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BACKGROUND Bowel perforation from biliary stent migration is a serious potential complication of biliary stents, but fortunately has an incidence of less than 1%. CASE SUMMARY We report a case of a 54-year-old Caucasian woman with a history of Human Immunodeficiency virus with acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, alcoholic liver cirrhosis, portal vein thrombosis and extensive past surgical history who presented with acute abdominal pain and local peritonitis. On further evaluation she was diagnosed with small bowel perforation secondary to migrated biliary stents and underwent exploratory laparotomy with therapeutic intervention. CONCLUSION This case presentation reports on the unusual finding of two migrated biliary stents, with one causing perforation. In addition, we review the relevant literature on migrated stents.

Cholecystocolonic fistulas (CCF) are a rare but significant complication of biliary disease, frequently presenting as gallstone ileus. Although there is no one agreed-upon procedure, enterolithotomy appears to be the initial treatment of choice; with a subsequent cholecystectomy performed ~4–8 weeks later. Alternatively, a patient may undergo a single-stage procedure, at which time an enterolithotomy, cholecystectomy and fistula closure are performed. Herein, we describe two patients with chronic cholecystitis and subsequent development of CCF with differing presentations. We report the clinical, radiographic and intraoperative findings and discuss the surgical treatment options for each patient, respectively.

We present a case of a patient who suffered subarachnoid haemorrhage (SAH), complicated by takotsubo syndrome, paroxysmal atrial fibrillation and ECG repolarisation abnormality, compatible with Brugada phenocopy. The early repolarisation morphology showed a paradox association with the cardiac cycle length; a relationship not yet documented in SAH. Our observation also sheds light on the genesis of the "spiked helmet" ECG sign.

Duodenal ulcer perforation is very uncommon in the pediatric population; hence, it is usually not considered in the differential diagnosis of acute abdomen in this age group. In our small community hospital, we had two rare cases of perforated peptic ulcer in the pediatric population within a short span of time. A 14-year-old male and a 13-year-old female child presented to the emergency room with acute abdominal pain. No other symptoms were reported and neither had any history of peptic ulcer disease. Abdominal CT showed pneumoperitoneum consistent with perforated hollow viscus. Subsequent exploratory laparotomy indicated perforated duodenal ulcer in both children. These cases illustrate that perforated peptic ulcers should be considered in children presenting with acute abdomen.

Appendectomy for presumed appendicitis is the most common surgical emergency during pregnancy. Delayed diagnosis and treatment of appendicitis carries risk for the fetus and mother. We sought to evaluate the accuracy of MRI in pregnant patients with suspected appendicitis. All pregnant patients with suspected appendicitis between January 2014 and April 2016 were included. MRI reports were categorized into positive, negative, and inconclusive groups. Diagnosis of appendicitis was based on pathology report. Fifty-two patients were included in the study. The MRI was positive in two, negative in 29, and inconclusive in 21 patients. Twelve patients had surgery, 11 of which had positive appendicitis on pathology. Both positive MRI patients had appendicitis. In the negative MRI group, 3 of 29 (10%) had appendicitis. In the inconclusive MRI group, 6 of 21 (29%) had appendicitis. A positive MRI result was very specific with a 100 per cent positive predictive value; however, the sensitivity was as low as 18 per cent (diagnosed only 2 of 11 cases). Although a positive MRI finding was reliable in making a decision to operate, a negative or inconclusive MRI was not. In patients with a high clinical suspicion of appendicitis, surgery should still be considered even without definitive positive MRI findings.

This study deals with populations of the European-South-Siberian geoelement Adenophora liliifolia (L.) A. DC. in the Czech Republic, Slovakia, Hungary, Romania, and Poland, where this species has its European periphery distribution. We studied the population size, genetic variability, site conditions, and vegetation units in which A. liliifolia grows. Recent and historical localities of A. liliifolia were ranked into six vegetation units of both forest and non-forest character. A phytosociological survey showed differences in the species composition among localities. Only a weak pattern of population structure was observed (only 22% of total genetic variation present at the interpopulation level, AMOVA analysis), with moderate values for gene diversity (Hj = 0.141) and polymorphism (P = 27.6%). Neighbor-joining and Bayesian clusterings suggest a similar genetic background for most of the populations from Slovakia, the Czech Republic, and Poland, contrary to the populations from Hungary, Romania, as well as two populations from Central and South Slovakia. This might be explained by a relatively recent fragmentation of the A. liliifolia populations in Central Europe. Nevertheless, it seems that several populations in Romania, South Hungary, and Slovakia were isolated for a longer period of time and their genetic differentiation is more evident.

Aim: Patients in the intensive care unit (ICU) have significantly increased mortality rates. Frequently, clinicians are called upon to help families make decisions regarding aggressiveness of care. Having a realistic expectation of outcome is critical for these discussions. This article looked at survival and outcomes following initiation of vasopressors. Methods: All patients admitted to the ICU between January and June 2011were included. Patients were classified into those who had been started on vasopressors (VP+) and those who had not (VP−). Outcomes of these groups including survival were calculated and compared. Results: A total of 1023 patients were included: 169 in the VP+ group and 854 in the VP− group. The survival rate in the VP+ group was 29.6% compared to 92.0% in the VP− group. This was both clinically and statistically significant ( P < .001). Conclusion: Patients started on vasopressors in the ICU have very poor outcomes. Being able to quantify this accurately is important to clinicians having discussions with family members.

