Precision Nanomedicine with Bio-Inspired Nanosystems: Recent Trends and Challenges in Mesenchymal Stem Cells Membrane-Coated Bioengineered Nanocarriers in Targeted Nanotherapeutics.

In the recent past, the formulation and development of nanocarriers has been elaborated into the broader fields and opened various avenues in their preclinical and clinical applications. In particular, the cellular membrane-based nanoformulations have been formulated to surpass and surmount the limitations and restrictions associated with naïve or free forms of therapeutic compounds and circumvent various physicochemical and immunological barriers including but not limited to systemic barriers, microenvironmental roadblocks, and other cellular or subcellular hinderances-which are quite heterogeneous throughout the diseases and patient cohorts. These limitations in drug delivery have been overcome through mesenchymal cells membrane-based precision therapeutics, where these interventions have led to the significant enhancements in therapeutic efficacies. However, the formulation and development of nanocarriers still focuses on optimization of drug delivery paradigms with a one-size-fits-all resolutions. As mesenchymal stem cell membrane-based nanocarriers have been engineered in highly diversified fashions, these are being optimized for delivering the drug payloads in more and better personalized modes, entering the arena of precision as well as personalized nanomedicine. In this Review, we have included some of the advanced nanocarriers which have been designed and been utilized in both the non-personalized as well as precision applicability which can be employed for the improvements in precision nanotherapeutics. In the present report, authors have focused on various other aspects of the advancements in stem cells membrane-based nanoparticle conceptions which can surmount several roadblocks and barriers in drug delivery and nanomedicine. It has been suggested that well-informed designing of these nanocarriers will lead to appreciable improvements in the therapeutic efficacy in therapeutic payload delivery applications. These approaches will also enable the tailored and customized designs of MSC-based nanocarriers for personalized therapeutic applications, and finally amending the patient outcomes.

The Impact of Obesity on Reflux Recurrence Following Laparoscopic Anti-reflux Surgery: An Evidence-Based Systematic Review and Meta-Analysis.

Gastroesophageal reflux disease (GERD) is frequently seen in the Western population. Laparoscopic anti-reflux surgery (LARS) is effective in managing this condition. Obesity is strongly associated with GERD, and with the rising rate of obesity, there is, therefore, a concurrently increasing frequency of LARS performed. We aim to review the outcomes of LARS in patients with obesity, including the recurrence of GERD symptoms and peri-operative complications. A systematic review and meta-analysis were performed for articles from June 1992 to June 2022. The literature was reviewed for outcomes of LARS in patients with obesity (BMI≥30). Eligibility criteria included specific BMI, study design, type of surgery, and outcomes. The recurrence of symptoms and peri-operative complications were assessed. Thirty-one studies were thoroughly reviewed. Nine studies (five retrospective and four prospective) were selected for meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow, which included 1,499 patients with obesity and 5,521 without. Laparoscopic Nissen fundoplication was the most common procedure performed. The recurrence of symptoms was significantly lower in patients without obesity (p=0.0001). There was no statistically significant difference between patients with and without obesity in peri-operative complications, re-intervention, and early return to theatres. A higher recurrence rate of GERD symptoms post-LARS was reported in patients with obesity. Further research is required to decrease such risks and propose different methods, such as weight loss prior to surgery or Roux-en-Y (R&Y) gastric bypass. Risks and benefits should be considered by clinicians prior to offering LARS to patients with obesity.

Renal Angiomyolipoma Rupture Following COVID-19 Infection: A Case Report.

The novel Coronavirus (COVID-19) is one of the most recent Pandemics that invaded the earth and is still active. It caused and is still causing hundreds of thousands of patients high morbidity and mortality rates, with no definitive cure at this moment. COVID-19 has been proven to be associated with pathologic changes in coagulation, characterized by either thromboembolic or bleeding events. We describe this case of a 44-year-old male patient who walked into our emergency department with flank pain and was later discovered to have had renal angiomyolipoma (AML) rupture during his COVID-19 infection, ultimately requiring admission for hemorrhage control via interventional radiology (IR) drainage. Here, we discuss the role of front-line physicians and how they should keep a low threshold for the different presentations that could be associated with COVID-19 infection, such as what was found in this case.

