The fluorosis conundrum: bridging the gap between science and public health.

Fluorosis, a chronic condition brought on by excessive fluoride ingestion which, has drawn much scientific attention and public health concern. It is a complex and multifaceted issue that affects millions of people worldwide. Despite decades of scientific research elucidating the causes, mechanisms, and prevention strategies for fluorosis, there remains a significant gap between scientific understanding and public health implementation. While the scientific community has made significant strides in understanding the etiology and prevention of fluorosis, effectively translating this knowledge into public health policies and practices remains challenging. This review explores the gap between scientific research on fluorosis and its practical implementation in public health initiatives. It suggests developing evidence-based guidelines for fluoride exposure and recommends comprehensive educational campaigns targeting the public and healthcare providers. Furthermore, it emphasizes the need for further research to fill the existing knowledge gaps and promote evidence-based decision-making. By fostering collaboration, communication, and evidence-based practices, policymakers, healthcare professionals, and the public can work together to implement preventive measures and mitigate the burden of fluorosis on affected communities. This review highlighted several vital strategies to bridge the gap between science and public health in the context of fluorosis. It emphasizes the importance of translating scientific evidence into actionable guidelines, raising public awareness about fluoride consumption, and promoting preventive measures at individual and community levels.

Clinically important left superior polar artery giving rise to a left inferior suprarenal artery and an aberrant left inferior polar artery: a case report.

The renal arteries arise from the lateral side of the abdominal aorta at the L2 vertebral level, just below the origin of the superior mesenteric artery. Multiple aberrant renal arteries can pose difficulties in renal transplantation, interventional radiological and urological procedures, renal artery embolization, angioplasty, or vascular reconstruction for congenital and acquired lesions. We present a case of a left kidney supplied by the left renal artery along with superior and inferior polar arteries, arising from the aorta and inferior mesenteric artery respectively. The inferior mesenteric artery was crossed by the left ureter and inferior mesenteric vein. The superior polar artery gave rise to an inferior suprarenal artery making the variation important for clinicians and surgeons.

As artérias renais originam-se do lado lateral da aorta abdominal, no nível da vértebra L2, logo abaixo da origem da artéria mesentérica superior. A presença de múltiplas artérias renais aberrantes pode representar dificuldades para transplante renal, procedimentos radiológicos e urológicos intervencionistas, embolização da artéria renal, angioplastia e reconstrução vascular para lesões congênitas e adquiridas. Apresentamos um caso de rim esquerdo vascularizado pela artéria renal esquerda e pelas artérias polares superior e inferior, as quais se originavam da aorta e da artéria mesentérica inferior, respectivamente. A artéria mesentérica inferior era cruzada pelo ureter esquerdo e pela veia mesentérica inferior. A artéria polar superior dava origem à artéria suprarrenal inferior, o que torna essa variação importante para clínicos e cirurgiões.

Concurrent Variations of Celiac and Superior Mesenteric Arteries.

Celiac trunk is the first ventral branch of the abdominal aorta. It usually terminates by giving three branches; the common hepatic artery, the left gastric artery and the splenic artery. We report a rare variation of the branching pattern of the celiac trunk. The Celiac trunk divided into two branches; left gastric artery and splenicogastroduodenal trunk. The splenico-gastroduodenal trunk divided into splenic and gastroduodenal arteries. The superior mesenteric artery and hepatic artery took origin from a common hepato-mesenteric trunk. The hepatic artery had a winding course around the portal vein and hepatic duct. The knowledge of these variations is important while doing radiological investigations and liver transplant and pancreatic surgeries.

Fluoride-Induced Mitochondrial Dysfunction and Approaches for Its Intervention.

Fluoride is present everywhere in nature. The primary way that individuals are exposed to fluoride is by drinking water. It's interesting to note that while low fluoride levels are good for bone and tooth growth, prolonged fluoride exposure is bad for human health. Additionally, preclinical studies link oxidative stress, inflammation, and programmed cell death to fluoride toxicity. Moreover, mitochondria play a crucial role in the production of reactive oxygen species (ROS). On the other hand, little is known about fluoride's impact on mitophagy, biogenesis, and mitochondrial dynamics. These actions control the growth, composition, and organisation of mitochondria, and the purification of mitochondrial DNA helps to inhibit the production of reactive oxygen species and the release of cytochrome c, which enables cells to survive the effects of fluoride poisoning. In this review, we discuss the different pathways involved in mitochondrial toxicity and dysfunction induced by fluoride. For therapeutic approaches, we discussed different phytochemical and pharmacological agents which reduce the toxicity of fluoride via maintained by imbalanced cellular processes, mitochondrial dynamics, and scavenging the ROS.

