Outcome of long-term biliary stenting for stones in the 2010s: beware the cholecystectomised!

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for most patients with common bile duct stones (CBDS). Duct clearance at initial ERCP may not be achieved in a third of patients, many of whom may be elderly with multiple comorbidities rendering them at potentially high risk for further procedures. We aimed to quantify the rate of biliary sequelae and mortality among a large cohort undergoing a single ERCP with sphincterotomy and stent insertion without having undergone complete ductal clearance (permanent stent insertion, PSI), and to examine factors that may predispose to adverse outcomes. Design/method: Outcomes of all ERCPs undertaken on the intact papilla between February 2010 and January 2020 were distilled to identify a cohort who had undergone PSI for initially irretrievable CBDS. These were subjected to retrospective follow-up until the development of biliary sequelae, death or survival into 2023. Results: There were 2175 index ERCPs for CBDS, of whom 114 met the PSI criteria. Eleven did not survive their index hospitalisation, leaving 103 for follow-up. Of these, 25 (24%) developed late biliary sequelae, 19 (18%) required at least one further ERCP and 8 (8%) died from biliary sequelae. Adverse outcomes were found to be more common among those who had undergone cholecystectomy prior to ERCP, and those with periampullary diverticula. Conclusions: Long-term biliary stenting following sphincterotomy remains a valid option for selected patients with initially irretrievable bile duct stones who could be at high risk from repeat procedures.

Expert eValuation of Efficacy and Rationality of Vildagliptin "EVER-Vilda": An Indian Perspective.

Vildagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor is effective in reducing HbA1c levels in patients with type 2 diabetes (T2DM) when administered as monotherapy, dual or triple combination therapy. In India, Vildagliptin is commonly prescribed in T2DM patients because it reduces mean amplitude of glycemic excursion (MAGE), has lower risk of hypoglycemia and is weight neutral. Early combination therapy with vildagliptin and metformin is effective and well-tolerated in patients with T2DM, regardless of age or ethnicity. In view of already existing data on vildagliptin and the latest emerging clinical evidence, a group of endocrinologists, diabetologists and cardiologists convened for an expert group meeting to discuss the role and various combinations of vildagliptin in T2DM management. This practical document aims to guide Physicians and Specialists regarding the different available strengths and formulations of vildagliptin for the initiation and intensification of T2DM therapy.

Recurrent Spontaneous Pneumothorax Secondary to Marijuana and Tobacco Abuse.

Primary spontaneous pneumothorax occurs in patients without apparent clinical lung disease, with a higher incidence in tall, thin males between the ages of 10 and 30. Tension pneumothorax is a life-threatening condition that can develop within minutes due to progressive air accumulation in the pleural space; mechanical pressure can lead to significant cardiorespiratory compromise. Tobacco association with a higher incidence of spontaneous pneumothorax has been well documented, but marijuana and spontaneous pneumothorax connection has not been well studied. However, it has been observed that patients who use marijuana and tobacco simultaneously have a higher incidence of spontaneous tension and larger pneumothoraces, as well as longer postoperative stay and higher recurrence than cigarette-only users. We present a case of a 26-year-old young male with a history only significant for excessive tobacco and marijuana smoking who developed multiple recurrent spontaneous pneumothorax and had to undergo right-sided video-assisted thoracoscopic surgery (VATS) with minimally invasive thoracotomy and had a prolonged hospital stay. With our case report, we hope to add to the evidence the effects of combined marijuana and tobacco smoking on bullous lung disease and pneumothorax while emphasizing the importance of conducting a detailed substance use history in patients with spontaneous pneumothorax.

Low-Loss Paper-Substrate Triple-Band-Frequency Reconfigurable Microstrip Antenna for Sub-7 GHz Applications.

