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Choledochal cysts (CCs) are rare cystic dilatations of the intrahepatic and/or extrahepatic bile ducts. We review the pathophysiology, diagnosis, and management of CCs.MEDLINE/PubMed and Web of Science databases were queried for "choledochal cyst", "bile duct cyst", "choledochocele", and "Caroli disease". Data were synthesized and systematically reviewed.Classified according to the Todani Classification, CCs are generally believed to arise secondary to reflux of pancreatic enzymes into the biliary tree due to anomalous pancreaticobiliary duct union. Complications of CCs include abdominal pain, jaundice, cystolithiasis, cholecystitis, pancreatitis, liver abscess, liver cirrhosis and malignant transformation (3-7.5%). Radiological and endoscopic imaging is the cornerstone of CC diagnosis and full delineation of cyst anatomy is imperative for proper management. Management is generally guided by cyst classification with complete cyst excision necessary for CCs with high potential of malignant transformation such as types I and IV. 5-year overall survival after choledochal cyst excision is 95.5%.Most CCs should undergo surgical intervention to mitigate the risk of cyst related complications such as cholangitis and malignant transformation.

The supine hypotension syndrome (SHS) is a reduction in maternal systolic blood pressure of 15 and 30 mm Hg or an increase in heart rate of 20 beats/min, with or without symptoms, when the patient is in the supine position. SHS is caused by aortocaval compression and can lead to decreased uteroplacental perfusion and nonreassuring fetal heart rate patterns. It begins around 18–20 weeks and typically manifests as pallor, hypotension, dizziness, nausea, tachycardia and sweating during the third trimester. Vasodilation imposed by systemic anesthetics and neuraxial blockade may amplify the reduction in maternal blood pressure caused by SHS. Proper left uterine displacement is a pivotal preventive and therapeutic intervention in managing parturients beyond 20 weeks gestation.

Epidural analgesia is the gold standard modality to alleviate pain associated with labor. Over the past decades, an association between epidural analgesia and undesirable obstetric effects has been reported. Reported undesirable obstetric effects include prolonged labor, increased incidence of assisted vaginal delivery, and increased rate of cesarean delivery. Currently, evidence indicates that the only undesirable effect of labor epidural analgesia is a prolongation of the second stage of labor, with concerns about maternal and neonatal outcomes associated with the duration of the second stage of labor or active pushing. The risks of postpartum hemorrhage, advanced degree of perineal lacerations, chorioamnionitis, as well as neonatal complications, have been observed to be higher with the prolongation of second stage. Prolongation of the second stage of labor can be minimized by using a low-concentration local anesthetic solution for epidural analgesia.

Umbilical cord prolapse is an obstetric emergency. The prolapse occurs when the cord slips ahead (overt umbilical cord prolapse) or alongside (occult umbilical cord prolapse) the presenting part of the fetus and protrudes into the cervical canal or beyond. Compression of the prolapsed cord leads to occlusion of the umbilical vein and vasospasm of the umbilical artery, which compromises fetal oxygenation. The discussion includes common risk factors, prevention, pathophysiology, clinical presentation of cord prolapses, prevention, and management to improve neonatal outcome. The anesthetic technique that provides the shortest induction time is the best choice. Although regional anesthesia can be used, general anesthesia is usually chosen for an emergent delivery.

Postpartum hemorrhage (PPH) is a significant and life-threatening obstetric complication. It is defined as blood loss greater than or equal to 1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours of birth. The increase in uterine blood flow and the role of placental implantation, separation, and uterine contractility renders the management of PPH critical and multifaceted. Common causes of PPH include uterine atony, genital trauma, retained placenta, uterine inversion, and placenta accreta. Measures to minimize PPH should be implemented when appropriate. Proper assessment and prompt management of obstetric hemorrhage is critical for maternal well-being and survival.