Effect of naringin on sodium fluoride­induced neurobehavioral deficits in Wistar rats.

There is a lack of treatment for the detrimental effects of fluorosis. Sodium fluoride at a concentration of 10 ppm induces stress, depression and memory impairment in adult Wistar rats. Naringin, a flavanone glycoside isolated from citrus fruits such as lemons and oranges, possesses anti-inflammatory, antioxidant and neuroprotective properties; therefore, it was used for treatment of fluoride induced toxicity in the present study. Adult Wistar rats were divided into eight groups (n=8). The normal control (NOR) group was provided with normal tap water. The sodium fluoride (FLU)10 group received water containing 10 ppm sodium fluoride for 60 days. The treatment groups (FLU10NAR100 and FLU10NAR50) received drinking water with 10 ppm sodium fluoride ad libitum along with Naringin 100 and 50 mg/kg body weight (bw) per oral gavage, respectively. The NAR100 and NAR50 groups received Naringin 100 and 50 mg/kg bw. The PRONAR100 and PRONAR50 groups received Naringin 100 and 50 mg/kg bw for the first 15 days and then subsequently received FLU10 ppm for 60 days (total of 75 days). All animals were subjected to behavioural tests consisting of the open field test (OFT), forced swim test (FST) and novel object recognition test (NORT). After euthanasia, the hippocampus and prefrontal cortex were stained with Cresyl violet. To measure the oxidative stress caused by fluoride and its effect on antioxidant levels, estimation of reduced glutathione (GSH) by Ellman's method, lipid peroxidation (LPO) measured in terms of the MDA:thiobarbituric acid reaction and catalase was performed. To evaluate the effect of fluoride on activity of acetylcholine, estimation of acetylcholinesterase (AChE) by Ellman's method was performed. In NORT and FST, significant changes (P<0.05) were present in the FLU10NAR100 and FLU10NAR50 groups compared with the FLU10 group, showing recovery from memory deficit and depression. The OFT results were insignificant. The LPO was reduced in all the other groups except the FLU10 group, with statistically significant changes. Catalase activity was significantly lower in FLU10 as compared with the NAR100, NAR50, PRONAR100 and PRONAR50 groups. GSH and AChE activities did not show significant changes as compared with the FLU10 group. The CA3 and prefrontal cortex viable and degenerated neuron count in the FLU10 group were insignificant compared with all other groups, except for the NAR100 and NAR50 groups. Thus, Naringin can be a useful drug to avoid the neurological effects of fluoride.

Molecular and immunohistochemical alterations in fluoride-induced neurological impediment in adult rats.

This study highlights the potential neurotoxic and impaired behavioral effects associated with high fluoride concentrations in drinking water. PURPOSE: Fluoride is known to cause neurotoxicity, evinced by lower I.Q. levels in children from high-fluoride regions as compared to those in low-fluoride regions. Thus, the present study was designed to investigate the molecular mechanism behind the neurological and behavioural changes induced by sodium fluoride in Wistar rats. MATERIAL AND METHODS: A total of 24 female Wistar rats, aged six weeks and weighing approximately 150-220 g, were randomly divided into three groups: Group I (control) received reverse osmosis (R.O.) water, Group II received Sodium Fluoride (NaF) at 10 ppm, and Group III received NaF at 50 ppm in their drinking water for 60 days. The animals underwent behavioural tests including the Forced Swim Test (F.S.T.), Open Field Test (OFT), and Novel Object Recognition Test (N.O.R.T.), to assess any alterations in behaviour. After 60 days, the animals were euthanized, and their blood and brain samples were analysed to evaluate biochemical changes by Western Blot/I.H.C. analysis of B.A.X., Bcl2, LC3B, TLR4, PARP1, p53, Caspase, α-Synuclein, PARKIN, NeuN, KI67, DNM-1, and M.F.N. for assessing molecular pathways for toxicity. RESULTS: Impaired locomotion, memory impairment, and behaviour resembling depression in the animals were evinced by reduced mobility index in the F.S.T., discrimination index in the N.O.R.T., and reduced locomotor activity in the open field test results. Additionally, alterations in antioxidant levels and oxidative stress parameters were observed in the brain. The expression levels of various apoptotic and inflammatory biomarkers (B.A.X., Bcl2, TLR4, PARP1, p53, and Caspase) showed apoptosis in neurons. The confocal studies showed increased expression of inflammatory (α-Synuclein, PARKIN), apoptotic (LC3B, B.A.X., p53, KI67), and mitochondrial dysfunction (NeuN, DNM-1, M.F.N.) markers in fluoride-treated animals. Toxicity was more prominent in 50 ppm of fluoride-treated animals. CONCLUSION: Fluoride showed potent neuronal toxicity as evidenced by alterations of various molecular markers.

