Consequences and management of guidewire fracture-entrapment in the left circumflex artery: a case report.

Background: Entrapment and fracture of the coronary guidewire are rare but major complications of percutaneous coronary intervention (PCI). The incidence of these complications is reported to be <1%. Case summary: A 52-year-old male patient with diabetes and dyslipidaemia presented with posterior wall myocardial infarction. An angiogram revealed occlusion in the left circumflex (LCX) artery. Attempts to pass a guidewire through the lesion led to its entrapment and eventual fracture. Several techniques and manoeuvres failed to retrieve the fractured guidewire, which remained lodged in the LCX. An endovascular snare catheter also proved unsuccessful. The fragment was eventually removed using the triple-wire technique, although this caused coronary perforation and dissection. The perforation was identified and stented. A subsequent stent addressed a dissection in the left main/left ascending artery area, likely caused by the coronary snare. These interventions were crucial in stabilizing the patient's condition, leading to recovery with a left ventricular ejection fraction of 50% and a viable LCX artery. The patient exhibited an uneventful progression at the 1-year follow-up. Discussion: Coronary guidewire fracture during PCI is a rare event often associated with coronary calcifications. Percutaneous removal remains the mainstay treatment for fragment removal; however, it carries risks. The triple-wire technique, a newer method that entangles and extracts the fractured guidewire without specialized equipment, was effective in removing the fragmented guidewire. If asymptomatic, leaving the wire in situ is documented as a favourable approach. This case highlights that the triple-wire technique can effectively be used for the extraction of fractured guidewire fragments from the coronary vessels.

Wide-Awake Tenolysis for Tendon Entrapment in a Distal Radial Epiphyseal Separation (Volar Displacement Type): A Case Report.

The patient was a 13-year-old male who fell while riding a bicycle and was initially diagnosed with a distal radial epiphyseal separation (volar displacement type) that was conservatively managed. Four months post-injury, he complained of limited movement in his left index finger and was referred to our hospital. Upon examination, the patient also complained of limited movement of the left index finger in wrist flexion. The wrist range of motion was 50° of volar flexion, 50° of dorsiflexion, 90° of pronation, and 90° of supination with the fingers extended. The X-ray revealed a radiolucent area in the distal radius. Ultrasound, computed tomography, and magnetic resonance imaging scans demonstrated entrapment of the extensor tendon within the medullary cavity of the radius. Five months post-injury, surgery was performed using the wide-awake local anesthesia no-tourniquet (WALANT) technique. A dorsal wrist approach was utilized, and the extensor digitorum communis tendon was found to be trapped within the medullary cavity of the radius. The tendon was released using an air drill, and sufficient improvement in the left index finger flexion was confirmed with active movement before concluding the surgery. At the 11-month postoperative follow-up, the patient showed excellent outcomes with a wrist range of motion of 75° of volar flexion, 85° of dorsiflexion, 90° of pronation, and 90° of supination. Tendon entrapment of the extensor tendons has been reported as a long-standing complication associated with distal radius fractures, particularly with volar displacement types. A benefit of the WALANT technique is the ability to communicate with the patient during surgery, allowing for active movements of the fingers and wrist. This is particularly useful in tendon surgeries for determining tendon tension. We report a case of successful tenolysis surgery using the WALANT technique for a patient with a conservatively managed distal radial epiphyseal separation (volar displacement type), who experienced a limited flexion of the index finger due to tendon entrapment.

Electrodiagnosis and Ultrasound Imaging for Ulnar Nerve Entrapment at the Elbow: A Review.

