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We report a case of a patient with severe fetal hydrops and refractory ascites, diagnosed as mucopolysaccharidosis type VII (MPS VII) by whole-exome sequencing, and discharged at 5 months of age after long-term ventilatory management. A male neonate was born by emergency cesarean section due to fetal distress at 301/7 weeks' gestation. Physical examination and X-rays revealed pleural effusion, ascites, and generalized edema, indicating severe fetal hydrops. He underwent tracheal intubation because of respiratory distress that was attributed to massive ascites, pulmonary hypoplasia, and pulmonary hypertension. He received mechanical ventilation and inhaled nitric oxide therapy. Prednisone, octreotide, and a factor XIII preparation were used as the treatment for ascites, and the ascites gradually decreased. He was extubated within 2 months of age. At 4 months of age, the results of whole-exome sequencing of the cord blood showed a compound heterozygous mutation in the GUSB gene, the gene responsible for MPS VII. Enzyme replacement therapy was initiated, and the ascites was resolved. Careful systemic management, including lung-protective respiratory management and the early establishment of nutrition, is important for the long-term survival of infants with fetal hydrops, and early aggressive workup, including whole-genome sequencing for the cause, should be performed in the case of refractory ascites.

The type III-E CRISPR–Cas7-11 effector binds a CRISPR RNA (crRNA) and the putative protease Csx29 and catalyzes crRNA-guided RNA cleavage. We report cryo–electron microscopy structures of the Cas7-11–crRNA–Csx29 complex with and without target RNA (tgRNA), and demonstrate that tgRNA binding induces conformational changes in Csx29. Biochemical experiments revealed tgRNA-dependent cleavage of the accessory protein Csx30 by Csx29. Reconstitution of the system in bacteria showed that Csx30 cleavage yields toxic protein fragments that cause growth arrest, which is regulated by Csx31. Csx30 binds Csx31 and the associated sigma factor RpoE (RNA polymerase, extracytoplasmic E), suggesting that Csx30-mediated RpoE inhibition modulates the cellular response to infection. We engineered the Cas7-11–Csx29–Csx30 system for programmable RNA sensing in mammalian cells. Overall, the Cas7-11–Csx29 effector is an RNA-dependent nuclease-protease.

Orientado pelas teorias pós-crítica do currículo, esse estudo objetiva compreender as torcidas organizadas como espaços formativos, que atuam na constituição de sujeitos torcedores. Trabalhando com um grupo chamado Movimento 105 Minutos, focalizamos as pedagogias presentes nas interações de seus membros, tomando-as como integrantes de um currículo cultural. Para tanto, foram feitas uma pesquisa bibliográfica, observações participantes e entrevistas semiestruturadas. Na produção dos dados, utilizamos a teoria do discurso de Michel Foucault. Como resultados, notamos um currículo que busca formar torcedores caracterizados pelo amor, apoio e fidelidade incondicional ao clube, aspectos manifestados tanto em falas, quanto em ações. Nesse sentido, os sujeitos adotam posturas ritualizadas, valendo-se de elementos materiais e simbólicos, a fim de formar uma identidade de grupo e transmitir seus modos de torcer.

The appropriate method of preoperative endoscopic biliary drainage (EBD) for cholangiocarcinoma with hilar biliary obstruction remains controversial. The inside-stent technique is a method of placing plastic stents entirely inside the bile duct. Several studies of patients with unresectable stage have reported longer stent patency compared with conventional endoscopic biliary stenting (EBS). Inside-stent techniques have been introduced as a bridge-to-surgery option and as an alternative to conventional EBS.We aimed to evaluate the clinical outcomes of inside stent use and conventional EBS.During this retrospective multicenter study, we reviewed consecutive patients with cholangiocarcinoma who underwent radical surgery after conventional EBS or inside-stent insertion. Adverse event (AE) rates after EBD and post-surgical AEs were compared. A multivariable analysis was performed to identify factors affecting cholangitis after EBD.Conventional EBS and inside-stent procedures were performed for 56 and 73 patients, respectively. Patient backgrounds were similar between groups, except for percutaneous transhepatic portal vein embolization. The waiting time before surgery was similar between groups (28.5 days vs. 30 days). There were no significant differences in the cholangitis rate (21.4% vs. 26.0%; P = 0.68) and all AEs (25.0% vs. 30.1%; P = 0.56) between groups. The post-surgical AE rate was similar between the groups. The multivariable analysis found that preprocedural cholangitis was a risk factor for cholangitis after EBD (odds ratio: 5.67; 95% confidence interval: 1.61-19.9).The outcomes of inside-stent techniques and conventional EBS for the management of preoperative EBD are comparable for patients with cholangiocarcinoma.

