Levels of Vitamin D Are Low After Crohn's Disease Is Established But Not Before.

BACKGROUND & AIMS: Low serum levels of vitamin D have been associated with Crohn's disease (CD). However, it is unclear whether low vitamin D levels cause CD or CD reduces serum vitamin D. METHODS: United States military personnel with CD (n = 240) and randomly selected individuals without CD (controls, n = 240) were matched by age, sex, race, military branch, and geography. We measured 25-hydroxyvitamin D in sera 8-3 years (pre-2) and 3 years to 3 months before diagnosis (pre-1) and 3 months before through 21 months after diagnosis (pre-0). We genotyped VDR and GC vitamin D related polymorphisms. We used conditional logistic regression, including adjustments for smoking, season, enlistment status, and deployment, to estimate relative odds of CD according to vitamin D levels and interactions between genetic factors and levels of vitamin D. RESULTS: Levels of vitamin D before diagnosis were not associated with CD in pre-2 (P trend = .65) or pre-1 samples (P trend = .84). However, we found an inverse correlation between CD and highest tertile of vitamin D level in post-diagnosis samples (P trend = .01; odds ratio, 0.51; 95% CI, 0.30-0.86). Interactions were not detected between vitamin D levels and VDR or GC polymorphisms. We observed an association between VDR Taq1 polymorphism and CD (independent of vitamin D) (P = .02). CONCLUSIONS: In serum samples from military personnel with CD and matched controls, we found no evidence for an association between CD and vitamin D levels up to 8 years before diagnosis. However, we observed an inverse-association between post-diagnosis vitamin D levels and CD. These findings suggest that low vitamin D does not contribute to development of CD-instead, CD leads to low vitamin D.

Penile anthropometry in North Indian children.

INTRODUCTION: Physicians frequently encounter questions by parents regarding the normal size of a child's penis. We evaluated normal variations of penile dimensions, correlation of penile length with height, weight, and body mass index (BMI) of boys and analyzed the differences in penile dimensions from those reported from other countries. MATERIALS AND METHODS: A cross-sectional study was conducted at our institution during October 2012-December 2012. A total of 250 subjects (birth to 10 years) were evaluated and divided into 10 groups with 1-year interval taking 25 children in each. Penile dimensions measured twice by a single observer with Vernier calipers included the length of flaccid penis fully stretched and diameters at mid-shaft and corona. Diameters were multiplied by pi (π = 3.14) to calculate circumferences. Mean, standard deviation, and range were calculated. Height, weight, and BMI were noted and statistically correlated with the penile length using the Pearson correlation coefficient. Data were compared with similar studies reported on other populations in the past and individually evaluated with every study using Student's t-test. RESULTS: The mean values for the penile length, mid-shaft circumference, and coronal circumference were 3.34, 3.05, 3.29 cm during infancy, 4.28, 3.86, 4.11 cm during 4-5 years, and 5.25, 4.78, 5.05 cm during 9-10 years, respectively. The penile length increased with advancing age in successive age groups, but it did not have a direct correlation with either height, weight, or BMI. Penile dimensions in North Indian children were found to be statistically smaller in comparison with most studies from other countries. CONCLUSION: We provide the normal range and variations of penile dimensions in North Indian children.

Outcome of tubularized incised plate urethroplasty with spongioplasty alone as additional tissue cover: A prospective study.

