Early selective enteral feeding in combination with active decompression of duodenum in treatment of moderate and severe acute pancreatitis - A proof-of-concept clinical study.

BACKGROUND: Acute pancreatitis (AP) is a significant clinical challenge with rising global incidence and substantial mortality rates, necessitating effective treatment strategies. Current guidelines recommend pain and fluid management and early enteral feeding to mitigate complications, yet optimal feeding route remains debated. METHODS: We conducted a prospective, randomized, controlled trial at nine centers from October 2020 to May 2023, enrolling 154 patients with moderate to severe AP. Patients were stratified into biliary and non-biliary categories and randomized 1:1 to receive either standard of care (SoC) or SoC plus PandiCath®, a novel catheter enabling selective enteral feeding and duodenal decompression. The primary clinical endpoint (PCE) was a composite of de novo multiple organ dysfunction syndrome (MODS), infectious complications, pancreatic and intestinal fistula formation, bleeding, abdominal compartment syndrome, obstructive jaundice, and AP-related mortality. RESULTS: In the primary modified intention-to-treat analysis, PandiCath® significantly reduced the PCE compared to SoC alone (P = 0.032). The Relative Risk (RR = 0.469, 95 % CI 0.228-0.964) and Number Needed to Treat (NNT = 6.384, 95 % CI 3.349-68.167) indicated its substantial clinical benefit, primarily driven by reduced rates of de novo MODS and infectious complications. These findings were further supported by the evaluation of other populations, including the standard intention-to-treat analysis. CONCLUSION: PandiCath®, facilitating targeted enteral feeding while isolating and decompressing the duodenum, demonstrates promise in improving outcomes for AP patients at risk of severe complications. Further studies are warranted to validate these findings and explore optimal timing and patient selection for this intervention.

[Internet-based self-help for loneliness-a systematic review]. / Internetbasierte Selbsthilfe bei Einsamkeit ­ Eine systematische Übersicht.

BACKGROUND: Recently, the phenomenon of loneliness has received increasing attention. Loneliness is widespread and can have adverse consequences for mental and physical health if prolonged. Internet-based interventions (IBIs) for self-help have proven to be effective for a variety of psychological disorders. Due to several specific aspects, IBIs are also a relevant option for loneliness. This systematic review aims to present the current research on self-help IBIs for reducing loneliness. METHODS: A systematic literature search was conducted in the databases Web of Science, PubMed, Scopus, PsycInfo, MedLine, PsycIndex, Cochrane Library and PsyArXiv between December 2023 and early January 2024. We included original German or English studies that addressed IBIs for self-help to reduce loneliness. RESULTS: In total, eight studies published between 2017 and 2024 were included in the qualitative analysis. All studies were conducted in high-income countries, included predominantly well-educated female adults and were mostly satisfactory regarding their internal validity. DISCUSSION: The results of this review suggest that self-help IBIs may be a promising option for alleviating loneliness. However, the work also points to the need for further research. Future studies should consider larger samples and people of different ages, genders and education levels in order to generalise the results of the present review.

Age, Sex, and Clinical Characteristics of Juvenile Open-Angle Glaucoma Patients in a Saudi Tertiary Hospital: A Retrospective Study of Surgical and Non-Surgical Outcomes.

Background/Objectives: Juvenile Open Angle Glaucoma (JOAG) is a condition that presents peculiar issues because it starts at a very early age and, in the end, causes substantial vision loss. This study aimed to analyze the age and gender distribution and treatment outcomes in JOAG patients. Methods: We carried out a retrospective study at King Abdul Aziz University Hospital, Riyadh, Saudi Arabia, from 2015 to 2022. We extracted data from the medical records. Visual acuity data were converted to the logarithm of the minimum angle resolution (LogMAR) for standardized analysis. The CARL ZEISS Humphrey 745i Field Analyzer/HFA II-i Visual Field Analyzer was used to perform visual field examinations under the 24-2 program SITA standard. Results: The study involved 45 JOAG patients (87 affected eyes) with a mean age of 26.91 years. Myopia was the prevailing trait (93%), and a family history of glaucoma was found in 51.1% of cases. Most of the patients presented with severe visual field defects in both eyes (right-57.1%, left-44.4%). Regarding visual acuity, we found that the majority of affected categories belonged to either mild or moderate in both eyes. Initial and final Intraocular pressure (IOP) measurements together showed a significant reduction (p < 0.001) and clearly demonstrated the need for IOP control. Surgical and non-surgical treatments significantly reduced IOP, with no gender or eye differences Conclusions: This research offers important data concerning JOAG demographics (age and gender), clinical picture, and treatment results. Though early-onset presents challenges, multidimensional therapeutic methods have great potential to get JOAG under control and maintain visual function. Additional research is needed to study the genetic causes of JOAG and assess the long-term treatment outcomes.

