Managing Allergic Nickel Dermatitis in Occupational Settings: A Case Report.

Contact dermatitis is a common cutaneous inflammatory condition, triggered by exposure to irritant substances or allergens. Nickel is the most prevalent allergen, a metal widely used in accessories, furniture, office materials, food and in industry, with multiple exposure pathways, making it difficult to assess which exposure is causing allergic dermatitis. Here, we report a case of an administrative worker with chronic hand eczema, limited to the radial metacarpophalangeal region of the left hand, caused by occupational exposure to nickel, confirmed by nickel deposition test on the hand and a positive test with a metallic stapler used at her workplace.

Revision/Conversion Surgeries After One Anastomosis Gastric Bypass-An Experts' Modified Delphi Consensus.

PURPOSE: There is a lack of evidence for treatment of some conditions including complication management, suboptimal initial weight loss, recurrent weight gain, or worsening of a significant obesity complication after one anastomosis gastric bypass (OAGB). This study was designed to respond to the existing lack of agreement and to provide a valuable resource for clinicians by employing an expert-modified Delphi consensus method. METHODS: Forty-eight recognized bariatric surgeons from 28 countries participated in the modified Delphi consensus to vote on 64 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus. RESULTS: A consensus was achieved for 46 statements. For recurrent weight gain or worsening of a significant obesity complication after OAGB, more than 85% of experts reached a consensus that elongation of the biliopancreatic limb (BPL) is an acceptable option and the total bowel length measurement is mandatory during BPL elongation to preserve at least 300-400 cm of common channel limb length to avoid nutritional deficiencies. Also, more than 85% of experts reached a consensus on conversion to Roux-en-Y gastric bypass (RYGB) with or without pouch downsizing as an acceptable option for the treatment of persistent bile reflux after OAGB and recommend detecting and repairing any size of hiatal hernia during conversion to RYGB. CONCLUSION: While the experts reached a consensus on several aspects regarding revision/conversion surgeries after OAGB, there are still lingering areas of disagreement. This highlights the importance of conducting further studies in the future to address these unresolved issues.

Remnant Gastrectomy and Gastric Bypass: A Systematic Review of Indications and Outcomes of Resectional Gastric Bypass.

BACKGROUND: In this systematic review, we aim to evaluate the reasons and outcomes behind remnant gastrectomy with or after gastric bypass procedures. RESULTS: A total of 66 studies examining 1918 patients were included in this study with 70% of female predominance. Twenty studies reported RGB on 1751 patients and 46 studies reported remnant gastrectomy after gastric bypass in 167 patients. The most common etiology of RGB was related to the in situ remnant stomach neoplasia in 10 studies on 981 patients; mostly for preventive intentions in high prevalence areas. Remnant gastrectomy after gastric bypass was performed to treat a complication such as GGF, retrograde bile reflux gastritis, cancer mostly adenocarcinoma. Studies revealed that RGB has similar weight loss in comparison to standard Roux-en-Y gastric bypass.

Sneddon's Syndrome and the Capability to Work: With Regard to a Clinical Case.

Sneddon's syndrome is a rare condition characterized by the presence of neurocutaneous lesions, including reticular livedo and an increase in thrombotic risk, and it is associated with a greater risk of cerebrovascular disease. It is diagnosed through a skin biopsy and neurological manifestations. In this study, we present a clinical report of a 39-year-old nurse exposed to shift and night work in an intensive care unit. She was diagnosed with Sneddon's syndrome, whose workplace had to be readapted, considering the complications and restrictions of her condition and aiming her protection and healthcare promotion. Night work can exacerbate cerebral and cardiovascular events due to its impact on metabolism, blood pressure profile, and hormone concentrations. Therefore, given a syndrome characterized by an increased thrombotic risk associated with cerebrovascular events, the restriction of night work is imperative. The occupational physician is responsible for intervening in the workplace and preventing long-term consequences for employees.

Fosfomycin-Induced Liver Injury: A Case Report.

