Emerson Hospital

Abstract Background Single-anastomosis duodenal-ileal bypass and duodeno-ileal bipartition are effective metabolic surgeries but remain technically demanding due to the complexity and risk of duodeno-ileal anastomotic leaks.. Magnetic compression anastomosis using Self-Forming Magnets (SFM) offers a simplified, sutureless alternative that may reduce procedural risk. This study evaluated the feasibility, safety, and four-year outcomes of the SFM Sutureless Neodymium Anastomosis Procedure (SNAP) in patients with obesity and type 2 diabetes mellitus (T2DM). Methods This prospective, single-center study included patients with obesity and T2DM. The SNAP technique involved endoscopic and laparoscopic deployment of SFMs to create a duodeno-ileal anastomosis without sutures or staples. Primary endpoint was change in hemoglobin A1c (HbA1c) through 48 months. Secondary endpoints included percent total weight loss (%TWL) and safety outcomes. Results Fourteen patients (age 48 ± 9 years; 50% female; baseline BMI 40.4 ± 3.7 kg/m²) underwent successful SNAP creation (technical success 100%). Mean procedural time was 68 ± 20 minutes. No adverse events occurred. HbA1c significantly decreased from 8.3 ± 1.3% to 6.4 ± 0.6%, 6.6 ± 1.2%, 6.4 ± 1.5%, and 6.9 ± 1.8% at 12, 24, 36, and 48 months, respectively (all p < 0.05). Corresponding %TWL was 13.4 ± 8.6%, 14.2 ± 11.5%, 15.6 ± 13.6%, and 13.5 ± 12.9%. Conclusions SFM-assisted duodeno-ileal bipartition using the SNAP technique is feasible, safe, and durable, producing clinically meaningful and sustained weight loss and glycemic improvement over four years. This magnet-based, sutureless approach may represent a less invasive alternative to conventional duodeno-ileal anastomosis in metabolic surgery.

BackgroundValidity of the 2021 NINDS Traumatic Encephalopathy Syndrome (TES) criteria, proposed to diagnose chronic traumatic encephalopathy (CTE) in life, has not been assessed.MethodsBrain donors were selected across 6 brain banks (15+ donors each), 9 repetitive head impact (RHI)/traumatic brain injury (TBI) groups (15+ donors each): college or professional American football; less than college football; college or professional contact sports, not football; less than college contact sports, not football; military combat, no contact sports; military combat and contact sports, concussion with loss of consciousness, no RHI; moderate to severe TBI, no RHI; no RHI/TBI; and 5 age groups (25+ donors each): 20‐34; 35‐49; 50‐64; 65‐79; 80+. Blinded to clinical information, neuropathologists applied NINDS/NIBIB CTE neuropathological criteria and staging (I‐IV). Blinded to neuropathological information, clinicians interviewed informants and reviewed medical records, and an expert panel adjudicated TES diagnoses, including provisional levels of CTE certainty (suggestive/possible/probable). Clinical and neuropathological diagnoses were a priori dichotomized for primary and age‐stratified analyses: TES with possible/probable CTE vs. no TES/TES with suggestive CTE; CTE stages II‐IV vs. no CTE/stage I CTE.ResultsAmong 193 brain donors [men: 153 (79.3%), mean age: 66.4 (SD:22.0), white race: 158 (81.9%)], 57 (29.5%) donors met clinical criteria for TES with possible/probable CTE and 42 (21.8%) donors met neuropathological criteria for CTE stages II‐IV. Using neuropathological diagnosis as the gold‐standard, TES criteria sensitivity, specificity, positive likelihood ratio (LR) and negative LR were overall: 0.79, 0.84, 4.9, 0.25; age 50: 0.93, 0.90, 9.6, 0.07; age <50: 0.42, 0.66, 1.22, 0.89. Twenty‐four donors who met clinical but not neuropathological criteria (false‐positives), had stage I CTE (5) or other pathologies including vascular disease (11), Alzheimer's disease (9), Lewy body disease (2), motor neuron disease (2) and limbic predominant age‐related TDP43 encephalopathy (1). Nine donors who met neuropathological but not clinical criteria (false‐negatives) had TES with suggestive CTE (3), another etiology fully explain the syndrome (4), insufficient RHI exposure (1) or inconclusive course (1).ConclusionThe 2021 TES criteria were sensitive and specific for CTE pathology across a range of RHI/TBI exposures, particularly above age 50, raising optimism for use in clinical care.

