COVID-19 death risk predictors in Brazil using survival tree analysis: a retrospective cohort from 2020 to 2022.

PURPOSE: This study analyses the survival of hospitalized patients with Severe Acute Respiratory Syndrome (SARS) due to COVID-19 and identifies the risk groups for death due to COVID-19 from the identification of potential interactions between its predictors. METHODS: This was a retrospective longitudinal study with data from 1,756,917 patients reported in the Influenza Epidemiological Surveillance Information System from 26 February 2020 to 31 December 2022. In this study, all adult and older (≥ 20 years) patients were hospitalized with SARS due to COVID-19, with death as the outcome. Survival tree analysis was used to identify potential interactions between the predictors. A model was built for each year of study. RESULTS: Hospital lethalitywas 33.2%. The worst survival curve was observed among those who underwent invasive mechanical ventilation and were aged 80 years or older in the three years of the pandemic. Black and brown race/color were predictors of deaths in the years 2020 and 2021 when there was greater demand from the health system due to the greater number of cases. CONCLUSION: By applying survival tree analysis we identified several numbers of homogeneous subgroups with different risks for mortality from COVID-19. These findings show the effects of wide inequalities of access by the population, requiring effective policies for the reduction and adequate management of the disease.

360° around the orbit: key surgical anatomy of the microsurgical and endoscopic cranio-orbital and orbitocranial approaches.

OBJECTIVE: Several pathologies either invade or arise within the orbit. These include meningiomas, schwannomas, and cavernous hemangiomas among others. Although several studies describing various approaches to the orbit are available, no study describes all cranio-orbital and orbitocranial approaches with clear, surgically oriented anatomical descriptions. As such, this study aimed to provide a comprehensive guide to the microsurgical and endoscopic approaches to and through the orbit. METHODS: Six formalin-fixed, latex-injected cadaveric head specimens were dissected in the surgical anatomy laboratory at the authors' institution. In each specimen, the following approaches were modularly performed: endoscopic transorbital approaches (ETOAs), including a lateral transorbital approach and a superior eyelid crease approach; endoscopic endonasal approaches (EEAs), including those to the medial orbit and optic canal; and transcranial approaches, including a supraorbital approach, a fronto-orbital approach, and a 3-piece orbito-zygomatic approach. Each pertinent step was 3D photograph-documented with macroscopic and endoscopic techniques as previously described. RESULTS: Endoscopic endonasal approaches to the orbit afforded excellent access to the medial orbit and medial optic canal. Regarding ETOAs, the lateral transorbital approach afforded excellent access to the floor of the middle fossa and, once the lateral orbital rim was removed, the cavernous sinus could be dissected and the petrous apex drilled. The superior eyelid approach provides excellent access to the anterior cranial fossa just superior to the orbit, as well as the dura of the lesser wing of the sphenoid. Craniotomy-based approaches provided excellent access to the anterior and middle cranial fossa and the cavernous sinus, except the supraorbital approach had limited access to the middle fossa. CONCLUSIONS: This study outlines the essential surgical steps for major cranio-orbital and orbitocranial approaches. Endoscopic endonasal approaches offer direct medial access, potentially providing bilateral exposure to optic canals. ETOAs serve as both orbital access and as a corridor to surrounding regions. Cranio-orbital approaches follow a lateral-to-medial, superior-to-inferior trajectory, progressively allowing removal of protective bony structures for proportional orbit access.

Anesthetic recovery outcomes after 2 methods of nasal mucosal preparation for endoscopic sinus surgery.

