## Δευτέρα, 3 Δεκεμβρίου 2018

### Purpose

Physiological markers that estimate sympathetic activation may be used to infer pain and stress in humans. To date, effective reproducible methods are invasive and pose an undesired risk to participants. Previous work in animal models has used infrared thermography to measure the temperature of the lacrimal caruncle region and may be a promising method for measuring stress and pain non-invasively. The current study aimed to determine whether this method is useful in humans.

### Methods

Sixteen young healthy participants (age: 18–35) were recruited and underwent sympathetic activation using a cold pressor test (CPT) and a muscle chemoreflex (MCR), and completed a control trial. Throughout all trials, infrared thermographic imaging of the lacrimal caruncle, heart rate, heart rate variability, mean arterial blood pressure and pulse transit time were measured.

### Results

Heart rate (MCR: 4 ± 3 bpm, CPT: 17 ± 4 bpm p < 0.01) and mean arterial pressure increased (MCR: 6 ± 2, CPT: 5 ± 2 mmHg, p < 0.01) and pulse transit time decreased (p = 0.03) with both sympathetic activation interventions. However, lacrimal caruncle temperature did not vary under any condition remaining at 35.2 ± 0.2 °C which was similar to baseline.

### Conclusions

Our findings suggest infrared thermographic monitoring of eye temperature in humans does not reliably relate to sympathetic activation. This could be due to hemodynamic responses at the lacrimal caruncle that may be more complex than previously proposed with sympathetic activation. Alternatively, pulse transit time seems like a promising non-invasive measure of changes in sympathetic activation in humans.

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### Purpose

Reduction of noise of breath-by-breath gas-exchange data is crucial to improve measurements. A recently described algorithm ("independent breath"), that neglects the contiguity in time of breaths, was tested.

### Methods

Oxygen, carbon dioxide fractions, and ventilatory flow were recorded continuously over 26 min in 20 healthy volunteers at rest, during unloaded and moderate intensity cycling and subsequent recovery; oxygen uptake ( $$\dot {V}_{\text{2}}}$$ ) was calculated with the "independent breath" algorithm (IND) and, for comparison, with three other "classical" algorithms. Average $$\dot {V}_{\text{2}}}$$ and standard deviations were calculated for steady-state conditions; non-linear regression was run throughout the $$\dot {V}_{\text{2}}}$$ data of the transient phases (ON and OFF), using a mono-exponential function.

### Results

Comparisons of the different algorithms showed that they yielded similar average $$\dot {V}_{\text{2}}}$$ at steady state (p = NS). The standard deviations were significantly lower for IND (post hoc contrasts, p < 0.001), with the slope of the relationship with the corresponding data obtained from "classical" algorithms being < 0.69. For both transients, the overall kinetics (evaluated as time delay + time constant) was significantly faster for IND (post hoc contrasts, p < 0.001). For the ON transient, the asymptotic standard errors of the kinetic parameters were significantly lower for IND, with the slope of the regression line with the corresponding values obtained from the "classical" algorithms being < 0.60.

### Conclusion

The "independent breath" algorithm provided consistent average O2 uptake values while reducing the overall noise of about 30%, which might result in the halving of the required number of repeated trials needed to assess the kinetic parameters of the ON transient.

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### Performances of the Rapid Polymyxin Acinetobacter and Pseudomonas Tests for Colistin Susceptibility Testing

Microbial Drug Resistance, Ahead of Print.

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### Introduction

Double lumen tube (DLT) intubation is used for lung isolation but is not without disadvantages including increased intubation time, anesthesia expertise, risk of airway trauma, and costs over single lumen tube (SLT) intubation. SLT intubation with CO2 insufflation can be used as an alternative for lung isolation. We reviewed our experience with this technique during thoracoscopic surgery.

### Methods

We performed a retrospective review of a prospectively maintained IRB-approved database from 2009 to 2018. Operations were performed with CO2 insufflation up to 15 mmHg. Indications for surgery, operative details, intraoperative complications, pathology, and postoperative complications were reviewed.