In the era of immune checkpoint blockade, the role of cancer vaccines in immune priming has provided additional potential for therapeutic improvements. Prior studies have demonstrated delayed type hypersensitivity and anti-tumor immunity with vaccines engineered to secrete granulocyte-macrophage colony-stimulating factor (GM-CSF). The safety, efficacy and anti-tumor immunity of GM-CSF secreting vaccine in patients with previously treated stage III or IV melanoma needs further investigation. In this phase II trial, excised lymph node metastases were processed to single cells, transduced with an adenoviral vector encoding GM-CSF, irradiated, and cryopreserved. Individual vaccines were composed of 1x106, 4x106, or 1x107 tumor cells, and were injected intradermally and subcutaneously at weekly and biweekly intervals. The primary endpoints were feasibility of producing vaccine in stage III patients and determining the proportion of patients alive at two years in stage IV patients. GM-CSF vaccine was successfully developed and administered in all 61 patients. Toxicities were restricted to grade 1-2 local skin reactions. The median OS for stage III patients (n = 20) was 71.1 (95% CI, 43.7 to NR) months and 14.9 (95%CI, 12.1 to 39.7) months for stage IV patients. The median PFS in stage III patients was 50.7 (95%CI, 36.3 to NR) months and 4.1 (95% CI, 3.0-6.3) months in stage IV patients. In the overall population, the disease control rate was 39.3% (95%CI, 27.1 to 52.7%). In stage III patients, higher pre-treatment plasma cytokine levels of MMP-1, TRAIL, CXCL-11, CXCL-13 were associated with improved PFS (p<0.05 for all). An increase in post-vaccination levels of IL-15 and TRAIL for stage III patients was associated with improved PFS (p=0.03 for both). Similarly, an increase in post-vaccination IL-16 level for stage IV patients was associated with improved PFS (p=0.02) and clinical benefit. Vaccination with autologous melanoma cells secreting GM-CSF augments antitumor immunity in stage III and IV patients with melanoma, is safe, and demonstrates disease control. Luminex data suggests that changes in inflammatory cytokines and immune cell infiltration promote tumor antigen presentation and subsequent tumor cell destruction. Additional investigation to administer this vaccine in combination with immune checkpoint inhibitors is needed.

ObjectiveTo identify the differences in risk-factors between sexes and age in US rugby-7s.DesignLogistic regression.SettingUSA Rugby tournaments (U-19 to Elite; 2010–2016).Participants1,307 (68%=men, 31%=women) injured U.S. Rugby-7s players.Assessment of Risk FactorsA cross-sectional analysis using the RISERugby Injury Registry. Anthropometric data, injury mechanism, and other factors were tabulated by HNF injuries. Logistic regression determined relationship between sex and HNF injuries. A multivariable model was used to calculate the probability of HNF injuries and differences between sex.ResultsFrom 2010–2016, 1,679 match injuries were seen (68%=men, 32%=women). A total of 474 (28%) HNF injuries were documented. The most commonly injured body part was the head (48%) with concussions (40%). Final model revealed sex, age, position during contact, contact surface, and play legality were significantly associated with HNF injuries. Controlling for play-legality and position during contact, U18-men injured during contact with an opposing player had the highest probability of HNF injuries (51%) and a higher probability than U18 women (P=0.004). Meanwhile, women 18–24 (P=0.019) and over 30 (P=0.042) had a higher probability of HNF injury when injured during contact with the ground.ConclusionsUnder-18 male players involved in contact with players were most at risk for HNF injuries. Adult women 18–24 and 30-years old had a higher probability of sustaining a HNF injury during contact with the ground. Tackle techniques/execution, break falls, including collisions, employed by new rugby-7s players, should be studied for injury reduction.

