Cholinergic changes in Lewy body disease: implications for presentation, progression and subtypes.

Cholinergic degeneration is significant in Lewy body disease, including Parkinson's disease, dementia with Lewy bodies, and isolated REM sleep behaviour disorder. Extensive research has demonstrated cholinergic alterations in the CNS of these disorders. More recently, studies have revealed cholinergic denervation in organs that receive parasympathetic denervation. This enables a comprehensive review of cholinergic changes in Lewy body disease, encompassing both central and peripheral regions, various disease stages and diagnostic categories. Across studies, brain regions affected in Lewy body dementia show equal or greater levels of cholinergic impairment compared to the brain regions affected in Lewy body disease without dementia. This observation suggests a continuum of cholinergic alterations between these disorders. Patients without dementia exhibit relative sparing of limbic regions, whereas occipital and superior temporal regions appear to be affected to a similar extent in patients with and without dementia. This implies that posterior cholinergic cell groups in the basal forebrain are affected in the early stages of Lewy body disorders, while more anterior regions are typically affected later in the disease progression. The topographical changes observed in patients affected by comorbid Alzheimer pathology may reflect a combination of changes seen in pure forms of Lewy body disease and those seen in Alzheimer's disease. This suggests that Alzheimer co-pathology is important to understand cholinergic degeneration in Lewy body disease. Thalamic cholinergic innervation is more affected in Lewy body patients with dementia compared to those without dementia, and this may contribute to the distinct clinical presentations observed in these groups. In patients with Alzheimer's disease, the thalamus is variably affected, suggesting a different sequential involvement of cholinergic cell groups in Alzheimer's disease compared to Lewy body disease. Patients with isolated REM sleep behaviour disorder demonstrate cholinergic denervation in abdominal organs that receive parasympathetic innervation from the dorsal motor nucleus of the vagus, similar to patients who experienced this sleep disorder in their prodrome. This implies that REM sleep behaviour disorder is important for understanding peripheral cholinergic changes in both prodromal and manifest phases of Lewy body disease. In conclusion, cholinergic changes in Lewy body disease carry implications for understanding phenotypes and the influence of Alzheimer co-pathology, delineating subtypes and pathological spreading routes, and for developing tailored treatments targeting the cholinergic system.

A prospective, multicenter, three-cohort study evaluating contrast-induced acute kidney injury (CI-AKI) in patients with cirrhosis.

BACKGROUND & AIMS: Nephrotoxicity of intravenous iodinated contrast media (ICM) in cirrhosis is still a debated issue, due to scarce, low-quality and conflicting evidence. This study aims to evaluate the incidence and predisposing factors of acute kidney injury (AKI) in patients with cirrhosis undergoing contrast-enhanced computed tomography (CECT). METHODS: We performed a prospective, multicenter, cohort study including 444 inpatients, 148 with cirrhosis (cohort 1) and 163 without cirrhosis (cohort 3) undergoing CECT and 133 with cirrhosis (cohort 2) unexposed to ICM. Kidney function parameters were assessed at T0, 48-72 h (T1), 5 and 7 days after CECT/enrollment. Urinary neutrophil gelatinase-associated lipocalin (U-NGAL) was measured in 50 consecutive patients from cohort 1 and 50 from cohort 2 as an early biomarker of tubular damage. RESULTS: AKI incidence was not significantly increased in patients with cirrhosis undergoing CECT (4.8%, 1.5%, 2.5% in cohorts 1, 2, 3 respectively, p = n.s.). Most AKI cases were mild and transient. The presence of concomitant infections was the only independent predictive factor of contrast-induced AKI (odds ratio 22.18; 95% CI 2.87-171.22; p = 0.003). No significant modifications of U-NGAL between T0 and T1 were detected, neither in cohort 1 nor in cohort 2 (median ΔU-NGAL: +0.2 [-7.6 to +5.5] ng/ml, +0.0 [-6.8 to +9.5] ng/ml, respectively [p = 0.682]). CONCLUSIONS: AKI risk after CECT in cirrhosis is low and not significantly different from that of the general population or of the cirrhotic population unexposed to ICM. It mostly consists of mild and rapidly resolving episodes of renal dysfunction and it is not associated with tubular kidney injury. Patients with ongoing infections appear to be the only ones at higher risk of AKI. IMPACT AND IMPLICATIONS: Nephrotoxicity due to intravenous iodinated contrast media (ICM) in patients with cirrhosis is still a debated issue, as the available evidence is limited and based on very heterogeneous studies, often conducted on small and retrospective cohorts. In this prospective three-cohort study we found that intravenous administration of ICM was associated with a low risk of AKI, similar to that of the general population and to that of patients with cirrhosis unexposed to ICM. Patients with ongoing infections were the only ones to have a significantly increased risk of contrast-induced AKI. Therefore, the actual recommendations of performing contrast imaging studies cautiously in cirrhosis do not seem to be reasonable anymore, with the exception of infected patients, who have a significantly higher risk of contrast-induced AKI.

