Small Bowel Obstruction Secondary to a Metamucil Bezoar: Case Report and Review of the Literature

Bezoar-induced small bowel obstruction is a rare entity. It should be highly suspected in patients with gastric hypomotility disorders, psychiatric conditions, prior abdominal or bariatric surgery, or improper intake of medication. Their diagnosis is quite challenging and surgical exploration remains the best treatment of choice to ensure the viability of the small bowel tissue and relieve the obstruction. This is a case of a 48-year-old female with no previous abdominal surgery who presented with acute abdominal pain. The patient’s history was remarkable for the daily ingestion of 1.5 teaspoons of Metamucil with minimal amount of water. Computed tomography scan demonstrated dilated small bowel loops and a transition zone at the level of the mid jejunum. On laparoscopy, the patient was found to have a hard mass in the mid jejunum amenable to gentle fragmentation and breakdown. Metamucil bezoars are due to the solidification of psyllium-based substances in the gastrointestinal tract. The usual management of small bowel obstruction induced by a bezoar is exploratory laparotomy with enterotomy and primary anastomosis. Laparoscopic intervention has gained popularity among surgeons with good outcome and lower morbidity. In this unusual case, the small bowel obstruction induced by the Metamucil bezoar was safely treated with laparoscopic fragmentation alone

Health care workers in conflict and post-conflict settings: Systematic mapping of the evidence

Background Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict. Objective The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale. Methods We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme. Results Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%). Conclusions This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters

Use of Evidence-Based Practice Among Athletic Training Educators, Clinicians, and Students, Part 1: Perceived Importance, Knowledge, and Confidence

Context: Although evidence-based practice (EBP) has become more prevalent, athletic trainers\u27 perceptions of importance and knowledge of these concepts and their confidence in EBP are largely unknown. Objective: To assess perceived importance and knowledge of and confidence in EBP concepts in athletic trainers in various roles and with different degree levels. Design: Cross-sectional study. Setting: Online survey instrument. Patients or Other Participants: The survey was sent to 6702 athletic training educators, clinicians, and postprofessional students. A total of 1209 completed the survey, for a response rate of 18.04%. Main Outcome Measure(s): Demographic information and perceived importance and knowledge of and confidence in the steps of EBP were obtained. One-way analysis of variance, a Kruskal-Wallis test, and an independent-samples t test were used to determine differences in scores among the demographic variables. Results: Athletic trainers demonstrated low knowledge scores (64.2% ± 1.29%) and mild to moderate confidence (2.71 ± 0.55 out of 4.0). They valued EBP as moderately to extremely important (3.49 ± 0.41 out of 4.0). Perceived importance scores differed among roles (clinicians unaffiliated with an education program scored lower than postprofessional educators, P = .001) and highest educational degree attained (athletic trainers with terminal degrees scored higher than those with bachelor\u27s or master\u27s degrees, P \u3c .001). Postprofessional athletic training students demonstrated the highest total EBP knowledge scores (4.65 ± 0.91), whereas clinicians demonstrated the lowest scores (3.62 ± 1.35). Individuals with terminal degrees had higher (P \u3c .001) total knowledge scores (4.31 ± 1.24) than those with bachelor\u27s (3.78 ± 1.2) or master\u27s degrees (3.76 ± 1.35). Postprofessional educators demonstrated greater confidence in knowledge scores (3.36 ± 0.40 out of 4.0) than did those in all other athletic training roles (P \u3c .001). Conclusions: Overall knowledge of the basic EBP steps remained low across the various athletic trainers\u27 roles. The higher level of importance indicated that athletic trainers valued EBP, but this value was not reflected in the knowledge of EBP concepts. Individuals with a terminal degree possessed higher knowledge scores than those with other educational preparations; however, EBP knowledge needs to increase across all demographics of the profession

Hub Angle Control for A Single Link Flexible Manipulator Based on Cuckoo Search Algorithm

Flexible manipulators are one of the promising devices that can be applied in many fields especially in automation and manufacturing fields as they are designed to reduce energy consumption and increase the speed of operation. However, agitation process experienced in the complex structure of the system which causes unwanted vibration will affect the precision of operation. Thus, an efficient control system is required to make them functional. Therefore, the development of an accurate model of flexible manipulator was presented prior to establishing active vibration control to suppress the vibration and increase efficiency of the system. This paper presents the development of a Proportional-IntegralDerivative controller based on cuckoo search algorithm for a single link flexible manipulator system. Initially, the system was modelled using input and output experimental data of the hub angle. System identification was implemented via swarm intelligence algorithm known as cuckoo search algorithms based on auto regressive with exogenous model structure. Then, the performance of proposed algorithms was validated based on three robustness methods known as mean squared error, pole zero diagram stability and correlation tests. The simulation results showed superior performance of cuckoo search algorithm by achieving lowest mean squared error, good correlation tests and high root locus stability. Then, the cuckoo search model was implemented in the proposed control scheme with the aim of accurate positioning at the end point of flexible manipulator