Management of Potential Organ Donor: Indian Society of Critical Care Medicine-Position Statement.

This position statement is documented based on the input from all contributing coauthors from the Indian Society of Critical Care Medicine (ISCCM), following a comprehensive literature review and summary of current scientific evidence. Its objective is to provide the standard perspective for the management of potential organ/tissue donors after brain death (BD) in adults only, regardless of the availability of technology. This document should only be used for guidance only and is not a substitute for proper clinical decision making in particular circumstances of any case. Endorsement by the ISCCM does not imply that the statements given in the document are applicable in all or in a particular case; however, they may provide guidance for the users thus facilitating maximum organ availability from brain-dead patients. Thus, the care of potential brain-dead organ donors is "caring for multiple recipients." How to cite this article: Zirpe K, Pandit R, Gurav S, Mani RK, Prabhakar H, Clerk A, et al. Management of Potential Organ Donor: Indian Society of Critical Care Medicine-Position Statement. Indian J Crit Care Med 2024;28(S2):S249-278.

[Conditioning of the immune system-Already clinically usable?] / Konditionierung des Immunsystems ­ Schon klinisch nutzbar?

The brain and the immune system permanently exchange information via various neuronal and humoral signaling pathways. This communication network forms the basis for controlling peripheral immune functions via associative learning or conditioning processes. Establishing a learned immune reaction, an immunomodulatory drug that represents the unconditioned stimulus (US) is paired with a new odor or taste stimulus. Re-presentating this previously neutral odor or taste stimulus, its now functions as a conditioned stimulus (CS) and triggers reactions in the immune system similar to those formerly induced by the drug used as US. Using different learning protocols, it was possible to condition immunopharmacological effects in animal disease models, such as lupus erythematosus, contact allergy or rheumatoid arthritis, thereby reducing disease symptoms. Preliminary experimental studies in healthy volunteers and patients confirmed a possible clinical use of learned immune responses with the aim of using associative learning protocols as complementary measures to pharmacological interventions in clinical practice in order to reduce drug doses and thus undesirable drug side effects while maintaining therapeutic efficacy. However, there is still a great need for further research to understand the mechanisms of learned immune responses in preclinical studies and to optimize the associative learning processes for using them in the clinical routine in studies with healthy volunteers and patients.

Attributes That Affect the Choice of Treatment for Preschool Age Children Who Stutter: An Observational Study.

INTRODUCTION: Little is known about the clinical decision-making process that speech-language pathologists (SLPs) make when they decide which treatment approach they will use with preschool age children who stutter (PCWS). Frequently used approaches are the Lidcombe Program, RESTART-DCM, Mini-KIDS, the Palin Parent-Child Interaction program, and the Social Cognitive Behavior Therapy. In this study, we explored which attributes play a role in the complex process that precedes this clinical decision. We also explored if SLPs from the Netherlands, who are expected to follow the recommendations formulated in the Dutch professional stuttering guidelines, use different treatment approaches than SLPs from Belgium, who do not have specific guidelines to follow. Finally, we explored whether the number of years of experience of SLPs had an impact on the choice for treatment. METHODS: This study used an observational design in which 36 SLPs, additionally qualified in the treatment of stuttering, completed a questionnaire. The SLPs spoke Dutch, resided in the Netherlands or Belgium, and used more than one treatment approach for PCWS in their standard practice. RESULTS: The following attributes affected the choice for treatment approach of most SLPs: (1) the child's reactions to the stuttering, (2) the child's language (and speech) skills, (3) the child's age, (4) the family's lifestyle, (5) the parent's ease to understand a treatment approach as judged by the SLPs, and (6) the amount and quality of published research-based evidence. The decision-making of experienced SLPs is significantly more affected by the child's stuttering severity and time since onset compared to less experienced SLPs (both U = 90, p = 0.05). Dutch SLPs did not take other attributes into account than Belgian SLPs. DISCUSSION/CONCLUSION: This study was a first attempt to explore which attributes affect the decision for a specific treatment. Further prospective research is needed.

