Non-Operative Approach to Contained Perforated Marginal Ulcers: A Systematic Review and Case Series.

BACKGROUND: Perforated marginal ulcers (PMUs) are a rare but known complication of bariatric surgery. Management typically involves prompt surgical intervention, but limited data exists on non-operative approaches. This study reviews published data on non-operative management of PMUs and presents a case series of patients who were managed non-operatively. Our hypothesis is that certain patients with signs of perforation can be successfully managed non-operatively with close observation. METHODS: We completed a systematic review searching PubMed, Embase, Web of Science, Cochrane, and clinicaltrials.gov. Ultimately 3 studies described the presentation and non-operative management of 5 patients. Additionally, we prospectively collected data from our institution on all patients who presented between Dec. 2022 and Dec. 2023 with PMUs confirmed on imaging and managed non-operatively. RESULTS: In our literature review, three patients had Roux-en-Y gastric bypass (RYGB), while two had one anastomosis gastric bypass. One patient required surgery two days after admission. Another underwent elective conversion surgery weeks later for a non-healing ulcer. Two received endoscopic interventions. One patient recovered with nil-per-os (NPO) status, and intravenous proton pump inhibitor (PPI) treatment. The patients in our case series presented with normal vital signs, an average of 30 months after RYGB, and with CT scan signs of perforation. None of these patients required surgical or endoscopic intervention. CONCLUSION: In conclusion, while perforated marginal ulcers have traditionally been considered a surgical emergency, some patients can be successfully treated with non-operative management. More research is needed to identify the clinical presentation features, comorbidities, and imaging findings of this group.

Safety and Clinical Value of Prophylactic Ureteral Stenting Before Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: Prophylactic ureteral stents (PUS) are typically placed prior to complex abdominal or pelvic operations at the surgeon's discretion to help facilitate detection of iatrogenic ureteral injury. However, its usefulness and safety in the setting of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) have not been examined. This study aims to evaluate the potential clinical value and risk profile of prophylactic ureteral stent placement prior to CRS-HIPEC. METHODS: We performed a single-institutional retrospective analysis of 145 patients who underwent CRS-HIPEC from 2013 to 2021. Demographic and operative characteristics were compared between patients who underwent PUS placement and those that did not. Ureteral stent-related complications were evaluated. RESULTS: Of the 145 patients included in the analysis, 124 underwent PUS placement. There were no significant differences in patient demographics, medical comorbidities, or tumor characteristics. Additionally, PUS placement did not significantly increase operative time and was not associated with increased pelvic organ resection. However, patients who underwent prophylactic ureteral stenting had significantly higher peritoneal carcinomatosis index score (15.1 vs 9.1, P=.002) and increased rate of ureteral complications (24.2% vs 14.3%, P=.04), which led to lengthened hospital stay (13.2 days vs 8.1 days, P= .03). Notably, the sole ureteral injury and three cases of hydronephrosis were seen in patients who underwent PUS. CONCLUSION: Prophylactic ureteral stent placement in patients undergoing CRS-HIPEC may be useful, particularly in patients with predetermined extensive pelvic disease. However, PUS placement is not without potential morbidity and should be selectively considered in patients for whom benefits outweigh the risks.

In vitro study of chlorine dioxide on porcine intestinal epithelial cell gene markers.

BACKGROUND: Chlorine dioxide (ClO2 ) is an inorganic, potent biocide and is available in highly purified aqueous solution. It can be administered as an oral antiseptic in this form. OBJECTIVES: Our aim is to determine the level of inflammatory markers and cytochrome genes expressed by enterocytes exposed to different concentrations of hyperpure chlorine dioxide solution. METHODS: Porcine jejunal enterocyte cell (IPEC-J2) cultures were treated with the aqueous solution of hyper-pure chlorine dioxide of various concentrations. We determined the alterations in mRNA levels of inflammatory mediators, such as IL6, CXCL8/IL8, TNF, HSPA6 (Hsp70), CAT and PTGS2 (COX2); furthermore, the expression of three cytochrome genes (CYP1A1, CYP1A2, CYP3A29) were analysed by quantitative PCR method. RESULTS: The highest applied ClO2 concentration reduced the expression of all three investigated CYP genes. The gene expression of PTGS2 and CAT were not altered by most concentrations of ClO2 . The expression of IL8 gene was reduced by all applied concentrations of ClO2 . TNF mRNA level was also decreased by most ClO2 concentrations used. CONCLUSIONS: Different concentrations of chlorine dioxide exhibited immunomodulatory activity and caused altered transcription of CYP450 genes in porcine enterocytes. Further studies are needed to determine the appropriate ClO2 concentration for oral use in animals.

