Extensive porto-mesenteric thrombosis presents a significant challenge in liver transplantation and was previously considered a contraindication. However, advancements in surgical techniques have made liver transplantation feasible. For optimal allograft function, adequate portal flow is crucial, as it generates shear stress that stimulates regeneration. In such cases, portal inflow options include the left renal vein (reno-portal anastomosis; RPA), the inferior vena cava (cavo-portal hemi-transposition; CPHT), any patent splanchnic territory, portal vein arterialization, or multi-visceral transplantation. Among these, CPHT and RPA are the most commonly performed. Generally, CPHT is used in pediatric liver transplantation; however, it is rarely reported in adult living donor liver transplantation (LDLT) due to technical challenges. In this report, we describe our technical modifications to CPHT and present the results in two patients with extensive porto-mesenteric thrombosis who underwent LDLT.

Background: Acute-on-chronic liver failure (ACLF) is associated with high mortality, but transplantation improves survival. Optimizing organ function is time-consuming and can increase infection risk. This study investigated the optimal pretransplant waiting period. Methods: In this retrospective study of patients with ACLF who underwent transplantation between January 2021 and August 2024, perioperative details and morbidity were compared between survival and mortality groups. Receiver operating characteristic (ROC) analysis was used to determine the cutoff for the pretransplant waiting period. Results: Among 112 patients with ACLF under the European Association for the Study of the Liver criteria, 61 (54.5%) underwent living donor liver transplantation (mean age, 41 years; 51 males [83.6%]). The most common etiology was viral infection (44.2%). The median Chronic Liver Failure Consortium (CLIF-C) score was 44 (respiratory failure, 14.7%; renal failure, 16.4%). There were 14 (22.9%) posttransplant deaths. The median waiting period between admission and surgery was longer in the mortality group (8 vs.4 days, P=0.2). The area under the ROC curve for the optimal pretransplant waiting period was 0.723 (P=0.01). A cutoff of 5 days predicted mortality with 71.4% sensitivity and 61.9% specificity. On univariate analysis, survivors and nonsurvivors differed significantly in age, hemoglobin level, warm ischemia time, and postoperative gastrointestinal (GI) bleeding; on multivariate analysis, postoperative GI bleeding independently predicted mortality. During a median follow-up of 17 months, no deaths occurred. Conclusions A pretransplant waiting period of 5 days predicted mortality; furthermore, postoperative GI bleeding was an independent predictor of mortality. Further studies are required to confirm these findings.

Background: and Purpose We aimed to evaluate whether early versus late initiation of direct oral anticoagulant (DOAC) after acute ischemic stroke (AIS) yields different safety and efficacy outcomes in Asian versus non-Asian patients. Methods: We analyzed Early versus Late initiation of direct oral Anticoagulants in post-ischaemic stroke patients with atrial fibrillatioN (ELAN) trial data from 2,013 AIS patients with atrial fibrillation (AF) randomized to early (≤48 hours for minor/moderate stroke, 6–7 days for major stroke) or late DOAC initiation (3–4 days for minor ischemic stroke, 6–7 days for moderate ischemic stroke, 12–14 days for major ischemic stroke). Patients were categorized by region as Asian (Japan and India) or non-Asian. The primary outcome was a composite of major extracranial bleeding, symptomatic uncerintracranial hemorrhage (SICH), recurrent ischemic stroke, systemic embolism (SE), or vascular death at 30 days (trial registration: ClinicalTrials.gov number, NCT03148457). Results: Among 1,975 patients, 245 were Asian (192 from Japan and 53 from India) and 1,730 were non-Asian. The primary outcome occurred in 6.5% of Asian patients (4.8% early vs. 8.3% late) and 3.1% of non-Asian patients (2.7% vs. 3.6%) (p<0.01). Higher rates of recurrent ischemic stroke (4.1% [2.4% vs. 5.8%] vs. 1.7% [1.3% vs. 2.1%], p=0.02) and SE (2.0% [0.8% vs. 3.3%] vs. 0.5% [0.4% vs. 0.6%], p=0.02) accounted for this difference. No significant differences were observed in major extracranial bleeding, SICH, recurrent ischemic stroke, SE, or vascular death. No significant interaction was observed between region and treatment allocation. Conclusions Although Asian patients had worse baseline profiles and outcomes, treatment effects did not differ by region, supporting the generalizability of early DOAC initiation in Asian AIS patients without region-specific timing modifications.

