Endoscopic variceal ligation versus propranolol for the primary prevention of oesophageal variceal bleeding in patients with hepatocellular carcinoma: an open-label, two-centre, randomised controlled trial.

OBJECTIVE: This randomised trial aimed to address whether endoscopic variceal ligation (EVL) or propranolol (PPL) is more effective at preventing initial oesophageal variceal bleeding (EVB) in patients with hepatocellular carcinoma (HCC). DESIGN: Patients with HCC and medium-to-large oesophageal varices (EVs) but without previous EVB were randomised to receive EVL (every 3-4 weeks until variceal eradication) or PPL (up to 320 mg daily) at a 1:1 ratio. Long-term follow-up data on EVB, other upper gastrointestinal bleeding (UGIB), non-bleeding liver decompensation, overall survival (OS) and adverse events (AEs) were analysed using competing risk regression. RESULTS: Between June 2011 and April 2021, 144 patients were randomised to receive EVL (n=72) or PPL (n=72). In the EVL group, 7 patients experienced EVB, and 30 died; in the PPL group, 19 patients had EVB, and 40 died. The EVL group had a lower cumulative incidence of EVB (Gray's test, p=0.009) than its counterpart, with no mortality difference (Gray's test, p=0.085). For patients with Barcelona Clinic Liver Cancer (BCLC) stage A/B, EVL was better than PPL in reducing EVB (p<0.001) and mortality (p=0.003). For patients beyond BCLC stage B, between-group outcomes were similar. Other UGIB, non-bleeding liver decompensation and AEs did not differ between groups. A competing risk regression model confirmed the prognostic value of EVL. CONCLUSION: EVL is superior to PPL in preventing initial EVB in patients with HCC. The benefits of EVL on EVB and OS may be limited to patients with BCLC stage A/B and not to those with BCLC stage C/D. TRIAL REGISTRATION NUMBER: NCT01970748.

A Randomized Controlled Trial of Propranolol Use During Ligation Program for Secondary Prophylaxis of Esophageal Variceal Bleeding.

INTRODUCTION: Endoscopic variceal ligation (EVL) plus nonselective ß-blockers (NSBB) is the standard of care for secondary prophylaxis of esophageal variceal bleeding (EVB). This trial aimed to compare the rebleeding rates between EVL plus NSBB till eradication of esophageal varices (EEV) and EVL plus long-term NSBB. METHODS: After control of acute EVB, patients with cirrhosis were randomized into 2 groups, with group A patients receiving EVL plus propranolol till EEV, while group B patients received standard of care with continuation of propranolol. Recurrent varices were ligated at follow-up endoscopy in both groups. RESULTS: The median follow-up period was 23.0 months in group A (n = 106) and 23.6 months in group B (n = 106). Twelve patients (11.3%) in group A and 11 (10.4%) in group B had recurrent EVB. The difference in rebleeding rates and the 95% confidence interval (CI) was 0.9% (-7.5% to 9.3%). The upper 95% CI bound of the difference was within the margin of 13.2%, and the noninferiority of group A to group B was established. Thirty-eight patients (35.8%) in group A and 40 (37.7%) in group B had further decompensation, with the difference (95% CI) of -1.9% (-14.9% to 11.1%). Twenty-four patients (22.6%) in group A and 26 (24.5%) in group B expired, with the difference (95% CI) in mortality rates of -1.9% (-13.3% to 9.5%). DISCUSSION: EVL plus propranolol till EEV was noninferior to EVL plus continuing propranolol in secondary prophylaxis of EVB, but the impact on further decompensation and transplantation-free survival deserved further investigation.

Impact of nutritional support routes on mortality in acute pancreatitis: A network meta-analysis of randomized controlled trials.