Entrapment neuropathy of the ulnar nerve at the elbow, the so-called cubital tunnel syndrome, is the second most frequent focal mononeuropathy after carpal tunnel syndrome in adults. Currently, there is a pressing need to identify cost-effective biomarkers and procedures capable of accurately detecting alterations in ulnar nerve structural and functional integrity. Established electrophysiological techniques, such as motor and sensory nerve conduction studies, along with needle electromyography of specific muscles, represent the gold standard for ulnar nerve electrodiagnosis. Concurrently, the introduction of neuromuscular ultrasound and its integration into electromyographic laboratories has significantly impacted structural diagnosis and the precise localization of ulnar nerve pathology over the past two decades. In this review, our objective is to summarize the current knowledge on both classical and advanced diagnostic methods utilized in clinical neurophysiology laboratories. We aim to provide a synthesis of modern electrodiagnostic and neurosonographic techniques, with a particular emphasis on easily attainable, clinically relevant parameters.

Extensor Retinaculum Syndrome of the Ankle: An Adult Case Series.

Background: Extensor retinaculum syndrome (ERS) is a relatively rarely diagnosed compartment syndrome-like entity caused by elevated pressures in the tissues deep to the superior extensor retinaculum (SER). ERS is identified as out-of-proportion anterior ankle pain, pain with passive toe plantarflexion, elevated SER pressures (>40 mm Hg), and ultimately toe extension weakness and first web space numbness. Although previously described in a pediatric population, this case series is the first to our knowledge in an adult population. Methods: Seven nonconsecutive cases over 18 years from 2 surgeons are reported who underwent complete SER release for ERS either through the direct lateral approach to the fibula or the anterolateral approach to the distal tibia. All were associated with traumatic injuries including 3 bimalleolar ankle fractures, 3 tibial pilon fractures, and 1 distal tibial/fibular shaft fracture. All patients developed writhing anterior ankle pain worsened with passive toe plantarflexion. SER compartment pressures ranged from 50 to >135 mm Hg. Five cases displayed decreased first web space sensation. Results: The diminished or absent first web space sensation uniformly improved post-release. Complications included 1 patient with complex regional pain syndrome type 1, 1 patient required hardware removal, and 2 had persistent but improved first web space sensation changes. Conclusion: Clinical suspicion for possible ERS should arise after distal tibial/fibular fractures when the excruciating pain localizes to the ankle instead of the classic anterior leg muscle bellies. If pain is worsened with passive toe plantarflexion, this diagnosis should be considered. Recommended treatment involves complete release of the SER anywhere on the anterior surface between the tibia and fibula depending on the approach needed for fixation of the associated fracture. Level of Evidence: Level IV, case series.

Entrapment in the military context: Factor structure and associations with suicidal thoughts and behaviors.

BACKGROUND: Improved understanding of how US service members transition from chronic/baseline to acute suicide risk is warranted. One such model, the Integrated Motivational Volitional Model of Suicide, posits entrapment as central to this process. However, entrapment has not been extensively investigated within military populations. METHODS: This study examines the factor structure, reliability, and predictive validity of the Entrapment Scale (E-Scale) within a military population. Exploratory structural equation modeling (SEM) and confirmatory factor analysis compared one- versus two-factor structures of the E-Scale. Autoregressive SEM assessed if E-Scale scores predicted suicidal ideation and suicide attempt likelihood at 6- and 12-month follow-up, and examined whether the impact of entrapment was moderated by social support (i.e., appraisal, tangible, and belonging). RESULTS: Results favored a two-factor solution (external and internal) of entrapment. The relationship between entrapment and suicide outcomes was moderated by perceived social support but in unexpected directions. Unexpectedly, social support strengthened the relationship between external entrapment and suicide outcomes for most models. Only tangible support moderated the relationship between internal entrapment (IE) and suicide outcomes as predicted. CONCLUSIONS: IE is linked with suicidal ideation in the short-term, whereas external entrapments relationship with suicide outcomes may reflect more persistent social challenges for military members.

Peripheral nerve injuries in the performing artist.