PURPOSE: Our institution uses two approaches for nasal mucosal preparation during endoscopic sinus surgery (ESS) to improve surgical field visualization: topical epinephrine (TE) versus topical cocaine with injection of lidocaine containing epinephrine (TCLE). We aimed to compare anesthetic outcomes after ESS using these techniques. METHODS AND MATERIALS: We retrospectively identified adult patients at our institution who underwent ESS from May 2018 through January 2023 under general anesthesia with propofol and remifentanil infusions. Postoperative anesthetic outcomes, including pain and recovery time, were compared between patients who had mucosal preparation with TE versus TCLE using inverse probability of treatment weighting (IPTW) to adjust for potential confounders. RESULTS: Among 1449 patients who underwent ESS, 585 had TE, and 864 had TCLE. Compared with TE, during anesthetic recovery, the TCLE group had fewer episodes of severe pain (numeric pain score ≥ 7) (IPTW-adjusted odds ratio, 0.65; 95 % CI, 0.49-0.85; P = .002), less opioid analgesic administration (IPTW-adjusted odds ratio, 0.55; 95 % CI, 0.44-0.69; P < .001), and shorter recovery room stay (IPTW-adjusted ratio of the geometric mean, 0.90; 95 % CI, 0.85-0.96; P = .002). Postoperative nausea and vomiting and postoperative sedation were similar between groups. CONCLUSIONS: Patients who received preparation of the nasal mucosa with TCLE, compared with TE, were less likely to report severe pain or receive an opioid analgesic in the postanesthesia recovery room and had faster anesthetic recovery. This observation from our large clinical practice indicates that use topical and local anesthetic during endoscopic sinus surgery may have benefit for ambulatory ESS patients.

A Case of Nasoseptal Flap Reconstruction for Refractory Medial Canthal Fistula.

Sino-orbital cutaneous fistulas (SOCFs) are a rare and challenging complication from conditions including granulomatosis with polyangiitis. SOCFs are difficult to manage due to poor vascular supply, compromised tissue, and systemic immunocompromise, which lead to a high rate of recurrence. Given the overall rarity of SOCFs, optimal surgical repair remains controversial, with options ranging from conservative management, onlay grafts, and vascularized flaps. This case report describes a novel one-step approach to SOCF closure using a composite chondral mucosal nasoseptal flap in a patient with a large left medial canthal SOCF that had recurred despite 2 prior attempts at closure including a vascularized paramedian forehead flap. Nasoseptal flaps may provide vascularized mucosal tissue to allow for greater success in closure over traditional, external flaps, and skin grafts.

Mitochondrion genomes of seven species of the endangered genus Sporophila (Passeriformes: Thraupidae).

We announce the mitochondrial genomes of seven species of the genus Sporophila (S. bouvreuil, S. iberaensis, S. melanogaster, S. minuta, S. nigrorufa, S. pileata, and S. ruficollis) which were validated by comparative genomic and phylogenetic analysis with related species. The mitochondrial genomes of seven passerines of the genus Sporophila were assembled (three complete and four nearly complete genomes) and were validated by reconstructing phylogenetic relations within Thraupidae. The complete mitogenomes ranged from 16,781 bp in S. ruficollis to 16,791 bp in S. minuta. We identified a conserved genome composition within all mitogenomes with 13 protein-coding genes, 22 tRNAs and two rRNAs. We observed a bias in the nucleotide composition and six mutational hotspots in Sporophila mitogenomes. Our mitogenome-based phylogenetic tree has S. minuta, S. maximiliani and S. nigricollis as sister species of the remaining species in the genus. We present new mitogenome sequences for seven Sporophila species, providing new genomic resources that may be useful for research on the evolution, comparative genetics, and conservation of this threatened group.

Imaging Features and Complications of Facial Cosmetic Procedures.

