Management Of Complicated Disease Research Articles

Predictors of operative management in diabetic foot ulcers.

Surgery plays a key role in the management of complicated diabetic foot disease (DFD). Currently, indications for medical versus surgical management are poorly defined. Prompt identification of patients who require surgery may reduce morbidities and length of hospital stay. This study aims to analyse factors in DFD that necessitate early surgical interventions. All patients admitted under a multi-disciplinary diabetic foot team in a tertiary institution over 2years were included in a retrospective case-control study comparing patients who received medical management and patients who received surgical management. Logistic regression was performed to identify factors associated with surgical management of diabetic foot complications. Three hundred and forty patients were included. 49% of patients required surgical management. Toe ulceration, elevated C-reactive protein (CRP), and the presence of osteomyelitis were associated with surgical management. Multivariate analysis calculated an odds ratio (OR) of 1.01 for CRP (p<0.001), OR 2.19 (p<0.019) favouring surgical management for forefoot ulcers, and OR 2.2 (p<0.019) if osteomyelitis was present. Patients with elevated CRP levels, a forefoot diabetic ulcer and established osteomyelitis were more likely to undergo surgical management. Prompt recognition of these patients has the potential benefit of earlier decision making in definitive surgical interventions.

The OCCHLTH Mnemonic-Construction and Content of a Tool for Increasing Awareness of Occupational Illness and Injury.

Unidentified or nonmitigated occupational illnesses and injuries can complicate disease management. The "occupational health" (OCCHLTH) mnemonic aims to raise awareness of work-related exposures and associated illnesses and injuries. Occupational safety and health history-taking elements were combined with peer-reviewed information [from the PubMed database (first review January 1, 2000, to February 8, 2016; updated to February 8, 2021)] about workplace exposure-outcome associations to create the mnemonic. Seven components constitute the OCCHLTH mnemonic. Literature results support its categories and subcategories. Three components represent symptom onset and health conditions. Four represent occupational exposures. Evaluating published occupational illness cases explored mnemonic applicability. Awareness of occupational risk factors can affect clinical decision-making. The OCCHLTH mnemonic encourages consideration of occupational causes of illness and injury to optimize patient care. Further evaluation of the utility of the OCCHLTH mnemonic is needed.

Minimally Invasive Management of Complicated and Re-operative Crohn's Disease

AbstractMinimally invasive techniques for the surgical management of Crohn's disease have become the recommended approach for initial surgical intervention in noncomplicated patients as there is lower morbidity for patients without compromising treatment outcomes. There has been a push to expand minimally invasive approaches to complex and recurrent diseases, trying to benefit these difficult patients. However, until recently there have been little data to support the adoption of minimally invasive surgery (MIS) in these scenarios. This article aims to build on the 2019 Clinics in Colon and Rectal Surgery article on complex Crohn's and MIS by introducing new data in support of these approaches. Decisions for technique should be based on patient characteristics, but minimally invasive techniques have emerged as valid and possibly superior for complex and recurrent disease.

Perceived Social Stigma, Family Support and Mental Health Issues in Individuals Living with HIV/AIDS

Background: In Pakistan, the HIV/AIDS epidemic is compounded by significant socio-economic challenges and a pervasive stigma that undermines effective treatment and prevention strategies. The psychological impacts of HIV/AIDS, such as anxiety, depression, and stress, further complicate disease management, affecting patients' willingness to adhere to treatment and disclose their status. Objective: This study aimed to assess the prevalence of mental health issues among individuals living with HIV/AIDS in Pakistan and explore the relationships between perceived social stigma, family support, and mental health outcomes. Methods: A cross-sectional study was conducted involving 150 diagnosed HIV/AIDS patients from Nankana Sahib and Faisalabad districts. Participants were selected using purposive sampling. Data were collected through validated Urdu versions of the Depression Anxiety Stress Scales (DASS), a discrimination scale, and a family support scale. Statistical analysis was performed using SPSS version 25, focusing on descriptive statistics, correlation coefficients, and linear regression models. Results: The results indicated that the mean scores for depression, anxiety, and stress were significantly high at 66.6980 ± 17.56598. A strong positive correlation was observed between perceived discrimination (DISC) and DASS scores (r = 0.890, p &lt; 0.01), while perceived family support (PFS) was negatively correlated with DISC scores (r = -0.166, p = 0.043). Regression analysis showed that increased family support significantly mitigated mental health issues, reducing the mean stress, anxiety, and depression scores among participants. Conclusion: The study highlights the critical role of family support in reducing mental health issues among HIV/AIDS patients in Pakistan. Enhancing family involvement and reducing social stigma could improve treatment adherence and overall health outcomes.