Objetivo do estudo: O presente estudo se estabelece no campo das políticas públicas de esporte e do lazer, tendo como objetivo analisar o cenário institucional dos municípios que implementaram o PELC entre 2013 e 2017. Metodologia: Para isso, foi aplicado um questionário digital para 105 prefeituras, obtendo 19 respostas que apontaram para dois eixos de análise: administrativo e gerencial. Relevância: Ao analisar o legado de um programa nacional de esporte e lazer ancorado pelos princípios da municipalização, a pesquisa em tela oferece um lastro de dados que possibilita avaliar as políticas públicas sob a ótica do federalismo e da descentralização. Principais resultados: Dentre os dados encontrados, destaca-se que a presença de órgãos próprios gestores do esporte e do lazer aumenta a possibilidade de institucionalização das ações nessas áreas, pois pode ampliar os mecanismos de participação, a perenidade das políticas, sua avaliação e monitoramento, assim como a criação e manutenção de quadros profissionais próprios. Sobre isso, notou-se a valorização das práticas de formação continuada e o enfrentamento de práticas hegemônicas, como as físico-esportivas. Contribuições teóricas: Dentre as contribuições teóricas da pesquisa, destaca-se que no contexto analisado, o princípio de indução à municipalização, materializado por projetos e programas federais de esporte e lazer, configura-se como estratégia eficaz para a descentralização executiva dos serviços públicos. Todavia, a continuidade das ofertas se condiciona pelo fortalecimento do cenário institucional local, ensejando investigações futuras em caráter longitudinal.

We attempted to determine the indications and limitations of steroid therapy as the first-line therapy in patients with autoimmune pancreatitis (AIP) with cyst formation (ACF).This Japanese multicenter survey was conducted to examine the merits/demerits of steroid treatment as the initial therapy for ACF.Data of a total of 115 patients with ACF were analyzed. Complete remission was achieved in 86% (86/100) of patients who had received steroid treatment, but only 33.3% (5/15) of patients who had not received steroids. Relapse after the remission (n = 86) occurred in 7.6% (6/86) of patients who had received steroid therapy, but 40% (2/5) of patients who had not received steroid therapy. Multivariate analysis identified adoption of the wait and watch approach without steroid treatment (odds ratio = 0.126, P .001) as a significant and independent negative predictor of remission of ACF. As for predictors of relapse, the presence of varix (odds ratio = 5.83, P = .036) was identified as an independent risk factor.Steroid therapy plays an important role as first-line therapy in AIP patients with pancreatic cyst formation, however, varix formation, besides the diameter of the cyst(s), is a risk factor for refractoriness to steroid therapy.

Interventional endoscopic ultrasonography is performed for various situations that require drainage, after which stent migration is the most severe adverse event. Several lumen-apposing metal stents (LAMS) and covered self-expandable metal stents (CSEMS) provide antimigration systems; however, their anchoring ability has not been studied well. Therefore, we measured and compared the anchoring force (ACF) of commercially available LAMS and CSEMS.Anchoring force was measured for five types of LAMS (NAGI, SPAXUS, Plumber, and AXIOS 8 and 10 mm) and seven types of CSEMS (BCL, SHCL, BCG, BPD [four types of HANAROSTENT], HILZO, Niti-S [Spring Stopper], and Wallflex). We created a phantom model for inducing stent migration. It has a rotatable part as a curved fixture, and we measured ACF at angles between 0° and 40°.The mean ACF at 0° and 20° were NAGI 1.50, 1.84 N, SPAXUS 1.73, 1.72 N, Plumber 2.64, 2.03 N, and AXIOS 3.96, 3.61 N, respectively; and BCL 0.48, 0.53 N, Wallflex 0.53, 0.48 N, SHCL 0.64, 0.73 N, HILZO 1.09, 1.09 N, BCG 1.22, 1.20 N, BPD 1.78, 1.67 N, and Spring Stopper 2.29, 2.51 N.We measured ACF in LAMS and CSEMS with a new phantom model. The highest value among the LAMS was for the AXIOS and among the CSEMS was for the Spring Stopper. Some of the ACF values varied with the direction of pull. These findings may have a significant impact on stent selection for interventional endoscopic ultrasonography, and this model can be used to evaluate newly developed stents.