Margins of Melanoma Excision and Modifications to Standards.

Surgery with wide local excision is the mainstay of treatment for primary melanoma. Surgical margins differ depending on the depth of the primary lesion, subtype, and anatomic, cosmetic, or functional considerations. Adjuncts or alternative treatments to wide local excision are limited to specific patient populations and mainly experimental in nature.

Minimally Invasive Distal Pancreatectomy Is Associated with Decreased Postoperative Neutrophil to Lymphocyte Ratio.

Purpose: The neutrophil-to-lymphocyte ratio (NLR) is a marker of inflammation that has been investigated as a prognostic factor in many diseases. We hypothesized that NLR would be lower in patients undergoing minimally invasive distal pancreatectomy (MIDP). Methods: Using a prospective database, we identified patients who underwent open or minimally invasive (laparoscopic/robotic) distal pancreatectomy and splenectomy from 2006 to 2018. Patients were grouped according to their type of surgery and matched by age, gender, and benign or malignant pathology. The NLR was calculated from a complete blood count with differential on the second postoperative day. Statistical calculations were performed in Stata (v13.0). Results: A total of 106 patients were included, with 53 MIDP and 53 open cases. MIDP was associated with a significantly lower postoperative NLR than open surgery (13.3 vs. 17.2, p = 0.01). NLR did not vary significantly between patients who developed complications and those who did not (15.4 vs. 15.3, p = 0.95). Patients undergoing MIDP had decreased length of postoperative hospital stay (4 days vs. 5 days, p = 0.003). Multivariable linear regression failed to find a significant decrease in NLR with the use of laparoscopy (p = 0.14) when accounting for age, body mass index, surgical blood loss, pathology, and operative time as covariates. Conclusion: The NLR is significantly decreased when performing MIDP versus open distal pancreatectomy, but correlation with clinical outcomes has yet to be proven.

The determination of monomers and oligomers from polyester-based can coatings into foodstuffs over extended storage periods.

The polymeric coating used in metal packaging such as cans for foods and beverages may contain residual amounts of monomers used in the production of the coating, as well as unreacted linear and cyclic oligomers. Traditionally, although designed for use with plastic food contact materials, food simulants have been used to determine the migration of monomers from coatings into foodstuffs. More recently, food simulants have also been used to determine oligomeric species migrating from can coatings. In the work reported here, the migration of both monomers and oligomers from polyester-based can coatings into food simulants and foodstuffs, some of which were towards the end of their shelf-life, is compared. The concentrations of monomers and selected oligomers in canned foods at the end of their shelf life were found to be significantly lower than those in food simulants, which in turn was lower than those in the extraction solvent acetonitrile.

A Stab in the Dark: A Case Report of an Atypical Presentation of Giant Cell Arteritis (GCA).