An AIEgen and Iodine Double-Ornamented Platinum(II) Complex for Bimodal Imaging-Guided Chemo-Photodynamic Combination Therapy.

Real-time biodistribution monitoring and enhancing the therapeutic efficacy of platinum(II)-based anticancer drugs are urgently required to elevate their clinical performance. Herein, a tetraphenylethene derivative (TP) with aggregation-induced emission (AIE) properties and an iodine atom are selected as ligands to endow platinum (II) complex TP-Pt-I with real-time in vivo self-tracking ability by fluorescence (FL) and computerized tomography (CT) imaging, and improved anticancer efficacy by the combination of chemotherapy and photodynamic therapy. Especially, benefiting from the formation of a donor-acceptor-donor structure between the AIE photosensitizer TP and Pt-I moiety, the heavy atom effects of Pt and I, and the presence of I, TP-Pt-I displayed red-shifted absorption and emission wavelengths, enhanced ROS generation efficiency, and improved CT imaging capacity compared with the pristine TP and the control agent TP-Pt-Cl. As a result, the enhanced intratumoral accumulation of TP-Pt-I loaded nanoparticles is readily revealed by dual-modal FL and CT imaging with high contrast. Meanwhile, the TP-Pt-I nanoparticles show significantly improved tumor growth-inhibiting effects on an MCF-7 xenograft murine model by combining the chemotherapeutic effects of platinum(II) and the photodynamic effects of TP. This self-tracking therapeutic complex thus provides a new strategy for improving the therapeutic outcomes of platinum(II)-based anticancer drugs.

Different prognostic significance of coronary artery and aortic valve calcium in patients with chest pain.

OBJECTIVES: Coronary artery calcification (CorCa) identifies high cardiovascular risk in the general population. In this setting, aortic valve calcification (AoCa) showed contradictory results. Our goal has been to assess the prognostic power of CorCa and AoCa in patients with chest pain who underwent an ECG-gated cardiac multidetector CT (cardiac-MDCT). METHODS: A total of 528 patients without previous known coronary artery disease, with chest pain who underwent a cardiac-MDCT multidetector, were retrospectively recruited. The primary endpoint included death, acute coronary syndrome, stroke, and heart failure. RESULTS: A total of 61 patients (11.6%) had an event during a mean follow-up of almost 6 years (5.95 ± 2.98). The most frequent event was acute coronary syndrome (6.4%). Total mortality was 4.5%. Patients with CorCa > 0 had more events than those without CorCa (17.3% versus 4.3%; p < 0.001). Likewise, when only patients without AoCa were considered (n = 118), clinical events were more frequent in those with CorCa (12.7% versus 3.6%; p = 0.004). After excluding patients with coronary artery disease, events were more frequent in those with CorCa (12.6% versus 4.3%; p = 0.004). The higher the Agatston score, the more frequent the events. Patients with AoCa > 0 had more events than those without (16.5% versus 7.3%; p < 0.001), but in patients without CorCa, no difference in events was seen (6.2% versus 3.6%; p = 0.471). A Cox regression analysis showed age, smoking, prior stroke, and CorCa but not AoCa to be independently related to events. CONCLUSIONS: In summary, CorCa, but not AoCa, is related to cardiovascular events in patients with chest pain who undergo a cardiac-MDCT. CLINICAL RELEVANCE STATEMENT: We show that coronary artery calcification, but not aortic valve calcification, detected in a coronary CT scan is tightly related to cardiovascular events. Although this is a message already shown by other groups in the general population, we do believe that this work is unique because it is restricted to patients with chest pain sent to coronary CT. In other words, our work deals with what we face in our routine everyday practice. KEY POINTS: • The presence and the amount of coronary artery calcification are associated with cardiovascular events in patients with chest pain. • Aortic valve calcification is not associated with cardiovascular events in patients with chest pain.