The Apgar scoring system was developed in 1953 by Virginia Apgar to differentiate between infants who require resuscitation efforts and those for whom routine care is sufficient. Apgar scoring is performed while care is being delivered. The Apgar system has since become a standard neonatal assessment tool, comprising 1- and 5-minute assessments of appearance, pulse, grimace, activity, and respiration. A score of 8 to 10 is normal, while a score of 0 to 3 is a sign of fetal distress requiring immediate resuscitation. The low score is considered a nonspecific sign of illness, which may be one of the first indications of encephalopathy. The score is used in conjunction with routine neonatal assessment.

The risk for aspiration pneumonia is increased during pregnancy. The reported incidence of aspiration pneumonia has significantly dropped in recent years due to liberal use of neuraxial anesthesia. Aspiration of a significant volume of particulate acidic gastric contents can lead to higher morbidity and mortality. Factors determining the morbidity and mortality associated with aspiration include the type and volume of aspirate, the therapy administered, the physical status of the patient, and the criteria used for making the diagnosis. Aspiration pneumonia is best managed by prevention using pharmacological agents and rapid sequence induction. If aspiration occurs, prompt recognition of the complication and following current management recommendations may limit the extent of lung injury.

The placenta is closely involved in exchange of fetal and maternal blood for transfer of waste, nutrients, gases, and drugs. The placenta allows bidirectional transfer of various substances through an imperfect barrier involving complex transport mechanism. The permeability of the membrane and availability of certain processes limits movement freely. Modes of placental transfer include simple diffusion, facilitated diffusion, active transport, and pinocytosis. Multiple factors impact the placental transfer for nutrients, drugs, and waste substances, such as degree of ionization and molecular size. Knowledge of the drugs that cross the placenta is critical for ensuring fetal safety during pregnancy and delivery.

Embolic disorders are a major cause of maternal mortality in the United States, accounting for approximately 20% of all maternal deaths. It comprises mainly amniotic fluid embolism, venous thromboembolism, and venous air embolism. Each of the disorders has a different clinical course and management. Early recognition and management are necessary to reduce morbidity and mortality. High-risk patients with history of thrombosis, acquired or inherited thrombophilias, or patients with a mechanical heart valve should be anticoagulated during pregnancy as well as the postpartum period. Anesthetic considerations of the embolic disorders include preoperative assessment of high-risk patients for safe neuraxial anesthesia administration and management of intraoperative cardiovascular collapse that may result from massive embolism.

Retained placenta is a failure to deliver the placenta completely within 30 minutes (active management of labor) or 60 minutes (physiologic management of labor) after the delivery of the fetus. Reported incidence ranges from 0.01% to 6.3% of vaginal deliveries. The retained placenta can lead to various complications, including life-threatening postpartum hemorrhage. Treatment involves early extraction of the retained placenta while preparing for resuscitation if hemodynamic instability ensues. General and neuraxial anesthesia can be considered for the extraction procedure, bearing in mind that neuraxial anesthesia is best suited for hemodynamically stable patients. Uterine relaxation with pharmacological means is usually required to facilitate extraction.

We aimed to develop deep learning models using longitudinal chest X-rays (CXRs) and clinical data to predict in-hospital mortality of COVID-19 patients in the intensive care unit (ICU).Six hundred fifty-four patients (212 deceased, 442 alive, 5645 total CXRs) were identified across two institutions. Imaging and clinical data from one institution were used to train five longitudinal transformer-based networks applying five-fold cross-validation. The models were tested on data from the other institution, and pairwise comparisons were used to determine the best-performing models.A higher proportion of deceased patients had elevated white blood cell count, decreased absolute lymphocyte count, elevated creatine concentration, and incidence of cardiovascular and chronic kidney disease. A model based on pre-ICU CXRs achieved an AUC of 0.632 and an accuracy of 0.593, and a model based on ICU CXRs achieved an AUC of 0.697 and an accuracy of 0.657. A model based on all longitudinal CXRs (both pre-ICU and ICU) achieved an AUC of 0.702 and an accuracy of 0.694. A model based on clinical data alone achieved an AUC of 0.653 and an accuracy of 0.657. The addition of longitudinal imaging to clinical data in a combined model significantly improved performance, reaching an AUC of 0.727 (p = 0.039) and an accuracy of 0.732.The addition of longitudinal CXRs to clinical data significantly improves mortality prediction with deep learning for COVID-19 patients in the ICU.• Deep learning was used to predict mortality in COVID-19 ICU patients. • Serial radiographs and clinical data were used. • The models could inform clinical decision-making and resource allocation.