### Results

We identified 123 patients (70 females [57%]) with a median age of 40 years (range 16–80 years) and a median BMI of 26.2 kg/m2 (range 15–59 kg/m2) that underwent minimally invasive thoracoscopic procedures with this technique. Procedures included: mediastinal mass resection or biopsy (41%), sympathectomy (37%), wedge resection (10%), first rib resection (6%), diaphragm plication (2%), segmentectomy (2%), decortication (2%), pleural biopsy (2%), and pericardial cyst resection (1%). Median operative time was 90 min (range 25–584 min) and median intraoperative blood loss was 10 mL (range 2–200 mL). Intraoperative hemodynamic parameters were obtained at procedure start, 1 h after CO2 insufflation, and at procedure completion: we observed significant changes in heart rate and systolic blood pressure (P = 0.027 and P < 0.001, respectively) although clinically inconsequential. Mean end-tidal CO2 1 h after insufflation was 36.6 ± 4.5 mmHg. There were no intraoperative complications and no conversions to a DLT. Median length of stay was 1 day (range 0–14 days). Five complications (4%) were observed and no mortalities.

### Conclusions

SLT intubation and CO2 insufflation is a feasible and safe alternative to DLT intubation for lung isolation. This can be a useful strategy to accomplish lung isolation for some thoracoscopic procedures, in particular when expertise for DLT placement is unavailable.

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### Background

Endoscopic submucosal dissection (ESD) is a standard treatment option for early gastric cancer (EGC) in Asia; however, data about ESD efficacy in Western populations are limited. Furthermore, outcomes of EGC treatment after ESD or surgery have not been compared in Western cohorts. This study aimed to compare short-term and long-term results of ESD and surgery for EGC.

### Methods

This retrospective case–control study included patients with EGC treated in two largest cancer centers in Eastern Lithuania between 2005 and 2016. Propensity score nearest-neighbor 1:1 matching, based on clinicopathologic characteristics, was performed between patients who underwent ESD and surgery. The primary endpoint of the study was 5-year disease-free survival (DFS).

### Results

Of 260 eligible patients, 42 (16.1%) underwent ESD. After matching, two well-balanced groups consisting of 42 patients in each were analyzed. The operation time (83 vs. 151 min., p = 0.001) and postoperative hospitalization stay (5.4 vs. 13.4 days, p = 0.001) was significantly shorter in the ESD group. 5-year DFS rate was significantly higher in the surgery group (97.6% vs. 77.5%, p = 0.002). However, this difference was reduced after exclusion of non-curative ESD cases (97.6% vs. 89.7%, p = 0.099). There was no significant difference in 5-year OS rate between the study groups (73.8% vs. 69.0%, p = 0.599).

### Conclusions

ESD might be an excellent alternative to surgery for EGC if curative resection is achieved. Non-curative ESD is associated with poor DFS and high rate of recurrence. Additional surgery should be recommended after non-curative ESD whenever treatment-associated risk is acceptable.

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### Background

The aim of this study was to compare inflammatory stress response between laparoscopic percutaneous inguinal ring suturing (PIRS) and open modified Marcy technique for pediatric inguinal hernia repair.

### Methods

From May 2017 to April 2018, 32 male children with median age of 4.5 years undergoing inguinal hernia repair were included in randomized controlled trial. The patients were divided in two groups, by using random number generator, depending on surgical approach. The blood was tested in three time frames for white blood cells count (WBC), C-reactive protein (CRP), Interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-α).

### Results

Significant increase in concentration for all inflammatory biomarkers, that occur over time, has been found (p < 0.001 for all). Additionally, it was also found that the type of surgery significantly influenced the level of WBC, CRP, and IL-6 with Marcy showing a higher level of inflammatory response (WBC 11.4 ± 3.1 × 109/L; CRP 11.5 mg/L; IL-6 11.0 pg/mL) than the PIRS (WBC 7.6 ± 1.6 × 109/L; CRP 0.8 mg/L; IL-6 2.0 pg/mL) (p < 0.001 for all). Similar pattern was also found for TNF-α (Marcy 16.8 pg/mL; PIRS 10.1 pg/mL), but correlation between surgery type and concentration of this biomarker was significant only at the 0.1 level (p = 0.055). The mean operation time was significantly shorter (9 ± 2 min) in PIRS group compared to Marcy group (25 ± 7 min) (p < 0.001). Significantly lower median of visual analog scale score (VAS) was found in PIRS group (VAS = 2) compared to Marcy group (VAS = 6) (p < 0.001).