Facial aesthetic procedures have become increasingly popular and complex, making knowledge of facial anatomy crucial for achieving desired outcomes without complications. Some of the most common procedures include blepharoplasty, bichectomy, face-lifts, facial implants, thread lifting, and fillers. Blepharoplasty and bichectomy are surgical procedures that respectively aim to restore youthful contours to the periorbita and create a slimmer lower face by removing Bichat fat from the maxillofacial region. Facial implants are used for aesthetic augmentation of the skeletal structure and restoration of facial contour by using biomaterials or autogenous bone grafts. Face-lift surgeries involve incisions and removal of excess skin, and thread lifts involve less invasive procedures performed by inserting threads beneath the skin, with the aim to lift the skin and thus reduce wrinkles and sagging. Fillers improve wrinkles and loss of facial volume, with biologic types made from animal, human, or bacterial sources (such as hyaluronic acid), while synthetic fillers include substances such as paraffin, silicone, calcium hydroxyapatite, polymethylmethacrylate microspheres, polyacrylamide hydrogel, hydroxyethyl-ethyl methacrylate, and poly-l-lactic acid. Synthetic fillers can be classified as rapidly resorbable (<12 months), slowly resorbable (<24 months), or permanent. Imaging modalities such as US, CT, and MRI can help identify and analyze each type of facial aesthetic procedure or filler, as well as their possible complications such as foreign-body granuloma, noninflammatory nodule, late intermittent persistent edema, filler migration, infection, or complications after removal of the buccal fat pad. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center The online slide presentation from the RSNA Annual Meeting is available for this article.

Combined endoscopic endonasal and sublabial transmaxillary approaches for resection of intracranially extended juvenile nasopharyngeal angiofibroma.

BACKGROUND: Juvenile nasopharyngeal angiofibromas (JNAs) are rare, benign, and locally invasive nasopharyngeal tumors. Endoscopic endonasal resection is effective, non-invasive, with low complication rates. Until recently, endoscopic resection was not suitable for intracranially invasive tumors. PURPOSE/METHOD: We describe resection steps of an intracranially extending JNA with a combined endoscopic endonasal and endoscopic-assisted sublabial transmaxillary approaches. Indications, advantages, and approach-specific complications are also discussed. The main surgical steps are shown in an operative video. CONCLUSION: Surgical excision of JNAs by a combined endoscopic endonasal and sublabial transmaxillary approaches represents a safe and effective treatment for selected intracranially invasive JNA.

Endoscopic endonasal surgical anatomy of the optic canal: key anatomical relationships between the optic nerve and ophthalmic artery.

PURPOSE: A detailed understanding of the neurovascular relationships between the optic nerve (ON) and the ophthalmic artery (OA) in the optic canal (OC) is paramount for safe surgery. We focused on the neurovascular anatomy of this area from both an endoscopic endonasal and transcranial trajectories to compare the surgical exposures and perspectives offered by these different views and provide recommendations to increase the intraoperative safety. METHODS: Twenty sides of ten formalin-fixed, latex-injected head specimens were utilized. The surgical anatomy and anatomical relationships of the OA in relationship to the ON along their intracranial and intracanalicular segments was studied from endoscopic endonasal and transcranial perspectives. RESULTS: Three types of OA-ON relationships at the origin of the OA were identified: inferomedial (type 1, 35%), inferior (type 2, 55%), and inferolateral (type 3, 10%). The endoscopic endonasal trajectory offers an inferomedial perspective of the ON-OA neurovascular complex, in which the OA, especially when located inferomedially, is first encountered. When comparing with the transcranial view, all OA were covered by the nerve, type 1 was located below the medial third, type 2 below the middle third, and type 3 below the lateral third of the OC. The mean extension of the intracanalicular portion of both OA and ON was 8.9 mm, while the intracranial portion of the OA and ON were 9.3 mm and 12.4 mm, respectively. The OA, endoscopically, is located within the inferior half of the OC, and occupies 39%, 43%, and 42% of the OC height at its origin, mid, and end points, respectively. The mean distance between the superior margin of the OC at its origin and superior margin of the OA is 1.4 mm. CONCLUSIONS: Detailed anatomical understanding of the OC, and the ON and OA at their intracranial and intracanalicular segments is paramount to safe surgery. When opening the OC dura endoscopically, our results suggest that a medial incision along the superior third of the OC with a proximal to distal direction is recommended to avoid injury of the OA.

The "candy wrapper" of the pituitary gland: a road map to the parasellar ligaments and the medial wall of the cavernous sinus.