BACKGROUND: Nutritional administration in acute pancreatitis (AP) management has sparked widespread discussion, yet contradictory mortality results across meta-analyses necessitate clarification. The optimal nutritional route in AP remains uncertain. Therefore, this study aimed to compare mortality among nutritional administration routes in patients with AP using consistency model. METHODS: This study searched four major databases for relevant randomized controlled trials (RCTs). Two authors independently extracted and checked data and quality. Network meta-analysis was conducted for estimating risk ratios (RRs) with 95% confidence interval (CI) based on random-effects model. Subgroup analyses accounted for AP severity and nutrition support initiation. RESULTS: A meticulous search yielded 1185 references, with 30 records meeting inclusion criteria from 27 RCTs (n = 1594). Pooled analyses showed the mortality risk reduction associated with nasogastric (NG) (RR = 0.34; 95%CI: 0.16-0.73) and nasojejunal (NJ) feeding (RR = 0.46; 95%CI: 0.25-0.84) in comparison to nil per os. Similarly, NG (RR = 0.45; 95%CI: 0.24-0.83) and NJ (RR = 0.60; 95%CI: 0.40-0.90) feeding also showed lower mortality risk than total parenteral nutrition. Subgroup analyses, stratified by severity, supported these findings. Notably, the timing of nutritional support initiation emerged as a significant factor, with NJ feeding demonstrating notable mortality reduction within 24 and 48 h, particularly in severe cases. CONCLUSION: For severe AP, both NG and NJ feeding appear optimal, with variations in initiation timings. NG feeding does not appear to merit recommendation within the initial 24 h, whereas NJ feeding is advisable within the corresponding timeframe following admission. These findings offer valuable insights for optimizing nutritional interventions in AP.

Mac-2-Binding Protein Glycosylation Isomer to Albumin Ratio Predicts Bacterial Infections in Cirrhotic Patients.

INTRODUCTION: Mac-2-binding protein glycosylation isomer (M2BPGi) is a novel biomarker for liver fibrosis, but little is known about its role in cirrhosis-associated clinical outcomes. This study aimed to investigate the predictive role of M2BPGi in cirrhosis-associated complications. METHODS: One hundred and forty-nine cirrhotic patients were retrospectively enrolled. Patients were followed up for 1 year, and cirrhosis-associated clinical events were recorded. Receiver operating characteristic curve (ROC) analysis was used to establish the values of the predictive models for cirrhotic outcomes, and Cox proportional hazards regression models were used to identify predictors of clinical outcomes. RESULTS: Sixty (40.3%) patients experienced cirrhosis-associated clinical events and had higher M2BPGi levels compared to those without events (8.7 vs. 5.1 cutoff index, p < 0.001). The most common cirrhosis-associated complications were bacterial infections (24.2%). On ROC analysis, M2BPGi to albumin ratio (M2BPGi/albumin) had comparable discriminant abilities for all cirrhosis-associated events (area under the ROC curve [AUC] = 0.74) compared with M2BPGi, Child-Pugh, model for end-stage liver disease, albumin-bilirubin scores, and neutrophil-to-lymphocyte ratio and was superior to M2BPGi alone for all bacterial infectious events (AUC = 0.80). Cox regression analysis revealed that the M2BPGi/albumin, but not M2BPGi alone, independently predicted all cirrhosis-associated events (hazard ratio [HR] = 1.34, p = 0.038) and all bacterial infectious events (HR = 1.51, p = 0.011) within 1 year. However, M2BPGi/albumin did not predict other cirrhotic complications and transplant-free survival. DISCUSSION/CONCLUSION: M2BPGi/albumin might serve as a potential prognostic indicator for patients with cirrhosis, particularly for predicting bacterial infections.

Survival time analysis of remaining teeth following replacement of unilateral free-end missing teeth: A comparison between fixed implant-supported prostheses and removable partial dentures.

