Percutaneous Coronary Intervention-Related Iatrogenic Fistula in Acute Coronary Syndrome.

Iatrogenic coronary artery fistula (CAF) can occur following acute myocardial infarction, percutaneous coronary intervention (PCI) procedures, and heart surgery. Iatrogenic CAF linked to PCI has a low incidence rate. Early diagnosis and treatment are crucial when an iatrogenic fistula develops, as it may lead to cardiac tamponade, myocardial infarction, or death. In this report, we present a case of iatrogenic CAF secondary to coronary perforation caused by guidewire-induced trauma, followed by stent implantation and balloon inflation in the context of acute coronary syndrome (ACS). It was successfully managed through prolonged balloon inflation within the previously implanted stent just prior to the rupture zone.

Axillary Artery Injury Encountered During Chest Wall Tumor Resection.

Axillary artery injuries are rare because of their anatomy but are sometimes fatal because of the difficulty of obtaining vascular integrity. We report a 50-year-old patient with an iatrogenic axillary arterial injury that occurred during the resection of a chest wall tumor. The injury occurred during an incision of the intercostal muscle along the superior margin of the second rib. Following primary hemostasis achieved by forceps and amputation of the pectoralis minor muscle, the injury site was exposed sufficiently and successfully repaired by a vascular surgeon. This successful case provided valuable insight into strategies, primary hemostasis, and subsequent revascularization for an intraoperative vascular injury.

Postoperative rectovaginal fistula: stoma may not be necessary-a French retrospective cohort.

BACKGROUND: Postoperative rectovaginal fistula leads to a loss of patients' quality of life and presents significant challenges to the surgeon. The literature focusing specifically on postoperative rectovaginal fistulas is limited. The objective of the present study is to identify factors that can enhance the success of the management of this postoperative rectovaginal fistula. METHODS: This retrospective multicentric study included all patients undergoing surgery for rectovaginal fistulas, excluding those for whom the etiology of rectovaginal fistula was not postoperative. The major outcome measure was the success of the procedure. RESULTS: A total of 82 patients with postsurgical fistulas were identified, of whom 70 were successfully treated, giving a success rate of 85.4%. On average, these patients required 3.04 ± 2.72 interventions. The creation of a diversion stoma did not increase the success rate of management [odds ratio (OR) = 0.488; 95% confidence interval (CI) 0.107-2.220]. Among the 217 procedures performed, 69 were successful, accounting for a 31.8% success rate. The number of interventions and the creation of a diversion stoma did not correlate with the success of management. However, direct coloanal anastomosis was significantly associated with success (OR = 35.06; 95% CI 1.271-997.603; p = 0.036) as compared with endorectal advancement flap (ERAF). Other procedures such as Martius flap did not show a significantly higher success rate. CONCLUSION: The creation of a diversion stoma is not necessary in closing a fistula. ERAF should be considered as a first-line treatment prior to proposing more invasive approach such as direct coloanal anastomosis.

Amyloid nomenclature 2024: update, novel proteins, and recommendations by the International Society of Amyloidosis (ISA) Nomenclature Committee.

The ISA Nomenclature Committee met at the XIX International Symposium of Amyloidosis in Rochester, MN, 27 May 2024. The in-person event was followed by many electronic discussions, resulting in the current updated recommendations. The general nomenclature principles are unchanged. The total number of human amyloid fibril proteins is now 42 of which 19 are associated with systemic deposition, while 4 occur with either localised or systemic deposits. Most systemic amyloidoses are caused by the presence of protein variants which promote misfolding. However, in the cases of AA and ATTR the deposits most commonly consist of wild-type proteins and/or their fragments. One peptide drug, previously reported to create local iatrogenic amyloid deposits at its injection site, has been shown to induce rare instances of systemic deposition. The number of described animal amyloid fibril proteins is now 16, 2 of which are unknown in humans. Recognition of the importance of intracellular protein aggregates, which may have amyloid or amyloid-like properties, in many neurodegenerative diseases is rapidly increasing and their significance is discussed.

Super-selective renal artery embolization (SRAE) for iatrogenic and traumatic renal hemorrhage.

