Background There is no objective scale for assessment of operative skill in laparoscopic gastric bypass (LGBP). The objective of this study was to develop and demonstrate feasibility of use, ...validity, and reliability of a Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale. Study Design The BOSATS scale was developed using a hierarchical task analysis (HTA), a Delphi questionnaire, and a panel of international experts in bariatric surgery. The feasibility of use, reliability, and validity of the developed scale were demonstrated by reviewing 52 prospectively collected video recordings of LGBP performed by novice and experienced surgeons. Results A total of 214 discrete steps were identified in HTA. A total of 12 and 17 panel members completed the first and second round of the Delphi questionnaire, respectively. Consensus among the panel was achieved after the second round (Cronbach's alpha = 0.85). The BOSATS scale demonstrated high inter-rater (intraclass correlation coefficient ICC = 0.954; p < 0.001) and test-retest reliability (ICC = 0.99; p < 0.001). Significant differences between BOSATS scores of experienced and novice surgeon groups were noted for the creation of jejunojejunostomy (JJ), gastric pouch, linear stapled gastrojejunostomy (GJ), circular stapled GJ, and hand-sewn GJ. Moderate to high correlations between BOSATS scale and Objective Structured Assessment of Technical Skills Global Rating Scale (OSATS GRS) were seen for JJ (rho = 0.59; p = 0.001), gastric pouch (rho = 0.48; p = 0.0004), linear stapled GJ (rho = 0.70; p = 0.0001), and hand-sewn GJ (rho = 0.96; p < 0.0001). Conclusions The BOSATS scale is a feasible to use, reliable, and valid instrument for objective assessment of operative performance in LGBP. Implementation of this scale is expected to facilitate deliberate practice and provide a means for future certification in bariatric surgery.
The unsteady hydro-magnetic free convection flow with heat transfer of a linearly viscous, incompressible, electrically conducting fluid near a moving vertical plate with the constant heat is ...investigated. The flow domain is the porous half-space and a magnetic field of a variable direction is applied. The Caputo time-fractional derivative is employed in order to introduce a thermal flux constitutive equation with a weakly memory. The exact solutions for the fractional governing differential equations for fluid temperature, Nusselt number, velocity field, and skin friction are obtained by using the Laplace transform method. The numerical calculations are carried out and the results are presented in graphical illustrations. The influence of the memory parameter (the fractional order of the time-derivative) on the temperature and velocity fields is analyzed and a comparison between the fluid with the thermal memory and the ordinary fluid is made. It was observed that due to evolution in the time of the Caputo power-law kernel, the memory effects are stronger for the small values of the time t. Moreover, it is found that the fluid flow is accelerated / retarded by varying the inclination angle of the magnetic field direction.
Effects of the uniform transverse magnetic field on the transient free convective flows of a nanofluid with generalized thermal transport between two vertical parallel plates have been analyzed. The ...fluid temperature is described by a time-fractional differential equation with Caputo derivatives. Closed form of the temperature field is obtained by using the Laplace transform and fractional derivatives of the Wright’s functions. A semi-analytical solution for the velocity field is obtained by using the Laplace transform coupled with the numerical algorithms for the inverse Laplace transform elaborated by Stehfest and Tzou. Effects of the derivative fractional order and physical parameters on the nanofluid flow and heat transfer are graphically investigated.
Axisymmetric granular flows in vertical cylindrical pipes under action of gravity are studied using mathematical particle–particle models based on the Hertz–Mindlin theory. By and large, in granular ...flows, the density field and the pressure are unknown scalar functions. A well-known relationship between these fields gives the pressure field a power law of the density. The aim of this paper was to study unsteady, axisymmetric, fully developed granular flow under gravity action in a vertical cylindrical pipe, under the assumptions that the density field is constant and the velocity on the pipe’s wall is time-dependent. Using integral transforms method and appropriate initial-boundary conditions, the analytical solution for axial velocity is determined. The obtained analytical solution is used to determine the steady-state solution (the solution for large values of the time). The properties of the flow in some particular cases of the velocity on the pipe’s surface are analyzed and the transient flow is compared with the stationary one.
Two-dimensional advection–diffusion processes with memory and a source concentrated in the symmetry center of the domain have been investigated. The differential equation of the studied model is a ...fractional differential equation with short-tail memory (a differential equation with Caputo–Fabrizio time-fractional derivatives). An analytical solution of the initial-boundary value problem has been determined by employing the Laplace transform and double sine-Fourier transforms. A numerical solution of the studied problem has been determined using finite difference approximations. Numerical simulations for both solutions have been carried out using the software Mathcad.
Despite the well-established efficacy of tumor necrosis factor (TNF) antagonists as treatment options for Crohn's disease, many pediatric patients need a change in therapy due to adverse events and ...loss of response, highlighting the necessity for medications with a different mechanism of action. Ustekinumab has been shown to be effective in inducing clinical remission in some adults with disease refractory to anti-TNF agents, however, minimal data exists in the pediatric population.
We conducted a retrospective chart review of 11 pediatric patients receiving ustekinumab, specifically extracting baseline data, information on prior treatment and response, indications for starting ustekinumab, clinical information, and laboratory parameters pre- and post-therapy. Clinical response was defined as a decrease in abbreviated Pediatric Crohn's Disease Activity Index score.