Digital pathology is a relatively new field that stands to gain from modern big data and machine learning techniques. In the United States alone, millions of pathology slides are created and interpreted by a human expert each year, suggesting that there is ample data available to support machine learning research. However, the relevant corpora that currently exist contain only hundreds of images, not enough to develop sophisticated deep learning models. This lack of publicly accessible data also hinders the advancement of clinical science. Our digital pathology corpus is an effort to place a large amount of clinical pathology images collected at Temple University Hospital into the public domain to support the development of automatic interpretation technology. The goal of this ambitious project is to create a corpus of 1M images. We have already released 10,000 images from 600 clinical cases. In this paper, we describe the corpus under development and discuss some of the underlying technology that was developed to support this project.

Appendectomy for presumed appendicitis is the most common surgical emergency during pregnancy. Delayed diagnosis and treatment of appendicitis carries risk for the fetus and mother. We sought to evaluate the accuracy of MRI in pregnant patients with suspected appendicitis. All pregnant patients with suspected appendicitis between January 2014 and April 2016 were included. MRI reports were categorized into positive, negative, and inconclusive groups. Diagnosis of appendicitis was based on pathology report. Fifty-two patients were included in the study. The MRI was positive in two, negative in 29, and inconclusive in 21 patients. Twelve patients had surgery, 11 of which had positive appendicitis on pathology. Both positive MRI patients had appendicitis. In the negative MRI group, 3 of 29 (10%) had appendicitis. In the inconclusive MRI group, 6 of 21 (29%) had appendicitis. A positive MRI result was very specific with a 100 per cent positive predictive value; however, the sensitivity was as low as 18 per cent (diagnosed only 2 of 11 cases). Although a positive MRI finding was reliable in making a decision to operate, a negative or inconclusive MRI was not. In patients with a high clinical suspicion of appendicitis, surgery should still be considered even without definitive positive MRI findings.

Perforation of the gastrointestinal tract may present with abdominal pain and imaging demonstrating pneumoperitoneum. These findings usually require exploratory laparotomy for diagnosis and treatment. Tubo-ovarian abscess (TOA) is a complication of pelvic inflammatory disease presenting as an encapsulated inflammatory mass, but it can occasionally involve other pelvic organs. TOA is most commonly seen in females of reproductive age. Here we report a case of a 63-year-old female presenting with abdominal pain, fever and vomiting. Chest x rays and computed tomography scan revealed pneumoperitoneum. Emergent exploratory laparotomy was performed, and the findings were consistent with TOA and intact bowel. The patient recovered well after surgery with antibiotic therapy. In conclusion, while pneumoperitoneum is mostly caused by perforation of the gastrointestinal tract, other possibilities such as gynecological complications should be considered.

Objective. Despite much effort, obesity remains a significant public health problem. One of the main contributing factors is patients’ perception of their target ideal body weight. This study aimed to assess this perception.Methods. The study took place in an urban area, with the majority of participants in the study being Hispanic (65.7%) or African-American (28.0%). Patients presented to an outpatient clinic were surveyed regarding their ideal body weight and their ideal BMI calculated. Subsequently they were classified into different categories based on their actual measured BMI. Their responses for ideal BMI were compared.Results. In 254 surveys, mean measured BMI was 31.71 ± 8.01. Responses to ideal BMI had a range of 18.89–38.15 with a mean of 25.96 ± 3.25. Mean (±SD) ideal BMI for patients with a measured BMI of P<0.001, ANOVA).Conclusions. Most patients had an inflated sense of their target ideal body weight. Patients with higher measured BMI had higher target numbers for their ideal BMI. Better education of patients is critical for obesity prevention programs.

Inadequate pain control after ambulatory surgery can lead to unexpected return visits to the hospital. The purpose of this study was to compare patients based on which medications they were prescribed and to see whether this affected the rate of return to the hospital. A retrospective chart review of patients who underwent ambulatory laparoscopic cholecystectomy between January 2009 and December 2013 was performed. Patients were divided into two groups based on the pain medication prescribed after surgery: Opioids and nonopioids. Patients returning to the Emergency room (ER) within seven days were evaluated. If no complication or other diagnosis was identified, the patient was considered to have returned for inadequate pain control. The two groups were statistically compared with each other using Fisher's exact chi-squared test. A total of 749 patients underwent laparoscopic cholecystectomy during the study period: 180 (25.2%) were prescribed opioids, whereas, 560 (74.8%) were prescribed nonopioids. In the nonopioid group, 14 (1.9%) returned to the ER for pain, whereas no patient in the opioid group returned for pain. This difference was statistically significant ( P = 0.027). In conclusion, patients who were given opioid pain medications after ambulatory laparoscopic cholecystectomy were less likely to return to the ER for pain. This implied that opioids were better at pain control and helped avoid the costs of unnecessary ER visits. Future research should be aimed at more direct measures of pain control, as well as the role of opioids after inpatient surgery.