PURPOSE: To present the radiological and clinical outcomes of super-selective transcatheter renal artery embolization in patients with renal injury hemorrhage, and share our experience. METHODS: 43 patients with renal injury hemorrhage who underwent 46 SRAEs were enrolled in this retrospective review study. Records, images, and outcomes were reviewed. The individual embolic method and its observed effects were investigated. RESULTS: Angiography showed free extravasation in 25 angiograms, pseudoaneurysm in 15 angiograms, and arteriovenous fistulas in 1 angiogram. Most patients achieved initial clinical success (38/43, 88.4%), and 41 patients achieved final clinical success (41/43, 95.3%). 9/11 patients who adopted empirical embolization achieved initial clinical success (81.8%). In our study, the combination of PVA particles and micro-coils has emerged as the most commonly utilized material combination (24/46, 52.2%). Significant differences in hemoglobin levels were observed before and after the embolization procedure (p = 0.026, 95%CI: 1.03-15.54). Post-embolization clinical follow-up showed no evidence of recurrent hematuria, progression of hematoma, hypertension, and no reflux of the embolic agent. CONCLUSION: Though SRAE showed satisfactory results across a broad range of renal injury hemorrhage, there are still some aspects that need attention: (1) Surgical procedure should be understood, including the surgical site, access routes, and placement of implants, such as double-J stents. (2) In cases where identifying the bleeding point proves challenging, consider the possibility of an accessory renal artery. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2400085050, Registration Date: 30 May 2024, retrospectively, non-randomized.

Laparoscopic modified simple ureteroneocystomy in iatrogenic lower third ureter injury during gynecology surgery.

OBJECTIVE: Our objective was to propose a laparoscopic modified simple ureteroneocystostomy for repairing iatrogenic ureteral injuries. In laparoscopic modified simple ureteroneocystostomy, the highest point of the bladder was found by cystoscopy, then we implanted a "fish mouth" ureter end into the bladder, leaving at least 1 cm of ureter end in the bladder as an anti-reflux procedure. CASE REPORT: We retrospectively reviewed a case series of lower third iatrogenic ureter injury during gynecology surgery of 11 patients who received laparoscopic modified simple ureteroneocystostomy at Da Lin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, from January 2011 to December 2020. One patient needs percutaneous nephrotomy due to infection and had the ureteroneocystostomy two months later. No obstruction, ureter stenosis/stricture, bladder leakage or other renal complications were noted after repair. CONCLUSION: Laparoscopic modified simple ureteroneocystostomy is technically feasible for repairing lower third ureter injuries, with no major complications.

Refractory Obstructive Sleep Apnea Secondary to Vagal Nerve Stimulation.

Vagal nerve stimulator (VNS) devices are commonly used as a non-pharmacologic option for improved seizure control in patients with refractory epilepsy. However, a side effect associated with VNS device placement includes sleep-disordered breathing, which is complicated by the fact that a significant minority of patients with epilepsy have sleep-disordered breathing. We describe a patient with iatrogenically worsened refractory obstructive sleep apnea (OSA) secondary to VNS device placement, which resolved upon turning off the VNS device. This case highlights the need to screen for OSA in patients who are candidates for VNS device placement, as iatrogenic sleep-disordered breathing could place the patient at risk for adverse clinical outcomes, as well as paradoxically worsen seizure control due to poor quality sleep.

[A case of young onset cerebral amyloid angiopathy associated with dural grafting].

A 47-year-old man was admitted to our hospital because of sudden-onset motor aphasia and right hemiplegia. His past medical history was notable for left craniotomy and hematoma evacuation following a traumatic brain hemorrhage approximately 40 years earlier, for which dural grafting was performed. He also had a history of three lobar hemorrhages in the left hemisphere since the age of 42 years. Brain CT imaging revealed an acute left frontal lobar hemorrhage. His initial brain MRI conducted at our hospital demonstrated hemorrhagic findings with left hemisphere dominance, including acute and old lobar hemorrhage, cortical superficial siderosis, and cerebral microbleeds. Cerebrospinal fluid analyses demonstrated reduced levels of cerebral amyloid-ß 42, and elevated total tau. His apolipoprotein E genotype was ε3/ε3. Whole-exome sequencing did not detect mutations in genes associated with Alzheimer's disease, including presenilin 1, presenilin 2, and amyloid precursor protein. These findings led to a clinical diagnosis of iatrogenic cerebral amyloid angiopathy (CAA) using recently proposed diagnostic criteria, which do not require pathological evaluation of the brain. Iatrogenic CAA should be considered as a cause of lobar hemorrhage in young patients, especially those with a past history of neurosurgery.