Combination Therapy: A New Tool for the Management of Obesity.

Obesity is a chronic lifestyle issue with devastating results. Behavioral changes are one of the initial lines of management strategies for obesity, but they are not very efficient management strategies. Many people also use surgical intervention to maintain a healthy weight, now considered to be the most common and effective obesity management. Chemically synthesized medicines fill the gap between lifestyle interventions and minimally invasive surgical management of obesity. The most common issue associated with monotherapy without side effects is its moderate effectiveness and higher dose requirement. Combination therapy is already used for many serious and complicated disease treatments and management and has shown efficacy as well. Generally, we use two or more medicines with different mechanisms of action for a better effect. The commonly used combination therapy for obesity management includes low-dose phentermine and prolonged and slow-releasing mechanism topiramate; naltrexone, and bupropion. Phentermine with inhibitors of Na-glucose cotransporter-2 or glucagon-like peptide-1 (GLP-1) agonists with gastric hormone or Na-glucose cotransporter-2 are two more viable combo therapy. This combination strategy aims to achieve success in bariatric surgery and the scientific community is working in this direction.

Surgical management of complicated Crohn's disease

Surgical management of pediatric Crohn's disease is fundamentally palliative, aiming to treat the sequalae of complicated disease while preserving intestinal length. Multidisciplinary discussion of risk factors and quality of life should take place prior to operative intervention. Though the surgical management of pediatric Crohn's disease is largely based on the adult literature, there are considerations specific to the pediatric population – notably disease and treatment effects on growth and development. Intrabdominal abscess is approached with percutaneous drainage when feasible, reserving surgical intervention for the patient who is unstable or failing medical therapy. Pediatric patients with fibrostenotic disease should be considered for strictureplasty when possible, for maximum preservation of bowel length. Patients with medically refractory Crohn's proctocolitis should be treated initially with fecal diversion without proctocolectomy.

Identification of Resistance to Target Spot of Tomato Caused by Corynespora cassiicola in Wild Tomato Accessions

Tomato (Solanum lycopersicum) is an important vegetable crop and a valuable source of nutrients for the human diet. The southeast is the main fresh market tomato producer of the United States, with much of the production concentrated in Florida. However, production in this region is threatened by plant diseases such as target spot of tomato (TS) caused by Corynespora cassiicola, a multitrophic fungus widely distributed in tropical and subtropical areas. TS can infect foliage and fruit, often resulting in significant yield losses in conductive environments. There are no known TS-resistant cultivars, and control relies entirely on fungicidal sprays. However, several studies have demonstrated that the fungus is developing resistance to commonly used fungicides which further complicates disease management. The objective of this work was to identify sources of resistance to TS from wild Solanum accessions. Initial screens of 83 accessions informed the selection of 24 accessions for a more robust screening in which six diverse C. cassiicola isolates were used for single-isolate inoculation experiments. The results from a broad-sense mixed-model analysis including data from all six experiments demonstrated that all 24 accessions had significantly lower disease severities compared with the susceptible controls, suggesting that all accessions potentially harbor resistance quantitative trait loci (QTLs). Solanum cheesmaniae accession LA0524, S. galapagense accessions LA0483 and LA0532, and S. pimpinellifolium accession LA2093 were among the most resistant accessions tested and may be particularly useful for introgression of resistance into cultivated germplasm and for mapping of TS resistance QTLs.