Dancers and musicians have unique physical demands that can lead to injury of the peripheral nerves. Specific dance movements and specific instrument positions, combined with countless hours of practice and repetition, create an environment for potential nerve injury. Familiarity with these variables and recognition of the common presentations of neuropathic syndromes are essential in the evaluation of a performing artist with a suspected peripheral nerve injury. Assessment should include an understanding and analysis of their dance style or instrument playing posture, particularly in the position or motion that recreates the symptoms if possible. Practice and performance schedules should also be considered. Diagnosis may require electrodiagnostic testing, imaging, or diagnostic injections. Treatment should be comprehensive and may include modifications in practice schedule, posture/position, and technique in addition to consideration of medications, splints/orthoses, physical therapy, and injections. The instructor/teacher should be involved in the treatment plan if applicable. Complete rest in this population may not be realistic or necessary. Early and accurate diagnosis of nerve injury is important for safe return to dance or instrumental music.

Childhood trauma and suicide risk: Investigating the role of adult attachment.

BACKGROUND: Suicide is a leading cause of death globally and a serious public health concern. Childhood trauma has been found to be associated with adult suicide vulnerability. Recent research has turned attention to investigating the role of attachment in the context of the childhood trauma-adult suicide relationship. The current study investigated for the first time whether attachment influences and moderates the childhood trauma-suicidality relationship, using a daily diary design, in the general population. METHODS: 481 participants completed questionnaires assessing experiences of childhood trauma, attachment patterns, and history of suicidality. 243 participants continued to a daily diary phase where measures of daily stress, defeat and entrapment were completed for 7 consecutive days. RESULTS: Higher levels of childhood trauma were associated with a history of suicide ideation and attempt and also higher levels of daily defeat, entrapment and stress during the 7 day study. Similarly, higher levels of attachment anxiety and avoidance were associated with a history of suicide ideation and attempt together with higher levels of daily defeat, entrapment and stress. However, the effects of childhood trauma on suicide history and on daily suicide vulnerability factors were not moderated by attachment anxiety or avoidance. LIMITATIONS: The measure of childhood trauma was a retrospective self-report tool that may be influenced by memory biases. CONCLUSIONS: Childhood trauma and insecure attachment are implicated in adult suicide risk. Interventions aimed at mitigating the negative effects of childhood trauma and insecure attachment should also incorporate components that target modifiable risk factors such as defeat, entrapment and stress.

How to manage an entrapped undeflatable coronary balloon.

An entrapped undeflatable coronary balloon is a rare complication during percutaneous coronary intervention. It is a complication that can be stressful for the operator, with potentially catastrophic implications for the patient. A fully inflated balloon in the coronaries impedes the blood flow to the distal myocardium and hence causes ischemia, that could jeopardize the hemodynamics of the patients and potentially lead to life-threatening complications. In this article, we go over the bail-out techniques that have been tried while highlighting the pros and cons of each technique.

Effect of exercise on cluneal nerve entrapment neuropathy: a case report.

BACKGROUND: Low back pain is an important disability problem frequently encountered in the clinic. In the literature, it has been shown that neuropathic pain in chronic low back pain is quite common in patients. Although superior cluneal nerve entrapment syndrome is an underdiagnosed cause of low back and leg pain, differential diagnosis is very important anatomically and clinically. The superior cluneal nerves are pure sensory nerves that innervate the skin of the upper part of the buttocks. In the literature, methods such as surgery, nerve blockade, prolotherapy, and acupuncture have been used in the treatment of cluneal nerve entrapment syndrome, but there are no studies on exercise. In this case report, our aim is to explain the importance of differential diagnosis in cluneal nerve entrapment syndrome, which is one of the common causes of low back pain in the clinic, and the effects of exercise in this disease. CASE PRESENTATION: A 22-year-old, Turkish-ethnicity, male patient with complaints of low back pain, neck-back pain, and weakness did not use alcohol or cigarettes. In his family history, there was a history of diabetes in the mother and diabetes and heart failure in the father. He had a history of osteoporosis, epilepsy, asthma, sarcoidosis, and cardiac arrhythmia. The patient reported that he suffered from constipation three to four times a month. As a result of the detailed evaluation, the planned exercise prescription was taught to the patient, and after it was confirmed that the patient did the exercises correctly for 3 days, the exercise brochure was given and followed as a home exercise program for 8 weeks. CONCLUSIONS: Lumbar stabilization exercises, gluteal muscle strengthening exercises, thoracolumbar fascia mobilization, and stretching exercises, which will be given in accordance with the clinical anatomy of the disease after the correct diagnosis in cluneal nerve entrapment syndrome, have been beneficial for the patient. However, we think that randomized controlled studies with a large sample will contribute to the literature.

