Efficacy and safety of a novel polytetrafluoroethylene-coated self-expandable metal stent for distal malignant biliary obstruction.

Background: Stent migration and sludge formation remain significant problems associated with covered self-expandable metal stents (CSEMSs). The EGIS biliary stent fully covered flare type (EGIS biliary stent), a new type of polytetrafluoroethylene-coated self-expandable metal stent with low axial force and an anti-migration system, was developed to overcome these disadvantages. We conducted this study to evaluate the efficacy and safety of this stent in comparison with conventional CSEMS (c-CSEMS). Methods: We retrospectively analyzed consecutive patients with unresectable pancreatic cancer who received initial CSEMS for distal malignant biliary obstruction. The primary outcome was time to recurrent biliary obstruction (RBO). Secondary outcomes included technical success rate, functional success rate, stent-related adverse events, causes of RBO, and re-intervention. Results: A total of 40 patients were included (EGIS group: 20; c-CSEMS group: 20). The technical and functional success rates were similar between the two groups. Stent-related adverse event rates (20% vs. 15%, p > 0.99) and overall RBO rates (56% vs. 50%, p > 0.99) were not significantly different between the two groups. Stent migration was the most common cause of RBO in the EGIS group, while stent occlusion was in the c-CSEMS group. The median time to RBO (102 vs. 434 days, p = 0.10) was not significantly different between the two groups. Endoscopic transpapillary re-intervention was successful in most patients in both groups. Conclusions: The EGIS biliary stent was not associated with a longer time to RBO compared to c-CSEMS. Further improvements, especially against stent migration, are needed to improve its efficacy.

Unmasking the hidden culprit: Recurrent syncope in a 62-year-old man linked to severe internal carotid artery stenosis.

Syncope, a brief loss of consciousness, has many potential causes, with internal carotid artery (ICA) stenosis being a relatively uncommon but serious one. We present the case of a 62-year-old man from Dhaka, Bangladesh, who experienced recurrent syncope over 6 months, characterized by a brief loss of consciousness, occasional dizziness, and blurred vision. Despite a history of hypertension and hyperlipidemia, initial cardiac and neurogenic investigations were inconclusive. Magnetic resonance angiography revealed 90% stenosis of the right ICA, which was confirmed by digital subtraction angiography. The patient was treated with antiplatelet therapy, statins, and antihypertensives, and underwent carotid artery stenting. His postoperative recovery was uneventful, and he remained symptom-free during follow-up. This case underscores the importance of considering ICA stenosis in patients with recurrent syncope and comorbid vascular disease, particularly in resource-limited settings where timely diagnosis and intervention can prevent serious cerebrovascular complications.

Recurrent simultaneous central nervous system demyelination with possible peripheral demyelination / nodopathy in a seronegative patient.

Combined central and peripheral demyelination (CCPD) is a rare disease entity. Onset with the simultaneous central nervous system (CNS) and peripheral nervous system (PNS) involvement and its recurrence are exceptional. Anti-neurofascin antibodies have been shown to be present in up to 70% of cases, yet seronegative patients also exist. We present a case of seronegative recurrent CCPD. The PNS involvement was compatible with two episodes of recurrent Guillain-Barre syndrome (GBS), whereas the CNS involvement pattern was not typical for either multiple sclerosis (MS) or acute disseminated encephalomyelitis. The prognosis was excellent with pulse methylprednisolone, intravenous immunoglobulin, and plasmapheresis. This case highlights the varied clinical presentations of CCPD, extending beyond the realms of MS and chronic inflammatory demyelinating polyneuropathy, and underscores the potential for relapse. Importantly, to the best of our knowledge, this represents the inaugural instance of CCPD featuring PNS involvement in the form of recurrent GBS.

Novel Serum Markers that Distinguish Behcet's Disease from Idiopathic Recurrent Aphthous Stomatitis.

