Continuous theta burst stimulation for bipolar depression: A multicenter, double-blind randomized controlled study exploring treatment efficacy and predictive potential of kynurenine metabolites.

BACKGROUND: While theta burst stimulation (TBS) shows promise in Major Depressive Disorder (MDD), its effectiveness in bipolar depression (BD-D) remains uncertain. Optimizing treatment parameters is crucial in the pursuit of rapid symptom relief. Moreover, aligning with personalized treatment strategies and increased interest in immunopsychiatry, biomarker-based stratification of patients most likely to benefit from TBS might improve remission rates. We investigated treatment effectiveness of continuous TBS (cTBS) compared to sham in BD-D, and assessed the capacity of plasma kynurenine pathway metabolites to predict treatment outcome. METHODS: Thirty-seven patients with BD-D underwent accelerated active or sham cTBS treatment in a multicenter, double-blind, randomized controlled trial. Depressive symptoms were measured with the 17-item Hamilton Depression Rating Scale (HDRS-17) before treatment (T0), 3-4 days posttreatment (T1) and 10-11 days posttreatment (T2). Plasma tryptophan, kynurenine, kynurenic acid and quinolinic acid concentrations were quantified with ELISA. Linear mixed models were used for statistical analyses. RESULTS: Although the total sample showed depressive symptom improvement, active cTBS did not demonstrate greater symptom alleviation compared to sham. However, higher baseline quinolinic acid significantly predicted symptom improvement in the active treatment group, not in sham-stimulated patients. LIMITATIONS: The modest sample size limited the power to detect significant differences with regard to treatment effect. Also, the follow-up period was 10-11 days, whereas similar studies usually follow up for at least one month. CONCLUSION: More research is required to optimize cTBS for BD-D and explore the involvement of quinolinic acid in treatment outcome.

Acute Rejection Rates in Vascularized Composite Allografts: A Systematic Review of Case Reports.

INTRODUCTION: Vascularized Composite Allografts (VCA) are usually performed in a full major histocompatibility complex mismatch setting, with a risk of acute rejection depending on factors such as the type of immunosuppression therapy and the quality of graft preservation. In this systematic review, we present the different immunosuppression protocols used in VCA and point out relationships between acute rejection rates and possible factors that might influence it. METHODS: This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We systematically searched Medline (PubMed), Embase, and The Cochrane Library between November 2022 and February 2023, using following Mesh Terms: Transplant, Transplantation, Hand, Face, Uterus, Penis, Abdominal Wall, Larynx, and Composite Tissue Allografts. All VCA case reports and reviews describing multiple case reports were included. RESULTS: We discovered 211 VCA cases reported. The preferred treatment was a combination of antithymocyte globulins, mycophenolate mofetil (MMF), tacrolimus, and steroids; and a combination of MMF, tacrolimus, and steroids for induction and maintenance treatment, respectively. Burn patients showed a higher acute rejection rate (P = 0.073) and were administered higher MMF doses (P = 0.020). CONCLUSIONS: In contrast to previous statements, the field of VCA is not rapidly evolving, as it has encountered challenges in addressing immune-related concerns. This is highlighted by the absence of a standardized immunosuppression regimen. Consequently, more substantial data are required to draw more conclusive results regarding the immunogenicity of VCAs and the potential superiority of one immunosuppressive treatment over another. Future efforts should be made to report the VCA surgeries comprehensively, and muti-institutional long-term prospective follow-up studies should be performed to compare the number of acute rejections with influencing factors.

Autologous fat transfer for hand rejuvenation: A systematic review on technique and outcome.

