Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes (ULTIMATE-DAPT): a randomised, placebo-controlled, double-blind clinical trial.

BACKGROUND: Following percutaneous coronary intervention with stent placement to treat acute coronary syndromes, international clinical guidelines generally recommend dual antiplatelet therapy with aspirin plus a P2Y12 receptor inhibitor for 12 months to prevent myocardial infarction and stent thrombosis. However, data on single antiplatelet therapy with a potent P2Y12 inhibitor earlier than 12 months after percutaneous coronary intervention for patients with an acute coronary syndrome are scarce. The aim of this trial was to assess whether the use of ticagrelor alone, compared with ticagrelor plus aspirin, could reduce the incidence of clinically relevant bleeding events without an accompanying increase in major adverse cardiovascular or cerebrovascular events (MACCE). METHODS: In this randomised, placebo-controlled, double-blind clinical trial, patients aged 18 years or older with an acute coronary syndrome who completed the IVUS-ACS study and who had no major ischaemic or bleeding events after 1-month treatment with dual antiplatelet therapy were randomly assigned to receive oral ticagrelor (90 mg twice daily) plus oral aspirin (100 mg once daily) or oral ticagrelor (90 mg twice daily) plus a matching oral placebo, beginning 1 month and ending at 12 months after percutaneous coronary intervention (11 months in total). Recruitment took place at 58 centres in China, Italy, Pakistan, and the UK. Patients were required to remain event-free for 1 month on dual antiplatelet therapy following percutaneous coronary intervention with contemporary drug-eluting stents. Randomisation was done using a web-based system, stratified by acute coronary syndrome type, diabetes, IVUS-ACS randomisation, and site, using dynamic minimisation. The primary superiority endpoint was clinically relevant bleeding (Bleeding Academic Research Consortium [known as BARC] types 2, 3, or 5). The primary non-inferiority endpoint was MACCE (defined as the composite of cardiac death, myocardial infarction, ischaemic stroke, definite stent thrombosis, or clinically driven target vessel revascularisation), with an expected event rate of 6·2% in the ticagrelor plus aspirin group and an absolute non-inferiority margin of 2·5 percentage points between 1 month and 12 months after percutaneous coronary intervention. The two co-primary endpoints were tested sequentially; the primary superiority endpoint had to be met for hypothesis testing of the MACCE outcome to proceed. All principal analyses were assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT03971500, and is completed. FINDINGS: Between Sept 21, 2019, and Oct 27, 2022, 3400 (97·0%) of the 3505 participants in the IVUS-ACS study were randomly assigned (1700 patients to ticagrelor plus aspirin and 1700 patients to ticagrelor plus placebo). 12-month follow-up was completed by 3399 (>99·9%) patients. Between month 1 and month 12 after percutaneous coronary intervention, clinically relevant bleeding occurred in 35 patients (2·1%) in the ticagrelor plus placebo group and in 78 patients (4·6%) in the ticagrelor plus aspirin group (hazard ratio [HR] 0·45 [95% CI 0·30 to 0·66]; p<0·0001). MACCE occurred in 61 patients (3·6%) in the ticagrelor plus placebo group and in 63 patients (3·7%) in the ticagrelor plus aspirin group (absolute difference -0·1% [95% CI -1·4% to 1·2%]; HR 0·98 [95% CI 0·69 to 1·39]; pnon-inferiority<0·0001, psuperiority=0·89). INTERPRETATION: In patients with an acute coronary syndrome who had percutaneous coronary intervention with contemporary drug-eluting stents and remained event-free for 1 month on dual antiplatelet therapy, treatment with ticagrelor alone between month 1 and month 12 after the intervention resulted in a lower rate of clinically relevant bleeding and a similar rate of MACCE compared with ticagrelor plus aspirin. Along with the results from previous studies, these findings show that most patients in this population can benefit from superior clinical outcomes with aspirin discontinuation and maintenance on ticagrelor monotherapy after 1 month of dual antiplatelet therapy. FUNDING: The Chinese Society of Cardiology, the National Natural Scientific Foundation of China, and the Jiangsu Provincial & Nanjing Municipal Clinical Trial Project. TRANSLATION: For the Mandarin translation of the abstract see Supplementary Materials section.

Social Determinants of Health Disparities Increase Five-Year Revision Rates but Not Postoperative Complications Following Primary Hip Arthroscopy.