Evidence of the efficacy and safety of colorectal stent placement for palliation remains insufficient. This single-arm, prospective, multicenter study with WallFlex enteral colonic stent included 200 consecutive patients with malignant large bowl obstruction in the palliation cohort. The technical and clinical success, as well as stent patency and complications as short-term (≤ 7 days) and long-term (> 7days) outcomes, of high axial force self-expandable metal stent (SEMS) placement was evaluated. The technical and clinical success rates were 98.5% and 94.5%, respectively. Non recurrent colorectal obstruction at 1 year was 63.9%, and 71.2% of the patients remained free of recurrent colorectal obstruction until death or the last follow-up. Fifty-six patients (28.0 %) received chemotherapy and five patients were administered bevacizumab after stent placement. The overall complication rate was 47%, including four (2.0%) early-onset and ten (5.0%) late-onset perforations, mostly due to stent-edge injury. Only the use of a long SEMS was a risk factor for perforation. In conclusion, endoscopic colorectal stenting using high axial force SEMS is an effective and safe procedure for palliation in patients with malignant colorectal obstruction. However, care should be taken to avoid perforation at the stent edge when using a long SEMS.

Highly electrically and thermally conducting films of expanded graphite/polymer nanocomposites were fabricated using an approach based on solution mixing methods. The use of Hydroxyethylcellulose and benzylic alcohol based solutions provides efficient dispersion and better exfoliation of multilayer graphene (nanographite) flakes that are further aligned in extended 2D layers forming continuous conductive pathways during lamination (hot calendering) process. Very high electrical conductivity (190 S/cm) was obtained for fabricated layered films. In contrast, for films produced by a conventional mixing and deposition method with acrylic copolymer and the same nanographitic material, with flakes randomly distributed within the composite, much lower conductivities (2.4 S/cm) were obtained.

Background Endoscopy is an important form of clinical gastroenterology education because it gives students the opportunity to learn about diagnosis procedures and even treatment. During the COVID-19 pandemic, medical students were observed from outside the endoscopy room due to the risk of airborne infection. In this study, we investigated the efficacy of combining endoscopy education with doctor's-eye-view videos of the procedure obtained using live-action cameras (GoPro®). Methods From February to May 2021, endoscopists wore GoPro Hero8 cameras on their heads to display a doctor's-eye view video outside the room. The efficacy of the GoPro videos in combination with endoscopic monitoring was evaluated by 15 participating medical students. The participants rated the efficacy on a 5-point scale and commented on the positive and negative points. Results A total of 78.6% of participants evaluated the GoPro as good; 57.2% answered that it increased their understanding, with 71.4% stating that it increased their understanding of procedures in particular. A total of 85.7% of the students answered that their interest in endoscopy had increased, and 85.7% evaluated the benefit of the GoPro videos as good. In addition, 64.3% answered that the method was effective in preventing COVID-19 infection. Education using GoPro videos enabled students to feel as if they were conducting the endoscopy themselves and enabled them to concentrate on learning. Conclusions Practical endoscopic education using a GoPro is an effective educational tool that not only increases understanding of endoscopic practice but also stimulates students’ interest and awareness of their future as doctors.