INTRODUCTION: Additional cover after neourethra formation to decrease the fistula rate, has been described using the dartos, tunica, denuded skin and corpus spongiosum. The use of corpus spongiosum alone to cover the neourethra is infrequent. The objective of this study was to evaluate the efficacy of spongioplasty alone as an intervening layer in the prevention of urethral fistula following tubularized incised plate urethroplasty (TIPU). MATERIALS AND METHODS: A prospective study was performed including 113 primary hypospadias cases undergoing TIPU with spongioplasty from June 2010 to March 2012. Correction of chordee was carried out by penile degloving alone in 5, mobilization of urethral plate with spongiosum in 22 and combination of both in 45 cases. Intra-operatively, spongiosum was taken to be poorly developed if it was thin and fibrous, moderate if good spongiosal tissue with good vascularization and well-developed if healthy robust spongiosum, which became bulkier than native spongiosum after tubularisation. Spongioplasty was done in a single layer after mobilization of spongiosum, starting just proximal to the native meatus and into the glans distally. RESULTS: The mean age of the patients was 11.53 years. The type of hypospadias was distal, mid and proximal in 81, 12 and 20 cases respectively. Spongiosum was poorly developed in 13, moderate in 53 and well-developed in 47 cases. The mean hospital stay was 8-10 days and follow-up ranged from 6 months to 2 years. Urethral fistula was seen in six patients (11.3%) with moderate spongiosum (distal 1, mid 1 and proximal 4), and three (23.03%) with poorly developed spongiosum (one each in distal, mid and proximal) with an overall 7.96% fistula rate. None of the patients with well-developed spongiosum developed a fistula. Poorer spongiosum correlated with a greater number of complications (P = 0.011). Five out of thirteen cases with poor spongiosum (38.46%) had proximal hypospadias, i.e. more proximal was the hypospadias, poorer was the development of the spongiosum (P = 0.05). Meatal stenosis was seen in two patients (1.76%) with proximal hypospadias, one with moderate and the other with poorly developed spongiosum. More proximal was the hypospadias, greater were the number of complications (P = 0.0019). CONCLUSION: TIPU with spongioplasty reconstructs a near normal urethra with low complications. Better developed and thicker spongiosum results in lower incidence of fistula and meatal stenosis. More proximal hypospadias is associated with poorer spongiosum. We recommend spongioplasty to be incorporated as an essential step in all patients undergoing tubularized incised-plate repair for hypospadias.

A modified particle swarm optimization rat search algorithm and its engineering application.

Solar energy generation requires photovoltaic (PV) systems to be optimised, regulated, and simulated with efficiency. The performance of PV systems is greatly impacted by the fluctuation and occasionally restricted accessibility of model parameters, which makes it difficult to identify these characteristics over time. To extract the features of solar modules and build highly accurate models for PV system modelling, control, and optimisation, current-voltage data collecting is essential. To overcome these difficulties, the modified particle swarm optimization rat search algorithm is presented in this manuscript. The modified rat search algorithm is incorporated to increase the PSO algorithm's accuracy and efficiency, which leads to better outcomes. The RSA mechanism increases both the population's diversity and the quality of exploration. For triple diode model of both monocrystalline and polycrystalline, PSORSA has showed exceptional performance in comparison to other algorithm i.e. RMSE for monocrystalline is 3.21E-11 and for polycrystalline is 1.86E-11. Similar performance can be observed from the PSORSA for four diode model i.e. RMSE for monocrystalline is 4.14E-09 and for polycrystalline is 4.72E-09. The findings show that PSORSA outperforms the most advanced techniques in terms of output, accuracy, and dependability. As a result, PSORSA proves to be a trustworthy instrument for assessing solar cell and PV module data.

A Multicenter Retrospective Cohort Study on Management Protocols and Clinical Outcomes After ABO-incompatible Kidney Transplantation in India.

BACKGROUND: There is no robust evidence-based data for ABO-incompatible kidney transplantation (ABOiKT) from emerging countries. METHODS: Data from 1759 living donor ABOiKT and 33 157 ABO-compatible kidney transplantations (ABOcKT) performed in India between March 5, 2011, and July 2, 2022, were included in this retrospective, multicenter (n = 25) study. The primary outcomes included management protocols, mortality, graft loss, and biopsy-proven acute rejection (BPAR). RESULTS: Protocol included rituximab 100 (232 [13.18%]), 200 (877 [49.85%]), and 500 mg (569 [32.34%]); immunoadsorption (IA) (145 [8.24%]), IVIG (663 [37.69%]), and no induction 200 (11.37%). Mortality, graft loss, and BPAR were reported in 167 (9.49%), 136 (7.73%), and 228 (12.96%) patients, respectively, over a median follow-up of 36.3 mo. In cox proportional hazard model, mortality was higher with IA (hazard ratio [HR]: 2.53 [1.62-3.97]; P < 0.001), BPAR (HR: 1.83 [1.25-2.69]; P = 0.0020), and graft loss (HR: 1.66 [1.05-2.64]; P = 0.0310); improved graft survival was associated with IVIG (HR: 0.44 [0.26-0.72]; P = 0.0010); higher BPAR was reported with conventional tube method (HR: 3.22 [1.9-5.46]; P < 0.0001) and IA use (HR: 2 [1.37-2.92]; P < 0.0001), whereas lower BPAR was reported in the prepandemic era (HR: 0.61 [0.43-0.88]; P = 0.008). Primary outcomes were not associated with rituximab dosing or high preconditioning/presurgery anti-A/anti-B titers. Incidence of overall infection 306 (17.39%), cytomegalovirus 66 (3.75%), and BK virus polyoma virus 20 (1.13%) was low. In unmatched univariate analysis, the outcomes between ABOiKT and ABOcKT were comparable. CONCLUSIONS: Our largest multicenter study on ABOiKT provides insights into various protocols and management strategies with results comparable to those of ABOcKT.