Because of work hour regulations, many surgical residency programs have moved to a night float system. Previously, our medical students took call for 24 hours, whereas currently they also follow a night float system. This study looked at their evaluations of these 2 systems.Students were anonymously surveyed to evaluate the rotation (on a 5-point scale) as well as various components including night call. Responses from each group were compared.There were 104 students included: 46 in the traditional 24-hour call group and 58 in the night float group. Students rated night call significantly higher in the night float system (4.62 ± .64 vs 3.52 ± 1.00, P.001). There was no difference in the other components or the overall evaluation.After switching to a night float system, students had a much more positive perception of their night call experience. We believe more clerkships should switch to a night float system.

Appendicitis has always been an indication for an urgent operation, as delay is thought to lead to disease progression and therefore worse outcomes. Recent studies suggest that appendectomy can be delayed slightly without worse outcomes, however the literature is contradictory. The goal of our study was to examine the relationship between this delay to surgery and patient outcomes. We reviewed all patients that underwent an appendectomy in our institution from January 2009 to December 2010. We recorded the time of surgical diagnosis from when both the surgical consult and the CT scan (if done) were completed. The delay from surgical diagnosis to incision was measured, and patients were divided into two groups: early (≤6 hours delay) and late (>6 hours delay). Outcome measures were 30-day complication rate, length of stay, perforation rate, and laparoscopic to open conversion rate. Three hundred and seventy-seven patients had appendectomies in the study period, and 35 patients were excluded as per the exclusion criteria leaving 342 in the study: 269 (78.7%) in the early group and 73 (21.3%) in the late group. Complications occurred in 21 patients (6.1%) with no difference between the groups: 16/253 (5.9%) in the early group and 5/73 (6.8%) in the late group ( P = 0.93, χ2). The mean (± standard deviation) length of stay was 86.1 ± 67.1 hours in the early group, and 95.9 ± 73.0 hours in the late group. This difference was not significant ( P = 0.22). Delaying an appendectomy more than 6 hours, but less than 24 hours from diagnosis is safe and does not lead to worse outcomes. This can help limit the disruption to the schedules of both the surgeon and the operating room.

Laparoscopic cholecystectomy is the gold-standard procedure for management of symptomatic gallstone disease. Increased rates of conversion to an open procedure, increased postoperative complications, and longer lengths of stay are seen in thick-walled gallbladders. Previous studies have only evaluated gallbladder walls as being thick or not thick, without looking at the degree of thickness. We hypothesized that, the more severe the wall thickening, the greater the chance of conversions and complications, and the longer the lengths of stay. All attempted laparoscopic cholecystectomies in our institution between 2006 and 2009 were retrospectively reviewed. Patients undergoing cholecystectomy for reasons other than gallstones (e.g., polyps or cancer) and those without preoperative ultrasounds were excluded. Patients were divided into four groups based on the degree of gallbladder wall thickness: normal (1–2 mm), mildly thickened (3–4 mm), moderately thickened (5–6 mm), and severely thickened (7 mm and above). Outcomes were compared amongst the groups. 874 patients were included in the study. There were 68 conversions (7.8 %) and 58 complications (6.6 %). The incidence of conversions was 3.1, 5.1, 14.9, and 16.8 % in the four groups, respectively (p

A study tracking thermotolerant campylobacters from the setting of the broilers throughout the whole rearing period, slaughter and sale of chicken products in five consecutive broiler rotations of the same henhouse as well as in two different other farms was conducted in a well-defined geographic area (Hajdu-Bihar county, Hungary) between March 2006 and Feb 2007. All notified cases of human campylobacteriosis in this area during the study period were also included. One hundred and one, 44, 23 and 282 Campylobacter jejuni and 13, 15, 20 and 60 C. coli were isolated from broiler houses, slaughterhouses, retail shops and human samples, respectively. Sixty-two isolates collected from broilers or their environment selected from different flocks (57 C. jejuni , 5 C. coli ), 92 isolates collected from abattoirs and retail shops (72 C. jejuni , 20 C. coli ), as well as 85 randomly selected human isolates (74 C. jejuni , 11 C. coli ) were subjected to PFGE analysis using restriction enzymes Kpn I and Sma I. Sixty-six of the isolates produced unique Sma-Kpn profiles; the majority (46) of these were of human origin. The remaining isolates formed PFGE clusters of between 2–25 isolates with 14 (12 C. jejuni and 2 C. coli ) main clusters comprised of five or more isolates with identical Kpn I- Sma I patterns. Two genetic clones of C. jejuni (clone A, n = 25; clone B, n = 20) included 18% of isolates from different sources. Generally, isolates from one cluster were found in 1–3 different flocks, notably, clone B was present in three rotations including those from the two independent farms. Six of the seven investigated flocks had one or two characteristic prevalent clones. Transmission of clones between consecutive flocks was frequently seen. Spread of both C. jejuni and C. coli was traced multiple times along the food chain; eight C. jejuni , but no C. coli clones were detected both in broilers and humans. These data suggest that broilers were the major source for C. jejuni but not for C. coli in the studied area and period. For C. jejuni the carryover of strains between consecutive flocks may be a common event, but the strain is eventually replaced by another and consecutive carryover events seem to be infrequent. The majority of the human disease was due to nonepidemic strains; some clones were transmitted from more than one broiler flocks (including epidemiologically unrelated flocks) to humans multiple times.