BACKGROUND: Behcet's disease (BD) is a rare and recurrent autoinflammatory disorder characterized by systemic vasculitis, frequently manifested as recurrent aphthous stomatitis (RAS). We aim to identify specific serum proteins to discriminate between BD and idiopathicRAS. METHOD: Peripheral blood was collected from 12 BD patients, 12 idiopathic RAS patients, and 21 healthy volunteers. The serum samples underwent Tandem Mass Tag-based mass spectrometry analysis. Differentially expressed proteins (DEPs) were identified for KEGG pathway enrichment, Gene Ontology (GO), and protein-protein interaction (PPI) analyses. ELISA was utilized to verify two BD-specific DEPs in another cohort consisting of 18 BD patients, 18 idiopathic RAS patients, and 18 controls. RESULTS: Compared with RAS serum, BD serum showed 242 DEPs. 49 proteins were differentially expressed in BD but not RAS serum compared to healthy controls. KEGG pathway and GO analyses revealed that DEPs in BD and RAS have similar biological functions and cellular distributions, featuring a significant association with pathways regulating blood coagulation and immune response. When comparing DEPs between BD and RAS, several keratins emerged as markers that distinguish RAS from BD. We also identified multiple DEPs in BD but not RAS patients. PPI analysis uncovered that lipoprotein metabolism regulators serve as hub proteins, indicating their potentially essential roles in BD pathology. In addition, ELISA results confirmed the elevated LRG1 and SOD3 levels in BD, but not RAS patients, compared to healthy donors. CONCLUSION: Our data uncovered novel serum proteins that distinguish BD from RAS, which may potentially be useful in BD diagnosis and treatment.

Inhibition of BCAT1 expression improves recurrent miscarriage by regulating cellular dysfunction and inflammation of trophoblasts.

Sustained or chronic inflammation in the placenta can result in placental insufficiency, leading to adverse reproductive outcomes such as pregnancy loss. Branched-chain amino acid transaminase 1 (BCAT1) expresses in the placenta and is involved in the pathological inflammatory response, but its role in recurrent miscarriage (RM) has not been fully investigated. In the present study, we delved into the effects of BCAT1 on trophoblast inflammation induced by lipopolysaccharide (LPS) and a mouse model of pregnancy loss induced by LPS. In vitro, after the HTR-8/SVneo cells were treated with LPS and BCATc inhibitor 2 (a selective BCAT inhibitor), the cell apoptosis was verified by TUNEL assay, and the activity of caspase-3 and caspase-9 was detected. Real-time PCR, enzyme-linked immunosorbent assay (ELISA), and immunofluorescence (IF) were used to determine the expression of inflammatory cytokines (TNF-α, IL-6, and IL-1ß) and inflammasomes (NLRP3 and ASC) in LPS-treated trophoblast cells. Western blot analysis was performed to verify the expression of phospho-IκBα (p-IκBα) in cells and NF-κB p65 in the nuclei. IF staining was used to detect the nuclear translocation of NF-κB p65. The DNA binding activity of NF-κB was detected by an electrophoretic mobility shift assay (EMSA). The results demonstrated that inhibition of BCAT1 reduced trophoblast apoptosis, suppressed the release of proinflammatory cytokines, and prevented NLRP3 inflammasome activation in response to LPS. Additionally, BCAT1 inhibition blocked the activation of the NF-κB pathway in trophoblasts. This study highlights the potential therapeutic role of targeting BCAT1 in preventing adverse reproductive outcomes associated with chronic placental inflammation.

Clinical, radiographic and biochemical assessment of proximal cavities restored with composite resin using incremental vs. bulk packing techniques: One-year randomized clinical trial.