PURPOSE: To investigate the impact of social determinants of health (SDOH) disparities on 30-day emergency department (ED) visits, 90-day postoperative complications, and five-year secondary surgery rates after primary hip arthroscopy using a large national database. METHODS: A national administrative claims database was used to identify patients who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2022. Patients were queried for whether they experienced any SDOH disparities, including economic, educational, environmental, or social disparities; those experiencing SDOH within 1 year prior to primary hip arthroscopy were matched 1:1 by age, sex, Elixhauser Comorbidity Index score, diabetes, obesity, and tobacco use to patients not experiencing any lifetime SDOH disparities. Odds of 90-day complications and 30-day ED visits were compared using multivariable logistic regression. Rates of five-year revision hip arthroscopy and of any secondary surgery (revision hip arthroscopy or total hip arthroplasty) were compared by Kaplan-Meier analysis. RESULTS: A total of 3,383 primary hip arthroscopy patients who experienced SDOH disparities were matched 1:1 to a control cohort of 3,383 patients who had not experienced SDOH (age, 41.0 years, 79.6% female, for both cohorts). Odds of adverse events following arthroscopy were low and not different between cohorts (SDOH: 1.51%, vs. No SDOH: 1.57%; P=0.09). Additionally, there was no difference in odds of 30-day ED visits (SDOH: 5.65%, vs. No SDOH: 4.79%; P=0.10). The rate of five-year revision hip arthroscopy was significantly greater among patients experiencing SDOH disparities (5.4% vs. 4.1%; P=0.02); however, there was no difference in rates of any secondary surgery between cohorts (11.8% vs. 10.4%; P=0.10). CONCLUSION: Patients experiencing SDOH disparities had similar odds of postoperative complications and ED visits after primary hip arthroscopy but greater rates of five-year revision hip arthroscopy compared to a matched-control cohort of patients not experiencing SDOH disparities. LEVEL OF EVIDENCE: 3; retrospective case-control study.

Intrauterine growth pattern in Butajira HDSS, Southern Ethiopia: BUNMAP pregnancy cohort.

BACKGROUND: Abnormal fetal growth pattern during pregnancy including excessive fetal size and intrauterine growth restrictions are the major determinants for perinatal outcomes and postnatal growth. Ultrasonography is a useful tool in monitoring fetal growth for appropriate care and interventions. However, there are few longitudinal studies using serial ultrasonography in low and middle-income countries. Moreover, the reference charts used for fetal growth monitoring in low-income countries comes from high income countries with distinct population features. Therefore, the purpose of this study was to evaluate the intrauterine growth pattern of the fetus using serial ultrasonography. METHODS: We conducted a prospective community-based cohort study from March 2018 to December 2019. Pregnant women with gestational age of 24 weeks or below living in the Butajira HDSS were enrolled. We followed the pregnant women until delivery. Serial ultrasound measurements were taken, and fetal weight was estimated using the Hadlock algorithm based on biparietal diameter, head circumference, abdominal circumference, and femur length. The z-scores and percentiles of biometric measurements were calculated and compared to the INTERGROWTH-21st International Standards for Fetal Growth. RESULTS: We reviewed a total of 2055 ultrasound scans and 746 women who fulfill the inclusion criteria were involved". We found similar distribution patterns of biometric measurements and estimated fetal weight compared to the previous study done in Ethiopia, the WHO and INTERGROWTH-21st references. In our study, the 5th,50th and 95th percentiles of estimated fetal weight distribution have a similar pattern to the WHO and INTERGROWTH-21st charts. The 50th and 95th percentile had also a similar distribution pattern with the previous study conducted in Ethiopia. We found that 10% of the fetus were small for gestational age (below the 10th percentile) based on the Z-score of estimated fetal weight. CONCLUSION: Our study evaluated the fetal growth patterns in rural community of Ethiopia using serial ultrasound biometric measurements. We found similar IUG patterns to the WHO and INTERGROWTH-21st reference standards as well as the previous study conducted in Ethiopia.

Unhealthy weight control behaviors among Ethiopian female adolescents.

BACKGROUND: Unhealthy weight control behaviors are a serious concern, impairing the quality of life in adolescents. Although recent epidemiological studies indicate a high level of disordered eating in developing countries, such data in Ethiopia are scarce. Thus, this study aimed to determine the extent of unhealthy weight control behaviors (i.e., purging and nonpurging) and corresponding associated factors among urban Ethiopian adolescents. METHOD: A cross-sectional study using self-administered questionnaires was applied to 690 randomly selected female high school adolescents in Addis Ababa, Ethiopia in 2017. Measures included unhealthy weight control behaviors, body mass index, subjective perception of body weight, appearance satisfaction, depressive symptoms, and socio-demographic factors. Logistic regression was applied for data analyses, that is, adjusted odds ratio (aOR) with 95% confidence interval (CI). RESULTS: The level of unhealthy weight control behaviors (i.e., a score of at least once a week in the last 1 month) was 30.7% (N = 208). Specifically, the extent of purging and nonpurging weight control behaviors was 1.5% (N = 10) and 29.8% (N = 202), respectively. Factors that were significantly associated with unhealthy weight control behaviors were perception of being overweight [aOR = 3.01; 95%CI: 1.11-8.11], being overweight [aOR = 3.28; 95%CI: 1.54-7.01], severe depression [aOR = 4.09; 95%CI: 1.73-9.96], and high socio-economic status [aOR = 2.07; 95%CI: 1.30-2.80]. CONCLUSION: This study reveals a considerable level of unhealthy weight control behaviors among female adolescents in an urban setting in Ethiopia. Researchers and policy makers should focus their attention upon this emerging public health challenge and develop associated strategies.

Neutralization of cobra venom by cocktail antiserum against venom proteins of cobra (Naja naja naja).