In this paper, a low-cost resin-coated commercial-photo-paper substrate is used to design a printed reconfigurable multiband antenna. The two PIN diodes are used mainly to redistribute the surface current that provides reconfigurable properties to the proposed antenna. The antenna size of 40 mm × 40 mm × 0.44 mm with a partial ground, covers wireless and mobile bands ranging from 1.91 GHz to 6.75 GHz. The parametric analysis is performed to achieve optimized design parameters of the antenna. The U-shaped and C-shaped emitters are meant to function at 2.4 GHz and 5.9 GHz, respectively, while the primary emitter is designed to operate at 3.5 GHz. The proposed antenna achieved peak gain and radiation efficiency of 3.4 dBi and 90%, respectively. Simulated and measured results of the reflection coefficient, radiation pattern, gain, and efficiency show that the antenna design is in favorable agreement. Since the proposed antenna achieved wideband (1.91-6.75 GHz) using PIN diode configuration, using this technique the need for numerous electronic components to provide multiband frequency is avoided.

Preventive Saline Irrigation of the Bile Duct to Reduce the Rate of Residual Common Bile Duct Stones Without Intraductal Ultrasonography: A Systematic Review and Meta-Analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) has been proven efficacious in the removal of CBD stones. Even after endoscopic stone removal, recurring cholangitis due to a residual common bile duct (CBD) stone is prevalent in clinical practice with a residual recurrence rate of 4-24% after successful stone retrieval. This comprehensive study and meta-analysis aimed to determine if preventive saline irrigation of the bile duct (PSIB) reduces the amount of residual CBD stones. Through a comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science until November 20, 2022, we identified 164 articles comparing the efficacy of PSIB and non-PSIB post-endoscopic CBD stone removal. After stringent selection, three studies were included for meta-analysis using ReviewManager (ReVman version 5.4.1; Cochrane, London, UK). Using a random effect (RE) model, we derived a pooled odds ratio (OR) with confidence interval (CI) (95%CI). A total of three studies have been included in the analysis. Out of which, two are randomized controlled trials (RCTs) and one is a non-randomized study. Out of 323 patients, 157 underwent PSIB after an endoscopic stone removal of CBD stones to reduce the residual of CBD stones, whereas 166 did not undergo saline irrigation (non-PSIB). In our analysis, PSIB significantly reduced the risk of residual stones (OR: 0.22, 95%CI: 0.11-0.45). However, there was no notable link between PSIB and post-irrigation cholangitis (OR: 1.08, 95%CI: 0.21-2.21). Although not statistically significant, PSIB showed a trend toward lowered risks of post-procedural pancreatitis (OR: 0.65), bleeding (OR: 0.68), and other complications (OR: 0.64). PSIB effectively reduces residual CBD stones after endoscopy, offering a cost-effective alternative to invasive procedures such as intraductal ultrasound (IDUS). However, larger RCTs are needed to validate its definitive role.

Quad Element MIMO Antenna for C, X, Ku, and Ka-Band Applications.

This article presents a quad-element MIMO antenna designed for multiband operation. The prototype of the design is fabricated and utilizes a vector network analyzer (VNA-AV3672D) to measure the S-parameters. The proposed antenna is capable of operating across three broad frequency bands: 3-15.5 GHz, encompassing the C band (4-8 GHz), X band (8-12.4 GHz), and a significant portion of the Ku band (12.4-15.5 GHz). Additionally, it covers two mm-wave bands, specifically 26.4-34.3 GHz and 36.1-48.9 GHz, which corresponds to 86% of the Ka-band (27-40 GHz). To enhance its performance, the design incorporates a partial ground plane and a top patch featuring a dual-sided reverse 3-stage stair and a straight stick symmetrically placed at the bottom. The introduction of a defected ground structure (DGS) on the ground plane serves to provide a wideband response. The DGS on the ground plane plays a crucial role in improving the electromagnetic interaction between the grounding surface and the top patch, contributing to the wideband characteristics of the antenna. The dimensions of the proposed MIMO antenna are 31.7 mm × 31.7 mm × 1.6 mm. Furthermore, the article delves into the assessment of various performance metrics related to antenna diversity, such as ECC, DG, TARC, MEG, CCL, and channel capacity, with corresponding values of 0.11, 8.87 dB, -6.6 dB, ±3 dB, 0.32 bits/sec/Hz, and 18.44 bits/sec/Hz, respectively. Additionally, the equivalent circuit analysis of the MIMO system is explored in the article. It's worth noting that the measured results exhibit a strong level of agreement with the simulated results, indicating the reliability of the proposed design. The MIMO antenna's ability to exhibit multiband response, good diversity performance, and consistent channel capacity across various frequency bands renders it highly suitable for integration into multi-band wireless devices. The developed MIMO system should be applicable on n77/n78/n79 5G NR (3.3-5 GHz); WLAN (4.9-5.725 GHz); Wi-Fi (5.15-5.85 GHz); LTE5537.5 (5.15-5.925 GHz); WiMAX (5.25-5.85 GHz); WLAN (5.725-5.875 GHz); long-distance radio telecommunication (4-8 GHz; C-band); satellite, radar, space communications and terrestrial broadband (8-12 GHz; X-band); and various satellite communications (27-40 GHz; Ka-band).

