Small ruptured cerebral aneurysms-do they rupture on formation or not?

PURPOSE: Of patients presenting with subarachnoid haemorrhage, most are due to rupture of a small aneurysm. It has been postulated that in most cases, these aneurysms form and rupture rapidly over a short period of time of days to weeks. We evaluated the hypothesis that such aneurysms therefore should never be discoverable as a pre-existing condition on medical imaging studies. METHODS: All patients presenting with subarachnoid haemorrhage due to a small cerebral aneurysm over an 11-year period were reviewed for prior imaging studies capable of detecting small aneurysms. In the subgroup that had such imaging studies, these were reviewed for the presence or absence of the index aneurysm. RESULTS: Of 851 patients presenting with subarachnoid haemorrhage over an 11-year period, 35 had prior imaging studies capable of detecting small aneurysms. In 18 out of these 35 (51%) patients, the index aneurysm was identified as a small unruptured aneurysm on these prior studies. The median time between prior imaging and aneurysm rupture was 31 months. CONCLUSION: The theory that nearly all cases of subarachnoid haemorrhage due to small aneurysms occur as a result of aneurysm formation, and rupture over a short time period is incorrect. Our findings indicate that at least half of all subarachnoid haemorrhage cases arise from the population harbouring small aneurysms as a pre-existing condition.

Successful cerebral intravascular thrombectomy stops the heart stopping.

A 65-year-old man presented with an acute ischaemic stroke due to right posterior cerebral artery occlusion, complicated by episodes of sinus arrest in the absence of intrinsic cardiac disease. His neurological deficits and sinus node dysfunction resolved following mechanical thrombectomy. We believe this to be a novel case where thrombectomy resulted in successful treatment of cerebral ischaemia mediated cardiac autonomic dysfunction.

Impact of Body Temperature Before and After Endovascular Thrombectomy for Large Vessel Occlusion Stroke.

Background and Purpose- In ischemic stroke, body temperature is associated with functional outcome. However, the relationship between temperature and outcome may differ in the intraischemic and postischemic phases of stroke. We aimed to determine whether body temperature before or after endovascular thrombectomy (EVT) for large vessel occlusion stroke is associated with clinical outcomes. Methods- Consecutive EVT patients were identified from a prospective registry. Temperature measurements within 24 hours of admission were stratified into pre-EVT (preprocedural and intraprocedural) and post-EVT measurements, which served as surrogates for the intraischemic and postischemic phases of large vessel occlusion stroke, respectively. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0, 1, or 2 at 3 months. Secondary outcomes included the ordinal shift of modified Rankin Scale scores at 3 months, symptomatic intracerebral hemorrhage, and mortality at 3 months. Results- Four hundred thirty-two participants were included (59% men, mean±SD age 65.6±15.7 years). Multivariable logistic regression demonstrated that higher median pre-EVT temperature (per 1°C increase) was an independent predictor of reduced functional independence (odds ratio [OR], 0.66 [95% CI, 0.46-0.94]; P=0.02), poorer modified Rankin Scale scores (common OR, 1.42 [95% CI, 1.08-1.85]; P=0.01), and increased mortality (OR, 1.65 [95% CI, 1.02-2.69]; P=0.04). Peak post-EVT temperature (per 1°C increase) was a significant predictor of elevated modified Rankin Scale scores (common OR, 1.39 [95% CI, 1.03-1.90]; P=0.03) and higher mortality (OR, 1.66 [95% CI, 1.04-2.67]; P=0.03). Conclusions- In patients with large vessel occlusion stroke treated with EVT, higher body temperatures during both the intraischemic and postischemic phases were associated with poorer clinical outcomes. Future research investigating the maintenance of normothermia or therapeutic hypothermia in patients needing to be transferred from primary to EVT-capable stroke centers could be considered.

Vertebrobasilar Artery Calcification and Outcomes in Posterior Circulation Large Vessel Occlusion Thrombectomy.