Helicobacter pylori Treatment Regimen Selection and Eradication Rates Across Department of Defense Patients for Fiscal Years 2016-2018.

INTRODUCTION: The objective of this study was to measure the number of treatment successes and failures of various Helicobacter pylori treatment regimens among DoD beneficiaries. MATERIALS AND METHODS: This was a retrospective cross-sectional study of all adult DoD beneficiaries with H. pylori diagnosis, treatment, and eradication testing from October 2015 to September 2018. All stool antigen testing, urea breath test, and immunoglobulin G serologies were identified. Patients were excluded if they did not have a positive test, did not have treatment, or did not have eradication testing. RESULTS: In total, 20,548 H. pylori diagnostic tests were performed over the study period. A total of 1,592 non-active duty and 374 active duty patients were diagnosed with H. pylori, were treated, and had eradication testing. The best performing regimens were tetracycline-based bismuth quadruple therapy and tinidazole-based clarithromycin triple therapy with eradication rates of 85% and 82%, respectively. Clarithromycin triple therapy was the most prescribed (63.9% of all regimens included in analysis). Of the 1,592 non-active duty and 374 active duty patients, 75.5% (1,202) and 70.6% (264) cleared the infection with treatment, respectively (P = 0.0449). Although trends were identified in differences in geographic eradication rates, none of these achieved the threshold of significance. CONCLUSIONS: This is the largest and most geographically widespread H. pylori treatment efficacy study in the USA over 20 years. None of the treatment regimens (when used in over five patients) achieved an eradication rate greater than 90%, but tetracycline-based bismuth quadruple therapy performed best among all regimens and populations. Eradication rates were lower in the active duty populations, with no treatment regimen achieving an eradication rate greater than 80%.

Sustainable development of fuel cell using enhanced weighted mean of vectors algorithm.

Using the mathematical model of a Direct Methanol Fuel Cell (DMFC) stack, a new optimum approach is presented for estimating the seven unknown parameters i.e., ( e o , α , R , j e i d , C 1 , ß ,req) optimally. Specifically, a method is proposed for minimization of the Sum of Squared Errors (SSE) associated with the estimated polarization profile, based on the experimental data from simulations. The Enhanced Weighted mean of vectors (EINFO) algorithm is a novel metaheuristic method that is proposed to achieve this goal. An analysis of the results of this method is then compared to various metaheuristic algorithms such as the Particle Swarm Optimization (PSO), Sine Cosine Algorithm (SCA), Dragonfly Algorithm (DA), Atom Search Optimization (ASO), and Weighted mean of vectors (INFO) well known in literature. As a final step to confirm the proposed approach's effectiveness, the sensitivity analysis is carried out using temperature changes, along with comparison against different approaches described in the literature to demonstrate its superiority. After comparison of parameter estimation and different operating temperature a non-parametric test is also performed and compared with the rest of the metaheuristic algorithms used in the manuscript. From these tests it is concluded that the proposed algorithm is superior to the rest of the compared algorithms.

Entero-Urachal Fistula: An Unusual Initial Presentation of Penetrating and Stricturing Crohn's Disease.

Crohn's disease (CD) has a wide variety of clinical presentations, ranging from abdominal pain to stricture and fistula. Fistulas involving the genitourinary tract can be severe and often require surgical intervention. Given the array of presenting symptoms, a delay in diagnosis can occur. We present the case of a healthy active duty soldier, with no previous medical history, found to have CD through an initial presentation of isolated umbilical drainage. Imaging workup identified an entero-uracho-cutaneous fistula with involvement of the transverse colon. Urachal anomalies are uncommon, and entero-urachal fistula as an initial presentation of CD is exceedingly rare. This case highlights the need to consider CD in the differential for patients with umbilical drainage despite a lack of concurrent more frequent presenting symptoms (abdominal pain, bloody diarrhea, and perianal fistula). Maintaining awareness of uncommon initial presentations of CD can minimize delay in diagnosis and thereby mitigate the risk of severe complications.