Fosfomycin is an antibiotic frequently used to treat uncomplicated urinary tract infections. It is normally well-tolerated, but there are some reports of clinically relevant liver injury. We present the case of a 73-year-old female who presented with paucisymptomatic hepatocellular acute liver injury six days after taking fosfomycin. After ruling out viral, ischemic, and autoimmune hepatitis, as well as Wilson disease and biliary disorders, she was diagnosed with drug-induced liver injury (DILI) related to fosfomycin. The patient showed major improvement during the first week and the resolution of liver injury one month after onset. This case report aims to underscore the potential hepatotoxicity of fosfomycin.

Zieve's Syndrome: An Underdiagnosed Cause of Non-immune Hemolytic Anemia.

Zieve's syndrome is an underdiagnosed condition characterized by the triad of jaundice, hemolytic anemia, and hyperlipidemia in the setting of chronic alcohol use. It may be accompanied by acute alcoholic hepatitis. The distinction between the coexistence of acute alcoholic hepatitis with Zieve's syndrome and Zieve's syndrome in isolation is crucial, given the different treatments and prognoses in these situations. A 35-year-old woman presented with complaints of abdominal discomfort, nausea, and vomiting in the previous week. She was a heavy drinker with resultant cirrhosis, splenomegaly, and esophageal varices. An ancillary test showed hemolytic anemia, moderately elevated transaminases, hyperbilirubinemia, and coagulopathy. A negative direct Coombs test established the anemia as non-immune, supporting the diagnosis of Zieve's syndrome despite the absence of hyperlipidemia. Maddrey's discriminant function score was 92 points, so she was treated with supportive measures, as well as corticosteroids in the setting of acute alcoholic hepatitis. The patient showed a favorable clinical and analytical evolution and was discharged home one month following admission with her hemoglobin levels stabilized. Previous literature focused on the distinction between Zieve's syndrome and acute alcoholic hepatitis but they may coexist.

A Case of Acute Eosinophilic Pneumonia Associated With Non-steroidal Anti-inflammatory Drugs.

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used and their gastric, cardiovascular, and renal adverse effects have been well documented. Although rare, NSAID-induced acute eosinophilic pneumonia (AEP) may occur. We report a case of AEP related to naproxen and celecoxib. The patient presented with dry cough and breathlessness two weeks after she started taking these drugs. The chest radiograph displayed bilateral opacities and she had peripheral eosinophilia. Bronchoalveolar lavage was performed at a time when blood eosinophilia was already decreasing and cell analysis revealed 63700 cells/mL with 9% eosinophil. After ruling out other possible etiologies, drug-induced AEP was diagnosed. The patient improved after drug discontinuation. When it comes to drug-induced AEP identifying a causative agent is essential as cessation of the drug is the mainstay of the treatment.

Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study.

BACKGROUND: Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. METHODS: A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved. RESULTS: A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. CONCLUSION: This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

OAGB Bowel Function in Patients With up to 5 Years Follow-Up: Updated Outcomes.

OBJECTIVE: One-anastomosis gastric bypass (OAGB) is considered an effective technique in weight reduction and remission of comorbidities. However, in common with many bariatric and metabolic/bariatric procedures, gastrointestinal side effects are frequently reported, but clinical experience varies. The objective of this study was to analyze the bowel function of patients who undergo OAGB looking at 5-year postoperative outcomes. METHOD: This study is cross-sectional, descriptive and analytical, developed with individuals undergoing OAGB (n = 208) in yhe period between 2015 and 2020. The time periods evaluated were 1 to 6 months (T1), 6 to 12 months (T2), and 1 to 5 years (T3). Data analysis was performed using SPSS v.28.0, considering a significance level p ≤ 0.05. RESULTS: 114 participants (54.8%), 79.8% women, mean age 47.0 ± 12.6 years, and BMI 40.1 ± 5.6 kg/m2, 51.9% dyslipidemia, 43.6% arterial hypertension, and 19.1% diabetes mellitus. The T1 group had more severe symptoms/nausea than the T2 group. The T2 group had a significantly lower defecation frequency than the T1 and T3 groups. As for the occurrence of diarrhea, associations were not found in the considered groups. The T3 group had a greater severity of constipation associated with greater difficulty in consuming red meat, white meat, rice, vegetables, and salads. CONCLUSIONS: Gastrointestinal symptoms are prevalent in the first postoperative months. However, diarrhea was not common. The patient selection policy and surgical technique were decisive in this result. Constipation was prevalent in patients between 1 and 5 postoperative years. It was also prevalent in those who had food intolerance, which from a nutritional point of view is an adverse factor for optimal bowel function.