Laparoscopic cholecystectomy (LC) is the standard of care for gallstone disease. Some cases will be converted to open surgery and others will have complications, both leading to worse outcomes. The purpose of this study was to evaluate whether an increased body mass index (BMI) is associated with increased rates of conversion or complication.A retrospective chart review of 1,027 patients who underwent an attempted LC between January 2006 and December 2009 was performed. Patients were divided into five groups depending on their BMI: 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, and ≥ 40. The primary endpoints were conversion rates, complication rates, and postoperative length of stay (LOS). Multivariate logistic regression was used to identify independent risk factors for worse outcomes.There were 211 (20.5%), 325 (31.6%), 268 (26.1%), 135 (13.1%), and 88 (8.6%) patients in the groups with BMI values of 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, and ≥ 40, respectively. Seventy-three patients (7.1%) required conversion to open surgery, and 64 patients (6.2%) developed complications. The rate of conversion was similar amongst all the BMI groups (P = 0.366), as was the rate of complication (P = 0.483). Mean (± SD) postoperative LOS was 1.74 ± 3.87 days, and there was no difference between the BMI groups (P = 0.596). Male gender and emergent cholecystectomy were independent predictors of increased conversions and complications. Diabetes was a risk factor for conversion, whereas age65 years was a risk factor for complications.Increased BMI was not associated with worse outcomes after LC. Compared with normal weight patients, obese and even morbidly obese patients have no increased risk of conversion to open surgery, nor is there an increased risk of perioperative complications. Obese and morbidly obese patients who require a cholecystectomy should be considered in the same category as normal weight patients, and LC should be the standard of care.

Aims: We developed, optimized and tested two novel PCR assays specific for Salmonella enterica subspecies enterica serovar Infantis. Methods and Results: The fljB gene was chosen as the target sequence. Primers were designed on a consensus sequence built by sequencing the fljB gene of five genetically unrelated Hungarian S. Infantis strains and using sequence data from the GenBank (http://www.ncbi.nih.gov). Two alternative assays were designed, which share the reverse primer. Both proved to be highly specific to S. Infantis, neither reacted with 42 other nontyphoidal serovariants tested. The detection limit of the assays was determined to be 105 CFU ml−1 from pure culture, and 106 CFU g−1 from artificially spiked chicken faeces samples. Conclusions: Although the detection limit is rather high to allow for using them for direct detection, the assays may be useful in identification of S. Infantis both for diagnostic and for research purposes. Significance and Impact of the Study: The described PCR assays allow for the correct identification of S. Infantis even when traditional serotyping methods fail because lack of expression of flagellar antigens.

Summary A duplex reverse transcription-polymerase chain reaction (dRT-PCR) assay has been developed for the simultaneous, rapid and specific detection/discrimination of avian influenza virus (AIV) and Newcastle disease virus (NDV). Primers targeting the matrix protein gene (M) of AIV and the fusion protein gene (F) of NDV were evaluated experimentally with 13 AIV and 19 NDV strains. PCR products of the expected size of 144 bp and 316 bp were amplified from AIV/NDV samples, respectively, while no cross-reaction was observed with negative controls or with 16 other avian pathogens. The endpoint of detection was defined as approximately 10+0.5 50% egg infectious dose (EID50)/0.2 ml for AIV and 10+2.2 EID50/0.2 ml for NDV. The assay was able to detect AIV/NDV with similar sensitivity in spiked stool samples and in specimens from vaccinated birds. The developed dRT-PCR assay is a rapid, cost-effective tool, which provides powerful novel means for the early diagnosis of avian influenza and Newcastle disease.

A 53-year-old man with multiple medical conditions presented to the emergency department with complaints of vomiting, anorexia and diffuse colicky abdominal pain for 3 d. A computed tomography scan of the abdomen and pelvis showed radiographic findings consistent with Rigler triad seen in small proportion of patients with small bowel obstruction secondary to gallstone impaction. In addition there was a gastric outlet obstruction, consistent with Bouveret’s syndrome. The patient underwent an exploratory laparotomy and enterotomy with multiple stones extracted. The patient had an uneventful post-surgical clinical course and was discharged home.

