Transobturator Tension-Free Vaginal Flap Operation versus Synthetic Transobturator Tape for Treatment of Female Stress Urinary Incontinence: A Prospective Randomized Study.

INTRODUCTION: Synthetic mid-urethral slings (MUSs) are the gold standard treatment for female stress urinary incontinence (SUI). Recently, there have been reports of serious adverse events with synthetic tapes such as urethral erosion, vaginal erosion, and mesh infection. Tension-free vaginal flap (TVF) operation has been proven to be successful as a natural alternative to synthetic slings. We propose our novel technique, the transobturator tension-free vaginal flap (TO-TVF), utilizing native vaginal tissue and being suspended via transobturator route. METHODS: This prospective study was conducted on 72 female patients with SUI, presenting at Alexandria University Hospital. Patients were randomized into 2 groups, group 1: 37 patients subjected to TO-TVF and group 2: 35 patients to conventional transobturator tape (TOT). In TO-TVF, a rectangular vaginal wall flap is created. A polypropylene monofilament mesh is sutured to each edge of the vaginal flap. This is inserted like conventional outside-in TOT. Patients were subjected to PGI and UDI-6 questionnaires and urodynamic study before and 6 months postoperatively. RESULTS: Both groups showed comparable and significant improvements in questionnaires. Mean operative time for TO-TVF and conventional TOT was 26.31 ± 5.2 min and 21.8 ± 3.1 min, respectively. Cure rate was 89% in group 1 and 91.4% in group 2, which was not statistically significant. No significant intraoperative complications were encountered. We had no cases of vaginal or urethral erosion in both groups. CONCLUSIONS: TO-TVF is a cost-effective, feasible, safe, and effective surgical alternative to synthetic MUS. Synthetic mesh tissue anchoring properties are maintained for better adjustment of tension. However, long-term follow-up on a large cohort of patients is still needed.

Management of pediatric blunt abdominal trauma with split liver or spleen injuries: a retrospective study.

BACKGROUND: Blunt abdominal trauma is a prevailing cause of pediatric morbidity and mortality. It constitutes the most frequent type of pediatric injuries. Contrast-enhanced sonography (CEUS) and contrast-enhanced computed tomography (CECT) are considered pivotal diagnostic modalities in hemodynamically stable patients. AIM: To report the experience in management of pediatric split liver and spleen injuries using CEUS and CECT. PATIENTS AND METHODS: This study included 246 children who sustained blunt abdominal trauma, and admitted and treated at three tertiary hospitals in the period of 5 years. Primary resuscitation was offered to all children based on the advanced trauma and life support (ATLS) protocol. A special algorithm for decision-making was followed. It incorporated the FAST, baseline ultrasound (US), CEUS, and CECT. Patients were treated according to the imaging findings and hemodynamic stability. RESULTS: All 246 children who sustained a blunt abdominal were studied. Patients' age was 10.5 ± 2.1. Road traffic accidents were the most common cause of trauma; 155 patients (63%). CECT showed the extent of injury in 153 patients' spleen (62%) and 78 patients' liver (32%), while the remaining 15 (6%) patients had both injuries. CEUS detected 142 (57.7%) spleen injury, and 67 (27.2%) liver injury. CONCLUSIONS: CEUS may be a useful diagnostic tool among hemodynamically stable children who sustained low-to-moderate energy isolated blunt abdominal trauma. It may be also helpful for further evaluation of uncertain CECT findings and follow-up of conservatively managed traumatic injuries.

Combined anterior and posterior ring fixation versus posterior ring fixation alone in the management of unstable Tile B and C pelvic ring injuries: A randomized controlled trial.