Arthroscopic rotator cuff repair is the gold standard for treatment, but current techniques have shortcomings, especially for larger tears. Single-row repairs often fail to fully restore the footprint, leading to high retear rates. Although triple-row and double-row repairs show promise, concerns regarding retear persist. Biomechanical studies favor triple-row repair for better coverage and pressure distribution. Techniques such as linked double-row and double-pulley methods enhance strength. Secondary cuff failures near the musculotendinous junction are commonly caused by stress concentration. To address these challenges, novel methods have employed linked, knotless, and bridging constructs. Our approach, the double pulley-triple row, aims to minimize retears, especially at the musculotendinous junction, and provides uniform pressure distribution, which is particularly beneficial for large tears. The surgical steps involve standard arthroscopic procedures with specific instruments. Despite these challenges, our method combines proven techniques for optimized outcomes and promising improved results in rotator cuff repair.

Rotator cuff tears are common shoulder injuries that often necessitate surgical intervention, particularly when nonoperative treatments fail. Arthroscopic rotator cuff repair is the current gold standard; however, challenges, such as high retear rates, especially in large tears, persist. Traditional techniques, such as single-row and double-row repairs, have limitations in fully restoring the anatomical footprint and ensuring optimal healing. This review examines the novel double pulley-triple row technique, which aims to overcome these limitations by enhancing the footprint contact area, load distribution, and tendon healing. By evaluating the double pulley-triple row method in comparison to established techniques, this study explores the potential advantages, limitations, and future directions of rotator cuff repair.

Objectives: The integration of large language models (LLMs), particularly those based on the generative pre-trained transformer (GPT) architecture, has begun to revolutionize various fields, including dentistry. Despite these promising applications, the use of GPT in dentistry presents several challenges. Ongoing research and the development of robust ethical frameworks are essential to mitigate these issues and enhance the responsible deployment of GPT technologies in clinical settings. Hence, this systematic review aims to explore the trends, applications, strengths, and challenges associated with the use of GPT in dentistry. Methods: Articles were selected if they contained detailed information on the application of GPT in dentistry. The search strategy used in systematic reviews follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search of databases and other sources yielded a total of 704 studies. After removing duplicates and conducting a full-text screening, 16 articles were included in the review. The methodological quality of the research was evaluated using the Critical Appraisal Skills Programme (CASP) checklist. Results: Out of a total of 91 articles published on GPT in dentistry, 20 were editorials and 11 were narrative reviews; these were excluded, leaving 60 original research articles for further analysis. The articles were assessed based on the type of results they provided. Ultimately, 16 articles that reported positive findings with robust methodology were included in this review Conclusions The results highlight mixed responses; therefore, further research on integration into clinical workflows must be conducted with extensive methodological rigor.

Chronic insomnia affects 10%–15% of the population, with one-third of Western adults struggling with sleep initiation or maintenance. Binaural beats, which involve two audio frequencies, have shown the potential for enhancing sleep and mood. This study examined the efficacy of customized binaural audio tracks generated using facial analysis software to treat chronic insomnia. Methods: A 45-minute personalized binaural beat audio session was delivered using the Spatial app and headband (SoundHealth) to 20 participants with moderate-to-severe insomnia, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and Insomnia Severity Index (ISI) criteria, over four weeks in California. Statistical analysis (paired t-test and linear mixed modeling) was used to compare baseline ISI scores to posttreatment scores, with p<0.05 indicating significance. The study assumed 80% power and aimed to achieve a 7-point ISI reduction. Results: All participants completed the study with no adverse events or full protocol adherence. The cohort was 60% White, with a 3:1 female-to-male ratio and an average age of 51.9 years. The baseline ISI was 19.8, dropping to 8.5 after four weeks, showing an 11.3-point reduction (95% confidence interval [CI]: -15 to -7.6, p<0.001). Mixed modeling indicated a similar ISI decrease of 11.28 points (95% CI: -14.98 to -7.57, p<0.001). The treatment response rate was 70%. Conclusions: Customized binaural beats show promise for insomnia treatment, with no adverse effects and high adherence. Most participants improved to no insomnia or subthreshold insomnia. Further research is needed to validate these results using larger samples and to assess long-term effects.

