BACKGROUND:Arterial blood gas analysis (ABGA) is the reference standard for the diagnosis of respiratory failure (RF) and metabolic disturbance (MD), but peripheral venous blood gas analysis (PVBGA) is increasingly being used for the estimation of carbon dioxide, pH, and other variables in the context of acutely unwell adults presenting to hospitals and emergency departments. OBJECTIVES:The primary objective of this review is to evaluate the performance of PVBGA by comparing it with the reference standard ABGA, which is assumed to be error-free for the diagnosis of (1) respiratory failure, (2) hypercarbia, and (3) metabolic disturbance (the three target conditions) in adults. The secondary objective is to evaluate the performance of the index test to diagnose nine specific subtypes of respiratory failure and metabolic disturbance. The definitions for these additional conditions are determined by changes to one or more of the following: pH (acidity), pO2 (partial pressure of oxygen), pCO2 (partial pressure of carbon dioxide), HCO3 (bicarbonate), as stated in the Methods section of this review (target conditions). We aimed to explore the following covariates: participant demographics (e.g. age, weight, and sex); participant comorbidities (e.g. chronic lung disease, chest wall deformity, and central nervous system disorder such as spinal cord injury); and the indication for blood gas sampling (e.g. shortness of breath, critical illness, resuscitation, trauma, or whilst under general anaesthesia). SEARCH METHODS:On 10 July 2024, we searched the electronic databases MEDLINE, EMBASE, CINAHL, and LILACS. We also manually searched 19 respiratory and critical care journals, and we searched ClinicalTrials.gov for ongoing trials. SELECTION CRITERIA:We considered consecutive series studies and case-control studies that directly compared the index test PVBGA to the reference standard ABGA for adults over the age of 16 years. The included studies contained data for any one of the target conditions of respiratory failure and metabolic disturbance, as determined by individual changes to pO2 (partial pressure of oxygen), pCO2 (partial pressure of carbon dioxide), pH (acidity), and HCO3 (bicarbonate) concentration. Studies that only provided mean values for summed data were ineligible for inclusion. However, we invited authors of such studies to provide individual patient data for inclusion in this systematic review. There are nine studies awaiting classification. DATA COLLECTION AND ANALYSIS:Two authors independently evaluated the quality of the relevant studies and extracted data from them. We conducted a quality assessment using the QUADAS-2 tool. Our statistical analysis used 2 x 2 tables for the positive and negative results of each test. We estimated a bivariate meta-analysis of sensitivity and specificity. MAIN RESULTS:We included six studies (919 participants) in our quantitative analysis. All studies were at high risk of bias due to one or more of the following factors: patient selection, since it was unclear if consecutive patients were included or where they were located; index test, with poor reporting of cut-offs; flow and timing domain because the fraction of inspired oxygen was frequently not stated and any difference between the collection of the VBGA and the ABGA could introduce bias. Respiratory failure For the diagnosis of respiratory failure of any type, when using PVBGA, the estimated summary sensitivity (Sn) was 97.6% (95% credible interval (CI) 94.1 to 99.4) and the estimated summary specificity (Sp) was 36.9% (95% CI 17.1 to 60.1) (6 studies, 805 participants of whom 291 (36%) were diagnosed with respiratory failure by ABGA; sensitivity: low-certainty evidence; specificity: very low certainty evidence). Isolated hypercarbia For the diagnosis of isolated hypercarbia (regardless of oxygen level), when using PVBGA, the estimated summary Sn was 97.1% (95% CI 93.3 to 99.2); the estimated summary Sp value was 53.9% (95% CI 39.8 to 66.7) (6 studies with 805 participants, 269 (33%) with ABGA confirmation; low-certainty evidence). Other findings Results for metabolic disturbance and our secondary target conditions are presented in the full review. AUTHORS' CONCLUSIONS:Very limited data suggest PVBGA performs poorly as a diagnostic test for respiratory failure compared to the reference standard of ABGA. The index test PVBGA was highly sensitive for the diagnosis of respiratory failure and isolated hypercarbia, but its specificity was poor for these two primary target conditions. The high sensitivity means PVBGA may have a useful role as a "rule out test" for respiratory failure and isolated hypercarbia; however, the high false-positive rates make the clinical interpretation of a positive test difficult. Moreover, we are uncertain regarding these estimates because we have only low to very low certainty about the evidence. Further studies that use (ABGA) established thresholds for the diagnosis of each target condition are needed.