### Conclusions

Use of laparoscopic (PIRS) technique in children shows significantly lower surgical stress in comparison to open hernia repair.

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### Background

Endoscopic removal of benign colon polyps is not always possible, even with advanced endoscopic techniques. Segmental colectomy has been the traditional therapy but is associated with an increased risk of complications and may be unnecessary since fewer than 20% of these polyps harbor malignancy. Combined endo-laparoscopic surgery (CELS) has emerged as an alternative method to address these polyps. While feasibility, safety, and improved short-term patient outcomes have been demonstrated, there has never been an evaluation of cost comparing these two approaches within a single institution.

### Methods

In this observational cohort study, we compared short-term outcomes and costs of 11 patients who underwent CELS for right colon polyps with 11 patients who underwent a laparoscopic right colectomy between April 2014 and November 2017. The cost analysis covered the perioperative period from operating room to hospital discharge.

### Results

A total of 11 patients underwent an attempted CELS procedure for right colon polyps with a success rate of 90% (10/11). The median length of stay (LOS) for CELS patients was 1 day. LOS for patients who underwent a laparoscopic right colectomy at TMC was 3.82 days. The median OR time for CELS was 166.73 (± 57.88) min, compared to 204.73 (± 51.49) min for a laparoscopic right colectomy. The calculated total cost for a CELS patient was $5523.29, compared to$12,626.33 for a laparoscopic right colectomy, for a cost-savings of \$7103.04 per patient.

### Conclusions

CELS procedures are associated with good short-term outcomes and are performed at a lower cost compared to traditional laparoscopic colectomy, with the most significant cost saver being shorter hospital LOS. This is the first study to directly compare the cost of CELS to traditional laparoscopic colectomy in the surgical management of benign colon polyps within a single institution.

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### Background

The purpose of the study was to compare the safety and effectiveness of laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) with preoperative endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (pre-ERCP+LC) for cholecystocholedocholithiasis.

### Methods

An electronic search was performed using the following databases: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until 1 July 2018. Randomized controlled trials (RCTs) comparing LCBDE+LC versus pre-ERCP+LC were included. The common bile duct (CBD) stone clearance rate, postoperative bile leakage, postoperative pancreatitis, morbidity, mortality, and overall hospital stay were analyzed.

### Results

Twelve RCTs involving 1545 patients were included in this meta-analysis. Of the 12 RCTs, seven confirmed and five did not confirm CBD stones preoperatively. The meta-analysis showed a significantly higher CBD stone clearance rate for pre-ERCP+LC than LCBDE+LC. A similar result was found in the subgroup analysis of patients with confirmed CBD stones. A significantly lower postoperative bile leakage rate was found for pre-ERCP+LC than LCBDE+LC in all 12 RCTs and in the subgroup of patients with confirmed CBD stones. However, a significantly higher rate of pancreatitis was found in pre-ERCP+LC and in the subgroup of patients with confirmed CBD stones. LCBDE+LC was superior to pre-ERCP+LC in terms of the overall hospital stay. No significant differences were found in morbidity or mortality.

### Conclusions

Pre-ERCP+LC is associated with a higher CBD stone clearance rate, lower postoperative bile leakage rate, and higher rate of pancreatitis. LCBDE+LC might help to shorten the hospital stay. Further studies on this topic are recommended.

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### Rare Case of Severe Lower Gastrointestinal Bleeding: Primary Colonic Choriocarcinoma

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### Harmonization of quality of care in an IBD center impacts disease outcomes: importance of structure, process indicators and rapid access clinic

We aimed to evaluate the quality of care at a tertiary inflammatory bowel disease (IBD) center using quality of care indicators (QIs) including patient assessment strategy, monitoring, treatment decisions and outcomes.