[Analysis of traditional Chinese medicine diagnosis and treatment for erectile dysfunction related to COVID-19 infection].

The incidence of erectile dysfunction (ED) has been reported to increase after COVID-19 infection, and it is common in COVID-19 patients during recovery. This paper presents a summary of the latest research progress on COVID-19-induced ED and explores the traditional Chinese medicine (TCM) diagnosis and treatment approach based on TCM theory and clinical experience. COVID-19 infection may lead to ED through endothelial dysfunction, testicular injury, hormonal imbalance, and psychological factors. The pathogenesis of COVID-19-related ED is mainly characterized by deficiency of the body's essence and excess of pathogenic factors. In the early stage, it is dominated by deficiency of qi and yin, while in the middle stage, it is mainly due to deficiency of qi and blood stasis. In the long-term, ED is based on the imbalance of yin and yang, with liver stagnation and qi stagnation often co-existing. Clinical manifestations of ED vary, and treatment should focus on tonifying qi and nourishing yin, promoting blood circulation, regulating yin and yang, and soothing liver depression according to TCM diagnosis and treatment principles.

Reattachment of Fractured Tooth Fragment by Multidisciplinary Treatment Approach.

Dental anterior fractures are common injuries, especially in those who practice extreme sports. This report describes a 25-year-old Bolivian patient who attended our private dental clinic in La Paz, Bolivia after experiencing an accident during downhill mountain biking. An intraoral examination revealed a fracture line on the buccal side in the middle third of the coronal portion of the right central maxillary incisor which extended towards the proximal and lingual sides. Multidisciplinary treatment, including crown lengthening, osteotomy, root canal treatment, fiberglass post insertion, and reattachment of the fracture segment was performed. A follow-up examination at 10 months later revealed that the tooth was completely reestablished both functionally and esthetically and that there was no periapical pathosis or discomfort. This outcome suggests that if a patient seeks a dental consultation soon after a complex crown-root fracture has occurred, and if the broken tooth segment is available, then reattachment offers an economical and simple treatment option which will allow immediate restoration of functionality and esthetic standards. Continued follow-up should form part of such a treatment plan to allow long-term pulp vitality and periodontal health status to be monitored.

ß3-Adrenoceptor, a novel player in the round-trip from neonatal diseases to cancer: Suggestive clues from embryo.

The role of the ß-adrenoceptors (ß-ARs) in hypoxia-driven diseases has gained visibility after the demonstration that propranolol promotes the regression of infantile hemangiomas and ameliorates the signs of retinopathy of prematurity (ROP). Besides the role of ß2-ARs, preclinical studies in ROP have also revealed that ß3-ARs are upregulated by hypoxia and that they are possibly involved in retinal angiogenesis. In a sort of figurative round trip, peculiarities typical of ROP, where hypoxia drives retinal neovascularization, have been then translated to cancer, a disease equally characterized by hypoxia-driven angiogenesis. In this step, investigating the role of ß3-ARs has taken advantage of the assumption that cancer growth uses a set of strategies in common with embryo development. The possibility that hypoxic induction of ß3-ARs may represent one of the mechanisms through which primarily embryo (and then cancer, as an astute imitator) adapts to grow in an otherwise hostile environment, has grown evidence. In both cancer and embryo, ß3-ARs exert similar functions by exploiting a metabolic shift known as the Warburg effect, by acquiring resistance against xenobiotics, and by inducing a local immune tolerance. An additional potential role of ß3-AR as a marker of stemness has been suggested by the finding that its antagonism induces cancer cell differentiation evoking that ß3-ARs may help cancer to grow in a nonhospital environment, a strategy also exploited by embryos. From cancer, the round trip goes back to neonatal diseases for which new possible interpretative keys and potential pharmacological perspectives have been suggested.

Evaluation of a Multidisciplinary Integrated Treatment Approach Versus Standard Model of Care for Functional Gastrointestinal Disorders (FGIDS): A Matched Cohort Study.