Background and Purpose- Intracranial carotid artery calcification is associated with worse outcome in anterior circulation stroke patients who undergo endovascular thrombectomy. We investigated the association between vertebrobasilar artery calcification (VBAC) and outcome in patients undergoing endovascular thrombectomy for posterior circulation large vessel occlusion. Methods- Consecutive patients treated for posterior circulation large vessel occlusion from a prospective single-center registry were studied. VBAC was manually segmented on computed tomography brain scans. The associations between VBAC and VBAC volume, functional independence (90-day modified Rankin Scale score of 0-2), and 90-day mortality were assessed using propensity score-adjusted logistic regression. Results- Sixty-four posterior circulation large vessel occlusion patients were included. Twenty-five (39.1%) patients had VBAC, and of these, the median (interquartile range) VBAC volume was 19.8 (6.65-23.4) mm3. VBAC was associated with reduced functional independence (OR, 0.19 [95% CI, 0.04-0.78]; P=0.03) and increased mortality (OR, 9.44 [95% CI, 2.43-36.62]; P=0.005). Larger VBAC volumes were a significant predictor of reduced functional independence and increased mortality. Conclusions- VBAC is an independent predictor of outcome in patients undergoing endovascular thrombectomy for posterior circulation large vessel occlusion. Considering the presence of VBAC might improve prognostication and shared treatment decision-making between patients, families, and physicians.

Imaging in acute ischaemic stroke: pearls and pitfalls.

Prompt and accurate diagnosis is the foundation of acute ischaemic stroke care. Multiple positive endovascular thrombectomy trials in ischaemic stroke patients with large vessel occlusions have further emphasised this but also added complexity to treatment decisions. CT angiography is now routine for patients who present with an acute stroke syndrome around the world. Members of the neurology and stroke teams (rather than radiologists) are often the first doctors to lay eyes on the CT images and are best equipped to integrate the clinical picture with the imaging findings. A sound understanding of acute stroke imaging is therefore essential for clinicians who work with acute stroke patients. This review describes some pearls we have gleaned from our own experience in acute stroke imaging as well as some potential follies to be avoided.

An analysis of near misses identified by anesthesia providers in the intensive care unit.

BACKGROUND: Learning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and system weaknesses not identified by other providers, and may differ in character and causality from near misses in other anesthesia locations. METHODS: We analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We compared causative mechanisms of ICU near misses with near misses in other anesthesia locations. RESULTS: A total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal mechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses from the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be associated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated with equipment issues (23 % vs. 48 %, p = 0.02). CONCLUSIONS: A limited number of causal mechanisms explained the majority of ICU near misses, providing targets for quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist consultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the ICU patient safety movement.

Flow reversal during stroke thrombectomy.

When performing mechanical thrombectomy for stroke patients, some physicians use balloon guide catheters (BGCs) in order to achieve flow reversal and thereby improve reperfusion quality. There is substantial evidence favoring the use of BGCs to improve reperfusion rates and clinical outcomes for thrombectomy patients; however, as we will outline in this review, there is also evidence that BGCs do not achieve reliable flow reversal in many circumstances. Therefore, if we are able to modify our techniques to improve the likelihood of flow reversal during thrombectomy maneuvers, we may be able to further improve reperfusion quality and clinical outcomes. This paper provides an overview of concepts on this topic and outlines some potential techniques to facilitate flow reversal more consistently, including a method to visually confirm it, with the aim of making iterative improvements towards optimal reperfusion for stroke patients.

Validation of an axially distributed model for quantification of myocardial blood flow using ¹³N-ammonia PET.

BACKGROUND: Estimation of myocardial blood flow (MBF) with cardiac PET is often performed with conventional compartmental models. In this study, we developed and evaluated a physiologically and anatomically realistic axially distributed model. Unlike compartmental models, this axially distributed approach models both the temporal and the spatial gradients in uptake and retention along the capillary. METHODS: We validated PET-derived flow estimates with microsphere studies in 19 (9 rest, 10 stress) studies in five dogs. The radiotracer, (13)N-ammonia, was injected intravenously while microspheres were administered into the left atrium. A regional reduction in hyperemic flow was forced by an external occluder in five of the stress studies. The flow estimates from the axially distributed model were compared with estimates from conventional compartmental models. RESULTS: The mean difference between microspheres and the axially distributed blood flow estimates in each of the 17 segments was 0.03 mL/g/minute (95% CI [-0.05, 0.11]). The blood flow estimates were highly correlated with each regional microsphere value for the axially distributed model (y = 0.98x + 0.06 mL/g/minute; r = 0.74; P < .001), for the two-compartment (y = 0.64x + 0.34; r = 0.74; P < .001), and for three-compartment model (y = 0.69x + 0.54; r = 0.74; P < .001). The variance of the error of the estimates is higher with the axially distributed model than the compartmental models (1.7 [1.3, 2.1] times higher). CONCLUSION: The proposed axially distributed model provided accurate regional estimates of MBF. The axially distributed model estimated blood flow with more accuracy, but less precision, than the evaluated compartmental models.