Inadequate pain control after ambulatory surgery can lead to unexpected return visits to the hospital. The purpose of this study was to compare patients based on which medications they were prescribed and to see whether this affected the rate of return to the hospital. A retrospective chart review of patients who underwent ambulatory laparoscopic cholecystectomy between January 2009 and December 2013 was performed. Patients were divided into two groups based on the pain medication prescribed after surgery: Opioids and nonopioids. Patients returning to the Emergency room (ER) within seven days were evaluated. If no complication or other diagnosis was identified, the patient was considered to have returned for inadequate pain control. The two groups were statistically compared with each other using Fisher's exact chi-squared test. A total of 749 patients underwent laparoscopic cholecystectomy during the study period: 180 (25.2%) were prescribed opioids, whereas, 560 (74.8%) were prescribed nonopioids. In the nonopioid group, 14 (1.9%) returned to the ER for pain, whereas no patient in the opioid group returned for pain. This difference was statistically significant (P = 0.027). In conclusion, patients who were given opioid pain medications after ambulatory laparoscopic cholecystectomy were less likely to return to the ER for pain. This implied that opioids were better at pain control and helped avoid the costs of unnecessary ER visits. Future research should be aimed at more direct measures of pain control, as well as the role of opioids after inpatient surgery.

To investigate the learning curve and perioperative outcomes of single-site robotic cholecystectomy during the first 102 cases by a single surgeon. A retrospective review of a prospectively maintained database was performed on the first 102 cases of single-site robotic cholecystectomy. Patients were divided into five chronological groups based on the date of surgery, with 20 patients in each group except the 5th group which had 22 patients. The groups were compared by docking time, robotic dissection time, and overall surgery time. A P value of 0.05 was used as statistically significant. The female to male ratio was 2:1. The mean age was 51 years (18–87) and the mean BMI was 28.26 (18–41). Overall, 69 % of the patients underwent elective cholecystectomy and 31 % required urgent surgery. In all, 17 % of patients had previous abdominal surgeries. In total, 45 % of procedures were regarded as same day surgery. The total mean length of stay was 1.97 days (0–8). The mean operative time was 110 min (36–265), mean robotic console time 70 min (26–179), and mean docking time 9 min (1–26). The overall conversion rate was 3.9 % and the complication rate was 4 %. The docking time, robotic time, and average operative time were significantly different in the first group as compared to the remaining the five groups (P = 0.001). Single-site robotic cholecystectomy is safe in both elective and urgent conditions, and in patients with previous abdominal surgeries. It has a short learning curve.

To compare the outcomes between the laparoscopic and open approaches for partial colectomy in elderly patients aged 65 years and over using the American College of Surgeons - National Surgical Quality Improvement Program (ACS NSQIP) database.The ACS NSQIP database for the years 2005-2011 was queried for all patients 65 years and above who underwent partial colectomy. 1:1 propensity score matching using the nearest- neighbor method was performed to ensure both groups had similar pre-operative comorbidities. Outcomes including post-operative complications, length of stay and mortality were compared between the laparoscopic and open groups. χ(2) and Fisher's exact test were used for discrete variables and Student's t-test for continuous variables. P0.05 was considered significant and odds ratios with 95%CI were reported when applicable.The total number of patients in the ACS NSQIP database of the years 2005-2011 was 1777035. We identified 27604 elderly patients who underwent partial colectomy with complete data sets. 12009 (43%) of the cases were done laparoscopically and 15595 (57%) were done with open. After propensity score matching, there were 11008 patients each in the laparoscopic (LC) and open colectomy (OC) cohorts. The laparoscopic approach had lower post-operative complications (LC 15.2%, OC 23.8%, P0.001), shorter length of stay (LC 6.61 d, OC 9.62 d, P0.001) and lower mortality (LC 1.6%, OC 2.9%, P0.001).Even after propensity score matching, elderly patients in the ACS NSQIP database having a laparoscopic partial colectomy had better outcomes than those having open colectomies. In the absence of specific contraindications, elderly patients requiring a partial colectomy should be offered the laparoscopic approach.

Background: Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP) both effectively treat the insulin resistance associated with type 2 diabetes mellitus (T2DM). Restriction of caloric consumption, alterations in the entero-insular axis or weight loss may contribute to lowering insulin resistance after these procedures. The relative importance of these mechanisms, however, following LAGB and LRYGBP remain unclear. The aim of this study was to compare directly the short-term changes in insulin resistance following LAGB and LRYGBP in similar populations of patients. Methods: Patient preference determined operation type. The Homeostasis Model Assessment for Insulin Resistance (HOMA IR) was used to measure insulin resistance. Preoperative values were compared to postoperative levels obtained within 90 days of surgery. Significant differences between groups were tested by ANOVA. Results: There were no significant preoperative differences between groups. The 56 LAGB patients had a mean age of 42.5 years (25.7-63), BMI of 45.5 kg/m2 (35-66) and preoperative HOMA IR of 4.1 (1.4-39.2). 75% of LAGB patients were female and 43% had T2DM. The 61 LRYGBP patients had a median age of 39.9 years (22.1-64.3), BMI of 45.0 kg/m2 (36-62), and preoperative HOMA IR of 5.0 (0.6-56.5). 79% of LRYGBP patients were women and 44.3% had T2DM. Median follow-up for LAGB patients was 45 days (18-90) and for LRYGBP patients 46 days (8-88 days). LAGB patients had a median of 14.8% excess weight loss (6.9%-37.0%) and LRYGB patients 24.2% (9.8%-51.4%). Postoperative HOMA IR was significantly less after LRYGBP, 2.2 (0.7-12.2), than LAGB, 2.6 (0.8-29.6), although change in HOMA IR was not significantly different. Change in HOMA IR for both groups did not vary with length of follow-up or weight loss but correlated best with preoperative HOMA IR (LAGB r=0.8264; LRYGBP r=0.9711). Conclusions: Both LAGB and LRYGBP significantly improved insulin resistance during the first 3 months following surgery. Both operations generated similar changes in HOMA IR, although postoperative HOMA IR levels were significantly lower after LRYGBP. These findings suggest that caloric restriction plays a significant role in improving insulin resistance after both LAGB and LRYGBP.