Enhancing Traditional Chinese Medicine healthcare system in Taiwan post-COVID-19 pandemic: A strategic focus on specialization.

Despite the advancements in precision medicine, regenerative medicine, and smart healthcare, traditional Chinese medicine (TCM) remains vital in Taiwan, reflecting its cultural and historical heritage. TCM is commonly used in conjunction with or as an alternative to conventional medicine and is reimbursed by Taiwan's National Health Insurance, enabling the Taiwanese people to integrate traditional and modern treatments for comprehensive healthcare. This article explores the critical role of specialization in TCM amid evolving healthcare challenges. This highlights the need for specialized knowledge among TCM physicians to manage iatrogenic risks, such as drug-herb interactions, and to improve healthcare outcomes, particularly when integrating TCM with Western medicine. Specialization enhances treatment precision, patient outcomes, and clinical research quality. Drawing on South Korea's experience in establishing a specialist physician system for traditional Korean medicine, Taiwan's Ministry of Health and Welfare's initiatives to advance systematic TCM training and regulatory frameworks were examined, showcasing the development and implementation of a TCM specialist physician training program. In conclusion, specialized physician training in TCM improves patient care, optimizes healthcare utilization, and promotes long-term sustainability of the health insurance system by aligning TCM practices with modern healthcare needs.

Interictal psychosis of epilepsy: What is the role of the neurologist?

Psychotic disorders are more frequent in people with epilepsy than the general population. They constitute one of the most serious psychiatric comorbidities which require an immediate psychopharmacologic intervention. Yet, access to psychiatrists is often limited or not available and the neurologists taking care of these patients are called-upon to start treatment with antipsychotic medication. The purpose of this manuscript is to provide clinicians with pragmatic psychopharmacologic strategies to treat interictal psychotic disorders in patients with epilepsy. We review the case of a 45 years-old man with a 35-year history of treatment-resistant focal epilepsy of bitemporal origin who developed a de-novo psychotic episode that began with insomnia, mood lability and agitation and evolved into paranoid delusions, auditory hallucinations and a thought disorder. The patient was diagnosed with an interictal psychotic episode and was treated with aripiprazole which resulted in significant improvement after reaching a 20 mg /day dose and allowed for the patient to be discharged home. In summary, interictal psychotic episodes of epilepsy are relatively frequent in patients with epilepsy and require of an early psychopharmacologic treatment to facilitate their remission or stabilization until mental health professionals can take over their long-term care. Compared to primary psychotic disorders, interictal psychotic episodes respond better and at lower doses of antipsychotic drugs.

Management and prognosis of iatrogenic perforations of the cervical oesophagus and hypopharynx.

Objective: The study aimed to identify factors affecting the management and prognosis of iatrogenic cervical oesophageal and hypopharyngeal perforations (iCEHPs). Methods: We retrospectively analysed 24 patients treated for iCEHP between 2004 and 2021 at a tertiary university medical centre. Data on demographics, clinical features, imaging, management and outcomes were collected. Factors associated with primary management and patient outcome were assessed. Results: The most common management approach was surgical neck exploration (15 patients, 62.5%). Surgical management was used in 93% of uncontained perforations compared to 11% of contained perforations (p < 0.001). Surgically-treated patients had higher levels of C-reactive protein (CRP) than conservatively-treated patients (median, 18.3 vs 4.8 mg/dL; p = 0.001). Delayed diagnosis (≥ 24 hours) was associated with increased mortality (100 vs 5%; p = 0.011). The mortality rate was significantly higher in patients who had a history of neck irradiation than in patients who did not (67 vs 5%; p = 0.032). Conclusions: Early diagnosis of iCEHP improves outcomes. The appropriate management should be carefully selected on the basis of CRP level and imaging findings. Prior neck radiation is a poor prognostic factor.

Trial selection criteria should not be used for clinical decisions and recommendations: the thrombectomy trials example.