Diagnostic performance of resting CT myocardial perfusion in patients with possible acute coronary syndrome.

OBJECTIVE: Coronary CT angiography has high sensitivity, but modest specificity, to detect acute coronary syndrome. We studied whether adding resting CT myocardial perfusion imaging improved the detection of acute coronary syndrome. SUBJECTS AND METHODS: Patients with low-to-intermediate cardiac risk presenting with possible acute coronary syndrome received both the standard of care evaluation and a research thoracic 64-MDCT examination. Patients with an obstructive (> 50%) stenosis or a nonevaluable coronary segment on CT were diagnosed with possible acute coronary syndrome. CT perfusion was determined by applying gray and color Hounsfield unit maps to resting CT angiography images. Adjudicated patient diagnoses were based on the standard of care and 3-month follow-up. Patient-level diagnostic performance for acute coronary syndrome was calculated for coronary CT, CT perfusion, and combined techniques. RESULTS: A total of 105 patients were enrolled. Of the nine (9%) patients with acute coronary syndrome, all had obstructive CT stenoses but only three had abnormal CT perfusion. CT perfusion was normal in all other patients. To detect acute coronary syndrome, CT angiography had 100% sensitivity, 89% specificity, and a positive predictive value of 45%. For CT perfusion, specificity and positive predictive value were each 100%, and sensitivity was 33%. Combined cardiac CT and CT perfusion had similar specificity but a higher positive predictive value (100%) than did CT angiography. CONCLUSION: Resting CT perfusion using CT angiographic images may have high specificity and may improve CT positive predictive value for acute coronary syndrome without added radiation and contrast. However, normal resting CT perfusion cannot exclude acute coronary syndrome.

Transgenic expression and purification of myosin isoforms using the Drosophila melanogaster indirect flight muscle system.

Biophysical and structural studies on muscle myosin rely upon milligram quantities of extremely pure material. However, many biologically interesting myosin isoforms are expressed at levels that are too low for direct purification from primary tissues. Efforts aimed at recombinant expression of functional striated muscle myosin isoforms in bacterial or insect cell culture have largely met with failure, although high level expression in muscle cell culture has recently been achieved at significant expense. We report a novel method for the use of strains of the fruit fly Drosophila melanogaster genetically engineered to produce histidine-tagged recombinant muscle myosin isoforms. This method takes advantage of the single muscle myosin heavy chain gene within the Drosophila genome, the high level of expression of accessible myosin in the thoracic indirect flight muscles, the ability to knock out endogenous expression of myosin in this tissue and the relatively low cost of fruit fly colony production and maintenance. We illustrate this method by expressing and purifying a recombinant histidine-tagged variant of embryonic body wall skeletal muscle myosin II from an engineered fly strain. The recombinant protein shows the expected ATPase activity and is of sufficient purity and homogeneity for crystallization. This system may prove useful for the expression and isolation of mutant myosins associated with skeletal muscle diseases and cardiomyopathies for their biochemical and structural characterization.

An audit of the use of CT pituitary scans to exclude a pituitary macroadenoma.

BACKGROUND: Pituitary imaging is often required to exclude an adenoma suspected clinically or biochemically. Although magnetic resonance (MR) is the gold standard, computerised tomography (CT) is faster, cheaper and induces less claustrophobia. Our audit at Auckland City Hospital, New Zealand, investigated whether the use of CT of the pituitary as the first line imaging to assess for a pituitary macroadenoma reduces the need for MR. METHODS: We investigated the usefulness of CT pituitary imaging in the exclusion of pituitary macroadenoma between 2012 and 2020. A re-audit was then undertaken for a period of one year between March 2021 and March 2022 to assess outcomes once a departmental policy change was implemented. At Auckland City Hospital, 32 patients across eight years were eligible for this analysis, of which 31 had data available. In our re-audit, 29 patients were eligible for this analysis. We collected data on patient demographics, relevant hormone levels, indication for imaging and imaging results and subsequent management. RESULTS: After CT pituitary imaging, 28/31 (90%) of patients did not require further imaging because the clinical question had been addressed. One year after routine initial CT pituitary imaging was implemented by the Auckland City Hospital Endocrinology Department, 29 CT pituitary scans were performed to exclude a pituitary macroadenoma. Of these patients one required further imaging due to the finding of an expanded pituitary sella but not a pituitary macroadenoma. CONCLUSION: CT pituitary imaging to exclude a pituitary macroadenoma is a useful test that may reduce the need for MR pituitary scans. TRIAL REGISTRATION: Not applicable. This was an audit as defined by the New Zealand National Ethics Advisory Committee guidelines. Please see 'Declarations' section.