Naja naja venom was characterized by its immunochemical properties and electrophoretic pattern which revealed eight protein bands (14 kDa, 24 kDa, 29 kDa, 45 kDa, 48 kDa, 65 kDa, 72 kDa and 99 kDa) by SDS-PAGE in reducing condition after staining with Coomassie Brilliant Blue. The results showed that Naja venom presented high lethal activity. Whole venom antiserum or individual venom protein antiserum (14 kDa, 29 kDa, 65 kDa, 72 kDa and 99 kDa) of venom could recognize N. naja venom by Western blotting and ELISA, and N. naja venom presented antibody titer when assayed by ELISA. The neutralization tests showed that the polyvalent antiserum neutralized lethal activities by both in vivo and in vitro studies using mice and Vero cells. The antiserum could neutralize the lethal activities in in-vivo and antivenom administered after injection of cobra venom through intraperitoneal route in mice. The cocktail antiserum also could neutralize the cytotoxic activities in Vero cell line by MTT and Neutral red assays. The results of the present study suggest that cocktail antiserum neutralizes the lethal activities in both in vitro and in vivo models using the antiserum against cobra venom and its individual venom proteins serum produced in rabbits.

FEM simulations for double diffusive transport mechanism hybrid nano fluid flow in corrugated enclosure by installing uniformly heated and concentrated cylinder.

Generation of fluid flow due to simultaneous occurrence of heat and mass diffusions caused by buoyancy differences is termed as double diffusion. Pervasive applications of such diffusion arise in numerous natural and scientific systems. This article investigates double diffusion in naturally convective flow of water-based fluid saturated in corrugated enclosure and containing hybrid nano particles composed of Copper (Cu) and Alumina (Al2O3). Impact of uniformly applied magnetic field is also accounted. To produce thermosolutal convective potential circular cylinder of constant radius is also adjusted by providing uniform temperature and concentration distributions. Finite element approach is capitalized to provide solution of utilized governing equations by utilizing Multiphysics COMSOL software. Wide-range of physical parameters are incorporated to depict their influence on associated distributions (velocity, temperature and concentration). Interesting physical quantities like Nusselt number, Sherwood numbers are also calculated against involved sundry parameters. It is note worthily observed that maximum strength of stream lines [Formula: see text] is 3.3 at [Formula: see text] and drops to 1.2 when [Formula: see text] is increased to 0.04. Furthermore, in the hydrodynamic case (Ha = 0), it is observed that the velocity field exhibits an increasing trend compared to the hydromagnetic case [Formula: see text] which is proved from the attained values of stream-function i.e., [Formula: see text] (in the absence of a magnetic field) and [Formula: see text] (in the presence of a magnetic field). It is revealed from the statistics of Nusselt number that increase in volume fraction of nano particles from 0 to 0.4, heat flux coefficient upsurges up to 7% approximately. Since, present work includes novel physical aspects of thermosolutal diffusion generated due to induction of hybrid nanoparticles in water contained in corrugated enclosure, so this study will provide innovative thought to the researchers to conduct research in this direction.

Puncture Capsulotomy Technique During Hip Arthroscopy.