Anti-synthetase syndrome in a child with pneumomediastinum: a case report and literature review.

BACKGROUND: Anti-synthetase syndrome (ASS) is a group of rare clinical subtypes within inflammatory myopathies, predominantly affecting adult females. Instances of critical illness associated with ASS in children are even rarer. CASE PRESENTATION: We report the case of a 7-year-old boy finally diagnosed with ASS, combined with pneumomediastinum. He presented with intermittent fever persisting for 12 days, paroxysmal cough for 11 days, chest pain, and shortness of breath for 4 days, prompting admission to our hospital. Pre-admission chest CT revealed diffuse pneumomediastinum, subcutaneous pneumatosis in the neck and bilateral chest wall, consolidation, atelectasis, and reticular nodular shadowing in both lungs, as well as pericardial effusion and bilateral pleural effusions. Laboratory tests revealed a positive result for serum MP immunoglobulin M (MP-IgM) and MP immunoglobulin G (MP-IgG). The patient was initially diagnosed with mycoplasma pneumoniae (MP) infection, and following 3 days of antibiotic treatment, the patient's tachypnea worsened. Positive results in muscle enzyme antibody tests included anti-PL-12 antibody IgG, anti-Jo-1 antibody IgG, and anti-RO-52 antibody IgG. Ultrasonography detected moderate effusions in the right shoulder, bilateral elbow, and knee joints. Corticosteroids pulse therapy was initiated on the 27th day following disease onset, and continued for 3 days, followed by sequential therapy for an additional 12 days. The child was discharged on the 43rd day, and subsequent follow-up revealed a significant improvement in consolidation and interstitial lesions in both lungs. CONCLUSIONS: ASS in children may combine with rapidly progressive interstitial lung disease (RPILD) and pneumomediastinum. It is crucial to promptly identify concurrent immunologic abnormalities during the outbreak of MP, particularly when the disease exhibits rapid progression with ineffective conventional antibiotic therapy.

Congenital crico-thyroid dysplasia: a comprehensive description.

INTRODUCTION: We describe a first case of human congenital crico-thyroid dysplasia associated to a right sided aortic arch and an aberrant subclavian artery. CASE PRESENTATION: Our patient presented with a two-weeks history of acute dyspnea, and reported hoarseness since his childhood. An urgent tracheotomy was performed, followed by direct laryngoscopy. Endoscopic examination showed a deviation of the dorsoventral axis of the larynx, with an obstructive submucosal swelling the area of the right false cord and aryepiglottic fold. Computed tomography conducted the following day confirmed the crico-thyroid dysplasia, an infected laryngocele, and the presence of a right sided aortic arch and an aberrant subclavian artery. CONCLUSION: The embryological basis of these anomalies is attributed to congenital defects of the development of the fourth and sixth pharyngeal arches. To our knowledge, the congenital crico-thyroid dysplasia has not been previously reported in human. This case underscores the importance of recognizing anatomical variations in laryngeal cartilages, understanding their embryological origins, and potential associated malformations.

Isoprognostic functional CT map for open partial horizontal laryngectomy.

PURPOSE: To identify a radiological map of laryngeal subsites whose involvement by the tumor could predict patients' functional outcomes after open partial horizontal laryngectomy (OPHL). METHODS: The present retrospective analysis concerned 96 patients with glottic squamous cell carcinoma, who were radiologically staged with contrast-enhanced neck CT scans before undergoing supracricoid or supratracheal laryngectomy. A radiological map of patients' functional risk was developed by considering the distribution of functional outcomes in relation to the laryngeal subsites involved. The functional outcomes considered were: (i) decannulation at discharge; (ii) time to removal of the nasogastric feeding tube (NFT); (iii) postoperative complication rate; and (iv) length of hospital stay. RESULTS: Involvement of the anterior supraglottis was related to a longer need for NFT, and a longer hospital stay (p = 0.003, and p = 0.003, respectively). Involvement of the posterior glottis negatively affected the time to decannulation, and the likelihood of postoperative complications (p = 0.000, and p = 0.002, respectively). CONCLUSIONS: Anterior glottic small tumors (without significant subglottic and/or supraglottic extension) are related to the best functional outcomes after OPHL, since the suprahyoid epiglottis and both the arytenoids are likely to be spared.

Hemorrhage risk prediction after computed tomography-guided lung biopsy: Clinical parameters and quantitative pulmonary vascular analysis.