A Novel Inhalable Dry Powder to Trigger Delivery of Voriconazole for Effective Management of Pulmonary Aspergillosis.

Invasive pulmonary aspergillosis (IPA) is a fatal fungal infection with a high mortality rate. Voriconazole (VCZ) is considered a first-line therapy for IPA and shows efficacy in patients for whom other antifungal treatments have been unsuccessful. The objective of this study was to develop a high-potency VCZ-loaded liposomal system in the form of a dry-powder inhaler (DPI) using the spray-drying technique to convert liposomes into a nanocomposite microparticle (NCMP) DPI, formulated using a thin-film hydration technique. The physicochemical properties, including size, morphology, entrapment efficiency, and loading efficiency, of the formulated liposomes were evaluated. The NCMPs were then examined to determine their drug content, production yield, and aerodynamic size. The L3NCMP was formulated using a 1:1 lipid/L-leucine ratio and was selected for in vitro studies of cell viability, antifungal activity, and stability. These formulated inhalable particles offer a promising approach to the effective management of IPA.

Changes in Ultrasound Parameters of the Median Nerve at Different Positions of the Radiocarpal Joint in Patients with Carpal Tunnel Syndrome.

Ultrasound imaging (US) is being increasingly used to aid in the diagnosis of entrapment neuropathies. This study aims to evaluate the shear modulus and cross-sectional area (CSA) of the median nerve in patients with carpal tunnel syndrome (CTS). A total of 35 patients with CTS participated in the study. CSA and shear modulus testing were performed in shear wave elastography (SWE) mode in five positions of the right and left radiocarpal joints (intermediate position 0°, 45° of extension, maximum extension, 45° of flexion, and maximum flexion). There were significant side-to-side differences in the median nerve shear modulus at each wrist position as compared to the asymptomatic side. There were significant side-to-side differences in the median nerve CSA at each wrist position as compared to the asymptomatic side. Shear modulus increases in patients with CTS at different angular positions of flexion and extension of the radiocarpal joint. In individuals with CTS, the CSA of the median nerve is greater on the symptomatic side compared to the asymptomatic side. The CSA decreases in positions of maximum extension and 45° of flexion and in maximum flexion relative to the resting position.

Surgical cavity dilatation after resection of IDH-mutated astrocytoma of the mesial temporal lobe: illustrative cases.

BACKGROUND: Space-occupying tumor bed cysts may exceptionally happen after the resection of diffuse low-grade glioma. Their mechanism and management remain debated. The authors report two cases of tumor bed cysts occurring after the resection of a left temporal diffuse low-grade glioma with two different evolutions. OBSERVATIONS: The first patient showed a spontaneous decrease in the cyst volume and did not report any symptoms. In contrast, the second patient showed a progressive increase in the cyst volume and reported headaches and difficulties in finding words. Endoscopic cyst fenestration was performed and led to symptom relief and normalization of the surgical cavity. LESSONS: A tumor bed cyst is a rare complication of temporal low-grade glioma resection. Its formation is due to entrapment of the choroid plexus in the temporal horn widely opened into the surgical cavity. Endoscopic cyst fenestration should be offered only in symptomatic cases. https://thejns.org/doi/10.3171/CASE23674.

Evaluating dasatinib nanocarrier: Physicochemical properties and cytotoxicity activity on cancer cells.