Background: Giant cell arteritis/temporal arteritis (GCA) is an inflammatory condition that affects large to medium vessels such as the aorta and its primary branches. Patients classically present with fatigue, fever, headache, jaw claudication and in severe cases, may suffer either transient (amaurosis fugax) or permanent visual loss. The reference standard for diagnosis is the temporal artery biopsy (TAB) and the mainstay of treatment is with immunosuppression. Our patient JG, presented with a range of non-specific symptoms that mimicked generalised sepsis, but was ultimately diagnosed with GCA through effective, methodical multi-disciplinary team (MDT) work. Clinical case: JG, an 81 year old gentleman, presented acutely with a 3-4 weeks history of fatigue, lethargy, pyrexia and a marked inflammatory response suggestive of a sepsis but without a clear primary source or clinical features of vasculitis. His inflammatory markers were markedly raised although his erythrocyte sedimentation rate (ESR) was not elevated. He was initially treated for sepsis of unknown origin however, body imaging after admission suggested a possible infection around a previous aortic graft site. This was refuted in subsequent 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET/CT) scanning. Microbiological, parasitic, as well as autoimmune assays were unremarkable. He underwent a TAB which was diagnostic for GCA and as a result, was started on oral corticosteroids with immediate symptom relief. He was discharged and followed up on an outpatient basis. Conclusions: This case highlights how a vasculitis can present with a range of non-specific symptoms that may resemble a fever of unknown origin (FUO)/sepsis that can lead to a delay in making the correct diagnosis. It also highlights the importance of considering a diagnosis of vasculitis in patients who present with a FUO where there is no clear focus of infection. Delays in diagnosis and management of these conditions can potentially lead to significant irreversible morbidity.

Google Trends can improve surveillance of Type 2 diabetes.

Recent studies demonstrate that people are increasingly looking online to assess their health, with reasons varying from personal preferences and beliefs to inability to book a timely appointment with their local medical practice. Records of these activities represent a new source of data about the health of populations, but which is currently unaccounted for by disease surveillance models. This could potentially be useful as evidence of individuals' perception of bodily changes and self-diagnosis of early symptoms of an emerging disease. We make use of the Experian geodemographic Mosaic dataset in order to extract Type 2 diabetes candidate risk variables and compare their temporal relationships with the search keywords, used to describe early symptoms of the disease on Google. Our results demonstrate that Google Trends can detect early signs of diabetes by monitoring combinations of keywords, associated with searches for hypertension treatment and poor living conditions; Combined search semantics, related to obesity, how to quit smoking and improve living conditions (deprivation) can be also employed, however, may lead to less accurate results.

Reduced bioavailable manganese causes striatal urea cycle pathology in Huntington's disease mouse model.

Huntington's disease (HD) is caused by a mutation in the huntingtin gene (HTT), resulting in profound striatal neurodegeneration through an unknown mechanism. Perturbations in the urea cycle have been reported in HD models and in HD patient blood and brain. In neurons, arginase is a central urea cycle enzyme, and the metal manganese (Mn) is an essential cofactor. Deficient biological responses to Mn, and reduced Mn accumulation have been observed in HD striatal mouse and cell models. Here we report in vivo and ex vivo evidence of a urea cycle metabolic phenotype in a prodromal HD mouse model. Further, either in vivo or in vitro Mn supplementation reverses the urea-cycle pathology by restoring arginase activity. We show that Arginase 2 (ARG2) is the arginase enzyme present in these mouse brain models, with ARG2 protein levels directly increased by Mn exposure. ARG2 protein is not reduced in the prodromal stage, though enzyme activity is reduced, indicating that altered Mn bioavailability as a cofactor leads to the deficient enzymatic activity. These data support a hypothesis that mutant HTT leads to a selective deficiency of neuronal Mn at an early disease stage, contributing to HD striatal urea-cycle pathophysiology through an effect on arginase activity.

Allosteric activation of M4 muscarinic receptors improve behavioral and physiological alterations in early symptomatic YAC128 mice.

Mutations that lead to Huntington's disease (HD) result in increased transmission at glutamatergic corticostriatal synapses at early presymptomatic stages that have been postulated to set the stage for pathological changes and symptoms that are observed at later ages. Based on this, pharmacological interventions that reverse excessive corticostriatal transmission may provide a novel approach for reducing early physiological changes and motor symptoms observed in HD. We report that activation of the M4 subtype of muscarinic acetylcholine receptor reduces transmission at corticostriatal synapses and that this effect is dramatically enhanced in presymptomatic YAC128 HD and BACHD relative to wild-type mice. Furthermore, chronic administration of a novel highly selective M4 positive allosteric modulator (PAM) beginning at presymptomatic ages improves motor and synaptic deficits in 5-mo-old YAC128 mice. These data raise the exciting possibility that selective M4 PAMs could provide a therapeutic strategy for the treatment of HD.