BACKGROUND/PURPOSE: We evaluated the utility of combining quantitative pulmonary vasculature measures with clinical factors for predicting pulmonary hemorrhage after computed tomography (CT)-guided lung biopsy. METHODS: Patients who underwent CT-guided lung biopsy were retrospectively included in this study. Clinical and radiographic vasculature variables were evaluated as predictors of pulmonary hemorrhage. The radiographic pulmonary vascular analysis included vessel count, density, diameter, and area, and also blood volume in small vessels with a cross-sectional area ≤5 mm2 (BV5) and total blood vessel volume (TBV) in the lungs. Univariate and multivariate logistic regressions were used to identify the independent risk factors of higher-grade pulmonary hemorrhage and establish the prediction model presented as a nomogram. RESULTS: The study included 126 patients; discovery cohort n = 103, and validation cohort n = 23. All pulmonary hemorrhage, higher-grade (grade ≥2) pulmonary hemorrhage, and hemoptysis occurred in 42.9%, 15.9%, and 3.2% of patients who underwent CT-guided lung biopsies. In the discovery cohort, patients with larger lesion depth (p = 0.013), higher vessel density (p = 0.033), and higher BV5 (p = 0.039) were more likely to experience higher-grade hemorrhage. The nomogram prediction model for higher-grade hemorrhage built by the discovery cohort showed similar performance in the validation cohort. CONCLUSIONS: Higher-grade pulmonary hemorrhage may occur after CT-guided lung biopsy. Lesion depth, vessel density, and BV5 are independent risk factors for higher-grade pulmonary hemorrhage. Nomograms integrating clinical parameters and radiographic pulmonary vasculature measures offer enhanced capability for assessing hemorrhage risk following CT-guided lung biopsy, thereby facilitating improved patient clinical care.

An Automatic Method for Elbow Joint Recognition, Segmentation and Reconstruction.

Elbow computerized tomography (CT) scans have been widely applied for describing elbow morphology. To enhance the objectivity and efficiency of clinical diagnosis, an automatic method to recognize, segment, and reconstruct elbow joint bones is proposed in this study. The method involves three steps: initially, the humerus, ulna, and radius are automatically recognized based on the anatomical features of the elbow joint, and the prompt boxes are generated. Subsequently, elbow MedSAM is obtained through transfer learning, which accurately segments the CT images by integrating the prompt boxes. After that, hole-filling and object reclassification steps are executed to refine the mask. Finally, three-dimensional (3D) reconstruction is conducted seamlessly using the marching cube algorithm. To validate the reliability and accuracy of the method, the images were compared to the masks labeled by senior surgeons. Quantitative evaluation of segmentation results revealed median intersection over union (IoU) values of 0.963, 0.959, and 0.950 for the humerus, ulna, and radius, respectively. Additionally, the reconstructed surface errors were measured at 1.127, 1.523, and 2.062 mm, respectively. Consequently, the automatic elbow reconstruction method demonstrates promising capabilities in clinical diagnosis, preoperative planning, and intraoperative navigation for elbow joint diseases.

Comparison of Alveolar Bone Grafting Outcomes using CBCT in Individuals with UCLP Based on the Presurgical Orthodontic Treatment Methods.

OBJECTIVE: The purpose is to evaluate outcomes of alveolar bone grafting based on the pre-grafting orthodontic preparation methods. DESIGN: Retrospective analysis of individuals with unilateral cleft lip and palate. SUBJECTS AND SETTINGS: 28 individuals with non-syndromic UCLP from two craniofacial centers, 14 individuals each from XXXX and XXXX. INTERVENTIONS: The alignment group underwent maxillary expansion with incisors alignment while the non-alignment group underwent only maxillary expansion for presurgical orthodontic preparation. METHODS: Initial and post-surgical CBCT scans were compared to observe changes in angulation of the incisor adjacent to the cleft site, alveolar bony root coverage, and bone graft outcomes. RESULTS: In the alignment group, the buccolingual rotation decreased by 32.35 degrees (p = .0002), the anteroposterior inclination increased by 14.01 degrees (p = .0004), and the mesiodistal angulation decreased by 17.88 degrees (p = .0001). Alveolar bony coverage did not change after bone graft in both groups, and no difference was observed between the groups. Chelsea scale showed satisfactory bone graft outcome (category A, C) in 12 cases (85.71%) in the alignment group and 11 cases (78.51%) in the non-alignment group. The volumetric measurement showed the alignment group had better bone fill of 69.85% versus 51.45% in the non-alignment group (p = .0495). CONCLUSIONS: Alveolar bony coverage on the tooth adjacent to cleft sites did not change with alveolar bone grafting surgery in either of the alignment and non-alignment group. Presurgical orthodontic alignment does not induce root exposure nor poorer bone grafting outcome.