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.

OGCI Climate Investments is an investment organization that specializes in methane, efficiency, and carbon capture, utilization, and storage (CCUS). The team has evaluated many carbon capture and storage (CCS) development stage projects involving elements of the capture, compression, transport, and storage value chain. A set of tools has been formulated for high-level cost estimates that can be used to sense-check developer proposals. The cost tools use publicly available CapEx and OpEx information and engineering best practices for cost-scaling methodologies. Cost models are constructed in a modular approach, with solvent-based CO2 capture, compression/dehydration, transport, and storage elements, and associated fixed and variable OpEx. The CO2 capture scope is further disaggregated into inside boundary limits (ISBL) and outside boundary limits (OSBL) estimates. This cost tool has proven to be useful in due diligence exercises for evaluating the merits of proposed projects for investment. Different configurations evaluated include post-combustion carbon capture projects from a variety of flue gas sources with different CO2 concentrations and at different scales, number of parallel trains of equipment, strategies for waste heat, steam or cooling utility supply, configurations to aggregate capture equipment from various sources or to gather CO2 from facilities, disaggregation of equipment in the value chain, etc. This paper provides hypothetical case studies to illustrate how such cost estimating provides useful insights into the economic viability of different types of projects at various levels of incentives. It also discusses limitations and development trends, such as commodity cycles and related engineering, procurement, and construction costs.

PURPOSE To report pancreas surveillance outcomes of high-risk individuals within the multicenter Cancer of Pancreas Screening-5 (CAPS5) study and to update outcomes of patients enrolled in prior CAPS studies. METHODS Individuals recommended for pancreas surveillance were prospectively enrolled into one of eight CAPS5 study centers between 2014 and 2021. The primary end point was the stage distribution of pancreatic ductal adenocarcinoma (PDAC) detected (stage I v higher-stage). Overall survival was determined using the Kaplan-Meier method. RESULTS Of 1,461 high-risk individuals enrolled into CAPS5, 48.5% had a pathogenic variant in a PDAC-susceptibility gene. Ten patients were diagnosed with PDAC, one of whom was diagnosed with metastatic PDAC 4 years after dropping out of surveillance. Of the remaining nine, seven (77.8%) had a stage I PDAC (by surgical pathology) detected during surveillance; one had stage II, and one had stage III disease. Seven of these nine patients with PDAC were alive after a median follow-up of 2.6 years. Eight additional patients underwent surgical resection for worrisome lesions; three had high-grade and five had low-grade dysplasia in their resected specimens. In the entire CAPS cohort (CAPS1-5 studies, 1,731 patients), 26 PDAC cases have been diagnosed, 19 within surveillance, 57.9% of whom had stage I and 5.2% had stage IV disease. By contrast, six of the seven PDACs (85.7%) detected outside surveillance were stage IV. Five-year survival to date of the patients with a screen-detected PDAC is 73.3%, and median overall survival is 9.8 years, compared with 1.5 years for patients diagnosed with PDAC outside surveillance (hazard ratio [95% CI]; 0.13 [0.03 to 0.50], P = .003). CONCLUSION Most pancreatic cancers diagnosed within the CAPS high-risk cohort in the recent years have had stage I disease with long-term survival.

