Recurrent Obturator Hernia: A Rare Entity.

Obturator hernias are rare with an incidence of less than 1% of all hernias and are most common in frail, elderly females. They are difficult to diagnose and even more difficult to repair. They often present with a small bowel obstruction from the incarcerated bowel. We report a case of a recurrent obturator hernia after a laparoscopic repair using a patch of omentum. The recurrence was repaired laparoscopically with a trans-abdominal preperitoneal repair (TAPP) with mesh. Given the rarity of the disease, there is scarce literature on the ideal method of repair, especially in patients with recurrence. However, with recent trends toward minimally invasive preperitoneal mesh hernia repairs for inguinal and ventral hernias, this type of repair should be strongly considered for patients with obturator hernias as well.

A multicentre review of the direct-access mammography programme in Ireland for women with breast pain.

AIM: To assess the current use of the direct access mammography pathway for breast pain and the rate of breast cancer detection in this patient cohort. MATERIALS AND METHODS: A retrospective review of general practitioner (GP)-referred mammograms performed during a 12-month period from January to December 2022 across four tertiary referral centres. With the use of medical records and GP referrals, patient demographics, presenting symptoms, family history, and clinical outcomes were recorded. RESULTS: The present study comprised 2,046 patients of which 21.6% did not report breast pain at the time of referral. Thirty-five per cent had a positive family history with 40% of these patients having no breast pain. Twelve per cent were recalled with 30% of these patients requiring biopsy. An overall cancer detection rate (CDR) of 7 per 1000 was determined for women with mastalgia. A CDR of 0 per 1,000 was determined for women <50 years with mastalgia alone and no additional risk factors for malignancy. Fisher's exact test showed no statistically significant association between breast pain and breast cancer. CONCLUSION: There was no statistically significant relationship found between breast pain and breast cancer. This review suggests a low cancer detection rate in women <50 years. In women <50 years with mastalgia without additional symptoms or family history, breast imaging is not required.

An Analysis of an Exercise is Medicine on Campus ® Program: A Case Report.

BACKGROUND: The objective of this study was to assess the efficacy of an Exercise is Medicine on Campus® program on university student biometrics and muscular endurance. It was hypothesized that participants in the 12-week program would experience significant improvements in body mass index, blood pressure, body fat percentage, waist circumference, and muscular endurance. METHODS: To be eligible for the program, participants must have met two of the three criteria: (1) blood pressure over 140 and/or 90 (3 consecutive measurements over 2 weeks), (2) BMI over 30, and/or (3) diagnosed chronic condition or currently taking medication for chronic condition. Participants engaged in six bi-weekly exercise instructional meetings that lasted approximately 30 minutes in length. Participants completed measures of resting heart rate, waist-to-hip ratio, body composition percentage via bioelectrical impedance, and muscular endurance before and after the program. RESULTS: Although not statistically significant, there was a decrease in BMI, blood pressure, body fat percentage, and waist circumference from pre- to post-program. Two-tailed t-tests revealed significant improvements in squats (P = .04), pushups (P = .05), and curl-ups (P = .03) from pre- to post-program. CONCLUSION: The results are discussed in terms of current research and future university campus application.

A RE-AIM analysis of the sources of strength program in a United States high school.

The purpose of this study was to analyze the Sources of Strength program implemented at a high school in the southeastern United States using the RE-AIM framework. Students (n = 1,250) were recruited from one high school in the southeastern United States that was implementing Sources of Strength. College undergraduate students mentored high school peer leaders to implement Sources of Strength to promote opioid and suicide protective factors for the high school. This was a cross-sectional design in which a post-implementation survey assessed program effectiveness, satisfaction, and feedback for maintenance. Analysis used the RE-AIM framework of reach, effectiveness, adoption, implementation, and maintenance. Reach: 100 % of students participated in at least one campaign. Effectiveness: Mean protective factor scores were 3.83 for happiness; 3.93 for knowledge of coping skills, and 3.38 for practice of coping skills. Adoption: One high school and 100 % of classrooms participated in at least one campaign. Implementation: 18 high school peer leader meetings were facilitated by the undergraduate mentors. Maintenance: High school students qualitatively provided input on future campaign needs, and the program was continued following this RE-AIM analysis. The Sources of Strength program promoted suicide and opioid protective factors in high school students during COVID-19. Future research should compare the efficacy of Sources of Strength at baseline and follow-up with multiple high school sites.

