Establishment of a swine model of delayed bleeding after endoscopic procedure.

Objectives: Although delayed bleeding after endoscopic procedures has become a problem, currently, there are no appropriate animal models to validate methods for preventing it. This study aimed to establish an animal model of delayed bleeding after endoscopic procedures of the gastrointestinal tract. Methods: Activated coagulation time (ACT) was measured using blood samples drawn from a catheter inserted into the external jugular vein of swine (n = 7; age, 6 months; mean weight, 13.8 kg) under general anesthesia using the cut-down method. An upper gastrointestinal endoscope was inserted orally, and 12 mucosal defects were created in the stomach by endoscopic mucosal resection using a ligating device. Hemostasis was confirmed at this time point. The heparin group (n = 4) received 50 units/kg of unfractionated heparin via a catheter; after confirming that the ACT was ≥200 s 10 min later, continuous heparin administration (50 units/kg/h) was started. After 24 h, an endoscope was inserted under general anesthesia to evaluate the blood volume in the stomach and the degree of blood adherence at the site of the mucosal defect. Results: Delayed bleeding was observed in three swine (75%) in the heparin-treated group, who had a maximum ACT of >220 s before the start of continuous heparin administration. In the non-treated group (n = 3), no prolonged ACT or delayed bleeding was observed at 24 h. Conclusion: An animal model of delayed bleeding after an endoscopic procedure in the gastrointestinal tract was established using a single dose of heparin and continuous heparin administration after confirming an ACT of 220 s.

Pharmacobezoar Associated Prolonged Clinical Course in a Patient with Immediate Release Quetiapine Overdose.

INTRODUCTION: Quetiapine is available in both immediate-release (IR) and extended-release (XR) formulations. Quetiapine XR overdose is known to cause delayed increase in serum quetiapine concentrations. However, it is not certain whether quetiapine IR overdose would similarly cause a delayed increase in serum quetiapine concentrations. CASE REPORT: A 57-year-old woman with depression who was taking half a tablet of 25 mg quetiapine IR daily was transported to our emergency department with a complaint of disturbance of consciousness 12 h after a quetiapine IR overdose. On arrival, her initial vital signs were heart rate of 116 beats per minute, blood pressure of 77/43 mm Hg, and oxygen saturation of 91% under 10 L oxygen administration. Whole body plain computed tomography showed a large amount of gastric hyperdense content suggesting pharmacobezoar with a volume of 71.2 ml. After treatment with respiratory and circulatory support, gastric lavage was performed. Her disturbance of consciousness persisted until day 5, and she was extubated on day 7. The serum concentrations of quetiapine were 2690 ng/mL at 12 h after overdose, 5940 ng/mL at 40 h, and 350 ng/mL at 124 h after overdose. Serum concentrations of other co-ingestions were all below lethal levels. CONCLUSION: A massive quetiapine IR overdose with pharmacobezoars can cause a delayed increase in serum quetiapine concentrations.

The Immediate and Delayed Maximal Non-Irritating Skin Testing Concentrations of ß-lactam Antibiotics.

BACKGROUND: Maximal skin testing (ST) nonirritant concentrations (NICs) are consistent for penicillin and aminopenicillin amongst guidelines. However, there is variability amongst guidelines for maximal ST NICs of cephalosporins. OBJECTIVE: To determine maximal immediate and delayed ST NICs of 15 ß-lactams in ß-lactam-tolerant and ß-lactam-naïve participants. METHODS: We performed a single-center, nonrandomized prospective study between September 2019 and January 2022 in adult participants. Participants received skin prick testing (SPT) and intradermal test (IDT) injections at six increasing concentrations of 1 or more ß-lactams. A concentration was considered irritant when more than 5% of participants had a positive test. A positive test was defined as a wheal ≥3 mm than negative control accompanied by a ≥5 mm flare for SPT/IDT and induration ≥5 mm with associated erythema at 48 hours for delayed readings (dIDT). Sensitivity analyses using 3 alternative IDT positive criteria were conducted. RESULTS: A total of 747 participants with a median age of 64 (IQR 54-72), 52% males, 85% White, and 92% Non-Hispanic underwent 20,858 skin tests. All undiluted SPT concentrations were nonirritant. We found the following maximal IDT/dIDT NICs (mg/ml): ampicillin (41.6/125), ampicillin-sulbactam (93.8/187.5), aztreonam (6.3/25), cefazolin (55/165), cefepime (35/140), cefoxitin (45/90), ceftaroline (7.5/15), ceftriaxone (58.3/175), cefuroxime (55/110), ertapenem (16.6/50), imipenem-cilastin (6.3/25), meropenem (8.3/25), nafcillin (31.3/62.5), oxacillin (20.9/83.5), and piperacillin-tazobactam (112.5/225). dIDTs were almost all completely non-irritant close or at undiluted concentrations. There were no differences when we applied 3 IDT positivity criteria to our raw data. CONCLUSION: Our results suggest that SPTs with undiluted stock ß-lactam antibiotic concentrations are nonirritant. Compared to previously published nonirritant concentrations, we propose a 2 to 50-fold increase to the maximal IDT and dIDT NICs of 15 ß-lactam antibiotics. When performing dIDTs, a higher concentration should be used rather than the same IDT concentration.