OBJECTIVES: This retrospective study aimed to investigate the differences in tooth loss rate between fixed implant-supported prostheses (FISPs) and removable partial dentures (RPDs) in cases of unilateral free-end missing teeth. MATERIALS AND METHODS: The data of 324 patients who underwent treatment with FISPs or RPDs for unilateral free-end missing teeth and satisfied the applicable criteria, were evaluated (47 in the FISPs group and 277 in the RPDs group). After propensity score (PS) matching, which was used to extract patients with similar background factors related to prosthetic selection at baseline, survival time analyses were performed with tooth loss as the endpoint. The adjusted variables were age, sex, number of restored teeth, periodontal status, and the practicing dentist's experience in years. The remaining teeth were classified into subcategories in relation to the missing molars. RESULTS: Overall, 58 patients (29 in each group) selected by PS matching were evaluated in the final analysis. The total number of lost teeth was 35 (FISPs group: n = 10; RPDs group: n = 25). The mean (±SD) period to tooth loss and the 10-year survival rates in the FISPs and RPDs groups were 51.6 (±30.1) months and 42.3 (±29.7) months, 70.5% and 16.4%, respectively. The log-rank test showed that significantly longer survival time in FISPs compared with RPDs. CONCLUSIONS: After adjustments for confounding factors using PS matching, replacing unilateral free-end missing teeth with FISPs may exhibit a lower tooth loss rate in adjacent and contralateral teeth compared to replacing with RPDs.

Effectiveness of betadine-coating gastrostomy tube to reduce peristomal infection after percutaneous endoscopic gastrostomy: a randomized controlled trial.

BACKGROUND: Peristomal wound infection is a common complication in patients receiving percutaneous endoscopic gastrostomy (PEG). The main reason for peristomal infection might be the oral microbes coating the gastrostomy tube during implantation. Povidone-iodine solution can be applied for skin and oral decontamination. We designed a randomized controlled trial to test the effectiveness of a Betadine® (povidone-iodine) coated gastrostomy tube to reduce peristomal infection after percutaneous endoscopic gastrostomy. METHODS: A total of 50 patients were randomized to Betadine and control groups (25 patients in each group) from April 2014 to August 2021 at a tertiary medical center. All patients received the pull method for PEG implantation using a 24-french gastrostomy tube. The primary endpoint was peristomal wound infection rate 2 weeks after the procedure. RESULTS: Changes in Neutrophil/Lymphocyte ratio (N/L ratio) and C-Reative protein (Delta CRP) at 24 h after PEG were higher in the control group than in the Betadine group (N/L ratio, 3.1 vs. 1.2, p = 0.047; CRP, 2.68 vs.1.16, p = 0.009). The two groups did not differ in post-PEG fever, peristomal infection, pneumonia, or all-cause infection. Delta CRP could predict peristomal infection and all-cause infection within 2 weeks (AUROC 0.712 vs. 0.748; p = 0.039 vs. 0.008). The best cut-off-point of Delta CRP for the diagnosis of peristomal wound infection was 3 mg/dl. CONCLUSION: The betadine coating gastrostomy tube method could not reduce peristomal infection after percutaneous endoscopic gastrostomy. CRP elevation of less than 3 mg/dl may be used to exclude the potential peristomal wound infection. TRIAL REGISTRATION: NCT04249570 ( https://clinicaltrials.gov/ct2/show/NCT04249570 ).

Triage policy to postpone endoscopy for patients with low-risk varices is safe during the lockdown period of COVID-19 pandemic.

BACKGROUND & AIMS: During the COVID-19 pandemic, most of the endoscopic services were electively postponed or suspended. We aimed to assess the safety of a triage policy in patients receiving esophageal variceal ligation during the COVID-19 pandemic. METHODS: Triage policy of endoscopic variceal ligation (EVL) was implemented in our hospital during the lockdown period from 15th May 2021 to 26th July 2021. One experienced gastroenterologist reviewed the prior-scheduled list of patients for the EVL prophylaxisprogram. We compared the clinical characteristics and outcomes with those receiving endoscopy due to esophageal varices from 17th May 2020 to 28th July 2020. RESULTS: Of the 124 patients receiving EVL, a higher percentage of esophageal variceal bleeding (EVB) was noted (9/32, 28.1% vs. 8/92, 8.7%, p = 0.006) during the lockdown period, with a higher percentage of EVB in the referrals (7/9, 77.8% vs. 2/14, 14.2%, p = 0.007). Among patients who received prophylactic EVL, 6 of 78 (7.7%) experienced EVB during the normal period, which is no different to 2 of 23 (8.7%) during the lockdown period. Twenty-three patients whose endoscopies were postponed by triage policy due to low-risk or eradicated varices did not experience EVB during the lockdown period. Child-Turcotte-Pugh (CTP) class C was predictive of EVB (relative risk 8.400, P = 0.033), entering the program of prophylactic EVL was the protective factor of EVB (relative risk 0.016, P = 0.002). CONCLUSION: Entrance into the prophylaxis program does not only decreases risk of EVB but also fosters comprehensive triage to postpone endoscopy during the lockdown period.