Refeeding syndrome as an unusual cause of anion gap metabolic acidosis.

Refeeding syndrome is characterized by hypophosphatemia in the setting of malnutrition. It is commonly seen in patients with anorexia, alcoholism, or malignancy, and it is often a missed diagnosis. Because of the potential morbidity associated with missing the diagnosis of refeeding syndrome, it is important to monitor for this disease in any malnourished patient. We present a case of a 49-year-old male with chronic alcohol abuse who presented for alcohol detoxification and was found to have low phosphate, potassium, and magnesium on presentation, in addition to an elevated anion gap of unclear etiology. After extensive workup to evaluate the cause of his elevated anion gap and worsening of his electrolyte abnormalities despite replenishment, it was felt his symptoms were a result of refeeding syndrome. After oral intake was held and aggressive electrolyte replenishment was performed for 24 hours, the patient's anion gap closed and his electrolyte levels stabilized. This case demonstrates a unique presentation of refeeding syndrome given the patient's profound metabolic acidosis that provided a clue toward his eventual diagnosis. The standard workup for an anion gap metabolic acidosis was negative, and it was not until his refeeding syndrome had been treated that the anion gap closed.

Ooh-rah! An unusual cause of spontaneous pneumomediastinum.

Spontaneous pneumomediastinum (SPM) with associated subcutaneous emphysema is an uncommon and generally benign condition. We describe an occurrence of SPM that occurred from yelling in a U.S. Marine Corps Drill Instructor. The patient describes yelling at Marine recruits the day prior when he felt a pop "behind his nose." Upon arrival to the Emergency Department, the patient was normotensive, afebrile, and maintaining an oxygen saturation of 100% on room air. Chest films demonstrated pneumomediastinum and subcutaneous emphysema. A computed tomography scan of the head, neck, and chest showed pneumomediastinum and air tracking along the trachea, great vessels, and esophagus with subcutaneous emphysema and without pneumothorax or esophageal injury. The patient was admitted to internal medicine and discharged after 24 hours of observation with improved pain and decreased subcutaneous air. Pneumomediastinum is commonly associated with blunt and penetrating trauma, infection, and esophageal rupture. Life-threatening complications include tension pneumomediastinum/pneumothorax and rupture of intrathoracic viscus. Treatment includes rest, oxygen therapy, and analgesia. SPM has never been described as a result of a yelling, and persistent yelling is common for a drill instructor. SPM can present in primary care and operational settings, and recognition and prompt treatment is crucial for these patients.

Minimizing scattered radiation dose in cardiac catheterization laboratory during interventional procedures using lead free drape - MILD study.

OBJECTIVE: RADPAD is a lead-free sterile drape that reduces scattered radiation during fluoroscopic procedures. We aimed to study the effect of using RADPAD on primary operator (PO) and secondary operator (SO) during coronary angiography (CAG) as well as percutaneous coronary intervention (PCI). METHODS: 137 patients undergoing elective CAG and PCIwere randomized in a 1:1 pattern with or without the RADPAD. The ratio of PO received dose in mrem to total Air Kerma (AK) in mGy, Dose Area Product (DAP) in mGycm2 and Cine Adjusted Screening Time (CAST) in minute, at the end of the procedure with or without RADPAD were measured and designated as dose relative to AK, DAP and CAST. The exposure ratios were compared for both cohorts. RESULTS: There was no significant difference in CAST, DAP and AK between the two patient cohorts. PO radiation dose relative to CAST was 0.15 ± 0.18 mrem/min for RADPAD cohort and 0.43 ± 0.31 mrem/min for No RADPAD cohort (p < 0.00001). PO dose relative to DAP was 0.00042 ± 0.00049 mrem/mGycm2 for RADPAD cohort and 0.0011 ± 0.0013 mrem/mGycm2 for No RADPAD cohort (p = 0.000014). PO dose relative to AK was 0.0030 ± 0.0037 mrem/mGy for RADPAD cohort and 0.0071 ± 0.0049 mrem/mGy for No RADPAD cohort (p < 0.00001). All PO doses relative to CAST, DAP and AK were significantly reduced in the RADPAD cohort compared to the No RADPAD cohort. Similar findings were observed for the SO also. CONCLUSION: RADPAD significantly reduces radiation exposure to both PO and SO during CAG and PCI.