Sleep disturbances (eg, insomnia, hypersomnia, poor sleep quality) are a prominent feature of bipolar disorder (BD). Furthermore, sleep difficulties are present across all phases of BD, including euthymia, and these difficulties contribute to the risk and maintenance of depressive and (hypo)manic episodes. Although existing pharmacological and psychosocial treatments offer hope for ameliorating sleep difficulties in BD, conventional treatments are limited in their ability to accurately capture detailed sleep patterns, detect early onset of sleep difficulties, and deliver personalized interventions. Widely accessible contemporary digital technologies show promise for mitigating these limitations and advancing sleep treatment for individuals with BD. We summarize and synthesize research examining the use of three digital tools for sleep assessment and intervention in BD: smartphone applications, ecological momentary assessment, and actigraphy. We also discuss the benefits, risks, and limitations of these technologies. [ Psychiatr Ann . 2023;53(11):496–501.]

Acute pancreatitis is an unusual cause of childhood abdominal pain, with a more varied etiology than adult-onset pancreatic inflammation. The most commonly encountered congenital causes of acute pancreatitis are developmental abnormalities of the pancreaticobiliary system, such as pancreas divisum, anomalous pancreaticobiliary ductal union, annular pancreas, choledochal cyst, ectopic pancreatic tissue sources, and enteric duplication cysts. These conditions may present with acute pancreatitis in childhood, but more often occur in adulthood. However, all of these anomalies have been reported without associated pancreatitis. Up to 10% of the Western population has been noted to have a congenital structural variant of the pancreas, but the majority of these variations are silent as the true incidence of pancreatitis is two orders of magnitude less. Biliopancreatic ductal system variants are sometimes encountered in the diagnostic evaluation of idiopathic acute pancreatitis, at which time their consequence and management provides the clinician with a significant question of relevance. When the cause of idiopathic acute pancreatitis is cryptic, an approach demonstrating a foundation in embryology and diligent investigation of nonanatomic congenital causes is necessary to direct appropriate therapy. Associated anomalies must also be sought, as in the case of annular pancreas. Previous case series in the literature provide useful longitudinal data to help in predicting outcomes and avoiding known pitfalls, although series are small by nature of the distribution of the cases they describe.

Introduction: Paxlovid (nirmatrelvir-ritonavir) received Emergency Use Authorization (EUA) for mild to moderate COVID-19 among those at high risk for severe disease. Hyponatremia is not yet listed as an adverse reaction to either Paxlovid or ritonavir alone in UpToDate. The package insert lists hyponatremia if Paxlovid is administered with finerenone, due to the increased concentration of finerenone caused by a drug-drug interaction. The EUA lists one case of mild hyponatremia in a patient with 10 other adverse events, none of which thought to be related to Paxlovid. The Liverpool COVID-19 website allows review of concomitant medications for drug interaction prior to prescribing, although it is unclear how widespread its use is among prescribers. The objective of this case series is to review 4 cases of severe hyponatremia in patients receiving Paxlovid that required intensive care unit (ICU) admission. Description: During a 6-week period from June to July 2022, our community hospital treated 7 adult patients in the ICU for severe hyponatremia, defined as sodium (Na) less than 120 mEq/L. Of those 7, three patients did not have COVID-19. The remaining four patients had been prescribed and were taking Paxlovid for COVID-19, with Na levels upon admission ranging from 112 to 115 mEq/L. Weakness, nausea and dehydration were all common side effects upon presentation. Use of the Liverpool COVID-19 interaction checker revealed a potential weak interaction in only 1 of 4 patients that venlafaxine concentrations could potentially be increased and venlafaxine has been associated with hyponatremia. With cessation of the drug and conventional treatment measures for severe hyponatremia including hypertonic saline, the hyponatremia corrected appropriately in all four cases. Discussion: COVID-19 itself has been associated with hyponatremia of unclear mechanism, however two large studies of 1099 & 5700 patients hospitalized for COVID-19 showed average Na levels of 138 & 136 mEq/L, respectively. We admitted 4 patients to the ICU in a 6-week period for severe hyponatremia while taking Paxlovid. Although the mechanism is unknown, this could be a signal that warrants further investigation. Vigilant review of concomitant medications when prescribing Paxlovid using the Liverpool interaction checker is needed.