Video 1The duct was cannulated with a modified MTW catheter using the hitch-and-ride method. A duodenal flap of the 5F, 7-cm pancreatic plastic stent was cut with a surgical scalpel and tied to the duodenal edge of the stent with a 0.3-mm silk suture. The suture tied to the stent was ligated at the center. The sutured stent was inserted into the pancreatic duct above the minor duodenal papilla. The tumor and silk suture were held together by a 25-mm oval polypectomy snare and were resected. The suture tied to the pancreatic plastic stent was grasped by biopsy forceps and pulled into the duodenum.

Esse estudo teve como objetivo analisar os processos formativos vividos pelos/as animadores/as dos eventos com ênfase em suas trajetórias e construção de saberes que foram mobilizados para sua formação profissional. Foram entrevistados/as quinze profissionais que atuam no âmbito do lazer, sendo sete mulheres e oito homens. Identificamos que os animadores mobilizam saberes para a prática profissional relacionados tanto ao domínio de conteúdos e atividades quanto à postura pessoal e profissional necessária para prática de animação. Os contextos em que esses saberes foram construídos são variados e contemplam as vivências lúdicas na infância, o contato com práticas culturais, como o esporte, a dança e o teatro, além das experiências laborais e dos momentos de lazer dos sujeitos. Entre as instituições que influenciaram esse percurso formativo, estão os estabelecimentos de ensino, a igreja e escolas de arte.

Supplementary Figure 1 PDF file - 186K, Exogenous EGF rescued gemcitabine-induced apoptosis in vitro

Supplementary Table 1 PDF file - 108K, Adding erlotinib to gemcitabine synergistically inhibited the growth of mouse and human PDAC cells

Supplementary Figure 5 PDF file - 1755K, Gemcitabine-induced EGFR/ErbB2-MAPK signal activation was a common phenomenon in PDAC and lung cancer cells irrespective of KRAS mutation status and gemcitabine sensitivity.

Supplementary Figure 4 PDF file - 177K, The effect of erlotinib was mainly through the inhibition of MAPK signaling

Supplementary Materials PDF file - 91K, Supplementary Methods and Figure Legends

Supplementary Figure 3-1 PDF file - 354K, Gemcitabine-induced expression of EGFR ligands was dependent on active MAPK signaling in the PDAC cells

Supplementary Figure 3-2 PDF file - 172K, Gemcitabine-induced expression of EGFR ligands was dependent on active MAPK signaling in the lung cancer cells

Supplementary Figure 2 PDF file - 97K, MEK inhibition reduced the gemcitabine-induced activation of EGFR and ErbB2 in the PDAC cells

Background: With the increasing popularity of endoscopic ultrasound (EUS)-guided transmural interventions, walled-off necrosis (WON)of the pancreas is increasingly managed via non-surgical endoscopic interventions. However, there has been an ongoing debate over the appropriate treatment strategy following the initial EUS-guided drainage. Endoscopic necrosectomy (EN) directly removes intracavity necrotic tissue, potentially facilitating early resolution of the WON, but may associate with a high rate of adverse events. Given the increasing safety of EN, this trial aims to assess the superiority of immediate EN over the step-up approach in terms of time required for WON resolution. Methods: The WONDER-01 trial is a multicentre, open-label, superiority, randomised controlled trial, which will enrol WON patients aged ≥ 18 years requiring EUS-guided treatment in 23 centres in Japan. This trial plans to enrol 70 patients who will be randomised at a 1:1 ratio to receive either the immediate EN or drainage-oriented step-up approach (35 patients per arm). In the immediate EN group, EN will be initiated during (or within 72 hours of) the EUS-guided drainage session. In the step-up approach group, drainage-based step-up treatment with on-demand EN will be considered after 72-96 hours observation. The primary endpoint is time to clinical success, which is defined as a decrease in a WON size to ≤ 3 cm and an improvement of inflammatory markers (i.e., body temperature, white blood cell count, and C-reactive protein). Secondary endpoints include technical success, adverse events including mortality, and recurrence of the WON. Discussion: The WONDER-01 trial will investigate the efficacy and safety of immediate EN compared to the step-up approach for WON patients receiving EUS-guided treatment. The findings will help us to establish new treatment standards for patients with symptomatic WON. Trial registration: ClinicalTrials.gov NCT05451901, registered on 11 July 2022. UMIN000048310, registered on 7 July 2022. jRCT1032220055, registered on 1 May 2022.