Three-dimensional Analysis of the Temporal Bone Morphology in Patients with Craniofacial Microsomia.

OBJECTIVE: To characterise the morphology of temporal bone in patients with craniofacial microsomia (CFM). DESIGN: A retrospective study. SETTING: A craniofacial centre. PATIENTS: Ninety-four patients with unilateral craniofacial microsomia. INTERVENTIONS: Mimics 21.0 (Materialise Inc., Belgium) was used to locate temporal bone landmarks on preoperative computed tomography data. The spatial Cartesian coordinate system was established in 3-matic 13.0 (Materialise Inc., Belgium). The coordinates of each landmark and the distances and angles between the landmarks were calculated. A classification system was used to quantify the severity of the zygomatic arch deformity. MAIN OUTCOME MEASURE(S): The bilateral differences in coordinates, linear and angular measurements, and the severity of temporal bone deformity (TTL δ, Psag δ, Paxiδ, and Tsag δ) among the groups were compared using the paired t-test and Kruskal-Wallis test, respectively. RESULTS: Compared to those of the unaffected side, the landmarks of the inner ear and petrous part on the affected side showed a decrease in the Z-coordinate or an increase in the X-coordinate. A superolateral rotation tendency of the temporal bone on the affected side was found. There were no significant differences in the linear and angular measurements between the groups. The degree of zygomatic arch deformation was lower in the mild group; however, no significant difference was found between the moderate and severe groups. CONCLUSIONS: In patients with CFM, asymmetry of the temporal bone and its inner organs (vestibulocochlear organ, facial nerve, and vessels) exists in multiple dimensions; its severity is not completely consistent with the degree of mandibular involvement.

Cortical Bone Thickness and Morphology at the Infrazygomatic Crest Area in Growing Thai Patients with UCLP: A CBCT Study.

OBJECTIVES: To determine and compare buccal cortical bone thickness and morphology (in terms of shape and height) at the infrazygomatic (IZ) crest in growing Thai patients with unilateral cleft lip and palate (UCLP) using cone-beam computed tomography (CBCT) with the ultimate goal of identifying potential sites that are suitable for the placement of miniplates. DESIGN: Prospective study. SETTLING: Institutional research. PATIENTS: Twenty-four Thai patients with non-syndromic complete UCLP with Class III skeletal discrepancy aged 10-14 years. INTERVENTIONS: A total of 48 CBCT images captured the IZ crest. Five horizontal and six vertical reference planes were established in the IZ crest area. MAIN OUTCOME MEASURE: The mean buccal cortical bone thickness of the cleft and non-cleft sides were 1.13 ± 0.45 mm and 1.15 ± 0.46 mm, respectively. The most frequently observed shape for the IZ crest was the external concave contour. There were no statistically significant differences in cortical bone thickness and shape distribution between the cleft and non-cleft sides. (P > .05). RESULTS: The thickness of the buccal cortical bone increased anteriorly and superiorly from V + 0 and H + 0. The average height of IZ crest on the cleft side was 16.20 ± 1.59 mm and 16.78 ± 1.84 mm on the non-cleft side. Notably, significant differences were detected in terms of height between the cleft and non-cleft side and cortical bone thickness by gender (P < .05). CONCLUSIONS: The IZ crest was found to provide sufficient support for the insertion of a miniplate, particularly in the superior and anterior regions, ensuring primary stability in growing Thai patients with UCLP.

The effect of spanning external fixation on entrapped structures in tibial pilon fractures.