BACKGROUND: Functional gastrointestinal disorders (FGID) are linked to a variety of potential causes, and treatments include reassurance, life-style (including diet), psychological, or pharmacologic interventions. AIMS: To assess whether a multidisciplinary integrated treatment approach delivered in a dedicated integrated care clinic (ICC) was superior to the standard model of care in relation to the gastrointestinal symptom burden. METHODS: A matched cohort of 52 consecutive patients with severe manifestation of FGID were matched with 104 control patients based upon diagnosis, gender, age, and symptom severity. Patients in the ICC received structured assessment and 12-weeks integrated treatment sessions provided as required by gastroenterologist and allied health team. Control patients received standard medical care at the same tertiary center with access to allied health services as required but no standardized interprofessional team approach. Primary outcome was reduction in gastrointestinal symptom burden as measured by the Structured Assessment of Gastrointestinal Symptoms Scale (SAGIS). Secondary outcome was reduction in anxiety and depressive symptoms as measured by the Hospital Anxiety and Depression Scale (HADS). RESULTS: Mixed models estimated the within ICC change in SAGIS total as -9.7 (95% CI -13.6, -5.8; p < 0.0001), compared with -1.7 (95% CI -4.0, 0.6; p = 0.15) for controls. The difference between groups reached statistical significance, -7.6 (95% CI -11.4, -3.8; p < 0.0001). Total HADS scores in ICC patients were 3.4 points lower post-intervention and reached statistical significance (p = 0.001). CONCLUSION: This matched cohort study demonstrates superior short-term outcomes of FGID patients in a structured multidisciplinary care setting as compared to standard care.

REVIEW: Practical strategies to maintain anabolism by intravenous nutritional management in children with inborn metabolic diseases.

One of the most vital elements of management for patients with inborn errors of intermediary metabolism is the promotion of anabolism, the state in which the body builds new components, and avoidance of catabolism, the state in which the body breaks down its own stores for energy. Anabolism is maintained through the provision of a sufficient supply of substrates for energy, as well as critical building blocks of essential amino acids, essential fatty acids, and vitamins for synthetic function and growth. Patients with metabolic diseases are at risk for decompensation during prolonged fasting, which often occurs during illnesses in which enteral intake is compromised. During these times, intravenous nutrition must be supplied to fully meet the specific nutritional needs of the patient. We detail our approach to intravenous management for metabolic patients and its underlying rationale. This generally entails a combination of intravenous glucose and lipid as well as early introduction of protein and essential vitamins. We exemplify the utility of our approach in case studies, as well as scenarios and specific disorders which require a more careful administration of nutritional substrates or a modification of macronutrient ratios.

Treatment Paradigms for Older Adults with Pancreatic Cancer: a Nuanced Approach.

OPINION STATEMENT: Pancreatic cancer is increasing in incidence in the USA. This disease disproportionately affects older adults, and as the percentage of adults > 65 years old increases with the aging of the baby boomers, the prevalence is expected to rise over the coming decade. These patients are often more susceptible to disease-related symptoms and have less ability to withstand both cancer and treatment-related side effects. Therefore, it is imperative that treating physicians thoughtfully consider their recommended treatment approach towards this vulnerable patient population. This review focuses on the current state of research of older adults with pancreatic adenocarcinoma, highlighting deficiencies in the representation of this patient population in clinical trials. It is vital that the treating physicians take a nuanced approach towards therapy of localized and metastatic disease in geriatric patients. A one size fits all treatment algorithm is no longer appropriate in any cancer patient, let alone the elders who are particularly vulnerable to developing treatment-related toxicities. To help guide therapy decisions, it is important to perform a comprehensive geriatric assessment which may uncover unexpected frailty and lead to a change in the recommended treatment approach. In this way, we can support older adults during therapy for this aggressive malignancy and provide optimal care.

[Personal preference, experience, intuition and school of surgery dominate the use of wound drainage in dermatosurgery]. / Persönliche Präferenz, Erfahrung, Intuition und operative Schule dominieren die Verwendung postoperativer Wunddrainagen in der Dermatochirurgie.