Introduction: Percutaneous nephrolithotomy is generally considered a safe option for the management of large complex or infectious upper urinary tract calculi. Biliary tract injury is a rare and potentially serious complication of percutaneous nephrolithotomy that can even lead to mortality, especially in cases where biliary peritonitis develops. All reported cases of biliary tract injury have been managed by either open or laparoscopic cholecystectomy. Case Presentation: Herein for the first time, we report a 39-year old woman with biliary tract injury following percutaneous nephrolithotomy who was managed less invasively by insertion of a percutaneous cholecystostomy tube. The patient was discharged home shortly thereafter, and the tube was later removed at a follow up visit after a normal cholangiogram. Conclusions: Biliary tract injury is a rare and potentially serious complication of percutaneous nephrolithotomy that can even lead to mortality. If a biliary tract injury is suspected during percutaneous renal procedures, diverting the bile away from the leak may resolve the problem without the need for a cholecystectomy. Ideally this can be done with ERCP and a stent, but in cases where this is not technically feasible; a percutaneous cholecystostomy can be successful at accomplishing the same result.

Introduction: The intrauterine device (IUD) is a popular family planning method worldwide. Some of the complications associated with insertion of an IUD are well described in the literature. The frequency of IUD perforation is estimated to be between 0.05 and 13 per 1000 insertions. There are many reports of migrated intrauterine devices, but far fewer reports of IUDs which have penetrated into the small intestine. Case Description: Herein we report a case of perforated intrauterine device embedded in the small intestine. By using a wound protector retraction device, and fashioning the anastomosis extra-corporeally, we were able to more easily perform this laparoscopically. This left the patient with a quicker recovery, and a better cosmetic result. Discussion: IUD perforation into the peritoneal cavity is a known complication, and necessitates close follow-up. Most, if not all, should be removed at the time of diagnosis. In the majority of previously reported cases, removal was done through laparotomy. Even in cases where removal was attempted laparoscopically, many were later converted to laparotomy. Surgeons should be aware of different techniques, including using a wound protector retraction device, in order to facilitate laparoscopic removal.

Transmitter- und/oder Modulatorsubstanzen –“Calcitonin gene related peptide” (CGRP), Substanz P (SP), Neuropeptid Y (NPY), vasointestinalen Polypeptid (VIP) – werden Beteiligung am Knochenwachstum, bei der Frakturheilung und am “internal remodeling” zugeschrieben. Der immunohistochemischen Nachweis neuropeptidpositiver Fasern im normalen Knochen last eine Wirkung in der Fruhphase der Frakturheilung vermuten. Es stellt sich die Frage nach dem Zeitpunkt des Erscheinens neuropeptidpositiver Fasern, ihrer Lokalisation, ihrer Chemospezifitat und ihrem Entstehungsmodus. Die Untersuchungen wurden an einem Distanzosteosynthesemodell der Kaninchentibia durchgefuhrt. Fur die indirekte immunohistochemische Technik wurden Primar- und Sekundarantikorper eingesetzt. Neben einer konventionellen statistischen Auswertung stand die anschauliche stereologische Berechnung der Nervenfaserlange/Gewebevolumen im Vordergrund. Nach histologischer Aufarbeitung von Gewebeproben, sowohl aus dem interfragmentaren Spalt als auch aus dem Mark, liesen sich mittels der indirekten immunohistochemischen Technik die Neuropeptide CGRP, SP und NPY darstellen. Das “sprouting” CGRP- und SP-erger Nervenfasern geht vom Markraum aus. Eine Vaskularisation in der Fruhphase der Osteoneogenese nach Fraktur erscheint ohne nervalpeptiderge Einflussnahme und/oder Vermittlung nicht denkbar.

A primer pair (p289/290) based on the RNA polymerase sequence of 25 prototype and currently circulating strains of human caliciviruses (HuCVs) was designed for the detection of both Norwalk-like caliciviruses (NLVs) and Sapporo-like caliciviruses (SLVs) by reverse transcription-polymerase chain reaction (RT-PCR). This primer pair produces RT-PCR products of 319 bp for NLVs and 331 bp for SLVs. The usefulness of this primer pair was shown by its detection of prototype NLVs (Norwalk, Snow Mountain, Hawaii and Mexico viruses) and SLVs (Sapporo/82, Hou/86, Hou/90 and Lon/92) and currently circulating strains of NLVs and SLVs in children and adults. This primer pair also detected more viruses in either NLV or SLV genera than previously designed primers. This primer pair is useful for broad detection of HuCVs for clinical and epidemiologic studies as well as for environmental monitoring.