Role of Flavonoids in Modulation of Mitochondria Dynamics during Oxidative Stress.

BACKGROUND: Flavonoids are a widespread category of naturally occurring polyphenols distinguished by the flavan nucleus in plant-based foods and beverages, known for their various health benefits. Studies have suggested that consuming 150-500 mg of flavonoids daily is beneficial for health. Recent studies suggest that flavonoids are involved in maintaining mitochondrial activity and preventing impairment of mitochondrial dynamics by oxidative stress. OBJECTIVE: This review emphasized the significance of studying the impact of flavonoids on mitochondrial dynamics, oxidative stress, and inflammatory response. METHODS: This review analysed and summarised the findings related to the impact of flavonoids on mitochondria from publicly available search engines namely Pubmed, Scopus, and Web of Science. DESCRIPTION: Any disruption in mitochondrial dynamics can contribute to cellular dysfunction and diseases, including cancer, cardiac conditions, and neurodegeneration. Flavonoids have been shown to modulate mitochondrial dynamics by regulating protein expression involved in fission and fusion events. Furthermore, flavonoids exhibit potent antioxidant properties by lowering the production of ROS and boosting the performance of antioxidant enzymes. Persistent inflammation is a characteristic of many different disorders. This is because flavonoids also alter the inflammatory response by controlling the expression of numerous cytokines and chemokines involved in the inflammatory process. Flavonoids exhibit an impressive array of significant health effects, making them an effective therapeutic agent for managing various disorders. Further this review summarised available mechanisms underlying flavonoids' actions on mitochondrial dynamics and oxidative stress to recognize the optimal dose and duration of flavonoid intake for therapeutic purposes. CONCLUSION: This review may provide a solid foundation for developing targeted therapeutic interventions utilizing flavonoids, ultimately benefiting individuals afflicted with various disorders.

Neuroprotective effect by naringin against fluorosis-induced neurodegeneration in adult Wistar rats.

Fluorosis is widespread in several areas of the world and including India leading to dental and skeletal fluorosis as well as neurological manifestations. With a limited number of treatment options available, we have tried to address the issue with a nutraceutical such as naringin which is an alkaloid derived from the citrus fruit. Naringin is a potent antioxidant and has neuroprotective action which can counteract the redox imbalance induced by sodium fluoride ingestion. Neurological effects of fluorosis were evaluated in Wistar rats by open field test (OFT) and novel object recognition test (NORT) along with lipid peroxidation (LPO) and glutathione estimation in brain homogenate and cresyl violet staining of CA3 neurons in the hippocampus. Animals were divided into groups namely, normal, vehicle, fluoride, naringin 100 mg/kg bd.wt group and fluoride with naringin (FLU-NAR) group. Fluorosis was induced by providing 100 ppm of sodium fluoride ad libitum in drinking water for 30 days and prophylactic treatment of naringin for 15 days per oral. OFT, NORT and forced swim test showed significant (P ≤ 0.05) changes in the FLU-NAR group as compared to the fluoride group indicating behavioral changes in the fluoride group and positive changes in the FLU-NAR group with attenuation of stress, fear, hyperactivity and memory impairment. The decrease in LPO and increase in glutathione levels in the treatment group compared to the fluoride group were supported by histological improvement as compared to the fluoride group. Prophylactic treatment of naringin showed its possible neuroprotective effect, thus giving an alternative treatment strategy to deal with neurological manifestations of fluorosis.

Rare case of median nerve and brachial artery entrapment by an abnormal musculo-fascial tunnel in the arm: possible cause of neurovascular compression syndrome.