Dimensional changes of complete dentures fabricated by milled and printed techniques: An in vitro study.

STATEMENT OF PROBLEM: Information on the dimensional changes in maxillary and mandibular dentures made by using computer-aided design and computer-aided manufacturing (CAD-CAM) techniques under uniform testing conditions is lacking. PURPOSE: The purpose of this in vitro study was to evaluate the dimensional changes and reproducibility of maxillary and mandibular dentures by using CAD-CAM-milled and 3D-printed techniques. MATERIAL AND METHODS: Maxillary and mandibular edentulous models with wax occlusal rims were scanned, and dentures were designed by using a CAD software program and fabricated by using 2 techniques and materials: CAD-CAM-milled (CCM) and 3D-printed (3DP). The 3DP fabrications included 4 subgroups: dentures printed with a 90-degree build angle with UV light polymerization on the reference model (3DP 90M), dentures printed with a 90-degree build angle and light polymerization without the reference model (3DP 90), dentures printed with a 45-degree build angle with light polymerization on the reference model (3DP 45M), and dentures printed with a 45-degree build angle and light polymerization without the reference model (3DP 45). The preprocessing and postprocessing scan files of each denture produced by CCM and 3DP were superimposed by using a surface matching software program. Ten points each on maxillary and mandibular dentures were measured for deviations after processing. Additionally, for each denture, the widths were measured between the canines and molars, the anteroposterior plane from cusp tips between the canines and molars, and the vertical plane from the cusp tip of the canines to the marginal gingiva. They were then compared with those in the denture design CAD cast. The Kruskal-Wallis analysis of variance test was used for statistical analyses (α=.05). RESULTS: According to digital superimposition, CCM had the smallest values of deviation with no statistical difference (P>.05), indicating more uniform results from measurement points in both maxillary and mandibular dentures, followed by 3DP 90M, 3DP 90, 3DP 45M, and 3DP 45. Regarding the width measurements, CCM had the smallest values of deviation (P<.05). In 3DP, smaller deviation values were observed at the vertical plane from the tip of the canine to the marginal gingiva, and larger values were observed in the intermolar width (P<.05). CONCLUSIONS: CCM exhibited smaller dimensional changes and better reproducibility among the tested techniques. In 3DP, the build angle and methods of light postprocessing influenced the dimensional stability. The 90-degree build angle with additional light polymerization on the cast improved the dimensional deviations.

Prophylactic clipping after endoscopic mucosal resection of large nonpedunculated colorectal lesions: A meta-analysis.