BACKGROUND: Bulk-fill resin composites may suffer from recurrent caries around compound proximal restorations in posterior teeth, especially at the proximo-gingival interface.Over 12 months, will the bulk fill technique affect the caries recurrence rate at gingival margins when compared to the conventional incremental packing technique? How early will the first clinical, radiographical, and biochemical evidence of caries recurrence occur? METHODS: After randomization, in 30 patients with two compound (OM or OD) supragingival lesions, one tooth was restored using the bulk fill technique on one side (group 1) (n = 15). In contrast, the other tooth on the other side was restored utilizing the incremental layering technique (group 2) (n = 15). Both teeth received restorative material (X-tra fil, Voco, Cuxhaven, Germany). The FDI criteria were used to evaluate restorations. As for the periodontal assessment, the gingival index, plaque index, papillary bleeding scoring index and periodontal pocket depth were evaluated. The gingival crevicular fluid (GCF) specimens were gathered, and MMP-9 was extracted and quantitated by ELISA. A customized radiographic template was designed, and 3D printed digital bitewing radiographs were taken. Assessments were done clinically, radiographically and biochemically at baseline (1 week) and after 3, 6 and 12 months. Data was statistically analyzed. RESULTS: The null hypothesis was accepted clinically; no statistically significant differences appeared between bulk and incrementally filled posterior restorations. As for the radiographic assessment, the null hypothesis was accepted except for increased periodontal ligament width at 3 months. The null hypothesis for the biochemical evaluation was rejected as there were significant changes in levels of MMP-9 at different testing times. CONCLUSIONS: 1. With similar results but less sensitivity and significant time saving, the bulk fill technique can be considered an efficient alternative to the incremental fill technique in restoring proximal cavities. 2. Early evidence of caries recurrence can be correlated to an increase in the MMP-9 level in gingival crevicular fluid, followed by an increase in radiographic periodontal ligament width measurement. TRIAL REGISTRATION: An ethical approval from the Research Ethics Committee at the Faculty of Dentistry, October 6 University, (Approval No. RECO6U/5-2022). The study was registered at the Pan African Clinical Trials Registry on 24/07/2023 with an identification number (PACTR202307573531455).

Calcinosis Universalis Secondary to Silicone Injections in a Patient With HIV and Chronic Kidney Disease: A Case Report of Silicone-Induced Hypercalcemia.

Medical literature has long reported evidence of complications associated with cosmetic procedures, including silicone injections. Recent years have seen an increase in case reports involving hypercalcemia resulting from these injections. A common current hypothesis for the development of hypercalcemia associated with silicone injections is granulomatous inflammation against a foreign body.  This report aimed to describe the case of a 44-year-old African American male with human immunodeficiency virus (HIV) and chronic kidney disease (CKD) who presented to our hospital and was diagnosed with calcinosis universalis secondary to a history of silicone injections, as well as to present a literature review of silicone-induced hypercalcemia. This was a case report (n=1) from a large academic medical center for which the patient, who first presented in May 2023, had two inpatient admissions and two outpatient visits before being lost to follow-up. Relevant images, laboratory results, and treatments were included.  The patient's history was significant for HIV, hypertension, CKD, recurrent nephrolithiasis, and tobacco use disorder. Physical examination was positive for flank pain while labs were significant for Na 137 mmol/L, K 2.7 mmol/L, blood urea nitrogen (BUN) 28 mg/dL, creatinine 3.72 mg/dL, calcium 13.4 mg/dL, hemoglobin 9.3 g/dL, white blood cell count 6,700 u/L and platelet count 105,000 u/L. Renal ultrasound revealed bilateral nephrolithiasis and left-sided hydronephrosis. Computerized tomography (CT) upon admission showed hyperlucid deposits in the bilateral gluteal area. Initial management included intravenous (IV) fluids and one dose of IV pamidronate, which resulted in reduced calcium levels during the admission. Subsequent management included outpatient follow-up with endocrinology during which denosumab was prescribed. This case had similar findings to other reports in the literature detailing silicone-induced hypercalcemia, which also reported abnormal imaging or nephrolithiasis, low-normal parathyroid hormone (PTH), normal 25-hydroxyvitamin D, and elevated 1,25-dihydroxyvitamin D. Silicone injection-induced hypercalcemia should be considered as a differential diagnosis in patients presenting with otherwise unexplained elevated serum calcium and a history of past cosmetic procedures. If suspected, the use of imaging techniques (e.g. positron emission tomography (PET) scans or MRI) may help ascertain the diagnosis. Further research is needed to determine the most appropriate therapies for complex patients such as those with immunodeficiency or renal disease.