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### Gut mucosal-associated microbiota better discloses Inflammatory Bowel Disease differential patterns than fecal microbiota

growing evidence supports the potential role of intestinal microbiota in the pathophysiology of Inflammatory Bowel Diseases (IBD) even if the literature does not reveal uniform alterations. The aim of the study was to evaluate the mucosal (MM) and fecal microbiota (FM) composition in a cohort of IBD patients compared to healthy controls (CTRLs).

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### Impairment of brain functions in Parkinson’s disease reflected by alterations in neural connectivity in EEG studies: a viewpoint

Parkinson's disease (PD) is characterized mainly by motor symptoms of tremor, rigidity, bradykinesia, and postural instability (Aarsland et al. 2011) and is accompanied by several non-motor symptoms. The phenotype of the disease varies among patients. The speed progression is very individual, as is the representation of motor and non-motor symptoms (Eggers et al. 2012). Cognitive impairment and dementia are common in advanced PD. Severe cognitive impairment increases disability and mortality in advanced PD.

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### Load-Bearing Capacity and Deformation of Jammed Architectural Structures

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### Digital Wood: 3D Internal Color Texture Mapping

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### Purpose

All-out, non-steady state running makes for difficult comparisons regarding linear and shuttle running; yet such differences remain an important distinction for field-based sports. The purpose of the study was to determine whether an energetic approach could be used to differentiate all-out linear from shuttle running.

### Methods

Fifteen male field-sport athletes volunteered for the study (means ± SD): age, 21.53 ± 2.23 years; height, 1.78 ± 0.68 m; weight, 83.85 ± 11.73 kg. Athletes completed a graded exercise test, a 3-min linear all-out test and two all-out shuttle tests of varied distances (25 m and 50 m shuttles).

### Results

Significant differences between the all-out tests were found for critical speed (CS) [F(8.97), p < 0.001), D′ (finite capacity for running speeds exceeding critical speed) [F(7.83), p = 0.001], total distance covered [F(85.31), p < 0.001], peak energetic cost (  ) [F(45.60), p < 0.001], peak metabolic power ( $$\dot {P}$$ ) [F(23.36), p < 0.001], average $${\text{EC}}$$ [F(548.74), p < 0.001], maximal speed [F(22.87), p < 0.001] and fatigue index [F(3.93), p = 0.027]. Non-significant differences were evident for average $$\dot {P}$$ [F(2.47), p = 0.097], total $${\text{EC}}$$ [F(0.86), p = 0.416] and total $$\dot {P}$$ [F(2.11), p = 0.134].

### Conclusions

The energetic approach provides insights into performance characteristics that differentiate linear from shuttle running, yet surprising similarities between tests were evident. Key parameters from all-out linear and shuttle running appear to be partly interchangeable between tests, indicating that the final choice between linear and shuttle testing should be based on the requirements of the sport.

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### Background

Biannual ultrasound (US) is recommended as the clinical screening tool for hepatocellular carcinoma (HCC). The effectiveness of surveillance according to the place where US is performed has not been previously reported.

### Aims

To compare the effectiveness of US performed in the center responsible for follow-up as opposed to US proceeding from centers other than that of follow-up.

### Methods

This is a multicenter cohort study from Argentina. The last US was categorized as done in the same center or done in a different center from the institution of the patient's follow-up. Surveillance failure was defined as HCC diagnosis not meeting Barcelona Clinic Liver Cancer (BCLC) stages 0-A or when no nodules were observed at HCC diagnosis.

### Results

From 533 patients with HCC, 62.4% were under routine surveillance with a surveillance failure of 38.8%. After adjusting for a propensity score matching, BCLC stage and lead-time survival bias, surveillance was associated with a significant survival benefit [HR of 0.51 (CI 0.38; 0.69)]. Among patients under routine surveillance (n = 345), last US was performed in the same center in 51.6% and in a different center in 48.4%. Similar rates of surveillance failure were observed between US done in the same or in a different center (32% vs. 26.3%; P = 0.25). Survival was not significantly different between both surveillance modalities [HR 0.79 (CI 0.53; 1.20)].