Background and aims: There is a lack of biliary epithelial molecular markers for primary sclerosing cholangitis (PSC). We analyzed candidates from disease susceptibility genes identified in recent genome-wide association studies. Methods: Expression was quantified using immunohistochemistry in biliary epithelia in liver biopsy samples from patients with PSC (N = 45) and controls (N = 12). Samples from patients with primary biliary cholangitis (PBC) were used as disease controls (N = 20). Results: The levels of hepatic expression of ATXN2, HHEX, PRDX5, MST1, and TNFRSF14 were significantly altered in the PSC group. We focused on the immune-related receptor, TNFRSF14. Immunohistochemistry revealed that TNFRSF14 positivity was significantly higher in biliary epithelia in the PSC group (96 %) than in the control (42 %) and PBC (55 %) groups. High expression of TNFRSF14 was observed only in patients with PSC. Moreover, the expression of LIGHT, which encodes a TNFRSF14-activating ligand, was increased in PSC liver. Immunohistochemistry showed that high expression of LIGHT was more common in PSC biliary epithelia (53 %) than in the PBC (15 %) or control (0 %) groups; moreover, it was positively associated with fibrotic progression. Conclusions: TNFRSF14 and LIGHT are attractive candidate markers for PSC.

Supplemental material, sj-docx-1-nnr-10.1177_15459683231166939 for New Artificial Intelligence-Integrated Electromyography-Driven Robot Hand for Upper Extremity Rehabilitation of Patients With Stroke: A Randomized, Controlled Trial by Yuhei Murakami, Kaoru Honaga, Hidemi Kono, Koshiro Haruyama, Tomofumi Yamaguchi, Mami Tani, Reina Isayama, Tomokazu Takakura, Akira Tanuma, Kozo Hatori, Futoshi Wada and Toshiyuki Fujiwara in Neurorehabilitation and Neural Repair

Predictive factors for intrahepatic cholangiocarcinoma in long-term follow-up of hepatolithiasis are unknown. We thus conducted a cohort study to investigate the predictive factors for developing intrahepatic cholangiocarcinoma in hepatolithiasis.This cohort is comprised of 401 patients registered in a nationwide survey of hepatolithiasis for 18 years of follow-up. Cox regression analysis was used to elucidate predictive factors for developing intrahepatic cholangiocarcinoma.The median follow-up period of patients was 134 months. Twenty-two patients developed intrahepatic cholangiocarcinoma and all died. Identified independent significant factors were as follows: age 63 years or older (hazard ratio [HR] 3.344), residual stones at the end of treatment (HR 2.445), and biliary stricture during follow-up (HR 4.350). The incidence of intrahepatic cholangiocarcinoma in patients with three factors was significantly higher than that in patients with one or two factors. The incidence in the groups with one or two predictive factors was not different. In 88.9% of patients with both biliary stricture and intrahepatic cholangiocarcinoma, the duration between the diagnoses of biliary stricture and intrahepatic cholangiocarcinoma was ≥ 5 years. However, once intrahepatic cholangiocarcinoma developed, 77.8% of patients died within 1 year. Of 24 patients with no symptoms, no previous choledocoenterostomy, no signs of malignancy, no biliary stricture, and no treatment for hepatolithiasis during follow-up, only one developed intrahepatic cholangiocarcinoma.Regarding carcinogenesis, complete stone clearance and releasing biliary stricture can prevent the development of intrahepatic cholangiocarcinoma and improve the prognosis of hepatolithiasis.

