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Medicina, Volume 60, Issue 9 (September 2024) – 182 articles

Cover Story (view full-size image): The paper reviews the potential of nanomedicines, showing the innovative role of these cutting-edge medications in revolutionizing brain health. By enhancing drug delivery to the brain, nanomedicine offers new hope for neuroprotection, helping to shield the brain from degeneration. Additionally, it aids in nerve regeneration and plays a key role in regulating the blood–brain barrier—an essential factor in treating complex neurological conditions. View this paper
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8 pages, 703 KiB  
Article
The Role of Monocyte Distribution Width in the Early Prediction of Sepsis in Patients Undergoing Cardiovascular Surgery: A Cross-Sectional Study
by Abdullah Özer, Sercan Tak, Hüseyin Demirtaş, Alperen Kutay Yıldırım, Elif Şimşek, Gürsel Levent Oktar and Zühre Kaya
Medicina 2024, 60(9), 1558; https://doi.org/10.3390/medicina60091558 - 23 Sep 2024
Viewed by 725
Abstract
Background and Objectives: This is the first study to examine the role of monocyte distribution width (MDW) in predicting sepsis after cardiovascular surgery. Methods: This study included 43 consecutive patients who had undergone cardiovascular surgery between July 2021 and July 2022. All patients [...] Read more.
Background and Objectives: This is the first study to examine the role of monocyte distribution width (MDW) in predicting sepsis after cardiovascular surgery. Methods: This study included 43 consecutive patients who had undergone cardiovascular surgery between July 2021 and July 2022. All patients were examined at the following three time points (TPs): preoperative period (TP1), postoperative at 24 h (TP2), and discharge (TP3). SOFA score, leukocyte count, neutrophil-to-lymphocyte ratio (NLR), MDW, C-reactive protein (CRP), and procalcitonin (PCT) levels were tested at each TPs. The Sepsis-3 criteria were used to diagnose patients with sepsis. Results: The mean values of all variables (leukocyte count, NLR, MDW, CRP, and PCT levels) were significantly higher at TP2 and TP3 than at TP1 (p < 0.05). All these values were significantly higher at TP2 than at TP3 (p < 0.05). Patients with sepsis had significantly higher mean values for leukocyte count, NLR, MDW, CRP, and PCT levels than those without sepsis (p < 0.05). There was a significant correlation between MDW and inflammatory markers (CRP, PCT, and NLR) during the three time periods (p < 0.05). According to the ROC analysis, the optimal MDW cutoff value with the highest sensitivity and specificity for predicting sepsis in the postoperative period was 20.5. Conclusions: Our findings indicate that elevated MDW levels may be a valuable predictor of sepsis in patients following cardiovascular surgery. Full article
(This article belongs to the Section Surgery)
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<p>Receiver operating characteristic curve analysis of monocyte distribution width for predicting sepsis after cardiovascular surgery.</p>
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10 pages, 548 KiB  
Article
Diagnostic Accuracy of Five Molecular Assays for the Detection of Dengue Virus
by Marianna Scarpaleggia, Giada Garzillo, Miriana Lucente, Chiara Fraccalvieri, Nadia Randazzo, Elvira Massaro, Barbara Galano, Valentina Ricucci, Bianca Bruzzone and Alexander Domnich
Medicina 2024, 60(9), 1557; https://doi.org/10.3390/medicina60091557 - 23 Sep 2024
Viewed by 1007
Abstract
Background and Objectives: The steady spread of dengue virus (DENV) poses a profound public health threat worldwide. Reverse transcription real-time polymerase chain reaction (RT2-PCR) has been increasingly recognized as a reference method for the diagnosis of acute dengue infection. The goal of [...] Read more.
Background and Objectives: The steady spread of dengue virus (DENV) poses a profound public health threat worldwide. Reverse transcription real-time polymerase chain reaction (RT2-PCR) has been increasingly recognized as a reference method for the diagnosis of acute dengue infection. The goal of this study was to assess the diagnostic accuracy of five different RT2-PCR kits for the detection of DENV in a historically processed set of sera samples. Materials and Methods: In this retrospective study, 25 sera samples from routinely processed unique adult patients with a known DENV status (previously tested in both molecular and serological assays) were tested in parallel using four conventional (RealStar Dengue PCR Kit 3.0, Clonit’ngo Zika, Dengue & Chikungunya, BioPerfectus Zika Virus/Dengue Virus/Chikungunya Virus Real Time PCR Kit and Novaplex Tropical fever virus) and one sample-to-result (STANDARD M10 Arbovirus Panel) RT2-PCR assays. Additionally, an end-point dilution analysis was conducted in quintuplicate on six serial dilutions of an RNA preparation obtained from a culture-grown DENV serotype 1 strain for a total of 150 tests. Results: The overall accuracy of the evaluated tests ranged from 84% to 100%. In particular, the sensitivity of three conventional RT2-PCR assays (RealStar, Clonit’ngo and Novaplex) was 100% (95% CI: 79.6–100%), while it was lower (73.3%; 95% CI: 48.1–89.1%) for the BioPerfectus kit. The sample-to-result STANDARD M10 panel performed comparatively well, showing a sensitivity of 92.9% (95% CI: 68.5–98.7%). No false positive results were registered in any assay. The end-point dilution analysis suggested that the RealStar kit had the lowest limit of detection. Conclusions: Available RT2-PCR kits for the detection of DENV are highly specific and generally sensitive and, therefore, their implementation in diagnostic pathways is advisable. Full article
(This article belongs to the Section Infectious Disease)
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<p>Distributions of cycle threshold (Ct) values, by assay. * <span class="html-italic">p</span> &lt; 0.05; *** <span class="html-italic">p</span> &lt; 0.001. All <span class="html-italic">p</span>-values are adjusted for multiple comparisons.</p>
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11 pages, 2116 KiB  
Article
Therapeutic Potential of Vitamin B Complex in Peripheral Nerve Injury Recovery: An Experimental Rat Model Study
by Ahmet Kahraman, Metin Temel, Numan Atilgan, Ahmet Saray and Recep Dokuyucu
Medicina 2024, 60(9), 1556; https://doi.org/10.3390/medicina60091556 - 23 Sep 2024
Viewed by 1673
Abstract
Objectives: Vitamin B complexes are frequently used in clinical practice for peripheral nerve trauma. However, there is a lack of scientific data on their effectiveness. This study aims to investigate the impact of the vitamin B complex on nerve recovery in a [...] Read more.
Objectives: Vitamin B complexes are frequently used in clinical practice for peripheral nerve trauma. However, there is a lack of scientific data on their effectiveness. This study aims to investigate the impact of the vitamin B complex on nerve recovery in a rat model of peripheral nerve paralysis. Materials and Methods: Sixty male Wistar Albino rats were divided into six groups. Models of nerve injury, including blunt trauma, nerve incision, and autograft, were performed on all rats approximately 1 cm distal to the sciatic notch. B-complex vitamins were injected intraperitoneally at 0.2 mL/day to the treatment groups. The control groups were given 0.2 mL/day saline. After 1 month, the study was terminated, electromyography (EMG) was performed to measure the conduction velocity, and nerve tissue was taken from the repair line. The sciatic function indexes (SFIs) were calculated and analyzed. The histopathological samples were stained with hematoxylin and eosin and Toluidine blue and examined with a light microscope. Pathologically, myelination, fibrosis, edema, and mast cell densities in the nervous tissue were evaluated. Results: The vitamin B treatment groups demonstrated significant improvements in SFI compared to the control groups, indicating functional improvement in nerve damage (p < 0.05). In the nerve graft group, the vitamin B group showed a shorter latency, higher velocity, and larger peak-to-peak compared to the controls (p < 0.05). In the nerve transection group, the vitamin B group had better latency, velocity, and peak-to-peak values than the controls (p < 0.05). In the crush injury group, the vitamin B group exhibited an improved latency, velocity, and peak-to-peak compared to the controls (p < 0.05). Better myelination, less fibrosis, edema, and mast cells were also in the vitamin B group (p < 0.05). Conclusions: Vitamin B treatment significantly improves nerve healing and function in peripheral nerve injuries. It enhances nerve conduction, reduces fibrosis, and promotes myelination, indicating its therapeutic potential in nerve regeneration. Full article
(This article belongs to the Special Issue Current Therapies for Trauma and Surgical Critical Care)
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<p>Surgical procedures according to groups.</p>
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<p>Comparison of sciatic function index (SFI) between groups.</p>
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<p>(<b>A</b>) In transverse sections stained with Giemsa and Mason, the connective tissue sheaths of the nerve appeared in their normal structure. (<b>B</b>) Minimal edema was evaluated between the axons as vacuolization in the endoneurium layer. Sections stained with phosphotungstic acid-hematoxylin (PTAH) displayed irregularities and variations in the thicknesses of the myelin sheaths, along with non-myelinated axons wrapped in Schwann cell sheaths among the myelinated axons. (<b>C</b>) In other transverse sections stained with Giemsa and Mason, dense fibrosis and small axons were observed around the nerve’s peripheral region, whereas medium-sized axons were detected in the central region without fibrosis. (<b>D</b>) Sections stained with PTAH showed that thin to medium-thick myelin sheaths were predominant, with occasional irregularities and fluctuations. Minimal fibrosis was found in the endoneural tissue between the axons, and unmyelinated axons were also present. (<b>E</b>) Additional sections stained with Giemsa and Mason revealed varying sizes of axon sections accompanied by minimal edema. (<b>F</b>) In sections stained with PTAH, medium-sized myelinated axons with regular myelin sheaths were primarily observed. Some myelinated axons exhibited vacuoles between the axolemma and myelin sheaths, and there were also partially [<a href="#B12-medicina-60-01556" class="html-bibr">12</a>] myelin-free axon sections.</p>
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5 pages, 292 KiB  
Case Report
Granulomatosis with Polyangiitis Discovered Because of Repeated Upper Eyelid Swelling
by Suguru Nakagawa, Kiyohito Totsuka, Shinichiro Kagami and Yohei Nomoto
Medicina 2024, 60(9), 1555; https://doi.org/10.3390/medicina60091555 - 23 Sep 2024
Viewed by 669
Abstract
Background and objectives: The initial symptom that triggers granulomatosis with polyangiitis (GPA) diagnosis is rarely ocular. We describe a case with a single ocular lesion identified as probable GPA due to proteinase 3 (PR3)-antineutrophil cytoplasmic antibody (ANCA)-positivity according to the diagnostic criteria [...] Read more.
Background and objectives: The initial symptom that triggers granulomatosis with polyangiitis (GPA) diagnosis is rarely ocular. We describe a case with a single ocular lesion identified as probable GPA due to proteinase 3 (PR3)-antineutrophil cytoplasmic antibody (ANCA)-positivity according to the diagnostic criteria of the Ministry of Health in Japan; the lesion repeatedly worsened. Materials and methods: A 25-year-old female visited the Department of Ophthalmology, Asahi General Hospital, with upper eyelid swelling and conjunctival and episcleral hyperemia of the left eye. Both hordeolum and eyelid cellulitis were suspected, as the condition was resistant to treatment with antibiotic eye drops. Episcleritis was suspected due to localized hyperemia in the upper part of the eye. Upon treatment with antibacterial agents and steroid eye drops, the swelling and the hyperemia repeatedly worsened every week. Results: Blood samples were positive for PR3-ANCA, and GPA with an isolated ocular lesion was considered. After oral steroid treatment, the patient had no recurrence for 4 years. There was no systemic involvement in the upper respiratory tract, lungs, or kidneys. Conclusions: Diagnosing GPA with ocular symptoms as initial manifestations is challenging. GPA should be considered in treatment-resistant eyelid, orbital, and episcleral lesions, even at a young age. Full article
(This article belongs to the Section Ophthalmology)
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<p>(<b>A</b>). Eyelid findings at the initial examination. Upper eyelid swelling is observed. (<b>B</b>). Eyelid findings 3 days after the initial examination. Upper eyelid swelling improved with antibacterial and steroid eye drops. (<b>C</b>). Eyelid findings 1 month after the initial examination. Upper eyelid swelling worsened again. (<b>D</b>). Eyelid photograph 4 months after systematic steroid treatment. The eyelid swelling resolved. (<b>E</b>). Anterior segment of the eye at the initial examination. Episcleritis is observed in the upper eye. (<b>F</b>). Anterior segment of the eye 3 days after the initial examination. Hyperemia in the upper eye improved with antibacterial and steroid eye drops. (<b>G</b>). Anterior segment of the eye 1 month after the initial examination. Episcleritis exacerbated again. (<b>H</b>). Anterior segment of the eye 4 months after steroid treatment. No hyperemia was observed, and episcleritis resolved. (<b>I</b>). Orbital magnetic resonance image (short TI inversion recovery) at the initial examination. Edematous signal changes are observed in the left eyelid and orbicular muscle. Periorbital cellulitis was suspected.</p>
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10 pages, 15569 KiB  
Case Report
Recurrent Spinal Canal Stenosis after Decompression and Fusion Surgery Due to Bone Overgrowth: Case Report
by Yong-Chan Cho, Dae-Woong Kim, Soon-Do Wang, Chang-Hyun Kim and Chang-Hwa Hong
Medicina 2024, 60(9), 1554; https://doi.org/10.3390/medicina60091554 - 23 Sep 2024
Viewed by 693
Abstract
Bone regrowth commonly occurs following lumbar decompression surgery. Although it is rare for neurological symptoms to occur due to bone regrowth, this study describes two patients who underwent both decompression and fusion surgeries but experienced spinal canal restenosisthat was severe enough to induce [...] Read more.