One Anastomosis Transit Bipartition (OATB): Rational and Mid-term Outcomes.

BACKGROUND: The "One-anastomosis transit bipartition" (OATB) is a promising emerging technique in the metabolic syndrome treatment. OBJECTIVE: To demonstrate the results achieved with OATB in the first 5 years after surgery. METHOD: Cross-sectional, retrospective study, with individuals undergoing primary OATB. Individuals included in the study were: ≥ 18 years, BMI ≥ 35 kg/m2; and excluded smoking habits, drug dependence, inflammatory bowel diseases. The data analyzed demographic, anthropometric, surgical, clinical, and nutritional. RESULTS: Sixty eight participants, 75% women, average age 45.5 years and BMI 41 kg/m2. Associated diseases: osteoarthritis (52.9%), hypertension (48.5%) and type 2 diabetes mellitus-T2DM (39.7%). All underwent laparoscopy, without conversions. Average operative time is 122.6 ± 31.7 min, and hospital stay is 2.2 ± 0.8 days. The common channel length 27 and 41 patients with 250 cm and 300 cm respectively. We registered no intraoperative complications, 2 (2.9%) early complications, and 14 (20.6%) late complications. In the first 6 months, 94.7% (250 cm) and 88.9% (300 cm) of the patients no longer used medication for T2DM, with no statistical difference between the two groups. The incidence of nutritional disorders at any time during follow-up: hypovitaminosis D (14.7%), folate hypovitaminosis (14.7%), elevated PTH (7.4%), hypoproteinemia (5.9%) and anemia (5.9%). We found no statistically significant difference between 250 and 300 cm common channel groups. CONCLUSION: We conclude that OATB is a safe and effective technique, demonstrating good control of T2DM and metabolic syndrome. There is a requirement to treat previous nutritional deficits. We need more long-term evidence and comparison to other surgical techniques.

ANCA-associated vasculitis: overview and practical issues of diagnosis and therapy from a European perspective.

Antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) is a heterogeneous group of rare diseases characterized by necrotizing inflammation predominantly of small vessels and the presence of these circulating antibodies. AAV comprises three important diseases, namely granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis, which affect multiple organ systems, significantly affecting patients' quality of life and survival. The diagnosis is established according to the clinical manifestations, detectable ANCA, and histopathology findings. Primary treatment strategies are adapted to the severity of the disease and based on immunosuppression with corticosteroids and cyclophosphamide, with increasing adoption of new, less toxic agents aimed at sustained remission of the disease, such as rituximab, methotrexate, and mycophenolate mofetil. Several international medical organizations have proposed recommendations for diagnosing and managing these diseases to standardize the procedures. In this study, we provide an up-to-date European perspective on AAV management, compiling current and relevant information regarding its epidemiology, symptoms, diagnosis, treatment strategies, and prognosis.

Spontaneous Pneumomediastinum: A Rare Cause of Chest Pain.

Spontaneous pneumomediastinum is a rare medical condition characterized by the presence of free air in the mediastinum, not preceded by trauma, surgery, or another medical procedure. It predominantly affects young adult males and usually has a benign course, and in most cases, it is not possible to identify the precipitating factor. There are some conditions that predispose to its occurrence, namely those that lead to an increase in intrapleural pressure, such as coughing, vomiting, or vigorous exercise. We report a case of a 21-year-old male who presented with acute-onset shortness of breath after an episode of coughing and was found to have mediastinal and subcutaneous emphysema. Clinical, laboratory, and radiological studies did not demonstrate any predisposing factor, and the case was classified as spontaneous pneumomediastinum.