PURPOSE: Combined anterior and posterior ring (APR) fixation is classically performed in Tile B2 and C1 injuries to achieve superior biomechanical stability. However, the posterior ring (PR) is the main weight bearing portion that is responsible for weight transmission from the upper parts of the body to the lower limbs through the sacrum and the linea terminalis. It is hypothesized that isolated PR fixation can achieve comparable radiological and clinical outcomes to APR fixation. Therefore, we conducted this study to compare the two fixation principles in managing Tile B2 and C1 injuries. METHODS: Our study included 20 patients with Tile B2 injuries and 20 patients with Tile C1 injuries. This study was a randomized control single-blinded study via computerized random numbers with a 1:1 allocation by using random block method. The study was performed at a level one trauma center. A total of 40 patients with Tile B2 and C1 injuries underwent combined APR or isolated PR fixation (Group A and B, respectively). Matta & Tornetta radiological principles and Majeed pelvic scoring system were used for the assessment of primary outcomes and postoperative complications. Secondary outcomes included operative time, amount of blood loss, intraoperative assessment of reduction, need of another operation, length of hospital stay, ability to weight bear postoperatively and pain control metrics. We used student t-test to compare the difference in means between two groups, and Chi-square test to compare proportions between two qualitative parameters. We set the confidence interval to 95% and the margin of error accepted to 5%. So, p ≤ 0.05 was considered statistically significant. RESULTS: The mean follow-up duration was 18 months. The operative time (mean difference 0.575 h) and the intraoperative blood loss (mean difference 97.5 mL) were lower in Group B. Also, despite the higher frequency of rami displacement before union in the same group, there were no significant differences in terms of radiological outcome (excellent outcome with OR = 2.357), clinical outcome (excellent outcome with OR = 2.852) and postoperative complications assessment (OR = 1.556) at last follow-up. CONCLUSION: The authors concluded that isolated PR fixation could favorably manage Tile B2 and C1 pelvic ring injuries with Nakatani zone II pubic rami fractures and intact inguinal ligament. Its final radiological and clinical outcomes and postoperative complications were comparable to combined APR fixation, but with less morbidity (shorter operation time, lower amount of blood, and no records of postoperative wound infection).

Biomechanics of hamstring tendon, quadriceps tendon, and bone-patellar tendon-bone grafts for anterior cruciate ligament reconstruction: a cadaveric study.

PURPOSE: The three most commonly used autografts for anterior cruciate ligament reconstruction (ACL) are: bone-patellar tendon-bone (BTB), hamstring tendons (HT), and quadriceps tendon (QT). A cadaveric study was performed to determine if there were any differences in mechanical and structural properties under biomechanical testing. METHODS: Twenty-seven graft specimens were harvested from 9 human cadaveric legs. Mean donor age was 75.2 years (range 53-85 years). Twenty-two specimens (8 HT, 7 QT, and 7 BTB) completed cyclic preconditioning from 50 to 800 N for 200 cycles and a load to failure test at an extension rate of 1 mm/s. Structural and mechanical properties of BTB, HT, and QT grafts were compared using a one-way ANOVA and Tukey's honest significant difference. RESULTS: There was no difference in the ultimate load to failure (N) across all 3 graft types (p = 0.951). Quadriceps tendon demonstrated greater cross-sectional area (mm2) when compared to both HT and BTB (p = 0.001) and was significantly stiffer (N/mm) than HT but not BTB (p = 0.004). Stress (N/mm2) of the HT at ultimate load was greater than QT but not BTB (p = 0.036). Elastic modulus (MPa) of HT was greater than both QT and BTB (p = 0.016). CONCLUSION: There was no difference in the ultimate load to failure of BTB, HT, and QT grafts harvested from the same specimens. All 3 grafts had similar loads to failure with a significant increase in stiffness when compared to the native ACL. Furthermore, QT demonstrated more favourable structural properties compared to HT and BTB with greater cross-sectional area to both HT and BTB and greater stiffness compared to HT.

Mechanistic In Situ ATR-FTIR Studies on the Adsorption and Desorption of Major Intermediates in CO2 Electrochemical Reduction on CuO Nanoparticles.

Increasing levels of carbon dioxide (CO2) from human activities is affecting the ecosystem and civilization as we know it. CO2 removal from the atmosphere and emission reduction by heavy industries through carbon capture, utilization, and storage (CCUS) technologies to store or convert CO2 to useful products or fuels is a popular approach to meet net zero targets by 2050. One promising process of CO2 removal and conversion is CO2 electrochemical reduction (CO2ER) using metal and metal oxide catalysts, particularly copper-based materials. However, the current limitations of CO2ER stem from the low product selectivity of copper electrocatalysts due to existing knowledge gaps of the reaction mechanisms using surfaces that normally have native oxide layers. Here, we report systematic control studies of the surface interactions of major intermediates in CO2ER, formate, bicarbonate, and acetate, with CuO nanoparticles in situ and in real time using attenuated total reflection Fourier-transform infrared spectroscopy (ATR-FTIR). Spectra were collected as a function of concentration, pH, and time in the dark and the in absence of added electrolytes. Isotopic exchange experiments were also performed to elucidate the type of surface complexes from H/D exchange. Our results show that the organics and bicarbonate form mostly outer-sphere complexes mediated by hydrogen bonding with CuO nanoparticles with Gibbs free energy of adsorption of about -25 kJ mol-1. The desorption kinetics of the surface species indicated relatively fast and slow regions reflective of the heterogeneity of sites that affect the strength of hydrogen bonding. These results suggest that hydrogen bonding, whether intermolecular or with surface sites on CuO nanoparticles, might be playing a more important role in the CO2ER reaction mechanism than previously thought, contributing to the lack of product selectivity.

Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG), an EAST Multicenter Study.

OBJECTIVE: We sought to describe contemporary presentation, treatment, and outcomes of patients presenting with acute (A), perforated (P), and gangrenous (G) appendicitis in the United States. SUMMARY BACKGROUND DATA: Recent European trials have reported that medical (antibiotics only) treatment of acute appendicitis is an acceptable alternative to surgical appendectomy. However, the type of operation (open appendectomy) and average duration of stay are not consistent with current American practice and therefore their conclusions do not apply to modern American surgeons. METHODS: This multicenter prospective observational study enrolled adults with appendicitis from January 2017 to June 2018. Descriptive statistics were performed. P and G were combined into a "complicated" outcome variable and risk factors were assessed using multivariable logistic regression. RESULTS: A total 3597 subjects were enrolled across 28 sites: median age was 37 (27-52) years, 1918 (53%) were male, 90% underwent computed tomography (CT) imaging, 91% were initially treated by appendectomy (98% laparoscopic), and median hospital stay was 1 (1-2) day. The 30-day rates of Emergency Department (ED) visit and readmission were 10% and 6%. Of 219 initially treated with antibiotics, 35 (16%) required appendectomy during index hospitalization and 12 (5%) underwent appendectomy within 30 days, for a cumulative failure rate of 21%. Overall, 2403 (77%) patients had A, whereas 487 (16%) and 218 (7%) patients had P and G, respectively. On regression analysis, age, symptoms >48 hours, temperature, WBC, Alvarado score, and appendicolith were predictive of "complicated" appendicitis, whereas co-morbidities, smoking, and ED triage to appendectomy >6 hours or >12 hours were not. CONCLUSION: In the United States, the majority of patients presenting with appendicitis receive CT imaging, undergo laparoscopic appendectomy, and stay in the hospital for 1 day. One in five patients selected for initial non-operative management required appendectomy within 30 days. In-hospital delay to appendectomy is not a risk factor for "complicated" appendicitis.

Platelet-rich fibrin: an autologous biomaterial for healing assistance of pharyngeal repair in total laryngectomy.

OBJECTIVES: The aim of this study was to evaluate the potential role of platelet-rich fibrin (PRF) application on the pharyngeal repair on decreasing the incidence of pharyngocutaneous fistula (PCF) after total laryngectomy. METHODS: This randomized controlled clinical trial was conducted on 67 patients with advanced laryngeal carcinoma who underwent total laryngectomy, over 2 years in the Otorhinolaryngology Department, Mansoura University Hospitals, Egypt. Patients were randomly assigned into two groups: PRF group (n = 35) and control group (n = 32). Risk factors for development of PCF as well as the incidence of PCF were studied in both groups. RESULTS: There was no statistically significant difference between groups regarding demographic data, medical comorbidities, basal hemoglobin and albumin levels, data related to the tumor (location, grade and TNM staging) and surgical details (preoperative tracheotomy and neck dissection). However, regarding the incidence of PCF, there was a statistically significant difference between groups as shown in Table 2. PCF was detected in 2/35 patients (5.7%) in the PRF group and in 10/32 patients (31.3%) in the control group (p = 0.004). CONCLUSION: PRF application on the pharyngeal repair after total laryngectomy enhances the healing process and consequently decreases the incidence of PCF.

An Eco-Friendly Approach to the Control of Pathogenic Microbes and Anopheles stephensi Malarial Vector Using Magnesium Oxide Nanoparticles (Mg-NPs) Fabricated by Penicillium chrysogenum.