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with a history of repetitive head impacts (RHI). CTE was described in boxers as early as the 1920s and by the 1950s it was widely accepted that hits to the head caused some boxers to become “punch drunk.” However, the recent discovery of CTE in American and Australian-rules football, soccer, rugby, ice hockey, and other sports has resulted in renewed debate on whether the relationship between RHI and CTE is causal. Identifying the strength of the evidential relationship between CTE and RHI has implications for public health and medico-legal issues. From a public health perspective, environmentally caused diseases can be mitigated or prevented. Medico-legally, millions of children are exposed to RHI through sports participation; this demographic is too young to legally consent to any potential long-term risks associated with this exposure. To better understand the strength of evidence underlying the possible causal relationship between RHI and CTE, we examined the medical literature through the Bradford Hill criteria for causation. The Bradford Hill criteria, first proposed in 1965 by Sir Austin Bradford Hill, provide a framework to determine if one can justifiably move from an observed association to a verdict of causation. The Bradford Hill criteria include nine viewpoints by which to evaluate human epidemiologic evidence to determine if causation can be deduced: strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experiment, and analogy. We explored the question of causation by evaluating studies on CTE as it relates to RHI exposure. Through this lens, we found convincing evidence of a causal relationship between RHI and CTE, as well as an absence of evidence-based alternative explanations. By organizing the CTE literature through this framework, we hope to advance the global conversation on CTE mitigation efforts.

Introduction: Robust outcome data collection is critical for stroke care and clinical trials. However, reaching patients after discharge from acute care is challenging. This study examined the feasibility, acceptability, and accuracy of collecting outcomes through a text message-based program after stroke. Methods: Patients discharged between June 8 th , 2020 and February 1 st , 2021 from Massachusetts General Hospital with an ICD-10 Code of stroke who consented to receiving messages, were enrolled in a message-based program upon acute stroke discharge. Participants received weekly brain health tips and assessments of the Modified Rankin Scale (mRS) and PROMIS Global-10 at 30, 60, and 90 days post-stroke via text message prompts. Participants were sent a satisfaction survey upon program conclusion. Data from routine 90-day follow-up phone calls were extracted from clinical charts of patients discharged during a representative 3 month period for comparison. Descriptive statistics, group comparisons, and inter-modal reliability (text message versus phone) were performed. Results: Of 530 patients with stroke discharged during the study period, 350 enrolled in the message program. Forty-one percent of the patients answered one or more of the assessment prompts. The 90-day mRS collected by messaging was 1[0-3] and the PROMIS Global Physical and Mental Health were 15[12.5-17] and 13[11-16], respectively. We reached 104/169 (61.54%) patients by phone. There were no statistically significant differences on 90-day outcome scores between those who responded via messages or phone. Inter-modal reliability (message versus phone) was moderate for mRS (κ=.521) but poor for PROMIS scores (κ&lt;.1). Nearly all participants (90%) felt it was helpful to receive information about stroke via messages and found the program adequate (63%) and not burdensome (94%). Discussion: Post-stroke outcomes data collection via text-messaging is feasible, acceptable, and moderately accurate compared to phone-based methods. Inter-modal reliability was higher for functional outcomes as compared to PROMs. Further validation of specific measures is required; yet, these findings suggest that future programs could use messaging to identify patients at risk for poor outcome.