Successful Coil Embolization of Active Bleeding From a Replaced Left Hepatic Artery to the Left Gastric Artery Associated With a Traumatic Rupture of a Simple Hepatic Cyst Causing Hemodynamic Instability.

Intra-abdominal hemorrhage resulting from a ruptured, large hepatic cyst in a polycystic liver disease (PCLD) patient is rare and potentially fatal if not addressed promptly. Only a few isolated cases have previously been reported. The usual patient profile consists of elderly patients on anticoagulation, as is demonstrated in our case. Intra-hepatic cysts are broadly classified into congenital, traumatic, infectious, parasitic, and neoplastic. Congenital intra-hepatic cysts can consist of both simple and PCLD, as is outlined in our case. Simple cysts are usually asymptomatic, but occasionally they may achieve larger dimensions and lead to complications such as rupture, obstruction, infection, hemorrhage, and even portal hypertension. We present an uncommon case of a 78-year-old patient with PCLD on rivaroxaban who presented initially with diffuse abdominal pain, distension, and progression into hemodynamic instability. A computerized tomography (CT) scan revealed a ruptured left hepatic lobe cyst, causing hemoperitoneum and resulting in an acute abdomen. This case was complicated by the patient's anticoagulation status and anomalous hepatic vasculature pattern. Interventional radiology (IR) successfully identified the aberrant bleeding vessel and stopped the active extravasation with super-selective coil embolization.

Necrotizing Fasciitis Masquerading as Stroke: A Diagnostic Dilemma.

Necrotizing fasciitis (NF) poses a diagnostic challenge due to its rarity and similarity in presentation with other critical conditions. We report a case of a 79-year-old male who initially presented with altered mental status and stroke-like symptoms; he was ultimately diagnosed with abdominal wall NF spreading to the lower extremity. Despite a history of cecal mass perforation noted in prior imaging, the patient had been discharged from an outside emergency room on antibiotics, highlighting a missed opportunity for early intervention. Subsequent deterioration led to sepsis, organ failure, and ultimately, the detection of NF. Prompt recognition of subtle skin changes and laboratory abnormalities, along with a detailed physical examination, is essential for a timely and accurate diagnosis. Surgical debridement, coupled with broad-spectrum antibiotics, remains the cornerstone of treatment. Delays in surgical management significantly increase mortality, emphasizing the importance of prompt diagnosis and intervention. This case underscores the necessity for heightened awareness among healthcare providers to recognize NF promptly, especially when its clinical presentation overlaps with other critical conditions. Multidisciplinary collaboration and continued education are imperative to improve outcomes and prevent delays in the diagnosis and treatment of NF.

Iron Dioxygen Adduct Formed during Electrochemical Oxygen Reduction by Iron Porphyrins Shows Catalytic Heme Dioxygenase Reactivity.

Heme dioxygenases oxidize the indole ring of tryptophan to kynurenine which is the first step in the biosynthesis of several important biomolecules like NAD, xanthurenic acid, and picolinic acid. A ferrous heme dioxygen adduct (or FeIII-O2•-) is the oxidant, and both the atoms of O2 are inserted in the product and its catalytic function has been difficult to emulate as it is complicated by competing rapid reactions like auto-oxidation and/or formation of the µ-oxo dimer. In situ resonance Raman spectroscopy technique, SERRS-RDE, is used to probe the species accumulated during electrochemical ORR catalyzed by site-isolated imidazole-bound iron porphyrin installed on a self-assembled monolayer covered electrode. These in situ SERRS-RDE data using labeled O2 show that indeed a FeIII-O2•- species accumulate on the electrode during ORR between -0.05 and -0.30 V versus Ag/AgCl (satd. KCl) and is reduced by proton coupled electron transfer to a FeIII-OOH species which, on the other hand, builds up on the electrode between -0.20 and -0.40 V versus Ag/AgCl (satd. KCl). This FeIII-OOH species then gives way to a FeIV═O species, which accumulates at -0.50 V versus Ag/AgCl (satd. KCl). When 2,3-dimethylindole is present in the solution and the applied potential is held in the range where FeIII-O2•- species accumulate, it gets oxidized to N-(2-acetylphenyl)acetamide retaining both the oxygens from O2 mimicking the reaction of heme dioxygenases. Turnover numbers more than 104 are recorded, establishing this imidazole-bound ferrous porphyrin as a functional model of heme dioxygenases.

Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use.

STUDY OBJECTIVE: Evaluate the utility of routine rescanning of older, mild head trauma patients with an initial negative brain computed tomography (CT), who is on a preinjury antithrombotic (AT) agent by assessing the rate of delayed intracranial hemorrhage (dICH), need for surgery, and attributable mortality. METHODS: Participating centers were trained and provided data collection instruments per institutional review board-approved protocols. Data were obtained from manual chart review and electronic medical record download. Adults ≥55 years seen at Level I/II Trauma Centers, between 2017 and 2019 with suspected head trauma, Glasgow Coma Scale 14 to 15, negative initial brain CT, and no other Abbreviated Injury Scale injuries >2 were identified, grouped by preinjury AT therapy (AT- or AT+) and compared on dICH rate, need for operative neurosurgical intervention, and attributable mortality using univariate analysis (α=.05). RESULTS: A total of 2,950 patients from 24 centers were enrolled; 280 (9.5%) had a repeat brain CT. In those rescanned, the dICH rate was 15/126 (11.9%) for AT- and 6/154 (3.9%) in AT+. Assuming nonrescanned patients did not suffer clinically meaningful dICH, the dICH rate would be 15/2001 (0.7%) for AT- and 6/949 (0.6%) for AT+. No surgical operations were done for dICH. All-cause mortality was 9/2950 (0.3%) and attributable mortality was 1/2950 (0.03%). The attributable death was an AT+, dICH patient whose family declined intervention. CONCLUSION: In older patients with an initial Glasgow Coma Scale of 14 to 15 and a negative initial brain CT scan, the dICH rate is low (<1%) and of minimal clinical consequence, regardless of AT use. In addition, no patient had operative neurosurgical intervention. Therefore, routine rescanning is not supported based on the results of this study.

Mural Wnt/ß-catenin signaling regulates Lama2 expression to promote neurovascular unit maturation.

Neurovascular unit and barrier maturation rely on vascular basement membrane (vBM) composition. Laminins, a major vBM component, are crucial for these processes, yet the signaling pathway(s) that regulate their expression remain unknown. Here, we show that mural cells have active Wnt/ß-catenin signaling during central nervous system development in mice. Bulk RNA sequencing and validation using postnatal day 10 and 14 wild-type versus adenomatosis polyposis coli downregulated 1 (Apcdd1-/-) mouse retinas revealed that Lama2 mRNA and protein levels are increased in mutant vasculature with higher Wnt/ß-catenin signaling. Mural cells are the main source of Lama2, and Wnt/ß-catenin activation induces Lama2 expression in mural cells in vitro. Markers of mature astrocytes, including aquaporin 4 (a water channel in astrocyte endfeet) and integrin-α6 (a laminin receptor), are upregulated in Apcdd1-/- retinas with higher Lama2 vBM deposition. Thus, the Wnt/ß-catenin pathway regulates Lama2 expression in mural cells to promote neurovascular unit and barrier maturation.

Hyperglycemia in nondiabetic adult trauma patients is associated with worse outcomes than diabetic patients: An analysis of 95,764 patients.