BACKGROUND AND AIMS:Bariatric surgical options in obese patients include sleeve gastrectomy (SG) and roux-en-Y gastric bypass (RYGB), which may not be equivalent in risk of postoperative reflux symptoms. We evaluated risk and predictive factors for postbariatric surgery reflux symptoms. METHODS:Patients with obesity evaluated for bariatric surgery over a 15-month period were prospectively followed with validated symptom questionnaires (GERDQ, dominant symptom index: product of symptom frequency and intensity from 5-point Likert scores) administered before and after SG and RYGB. Esophageal testing included high-resolution manometry in all patients, and ambulatory reflux monitoring off therapy in those with abnormal GERDQ or prior reflux history. Univariate comparisons and multivariable analysis were performed to determine if preoperative factors predicted postoperative reflux symptoms. RESULTS:Sixty-four patients (median age 49.0 years, 84% female, median BMI 46.5 kg/m 2 ) fulfilled inclusion criteria and underwent follow-up assessment 4.4 years after bariatric surgery. Baseline GERDQ and dominant symptom index for heartburn were significantly higher in RYGB patients ( P ≤0.04). Despite this, median GERDQ increased by 2 (0.0 to 4.8) following SG and decreased by 0.5 (-1.0 to 5.0) following RYGB ( P =0.02). GERDQ became abnormal in 43.8% after SG and 18.8% after RYGB ( P =0.058); abnormal GERDQ improved in 12.5% and 37.5%, respectively ( P =0.041). In a model that included age, gender, BMI, acid exposure time, and type of surgery, multivariable analysis identified SG as an independent predictor of postoperative heartburn (odds ratio 16.61, P =0.024). CONCLUSIONS:Despite preferential RYGB when preoperative GERD was identified, SG independently predicted worsening heartburn symptoms after bariatric surgery.

Introduction:There is clinical equipoise as to whether hyperoxia is injurious to the myocardium, both in the setting of acute ischaemic insults and on the stable myocardium. This study examined the effect of extreme hyperoxia - in the form of hyperbaric oxygen treatment - on the myocardium through measurement of high-sensitivity cardiac troponin. Methods:Forty-eight individuals were enrolled to undergo a series of 30 exposures to hyperbaric oxygen for treatment of non-cardiac pathologies. High-sensitivity troponin T was measured before and after each session. Results:There was no clinically significant difference in troponin measurements following acute or recurrent sequential exposures to extreme hyperoxia, despite the studied patient population having a high rate of previous ischaemic heart disease or cardiovascular risk factors. Conclusions:This study demonstrates that profound hyperoxaemia does not induce any measurable cardiac injury at a biochemical level. Neither is there a reduction in cardiac troponin to suggest a cardioprotective effect of hyperbaric hyperoxia. This provides some reassurance as to the cardiac safety of the routine use of hyperbaric oxygen treatment in management of non-cardiac pathology.

BACKGROUND AND AIMS:The gas-filled intragastric balloon (IGB) system (Obalon) and the fluid-filled IGB system (Orbera) are the current FDA-approved IGB systems to treat obesity; however, they have not been previously compared in clinical practice. The aims of this study were to compare their efficacy, tolerance, and safety in a clinical setting.MATERIALS AND METHODS:This is a retrospective cohort study of consecutive patients treated with the gas-filled IGB or fluid-filled IGB between October 2015 and May 2020 at 2 academic centers. The primary endpoints included percent total body weight loss at balloon removal in patients who completed at least 20 weeks of therapy, the difference in adverse events that required urgent evaluation or hospitalization, and early removal in the 2 groups.RESULTS:A total of 87 patients underwent successful IGB placement (gas-filled IGB n=57, age 48.9±8.8, body mass index 35.5±5 kg/m 2 ; fluid-filled IGB n=30, age 49.2±14.3, body mass index 38.8±6 kg/m 2 ). Eleven patients underwent early device removal. There were no differences in percent total body weight loss at balloon removal and 12 months between the balloon systems ( P =0.39). Patients who received the fluid-filled IGB were more likely to require urgent evaluation or treatment, require hospital stay >24 hours, and need early balloon system removal compared with patients treated with the gas-filled IGB.CONCLUSION:In this 2-center cohort, both FDA-approved gastric balloon systems had the same effectiveness, but the gas-filled IGB had fewer serious adverse events and better tolerability than the fluid-filled IGB.