BACKGROUND AND AIM: It is not clear whether prophylactic clipping after endoscopic mucosal resection (EMR) of large nonpedunculated colorectal lesions (LNPCLs) prevents delayed bleeding (DB). We aimed to conduct a meta-analysis to clarify the efficacy of prophylactic clipping in prevention of DB following EMR of LNPCLs. METHODS: We searched PubMed, EMBASE, Web of Science, ScienceDirect, Cochrane Library databases, and ClinicalTrials.gov for studies that compared clipping versus (vs) nonclipping in prevention of DB following EMR of LNPCLs. Pooled odds ratio (OR) was determined using a random effects model. The pooled ORs of DB, perforation, and post-polypectomy syndrome in the clipping group compared with the nonclipping group comprised the outcomes. Subgroup analyses based on study design, polyp location, and completeness of wound closure were performed. RESULTS: Five studies with a total of 3112 LNPCLs were extracted. Prophylactic clipping reduced the risk of DB compared with nonclipping (3.3% vs 6.2%, OR: 0.494, P = 0.002) following EMR of LNPCLs. In subgroup analysis, prophylactic clipping reduced DB of LNPCLs at proximal location (3.8% vs 9.8%, P = 0.029), but not of them at distal location (P = 0.830). Complete wound closure showed superior efficacy to prevent DB compared with partial closure (2.0% vs 5.4%, P = 0.004). No benefit of clipping for preventing perforation or post-polypectomy syndrome was observed (P = 0.301 and 0.988, respectively). CONCLUSIONS: Prophylactic clipping can reduce DB following EMR of LNPCLs at proximal location. Besides, complete wound closure showed superior efficacy to prevent DB compared with partial closure. Further cost analyses should be conducted to implement the most cost-effective strategies.

Effects of fabrication techniques on denture base adaptation: An in vitro study.

STATEMENT OF PROBLEM: Information about the accuracy of maxillary and mandibular denture bases made with different fabrication techniques under uniform test conditions is lacking. PURPOSE: The purpose of this in vitro study was to evaluate the denture base adaptation of computer-aided design and computer-aided manufactured (CAD-CAM) milled, 3D printed, and conventional heat-polymerized resin fabrication techniques. MATERIAL AND METHODS: Maxillary and mandibular edentulous models fabricated from cobalt-chromium alloy were scanned, and 2-mm-thick denture bases were designed and fabricated by using 4 fabrication techniques and materials: CAD-CAM milled (CCM), 3D printed (3DP), injection molded (IM), and compression molded (CM). Denture base adaptation was assessed by measuring the thickness of silicone between the denture base and model under a 49-N load at 8 sites. A digital superimposition method was used to compare different groups, and adaptation was assessed by superimposing the scanning data from denture bases and models. The pairwise Wilcoxon signed rank test and Kruskal-Wallis analysis of variance were used for statistical analyses (α=.05). RESULTS: According to the silicone thickness method, the lowest values (0.127-0.567 mm) were present at the bilateral maxillary tuberosities, and the highest values (0.529-2.211 mm) occurred at the postpalatal seal area in all groups. The CCM group had the lowest silicone thickness (P<.05). The 3DP group recorded greater thickness than the IM and CM groups (P<.05). In the mandible, the 3DP group recorded the lowest silicone thickness, followed by the CCM group. The overall results for digital superimposition revealed no significant difference (P>.05) in the trueness of the intaglio surfaces among CCM, IM, and CM. The 3DP group recorded the lowest trueness significantly among all the groups. CONCLUSIONS: CCM, IM, and CM exhibited superior denture adaptation, especially CCM, to both maxillary and mandibular arches compared with 3DP.

Combination of albumin-bilirubin grade and platelets to predict a compensated patient with hepatocellular carcinoma who does not require endoscopic screening for esophageal varices.

BACKGROUNDS AND AIMS: There is no consensus on screening for high-risk esophageal varices (HRV) in patients with hepatocellular carcinoma (HCC). Here, we aimed to investigate the prevalence and risk factors of HRV in patients with HCC and to assess the combination of albumin-bilirubin grade and platelet count (ALBI-PLT score) for predicting compensated patients who do not need unnecessary endoscopic screening for HRV. METHODS: The ALBI-PLT score was calculated by adding the ALBI grade and points for platelet count (1 point if platelet count >150,000/mm3 and 2 points if ≤150,000/mm3). The predictive value of the ALBI-PLT score for HRV was analyzed in 887 compensated patients enrolled from October 2007 to April 2014 (study cohort). This was validated in 215 compensated patients from May 2014 to December 2015 (validation cohort). RESULTS: In the study cohort, the rates of HRV were 2.9% and 21.1% in compensated HCC patients with an ALBI-PLT score of 2 and >2, respectively. The negative predictive values of the ALBI-PLT score for predicting HRV were 97.1% and 98.1% in the study and validation cohorts, respectively. For compensated patients who did not receive endoscopic screening at the time of HCC diagnosis, the 5-year cumulative variceal hemorrhage rate was lower in patients with an ALBI-PLT score of 2 than in those with an ALBI-PLT score >2 (1.7% vs 9.1%, P = .007). CONCLUSION: In patients with HCC with compensated liver function, an ALBI-PLT score of 2 predicted a very low risk of HRV and variceal hemorrhage; therefore, endoscopic screening for esophageal varices is not recommended for these patients.