BACKGROUND: The use of drainage systems in dermatosurgery has so far been carried out without evidence-based data. The indications, complications and contraindications are traditionally passed on from surgeon to surgeon but have so far not been defined. METHOD: An Internet-based survey was created and sent out to members of the German Society for Dermatosurgery (DGDC). The questions were on the general treatment approach in German language countries with reference to the use of wound drainage following dermatological operations as well as the utilization habits and experiences with drainage-associated complications. RESULTS: Of the DGDC members contacted 12.73% completed the questionnaire. Drainages were predominantly used in the clinical environment and all drainage systems in question were used. The extent and complexity of the intervention were essential criteria when evaluating the indications. The use of drainages was dependent on the age of the participant and mostly carried out in patients where complications in the postoperative course were to be expected (e.g. obesity, nicotine use, diabetes). CONCLUSION: In summary, the majority of the participants used wound drainages and mostly intuitively. Uniform and fixed evidence-based parameters for the use of wound drainages are lacking. In the assessment of the necessity for a wound drainage, an individually expressed need of safety seems to play a large role for some dermatosurgeons and an eminence-based action for others.

A clinical study on the effectiveness of biopsychosocial-spiritual treatment approach for diabetic patients.

The purpose of conducting this study was to examine the effectiveness of a biopsychosocial-spiritual model in the management of symptoms of a diabetic patient. A 38-year-old female diagnosed with diabetes complained of bouts of sadness and fatigue, a reduced interaction with others, difficulty in falling asleep, felt irritable and experienced severe pain in the joints. The Siddique Shah Depression scale was used to assess her in a semistructured interview with a subjective rating in which she scored a depression of 293.83 (F06.31) due to diabetes. A total number of 11 sessions were held with her during the implementation phase of the intervention plan. A post assessment was carried out and from the pre and post rating on Siddique Shah Depression Scale, it was evident that her overall symptoms had improvement by 33%. Current study highlights the effec tiveness of a biopsychosocial-spiritual treatment approach for managing symptoms associated with diabetes.

Feasibility, acceptance, safety, and effectiveness of antibiotic therapy as alternative treatment approach to appendectomy in uncomplicated acute appendicitis.

PURPOSE: Based on results from randomized controlled trials, there is an increasing discussion if antibiotic treatment is an equivalent therapeutic approach to appendectomy in uncomplicated acute appendicitis. This observational prospective study evaluates its feasibility, safety, and effectiveness in clinical practice. METHODS: The study included all consecutive adults treated for acute appendicitis over an 18-month period in one hospital. Patients receiving antibiotics were compared to those treated surgically. Follow-up comprised 1 year. The primary endpoint was treatment success, defined as no secondary appendectomy during follow-up (antibiotic group) or successful appendectomy (primary surgical group). Secondary endpoints were complications, duration of hospital stay, pain intensity, and length of absence from work. RESULTS: 54/124 (43.6%) patients were primarily treated with antibiotics and 70/124 (56.4%) surgically. Treatment success at 1 year was 77.1% (95%-CI 62.8-88%) for antibiotic and 100% for surgical treatment. Complications were non-significantly less frequent both among all patients treated with antibiotics and among patients undergoing secondary appendectomy compared to patients undergoing primary appendectomy (20.8% vs. 27.1% and 9.1% vs. 27.1%). The initial hospital stay was significantly shorter in the antibiotic group (mean 3.6 vs. 4.8 days, median 3 days, p = 0.03). After 1 year, the cumulative hospital stay was not different between groups. CONCLUSIONS: Appendectomy remains the most effective treatment for the definitive cure of acute appendicitis. However, antibiotic therapy can be a safe alternative approach for selected patients with uncomplicated acute appendicitis. TRIAL REGISTRATION: DRKS00010401.

The case for a medication first approach to the treatment of opioid use disorder.