A pilot evaluation of the Food as Medicine program for patients with type 2 diabetes.

The objective of this study was to determine the effectiveness of the Food as Medicine Program (modified and adapted based on supporting research of the Fresh Food Farmacy™ program) that was implemented at a southeast regional hospital with voluntary participants with diabetes. It was hypothesized that participants would experience a decline in type 2 diabetes symptoms following the 12-month program of bi-monthly healthy groceries, nutritional guidance, educational sessions, and group health coaching. For this initial pilot study, four cohorts of patients were admitted consisting of 20 participants. The 12-month program included bi-monthly food pick-ups, nutritional recipes, and bi-monthly group educational and health coaching sessions for participants. They also completed pre- and post-program assessments, including a medical history questionnaire, biometric screening (HbA1c, weight, BMI, and blood pressure), and health behavior questionnaires. While there were not statistically significant differences from pre- to post-program, mean HbA1c slightly decreased from the time of the initial test (i.e., month 1) to follow-up testing (i.e., month 12). The pre- to post-program trends for diabetes self-care activities indicated improvements for general and specific diet maintenance, days of exercise per week, blood glucose testing per week, foot care, and smoking habits. Participants also exhibited a decrease in diabetes distress for emotional, physical, regimen, and interpersonal distress from pre- to post-program. This is very important as self-regulation of behaviors is necessary to successful management of diabetes. The results are discussed in relation to the limitations created by COVID-19, along with future implementation suggestions.

Minimally Invasive Surgery for Median Arcuate Ligament Syndrome and Celiac Artery Stenosis.

Median arcuate ligament syndrome (MALS) is a pathology commonly reported in educational literature, although in reality it is scarcely seen. Herein, we present the case of a 48-year-old female patient who presented with nausea, vomiting, and unintentional weight loss. After thorough work up of her symptoms through a variety of different modalities, MALS was confirmed and she underwent surgical release via a minimally invasive approach. The authors of this article feel that this case is important to present due to paucity of reported cases in the literature. In addition, this patient was exceptionally unique to report as we selected to perform a slight adaptation of a minimally invasive approach, while there are multiple different treatment techniques and management plans that have previously been described in a variety of different literatures and require further discussion.

Fatal Sequelae of Reperfusion Injury in Postoperative Gastric Bypass.

BACKGROUND Obesity is a pandemic that is currently uncontrolled. In the surgical population, bariatric surgery is a sustainable and attractive option. However, both obesity and surgery can independently increase the risk for venous thromboembolism and subsequent significant and even fatal adverse effects. CASE REPORT We present the unique case of a 63-year-old woman who developed substantial venous thrombosis in the postoperative period following a laparoscopic hiatal hernia repair and Roux-en-Y gastric bypass. Venous thrombosis following surgery is a known possible complication, but we felt that this case required reporting due to the extreme extent of thrombosis and the significant course of events that occurred following her readmission. Due to the increased thrombus burden, the patient developed phlegmasia cerulea dolens and required operative thrombectomy. With restoration of blood flow following the procedure, the patient's clinical status rapidly declined, likely due to reperfusion injury. Ultimately, she developed multisystem organ failure, which included the constellation of shock, hypoxic respiratory failure, acute renal failure, shock liver, and, finally, cardiopulmonary arrest. CONCLUSIONS As the authors of this paper, we were especially inclined to report this particular case as the patient's clinical course was exceedingly complex due to her presenting phlegmasia cerulea dolens. The course was further complicated postoperatively by the detrimental sequelae of massive reperfusion injury, which likely eventually led to her death. We felt this pertinent to present because, after an extensive PubMed literature review, this sequence of events following gastric bypass surgery has yet to be reported in the literature.