Gallbladder volvulus.

Gallbladder volvulus is a rare entity. The condition results in rotation of the gallbladder on its mesentery along the axis of cystic duct and artery. Gallbladder volvulus is a condition in which the organ twists on its long axis to the point where its vascular supply is compromised.

A Case Report on Fish Bone Perforating Meckel's Diverticulum Mimicking Appendicitis.

Meckel's diverticulum (MD) is the most frequent congenital abnormality of the digestive tract. Although it is silent, it can rarely come up as a complicated case including but not limited to obstruction, inflammation, and neoplasm. Perforation as a consequence of MD is extremely infrequent and mostly related to foreign objects. We report a case of a 24-year-old man who presented to the emergency department with signs and symptoms suggestive of acute appendicitis. Computed tomography (CT) of the abdomen demonstrated foreign body perforation from a protrusion outside the small bowel. The patient underwent laparoscopy and a fish bone perforating MD was found which was removed.

Religious Fasting of Muslim Patients After Metabolic and Bariatric Surgery: a Modified Delphi Consensus.

BACKGROUND: Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. METHODS: A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. RESULTS: The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. CONCLUSION: Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

Primary Mediastinal Ewing sarcoma presenting as a massive lung lesion with a mediastinal shift.

Primary pulmonary Ewing sarcoma can present as a massive mass in the left hemithorax covering the entire lung and can press the pulmonary artery and cause a significant mediastinal shift.

Extensive Surgical Emphysema Following Stab Injury to the Neck.

Extensive surgical emphysema can lead to a life-threatening condition causing hemodynamic instability and significant physician challenges in its management. Here we describe an uncommon case of extensive subcutaneous emphysema caused by stabbing neck, which led to complications such as pneumothorax, pneumopericardium, pneumomediastinum as well as pneumoperitoneum. The role of radiological imaging is crucial in managing this relatively uncommon presentation. This article highlights clinical presentation, radiological findings, and various management options.

A Unique Case of Low-Grade Mucinous Neoplasm in Stump Appendectomy.

BACKGROUND: We describe a case of a young male with a history of appendectomy one year ago, who developed symptoms of stump appendicitis, and after removing this stump, histopathology showed low grade neoplasm. Summary. Stump appendicitis is an uncommon complication after appendectomy and may lead to serious complications. Management of low-grade appendiceal mucinous neoplasm (LAMN) is controversial, and we discuss the importance of the case. CONCLUSION: The case of young male post stump appendectomy with histopathology showing LAMN in the stump of the appendix, which to our knowledge, is the first in the medical literature and, discuss the stump appendicitis and incomplete appendectomy concerning malignancy, mucinous neoplasm, and adenocarcinoma.

ABC/2 estimation in intracerebral hemorrhage: A comparison study between emergency radiologists and emergency physicians.

OBJECTIVES: We aimed to define levels of agreement (LOA) between emergency radiologists (RAD) and emergency medicine (EM) physicians for estimating bleed volume in intracranial hemorrhages (ICH) using ABC/2 formula. METHODS: A prospective study of a curated sample of head CT's were performed in an emergency department. Raters independently reviewed the scans. Perpendicular maximal dimensions (A and B) were measured on an axial CT image. The 'C' dimension was a product of slice thickness and number of slices with visible bleed. RESULTS: A hundred CT head examinations were included with a median age of 50 years (IQR 43 to 57). The median bleed volume was 11.2 mL (IQR 6.6-18.6) per the index radiologist estimations. The overall mean of differences between the RAD mean and the EM mean estimated bleed volume was 0.3 (95% CI -1.5 to +1.7) in milliliters. The percentage difference between EM and RAD expressed as median was 1.9% (IQR -13.4% to +14.1%). Compared to the index RAD the mean of differences for bleed volume [rater, mean (95% CI) in milliliters] were: second RAD, 1.19 (1.14 to 1.24); EM attending, 1.05 (0.98 to 1.13); senior fellow, 1.05 (1.00 to 1.10); junior fellow, 1.19 (1.06 to 1.33); senior resident, 1.29 (1.19 to 1.39); junior resident, 1.11 (1.03 to 1.20). The difference between EM versus radiologist, junior versus senior EM physician estimation of bleed size was clinically insignificant. CONCLUSIONS: Excellent level of agreement was found between emergency physicians and emergency radiologists for estimating ICH bleed volumes using ABC/2 formula.