PURPOSE: The anatomy of the medial wall of the cavernous sinus (MWCS) and parasellar ligaments (PLs) has acquired increasing importance in endoscopic endonasal (EE) surgery of the cavernous sinus (CS), including resection of the MWCS in functioning pituitary adenomas (FPAs). Although anatomical studies have been published, it represents a debated topic due to their complex morphology. The aim is to offer a description of the PLs that originate from the MWCS and reach the lateral wall of the cavernous sinus (LWCS), proposing the "candy wrapper" model. The relationships between the neurovascular structures and histomorphological aspects were investigated. METHODS: Forty-two CSs from twenty-one human heads were studied. Eleven specimens were used for EE dissection; five underwent a microscopic dissection. Five specimens were used for histomorphological analysis. RESULTS: Two groups of PLs with a fan-shaped appearance were encountered. The anterior group included the periosteal ligament (55% sides) and the carotico-clinoid complex (100% sides), formed by the anterior horizontal and the carotico-clinoid ligaments. The posterior group was formed by the posterior horizontal (78% sides), and the inferior hypophyseal ligament (34% sides). The periosteal ligament originated inferiorly from the MWCS, reaching the periosteal dura. The anterior horizontal ligament was divided in a superior and inferior branch. The superior one continued as the carotid-oculomotor membrane, and the inferior branch reached the CN VI. The carotico-clinoid ligament between the middle and anterior clinoid was ossified in 3 sides. The posterior horizontal ligament was related to the posterior genu and ended at the LWCS. The inferior hypophyseal ligament followed the homonym artery. The ligaments related to the ICA form part of the adventitia. CONCLUSION: The "candy wrapper" model adds further details to the previous descriptions of the PLs. Understanding this complex anatomy is essential for safe CS surgery, including MWCS resection for FPAs.

Infrared image method for possible COVID-19 detection through febrile and subfebrile people screening.

This study proposed an infrared image-based method for febrile and subfebrile people screening to comply with the society need for alternative, quick response, and effective methods for COVID-19 contagious people screening. The methodology consisted of: (i) Developing a method based on facial infrared imaging for possible COVID-19 early detection in people with and without fever (subfebrile state); (ii) Using 1206 emergency room (ER) patients to develop an algorithm for general application of the method, and (iii) Testing the method and algorithm effectiveness in 2558 cases (RT-qPCR tested for COVID-19) from 227,261 workers evaluations in five different countries. Artificial intelligence was used through a convolutional neural network (CNN) to develop the algorithm that took facial infrared images as input and classified the tested individuals in three groups: fever (high risk), subfebrile (medium risk), and no fever (low risk). The results showed that suspicious and confirmed COVID-19 (+) cases characterized by temperatures below the 37.5 °C fever threshold were identified. Also, average forehead and eye temperatures greater than 37.5 °C were not enough to detect fever similarly to the proposed CNN algorithm. Most RT-qPCR confirmed COVID-19 (+) cases found in the 2558 cases sample (17 cases/89.5%) belonged to the CNN selected subfebrile group. The COVID-19 (+) main risk factor was to be in the subfebrile group, in comparison to age, diabetes, high blood pressure, smoking and others. In sum, the proposed method was shown to be a potentially important new tool for COVID-19 (+) people screening for air travel and public places in general.

Wild meat trade over the last 45 years in the Peruvian Amazon.

The trade in wild meat is an important economic component of rural people's livelihoods, but it has been perceived to be among the main causes of the decline of wildlife species. Recently, the COVID-19 pandemic has brought to light an additional concern of wildlife markets as a major human-health challenge. We analyzed data from the largest longitudinal monitoring (1973-2018) of the most important urban wild-meat markets in Iquitos, Peru, to examine the trends in and impacts of these markets on people's livelihoods. Over the last 45 years, wild meat sales increased at a rate of 6.4 t/year (SD 2.17), paralleling urban population growth. Wild meat sales were highest in 2018 (442 t), contributing US$2.6 million (0.76%) to the regional gross domestic product. Five species of ungulates and rodents accounted for 88.5% of the amount of biomass traded. Vulnerable and Endangered species represented 7.0% and 0.4% of individuals sold, respectively. Despite growth in sales, the contribution of wild meat to overall urban diet was constant: 1-2%/year of total meat consumed. This result was due to greater availability and higher consumption of cheaper meats (e.g., in 2018, poultry was 45.8% cheaper and was the most consumed meat) coupled with the lack of economic incentives to harvest wild meat species in rural areas. Most wild meat was sold salted or smoked, reducing the likelihood of foodborne diseases. Community-based wildlife management plans and the continued trade bans on primates and threatened taxa may avoid biodiversity loss. Considering the recent COVID-19 pandemic, future management plans should include potential viral hosts and regulation and enforcement of hygiene practices in wild-meat markets.