Recovery from sport-induced muscle damage in relation to match-intervals in major events.

Muscle damage could affect the next match performance in sports when the time to recover from a previous match is shorter. We examined the interval between matches in nine team sports (e.g., soccer, rugby, field hockey, basketball, volleyball, baseball) and two racket sports (badminton, tennis) in World Cups held in 2022-2023, 2020 Tokyo Olympic Games and Gland Slam in 2023. We then performed narrative review using three electronic databases (PubMed, Scopus, Google Scholar) to get information about muscle damage and recovery in the 11 sports, and discussed whether the intervals in the events would be enough for athletes. We found that the match intervals varied among sports and events ranging from 0 to 17 days. The interval was the shortest for softball (0-2 days) and the longest (5-17 days) for rugby. Regarding muscle damage, changes in muscle function and/or performance measures after a match were not reported for cricket, volleyball and softball, but some information was available for other sports, although the studies did not necessarily use athletes who participated in the major events. It was found that recovery was longer for soccer and rugby than other sports. Importantly, the match-intervals in the events did not appear to accommodate the recovery time required from the previous match in many sports. This could increase a risk of injury and affect players' conditions and health. Changing the match-intervals may be difficult, since it affects the budget of sporting events, but an adequate interval between matches should be considered for each sport from the player's and coach's point of view.

Decreased Positive Fecal Occult Blood Tests and Delayed Medical Presentation for Colorectal Cancer during the Initial COVID-19 Pandemic Period: A Single-center Experience.

Objectives: This study aimed to investigate the impact of the COVID-19 pandemic on the examination and treatment of colorectal cancer (CRC) and on the behaviors of patients and practitioners. Methods: This is a retrospective analysis of the CRC patients who presented to our department between April 2019 and March 2021 and underwent surgery. Clinical presentation of CRC and time from symptom onset to medical presentation were compared between the control (April 2019 to March 2020, n=124) and COVID-19 pandemic periods (April 2020 to March 2021, n=111). Results: Two hundred and thirty-five patients were reviewed. The rate of positive fecal occult blood tests was significantly lower during the COVID-19 pandemic period (13.5 vs. 25.0%, P = 0.027). Among the symptomatic patients who had melena and abdominal symptoms, the time from symptom onset to medical presentation was significantly longer during the COVID-19 period (115 vs. 31 days, P < 0.001). In addition, the interval between presenting to a practitioner and being referred to our department was similar between the two periods (19 vs. 13 days, P = 0.092). There were no significant differences in the stage of cancer between the two periods. The rate of preoperative sub-obstruction was significantly higher during the COVID-19 period (41.4 vs 23.4%, P = 0.003). There was no significant difference in overall survival and recurrence-free survival between two periods. Conclusions: Hesitation to seek examination and treatment for CRC was observed in patients but not in practitioners during the COVID-19 pandemic period. The prognosis did not change.

Colorectal Post-polypectomy Bleeding in Outpatient versus Inpatient Treatment: Propensity Score Matching Analysis.