Study on pharmacokinetic and tissue distribution of hyperin, astragalin, kaempferol-3-O-ß-D-glucuronide from rats with multiple administrations of Semen Cuscutae processed with salt solution with effect of treating recurrent spontaneous abortion.

Introduction: Semen Cuscutae is a traditional Chinese medicine (TCM) that tonifies the kidneys and prevents miscarriage. According to Chinese medicine theory, kidney deficiency is one of the main causes of recurrent spontaneous abortion (RSA). The previous studies showed that raw product of Semen Cuscutae (SP) and Semen Cuscutae processed with salt solution (YP) have ameliorative effects on RSA, and that YP is superior to SP. However, the active components of YP to ameliorate RSA remain unclear and require further studies. The objective of this study is to investigate the active components of YP in ameliorating RSA. Methods: First, a rat model of RSA was established using hydroxyurea in combination with mifepristone. Aqueous decoction of YP was given by gavage to rats. Second, pregnant rats were sampled on days 5, 7, 9, 10 and 12 during the modelling period. The content of Hyperin (HY), astragalin (AS) and kaempferol-3-O-ß-D-glucuronide (KA) in blood and liver, heart, spleen, lung and kidney tissues were detected by liquid chromatography-mass spectrometry (LC-MS). The pharmacodynamic indicators including progesterone (P), chorionic gonadotropin ß (ß-HCG), estradiol (E2), tumor necrosis factor-α (TFN-α), interleukin 4 (IL-4), and tryptophan (TRP) were measured by enzyme-linked immunosorbent assay (ELISA) Pearson's correlation analysis and grey relational analysis were used to establish the relationship between the pharmacodynamic indexes and chemical constituents. Results: The pharmacokinetic results showed that the area under curve (AUC) value of KA was the largest. The tissue distribution results showed that astragalin was widely distributed in liver, heart, spleen, lung and kidney in the RSA model rats, while HY was detected only in the uterus, and KA was detected only in the kidney. The pearson correlationl analysis showed that KA was significantly and positively correlated with the contents of E2, P, ß-HCG and TRP. Both AS and HY were significantly negatively correlated with the content of TNF-α, respectively. Discussion: This study reveals the pharmacokinetics and tissue distribution of KA, AS and HY in rats with RSA. It was elucidated that all three were involved in the regulation of progesterone levels and immune function. It initially revealed the mechanism of action of YP in enhancing the improvement of RSA, and it provided a theoretical basis for the quality assessment of YP.

Complete response to disitamab vedotin in HER2-low metastatic endometrial carcinoma: a case report and review of the literature.

Endometrial cancer (EC) is one of the most common gynecologic malignancies with increasing morbidity. The prognosis for patients diagnosed with early-stage EC remains favorable; however, for patients with recurrent or metastatic EC, the prognosis is poor and treatment options, until recently, are limited. Antibody drug conjugates (ADCs) represent innovative strategies in cancer treatment; however, there are less investigations regarding their efficacy in EC. This report describes an EC case with low human epidermal growth factor receptor 2 (HER2) immunohistochemistry (IHC) expression score (IHC 2+) that experienced recurrent metastasis in the abdominal and peritoneal following post-surgical chemotherapy and radiotherapy. Subsequently, the commencement of HER2-targeted ADC, disitamab vedotin (RC48; 2.5 mg/kg), administered intravenously every two weeks, was initiated. The tumor lesions shrunk markedly after three cycles of treatment and disappeared by the completion of ten cycles of therapy. The patient is still in remission at present. The current findings imply the potential efficacy of HER2-targeted ADCs for patients with HER2-low metastatic EC.

"She mimicked the manipulations on my hand": fostering embodied care among children with recurrent acute respiratory tract infections in Southern China.