Background: A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy1,2. Among these, the interportal and T-capsulotomies are the most commonly utilized; however, these approaches transect the iliofemoral ligament, which normally resists anterior subluxation and stabilizes extension3. Thus, these approaches may introduce capsuloligamentous instability1,4-7 and have been associated with complications such as dislocation, postoperative pain, microinstability, seroma, and heterotopic ossification5,8-12. Although prior literature has demonstrated durable mid-term results for patients undergoing capsulotomies with capsular closure6,13, avoidance of iatrogenic injury to the hip capsule altogether is preferable. Thus, the puncture capsulotomy technique we present is minimally invasive, preserves the biomechanics of the hip joint and capsule without disrupting the iliofemoral ligament, and allows for appropriate visualization of the joint through placement of multiple small portals. Description: Following induction of anesthesia and with the patient supine on a hip traction table, the nonoperative leg is positioned at 45° abduction with support of a well-padded perineal post, and the operative hip is placed into valgus against the post14. Intra-articular fluid distention with normal saline solution is utilized to achieve approximately 9 mm of inferior migration of the femoral head and decrease risk of iatrogenic nerve injury15. Then, under fluoroscopic guidance, an anterolateral portal is created 1 cm anterior and 1 cm superior to the greater trochanter at an approximately 15° to 20° angle. Second, via arthroscopic visualization, the anterior portal is created 1 cm distal and 1 cm lateral to the intersection of a vertical line drawn at the anterior superior iliac spine and a horizontal line at the level of the anterolateral portal. Third, equidistant between the anterior and anterolateral portals, the mid-anterior portal is created distally. Finally, at one-third of the distance between the anterior superior iliac spine and the anterolateral portal, the Dienst portal is created. Thus, these 4 portals form a quadrilateral arrangement through which puncture capsulotomy can be performed5. Alternatives: Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure1,2,4,6,7,16. Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability1,4-7,17. Rationale: The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals. The technique does not transect the iliofemoral ligament and thus does not introduce capsuloligamentous instability. Furthermore, although good mid-term outcomes have been reported with capsular closure6,13,18, the present technique avoids creating unnecessary injury to the capsule and complications of an unrepaired capsule or, conversely, of plication. Expected Outcomes: Patients who underwent the puncture capsulotomy technique showed significant improvements in multiple functional outcome scores at a mean follow-up of 30.4 months, including the International Hip Outcome Tool (iHOT-33) (39.6 preoperatively to 76.1 postoperatively), Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL) (70.0 to 89.3), HOS Sport-Specific Subscale (HOS-SSS) (41.8 to 75.7), and modified Harris hip score (mHHS) (60.1 to 84.9). At 2 years postoperatively with respect to iHOT-33, 81.0% of patients achieved the minimal clinically important difference, 62.0% achieved the patient acceptable symptom state, and 58.9% achieved substantial clinical benefit. In addition, mean visual analog scale pain scores improved significantly over the follow-up period (6.3 to 2.2; p < 0.001). Finally, there were zero occurrences of infection, osteonecrosis of the femoral head, dislocation or instability, or femoral neck fracture in patients treated with puncture capsulotomy19,20. Important Tips: Anterolateral portal placement should be performed using the intra-articular fluid distention technique with fluoroscopy to avoid risk of iatrogenic labral damage and distraction-induced neurapraxia. Subsequent portals must then be placed under direct arthroscopic visualization.On establishment of the anterolateral portal, the scope should be switched to the anterior portal to ensure that the anterolateral portal has not been placed through the labrum and to adjust its placement to better access pathology. This portal, as well as all others, may be subsequently modified by adjusting the angle of the cannula, without making a new skin incision.If a cam lesion is located more anteromedially or posterolaterally, an additional accessory portal may be made distal or proximal to the anterolateral portal, respectively, in order to enhance visualization.Intermittent traction is utilized throughout the surgery. No traction is utilized during preparing and draping, suture tensioning and tie-down, and femoroplasty, with minimal traction during acetabuloplasty; these precautions serve to prevent iatrogenic superficial peroneal nerve injury.There can be a steep learning curve for this technique. In particular, greater surgical experience is required to perform adequate femoral osteoplasty for large cam lesions with this approach21.Instrument maneuverability and visualization can be somewhat constrained with this approach.It is more difficult to perform certain procedures with this technique, including segmental and circumferential labral reconstructions, particularly with remote grafts5. Acronyms and Abbreviations: iHOT-33 = International Hip Outcome Tool-33HOS-ADL = Hip Outcome Score-Activities of Daily Living subscaleHOS-SSS = Hip Outcome Score-Sport-Specific SubscaleAP = anteroposteriorMRA = magnetic resonance arthrogramMRI = magnetic resonance imagingCT = computed tomographyASIS = anterior superior iliac spinemHHS = modified Harris hip score.

Chronic thromboembolic pulmonary hypertension and balloon pulmonary angioplasty - Where are we in 2024?

Pulmonary endarterectomy (PEA) is the first-line treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients with CTEPH are considered inoperable, and in the last decade, balloon pulmonary angioplasty (BPA) has emerged as a viable therapeutic option for these patients with prohibitive surgical risk or recurrent pulmonary hypertension following PEA. Numerous international centers have increased their procedural volume of BPA and have reported improvements in pulmonary hemodynamics, patient functional class and right ventricular function. Randomized controlled trials have also demonstrated similar findings. Recent refinements in procedural technique, increased operator experience and advancements in procedural technology have facilitated marked reduction in the risk of complications following BPA. Current guidelines recommend BPA for patients with inoperable CTEPH and persistent pulmonary hypertension following PEA. The pulmonary arterial endothelium plays a vital role in the pathophysiologic development and progression of CTEPH.

Biceps tenotomy vs. tenodesis: an ACS-NSQIP analysis of postoperative outcomes and utilization trends.