Understanding the Nuances of Hepatic Portal Venous Gas in Pneumatosis Intestinalis: An Indication of Bowel Ischemia?

Pneumatosis intestinalis (PI) is a relatively rare gastrointestinal finding that has a wide variety of causes - ranging from benign to life-threatening. It is described as the pathological presence of gas within the bowel wall with multiple hypotheses emerging as to the likely mechanism. An important indicator of a life-threatening source of PI is the presence of gas within the hepatic portal vein, referred to as hepatic portal venous gas (HPVG). While non-specific for isolated PI, HPVG has been reported in PI patients to be associated with bowel ischemia and is thereby considered an indication for emergent management. Herein we report a case involving an atypical presentation of altered mental status in which the patient was found to have PI with contemporaneous HPVG. These findings have been reported to have a high mortality rate. Our patient rapidly deteriorated during their hospital course, expiring shortly after being deemed a poor surgical candidate due to their severe co-morbidity burden. Through this case, we review evidence supporting the management of patients with PI and concurrent HPVG from an extensive review of available literature. While PI is a non-specific finding and commonly a source of diagnostic confusion, a better understanding of its natural course and potentially unorthodox sequela may afford more directed and crucial care for critically ill patients, in which time is often a precious commodity.

Design and Analysis of Modified U-Shaped Four Element MIMO Antenna for Dual-Band 5G Millimeter Wave Applications.

A novel compact-slotted four element multiple input multiple output (MIMO) planar monopole antenna is proposed for 5G mmWave N257/N258 and N262 band applications. The antenna, with dimensions of 12 mm × 11.6 mm × 0.508 mm (1.036λo ×1.001λo×0.043λo where λo is computed at lowest cutoff frequency), is fabricated on a Rogers RT/duroid 5880 (tm) substrate with a relative permittivity of 2.2 and a dielectric loss tangent of 0.0009. The suggested antenna consists of four U-shaped radiating elements (patches) on top of the dielectric material and a slotted ground on the bottom. The radiating elements are fed by a 50-ohm microstrip line feed. To improve the impedance performance of the MIMO antenna, a rectangular strip of 1.3 mm × 0.2 mm and a couple of rectangular slots are added to each radiating element. The first operating band at 27.1 GHz, ranging from 25.9 GHz to 27.8 GHz, is achieved by using slotted U-shaped radiating elements. The second operating band at 48.7 GHz, ranging from 47.1 GHz to 49.9 GHz, is obtained by etching hexagonal slots on the ground. The antenna design achieves an isolation of >27 dB through the orthogonal positioning of radiating elements and slots on the ground. The designed antenna operates at 27 GHz (N257/N258) and 48.7 GHz (N262) bands, exhibiting stable radiation patterns, a peak gain of >5.95 dBi, radiation efficiency of >90%, an envelope correlation coefficient of <10-6, a total active reflection coefficient of ≤-10 dB, channel capacity losses of <0.03 bits/s/Hz, and a mean effective gain of ≤-3 dB. The simulated and measured results of the antenna show good agreement, making it well-suited for 5G mmWave communication applications.