The discovery of eco-friendly, rapid, and cost-effective compounds to control diseases caused by microbes and insects are the main challenges. Herein, the magnesium oxide nanoparticles (MgO-NPs) are successfully fabricated by harnessing the metabolites secreted by Penicillium chrysogenum. The fabricated MgO-NPs were characterized using UV-Vis, XRD, TEM, DLS, EDX, FT-IR, and XPS analyses. Data showed the successful formation of crystallographic, spherical, well-dispersed MgO-NPs with sizes of 7-40 nm at a maximum wavelength of 250 nm. The EDX analysis confirms the presence of Mg and O ions as the main components with weight percentages of 13.62% and 7.76%, respectively. The activity of MgO-NPs as an antimicrobial agent was investigated against pathogens Staphylococcus aureus, Bacillus subtilis, Pseudomonas aeruginosa, Escherichia coli, and Candida albicans, and exhibited zone of inhibitions of 12.0 ± 0.0, 12.7 ± 0.9, 23.3 ± 0.8, 17.7 ± 1.6, and 14.7 ± 0.6 mm respectively, at 200 µg mL-1. The activity is decreased by decreasing the MgO-NPs concentration. The biogenic MgO-NPs exhibit high efficacy against different larvae instar and pupa of Anopheles stephensi, with LC50 values of 12.5-15.5 ppm for I-IV larvae instar and 16.5 ppm for the pupa. Additionally, 5 mg/cm2 of MgO-NPs showed the highest protection percentages against adults of Anopheles stephensi, with values of 100% for 150 min and 67.6% ± 1.4% for 210 min.

Opioids After Surgery in the United States Versus the Rest of the World: The International Patterns of Opioid Prescribing (iPOP) Multicenter Study.

OBJECTIVE: The International Patterns of Opioid Prescribing study compares postoperative opioid prescribing patterns in the United States (US) versus the rest of the world. SUMMARY OF BACKGROUND DATA: The US is in the middle of an unprecedented opioid epidemic. Diversion of unused opioids contributes to the opioid epidemic. METHODS: Patients ≥16 years old undergoing appendectomy, cholecystectomy, or inguinal hernia repair in 14 hospitals from 8 countries during a 6-month period were included. Medical records were systematically reviewed to identify: (1) preoperative, intraoperative, and postoperative characteristics, (2) opioid intake within 3 months preoperatively, (3) opioid prescription upon discharge, and (4) opioid refills within 3 months postoperatively. The median/range and mean/standard deviation of number of pills and OME were compared between the US and non-US patients. RESULTS: A total of 4690 patients were included. The mean age was 49 years, 47% were female, and 4% had opioid use history. Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients (P < 0.001). The median number of opioid pills and OME prescribed were 20 (0-135) and 150 (0-1680) mg for US versus 0 (0-50) and 0 (0-600) mg for non-US patients, respectively (both P < 0.001). The mean number of opioid pills and OME prescribed were 23.1 ±â€Š13.9 in US and 183.5 ±â€Š133.7 mg versus 0.8 ±â€Š3.9 and 4.6 ±â€Š27.7 mg in non-US patients, respectively (both P < 0.001). Opioid refill rates were 4.7% for US and 1.0% non-US patients (P < 0.001). CONCLUSIONS: US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US.

Prevalence of erectile dysfunction in Egyptian males with metabolic syndrome.

Objectives: Determination of the potential effect of metabolic syndrome (MetS) on erectile function in Egyptian men and description of the sociodemographic characteristics of these men.Materials and methods: A cohort of 615 patients presenting to urology department aged between 30 and 75 years were prospectively assessed and divided into two groups. Group I (n = 325) diagnosed with MetS and mean age of 56.07 ± 8.51 years. Group II (n = 290) subjects with no MetS and mean age 54.97 ± 8.14 years. Patients filled the IIEF questionnaire, medical, personal history, and BMI data were tabulated. Metabolic syndrome was determined when three or more of the five risk factors were present according to the NCEP.Results: In Group I (79.4%) of the patients had erectile dysfunction (ED). Of these, 20.3% had mild, 22.5% had moderate, and 36.6% had severe ED and 30% of patients without MetS had ED. Of these, 17.2% had mild, 5.9% had moderate, and 6.9% had severe ED (p < .001; odds ratio 5.549; 95% CI 3.101-9.928). Patients with metabolic syndrome had lower IIEF-EF domain scores. Logistic regression analysis revealed that DM, dyslipidemia, age, and HTN were the most important criteria for ED in the MetS group (p < .01). While in the group without MetS, DM, HTN, HDL, and age were the most important risk factors (p < .01), and TG and BMI were less important.Conclusions: MetS is a potential risk factor for ED in Egyptian men. Patients with MetS should be questioned about ED. The diabetic patients are most risky for ED.