Objective: Dasatinib-(DAS) is a tyrosine kinase inhibitor usually used to treat leukemia. However, DAS is a poorly water-soluble drug. Therefore, oil-in-water emulsions were used for DAS to enhance its solubility and cancer treatment efficacy. This study aims to develop an appropriate DAS nanoemulsion (NE) that can overcome the issue of DAS solubility and provide an effective anticancer effect. Methods: Spherical particles dispersed in an aqueous media approach within an oily phase (oleic acid, Kolliphor RH40, and dipropylene glycol) were used to formulate DAS-NE using high-energy methods. Different formulas were developed and an appropriate formula was analyzed to identify its physicochemical properties. Raw DAS and nonformula cytotoxicity were evaluated through MTT assay against three cancer cell lines, MCF7 (human breast adenocarcinoma), HT29, and SW480 (human colorectal carcinomas), in addition to MRC5 (Normal human fetal lung fibroblast). Results: Different DAS-NEs (1-7) have been developed successfully. Formulas had a droplet size of a diameter ranging from 84.167 ± 10.178 nm to 273.433 ± 45.267 nm. The drug content of the appropriate formula (DAS-NE3) was found to be 83.2%. The drug release result of DAS-NE3 when compared to raw DAS was about 58%, falling to 13% after 24 h. The DAS-NE3 showed cytotoxicity against the three cancer cells below 26.11 µM but showed 30-fold significantly increased selectivity against MRC5 normal cells compared to that of raw DAS. Conclusion: This study shows that the DAS-NE3 formula may provide a potentially effective and sustained drug delivery for cancer treatment. This provides valuable information to the scientific community and the pharmaceutical industry.

Ultrasound-Based Multi-Planar Bilateral Comparisons as a Diagnostic and Treatment-Definition Method for Unilateral Peripheral Nerve Entrapment.

OBJECTIVE: The primary goal was to determine the performance of the cross-section area swelling rate (CSASR) for diagnostic and therapeutic purposes based on the reference standard of electrodiagnosis examination (EDX) in this diagnostic test study. METHODS: First, patients with symptoms like unilateral carpal tunnel syndrome (CTS), cubital tunnel syndrome (CuTS), and radial nerve compression (RNC) underwent EDX and ultrasound examination. Second, patients with positive ultrasound were calculated for the CSASR of diseased nerve. Based on previously established CSASR criteria, each patient was categorized as having or not having peripheral nerve entrapment, and for those meeting diagnostic criteria, non-surgical or surgical treatment was recommended. Then, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rate (ACC) of ultrasound diagnosis and therapeutic decision-making were calculated based on the reference standard of EDX that had been historically used in the practice. RESULTS: The total sensitivity, specificity, PPV, NPV, and ACC of ultrasound diagnosis are respectively 93.4, 85.2, 94.7, 82.1, and 91.3%. Which of therapeutic decision-making by ultrasound are, respectively, 83.3, 52.2, 78.4, 60.0, and 73.2%. CONCLUSION: The sensitivity and Youden's index of CSASR diagnostic threshold for CuTS is higher than other ultrasound methods. The CSASR diagnostic threshold for CuTS has a potential diagnostic role, but the current date is still not enough to support the potential diagnostic role for CTS or RNS. There is insufficient evidence to suggest that CSASR for CuTS can be used in isolation for diagnosis. Additional research is needed to confirm the diagnostic role of CSASR. The current results suggest that this ultrasound examination method is not suitable for therapeutic decision-making.

Effects of Radial Extracorporeal Shockwave Therapy on Piriformis Syndrome: A Single-Case Experimental Design.

The effects of radial extracorporeal shockwave therapy (rESWT) on piriformis syndrome were investigated using a single-case study design. This study used an AB single case with a follow-up phase design. The baseline phase consisted of general physical therapy, including piriformis stretching, while the experimental phase consisted of rESWT in addition to general physical therapy. A man in his 70s diagnosed with piriformis syndrome participated in the study. The Numerical Rating Scale (NRS) score, piriformis hardness, and cross-sectional area of the sciatic nerve were measured to determine the effectiveness of the intervention. The baseline and experimental phases were compared using a binomial distribution based on the celeration line. The NRS score, piriformis hardness, and cross-sectional area of the sciatic nerve were significantly decreased in the experimental phase compared to the baseline phase (NRS, p<0.001; piriformis hardness, p<0.001; cross-sectional area of the sciatic nerve, p<0.001). This effect was carried over to the follow-up phase for all variables. rESWT for piriformis syndrome improved the clinical symptoms, piriformis hardness, and cross-sectional area of the sciatic nerve. However, these results are exploratory and require further validation in future clinical trials.