Background: Age-related changes to the dorsum of the hand present as dyschromia, soft-tissue atrophy, and volume loss, resulting in wrinkles and prominent deep structures. Volume augmentation by means of autologous fat transfer (AFT) is one of the options to rejuvenate the hand; theoretically, autologous fat is the ideal filler because of durability and biocompatibility. Objective: This systematic review aims to summarize and describe the current evidence on the technique, effectiveness, and safety of AFT in hand rejuvenation. Methods: Three major databases, PubMed, Embase, and Web of Science, were systematically searched up to November 2020 for studies reporting on AFT and hand rejuvenation. Results: A total of 10 articles were included, reporting on a total of 320 patients treated by AFT to improve the aesthetic appearance of the dorsum of the hand. Some degree of postoperative oedema was present in nearly all patients. Other complications were infection (0.67%), cysts/irregularities (1.3%), temporary dysesthesia (5.3%), and ecchymosis (7%). There were no major complications. Of all patients, 97.6% self-reported to be satisfied with the result. Conclusions: Overall, by combining the current evidence, AFT is considered a promising and safe technique to rejuvenate the aging hand with very high patient satisfaction. Future research, using validated patient questionnaires, objective volumetric measurements, and longer follow-up, is needed to confirm these results. Level of Evidence: 3.

A submucosal bladder stone in a 65-year-old woman.

We describe a case of a 65-year-old woman with a submucosal bladder stone with no apparent underlying cause. She presented with lower abdominal pain, dysuria, and a history of recurrent cystitis. Ultrasound and computed tomography of the lower abdomen revealed the presence of lithiasis nearby to the left ostium. During ureterorenoscopy, stone was found neither in the bladder nor in the left ureter. Instead, we observed a macroscopic bulge close to the left ureter. After opening of the mucosa, a stone became visible and could be removed. Mostly, imaging of the calculus was done some time before surgery. During this time interval, it is a possibility that the stone has already passed the urinary tract. Our case illustrates that it is important for each patient to search for the calculus extensively to prevent needless symptoms and investigations.

GIANT BASAL CELL CARCINOMA ON THE FOREHEAD AND WHY WE SHOULD PREVENT THEM - CASE REPORT.

Basal cell carcinoma (BCC) is the most prevalent malignancy, with rising incidence worldwide. Despite its naturally slow growth and initially low metastatic potential, it can cause significant morbidity and mortality when unrecognized, inadequately treated or poorly followed up. Authors present the case of a 61-year-old male with a 7-year history of multiple incomplete excisions of a “simple” BCC on the forehead. A CT scan of the head revealed an invasive mass (5.2 cm laterolateral x 4.0 cm craniocaudal) in the frontal area. There was no evidence of metastasis. Complete resection of the lesion and reconstruction was achieved in three stages. Final reconstruction was achieved using a left frontal fasciocutaneous flap. The secondary defect was closed with an advancement flap of the scalp and donor sites were covered using a split-thickness skin graft from the upper limb. This case demonstrates the necessity for vigilance in the approach to, diagnosis, treatment and follow-up of these skin neoplasms. The development of giant BCCs should be avoided at all costs. Increased size of BCCs corresponds with increased recurrence rate, metastatic rate, morbidity, mortality, treatment difficulties and overall costs.

A prospective randomized double-blind trial of the efficacy of a bilateral lumbar erector spinae block on the 24h morphine consumption after posterior lumbar inter-body fusion surgery.

BACKGROUND: Spine surgery is associated with considerable postoperative pain and can be challenging to treat. A loco-regional technique suitable for spine surgery should cover the dorsal root of the spinal nerves at the levels where surgery is performed. The erector spinae block is a loco-regional technique with promising results and was recently described at the thoracic level. There are no randomized trials of this technique on a lumbar level. This study tests the hypothesis that the 24-h postoperative morphine consumption is significantly lower in patients undergoing posterior lumbar inter-body fusion surgery with a lumbar erector spinae (LUMBES) block when compared with a sham block. METHODS: This prospective randomized double-blind multicenter study will randomly allocate 80 adult patients undergoing elective posterior lumbar inter-body fusion surgery during general anesthesia to one of two groups as follows: (1) bilateral erector spinae block (20 mL 0.25% levobupivacaine) or (2) bilateral sham block (20 mL NaCl 0.9%). Our primary endpoint is 24-h postoperative morphine consumption. Secondary endpoints include 72-h morphine consumption, intraoperative sufentanil dosage, postoperative pain scores at regular time intervals both at rest and during movement, time to first postoperative mobilization, and the Quality of Recovery 40 survey score. DISCUSSION: The LUMBES trial is a pragmatic clinical study that will provide evidence of whether a bilateral lumbar erector spinae block is effective in reducing 24-h postoperative morphine consumption in patients undergoing lumbar inter-body fusion surgery. If this hypothesis is confirmed, this finding could contribute to more widespread implementation of this technique. TRIAL REGISTRATION: Local ethics committee B300201837508, ClinicalTrials.gov identifier: NCT03825198 . Registered on 31 Jan 2019.