Bone regrowth commonly occurs following lumbar decompression surgery. Although it is rare for neurological symptoms to occur due to bone regrowth, this study describes two patients who underwent both decompression and fusion surgeries but experienced spinal canal restenosisthat was severe enough to induce neurological symptoms. A 32-year-old man underwent posterior decompression and posterior lumbar interbody fusion for lumbar canal stenosis at the L4/L5 level 5 years prior. However, the sudden onset of lower back pain occurred 5 years later. Bone overgrowth on the left side was observed at the L4/L5 level. A second surgery was performed, and the patient’s symptoms improved significantly. In the second case, a 56-year-old man underwent posterior decompression and posterior lumbar fusion at the L3/L4 and L4/L5 levels for an L4 burst fracture. One month later, he complained of lower back pain and underwent a second posterior decompression surgery. One year later, he presented to an outpatient clinic with lower back pain and neurological symptoms. Bone overgrowth was observed on both sides at the L4/L5 level. Thus, screw removal and laminectomy at the L3, L4, and L5 levels were performed as a third surgery. This study discusses the factors affecting bone regrowth and the methods that can be used to prevent it. Full article
(This article belongs to the Section Orthopedics)
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<p>L-spine lateral radiography before surgery shows spondylolisthesis at the L4/L5 level.</p>
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<p>CT image after the aggressive decompression and fusion surgery at L4/L5.</p>
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<p>Images 5 years after the surgery. (<b>a</b>–<b>d</b>) CT image shows restenosis of facet joint on left side at L4/L5 level. (<b>e</b>–<b>i</b>) L-spine MR image shows restenosis of left side at L4–5 level.</p>
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<p>Radiographicimage after the aggressive decompression and fusion surgery at L4/L5.</p>
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<p>(<b>a</b>,<b>b</b>) Radiographic image before the first surgery showing burst fracture at L4. (<b>c</b>–<b>f</b>) CT image before the first surgery showing central canal stenosis at the L4/L5 level.</p>
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<p>Radiographic image after the first surgery showing L3/L4/L5 fusion state.</p>
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<p>CT image 1 month after first surgery showing post-traumatic stenosis on the right side at the L4/L5 level.</p>
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<p>Posterior decompression (facetectomy) surgery was performed.</p>
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<p>CT imaging showed central stenosis and bilateral neural foraminal stenosis at L4/L5 due to bone overgrowth.</p>
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<p>Radiographic images after the third surgery showing a well-decompressed state.</p>
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7 pages, 2099 KiB  
Case Report
Synchronous Seminoma of Testis and Renal Cell Carcinoma: A Rare Case Report
by Stasys Auskalnis, Rasa Janciauskiene, Urte Rimsaite, Aurelija Alksnyte and Rasa Ugenskiene
Medicina 2024, 60(9), 1553; https://doi.org/10.3390/medicina60091553 - 23 Sep 2024
Viewed by 814
Abstract
Background and Objectives: Seminoma is the most common solid malignant tumour in young men. Clear-cell kidney carcinoma is the most common malignancy of the genitourinary tract. However, the synchronous occurrence of both of these tumours is rare. Case presentation: We present the [...] Read more.
Background and Objectives: Seminoma is the most common solid malignant tumour in young men. Clear-cell kidney carcinoma is the most common malignancy of the genitourinary tract. However, the synchronous occurrence of both of these tumours is rare. Case presentation: We present the case of a 36-year-old patient who presented to a medical facility at the end of 2019 with an enlarged right testicle. A unilateral orchofuniculectomy was performed, and a mass measuring 30 cm was removed. During histological examination, testicular seminoma pT2, R0, was diagnosed. An abdominal computed tomography (CT) scan showed a 6.4 cm × 6.8 cm × 6.7 cm tumour in the right kidney and a metastatic-like lesion in the right adrenal gland. A right nephrectomy and an adrenalectomy and paraaortic and paracaval lymphadenectomies were performed. A histological evaluation confirmed the presence of clear-cell renal carcinoma pT2aR0 G2, adrenal hyperplasia, and seminoma metastases in the removed lymph node. Chemotherapy with a Bleomycin, Etoposide, and Cisplatin (BEP) regimen was carried out. Three years after the last cycle of chemotherapy, a follow-up CT scan showed metastases in the left kidney, the right ischium, and the right lung. A well-differentiated clear-cell carcinoma G1 of the left kidney and metastasis of clear-cell carcinoma G2 in the right ischium were confirmed after the biopsy, and no tumour lesions were found in the lung tissue specimen. Treatment with targeted therapy with Sunitinib was started because the risk was favourable according to the Heng criteria. Genetic testing was performed, and the following genes were analysed: VHL, BAP1, CHEK2, FH, MET, MUTYH, APC, and STK11. The testing did not reveal any pathogenic or potentially pathogenic mutations or sequence changes of unknown clinical significance in the genes analysed. Conclusions: According to the authors, the occurrence of synchronous primary tumours is linked to one’s genetic predisposition. DNA sequencing of tumour tissue could provide more information on the corresponding aetiopathogenesis. Full article
(This article belongs to the Section Oncology)
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<p>CT image. Pathological paraaortic and paracaval lymph nodes.</p>
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<p>CT image. Tumour mass in the inferior part of the right kidney.</p>
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<p>CT image. Post-right-nephrectomy view. Cyst in the left kidney is shown.</p>
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<p>CT image. Metastatic lesions in the left kidney.</p>
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<p>CT image. Osteoclastic-type metastatic tumour in the pelvic bones.</p>
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<p>CT image. Pathological lymph node with central necrosis in the hilum of the right lung.</p>
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14 pages, 5390 KiB  
Article
Evaluation of the Efficacy of Ozone Therapy on Liver Tissue in the Treatment of Sepsis in Rats with Cecal Perforation
by Selin Erel, Ayşegül Küçükk, Kürşat Dikmen, Esin Tekin, Zeynep Yığman, Müşerref Şeyma Ceyhan, Seda Gökgöz, Hasan Bostancı, Mustafa Arslan and Mustafa Kavutcu
Medicina 2024, 60(9), 1552; https://doi.org/10.3390/medicina60091552 - 22 Sep 2024
Viewed by 894
Abstract
Background and Objectives: Sepsis and its related complications are associated with high morbidity and mortality, often leading to liver damage. Ozone, a molecule with anti-inflammatory and antioxidant properties, may offer protective effects. This study aimed to evaluate the therapeutic and protective impact of [...] Read more.
Background and Objectives: Sepsis and its related complications are associated with high morbidity and mortality, often leading to liver damage. Ozone, a molecule with anti-inflammatory and antioxidant properties, may offer protective effects. This study aimed to evaluate the therapeutic and protective impact of ozone on liver injury in a rat model of sepsis induced by cecal ligation and perforation (CLP). Material and Methods: A total of 36 rats were randomly divided into five groups: control (Group C), ozone (Group O), cecal ligation and perforation (Group CLP), ozone + cecal ligation and perforation (Group O+CLP), and cecal ligation and perforation + ozone (Group CLP+O). In the ozone groups, 4 mL of ozone (20 µ/mL) was injected intraperitoneally. Biochemical and histopathological parameters were evaluated in liver tissue samples obtained at the end of 24 h. Results: Polymorphonuclear leukocyte and monocyte infiltration and the total injury score were significantly reduced in the ozone-treated groups compared to the CLP group (p < 0.001). Tumor necrosis factor and interleukin 10 levels in the rat liver tissue were significantly reduced in the O+CLP and CLP+O groups compared to the CLP group, with the O+CLP group showing a more substantial decrease than the CLP+O group (p < 0.001). Thiobarbituric acid reactive substances and glutathione s-transferase levels were significantly lower in the ozone-treated groups compared to the CLP group (p < 0.001). Catalase activity was significantly elevated in the O+CLP group compared to the CLP group (p < 0.001). Serum aspartate transaminase, alanine transaminase, gamma-glutamyl transferase, and total bilirubin were significantly increased in the CLP group and decreased in the ozone-treated groups (p < 0.001, p < 0.001, p = 0.01, p < 0.001 respectively). Conclusions: Administering ozone to rats one hour before the CLP significantly mitigated liver damage, showing a more pronounced effect compared to administering ozone one hour after CLP. The results indicate that ozone could serve a protective function in managing sepsis-induced liver damage. Full article
(This article belongs to the Section Gastroenterology & Hepatology)
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<p>Micrographs representing the H&amp;E-stained sections of specimens from the control (<b>A</b>,<b>B</b>), ozone (<b>C</b>,<b>D</b>), and CLP (<b>E</b>–<b>H</b>) groups. Black arrow, necrosis; black arrowhead, varying levels of vacuolization in hepatocytes; wavy black arrow, congestion; curved black arrow, interstitial edema. Magnifications are 200× for micrographs (<b>A</b>,<b>C</b>,<b>E</b>,<b>G</b>) and 400× for (<b>B</b>,<b>D</b>,<b>F</b>,<b>H</b>). Stain: H&amp;E.</p>
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<p>Micrographs representing the H&amp;E-stained sections of specimens from the CLP (<b>A</b>–<b>D</b>), O+CLP (<b>E</b>,<b>F</b>), and CLP+O (<b>G</b>,<b>H</b>) groups. Black arrow, necrosis; white arrowhead, polymorphonuclear leukocyte and monocyte infiltration; curved black arrow, interstitial edema. Magnifications are 200× for micrographs (<b>A</b>,<b>C</b>,<b>E</b>,<b>G</b>) and 400× for micrographs (<b>B</b>,<b>D</b>,<b>F</b>,<b>H</b>). Stain: H&amp;E.</p>
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<p>Micrographs (<b>A</b>,<b>C</b>,<b>E</b>,<b>G</b>,<b>I</b>) represent the IL10 immunostaining intensity of specimens from the control (<b>A</b>), ozone (<b>C</b>), and CLP (<b>E</b>), O+CLP (<b>G</b>), and CLP+O (<b>I</b>) groups. Micrographs (<b>B</b>,<b>D</b>,<b>F</b>,<b>H</b>,<b>J</b>) represent the TNF-α immunostaining intensity of specimens from the control (<b>B</b>), ozone (<b>D</b>), and CLP (<b>F</b>), O+CLP (<b>H</b>), and CLP+O (<b>J</b>) groups. Magnification is 200× for all micrographs.</p>
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15 pages, 2701 KiB  
Review
When the Going Gets Tough: A Review of Total Hip Arthroplasty in Patients with Ipsilateral Above- and Below-Knee Amputation
by Alberto Di Martino, Enrico Capozzi, Matteo Brunello, Claudio D′Agostino, Laura Ramponi, Alessandro Panciera, Federico Ruta and Cesare Faldini
Medicina 2024, 60(9), 1551; https://doi.org/10.3390/medicina60091551 - 22 Sep 2024
Viewed by 1477
Abstract
Life expectancy and overall function of amputated patients have improved significantly over the last few decades; for this reason, amputees are more exposed to primary or secondary degenerative disease of the hip, requiring total hip arthroplasty (THA) surgery. However, during training, not all [...] Read more.
