Evolution of spontaneous portosystemic shunts over time and following aetiological intervention in patients with cirrhosis.

Background & Aims: Spontaneous portosystemic shunts (SPSS) develop frequently in cirrhosis. Changes over time and the effect of aetiological interventions on SPSS are unknown, so we aimed to explore the effect of these variables on SPSS evolution. Methods: Patients with cirrhosis from the Baveno VI-SPSS cohort were selected provided a follow-up abdominal CT or MRI scan was available. Clinical and laboratory data were collected at baseline and follow-up. Imaging tests were reviewed to evaluate changes in the presence and size of SPSS (large (L)-SPSS was ≥8 mm) over time. Regarding alcohol- or HCV-related cirrhosis, two populations were defined: cured patients (abstinent from alcohol or successful HCV therapy), and non-cured patients. Results: A total of 617 patients were included. At baseline SPSS distribution was 22% L-SPSS, 30% small (S)-SPSS, and 48% without (W)-SPSS. During follow-up (median follow-up of 63 months), SPSS distribution worsened: L-SPSS 26%, S-SPSS 32%, and W-SPSS 42% (p <0.001). Patients with worse liver function during follow-up showed a simultaneous aggravation in SPSS distribution. Non-cured patients (n = 191) experienced a significant worsening in liver function, more episodes of liver decompensation and lower transplant-free survival compared to cured patients (n = 191). However, no differences were observed regarding SPSS distribution at inclusion and at follow-up, with both groups showing a trend to worsening. Total shunt diameter increased more in non-cured (52%) than in cured patients (28%). However, total shunt area (TSA) significantly increased only in non-cured patients (74 to 122 mm2, p <0.001). Conclusions: The presence of SPSS in cirrhosis increases over time and parallels liver function deterioration. Aetiological intervention in these patients reduces liver-related complications, but SPSS persist although progression is decreased. Impact and implications: There is no information regarding the evolution of spontaneous portosystemic shunts (SPSS) during the course of cirrhosis, and especially after disease regression with aetiological interventions, such as HCV treatment with direct-acting antivirals or alcohol abstinence. These results are relevant for clinicians dealing with patients with cirrhosis and portal hypertension because they have important implications for the management of cirrhosis with SPSS after disease regression. From a practical point of view, physicians should be aware that in advanced cirrhosis with portal hypertension, after aetiological intervention, SPSS mostly persist despite liver function improvement, and complications related to SPSS may still develop.

Vitamins and Minerals for Blood Pressure Reduction in the General, Normotensive Population: A Systematic Review and Meta-Analysis of Six Supplements.

Hypertension is the leading preventable risk factor for cardiovascular disease and all-cause mortality worldwide. However, studies have shown increased risk of mortality from heart disease and stroke even within the normal blood pressure (BP) range, starting at BPs above 110-115/70-75 mm Hg. Nutraceuticals, such as vitamins and minerals, have been studied extensively for their efficacy in lowering BP and may be of benefit to the general, normotensive population in achieving optimal BP. Our study investigated the effects of six nutraceuticals (Vitamins: C, D, E; Minerals: Calcium, Magnesium, Potassium) on both systolic blood pressure (SBP) and diastolic blood pressure (DBP) in this population. We performed a systematic review and pairwise meta-analysis for all six supplements versus placebo. Calcium and magnesium achieved significant reductions in both SBP and DBP of -1.37/-1.63 mm Hg and -2.79/-1.56 mm Hg, respectively. Vitamin E and potassium only yielded significant reductions in SBP with values of -1.76 mm Hg and -2.10 mm Hg, respectively. Vitamins C and D were not found to significantly lower either SBP or DBP. Future studies should determine optimal dosage and treatment length for these supplements in the general, normotensive population.

Artificial intelligence enabled COVID-19 detection: techniques, challenges and use cases.

Deep Learning and Machine Learning are becoming more and more popular as their algorithms get progressively better, and their use is expected to have the large effect on improving the health care system. Also, the pandemic was a chance to show how adding AI to healthcare infrastructure could help, since infrastructures around the world are overworked and falling apart. These new technologies can be used to fight COVID-19 because they are flexible and can be changed. Based on these facts, we looked at how the ML and DL-based models can be used to deal with the COVID-19 pandemic problem and what the pros and cons of each are. This paper gives a full look at the different ways to find COVID-19. We looked at the COVID-19 issues in a systematic way and then rated the methods and techniques for finding it based on their availability, ease of use, accuracy, and cost. We have also shown in pictures how well each of the detection techniques works. We did a comparison of different detection models based on the above factors. This helps researchers understand the different methods and the pros and cons of using them as the basis for their research. In the last part, we talk about the open challenges and research questions that come with putting these techniques together with other detection methods.