The role of a covered vs. an uncovered self-expandable metal stent (SEMS) for malignant distal biliary obstruction (MDBO) is not clear. This meta-analysis compared the efficacy of covered vs. uncovered SEMS for patients with MDBO after endoscopic insertion.A systematic meta-analysis of all relevant articles listed in PubMed, the Cochrane Library, and Google Scholar databases was performed. Fixed effects or random effects models were used to investigate pooled effects with 95% confidence intervals (CIs).The meta-analysis included 2358 patients from 12 eligible studies. Time to recurrent biliary obstruction (RBO) was significantly longer for covered SEMS (mean difference, 45.51 days; 95% CI 11.79-79.24). Although there was no significant difference in the RBO rate, subgroup analysis in pancreatic cancer occupying more than 90% (PC) revealed that the RBO rates were significantly lower for covered SEMS (odds ratio [OR] 0.43, 95% CI 0.25-0.74). Stent migration, sludge formation, and overgrowth were significantly more common with a covered SEMS (OR 7.92, 95% CI 4.01-15.64; OR 3.25, 95% CI 1.89-5.59; OR 2.03, 95% CI 1.20-3.43, respectively). The rate of ingrowth was significantly lower for covered SEMS. There was no significant difference in total procedure-related adverse events between the two types of SEMS.A covered SEMS is superior to an uncovered SEMS with respect to prevention of RBO in patients with MDBO, particularly those caused by PC.

Endoscopic ultrasound/endosonography-guided pancreaticogastrostomy (EUS-PGS) is a useful alternative when endoscopic retrograde pancreatography is difficult. Recently, many procedures, including peroral pancreatoscopy (POPS), have been performed through the mature fistula (MF) created by EUS-PGS. We evaluate the efficacy and safety of POPS to diagnose and treat pancreatic ductal stricture/pancreato-jejunal anastomotic stricture (PDS/PJAS) through the MF.Twenty patients underwent EUS-PGS; 13 of these underwent POPS through the MF at Juntendo University Hospital. All patients were studied retrospectively in terms of technical and clinical success rates and adverse events (AEs).The technical and clinical success rates of EUS-PGS were 95% and 100%. The early and late AEs rates were 20% and 15%. The technical success rate of POPS was 100%, with one AE. Biopsy of PDS/PJAS under POPS guidance revealed recurrent/residual intrapapillary mucinous adenoma (3 patients) and benign fibrotic stricture (10 patients). In the latter patients, multiple plastic stents were placed to dilate PDS/PJAS. Four patients with improvement of PDS/PJAS were stent free, but the remaining patients were not yet.Endoscopic ultrasound/endosonography-guided pancreaticogastrostomy and various procedures (including POPS) performed through the MF are feasible and effective and can diagnose and treat PDS/PJAS with acceptable AEs rates.

Purpose This paper is an excerpt from a countrywide study entitled “Leisure in Brazil: representations and realizations of daily experiences”, which aims to investigate what Brazilians do in their leisure time, what they would like to do and why they do not do it. Design/methodology/approach Specifically, in this paper, the authors analyze data referring to the elderly population from southeastern Brazil. Sampling of the national survey comprised representative quotas of the population, considering region and state, and, in each state, quotas of sex, age, education level and family income, according to data obtained by IBGE in 2010. A total of 2,400 interviews were conducted in total. For the present study, the 91 interviews conducted with elderly subjects from the Southeast region of Brazil were considered. Findings The majority of participants understand leisure as a time for resting and fun and have physical/sports interests as their favorite leisure activity during the week. On weekends, social and tourism interests stand out, and idleness stands out in the preference of this public during the holiday period. Lack of time and financial resources are the main barriers to the access to and permanence in the desired leisure practices. Originality/value Having knowledge of the relationship between leisure and aging in Brazil is a way to contribute to the potential of this stage of life, based on the quality of life and continued learning provided by the content they enjoy.

BACKGROUND/PURPOSE Patients with pancreatic ductal adenocarcinoma (PDAC) with peritoneal dissemination have a dismal prognosis because discontinuation of systemic chemotherapy is required for massive ascites or poor performance status. The natural history, diagnosis and treatment of PDAC with peritoneal dissemination have not been fully investigated. METHODS We systematically reviewed published information on the clinical diagnosis and treatment of PDAC with peritoneal dissemination using the PubMed database (2000-2020) and provided recommendations in response to clinical questions. This guideline was created according to the "Minds Clinical Practice Guideline Development Guide 2017". The literature quality and body of evidence were evaluated with the GRADE System and classified into four levels ("strong", "medium", "weak", "very weak"). The strength of each final recommendation was decided by a vote of committee members based on the GRADE Grid method. RESULTS These guidelines address 3 subjects: diagnostic, chemotherapeutic, and surgical approaches. They include 9 clinical questions and statements with recommendation strengths, evidence levels, and agreement rates, in addition to one "column". CONCLUSIONS This is the English synopsis of the 2021 Japanese clinical practice guideline for PDAC with peritoneal dissemination. It summarizes the clinical evidence for the diagnosis and treatment of PDAC with peritoneal dissemination and provides future perspectives.