Life expectancy and overall function of amputated patients have improved significantly over the last few decades; for this reason, amputees are more exposed to primary or secondary degenerative disease of the hip, requiring total hip arthroplasty (THA) surgery. However, during training, not all the surgeons acquire adequate skills to manage these patients, and only a few studies and case reports describe technical pearls and outcomes of THA in patients with ipsilateral lower limb amputation, either above or below the knee. The objective of this narrative review is to present current evidence and surgical tips for performing THA in ipsilateral amputated patients, with a focus on the differences between patients with above- (AKA) and below-knee amputation (BKA). We reviewed manuscripts in major scientific databases, cross-referencing to retrieve adjunctive manuscripts, and summarized all relevant cases. We found 17 manuscripts, spanning 70 years of literature, collecting a total of 39 patients who underwent THA on an ipsilateral amputated limb: 13 AKA, 23 BKA, and 3 through-knee-amputation (TKA). The cohort primarily consists of patients with post-traumatic hip arthritis, often associated with sequelae such as fractures to other bones, soft tissue compromise and heterotopic calcifications. Managing with amputated patients requires careful planning, which includes the study of the residual bone, muscle anatomy, and the level of femoral amputation, as these factors present significant surgical challenges, especially in patients without a knee joint. In dealing with the post-traumatic and multi-comorbidity patients, rehabilitation goals should be considered prior to surgery and should drive the surgical strategy. We found that BKA patients typically have high functional demands, necessitating precise positioning of the components and an aggressive post-operative physiotherapy regimen to avoid unsatisfactory outcomes. AKA patients, on the other hand, often present with altered anatomy, and typically require more surgical instruments and expertise to achieve intraoperative dislocation of the hip joint. Full article
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<p>(<b>A</b>) In case of total hip arthroplasty in above-knee-amputated patients, the absence of the knee joint may compromise the ability of the surgeon to dislocate the hip. The insertion of two Steinman pins or Shanz screws (<b>A</b>) at the distal part of the femur allow to control the intraoperative position of the femur (<b>A</b>). Pins (orange arrows) are usually inserted perpendicular to the femur in line with the incision, avoiding the distal part of the stump. (<b>B</b>) These pins are used as a lever to intraoperatively control the hip joint, allowing complex movements like femoral head (blue arrows) dislocation through 90° internal rotation of the femur (<b>C</b>).</p>
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<p>A case of total hip arthroplasty(THA) in a post-traumatic above-knee-amputated (AKA) patient with pelvic non-union after the fracture was managed by fixation with plate and screws; severe secondary hip arthritis developed, together with massive periarticular heterotopic ossification (orange arrows). (<b>A</b>,<b>B</b>). Ossification removal and total hip arthroplasty were performed via a posterolateral approach, using two Steinman pins to intraoperatively dislocate the femoral head (<b>C</b>). Revision of the stump was required to improve soft tissue coverage, approximately 2 months after THA, and it healed uneventfully (<b>D</b>,<b>E</b>). At 6 months follow-up, patient had fully regained hip range of motion and recovered the iliopsoas muscle (<b>F</b>,<b>G</b>), and ambulated with an external prothesis and a cane (<b>H</b>).</p>
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<p>Patient with hypoplasia of the right limb (<b>A</b>) who underwent a total hip arthroplasty (THA) on the ipsilateral side, after a below-knee amputation with knee arthrodesis. Patient used a prosthesis early after surgery through a cast to condition the limb to its use, allowing the patient to wear and ambulate with an external prothesis as an above-knee-amputated patient (<b>B</b>). At 12 months follow-up after THA, the patient walks with an external prothesis and no aids (<b>C</b>).</p>
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21 pages, 2145 KiB  
Review
The Effectiveness of Interventions Targeting Adolescents in HPV Vaccination—A Scoping Review
by Camelia Florina Iova, Lucia Georgeta Daina, Mădălina Diana Daina and Timea Claudia Ghitea
Medicina 2024, 60(9), 1550; https://doi.org/10.3390/medicina60091550 - 22 Sep 2024
Viewed by 893
Abstract
Adolescents are the target group for HPV vaccination. Studies that examine factors influencing acceptability among adolescents and interventions aimed at improving knowledge, attitudes, perceptions, intentions, and, most importantly, vaccination rates are less common than those addressing parents or healthcare professionals. The specialized literature [...] Read more.
Adolescents are the target group for HPV vaccination. Studies that examine factors influencing acceptability among adolescents and interventions aimed at improving knowledge, attitudes, perceptions, intentions, and, most importantly, vaccination rates are less common than those addressing parents or healthcare professionals. The specialized literature was searched for studies evaluating the impact of various interventions on adolescents. In the final analysis, 41 studies were included (35 original studies and 6 reviews). Educational interventions increased adolescents’ knowledge scores in the selected studies. Peer education proved highly effective in rapidly and significantly improving knowledge about HPV. Additionally, multicomponent interventions generated awareness and knowledge that persisted for months after the interventions. HPV vaccine uptake increased following educational interventions in 11 out of the 14 studies that evaluated this outcome; studies presenting multicomponent interventions also proved effective in improving vaccination rates. Higher HPV vaccine series completion was reported following a reminder system strategy. Interventions directed at adolescents, combined with strategies involving parents and healthcare professionals, can play an important role in improving HPV vaccination rates. Educated adolescents must be involved in decisions about their own health and can be a valuable source of information for their peers and parents. Full article
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<p>Flow chart of article selection process [<a href="#B11-medicina-60-01550" class="html-bibr">11</a>].</p>
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<p>Knowledge improvement post-intervention across different age groups.</p>
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<p>Vaccine intention across age group.</p>
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<p>The vaccine uptake and completion rates post-intervention across different age groups.</p>
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10 pages, 963 KiB  
Article
Functional Mobility and Balance Confidence Measures Are Associated with Disability among Community-Dwelling Older Adults
by Norah A. Alhwoaimel, Mohammed M. Alshehri, Ahmed S. Alhowimel, Aqeel M. Alenazi and Bader A. Alqahtani
Medicina 2024, 60(9), 1549; https://doi.org/10.3390/medicina60091549 - 22 Sep 2024
Viewed by 701
Abstract
Background and Objectives: Our objectives were to examine the association between balance confidence, functional mobility measures, and the presence of disability in older adults in Saudi Arabia and to identify the optimal cutoff scores for these measures that predict disability. Materials and Methods: [...] Read more.
Background and Objectives: Our objectives were to examine the association between balance confidence, functional mobility measures, and the presence of disability in older adults in Saudi Arabia and to identify the optimal cutoff scores for these measures that predict disability. Materials and Methods: A cross-sectional study was conducted among 324 community-dwelling older adults (65 ± 7 years, 59% women). Disability was assessed using the Arabic version of the basic activities of daily living (ADLs) scale. Balance confidence was evaluated using the Arabic version of the Activities -Specific Balance Confidence (ABC) scale, and functional mobility was assessed using the 30-Second Chair Stand Test (30s-CST). Results: The prevalence of disability was 33.6% among the participants. Logistic regression revealed a 6% increase in disability odds for each one-unit decrease in the 30s-CST (OR: 0.94) and a 3% increase per one-point decrease in the ABC score (OR: 0.97). The optimal cutoff scores were ≤5 repetitions for the 30s-CST (sensitivity: 74.4%; specificity: 51.4%; AUC: 0.64) and ≤40 for the ABC scale (sensitivity: 80.8%; specificity: 61.4%; AUC: 0.75). Conclusions: Impaired balance and functional mobility are significantly associated with disability among older adults. The 30s-CST and the ABC scale can be used as effective screening tools, but the cross-sectional design of the current study limits its generalizability. Longitudinal research is needed to validate these findings. Full article
(This article belongs to the Section Epidemiology & Public Health)
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<p>ROC curve for optimal cutoff score for 30s-CST associated with disability. The red line is the no discrimination line (AUC =0.5), and the blue line represents test with very high sensitivity (74.44%) but low specificity (51.4%).</p>
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<p>ROC curve for optimal cutoff scores for ABC associated with disability. The red line is the no discrimination line (AUC = 0.5), and the blue line represents test with very high sensitivity (80.8%) but low specificity (61.4%).</p>
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12 pages, 311 KiB  
Article
Application of Closed Incision Negative Pressure Wound Therapy in Ventral Hernia Repair Surgery Using a Polypropylene Mesh: A Randomized Clinical Trial
by Petr Jelinek, Jan Hrubovcak, Radovan Hajovsky, Jan Velicka and Martin Pies
Medicina 2024, 60(9), 1548; https://doi.org/10.3390/medicina60091548 - 22 Sep 2024
Viewed by 718
Abstract
Background and Objectives: Surgical site infections (SSIs) are a significant complication following ventral hernia repair, potentially leading to prolonged hospital stays and increased morbidity. This study aimed to evaluate whether closed incision negative pressure wound therapy (ciNPWT) reduces the incidence of SSI [...] Read more.
Background and Objectives: Surgical site infections (SSIs) are a significant complication following ventral hernia repair, potentially leading to prolonged hospital stays and increased morbidity. This study aimed to evaluate whether closed incision negative pressure wound therapy (ciNPWT) reduces the incidence of SSI after ventral hernia repair with polypropylene mesh compared to standard wound care. Materials and Methods: A randomized study was conducted with 100 patients undergoing ventral hernia repair using a polypropylene mesh. Participants were divided into two groups: a control group (n=50), which received standard sterile gauze dressing with an iodine-based disinfectant, and an intervention group (n=50), treated with the ciNPWT system (Vivano® by HARTMANN) for 5 days postoperatively. The primary outcome was the incidence of SSI within one year after surgery. Secondary outcomes included the influence of factors such as age, sex, smoking status, and hernia size on SSI occurrence. The study was approved by the Ethics Committee at the University Hospital Ostrava, adhering to the ethical standards of the Helsinki Declaration. Results: The incidence of SSI was lower in the ciNPWT group compared to the standard care group (4% vs. 12%), though this difference did not reach statistical significance. No significant effect of sex or smoking status on SSI was observed. The control group had a shorter mean length of hospital stay. Larger hernias in the non-ciNPWT group were more prone to SSIs, as expected. Conclusions: Although limited by a small sample size, the findings suggest that ciNPWT may be associated with a reduced rate of SSI following ventral hernia repair. Further studies with larger populations are needed to confirm these results. Full article
(This article belongs to the Section Surgery)
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<p>Boxplot of age by sex. On each blue box, the central red mark indicates the median, and the bottom and top edges of the box indicate the 25th and 75th percentiles, respectively. The whiskers extend to the most extreme data points not considered outliers, and the outliers are plotted individually using the + marker red symbol.</p>
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<p>Histogram of BMI.</p>
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<p>Bar graph of SSI vs. Sex.</p>
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<p>Boxplot of SSI vs. Sex.</p>
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<p>Bar graph of SSI vs. Smoking.</p>
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<p>Bar graph of SSI vs. Sterile gauze/ciNPWT.</p>
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<p>Boxplot of Hospital stay vs. Sterile gauze/ciNPWT.</p>
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<p>Boxplot of Hospital stay vs. Sterile gauze/ciNPWT vs. SSI.</p>
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<p>Boxplot of Hospital stay vs. Sterile gauze/ciNPWT vs. SSI vs. Sex.</p>
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<p>Boxplot of hernia size vs. Sterile gauze/ciNPWT vs. SSI.</p>
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<p>Boxplot of age vs. Sterile gauze/ciNPWT vs. SSI vs. Sex.</p>
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<p>Bar graph of sex vs. Sterile gauze/ciNPWT vs. SSI vs. Number of patients.</p>
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<p>Boxplot of Smoking vs. Hospital stay.</p>
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<p>Boxplot of Smoking vs. Hernia size.</p>
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15 pages, 559 KiB  
Article
Orienteering Is More than Just Running! Acute Effect of Competitive Pressure on Autonomic Cardiac Activity among Elite Orienteering Athletes
by Recep Gorgulu, Hilal Oruç, Cristian Vasile, Ionuț Corlaci and Florin Voinea
Medicina 2024, 60(9), 1547; https://doi.org/10.3390/medicina60091547 - 21 Sep 2024
Viewed by 722
Abstract
Background and Objectives: Orienteering is a sport characterized by high physical exertion and intense mental demands, which increase susceptibility to errors. Understanding the impact of such errors on psychophysiological responses, particularly on heart rate variability (HRV), is essential. This study aimed to [...] Read more.
Background and Objectives: Orienteering is a sport characterized by high physical exertion and intense mental demands, which increase susceptibility to errors. Understanding the impact of such errors on psychophysiological responses, particularly on heart rate variability (HRV), is essential. This study aimed to investigate the relationship between psychophysiological indicators and checkpoint errors made by elite orienteers during official competition. Materials and Methods: Fifty-three orienteers participated in this study, and their performance was continuously monitored and recorded by using a global positioning system (GPS) and HRV data. Errors made during the orienteering events were identified and analyzed. HRV data were examined in three temporal segments: before, during, and after the identified and standardized errors. Results: The analyses indicated that errors significantly impacted HRV indices across multiple domains: the time domain, frequency domain, and nonlinear domain. Additionally, a significant effect of sex on the normalized the root mean square of successive differences (r-MSSD) before and after the error was observed. Conclusions: The findings of this study underscore the significant impact of errors made by orienteers on cardiovascular responses, as evidenced by measurable alterations in HRV metrics. Cardiovascular activity, represented by the HRV, can provide useful information for coaches and sport psychologists to adopt effective training programs for athletes. Full article
(This article belongs to the Section Sports Medicine and Sports Traumatology)
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<p>Demonstration of procedure of the study.</p>
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11 pages, 864 KiB  
Article
Comparing Implant Macrodesigns and Their Impact on Stability: A Year-Long Clinical Study
by Julie Popovski, Mirko Mikic, Dimitar Tasevski, Sasa Dabic and Rasa Mladenovic
Medicina 2024, 60(9), 1546; https://doi.org/10.3390/medicina60091546 - 21 Sep 2024
Viewed by 661
Abstract
Background and Objectives: The aim of this study was to clinically evaluate the primary and secondary stability of dental implants with different macrodesigns using resonance frequency analysis and to determine whether implant design and length influence implant stability. Materials and methods: [...] Read more.