Benefits of mindful self-compassion for frontline nurses.

ABSTRACT: Nurses who regularly engage in self-compassion training may be more resilient to stressors and burnout, and thus able to provide more compassionate care to patients. The article explores the benefits and strategies of practicing mindful self-compassion (MSC) for nurses, reviews the effectiveness of an MSC curriculum, and discusses practical techniques for nurses to put MSC theory into practice.

The impact of COVID-19 on college anxiety, optimism, gratitude, and course satisfaction.

ObjectiveTo examine the relationship between college student anxiety, optimism, gratitude, and perception of the Physical Activity and Lifestyle program (PAL) instructional response/effectiveness following COVID-19. Participants: Data were collected from a southeastern, midsize university (n = 1640) during April 2020. Methods: Participants responded to a Web-based survey that included mental health factors (optimism, gratitude, anxiety) and perceptions of COVID-19 academic response. Results: The results of this study revealed a significant, negative relationship between anxiety and optimism (r = .36), gratitude (r = -.12), and perceived instruction following COVID-19 (r = -.11). There were statistically significant differences in perceived PAL instructional response/effectiveness following COVID-19 between anxiety classification, with severely anxious students expressing lower instructional response to COVID-19 when compared to moderately or mildly anxious students, [F(2,1516) = 10.60, p < .001]. Conclusions: The results inform educators on the importance of effective education and coping strategies following online transition during a pandemic.

The role of infiltrating lymphocytes in the neo-adjuvant treatment of women with HER2-positive breast cancer.

BACKGROUND: Pre-treatment tumour-associated lymphocytes (TILs) and stromal lymphocytes (SLs) are independent predictive markers of future pathological complete response (pCR) in HER2-positive breast cancer. Whilst studies have correlated baseline lymphocyte levels with subsequent pCR, few have studied the impact of neoadjuvant therapy on the immune environment. METHODS: We performed TIL analysis and T-cell analysis by IHC on the pretreatment and 'On-treatment' samples from patients recruited on the Phase-II TCHL (NCT01485926) clinical trial. Data were analysed using the Wilcoxon signed-rank test and the Spearman rank correlation. RESULTS: In our sample cohort (n = 66), patients who achieved a pCR at surgery, post-chemotherapy, had significantly higher counts of TILs (p = 0.05) but not SLs (p = 0.08) in their pre-treatment tumour samples. Patients who achieved a subsequent pCR after completing neo-adjuvant chemotherapy had significantly higher SLs (p = 9.09 × 10-3) but not TILs (p = 0.1) in their 'On-treatment' tumour biopsies. In a small cohort of samples (n = 16), infiltrating lymphocyte counts increased after 1 cycle of neo-adjuvant chemotherapy only in those tumours of patients who did not achieve a subsequent pCR. Finally, reduced CD3 + (p = 0.04, rho = 0.60) and CD4 + (p = 0.01, rho = 0.72) T-cell counts in 'On-treatment' biopsies were associated with decreased residual tumour content post-1 cycle of treatment; the latter being significantly associated with increased likelihood of subsequent pCR (p < 0.01). CONCLUSIONS: The immune system may be 'primed' prior to neoadjuvant treatment in those patients who subsequently achieve a pCR. In those patients who achieve a pCR, their immune response may return to baseline after only 1 cycle of treatment. However, in those who did not achieve a pCR, neo-adjuvant treatment may stimulate lymphocyte influx into the tumour.

Self-compassion training within a workplace physical activity program: A pilot study.