Cervical Spine Clearance in Trauma Patients with an Unreliable Physical Examination.

BACKGROUND: The objective of this study was to describe and compare the timing of cervical spine clearance in trauma patients with an unreliable physical examination. METHODS: We prospectively included adult trauma patients admitted with a cervical collar and an unreliable clinical examination (as defined by the NEXUS criteria) at two level 1 trauma centers: one in the USA (US) and one in Denmark (DK). We excluded patients with cervical spine injuries requiring a collar or surgery as treatment and patients with a collar placed after hospital arrival. The primary outcome was time from emergency department (ED) arrival to collar removal. Secondary outcomes included time to CT of the cervical spine (CTCS). At the US trauma center, an institutional protocol allowing cervical spine clearance exclusively by CTCS was in place. At the Danish trauma center, cervical spine clearance was based on a clinical evaluation by an orthopedic surgeon, usually after CTCS. RESULTS: A total of 113 patients were included (US: n = 56; DK: n = 57). The median age was 47 years, and 68% were males. The main reasons for an unreliable physical examination were a Glasgow Coma Scale score below 14 (35%), distracting injuries (26%), cervical spine tenderness (13%) and intoxication (13%). The injury severity score at the US trauma center was higher than at the DK trauma center (median: 17 vs. 11, p = 0.03). Both time to CTCS (median: 41 vs. 18 min, p < 0.0001) and time to collar removal (median: 1042 vs. 49 min, p < 0.0001) were significantly greater at the US trauma center. CONCLUSIONS: Time to collar removal was significantly greater in a trauma center utilizing a cervical spine clearance protocol based on CTCS. As patients may develop complications related to the collar, future studies should clarify how early removal can be implemented without increasing the risk of morbidity.

Revisability of polyetheretherketone suture anchors utilised in primary and revision Bankart repair.

BACKGROUND: Polyetheretherketone (PEEK) suture anchors are frequently used in Bankart shoulder stabilisation. This study analyzed the primary stability and revisability of PEEK anchors in-vitro in case of primary Bankart repair and revision Bankart repair after failed primary repair. METHODS: To simulate primary Bankart repair, 12 anchors (Arthrex PEEK PushLock® 3.5 mm) were implanted in 1, 3, 5, 7, 9 and 11 o'clock positions in cadaveric human glenoids and then cyclically tested. To simulate revision Bankart repair, 12 anchors were implanted in the same manner, over-drilled and 12 new anchors of the same diameter were implanted into the same bone socket as the primary anchors and then cyclically tested. The maximum failure loads (Fmax), system displacements, force at clinical failure and modes of failure were recorded. RESULTS: One primary anchor failed prematurely due to a technical problem. Three out of 12 revision anchors (25%) dislocated while setting the 25 N preload. The Fmax, the displacement and clinical failure of the remaining 9 revision anchors were non-significant when compared to the 11 primary repair anchors. The main mode of failure in the primary and revision Bankart surgery group was suture slippage. Anchor dislocations were observed four times in the primary and once in the revision repair groups. CONCLUSIONS: Revision Bankart repair using PEEK anchors of the same diameter in a pre-existing bone socket is possible but bears high risk of premature anchor failure and can jeopardize the reconstruction. PEEK suture anchor in revision Bankart surgery should be implanted in a new bone socket if possible.

Targeting MAPKs, NF-κB, and PI3K/AKT pathways by methyl palmitate ameliorates ethanol-induced gastric mucosal injury in rats.