Data to Action: Community-Based Participatory Research to Address Concerns about Metal Air Pollution in Overburdened Neighborhoods near Metal Recycling Facilities in Houston.

BACKGROUND: Exposures to environmental contaminants can be influenced by social determinants of health. As a result, persons living in socially disadvantaged communities may experience disproportionate health risks from environmental exposures. Mixed methods research can be used to understand community-level and individual-level exposures to chemical and nonchemical stressors contributing to environmental health disparities. Furthermore, community-based participatory research (CBPR) approaches can lead to more effective interventions. OBJECTIVES: We applied mixed methods to identify environmental health perceptions and needs among metal recyclers and residents living in disadvantaged neighborhoods near metal recycling facilities in Houston, Texas, in a CBPR study, Metal Air Pollution Partnership Solutions (MAPPS). Informed by what we learned and our previous findings from cancer and noncancer risk assessments of metal air pollution in these neighborhoods, we developed an action plan to lower metal aerosol emissions from metal recycling facilities and enhance community capacity to address environmental health risks. METHODS: Key informant interviews, focus groups, and community surveys were used to identify environmental health concerns of residents. A diverse group from academia, an environmental justice advocacy group, the community, the metal recycling industry, and the local health department collaborated and translated these findings, along with results from our prior risk assessments, to inform a multifaceted public health action plan. RESULTS: An evidence-based approach was used to develop and implement neighborhood-specific action plans. Plans included a voluntary framework of technical and administrative controls to reduce metal emissions in the metal recycling facilities, direct lines of communication among residents, metal recyclers, and local health department officials, and environmental health leadership training. DISCUSSION: Using a CBPR approach, health risk assessment findings based on outdoor air monitoring campaigns and community survey results informed a multipronged environmental health action plan to mitigate health risks associated with metal air pollution. https://doi.org/10.1289/EHP11405.

Improved catheter delivery for aspiration thrombectomy using Tenzing 7 ledge reducing catheter and FreeClimb 70.

PURPOSE: Previous comparative mechanical thrombectomy device trials reported a substantial crossover rate from first-line aspiration to stent-retriever thrombectomy. A specialized delivery catheter may help track large-bore aspiration catheters to target occlusions. We report our multicenter experience of aspiration thrombectomy of intracranial large vessel occlusions using the FreeClimbTM 70 and Tenzing® 7 delivery catheter (Route 92, San Mateo, CA). METHODS: After local Institutional Review Board approval, we retrospectively reviewed the clinical, procedural, and imaging data of patients who underwent mechanical thrombectomy with the FreeClimb 70 and Tenzing 7. RESULTS: FreeClimb 70 was successfully delivered using Tenzing 7 to target occlusion in 30/30 (100%) patients (18 M1, 6 M2, 4 ICA-terminus, and 2 basilar artery occlusions), without the use of a stent-retriever for anchoring. In 21/30 (70%) cases, a leading microwire was not needed to advance the Tenzing 7 to the target. Median (interquartile range) time from groin puncture to first pass was 12 (interquartile range 8-15) minutes. Overall first pass effect, or first pass effect (modified thrombolysis in cerebral ischemia 2C-3), was achieved 16/30 (53%). For M1 occlusions, first pass effect was 11/18 (61%). Successful reperfusion (modified thrombolysis in cerebral ischemia ≥ 2B) was achieved in 29/30 (97%) cases after a median of 1 pass (interquartile range 1-3). Median groin puncture to reperfusion time was 16 (interquartile range 12-26) minutes. There were no procedural complications or symptomatic intracranial hemorrhage. Average improvement in National Institutes of Health Stroke Scale at discharge was 6.6 ± 7.1. There were three patient deaths (renal failure, respiratory failure, and comfort care). CONCLUSIONS: Initial data support the use of Tenzing 7 with FreeClimb 70 catheter for reliable access to rapid, effective, and safe aspiration thrombectomy of large vessel occlusions.