Background: While studies have assessed comparative rates of restoration of shoulder function and alleviation of symptoms, comparative systemic postoperative complication rates between biceps tenotomy and tenodesis have yet to be assessed. The purpose of the present study was to use a national administrative database to perform a comprehensive investigation into 30-day complication rates after biceps tenotomy versus tenodesis, thus providing valuable insights for informed decision-making by clinicians and patients regarding the optimal surgical approach for pathologies of the long head of the biceps tendon. Methods: The National Surgical Quality Improvement Program database was queried to analyze postoperative complication rates and metrics associated with biceps tenotomy and tenodesis. Patient data spanning from 2012 to 2021 was extracted, with relevant variables assessed to identify and compare these two surgical approaches. Adjusted and unadjusted analyses were utilized to analyze patient demographics, comorbidities, operative times, lengths of stay, readmissions, adverse events, and yearly surgical volume, along with trends in usage, across cohorts. Results: Of 11,527 total patients, 264 (2.29%), 6826 (59.22%), and 4437 (38.49%) underwent tenotomy, tenodesis with open repair, and tenodesis with arthroscopic repair, respectively. Tenotomy operative times ([mean ± SD]: 66.25 ± 44.76 minutes) were shorter than those for open tenodesis (78.83 ± 41.82) and arthroscopic tenodesis (75.98 ± 40.16). Conversely, tenotomy patients had longer hospital days (0.88 ± 4.86 days) relative to open tenodesis (.08 ± 1.55) and arthroscopic tenodesis (.12 ± 2.70). Multivariable logistic regression controlling for demographics and comorbidities demonstrated that patients undergoing tenodesis were less likely to be readmitted (adjusted odds ratio [AOR]: 0.42, 95% confidence interval [CI]: 0.17-0.98, P = .050) or sustain serious adverse events (AOR: 0.27, 95% CI: 0.13-0.57, P < .001), but equally likely to sustain minor adverse events (AOR: 0.87, CI: 0.21-3.68, P = .850), compared with patients undergoing tenotomy. Lastly, comparing utilization rates from 2012 to 2021 revealed a significant decrease in the proportion of tenotomy (from 6.2% to 1.0%) compared to open tenodesis (from 41.0% to 57.3%) and arthroscopic tenodesis (52.8% to 41.64%; P trend = .001). Conclusion: To our knowledge, this is the first large national database study investigating postoperative complication rates between the various surgical treatments for pathologies of the long head of the biceps tendon. Our results suggest that tenodesis yields fewer serious adverse events and lower readmission rates than tenotomy. We also found a shorter operative time for tenotomy. These findings support the increased utilization of tenodesis relative to tenotomy in recent years.

Association Between Severity of Chondrolabral Junction Breakdown and Functional Outcomes After Hip Arthroscopy for Acetabular Labral Tears.

BACKGROUND: Despite focus on surgical preservation of the chondrolabral junction (CLJ), the transition zone between the acetabular cartilage and labrum, the association between severity of CLJ breakdown and functional outcomes after hip arthroscopy remains unexplored. PURPOSE: To assess the influence of CLJ breakdown on patient-reported outcome measures (PROMs) at a 24-month follow-up after hip arthroscopy for symptomatic labral tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of prospectively collected data was conducted to identify patients ≥18 years of age with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to femoroacetabular impingement. The Beck classification of transition zone cartilage was used to grade CLJ damage; patients with grades 0 to 2 were stratified into the mild CLJ damage cohort, and those with grades 3 and 4 were stratified into the severe CLJ damage cohort. PROMs were collected at baseline and at 3, 6, 12 months, and annually thereafter postoperatively. Linear mixed-effects models were used to compare PROMs. Rates of achieving clinically meaningful thresholds and subsequent surgery rates were also compared. RESULTS: In total, 198 patients met the inclusion criteria, with a mean follow-up of 3.54 ± 1.26 years. A total of 95 patients with severe CLJ damage (mean age, 34.9 ± 10.5 years) were compared with 103 patients with mild CLJ damage (mean age, 38.2 ± 11.9 years). Hip Outcome Score-Activities of Daily Living (HOS-ADL), Non-Arthritic Hip Score (NAHS), and visual analog score for pain were inferior in the severe CLJ group at enrollment and all follow-up time points (P≤ .05). However, patients with severe CLJ breakdown exhibited greater improvements in HOS-ADL and NAHS at the 24-month follow-up and achieved clinically meaningful thresholds at equivalent rates to patients with mild CLJ breakdown. Subsequent surgery rates were 6.8% and 12.6% in patients with mild versus severe CLJ damage, respectively (P = .250). CONCLUSION: Severe CLJ breakdown is associated with increased pain and decreased functional level preoperatively and up to 24 months after hip arthroscopy. Despite this, patients with severe CLJ breakdown experienced greater improvements in functional outcomes at a 24-month follow-up and achieved clinical thresholds at similar rates to patients with mild CLJ damage. Thus, while worse baseline pain and functional levels may indicate severe CLJ breakdown, these patients still benefit substantially from hip arthroscopy.

Biceps tenotomy vs. tenodesis in patients undergoing transtendinous repair of partial thickness rotator cuff tears.