Depression is a common mental health problem that is associated with significant disability and mortality. Electroconvulsive therapy (ECT) has been demonstrated to be effective at resolving expression of suicidal intent in patients with depression. In less acute situations, patients are usually referred for ECT after several medication trials. Neuromuscular blocking agents (NMBAs) are used to block tonic-clonic motor activity and associated physical harm during the delivery of ECT. Succinylcholine (Sch), with its rapid onset of muscle relaxation, short self-terminating duration of action, and rapid subsequent return of spontaneous ventilation, is the NMBA of choice for ECT. However, the use of Sch is problematic or contraindicated is some situations. Although non-depolarizing NMBAs can be used, the variable time to onset of adequate muscle relaxation and prolonged duration of action have limited their widespread acceptance as alternatives to Sch. Recently, however, with the widespread availability of sugammadex, a chemically modified γ-cyclodextrin that rapidly and predictably reverses the effect of non-depolarizing NMBAs, the muscle relaxation achieved by rocuronium can predictably and effectively be reversed. In situations where Sch is contraindicated or otherwise problematic, rocuronium, followed by pharmacological antagonism with sugammadex, can provide a safe and effective muscle relaxation approach comparable to that of Sch in terms of duration of action. This review provides a summary of the current state of evidence for the use of sugammadex during ECT, which should lend support to further acceptance and future studies of sugammadex in the context of ECT.

PURPOSE: Non-operative management (NOM) has been validated for blunt liver and splenic injuries. Literature on continuous intra-abdominal pressure (IAP) monitoring as a part of NOM remains to be equivocal. The study aimed to find any correlation between clinical parameters and IAP, and their effect on the NOM of patients with blunt liver and splenic injury. METHOD: A prospective cross-sectional study conducted at a level I trauma center from October 2018 to January 2020 including 174 patients who underwent NOM following blunt liver and splenic injuries. Hemodynamically unstable patients or those on ventilators were excluded, as well as patients who suffered significant head, spinal cord, and/or bladder injuries. The study predominantly included males (83.9%) with a mean age of 32.5 years. IAP was monitored continuously and the relation of IAP with various parameters, interventions, and outcomes were measured. Data were summarized as frequency (percentage) or mean ± SD or median (Q₁, Q₃) as indicated. χ² or Fisher's exact test was used for categorical variables, while for continuous variables parametric (independent t-test) or nonparametric tests (Wilcoxon rank sum test) were used as appropriate. Clinical and laboratory correlates of IAP < 12 with p < 0.200 in the univariable logistic regression analysis were included in the multivariable analysis. A p < 0.05 was used to indicate statistical significance. RESULTS: Intra-abdominal hypertension (IAH) was seen in 19.0% of the study population. IAH was strongly associated with a high injury severity score (p < 0.001), and other physiological parameters like respiratory rate (p < 0.001), change in abdominal girth (AG) (p < 0.001), and serum creatinine (p < 0.001). IAH along with the number of solid organs involved, respiratory rate, change in AG, and serum creatinine was associated with the intervention, either operative or non-operative (p = 0.001, p = 0.002, p < 0.001, p < 0.001, p = 0.013, respectively). On multivariable analysis, IAP (p = 0.006) and the mean change of AG (p = 0.004) were significantly associated with the need for intervention. CONCLUSION As a part of NOM, IAP should be monitored as a continuous vital. However, the decision for any intervention, either operative or non-operative cannot be guided by IAP values alone.
Humans ; Male ; Adult ; Female ; Wounds, Nonpenetrating/physiopathology* ; Spleen/injuries* ; Prospective Studies ; Cross-Sectional Studies ; Liver/injuries* ; Middle Aged ; Monitoring, Physiologic/methods* ; Pressure ; Abdominal Injuries/physiopathology* ; Intra-Abdominal Hypertension ; Young Adult