Emergency Physician Interpretation of Point-of-care Ultrasound for Identifying and Grading of Hydronephrosis in Renal Colic Compared With Consensus Interpretation by Emergency Radiologists.

OBJECTIVE: The ability of emergency physicians (EPs) to identify hydronephrosis using point-of-care ultrasound (POCUS) has been assessed in the past using computed tomography (CT) scans as the reference standard. We aimed to determine the ability of EPs to identify and grade hydronephrosis on POCUS using the consensus interpretation of POCUS by emergency radiologists as the reference standard. METHODS: The study was conducted at an urban academic emergency department (ED) as a secondary analysis of previously collected ultrasound data from the EP-performed POCUS databank. Patients were eligible for inclusion if they had both POCUS and CT scanning performed during the index ED visit. Two board-certified emergency radiologists and six EPs interpreted each POCUS study independently. The interpretations were compared with the consensus interpretation by emergency radiologists. Additionally, the POCUS interpretations were also compared with the corresponding CT findings. Institutional approval was obtained for conducting this study. All the analyses were performed using Stata MP 14.0 (StataCorp). RESULTS: A total of 651 patient image-data sets were eligible for inclusion in this study. Hydronephrosis was reported in 69.6% of POCUS examinations by radiologists and 72.7% of CT scans (p = 0.22). Using the consensus radiology interpretation of POCUS as the reference standard, EPs had an overall sensitivity of 85.7% (95% confidence interval [CI] = 84.3%-87.0%), specificity of 65.9% (95% CI = 63.1%-68.7%), positive likelihood ratio of 2.5 (95% CI = 2.3-2.7), and negative likelihood ratio of 0.22 (95% CI = 0.19-0.24) for hydronephrosis. When using CT scan as the reference standard, the EPs had an overall sensitivity of 81.1% (95% CI = 79.6% to 82.5%), specificity of 59.4% (95% CI = 56.4%-62.5%), positive likelihood ratio of 2.0 (95% CI = 1.8-2.2), and negative likelihood ratio of 0.32 (95% CI = 0.29-0.35) for hydronephrosis. The specificity of EPs was improved to 94.6% (95% CI = 93.7%-95.4%) for categorizing the degree of hydronephrosis as "moderate or severe" versus "none or mild," with positive likelihood ratio of 6.33 (95% CI = 5.3-7.5) and negative likelihood ratio of 0.69 (95% CI = 0.66-0.73). CONCLUSIONS: Emergency physicians were found to have moderate to high sensitivity for identifying hydronephrosis on POCUS when compared with the consensus interpretation of the same studies by emergency radiologists. These POCUS findings by EPs produced more definitive results when at least moderate degree of hydronephrosis was present.

Medical Students Teaching Medical Students Surgical Skills: The Benefits of Peer-Assisted Learning.

OBJECTIVE: Teaching surgical skills is a labor intensive process, requiring a high tutor to student ratio for optimal success, and teaching for undergraduate students by consultant surgeons is not always feasible. A surgical skills course was developed, with the aim of assessing the effectiveness of undergraduate surgical peer-assisted learning. DESIGN: Five surgical skills courses were conducted looking at eight domains in surgery, led by foundation year doctors and senior medical students, with a tutor to student ratio of 1:4. Precourse and postcourse questionnaires (Likert scales 0-10) were completed. Mean scores were compared precourse and postcourse. SETTING: Surgical skills courses took place within clinical skills rooms in the Queen Elizabeth Hospital Birmingham (UK). PARTICIPANTS: Seventy students (59 medical, 2 dental, and 9 physician associate students) from a range of academic institutions across the UK completed the course. RESULTS: There was an overall increase in mean scores across all eight domains. Mean improvement score precourse and postcourse in WHO surgical safety checklist (+3.94), scrubbing (+2.99), gowning/gloving (+3.34), knot tying (+5.53), interrupted sutures (+5.89), continuous sutures (+6.53), vertical mattress sutures (+6.46), and local anesthesia (+3.73). CONCLUSIONS: Peer-assisted learning is an effective and feasible method for teaching surgical skills in a controlled environment, subsequently improving confidence among healthcare undergraduates. Such teaching may provide the basis for feasibly mass-producing surgical skills courses for healthcare students.