Objectives: Delayed bleeding is the most frequent adverse event associated with endoscopic mucosal resection (EMR) and hot snare polypectomy (HSP) of colorectal polyps. However, whether the incidence of delayed bleeding differs between outpatient and inpatient treatment is unknown. Therefore, in this study, we aimed to evaluate delayed bleeding rates between outpatient and inpatient endoscopic treatments and clarify the safety of outpatient treatment. Methods: We enrolled 469 patients (1077 polyps) and 420 patients (1080 polyps) in the outpatient and inpatient groups, respectively, who underwent EMR or HSP for colorectal polyps at our institution between April 2020 and May 2023. Using propensity score matching, we evaluated the delayed bleeding rates between the two groups. Delayed bleeding was defined as a hemorrhage requiring endoscopic hemostasis occurring within 14 days of the procedure. Results: Propensity score matching created 376 (954 polyps) matched patient pairs. The median maximum diameter of polyps removed was 10 mm in both groups. Delayed bleeding rates per patients were 1.3% (5/376) in the outpatient group and 2.9% (11/376) in the inpatient group (P=0.21). In term of per polyp, early delayed bleeding (occurring within 24 hours) rates were higher in the inpatient group than outpatient group (0.2% [2/954] vs. 1.1% [10/954], respectively; P=0.04). No severe bleeding requiring a transfusion occurred in either group. Conclusions: Outpatient endoscopic treatment did not increase delayed bleeding compared with inpatient treatment. Outpatient treatment would be safe and common for the removal of colorectal polyps.

Stroke-Like Migraine Attacks After Radiation Therapy (SMART) Syndrome: A Case Report.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare and delayed complication of brain irradiation involving impaired cerebrovascular autoregulation, and diagnosis is based on distinct clinic-radiographic findings and exclusion of differentials. We report a 38-year-old man, who received cranial irradiation 28 years before and developed episodes of headache and visual aura, followed by left hemianopia, aphasia, behavioral disturbances, and focal seizures. An MRI of the brain revealed gyral swelling with restricted diffusion and mild contrast enhancement over the right temporoparietal and occipital region, and fludeoxyglucose-FDG PET scan showed hyperperfusion in the corresponding brain region. He improved completely with pulse steroids and antiseizure medications. The recognition of this syndrome is important as we can reassure patients and their families and help avoid unnecessary and invasive diagnostic tests.

Monoclonal antibody anti-sclerostin for treatment of pelvic insufficiency fractures in adult hypophosphatasia: A case report.

Hypophosphatasia is a rare inherited metabolic disease leading to inhibition of bone and teeth mineralization that can be complicated by multiple insufficiency fractures. Treatment is currently limited to enzyme replacement therapy using bone-targeting recombinant human alkaline phosphatase, or asfotase alfa. Romosozumab is a monoclonal anti-sclerostin antibody originally indicated for the treatment of osteoporosis in postmenopausal women with high-risk of fracture. Recently its indication had been expanded to other metabolic bone disorders such as osteogenesis imperfecta. We report a unique case of a 67-yer-old female with hypophosphatasia complicated by multiple delayed-union and nonunion insufficiency fractures of the pelvis. After 12-month therapy with Romosozumab to address her osteoporosis, the patient healed her fractures and increased her bone mass density. Our case report shows interesting effects of Romozumab in an adult patient with hypophosphatasia. It not only helped increase bone density, but also help in the healing process of delayed-union and nonunion insufficiency fractures of the pelvis and prevented the occurrence of new fractures during the treatment period. To our knowledge, this is the first report describing the potential effect of Romosozumab on insufficiency fractures in patients with hypophosphatasia.

Glucagon-like Peptide-1 Receptor Agonists and Capsule Endoscopy in Patients with Diabetes: A Matched Cohort Study.

BACKGROUND AND AIMS: Video capsule endoscopy (VCE) is valuable for assessing conditions like gastrointestinal bleeding, anemia, and inflammatory bowel disease. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are prescribed for diabetes and weight loss, with their pharmacologic effects including delaying gastric emptying. This study investigates the impact of GLP-1 RA usage on VCE outcomes in patients with diabetes. METHODS: This retrospective cohort study involves patients with diabetes undergoing VCE while on GLP-1 RA, matched 1:1 ratio with controls based on demographics and diabetes related factors, who are not on GLP-RA. The primary outcome is gastric transit time in VCE studies, with secondary outcome being incomplete small bowel evaluation and the small bowel transit time. RESULTS: In the 68 GLP-1 RA patient cohort, five (7%) experienced VCE failure to pass through the stomach, while all controls passed successfully (p=0.06). GLP-1 RA patients had longer gastric transit time (99.3 ± 134.2 minutes) compared to controls (25.3 ± 31.6 minutes, p <0.001). Multivariate analysis revealed GLP-1 RA usage was associated with increased gastric transit time by 74.5 minutes (CI: 33.8-115.2, p <0.001) compared to controls, after adjusting on relevant factors. Sixteen GLP-1 RA patients (23.5%) experienced incomplete passage of the VCE through the small intestine, a significantly higher rate compared to three patients in the control group (4.4%) (p<0.01). CONCLUSIONS: GLP-1 RA usage is associated with prolonged gastric transit time and a higher rate of incomplete small bowel evaluation during VCE. Future studies may be crucial for evaluating strategies to mitigate these effects.