Use of atmospheric pressure solids analysis probe time-of-flight mass spectrometry to screen for plasticisers in gaskets used in contact with foods.

RATIONALE: Plasticisers are used in the PVC gaskets of metal closures on glass jars and bottles used for foods and beverages. They may migrate and so contaminate the packed foodstuff. The plasticisers are present in a high proportion and are often a complex mixture of substances leading to time-consuming analytical methodologies. This work describes a rapid screening method to identify the plasticisers used. METHODS: Analysis was carried out by direct sampling of the gaskets using atmospheric pressure solids analysis probe (ASAP) with time-of-flight (TOF) mass spectrometry (MS) using a SYNAPT G2 HDMS system. The accurate mass information collected was then compared to a user-prepared database of plasticisers to aid identification. RESULTS: The rapid identification approach was shown to be successful for 24 gasket samples previously analysed by alternative more lengthy gas chromatographic (GC) methods. Quantification by dissolution followed by standard addition was also demonstrated to be reliable. CONCLUSIONS: The ASAP-TOFMS method is a useful technique for rapidly screening gaskets for the presence of plasticisers. It can be used to identify specific gaskets deserving of further quantitative analysis by chromatographic methods, saving time and money by avoiding unnecessary analyses. Copyright © 2015 John Wiley & Sons, Ltd.

Environmental fate of processed natural rubber latex.

In this study, processed natural rubber latex was degraded in outdoor aquatic microcosms, under a number of treatment scenarios for 200 days. The analytical strategy adopted aimed to characterise a range of volatile, semi-volatile and non-volatile substances. Zinc, was shown to migrate from the latex into solution and increase in concentration over time. Dissolved compounds for which predicted formulas were generated largely consisted of oxygen containing compounds, and are potential oxidised polyisoprene oligomers of various chain lengths. A classification of samples based on principal component analysis showed a clear separation of the degraded latex samples from the representative controls. This technique identified an increase in the complexity of the substances produced and showed that these substances undergo further degradation and transformation processes. A number of volatile substances were also identified indicating the atmosphere to be a potential receiving environmental compartment for polymer degradates. Overall, the results show that complex mixtures of substances are produced when polymer-based materials degrade under environmental conditions.

Exposure to phthalic acid, phthalate diesters and phthalate monoesters from foodstuffs: UK total diet study results.

Phthalates are ubiquitous in the environment and thus exposure to these compounds can occur in various forms. Foods are one source of such exposure. There are only a limited number of studies that describe the levels of phthalates (diesters, monoesters and phthalic acid) in foods and assess the exposure from this source. In this study the levels of selected phthalate diesters, phthalate monoesters and phthalic acid in total diet study (TDS) samples are determined and the resulting exposure estimated. The methodology for the determination of phthalic acid and nine phthalate monoesters (mono-isopropyl phthalate, mono-n-butyl phthalate, mono-isobutyl phthalate, mono-benzyl phthalate, mono-cyclohexyl phthalate, mono-n-pentyl phthalate, mono-(2-ethylhexyl) phthalate, mono-n-octyl phthalate and mono-isononyl phthalate) in foods is described. In this method phthalate monoesters and phthalic acid are extracted from the foodstuffs with a mixture of acidified acetonitrile and dichloromethane. The method uses isotope-labelled phthalic acid and phthalate monoester internal standards and is appropriate for quantitative determination in the concentration range of 5-100 µg kg⁻¹. The method was validated in-house and its broad applicability demonstrated by the analysis of high-fat, high-carbohydrate and high-protein foodstuffs as well as combinations of all three major food constituents. The methodology used for 15 major phthalate diesters has been reported elsewhere. Phthalic acid was the most prevalent phthalate, being detected in 17 food groups. The highest concentration measured was di-(2-ethylhexyl) phthalate in fish (789 µg kg⁻¹). Low levels of mono-n-butyl phthalate and mono-(2-ethylhexyl) phthalate were detected in several of the TDS animal-based food groups and the highest concentrations measured corresponded with the most abundant diesters (di-n-butyl phthalate and di-(2-ethylhexyl) phthalate). The UK Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) considered the levels found and concluded that they did not indicate a risk to human health from dietary exposure alone.