INTRODUCTION: When young children experience recurrent respiratory infections, caregivers face the challenge of preventing new episodes whilst maintaining close rapport with their children. Pediatric massage, such as pediatric Tuina, entails soft massage of the skin, administered by trained providers. This non-pharmaceutical measure is used to prevent new respiratory infections in China. The aim of this study is to deepen our understanding of caregivers' experiences and perceptions of providing pediatric Tuina treatment to their children with recurrent respiratory tract infections. METHODS: A qualitative study, based on semi-structured interviews, was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist. Sixteen mothers from Southern China, whose children had received pediatric Tuina for recurrent respiratory tract infections, participated online. Analysis was conducted according to the principles of reflexive thematic analysis, using the NVivo qualitative research software. RESULTS: The overarching theme was "Fostering embodied care with children". Caregivers assessed pediatric Tuina by hearing others' experiences of pediatric Tuina, as well as observing the manipulations on their child's body and their bodily reactions during pediatric Tuina sessions. Caregivers also closely observed children's bodily changes after pediatric Tuina sessions. Embodied attachment between children and adults was nurtured through the pediatric Tuina. Compared to other treatments or medical consultations, children were more relaxed and more involved in embodied care, which involved direct skin touching and verbal communication from the pediatric Tuina provider. Children also took the initiative to bring pediatric Tuina into their family life, by asking caregivers to perform it on them and mimicking the manipulations on the caregivers' hand. CONCLUSIONS: Pediatric Tuina served as a means of interaction between children and adults, fostering an embodied care on both a physical and emotional level. Beyond its potentially preventive effect on recurrent respiratory tract infections, pediatric Tuina could be a support for parents of children with recurrent or chronic disease at home.

Advances in Recurrent Respiratory Papillomatosis Treatment: Adjuvant Intralesional Bevacizumab's Impact, Potential and Insights from a Case Series Study.

Recurrent respiratory papillomatosis is an aggressive benign disease characterised by the repeated growth of multiple warts involving the larynx as well as other parts of the respiratory tract. Recurrent respiratory papillomatosis is most commonly caused by human papillomaviruses 6 and 11. It requires multiple surgical procedures for tumour debulking.Our study aims to evaluate the impact and potential of adjuvant intralesional bevacizumab in the treatment of recurrent respiratory papillomatosis while providing valuable insights based on a case series analysis.A prospective study of a total of 13 patients with Recurrent respiratory papillomatosis attending a tertiary care hospital with ages ranging from 3 to 30 years was conducted from February 2018 to February 2023 by intralesional bevacizumab 1 ml with a concentration of 2.5 mg/ml per dose, 3 injections, each once every 4 weeks by calculating the number of operative procedures per year, duration of time between procedures, calculating the Derkay score before 1 year of the first injection and after 1 year of the last dose injection of bevacizumab treatment. Inclusion criteria are ages between 3 and 30 years with recurrent respiratory papillomatosis who underwent at least 4 or more surgical procedures with no adjuvant therapies. In all our cases, the affected area was the larynx.Adjuvant therapy with intralesional bevacizumab increases the duration of time between surgical procedures and reduces the number of operative procedures each year with an overall improvement in the Derkay score. No adverse drug effects have been reported in our study.Intralesional Bevacizumab is an effective and safe adjuvant treatment option for recurrent respiratory papillomatosis. It increases the duration of time between surgical procedures and decreases the number of procedures per year with an overall improvement in the Derkay score.

Diagnosis and Management of Paradoxical Cerebrospinal Rhinnorhea in Mondini's Dysplasia.

Objectives: To highlight a case of unilateral Mondini's dysplasia and it's potential to manifest as paradoxical cerebrospinal fluid (CSF) rhinorrhoea and recurrent meningitis in an adult. Methods: A single case report with presentation and management of a patient with left sided Mondini's Dysplasia who presented with watery nasal discharge in the background of recurrent meningitis. We review the differential diagnoses and the importance of a multi-disciplinary approach to management. Results: Post-auricular approach was taken and the leak was identified at the footplate of Stapes and sealed with fascia lata. The middle ear was obliterated and blind sac closure was done. The patient made a good recovery. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-024-04903-5.

Non-recurrent Laryngeal Nerve - A Rare Anatomical Anomaly that Increases the Risk of Nerve Injury during Thyroidectomy.