BACKGROUND: Desire2Move (D2M) is an 8-week team-based, workplace program that incorporates competition and self-monitoring to encourage physical activity (PA). OBJECTIVE: The purpose of this pilot study was to evaluate the effectiveness of a self-compassion (SC) intervention within the existing workplace PA program. METHODS: University employees (n = 20) were assigned to a SC treatment group or an attention control group. Participants logged their PA minutes using MapMyRun. Treatment group. participants received a 7-week, SC podcast intervention. Participants self-reported PA, SC, and demographic information at pre- and post-intervention. Separate ANOVAs were used to determine group differences. RESULTS: There was not a statistically significant group x time interaction for SC, F(1, 18) = 0.02, p = 0.90, or main effects for time, F(1, 18) = 0.28, p = 0.61, or group, F(1, 18) = 1.70, p = 0.21, g = -0.42 [95%CI = -3.13, 2.29]. There were not significant differences between groups for total PA minutes during D2M, F(1, 18) = 2.15, p = 0.16, g = -0.63 [-1.53,0.27]. Overall, participants engaged in more than the recommended levels of PA each week. CONCLUSIONS: This pilot study provided feedback and guidance for future online SC training within a workplace PA intervention.

Characterization of the Mercury pulsed power x-ray source spectrum using multichannel density aerogel Cherenkov detectors.

The Aerogel Cherenkov Detector for Cygnus (ACD/C) is a time-dependent, x-ray spectral detector that uses SiO2 aerogels spanning an index of refraction (n = 1.02-1.07) corresponding to a 1.1-2.3 MeV x-ray energy threshold. The ACD/C was developed for pulsed power x-ray sources like Cygnus located at the Nevada National Site and Mercury located at the Naval Research Laboratory (NRL). Aerogels sit between the measurement capabilities of gas (>2 MeV) and solids such as fused silica (>0.3 MeV). The detector uses an aluminum converter to Compton scatter incoming x-rays and create relativistic electrons, which produce Cherenkov light in an aerogel or a fused silica medium. The ACD/C was fielded at the NRL when Mercury was tuned to produce up to 4.8 MeV endpoint bremsstrahlung. Despite a high radiation and electromagnetic interference background, the ACD/C was able to achieve high signal over noise across five aerogel densities and fused silica, including a signal to noise for a 1.1 MeV aerogel threshold. Previous experiments at Cygnus observed a signal that was comparable to the noise (1×) at the same threshold. The ACD/C observed time-resolved rise and fall times for different energy thresholds of the photon spectrum. Monte Carlo simulations of the ACD/C's aerogel response curves were folded with a simulation of Mercury's photon energy spectrum and agree within the error to the observed result.

Visualizing Nuclear Scission through a Multifield Extension of Topological Analysis.

In nuclear science, density functional theory (DFT) is a powerful tool to model the complex interactions within the atomic nucleus, and is the primary theoretical approach used by physicists seeking a better understanding of fission. However DFT simulations result in complex multivariate datasets in which it is difficult to locate the crucial `scission' point at which one nucleus fragments into two, and to identify the precursors to scission. The Joint Contour Net (JCN) has recently been proposed as a new data structure for the topological analysis of multivariate scalar fields, analogous to the contour tree for univariate fields. This paper reports the analysis of DFT simulations using the JCN, the first application of the JCN technique to real data. It makes three contributions to visualization: (i) a set of practical methods for visualizing the JCN, (ii) new insight into the detection of nuclear scission, and (iii) an analysis of aesthetic criteria to drive further work on representing the JCN.

Acute upper arm ischaemia: a rare presentation of non-Hodgkin's lymphoma.

Digital ischaemia has been sparsely reported in current literature. Its association with lymphomatous conditions has been described in even more exceptional occurrences. We present the first case of upper arm ischaemia associated with non-Hodgkin's lymphoma. A brief literature review of this rare phenomenon is also accompanied with it.

Disc displacement patterns in lumbar anterior spondylolisthesis: contribution to foraminal stenosis.

