Yield of Brain MRI in Clinically Diagnosed Epilepsy in the Kingdom of Bhutan: A Prospective Study

Background: People with epilepsy (PWE) in low- and middle-income countries may not access the health resources that are considered optimal for epilepsy diagnosis. The diagnostic yield of magnetic resonance imaging (MRI) has not been well studied in these settings. Objectives: To report the diagnostic yield of brain MRI and identify clinical associations of abnormal MRI findings among PWE in a neurocysticercosis-endemic, resource-limited setting and to identify the proportion and putative structural brain causes of drug-resistant epilepsy. Methods: PWE were prospectively enrolled at the Jigme Dorji Wangchuck National Referral Hospital in Bhutan (2014-2015). Each participant completed clinical questionnaires and a 1.5-Tesla brain MRI. Each MRI was reviewed by at least 1 radiologist and neurologist in Bhutan and the United States. A working definition of drug-resistant epilepsy for resource-limited settings was given as (a) seizures for >1 year, (b) at least 1 seizure in the prior year, and (c) presently taking 2 or more antiepileptic drugs (AEDs). Logistic regression models were constructed to test the cross-sectional association of an abnormal brain MRI with clinical variables. Findings: A total of 217 participants (125 [57%] female; 54 [25%] neurocysticercosis (n = 26, 12%, including 1 child) and congenital/perinatal abnormalities (n = 29, 14%, including 14 children). The number of AEDs (odds ratio = .59, 'P' = .03) and duration of epilepsy (odds ratio = 1.11, 'P' = .02) were significantly associated with an abnormal MRI. Seizure in the prior month was associated with the presence of mesial temporal sclerosis (odds ratio = .47, 'P' = .01). A total of 25 (12%) participants met our definition of drug-resistant epilepsy, with mesial temporal sclerosis (n = 10), congenital malformations (n = 5), and neurocysticercosis (n = 4) being the more common findings. Conclusions: The prevalence of abnormalities on brain MRI for PWE in resource-limited settings is high as a result of a diffuse range of etiologies, most commonly mesial temporal sclerosis. Drug-resistant epilepsy accounted for 12% of the referral population in a conservative estimation

A Missense Variant in PTPN22 is a Risk Factor for Drug-induced Liver Injury

Background & Aims We performed genetic analyses of a multiethnic cohort of patients with idiosyncratic drug-induced liver injury (DILI) to identify variants associated with susceptibility. Methods We performed a genome-wide association study of 2048 individuals with DILI (cases) and 12,429 individuals without (controls). Our analysis included subjects of European (1806 cases and 10,397 controls), African American (133 cases and 1,314 controls), and Hispanic (109 cases and 718 controls) ancestry. We analyzed DNA from 113 Icelandic cases and 239,304 controls to validate our findings. Results We associated idiosyncratic DILI with rs2476601, a nonsynonymous polymorphism that encodes a substitution of tryptophan with arginine in the protein tyrosine phosphatase, nonreceptor type 22 gene (PTPN22) (odds ratio [OR] 1.44; 95% confidence interval [CI] 1.28–1.62; P = 1.2 × 10–9 and replicated the finding in the validation set (OR 1.48; 95% CI 1.09–1.99; P = .01). The minor allele frequency showed the same effect size (OR > 1) among ethnic groups. The strongest association was with amoxicillin and clavulanate-associated DILI in persons of European ancestry (OR 1.62; 95% CI 1.32–1.98; P = 4.0 × 10–6; allele frequency = 13.3%), but the polymorphism was associated with DILI of other causes (OR 1.37; 95% CI 1.21–1.56; P = 1.5 × 10–6; allele frequency = 11.5%). Among amoxicillin- and clavulanate-associated cases of European ancestry, rs2476601 doubled the risk for DILI among those with the HLA risk alleles A*02:01 and DRB1*15:01. Conclusions In a genome-wide association study, we identified rs2476601 in PTPN22 as a non-HLA variant that associates with risk of liver injury caused by multiple drugs and validated our finding in a separate cohort. This variant has been associated with increased risk of autoimmune diseases, providing support for the concept that alterations in immune regulation contribute to idiosyncratic DILI

Wind-driven ventilation improvement with plan typology alteration: a CFD case study of traditional Turkish architecture