Low air temperature increases the risk of oesophageal variceal bleeding: a population and hospital-based case-crossover study in Taiwan.

BACKGROUND & AIMS: Studies concerning seasonal variations and the impact of air temperature on oesophageal variceal bleeding have yielded conflicting results. We aimed to explore the impact of air temperature on the occurrence of variceal bleeding. METHODS: A case-crossover study design was employed, and two cohorts were used, including the NHI-EVB cohort from the National Health Insurance Research Database of Taiwan from 1 January 1999 to 31 December 2010, and the VGH-EVB cohort from the Taipei Veterans General Hospital, from 4 May 2002 to 31 December 2010. A conditional logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: In total, 2542 cases from the NHI-EVB cohort and 220 cases from the VGH-EVB cohort were analysed. Our analysis showed that low air temperature (LAT) increased the risk of variceal bleeding regardless of age, sex, decompensated cirrhosis, Child-Pugh classification, aetiology of liver disease and concomitant hepatocellular carcinoma; the lag effect was also observed. The ORs per 5°C decrease in daily mean air temperature were 1.144 (95% CI, 1.060-1.235) for the NHI-EVB cohort and 1.307 (95% CI: 1.031-1.658) for the VGH-EVB cohort. Oesophageal variceal bleeding in patients with small varices, end-stage liver disease score ≧15 or those using non-selective beta blockers was not influenced by air temperature. CONCLUSIONS: Patients have higher risk of oesophageal variceal bleeding at low air temperature regardless of age, sex, aetiology of cirrhosis, Child-Pugh classification, decompensated cirrhosis and concomitant hepatocellular carcinoma and can be protected by use non-selective beta blockers.

Clinical performance and satisfaction of removable prostheses with self-adjusting magnetic attachments.

STATEMENT OF PROBLEM: Conventional magnetic attachments have rigid assemblies and are unable to compensate for the movement of the prosthesis under function, which may result in the deepening of periodontal pockets and an increase in the mobility of abutment teeth. PURPOSE: The purpose of this study was to evaluate the clinical performance and satisfaction of participants with removable prostheses with self-adjusting magnetic attachments that allow vertical and rotational movement. MATERIAL AND METHODS: The clinical performance of 17 prostheses with 22 self-adjusting magnetic attachments in 16 participants was analyzed for a mean of 3.1 years. Periodontal indices, including probing pocket depth and tooth mobility, were measured at denture placement (baseline) and from 0.5 to 5 years after insertion. Control data were obtained from the remaining teeth, which were restored by resin or metal coping. Prosthetic parameters, including the reduction of retention in self-adjusting magnetic attachments, reline, or fracture of dentures, were also recorded. A visual analog scale questionnaire on participant satisfaction with stability, comfort, and cleaning of the prostheses was completed. The Wilcoxon signed rank test and 1-way analysis of variance (α=.05) were performed on data collected at the time of prostheses placement and final follow-up evaluation. RESULTS: No significant differences were found in terms of probing pocket depth and tooth mobility between the baseline and postinsertion data for self-adjusting magnetic attachments and control teeth. Retention in all prostheses was stable, without reduction. Higher visual analog scale scores for "easy cleaning" were noted. CONCLUSIONS: No significant difference between baseline and postinsertion was noted regarding the periodontal condition of self-adjusting magnetic attachments and control teeth with resin or metal coping materials.

The effect of immersion in water on deformation with the variety of denture base materials and manufacturing techniques.