The chicken has been considered as the natural host for chicken anaemia virus (CAV). To examine the prevalence of CAV in domestic and wild birds in Japan, we analyzed serum samples collected from 211 chickens, 168 Japanese quail, 105 pigeons, 113 ducks and 116 crows for the presence of antibodies to CAV by a micro-scale virus neutralization (VN) test. Nine of the 13 chicken flocks (69.2%) were found to be positive for VN antibodies to CAV. Of the 211 individual chicken serum samples, 127 (60.2%) were positive. VN antibodies were detected in 103 of the 168 (61.3%) quail samples with titres ranging from 1:20 to >/= 1:2560. Serum samples collected from quail in 1992 were found to possess a lower rate of antibody-positive sera (7.7%) and lower antibody titres (1:20 to 1:80) than those collected in 1995 (90.2% and 1:20 to >/= 1:2560, respectively). None of the pigeon, duck and crow samples neutralized CAV at a 1:20 dilution. These results indicate that quail might be one of the hosts of CAV or CAV-like virus in Japan. This is the first report of VN antibodies to CAV in a species other than chicken.

The separation of enantiomers of ten chiral arylpropionic acid derivatives was studied on six different polysaccharide-based chiral HPLC columns with various normal-phase eluents. Along with the successful separation of analyte enantiomers, the emphasis of this study was on the effect of the chiral selector and mobile phase composition as well as of the separation temperature on the elution order of enantiomers. The interesting phenomena of reversal of enantiomer elution order function of the polysaccharide backbone (cellulose or amylose), type of derivative (carbamate or benzoate), nature and position of the substituent(s) in the phenylcarbamate moiety, the polar modifier of the mobile phase (ethanol or 2- propanol), its content in the mobile phase, and separation temperature were investigated. In addition, an unusual increase in retention with increasing temperature was observed for some arylpropionic acid derivatives.

Part of the ongoing healthcare debate is the care of uninsured patients. A common theory is that without regular outpatient care, these patients present to the hospital in the late stages of disease and therefore have worse outcomes. The purpose of this study was to evaluate any differences in outcomes after laparoscopic cholecystectomies between insured and uninsured patients. We reviewed all laparoscopic cholecystectomies (LC) done in our institution between 2006 and 2009. Patients were divided into two groups: insured patients (IP) and uninsured patients (UIP). Outcomes, including conversion and complication rates and postoperative length of stay (LOS), were collected and statistically analyzed using χ2 and ANOVA tests. There were 1,090 LCs done during the study period: 944 patients (86.6 %) were insured (IP) and 146 (13.4 %) were uninsured (UIP). In the IP group there were 63/944 (6.7 %) conversions and 59/944 (6.3 %) complications, while in the UIP group there were 15/146 (10.3 %) conversions and 12/146 (8.2 %) complications. There was no statistically significant difference in either of these categories. Mean (±SD) LOS was 1.73 ± 4.34 days for the IP group and 2.72 ± 4.35 days for the UIP group (p = 0.010, ANOVA). Uninsured patients were much more likely to have emergency surgery (99.3 % vs. 47.9 %, p

Screening can increase early detection and reduce rates of advanced-stage cancer. Uninsured patients have been shown to have lower rates of screening. Previous studies have shown that uninsured patients and patients with Medicaid present with more advanced stages of cancer. The aim of this study was to measure the effect of insurance status in the setting of a safety-net hospital.Patients in our tumor registry with a diagnosis of breast or colorectal cancer between 2001 and 2010 were included. On the basis of their insurance status, they were divided into the following groups: Medicaid, Medicare, Medicare age65 years, commercial, uninsured, and unknown. Cancer stage was recorded for each patient, with stages III and IV considered advanced disease. The primary end point was the rate of advanced disease in each patient group.A total of 910 patients were included in the study: 836 (91.9%) insured, 54 (5.9%) uninsured, and 20 (2.2%) unknown. Of the insured patients, 301 (36.0%) had Medicaid; 237 (30.7%) of 836 insured patients had advanced disease, compared with 27 (50.0%) of 54 uninsured patients (odds ratio, 1.63; P = .003). Of patients with Medicaid, 83 (27.6%) of 301 had advanced disease, which was not statistically different from patients with other insurance.In a safety-net hospital, patients with Medicaid had rates of advanced-stage cancer similar to those in patients with other types of insurance. However, patients with no insurance had significantly higher rates of advanced disease. This has significant ramifications in view of the new healthcare law, which will convert many patients from being uninsured to having Medicaid.