Comercio de Carne de Monte en los Últimos 45 Años en la Amazonia Peruana Resumen El comercio de carne de monte es un componente económico importante del sustento de habitantes de zonas rurales, pero se ha percibido como una de las principales causas de la declinación de especies de vida silvestre. Recientemente, la pandemia de COVID-19 ha traído a la luz una preocupación adicional de los mercados de vida silvestre como un reto importante para la salud humana. Analizamos datos del monitoreo longitudinal más extenso (1973-2018) de los mercados urbanos de carne de monte más importantes en Iquitos, Perú, para examinar las tendencias y los impactos de estos mercados sobre el sustento de los habitantes. Las ventas de carne de monte incrementaron en los últimos 45 años a una tasa de 6.4 t/año (DS 2.17), en paralelo con el crecimiento de la población. Las ventas de carne de monte fueron más altas en 2018 (442 t), aportando U.S. $2.6 millones (0.76%) al producto interno bruto de la región. Cinco especies de ungulados y roedores comprendieron el 88.5% de la biomasa comercializada. Especies vulnerables y en peligro representaron 7.0% y 0.4% de los individuos vendidos, respectivamente. A pesar del incremento de las ventas, la contribución de la carne de monte al total de la dieta urbana fue constante: 1-2%/año del total de carne consumida. Este resultado se debió a una mayor disponibilidad y consumo de carnes más baratas (e. g., en 2018 la carne de pollo fue 45.8% más barata y fue la más consumida) aparejado con la falta de incentivos económicos para cosechar carne de especies silvestres en áreas rurales. La mayor parte de la carne de monte se vendía salada o ahumada, reduciendo con ello la probabilidad de enfermedades transmitidas por alimentos. Los planes de manejo de vida silvestre basados en comunidades y la prohibición continua del comercio de primates y taxa amenazados pueden evitar la pérdida de biodiversidad. Considerando la reciente pandemia de COVID-19, los planes de manejo futuros deben incluir potenciales huéspedes virales y la regulación y aplicación de prácticas de higiene en los mercados de carne de especies silvestres.

Imaging the External Ear: Practical Approach to Normal and Pathologic Conditions.

The external ear (EE) is an osseous-cartilaginous structure that extends from the auricle to the tympanic membrane. It is divided into two parts: the auricle (or pinna) and the external auditory canal (EAC). Given the ease of access to the EE, imaging studies are not always needed to make a diagnosis. However, when lesions block visual access to areas deep to the EE abnormality, complications are suspected, or there is lack of response to treatment, imaging becomes essential. A basic understanding of the embryologic development and knowledge of the anatomy of the auricle and EAC are useful for accurate diagnosis of EE lesions. Congenital, traumatic, inflammatory, neoplastic, and vascular conditions can affect the EE. An overview of the anatomy and embryologic development of the EE is presented, with discussion and illustrations of common and uncommon conditions that affect EE structures and a focus on the CT and MRI features that are of interest to radiologists. CT is usually the first diagnostic modality used to evaluate the EAC and is the superior method for demonstrating bone changes. MRI provides excellent tissue characterization and enables one to better define lesion extension and perineural tumor spread. In addition, a flowchart to facilitate the differential diagnosis of EE abnormalities is provided. Online supplemental material is available for this article. ©RSNA, 2022.

Efficacy and safety of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for IgA nephropathy in children.