Aligned with achieving the goal of net-zero buildings, the implementation of energy-saving techniques in minimizing energy demands is proving more vital than at any time. As practical and economic options, passive strategies in ventilation developed over thousands of years have shown great potential for the reduction of residential energy demands, which are often underestimated in modern building’s construction. In particular, as a cost-effective passive strategy, wind-driven ventilation via windows has huge potential in the enhancement of the indoor air quality (IAQ) of buildings while simultaneously reducing their cooling load. This study aims to investigate the functionality and applicability of a common historical Turkish architectural element called “Cumba” to improve the wind-driven ventilation in modern buildings. A case study building with an archetypal plan and parameters was defined as a result of a survey over 111 existing traditional samples across Turkey. Buildings with and without Cumba were compared in different scenarios by the development of a validated CFD microclimate model. The results of simulations clearly demonstrate that Cumba can enhance the room’s ventilation rate by more than two times while harvesting wind from different directions. It was also found that a flexible window opening strategy can help to increase the mean ventilation rate by 276%. Moreover, the room’s mean air velocity and ventilation rate could be adjusted to a broad range of values with the existence of Cumba. Thus, this study presents important findings about the importance of plan typology in the effectiveness of wind-driven ventilation strategies in modern dwellings

New approach in transanal endoscopy microsurgery

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Laparoscopic ultrasonography as a good alternative to intraoperative cholangiography (IOC) during laparoscopic cholecystectomy: results of prospective study.

Intraoperative cholangiography (IOC), used routinely or selectively, is the standard method for bile duct imaging during cholecystectomy. Laparoscopic ultrasonography (LUS) has emerged as a possible, safe and quick alternative. This study examined the evolving use and the performance of these two methods as primary technique for routine bile duct imaging, so as to detect common bile duct stones (CBDS) and to prevent common bile duct injury (CBDI). A prospective database permitted to evaluate the results of the two methods in 968 consecutive cholecystectomies. Nine hundered and twenty five were performed by laparoscopy, 18 (1.9%) by laparotomy and 25 (2.6) necessitated a conversion. The systematic use of the IOC was gradually replaced by a systematic use of the LUS. The success to delineate and evaluate the CBD, the detection of a CBDS, any type of bile duct complication, especially of CBDI, were registered. All the CBDS suspected by LUS were controlled by IOC. The patients were followed during 1 and 6 months. Six hundred and eighty five IOC and 269 LUS were performed. The procedure was technically unsuccessful in 35 IOC (5.1%) (mainly due to difficulty in catheterising the cystic duct) and in 2 LUS (1%) (due to steatosis). Concerning the detection of CBDS, 31 were detected by IOC (4.5%) and 16 by LUS (6%). Five IOC were considered as false positive, 1 as false negative (sensitivity and specificity of 96,9 and 99,2%) and 1 LUS as false positive (sensitivity and specificity of 100 and 99,6%). Five CBDI were detected in the complete seria: 2 during the dissection before the IOC, 1 thermic injury, 1 late stenosis, 1 lateral stenosis by the cystic clip detected by LUS. However none of these CBDI could have been prevented by IOC. In our experience, in this prospective study, LUS has been certainly as effective as IOC as a primary imaging technique for bile duct. It permitted to detect CBDS with a high specificity and sensitivity, and CBDS and was not followed by an increase in CBDI

In-depth Clinical, Haemodynamic and Volumetric Assessment of the RAPID-type Auxiliary Liver Transplantation; Are We Simply Dealing with a Transplant Model of ALPPS?