Entrapment neuropathies of the peripheral nervous system are frequently encountered due to anatomical variations. Median nerve is the most vulnerable nerve to undergo entrapment neuropathies. The clinical complications are mostly manifested by median nerve impingement in forearm and wrist areas. Median nerve entrapment could also occur at the arm, due to the presence of ligament of Struthers. Here we report a rare case of proximal entrapment of median nerve and brachial artery in the arm by an abnormally formed musculo-fascial tunnel. The tunnel was formed by the muscle fibers of brachialis and medial intermuscular septum in the lower part of arm. Due to this, the median nerve coursed deep, below the tunnel and continued distally into the forearm, underneath the pronator teres muscle and hence did not appear as a content of cubital fossa. The present entrapment of neurovascular structures in the tunnel might lead to pronator syndromes or other neurovascular compression syndromes.

Clinically important left superior polar artery giving rise to a left inferior suprarenal artery and an aberrant left inferior polar artery: a case report / Artéria polar superior esquerda de importância clínica dando origem à artéria suprarrenal inferior esquerda e artéria polar inferior esquerda aberrante: relato de caso

Abstract The renal arteries arise from the lateral side of the abdominal aorta at the L2 vertebral level, just below the origin of the superior mesenteric artery. Multiple aberrant renal arteries can pose difficulties in renal transplantation, interventional radiological and urological procedures, renal artery embolization, angioplasty, or vascular reconstruction for congenital and acquired lesions. We present a case of a left kidney supplied by the left renal artery along with superior and inferior polar arteries, arising from the aorta and inferior mesenteric artery respectively. The inferior mesenteric artery was crossed by the left ureter and inferior mesenteric vein. The superior polar artery gave rise to an inferior suprarenal artery making the variation important for clinicians and surgeons.

Resumo As artérias renais originam-se do lado lateral da aorta abdominal, no nível da vértebra L2, logo abaixo da origem da artéria mesentérica superior. A presença de múltiplas artérias renais aberrantes pode representar dificuldades para transplante renal, procedimentos radiológicos e urológicos intervencionistas, embolização da artéria renal, angioplastia e reconstrução vascular para lesões congênitas e adquiridas. Apresentamos um caso de rim esquerdo vascularizado pela artéria renal esquerda e pelas artérias polares superior e inferior, as quais se originavam da aorta e da artéria mesentérica inferior, respectivamente. A artéria mesentérica inferior era cruzada pelo ureter esquerdo e pela veia mesentérica inferior. A artéria polar superior dava origem à artéria suprarrenal inferior, o que torna essa variação importante para clínicos e cirurgiões.

Bifurcated Great Saphenous Vein: A Report on Its Therapeutic and Diagnostic Perspectives.

The great saphenous vein (GSV) is the longest superficial vein in the body extending from the medial malleolus to groin skin crease level. The clinical usage of GSV has made its anatomical variations noteworthy. Since many tributaries accompany it, GSV is often mistaken with the variant vein. Duplication and persistence of accessory GSV are the two major clinically significant anatomical variations of the GSV which is frequently misinterpreted as a synonym. In the present case, we report a unique variation of GSV wherein it bifurcated into anterior and posterior divisions of two uneven calibers at knee region, which then reunited at thigh region to form a single vein before its termination into the femoral vein. Locating such variations of bifurcated GSV is a challenging task for both diagnostic and therapeutic tactics, particularly in venography procedures as it might lead to iatrogenic traumatic injury of the vessel.

Bilateral low origin of testicular artery: a case report.

The testicular artery is frequently subjected to radiographic imaging techniques such as angiography for diagnosis and treatment of conditions like epididymitis, testicular torsion, tumor, hematoma, and hydrocele and in cases of undescended testis. Radiologists and surgeons should therefore be aware of testicular artery variants. Although there are numerous studies and case reports that mention testicular artery variants, this is probably the first case, reporting a bilateral low origin of the testicular artery and discussing its probable embryological etiology.

A artéria testicular é frequentemente examinada por técnicas de imagem como angiografia, para o diagnóstico e tratamento de condições como epididimite, torsão testicular, tumor, hematoma e hidrocele, e também em casos de criptorquidia. Sendo assim, radiologistas e cirurgiões devem estar cientes de variantes anatômicas da artéria testicular. Embora numerosos estudos e relatos de caso mencionem variantes da artéria testicular, este provavelmente é o primeiro caso a descrever origem bilateral baixa da artéria testicular e a discutir sua provável etiologia embriológica.