Fournier's gangrene reconstruction: A 10-year retrospective analysis of practice at Guys and St Thomas's NHS Foundation Trust.

Fournier's gangrene is a rare and potentially fatal condition that affects the external genitalia and perineum as a necrotizing soft-tissue infection. It is equally prevalent in men and women and although there are many ways to manage the condition, it must be done so effectively because there is a chance that life-threatening complications could develop. This retrospective study set out to fill any knowledge gaps, compare reconstructive options to those described in the literature, and promote reflection on current management. Between January 2010 and January 2020, all perineal debridement operation notes were examined. The primary conclusions were that a large majority of defects could be repaired using split skin grafts to reduce surgical time and donor site morbidity. To avoid secondary contracture and the need for revision surgery, full-thickness skin grafts should be used whenever possible to treat penile defects.

Utility of an integrated health system specialty pharmacy in provision of extended-release buprenorphine for patients with opioid use disorder.

PURPOSE: Extended-release (ER) monthly injectable buprenorphine offers an alternative to daily sublingual (SL) dosing for treatment of opioid use disorder (OUD) that may be attractive to several patient populations, including those with barriers to adherence and the frequent follow-up that are necessary for traditional SL buprenorphine. Despite the potential benefits of ER-buprenorphine, there are significant barriers to healthcare provider adoption that may prevent utilization in the populations that would benefit. SUMMARY: Our health system began providing clinic-administered ER-buprenorphine as treatment for OUD in May 2018 at a single clinic. Expansion was limited due to difficulties with delayed and inaccurate medication delivery and heavy administrative burden. To facilitate uptake of ER-buprenorphine for patients who could benefit, our integrated health-system specialty pharmacy (HSSP) assumed responsibility for medication distribution and administrative management beginning in October 2019. The HSSP provided accurate medication delivery, alleviated administrative burdens of benefits investigation and Risk Evaluation and Mitigation Strategy compliance, and decreased medication wastage by implementing a medication return process. Subsequently, ER-buprenorphine services were expanded to 4 additional sites, allowing 244 more patients to receive treatment. CONCLUSION: HSSP support can provide significant benefit to patients and the health system through coordinating ER-buprenorphine dispensing and delivery.

Double-layer biodegradable temporising matrix reconstruction for abdominal skin and soft-tissue reconstruction.

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally invasive dermal sarcoma. The management is generally surgical, with wide local excision (WLE) forming the mainstay of treatment. Large abdominal wall defects are most aesthetically reconstructed using pedicled or free flaps; however, these require tumour-free surgical margins, and are off-set by donor site morbidity. We describe an alternative, aesthetic and low-morbidity technique for reconstruction of a subfascial defect following WLE of DFSP in a young woman in her early 20s, using two layers of a novel synthetic dermal matrix (NovoSorbBTM). To our knowledge, a double-layer reconstruction using an artificial dermal matrix has never been described for trunk reconstruction. We found that double-layer biodegradable temporising matrix can restore the inherent thickness and pliability of skin in a partial-thickness abdominal wall defect and offers improved durability and cosmesis compared with skin grafting or indeed single layer skin substitutes alone.

The role of biodegradable temporizing matrix in the management of a patient with major burns and anorexia nervosa.

Severe malnutrition secondary to anorexia nervosa results in deeper burns and significantly impacts wound healing, which represents a major challenge to burn management. The use of acellular dermal matrices, such as biodegradable temporizing matrix (BTM), is a valuable tool to overcome the surgical limitations. We describe a case of a 36-year-old female with a background of anorexia nervosa (body mass index of 12.3) presenting with a 30% total burns surface area (TBSA) burn. All of her burns were excised down to fascia due to the absence of subcutaneous fat. Her thin skin and depleted nutritional status significantly impacted reconstructive options. BTM was utilized to create a neodermis and provide adequate time to optimize the nutritional status before autologous skin resurfacing 3 weeks later, which yielded robust coverage with minimal donor site morbidity. Despite initial surgical and nutritional challenges, excellent outcomes were achieved in terms of wound healing, scar contractures and mobility.