Background and Objectives: The aim of this study was to clinically evaluate the primary and secondary stability of dental implants with different macrodesigns using resonance frequency analysis and to determine whether implant design and length influence implant stability. Materials and methods: This study included 48 healthy patients receiving dental implants, and a pre-implant planning protocol was used, which involved detailed bone analysis, clinical examinations, and Cone beam computed tomography (CBCT) analysis. The implants were of various types and dimensions (Alpha-Bio Tec (Israel), DFI, SPI, and NEO), and the surgical procedures were performed using standard methods. Implant stability was measured using resonance frequency analysis (RFA) immediately after placement and after 3, 6, and 12 months. The total number of implants placed in all patients was 96. Results: The average primary stability value for 10 mm SPI implants placed in the maxilla was 68.2 ± 1.7 Implant Stability Quotient (ISQ) units, while for 10 mm NEO implants, it was 74.0 ± 0.9. The average primary stability value for a 10 mm DFI implant placed in the mandible was 72.8 ± 1.2 ISQ, while for a 10 mm NEO implant placed in the mandible, it was 76.3 ± 0.8 ISQ. Based on the Friedman ANOVA test, the differences in the stability measurements for the 10 mm and 11.5 mm SPI implants and for the 10 mm and 11.5 mm NEO implants in the maxilla on day 0 and after 3, 6, and 12 months were significant at p < 0.05. Similarly, based on the Friedman ANOVA test, the differences in the stability measurements for the 10 mm and 11.5 mm DFI implants and for the 10 mm and 11.5 mm NEO implants in the mandible on day 0 and after 3, 6, and 12 months were significant at p < 0.05 (p = 0.00000). Conclusions: Universal tapered implants of the NEO type stood out as the optimal choice, as they provided statistically significantly higher primary stability in both soft and hard bone types compared to other implants. The implant length did not significantly affect this stability. Full article
(This article belongs to the Special Issue Recent Advances in Dental Implants and Oral Health)
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<p>(<b>A</b>) DFI, (<b>B</b>) NEO, and (<b>C</b>) SPI implants.</p>
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<p>Stability measurement.</p>
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17 pages, 3612 KiB  
Article
Immune mRNA Expression and Fecal Microbiome Composition Change Induced by Djulis (Chenopodium formosanum Koidz.) Supplementation in Aged Mice: A Pilot Study
by Brian Harvey Avanceña Villanueva, Huai-Ying Huang, Yu-Chang Tyan, Pei-Ju Lin, Chang-Wei Li, Hoang Minh, Lemmuel L. Tayo and Kuo-Pin Chuang
Medicina 2024, 60(9), 1545; https://doi.org/10.3390/medicina60091545 - 20 Sep 2024
Viewed by 1079
Abstract
Background and Objectives: The aging process has always been associated with a higher susceptibility to chronic inflammatory lung diseases. Several studies have demonstrated the gut microbiome’s influence on the lungs through cross-talk or the gut–lungs axis maintaining nutrient-rich microenvironments. Taiwan djulis ( [...] Read more.
Background and Objectives: The aging process has always been associated with a higher susceptibility to chronic inflammatory lung diseases. Several studies have demonstrated the gut microbiome’s influence on the lungs through cross-talk or the gut–lungs axis maintaining nutrient-rich microenvironments. Taiwan djulis (Chenopodium formosanum Koidz.) provides antioxidant and anti-inflammatory characteristics that could modulate the gut microbiome. This could induce the gut–lung axis through microbial cross-talk, thus favoring the modulation of lung inflammation. Materials and Methods: Here, we investigate the immune mRNA expression in the spleen, fecal microbiome composition, and hyperplasia of the bronchial epithelium in aged 2-year-old BALB/c mice after 60 days of supplementation of djulis. Results: The pro-inflammatory cytokines IFN-γ, TNF-α, and IL-1β, T; cells CD4 and CD8; and TLRs TLR3, TLR4, TLR5, TLR7, TLR8, and TLR9 were reduced in their mRNA expression levels, while the anti-inflammatory cytokines IL-2, IL-4, and IL-10 were highly expressed in the C. formosanum-treated group. Interestingly, the fecal microbiome composition analysis indicated higher diversity in the C. formosanum-treated group and the presence of butyrate-producing bacteria that are beneficial in the gut microbiome. The histopathology showed reduced hyperplasia of the bronchial epithelium based on the degree of lesions. Conclusions: Our findings suggest that Taiwan djulis can modulate the gut microbiome, leading to microbial cross-talk; reducing the mRNA expression of pro-inflammatory cytokines, T cells, and TLRs; and increasing anti-inflammatory cytokines in the spleen, as cytokines migrate in the lungs, preventing lung inflammation damage in aged mice or the gut–lung axis. Thus, Taiwan djulis could be considered a beneficial dietary component for the older adult population. The major limitation includes a lack of protein validation of cytokines and TLRs and quantification of the T cell population in the spleen as a marker of the gut–lung axis. Full article
(This article belongs to the Section Hematology and Immunology)
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<p>The aged mice’s body weight in the control group and <span class="html-italic">C. formosanum</span>-treated group were measured every 7 days. No significant change in body weight was observed with or without the <span class="html-italic">C. formosanum</span> treatment.</p>
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<p>Cytokine fold change (2<sup>−(ΔΔCt)</sup>) levels in the aged mice. The <span class="html-italic">C. formosanum</span>-treated group had lower levels compared to the control group. The mRNA was extracted from the spleen of the aged mice after 60 days of treatment. Quantifications of the expression of each cytokine, IFN-γ, TNF-α, IL-1β, IL-2, IL-4, and IL-10, were performed using real-time RT-PCR, with β-actin as an internal control. Significant difference (<span class="html-italic">p</span> value &lt; 0.0001) is notated as ****.</p>
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<p>T cell fold change (2<sup>−(ΔΔCt)</sup>) levels in aged mice. The <span class="html-italic">C. formosanum</span>-treated group had lower levels compared to the control group. The mRNA was extracted from the spleen of the aged mice after 60 days of treatment. Quantifications of the expression of each T cell, CD4 and CD8, were performed using real-time RT-PCR, with β-actin as an internal control. Significant difference (<span class="html-italic">p</span> value &lt; 0.0001) is notated as ****.</p>
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<p>Toll-like receptor fold change (2<sup>−(ΔΔCt)</sup>) levels in the aged mice. The <span class="html-italic">C. formosanum</span>-treated group had lower levels compared to the control group. The mRNA was extracted from the spleen of the aged mice after 60 days of treatment. Quantifications of the expression of each Toll-like receptor, TLR3, TLR4, TLR5, TLR7, TLR8, and TLR9, were performed using real-time RT-PCR, with β-actin as an internal control. A significant difference (<span class="html-italic">p</span> value &lt; 0.0001) is noted as ****, a <span class="html-italic">p</span> value of 0.0001 is noted as ***, and a <span class="html-italic">p</span> value of 0.0057 is noted as **.</p>
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<p>Histopathological image of aged mice lungs at ×400 magnification. (<b>A</b>) Lung section from non-treated aged mice showing hyperplasia of the bronchial epithelium (indicated with arrows, which are infiltrated inflammatory immune cells). (<b>B</b>) Lung section from <span class="html-italic">C. formosanum</span>-treated animals showing a standard histological architecture with no hyperplasia of the bronchial epithelium. The lung samples were stained with hematoxylin-eosin (H&amp;E) stain and were observed under a light microscope.</p>
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<p>Boxplots of the (<b>A</b>) weighted and (<b>B</b>) unweighted UniFrac distances between the control (indicated by blue color box) and <span class="html-italic">C. formosanum</span>-treated aged (indicated by orange color box) mouse groups. A distance of 0 indicates that the samples are identical, and higher values (up to a maximum of 1) indicate the extent of differences between the compared models. Boxes show the 25th and 75th percentiles, with the median represented by a horizontal line. A significant difference is notated as * (<span class="html-italic">p</span> value &lt; 0.05) and ** (<span class="html-italic">p</span> value &lt; 0.001).</p>
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<p>Characterization of microbiomes in the control and <span class="html-italic">C. formosanum</span>-treated aged mouse groups using LEfSe analysis. A histogram of the LDA scores (log10) computed for features with differential abundance. Positive (green) LDA scores implied an increased abundance of taxonomic features in the <span class="html-italic">C. formosanum</span>-treated aged mouse group, while negative (red) LDA scores signified the microbial biomarkers that were enriched in the control aged mouse group.</p>
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16 pages, 375 KiB  
Article
Correlation between Overweight, Obesity, Gestational Diabetes Mellitus, Adipokines (Adipolin and Adiponectin), and Adverse Pregnancy Outcomes: A Pilot Study
by Muntean Mihai, Săsăran Vladut, Luca Sonia-Teodora, Suciu Laura Mihaela, Nyulas Victoria, Muntean Irina Elena and Mărginean Claudiu
Medicina 2024, 60(9), 1544; https://doi.org/10.3390/medicina60091544 - 20 Sep 2024
Viewed by 1114
Abstract
Background: The prevalence of overweight (OW), obesity (OB), and gestational diabetes mellitus (GDM) has been increasing worldwide in recent years. Adipolin is a new adipokine with reduced circulating levels in obesity and type 2 diabetes mellitus (T2DM). Objectives: Our prospective case-control [...] Read more.
Background: The prevalence of overweight (OW), obesity (OB), and gestational diabetes mellitus (GDM) has been increasing worldwide in recent years. Adipolin is a new adipokine with reduced circulating levels in obesity and type 2 diabetes mellitus (T2DM). Objectives: Our prospective case-control study aimed to evaluate the maternal serum levels of adipolin and adiponectin, metabolic parameters, and anthropometric characteristics at the time of oral glucose tolerance test (OGTT) in pregnant women with a pre-pregnancy body mass index (BMI) ≥ 25 Kg/m2 and correlate them with newborn adipolin, adiponectin levels, and anthropometric characteristics of the newborns, and secondly to evaluate pregnancy outcomes. Material and Methods: After the OGTT results, we had 44 OW/OB pregnant women with GDM, 30 OW/OB pregnant women without GDM, and 92 lean healthy (LH) pregnant women. Data were analyzed by ANOVA and correlation tests, with a p-value < 0.05 considered significant. Results: We found no differences between adipolin values of the OW/OB pregnant women with GDM and the LH group (p > 0.99), OW/OB without GDM and the LH group (p = 0.56), and between OW/OB groups (p = 0.57). OW/OB pregnant women with GDM had a higher rate of gestational hypertension compared with the LH group (p < 0.0001). Newborns from OW/OB pregnant women with GDM were more frequently diagnosed with jaundice (p = 0.02), and they required more frequent admission to the neonatal intensive care unit (NICU) for treatment of respiratory distress (p = 0.01) compared with newborns from LH mothers. Conclusions: Our study revealed that the serum levels of adipolin in the second trimester among the group of OW/OB pregnant women with GDM, matched for age and BMI with OW/OB pregnant women without GDM, were not significantly different. This suggests that adipolin may not play an essential role in the occurrence of GDM in these patients. Despite good glycemic control during pregnancy, OW/OB pregnant women with GDM and their newborns tend to have more complications (gestational hypertension, jaundice, NICU admission) than LH pregnant women and their newborns, highlighting the importance of weight control before pregnancy. Full article
8 pages, 4366 KiB  
Case Report
Symptomatic Vasospasm Refractory to Clazosentan after Subarachnoid Hemorrhage of Ruptured Vertebral Artery Dissecting Aneurysm: Clinical Implications from Two Contrasting Cases
by Yasuyuki Yoshida, Tatsushi Mutoh, Junta Moroi and Tatsuya Ishikawa
Medicina 2024, 60(9), 1543; https://doi.org/10.3390/medicina60091543 - 20 Sep 2024
Cited by 1 | Viewed by 796
Abstract
Clazosentan prevents vasospasms after aneurysmal subarachnoid hemorrhage (SAH). However, clinical data on patients with SAH with ruptured vertebral artery dissecting aneurysms (VADAs) are limited. We report the case of a 49-year-old male patient with mild-grade (WFNS grade 1) thick and diffuse (modified Fisher [...] Read more.
