Spade-Shaped Anastomosis after Laparoscopic Proximal Gastrectomy Using Double Suture Anchoring between the Posterior Wall of the Esophagus and the Anterior Wall of the Stomach (SPADE Operation): A Case Series

We introduced SPADE operation, a novel anastomotic method after laparoscopic proximal gastrectomy (PG). Technical modifications were performed and settled. This report aimed to demonstrate the short-term clinical outcomes after settlement. Data from 34 consecutive patients who underwent laparoscopic PG with SPADE between June 2017 and March 2020 were retrospectively reviewed. Reflux was evaluated based on the patients’ symptoms and follow-up endoscopy using Los Angeles (LA) classification and RGB Classification (Residue, Gastritis, Bile). Other complications were classified using the Clavien–Dindo method. The incidence of reflux esophagitis was 2.9% (1/34). Bile reflux was observed in six patients (17.6%), and residual food was observed in 16 patients (47.1%) in the endoscopy. Twenty-eight patients had no reflux symptoms (82.4%), while five patients (14.7%) and one patient (2.9%) had mild and moderate reflux symptoms, respectively. The rates of anastomotic stricture and ileus were 14.7% (5/34) and 11.8% (4/34), respectively. No anastomotic leakage was observed. The incidence of major complications (Clavien-Dindo grade III or higher) was 14.7%. The SPADE operation following laparoscopic PG is effective in reducing gastroesophageal reflux. Its clinical usefulness should be validated using prospective clinical trials.

Mutation of Mycobacterium tuberculosis and Implications for Using Whole-Genome Sequencing for Investigating Recent Tuberculosis Transmission

Tuberculosis (TB) control programs use whole-genome sequencing (WGS) of Mycobacterium tuberculosis (Mtb) for detecting and investigating TB case clusters. Existence of few genomic differences between Mtb isolates might indicate TB cases are the result of recent transmission. However, the variable and sometimes long duration of latent infection, combined with uncertainty in the Mtb mutation rate during latency, can complicate interpretation of WGS results. To estimate the association between infection duration and single nucleotide polymorphism (SNP) accumulation in the Mtb genome, we first analyzed pairwise SNP differences among TB cases from Los Angeles County, California, with strong epidemiologic links. We found that SNP distance alone was insufficient for concluding that cases are linked through recent transmission. Second, we describe a well-characterized cluster of TB cases in California to illustrate the role of genomic data in conclusions regarding recent transmission. Longer presumed latent periods were inconsistently associated with larger SNP differences. Our analyses suggest that WGS alone cannot be used to definitively determine that a case is attributable to recent transmission. Methods for integrating clinical, epidemiologic, and genomic data can guide conclusions regarding the likelihood of recent transmission, providing local public health practitioners with better tools for monitoring and investigating TB transmission.

Thermal Suitability of the Los Angeles River for Cold Water Resident and Migrating Fish Under Physical Restoration Alternatives

Anthropogenic development has adversely affected river habitat and species diversity in urban rivers, and existing habitats are jeopardized by future uncertainties in water resources management and climate. The Los Angeles River (LAR), for example, is a highly modified system that has been mostly channelized for flood control purposes, has altered hydrologic and hydraulic conditions, and is thermally altered (warmed), which severely limits the habitat suitability for cold water fish species. Efforts are currently underway to provide suitable environmental flows and improve channel hydraulic conditions, such as depth and velocity, for adult fish migration from the Pacific Ocean to upstream spawning areas. However, the thermal responses of restoration alternatives for resident and migrating cold water fish have not been fully investigated. Using a mechanistic model, we simulated the LAR’s water temperature under baseline conditions and future alternative restoration scenarios for migration of the native, anadromous steelhead trout in Southern California and the historically resident Santa Ana sucker. We considered three scenarios: 1) increasing roughness of the low-flow channel, 2) increasing the depth and width of the low-flow channel, and 3) allowing subsurface inflow to the river at a soft bottom reach in the LA downtown area. Our analysis indicates that the maximum weekly average temperature (MaxWAT) in the baseline condition was 28.9°C, suggesting that the current river temperatures would act as a limiting factor during the steelhead migration season and habitat for Santa Ana sucker. The MaxWAT dropped about 3%–28°C after applying all the considered scenarios at the study site, which is 3°C higher than the determined steelhead survival threshold. Our simulations suggest that without consideration of thermal restoration, restoring hydraulic conditions may be insufficient to support cold water fish migration or year-round resident native fish populations, particularly with potential river temperature increases due to climate change.