Heart Failure Readmissions: A Deep Dive into Patient Demographics, Comorbidities, and Systemic Challenges

Background: Heart failure (HF) is a leading cause of hospital readmissions, presenting significant challenges in healthcare. Comorbid conditions like diabetes and hypertension are prevalent among HF patients and may complicate disease management. Understanding these dynamics is crucial for developing effective intervention strategies. Objective: This study aims to analyze the factors contributing to HF readmissions, focusing on patient demographics, comorbidities, and systemic healthcare challenges. Methods: A comprehensive, retrospective cohort analysis was conducted at a tertiary care cardiac center. The study included 1,000 patients with a documented history of HF and instances of hospital readmissions. Patient selection was based on age (≥18 years), a diagnosis of HF, and readmission within six months post-discharge. Exclusion criteria included planned readmissions for elective procedures and cognitive impairments impeding consent. Data collection encompassed patient demographics, clinical history, comorbidity details, initial hospitalization, and readmission information. Descriptive statistics were employed to analyze and summarize the data. Results: The cohort comprised 80% male (n=800) and 20% female (n=200) with a mean age of 58 years. The median hospital stay was 6 days. Comorbidities included diabetes (78%, n=780) and hypertension (56%, n=560). The primary cause of HF was ischemic cardiomyopathy (82%, n=820). The leading reasons for readmission were lack of counseling (42%, n=420), underdosage of medication (16%, n=160), and non-compliance to medication (13%, n=130). Other factors included volume overload (11%, n=110), secondary hypertensive failure (9%, n=90), infections (6%, n=60), anemia (2%, n=20), and progressive renal failure (1%, n=10). Conclusion: The study highlights the complexity of managing HF, emphasizing the need for comprehensive approaches addressing patient education, medication management, and comorbidity control. Improved patient counseling and adherence to treatment regimens could significantly reduce HF readmissions.

Exploring Patterns of COPD Exacerbations and Comorbid Flare-Ups.

Comorbidities are known to complicate disease management in patients with Chronic Obstructive Pulmonary Disease (COPD). This is partly due to lack of insight into the interplay of acute exacerbations of COPD (AECOPD) and comorbid flare-ups. This study aimed to explore patterns of AECOPDs and comorbid flare-ups. Data of increased symptoms were extracted from a 12-month daily symptom follow-up database including patients with COPD and comorbidities (chronic heart failure (CHF), anxiety, depression) and transformed to visualizations of AECOPDs and comorbid flare-up patterns over time. Patterns were subsequently categorized using an inductive approach, based on both predominance (ie, which occurs most often) of AECOPDs or comorbid flare-ups, and their simultaneous (ie, simultaneous start in ≥ 50%) occurrence. We included 48 COPD patients (68 ± 9 years; comorbid CHF: 52%, anxiety: 40%, depression: 38%). In 25 patients with AECOPDs and CHF flare-ups, the following patterns were identified: AECOPDs predominant (n = 14), CHF flare-ups predominant (n = 5), AECOPDs nor CHF flare-ups predominant (n = 6). Of the 24 patients with AECOPDs and anxiety and/or depression flare-ups, anxiety and depression flare-ups occurred simultaneously in 15 patients. In 9 of these 24 patients, anxiety or depression flare-ups were observed independently from each other. In 31 of the included 48 patients, AECOPDs and comorbid flare-ups occurred mostly simultaneously. Patients with COPD and common comorbidities show a variety of patterns of AECOPDs and comorbid flare-ups. Some patients, however, show repetitive patterns that could potentially be used to improve personalized disease management, if recognized.

Challenges in the Management of Invasive Fungal Infections in the Middle East: Expert Opinion to Optimize Management Using a Multidisciplinary Approach.

Invasive fungal infection (IFI) is a significant global healthcare concern among critically ill and immunocompromised patients. In Middle Eastern countries, IFI has been steadily increasing among hospitalized patients in the past two decades. Diagnosis of IFI at an early stage is crucial for efficient management. Invasive fungal infection management is complex and requires the involvement of physicians from different specialties. There are several challenges associated with IFI management in the countries in the Middle East. This review aims to understand the key challenges associated with IFI management in the Middle East, encompassing epidemiology, diagnosis, therapeutic options, and optimizing a multidisciplinary approach. In addition, this review aims to incorporate expert opinions from multidisciplinary fields for optimizing IFI management in different Middle Eastern countries by addressing key decision points throughout the patient's journey. Lack of epidemiological data on fungal infections, slow and poorly sensitive conventional culture-based diagnostic tests, limited availability of biomarker testing, lack of awareness of clinical symptoms of the disease, limited knowledge on fungal infections, lack of local practice guidelines, and complicated disease management are the major challenges associated with IFI diagnosis and management in the Middle Eastern countries. Implementation of a multidisciplinary approach, antifungal stewardship, improved knowledge of fungal infections, the use of rapid diagnostic tests, and enhanced epidemiological research are warranted to lower the IFI burden in the Middle East.