Introduction Cisplatin (CIS), which is used as a therapeutic antineoplastic agent may produce gonadotoxicity in a process linked to chemotherapy. Taurine, through its potential antioxidant effect, has a protective role against cisplatin-induced oxidative stress and apoptosis. Objective To investigate whether taurine intake can ameliorate testicular damage induced by cisplatin and to study the possible mechanism that mediates this action, either through its antioxidant action alone or in addition to its anti-apoptotic effects. Patients and methods Fifty healthy adult white male albino rats were randomly distributed into five groups, each involving ten animals. The first group represents the negative control group. The other four groups received three equal doses (3 mg/kg body weight) intraperitoneal injections of cisplatin on alternate days. In the positive control group (group 2), saline only was given. Groups 3, 4 &5 received taurine in distilled water at oral doses of 50, 150, 250 mg/kg, respectively, on alternate days followed by cisplatin (each injection of cisplatin was given 1 day after taurine). On the 28th day after the first dose of normal saline, cisplatin or taurine, blood samples were examined for testosterone levels. All rats were killed and their testes were examined. Results Rats treated with cisplatin alone showed reduced body weight in addition to reduced testicular weight, impaired sperm counts, and oxidative stress (reduced GSH, increased MDA level), decreased plasma testosterone, apoptotic marker (increased Bax, decreased bcl2). However following taurine induction, the figures for GSH and MDA changed significantly (P Conclusions Cisplatin-induced germ cell apoptosis may result in decreasing spermatogenesis. However, taurine could effectively prevent nearly all of these cisplatin-induced testicular abnormalities, thereby proving to be an effective cytoprotectant.

Key Points Question Which applications of artificial intelligence (AI) in biomedical research could generate the most translational value (ie, ability to lead to development that has measurable value for human health)? Findings In this cohort study using bibliometric analysis, 2 citation-based metrics were used as proxies for translational impact, and 75 unique medical applications of AI were identified from a set of 16 629 National Institutes of Health awards related to AI, using natural language processing. Varied applications were found to have high translatability, but bias against applications in basic biochemical analysis was evident. Meaning These findings suggest that National Institutes of Health award data applications of AI in biomedical research are not equivalent: some demonstrate greater potential for translational impact than others., Importance Despite the rapid growth of interest and diversity in applications of artificial intelligence (AI) to biomedical research, there are limited objective ways to characterize the potential for use of AI in clinical practice. Objective To examine what types of medical AI have the greatest estimated translational impact (ie, ability to lead to development that has measurable value for human health) potential. Design, Setting, and Participants In this cohort study, research grants related to AI awarded between January 1, 1985, and December 31, 2020, were identified from a National Institutes of Health (NIH) award database. The text content for each award was entered into a Natural Language Processing (NLP) clustering algorithm. An NIH database was also used to extract citation data, including the number of citations and approximate potential to translate (APT) score for published articles associated with the granted awards to create proxies for translatability. Exposures Unsupervised assignment of AI-related research awards to application topics using NLP. Main Outcomes and Measures Annualized citations per $1 million funding (ACOF) and average APT score for award-associated articles, grouped by application topic. The APT score is a machine-learning based metric created by the NIH Office of Portfolio Analysis that quantifies the likelihood of future citation by a clinical article. Results A total of 16 629 NIH awards related to AI were included in the analysis, and 75 applications of AI were identified. Total annual funding for AI grew from $17.4 million in 1985 to $1.43 billion in 2020. By average APT, interpersonal communication technologies (0.488; 95% CI, 0.472-0.504) and population genetics (0.463; 95% CI, 0.453-0.472) had the highest translatability; environmental health (ACOF, 1038) and applications focused on the electronic health record (ACOF, 489) also had high translatability. The category of applications related to biochemical analysis was found to have low translatability by both metrics (average APT, 0.393; 95% CI, 0.388-0.398; ACOF, 246). Conclusions and Relevance Based on this study's findings, data on grants from the NIH can apparently be used to identify and characterize medical applications of AI to understand changes in academic productivity, funding support, and potential for translational impact. This method may be extended to characterize other research domains., This cohort study examines the translatability of findings from studies on artificial intelligence funded by the National Institutes of Health (NIH).