Excessive drinking of alcohol has been frequently associated with gastric injury; however, its underlying molecular mechanisms have been inadequately investigated. Methyl palmitate (MP) has demonstrated marked hepato-, cardio- and pulmonary protective features; however, its effects on ethanol-induced gastric injury have not been studied. The aim of the present study was to evaluate the potential gastroprotective activity of MP against ethanol-evoked gastric mucosal damage in rats and associated molecular mechanisms, for example, mitogen-activated protein kinases (MAPKs), nuclear factor κB (NF-κB), and phosphoinositide 3 kinase/protein kinase B (PI3K/AKT) pathways. The rat stomachs were examined in terms of the inflammatory, oxidative, and apoptotic perturbations. Current data demonstrated that pretreatment with MP attenuated the gross gastric damage, scores of ulcer index, area of mucosal lesions and histopathology outcomes; actions which were similar to the reference antiulcer omeprazole. MP inhibited NF-κB expression, its nuclear translocation, and the expression of its downstream signals, for example, tumor necrosis factor-α and myeloperoxidase besides restoration of interleukin-10 levels. Western blot analysis revealed that MP counteracted the disruption of MAPKs signaling via lowering p-c-Jun N-terminal kinase 1/2 (p-JNK1/2) expression and restoring the phospho-extracellular signal-regulated kinase 1/2 (p-ERK1/2) levels without affecting p-p38MAPK levels. Additionally, MP improved the antioxidant milieu via diminishing lipid peroxides and enhancing glutathione, glutathione peroxidase, total antioxidant capacity and mucosal nitric oxide. In the context of apoptosis, MP inhibited the cleavage of caspase-3 and poly(ADP-ribose)polymerase (PARP) and Bax protein expression with upregulating B cell lymphoma-2 expression (Bcl-2), thus, promoting gastric cellular survival. This was confirmed by MP activation of the PI3K/AKT pathway manifested by enhanced expression of PI3K p110α and p-AKT. Together, the present findings report the gastroprotective actions of MP mediated via its anti-inflammatory, antioxidant, and antiapoptotic actions. The underlying molecular mechanisms involve, at least partly, the modulation of MAPKs, NF-κB and PI3K/AKT transduction.

Description and Impact of a Comprehensive Multispecialty Multidisciplinary Intervention to Decrease Opioid Prescribing in Surgery.

INTRODUCTION: Diversion of excess prescription opioids contributes to the opioid epidemic. We sought to describe and study the impact of a comprehensive departmental initiative to decrease opioid prescribing in surgery. METHODS: A multispecialty multidisciplinary initiative was designed to change the culture of postoperative opioid prescribing, including: consensus-built opioid guidelines for 42 procedures from 11 specialties, provider-focused posters displayed in all surgical units, patient opioid/pain brochures setting expectations, and educational seminars to residents, advanced practice providers, residents and nurses. Pre- (April 2016-March 2017) versu post-initiative (April 2017-May 2018) analyses of opioid prescribing at discharge [median oral morphine equivalent (OME)] were performed at the specialty, prescriber, patient, and procedure levels. Refill prescriptions within 3 months were also studied. RESULTS: A total of 23,298 patients were included (11,983 pre-; 11,315 post-initiative). Post-initiative, the median OME significantly decreased for 10 specialties (all P values < 0.001), the percentage of patients discharged without opioids increased from 35.7% to 52.5% (P < 0.001), and there was no change in opioids refills (0.07% vs 0.08%, P = 0.9). Similar significant decreases in OME were observed when the analyses were performed at the provider and individual procedure levels. Patient-level analyses showed that the preinitiative race/sex disparities in opioid-prescribing disappeared post-initiative. CONCLUSION: We describe a comprehensive multi-specialty intervention that successfully reduced prescribed opioids without increase in refills and decreased sex/race prescription disparities.

Venlafaxine and carvedilol ameliorate testicular impairment and disrupted spermatogenesis in rheumatoid arthritis by targeting AMPK/ERK and PI3K/AKT/mTOR pathways.

Testicular impairment has been commonly described in long-standing rheumatoid arthritis (RA) patients. Since depression and cardiovascular disorders are the most disturbing co-morbidities of RA, investigating the efficacy of the anti-depressant venlafaxine or the beta-blocker carvedilol in RA-associated testicular dysfunction may add to their clinical utility for RA patients. Previously, both agents have demonstrated significant in vivo anti-oxidant and anti-inflammatory actions. In the current study, venlafaxine (50 mg/kg/day) and carvedilol (10 mg/kg/day) were orally administered to adjuvant arthritic rats for 20 days. Interestingly, venlafaxine and carvedilol effectively suppressed paw edema and mitigated the testicular histopathological aberrations and the disrupted spermatogenesis. Both drugs enhanced testicular steroidogenesis through upregulation of 3ß-HSD, 17ß-HSD and StAR gene expression with concomitant augmentation of serum testosterone. They also blunted the inflammatory burden via attenuation of myeloperoxidase, TNF-α and the protein expression of NF-κBp65 along with elevation of IL-10. They attenuated testicular oxidative perturbations via lowering lipid peroxides and nitric oxide and boosting glutathione levels. With regard to apoptosis, the two agents lowered the protein expression of caspase-3, cleaved caspase-3, cleaved PARP, Bax and p53, promoting germ cell survival. They also modulated the AMPK/ERK signaling via lowering of p-AMPK and upregulation of p-ERK1/2 along with PI3K/AKT/mTOR transduction by enhancing the PI3Kp110α, p-AKT and p-mTOR protein expression. Together, the present work demonstrates the beneficial effects of venlafaxine and carvedilol in RA testicular dysfunction and impaired spermatogenesis via modulation of AMPK/ERK and PI3K/AKT/mTOR signaling and intervention with the testicular oxidative stress, inflammation and apoptosis.