Diagnosis and treatment of focal-segmental glomerulosclerosis-2023

The histopathological term focal-segmental glomerulosclerosis comprises different pathogenic processes with the unifying features of ahigh proteinuria and the name-giving glomerular lesion pattern seen on light microscopy. Adifferentiation according to the underlying cause into primary, secondary and genetic forms is therefore of utmost importance. The pathogenesis of primary focal-segmental glomerulosclerosis remains unknown but, like minimal-change disease, an autoimmune-mediated process leading to podocyte damage is assumed. Consequently, the unifying term "podocytopathy" is increasingly being used for both entities. Supportive treatment measures to preserve kidney function are important in all subtypes. In contrast, immunosuppressive treatment is only indicated in primary focal-segmental glomerulosclerosis. Steroid-dependence, steroid-resistance and frequently relapsing disease often complicate disease management and necessitate alternative treatment strategies. Here, the Austrian Society of Nephrology (ÖGN) provides consensus recommendations on how to best diagnose and manage patients with focal-segmental glomerulosclerosis.

An Examination of Infection Incidence and Management in Systemic Lupus Erythematosus Patients: A Five-Year Review from a Saudi Arabian Center.

BACKGROUND Systemic lupus erythematosus (SLE) is a chronic autoimmune condition often associated with an increased susceptibility to infections. The infections in patients with SLE, primarily involving the skin, respiratory tract, and urinary tract, can significantly complicate disease management. This study aimed to evaluate the occurrence, management, and patient outcomes associated with infections in a group of 74 SLE patients at a single center in Saudi Arabia, spanning a 5-year period. MATERIAL AND METHODS An observational, retrospective study was conducted at the King Khalid University Hospital, Riyadh, Saudi Arabia. Patient medical records from January 2016 to December 2020 were examined. All adult SLE patients (age >14 years, as per hospital policy), confirmed by SLICC criteria, and admitted due to infections (determined by quick Sequential Organ Failure Assessment or qSOFA scores) were included in the study. RESULTS Of the 74 SLE patients studied, 79.7% were administered hydroxychloroquine. A majority (83.8%) were classified as low-risk for sepsis-associated mortality based on qSOFA scores (0-1), a fact noted by 41.9% of rheumatology fellows. The sputum cultures most frequently identified were Klebsiella pneumoniae, yeast, and Haemophilus influenzae (each accounting for 33.3% of cases). Furthermore, 4.1% of patients had extended-spectrum beta-lactamases infections, and 2.7% tested positive for COVID-19. A history of sepsis was more commonly observed among non-survivors (P=0.010). CONCLUSIONS The majority of patients were classified as low-risk for sepsis-associated mortality based on qSOFA scores, with two-thirds prescribed antibiotics within 1 h. The primary causes of death were multiorgan failure and cardiac arrest.

The AGE-RAGE Axis and the Pathophysiology of Multimorbidity in COPD.

Chronic obstructive pulmonary disease (COPD) is a disease of the airways and lungs due to an enhanced inflammatory response, commonly caused by cigarette smoking. Patients with COPD are often multimorbid, as they commonly suffer from multiple chronic (inflammatory) conditions. This intensifies the burden of individual diseases, negatively affects quality of life, and complicates disease management. COPD and comorbidities share genetic and lifestyle-related risk factors and pathobiological mechanisms, including chronic inflammation and oxidative stress. The receptor for advanced glycation end products (RAGE) is an important driver of chronic inflammation. Advanced glycation end products (AGEs) are RAGE ligands that accumulate due to aging, inflammation, oxidative stress, and carbohydrate metabolism. AGEs cause further inflammation and oxidative stress through RAGE, but also through RAGE-independent mechanisms. This review describes the complexity of RAGE signaling and the causes of AGE accumulation, followed by a comprehensive overview of alterations reported on AGEs and RAGE in COPD and in important co-morbidities. Furthermore, it describes the mechanisms by which AGEs and RAGE contribute to the pathophysiology of individual disease conditions and how they execute crosstalk between organ systems. A section on therapeutic strategies that target AGEs and RAGE and could alleviate patients from multimorbid conditions using single therapeutics concludes this review.