Background Indeterminate strictures pose a therapeutic dilemma. In recent years, cholangioscopy has evolved and the availability of cholangioscopy has increased. However, the position of cholangioscopy in the diagnostic algorithm to diagnose malignancy have not been well established. We aim to develop a consensus statement regarding the clinical role of cholangioscopy in the diagnosis of indeterminate biliary strictures. Methods The international experts reviewed the evidence and modified the statements using a three-step modified Delphi method. Each statement achieves consensus when it has at least 80% agreement. Results Nine final statements were formulated. An indeterminate biliary stricture is defined as that of uncertain etiology under imaging or tissue diagnosis. When available, cholangioscopic assessment and guided biopsy during the first round of ERCP may reduce the need to perform multiple procedures. Cholangioscopy are helpful in diagnosing malignant biliary strictures by both direct visualization and targeted biopsy. The absence of disease progression for at least 6 months is supportive of non-malignant etiology. Direct per-oral cholangioscopy provides the largest accessory channel, better image definition, with image enhancement but is technically demanding. Image enhancement during cholangioscopy may increase the diagnostic sensitivity of visual impression of malignant biliary strictures. Cholangioscopic imaging characteristics including tumor vessels, papillary projection, nodular or polypoid mass, and infiltrative lesions are highly suggestive for neoplastic/malignant biliary disease. The risk of cholangioscopy related cholangitis is higher than in standard ERCP, necessitating prophylactic antibiotics and ensuring adequate biliary drainage. Per-oral cholangioscopy may not be the modality of choice in the evaluation of distal biliary strictures due to inherent technical difficulties. Conclusion Evidence supports that cholangioscopy has an adjunct role to abdominal imaging and ERCP tissue acquisition in order to evaluate and diagnose indeterminate biliary strictures.

Ao compreender que vivemos em uma sociedade que exclui e silencia os sujeitos de práticas sociais e culturais, devido às avenidas identitárias que essas pessoas atravessam e que resultam em diversas discriminações – entre eles, as populações LGBT+ e tendo ainda em vista que essa exclusão promove uma negação do acesso a direitos, como o lazer, o presente estudo teve como objetivo identificar e analisar as pautas LGBT+ relacionadas às políticas públicas de lazer no cenário brasileiro. Como estratégia metodológica, utilizamos o recorte da pesquisa documental e a revisão bibliográfica. Para a análise documental foi realizada uma investigação das políticas públicas de lazer desenvolvidas em projetos de lei, no Plano Nacional de Direitos Humanos, resoluções, decretos, os textos-base para as conferências nacionais e os relatórios. Como resultados, percebemos o silenciamento em torno das pautas LGBT+ na produção documental das políticas públicas relacionadas ao lazer no cenário nacional, a ausência de conhecimentos e pesquisas específicas sobre esse público e suas necessidades no que diz respeito ao lazer, a reprodução de eventos como políticas isoladas de representação de lazer dessa população e, ainda, a existência de políticas públicas associadas especificamente ao controle e à biopolitização da vida por meio da normatização de questões de saúde isoladas das violências que essa população sofre.