Clazosentan prevents vasospasms after aneurysmal subarachnoid hemorrhage (SAH). However, clinical data on patients with SAH with ruptured vertebral artery dissecting aneurysms (VADAs) are limited. We report the case of a 49-year-old male patient with mild-grade (WFNS grade 1) thick and diffuse (modified Fisher grade 3) SAH who underwent endovascular trapping of a ruptured VADA, resulting in a poor functional outcome with a modified Rankin Scale score of 4 due to severe symptomatic vasospasm refractory to clazosentan, requiring repeated rescue endovascular therapies and chronic communicating hydrocephalus. A retrospective analysis of the clot density in the basal and Sylvian cisterns, assessed by the Hounsfield unit (HU) values of serial CT scans, in this patient showed persistent higher values, distinct from another VADA case that showed a decline in HU values with a good clinical course. These results imply the limited effectiveness of clazosentan in cases of thick and diffuse SAH after a ruptured VADA, even in good-clinical-grade patients treated with less invasive modalities. The HU values may become a simple quantitative marker for predicting symptomatic vasospasms and chronic hydrocephalus. Full article
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<p>Imaging findings. Initial brain CT scan (<b>a</b>) and CT angiography (<b>b</b>). A left VADA detected by CT angiography ((<b>b</b>) arrows: (<b>left</b>), anteroposterior projection; (<b>right</b>), left lateral projection) was successfully treated by internal coil trapping. (<b>c</b>) DSA before (<b>left</b>) and after (<b>right</b>) the treatment. Follow-up CT scans on day 14 (<b>d</b>) and day 90 (<b>e</b>) suggest multiple vasospasm-related infarctions in bilateral MCA regions and the occurrence of hydrocephalus, respectively.</p>
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<p>Imaging findings. (<b>a</b>) DSA of the right internal carotid artery anteroposterior projection showing vasospasm in the right MCA on day 9 (<b>left</b>), which was treated by intra-arterial fasudil and balloon angioplasty (<b>right</b>). (<b>b</b>) DSA on day 10 (<b>left</b>) demonstrated a new vasospasm in the left MCA; thus, we repeated the same endovascular therapy.</p>
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<p>Imaging findings. Initial brain CT scan (<b>a</b>) and CT angiography ((<b>b</b>) (<b>left</b>), anteroposterior projection; (<b>right</b>), left lateral projection). A left VADA ((<b>b</b>) arrows) successfully treated by endovascular trapping. (<b>c</b>) DSA before (<b>upper panels</b>) and after (<b>lower panels</b>) the treatment. (<b>d</b>) MR angiography of the posterior (<b>left panel</b>) and anterior (<b>right panel</b>) circulation on day 14.</p>
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<p>Serial brain CT imaging in the present case (<b>a</b>) with severe vasospasm on day 9 and a contracting case (<b>b</b>) with good clinical course without vasospasm following ruptured VADA.</p>
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<p>Representative brain CT imaging showing the location of analyzed HU values for assessing the density of the SAH clot. The HU values of the basal cistern (<b>a</b>) and Sylvian cistern (<b>b</b>) were measured as the average of the circular ROI values (87 mm<sup>2</sup>) of the bilateral carotid, interpeduncular, and lamina cisterns (<b>a</b>) and bilateral medial and lateral Sylvian cisterns (<b>b</b>), respectively. Each value has been shown to predict symptomatic vasospasm and hydrocephalus in patients with mild-grade SAH treated with endovascular coiling [<a href="#B16-medicina-60-01543" class="html-bibr">16</a>].</p>
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<p>Time course changes of CT scans (<b>left panels</b>) and HU values (<b>right panels</b>) of the basal cistern (<b>a</b>) and Sylvian cisterns (<b>b</b>) in the present SAH case who developed severe vasospasm (VS) and a similar case without vasospasm (non-VS) following ruptured VADA. The bilateral cisterns’ average ROIs (expressed as means ± SD) were calculated as described (<a href="#medicina-60-01543-f005" class="html-fig">Figure 5</a>). Note that the HU values in the present case were higher than those in the other. Arrows indicate the day when VS occurred.</p>
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27 pages, 467 KiB  
Review
Cardiovascular Effectiveness and Safety of Antidiabetic Drugs in Patients with Type 2 Diabetes and Peripheral Artery Disease: Systematic Review
by Antonio Cimellaro, Michela Cavallo, Marialaura Mungo, Edoardo Suraci, Francesco Spagnolo, Desirée Addesi, Medea Pintaudi and Carmelo Pintaudi
Medicina 2024, 60(9), 1542; https://doi.org/10.3390/medicina60091542 - 20 Sep 2024
Viewed by 1261
Abstract
Peripheral artery disease (PAD) is an atherosclerotic condition commonly complicating type 2 diabetes (T2D), leading to poor quality of life and increased risk of major adverse lower-limb (MALE) and cardiovascular (CV) events (MACE). Therapeutic management of PAD in T2D patients is much more [...] Read more.
Peripheral artery disease (PAD) is an atherosclerotic condition commonly complicating type 2 diabetes (T2D), leading to poor quality of life and increased risk of major adverse lower-limb (MALE) and cardiovascular (CV) events (MACE). Therapeutic management of PAD in T2D patients is much more arduous, often due to bilateral, multi-vessel, and distal vascular involvement, in addition to increased systemic polyvascular atherosclerotic burden. On the other hand, the pathophysiological link between PAD and T2D is very complex, involving mechanisms such as endothelial dysfunction and increased subclinical inflammation in addition to chronic hyperglycemia. Therefore, the clinical approach should not ignore vascular protection with the aim of reducing limb and overall CV events besides a mere glucose-lowering effect. However, the choice of the best medications in this setting is challenging due to low-grade evidence or lacking targeted studies in PAD patients. The present review highlighted the strong relationship between T2D and PAD, focusing on the best treatment strategy to reduce CV risk and prevent PAD occurrence and worsening in patients with T2D. The Medline databases were searched for studies including T2D and PAD up to June 2024 and reporting the CV effectiveness and safety of the most used glucose-lowering agents, with no restriction on PAD definition, study design, or country. The main outcomes considered were MACE—including nonfatal acute myocardial infarction, nonfatal stroke, and CV death—and MALE—defined as lower-limb complications, amputations, or need for revascularization. To the best of our current knowledge, GLP-1 receptor agonists and SGLT2 inhibitors represent the best choice to reduce CV risk in T2D and PAD settings, but a personalized approach should be considered. GLP-1 receptor agonists should be preferred in subjects with prevalent atherosclerotic burden and a history of previous MALE, while SGLT2 inhibitors should be used in those with heart failure if overall CV benefits outweigh the risk of lower-limb complications. Full article
10 pages, 770 KiB  
Article
Vaping: The Key to Quitting Cigarettes or a Gateway to Addiction?
by Jessica Emily Hill, Marepalli Bhaskara Rao and Tianyuan Guan
Medicina 2024, 60(9), 1541; https://doi.org/10.3390/medicina60091541 - 20 Sep 2024
Viewed by 1523
Abstract
Background and Objectives: In 2022, the Centers for Disease Control and Prevention (CDC) discovered that 2.55 million middle and high school students were using electronic cigarettes (e-cigarettes) in the US alone. E-cigarettes allow people to inhale a nicotine solution (e-liquid) into their [...] Read more.
Background and Objectives: In 2022, the Centers for Disease Control and Prevention (CDC) discovered that 2.55 million middle and high school students were using electronic cigarettes (e-cigarettes) in the US alone. E-cigarettes allow people to inhale a nicotine solution (e-liquid) into their bodies. While e-cigarettes are often advertised as a way to help people quit traditional tobacco products, the World Health Organization (WHO) has stated that there is no proof of e-cigarettes being effective at reducing an individual’s tobacco use. The objective of this study is to determine why adolescents start smoking e-cigarettes. Materials and Methods: For the following study, the National Youth Tobacco Survey (NYTS) 2021 was used. This is a nationally representative cross-sectional survey that includes middle and high school students. The data were analyzed using SAS v.9.4. The odds ratio for smoking e-cigarettes was evaluated for both sex and race via a logistic regression. Results: It was discovered that the percentage of only e-cigarette smokers (12.10%) was 5.5 times the percentage of only traditional smokers (2.19%). Additionally, the median age at which adolescents started smoking e-cigarettes was fifteen years with an IQR (Inter Quartile Range) of two. We used a logistic regression to show that biological sex and race were significant predictors of e-cigarette usage. Conclusions: In general, we saw that adolescents were mostly starting to smoke e-cigarettes because their friends were doing it, out of curiosity, they were depressed or anxious, and/or to get a “high”, implying that adolescents mostly started smoking in order to fit in and/or to numb themselves. Interestingly, reasons like cost, using them to quit smoking, seeing them in the media, and ease of attainment were ranked the lowest when it came to smoking e-cigarettes. However, their lower costs naturally lead to increased accessibility compared to traditional cigarettes, making them easier to reach the hands of teenagers. Overall, in this paper, we aim to identify if adolescents are choosing e-cigarettes as their first foray into tobacco products and why. Full article
(This article belongs to the Section Epidemiology & Public Health)
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<p>Age participants first started smoking e-cigarettes.</p>
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<p>Reasons for vaping—percentages—by sex.</p>
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13 pages, 3153 KiB  
Article
Sanger Sequencing Reveals Novel Variants in GLO-1, ACE, and CBR1 Genes in Patients of Early and Severe Diabetic Nephropathy
by Syed Zubair Hussain Shah, Amir Rashid, Asifa Majeed, Tariq Ghafoor and Nadeem Azam
Medicina 2024, 60(9), 1540; https://doi.org/10.3390/medicina60091540 - 20 Sep 2024
Viewed by 785
Abstract
Background and Objectives: Diabetes is a global health issue, with approximately 50% of patients developing diabetic nephropathy (DN) and 25% experiencing early and severe forms of the disease. The genetic factors contributing to rapid disease progression in a subset of these patients are [...] Read more.
Background and Objectives: Diabetes is a global health issue, with approximately 50% of patients developing diabetic nephropathy (DN) and 25% experiencing early and severe forms of the disease. The genetic factors contributing to rapid disease progression in a subset of these patients are unclear. This study investigates genetic variations in the GLO-1, CBR-1, and ACE genes associated with early and severe DN. Materials and Methods: Sanger DNA sequencing of the exons of CBR1, GLO1, and ACE genes was conducted in 113 patients with early and severe DN (defined as occurring within 10 years of the diagnosis of diabetes and with eGFR < 45 mL/min/1.73 m2) and 100 controls. The impact of identified genetic variations was analyzed using computational protein models created in silico with SWISS-Model and SWISS-Dock for ligand binding interactions. Results: In GLO1, two heterozygous missense mutations, c.102G>T and c.147C>G, and one heterozygous nonsense mutation, c.148G>T, were identified in patients. The SNP rs1049346 (G>A) at location 6:38703061 (GRCh38) was clinically significant. The c.147C>G mutation (C19S) was associated with ligand binding disruption in the GLO1 protein, while the nonsense mutation resulted in a truncated, non-functional protein. In CBR1, two heterozygous variations, one missense c.358G>A, and one silent mutation c.311G>C were observed, with the former (D120N) affecting the active site. No significant changes were noted in ACE gene variants concerning protein structure or function. Conclusions: The study identifies four novel and five recurrent mutations/polymorphisms in GLO1, ACE, and CBR1 genes associated with severe DN in Pakistani patients. Notably, a nonsense mutation in GLO1 led to a truncated, non-functional protein, while missense mutations in GLO1 and CBR1 potentially disrupt enzyme function, possibly accelerating DN progression. Full article
(This article belongs to the Section Urology & Nephrology)
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<p>(<b>a</b>) A picture of 1% agarose gel showing positive DNA bands on gel electrophoresis. (<b>b</b>) A picture of 2% agarose gel showing 325 bp fragments on gel electrophoresis amplified using a PCR.</p>
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<p>The electrochromatogram shows SNVs in <span class="html-italic">GLO1</span> and <span class="html-italic">ACE</span> genes. (<b>a</b>,<b>c</b>,<b>e</b>,<b>g</b>) are wild-type sequences, while (<b>b</b>,<b>d</b>,<b>f</b>,<b>h</b>) show mutated sequences (A = Green, G = Black, T = Red, C = Blue).</p>
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<p>The electrochromatogram shows SNVs in the <span class="html-italic">CBR1</span> gene. (<b>a</b>,<b>c</b>,<b>e</b>) are wild-type sequences, while (<b>b</b>,<b>d</b>,<b>f</b>) show mutated sequences (A = Green, G = Black, T = Red, C = Blue).</p>
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<p>The protein–ligand docking of GLO1 and S-P-Nitrobenzyloxycarbonylglutathione. (<b>a</b>) Wild-type protein docking with ligand. (<b>b</b>) Mutated C19S. (<b>c</b>) Truncated 18AA peptide (stop codon gained).</p>
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<p>The protein–ligand docking of CBR1 and glutathione with NADPH. (<b>a</b>) Normal protein docking with ligand. (<b>b</b>) D120N.</p>
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<p>The protein–ligand docking of ACE and angiotensin 1. (<b>a</b>) Wild-type protein docking with the ligand. (<b>b</b>) T113M novel mutation.</p>
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16 pages, 5270 KiB  
Article
Impact of Treatment with Direct Antivirals on Coagulation Parameters in Patients with Hepatitis C Virus-Related Liver Cirrhosis and Sustained Virological Response
by Laura Huiban, Carol Stanciu, Cristina Maria Muzica, Irina Girleanu, Raluca Avram, Ioana Damian, Robert Nastasa, Ermina Stratina, Sebastian Zenovia, Horia Minea, Remus Stafie, Adrian Rotaru, Ana-Maria Singeap, Stefan Chiriac, Ioana-Miruna Balmus and Anca Trifan
Medicina 2024, 60(9), 1539; https://doi.org/10.3390/medicina60091539 - 20 Sep 2024
Viewed by 606
Abstract
Background and Objectives: Sustained virologic responses (SVRs) lead to a decrease in portal hypertension, the regression of fibrosis, and the improvement in the hepatic synthesis of procoagulant and anticoagulant factors. We aimed to assess the influence of SVR on coagulation parameters in [...] Read more.