Movement ecology of exotic nilgai antelope: A threat to the re‐emergence of cattle fever ticks in the southern USA

AbstractWildlife plays an important role in the emergence of livestock diseases, and their movements can complicate disease management efforts. One of the most significant vector‐borne diseases of livestock worldwide is bovine babesiosis, spread by cattle fever ticks (CFTs; Rhipicephalus [=Boophilus] microplus and Rhipicephalus [=Boophilus] annulatus). Although CFTs were eradicated from the United States by 1943, bovine babesiosis and CFTs are prevalent in México. Recently, management of CFTs in the Texas–México region has been complicated by the presence of free‐ranging, exotic nilgai antelope (Boselaphus tragocamelus). Nilgai are abundant in this region and are competent hosts for CFTs. The goal of this study was to better understand nilgai movements and space use to inform CFT treatment strategies. We analyzed hourly locations from 40 GPS‐collared nilgai in Cameron County, TX, USA, from April 2019 to September 2020. We assigned each nilgai a movement behavior using the net squared displacement metric. We estimated nilgai home range sizes at different temporal scales (monthly, seasonally, and overall) using Brownian bridge movement models. We observed movement patterns consistent with residency (52.5%), seasonal movers (17.5%), dispersal (5%), and unclassified (25%). Resident nilgai had an average maximum axial distance of 7.8 km, while two young females made separate dispersal movements of about 40 km within a year. Overall, nilgai had large and highly variable home ranges: annual median home range estimate for females was 563 ha (range = 105–1545 ha), and for males, it was 937 ha (range = 221–1602 ha). Peak nilgai movements occurred during crepuscular hours, and median hourly movement for females was 57 m/h, and for males, it was 66 m/h. Nilgai home ranges and long‐distance movements have the potential to overlap multiple ranches, as the typical ranch size in South Texas ranges from 250 to 6000 ha. Resident nilgai were more likely to maintain local infestations of CFT. Dispersal events took place during peak tick season, demonstrating the potential for nilgai to aid in the spread of CFT. Understanding these behaviors will help the CFT Eradication Program develop more efficacious treatment strategies to treat infestations in nilgai.

Prolonged persistence of canine distemper virus RNA, and virus isolation in naturally infected shelter dogs.

Canine distemper virus remains an important source of morbidity and mortality in animal shelters. RT-PCR is commonly used to aid diagnosis and has been used to monitor dogs testing positive over time to gauge the end of infectious potential. Many dogs excrete viral RNA for prolonged periods which has complicated disease management. The goal of this retrospective study was to describe the duration and characteristics of viral RNA excretion in shelter dogs with naturally occurring CDV and investigate the relationship between that viral RNA excretion and infectious potential using virus isolation data. Records from 98 different humane organizations with suspect CDV were reviewed. A total of 5,920 dogs were tested with 1,393; 4,452; and 75 found to be positive, negative, or suspect on RT-PCR respectively. The median duration of a positive test was 34 days (n = 325), and 25% (82/325) of the dogs still excreting viral RNA after 62 days of monitoring. Virus isolation was performed in six dogs who were RT-PCR positive for > 60 days. Infectious virus was isolated only within the first two weeks of monitoring at or around the peak viral RNA excretion (as detected by the lowest cycle threshold) reported for each dog. Our findings suggest that peak viral RNA excretion and the days surrounding it might be used as a functional marker to gauge the end of infectious risk. Clarifying the earliest point in time when dogs testing positive for canine distemper by RT-PCR can be considered non-contagious will improve welfare and lifesaving potential of shelters by enabling recovered dogs to be cleared more quickly for live release outcomes.