BACKGROUND: The adverse impact of acute hyperglycemia is well documented but its specific effects on nondiabetic trauma patients are unclear. The purpose of this study was to analyze the differential impact of hyperglycemia on outcomes between diabetic and nondiabetic trauma inpatients. METHODS: Adults admitted 2018 to 2019 to 46 Level I/II trauma centers with two or more blood glucose tests were analyzed. Diabetes status was determined from International Classification of Diseases-10th Rev.-Clinical Modification, trauma registry, and/or hemoglobin A1c greater than 6.5. Patients with and without one or more hyperglycemic result >180 mg/dL were compared. Logistic regression examined the effects of hyperglycemia and diabetes on outcomes, adjusting for age, sex, Injury Severity Score, and body mass index. RESULTS: There were 95,764 patients: 54% male; mean age, 61 years; mean Injury Severity Score, 10; diabetic, 21%. Patients with hyperglycemia had higher mortality and worse outcomes compared with those without hyperglycemia. Nondiabetic hyperglycemic patients had the highest odds of mortality (diabetic: adjusted odds ratio, 3.11; 95% confidence interval, 2.8-3.5; nondiabetics: adjusted odds ratio, 7.5; 95% confidence interval, 6.8-8.4). Hyperglycemic nondiabetics experienced worse outcomes on every measure when compared with nonhyperglycemic nondiabetics, with higher rates of sepsis (1.1 vs. 0.1%, p < 0.001), more SSIs (1.0 vs. 0.1%, p < 0.001), longer mean hospital length of stay (11.4 vs. 5.0, p < 0.001), longer mean intensive care unit length of stay (8.5 vs. 4.0, p < 0.001), higher rates of intensive care unit use (68.6% vs. 35.1), and more ventilator use (42.4% vs. 7.3%). CONCLUSION: Hyperglycemia is associated with increased odds of mortality in both diabetic and nondiabetic patients. Hyperglycemia during hospitalization in nondiabetics was associated with the worst outcomes and represents a potential opportunity for intervention in this high-risk group. LEVEL OF EVIDENCE: Therapeutic/care management; Level III.

The public health burden of geriatric trauma: Analysis of 2,688,008 hospitalizations from Centers for Medicare and Medicaid Services inpatient claims.

BACKGROUND: Geriatric trauma care (GTC) represents an increasing proportion of injury care, but associated public health research on outcomes and expenditures is limited. The purpose of this study was to describe GTC characteristics, location, diagnoses, and expenditures. METHODS: Patients at short-term nonfederal hospitals, 65 years or older, with ≥1 injury International Classification of Diseases, Tenth Revision, were selected from 2016 to 2019 Centers for Medicare and Medicaid Services Inpatient Standard Analytical Files. Trauma center levels were linked to Inpatient Standard Analytical Files data via American Hospital Association Hospital ID and fuzzy string matching. Demographics, care location, diagnoses, and expenditures were compared across groups. RESULTS: A total of 2,688,008 hospitalizations (62% female; 90% White; 71% falls; mean Injury Severity Score, 6.5) from 3,286 hospitals were included, comprising 8.5% of all Medicare inpatient hospitalizations. Level I centers encompassed 7.2% of the institutions (n = 236) but 21.2% of hospitalizations, while nontrauma centers represented 58.5% of institutions (n = 1,923) and 37.7% of hospitalizations. Compared with nontrauma centers, patients at Level I centers had higher Elixhauser scores (9.0 vs. 8.8) and Injury Severity Score (7.4 vs. 6.0; p < 0.0001). The most frequent primary diagnosis at all centers was hip/femur fracture (28.3%), followed by traumatic brain injury (10.1%). Expenditures totaled $32.9 billion for trauma-related hospitalizations, or 9.1% of total Medicare hospitalization expenditures and approximately 1.1% of the annual Medicare budget. The overall mortality rate was 3.5%. CONCLUSION: Geriatric trauma care accounts for 8.5% of all inpatient GTC and a similar percentage of expenditures, the most common injury being hip/femur fractures. The largest proportion of GTC occurs at nontrauma centers, emphasizing their vital role in trauma care. Public health prevention programs and GTC guidelines should be implemented by all hospitals, not just trauma centers. Further research is required to determine the optimal role of trauma systems in GTC, establish data-driven triage guidelines, and define the impact of trauma centers and nontrauma centers on GTC mortality. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Vascular-derived SPARC and SerpinE1 regulate interneuron tangential migration and accelerate functional maturation of human stem cell-derived interneurons.