A National Survey on Perineal Reconstruction Following Standard and Extralevator Abdominoperineal Excision: Current Practices and Trends in the UK.

Background Challenging perineal defects resulting from extralevator (ELAPE) and standard abdominoperineal excision (APE) have given rise to an emerging multidisciplinary approach between colorectal and plastic surgeons. At present, there is a relative paucity of evidence on best practice. This study sought to assess current national practice concerning perineal reconstruction following APE/ELAPE in the United Kingdom (UK) and to determine the factors involved in reconstruction choice. Methodology An anonymised survey was circulated to consultant plastic surgeons at all 48 UK centres performing perineal reconstruction following APE/ELAPE. Responses were collected between October 2021 and April 2022. Results Complete responses were received from 24 units nationally. All units had a dedicated APE/ELAPE service. Overall, 70% adopted a standardised reconstructive approach, the most common being the inferior gluteal artery perforator flap (n = 11). Significant variation was identified in the reconstructive technique. Similar differences were observed in the perceived importance of surgical factors guiding the reconstructive decision-making process, the top priorities being the size of the defect and previous radiotherapy. Conclusions The variability of responses suggests a lack of national consensus on optimal reconstruction following APE/ELAPE, despite the majority of centres employing a standardised approach to reconstruction. Our study highlights important surgical decision-making factors and provides valuable insight to aid in developing national collaborative evidence-based guidelines on best practice.

Management of a rare, giant multicompartmental lipoma of the hand: a case report and review of the literature.

Lipomas are the commonest benign tumour, made up exclusively of adipose tissue, and can arise anywhere in the body. However, giant lipomas of the hand, defined as >5 cm in diameter, are rare. They have the potential to invade into surrounding areas and cause a multitude of symptoms due to the compression and proximity of underlying structures. We describe a case of a 64-year-old woman who presents with a swelling of the left thenar eminence, associated with numbness and tingling in all fingers. Magnetic resonance imaging and nerve conduction studies confirmed the diagnosis of a lipoma causing median nerve compression. The patient underwent elective surgical excision with good postoperative recovery. The excised lesion, measuring 12 × 7 × 2.4 cm, is one of the largest giant lipomas of the hand reported in literature, and the first to demonstrate invasion from the mid palmar space into both the dorsal sub-aponeurotic space and carpal tunnel.

Secondary Flexor Tendon Reconstruction: Protocol for a Systematic Review and Meta-Analysis.

Introduction: Flexor tendon injuries of the hand and wrist involve complete or partial severance of the tendon, and primary repair is standard treatment. In cases of significantly delayed presentation, rupture of the repair or segmental tendon loss may require 1- or 2-stage secondary tendon reconstruction where a tendon graft is used. There is a risk of poor functional outcome due to stiffness and reduced range of motion which may affect patient's employment and activities of daily living. This study seeks to systematically evaluate the current evidence to determine outcomes of secondary flexor tendon reconstruction in terms of functional outcomes, complications, patient-reported outcome measures (PROMS) and costs. Methods: This is a PROSPERO registered study protocol for systematic review and meta-analysis of comparative and non-comparative studies. Outcomes of intrasynovial versus extrasynovial tendon grafting and seniority of the surgeon will be analysed in addition to comparing graft weaving at the wrist and palm for both single- and two-stage tendon reconstruction. The primary outcome is functional active range of motion. Secondary outcomes are complications, PROMs and resource use. A comprehensive literature search will be conducted from 2000 to present. All studies involving secondary flexor tendon repairs will be involved, without limitation on language, and will be screened by two independent reviewers. Tools to appraise the quality of study methodology and/or bias will be used (e.g., Cochrane Collaborative Risk of Bias tool) and if feasible, a random effects meta-analysis will be conducted. Ethics and dissemination: Ethical approval was not required for this study. The results of this systematic review and meta-analysis will be published in a peer-reviewed journal, and presented at both national and international conferences involving hand surgeons. The data collected will allow patients to be counselled more accurately by clinicians and may suggest areas where further research could be undertaken. Systematic review registration: PROSPERO CRD42021296009. Highlights: Single- or two-stage secondary flexor tendon reconstruction is an important treatment modality in cases unsuitable for primary repair.This study seeks to systematically evaluate the current evidence to determine outcomes of secondary flexor tendon reconstruction in terms of functional. outcomes, complications, patient-reported outcome measures (PROMS) and costs.This is a PROSPERO registered study protocol for systematic review and meta-analysis of comparative and non-comparative studies.Outcomes of intrasynovial versus extrasynovial tendon grafting and seniority of the surgeon will be analysed in addition to comparing graft weaving at the wrist and palm for both single- and two-stage tendon reconstruction.This systematic review aims to evaluate and summarise the best current literature to determine outcomes of secondary flexor tendon reconstruction.