PURPOSE: To evaluate the effect of immersion in water on deformation of maxillary denture bases created by computer-aided design and computer-aided manufactured (CAD-CAM), and heat-polymerized resin fabrication techniques under loading condition. MATERIALS AND METHODS: Two-millimeter thick denture bases were fabricated using four techniques: CAD-CAM milling (CCM) (Polywax; Yamahachi), 3D printing (3DP) (BV0005; NextDent), compression molding (CM) (Luciton 199), and injection molding (IM) (Ivobase) (n = 5 per group). Three static 49 N loads were applied perpendicular to each denture base, and the mean strain value (MSV) was recorded by strain gauges attached to the denture surface. The denture bases were stored at 37°C in distilled water for 14 and 28 days, and the MSVs under the same static load were recorded. RESULTS: The highest MSVs were observed at the posterior palatal seal, tuberosity, and labial notches of the dentures. The lowest MSVs were recorded for the CCM group, then the CM and IM. The highest MSVs were recorded for the 3DP group. No significant differences in regional MSVs (P > .05) were observed among the CCM, CM, and IM after 14 and 28 days in water. Large deviations in MSVs were recorded for the 3DP group across the measurement sites after water exposure (P < .05). CONCLUSIONS: CCM had the lowest denture deformation under static loading. After immersion in water, the deformation changes under static loading were stable for CCM, CM, and IM. However, variations among the materials used in 3DP group influenced the mechanical performance and presented larger deformations. Int J Prosthodont. 10.11607/ijp.8332.

Sarcopenia-related gut microbial changes are associated with the risk of complications in people with cirrhosis.

Background & Aims: Sarcopenia and gut dysbiosis are common in individuals with cirrhosis. However, the association between sarcopenia and microbial alterations, and the subsequent impact on cirrhotic outcomes are poorly understood. This study aimed to identify muscle-dependent microbial changes and related risks of cirrhotic complications. Methods: From September 2018 to December 2020, 89 individuals with cirrhosis and 16 healthy volunteers were prospectively enrolled. Muscle and nutritional status, serum amino acids, and fecal microbiota were analyzed. The association between microbial signatures of sarcopenia and cirrhotic complications was investigated. Results: A decline in muscle mass and strength were associated with gut microbial alterations in individuals with cirrhosis. The greatest microbial dissimilarity was observed between those with sarcopenia (both decline in muscle mass and strength) and those with normal-muscle status (p = 0.035). Individuals with sarcopenia had lower serum levels of alanine, valine, leucine, isoleucine, proline, tryptophan and ornithine. Besides, gut microbial functions associated with amino acid biosynthesis were significantly reduced in individuals with sarcopenia and cirrhosis. Depletion of Dialister, Ruminococcus 2, and Anaerostipes were associated with cirrhotic sarcopenia, and significantly correlated with the serum levels of amino acids. Individuals with coexistent depletion of Ruminococcus 2 and Anaerostipes developed more infectious (44.4% vs. 3.0%) and non-infectious (74.1% vs. 3.0%) complications, and more hospitalizations (54 vs. 3) than those with cirrhosis with good microbial signatures (all p <0.001). In contrast, fecal enrichment of Ruminococcus 2 and Anaerostipes independently decreased the risk of 1-year complications. Conclusions: Sarcopenia-related fecal microbial alterations are associated with cirrhotic complications. These findings may facilitate measures to improve the outcomes of individuals with cirrhosis and sarcopenia by modifying gut microbiota. Impact and implications: The composition and biosynthetic functions of gut microbiota are significantly changed in individuals with sarcopenic cirrhosis. Those with a sarcopenia-related poor microbial signature, in which Ruminococcus 2 and Anaerostipes were both depleted, had significantly more infectious and non-infectious complications, as well as more hospitalizations. These findings highlight the therapeutic potential of modifying the gut microbiota of individuals with sarcopenic cirrhosis to improve their clinical outcomes.

Biomechanical rationale for six splinted implants in bilateral canine, premolar, and molar regions in an edentulous maxilla.