Topical Corticosteroids Decrease IL-25 Expression by Immunohistochemistry.

BACKGROUND: Interleukin-25 (IL-25) is an important contributing factor in the pathogenesis of allergic rhinitis. It leads to increasing peripheral and infiltrating eosinophilia as well as serum IgE, IgG, and Th2 cytokines (IL-4, IL-5, IL-13), which are responsible for the allergic symptoms. Intranasal steroids (INS) are effective in treating allergic rhinitis, but their effect on IL-25 release has not been studied. We aimed to study the link between IL-25 and the pathophysiology of allergic rhinitis as well as the effect of INS on its release. METHODOLOGY: This was a cohort, prospective, nonrandomized study that included 60 patients, 35 allergic rhinitis patients and 25 controls. We studied the effect of INS on IL-25 release. RESULTS: Of allergic rhinitis patients 68.6% had strong cytoplasmic stain of IL-25 in the epithelial layer, while 25.7% had intermediate stain. INS caused significantly reduced IL-25 stain as only 14.3% of patients had intermediate stain and 85.7% had weak stain. Moreover, a correlation was found between nasal smear eosinophilia and the degree of IL-25 staining in the epithelial layer. CONCLUSION: Intranasal corticosteroids appear to be effective in the downregulation of IL-25, which may explain some of the utility of intranasal corticosteroid treatment in improving allergic rhinitis symptoms.

Exploring the effect of PAs on physician trainee learning: An interview study.

BACKGROUND: Physician assistants (PAs) often have been embedded in academic medical centers to help ensure an adequate patient care workforce while supporting compliance with work-hour restrictions for residents and fellows (also called trainees). Limited studies have explored the effect of PAs on trainee learning. This qualitative study explored, from the perspective of physician faculty and PAs, how PAs working in the clinical learning environment can enhance or hinder trainee learning. METHODS: Using purposive sampling, 12 PAs and 12 physician faculty members in one US teaching hospital were selected for semistructured interviews. Data collection and analysis were characterized by an iterative process. Data analysis was informed by principles of conventional content analysis. RESULTS: Participants identified various ways in which PAs may affect trainee learning, intrinsically linked to the roles PAs assume in the clinical learning environment: clinician, teammate, and clinical teacher. Trainee learning may be enhanced because learning time can be optimized by having PAs in the clinical learning environment. Trainees can learn about PAs and how to collaborate with them, and PAs can enculturate and provide clinical instruction to trainees. Trainee learning may be hindered if learning opportunities for trainees go to PAs, trainees feel intimidated by experienced PAs, or trainees become too dependent on PAs. CONCLUSIONS: Our findings demonstrate enhancements and hindrances to trainees' learning linked to three key roles PAs perform in the clinical learning environment. These findings can inform how PAs are integrated into teaching services. Further investigation is needed to understand how PAs can balance their professional roles to foster effective collaborative practice and learning.

Long-term outcomes of sigmoid diverticulitis: a single-center experience.

BACKGROUND: During the last decade, guidelines for the treatment of sigmoid diverticulitis have dramatically changed. The aim of this study is to report the long-term outcomes of patients treated for diverticulitis at a nonspecialized single center. MATERIALS AND METHODS: After obtaining institutional review board approval, medical records of all patients admitted to our institution with the diagnosis of sigmoid diverticulitis between 1998 and 2008 were reviewed. A follow-up of at least 5 years was required. RESULTS: During the study period, 266 patients were admitted to our hospital due to sigmoid diverticulitis with a mean follow-up period of 120 ± 2 months. Of the entire cohort, 249 patients (93.5%) were treated conservatively and 17 (6.5%) patients required emergent surgery on initial presentation. Patients treated conservatively (n = 249) encountered a median of two recurrent episodes (range 0-4). During follow-up, none of these patients required emergent surgery, and 27 patients (11%) underwent elective surgery for recurrent episodes (n = 24), chronic smoldering disease (n = 2), and fistula (n = 1). Minor and major complication rates after elective surgery were 18.5% and 30%, respectively. Specifically, four patients (15%) suffered an anastomotic leak (AL). Late complications after elective surgery occurred in 33% of patients including incisional hernias (11%), bowel obstruction (3.7%), anastomotic stenosis (3.7%), and recurrent diverticulitis (15%). CONCLUSIONS: Patients treated conservatively during their index admission for sigmoid diverticulitis do not require emergent surgery during long-term follow-up and the majority of patients (89%) do not require elective surgery. Elective sigmoidectomy at nonspecialized centers may result in high rates of recurrent diverticulitis (15%) and anastomotic leak (15%).