Background: Patients with partial thickness rotator cuff tears (PTRCTs) often present with concurrent pathology of the long head of the biceps tendon (LHBT). To address both conditions simultaneously, long head of the biceps (LHB) tenotomy or tenodesis can be performed at the time of arthroscopic rotator cuff repair (RCR). This study aims to compare postoperative shoulder active range of motion (AROM) and complications following transtendinous RCR with concurrent LHB tenodesis or tenotomy. Methods: A total of 90 patients with PTRCTs met inclusion criteria for this study. Patients who underwent tear-completion-and-repair, revision surgery, or open repair of the LHB tendon were excluded. Patients were stratified into tenotomy, arthroscopic suprapectoral tenodesis, or no biceps operation cohorts and were propensity matched 1:1:1 on age, sex, body mass index, and smoking status. Primary outcome measures included AROM in forward flexion, abduction, external rotation, and internal rotation at 6 weeks, 3 months, and 6 months postoperatively. The development of severe stiffness and rates of rotator cuff retear at final follow-up were recorded as secondary outcomes. Results: When comparing the tenotomy and tenodesis cohorts, tenotomy patients were found to have increased AROM at 3 months in forward flexion (153.2° vs. 130.1°, P = .004), abduction (138.6° vs. 114.2°, P = .019), and external rotation (60.4° vs. 43.8°, P = .014), with differences in forward flexion remaining significant at 6 months (162.4° vs. 149.4°, P = .009). There were no significant differences in interval rates of recovery in any plane between cohorts. Additionally, there were no significant differences in rates of symptomatic retears between groups (P = .458). Rates of severe postoperative stiffness approached but did not achieve statistical significance between tenotomy (4.2%) and tenodesis (29.2%) cohorts (P = .066). Smoking status was a significant predictor of severe stiffness (odds ratio, 13.69; P = .010). Conclusion: Despite significant differences in absolute AROM between cohorts, the decision to perform tenotomy or tenodesis was not found to differentially affect rates of AROM recovery for patients undergoing arthroscopic transtendinous RCR for PTRCT. Notably, however, transient stiffness complications were more commonly observed in smokers, and data trends suggested an increased risk of stiffness for patients undergoing LHB tenodesis. Overall, postoperative stiffness is likely multifactorial and attributable to both patient- and procedure-specific factors, and LHB tenotomy may be more appropriate for patients with risk factors for developing stiffness postoperatively.

COVID-19-Related Spontaneous Aortic Arch Thrombus With Delayed Embolization.

Presentation of a 62-year-old man with baseline chronic obstructive pulmonary disease admitted to the hospital with dyspnea and newly diagnosed COVID-19 infection. CT scan of the chest was obtained to rule out pulmonary embolism. This revealed a mural thrombus of the inner curvature of the aortic arch with a floating component. Therapeutic full dose anticoagulation was initiated in combination with close clinical observation and treatment for modest hypoxia. He did well for 1 month and then returned with ischemic rest pain of the right foot. Angiography revealed thrombosis of all 3 tibial arteries in the right leg. Percutaneous mechanical thrombectomy with tissue plasminogen activator injection and angioplasty was performed with success in 1 tibial artery to achieve in line flow to the foot. After continued anticoagulation, the remainder of the tibial arteries autolysed and the aortic thrombus was noted to be resolved 4 months later. A brief pathophysiology discussion is included.

Fecal incontinence as the sole presentation of focal epilepsy; a case report.

Focal epilepsy is a surge in brain activity arising from a localised area of the cerebral cortex; it can be sub-classified in different categories including motor, sensory, autonomic and cognitive subtypes. A clinical case report of a 11-year-old girl was diagnosed with frequent fecal incontinence four or more times daily for more than two months. An electroencephalogram (EEG) study suggested a prominent interictal spike and sharp wave discharge on the left hemisphere, mainly at the frontotemporal region without loss of consciousness or even speech disruption. This could be due to the normal EEG study of the dominant hemisphere. A magnetic resonance imaging study was done to exclude space-occupying lesions or focal lesions of the left hemisphere of the brain. An impression was made with abnormal EEG showing focal epileptiform activity as a final diagnosis. The patient was treated with Leviteracetam anti-epileptic drug 250 mg twice daily with significant clinical improvement at a 3-month follow-up.

Knowledge, Attitudes, and Practices Regarding Brucellosis Among the General Population in Qassim Region, Saudi Arabia: A Cross-Sectional Study.

Background Brucellosis is an endemic infection in the Middle East. The World Health Organization has identified the illness as one of the most prevalent "neglected zoonotic diseases." Public perceptions regarding brucellosis infection vary across different regions. Thus, this study aimed to assess the knowledge, attitudes, and practices concerning brucellosis among the general population in the Qassim region of Saudi Arabia. Methods A descriptive, cross-sectional study was conducted in the Qassim region of Saudi Arabia between March 2023 and May 2023. We distributed an online questionnaire through social media platforms and received a total of 1,244 responses from different governorates in the Qassim region. Results The level of awareness of brucellosis was moderate. Out of the 1,244 participants, 706 (56.8%) were aware of the disease. Among the participants who were aware of the disease, their knowledge of brucellosis was assessed. The majority of these respondents demonstrated a good level of knowledge (70.5%). Regarding attitudes and practices toward brucellosis, no significant association was found between the participants' level of knowledge and their attitudes. Conclusion Awareness levels about brucellosis in the Qassim region vary depending on age group, area of residency, and other factors. The younger age group and certain governorates in the Qassim region showed low levels of awareness. Moreover, participants with good knowledge about the disease obtained their information from healthcare practitioners. The significant difference in our findings between Qassim's governorates demonstrates the need for more targeted awareness campaigns in areas with lower levels of awareness.

Knowledge and Attitude of the Public Toward Bariatric Weight Loss Surgery and Its Impact on Candidates and Patients in the Al-Qassim Region, Saudi Arabia.