Gender differences in tuberculosis patients with comorbidity: A cross-sectional study using national surveillance data and national health insurance claims data in South Korea.

The coexistence of tuberculosis and other chronic diseases complicates disease management. Particularly, the lack of information on the difference in the prevalence of chronic diseases in tuberculosis based on age and gender can hinder the establishment of appropriate public health strategies. This study aimed to identify age- and gender-based differences in the prevalence of chronic diseases as comorbidities in patients with tuberculosis. An anonymized data source was established by linking the national health insurance claims data to the Korean national tuberculosis surveillance data from 2014 to 2018. The prevalence of chronic diseases was stratified by gender and age (age groups: ≤64, 65-74, and ≥75 years), and the differences in the prevalence of chronic diseases were analyzed by multinomial logistic regression and classified using the Charlson Comorbidity Index. A total of 148,055 patients with tuberculosis (61,199 women and 86,856 men) were included in this study. Among the patients aged ≥65 years, 48.2% were female and 38.1% were male. In this age group, the probability of chronic disease comorbidity was higher in female patients than in male patients. The prevalence of congestive heart failure and dementia as comorbidities in patients with tuberculosis increased more drastically with age in women than in men. Thus, the present study confirmed gender and age differences in the distribution of comorbidities among patients with tuberculosis. A more comprehensive gender-responsive approach for patients with tuberculosis and chronic diseases is required to alleviate the double burden of infectious diseases and non-communicable diseases in an aging society.

DCRM Multispecialty Recommendations in Patients With Heart Failure

Diabetes mellitus (DM), hypertension, obesity, and atherosclerotic cardiovascular disease (ASCVD) are associated with heart failure (HF). Comorbid metabolic conditions in patients with HF are associated with worse outcomes and may affect the management of HF by limiting treatment options and reducing adherence to therapy. 1 Bozkurt B Aguilar D Deswal A Dunbar SB Francis GS Horwich T et al. Contributory risk and management of comorbidities of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in chronic heart failure: a scientific statement from the. American Heart Association. Circulation. 2016; 134: e535-e578 Google Scholar Practice guidelines for these diseases are drafted by the American Diabetes Association (ADA), the Kidney Disease Improving Global Outcomes (KDIGO) or the American College of Cardiology (ACC)/American Heart Association (AHA). These guidelines are drafted in silos, often without cross-collaboration with other cardiorenal/metabolic specialists. As a result, guidelines commonly differ in their recommendations. For example, the KDIGO guidelines and the ACC/AHA HF guidelines recommend different blood pressure goals for the management of hypertension. 2 Kidney disease: improving global outcomes blood pressure work g: KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021; 99: S1-87 Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar ,3 Heidenreich PA Bozkurt B Aguilar D Allen LA Byun JJ Colvin MM et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022; 145: e895-1032 PubMed Google Scholar Comanagement of DM, cardiorenal, and/or metabolic (DCRM) conditions is key to medical optimization. To introduce a more holistic approach to DCRM conditions, a volunteer task force created a multispecialty consensus for the management of complicated comorbid metabolic disease, the DCRM practice recommendations. 4 Handelsman Y Anderson JE Bakris GL Ballantyne CM Beckman JA Bhatt DL et al. DCRM Multispecialty Practice Recommendations for the management of diabetes, cardiorenal, and metabolic diseases. J Diabetes Complicat. 2022; 36108101 Crossref Scopus (4) Google Scholar Herein, we highlight the recommendations of these guidelines for the prevention and management of HF with concurrent DCRM comorbidities.

Novel approaches in search for biomarkers of cholangiocarcinoma.