### Conclusions

Routine surveillance for HCC in the daily practice improved survival either when performed in the same center or in a different center from that of patient's follow-up.

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### Background

The management of diverticulitis is compromised by difficulty in identifying patients who require surgery for recurrent or persistent disease. Here, we introduce the concept of multifocal diverticulitis (MFD), characterized by multiple episodes of diverticulitis occurring at different locations within the colon.

### Aims

To compare clinical characteristics, success of surgical management, and colonic transcriptomes of MFD patients to patients with conventional unifocal diverticulitis (UFD).

### Methods

This retrospective study included 404 patients with CT-confirmed diverticulitis episodes. Patients with diverticulitis seen in at least two different colonic locations were classified as the MFD group and compared to the UFD group based on number of episodes, sites of disease, family history, surgeries performed, and postoperative recurrence. RNA-seq was conducted on full-thickness colonic tissues of ten MFD and 11 UFD patients.

### Results

Twenty-eight patients (6.9%) with MFD were identified. MFD patients had more diverticulitis episodes and were more likely to have positive family history, have right-sided disease, require surgery, and have recurrence after surgery. All MFD patients treated with segmental resection had recurrence, while recurrence was less common in patients undergoing more extensive surgery (P < 0.001). Using RNA-seq, we identified 69 genes that were differentially expressed between MFD and UFD patients. Significantly down-regulated genes were associated with immune response pathways.

### Conclusions

MFD appears to be a more severe subset of diverticulitis with a possible genetic component. Transcriptomic data suggest that MFD may be associated with alteration of the immune response.

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### Background

There is a marked need for improved animal models of nonalcoholic steatohepatitis (NASH) to facilitate the development of more efficacious drug therapies for the disease.

### Methods

Here, we investigated the development of fibrotic NASH in male Wistar rats fed a choline-deficient l-amino acid-defined (CDAA) diet with or without cholesterol supplementation for subsequent assessment of drug treatment efficacy in NASH biopsy-confirmed rats. The metabolic profile and liver histopathology were evaluated after 4, 8, and 12 weeks of dieting. Subsequently, rats with biopsy-confirmed NASH were selected for pharmacological intervention with vehicle, elafibranor (30 mg/kg/day) or obeticholic acid (OCA, 30 mg/kg/day) for 5 weeks.

### Results

The CDAA diet led to marked hepatomegaly and fibrosis already after 4 weeks of feeding, with further progression of collagen deposition and fibrogenesis-associated gene expression during the 12-week feeding period. Cholesterol supplementation enhanced the stimulatory effect of CDAA on gene transcripts associated with fibrogenesis without significantly increasing collagen deposition. Pharmacological intervention with elafibranor, but not OCA, significantly reduced steatohepatitis scores, and fibrosis-associated gene expression, however, was unable to prevent progression in fibrosis scores.

### Conclusion

CDAA-fed rats develop early-onset progressive NASH, which offers the opportunity to probe anti-NASH compounds with potential disease-modifying properties.

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### Abstract

Calcitriol (1,25(OH)2D3) performs various activities throughout the body. Although low serum 25-hydroxyvitamin D [25(OH)D] levels are associated with several disease processes such as risk of fractures and falls, hypertension, cardiovascular disease, and diabetes mellitus, recent evidence attests that this important hormone also regulates several cellular pathways involved in cancer development and progression. Calcitriol modulates several genes controlling gut physiology and calcium homeostasis and also maintains the integrity of epithelial barriers, regulates the absorption of phosphate and calcium, and modulates host defense against pathogens and inflammatory response by interplaying with several types of secretory and immune cells. Vitamin D deficiency is significantly related to increased risk of developing certain types of cancer. This deficiency can be prevented by vitamin D supplementation which is both economical and safe. This can lower the risk of developing cancer and also improve the prognosis of patients with gastrointestinal malignancy, but epidemiological data remain inconsistent. Several retrospective observational studies have demonstrated the benefits of vitamin D supplementation, but a few randomized controlled trials have not seemingly supported the beneficial role of vitamin D supplementation in gastrointestinal cancers. Therefore, in this literature review, we aimed to examine the possible role of vitamin D in gastrointestinal malignancies, including gastric, esophageal, pancreatic, hepatic, and colorectal cancers.