Cortical interneurons establish inhibitory microcircuits throughout the neocortex and their dysfunction has been implicated in epilepsy and neuropsychiatric diseases. Developmentally, interneurons migrate from a distal progenitor domain in order to populate the neocortex - a process that occurs at a slower rate in humans than in mice. In this study, we sought to identify factors that regulate the rate of interneuron maturation across the two species. Using embryonic mouse development as a model system, we found that the process of initiating interneuron migration is regulated by blood vessels of the medial ganglionic eminence (MGE), an interneuron progenitor domain. We identified two endothelial cell-derived paracrine factors, SPARC and SerpinE1, that enhance interneuron migration in mouse MGE explants and organotypic cultures. Moreover, pre-treatment of human stem cell-derived interneurons (hSC-interneurons) with SPARC and SerpinE1 prior to transplantation into neonatal mouse cortex enhanced their migration and morphological elaboration in the host cortex. Further, SPARC and SerpinE1-treated hSC-interneurons also exhibited more mature electrophysiological characteristics compared to controls. Overall, our studies suggest a critical role for CNS vasculature in regulating interneuron developmental maturation in both mice and humans.

Decreased adult trauma admission volumes and changing injury patterns during the COVID-19 pandemic at 85 trauma centers in a multistate healthcare system.

BACKGROUND: Reports indicate social distancing guidelines and other effects of the COVID-19 pandemic impacted trauma patient volumes and injury patterns. This report is the first analysis of a large trauma network describing the extent of these impacts. The objective of this study was to describe the effects of the COVID-19 pandemic on patient volumes, demographics, injury characteristics, and outcomes. METHODS: For this descriptive, multicenter study from a large, multistate hospital network, data were collected from the system-wide centralized trauma registry and retrospectively reviewed to retrieve patient information including volume, demographics, and outcomes. For comparison, patient data from January through May of 2020 and January through May of 2019 were extracted. RESULTS: A total of 12 395 trauma patients (56% men, 79% white, mean age 59 years) from 85 trauma centers were included. The first 5 months of 2020 revealed a substantial decrease in volume, which began in February and continued into June. Further analysis revealed an absolute decrease of 32.5% in patient volume in April 2020 compared with April 2019 (4997 from 7398; p<0.0001). Motor vehicle collisions decreased 49.7% (628 from 1249). There was a statistically significant increase in injury severity score (9.0 vs. 8.3; p<0.001). As a proportion of the total trauma population, blunt injuries decreased 3.1% (87.3 from 90.5) and penetrating injuries increased 2.7% (10.0 from 7.3; p<0.001). A significant increase was found in the proportion of patients who did not survive to discharge (3.6% vs. 2.8%; p=0.010; absolute decrease: 181 from 207). DISCUSSION: Early phases of the COVID-19 pandemic were associated with a 32.5% decrease in trauma patient volumes and altered injury patterns at 85 trauma centers in a multistate system. This preliminary observational study describes the initial impact of the COVID-19 pandemic and warrants further investigation. LEVEL OF EVIDENCE: Level II (therapeutic/care management).

Robotic Versus Laparoscopic Colorectal Resection: Are We There Yet?