Patients ranged from 12 to 17 years of age upon initiation of treatment with ustekinumab. Five of 11 patients demonstrated a clinical response. Among these patients, 2 remained in clinical remission, while the remaining 3 experienced a secondary loss of response. The other 6 patients were primary nonresponders who either remained unwell or demonstrated slight clinical worsening. All patients who clinically responded to ustekinumab and had an initially elevated CRP experienced complete normalization of their values. Mucosal healing was seen on endoscopy in 1 responder, with 2 other patients showing endoscopic improvement.
These results demonstrate for the first time that ustekinumab has the potential to induce not only clinical and biochemical remission, but also endoscopic improvement, in the pediatric population. Future research is needed to determine factors that influence response to therapy.
The rotational motion of fractional Maxwell fluids in an infinite circular cylinder that applies a time-dependent but not oscillating couple stress to the fluid is investigated using the integral ...transform technique. Such a flow model was not analyzed in the past both for ordinary and fractional rate type fluids. This is due to their constitutive equations which contain differential expressions acting on the shear stresses. The obtained solutions fulfill all the enforced initial and boundary conditions and are easily reduced to the solutions of Newtonian or ordinary Maxwell fluids having similar motion. At the end, the influence of pertinent parameters on velocity and shear stress variations is graphically underlined and discussed.
Medical trainees' negative perceptions towards older adult care have been widely reported, catalyzing targeted curricula in geriatric medicine. Little is known about surgical residents' attitudes ...toward and perceptions of the educational value of caring for injured older adults. This information is needed to ensure the surgical workforce is adequately trained to care for this growing patient population. In this study, we assessed surgical trainees' attitudes towards geriatric trauma care to inform a curriculum in geriatric trauma.
We surveyed North American general surgery trainees' beliefs and attitudes toward caring for older trauma patients, and the educational value they ascribed to learning about older trauma patient care. Descriptive statistics were used to report participant characteristics and responses.
Three hundred general surgery trainees from 94 post-graduate programs responded. Respondents reported too much time co-ordinating care (56%), managing non-operative patients (56%), and discharge planning (65%), all activities important to the care of older trauma patients. They recognized the importance of geriatric trauma care for their future careers (52%) but were least interested in reading about managing geriatric trauma patients (28%). When asked to rank clinical vignettes by educational value, respondents ranked the case of an older adult as least interesting (74%). As respondents progressed through their training, they reported less interest in geriatric trauma care.
Our survey results demonstrate the generally negative attitudes and beliefs held by postgraduate surgical trainees towards the care of older adult trauma patients. Future work should focus on identifying specific changes to the postgraduate surgical curriculum which can effectively alter these attitudes and beliefs and improve the care for injured older adults.
Aim. A multidisciplinary team was created in our institution to manage patients with intestinal failure (INFANT: INtestinal Failure Advanced Nutrition Team). We aimed to evaluate the impact of the ...implementation of the team on the outcomes of this patient population. Methods. Retrospective chart review of patients with intestinal failure over a 6-year period was performed. Outcomes of patients followed up by INFANT (2010–2012) were compared to a historical cohort (2007–2009). Results. Twenty-eight patients with intestinal failure were followed up by INFANT while the historical cohort was formed by 27 patients. There was no difference between the groups regarding remaining length of small and large bowel, presence of ICV, or number of infants who reached full enteral feeds. Patients followed up by INFANT took longer to attain full enteral feeds and had longer duration of PN, probably reflecting more complex cases. Overall mortality (14.8%/7.1%) was lower than other centers, probably illustrating our population of “early” intestinal failure patients. Conclusions. Our data demonstrates that the creation and implementation of a multidisciplinary program in a tertiary center without an intestinal and liver transplant program can lead to improvement in many aspects of their care.
The treatment armamentarium in pediatric Crohn disease (CD) is very similar to adult-onset CD with the notable exception of the use of exclusive enteral nutrition (EEN the administration of a liquid ...formula diet while excluding normal diet), which is used more frequently by pediatric gastroenterologists to induce remission. In pediatric CD, EEN is now recommended by the pediatric committee of the European Crohn's and Colitis Organisation and the European Society for Paediatric Gastroenterology Hepatology and Nutrition as a first-choice agent to induce remission, with remission rates in pediatric studies consistently >75%. To chart and address enablers and barriers of use of EEN in Canada, a workshop was held in September 2014 in Toronto (Ontario), inviting pediatric gastroenterologists, nurses and dietitians from most Canadian pediatric IBD centres as well as international faculty from the United States and Europe with particular research and clinical expertise in the dietary management of pediatric CD. Workshop participants ranked the exclusivity of enteral nutrition; the health care resources; and cost implications as the top three barriers to its use. Conversely, key enablers mentioned included: standardization and sharing of protocols for use of enteral nutrition; ensuring sufficient dietetic resources; and reducing the cost of EEN to the family (including advocacy for reimbursement by provincial ministries of health and private insurance companies). Herein, the authors report on the discussions during this workshop and list strategies to enhance the use of EEN as a treatment option in the treatment of pediatric CD in Canada.
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