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### The effect of spinal mobilization with leg movement in patients with lumbar radiculopathy – A double blind randomized controlled trial

Publication date: Available online 3 December 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Kiran Satpute, Toby Hall, Richa Bisen, Pramod Lokhande

##### Abstract
###### Objectives

To evaluate the effect of spinal mobilization with leg movement (SMWLM) on low back and leg pain intensity, disability, pain centralization and patient satisfaction in subjects with lumbar radiculopathy.

###### Design

A double blind randomized controlled trial.

General Hospital

###### Interventions

Subjects were randomly allocated to receive SMWLM, exercise and electrotherapy (n = 30) or exercise and electrotherapy alone (n = 30). All subjects received 6 sessions over 2 weeks.

###### Main Outcome Measures

The primary outcomes were leg pain intensity and Oswestry disability index score. Secondary variables were low back pain intensity, global rating of change (GROC), straight leg raise (SLR) and lumbar range of motion (ROM). Variables were evaluated blind at base line, post intervention, and 3 and 6 months follow-up.

###### Results

Significant and clinically meaningful improvement occurred in all outcome variables. At 2 weeks the SMWLM group had significantly greater improvement than the control group in leg pain (MD 2.4, 95% CI 2.0 to 2.7) and disability (MD 3.9 (5.5 to 2.2). Similarly at 6 months the SMWLM group had significantly greater improvement than the control group in leg pain (MD 4.4, 95% CI 4.0 to 4.8) and disability (MD 4.7 (6.3to 3.1). The SMWLM group also reported greater improvement in the GROC and in SLR ROM.

###### Conclusion

In patients with lumbar radiculopathy, the addition of SMWLM provided significantly improved benefits in terms of leg and back pain, disability, SLR ROM and patient satisfaction in the short-and long-term.

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### The association between blood urea nitrogen to creatinine ratio and mortality in patients with upper gastrointestinal bleeding

Publication date: Available online 3 December 2018

Source: Arab Journal of Gastroenterology

Author(s): Kai-Hsiang Wu, Hsin-An Shih, Ming-Szu Hung, Cheng-Ting Hsiao, Yi-Chuan Chen

##### Abstract
###### Background and study aims

Azotaemia is commonly identified among patients with upper gastrointestinal bleeding (UGIB) due to absorption of blood products in the small bowel. Previous studies have found blood urea nitrogen-to-creatinine (BUN/Cr) ratio to be significantly elevated among patients UGIB bleeding compared to patients with lower GI bleeding. However, no studies have explored the relationship between BUN/Cr ratio and mortality. This study is aimed at investigating how BUN/Cr ratio relates to outcomes for UGIB patients.

###### Patients and methods

This study was conducted prospectively at a university-affiliated teaching hospital with approximate 70,000 annual emergency department (ED) visits. Data from a total of 258 adult UGIB patients were collected between March 1, 2011 and March 1, 2012. Cox regression analysis was used to identify risk factors for 30-day mortality.

###### Results

Malignancy and Rockall score were associated with increased risk of 30-day mortality (Unadjusted hazard ratio (HR): 3.87, 95% CI: 1.59–9.41, p = 0.0029; HR: 1.31, 95% CI: 1.02–1.71, p = 0.0476, respectively). However, BUN/Cr > 30 was associated with lower risk of 30-day mortality (HR: 0.32, 95% CI: 0.11–0.97, p = 0.0441).

###### Conclusions

A BUN/Cr ratio of >30 was found to be an independent risk factor for mortality and may be useful for pre-endoscopic assessment. Development of future risk scoring systems might warrant consideration of including BUN/Cr ratio as a parameter for estimating risk.