We present the first published case of successfully treated disseminated Aspergillus lentulus infection in a solid organ transplant recipient with invasive pulmonary disease, endophthalmitis, and a cerebral abscess. This case highlights important challenges associated with treating Aspergillus lentulus, particularly regarding antifungal resistance and toxicities associated with long-term antifungal therapy.

OBJECTIVES:Many studies document cognitive decline following specific types of acute illness hospitalizations (AIH) such as surgery, critical care, or those complicated by delirium. However, cognitive decline may be a complication following all types of AIH. This systematic review will summarize longitudinal observational studies documenting cognitive changes following AIH in the majority admitted population and conduct meta-analysis (MA) to assess the quantitative effect of AIH on post-hospitalization cognitive decline (PHCD). METHODS:We followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Selection criteria were defined to identify studies of older age adults exposed to AIH with cognitive measures. 6566 titles were screened. 46 reports were reviewed qualitatively, of which seven contributed data to the MA. Risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS:The qualitative review suggested increased cognitive decline following AIH, but several reports were particularly vulnerable to bias. Domain-specific outcomes following AIH included declines in memory and processing speed. Increasing age and the severity of illness were the most consistent risk factors for PHCD. PHCD was supported by MA of seven eligible studies with 41,453 participants (Cohen's d = -0.25, 95% CI [-0.02, -0.49] I2 35%). CONCLUSIONS:There is preliminary evidence that AIH exposure accelerates or triggers cognitive decline in the elderly patient. PHCD reported in specific contexts could be subsets of a larger phenomenon and caused by overlapping mechanisms. Future research must clarify the trajectory, clinical significance, and etiology of PHCD: a priority in the face of an aging population with increasing rates of both cognitive impairment and hospitalization.

OBJECTIVE:The aim was to investigate the association of cognitive trajectories and overnight surgical hospitalization in older adults, while controlling for and comparing to the association with acute medical hospitalizations.DESIGN:This is a secondary analysis of data from a population-based, longitudinal cohort study of older Australians.SETTING AND PARTICIPANTS:Cognition was assessed with 4 biennial waves of prospective neuropsychological data from 1026 Sydney Memory and Aging Study participants age 70 to 90 years at baseline. Hospitalization exposure was obtained from 10 years of electronically linked data from the New South Wales Admitted Patient Data Collection.METHODS:Latent growth curve modeling estimated global cognition z-score baseline and slope over 6 years, and the effects of contemporaneous surgical and medical hospitalization predictors while controlling for potential demographic and comorbidity confounders.RESULTS:After controlling for confounding variables, this analysis showed that overnight surgical hospitalizations were not associated with worse baseline global cognition or accelerated cognitive decline over 6 years. This was despite this cohort having more surgeries and more complex surgeries compared with Australian data for overnight hospitalizations in over 70-year-olds. Conversely, recent medical hospitalizations were associated with accelerated cognitive decline.CONCLUSIONS AND IMPLICATIONS:This analysis finds that surgery and anesthesia are unlikely to be risk factors for medium to long-term global cognitive decline in healthy older adults, while controlling for contemporaneous medical hospitalizations. These findings are contrary to prior conclusions from several surgical studies that may have been impeded by insufficient comparison groups. They are, however, consistent with recent population-based studies suggesting surgery has minimal association with cognitive decline in the medium to long-term. Future research needs to clarify the association of surgical hospitalization with the full spectrum of cognitive outcomes including subjective cognitive complaints and dementia, and importantly, how these cognitive outcomes correlate with clinically significant functional changes.