Post Roux-en-Y gastric bypass complications: A comparative study assessing the clinical effectiveness of oesophagogastroduodenoscopy and oral-contrast swallow.

INTRODUCTION: Anastomotic strictures at the gastrojejunal anastomosis have been reported to occur in 3-20% of patients following a Roux-en-Y gastric bypass (RYGB). Patients commonly present with dysphagia, vomiting and post-prandial pain. Clearly using the appropriate investigations to diagnose the potential complications have both clinical and economical benefits. The reported study compared whether Oesophagogastroduodenoscopy (OGD) or oral-contrast swallow should be employed in patient presenting with post-operative complications following RYGB. METHODS: A retrospective study was conducted on 112 patients between 2008 and 2012; at a level 4 bariatric surgery hospital. Patients who had ≥1 OGD to investigate a post-operative complication were included for analysis. Oral-contrast swallow radiology reports performed <28 days prior to an OGD were included for analysis. Patient demographics, OGD, oral-contrast swallow and additional interventions reports were collated from electronic records, pathology and radiology results. RESULTS: 112 patients underwent 1 or more OGD. 75% (n = 67) of patients were diagnosed with a post-operative complication with the most common, 51% (n = 57) being a gastrojejunal anastomotic stricture. 82% (n = 47) of patients presented with dysphagia + - vomiting prior to the diagnosis of gastrojejunal anastomotic strictures. 96% (n = 55) of patients with gastrojejunal anastomotic strictures were successfully treated with balloon dilation. 48% (n = 54) of patients had an oral-contrast swallow as a first line investigation for post-operative symptoms prior to the OGD. 15% (n = 8) of oral-contrast swallow were reported with a significant pathology, with only 1 stricture identified. 70% (n = 38) of oral-contrast swallows reported as normal had a pathology identified at OGD, including 28 strictures. CONCLUSION: We recommend that an OGD should be performed in patients presenting with symptoms consistent with a stricture following RYGB. The urgency of the OGD will be dictated by clinical correlation. The use of a water-soluble contrast swallow should be reserved for a suspected anastomotic leak.

Application of Box-Behnken design for preparation of levofloxacin-loaded stearic acid solid lipid nanoparticles for ocular delivery: Optimization, in vitro release, ocular tolerance, and antibacterial activity.

The aim of the present study was to develop and optimize levofloxacin loaded solid lipid nanoparticles for the treatment of conjunctivitis. Box-Behnken experimental design was applied for optimization of solid lipid nanoparticles. The independent variables were stearic acid as lipid (X1), Tween 80 as surfactant (X2) and sodium deoxycholate as co-surfactant (X3) while particle size (Y1) and entrapment efficiency (Y2) were the dependent variables. Further in vitro release and antibacterial activity in vitro were also performed. The optimized formulation of levofloxacin provides particle size of 237.82 nm and showed 78.71% entrapment efficiency and achieved flux 0.2,493 µg/cm(2)/h across excised goat cornea. In vitro release study showed prolonged drug release from the optimized formulation following Korsmeyer-Peppas model. Antimicrobial study revealed that the developed formulation possesses antibacterial activity against Staphylococcus aureus, and Escherichia coli equivalent to marketed eye drops. HET-CAM test demonstrated that optimized formulation was found to be non-irritant and safe for topical ophthalmic use. Our results concluded that solid lipid nanoparticles are an efficient carrier for ocular delivery of levofloxacin and other drugs.

Case report of complicated epidermoid cyst of the floor of the mouth: Radiology-histopathology correlation.