Selective improvement in Seattle Heart Failure Model risk stratification using iodine-123 meta-iodobenzylguanidine imaging.

BACKGROUND: The Seattle Heart Failure Model (SHFM) is a multivariable model that uses demographic and clinical markers to predict survival in patients with heart failure. Inappropriate activation of the sympathetic nervous system, which contributes to the progression of heart failure and increased mortality, can be assessed using iodine-123 meta-iodobenzylguanidine (MIBG) cardiac imaging. This study investigated the incremental value of MIBG cardiac imaging when added to the SHFM for prediction of all-cause mortality. METHODS: Survival data from 961 NYHA II-III subjects in the ADMIRE-HFX trial were included in this analysis. The predictive value of the SHFM alone and in combination with MIBG heart-to-mediastinum ratio (H/M) was compared for all-cause mortality (101 deaths during a median follow-up of 2 years). RESULTS: The addition of H/M to the SHFM in a Cox model significantly improved risk prediction (P < .0001), with a greater utility in higher risk SHFM patients. The observed 2-year mortality in the highest-risk SHFM subjects (rounded SHFM score of 1) was 24%, but varied from 46% with H/M <1.2 to 0% with H/M >1.8. Net reclassification improvement was 22.7% (P < .001), with 14.9% of subjects who died reclassified into a higher risk category than suggested by SHFM score alone (P = .01) and 7.9% of subjects who survived reclassified into a lower risk category (P < .0001). The 2-year integrated discrimination improvement (+4.14%, P < .0001) and the 1-year area under the receiver-operator characteristic curve (+0.04, P = .026) both showed significant improvement for the combined model with H/M compared to the SHFM alone. CONCLUSION: The addition of MIBG imaging to the SHFM improves risk stratification, especially in higher risk patients. MIBG may have clinical utility in higher risk patients who are being considered for devices such as ICD, CRT-D, LVAD, and cardiac transplantation.

Hemoglobin desaturation after propofol/remifentanil-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers.

BACKGROUND: In an earlier study investigating the "can't ventilate/can't intubate" clinical scenario, induction of anesthesia with thiopental 5 mg/kg and succinylcholine 1.0 mg/kg was associated with a significant risk of hemoglobin desaturation. It appeared that succinylcholine-induced apnea was responsible for the prolonged apnea. Our hypothesis was that using propofol and remifentanil for tracheal intubation might avoid prolonged apnea and subsequent desaturation attributable to muscle relaxation. METHODS: Twenty-four healthy volunteers ages 18 to 45 years participated. After oxygen administration to end-tidal oxygen >90%, volunteers received 2 mg/kg propofol and remifentanil either 2 mcg/kg (group 1; n = 12) or 1.5 mcg/kg (group 2; n = 12). Oxygen saturation (SpO(2)) was measured at a finger, an ear lobe, and the forehead. If SpO(2) decreased below 80%, volunteers received chin lift and, if persistent, assisted ventilation. RESULTS: Desaturation (SpO(2) < 80%) occurred in 5 volunteers: 4 in the higher remifentanil dose (2 mcg/kg) group and 1 in the lower dose (1.5 mcg/kg) group. Chin lift and assisted ventilation was necessary in 3 volunteers. The lowest SpO(2) was 82.4 ± 10.5 (mean ± SD) in the higher-dose group vs. 92.4 ± 8.6 with the lower dose of remifentanil (P = 0.019). Apnea time was shorter (P = 0.0093) with the lower dose (4.7 ± 1.5) than with the higher dose of remifentanil (6.1 ± 1.0). Conditions for intubation were excellent or acceptable in 11 volunteers (92%; 95% confidence interval [CI], 65%-99%) in the higher-dose group, and in 8 (67%; 95% CI, 39%-86%) with the lower dose. CONCLUSIONS: Administered with propofol 2 mg/kg, the remifentanil dose necessary to produce acceptable intubating conditions, 2 mcg/kg, produces apnea that carries a significant risk of desaturation, whereas a remifentanil dose of 1.5 mcg/kg does not reliably produce acceptable intubating conditions and does not eliminate the risk of desaturation.

Hematological and immunological responses to naturally occurring bovine respiratory disease in newly received beef calves in a commercial stocker farm.