Unified control of diverse actions in a wastewater treatment activated sludge system using reinforcement learning for multi-objective optimization.

The operation of modern wastewater treatment facilities is a balancing act in which a multitude of variables are controlled to achieve a wide range of objectives, many of which are conflicting. This is especially true within secondary activated sludge systems, where significant research and industry effort has been devoted to advance control optimization strategies, both domain-driven and data-driven. Among data-driven control strategies, reinforcement learning (RL) stands out for its ability to achieve better than human performance in complex environments. While RL has been applied to activated sludge process optimization in existing literature, these applications are typically limited in scope, and never for the control of more than three actions. Expanding the scope of RL control has the potential to increase the optimization potential while concurrently reducing the number of control systems that must be tuned and maintained by operations staff. This study examined several facets of the implementation of multi-action, multi-objective RL agents, namely how many actions a single agent could successfully control and what extent of environment data was necessary to train such agents. This study observed improved control optimization with increasing action scope, though control of waste activated sludge remains a challenge. Furthermore, agents were able to maintain a high level of performance under decreased observation scope, up to a point. When compared to baseline control of the Benchmark Simulation Model No. 1 (BSM1), an RL agent controlling seven individual actions improved the average BSM1 performance metric by 8.3 %, equivalent to an annual cost savings of $40,200 after accounting for the cost of additional sensors.

Outcomes of delayed tracheostomy among intubated patients during the coronavirus disease pandemic.

BACKGROUND: Respiratory distress and failure is a complication of the coronavirus disease (COVID-19) and tracheostomy may be necessary in cases of prolonged intubation in order to reduce mechanical ventilation duration. However, according to the Canadian Society of Otolaryngology-Head and Neck Surgery guidelines, which our institution applies, patients should not undergo tracheostomy unless cleared of the virus to reduce its spread among healthcare workers because tracheostomy is an aerosolized procedure. This study aimed to identify the outcomes of prolonged intubation in patients with and without COVID-19 who underwent tracheostomy and to determine the morbidity and mortality rates in both groups. METHODS: This retrospective cohort study included adult patients admitted to the intensive care unit of King Fahad Hospital of the University, Alkhobar, Saudi Arabia, between March 1 and October 31, 2020. This study compared and analyzed the outcomes of delayed tracheostomy in patients with and without COVID-19 in terms of complication, morbidity, and mortality rates. RESULTS: Of the 228 study participants, 111 (48.68%) had COVID-19. The mean age of the study participants was 58.67 years (SD = 17.36, max.=93, min.=20), and the majority were males (n = 149, 65.35%). Regarding tracheostomy in patients with COVID-19, 11 (9.91%) patients underwent tracheostomy; however, four (36.36%) of them had prolonged intubation. The mean intensive care unit admission length of stay for tracheostomy patients was 37.17 days, while it was 12.09 days for patients without tracheostomy (t(226)=-9.32, p < 0.001). Regarding prolonged intubation among patients with COVID-19 (n = 7, 6.31%), the complications were as follows: six people (85.71%) had dysphonia, one (14.29%) had vocal cord granuloma, and two (28.57%) had subglottic tracheal stenosis. The mortality rate among our study participants was 51.32%, and the risk was significantly higher in older people (Odds ratio = 1.04, 95% Confidence Interval [CI] = 1.02-1.06) and in delayed tracheostomy cases (OR = 2.95, 95% CI = 1.31-6.63). However, COVID-19 status was not significantly related to the risk of mortality. CONCLUSIONS: Delaying tracheostomy increases the risk of mortality. Therefore, we recommend weighing the risks and benefits for each patient to benefit both healthcare workers and patients with COVID-19.