Background: The opioid addiction and overdose crisis continues to ravage communities across the U.S. Maintenance pharmacotherapy using buprenorphine or methadone is the most effective intervention for Opioid Use Disorder (OUD), yet few have immediate and sustained access to these medications. Objectives: To address lack of medication access for people with OUD, the Missouri Department of Mental Health began implementing a Medication First (Med First) treatment approach in its publicly-funded system of comprehensive substance use disorder treatment programs. Methods: This Perspective describes the four principles of Med First, which are based on evidence-based guidelines. It draws conceptual comparisons between the Housing First approach to chronic homelessness and the Med First approach to pharmacotherapy for OUD, and compares state certification standards for substance use disorder (SUD) treatment (the traditional approach) to Med First guidelines for OUD treatment. Finally, the Perspective details how Med First principles have been practically implemented. Results: Med First principles emphasize timely access to maintenance pharmacotherapy without requiring psychosocial services or discontinuation for any reason other than harm to the client. Early results regarding medication utilization and treatment retention are promising. Feedback from providers has been largely favorable, though clinical- and system-level obstacles to effective OUD treatment remain. Conclusion: Like the Housing First model, Medication First is designed to decrease human suffering and activate the strengths and capacities of people in need. It draws on decades of research and facilitates partnerships between psychosocial and medical treatment providers to offer effective and life-saving care to persons with OUD.

[Lumbar spinal stenosis : From the diagnosis to the correct treatment]. / Lumbale Spinalkanalstenose : Von der Diagnose bis zur richtigen Therapie.

The number of patients with the diagnosis of lumbar spinal stenosis (LSS) is steadily increasing and simultaneously, the patients' expectations are also increasing. Nevertheless, evidence from studies for the appropriate treatment is still lacking. Treatment options mainly result from the practitioner 's experience and the clinical focus. The findings described in magnetic resonance imaging (MRI) often do not correlate with the patient's symptoms. Basically, the treatment should be started with a conservative treatment and preferably with a multimodal approach. Severe pain with extensive neurogenic claudication symptoms and unsuccessful conservative treatment should be treated surgically. Absolute indications for surgery, such as a conus-cauda syndrome are rare. The goal of all surgical procedures is to decompress the spinal canal without compromising the stability of the motion segment. Instability can also make an additional fusion necessary.

[Resection of a giant sacral schwannoma: case report and literature review]. / Udalenie gigantskoi nevrinomy v oblasti kresttsa: sluchai iz praktiki i obzor literatury.

Neurogenic sacral tumors are extremely rare. In most reported cases, this pathology was associated with neurofibromatosis. Sacral tumors manifest themselves at the stage when the neoplasm volume becomes giant, but these manifestations usually go unnoticed for the patient. Surgical approach to the sacral region is extremely challenging; intimate proximity of tumor capsule to vital organs, vessels, and nerves makes radical surgical treatment of these neoplasms rather difficult. A case report of radical resection of a schwannoma that was destroying the sacrum and continued to grow after radiotherapy is presented in this article.

HPV vaccination as preventive approach for recurrent respiratory papillomatosis - a 22-year retrospective clinical analysis.

BACKGROUND: Recurrent respiratory papillomatosis (RRP) is a rare, benign disease of the aerodigestive tract, especially the larynx, caused by infection with the human papillomavirus (HPV) types 6 or 11. Current management focuses on surgical debulking with microdebrider of papillomatous lesions with or without concurrent adjuvant therapy, e.g. Cidofovir®. This retrospective study evaluates the results of patients treated at a department of the university clinic between 1990 and 2012 and compares the results of the conventional treatment with a new treatment approach using adjuvant vaccination with Gardasil®. METHODS: A retrospective Kaplan Maier analysis of n = 24 patients diagnosed and treated with RPR was performed. The records were reviewed for gender, age at the time of first manifestation of disease and time to recurrence. RESULTS: Only n = 2 (15.4%) of the n = 13 vaccinated patients developed a recurrence of the disease after a mean time of 54.9 months (SD: 9.5 months). All patients who were not vaccinated (n = 11; 100%) developed a relapse after a mean time of 12.3 months (SD: 9.72 months). CONCLUSION: We propose that adjuvant HPV vaccination with Gardasil® might have a preventive effect in RRP by occluding new papilloma formation.

[What rheumatologists can learn from nephrologists]. / Was der Rheumatologe vom Nephrologen lernen kann.

Rheumatology and nephrology have some characteristics in common. In some places this leads to the marginalization of the respective other discipline, instead of an interdisciplinary morbidity-oriented approach. In order to cope with the complexity of systemic autoimmune diseases, a care mandate should be defined and interdisciplinary and cross-sectoral structures, such as interdisciplinary boards or special outpatient clinics should be established.