Background and Objectives: Sustained virologic responses (SVRs) lead to a decrease in portal hypertension, the regression of fibrosis, and the improvement in the hepatic synthesis of procoagulant and anticoagulant factors. We aimed to assess the influence of SVR on coagulation parameters in cirrhotic patients with HCV treated with DAAs. Methods: We performed a prospective study in the Institute of Gastroenterology and Hepatology Iasi, Romania, between January 2022 and February 2024. We included patients diagnosed with compensated and decompensated HCV-related liver cirrhosis, treated with direct antivirals (PrOD ± RBV or SOF/LED ± RBV) for 12/24 weeks. Blood samples for biochemical, immunological, and coagulation tests were collected at the baseline, end of treatment (EOT), and once sustained virological response had been achieved over a period of 12/24 weeks (SVR12/24). Results: We analyzed a group of 52 patients with HCV-related liver cirrhosis, predominantly female (68.0%), and the degree of severity of cirrhosis placed the patients mainly in Child–Pugh classes B (40%) and C (36%). All patients achieved SVRs. The MELD score decreased at EOT (13.48 ± 4.273; p = 0.001) and SVR (9.88 ± 2.774; p = 0.000), compared to the baseline (14.92 ± 4.707). The FibroScan values decreased at SVR (17.596 ± 3.7276; p = 0.000) compared to the baseline (26.068 ± 7.0954). For all common coagulation parameters (platelets, INR, PT, fibrinogen, aPTT), there was a trend towards improvement during treatment, including changes which were statistically significant for the majority of patients. Factor II was low at the baseline (75.40 ± 7.506) but increased at EOT (87.40 ± 9.587) and, later, at SVR (99.12 ± 11.695; p = 0.000). The FVIII values increased at the baseline (175.52 ± 16.414) and decreased at EOT (151.48 ± 13.703) and SVR (143.40 ± 13.937). The FvW values decreased during treatment (146.84 ± 9.428, at baseline; 141.32 ± 9.690, p = 0.000, at EOT; and 126.68 ± 17.960, at SVR). In regard to the anticoagulant factors (PC, PS, ATIII), a significant improvement was brought on by SVR. Advanced stages of liver disease showed the most diminished FII activity, while at the baseline and in Child–Pugh C patients we recorded the highest values of FVIII and FvW. Conclusions: Our study proved that the “reset” of coagulopathy might be due to the improvement in liver function due to viral eradication secondary to AAD therapy. Full article
(This article belongs to the Section Gastroenterology & Hepatology)
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<p>Flowchart of the study protocol.</p>
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<p>Usual coagulation parameters (platelet, INR, PT, fibrinogen, and aPTT)—evolution during antiviral treatment (baseline, EOT, and SVR). Tr, thrombocytes; INR, international normalized ratio; PT, prothrombin time; and aPTT, activated partial thromboplastin time.</p>
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<p>Procoagulant factors (FII, F VIII, and FvW)—evolution during antiviral treatment (baseline, EOT, and SVR). FII, factor II; F VIII, factor VIII; and FvW, factor von Willebrand.</p>
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<p>Anticoagulant factors (PC, PS, and AT III)—evolution during antiviral treatment (baseline, EOT, and SVR). PC, protein C; PS, protein S; and AT III, antithrombin III.</p>
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<p>Procoagulant factors—initial value and evolution of values over time, compared by Child–Pugh classes. (<b>A</b>) Factor II—the evolution according to the Child-Pugh class; (<b>B</b>) Factor VIII—the evolution according to the Child-Pugh class; (<b>C</b>) Factor vW—the evolution according to the Child-Pugh class.</p>
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<p>Procoagulant factors—initial value and evolution of values over time, compared by Child–Pugh classes. (<b>A</b>) Factor II—the evolution according to the Child-Pugh class; (<b>B</b>) Factor VIII—the evolution according to the Child-Pugh class; (<b>C</b>) Factor vW—the evolution according to the Child-Pugh class.</p>
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<p>Antithrombin III’s initial value and evolution of values over time, compared by Child–Pugh classes.</p>
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11 pages, 1705 KiB  
Article
Development of a Short-Term Embolic Agent Based on Cilastatin for Articular Microvessels
by Hyun Jin Kim, Areum Jeon, Eun Kyung Kang, Wen An, So Jung Lim, Kyu Chul Shin, Dong Hun Shin, Inyoung Hwang and Ju Seop Kang
Medicina 2024, 60(9), 1538; https://doi.org/10.3390/medicina60091538 - 20 Sep 2024
Viewed by 567
Abstract
Background and Objectives: This study aimed to develop an embolic agent with short-term embolic effects using cilastatin as the basic material. Materials and Methods: The particle size distribution of 25 mg cilastatin-based short-term embolic agents was evaluated microscopically under three different [...] Read more.
Background and Objectives: This study aimed to develop an embolic agent with short-term embolic effects using cilastatin as the basic material. Materials and Methods: The particle size distribution of 25 mg cilastatin-based short-term embolic agents was evaluated microscopically under three different mixing conditions. A total of thirty-six healthy male Sprague Dawley rats were divided into four groups. Each group of six rats was injected once into the tail artery with 0.4 mL each of (A) Cilastatin + D-Mannitol Mixture, (B) Iohexol, (C) Prepenem, and (D) embolization promoter (EGgel). Results: A visual inspection of the tail appearance of rats in each group was performed at 0, 3, 7, 15, and 21 days. At weeks 1 and 3, three rats per group were euthanized, and histopathological analyses were performed on the specimens obtained from each group. No significant differences were observed on day 7, but mild inflammation was observed in Group (D) on day 15. Histopathological inflammation scoring of tail central artery embolization was performed using a six-point scale (from 0 = absent to 5 = marked inflammation). Three groups were formed consisting of six male New Zealand white rabbits each: control, positive control, and test groups. The control group received an Iohexol injection (rabbits: 0.8 mL). The positive control and experimental groups were injected with prepenem and cilastatin/D-mannitol compound, respectively (0.8 mL), and vascular angiography was performed. The order of occlusion progression after embolization was as follows: test group, positive control group, and control group. Conclusions: We developed a cilastatin/D-mannitol compound that exhibits characteristics of short-term embolization by utilizing the pharmacokinetic properties of cilastatin and the crystalline material D-mannitol. We evaluated its particle size distribution microscopically, conducted histopathological evaluation including inflammation via animal experiments, and assessed the embolization effect. Full article
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<p>Particle size and distribution in compound; the image is an optical microscope photograph (<b>a</b>) of the Cilastatin/D-Mannitol combination, while the image on the right is taken with a scanning electron microscope (SEM) (<b>b</b>) The particle length is approximately 96.0 ± 30.0 μm.</p>
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<p>Histopathological observations of proximal and distal sections of the middle part of the rat tail stained with (<b>a</b>) Hematoxylin and eosin and (<b>b</b>) Masson’s trichrome, 7 days (<b>upper</b> panel) and 21 days (<b>lower</b> panel) after injection of the embolic substances. Group A: Cilastatin + D-Mannitol Mixture, Group B: Iohexol, Group C: Prepenem, Group D: EGgel. Magnifications: 20× (scale bar is 500 µm), 100× (scale bar is 100 µm).</p>
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<p>Histopathological observations of proximal and distal sections of the middle part of the rat tail stained with (<b>a</b>) Hematoxylin and eosin and (<b>b</b>) Masson’s trichrome, 7 days (<b>upper</b> panel) and 21 days (<b>lower</b> panel) after injection of the embolic substances. Group A: Cilastatin + D-Mannitol Mixture, Group B: Iohexol, Group C: Prepenem, Group D: EGgel. Magnifications: 20× (scale bar is 500 µm), 100× (scale bar is 100 µm).</p>
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<p>Angiographic analysis. The distribution pattern of Cilastatin/D-Mannitol (contrast solution) is evaluated by administering it into the ear artery of New Zealand white rabbits and imaging it with micro-CT (C-Arm) to assess the distribution time. The figures show (<b>a</b>) 10 s after iohexol administration, (<b>b</b>) 120 s after iohexol administration, (<b>c</b>) 55 s after prepenem administration, (<b>d</b>) 120 s after prepenem administration, (<b>e</b>) 40 s after Cilastatin/D-Mannitol administration, and (<b>f</b>) 120 s after Cilastatin/D-Mannitol administration.</p>
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<p>Angiographic analysis. The distribution pattern of Cilastatin/D-Mannitol (contrast solution) is evaluated by administering it into the ear artery of New Zealand white rabbits and imaging it with micro-CT (C-Arm) to assess the distribution time. The figures show (<b>a</b>) 10 s after iohexol administration, (<b>b</b>) 120 s after iohexol administration, (<b>c</b>) 55 s after prepenem administration, (<b>d</b>) 120 s after prepenem administration, (<b>e</b>) 40 s after Cilastatin/D-Mannitol administration, and (<b>f</b>) 120 s after Cilastatin/D-Mannitol administration.</p>
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18 pages, 762 KiB  
Article
Echocardiographic Indices in Patients with End-Stage Renal Disease and Their Association with Hemodialysis-to-Hemodiafiltration Transfer: A Prospective Observational Study
by Josipa Domjanović Matetić, Darija Baković Kramarić, Tea Domjanović Škopinić, Ivo Jeličić, Dijana Borić Škaro, Joško Božić and Andrija Matetic
Medicina 2024, 60(9), 1537; https://doi.org/10.3390/medicina60091537 - 20 Sep 2024
Viewed by 771
Abstract
Background and Objectives: The assessment of cardiac function in patients with end-stage renal disease (ESRD) is vital due to their high cardiovascular risk. However, contemporary echocardiographic indices and their association with hemodialysis-to-hemodiafiltration transfer are underreported in this population. Materials and Methods: [...] Read more.
Background and Objectives: The assessment of cardiac function in patients with end-stage renal disease (ESRD) is vital due to their high cardiovascular risk. However, contemporary echocardiographic indices and their association with hemodialysis-to-hemodiafiltration transfer are underreported in this population. Materials and Methods: This prospective cohort study enrolled 36 ESRD patients undergoing hemodialysis-to-hemodiafiltration transfer, with baseline and 3-month post-transfer comprehensive echocardiographic assessments. The key parameters included the global work index, global constructed work, global wasted work (GWW), global work efficiency (GWE), and global longitudinal strain (GLS), with secondary measures from conventional echocardiography. The baseline measures were compared to general population reference values and changes pre- to post-transfer were analyzed using the Mann–Whitney U test. Results: Patients exhibited significant deviations from reference ranges in GWW (179.0 vs. 53.0–122.2 mmHg%), GWE (90.0 vs. 53.0–122.2%), and GLS (−16.0 vs. −24.0–(−16.0)%). Post-transfer left ventricular myocardial work and longitudinal strain remained unchanged (p > 0.05), except for increased GWW (179.0, IQR 148.0–217.0 to 233.5, IQR 159.0-315.0 mmHg%, p = 0.037) and improved mid-inferior peak systolic longitudinal strain ((−17.0, IQR −19.0–(−11.0) to −18.7, IQR −20.0–(−18.0)%, p = 0.016). The enrolled patients also showed higher left atrial diameters, left ventricular volumes, and mass, with impaired systolic function in both ventricles compared to reference values. Conclusions: This study highlights baseline impairments in contemporary echocardiographic measures (GWW, GWE, GLS) in ESRD patients versus reference values, but found no association between hemodialysis-to-hemodiafiltration transfer and most myocardial work and strain parameters. Full article
(This article belongs to the Special Issue Cardiovascular Disease and Hemodialysis)
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<p>Comparison of baseline contemporary echocardiographic measures of left ventricular myocardial work and longitudinal strain to reference values from the general population (boxes and whiskers plots). Data are presented as boxes and whiskers (median (interquartile range) and minimum/maximum).</p>
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12 pages, 2926 KiB  
Review
Oncologic Outcomes after Percutaneous Ablation for Colorectal Liver Metastases: An Updated Comprehensive Review
by David-Dimitris Chlorogiannis, Vlasios S. Sotirchos and Constantinos T. Sofocleous
Medicina 2024, 60(9), 1536; https://doi.org/10.3390/medicina60091536 - 20 Sep 2024
Viewed by 1127
Abstract
Colorectal cancer is a major cause of cancer-related mortality, with liver metastases occurring in over a third of patients, and is correlated with poor prognosis. Despite surgical resection being the primary treatment option, only about 20% of patients qualify for surgery. Current guidelines [...] Read more.