Bifurcated Bicipital Aponeurosis Giving Origin to Flexor and Extensor Muscles of the Forearm - A Case Report.

Bicipital aponeurosis is usually attached to the antebrachial fascia on the medial side of forearm and to posterior border of ulna assisting in the supination of the forearm along with biceps brachii muscle. Variations in the bicipital aponeurosis may lead to neurovascular compression as reported earlier. In the present case, the bicipital aponeurosis had two slips i.e. medial and lateral. Medial slip gave origin to some fibers of pronator teres and flexor carpi radialis and the lateral slip gave origin to some fibers of brachioradialis. Such unusual slips of bicipital aponeurosis may distribute the stress concentration and may work in different directions affecting the supination of forearm by biceps brachii muscle and bicipital aponeurosis.

Clinical importance of a star shaped branch of internal iliac artery and unusual branches of an abnormal obturator artery: rare vascular variations.

The internal iliac artery (IIA) is one of the branches of the common iliac artery and supplies the pelvic viscera, the musculoskeletal part of the pelvis, the gluteal region, the medial thigh region and the perineum. During routine cadaveric dissection of a male cadaver for undergraduate Medical students, we observed variation in the course and branching pattern of the left IIA. The artery gave rise to two common trunks and then to the middle rectal artery, inferior vesicle artery and superior vesicle artery. The first, slightly larger, common trunk gave rise to an unnamed artery, the lateral sacral artery and the superior gluteal artery. The second, smaller, common trunk entered the gluteal region through the greater sciatic foramen, below the piriformis muscle and presented a stellate branching pattern deep to the gluteus maximus muscle. Two of the arteries forming the stellate pattern were the internal pudendal artery and the inferior gluteal artery. The other two were muscular branches.

A artéria ilíaca interna (AII) é um dos ramos da artéria ilíaca comum e supre as vísceras da pelve, a parte musculoesquelética da pelve, a região glútea, a região medial da coxa e o períneo. Durante a dissecção de rotina realizada em um cadáver do sexo masculino para estudantes de Medicina, observamos uma variação no curso e padrão de ramificação da AII esquerda. A artéria deu origem a dois troncos comuns e então à artéria retal média, artéria vesical inferior e artéria vesical superior. O primeiro tronco comum, ligeiramente maior, deu origem a uma artéria sem nome, à artéria sacral lateral e à artéria glútea superior. O segundo tronco comum, menor, adentrou a região glútea através do forame ciático maior, abaixo do músculo piriforme, e apresentou um padrão estrelado de ramificação na parte profunda do músculo glúteo máximo. Duas das artérias que formaram o padrão estrelado foram a artéria pudenda interna e a artéria glútea inferior. Os outros dois ramos eram musculares.

Unusual and Unique Variant Branches of Lateral Cord of Brachial Plexus and its Clinical Implications- A Cadaveric Study.

INTRODUCTION: Adequate knowledge on variant morphology of brachial plexus and its branches are important in clinical applications pertaining to trauma and surgical procedures of the upper extremity. AIM: Current study was aimed to report variations of the branches of the lateral cord of brachial plexus in the axilla and their possible clinical complications. MATERIALS AND METHODS: Total number of 82 upper limbs from 41 formalin embalmed cadavers was dissected. Careful observation was made to note the formation and branching pattern of lateral cord. Meticulous inspection for absence of branches, presence of additional or variant branches and presence of abnormal communications between its branches or with branches of other cords was carried out. RESULTS: In the present study, we noted varied branching pattern of lateral cord in 6 out of 82 limbs (7%). In one of the limb, the median nerve was formed by three roots; two from lateral cord and one from medial cord. Two limbs had absence of lateral pectoral nerve supplemented by medial pectoral nerves. One of which had an atypical ansa pectoralis. In 2 upper limbs, musculocutaneous nerve was absent and in both cases it was supplemented by median nerve. In one of the limb, coracobrachialis had dual nerve supply by musculocutaneous nerve and by an additional branch from the lateral cord. CONCLUSION: Variations of brachial plexus and its branches could pose both intraoperative and postoperative complications which eventually affect the normal sensory and motor functions of the upper limb.