The trend of disruption in the functional brain network topology of Alzheimer’s disease

Alzheimer’s disease (AD) is a progressive disorder associated with cognitive dysfunction that alters the brain’s functional connectivity. Assessing these alterations has become a topic of increasing interest. However, a few studies have examined different stages of AD from a complex network perspective that cover different topological scales. This study used resting state fMRI data to analyze the trend of functional connectivity alterations from a cognitively normal (CN) state through early and late mild cognitive impairment (EMCI and LMCI) and to Alzheimer’s disease. The analyses had been done at the local (hubs and activated links and areas), meso (clustering, assortativity, and rich-club), and global (small-world, small-worldness, and efficiency) topological scales. The results showed that the trends of changes in the topological architecture of the functional brain network were not entirely proportional to the AD progression. There were network characteristics that have changed non-linearly regarding the disease progression, especially at the earliest stage of the disease, i.e., EMCI. Further, it has been indicated that the diseased groups engaged somatomotor, frontoparietal, and default mode modules compared to the CN group. The diseased groups also shifted the functional network towards more random architecture. In the end, the methods introduced in this paper enable us to gain an extensive understanding of the pathological changes of the AD process

Functional Variant in Complement C3 Gene Promoter and Genetic Susceptibility to Temporal Lobe Epilepsy and Febrile Seizures

BACKGROUND: Human mesial temporal lobe epilepsies (MTLE) represent the most frequent form of partial epilepsies and are frequently preceded by febrile seizures (FS) in infancy and early childhood. Genetic associations of several complement genes including its central component C3 with disorders of the central nervous system, and the existence of C3 dysregulation in the epilepsies and in the MTLE particularly, make it the C3 gene a good candidate for human MTLE. METHODOLOGY/PRINCIPAL FINDINGS: A case-control association study of the C3 gene was performed in a first series of 122 patients with MTLE and 196 controls. Four haplotypes (HAP1 to 4) comprising GF100472, a newly discovered dinucleotide repeat polymorphism [(CA)8 to (CA)15] in the C3 promoter region showed significant association after Bonferroni correction, in the subgroup of MTLE patients having a personal history of FS (MTLE-FS+). Replication analysis in independent patients and controls confirmed that the rare HAP4 haplotype comprising the minimal length allele of GF100472 [(CA)8], protected against MTLE-FS+. A fifth haplotype (HAP5) with medium-size (CA)11 allele of GF100472 displayed four times higher frequency in controls than in the first cohort of MTLE-FS+ and showed a protective effect against FS through a high statistical significance in an independent population of 97 pure FS. Consistently, (CA)11 allele by its own protected against pure FS in a second group of 148 FS patients. Reporter gene assays showed that GF100472 significantly influenced C3 promoter activity (the higher the number of repeats, the lower the transcriptional activity). Taken together, the consistent genetic data and the functional analysis presented here indicate that a newly-identified and functional polymorphism in the promoter of the complement C3 gene might participate in the genetic susceptibility to human MTLE with a history of FS, and to pure FS. CONCLUSIONS/SIGNIFICANCE: The present study provides important data suggesting for the first time the involvement of the complement system in the genetic susceptibility to epileptic seizures and to epilepsy

A new integrated assessment framework for climate-smart nutrition security in sub-Saharan Africa : the integrated Future Estimator for Emissions and Diets (iFEED)

Funding statement This work was supported by the Biotechnology and Biological Sciences Research Council through UK Research and Innovation as part of the Global Challenges Research Fund, AFRICAP programme, grant number BB/P027784/1.Peer reviewedPublisher PD

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Etude à grande échelle des épilepsies temporales mésiales humaines pharmacorésistantes (altération de la neurotransmission et activation du système du complément dans le cortex entorhinal)