Background: Choice of bariatric procedure may be impacted by esophageal motor disorders and reflux disease, which are not routinely evaluated in obese subjects. Methods: Clinical characteristics on validated questionnaires and esophageal physiologic test findings were collected in 110 consecutive obese subjects (median age 48.5 years, 82% F, median BMI 46.9 kg/m(2)) evaluated for bariatric surgery. High resolution manometry (HRM) metrics included intragastric pressure (IGP), basal lower esophageal sphincter pressures (LESP), end-expiratory LESP, EGJ contractile integral (EGJ-CI), integrated relaxation pressure (IRP), distal contractile integral (DCI), and Chicago classification (CC) v4.0 diagnoses; acid exposure time (AET, normal if <4%) was obtained from ambulatory reflux monitoring. Comparative analyses determined differences between obese subjects and 15 institutional normal controls (median age 24.7 years, 53% F, median BMI 24.7 kg/m(2)) and if symptoms predicted abnormal tests. Results: Basal LESP and EGJ-CI were higher in obese subjects (P = .03) compared to controls, while end-expiratory LESP was similar (P = .97). IGP was also higher in obese subjects (P < .0001), which modestly correlated with BMI. The most common CC 4.0 diagnosis was ineffective esophageal motility (IEM, 11.8%). EGJ outflow obstruction was seen in 9.1% and achalasia in 0.9%. Hiatus hernia (type 2 or 3 EGJ morphology) was found in 28%. Of 34 patients completing ambulatory reflux monitoring, 15 (44%) had elevated AET, without symptom or motor predictors. Conclusions: Achalasia, esophageal outflow obstruction, and reflux were encountered in higher than expected proportions without specific symptoms in pre-bariatric surgery patients. Thus, esophageal physiologic testing may be of value prior to bariatric surgery.

Objective Delirium is common in intensive care patients and is associated with short- and long-term adverse outcomes. We investigated the long-term risk of cognitive impairment and post-traumatic stress disorder (PTSD) in intensive care patients with and without delirium. Methods This is a prospective cohort study in ICUs in two Australian university-affiliated hospitals. Patients were eligible if they were older than 18 years, mechanically ventilated for more than 24 h and did not meet exclusion criteria. Delirium was assessed using the Confusion Assessment Method for Intensive Care Unit. Variables assessing cognitive function and PTSD symptoms were collected at ICU discharge, after 6 and 12 months: Mini-Mental State Examination, Telephone Interview for Cognitive Status, Impact of Events Scale-Revised and Informant Questionnaire for Cognitive Decline (caregiver). Results 103 participants were included of which 36% developed delirium in ICU. Patients with delirium were sicker and had longer duration of mechanical ventilation and ICU length of stay. After 12 months, 41/60 (68.3%) evaluable patients were cognitively impaired, with 11.6% representing the presence of symptoms consistent with dementia. When evaluated by the patient’s caregiver, the patient’s cognitive function was found to be severely impaired in a larger proportion of patients (14/60, 23.3%). Delirium was associated with worse cognitive function at ICU discharge, but not with long-term cognitive function. IES-R scores, measuring PTSD symptoms, were significantly higher in patients who had delirium compared to patients without delirium. In regression analysis, delirium was independently associated with cognitive function at ICU discharge and PTSD symptoms at 12 months. Conclusions Intensive care survivors have significant rates of long-term cognitive decline and PTSD symptoms. Delirium in ICU was independently associated with short-term but not long-term cognitive function, and with long-term PTSD symptoms. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12616001116415, 15/8/2016 retrospectively registered, https://www.anzctr.org.au

PURPOSE OF REVIEW:Cognitive decline is frequently reported after hospitalisation in the contexts of surgery, delirium and critical care. The question not adequately addressed is whether all types of acute hospitalisations increase the risk of cognitive decline. As acute hospitalisations are common in the elderly, who are also vulnerable to cognitive decline, this possible association is of significant concern.RECENT FINDINGS:This review summarises cognitive outcomes from recent observational studies investigating acute hospitalisation (emergent and elective) in older age adults. Studies were identified from searching Medline, Embase and PsycINFO databases and citations lists. The highest incidence of cognitive decline has been reported following critical care admissions and admissions complicated by delirium, although all types of acute hospitalisations are implicated. Age is the most consistent risk factor for cognitive decline. Several etiological and therapeutic aspects are being investigated, particularly the measurement of inflammatory biomarkers and treatment with anti-inflammatory medications.SUMMARY:Acute hospitalisation for any reason appears to increase the risk of cognitive decline in older adults, but the cause remains elusive. Future research must clarify the nature and modifiers of posthospitalisation cognitive change, a priority in the face of an ageing population.