Colorectal cancer is a major cause of cancer-related mortality, with liver metastases occurring in over a third of patients, and is correlated with poor prognosis. Despite surgical resection being the primary treatment option, only about 20% of patients qualify for surgery. Current guidelines recommend thermal ablation either alone or combined with surgery to treat limited hepatic metastases, provided that all visible disease can be effectively eradicated. Several ablation modalities, including radiofrequency ablation, microwave ablation, cryoablation, irreversible electroporation and histotripsy, are part of the percutaneous ablation armamentarium. Thermal ablation, including radiofrequency, microwave ablation and cryoablation, can offer local tumor control rates comparable to limited resection for selected tumors that can be ablated with margins. This review aims to encapsulate the current clinical evidence regarding the efficacy and oncologic outcomes after percutaneous ablation for the treatment of colorectal liver metastatic disease. Full article
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<p>Sixty-one-year-old woman with metastatic colon cancer, status post chemotherapy, partial colectomy, hepatic arterial infusion pump chemotherapy and hepatic resection with intra-operative ablations, with new 1.2 cm segment 5 T2 hyperintense ((<b>A</b>): arrowhead)) FDG-avid (<b>B</b>) metastasis. This was treated with PET/CT-guided microwave ablation (<b>C</b>). The tumor was segmented on the immediate pre-ablation portal venous-phase CT, and subsequently registered to the post-ablation portal venous-phase CT ((<b>D</b>); purple border: segmented tumor, yellow border: 5 mm margin, light blue border: 10 mm margin), showing coverage of the tumor with adequate margins. Follow-up imaging after 6 weeks shows the segment 5 ablation zone without evidence of residual tumor ((<b>E</b>): hepatobiliary phase of MRI), with corresponding photopenic defect on concurrent PET/CT (<b>F</b>).</p>
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13 pages, 1732 KiB  
Article
Incidence of Rotational Malalignment after Intertrochanteric Fracture Intramedullary Nailing: A CT-Based Prospective Study
by Michail Vavourakis, Dimitrios Zachariou, Athanasios Galanis, Panagiotis Karampinas, Meletis Rozis, Evangelos Sakellariou, Christos Vlachos, Iordanis Varsamos, John Vlamis, Elias Vasiliadis and Spiros Pneumaticos
Medicina 2024, 60(9), 1535; https://doi.org/10.3390/medicina60091535 - 20 Sep 2024
Viewed by 546
Abstract
Background and Objectives: Rotational malformation after intramedullary nailing of intertrochanteric fractures is a relatively common, possibly severe, and difficult-to-detect complication, since intraoperative radiographic imaging allows for the assessment of the quality of reduction in the frontal and sagittal planes, but not in the [...] Read more.
Background and Objectives: Rotational malformation after intramedullary nailing of intertrochanteric fractures is a relatively common, possibly severe, and difficult-to-detect complication, since intraoperative radiographic imaging allows for the assessment of the quality of reduction in the frontal and sagittal planes, but not in the transverse plane. The purpose of this study is to evaluate the rotational malalignment after intramedullary nailing of intertrochanteric fractures and to investigate a possible connection with specific patients’ or fractures’ characteristics. Materials and Methods: 74 patients treated with intramedullary nailing due to an intertrochanteric fracture underwent a postoperative CT of the pelvis-hips and knees. The value of the anteversion was measured both in the operated-on (angle 1) and in the healthy hip (angle 2) based on the technique described by Jeanmart et al. and the difference in anteversion (D angle = angle 1 minus angle 2) was calculated. A positive D angle indicated the presence of excessive internal overcorrection of the distal fragment during fracture reduction, while a negative D angle indicated the presence of excessive external overcorrection. The absolute value of the D angle represents the postoperative difference in anteversion between the two hips. The patients were divided into three groups according to this value: group A, with D < 5° (physiological difference); group B, with 5° < D < 15° (acceptable rotational alignment); and group C, with D ≥ 15° (rotational deformity). Results: Group A constitutes 56.8%, group B 12.2%, and group C 31.1% of the study population. Overall, 79.7% of the patients presented a positive angle D, while, for group C, the percentage was even higher at 91.3%. According to the AO/OTA classification system, 37.8% of the cases were stable fractures, 47.3% were unstable fractures, and 14.9% were reverse oblique fractures. Based on our analysis, the type of fracture has a serious impact on the rotational alignment, since the statistical significance of the mean angle D for the three types of fracture is reliable (p = 0.029). Stable fractures present the lowest anteversion difference values, while reverse oblique fractures present the highest difference. Conclusions: Our study reveals that the percentage of rotational malalignment after the intramedullary nailing of intertrochanteric fractures remains high (31.1%), despite the proper use of radiographic imaging during the intraoperative fracture reduction. In most cases (91.3%), this malalignment appears to be a matter of internal overcorrection. A clear correlation between hip’s rotational deformity and patients′ functional outcome has yet to be proven, and constitutes our objective in the near future. Full article
(This article belongs to the Section Orthopedics)
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<p>Anteroposterior (<b>left</b>) and lateral (<b>right</b>) view of an intraoperative radiographic evaluation after the fixation of the intramedullary nail.</p>
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<p>Determining the center of the femoral head in the transverse section where it presents the maximum diameter (<b>A</b>). Determining the center of the femoral neck in the transverse section where it presents its narrowest width (<b>B</b>).</p>
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<p>A line is drawn which connects the center of the head with the center of the neck (yellow line (<b>A</b>), red line (<b>B</b>)).</p>
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<p>Tangent line to the posterior femoral condyles in the transverse section where they present the maximum anteroposterior diameter (<b>A</b>). Projective angle formed between the tangent line at the posterior femoral condyles and the line connecting the center of the head with the center of the neck. This angle expresses the femoral anteversion (<b>B</b>).</p>
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11 pages, 1147 KiB  
Article
Is Complete Excision Always Enough? A Quality of Sexual Life Assessment in Patients with Deep Endometriosis
by Raluca Gabriela Enciu, Octavian Enciu, Dragoș Eugen Georgescu, Adrian Tulin and Adrian Miron
Medicina 2024, 60(9), 1534; https://doi.org/10.3390/medicina60091534 - 20 Sep 2024
Viewed by 600
Abstract
Background and Objectives: The aim of this study was to find the factors associated with the severe impairment of QoSL and the factors associated with a better score in QoSL, as well as the evaluation of pain symptoms and QoSL after the [...] Read more.
Background and Objectives: The aim of this study was to find the factors associated with the severe impairment of QoSL and the factors associated with a better score in QoSL, as well as the evaluation of pain symptoms and QoSL after the complete and incomplete excision of rectovaginal nodules. Materials and methods: The present prospective study was conducted in a single tertiary center for endometriosis where 116 patients underwent laparoscopic surgery for deep endometriosis during a 3-year period. The goal of the intervention was to excise all endometriotic implants while conserving the rectum. Intraoperative findings were recorded after the intervention, and the patients were classified according to the ENZIAN classification and rASRM scores. QoSL was assessed using the EHP-30 Module C (QoSL Score). Results: When comparing the mean scores before and 2 years after the surgery, a highly significant improvement was found for QoSL and dysmenorrhea (p < 0.0001). The complete excision of rectovaginal nodules led to a significantly better QoSL and lower dyspareunia (p < 0.0001) than incomplete resection (p < 0.02). Conclusions: This prospective study proves that the complete laparoscopic excision of all endometriotic implants improved the QoSL and decreased the pain score of dyspareunia. Incomplete rectovaginal nodule excision was correlated with a poorer QoSL and a lower improvement of dysmenorrhea, dyspareunia, and chronic pelvic pain scores than complete excision. Full article
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<p>VAS for dyspareunia—patient distribution. Black columns—without medication; grey columns—with medication.</p>
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<p>Sexual QoL score—VAS dyspareunia correlation.</p>
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7 pages, 2490 KiB  
Case Report
Novel Nipple Reinnervation Technique Using N. Suralis Graft
by Jānis Lapiņš, Beatriz Soares Domingues Polita, Linda Kalniņa, Michal Grucki, Dzintars Ozols, Ansis Ģīlis, Arvīds Irmejs, Jānis Gardovskis and Jeļena Maksimenko
Medicina 2024, 60(9), 1533; https://doi.org/10.3390/medicina60091533 - 20 Sep 2024
Viewed by 701
Abstract
Following nipple-sparing mastectomy (NSM), patients commonly experience significant impairment or total loss of nipple sensitivity, which negatively impacts the patients’ quality of life, whereas patients who retain nipple sensation postoperatively experience enhanced physical, psychosocial, and sexual well-being. Reinnervation techniques such as nerve allografting [...] Read more.
Following nipple-sparing mastectomy (NSM), patients commonly experience significant impairment or total loss of nipple sensitivity, which negatively impacts the patients’ quality of life, whereas patients who retain nipple sensation postoperatively experience enhanced physical, psychosocial, and sexual well-being. Reinnervation techniques such as nerve allografting have been utilized to retain sensation. Despite the benefits of nerve allografts, such as lack of donor site morbidity, ease of use, and potentially shorter surgery time, there are shortcomings, such as the cost of commercially available acellular nerve allografts, and, most importantly, decreased sensory and motor function recovery for acellular nerve allografts with a diameter greater than 3 mm or a length greater than 50 mm. We present a technique where we performed immediate implant-based breast reconstruction combined with nipple–areola complex reinnervation using an autologous nerve graft. Following the procedure, the patient had improved sensory outcomes in the reconstructed breast and good quality-of-life indices. This report highlights the potential for sural nerve autografts in restoring breast sensation following mastectomy. Full article
(This article belongs to the Section Surgery)
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<p>The thickest terminal branch of the sural nerve is coapted to the areola-complex nerve stump. The smaller branches sutured directly to the undersurface of the areola.</p>
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<p>The proximal nerve anastomosis was completed to the fourth intercostal nerve end.</p>
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<p>Nine predefined points of the breast: 1—upper outer quadrant (UOQ); 2—lower outer quadrant (LOQ); 3—lower inner quadrant (LIQ); 4—upper inner quadrant (UIQ); 5—areola upper lateral (AUL); 6—areola lower lateral (ALL); 7—areola lower medial (ALM); 8—areola upper medial (AUM); 9—nipple (NIP).</p>
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<p>Sensibility grade of each predefined point over time.</p>
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<p>Sensibility grade of each predefined point over time.</p>
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10 pages, 289 KiB  
Article
Bariatric Surgery and Metabolic Status
by Anna Różańska-Walędziak, Krzysztof Wyszomirski, Małgorzata Kaszuba, Anna Mierzejewska, Ewa Skopińska and Maciej Walędziak
Medicina 2024, 60(9), 1532; https://doi.org/10.3390/medicina60091532 - 20 Sep 2024
Viewed by 1373
Abstract
Background and Objectives: Obesity is associated with numerous co-morbidities, including dyslipidemia, insulin resistance and diabetes mellitus. Bariatric surgery is the mainstay of treatment for obesity as the only method with confirmed long-term effects in weight reduction and the remission of comorbidities. Postoperative [...] Read more.
Background and Objectives: Obesity is associated with numerous co-morbidities, including dyslipidemia, insulin resistance and diabetes mellitus. Bariatric surgery is the mainstay of treatment for obesity as the only method with confirmed long-term effects in weight reduction and the remission of comorbidities. Postoperative recommendations leading to changes in dietary habits and changes in digestion and absorption in the gastrointestinal tract after bariatric surgery may additionally influence the levels of laboratory parameters that reflect the metabolic and nutritional status. The purpose of the study was to analyze the possible influence of changes in dietary habits after bariatric surgery on those laboratory results that reflect the metabolic and nutritional status. Materials and Methods: This was a retrospective study of 88 patients with a history of bariatric surgery. Data were gathered from before the surgery and at 6 months after the surgery and included diet structure and selected laboratory parameters reflecting the metabolic and nutritional status, i.e., levels of fasting glucose, glycated hemoglobin, cholesterol, low- and high-density lipoproteins, triglycerides, alanine and aspartate aminotransferases, proteins, ferrum, ferritin, vitamin B12, folic acid, vitamin D and calcium, the red blood cell count and the hematocrit. Results: Postoperative festive glucose levels were reduced by 14% and were more significant in patients after Roux-en-Y gastric bypass. There was an increase of 22% in concentrations of high-density lipoproteins. Triglyceride concentrations were reduced by 32%. Aminotransferase levels decreased by 43% for alanine aminotransferase and by 14% for aspartate aminotransferase. Among the changes in dietary habits, post-bariatric patients had a reduced consumption of red meat and an increased consumption of fish, milk and dairy products and wholegrain products. Vitamin D and ferrum levels were higher after the surgery, whereas vitamin B12 and folic acid levels remained unchanged. Conclusions: Improved dietary habits of patients after bariatric surgery may lead to changes in laboratory parameters that reflect the ameliorated metabolic and nutritional status of patients after bariatric surgery. Full article
(This article belongs to the Special Issue Gastric Sleeve Surgery: Techniques, Outcomes, and Future Directions)
21 pages, 9239 KiB  
Article
The HCV-Melanoma Paradox: First Multi-Cohort and Molecular Net-Work Analysis Reveals Lower Incidence but Worse Outcomes—Integrating Clinical, Real-World, and In Silico Data
by Essam Al Ageeli, Jawaher A. Abdulhakim, Mohammad H. Hussein, Maryam M. Alnoman, Samia S. Alkhalil, Peter P. Issa, Nader A. Nemr, Ahmed Abdelmaksoud, Dhaifallah A. Alenizi, Manal S. Fawzy and Eman A. Toraih
Medicina 2024, 60(9), 1531; https://doi.org/10.3390/medicina60091531 - 19 Sep 2024
Viewed by 797
Abstract
Background and Objectives: The relationship between hepatitis C virus (HCV) infection and melanoma remains poorly understood. This study aimed to investigate the association between HCV and melanoma, assess outcomes in patients with both conditions, and explore potential molecular mechanisms connecting the two [...] Read more.