PURPOSE: To describe the particular disc displacement pattern seen at MRI in patients with spondylolisthesis, and its potential contribution to foraminal stenosis. METHODS: 38 patients with symptomatic lumbar anterior spondylolisthesis and 38 sex and aged matched control patients with herniated disc disease, at corresponding disc space levels, were included for study. In each case note was made of the presence, absence and direction of disc displacement and also the presence and location of neural contact with the displaced disc. RESULTS: In 33 of 38 (86.8%) patients in the spondylolisthesis group, the vertical disc displacement was upward. In the control group only 3 patients (7.8%) had upward vertical disc displacement. 19 patients (53%) from the spondylolisthesis group had exit foraminal nerve root contact, compared to 7 patients (18.4%) from the control group. 27 control patients (71%) had contact within the lateral recess, compared to only 6 patients (17%) with spondylolisthesis. Differences for upward displacement were significant (p<0.05). CONCLUSION: Disc displacement in patients with spondylolisthesis is predominately in a cephalad and lateral direction. Although this disc displacement pattern can occur in patients without spondylolisthesis, its incidence is much greater in the subset of patients with concomitant spondylolisthesis. In the setting of acquired osseous narrowing of the exit foramen, this described pattern of disc displacement superiorly and laterally in spondylolisthesis increases the susceptibility of spondylolisthesis patients to radicular symptoms and accounts for the exiting nerve root being more commonly affected than the traversing nerve root.

Ultrasound-guided percutaneous drainage of meniscal cysts: preliminary clinical experience.

AIM: To evaluate the efficacy of ultrasound-guided percutaneous drainage of symptomatic meniscal cysts. MATERIALS AND METHODS: Patients with lateral knee joint tenderness and swelling and confirmed meniscal cyst on magnetic resonance imaging (MRI) were consecutively enrolled for ultrasound-guided percutaneous cyst aspiration. Cysts were injected with local anaesthetic and steroid before completion of procedure. All 18 patients (all male, average age 33 years) were subsequently followed up (average time 10 months) and meniscal cyst symptoms assessed by questionnaire. Fischer's exact test used to analyse the data. RESULTS: In every case the procedure was well tolerated, and each patient indicated that they would be willing to have a repeat procedure in the future. Ten patients reported complete resolution of symptoms secondary to therapeutic cyst aspiration and had resumed participation in high-performance sport. Two patients reported a satisfactory sustained response, reporting only occasional "twinges of pain". In the remaining six patients, symptoms returned after an initial pain-free period. The pain-free period ranged from 1-8 weeks. In this study, patient outcome did not significantly correlate with any meniscal cyst characteristic. CONCLUSION: Ultrasound-guided percutaneous aspiration of meniscal cysts is a well-tolerated, simple, and safe procedure. In this small patient series, it was associated with positive early results with favourable outcomes in the mid to long-term. It should be considered in patients unsuitable for surgical debridement or as an interim therapy if surgery is delayed or postponed.

Contribution of full-thickness supraspinatus tendon tears to acquired subcoracoid impingement.

AIM: To assess the relationship between the severity of full-thickness supraspinatus tendon tears and the development of subcoracoid impingement. MATERIALS AND METHODS: Fifty-one magnetic resonance imaging (MRI) shoulder examination reports with full-thickness supraspinatus tears were retrospectively identified and reviewed by two dedicated musculoskeletal radiologists. The appearances of the rotator cuff muscles, biceps tendon and the lesser tubercle were recorded. The acromio-humeral distance and the axial coraco-humeral distance were measured. The data were recorded and analysed electronically. RESULTS: The kappa values for inter-observer agreement were: 0.91 for acromio-humeral distance and 0.85 for coraco-humeral distance measurements. Twenty-six patients had significant retraction of the supraspinatus tendon, 85% (22 cases) of this group had imaging evidence of tear or tendonopathy of the subscapularis tendon. Twenty-five patients had no significant retraction of the supraspinatus, 56% (14 cases) of this group had imaging evidence of a subscapularis tear or tendonopathy. The acromio-humeral distance was significantly less in patients with supraspinatus tears and retraction (p<0.05). The subscapularis tendon was significantly more likely to be abnormal if the supraspinatus was retracted than if no retraction was present (p<0.05). There were no significant differences in coraco-humeral distances between the groups. CONCLUSION: Subscapularis tendon signal and structural changes are frequently associated with full-thickness supraspinatus tendon tears, particularly if the supraspinatus is significantly retracted. In this static MRI series, the data do not support the occurrence of classical subcoracoid impingement as an aetiology; however, they may support the possibility of a dynamic mechanism, to which future studies could be directed.