Introduction: Nonrecurrent laryngeal nerve (NRLN), a rare anatomical variation of recurrent laryngeal nerve, is a branch of the vagus nerve (Morais M, Capela-Costa J, Matos-Lima L, Costa-Maia J (2015) Nonrecurrent Laryngeal Nerve and Associated Anatomical Variations: The Art of Prediction. Eur Thyroid J 4(4):234-238). On the right side, the prevalence of NRLN is 0.3-0.8%, while on the left side, it is extremely rare with a prevalence of 0.004%. Case-Report: A female in her twenties presented with thyroid swelling for 3 years with an ultrasound neck showing a TIRADS IV lesion in the left thyroid lobe. Contrast-enhanced tomography of the neck reported a lesion in the left thyroid lobe causing mass effect in the form of contralateral deviation of trachea and splaying of bilateral common carotid arteries from its common origin - probability of thyroid neoplasm along with aberrant right subclavian artery with a retroesophageal course was noted. Intraoperatively, the right laryngeal nerve was identified near its entry point in right cricothyroid joint and was traced laterally and was found to be nonrecurrent lying superior to inferior thyroid artery. Total thyroidectomy was done preserving the left recurrent laryngeal nerve and right non recurrent laryngeal nerve. Conclusion: NRLN should be suspected in cases with vascular anomalies based on preoperative imaging. Meticulous dissection during thyroid surgery for identification of the recurrent laryngeal nerve or NRLN is still considered to be the precise approach to avoid nerve injury.

Recurrent Anterior Shoulder Dislocation with Coracoid Fracture in an Old Age Male: A Rare Case Report.

Introduction: Anterior shoulder dislocation is a common pathology in young males with less prevalence in other age groups. Anterior shoulder dislocation being the most common variety of dislocation among the shoulder dislocation can be managed both conservatively and surgically. Recurrent anterior dislocation in middle-aged males with a coracoid fracture is a rare entity and should be managed with proper pre-operative planning including computed tomography (CT) scan, magnetic resonance imaging (MRI), and surgery. Case Report: A 65-year-old male is a known case of recurrent anterior dislocation presented with anterior shoulder dislocation 1½ years back. Closed reduction was done. Radiological evaluations such as CT scan and MRI were done which were suggestive of bony Bankart and coracoid fracture which was managed with open Latarjet procedure. Conclusion: Recurrent anterior shoulder dislocation with a concomitant coracoid fracture is a rare entity in old age, which can be managed with a Latarjet procedure and has a good post-operative outcome.

Immunoglobulin G4-Related Disease Presenting as Recurrent Acute Pancreatitis.

Immunoglobulin G4-related disease (IgG4-RD) is a rare immune-mediated disease affecting multiple organs and tissues. There is often the presence of elevated serum Ig4 subtype with histological evidence of lymphoplasmacytic infiltration, fibrosis, and phlebitis. The mainstay of treatment is steroid therapy. This case report is based on a 24-year-old man with IgG4-related type 1 autoimmune pancreatitis (AIP) who also had elevated serum IgG4 subclass and histological features in keeping with IgG4-RD. The main complaints were dry cough, nasal congestion with sneezing, sore throat, and fever. Necessary investigations were performed and based on the International Consensus Diagnostic Criteria, the diagnosis of AIP type 1 was confirmed, which is a pancreatic manifestation of IgG4-RD. He was subsequently treated with prednisolone and azathioprine and is showing a good response to the treatment.

Closed-incision negative-pressure wound therapy after Bascom's cleft lift surgery for pilonidal sinus disease: A randomized study comparing healing.