Epidermoid cysts, true dermoid cysts and teratoid cysts compose the spectrum of cystic teratomas, which are defined as neoplasms whose tissue are derivatives of more than one germ layer, foreign to that part of the body from which the tumor arises. Epidermoid cysts of the floor of the mouth are rare lesions and are much less common than dermoid cysts in the head and neck. This case reports a 43-year-old male patient who presented with a longstanding midline swelling in the submental region. Initial imaging was done using ultrasound followed by computed tomography (CT) scan. Biopsy was taken and revealed a cyst wall lined with epidermal squamous epithelium along with areas of focal ulceration suggesting chronic inflammatory changes of the wall of the epidermoid cyst. There are characteristic and even pathognomonic imaging features of epidermoid cysts at the floor of the mouth in ultrasound and CT scan. Imaging has an important role in the surgical management plan according to the size and location of the cyst in relation to geniohyoid and mylohyoid muscles.

Role of Intravitreal Antivascular Endothelial Growth Factor Injections for Choroidal Neovascularization due to Choroidal Osteoma.

We treated 26 eyes of 25 young patients having a mean age of 30 years with intravitreal vascular endothelial growth factor (VEGF) inhibitor for choroidal new vessel (CNV) formation overlying choroidal osteoma over a mean follow-up of 26 months. Mean number of injections was 2.4 at 6 months, 3.2 at 12 months, and 5.5 at 24 months. CNV was subfoveal in 14 eyes, juxtafoveal in 5, extrafoveal in 5, and peripapillary in 2. By paired comparison, mean decrease from baseline was 119.7 microns at 6 months (n = 15; P = 0.001), 105.3 microns at 1 year (n = 10; P = 0.03), and 157.6 microns at 2 years (n = 7; P = 0.08). BCVA improved by 3.3 lines at 6 months after therapy (n = 26; P < 0.001), 2.8 lines (n = 20; P = 0.01) at 1 year, and 3.1 lines (n = 13; P = 0.049) at 2 years. We conclude that intravitreal anti-VEGF injections improve vision in majority of eyes with CNV from choroidal osteoma.

Microperimetry and optical coherence tomography in acute macular neuroretinopathy.

PURPOSE: To report optical coherence tomography and microperimetry findings in acute macular neuroretinopathy. METHODS: Case report. PATIENTS: A single patient with acute macular neuroretinopathy. CONCLUSION: Scotomata reported by a patient with acute macular neuroretinopathy correspond with findings of disruption of the photoreceptor inner segment-outer segment junction on optical coherence tomography and congruent decreased retinal function demonstrated with microperimetry.

Ocular hypertension associated with ocular sarcoidosis.

PURPOSE: To report bilateral ocular hypertension in association with ocular sarcoidosis. METHODS: Case note review of patients with a diagnosis of sarcoidosis-related uveitis. RESULTS: The authors identified 5 patients who fulfilled the diagnostic criteria for ocular sarcoidosis and who had intraocular pressures of > 40 mmHg in each eye. CONCLUSIONS: Physicians should be aware of the association of raised intraocular pressure with ocular sarcoidosis.

Pooled cataract waiting lists: views of hospital consultants, general practitioners and patients.

In the National Health Service general practitioners (GPs) usually refer patients to named consultants; thus, waiting times for a particular procedure can vary greatly even within a single centre. An alternative is to pool the waiting list, with patients treated in turn by the consultant available. We sought opinions on this strategy, from patients, GPs, and consultants, in relation to cataract surgery. Questionnaires were sent to 776 consultant ophthalmologists; telephone interviews were conducted with 50 randomly selected Birmingham GPs; and 85 Birmingham patients listed for cataract surgery were asked whether they would change consultant to be operated on sooner. 503 (64%) of the consultants responded. Of consultants, 30% favoured pooled lists and 67% were against. Of patients, 82% favoured pooled lists and 18% were against. Of GPs, 92% favoured pooled lists and 8% were against. Some consultants thought that pooled lists were suitable for routine cases but not for more complex cases. 82% of patients expressed willingness to change consultant in order to get an earlier operation. In units with surgeons whose cataract-surgery practices are similar, pooled lists are one way to maximize theatre use and equalize waiting times for routine cases. The model could be applied to other routine surgical procedures such as hip replacement, herniorrhaphy and prostatectomy.