BACKGROUND: IgA nephropathy (IgAN) is one of the most prevalent primary glomerulopathies in children. There are various studies investigating the efficacy of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) in adults with IgAN. However, only few studies evaluated the efficacy of these medications in pediatric patients. OBJECTIVE: To evaluate the efficacy and safety of ACEI/ARB in children with IgAN. DATA SOURCES: Databases including PubMed, Web of Science, Cochrane, Scopus, and Google Scholar were searched between the 1st of April and 20th of July of 2021 using the keywords "IgA Nephropathy," "Berger's Disease," "Angiotensin-Converting Enzyme Inhibitors," "Angiotensin Receptor Antagonists," "Angiotensin II Type 1 Receptor Blockers," and similar entry terms collected from the Medical Subject Headings (MeSH). STUDY ELIGIBILITY CRITERIA: Observational studies (case series, case-control, cohort, and cross-sectional) and clinical trials with descriptions of pediatric patients (under 19 years old) with histopathological diagnosis of IgA nephropathy and who received ACEI and/or ARB. PARTICIPANTS AND INTERVENTIONS: Pediatric patients (under 19 years old) with histopathological diagnosis of IgA nephropathy and who received ACEI and/or ARB. STUDY APPRAISAL: For quality assessment, the Risk of Bias 2 tool (RoB 2), the Risk Of Bias In Non-randomized Studies of Interventions tool (ROBINS-I), the National Institutes of Health (NIH) quality assessment tool, and the Newcastle-Ottawa Scale (NOS) were used. RESULTS: After recovering 1,471 studies, only eight, published between 2003 and 2019, met the eligibility criteria and were included in this systematic review. Of the 737 included children in the studies, 202 (25.8%) used ACEI/ARB and were compared with placebo and other therapy regimens. Of the seven studies that evaluated proteinuria, six reported an efficacy of ACEI/ARB in reducing this marker. ACEI/ARB also showed a possible effect in reducing hematuria and oxidative stress. The most common side effect was dizziness. LIMITATIONS: The number of studies about the treatment with ACEI/ARB in children with IgAN is scarce. In addition, the studies are very heterogeneous. There are few studies that compared ACEI/ARB with placebo. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: The use of ACEI and/or ARB appears to be safe and to reduce proteinuria in pediatric patients with IgAN. Nonetheless, further randomized controlled trials, with greater methodological rigor and longer follow-up time, are required to establish the efficacy and safety of this therapy in this population. SYSTEMATIC REVIEW REGISTRATION NUMBER: The protocol of this systematic literature review was registered in PROSPERO under the number CRD42021245375, and in the OSF registries ( https://osf.io/qft4z/ ) with the registration https://doi.org/10.17605/OSF.IO/VADYR . A higher resolution version of the Graphical abstract is available as Supplementary information.

An overview on the conversion of glycerol to value-added industrial products via chemical and biochemical routes.

Glycerol is a common by-product of industrial biodiesel syntheses. Due to its properties, availability, and versatility, residual glycerol can be used as a raw material in the production of high value-added industrial inputs and outputs. In particular, products like hydrogen, propylene glycol, acrolein, epichlorohydrin, dioxalane and dioxane, glycerol carbonate, n-butanol, citric acid, ethanol, butanol, propionic acid, (mono-, di-, and triacylglycerols), cynamoil esters, glycerol acetate, benzoic acid, and other applications. In this context, the present study presents a critical evaluation of the innovative technologies based on the use of residual glycerol in different industries, including the pharmaceutical, textile, food, cosmetic, and energy sectors. Chemical and biochemical catalysts in the transformation of residual glycerol are explored, along with the factors to be considered regarding the choice of catalyst route used in the conversion process, aiming at improving the production of these industrial products.

Endoscopic endonasal surgical anatomy through the prechiasmatic sulcus: the key window to suprachiasmatic and infrachiasmatic corridors.