Arthroscopic assisted versus open non-vascularized bone grafting in delayed union and nonunion of the scaphoid: a systematic review and meta-analysis.

BACKGROUND: Delayed union and nonunion of the scaphoid is a common complication often requiring surgical reconstruction and bone grafting. Our goal was to systematically assess the healing time and clinical outcomes following arthroscopic-assisted versus open non-vascularized bone grafting of the scaphoid. METHODS: A comprehensive search of the MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central databases was completed from inception to September 2023. We included randomized trials and observational studies that reported outcomes following scaphoid delayed union/nonunion comparing arthroscopic-assisted vs. open non-vascularized bone grafting. Two reviewers independently extracted data and assessed the risk of bias. One investigator assessed certainty of evidence and a senior investigator confirmed the assessment. We pooled effects using random-effects models, when possible, for all outcomes reported by more than 1 study. RESULTS: Overall, 26 studies and 822 patients were included in the study. Very low certainty evidence demonstrated that arthroscopic-assisted surgery may decrease healing time compared to open surgery (weighted mean difference [WMD] -7.8 weeks; 95%CI -12.8 to -2.8). Arthroscopic bone grafting did not result in an improvement in union rate (relative risk 1.01; 95%CI 0.9 to 1.09). The pooled data in arthroscopic graft group showed mean time to union of 11.4 weeks (95%CI: 10.4 to 12.5) with union rate of 95% (95%CI 91-98%). A single comparative study reported very low certainty evidence that arthroscopy-assisted vs. open surgery may not have an effect on pain relief (MD 0 cm, 95%CI -0.4 to 0.5 on VAS 10 cm for pain) or improving function (MD -1.2, 95% CI -4.8 to 2.3 on 100 points DASH). CONCLUSION AND FUTURE DIRECTIONS: Our results suggest that arthroscopic-assisted non-vascularized bone grafting may be associated with improved average weeks to heal in comparison with open surgery for scaphoid delayed union/nonunion reconstruction with overall comparable union rates. There is insufficient evidence to assess the effects of arthroscopic-assisted reconstruction on union rate, time to union, and patient-reported outcomes in patients with other important nonunion characteristics such as established humpback deformity.

Using olfactory cues in text materials benefits delayed retention and schemata construction.

Olfactory cues are considered a new sensory medium that can enhance learning, but the lack of empirical data has hampered their widespread use in educational practice. This requires empirical research to explore the effects of olfactory cues on learning. To address this research need, an experimental research study was conducted among 87 fourth graders from a Chinese elementary school. It explored the innovative design of adding olfactory cues to text materials by examining their effects on retention and schemata construction as learning outcomes, as well as their influence on learners' cognitive load and learning experience. In this between-subjects design experiment, the experimental group (n = 44) learned text materials with the introduction of olfactory cues, while the control group (n = 43) only learned text materials. After the learning activity, participants were asked to complete the questionnaires, immediate test, and delayed test. The results revealed that the usage of olfactory cues synchronized with text materials can enhance delayed retention, facilitate schemata construction, and improve learner experience without increasing cognitive load. This study confirms the potential of well-designed olfactory cues in educational practice and provides insights for designing and presenting multimedia learning resources.

Good outcome with conservative treatment of delayed spinal epidural hematoma following combined spinal-epidural anesthesia: a rare case report.

BACKGROUND: Delayed spinal epidural hematoma (SEH) following central neuraxial block (CNB) is a rare but serious complication. The underlying causes of SEH associated with neuraxial anesthesia are still unclear. Furthermore, the decision between surgical intervention and conservative management for SEH remains a complex and unresolved issue. CASE PRESENTATION: We report a case of delayed SEH in a 73-year-old woman who underwent vaginal hysterectomy under combined spinal-epidural anesthesia, with the administration of postoperative anticoagulants to prevent deep vein thrombosis on the 1st postoperative day (POD). She experienced symptoms 56 h after CNB. Magnetic resonance imaging (MRI) revealed a dorsal SEH at the L1-L4 level with compression of the thecal sac. On conservative treatment, full recovery was achieved after six months. CONCLUSIONS: This case reminds anesthesiologists should be alert to the possible occurrence of a delayed SEH following CNB, particularly with the administration of anticoagulants. Immediate neurological evaluation of neurological deficit and MRI are advised. Conservative treatment combined with close and dynamic neurological function monitoring may be feasible for patients with mild or nonprogressive symptoms even spontaneous recovery.