Compressive Neuropathies of the Upper Extremity: Anatomy for the Peripheral Nerve Surgeon.

Advance knowledge of anatomy is a prerequisite for the peripheral nerve surgeon. This article serves to provide an outline of anatomic regions where nerve entrapment or compression can occur. Each section is subdivided into anatomic regions where the etiology, indications, and relevant and aberrant anatomy are discussed, as well as common surgical approaches to the problematic anatomic site. The purpose is to provide an overview for the peripheral nerve surgeon and offer a valuable resource to provide a better understanding and optimal care for this patient population.

Reliability of PainDETECT for Evaluating Low Back Pain Caused by Cluneal Nerve Entrapment.

BACKGROUND: Superior/middle cluneal nerve entrapment (CN-E) is an elicitor of low back pain (LBP). The painDETECT questionnaire is used to characterize CN-E symptoms. METHODS: Nineteen consecutive patients with LBP caused by CN-E (superior CN-E = 7; middle CN-E = 12) participated in a Japanese language painDETECT questionnaire survey before surgery. A score of 12 or lower was recorded as 'neuropathic component unlikely', a score of 19 or higher as 'neuropathic pain likely', and scores between 13 and 18 as 'neuropathic pain possible'. LBP severity was recorded on a numerical rating scale, the Roland-Morris Disability Questionnaire, and the EuroQol-5 dimension-5 level. RESULTS: The mean painDETECT score was 11.8 and did not significantly differ between the superior CN-E and middle CN-E groups. We classified low back pain as unlikely to have a neuropathic component in 13 patients, as likely to have a neuropathic component in 2 patients, and as possibly neuropathic in 4 patients. There was no significant difference in the pain level of patients with scores of ≤12 and ≥13 on painDETECT. All patients reported trigger pain; the positive rate was high for electric shock pain, radiating pain, and pain attacks and low for a burning or tingling sensation, pain elicited by a light touch, and pain caused by cold or hot stimulation. CONCLUSION: The painDETECT questionnaire may not reliably identify LBP caused by superior/middle CN-E as neuropathic pain. A diagnosis of LBP due to CN-E must be made carefully because symptoms resemble nociceptive pain.

Preparation of Transglutaminase-Catalyzed Rice Bran Protein Emulsion Gels as a Curcumin Vehicle.

Protein-based emulsion gels have tunable viscoelasticity that can be applied to improve the stability of bioactive ingredients. As the by-product of rice processing, rice bran protein (RBP) has high nutritional value and good digestibility, exhibiting unique value in the development of hypoallergenic formula. In this study, the effect of transglutaminase (TGase) cross-linking on the physicochemical properties of RBP emulsion gels was investigated. To improve the stability of curcumin against environmental stress, the entrapment efficiency and stability of curcumin in the emulsion gel systems were also evaluated. The results indicated that TGase increased the viscoelastic modulus of RBP emulsion gels, resulting in a solid-like structure. Moreover, the entrapment efficiency of curcumin was increased to 93.73% after adding TGase. The thermal stability and photo-stability of curcumin were enhanced to 79.54% and 85.87%, respectively, compared with the sample without TGase addition. The FTIR results showed that TGase induced the cross-linking of protein molecules and the secondary structure change in RBP. Additionally, SEM observation confirmed that the incorporation of TGase promoted the formation of a compact network structure. This study demonstrated the potential of RBP emulsion gels in protecting curcumin and might provide an alternative strategy to stabilize functional ingredients.