Liquid-Infused Membranes Exhibit Stable Flux and Fouling Resistance.

Antifouling membranes that offer excellent operational lifetimes are critical technologies needed to meet the growing demand for clean water. In this study, we demonstrate antifouling membranes featuring an ultrathin oil layer that stayed immobilized on the surface and in the pore walls of poly(vinylidene fluoride) membranes for multiple cycles of operation at industrially relevant transmembrane pressures. An optimized quantity of a commercial Krytox oil with either a low (K103) or a high viscosity (K107) was infused onto the active surface and into the pores of membranes with a 0.45 µm pore size. The presence of the oil layer was qualitatively confirmed using crystal violet staining and variable pressure scanning electron microscopy. Using a dead-end stirred cell, a consistent pure water permeance value of 3000 L m-2 h-1 bar-1 was achieved for the K103 liquid-infused membranes for at least 10 operation cycles, which was expectedly lower than the permeance of bare control membranes (∼16 000 L m-2 h-1 bar-1), suggesting that a stable oil layer was formed on all membrane-active sites. To quantify if oil was lost during membrane operation, extensive thermogravimetric analysis was conducted on both the as-prepared and used membranes. When challenged with the microorganism, Escherichia coli K12, the liquid-infused membranes statistically reduced microbial attachment by ∼50% versus the control membranes. For the first time, we have demonstrated that by forming an immobilized, robust, and stable oil-coated membrane, we can generate high-performance membranes with stable permeance values that can be operated at relevant transmembrane pressures and provide long-lasting antifouling properties.

Adherence to self-administered biologic disease-modifying antirheumatic drugs across health-system specialty pharmacies.

PURPOSE: Adherence to self-administered biologic disease-modifying antirheumatic drugs (bDMARDs) is necessary for therapeutic benefit. Health-system specialty pharmacies (HSSPs) have reported high adherence rates across several disease states; however, adherence outcomes in rheumatoid arthritis (RA) populations have not yet been established. METHODS: We performed a multisite retrospective cohort study including patients with RA and 3 or more documented dispenses of bDMARDs from January through December 2018. Pharmacy claims were used to calculate proportion of days covered (PDC). Electronic health records of patients with a PDC of <0.8 were reviewed to identify reasons for gaps in pharmacy claims (true nonadherence or appropriate treatment holds). Outcomes included median PDC across sites, reasons for treatment gaps in patients with a PDC of <0.8, and the impact of adjusting PDC when accounting for appropriate therapy gaps. RESULTS: There were 29,994 prescriptions for 3,530 patients across 20 sites. The patient cohort was mostly female (75%), with a median age of 55 years (interquartile range [IQR], 42-63 years). The median PDC prior to chart review was 0.94 (IQR, 0.83-0.99). Upon review, 327 patients had no appropriate treatment gaps identified, 6 patients were excluded due to multiple unquantifiable appropriate gaps, and 420 patients had an adjustment in the PDC denominator due to appropriate treatment gaps (43 instances of days' supply adjusted based on discordant days' supply information between prescriptions and physician administration instructions, 11 instances of missing fills added, and 421 instances of clinically appropriate treatment gaps). The final median PDC after accounting for appropriate gaps in therapy was 0.95 (IQR, 0.87-0.99). CONCLUSION: This large, multisite retrospective cohort study was the first to demonstrate adherence rates across several HSSPs and provided novel insights into rates and reasons for appropriate gaps in therapy.

Swertisin, a novel SGLT2 inhibitor, with improved glucose homeostasis for effective diabetes therapy.