Background Several serious complications are associated with the lithotomy position, including well-leg compartment syndrome and peroneal nerve paralysis. The aims of this study were to identify risk factors for the intraoperative elevation of lower leg pressure and to evaluate the effectiveness of monitoring external pressure during surgery for preventing these complications. Methods The study included 106 patients with a diagnosis of sigmoid colon or rectal cancer who underwent elective laparoscopic surgery between June 2019 and December 2020. We divided the posterior side of the lower leg into four parts (upper outside, upper inside, lower outside, lower inside) and recorded the peak pressure applied to each area at hourly intervals during surgery (called "regular points") and when the operating position was changed (e.g., by head-tilt or leg elevation; called "points after change in position"). When the pressure was observed to be higher than 50 mmHg, we adjusted the position of the leg and re-recorded the data. Data on postoperative leg-associated complications were also collected. Results The pressure was measured at a total of 1125 points (regular, n = 620; after change of position, n = 505). The external pressure on the upper outer side of the right leg (median, 36 mmHg) was higher than that on any other area of the lower leg. The pressure increase to more than 50 mmHg was observed not only during the change of position (27.5%) but also during regular points (22.4%). Bodyweight, strong leg elevation, and low head position were identified as factors associated with increased external pressure. There have been no compression-related complications in 534 cases at our institution since the introduction of intraoperative pressure monitoring. Conclusions Several risk factors associated with increased external pressure on the lower leg were identified. Intraoperative pressure monitoring might help reduction of pressure-related complications, needing further and larger prospective data collections.

AIM Anti-ribosomal P protein antibodies (anti-ribo P) have been reported as one of the specific autoantibodies in patients with systemic lupus erythematosus (SLE) and has been demonstrated to bind and activate macrophages in vitro. Clinically, hyperferritinemia has been known to be a biomarker for macrophage activation. The aim of this study is to clarify the relationship of anti-ribo P and clinical characteristics and biomarkers including serum ferritin in patients with SLE. METHODS Clinical parameters and laboratory data were measured in patients with active SLE (N = 127) in our university hospital. The risk factors affected by anti-ribo P were retrospectively calculated by logistic regression analysis, and the correlation of anti-ribo P and clinical factors was demonstrated. RESULTS Anti-ribo P was significantly elevated in active SLE compared to non-SLE diseases (P

Background Pressure ulcers are the most common complications in bedridden patients or those with spinal cord injuries. Marjolin's ulcer refers to a malignant transformation arising from burn scars or chronic nonhealing wounds—such as pressure ulcers—over many years. Squamous cell carcinoma is the major histopathologic type of Marjolin's ulcer, and the gold standard for diagnosis is tissue biopsy. Medical professionals may have difficulty distinguishing pressure ulcers from Marjolin's ulcer, especially when the latter presents with invasive infections. Thus, malignant transformations arising from pressure ulcers are frequently overlooked. Herein, we describe a case of squamous cell carcinoma arising from pressure ulcers on the left ischium, which was initially identified as a necrotizing soft tissue infection. Case report A 59-year-old paraplegic patient presented with stage 3 left ischial pressure ulcer, which involves full-thickness skin loss and extends into deep subcutaneous tissue, and arrived at our hospital with suspected sepsis. Upon physical examination, the patient presented with fever and shivering. Initial examination and imaging findings revealed the presence of necrotizing soft tissue infections. Three weeks later, rapid increase in granulation in the deep part of the ulcer was observed. Samples from multiples ulcer sites were collected for tissue biopsy. Finally, histological examination revealed well-differentiated squamous cell carcinoma. The patient received radiation therapy and chemotherapy and died 11 months after the diagnosis. Conclusion Malignant transformations arising from pressure ulcers may closely resemble pressure ulcer infections. In these cases, tissue biopsies should be performed during primary care for the infection to exclude malignant transformations.

Background: Acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is a devastating and life-threatening condition during its clinical course. Biomarkers for precisely anticipating the prognosis of AE-IPF remain to be fully established. The objective of this study was to clarify whether S100A8 and S100A9, which are calcium-binding proteins mainly produced by activated neutrophils, are significant prognostic biomarkers in AE-IPF.Methods: Thirty-seven patients with AE-IPF who were diagnosed and treated at our hospital were retrospectively evaluated. The serum levels of S100A8 and S100A9 were measured using enzyme-linked immunosorbent assay, and the relationships between these levels and clinical parameters or prognosis were evaluated.Results: The serum levels of S100A8 (median 386.5ng/mL) and S100A9 (median 60.2ng/mL) in patients with AE-IPF were significantly higher than those in age-matched healthy controls and in patients at IPF diagnosis (p