The objective was to determine temporal changes in hematological and immune parameters in response to naturally occurring bovine respiratory disease (BRD) in commercially managed stocker calves. Forty newly weaned beef steers purchased from auction markets were housed at a commercial stocker operation in Crossville, TN. Blood samples, rectal temperature, and thoracic ultrasonography (TUS; 1: normal to 3: severe) were collected on days 0, 7, 14, and 21. Castration status (FC: freshly castrated; PC: previously castrated) was determined on arrival based on presence of a fresh castration site at the scrotum. Calves received antibiotics for BRD based on clinical severity scoring (CSS; 0: moribund, 4: moribund) and rectal temperature. Complete blood counts (CBC) were performed. Calves were categorized based on the number of treatments (NumTrt) received (0x, 1x, and 2x). Temporal variations in CBC and immune parameters were analyzed using mixed model repeated measure ANOVA (Proc GLIMMIX; SAS 9.4). Variation of CBCs and immune parameters based on TUS was determined using mixed model ANOVA. There was a NumTrt by day interaction effect on the responses of white blood cells (WBC) (P = 0.04) and haptoglobin (HPT) (P = 0.04). On day 21, WBC were greater in the 2x NumTrt group than other groups, but there were no differences in WBC between NumTrt levels on other days. Haptoglobin was greater in the 2x group on days 14 and 21 than 0x or 1x. Red blood cells (RBC) (P = 0.02) and WBC (P = 0.04) differed between FC and PC groups, and lower RBC and WBC were observed in the FC group. A castration status × day effect for mean corpuscular volume (MCV; P = 0.04) was observed where FC group had higher MCV at days 14 and 21 than the PC group. Tumor necrosis factor-α differed based on NumTrt (P = 0.03) and higher concentrations were found in 2x group. We observed a day effect for IL-1ß (P = 0.009) and TNF-α (P = 0.001). Significant effect of TUS on HPT at day 14 (P = 0.0004) and day 21 (P = 0.002) was observed. Combining HPT and platelet explained 15% of the variability in treatment status on a given day, whereas HPT and hemoglobin explained 10% of the variability in lung consolidation status. Although hematological and immunological parameters varied largely in our study, the potential of combining HPT with hematological variables should be studied further. Results from this study would help in understanding temporal changes in CBC and immune parameters in newly received stocker cattle.

Blood and immune parameters are altered during bovine respiratory disease (BRD) progression and can be used for predicting disease status. We aimed looking at the dynamics of hematology and immunology in newly received stocker cattle in naturally occurring BRD. Forty newly received stocker cattle were managed by a local producer and monitored for BRD occurrence for 21 d after receiving during the high-risk period. Newly weaned calves were monitored as they experience several stress factors and become prone to BRD. Additionally, there are limited data related to immunological changes that occur in high-risk stocker cattle. Since there is no perfect diagnostic test for BRD, the diagnosis of BRD is likely missed when only visual signs are used. We observed that haptoglobin (HPT) was the most important parameter to differentiate BRD severity. The combination of HPT with blood parameters (hemoglobin and platelets) was useful to predict treatment and lung infection status. Therefore, measuring hematological and immunological parameters might be helpful to determine BRD status and facilitate treatment decisions in newly received stocker cattle.

Bilateral ptosis/blepharitis due to lepromatous leprosy.

PURPOSE: To underscore the importance of histopathological evaluation in cases presenting with a constellation of unusual ocular inflammation and physical findings. OBSERVATION: A 51-year-old male, presented with a chief complaint of worsening visual field loss due to droopy eyelids two months post excision of a right upper eyelid squamous cell carcinoma. His past medical history included chronic edematous facial features, chronic sinusitis, unexplained peripheral neuropathy, and worsening fatigue. Pre-blepharoplasty work-up revealed mechanical ptosis from lid edema, madarosis, a concave nasal bridge, pancytopenia, and numerous burn marks due to inadvertent injuries. Bilateral blepharoplasty was performed, and the excised tissue submitted for histopathological evaluation that revealed non-caseating granulomatous perineural inflammation with numerous acid-fast bacilli in dermal layers and nerves. These findings prompted a diagnosis of lepromatous leprosy with suspected bone marrow involvement. The source of the infection was unknown. The blepharoplasty restored his visual fields and multi-drug therapy (MDT) improved his general health and wellbeing with concomitant reductions of pancytopenia, fatigue, and facial edema. CONCLUSIONS AND IMPORTANCE: Biopsy histopathology, in patients with longstanding ocular adnexal inflammation, can facilitate diagnosis and treatment. To the authors' knowledge, this is an unusual ocular leprosy presentation and represents the first leprosy case diagnosed via blepharoplasty.