BACKGROUND: Despite multiple calls for more inclusive studies, most clinical trial eligibility criteria remain too restrictive. Thrombectomy trials have been no exception. METHODS: We review the landmark trials that have shown the benefits of thrombectomy, their eligibility criteria, and consequences on clinical practice. We discuss the rationale behind various reasons for exclusions. We also examine the logical problem involved in using eligibility criteria as indications for treatment. RESULTS: Most thrombectomy trials have been too restrictive. This has been shown by a plethora of follow-up studies that have refuted most of the previously recommended trial eligibility restrictions. Meanwhile, the effect of clinical recommendations based on restrictive eligibility criteria is that treatment has been denied to the majority of patients who could have benefitted. Trial eligibility criteria cannot be used to make clinical decisions or recommendations unless, like any other medical diagnosis, they have been shown capable of reliably differentiating patients into those that will, and those that will not benefit from treatment. This goal can only be achieved with all-inclusive pragmatic trials. CONCLUSION: Restrictive eligibility criteria render clinical trials incapable of guiding medical decisions or recommendations.

Traumatic CSF rhinorrhea associated with COVID-19 testing: a case series and systematic review.

BACKGROUND: This report analyzes traumatic anterior skull base CSF leaks following nasopharyngeal swab testing for detection of SARS-CoV-2 in the largest case series to date, combined with a systematic literature review. METHODS: Retrospective multi-institutional case-series of traumatic anterior skull base CSF leak with clear antecedent history of COVID-19 swab was completed. A comprehensive search of databases was performed for the systematic literature review. RESULTS: Thirty-four patients with traumatic CSF leak after COVID-19 nasopharyngeal swab testing were identified. Women were more than twice as likely to experience a CSF leak, as compared to men. The majority of patients (58.8%) had no reported predisposing factor in their clinical history. Common defect sites included the cribriform plate (52.9%), sphenoid sinus (29.4%), and ethmoid roof (17.6%). Four patients (11.8%) presented with meningitis. The median time between the traumatic COVID swab and the detection of CSF leak was 4 weeks (IQR 1-9). Patients with meningitis had a median leak duration of 12 weeks (IQR 8-18). The average leak duration was significantly longer in patients with meningitis compared to without meningitis (p = 0.029), with a moderate effect size (r = - 0.68). Most cases (92.9%) managed with endoscopic endonasal surgical repair were successful. CONCLUSIONS: This report clarifies the presentation, risk factors, and management of CSF leaks attributable to diagnostic nasopharynx swabbing procedures in the COVID-19 era. Timely surgical repair is the recommended management option for such leaks.

Traumatic middle meningeal arteriovenous fistulas (MMAVFs): an exploratory systematic review.

This study aims to systematically review case reports and case series in order to compare the postoperative course of conservative, endovascular and surgical treatments for traumatic dural arteriovenous fistulas predominantly supplied by the middle meningeal artery (MMAVFs), which usually occur following head trauma or iatrogenic causes. We conducted a comprehensive search of PubMed, Embase, Scopus, Web of Science, and Google Scholar until June 23rd, 2024. Three cohorts were defined based on the treatment modality employed. The primary outcomes were the rates of overall obliteration and postoperative complications, with all-cause mortlality considered as secondary outcome. A total of 61 studies encompassing 78 pooled MMAVFs were included in the qualitative analysis. The predominant demographic consisted of males (53.9%) with a median age of 50.5 (IQR: 33.5-67.5) years. The main etiologies for fistula formation were head trauma (75.6%), cranial neurosurgical procedures (11.5%) and endovascular embolization (8.97%). Venous drainage patterns were categorized as follows based on anatomical confluence: Class I (16.7%), II (14.1%), III (12.8%), IV (14.1%), V (7.7%), and VI (3.9%). Regarding treatment efficacy, the overall obliteration rate was 89.74%, achieved through endovascular (95.83%), surgical (64.29%) or conservative (93.75%) approaches. In terms of safety, the overall postoperative complication rate was 6.49% with an all-cause mortality rate of 8.97%, predominantly observed in the surgical group (35.71%). Our systematic review highlights the challenging management of traumatic MMAVFs, frequently associated with head injuries. Endovascular therapy has emerged as the predominant treatment modality, demonstrating markedly higher rates of fistula obliteration, reduced all-cause mortality, and fewer postoperative complications.

Characteristics and management of iatrogenic urinary tract injuries in teaching hospital: A single-centered study.