Background Obesity is defined as abnormal or excessive fat accumulation that presents a serious health risk and is a major public health concern. Obesity prevention and management require evidence-based strategies that emphasize diet and physical activity. Bariatric surgery is also a life-changing procedure that can improve physical and mental health, but the stigma associated with it can prevent people from seeking treatment and affect their lives adversely. Studies have shown that bariatric surgery patients face discrimination from the public and healthcare professionals, which can lead to adverse psychological outcomes and hinder access to quality care. Goals and methods This study intends to explore the stigma related to bariatric surgery in Al-Qassim Region, Saudi Arabia, because it is crucial to understand its prevalence among the public and the influence it has on both those who have undergone the surgery and those who are considering it as an option. The participants had to complete an online questionnaire, comprised a general section and other sections based on whether or not the individual has, has not, or is considering bariatric surgery. Results A total of 988 individuals, 605 of whom were female (61.2%), agreed to participate in the study. The most common body mass index (BMI) category was 18.5-24.9 (43.5%, n=414). The majority of the participants had either agreed or strongly agreed that obesity is a disease (87.8%, n=867) and that genetic factors play a role in causing it (38.8%, n=383). The factors selected most commonly that increase the risk of obesity were "idle and lazy life" (76.5%, n=756) and "eating too much" (75.6%, n=747). Fewer than half of the participants (44.43%, n=439) reported that they had never thought about treating obesity through surgical operations, 9.62% (n=95) had considered it, and 3.74% (n=37) had actually undergone the surgery. Among those who underwent weight loss surgery (n=37), 43.20% (n=16) reported that they received critical comments or poor treatment from the community, 35.10% (n=13) felt ashamed or embarrassed to disclose their surgery, and 37.80% (n=14) avoided social situations or events because of those comments or poor treatment. The comments reported most often were "You have taken the easy way out instead of adopting a healthy lifestyle" (51.40%, n=19) and "Why didn't you try to go on a diet?" (51.40%, n=19). Among those who have intentions to undergo weight loss surgery (n=95), a significant proportion of the participants (43%, n=40) agreed or strongly agreed that concerns about public opinion or community treatment could affect their decision to undergo weight loss surgery. Moreover, 32.6% (n=31) of them agreed or strongly agreed that society has a negative attitude toward individuals who have undergone obesity treatment. When asked whether they had ever avoided telling people that they were considering surgery because of potential adverse reactions, 42.10% (n=40) of the participants responded that they had. Conclusion This study helped bring attention to, and prove, the stigma related to bariatric surgery in Al-Qassim Region. Such stigma has prevented patients from seeking or undergoing a surgical option to manage their weight, even if it is the option recommended for them. As such, public education and awareness campaigns are encouraged to help reduce the stigma, as well as improve access to bariatric surgery for those who need it.

In silico modeling for the nonlinear absorption kinetics of UK-343,664: a P-gp and CYP3A4 substrate.

The aim of this work was to extrapolate in vitro and preclinical animal data to simulate the pharmacokinetic parameters of UK-343,664, a P-glycoprotein (P-gp) and CYP3A4 substrate, in human. In addition, we aimed to develop a simulation model to demonstrate the involvement and the controversial complex interaction of intestinal P-gp and CYP3A4 in its nonlinear absorption, first-pass extraction, and pharmacokinetics using the advanced compartmental absorption and transit (ACAT) model. Finally, we aimed to compare the results predicted from the model to the reported findings in human clinical studies. In situ perfusion, allometric scaling, PBPK Rodger mechanistic approach, in vitro metabolism, and fitting to in vivo data were used to mechanistically explain the absorption, distribution and metabolism, respectively. GastroPlus was used to build the integrated simulation model in human for UK-343,664 to mechanistically explain the observed clinical data at 30, 100, 200, 400, and 800 mg oral doses. The measured in vitro value for CYP3A4 K(m) (465 µM) in rCYPs was converted to units of µg/mL, corrected for assumed microsomal binding (17.8%) and applied to all metabolic processes. The measured in vitro values of V(max) for CYP3A4 (38.9 pmol/min/pmol), 2C8, 2C9, 2C19, and 2D6 were used along with the in vitro CYP3A4 K(m) to simulate liver first pass extraction and systemic clearance. The measured in vitro values of V(max) for CYP3A4 and 2D6 were used along with the in vitro CYP3A4 K(m) to simulate gut first pass extraction. V(max) and K(m) values for P-gp were obtained by fitting to in vivo data and used to simulate gut efflux transport activity. Investigation of the interaction mechanism of P-gp and CYP3A4 in the intestine was achieved by comparing the influence of a virtual knockout of P-gp or gut metabolism on the fraction absorbed, fraction reaching the portal vein, and fraction metabolized in the gut. Comparison between simulation and in vivo results showed that the in silico simulation provided a mechanistic explanation of the observed nonlinear absorption kinetics of UK-343,664 in human following its administration in the range of 30-800 mg as oral solutions. The simulation results of the pharmacokinetic parameters, AUC and C(max), by GastroPlus were comparable with those observed in vivo. This simulation model is one possible mechanistic explanation of the observed in vivo data and suggests that the nonlinear dose dependence could be attributed to saturation of both the efflux transport by P-gp and the intestinal metabolism. However, the concentration ranges for either protein saturation did not overlap and resulted in much greater than dose proportional increases in AUC. At low doses, producing intraenterocyte concentrations below the fitted value of K(m) for P-gp, the influence of P-gp appears to be protective and results in a lower fraction of gut 3A4 metabolism. At higher doses, as P-gp becomes saturated the fraction of gut 3A4 extraction increases, and eventually at the highest doses, where 3A4 becomes saturated, the fraction of gut 3A4 extraction again decreases. Such a complex interpretation of this in vitro-in vivo extrapolation (IVIVE) is another example of the value and insight obtained by physiologically based absorption simulation.