Sarcopenia in patients with non-alcoholic fatty liver disease: is it a clinically significant entity?

Sarcopenia, described as the loss of muscle mass and/or strength, is gaining importance as it can be increasingly related to many chronic diseases. It is also associated with chronic liver disease, and recently it has been more frequently linked to non-alcoholic fatty liver disease (NAFLD) in particular. Both sarcopenia and NAFLD are subject to complex and intermingled pathophysiological processes, of which some are in common. Furthermore, it is presently unclear if sarcopenia directly contributes to NAFLD or vice versa. The mechanisms that are involved may include obesity, insulin resistance, vitamin D deficiency, aging, physical inactivity and certain cytokines. Current clinical evidence is subject to an important heterogeneity in methods and definitions, with additionally also a relative overrepresentation of evidence in Asian ethnicities. Nonetheless, all studies so far point towards the same association between sarcopenia and NAFLD, including an association with NAFLD-severity and NAFLD-related fibrosis. Since the field is in its infancy, clear definitions and further research are needed to aid to improve understanding of the association between NAFLD and sarcopenia. This can eventually lead to additional potential therapeutic interventions. This review attempts to give an overview of the current published literature that links sarcopenia to NAFLD, followed by a discussion of the presumably involved pathophysiological factors, and ends by discussing current unmet needs.

Laboratory and field validation of a combined NO2-SO2 Radiello passive sampler.

A combined NO2-SO2 Radiello radial-type diffusive sampler was validated under controlled laboratory conditions and compared with NO2-SO2 results of 3 other type of samplers in a field comparison at two locations Ghent-Mariakerke and Borgerhout in Flanders. Laboratory exposures at different temperatures (-5, 10 and 30 degrees C) and relative humidities (0, 50 and 80% RH) in combination with varying concentration levels and exposure times were carried out, with a focus on extreme conditions. Concentration level and exposure time were changed together following suppliers linear working range of samplers and assuring absolute amounts of compounds on the sampler corresponding to those of environmental levels. The average uptake rate for NO2 for 24 hour exposures at 10 degrees C and 50% RH and tested concentration levels (+/-73, 146 and 293 ppb NO2) was 0.076 +/- 0.011 ng ppb(-1) min(-1). Uptake rates during all experiments were lower than the uptake rate given in the instruction manual of the sampler. A significant effect of temperature and relative humidity on NO2 uptake rate was observed. The temperature effect from 10 to 30 degrees C corresponds to the temperature effect given by the supplier of the samplers. High relative humidity (70 to 80%) caused a strong non-reproducible decrease of uptake rate for NO2 at 24 hour experiments but this effect was not observed at longer exposures except for the tests at -5 degrees C. At the tested temperature below zero in combination with high relative humidity the sampler showed anomalous behaviour for NO2. The possible effect of concentration level and exposure time for NO2 needs further research. The average uptake rate for SO2 calculated from all exposures is 0.478 +/- 0.075 ng of sulfate ion each ppb min of SO2 and accords to suppliers uptake rate. No clear effects of temperature, relative humidity or concentration level/exposure time on the uptake rate for SO2 were found, partly due to the large scatter of results. Although NO2 accuracy of Radiello samplers was better during field campaigns than during laboratory validation, IVL and OGAWA samplers gave better results for NO2. In the field, IVL samplers showed best agreement with the continuous analyzers for both NO2 and SO2.

Effect of backyard burning on dioxin deposition and air concentrations.