Dual-Band, Wide-Angle, and High-Capture Efficiency Metasurface for Electromagnetic Energy Harvesting.

A dual-band metasurface (MS) with a wide reception angle operating at Wi-Fi bands (2.4 GHz and 5.4 GHz) is presented for electromagnetic (EM) energy harvesting applications. The MS unit cell comprises a subwavelength circular split ring resonator printed on the low-loss substrate. An air layer is sandwiched between two low-loss substrates to enhance the harvesting efficiency at operating frequencies. One of the main advantages of the proposed MS is that it uses only one harvesting port (via) to channel the captured power to the optimized load (50 Ω), which simplifies the design of a combined power network. According to the results of full-wave EM simulations, the proposed MS has a near-unity efficiency of 97% and 94% at 2.4 GHz and 5.4 GHz, respectively, for capturing the power of incident EM waves with normal incidence. Furthermore, the proposed MS harvester achieves good performance at up to 60° oblique incidence. To validate simulations, the MS harvester with 5 × 5-unit cells is fabricated and tested, and its EM properties are measured, showing good agreement with the simulation results. Because of its high efficiency, the proposed MS harvester is suitable for use in various microwave applications, such as energy harvesting and wireless power transfer.

A Compact MIMO Multiband Antenna for 5G/WLAN/WIFI-6 Devices.

This research work presents a compact design of a Multiple-Input Multiple-Output (MIMO) multiband antenna along with high-isolation characteristics. The presented antenna was designed for 3.50 GHz, 5.50 GHz, and 6.50 GHz frequencies for 5G cellular, 5G WiFi, and WiFi-6, respectively. The fabrication of the aforementioned design was undertaken using FR-4 (1.6 mm thickness) substrate material with a loss tangent and relative permittivity of about 0.025 and 4.30, respectively. The two-element MIMO multiband antenna was miniaturized to 16 × 28 × 1.6 mm3, making it desirable for devices operating in 5G bands. High isolation (>15 dB) was attained with thorough testing without employing a decoupling scheme in the design. Laboratory measurements resulted in a peak gain of 3.49 dBi and an efficiency of around 80% in the entire operating band. The evaluation of the presented MIMO multiband antenna was carried out in terms of the envelope correlation coefficient (ECC), diversity gain (DG), total active reflection coefficient (TARC), and Channel Capacity Loss (CCL). The measured ECC was less than 0.04, and the DG was well above 9.50. The observed TARC was also lower than -10 dB, and the CCL was below 0.4 bits/s/Hz in the entire operating band. The presented MIMO multiband antenna was analyzed and simulated using CST Studio Suite 2020.

Correction: Recurrent Brain Metastasis Versus Radiation-Induced Necrosis: A Case Report and Literature Review.

[This corrects the article DOI: 10.7759/cureus.34400.].

Lamin A/C cardiomyopathy presenting as high-grade atrioventricular (AV) block, atrial fibrillation, heart failure and ventricular tachycardia in a single-family cluster.

Mutations in the lamin A/C (LMNA) gene have been associated with both cardiac and skeletal muscle abnormalities. Cardiac manifestations in LMNA cardiomyopathy have a variable age of onset and range from mild to life-threatening. We describe a case series illustrating manifestations of LMNA mutation in a single family with an extensive history of cardiac disease, including sudden cardiac death, and the implications for diagnosis and management. This discussion highlights potential presentations of LMNA mutations and the importance of genetic testing in patients with a family history of conduction abnormalities.

Health Control of Tree Trunk Utilizing Microwave Imaging and Reverse Problem Algorithms.