Background and Objectives: The relationship between hepatitis C virus (HCV) infection and melanoma remains poorly understood. This study aimed to investigate the association between HCV and melanoma, assess outcomes in patients with both conditions, and explore potential molecular mechanisms connecting the two diseases. Materials and Methods: We conducted a retrospective cohort study of 142 melanoma patients, including 29 with HCV-related cirrhosis, and analyzed their clinical outcomes. For external validation, we used the TriNetX Global Collaborative Network database, comprising 219,960 propensity-matched patients per group. An in silico analysis was performed to identify the molecular pathways linking HCV and melanoma. Results: In the retrospective cohort, HCV-positive melanoma patients showed an increased risk of early relapse (41.4% vs. 18.6%, p = 0.014), recurrence (65.5% vs. 39.8%, p = 0.020), and mortality (65.5% vs. 23.0%, p < 0.001) compared to HCV-negative patients. TriNetX data analysis revealed that HCV-positive patients had a 53% lower risk of developing melanoma (RR = 0.470, 95% CI: 0.443–0.498, p < 0.001). However, HCV-positive melanoma patients had higher all-cause mortality (HR = 1.360, 95% CI: 1.189–1.556, p < 0.001). An in silico analysis identified key molecular players, including IL-6 and CTLA4, in the HCV-melanoma network. Conclusions: While HCV infection may be associated with a lower risk of melanoma development, HCV-positive patients who develop melanoma have poorer outcomes. The identified molecular pathways provide potential targets for future research and therapeutic interventions. Full article
(This article belongs to the Section Dermatology)
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<p>Distribution of melanoma patients. (<b>A</b>) Frequency of patients with HCV. (<b>B</b>) Distribution of samples according to the year of diagnosis.</p>
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<p>Multivariate Cox regression model for overall survival. The outcome was mortality, and other factors were included in the model as independent predictor factors. Hazards ratio and 95% confidence interval (CI) are reported. ** <span class="html-italic">p</span> &lt; 0.001.</p>
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<p>Kaplan–Meier survival curve. (<b>A</b>) Disease-free survival. (<b>B</b>) Overall survival. Survival times were assessed in months. The log-rank test was used to compare HCV and non-HCV patients.</p>
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<p>Workflow for patient recruitment from the TriNetX Global Collaborative Network.</p>
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<p>Overall survival in melanoma patients with and without HCV infection. Kaplan–Meier curve is shown, and the log-rank test was used.</p>
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<p>Identifying connecting molecular targets between HCV and cutaneous melanoma. The network was generated using Ingenuity Pathway analysis based on the findings in the QIAGEN Knowledge Base.</p>
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<p>Comparison analysis of RNA-sequencing experiments for melanoma versus normal skin and HCV versus non-HCV. The pathway heatmap displays the z-scores from pathway activity analysis (orange and blue rectangles) for activated and inhibited signaling pathways. From left to right are the following experiments: GSE100050, GSE122907, GSE4587, GSE114445, E-MTAB-6863, and GSE82177.</p>
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<p>Overlay of melanoma experiments on HCV-melanoma network. The highlighted molecular nodes were deregulated in four melanoma experiments (left to right bars: GSE100050, GSE122907, GSE4587, and GSE114445). Red node: upregulated, green node: downregulated, orange node: predicted activation, orange line = leads to activation, yellow line = inconsistent findings. * Indicates that the gene/protein in the related dataset file has duplicates mapped to a single gene/protein in the network.</p>
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13 pages, 1681 KiB  
Article
Evaluation of Maternal Ischemia-Modified Albumin Levels during Pregnancy and Their Effect on Fetal Birth Weight
by Uğur Çobanoğlu, Özer Birge, Mustafa Çetin and Emine Seda Güvendağ Güven
Medicina 2024, 60(9), 1530; https://doi.org/10.3390/medicina60091530 - 19 Sep 2024
Viewed by 614
Abstract
Background and Objectives: The purpose of this study is to evaluate the impact of maternal ischemia-modified albumin (IMA) levels on pregnancy-related complications, fetal growth, and development over time. Materials and Methods: The prospective longitudinal and single-center study included 43 pregnant women [...] Read more.
Background and Objectives: The purpose of this study is to evaluate the impact of maternal ischemia-modified albumin (IMA) levels on pregnancy-related complications, fetal growth, and development over time. Materials and Methods: The prospective longitudinal and single-center study included 43 pregnant women ages 18 to 43. Routine pregnancy follow-up began at the first antenatal examination for all pregnant women before 14 weeks gestation, with IMA levels measured during the first, second, and third trimesters. The albumin cobalt binding test was used to determine the amount of ischemia-modified albumin (IMA). The patients’ medical, sociodemographic, and nutritional data were analyzed. The primary outcome was to investigate how changes in maternal ischemia affected albumin levels during pregnancy and the relationship between these changes and newborn weight. Results: This study included 43 cases with a mean age of 28.5 ± 5.2 years and a mean gestation period of 39.2 ± 1.3 weeks. The mean IMA levels for cases in the first trimester, second trimester, and third trimester were 0.53 ± 0.06, 0.64 ± 0.11, and 0.64 ± 0.06, respectively. The second and third trimesters showed significantly higher levels of ischemia-modified albumin (IMA) than the first trimester (p < 0.01). There was no statistically significant difference in IMA levels between the second and third trimesters (p = 1.000; p > 0.05). There was no statistically significant correlation between fetal birth and percentage changes in IMA measurements between the first and second trimesters, the first and third trimesters, or the second and third trimesters (p > 0.05). Conclusions: Our study determined that maternal ischemia-modified albumin levels during pregnancy did not correlate with fetal birth weight. Our findings revealed that age, sociodemographic changes, BMI, weight gain, and pregnancy complications had no effect on the change in IMA levels during pregnancy. We believe that this result will serve as a benchmark for future studies on IMA levels during pregnancy. Full article
(This article belongs to the Section Obstetrics and Gynecology)
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<p>Relationship between gestational age and II–III trimester IMA percentage change (Pearson correlation coefficient 0.306).</p>
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14 pages, 4006 KiB  
Review
Mortality Risk and Antibiotic Therapy for Patients with Infections Caused by Elizabethkingia Species—A Meta-Analysis
by Chienhsiu Huang, Sufang Kuo and Lichen Lin
Medicina 2024, 60(9), 1529; https://doi.org/10.3390/medicina60091529 - 19 Sep 2024
Viewed by 744
Abstract
Background and Objectives: Patients with infections caused by Elizabethkingia species require prompt identification and effective antibiotic treatment since these spp. are typically resistant to multiple antibiotics and variable susceptibility patterns. Understanding the mortality risk of this disease is difficult because of the [...] Read more.
Background and Objectives: Patients with infections caused by Elizabethkingia species require prompt identification and effective antibiotic treatment since these spp. are typically resistant to multiple antibiotics and variable susceptibility patterns. Understanding the mortality risk of this disease is difficult because of the relatively low incidence of infections caused by Elizabethkingia spp. and the lack of published systematic evaluations of the risk factors for mortality. The aim of the present study was to investigate risk factors for mortality in patients with infections caused by Elizabethkingia spp. by conducting a meta-analysis of existing studies on these infections. Materials and Methods: Studies comparing patients who died from infections caused by Elizabethkingia spp. with patients who survived were considered for inclusion. Studies that reported one or more risk factors for mortality were considered. Clinical predisposing variables, predisposing comorbidities, and clinical outcomes of antibiotic treatment were among the risk factors for mortality. Results: The meta-analysis included twenty studies with 990 patients, and 298 patients (30.1%) died. The following risk factors for mortality were identified: intensive care unit admission, the need for mechanical ventilation, immunosuppressive or steroid therapy use, pneumonia, comorbid liver disease, and the use of inappropriate antimicrobial therapy. Conclusions: The use of appropriate antimicrobial therapy is critical for the effective management of infections caused by Elizabethkingia spp. Antimicrobial susceptibility testing would be a more reliable means of guiding treatment. The identification of the best antimicrobial drugs is needed to ensure optimal treatment recommendations for treating Elizabethkingia-related infections. Full article
(This article belongs to the Section Infectious Disease)
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<p>Flow diagram of the study selection process.</p>
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<p>Mortality in patients with and without pneumonia [<a href="#B14-medicina-60-01529" class="html-bibr">14</a>,<a href="#B16-medicina-60-01529" class="html-bibr">16</a>,<a href="#B20-medicina-60-01529" class="html-bibr">20</a>,<a href="#B22-medicina-60-01529" class="html-bibr">22</a>,<a href="#B24-medicina-60-01529" class="html-bibr">24</a>,<a href="#B33-medicina-60-01529" class="html-bibr">33</a>,<a href="#B34-medicina-60-01529" class="html-bibr">34</a>,<a href="#B35-medicina-60-01529" class="html-bibr">35</a>,<a href="#B36-medicina-60-01529" class="html-bibr">36</a>,<a href="#B39-medicina-60-01529" class="html-bibr">39</a>,<a href="#B40-medicina-60-01529" class="html-bibr">40</a>,<a href="#B41-medicina-60-01529" class="html-bibr">41</a>,<a href="#B42-medicina-60-01529" class="html-bibr">42</a>,<a href="#B43-medicina-60-01529" class="html-bibr">43</a>,<a href="#B44-medicina-60-01529" class="html-bibr">44</a>].</p>
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<p>Mortality in patients with and without ICU admission [<a href="#B20-medicina-60-01529" class="html-bibr">20</a>,<a href="#B21-medicina-60-01529" class="html-bibr">21</a>,<a href="#B24-medicina-60-01529" class="html-bibr">24</a>,<a href="#B34-medicina-60-01529" class="html-bibr">34</a>,<a href="#B36-medicina-60-01529" class="html-bibr">36</a>,<a href="#B40-medicina-60-01529" class="html-bibr">40</a>].</p>
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<p>Mortality in patients with and without mechanical ventilation [<a href="#B14-medicina-60-01529" class="html-bibr">14</a>,<a href="#B19-medicina-60-01529" class="html-bibr">19</a>,<a href="#B21-medicina-60-01529" class="html-bibr">21</a>,<a href="#B24-medicina-60-01529" class="html-bibr">24</a>,<a href="#B36-medicina-60-01529" class="html-bibr">36</a>,<a href="#B40-medicina-60-01529" class="html-bibr">40</a>].</p>
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<p>Mortality in patients receiving immunosuppressive or steroid therapy and not receiving such therapy [<a href="#B14-medicina-60-01529" class="html-bibr">14</a>,<a href="#B19-medicina-60-01529" class="html-bibr">19</a>,<a href="#B20-medicina-60-01529" class="html-bibr">20</a>,<a href="#B22-medicina-60-01529" class="html-bibr">22</a>,<a href="#B24-medicina-60-01529" class="html-bibr">24</a>,<a href="#B34-medicina-60-01529" class="html-bibr">34</a>,<a href="#B40-medicina-60-01529" class="html-bibr">40</a>,<a href="#B42-medicina-60-01529" class="html-bibr">42</a>].</p>
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<p>Mortality in patients with and without liver disease6 [<a href="#B14-medicina-60-01529" class="html-bibr">14</a>,<a href="#B16-medicina-60-01529" class="html-bibr">16</a>,<a href="#B20-medicina-60-01529" class="html-bibr">20</a>,<a href="#B22-medicina-60-01529" class="html-bibr">22</a>,<a href="#B33-medicina-60-01529" class="html-bibr">33</a>,<a href="#B37-medicina-60-01529" class="html-bibr">37</a>,<a href="#B38-medicina-60-01529" class="html-bibr">38</a>,<a href="#B40-medicina-60-01529" class="html-bibr">40</a>,<a href="#B41-medicina-60-01529" class="html-bibr">41</a>,<a href="#B42-medicina-60-01529" class="html-bibr">42</a>,<a href="#B44-medicina-60-01529" class="html-bibr">44</a>].</p>
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<p>Mortality in patients receiving inappropriate and appropriate antibiotic therapy [<a href="#B20-medicina-60-01529" class="html-bibr">20</a>,<a href="#B22-medicina-60-01529" class="html-bibr">22</a>,<a href="#B24-medicina-60-01529" class="html-bibr">24</a>,<a href="#B36-medicina-60-01529" class="html-bibr">36</a>,<a href="#B37-medicina-60-01529" class="html-bibr">37</a>,<a href="#B40-medicina-60-01529" class="html-bibr">40</a>].</p>
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