Cholangiocarcinoma (CCA) arises from the ductular epithelium of the biliary tree, either within the liver (intrahepatic CCA) or more commonly from the extrahepatic bile ducts (extrahepatic CCA). This disease has a poor prognosis and a growing worldwide prevalence. The poor outcomes of CCA are partially explained by the fact that a final diagnosis is challenging, especially the differential diagnosis between hepatocellular carcinoma and intrahepatic CCA, or distal CCA and pancreatic head adenocarcinoma. Most patients present with an advanced disease, unresectable disease, and there is a lack in non-surgical therapeutic modalities. Not least, there is an acute lack of prognostic biomarkers which further complicates disease management. Therefore, there is a dire need to find alternative diagnostic and follow-up pathways that can lead to an accurate result, either singlehandedly or combined with other methods. In the "-omics" era, this goal can be attained by various means, as it has been successfully demonstrated in other primary tumors. Numerous variants can reach a biomarker status ranging from circulating nucleic acids to proteins, metabolites, extracellular vesicles, and ultimately circulating tumor cells. However, given the relatively heterogeneous data, extracting clinical meaning from the inconsequential noise might become a tall task. The current review aims to navigate the nascent waters of the non-invasive approach to CCA and provide an evidence-based input to aid clinical decisions and provide grounds for future research.

The surgical management of complicated peptic ulcer disease: An EAST video presentation.

Peptic ulcer disease (PUD), once primary a surgical problem, is now medically managed in the majority of patients. The surgical treatment of PUD is now strictly reserved for life-threatening complications. Free perforation, refractory bleeding and gastric outlet obstruction, although rare in the age of medical management of PUD, are several of the indications for surgical intervention. The acute care surgeon caring for patients with PUD should be facile in techniques required for bleeding control, bypass of peptic strictures, and vagotomy with resection and reconstruction. This video procedures and techniques article demonstrates these infrequently encountered, but critical operations. A combination of anatomic representations and videos of step-by-step instructions on perfused cadavers will demonstrate the key steps in the following critical operations. Graham patch repair of perforated peptic ulcer is demonstrated in both open and laparoscopic fashion. The choice to perform open versus laparoscopic repair is based on individual surgeon comfort. Oversewing of a bleeding duodenal ulcer via duodenotomy and ligation of the gastroduodenal artery is infrequent in the age of advanced endoscopy and interventional radiology techniques, yet this once familiar procedure can be lifesaving. Repair of giant duodenal or gastric ulcers can present a challenging operative dilemma on how to best repair or exclude the defect. Vagotomy and antrectomy, perhaps the least common of all the aforementioned surgical interventions, may require more complex reconstruction than other techniques making it challenging for inexperienced surgeons. A brief demonstration on reconstruction options will be shown, and it includes Roux-en-Y gastrojejunostomy. Surgical management of PUD is reserved today for life-threatening complications for which the acute care surgeon must be prepared. This presentation provides demonstration of key surgical principles in management of bleeding and free perforation, as well as gastric resection, vagotomy and reconstruction. Video procedure and technique, not applicable.

Gastrointestinal Dysfunction in Parkinson's Disease: Current and Potential Therapeutics.

Abnormalities in the gastrointestinal (GI) tract of Parkinson’s disease (PD) sufferers were first reported over 200 years ago; however, the extent and role of GI dysfunction in PD disease progression is still unknown. GI dysfunctions, including dysphagia, gastroparesis, and constipation, are amongst the most prevalent non-motor symptoms in PD. These symptoms not only impact patient quality of life, but also complicate disease management. Conventional treatment pathways for GI dysfunctions (i.e., constipation), such as increasing fibre and fluid intake, and the use of over-the-counter laxatives, are generally ineffective in PD patients, and approved compounds such as guanylate cyclase C agonists and selective 5-hyroxytryptamine 4 receptor agonists have demonstrated limited efficacy. Thus, identification of potential targets for novel therapies to alleviate PD-induced GI dysfunctions are essential to improve clinical outcomes and quality of life in people with PD. Unlike the central nervous system (CNS), where PD pathology and the mechanisms involved in CNS damage are relatively well characterised, the effect of PD at the cellular and tissue level in the enteric nervous system (ENS) remains unclear, making it difficult to alleviate or reverse GI symptoms. However, the resurgence of interest in understanding how the GI tract is involved in various disease states, such as PD, has resulted in the identification of novel therapeutic avenues. This review focuses on common PD-related GI symptoms, and summarizes the current treatments available and their limitations. We propose that by targeting the intestinal barrier, ENS, and/or the gut microbiome, may prove successful in alleviating PD-related GI symptoms, and discuss emerging therapies and potential drugs that could be repurposed to target these areas.