Macaques are commonly used in biomedical research as animal models of human disease. The ABO phenotype of donors and recipients plays an important role in the success of transplantation and stem cell research of both human and macaque tissue. Traditional serological methods for ABO phenotyping can be time consuming, provide ambiguous results and/or require tissue that is unavailable or unsuitable. We developed a novel method to detect the A, B, and AB phenotypes of macaques using real-time quantitative polymerase chain reaction. This method enables the simple and rapid screening of these phenotypes in macaques without the need for fresh blood or saliva. This study reports the distribution of the A, B, and AB phenotypes of captive cynomolgus macaques that, while regionally variable, closely resembles that of rhesus macaques. Blood group B, as in rhesus macaques, predominates in cynomolgus macaques and its frequency distribution leads to a probability of major incompatibility of 41%. No silencing mutations have been identified in exon 6 or 7 in macaques that could be responsible for the O phenotype, that, although rare, have been reported. The excess homozygosity of rhesus and cynomolgus macaque genotypes in this study, that assumes the absence of the O allele, suggests the possibility of some mechanism preventing the expression of the A and B transferases.

A real-time reverse-transcription PCR was developed to detect and pathotype Newcastle disease viruses (NDV) in clinical samples. Degenerate oligonucleotide primers and TaqMan probes with nonfluorescent minor groove binder (MGB) quencher amplified and hybridized to a region in the fusion protein (F) gene that corresponds to the cleavage site of the F0 precursor, which is a key determinant of NDV pathogenicity. The application of degenerate primers and TaqMan MGB probes provided high specificity to the assay, as was shown by the successful and rapid pathotype determination of 39 NDV strains representing all the known genotypes (I to VIII) and pathotypes (lentogens/mesogens/velogens). The PCR assays specific for lentogenic and velogenic/mesogenic strains had high analytical sensitivity, detecting approximately 10 and 20 copies of the target molecule per reaction, respectively. The detection limit was also determined in terms of 50% egg infective dose (EID 50 ) by using dilution series of virus stock solutions to be approximately 10 1.0 and 10 −1.3 EID 50 /ml for lentogens and velogens/mesogens, respectively. Organ, swab, and stool specimens from experimentally infected animals were tested to prove the clinical suitability of the method. The results of this study suggest that the described real-time PCR assay has the potential to be used for the rapid detection/pathotyping of NDV isolates and qualitative/quantitative measurement of the virus load.

The phospholipid composition of Steinernema carpocapsae was studied in relation to diet and culture temperature. When reared at 18 and 27.5 C on Galleria mellonella or on an artificial diet supplemented with lard, linseed oil, or fish oil as lipid sources, nematode phospholipids contained an abundance of 20-carbon polyunsaturated fatty acids, with eicosapentaenoic acid (20:5(n - 3)) predominant, regardless of the fatty acid composition of the diet. Because the level of linolenic acid (18:3(n - 3)) in nematode phospholipids was very low and because eicosapentaenoic acid was present even when its precursor (linolenic acid) was undetectable in the diet, S. carpocapsae likely produces n - 3 polyunsaturated fatty acids by de novo biosynthesis, a pathway seldom reported in eukaryotic animals. Reduction of growth temperature from 25 to 18 C increased the proportion of 20:5(n - 3) but not other polyunsaturated fatty acids. A fluorescence polarization technique revealed that vesicles produced from phospholipids of nematodes reared at 18 C were less ordered than those from nematodes reared at 27.5 C, especially in the outermost region of the bilayer. Dietary fish oil increased fluidity in the outermost region but increased rigidity in deeper regions. Therefore, S. carpocapsae appears to modify its membrane physical state in response to temperature, and eicosapentaenoic acid may be involved in this response. The results also indicate that nematode membrane physical state can be modified dietarily, possibly to the benefit of host-finding or survival of S. carpocapsae at low temperatures.

The ever increasing complexity of electronic products of modern cars - like drive-by-wire systems - means that a very broad range of simulation must be used in the early phases of the development process to predict the product characteristics. Activities in the preparative development departments of leading german car manufactures show the challenges by the development of mechatronic products and the need for simulation of mechatronic systems. For an early validation of vehicle functionalities special simulators are used for specific domains - like mechanics, electronics and software. To provide timely simulation and review for complete mechatronic components, these simulators need first to be coupled with one another, to have an interdisciplinary behavior. The objective of our approach is the development of a distributed framework for cooperative multi-domain simulation, validation and debugging of complex mechatronic system behavior. The feasibility of our approach is shown by a case study of an automotive mechatronic system.

A presentation of the method of Near Field Signature Analysis as a tool for diagnostic failure localization in high frequency circuit assemblies will be given. Traditional techniques of localizing faults in RF circuits rely heavily on manual methods and ATE approaches have limitations based on how much intelligence can be embedded into the software. Following the trends of robotic application, this method combines precise mechanical positioning and non-contact probing with local synthetic measurement technology. The technique can shorten the time to diagnosis by augmenting the ATE with more positional information and save manual labor by creating an automated parallel operation for failed RF assemblies. It also may generate data of a prognostic value. A case study will be used to demonstrate quantitatively the possibilities and limitations of the technology. Multiple units of a typical microwave circuit assembly will be examined with this method at several measurement points. A following set of measurements on failing assemblies will be then be presented and compared with the reference measurements and their respective known-good measurements.