Comparison of the intestinal absorption and bioavailability of γ-tocotrienol and α-tocopherol: in vitro, in situ and in vivo studies.

The aim of this work was to compare the intestinal absorption kinetics and the bioavailability of γ-tocotrienol (γ-T3) and α-tocopherol (α-Tph) administered separately as oil solutions to rats in vivo. Also, to explain the significant difference in the oral bioavailability of the compounds: (1) the release profiles using the dynamic in vitro lipolysis model, (2) the intestinal permeability and (3) carrier-mediated uptake by Niemann-Pick C1-like 1 (NPC1L1) transporter were examined. Absolute bioavailability studies were conducted after oral administration of γ-T3 or α-Tph prepared in corn oil to rats. In situ rat intestinal perfusion with ezetimibe (a NPC1L1 inhibitor) was performed to compare intestinal permeability. The in vitro interaction kinetics with NPC1L1 was examined in NPC1L1 transfected cells. While the in vitro release studies demonstrated a significantly higher release rate of γ-T3 in the aqueous phase, the oral bioavailability of α-Tph (36%) was significantly higher than γ-T3 (9%). Consequent in situ studies revealed significantly higher intestinal permeability for α-Tph compared with γ-T3 in rats. Moreover, the NPC1L1 kinetic studies demonstrated higher Vmax and Km values for α-Tph compared with γ-T3. Collectively, these results indicate that intestinal permeability is the main contributing factor for the higher bioavailability of α-Tph. Also, these results emphasize the potentially important role of intestinal permeability in the bioavailability of γ-T3, suggesting that enhancing its permeability would increase its oral bioavailability.

Is it important to classify ischaemic stroke?

Thirty-five percent of all ischemic events remain classified as cryptogenic. This study was conducted to ascertain the accuracy of diagnosis of ischaemic stroke based on information given in the medical notes. It was tested by applying the clinical information to the (TOAST) criteria. Hundred and five patients presented with acute stroke between Jan-Jun 2007. Data was collected on 90 patients. Male to female ratio was 39:51 with age range of 47-93 years. Sixty (67%) patients had total/partial anterior circulation stroke; 5 (5.6%) had a lacunar stroke and in 25 (28%) the mechanism of stroke could not be identified. Four (4.4%) patients with small vessel disease were anticoagulated; 5 (5.6%) with atrial fibrillation received antiplatelet therapy and 2 (2.2%) patients with atrial fibrillation underwent CEA. This study revealed deficiencies in the clinical assessment of patients and treatment was not tailored to the mechanism of stroke in some patients.

Significance of induced hybridized metallic and non-metallic nanoparticles in single-phase nano liquid flow between permeable disks by analyzing shape factor.

The current communication is designed by keeping in the mind high heat transfer capabilities of nanoliquids with the dispersion of diversified-natured nanoparticles in poorly conducting base liquids. Here, an amalgamation of metallic (Cu) and hybridization of metallic and non-metallic oxide (Cu-TiO2) nanoparticles to uplift thermophysical attributes of water is deliberated. The magnetically affected flow between rotating disks under the impact and permeability aspect is assumed. Empirical relations for effective dynamic viscosity, density, and heat capacitance to show mesmerizing features of obliged nanoparticles are also expressed. In addition, mathematical relations also depend on morphological factors like shape, size, and diameter of inducted nanoparticles. The mathematical formulation of the problem is conceded in the form of a system of ODEs after using similarity transformation on dimensional PDEs. Simulations of the complex coupled differential structure are solved by using a numerical approach by employing shooting and Runge-Kutta procedures jointly. The impact of flow concerning variables on associated distributions is revealed through tabular and graphical manner. Quantities of engineering interest associated with work like wall friction and thermal flux coefficients at walls of the disk are also calculated. It is deduced from an examination that the addition of metallic particles raises heat transfer more than non-metallic particles. A significant impression of magnetic field on shear stress is executed by hybrid nanoparticles along the surface of disks. In addition, elevation in Nusselt number and depreciation in skin friction coefficient is revealed against increasing magnitude of nanoparticle volume fraction. A positive trend in skin friction coefficient is manifested against the increasing magnitude of Reynold number. It is also observed that by increasing the size and shape of hybrid nanoparticles thermal conductivity and viscosity of the base fluid increases.