AIM: Despite favourable outcomes in recurrence after off-midline closure techniques in pilonidal surgery, between 18% and 40% of patients suffer from prolonged postoperative wound healing. The aim of this work was to investigate if closed-incision negative-pressure wound therapy (NPWT) promotes wound healing after Bascom's cleft lift (BCL) surgery for complicated pilonidal sinus disease compared with conventional drainage and dressing. METHOD: Patients were randomized to either NPWT for 4-7 days or loop-vessel drain for 24 h and a dry dressing postoperatively. Healing was evaluated by a wound care nurse blinded for randomization at 2 and 12 weeks postoperatively (primary endpoint). Healing was defined as one or no closing defects of ≤5 mm and with no undermining. RESULTS: Although we had wanted to recruit 200 patients, the study was terminated at 118 patients (NPWT group, n = 60; control group, n = 58) after interim analysis. Patients were comparable by age, sex, body mass index, previous smoking status and indication for BCL surgery. At 2 weeks 12% of patients were healed in both the NPWT and control groups [risk difference = 0.00(95% CI -0.12 to 0.11), p = 1.00]. After 12 weeks, 68% of patients were healed in the NPWT group and 72% in the control group [risk difference = -0.03 (95% CI 0.19 to 0.13), p = 0.82]. There was no significant difference in pain experienced postsurgery. In a symptom-based questionnaire, the control group reported self-esteem to be less affected (p = 0.015). CONCLUSION: Closed-incision negative-pressure wound therapy did not significantly improve healing after BCL surgery for complicated pilonidal sinus disease.

Current perioperative care in patients undergoing a beyond total mesorectal excision procedure for rectal cancer: What are the differences with the colorectal enhanced recovery after surgery protocol?

AIM: Patients requiring a beyond total mesorectal excision (bTME) procedure for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) will probably benefit from enhanced recovery after surgery (ERAS) protocols. However, implementation of ERAS protocols in such groups of patients is considered challenging. The aims of this study were to evaluate ERAS-related outcomes of patients with LARC or LRRC undergoing bTME and to investigate the possibility of designing a tailored ERAS protocol. METHOD: This study was divided into four phases. Phase one consisted of a literature study to compare functional recovery and postoperative outcomes in patients undergoing bTME. In phase two, outcomes on ERAS care elements in bTME were retrospectively evaluated. In phase three, differences in ERAS-related outcomes and compliance of the colorectal ERAS protocol in patients who had undergone bTME were studied. In phase four, multidisciplinary team meetings were held to develop an ERAS protocol for bTME patients. RESULTS: Seven studies reported on ERAS-related outcomes in patients undergoing bTME. Median length of hospital stay was 9-19 days, median stay in the intensive care unit was 2-4 days and 30-day postoperative major complication rates were 22.6%-61.3%. Seventy-five bTME patients were included for retrospective analysis. In these patients, length of stay was 9.0 days and major postoperative complications were observed in 40.0%. The overall ERAS compliance was 44.4%. Compared with the colorectal ERAS protocol, the largest differences in management were observed in the use of epidural anaesthesia, the postoperative use of urethral catheters, oral intake and mobilization. CONCLUSION: Patients undergoing bTME for LARC or LRRC are substantially different from patients treated with the colorectal ERAS protocol, regarding ERAS-related outcomes. A tailored, multimodal ERAS protocol with specific modifications was developed by an expert multidisciplinary team for patients undergoing bTME for LARC or LRRC.

High Prevalence of Anti-Prothrombin IgM and IgG Autoantibodies in Women With Unexplained Recurrent Pregnancy Loss.

To investigate the association between anti-prothrombin IgM and IgG antibodies and recurrent pregnancy loss (RPL) in a cohort of Lebanese women, and their impact on pregnancy outcomes. This was a retrospective case-control study involving 207 women with RPL and 179 age-matched multiparous controls. Quantitative sandwich ELISA assayed anti-prothrombin IgM and IgG antibodies. Univariate and multivariate logistic regression were employed to assess the risk imparted by anti-prothrombin antibodies, while ROC analysis was used to determine their sensitivity and specificity. Our study revealed that women with RPL had significantly higher serum levels of anti-prothrombin IgM and IgG than controls. Univariate regression analysis demonstrated that elevated anti-prothrombin IgM (OR = 1.13; 95% CI = 1.07, 1.19; P < 0.001) and IgG (OR = 1.05; 95% CI = 1.03, 1.08; P < 0.001) were associated with increased RPL risk. Multivariate analysis confirmed these findings, indicating that anti-prothrombin IgM (aOR = 1.13; 95% CI = 1.05, 1.20; P < 0.001) and IgG (aOR = 1.08; 95% CI = 1.05, 1.11; P < 0.001) are independent risk factors. ROC analysis yielded an AUC of 0.720 for IgM and 0.649 for IgG, underscoring their predictive value and offering hope for improved risk assessment and management of RPL. Elevated levels of anti-prothrombin IgM and IgG are significantly associated with RPL, suggesting an autoimmune component to pregnancy loss. These findings highlight the importance of screening for these antibodies in women with unexplained RPL to guide management and therapeutic strategies.