Histopathologic prognostic factors of rectal cancer are closely associated with local recurrence and distant metastasis. We aim to investigate the feasibility of T2*WI in assessment of clinical prognostic factors of rectal cancer, and compare with DKI.This retrospective study enrolled 50 out of 205 patients with rectal cancer according to the inclusion criteria. The following parameters were obtained: R2* from T2*WI, mean diffusivity (MDThere were positive correlations between R2* and multiple prognostic factors of rectal cancer such as T category, N category, tumor grade, CEA level, and LVI (P 0.004). MDR2* and DKI-derived parameters were associated with different histopathological prognostic factors, and might act as noninvasive biomarkers for histopathological characterization of rectal cancer.

We aimed to study the risk factors of erectile dysfunction (ED) and different patterns of phosphodiestrase type 5 inhibitors (PDE5is) usage among Egyptian patients.One thousand five hundred consecutive Egyptian patients complaining of ED were included in this cross-sectional study from July (2014) to October (2015). Patients were requested to answer the international index of erectile function questionnaire (IIEF-5). Statistical differences between groups were tested using Chi square test and Spearman's rho correlation coefficient for qualitative variables.Remarkably, significant associations between IIEF scores and aging and diabetes mellitus (DM) and hypertension (HTN) and ischaemic heart disease (IHD) and hyperlipidaemia were shown in the studied patients (p.0001, p.0001, p.0001, p.0001, p.0001, respectively). Eventually, our study showed significant correlations between different age groups and morning erection and lower urinary tract symptoms and HTN and IHD and DM where the severity of ED was directly proportional to the absence or decreased strength of morning erection with aging and the increased incidence of LUTS and HTN and IHD and DM with aging (p.0001; p=.001; p.0001; p.0001; p.0001, respectively).Our study demonstrated that aging; DM, HTN and hyperlipidaemia are potential major risk factors of ED in Egypt for further validation. In addition, most of the participants used PDE5is without prior medical consultation together with concomitant administration of illicit drugs.

Personal and social attitudes toward pain may affect the perception of pain in pregnancy. Anxiety states and fear can increase susceptibility to pain. Low level of education, and misinformation may affect the pain experience. The pain experience is personal and abstract. The centrally received stimulus gets filtered, processed and perceived through a range of motivations, emotions, past experiences, cognitive, psychosocial, and cultural variables. Fear of birth pain is strongly associated with higher use of epidural analgesia, with lower satisfaction scores, and with less effective analgesia.

Pain during pregnancy and labor may result from a myriad of physiologic, hormonal, anatomic, psychologic, and pathologic factors. Presented are basic principles of pain management in pregnancy, and an overview of causes, clinical findings, diagnostics, and treatments of pregnancy-related pain.

Labor pain is one of most stressful experiences that can lead to serious psychological and physiological consequences for the mother and the fetus. Proper management of labor pain is pivotal to a safe and satisfactory labor and delivery experience. Analgesic modalities used for the management of labor pain include neuraxial techniques, peripheral nerve blocks, parenteral pain medications, and inhalational agents.

Peripheral nerve injury is a significant perioperative problem. Intraoperative position-related neurapraxia may indicate impending peripheral nerve injury and can be detected by changes in somatosensory evoked potentials (SSEP). The purpose of this retrospective analysis of spine surgeries performed under general anesthesia with SSEP monitoring was to determine the relationship between intraoperative mean arterial blood pressure (MAP) and intraoperative upper extremity position-related neurapraxia in the prone surrender (superman) position.We reviewed a computerized database of spine surgeries performed on adult patients in the prone surrender position. The authors reviewed intraoperative SSEP monitoring reports to identify the patients who developed intraoperative upper extremity position-related neurapraxia (case group) and patients who did not (control group). Propensity matching was performed to derive 2 demographically matched groups. Preoperative and intraoperative variables were included in the univariate Cox regression analysis of risk factors associated with neurapraxia. Multivariate Cox regression models were used to identify the independent risk factors.One hundred fifty-two patients were included in the analysis. The case group included 32 patients, whereas the control group included 120 matched patients. Intraoperative MAP55 mm Hg for a total duration of ≥5 minutes was an independent risk factor associated with a greater incidence of upper extremity position-related neurapraxia compared with a duration of5 minutes with MAP55 mm Hg (hazard ratio, 3.43; confidence interval, 1.445-8.148; P = 0.0052). Intraoperative MAP80 mm Hg for a total duration of55 minutes was an independent predictor associated with a lower incidence of neurapraxia compared with a total duration ≤55 minutes (hazard ratio, 0.341; confidence interval, 0.163-0.717; P = 0.0045).In this study, we identified the changes in intraoperative MAP as independent predictors associated with upper extremity position-related neurapraxia in the prone surrender position under general anesthesia.