BACKGROUND: Classically, the transtuberculum and transplanum approaches have been utilized to reach the suprachiasmatic and infrachiasmatic corridors. The aim of this study was to provide a better understanding of the key endoscopic endonasal anatomy of the suprachiasmatic and infrachiasmatic corridors provided through selective removal of the prechiasmatic sulcus (SRPS). METHOD: A SRPS was performed in 16 sides of 8 alcohol-fixed head specimens. Twenty anatomical measurements were collected on the suprachiasmatic and infrachiasmatic corridors. The transplanum and transtuberculum approaches were also performed. RESULTS: In the suprachiasmatic corridor, the SRPS exposed the anterior communicating artery (AComm) and the post-communicating segment of the anterior cerebral arteries in all the cases, while the pre-communicating segment of the anterior cerebral arteries, recurrent arteries of Heubner, and fronto-orbital arteries were visualized in 75% (12/16), 31% (5/16), and 69% (11/16) of cases, respectively. In the infrachiasmatic corridor, the ophthalmic segment of the internal carotid artery and superior hypophyseal arteries were always visible through the SRPS. The mean width and height of the prechiasmatic sulcus were 13.2 mm and 9.6 mm, respectively. The mean distances from the midpoint of the AComm to the anterior margin of the optic chiasm (OCh) was 5.3 mm. The mean width of the infrachiasmatic corridor was 12.3 mm at the level of the proximal margin of the ophthalmic segment of the internal carotid artery. The mean distances from the posterior superior limit of the pituitary stalk to the basilar tip and oculomotor nerve were 9.7 mm and 12.3 mm, respectively. CONCLUSIONS: The SRPS provides access to the main neurovascular and cisternal surgical landmarks of the suprachiasmatic and infrachiasmatic corridors. This anatomical area constitutes the key part of the approach to the suprasellar area. To afford adequate surgical maneuverability, the transplanum or transtuberculum approaches are usually a necessary extension.

Combined endoscopic endonasal transpterygoid and sublabial transmaxillary approaches for a large infratemporal fossa trigeminal schwannoma.

BACKGROUND: Trigeminal schwannomas (TSs) with solitary extracranial location are rare, and surgical excision is challenging. In recent years, the endoscopic endonasal transmaxillary transpterygoid approach (EETPA) has been advocated as an effective strategy for TSs in the infratemporal fossa (ITF). METHOD: We describe the steps of the EETPA combined with the sublabial transmaxillary approach for the surgical excision of a giant mandibular schwannoma of the ITF. Indications, advantages, and approach-specific complications are also discussed. The main surgical steps are shown in an operative video. CONCLUSION: A combined EETPA and sublabial transmaxillary approach represents a safe and effective option for the surgical excision of extracranial TSs.

The endonasal midline inferior intercavernous approach to the cavernous sinus: technical note, cadaveric step-by-step illustration, and case presentation.

PURPOSE: Traditional endoscopic endonasal approaches to the cavernous sinus (CS) open the anterior CS wall just medial to the internal carotid artery (ICA), posing risk of vascular injury. This work describes a potentially safer midline sellar entry point for accessing the CS utilizing its connection with the inferior intercavernous sinus (IICS) when anatomically present. METHODS: The technique for the midline intercavernous dural access is described and depicted with cadaveric dissections and a clinical case. RESULTS: An endoscopic endonasal approach exposed the periosteal dural layer of anterior sella and CS. The IICS was opened sharply in midline through its periosteal layer. The feather knife was inserted and advanced laterally within the IICS toward the anterior CS wall, thereby gradually incising the periosteal layer of the IICS. The knife was turned superiorly then inferiorly in a vertical direction to open the anterior CS wall. This provided excellent access to the CS compartments, maintained the meningeal layer of the IICS and the medial CS wall, and avoided an initial dural incision immediately adjacent to the ICA. CONCLUSION: The midline intercavernous dural access to the CS assisted by a 90° dissector-blade is an effective modification to previously described techniques, with potentially lower risk to the ICA.

Pneumatization of the Sphenoidal Sinus May Affect Endonasal Cranial Base Reconstruction.