Purpose: RAPID (Resection And Partial Liver Transplantation with Delayed total hepatectomy) consists of a left hepatectomy associated with orthotopic implantation of a left lobe. The rapid volumetric increase of the graft allows a right completion hepatectomy within 15 days. The technical difficulties encountered in this complex procedure are significant and there are still few cases described in the literature. Methods: Six donors and 6 recipients undergoing RAPID transplantation were included in a prospective single-centre protocol. We analyse the early kinetics growth rate (eKGR) by comparing it to that observed in patients receiving a partial graft alone. We performed intraoperative flow and pressure measurements in all patients. Data on conventional Living Donor Liver Transaplantation (LDLT) recipient were extracted retrospectively. We performed sequential hepatobiliary scintigraphy. Results: The indication for transplantation was colorectal and neuroendocrine metastases. Mean Graft-Recipient Weight Ratio was 0,41. No patient presented with Small-for-Size syndrome. 90 days mortality was 16.6%. The mean follow-up for the 5 living recipients was 648 days without associated morbidity. The clinical course of the donors was unremarkable. There was no difference in eKGR between RAPID and LDLT grafts. The indexed portal flow was significantly higher in RAPID than in LDLT. The technique exposes small volume grafts (GRWR <0.5) to full porto-mesenteric flow but this hyperflow only requires surgical modulation in 1 in 6 cases.Sequential analysis eKGR shows no linearity. It was greater in the first week than in the second week after transplantation: mean volume increase of 70.17±27.13% versus 24±12.77%. Conclusions: We highlight the excellent clinical results of the RAPID surgical technique despite initial graft volumes well below those recommended for conventional LDLT. The initial hypothesis of accelerated surgical liver regeneration has not been established: the growth rate of the grafts in the RAPID model corresponds to that found in LDLT

Analysis of Environmental Impact and Waste Management of Egg Poultry Industry in the Philippines: A Case of San Jose, Batangas

The poultry industry produces a lot of waste, and environmental issues grow as the egg industry expands. Poultry owners in the Philippines, notably in San Jose, Batangas, face numerous waste management concerns. This study examined these issues as well as their environmental safety policies. San Jose, in Batangas province, is renowned as "The Egg Basket of the Philippines" for its large-scale egg production. This study collected data using qualitative descriptive analysis. The poultry farms in the municipality were about 376 as of 2021, but with no definite total number of poultry owners. Interviews with the municipal agriculturist and ten poultry owners was utilized. The study revealed substantial waste management difficulties such as manure disposal, water and air pollution, odor disturbance and insects, weather conditions, and virus outbreaks (bird flu). The study's concerning SDGs were 6 (Clean Water and Sanitation) and 12 (Responsible Consumption and Production). Waste disposal over the past decades still poses a threat to the environment. The local government adopted poultry ordinances/resolutions: Resolution 164 of 2008, Resolution 341 of 2016, and Resolution 348 of 2016/Ordinance 007 series of 2016. These policies and initiatives were concluded to be environmentally friendly, but most poultry owners lack awareness of the said policies. Awareness is vital for better policy responses, and the municipality needs to develop its information dissemination. It is essential to improve waste management policies and farm monitoring methods. The local government should implement concrete socioeconomic and environmental programs to empower residents and poultry owners, especially the younger generation, and improve the municipality's knowledge of waste management techniques

Belgian prospective registry on laparoscopic liver surgery compared to open procedures: 3-year snapshot of multi centric activity

The Belgian Registry on Laparoscopic Liver Surgery is a prospective, non-compulsory, online registry of laparoscopic (LLS) and open (OLS) liver procedures, endorsed in 2016 by the Belgian Section of Hepato-Biliary and Pancreatic Surgery. The primary aim is to assess the evolution of laparoscopic liver surgery compared to the standard open approach in Belgium. Methods: Participating centers included, through a secured SSL server (www.brells.org), all consecutive liver surgeries from 2017 to 2019. Demographic, pre- intra- and postoperative data of all consecutive LLS and OLS were recorded. Results: In total 13 centers participated to the study. 1531 procedures were recorded (841 LLS and 690 OLS) in 1408 patients. Demographics of patients were similar between LLS and OLS. Indication for surgery were 57% liver metastases (49% LLS, 51% OLS), 29% primary liver tumors (57% LLS, 43% OLS) and 16% benign diseases (73%LLS, 27% OLS). Exclusive local thermal ablation (LA) accounted for 118 procedures. Excluding LA from analysis, rate of major hepatectomies was 18,2% (n=258) and median Ghent difficulty score was 5,6 (4,8 LLS vs 6,5 OLS). LLS were converted to OLS in 3,3% of cases. Overall morbidity and mortality were significantly lower in LLS compared to OLS respectively 27% vs 53% and 0,6% vs 2,9%. Length of hospital stay was significantly shorter in LLS (Median 4 vs 7 days). Conclusions: LLS are wide spreading in Belgium accounting globally to 55% of all liver surgeries. In selected patients, LLS are safe, advantageous and reproducible in major HPB centers. A low morbidity has been prospectively confirmed