This study examines the direct effects of 3 noncompetitive N-methyl-D-aspartate receptor antagonists, phencyclidine (PCP), (+)MK-801, and (-)MK-801, on bovine middle cerebral arteries (BMCA). Rings of BMCA were mounted in isolated tissue chambers equipped with isometric tension transducers to obtain pharmacologic dose-response curves. In the absence of endogenous vasoconstrictors, the 3 N-methyl-D-aspartate antagonists each produced direct constriction of BMCA. The thromboxane A2 receptor antagonist SQ-29,548, the TxA2 synthase inhibitor furegrelate, the calcium antagonist nimodipine, and calcium-deficient media all inhibited maximal phencyclidine or (+)MK-801-induced constriction. Direct constriction by PCP or (+)MK-801 was independent of the presence of endothelium. When BMCA were preconstricted with potassium-depolarizing solution, PCP, (+)MK-801, and (-)MK-801 each produced only concentration-dependent relaxation. When BMCA were preconstricted with the stable TxA2 analog U-46,619 and exposed to increasing concentrations of PCP, (+)MK-801, or (-)MK-801, tension increased. Thromboxane A2 may contract BMCA by acting as a potassium channel blocker; iberiotoxin and tetraethylammonium both constrict BMCA. In Ca-deficient media containing either potassium or U-46,619, phencyclidine and (+)MK-801 each produced competitive inhibition of subsequent Ca-induced constriction. In additional experiments, arterial strips were mounted in isolated tissue chambers to directly measure calcium uptake, using Calcium as a radioactive tracer. Both phencyclidine and (+)MK-801 blocked potassium-stimulated or U-46,619-stimulated Ca uptake into arterial strips. These results suggest that phencyclidine and (+)MK-801 have 2 separate actions on BMCA. They may constrict arterial rings by releasing TxA2 from cerebrovascular smooth muscle, and relax arterial rings by acting as calcium antagonists.

Introduction With the increase in penile augmentation procedures it becomes important to assess what is the normal erect penile size in both potent men and men with erectile dysfunction (ED). Aim The aim of this work is to define the average stretched penile size in normal men and ED patients. Main Outcome Measures Penile length and girth. Methods This study included 1,027 adult men presenting to a university hospital outpatient clinic. Two groups of patients were included in this research work. Group I comprises normal adult men (949) and Group II, ED patients (78). There were no differences of race, age, height, and weight. Penile length and girth were measured using a tape measure and rigid ruler in the fully stretched states in both groups. All penile measurements were performed by the same physician. Results In normal men (Group I) the mean of the fully stretched length was 12.9 ± 1.9 cm and the mean of the fully stretched girth was 8.9 ± 0.9 cm. In ED patients (Group II), the mean of the fully stretched length was 11.2 ± 1.5 cm and the mean of fully stretched girth was 8.8 ± 0.8 cm. Comparing the mean of fully stretched penile lengths in both groups revealed statistical significant difference ( P P = 0.474) between them. There were significant positive correlations between fully stretched penile lengths and fully stretched penile girths in both groups. Conclusion The average of fully stretched penile length in normal potent men is 12.9 cm, whereas the patients with ED tend to have significantly shorter penises (11.2 ± 1.5 cm). Kamel I, Gadalla A, Ghanem H, and Oraby M. Comparing penile measurements in normal and erectile dysfunction subjects. J Sex Med 2009;6:2305–2310.