OBJECTIVE: The aim of this study is to verify if the length of the nasoseptal flap is sufficient to cover the tuberculum sellae and planum sphenoidale of sphenoidal sinuses with varied degrees of pneumatization. METHODS: Retrospective study of paranasal sinus computed tomography comparing the potential length of the nasoseptal flap and the length of the nasoseptal flap required for reconstruction of transtuberculum and transplanum approaches in conchal, presellar, sellar, incomplete postsellar, and complete postsellar sphenoidal sinuses. RESULTS: The length of the nasoseptal flap required for reconstruction of transtuberculum and transplanum approaches was directly related to the degree of pneumatization of the sphenoidal sinus. The nasoseptal flap length was adequate to cover the cranial base after transtuberculum approaches of all cases from the conchal, presellar, and sellar groups and the majority of cases from postsellar pneumatization. For transplanum approaches, the nasosseptal flap was sufficient to reconstruct defects in most cases from conchal, pre-sellar, and sellar type sinuses and in 54,9% and 19,2% in incomplete and complete postsellar, respectively. CONCLUSIONS: In well pneumatized sphenoidal sinus, the nasoseptal flap may not be sufficient to cover the cranial base after transtuberculum and transplanum approaches.

Radiation exposure after myocardial perfusion imaging with Cadmium-Zinc-Telluride camera versus conventional camera.

BACKGROUND: Patient exposure to radiation during the management of coronary heart disease (CHD) can be reduced with more efficient technologies in nuclear medicine, such as the Cadmium-Zinc-Telluride (CZT) gamma-camera for myocardial perfusion imaging (MPI) studies. However, it has been suggested that CZT has lower specificity, which might lead to more downstream radiological procedures, particularly among obese individuals. METHODS AND RESULTS: We evaluated 244 patients with suspected CHD who underwent CZT-SPECT and matched 1:1 according to sex, age, and body mass index (BMI) with those undergoing MPI study with the Anger gamma-camera (Anger-SPECT). The outcome was the total radiation exposure from the MPI study added to the radiation exposure from all subsequent cardiac examinations during a 90-day follow-up. The total radiation dose after 90 days was significantly lower in the CZT-SPECT group (6.4 ± 4.8 vs 9.5±4.9 mSv, P < .001). After adjusting for potential confounders, CZT-SPECT remained associated with lower total radiation dose, but it significantly attenuated among obese individuals (Beta coefficient - 3.73 ± 0.86 for BMI < 30 vs - 2.30 ± 0.92 for BMI ≥ 30 Kg/m2, P for interaction < 0.032). CONCLUSIONS: CZT-SPECT was associated with lower total radiation doses compared to Anger-SPECT, albeit this benefit may be attenuated in obese individuals.

Clinical, cerebrospinal fluid, and neuroimaging findings in COVID-19 encephalopathy: a case series.

OBJECTIVE: To describe the clinical, neurological, neuroimaging, and cerebrospinal fluid (CSF) findings associated with encephalopathy in patients admitted to a COVID-19 tertiary reference center. METHODS: We retrospectively reviewed records of consecutive patients with COVID-19 evaluated by a consulting neurology team from March 30, 2020 through May 15, 2020. RESULTS: Fifty-five patients with confirmed SARS-CoV-2 were included, 43 of whom showed encephalopathy, and were further divided into mild, moderate, and severe encephalopathy groups. Nineteen patients (44%) had undergone mechanical ventilation and received intravenous sedatives. Eleven (26%) patients were on dialysis. Laboratory markers of COVID-19 severity were very common in encephalopathy patients, but did not correlate with the severity of encephalopathy. Thirty-nine patients underwent neuroimaging studies, which showed mostly non-specific changes. One patient showed lesions possibly related to CNS demyelination. Four had suffered an acute stroke. SARS-CoV-2 was detected by RT-PCR in only one of 21 CSF samples. Two CSF samples showed elevated white blood cell count and all were negative for oligoclonal bands. In our case series, the severity of encephalopathy correlated with higher probability of death during hospitalization (OR = 5.5 for each increment in the degree of encephalopathy, from absent (0) to mild (1), moderate (2), or severe (3), p < 0.001). CONCLUSION: In our consecutive series with 43 encephalopathy cases, neuroimaging and CSF analysis did not support the role of direct viral CNS invasion or CNS inflammation as the cause of encephalopathy.