Les épilepsies temporales mésiales (ETM) humaines sont la forme la plus fréquente et la plus sévère d épilepsies partielles et sont très fréquemment réfractaires aux médicaments anti-épileptiques. Elles représentent à ces titres un véritable enjeu à la fois médical, scientifique et économique. Les ETM se développent généralement à la suite d une atteinte du système nerveux central comme les traumatismes crâniens, les infections, ou les convulsions fébriles. Cet événement initial entraînerait une série d événements cellulaires et moléculaires dans des aires spécifiques du cerveau. Ces modifications confèrent progressivement de nouvelles propriétés au tissu épileptogène, et conduiraient au développement de crises épileptiques spontanées récurrentes. Les crises limbiques sont souvent associées à la sclérose de l hippocampe, cependant différentes études ont également souligné le rôle majeur que joue le cortex entorhinal (CE) dans le réseau épileptogène. De plus, le CE présente moins d altérations histopathologiques que l hippocampe et les modifications moléculaires et cellulaires qui lui sont associées sont encore peu caractérisées. Malgré les avancées dans la compréhension de la pathogenèse des épilepsies, les mécanismes physiopathologiques des ETM sont encore mal connus et parmi les quelques études à grande échelle réalisées chez l Homme aucune n a analysé le CE. Un premier crible à grande échelle par cDNA microarray, et dans un second temps des expériences de validation par RT-PCR quantitative ont permis d identifier 6 gènes différentiellement exprimés dans le CE de patients ETM en comparaison avec le cortex temporal externe (CTE) (zone non épileptogène) issu des mêmes patients (contrôles internes), ainsi qu avec quatre contrôles autopsiques non épileptiques. Deux gènes codant pour des récepteurs de neurotransmetteurs (HTR2A et NPY1R) et un gène codant pour une protéine, FHL2, s associant à la préséniline et à la sous unité mink du canal potassium KCNE1 sont sous-exprimés et trois gènes codant pour des protéines du système immunitaire et du complément (CD99, CD74 et C3) sont sur-exprimés dans le CE des patients ETM. Les expériences de Western blot quantitatif et d immunomarquage ont ensuite permis de confirmer la sous-expression de NPY1R dans le CE des huit patients MTLE testés et la surexpression de C3 dans le CE de 7 parmi 11 patients testés. De plus, les expériences d immunomarquage ont révélé l existence d une activation locale du système du complément spécifiquement et exclusivement dans le cortex entorhinal des patients, sous forme d infiltrats périvasculaires de leucocytes C3+ et / ou de dépôts de C3 et/ou de complexes C5b-9 (membrane attack complex : MAC) à la surface de neurones dans le CE de la majorité des patients analysés (9 sur 11). Ces résultats montrent que la dérégulation locale des systèmes de neurotransmission et l activation du système du complément sont fréquemment associées à l évolution des MTLE humaines. Ces résultats ouvrent de nouvelles perspectives pour le développement de nouvelles stratégies préventives, diagnostiques et thérapeutiques, notamment ciblées sur les gènes candidats identifiés dans cette étude.Human mesial temporal lobe epilepsies (MTLE) are the most frequent form of partial epilepsies and display high frequency of drug-resistance. They represent a major medical and scientific issue and a major health care problem. Generally, epilepsy may develop as a consequence of a brain-damaging insult such as head trauma, stroke, brain infection, or febrile seizure (FS). This initial insult triggers a cascade of progressive and parallel cellular and molecular events in specific areas of the brain, which may in turn confer new properties to the epileptogenic tissue, and result in the development of spontaneous recurrent seizures. While limbic seizures have often been associated with hippocampus sclerosis, several studies have also highlighted the major role that play the entorhinal cortex (EC) in MTLE. EC displays les dramatic histological changes than the hippocampus, with few or no detectable cell loss, and the molecular and cellular events have been little studied. Despite some progress in the understanding of the pathogenesis of human MTLE, their molecular bases remain mainly undetermined. Few large-scale studies have been performed in human MTLE, and none has analysed the entorhinal cortex. A two-step transcriptional analysis consisting of cDNA microarray experiment followed by quantitative RT-PCR validations was performed in the entorhinal cortex (epileptogenic area) of MTLE patients, as compared with lateral temporal neocortex (LTC)(non-epileptogenic control area) obtained from the same patients as well as to non-epileptic autopsic controls. Six consistently dysregulated genes were identified: three up-regulated genes encode proteins involved in the immune response : CD99, CD74, C3; two downregulated genes encode neurotransmitter receptors NPY1R, HTR2A and a third one FHL2 encodes a protein associating with the KCNE1 (mink) potassium channel subunit and with presenilin-2. Analysis of the qualitative and quantitative changes at the protein level, led to the confirmation of NPY1R downregulation and C3 upregulation by western blot and immunohistochemistry respectively. Furthermore, immunohistochemistry experiment revealed the existence of perivascular infiltration of C3 positive leucocytes and/or detected C3 and membrane attack complexes on a subset of neurons within the EC of nine out of the eleven MTLE patients. Overall our data indicate that local dysregulation of the neurotransmission and complement system is a frequent event in human MTLE. These data open new avenues for understanding the molecular basis of these epilepsies. It also provide new perspectives for the future development of preventive, diagnostic and therapeutic strategies, directed towards the molecular targets that we have identified.AIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocPARIS-BIUP (751062107) / SudocSudocFranceF