The voids in their trunk significantly affect tropical trees' health. Both the wood and timber industries may face substantial financial losses because of the lack of an effective technique to inspect the defected trees through deep zonal monitoring. Microwave imaging offers the advantages of mobility, processing time, compactness, and resolution over alternative imaging methods. An ultra-wide band (UWB) imaging system consisting of UWB antennas and a reverse problem algorithm is proposed. Several conditions, such as the size of trunk samples (16-30 cm), number of targets, size of voids, heterogeneity of media, and number of layers, are considered in experimental studies. Based on these studies, cylindrical wooden models with 100 and 140 mm diameters, one void at the center, and three voids in different locations were 3D printed. After proving the system's ability through simulation and measurements on 3D models, a rubber-wood trunk with a length of 75 cm was cut into smaller pieces. The images created utilizing the measured data showed that the system could detect voids in the rubber trunk. Furthermore, the system indicated a high percentage of reliability and repeatability.

Realizing the High Q-Factor of a CSIW Microwave Resonator Based on an MDGS for Semisolid Material Characterization.

In this work, the high-quality factor (Q-factor) and high sensitivity of a circular substrate-integrated waveguide (CSIW) are proposed for the characterization of semisolid materials. The modeled sensor was designed based on the CSIW structure with a mill-shaped defective ground structure (MDGS) to improve measurement sensitivity. The designed sensor oscillates at a single frequency of 2.45 GHz, which was simulated using an Ansys HFSS simulator. Electromagnetic simulation explains the basis of the mode resonance of all two-port resonators. Six variations of the materials under test (SUTs) were simulated and measured, including air (without an SUT), Javanese turmeric, mango ginger, black turmeric, turmeric, and distilled water (DI). A detailed sensitivity calculation was performed for the resonance band at 2.45 GHz. The SUT test mechanism was performed using a polypropylene tube (PP). The samples of dielectric material were filled into the channels of the PP tube and loaded into the center hole of the MDGS. The E-fields around the sensor affect the relationship with the SUTs, resulting in a high Q-factor value. The final sensor had a Q-factor of 700 and a sensitivity of 2.864 at 2.45 GHz. Due to the high sensitivity of the presented sensor for characterization of various semisolid penetrations, the sensor is also of interest for accurate estimation of solute concentration in liquid media. Finally, the relationship between the loss tangent, permittivity, and Q-factor at the resonant frequency were derived and investigated. These results make the presented resonator ideal for the characterization of semisolid materials.

A Miniaturized and Highly Sensitive Microwave Sensor Based on CSRR for Characterization of Liquid Materials.

In this work, a miniaturized and highly sensitive microwave sensor based on a complementary split-ring resonator (CSRR) is proposed for the detection of liquid materials. The modeled sensor was designed based on the CSRR structure with triple rings (TRs) and a curve feed for improved measurement sensitivity. The designed sensor oscillates at a single frequency of 2.5 GHz, which is simulated using an Ansys HFSS simulator. The electromagnetic simulation explains the basis of the mode resonance of all two-port resonators. Five variations of the liquid media under tests (MUTs) are simulated and measured. These liquid MUTs are as follows: without a sample (without a tube), air (empty tube), ethanol, methanol, and distilled water (DI). A detailed sensitivity calculation is performed for the resonance band at 2.5 GHz. The MUTs mechanism is performed with a polypropylene tube (PP). The samples of dielectric material are filled into PP tube channels and loaded into the CSRR center hole; the E-fields around the sensor affect the relationship with the liquid MUTs, resulting in a high Q-factor value. The final sensor has a Q-factor value and sensitivity of 520 and 7.032 (MHz)/εr) at 2.5 GHz, respectively. Due to the high sensitivity of the presented sensor for characterizing various liquid penetrations, the sensor is also of interest for accurate estimations of solute concentrations in liquid media. Finally, the relationship between the permittivity and Q-factor value at the resonant frequency is derived and investigated. These given results make the presented resonator ideal for the characterization of liquid materials.

Extraction of foreign body from the urinary bladder using nephroscope: A case report of endoscopy treatment.