Outcomes of interval appendectomy in comparison with appendectomy for acute appendicitis.

BACKGROUND: Traditionally, patients treated conservatively for periappendiceal abscess or phlegmon would subsequently undergo interval appendectomy (IA); however, recent evidence has shed doubt on the necessity of this procedure. This study aimed to assess the outcomes of patients who underwent IA, in comparison with those operated acutely for appendicitis. MATERIALS AND METHODS: A retrospective analysis identified patients who underwent IA between 2000 and 2016. Their course and outcomes were compared with those of our previously published cohort of patients who underwent appendectomy for acute appendicitis. RESULTS: During the study period, 106 patients underwent IA. Their mean age was 39.7 ± 16.2 y, and 60.4% were females. In their index admission, 75.5% presented with abscesses. IA was performed successfully in all patients, and no patient required colectomy. Pathology demonstrated neoplastic lesions in 6/106, but only one was malignant. IA patients were compared with a cohort of 1649 acute appendectomy patients. This group was significantly younger (33.7 ± 13.3 y). Operation time was comparable between the groups (46.0 ± 26.2 versus 42.7 ± 20.9 min, respectively, P = 0.33). In the IA group, significantly more laparoscopic operations were performed (100% versus 93.9%), but with a higher conversion rate to open (1.9% versus 0.13%, P < 0.001). Although the overall complication rate was comparable, more intraoperative complications (2.8% versus 0.3%, P < 0.001) and deep/organ-space surgical site infections (surgical site infection; 4.7% versus 1.2%, P = 0.003) were reported in the IA group. CONCLUSIONS: IA can be a challenging procedure and should not be performed on a routine basis. However, neoplasia must be actively ruled out, particularly in the older age group.

Reliability of sonoelastography in predicting pediatric cervical lymph node malignancy.

PURPOSE: Controversy exists as regards the best non-invasive diagnostic tool for pediatric cervical lymphadenopathy. The current work aimed to evaluate the reliability, sensitivity, specificity, and accuracy of sonoelastography in diagnosing benign and/or malignant pediatric cervical lymphadenopathy. METHODS: Prospective study took place over a period of 4 years from January 2013 to December 2016. A total of 177 lymph nodes (LNs) in 128 children with an age ranging from 11 months to 12 years were recruited in this study. Patients were 77 males and 51 females with a ratio of 3:2. All patients underwent a thorough history taking and clinical examination of the neck focusing on the cervical lymph nodes. After that, a B-mode sonography, Color Doppler ultrasound, and Sonoelastography were performed. Elastographic patterns of 1-5 were evaluated, whereas patterns of 3-5 (firm to hard) were suspected to have a malignant nature. Sonographic-guided aspiration cytology took place in 107 lymph nodes and excisional biopsy in 102 lymph nodes, whereas 13 lymph nodes responded adequately to conservative treatment. They proved to be benign reactive hyperplasia. RESULTS: The majority of LNs (87%) were of the malignant type that showed an elastographic pattern of 3-5. The same patterns were observed in only 6 (3.4%) of the benign LNs. Sonoelastography showed a sensitivity of 85.9%, specificity of 100%, PPV of 100%, NPV of 75.96%, and overall accuracy of 90.23% in distinguishing benign from malignant lymph nodes. Using the B-Mode ultrasound, an abnormal hilum was seen in 75%. The accuracy of color Doppler US reached 82.7%. CONCLUSIONS: Sonoelastography may be superior to other US modalities in elucidating different cervical lymph node biopsy helping to distinguish benign from malignant lesions. This may replace the lymph node biopsies in the future. Moreover, its use in the follow-up of patients with cervical malignancies may reduce the number of future biopsies. Further studies with more patients may be needed for a better assessment of results.