Converting carbon black into an efficient and multi-site ORR electrocatalyst: the importance of bottom-up construction parameters.

To boost efficient energy transitions, alternatives to expensive and unsustainable noble metal-based electrocatalysts for the oxygen reduction reaction (ORR) are needed. Having this in mind, carbon black - Black Pearls 2000 (BP) was enriched in active nitrogen-containing centers, including single-atom Fe-N sites surrounded by Fe nanoclusters, through a synthesis methodology employing only broadly available precursors. The methodical approach taken to optimize the synthesis conditions highlighted the importance of (1) a proper choice of the Fe precursor; (2) melamine as an N source to limit the formation of magnetite crystals and modulate the charge density nearby the active sites, and glucose to chelate/isolate Fe atoms and thus allow the Fe-N coordination to be established, with a limiting formation of Fe0 clusters; and (3) a careful dosing of the Fe load. The ORR on the optimized electrocatalyst (Fe0.06-N@BP) proceeds mostly through a four-electron pathway, having an onset potential (0.912 V vs. RHE) and limiting current density (4.757 mA cm-2) above those measured on Pt/C (0.882 V and 4.657 mA cm-2, respectively). Moreover, the current density yielded by Fe0.06-N@BP after 24 h at 0.4 V vs. RHE was still above that of Pt/C at t = 0 (4.44 mA cm-2), making it a promising alternative to noble metal-containing electrocatalysts in fuel cells.

Bariatric Evaluation Through AI: a Survey of Expert Opinions Versus ChatGPT-4 (BETA-SEOV).

BACKGROUND: Recent advancements in artificial intelligence, such as OpenAI's ChatGPT-4, are revolutionizing various sectors, including healthcare. This study investigates the use of ChatGPT-4 in identifying suitable candidates for bariatric surgery and providing surgical recommendations to improve decision-making in obesity treatment amid the global obesity epidemic. METHODS: We devised ten patient scenarios, thoughtfully encompassing a spectrum that spans from uncomplicated cases to more complex ones. Our objective was to delve into the decision-making process regarding the recommendation of bariatric surgery. From July 29th to August 10th, 2023, we conducted a voluntary online survey involving thirty prominent bariatric surgeons, ensuring that there was no predetermined bias in the selection of a specific type of bariatric surgery. This survey was designed to collect their insights on these scenarios and gain a deeper understanding of their professional experience and background in the field of bariatric surgery. Additionally, we consulted ChatGPT-4 in two separate conversations to evaluate its alignment with expert opinions on bariatric surgery options. RESULTS: In 40% of the scenarios, disparities were identified between the two conversations with ChatGPT-4. It matched expert opinions in 30% of cases. Differences were noted in cases like gastrointestinal metaplasia and gastric adenocarcinoma, but there was alignment with conditions like endometriosis and GERD. CONCLUSION: The evaluation of ChatGPT-4's role in determining bariatric surgery suitability uncovered both potential and shortcomings. Its alignment with experts was inconsistent, and it often overlooked key factors, emphasizing human expertise's value. Its current use requires caution, and further refinement is needed for clinical application.

The platelet-to-lymphocyte ratio as an indirect outcome predictor in primary hypertension: a retrospective study.