Transurethral foreign bodies (FBs) in the urinary tract are rare findings in a clinical setting. The most common cases are reported for FBs in the urinary bladder. The present report similarly aimed to examine a whole pen as a FB with a discussion about symptoms and complexities. Here, we significantly reported the management of pen extraction from the bladder of a female patient using nephroscope and proposed success with possible recommendations for treatment in future operations.

Single-fed broadband CPW-fed circularly polarized implantable antenna for sensing medical applications.

Biomedical telemetry relies heavily on implantable antennas. Due to this, we have designed and tested a compact, a circularly polarized, a low-profile biomedical implantable antenna that operate in the 2.45 GHz ISM band. In order to keep the antenna compact, modified co-planar waveguide (CPW) technology is used. Slotted rectangular patch with one 45-degree angle slot and truncated little patch on the left end of the ground plane generate a frequency-range antenna with circular polarization. Using a 0.25-millimeter-thick Roger Duroid-RT5880 substrate with a thickness of εr = 2.2, tanδ = 0.0009 provides flexibility. The volume of the antenna is 21 mm x 13.5 mm x 0.254 mm (0.25λg × 0.16λg × 0.003λg). The antenna covers 2.35-2.55 GHz (200 MHz) in free space and 1.63-1.17 GHz (1.17 GHz) in epidermal tissue. With skin tissue that has more bandwidth, the (x and y)-axis bends of the antenna are also simulated via the simulation. Bended antenna simulations and measurements show excellent agreement. At 2.45 GHz, the skin-like gel had -10dB impedance and 3dB axial ratio (AR) bandwidths of 47.7 and 53.8%, respectively. The ultimate result is that the SAR values are 0.78 W/kg in skin over 1 g of bulk tissue, as determined by simulations. The suggested SAR values are lower than the FCC's maximum allowable limit (FCC). This antenna is small enough to be implanted in the body, making it perfect for biomedical applications.

Recurrent Brain Metastasis Versus Radiation-Induced Necrosis: A Case Report and Literature Review.

Radiotherapy is the cornerstone of brain metastasis management. With the advancement of therapies, patients are living longer, exposing them to the long-term effects of radiotherapy. Using concurrent or sequential chemotherapy, targeted agents, and immune checkpoint inhibitors may increase the incidence and severity of radiation-induced toxicity. Recurrent metastasis and radiation necrosis (RN) appear indistinguishable on neuroimaging, making it a diagnostic dilemma for clinicians. Here, we present a case of RN in a 65-year-old male patient who previously had brain metastasis (BM) from primary lung cancer, misdiagnosed initially as recurrent BM.

Detection of Semi-Solid Materials Utilizing Triple-Rings CSRR Microwave Sensor.

This article proposes the design, fabrication and measurement of a triple-rings complementary split-ring resonator (CSRR) microwave sensor for semi-solid material detection. The triple-rings CSRR sensor was developed based on the CSRR configuration with curve-feed designed together, utilizing a high-frequency structure simulator (HFSS) microwave studio. The designed triple rings CSRR sensor resonates at 2.5 GHz, performs in transmission mode, and senses shift in frequency. Six cases of the sample under tests (SUTs) were simulated and measured. These SUTs are Air (without SUT), Java turmeric, Mango ginger, Black Turmeric, Turmeric, and Di-water, and detailed sensitivity analysis is conducted for the frequency resonant at 2.5 GHz. The semi-solid tested mechanism is undertaken using a polypropylene (PP) tube. The samples of dielectric material are filled into PP tube channels and loaded in the CSRR centre hole. The e-fields near the resonator will affect the interaction with the SUTs. The finalized CSRR triple-rings sensor was incorporated with defective ground structure (DGS) to deliver high-performance characteristics in microstrip circuits, leading to a high Q-factor magnitude. The suggested sensor has a Q-factor of 520 at 2.5 GHz with high sensitivity of about 4.806 and 4.773 for Di-water and Turmeric samples, respectively. The relationship between loss tangent, permittivity, and Q-factor at the resonant frequency has been compared and discussed. These given outcomes make the presented sensor ideal for detecting semi-solid materials.