Determination of phthalate diesters in foods.

Methodology for the determination of 15 phthalate diesters (dimethyl phthalate, diethyl phthalate, diisopropyl phthalate, diallyl phthalate, diisobutyl phthalate, di-n-butyl phthalate, di-n-pentyl phthalate, di-n-hexyl phthalate, benzyl butyl phthalate, dicyclohexyl phthalate, di-(2-ethylhexyl) phthalate, di-n-octyl phthalate, diisononyl phthalate, diisodecyl phthalate, and di-n-decyl phthalate) is described. The method was validated in-house and its broad applicability demonstrated by the analysis of high-fat, high-carbohydrate and high-protein foodstuffs as well as combinations of all three major food constituents. Following on from the analysis of the 20 UK Total Diet Study samples, 261 foodstuffs were purchased and tested for their phthalate levels. Phthalate diesters were confirmed to be present in 77 samples. Di-(2-ethylhexyl) phthalate was the most frequently detected (66 samples), although the highest levels found were for the isomeric mixture diisononyl phthalate. Additional studies confirmed that, for some foodstuffs, packaging materials did contribute to the phthalate diester concentration in the foodstuff and one example is presented.

Effects of environmental conditions on latex degradation in aquatic systems.

Following use polymer materials may be released to the natural environment distributed to various environmental compartments and may undergo a variety of mechanical and chemical weathering processes. This study characterised the degradation of a latex polymer of different thicknesses under a range of environmental conditions in outdoor microcosms. Samples were immersed in either demineralised water, artificial freshwater and marine water media and exposed for a period of 200-250 days with exposure starting at different times of the year. Effects of pH, agitation and the exclusion of light on degradation were also studied. At the end of the exposure period, recovery of polymer material ≥ 1.6 µm ranged from a low of 22.04% (± 16.35, for the freshwater treatment at pH5.5) to a high of 97.73% (± 0.38, for the exclusion of light treatment). The disappearance of the bulk material corresponded to an increase in nanoparticles and dissolved organic material in the test media. Modelled degradation kinetics were characterised by multi-phasic degradation patterns and the results indicated degradation rate is affected by light intensity and polymer thickness. Mass balance analysis indicates that losses of volatile materials to the air compartment may also be occurring.

Volatile fingerprints of seeds of four species indicate the involvement of alcoholic fermentation, lipid peroxidation, and Maillard reactions in seed deterioration during ageing and desiccation stress.

The volatile compounds released by orthodox (desiccation-tolerant) seeds during ageing can be analysed using gas chromatography-mass spectrometry (GC-MS). Comparison of three legume species (Pisum sativum, Lathyrus pratensis, and Cytisus scoparius) during artificial ageing at 60% relative humidity and 50 °C revealed variation in the seed volatile fingerprint between species, although in all species the overall volatile concentration increased with storage period, and changes could be detected prior to the onset of viability loss. The volatile compounds are proposed to derive from three main sources: alcoholic fermentation, lipid peroxidation, and Maillard reactions. Lipid peroxidation was confirmed in P. sativum seeds through analysis of malondialdehyde and 4-hydroxynonenal. Volatile production by ageing orthodox seeds was compared with that of recalcitrant (desiccation-sensitive) seeds of Quercus robur during desiccation. Many of the volatiles were common to both ageing orthodox seeds and desiccating recalcitrant seeds, with alcoholic fermentation forming the major source of volatiles. Finally, comparison was made between two methods of analysis; the first used a Tenax adsorbent to trap volatiles, whilst the second used solid phase microextraction to extract volatiles from the headspace of vials containing powdered seeds. Solid phase microextraction was found to be more sensitive, detecting a far greater number of compounds. Seed volatile analysis provides a non-invasive means of characterizing the processes involved in seed deterioration, and potentially identifying volatile marker compounds for the diagnosis of seed viability loss.