Background: Nondipper hypertensive patients have higher levels of platelet-to-lymphocyte ratio, a new studied inflammatory biomarker in primary hypertension. Furthermore, these patients have a higher risk of cardiovascular morbidity and mortality. This study aimed to assess the relationship between platelet-to-lymphocyte ratio and hypertensive pattern (dipper vs nondipper) and the association between the hypertensive pattern and major adverse cardiovascular events. Methods: A retrospective analysis was performed. One hundred fifty-three patients were included and classified as dipper or nondipper according to 24-hour ambulatory blood pressure measurements. Platelet-to-lymphocyte ratio was calculated based on complete blood count data. Results: The dipper group included 109 patients, and the nondipper group included 44 patients. Nondipper patients have 2.11 more risk of presenting a higher platelet-to-lymphocyte ratio than dipper individuals (odds ratio [OR] = 2.11; 95% CI, 1.220-3.664; P = .007). Nondipper patients also registered earlier cardiovascular events, such as acute myocardial infarction and stroke (P < .001). Conclusions: Nondipper hypertensive individuals registered higher levels of platelet-to-lymphocyte ratio and earlier cardiovascular events than dipper patients. Therefore, platelet-to-lymphocyte ratio could be used as an indirect predictor of cardiovascular risk in primary hypertension and contribute to optimize preventive strategies.

AI-based identification of therapeutic agents targeting GPCRs: introducing ligand type classifiers and systems biology.

Identifying ligands targeting G protein coupled receptors (GPCRs) with novel chemotypes other than the physiological ligands is a challenge for in silico screening campaigns. Here we present an approach that identifies novel chemotype ligands by combining structural data with a random forest agonist/antagonist classifier and a signal-transduction kinetic model. As a test case, we apply this approach to identify novel antagonists of the human adenosine transmembrane receptor type 2A, an attractive target against Parkinson's disease and cancer. The identified antagonists were tested here in a radio ligand binding assay. Among those, we found a promising ligand whose chemotype differs significantly from all so-far reported antagonists, with a binding affinity of 310 ± 23.4 nM. Thus, our protocol emerges as a powerful approach to identify promising ligand candidates with novel chemotypes while preserving antagonistic potential and affinity in the nanomolar range.

Human aromatic amino acid decarboxylase is an asymmetric and flexible enzyme: Implication in aromatic amino acid decarboxylase deficiency.

Human aromatic amino acid decarboxylase (AADC) is a pyridoxal 5'-phosphate-dependent enzyme responsible for the biosynthesis of dopamine and serotonin, essential neurotransmitters involved in motor and cognitive abilities. Mutations in its gene lead to AADC deficiency, a monogenic rare neurometabolic childhood parkinsonism characterized by severe motor and neurodevelopmental symptoms. Here, for the first time, we solved the crystal structure of human holoAADC in the internal aldimine (1.9 Å) and in the external aldimine (2.4 Å) of the substrate analog L-Dopa methylester. In this intermediate, the highly flexible AADC catalytic loop (CL) is captured in a closed state contacting all protein domains. In addition, each active site, composed by residues of both subunits, is connected to the other through weak interactions and a central cavity. By combining crystallographic analyses with all-atom and coarse-grained molecular dynamics simulations, SAXS investigations and limited proteolysis experiments, we realized that the functionally obligate homodimeric AADC enzyme in solution is an elongated, asymmetric molecule, where the fluctuations of the CL are coupled to flexibility at the edge between the N-terminal and C-terminal domains. The structural integrity of this peripheral protein region is essential to catalysis, as assessed by both artificial and 37 AADC deficiency pathogenic variants leading to the interpretation that structural dynamics in protein regions far from the active site is essential for CL flexibility and the acquirement of a correct catalytically competent structure. This could represent the molecular basis for pathogenicity prediction in AADC deficiency.

Amendment of soils with metal-rich sludge: Potential water toxicity due to metal release via over-time slaking.