Protean Drainage Patterns of the Left Renal Vein: A Cadaveric and Retrospective Clinical Study on the Surgical Implications and Technical Feasibility.

BACKGROUND: The diverse drainage patterns of the left renal vein (LRV), often with asymptomatic congenital anomalies, present considerable challenges in renal and retroperitoneal surgical contexts. The potential for significant bleeding and subsequent renal compromise upon vascular injury highlights the need for increased surgical awareness. OBJECTIVE: This study investigates the LRV's variable anatomical drainage patterns and morphometry. It also evaluates the embryological factors contributing to these variations and discusses their surgical implications and technical considerations. METHODS: Anatomical dissections were conducted on 21 adult human cadavers within the Department of Anatomy. Concurrently, a retrospective analysis was conducted on 15 patients who underwent various retroperitoneal surgical interventions in the Urology Department. Demographic variables and intraoperative findings were recorded and analyzed. RESULTS: Dissection analysis predominantly identified preaortic LRVs in 18 cadavers. Notable anatomical variations included a circumaortic left renal vein (CLRV), a delayed preaortic confluence of extrahilar duo LRVs, and an extrahilar tetramerous confluence with a retroiliac topography. The majority of LRVs usually end in the inferior vena cava. However, an extrahilar tetramerous variant had an unusual drainage pathway. Out of 15 cases, three (20%) had a retroaortic left renal vein (RLRV). One patient with a nonfunctioning kidney had type 1 RLRV, and another patient with pelvic ureteric junction obstruction had type 4 retroiliac left renal vein (RILRV). In both of these patients, symptoms were relieved after surgery. In a young patient with left varicocele and microscopic hematuria who had type 2 RLRV, symptoms resolved spontaneously after a few months. CONCLUSION: A thorough understanding of the variable anatomical drainage patterns of the LRV is crucial for surgeons. Accurate preoperative identification can provide valuable insights, potentially leading to improved surgical outcomes in renal procedures.

Postoperative Delirium and Neurocognitive Disorders: Updates for Providers Caring for Cancer Patients.

PURPOSE OF REVIEW: To provide up to date information on postoperative delirium and neurocognitive disorders in surgical cancer patients. RECENT FINDINGS: Established risk factors such as age, psychosocial factors, comorbidities, frailty and preexisting cognitive decline continue to exhibit associations with perioperative neurocognitive disorders (PND); novel risk factors identified recently include microbiome composition and vitamin D deficiency. Prevention measures include cognitive prehabilitation, perioperative geriatric assessment and multidisciplinary care, dexmedetomidine and multimodal analgesic techniques. Studies investigating ciprofol, remimazolam, esketamine, ramelteon and suvorexant have shown encouraging results. Controversy remains regarding the use of inhalational versus intravenous general anesthesia. Innovative approaches to address PND are a rapidly developing area of research, but more studies are needed to identify effective prevention and management interventions. Despite challenges and controversy in the field, implementation of best practice can reduce the detrimental impact of PND on patients, caregivers, and society at large.

Maculopapular rash with multiple drug hypersensitivity to cotrimoxazole, amikacin, piperacillin/tazobactam, and meropenem in a patient with hairy cell leukemia.

We describe a rare case of a 54-year-old female with hairy cell leukemia, who following treatment for neutropenic sepsis, developed an extensive severe maculopapular exanthema with perifollicular hemorrhage. Cladribine, cotrimoxazole, allopurinol, domperidone, amikacin, piperacillin/tazobactam, and meropenem had all been given in the 9 days prior to eruption onset. Three months later, drug patch testing/delayed intradermal testing was positive to cotrimoxazole, trimethoprim, amikacin, piperacillin/tazobactam, and meropenem, with additional evidence of penicillin cross-reactivity. Drug challenge tests were negative to allopurinol and domperidone. She was diagnosed with multiple drug hypersensitivity to cotrimoxazole, amikacin, piperacillin/tazobactam, and meropenem. Multiple drug hypersensitivity is a novel syndrome mainly seen with severe delayed type IV drug eruptions, involving long-lasting strong T-cell reactivity to two or more structurally unrelated drugs.

Modified Senning Procedure for Treatment of Transposition of the Great Arteries with Crisscross Heart.