The distribution of lung cancer across sectors of society in the United Kingdom: a study using national primary care data.

BACKGROUND: There is pressing need to diagnose lung cancer earlier in the United Kingdom (UK) and it is likely that research using computerised general practice records will help this process. Linkage of these records to area-level geo-demographic classifications may also facilitate case ascertainment for public health programmes, however, there have as yet been no extensive studies of data validity for such purposes. METHODS: To first address the need for validation, we assessed the completeness and representativeness of lung cancer data from The Health Improvement Network (THIN) national primary care database by comparing incidence and survival between 2000 and 2009 with the UK National Cancer Registry and the National Lung Cancer Audit Database. Secondly, we explored the potential of a geo-demographic social marketing tool to facilitate disease ascertainment by using Experian's Mosaic Public Sector ™ classification, to identify detailed profiles of the sectors of society where lung cancer incidence was highest. RESULTS: Overall incidence of lung cancer (41.4/100, 000 person-years, 95% confidence interval 40.6-42.1) and median survival (232 days) were similar to other national data; The incidence rate in THIN from 2003-2006 was found to be just over 93% of the national cancer registry rate. Incidence increased considerably with area-level deprivation measured by the Townsend Index and was highest in the North-West of England (65.1/100, 000 person-years). Wider variations in incidence were however identified using Mosaic classifications with the highest incidence in Mosaic Public Sector ™types 'Cared-for pensioners, ' 'Old people in flats' and 'Dignified dependency' (191.7, 174.2 and 117.1 per 100, 000 person-years respectively). CONCLUSIONS: Routine electronic data in THIN are a valid source of lung cancer information. Mosaic ™ identified greater incidence differentials than standard area-level measures and as such could be used as a tool for public health programmes to ascertain future cases more effectively.

Identification of unknown migrants from food contact materials.

Materials that come into contact with foodstuffs can transfer components that may cause odour or taint problems or in the worse case cause the foodstuff to be unsafe to eat. The identities of some of these are easily predicted from the chemistry of known components but others are not. In this respect, it is important to be able to identify and quantify these chemicals. This chapter describes the need for methods of identification of unknown chemicals that may migrate. Mass spectrometric analytical methods are described, including headspace-gas chromatography with mass spectrometry (HS-GC-MS), liquid injection gas chromatography with MS, and liquid chromatography with time-of-flight MS (LC-TOF-MS).

Analysis of reaction products of food contaminants and ingredients: bisphenol A diglycidyl ether (BADGE) in canned foods.

Bisphenol A diglycidyl ether (BADGE) is an epoxide that is used as a starting substance in the manufacture of can coatings for food-contact applications. Following migration from the can coating into food, BADGE levels decay and new reaction products are formed by reaction with food ingredients. The significant decay of BADGE was demonstrated by liquid chromatographic (LC) analysis of foodstuffs, that is, tuna, apple puree, and beer, spiked with BADGE before processing and storage. Life-science inspired analytical approaches were successfully applied to study the reactions of BADGE with food ingredients, for example, amino acids and sugars. An improved mass balance of BADGE was achieved by selective detection of reaction products of BADGE with low molecular weight food components, using a successful combination of stable isotopes of BADGE and analysis by LC coupled to fluorescence detection (FLD) and high-resolution mass spectrometric (MS) detection. Furthermore, proteomics approaches showed that BADGE also reacts with peptides (from protein digests in model systems) and with proteins in foods. The predominant reaction center for amino acids, peptides, and proteins was cysteine.