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### Abstract

This paper evaluates the effectiveness of, and highlights issues with, conventional paradigms in applied sports biomechanics research and comments on their capacity to optimise techniques of individual athletes. In empirical studies, group-based analyses often mask variability between athletes and only permit probabilistic 'in general' or 'on average' statements that may not be applicable to specific athletes. In individual-based analyses, performance parameters typically exhibit a small range and a flat response over iterative performance trials, making establishing associations between performance parameters and the performance criterion problematic. In theoretical studies, computer simulation modelling putatively enables athlete-specific optimum techniques to be identified, but given each athlete's unique intrinsic dynamics, it is far from certain that these optimum techniques will be attainable, particularly under the often intense psychological pressures of competition, irrespective of the volume of practice undertaken. Sports biomechanists and coaching practitioners are advised to be more circumspect with regard to interpreting the results of applied sports biomechanics research and have greater awareness of their assumptions and limitations, as inappropriate interpretation of results may have adverse consequences for performance and injury.

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### Correction to: The Effects of Hispanic Immigrant Mother’s Resiliency on Children’s Dietary Adjustment

The original version of this article unfortunately contained errors in Affiliation 3, Acknowledgement, Table 1 and in the text under Methods section. Also, a Co-corresponding author has to be included in the article.

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## Key points

It is unknown whether excessive reactive oxygen species (ROS) production drives the isocapnic hyperoxia (IH)‐induced decline in human cerebral blood flow (CBF) via reduced nitric oxide (NO) bioavailability and leads to disruption of the blood‐brain barrier (BBB) or neural‐parenchymal damage. We then simultaneously quantified CBF, metabolic rate for oxygen (CMRO2) and transcerebral exchanges of NO‐end products, oxidant, antioxidant, and neural‐parenchymal damage markers under IH with intravenous saline and vitamin C infusion. CBF and CMRO2 were reduced during IH, responses that were followed by increased oxidative stress and reduced NO bioavailability when saline was infused. No indication of neural‐parenchymal damage or disruption of the BBB was observed during IH. Antioxidant defences were increased during vitamin C infusion, while CBF, CMRO2, oxidant, and NO bioavailability markers remained unchanged. ROS play a role in the regulation of CBF and metabolism during IH without evidence of BBB disruption or neural‐parenchymal damage.

## Abstract

To test the hypothesis that isocapnic hyperoxia (IH) affects cerebral blood flow (CBF) and metabolism through exaggerated reactive oxygen species (ROS) production, reduced nitric oxide (NO) bioavailability, disturbances in the blood‐brain barrier (BBB), and neural‐parenchymal homeostasis, 10 men (24 ± 1yrs.) were exposed to a 10‐min IH trial (100%O2) while receiving intravenous saline and vitamin C (VC, ascorbic acid (AA), 3 g) infusion. Internal carotid (ICABF), vertebral artery (VABF), and total CBF (tCBF, Doppler ultrasound) were determined. Arterial and right internal jugular venous blood were sampled to quantify the cerebral metabolic rate of oxygen (CMRO2), transcerebral exchanges (TCE) of NO end‐products (plasma nitrite), antioxidants (AA and AA plus dehydroascorbic acid (AAPDA)) and oxidant biomarkers (thiobarbituric acid‐reactive substances (TBARS) and 8‐isoprostane), and an index of BBB disruption and neuronal‐parenchymal damage (neuron‐specific enolase (NSE)). IH reduced ICABF, tCBF, CMRO2 while VABF remained unchanged. Arterial 8‐isoprostane and nitrite TCE increased, indicating that CBF decline was related to ROS production and reduced NO bioavailability. AA, AADPA and NSE TCE did not change during IH. VC infusion did not change the resting hemodynamic and metabolic parameters but raised antioxidant defences, as indicated by increased AA/AAPDA concentrations. Negative AAPDA TCE, unchanged nitrite, reductions in arterial, venous 8‐isoprostane, and TBARS TCE indicated that VC infusion effectively inhibited ROS production and preserved NO bioavailability. Similarly, VC infusion prevented IH‐induced decline in regional and total CBF and re‐established CMRO2. These findings indicate that ROS play a role in CBF regulation and metabolism during IH without evidence of BBB disruption or neural‐parenchymal damage.