Failing pancreas and subsequent loss of pancreatic ß cells worsen diabetic conditions which are further alleviated by the mounting up of glucose levels. Inhibition of sodium glucose cotransporter 2 (SGLT2) in the kidney responsible for glucose reabsorption strikingly reduces blood glucose levels. Bioactive swertisin showed a promising glucose-lowering effect. Hence, we aimed to mechanistically dissect the glucose lowering property of swertisin. A systematic in silico, in vitro, and in vivo approach was directed for target analysis of swertisin. Molecular docking was performed with Swertisn-hSGLT2 complex. Glucose uptake assay and protein expression for SGLT2 and regulatory proteins were performed under swertisin effect. Various physiological and metabolic parameters were evaluated in STZ induced BALB/c mice using swertisin treatment. SGLT2 expression was evaluated in the kidney tissue of mice. Swertisn-hSGLT2 molecularly docked complex showed similar binding energy compared to the Canagliflozin-hSGLT2 complex. Swertisin inhibited glucose uptake and decreased expression of SGLT2 in HEK293 cells. Swertisin does not affect GLUT mediated glucose transport. Swertisin treated diabetic mice demonstrated remarkable improvement in overall glucose homeostasis. Reduced expression of SGLT2 was found in kidney tissue along with reduced PKC expression which is one of the key regulators of SGLT2. Our study explored SGLT2 as a selective target of swertisin for its swift glucose-lowering action which not only inhibits SGLT2 but also reduces its expression in diabetic condition. Thus, the potential property of swertisin as a glucose-lowering agent is remarkable which points towards the likelihood of a wider avenue of diabetes therapy.

Three-dimensional Printed Customized Adjustable Mallet Finger Splint: A Cheap, Effective, and Comfortable Alternative.

Mallet finger deformity is a common and debilitating injury of the fingertip, accounting for 10% of all tendon and ligament injuries. It involves a disruption of the terminal extensor mechanism of the distal phalanx. Patients can experience significant pain and swelling of the fingertip and have significant morbidity without treatment. Nonoperative treatment using joint immobilization with splints is the mainstay of management. Traditionally, prefabricated and thermoplastic splints have been utilized; however, issues with comfort and skin complications such as maceration can lead to patient noncompliance and eventually, poor outcomes. To address this, we demonstrate our experience with the design, manufacture, and application of individualized 3D printed mallet finger splints. The splints were found to provide advantages akin to traditional thermoplastic splints, with the addition of being low cost, easy to manufacture, and environmentally friendly.

Splenic artery pseudoaneurysm: Challenges of non-invasive and endovascular diagnosis and management.

Splenic artery pseudoaneurysms (PAs) are uncommon and often occur as a complication of pancreatitis or trauma. Unlike true aneurysms, PAs are symptomatic in a majority of cases and patients can present with a constellation of non-specific symptoms. Diagnosis can be challenging due to variation in presenting features and mimicking pathologies. PAs are associated with a very high morbidity and mortality if left untreated. We present an unusual case of a 47-year-old gentleman diagnosed with a splenic artery pseudoaneurysm despite initial negative catheter angiography and discuss the challenges of splenic artery pseudoaneurysm diagnosis and management.

Isolation and characterization of Lactococcus garvieae from the fish gut for in vitro fermentation with carbohydrates from agro-industrial waste.

This study focused on agro-industrial waste such as fruit peels by extracting prebiotics as a carbon source for lactic acid bacteria (LAB). Four strains of LAB were selected from Oreochromis niloticus (B2 and B3) and Nemipterus japonicas (R4 and R5), and identified as Lactococcus garvieae through 16S rRNA gene sequencing. The analysis of probiotic characteristics revealed that all four strains were able to tolerate sodium chloride (up to 7 %), bile salt (up to 3 %), and broad range of pH (2-9). Further, analysis of polysaccharide contents in the agro-industrial waste materials such as peels of pineapple, orange, lemon, sugarcane, pomegranate, and sweet lemon revealed that the concentration ranged from 3.91-163.85 mg/g. It was observed that orange peels (20.38-140.99 mg/g), sweet lemon peels (22.03-161.93 mg/g), and pomegranate peels (38.19-163.85 mg/g) yielded maximum indigestible polysaccharide. Evaluation of synbiotic combination of probiotic and prebiotic revealed that L. garvieae strains had better fermentation efficiency with orange, sweet lemon, and pineapple compared to lemon, sugarcane, and pomegranate. In nutshell, different types of agro-industrial waste evaluated in this research were found to be a cheap and fermentable carbon sources for LAB. Further study should be conducted to analyze this symbiotic combination as feed supplements for fish in aquaculture as well as various fermentation industries.