PURPOSE: Pilon fractures are often complex injuries involving severe soft tissue injury. Studies have shown pilon fractures may entrap soft tissue structures between fracture fragments. Staged fixation of pilon fractures with spanning external fixation (SEF) is important for soft tissue rest and plays an important role in the management of these injuries. While SEF has been shown to promote soft tissue rest prior to definitive fixation, no studies have shown the effect SEF has on entrapped structures (ES). The purpose of this study was to evaluate how SEF effects ES in pilon fractures. METHODS: A retrospective review of 212 pilon fractures treated at our institution between 2010 and 2022 was performed. Patients with a CT scan pre-SEF and post-SEF met inclusion criteria. CTs were reviewed to characterize ES in pre- and post-SEF imaging. RESULTS: Of the 19 patients with ES identified on CT pre-SEF, seven (36.8%) had full release of ES post-SEF and 12 (63.2%) had no release of ES. The posterior tibial tendon was the most commonly ES and remained entrapped in 62.5% of cases. Only 25% of 43-C3 fractures had release of ES post-SEF, while 100% of 43-C1 and 43-C2 fractures demonstrated complete release of ES post-SEF. CONCLUSION: Entrapped structures in pilon fractures are likely to remain entrapped post-SEF, with only one-third of our cohort demonstrating release. In 43-C3 patterns, if ES are identified on CT pre-SEF, surgeons should consider addressing these either through mini open versus open approaches at the time of SEF as they are likely to remain entrapped post-SEF.

The hyperemesis gravidarum and pulmonary embolism: A case report and review of literature.

Background: Nausea and vomiting occur in more than 70% of pregnant women,1 and only 2% of these females progress into hyperemesis gravidarum (HG).2 HG is the persistent and excessive vomiting before the 22nd week of gestation. HG patients can develop life-threatening electrolyte disturbances or thromboembolism. Pulmonary embolism (PE) is a thromboembolism that blocks and stops blood flow to an artery in the lung. Both HG and PE increase morbidity and mortality in pregnant patients. HG patients developing PE are reported only in two patients with fatal outcomes in the literature. We report a case of PE in a hospitalized HG patient with a better outcome. Case Presentation: A 26-year-old previously healthy gravida 3 and para 2 patient was admitted to the Women Wellness and Research Center with HG at 10 weeks of gestation. She developed nausea and vomiting at 6 weeks of gestation and was treated in the emergency department, where she was started on intravenous (IV) fluids for hydration, an antiemetic, and deltaparin for prevention of deep venous thrombosis (DVT), as she was pregnant and dehydrated. She was on potassium replacement therapy for hypokalemia. The patient was improving; still had vomiting, but less frequent. On day 3, following admission, the patient suddenly developed hemoptysis, chest pain, and palpitation. She was tachycardic (120 bpm) and tachypneic (30 breaths per minute). She was feeling dizzy, and her oxygen saturation (Spo2) was around 95%. Her chest was clear on examination. Computerized tomographic pulmonary angiography showed bilateral PE. She was admitted to the highdependency unit. The patient was tachypneic and tachycardic and required non-invasive ventilation. A therapeutic dose of enoxaparin (1 mg/kg) was started and supplemented with fentanyl plus paracetamol for analgesia, continued IV fluids, and promethazine.Her respiratory symptoms and tachycardia improved by day 6, she was transferred to the ward from there and discharged home by day 10, on enoxaparin therapeutic dose (1 mg/kg), and follow up in outpatient clinics showed no issues, and she is doing fine. Discussion: HG is a severe clinical disease in pregnancy where patients have intractable nausea and vomiting with increased morbidity and even mortality. These patients frequently present with ketonuria, dehydration, electrolyte abnormalities, and a weight loss of 7%. Rarely, these patients' present with severe vitamin deficiency, causing a neurological emergency called Wernicke's encephalopathy. The occurrence of DVT is one of the main risk factors due to prothrombotic conditions in pregnancy in combination with dehydration in these patients. The occurrence of PE is reported in two cases of HG in the post-mortem. Our patient developed bilateral PE, a medical emergency due to immobility, dehydration, and prothrombotic predominance during pregnancy. PE was detected early and managed, leading to a better outcome. Conclusion: HG should be diagnosed early, followed by admission of the patient to the hospital. Our patient with HG was complicated by a rare bilateral PE due to a combination of pregnancy, dehydration, and immobility, despite DVT prophylaxis with a favorable outcome. Clinicians should have an index of suspicion for DVT and PE in these dehydrated pregnant patients. A high index of suspicion, early diagnosis, and management by a multidisciplinary team are key for better outcomes of PE in our HG patient.

The effect of sarcopenia and sarcopenic obesity on survival in gastric cancer.