Safety and Effectiveness of Total Thyroidectomy and Its Comparison with Subtotal Thyroidectomy and Other Thyroid Surgeries: A Systematic Review.

Diseases associated with the thyroid gland are one of the most frequently seen endocrine disorders across the globe. Total thyroidectomy is currently the preferred treatment for many thyroid diseases. Controversies exist among surgeons regarding safety of total thyroidectomy due to the risk associated with it like postoperative hypoparathyroidism or recurrent laryngeal nerve damage. Since, in the recent years, the incidence of thyroidectomy is in increasing trend in south Indian population, this review aims to study the available data regarding the appropriateness and safety of total thyroidectomy and compares it with subtotal thyroidectomy and other thyroid surgeries. This is a retrospective comprehensive review of various articles and publications regarding total and partial thyroidectomy performed across the world. Many retrospective studies and few prospective studies suggest that the incidence of transient hypocalcemia is higher after total thyroidectomy than after subtotal thyroidectomy, but the incidence of other complications including recurrent laryngeal nerve palsy and postoperative hematoma is not significantly different between the two procedures. Hence in our review we found that total thyroidectomy is safe and cost effective with low complication rates and provides little significant advantage of being safer procedure compared to subtotal thyroidectomy.

Unilateral Double Great Saphenous Vein: A Clinically Significant Case Report.

Great saphenous vein (GSV) is the longest vein in the body originating from the dorsum of the foot at medial malleolus to the level of groin skin crease. It is one among the clinically significant superficial veins of the lower limb. Double or duplication of GSV is considered to be one of its rarest variant forms, which might be often mistaken with the accessory saphenous vein. The overall incidence of duplicated GSV is reported to be 1%. We report herein, a unilateral duplication of GSV with its morphological and clinical perspectives. The major clinical complication that is often encountered from its duplication is recurrent incompetence of the GSV, which predisposes varicosity. Therefore, a thorough knowledge of venous anatomy is important for clinicians and sonographers.

Presence of Arteriovenous Communication between Left Testicular Vessels and Its Clinical Significance.

Maintenance of testicular temperature below body temperature is essential for the process of spermatogenesis. This process of thermoregulation is mainly achieved by testicular veins through pampiniform venous plexus of the testis by absorbing the heat conveyed by the testicular arteries. However, this mechanism of thermoregulation may be hampered if an abnormal communication exists between the testicular vessels. We report herewith a rare case of arteriovenous communication between testicular artery and testicular vein on left side. The calibre of the communicating vessel was almost similar to left testicular artery. Such abnormal communication may obstruct the flow of blood in the vein by causing impairment in the perfusion pressure with the eventual high risk of varicocele.

Unique formation of sciatic nerve below the piriformis muscle - a case report.

Dorsal and ventral divisions of ventral rami of lower lumbar and sacral spinal nerve were found to pass ventral and dorsal to the piriformis muscle respectively. These divisions joined each other below the piriformis muscle to form sciatic nerve. This low formation of sciatic nerve was observed in distal part of left gluteal region of a 50-year-old male cadaver. The sciatic nerve thus formed passed caudally into back of thigh and divided into tibial and common peroneal nerves in the upper part of popliteal fossa. In addition, a communicating nerve from the sciatic nerve was found to join the common peroneal nerve in the popliteal fossa. Such variations may lead to piriformis syndrome or non-discogenic sciatica.

Atypical arterial supply to the spleen by polar branches of splenic artery and accessory splenic artery - a case report.

Vascular anomalies of the spleen are usually asymptomatic. However, variant anatomy of splenic artery becomes clinically important, when the patients undergo diagnostic angiography for gastrointestinal bleeding or during transcatheter therapy. We report here a concurrent variant arterial pattern of the spleen. The splenic artery was unusually elongated and excessively tortuous. Prior to its normal termination into segmental arteries, it gave superior and inferior polar arteries which entered the spleen distal to corresponding ends of the splenic hilum. In addition to this, the spleen also received an additional blood supply from an accessory splenic artery arising from left gastro-epiploic artery. The accessory splenic artery entered the substance of the spleen through its lateral end. Presence of such kind of concurrent variant arterial pattern of spleen makes the surgeons obligatory to have prior knowledge to prevent bleeding during any surgical or radiological interventional procedures targeting the spleen, pancreas etc.