PURPOSE: To determine the influence of number and location of implants loaded on the stress to the bone in an edentulous maxilla using a three-dimensional finite element model (3D FEM). MATERIAL AND METHODS: Computed tomographic data with the bone density of a dry skull were used to construct a 3D FEM. Titanium implants were simulated in the configuration as 14 unsplinted implants (US14), 14 splinted implants (S14), 6 splinted implants (canine, premolar, and molar regions, S6), 4 splinted implants (S4), and 6 anterior implants (incisors and canines, A6). Distributed loads of 200 N were applied on the occlusal table of the superstructures. RESULTS: The S6 model was subjected to a similar amount of stress and deformation to the US14 and the S14. The S4 and A6 models were subjected to approximately three times of stress under the vertical load, and approximately five times of stress under the inclined load, respectively, compared with the S6 model. CONCLUSIONS: The 3D FEM analyses suggest that the six splinted implants configuration has a similar stress and deformation pattern as compared with naturally positioned splinted 14 implants in the edentulous maxilla.

The risk of variceal bleeding during endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a widely performed procedure. However, the risk of variceal bleeding during ERCP has rarely been assessed. This study aims to evaluate the risk of variceal bleeding in patients with esophageal varices (EV) undergoing ERCP. METHODS: From October 2010 to November 2017, the study retrospectively enrolled 75 cirrhotic patients who received elective ERCP. The patient's risk of gastrointestinal (GI) and variceal bleeding and other procedure-related adverse events within 30 days of ERCP were evaluated. RESULTS: Among the 75 patients, 45 patients (60.0%) had EV. Most of the patients were males (65.3%), and there were high rates of viral hepatitis B-related cirrhosis (36.0%), Child-Pugh B (49.3%), and an indication of choledocholithiasis (40.0%). Thirty-three of 45 (73.3%) patients had high-risk EV, and nine (20.0%) patients had concomitant gastric varices. There was no esophageal variceal bleeding; however, one patient had gastric variceal bleeding after ERCP. Nonvariceal significant GI bleeding occurred in three patients with EV and one without EV ( p = 0.529). Post-ERCP pancreatitis occurred in three patients with EV and five without EV ( p = 0.169). No perforation or procedure-associated mortality was noted. CONCLUSION: The risk of esophageal variceal bleeding within 30 days of ERCP is neglectable, except for a patient who suffered from gastric variceal bleeding. Other complications, such as nonvariceal bleeding and pancreatitis, are also no higher in patients with EV. Therefore, ERCP is generally a safe procedure for a patient with high-risk esophageal varices.

Effect of scan delay on measurements of an occlusal pressure sensitive film: An in-vitro study.

BACKGROUND/PURPOSE: While scan delay may affect the measurements of an occlusal pressure-sensitive film, Dental Prescale II (DPS2), the duration of scan delay was rarely reported in previous studies. This study aimed to clarify the effect of scan delay on DPS2 measurements. MATERIALS AND METHODS: Two experiments were performed to clarify the effect of 0- to 10-min scan delay after DPS2 force registration. In both experiments, 11 loads were applied separately on a DPS2 film at 1-min interval between loads. Scanning was performed immediately after the 11th load in the 1-scan experiment and immediately after each load in the 11-scan experiment. A 300-N load was applied with a universal testing machine on 10 DPS2 films in each experiment and the DPS2 film was scanned with Bite Force Analyzer. Load measured, contact area, mean pressure, and maximum pressure were reported. ANOVA and Scheffé test were performed to compare the effect of number of scans and delay scan duration on these measurements with the critical value set at P ≤ 0.05. RESULTS: Number of scans had no significant effect on the four measurements studied. However, all measurements, except contact area, were significantly affected by scan delay; the longer the scan delay, the greater the increase in measurements. The load measured showed a rapid increase (13%) in the first 2 min, followed by a gradual increase from 2 min to 10 min (10%). CONCLUSION: Scan delay does affect DPS2 measurements, and it is important to standardize and report scan delay duration in clinical studies.