Aspiration thrombectomy using a novel 088 catheter and specialized delivery catheter.

BACKGROUND: We describe the first-in-human experience using the Route 92 Medical Aspiration System to perform thrombectomy in the initial 45 consecutive stroke patients enrolled in the SUMMIT NZ trial. This aspiration system includes a specifically designed delivery catheter which enables delivery of 0.070 inch and 0.088 inch aspiration catheters. METHODS: The SUMMIT NZ trial is a prospective, multicenter, single-arm study with core lab imaging adjudication. Patients presenting with acute ischemic stroke from large vessel occlusion are eligible to enrol. The study has had three phases which transitioned from use of the 0.070 inch to the 0.088 inch catheter. RESULTS: Vessel occlusions were located in the internal carotid artery (27%), M1 (60%) and M2 (13%). Median baseline National Institutes of Health Stroke Scale (NIHSS) was 16 (IQR 10). Across the three phases, the first-pass reperfusion rate of modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b was 62% using the Route 92 Medical system; this rate was 29% in phase 1, 56% in phase 2, and 80% in phase 3. The first-pass reperfusion rate of mTICI ≥2c was 42% overall, 29% in phase 1, 33% in phase 2, and 55% in phase 3. A final reperfusion rate of mTICI ≥2b was achieved in 96% of cases, with 36% of cases using adjunctive devices. Patients had an average improvement of 6.7 points in NIHSS from baseline at 24 hours, and at 90 days 48% were functionally independent (modified Rankin Scale 0-2). CONCLUSIONS: In this early experience, the Route 92 Medical Aspiration System has been effective and safe. The system has design features that improve catheter deliverability and have the potential to increase first-pass reperfusion rates in aspiration thrombectomy.

Design and implementation of a near-miss reporting system at a large, academic pediatric anesthesia department.

BACKGROUND: Current incident reporting systems encourage retrospective reporting of morbidity and mortality and have low participation rates. A near miss is an event that did not cause patient harm, but had the potential to. By tracking and analyzing near misses, systems improvements can be targeted appropriately, and future errors may be prevented. METHODS: An electronic, web based, secure, anonymous reporting system for anesthesiologists was designed and instituted at The Children's Hospital, Denver. This portal was compared to an existing hospital incident reporting system. RESULTS: A total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period 1 year ago. CONCLUSION: An anesthesia-specific anonymous near-miss reporting system, which eases and facilitates data entry and can prospectively identify processes and practices that place patients at risk, was implemented at a large, academic, freestanding children's hospital. This resulted in a dramatic increase in reported events and provided data to target and drive quality and process improvement.

Patient factors and outcomes associated with discordance between quantitative and qualitative cardiac PET ischemia information.

BACKGROUND: Cardiac PET can provide quantitative myocardial blood flow (MBF) estimates. The frequency and clinical significance of discordant ischemia information between quantitative and qualitative parameters is unclear. METHODS: This retrospective, cohort study analyzed 256 Rb-82 stress-rest PET/CT studies. Global MBF and myocardial flow reserve (MFR) were estimated in absolute units for quantitative results and sum-stress and difference scores were used for qualitative results. Four groups of patients were evaluated based on a specific definition of concordant and discordant quantitative and qualitative results. RESULTS: 31% of cases demonstrated discordance. Factors associated with microvascular disease were more common in the groups with abnormal quantitative results, regardless of the qualitative findings. Patients with concordant abnormal results had a significantly increased risk of myocardial infarction, heart failure, percutaneous intervention, and all-cause-mortality at 1 year compared to patients with concordant normal results. In patients with discordant results of abnormal quantitative and normal qualitative findings, there was a higher prevalence of heart failure than in controls (12.5% vs 0%, p = 0.01). CONCLUSIONS: Discordance in qualitative and quantitative ischemia measures from PET is common, and further study is needed to clarify its prognostic implications. Moreover, quantitative estimation of MBF and MFR appears to add value to qualitative visual interpretation by supporting qualitative findings when results are concordant. Abnormal quantitative findings, regardless of concordance or discordance with qualitative findings, occurred in patients with risk factors associated with diffuse disease and with increased risk of heart failure admission.