Reshape Duo is a saline-filled dual, integrated intragastric balloon (IGB) approved for weight loss in patients with obesity. Currently there is no data on outcomes in the US, outside of the pivotal trial, where the balloon and follow-up visits were at no charge. This is a retrospective review of prospectively maintained databases involving 7 centers (2 academic and 5 private practices). The study included adults with BMI>30 kg/m2 who had Reshape Duo intragastric balloon inserted for weight loss therapy. All procedures were performed by gastroenterologists. The cost for the intragastric balloon and the insertion and removal procedures and subsequent follow-up was paid by the patient and was not covered by insurance. Primary outcomes were percent total body weight loss (%TBWL) and percent excess weight loss (%EWL) at 1, 3, 6, 9 and 12 months. Secondary outcomes include adverse events and effects on blood pressure and metabolic markers. A total of 202 patients (mean age 47.8 + 10.8 years, 83% females) underwent IGB insertion. Mean BMI at baseline was 36.8 + 8.4 kg/m2. Mean %TBWL at 1, 3, 6, 9 and 12 months was 4.8 + 2.4, 8.8 + 4.3, 11.4 + 6.7, 13.3 + 7.8 and 14.7 + 11.8 percent respectively. Mean %EWL at 1,3, 6, 9 and 12 months was 13.2 + 7.2,23.8 + 11.8,29.9 + 18.2, 34.7 + 21.4 and 36.4 + 28.1 percent respectively. The mean absolute weight loss in first 3 months (8.9 + 4.8 kg) was significantly greater than months 3 to 6 (3.3 + 3.8 kg), (P<0.001). At 6 months, 60.4% patients achieved more than 10% TBWL and 55.4% had more than 25% EWL. On multivariable analysis, pre-balloon body weight significantly predicted absolute weight loss (Beta= 0.38,P=0.003). There were no variables predictive of %TBWL at 6 months. There was statistically significant improvement in systolic and diastolic blood pressure, hemoglobin A1c, fasting blood glucose and total cholesterol at 6 months. Nausea, vomiting and abdominal pain were the most common adverse effects, occurring in 149 (73.8%), 99 (49%) and 51 (25.2%) of patients, respectively. Seventeen patients (8.4%) developed esophageal tears during balloon insertion, which required no specific management.In one patient, the balloon migrated distally, causing small bowel obstruction requiring surgical intervention. There were no reported perforations. Thirteen patients (6.4%) had IGB removed before 6 months' dwell was complete due to intolerance. The outcomes following use of the Reshape intragastric balloon in the real world have been promising, with the majority of patients achieving and maintaining 10% TBWL with an acceptable adverse event profile. Further studies are required to assess the balloons impact over along term.Table 1- Outcomes of weight, % total body weight loss (TBWL), % excess weightloss (EWL) at 1, 3, 6, 9 and 12 months after balloon insertion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

