression analysis. Results: A total of 93 children were enrolled, and after 1 year 57 finished in Group O and 36 in Group N. The mean FAQLQ-PF score at baseline was significantly lower (i.e., better QoL) in group O than in group N. Multivariate logistic regression analysis identified comorbid asthma, comorbid atopic dermatitis and a poor QoL as factors predicting an unfavorable outcome. Conclusion: QoL may affect food allergy outcome. Intervention focusing on QoL may promote outgrowing food allergies.
Background Ebstein’s anomaly (EA) is a kind of congenital heart disease, which is currently widely treated by cone reconstruction. However, prediction of postoperative recovery is still challenging. Methods A retrospective analysis was performed on EA cases undergoing cone reconstruction from January 2010 to January 2016. Univariate and multivariate logistic regression analyses were performed, with postoperative adverse events defined as dependent variable and pre- and intra-operative parameters defined as independent variables. Predictive capacity of preoperative SPO2 and Great Ormond Street (GOS) score was evaluated using areas under the curve of receiver operating characteristic (ROC). Results Preoperative SPO2 was 95.7 ± 5.20%. Cardiopulmonary bypass, aortic cross-clamp, postoperative mechanical ventilation, and hospitalization time were 101.7 ± 28.26 min, 60.9 ± 18.04 min, 16 hours (8, 22), and 8 days (7, 11), respectively. The incidence of total postoperative adverse events including low cardiac output syndrome, mechanical ventilation more than 3 days, postoperative hospitalization more than 2 weeks, postoperative re-intubation, extracorporeal membrane oxygenation assistance, and death was 13.1% (n=13). Low pre-operative SPO2 (P=0.001, OR=0.834), GOS score (P=0.021, OR=0.368), and cardiopulmonary bypass time (P=0.034, OR=1.021) were risk factors for adverse events. Multivariate logistic regression analysis showed that low preoperative SPO2 (P=0.002, OR=0.846) and GOS score (P=0.043, OR=0.577) were independent risk factors for adverse events. The areas of SPO2 and GOS score under the ROC curve were 0.764 and 0.740, respectively. Conclusions Low pre-operative SPO2 and GOS score were predictors of adverse events after cone reconstruction, and SPO2 was more convenient and objective than GOS score.
In the last decades, the overlapping areas of intervention between cardiac surgeons and interventional cardiologists are rocketing, especially in the field of treatment of heart valve disease. But, while for the aortic valve the competition, even for non-high risk patients, has become tightened, in the context of mitral regurgitation, the surgery seems to not have competitors .In fact looking the results of studies published so far, a question arises: Is surgery the fair competitor for the Mitraclip? The meta-analysis by Abdul Khader et al summarized few evidences present in this field, only 11 observational studies and 1 randomized trial, providing an awesome response: “NO”. Is therefore not a case if recently two trials, MITRA-FR and COAPT, chose to use as competitor for MitraClip, more rightly, medical therapy instead of surgery. In conclusions, in case of mitral regurgitation, surgery is still largely the gold standard treatment and so MitraClip cannot be mention at all as competitor of surgery. It can be the right choice of case of primary MR where patients showed high risk for surgery. In case of secondary MR, especially with large and poor left ventricle we should wait for a clear answer on its role, yet.
Hybridization is a common and important stage in species formation in plants and animals. The evolutionary consequences of hybridization depend not only on reproductive compatibility between sympatric species, but also on factors like vulnerability to each other’s predators and parasites. We examine infection patterns of the blood parasite Haemoproteus lophortyx, a causative agent of avian malaria, at a site in the contact zone between California quail (Callipepla californica) and Gambel’s quail (C. gambelii). We tested whether species identity, sex, and year predicted infection status and intensity. While we found no effect of sex on the status or intensity of infection, we found differences in infection status and intensity across species and between years. The prevalence of infection in California and hybrid quail was lower than in Gambel’s quail. Once infected, however, California and hybrid quail had higher infection intensities than Gambel’s quail. California and hybrid quail exhibited no significant differences in prevalence or intensity of infection. These findings suggest that infection by H. lophortyx has the potential to influence species barrier dynamics in this system, however, more work is necessary to determine the exact evolutionary consequences of this blood parasite.
Background. The use of transcutaneous near-infrared spectroscopy (NIRS) for the monitoring of the perfusion of renal allografts in paediatric population has been proposed in the last years. This device might detect early decrease in allograft oxygenation allowing prompt detection of vascular complications. Methods. A systematic review of literature about the use of transcutaneous NIRS in monitoring allograft perfusion was performed according to the PRISMA guidelines. Results. The authors screened 1313 papers. The search yielded five pertinent articles. Three of them reported the experience of NIRS in kidney transplantation, for a total of 53 paediatric patients and 50 adults. In these studies, NIRS measurements was significantly related to serum creatinine, estimated glomerular filtration rate (eGFR), urinary neutrophil gelatinase-associated lipocalin (u-NGAL), serum lactate, resistive index assessed by doppler-ultrasonography and systolic blood pressure. In the paediatric studies no vascular complications were encountered. Conclusions. Preliminary studies have related NIRS monitoring to renal allograft perfusion and function. Further investigation is needed to establish the normal range of NIRS values for renal allografts and the factors influencing NIRS monitoring.