Analysis of alpha-synuclein, dopamine and parkin pathways in neuropathologically confirmed parkinsonian nigra.

The identification of mutations that cause familial Parkinson's disease (PD) provides a framework for studies into pathways that may be perturbed also in the far more common, non-familial form of the disorder. Following this hypothesis, we have examined the gene regulatory network that links alpha-synuclein and parkin pathways with dopamine metabolism in neuropathologically verified cases of sporadic PD. By means of an in silico approach using a database of eukaryotic molecular interactions and a whole genome transcriptome dataset validated by qRT-PCR and histological methods, we found parkin and functionally associated genes to be up-regulated in the lateral substantia nigra (SN). In contrast, alpha-synuclein and ubiquitin carboxyl-terminal hydrolase L1 (UCHL1) gene expression levels were significantly reduced in both the lateral and medial SN in PD. Gene expression for Septin 4, a member of the GTP-binding protein family involved in alpha-synuclein metabolism was elevated in the lateral parkinsonian SN. Additionally, catalase and mitogen-activated protein kinase 8 and poly(ADP-ribose) polymerase family member 1 (PARP1) known to function in DNA repair and cell death induction, all members of the dopamine synthesis pathway, were up-regulated in the lateral SN. In contrast, two additional PD-linked genes, glucocerebrosidase and nuclear receptor subfamily 4, group A, member 2 (NR4A2) showed reduced expression. We show that in sporadic PD, parkin, alpha-synuclein and dopamine pathways are co-deregulated. Alpha-synuclein is a member of all three gene regulatory networks. Our analysis results support the view that alpha-synuclein has a central role in the familial as well as the non-familial form of the disease and provide steps towards a pathway definition of PD.

The medial and lateral substantia nigra in Parkinson's disease: mRNA profiles associated with higher brain tissue vulnerability.

Sporadic Parkinson's disease (PD) is characterized by progressive death of dopaminergic neurons within the substantia nigra. However, pathological cell death within this nucleus is not uniform. In PD, the lateral tier of the substantia nigra (SNl) degenerates earlier and more severely than the more medial nigral component (SNm). The cause of this brain regional vulnerability remains unknown. We have used DNA oligonucleotide microarrays to compare gene expression profiles from the SNl to those of the SNm in both PD and control cases. Genes expressed more highly in the PD SNl included the cell death gene, p53 effector related to PMP22, the tumour necrosis factor (TNF) receptor gene, TNF receptor superfamily, member 21, and the mitochondrial complex I gene, NADH dehydrogenase (ubiquinone) 1beta subcomplex, 3, 12 kDa (NDUFbeta3). Genes that were more highly expressed in PD SNm included the dopamine cell signalling gene, cyclic adenosine monophosphate-regulated phosphoprotein, 21 kDa, the activated macrophage gene, stabilin 1, and two glutathione peroxidase (GPX) genes, GPX1 and GPX3. Thus, there is increased expression of genes encoding pro-inflammatory cytokines and subunits of the mitochondrial electron transport chain, and there is a decreased expression of several glutathione-related genes in the SNl suggesting a molecular basis for pathoclisis. Importantly, some of the genes that are differentially regulated in the SNl are known to be expressed highly or predominantely in glial cells. These findings support the view that glial cells can be primarily affected in PD emphasizing the importance of using a whole tissue approach when investigating degenerative CNS disease.