BACKGROUND & AIMS: Reshape Duo is a saline-filled dual, integrated intragastric balloon (IGB) approved by the Food and Drug Administration for weight loss in patients with obesity. In a prospective, randomized trial, obese patients who received the balloon had significantly greater percent excess weight loss (% EWL) compared with patients treated with diet and exercise alone. However, there are limited data on the real-world efficacy of the Reshape balloon. METHODS: We performed a retrospective study of data collected from 2 academic centers and 5 private practices in which all patients paid for the IGB and follow-up visits out of pocket. The IGB was removed after 6 months. We collected data (demographic, medical, and laboratory) from 202 adults (mean age 47.8 -10.8 years; 83% female) with a baseline mean body mass index of 36.8 + 8.4 kg/m(2) who had IGB insertion for weight loss therapy, along with counselling on lifestyle modifications focused on diet and exercise. Primary outcomes were percent total body weight loss (% TBWL) and % EWL at 1, 3, 6, 9, and 12 months after the procedure. RESULTS: Mean % TBWL at 1, 3, 6, 9 and 12 months was 4.8 +/- 2.4%, 8.8 +/- 4.3%, 11.4 +/- 6.7%, 13.3 +/- 7.8%, and 14.7 +/- 11.8%, respectively. Data were available from 101 patients at 6 months and 12 patients at 12 months; 60.4% of patients achieved more than 10% TBWL and 55.4% had more than 25% EWL. Seventeen patients (8.4%) had esophageal tears during balloon insertion, with no intervention required. Thirteen patients (6.4%) had their IGB removed before the end of the 6-month treatment period. Nausea, vomiting, and abdominal pain were the most common adverse effects, occurring in 149 (73.8%), 99 (49%), and 51 (25.2%) patients. In one patient, the IGB migrated distally leading to small intestinal obstruction requiring surgical removal. CONCLUSION: In a retrospective analysis of real-world patients who received the Reshape Duo IGB, we found it to be a safe and efficacious endoscopic method for producing weight loss, with most patients achieving greater than 10% TBWL at 6 months.

The physiologic response of the human body to different environments is a complex phenomenon to ensure survival. Immersion and compressed gas diving, together, trigger a set of responses. Monitoring those responses in real time may increase our understanding of them and help us to develop safety procedures and equipment. This review outlines diving physiology and diseases and identifies physiological parameters worthy of monitoring. Subsequently, we have investigated technological approaches matched to those in order to evaluated their capability for underwater application. We focused on wearable biomedical monitoring technologies, or those which could be transformed to wearables. We have also reviewed current safety devices, including dive computers and their underlying decompression models and algorithms. The review outlines the necessity for biomedical monitoring in scuba diving and should encourage research and development of new methods to increase diving safety.

BACKGROUND:In the intensive care unit (ICU), critical illness delirium occurs in the context of multiple comorbidities, multi-organ failure, and invasive management techniques, such as mechanical ventilation, sedation, and lack of sleep. Delirium is characterized by an acute confusional state defined by fluctuating mental status, inattention, and either disorganized thinking or an altered level of consciousness. The long-term cognitive and psychosocial function of patients that experience delirium in the ICU is of crucial interest because preliminary data suggest a strong association between ICU-related delirium and long-term cognitive impairment.OBJECTIVE:The aim of this study is to explore the relationship between delirium in the ICU and adverse outcomes by following mechanically ventilated patients for one year following their discharge from the ICU and collecting data on their long-term cognition and psychosocial function.METHODS:This study will be conducted by enrolling patients in two tertiary ICUs in Australia. We aim to recruit 200 patients who have been mechanically ventilated for more than 24 hours. Data will be collected at the following three time points: (1) at discharge where they will be administered the Mini-Mental State Examination (MMSE); (2) at 6 months after discharge from the ICU discharge where the Impact of Events Scale Revised (IES-R) and the Telephone Inventory for Cognitive Status (TICS) tests will be administered; and (3) at 12 months after discharge from the ICU where the patients will be administered the TICS and IES-R tests, as well as the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). The IQCODE will be administered to their "person responsible" or the significant other of the patient.RESULTS:Long-term cognition and psychosocial function will be the primary outcome of this study. Mortality will also be investigated as a secondary outcome. Active enrollment will take place until the end of September 2016 and data collection will conclude at the end of September 2017. The analysis and results are expected to be available by March 2018.CONCLUSION:Delirium during mechanical ventilation has been linked to longer ICU and hospital stays, higher financial burdens, increased risks of long-term cognitive impairment (ie, dementia), poor functional outcomes and quality of life, and decreased survival. However, delirium during mechanical ventilation in the ICU is not well understood. This study will advance our knowledge of the comprehensive, long-term effects of delirium on cognitive and psychosocial function.TRIAL REGISTRATION:Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001116415; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371216 (Archived by WebCite at http://www.webcitation.org/ 6nfDkGTcW).