Context and Aims: Despite its rarity, iatrogenic urinary tract injury can cause severe morbidity and mortality. The purpose of this study was to determine the frequency of urinary tract injuries caused by medical treatment in a hospital in Medan, Indonesia. Settings and Design: This retrospective descriptive study was conducted at H. Adam Malik General Hospital and Universitas Sumatera Utara Hospital in Medan from March to August 2022. Subjects and Methods: Medical data of individuals who had iatrogenic urinary tract injuries in a Medan teaching hospital from 2018 to 2022 were obtained using total sampling. SPSS version 25 was utilized to analyze patient characteristics, the type of surgery, urinary tract injuries, and urologic procedures. Results: There were 11 ureteral injuries and 23 bladder injuries in 32 iatrogenic urinary tract injuries. The average age of the patients was 40.5 ± 13.3. Patients who received obstetrical care had the highest rate of iatrogenic urinary tract injury (56.3%), followed by patients who received gynecological care (21.9%) and surgical care (21.9%). The procedure most likely to cause iatrogenic urinary tract injury was hysterectomy (40.6%). Bladder rupture (65.5%) and ureteral transection (28.1%) were common types of iatrogenic bladder and ureteral injuries. Majority of iatrogenic urinary tract injuries were treated with bladder repair (68.8%). Conclusions: Obstetrical and gynecologic procedures, especially hysterectomy, were the most common causes of iatrogenic urinary tract injury; bladder repair was the most common treatment. Iatrogenic urinary tract injury is best managed by knowing the anatomical position of the urinary tract inside the operative field.

Cushing's Syndrome Masquerading as Fibromyalgia: A Case Series.

Three young female patients with a history of generalized body pain were diagnosed with fibromyalgia. They visited several specialities which related patients' symptoms to their previous diagnosis of fibromyalgia and were treated symptomatically. These patients developed a multitude of clinical features including fractures, hypertension, abnormal weight gain, proximal myopathic pain and bruising. They were seen by rheumatologists whose assessment was that their clinical features were not entirely due to fibromyalgia and suspected that patients have a possible underlying endocrine cause. Patients were referred to an endocrinologist for further tests with suspicion of Cushing's syndrome. Laboratory tests and imaging confirmed a diagnosis of Cushing's syndrome. Two of them had adrenal adenoma and one had iatrogenic corticosteroid use. These cases emphasize the need for thorough clinical evaluation for patients who are thought to have fibromyalgia. Fibromyalgia is a diagnosis of exclusion.

Subclavian Artery Injury During Lung Tumor Resection.

An open penetrating injury of the subclavian artery is an extremely rare catastrophic situation in thoracic surgery. We experienced a 57-year-old case of iatrogenic subclavian artery injury during the resection of a lung tumor. The injury occurred during the dissection of the adhesion between the stapling site of the previous bullectomy and the chest wall. Systolic blood pressure dropped below 50 mmHg immediately after the injury. Following primary hemostasis achieved with suture closure, the site of injury was sufficiently exposed and successfully repaired.

Effect of Presence of Uni- or Bilateral Thyroid Adenoma on Recovery of Pituitary-Thyroid Axis and Creatinine Concentration in Radioiodine-Treated Cats.

Radioiodine therapy (RAIT) is the gold standard for treatment of hyperthyroidism in cats. The aim of this study was to evaluate the effect of the presence of uni- or bilateral thyroid adenoma on changes in total thyroxine (TT4), thyroid-stimulating hormone (TSH), and creatinine concentration over a period of 6 to 12 months following RAIT. Fifty-one hyperthyroid cats presented for RAIT between April 2021 and April 2022 were prospectively enrolled. Cats with an increased creatinine concentration (creatinine ≥ 140 µmol/L), renal morphology abnormalities, and suspected thyroid carcinoma were excluded. TT4, TSH, and creatinine were determined before and one week and one, three, six, and twelve months following RAIT. The effects of the re-examination timepoint following RAIT and the presence of uni- or bilateral thyroid adenoma based on technetium-99m scintigraphy on TT4, TSH, and creatinine were analysed by mixed effects modelling. Cats with bilateral adenoma had significantly higher TSH concentrations after RAIT compared to those with unilateral adenoma. TT4 concentration significantly decreased one week (p < 0.001) and again one month following RAIT (p < 0.001). TSH and creatinine concentration significantly increased one month post RAIT (both p < 0.001). As indicated by an increase in TSH concentration, the pituitary-thyroid axis needs a minimum of one month post RAIT to recover from hyperthyroidism-induced suppression, but hypothyroidism necessitating levothyroxine supplementation might not be diagnosed before 6 or even 12 months post RAIT. Although creatinine did not increase significantly after one month post RAIT in this cohort, an increased creatinine concentration was detected at later timepoints in individual cats.