CLINICAL DATA: A nine-month-old female infant diagnosed with transposition of the great arteries with symptoms of heart failure associated with cyanosis and difficulty in gaining weight was referred to our center with late diagnosis (at nine months of age). CHEST RADIOGRAPHY: Cardiomegaly; attenuated peripheral vascular markings.Electrocardiography: Sinus rhythm with biventricular overload and aberrantly conducted supraventricular extra systoles. ECHOCARDIOGRAPHY: Wide atrial septal defect, ventricular axis torsion with concordant atrioventricular connection and discordant ventriculoarterial connection. COMPUTED TOMOGRAPHY ANGIOGRAPHY: Concordant atrioventricular connection, right ventricle positioned superiorly and left ventricle positioned inferiorly; discordant ventriculoarterial connection with right ventricle connected to the aorta and left ventricle connected to pulmonary artery. DIAGNOSIS: Crisscross heart is a rare congenital heart defect, accounting for 0.1% of congenital heart diseases. It consists of the 90º rotation of ventricles' axis in relation to their normal position; therefore, ventricles are positioned in the superior-inferior direction rather than anterior-posterior. Most cases have associated cardiac anomalies, and in this case, it is associated with transposition of the great arteries. The complexity and rarity of its occurrence make diagnosis and surgical treatment challenging. OPERATION: Modified Senning procedure using the pericardial sac in the construction of a tunnel from pulmonary veins to the right atrium. Cardiopulmonary bypass time of 147 minutes with nine minutes of total circulatory arrest.

The Enigma of Delayed Neurotoxicity in Organophosphate Poisoning: A Case Report of Clinical Presentation With Normal MRI Findings.

Organophosphates (OP) are the most widely used pesticides globally and are misused for suicides because of their easy availability. It leads to functional impairment of distal segments of sensory and motor axons of peripheral nerves, as well as impacting the ascending and descending spinal tracts. It progresses through latent, progressive, static, and improvement phases. In the improvement phase, peripheral nerve regeneration occurs, revealing the spinal cord lesion with myelopathic features. The acute symptoms and treatments of OP poisoning have been extensively documented in the literature. Delayed neurotoxicity is a rare but debilitating condition that can manifest weeks after initial exposure. A high index of suspicion for OP-induced delayed neurotoxicity should be maintained in patients presenting with delayed neurological symptoms post-OP exposure, even with normal MRI findings. OP linked to delayed neuropathy include triorthocresyl phosphate, chlorpyriphos, malathion, fipronil, mipafox, matriphonate, and parathion. Among these, the most hazardous OP ester is tri-o-cresyl phosphate. We report a case of a 28-year-old male who developed neurotoxicity five weeks following OP poisoning with chlorpyrifos. Early diagnosis and symptomatic management are important for improving patient outcomes.

Effect of ultrafine grinding on the structure and physical properties of pregelatinized rice starch.

This study used a combination method of ultrafine grinding and pregelatinization to modify rice starch (RS) to delay its retrogradation and provide a rationale for prolonging rice product shelf life. The structure and physicochemical properties of the pregelatinized ultrafine grinding rice starch (PURS) were compared with those of RS, ultrafine grinding rice starch (URS), and pregelatinized rice starch (PRS). The microstructure, molecular weight, branched starch length distribution, short-range order, crystal structure, and physical properties of RS, URS, PRS, and PURS were analyzed, respectively. Results showed that RS, URS, PRS, and PURS granules exhibited similar spherical or polygonal shapes, and the content of amylose and short-branched starch in PURS increased compared with RS, URS, and PRS. Furthermore, the cross-polarization of PRS and PURS disappeared. Long-chain amylopectin and average molecular weight of PURS decreased significantly after ultrafine grinding. Our study suggested reduced breakdown value and setback value and improved gel stability, and PURS was beneficial for delaying retrogradation compared to RS, URS, and PRS. The ultrafine grinding method improved the water swelling capacity (WSC), solubility, pasting properties, and gelation properties of PRS. The hardness of PURS was reduced by ultrafine grinding. These suggest that the combination of ultrafine grinding and pregelatinization could improve the properties of RS. Pearson's correlation analysis showed that the structure of PURS significantly influenced the physicochemical properties. The present study was helpful in better understanding the importance of ultrafine grinding in improving the anti-retrogradation of PURS and provided new insights into extending the shelf life of rice products by ultrafine grinding and pregelatinization.