Promising clinical effect of arthroscopic autologous iliac bone grafting with suture anchor binding fixation for recurrent anterior shoulder instability.

Background: To evaluate the clinical efficacy of arthroscopic autologous iliac bone grafting with suture anchor binding fixation combined with a Bankart repair for recurrent anterior shoulder dislocation with a significant anterior glenoid defect. Methods: Patients with recurrent anterior shoulder dislocation with an anterior glenoid defect area greater than 20% admitted to our department from March 2019 to March 2022 were prospectively enrolled. Arthroscopic autologous iliac bone grafting with suture anchor binding fixation combined with a Bankart repair was performed. Computed tomography (CT) images were captured preoperatively, immediately after surgery, and at 3, 6, and 12 months postoperatively to evaluate the glenoid defect area, graft area, and graft healing. Shoulder function was assessed using the Instability Severity Index, Oxford Shoulder Instability, and Rowe scores recorded preoperatively and at the final follow-up. The shoulder range of motion, shoulder stability test, surgery-related complications, subluxation/dislocation, and revision surgery were also evaluated. Results: A total of 32 patients were included in the study, with an average follow-up time of 18.3 ± 6.3 months, when the graft healing rate was shown to be 100%. The area ratio of the graft to the glenoid was 37.6% ± 10.5% (range, 23.5%-44.1%) determined by an enface-view three-dimensional CT performed immediately after surgery, and 29.2 ± 8.2% (range, 19.6%-38.7%) at 12 months postoperatively. At the final follow-up, the glenoid defect had improved from 28.7 ± 6.4% (range, 20.5%-40.6%) before surgery to -10.2 ± 4.7% (range, -13.8% to 6.1%). The preoperative Rowe and Oxford scores were 56.4 ± 8.5 and 34.7 ± 7.1 respectively, which improved to 94.3 ± 6.7 and 15.3 ± 3.2 at the final follow-up (p < .001). All patients had no limited shoulder joint activity, no re-dislocation or revision surgery, and no neurovascular injury. Conclusions: For recurrent anterior shoulder dislocation with an anterior glenoid defect area greater than 20%, arthroscopic autologous iliac bone grafting with suture anchor fixation combined with a Bankart repair produced a promising clinical effect. A significant shoulder function score was achieved, as was a 100% bone healing rate and ideal glenoid reconstruction without major complications. Thus, this technique may be considered an alternative to the classic Latarjet approach to treat recurrent anterior shoulder dislocation with an anterior glenoid defect area greater than 20%. Level of Evidence: IV.

Recurrent syncope during mastication.

Steal syndrome is characterized by the disruption of blood flow from specific vascular territories due to perfusion via collateral vessels bypassing an obstructed artery segment. In the neurovascular setting, this can lead to entities such as subclavian steal syndrome or the less prevalent double steal phenomenon, primarily associated with atherosclerosis. We present a case of an early 80s patient with cerebrovascular insufficiency who exhibited neurological deficits during mastication. The angiographic evaluation showed occlusion at the origins of the left common carotid and of the brachiocephalic trunk. This configuration caused the left vertebral artery to be the only vessel filling anterograde. The flow in the right vertebral artery is retrograde, filling the subclavian and the right common carotid artery. Endovascular revascularization of the brachiocephalic trunk was successfully performed using a Gore Viabahn VBX Balloon Expandable Stent (W.L. Gore & Associates, Flagstaff, AZ, USA), leading to symptom resolution.