Industrial metal-rich sludge can improve soil properties, but it is potentially toxic to soils and adjacent aquatic systems. The soil-sludge-water interactions influence metals bioavailability over time, a phenomenon mostly regulated by the still debatable "sludge physical protection" or "sludge delayed release" hypotheses. The present study aimed to investigate: (1) whether sludge increases soil aggregate stability against slaking, (2) which hypothesis mostly regulates metal release from soils to water and (3) the ecotoxicity of the metals released during soil slaking for aquatic organisms. Under a realistic field scale, soils amended with an industrial sludge or spiked with equivalent metal solutions (of Cr, Cu, Ni, Zn) were collected over three months to test soil aggregate stability, the ecotoxicity of the slaking water and metal contents in soil and water. The "sludge physical protection" was verified for all metals, though for Cu the "sludge delayed release" hypothesis appears plausible after three months. Soil amendment with sludge did not lead to effects on the growth of the microalga Raphidocelis subcapitata, contrarily to the observed for the metal-spiked soil. Criteria regulating soils sludge-amendment management should thus include doses not hazardous to biota, and not only metal threshold levels.

Spontaneous reporting of adverse reactions associated with the COVID-19 vaccine in health care professionals: A descriptive observational study conducted in a Portuguese hospital.

Background: The coronavirus disease 2019 (COVID-19) was classified as a pandemic in March 2020 by the World Health Organization. The Pfizer-BioNTech COVID-19 vaccine was the first to be authorized in the European Union, based on data from phase 1, 2, and 3 clinical trials of limited duration. Concerns have been raised regarding the vaccine's safety profile. Some of the adverse drug reactions (ADRs) associated with vaccines may not have been identified during clinical trials. This study aimed to identify ADRs associated with the Pfizer-BioNTech vaccine in health care professionals at a Portuguese tertiary university hospital. Methods: The data used in this analysis consist of ADRs reported through a spontaneous notification system from vaccines administered between December 27, 2020, and January 31, 2021. ADRs were categorized according to the MedDRA terminology. Results: A total of 8,605 Pfizer-BioNTech vaccines were administered to 4568 health care professionals. ADRs were reported among 520 of the vaccines, with an incidence of 13.56% in women and 5.31% in men. The mean age of the population reporting ADRs was 41.52 years, with a standard deviation of 9.83 years. The most frequent ADRs were myalgia (n = 274), headache (n = 199), pyrexia (n = 164), injection site pain (n = 160), fatigue (n = 84), nausea (n = 81), chills (n = 65), lymphadenopathy (n = 64), and arthralgia (n = 53). Hypersensitivity reactions occurred in 15 health care professionals, with no anaphylactic reactions observed. A total of four Important Medical Events were observed, which consisted of two cases of syncope, one case of sudden hearing loss, and one case of transverse myelitis. Conclusion: The vaccine was well-tolerated among the study participants. Reactogenicity was greater after the second dose. The incidence of ADRs was higher in women and individuals aged between 40 to 49 years. Systemic adverse reactions were most frequently reported. Systematic monitoring of ADRs of COVID-19 vaccines in real-life context is essential for a more robust establishment of its safety profile.

Ecological risk assessment of the Paraíba River estuary (Brazil): Plan for a tier 1 screening phase for the ecotoxicological line of evidence.

The knowledge produced in temperate regions is still used today to evaluate environmental problems in the tropics, without taking into consideration environmental differences, such as local conditions, the sensitivity and ecology of species, and exposure routes of contaminants, essential for understanding and determining the fate and toxicity of chemicals. Considering that Environmental Risk Assessment (ERA) studies for tropical systems are scarce and need to be adjusted, the present study aims at contributing to the awareness and development of tropical ecotoxicology. The estuary of the Paraíba River in Northeast Brazil was selected as a model study-case, as it is a large estuary, subjected to a heavy human pressure due to the numerous social, economic and industrial activities. The present study describes the framework for the problem formulation phase of the ERA process; it first includes a detailed integration of the scientific information available on the study area, to then derive the conceptual model, and finally present the analysis plan for the tier 1 screening phase. The latter is designed to be fundamentally supported by the ecotoxicological line of evidence, to ascertain, without delay, where and why there are environmental problems (i.e., adverse biological effects); ecotoxicological tools developed in temperate climates will be optimized to assess water quality in a tropical system. In addition to its intrinsic value for protecting the study area, the results of the present study are expected to provide an important baseline for conducting ERA in similar tropical aquatic systems across the globe.