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## Key points

Remote ischaemic preconditioning (RIPC), induced by brief bouts of ischaemia followed by reperfusion, confers vascular adaptations that protect against subsequent bouts of ischaemia. However, the effect of RIPC repeated over several days on the human microcirculation is unknown. Using skin as a model, microvascular function was assessed at a control and a NO‐inhibited area of skin before, after, and 1 week after administering seven consecutive days of repeated RIPC on the contralateral arm. Maximal vasodilatation was increased by ∼20‐50% following seven days of repeated RIPC, and this response remained elevated one week after stopping RIPC. However, NO‐mediated vasodilatation was not affected by the RIPC stimulus. These data indicate that repeated RIPC augments maximal vasodilatation; however, the underlying mechanism for this improvement is largely independent of NO. This finding suggests a role for other endothelium derived mediators and/or for endothelium‐independent adaptations with repeated RIPC.

## Background

Remote ischaemic preconditioning (RIPC), induced by intermittent periods of ischaemia followed by reperfusion, confers cardiovascular protection from subsequent ischaemic bouts. RIPC increases conduit and resistance vessel function; however, the effect of RIPC on the microvasculature remains unclear. Using human skin as a microvascular model, we hypothesized that cutaneous vasodilatory (VD) function elicited by localized heating would be increased following repeated RIPC.

## Methods

Ten participants (23 ± 1 years, 6M 4F) performed RIPC for seven consecutive days. Each daily RIPC session consisted of 4 repetitions of 5 minutes of arm blood flow occlusion interspersed by 5 minutes reperfusion. Before, after, and one week after the 7 days of RIPC, two microdialysis fibres were placed in ventral forearm skin for continuous infusion of Ringer's solution or 20 mM L‐NAME. Red blood cell flux was measured by laser Doppler flowmetry at each fibre site during local heating (Tloc = 39 °C) and during maximal VD elicited by heating (Tloc = 43 °C) and 28 mM sodium nitroprusside infusion. Data were normalized to cutaneous vascular conductance (flux∙mmHg−1). Results: Seven days of RIPC did not alter the nitric oxide (NO) contribution to the VD response to local heating (p>0.05). However, the maximal VD was augmented (Pre: 2.5 ± 0.2, Post: 3.8 ± 0.5 flux∙mmHg−1; p<0.05) and remained elevated one week post RIPC (3.3 ± 0.4 flux∙mmHg−1; p<0.05).

## Conclusion

Repeated RIPC improves maximal VD but does not affect NO‐mediated VD in the cutaneous microvasculature. This finding suggests that other factors may explain the vasodilatory adaptations that occur following repeated RIPC.

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### Mutations in RELT Cause Autosomal Recessive Amelogenesis Imperfecta

Amelogenesis imperfecta (AI) is a collection of isolated (non‐syndromic) inherited diseases affecting dental enamel formation or a clinical phenotype in syndromic conditions. We characterized three consanguineous AI families with generalized irregular hypoplastic enamel with rapid attrition that perfectly segregated with homozygous defects in a novel gene: RELT that is a member of the tumor necrosis factor receptor superfamily (TNFRSF). RNAscope in situ hybridization of wild‐type mouse molars and incisors demonstrated specific Relt mRNA expression by secretory stage ameloblasts and by odontoblasts. Relt ‐/‐ mice generated by CRISPR/Cas9 exhibited incisor and molar enamel malformations. Relt ‐/‐ enamel had a rough surface and underwent rapid attrition. Normally unmineralized spaces in the deep enamel near the dentino‐enamel junction (DEJ) were as highly mineralized as the adjacent enamel, which likely altered the mechanical properties of the DEJ. Phylogenetic analyses demonstrated the existence of selective pressure on RELT gene outside of tooth development, indicating that the human condition may be syndromic, which possibly explains the history of small stature and severe childhood infections in two of the probands. Knowing a TNFRSF member is critical during the secretory stage of enamel formation advances our understanding of amelogenesis and improves our ability to diagnose human conditions featuring enamel malformations.