Hydrogen fuel and fuel cell technology for cleaner future: a review.

One of the main problems facing our planetary bodies is unexpected and sudden climate change due to continuously increasing global energy demand, which currently is being met by fossil fuels. Hydrogen is considered as one of the major energy solutions of the twenty-first century, capable of meeting future energy needs. Being 61a zero-emission fuel, it could reduce environmental impacts and craft novel energy opportunities. Hydrogen through fuel cells can be used in transport and distributed heating, as well as in energy storage systems. The transition from fossil-based fuels to hydrogen requires intensive research to overcome scientific and socio-economic barriers. The purpose of this paper is to reflect the current state, related issues, and projection of hydrogen and fuel elements within the conceptual framework of 61a future sustainable energy vision. An attempt has been made to compile in this paper the past hydrogen-related technologies, present challenges, and role of hydrogen in the future.

Parameter estimation of proton exchange membrane fuel cell using a novel meta-heuristic algorithm.

In recent years, proton exchange membrane fuel cells (PEMFCs) have been known to be a viable method for meeting the electrical energy needs, thereby enhancing the overall reliability of renewable energy systems. PEMFCs demonstrate various promising attributes like pollution-free, totally sustainable, non-self-discharging. These need hydrogen as fuel, and air for their operation, while the final product is pure water only. Thus, under varying operating conditions, the appropriate modeling and parameter optimization of PEMFCs have gained considerable importance in recent times. The evolutionary optimization approaches had been utilized in recent past for estimating PEMFCs parameters as exact modeling of the same does not exist in the literature. For the evaluation of PEMFCs performance criteria, a newly proposed algorithm is developed in this manuscript i.e. black widow optimization (BWO). Firstly, the performance of this proposed algorithm is checked by complex benchmark results. After that, this proposed algorithm is applied to extract the parameters of PEMFCs models under different operating temperatures. The parameter optimization results are obtained using BWO and are further compared with those obtained with five other algorithms, i.e., particle swarm optimization (PSO), multi-verse optimizer (MVO), sine cosine algorithm (SCA), whale optimization algorithm (WOA), and grey wolf optimization (GWO). The complete error analysis is carried out for the two data sheets of the PEMFCs to establish the superiority of BWO. It has been observed that the developed proposed algorithm gives better results when compared to those obtained with rest of the algorithms considered in this work. After calculating the error, non-parametric test is performed which suggests that the BWO is better than the rest of the compared algorithms.

Almost One-Third of Large Sessile Serrated Polyps Are Missed on CT Colonography.

BACKGROUND: Nearly one-third of colorectal cancers (CRC) arise via the serrated pathway. CT colonography (CTC) is a CRC screening examination. Endoscopic detection of sessile serrated polyps (SSPs) varies widely; it is unknown whether CTC effectively detects SSPs. The aim of this study is to determine whether CTC detects SSPs at an institution that performs a large volume of CTC. METHODS: We conducted a search of pathology records to identify serrated polyps (SPs) from 2005 to 2012. We extracted demographic data from the electronic health records (EHRs) of subjects with an SSP and examined endoscopy reports for location and size of each SSP. We identified subjects with a CTC within 1 year prior to the colonoscopy that found an SSP, and determined if the CTC identified the SSP. RESULTS: Our search found 3978 subjects with SP over the 7-year period. Seven hundred thirty-two subjects had at least 1 SSP. Eightytwo subjects had CTC done within 1 year prior to the colonoscopy that identified SSP. Seventy-nine subjects' polyps were identified on CTC. CT colonography was done an average of 38 ± 54 days prior to colonoscopy. One hundred fifteen SSPs were identified endoscopically. A total of 48.7% of all SSPs were identified via CTC; larger SSPs were more likely to be seen on CTC (P < .001), and 69.6% of SSPs larger than 10 mm were found via CTC. Proximal SSPs were more often identified than distal SSPs (P = .005). CONCLUSION: Given the miss rate for SSPs on CTC, endoscopists should be vigilant about examining the proximal colon in subjects referred after CTC, even if the imaging does not reveal a proximal polyp.