BACKGROUND: Sarcopenic obesity arises from increased muscle catabolism triggered by inflammation and inactivity. Its significance lies in its role in contributing to morbidity and mortality in gastric cancer. This study aims to explore the potential correlation between sarcopenia, sarcopenic obesity, and gastric cancer, as well as their effect on survival. MATERIALS AND METHODS: This retrospective study included 162 patients aged ≥ 18 years who were diagnosed with stomach cancer. Patient age, gender, diagnostic laboratory results, and cancer characteristics were documented. Sarcopenia was assessed using the skeletal muscle index (SMI) (cm2/m2), calculated by measuring muscle mass area from a cross-sectional image at the L3 vertebra level of computed tomography (CT). RESULTS: Among the 162 patients, 52.5% exhibited sarcopenia (with cut-off limits of 52.4 cm2/m2 for males and 38.5 cm2/m2 for females), and 4.9% showed sarcopenic obesity. Average skeletal muscle area (SMA) was 146.8 cm2; SMI was 50.6 cm2/m2 in men and 96.9 cm2 and 40.6 cm2/m2 in women, respectively. Sarcopenia significantly reduced mean survival (p = 0.033). There was no association between sarcopenic obesity and mortality (p > 0.05), but mortality was higher in sarcopenic obesity patients (p = 0.041). Patient weight acted as a protective factor against mortality, supporting the obesity paradox. Tumor characteristics, metabolic parameters, and concurrent comorbidities did not significantly impact sarcopenia or mortality. CONCLUSION: Sarcopenia is more prevalent in the elderly population and is linked to increased mortality in gastric cancer patients. Paradoxically, higher body mass index (BMI) was associated with improved survival. Computed tomography offers a practical and reliable method for measuring muscle mass and distinguishing these distinctions. TRIAL REGISTRATION: This study was approved by Istanbul Training and Research Hospital Clinical Research Ethics Committee of the University of Health Sciences (29.05.2020/2383).

Transient ischemic attack due to dynamic evolution of carotid artery web.

Carotid artery web (CaW) is a rare focal fibromuscular dysplasia, which is an underappreciated risk factor for transient ischemic attack. This case illustrates the dynamic evolution of secondary thrombus and plaque in CaW, and the importance of carotid doppler ultrasound in early detection and follow-up.

Association of medical tests use with care continuity in primary care service: evidence from the Department of Veterans Affairs.

BACKGROUND: Continuity of care (CoC) is an important component of health care delivery that can have cost implications and improve patient outcomes. We analysed data obtained from the Department of Veterans Affairs to examine the relationship between CoC and use of image-oriented diagnostic tests in patients with comorbid chronic conditions. METHODS: A longitudinal, retrospective cohort study involving participants ≥18 years old, with comorbid diabetes and chronic kidney disease. We used a multivariate linear regression model to test whether greater care continuity, measured using a care continuity index (CCI), is associated with less frequent use of diagnostic tests. RESULTS: Total of 267,442 patients and 8,142,036 tests were included. Of the diagnostic tests we chose to evaluate, the 4 most frequently ordered tests were X-ray (45.6%), electrocardiogram (EKG, 16.8%), computerized tomography (CT, 13.4%), and magnetic resonance imaging (MRI, 3.4%). Overall, greater CCI was associated with fewer use of tests (P < 0.001). A 1 standard deviation (SD, 0.27) increase in CCI was associated with 4.2% decrease (P < 0.001) in number of tests. But a mixed pattern existed. For X-ray and EKG, greater continuity was associated with less testing, 6.2% (P < 0.001) and 3.3% (P < 0.05) reductions, respectively. Whereas, for CT and MRI, greater continuity was associated with more testing, 2.3% (P < 0.001) and 1.4% increases (P < 0.01), respectively. CONCLUSION: Overall, greater CoC was associated with fewer use of tests, representing a greater presumed efficiency of care. This has implications for designing health care delivery.

Goldenhar syndrome complicated with subglottic airway stenosis: a case report.

BACKGROUND: Goldenhar syndrome is a congenital disease that involves an absence or underdevelopment of structures that arise from the first and second pharyngeal arches and more or less severe extracranial anomalies. A variety of supraglottic malformations may be observed, including mandibular hypoplasia, mandibular asymmetry and micrognathia. Subglottic airway stenosis (SGS), which can cause difficulties in airway management during the perioperative period, is seldom emphasized in literature descriptions of Goldenhar syndrome, but can be clinically significant. CASE PRESENTATION: An 18-year-old female with a history of Goldenhar syndrome presented for placement of a right mandibular distractor, right retroauricular dilator, and stage I transfer of a prefabricated expanded flap under general anesthesia. During tracheal intubation, the endotracheal tube (ETT) met resistance unexpectantly when attempting to pass through the glottis. Subsequently, we attempted the procedure with a smaller size ETT but again met resistance. With fiberoptic bronchoscope, we found that the whole segment of the trachea and bilateral bronchi were obvious narrow. Given the finding of unexpected severe airway stenosis and the associated risks with proceeding with the surgery, the operation was cancelled. We removed the ETT once the patient was fully awake. CONCLUSIONS: Anesthesiologists should be aware of this clinical finding when evaluating the airway of a patient with Goldenhar syndrome. Coronal and sagittal measurements on computerized tomography (CT) and three-dimensional image reconstruction can be used to evaluate the degree of subglottic airway stenosis and measure the diameter of the trachea.