Readability Analysis of Otolaryngology Consent Documents on the iMed Consent Platform

ABSTRACT Introduction The American Medical Association (AMA) and National Institutes of Health (NIH) recommend all patient information and consent materials be provided at the fourth- to sixth-grade level. The iMed Consent platform is used nationally by the Veterans Health Administration and private hospitals. We aimed to assess the readability of otolaryngology consents at the West Los Angeles Veterans Affairs (WLA-VA) hospital to determine whether they conform with AMA/NIH guidelines. Materials and Methods A readability analysis of 27 otolaryngology iMed consent documents was performed. The main outcome measure was the Flesch–Kincaid Grade Level (FKGL). The setting of the study was an otolaryngology clinic at a major VA hospital. All consents used in the WLA-VA otolaryngology clinic for the month of October 2018 were analyzed using readability metrics. These included the Flesch Reading Ease (FRE) score, the FKGL, the Gunning Fog Index (GFI), Simple Measure of Gobbledygook (SMOG), and Coleman–Liau Index (CLI). Results The following means of all consents were calculated for each of the readability metrics: FRE 56.3, FKGL 8.3, GFI 14.5, SMOG 11.3, and CLI 11.2. The standardized anesthesia and blood consent were analyzed separately with the following scores: FRE 45.1, FKGL 11.7, GFI 15.5, SMOG 14.6, and CLI 12.6. The average FKGL of the consents was found to be significantly above the sixth-grade level (P: .0013). Conclusion The average grade level of the otolaryngology iMed consents reviewed was at a reading level above the AMA/NIH recommendations. This objective measure should be taken into consideration when revising the iMed system and in the creation of future standardized consents. Readability analysis does not take into consideration the significant variance that exists as part of the verbal consent process that takes place between patient and provider.

Diversidad arbórea, uso y carbono almacenado en áreas con restauración productiva en Calakmul, Campeche

Los bosques tropicales de la Reserva de la Biosfera de Calakmul (REBICA) albergan una alta biodiversidad y brindan diversos servicios ecosistémicos amenazados por el avance de la frontera agropecuaria. La restauración productiva (RP), como estrategia que articula las necesidades de los productores y la conservación de los recursos naturales, fue implementada en módulos en los ejidos Benito Juárez II (BJ), Eugenio Echeverría Castellot I (EEC) y Los Ángeles (LA), aledaños a la REBICA. Los objetivos del trabajo fueron describir las estrategias de RP utilizadas y analizar las condiciones iniciales de composición, estructura, biomasa aérea y almacenamiento de carbono. Los ejidos EEC y LA se asociaron a sistemas agroforestales, mientras que en BJ se implementó un sistema silvopastoril, estimando densidades de 1 718 ind ha-1, 2 885 ind ha-1 y 1 854 ind ha-1 respectivamente. La diversidad verdadera (1D) varió de 20.8 en LA a 15.13 en EEC y 13.47 en BJ. Se reconocieron 16 usos potenciales para las especies identificadas de las cuales 47 estuvieron protegidas en los listados de CITES, UICN y la NOM-059. Los valores de carbono correspondieron a 6.96 Mg C ha-1 en BJ, 10.32 Mg C ha-1 en EEC y 34.40 Mg C ha-1 en LA. Las variaciones en la composición, estructura, biomasa y carbono estimadas indican que la estimación de esta línea base facilitará la generación de un programa de monitoreo que permita evaluar el impacto de las acciones de restauración implementadas y, en su caso, modificarlas para acelerar la recuperación de los atributos analizados.