Search

Magnetic sphincter augmentation (MSA) is a surgical treatment option for patients with gastroesophageal reflux disease (GERD). MSA consistently improves quality of life, maintains freedom from PPIs, and objectively controls GERD. However, up to 24% of patients did not achieve these outcomes. We sought to identify factors predicting outcomes after MSA placement with the aim of refining selection criteria. We retrospectively analyzed clinical, endoscopic, manometric, pH data, and intraoperative factors from two databases: Pivotal Trial (N= 99) and our prospectively maintained esophageal database (N= 71). A priori outcomes were defined as excellent (GERD-HRQL <5, no PPI, no esophagitis), good (GERD-HRQL 6–15, no PPI, grade A esophagitis), fair (GERD-HRQL 16 to 25, PPI use, grade B esophagitis), and poor (GERD-HRQL >25, PPI use, grade C/D esophagitis). Univariable and multivariable logistic regression analyses were performed to determine predictors of achieving an excellent/good outcome. A total of 170 patients underwent MSA with a median age of 53 years, [43–60] and a median BMI of 27 (IQR = 24–30). At baseline, 93.5% of patients experienced typical symptoms and 69% atypical symptoms. Median DeMeester score was 37.9 (IQR 27.9–51.2) with a structurally intact sphincter in 47%. Esophagitis occurred in 43%. At 48 [19–60] months after MSA, excellent outcomes were achieved in 47%, good in 28%, fair in 22%, and poor in 3%. Median DeMeester score was 15.6 (IQR = 5.8–26.6), esophagitis in 17.6% and daily PPI use in 17%. At univariable analysis, excellent/good outcomes were negatively impacted by BMI, preoperative LES residual pressure, Hill grade, and hiatal hernia. At multivariable analysis, BMI >35 (OR = 0.05, 0.003–0.78, p= 0.03), structurally defective LES (OR = 0.37, 0.13–0.99, p= 0.05), and preoperative LES residual pressure (OR = 0.89, 0.80–0.98, p= 0.02) were independent negative predictors of excellent/good outcome. Magnetic sphincter augmentation results in excellent/good outcomes in most patients but a higher BMI, structurally defective sphincter, and elevated LES residual pressure may prevent this goal.

Magnetic sphincter augmentation (MSA) has emerged as an alternative surgical treatment of gastroesophageal reflux disease (GERD). The safety and efficacy of MSA has been previously demonstrated, although adequate comparison to Nissen fundoplication (NF) is lacking, and required to validate the role of MSA in GERD management. A multi-institutional retrospective cohort study of patients with GERD undergoing either MSA or NF. Comparisons were made at 1 year for the overall group and for a propensity-matched group. A total of 415 patients (201 MSA and 214 NF) underwent surgery. The groups were similar in age, gender, and GERD-HRQL scores but significantly different in preoperative obesity (32 vs. 40 %), dysphagia (27 vs. 39 %), DeMeester scores (34 vs. 39), presence of microscopic Barrett’s (18 vs. 31 %) and hiatal hernia (55 vs. 69 %). At a minimum of 1-year follow-up, 354 patients (169 MSA and 185 NF) had significant improvement in GERD-HRQL scores (pre to post: 21–3 and 19–4). MSA patients had greater ability to belch (96 vs. 69 %) and vomit (95 vs. 43 %) with less gas bloat (47 vs. 59 %). Propensity-matched cases showed similar GERD-HRQL scores and the differences in ability to belch or vomit, and gas bloat persisted in favor of MSA. Mild dysphagia was higher for MSA (44 vs. 32 %). Resumption of daily PPIs was higher for MSA (24 vs. 12, p= 0.02) with similar patient-reported satisfaction rates. MSA for uncomplicated GERD achieves similar improvements in quality of life and symptomatic relief, with fewer side effects, but lower PPI elimination rates when compared to propensity-matched NF cases. In appropriate candidates, MSA is a valid alternative surgical treatment for GERD management.

Increased emergency department (ED) length of stay (LOS) has been associated with increased mortality in trauma patients. In 2010, we implemented a 247 open trauma bed protocol in our designated trauma intensive care units (TICUs) to facilitate rapid admission from the ED. This required maintenance of a daily bump list and timely transferring of patients out of the TICU. We hypothesized that ED LOS and mortality would decrease after implementation.

Sudden cardiac death (SCD) and sustained monomorphic ventricular tachycardia (SMVT) are frequently associated with prior or acute myocardial injury. Cardiovascular magnetic resonance (CMR) provides morphological, functional, and tissue characterization in a single setting. We sought to evaluate the diagnostic yield of CMR-based imaging versus non–CMR-based imaging in patients with resuscitated SCD or SMVT.

Evaluating the statistics of elemental mass transfer associated with metasomatism is a complex and time-intensive process. Hence, we developed a Matlab 5program, herein referred to as SACD, that has proven to be fast, efficient, and thorough at statistically analyzing elemental and rock-mass changes. The essence of SACD is that it calculates all pertinent statistics that stem from the null hypothesis, H0, that there is no change in elemental mass brought on by metasomatism. The results output by SACD were checked against published data from the Wepawaug Schist, Connecticut that was metamorphosed under Barrovian conditions, probably during the Acadian orogeny. Elemental and total rock-mass changes computed by SACD are nearly identical to those in the published literature but show that, contrary to the published literature, acceptance of H0carries with it an unacceptable risk. We urge anyone teaching the principles of elemental mass transfer to students to make use of this tool. It will free students from the tedium of number crunching and leave them more time to contemplate the physiochemical reasons for metasomatism, an Earth process that remains poorly understood and deserving of more of our time.

Over the past five years, the American public has witnessed a flurry of interest in “character” and “character or moral education.” In 1992, William Kilpatrick wrote a book that attracted widespread attention, Why Johnny Can't Tell Right from Wrong: Moral Illiteracy and the Case for Character Education.A year later, William Bennett's best-selling anthology of remedial readings appeared, The Book of Virtues.More recently, Gertrude Himmelfarb published a book on the Victorian golden age of morals. At the same time, within the educational field, a subprofession of consultants devoted to character work has aimed to affect schooling at the elementary and secondary levels. As early as the mid-1970's, theologians and ethicists began discussing the idea of character, taking their cue from Stanley Hauerwas. Common to all of these writers is the belief that character has a necessary tie to religion and democracy.

Thoracic duct injury is a rare but serious complication following surgery of the neck or chest that leads to uncontrolled chyle leak. Conventional management includes drainage, nutritional modification, or aggressive surgical interventions such as thoracic duct ligation, flap coverage, fibrin glue, or talc pleurodesis; few successful medical therapeutics are available. We report a case of a high-output chylothorax refractory to aggressive medical and surgical interventions. Chyle output decreased substantially after initiating midodrine, an α1-adrenergic agonist that causes vasoconstriction of the lymph system, reducing chyle flow. This case report suggests that midodrine may be a novel therapeutic for refractory chyle leaks.