Postoperative D-dimer levels predict venous thromboembolisms detected with contrast-enhanced computerized tomography in patients undergoing anterior cruciate ligament reconstruction.

BACKGROUND: In the literature, factors associated with postoperative venous thromboembolisms (VTEs) after anterior cruciate ligament reconstruction (ACLR) are limited. This study aimed to investigate the incidence of venous thromboembolisms (VTEs) after anterior cruciate ligament reconstruction (ACLR) and to identify risk and predictive factors for VTEs. METHODS: This retrospective study included 136 patients who underwent arthroscopic ACLR with mechanical prophylaxis between April 2012 and July 2022. Contrast-enhanced computed tomography (CT) was applied to detect VTEs comprising deep venous thromboses and pulmonary embolisms 7 days after surgery. Data including age, sex, body mass index, concomitant treatments, graft types, smoking status, operative and tourniquet times, postoperative D-dimer levels, and other laboratory test results, were collected for analyses. The incidence of radiographically confirmed VTEs and the associated risk factors, such as age, sex, body mass index, concomitant treatments, graft types, smoking status, operative and tourniquet times, postoperative D-dimer levels, and other laboratory test results, were analyzed. RESULTS: The overall incidence of radiographic VTEs was 11.0% (15 cases) in 136 patients. There was one symptomatic patient who had Homan's sign. Multivariable analysis indicated that postoperative D-dimer level was an independent factor related to a radiographic VTE after ACLR, although there was no association between radiographic VTEs and preoperative status or operation status. The optimal cutoff value for postoperative D-dimer level was 2.8 µg/ml according to the receiver operating characteristic curve analysis, with a sensitivity of 80.0% and specificity of 83.5%. CONCLUSION: The incidence of ACLR-associated radiographical VTEs (deep venous thrombosis and pulmonary embolism) under mechanical prophylaxis was 11.0% in this study. An elevated D-dimer level at 7 days after surgery is an independent predictor of VTE in patients undergoing ACLR. The postoperative D-dimer level is a more reliable marker for identifying VTE in patients who underwent ACLR.

Neuromonitoring in Children with Cerebrovascular Disorders.

BACKGROUND: Cerebrovascular disorders are an important cause of morbidity and mortality in children. The acute care of a child with an ischemic or hemorrhagic stroke or cerebral sinus venous thrombosis focuses on stabilizing the patient, determining the cause of the insult, and preventing secondary injury. Here, we review the use of both invasive and noninvasive neuromonitoring modalities in the care of pediatric patients with arterial ischemic stroke, nontraumatic intracranial hemorrhage, and cerebral sinus venous thrombosis. METHODS: Narrative review of the literature on neuromonitoring in children with cerebrovascular disorders. RESULTS: Neuroimaging, near-infrared spectroscopy, transcranial Doppler ultrasonography, continuous and quantitative electroencephalography, invasive intracranial pressure monitoring, and multimodal neuromonitoring may augment the acute care of children with cerebrovascular disorders. Neuromonitoring can play an essential role in the early identification of evolving injury in the aftermath of arterial ischemic stroke, intracranial hemorrhage, or sinus venous thrombosis, including recurrent infarction or infarct expansion, new or recurrent hemorrhage, vasospasm and delayed cerebral ischemia, status epilepticus, and intracranial hypertension, among others, and this, is turn, can facilitate real-time adjustments to treatment plans. CONCLUSIONS: Our understanding of pediatric cerebrovascular disorders has increased dramatically over the past several years, in part due to advances in the neuromonitoring modalities that allow us to better understand these conditions. We are now poised, as a field, to take advantage of advances in neuromonitoring capabilities to determine how best to manage and treat acute cerebrovascular disorders in children.