The influence from open burning of garden and household waste on locally measured dioxin deposition and air concentrations was evaluated in three sets of experiments: the combustion of garden waste in barrels and in open fires, and the incineration of household waste in an empty oil drum. Each set was composed of eight individual experiments over 4 h. Deposition gauges were located 20 m NE, SE, SW and NW with respect to the source and on a background location at 400 m SW. Air samples were taken in the plume with a medium volume sampler equipped with a quartz filter and a polyurethane plug. The results illustrate deposition increments in the wind direction at a distance of 20 m from the source of 0.8 pg TEQ/m2 day for garden waste and 2.5 pg TEQ/m2 day for household waste. Concentrations in the plume were increased by 160-580 fg TEQ/m3 over a period of 12 and 31 h respectively. Expressed at a reference CO2 concentration of 9% this corresponds with a range from 0.8 to 3.6 ng TEQ/m3, which is comparable with a poorly controlled MSWI. Emission factors in the order of magnitude of 4.5 ng TEQ/kg combusted garden waste and 35 ng TEQ/kg burned municipal waste were determined.

Health risk assessment of dioxin emissions from municipal waste incinerators: the Neerlandquarter (Wilrijk, Belgium).

Two municipal waste incinerators in the vicinity of a residential area close to the city of Antwerp caused concern to local habitants. Risk assessment was performed combining chemical, toxicological measurements and model calculations. As the first step in risk assessment an inventory was made of historic emissions from both incinerators with emphasis on dioxins. The operational atmospheric transport and deposition model for priority substances (OPS) was used to calculate the deposition of dioxins in the vicinity of incinerators. The observed soil contamination pattern did not correspond to the calculated deposition pattern, indicating that other sources may contribute at least partly to the local PCDD/PCDF contamination of the area. Dioxin exposure of people in the Neerlandquarter as a function of the food consumption behavior was calculated using a mathematical model (VLIER-HUMAAN) combined with transfer factors. According to the results of these calculations, just residing in the impact area does not result in a meaningful risk. Only if locally produced food was consumed (milk, meat and vegetables), exposure in the Neerlandquarter was enhanced compared to the average dioxin exposure estimated for the Flemish population. Exposure in 1997 was below the exposure in 1980. As a consequence of different eating habits and lower bodyweight, children are subjected to significantly higher exposure than adults. Adverse health outcomes from dioxin exposure in the past cannot be excluded. There was no evidence for enhanced exposure to genotoxicants based on a comparison of chromosomal damage to blood cells of children from the study area to those from a control group.

Air pollution measurements in traffic tunnels.

Air pollution measurements during April 1991 are reported from the Craeybeckx highway tunnel in Antwerp, Belgium. The tunnel was used daily by an average of 45,000 vehicles, of which 60% were gasoline fueled passenger cars, 20% diesel cars, and 20% trucks. Of the gasoline cars, only 3% had three-way catalysts. Tunnel air concentrations of nitrogen oxides, sulphur dioxide, carbon dioxide, carbon monoxide, nonmethane hydrocarbons, volatile organic compounds, polycyclic aromatic hydrocarbons, and lead are presented. The traffic emissions in the tunnel are calculated by the carbon balance method, which uses the increase of the total carbon concentration in the tunnel air as the reference quantity. Division of the concentration of any pollutant by the total carbon concentration gives emission factors per kilogram of carbon. These emission factors can be converted directly to emissions relative to fuel consumption or per kilometer. The fraction of diesel used in the tunnel was derived from sulphur to carbon ratios in tunnel air. A calculation procedure with breakdown of emission factors according to vehicle categories was used to estimate countrywide emissions. The estimated emissions were compared to results from the Flanders Emissions Inventory [Emissie Inventaris Vlaamse Regio (EIVR)] and calculated emissions according to the emission factors proposed by the European Commissions CORINAIR Working Group. For NOx there is excellent agreement. For carbon monoxide and hydrocarbons, the tunnel data produced higher emissions than the CORINAIR model would predict but lower than the official EIVR statistics. The estimated lead emissions from traffic are found to be 22 to 29% of the lead in gasoline.