BACKGROUND: Inflammatory bowel disease (IBD) patients often receive inconsistent care that can lead to suboptimal clinical outcomes. Physician performance measures and quality of care indicators for IBD were developed by the American Gastroenterological Association (AGA) and the Crohn's and Colitis Foundation of America (CCFA) with the goal to improve clinical outcomes, quality of life, and decrease healthcare costs. We aimed to assess adherence to IBD quality care indicators at a tertiary academic center by IBD-dedicated gastroenterologists (IBD-GIs) compared to general gastroenterologists practicing in the referring community that manage IBD patients (Gen-GIs). METHODS: A prospective review (January 1, 2017 to April 30, 2017) was conducted of consecutive outpatient visits at the gastroenterology clinic at Washington University in Saint Louis. Demographics and established quality of care indicators in IBD as published by AGA and CCFA including in collection were: documentation of IBD phenotype, vaccination status, and appropriate endoscopic evaluation. We compared adherence to quality of care indicators by IBD-GIs managing established IBD patients vs referred patients with IBD managed by community Gen-GIs using t-test, ANOVA (Prism, Irving CA). RESULTS: Over the study period, 478 patients (median age 42 years, 51% female, 14% African American) were evaluated in the clinic. Disease duration was a median of 14 years, and 55% had Crohn's disease. 235 patients were managed by IBD-GIs and 248 were managed by Gen-GIs with similar demographics among the two groups. IBD-GIs were significantly more adherent with recommended quality of care indicators compared to Gen-GIs, including IBD phenotype documentation (74% vs 33%, P<0.01), using steroid-sparing treatments to limit corticosteroid usage less than 12 weeks (75% vs 54%, P<0.01), and adherence colon cancer surveillance (62% vs 34%, P<0.01). In addition, regarding health maintenance, IBD-GIs vaccinated more patients compared to Gen-GIs including HBV (76% vs 57%, P=0.02), Influenza (59% vs 40%, P=0.01), and Pneumovax (36% vs 16%, P=0.01). CONCLUSION(S): IBD-GIs compared to Gen-GIs are consistently and significantly more adherent in the implementation of quality of care indicators for IBD. Our data suggest that patients with IBD might benefit from focused and comprehensive clinical care by IBD-dedicated gastroenterologists and highlights the need for further education of Gen-GI physicians in areas where specialized IBD care is not currently available. Additionally, there are significant areas of improvement in clinical care such as health maintenance, even in IBD dedicated providers.

Decompression sickness (DCS) is a systemic disorder, assumed due to gas bubbles, but additional factors are likely to play a role. Circulating microparticles (MPs)—vesicular structures with diameters of 0.1-1.0 μm—have been implicated, but data in human divers have been lacking. We hypothesized that the number of blood-borne, Annexin V-positive MPs and neutrophil activation, assessed as surface MPO staining, would differ between self-contained underwater breathing-apparatus divers suffering from DCS vs. asymptomatic divers. Blood was analyzed from 280 divers who had been exposed to maximum depths from 7 to 105 meters; 185 were control/asymptomatic divers, and 90 were diagnosed with DCS. Elevations of MPs and neutrophil activation occurred in all divers but normalized within 24 h in those who were asymptomatic. MPs, bearing the following proteins: CD66b, CD41, CD31, CD142, CD235, and von Willebrand factor, were between 2.4- and 11.7-fold higher in blood from divers with DCS vs. asymptomatic divers, matched for time of sample acquisition, maximum diving depth, and breathing gas. Multiple logistic regression analysis documented significant associations ( P < 0.001) between DCS and MPs and for neutrophil MPO staining. Effect estimates were not altered by gender, body mass index, use of nonsteroidal anti-inflammatory agents, or emergency oxygen treatment and were modestly influenced by divers' age, choice of breathing gas during diving, maximum diving depth, and whether repetitive diving had been performed. There were no significant associations between DCS and number of MPs without surface proteins listed above. We conclude that MP production and neutrophil activation exhibit strong associations with DCS.