BACKGROUND: Laparoscopy-assisted surgery (LAS) for colorectal cancer (CRC) was first described in 1991 and robotic-assisted surgery (RAS) for CRC was first reported in 2002; robotic-assisted colorectal surgery (RACS) is becoming increasingly popular. However, data comparing its outcomes to other established techniques remain limited to small case series. Our primary goal was to review the mortality outcome difference between laparoscopic versus robotic elective colon resection at a small, community hospital. STUDY DESIGN: We conducted a retrospective review of 2089 patients at the South Atlantic division for cases who underwent robotic and laparoscopic colectomies at our division in 2014-2018. All cases were elective surgeries and analysis was performed within these two subgroups. RESULTS: In this study, 306 patients underwent robotic colorectal surgery versus 1783 patients who underwent laparoscopic-assisted colorectal surgery. Readmission rate within 30 days of operation was significantly lower for laparoscopic-assisted colorectal resection (LACR) versus RACS (445.4% vs. 53.9%, p= 0.006). However, the length of hospital stay was significantly shorter for RACS with a median of three days (interquartile range {IQR}: 2-5) versus four days (IQR: 3-7) for LACR (p=0.0001). There were no significant differences between the two groups for post-operative incisional hernias, anastomotic leaks, post-operative pain control, surgical site infections, or rate of conversion to an open procedure. CONCLUSION:  Our study showed a similar outcome between LACR and RACS for post-operative incisional hernias, anastomotic leaks, post-operative pain control, surgical site infections, and rate of conversion to an open procedure. Also, our study showed a readmission rate within 30 days of operation was significantly lower for LACR versus RACS. However, the length of hospital stay was significantly shorter for RACS with a median of three days when compared to LACR. Future research should focus on surgeon-specific variables, such as comfort, ergonomics, distractibility, and ease of use, as other ways to potentially distinguish robotic from laparoscopic colorectal surgery.

Trauma Recidivism in an Aging Population: Who Is Most at Risk?

Background: Repeated episodes of trauma, particularly in older adults, result in increased morbidity and mortality. This study investigates trauma recidivism in our adult population to identify which patients in our region are more likely to become recidivists. Materials and Methods: This 4 year retrospective study (2013 to 2017) examines all patients 18 years of age or older with multiple hospital admissions for trauma, comparing patients ages 65 and older (older adults) to those ages 18 to 64 (younger adults). Exclusion criteria consisted of those younger than 18 and/or had a home zip code outside of the study region. Data included admission demographics, injury characteristics and other clinical metrics. Results: There were 240 younger adult and 182 older adult trauma recidivists included. In total, 4% of all patients were recidivists with significantly higher rates of recidivism among older adults (OR: 1.94 [1.59-2.36], p <0.001). Older adult recidivists were more likely to be female (OR: 4.28 [2.82-6.51], p <0.001) and suffer blunt trauma secondary to a fall (OR: 5.36 [3.91-7.35], p <0.001). Trauma recidivism in older adults also correlated with a higher Injury Severity Score, longer length of stay and an increased proportion of patients requiring to be discharged home with organizational help or to a rehabilitation facility. Conclusions: Trauma can be recurrent and associated with poor health outcomes, particularly in older adults. Recidivists in the studied region were significantly older with the most at-risk population consisting of females suffering blunt injury secondary to a fall. Improved prevention strategies are needed for this population.

Phrenic Nerve Blockade to Diagnose and Treat Diaphragmatic Pain After Surgical Repair of Congenital Diaphragmatic Eventration.

A 46-year-old woman presented with pain in the lateral side of the left chest wall and a sensation of fullness and pulling in the epigastric region, which started 4 weeks following diaphragmatic plication for left diaphragmatic eventration. The patient was diagnosed as suffering from post-thoracotomy pain syndrome (PTPS). A diagnostic intercostal nerve block relieved the chest wall pain, but not the epigastric pain. After a detailed evaluation, the epigastric pain was postulated to be of diaphragmatic origin and hence a diagnostic phrenic nerve block was performed which relieved the epigastric pain. Combined intercostal nerve neurolysis and phrenic nerve block relieved her pain completely. The phrenic nerve may play a role in pain transmission and the genesis of chronic pain following diaphragmatic surgery. Diaphragmatic pain following surgery may contribute to the development of chronic pain. Phrenic nerve blockade provides diagnostic information regarding the etiology of pain as well as being effective in providing analgesia. The technique of phrenic nerve block is presented and its role in the diagnosis and treatment of pain following thoracic surgery is reviewed.

Arc of Buhler Pseudoaneurysm Causing Fatal Retroperitoneal Hemorrhage; A Rare Case Report and Discussion of Relevant Literature.

Identification of any variant anatomy prior to surgery is as essential as having knowledge of normal anatomy. These surprises bring on many challenges along with as they can be fatal. We encountered a case of patient who succumbed down to an unrecognized rare mesenteric vasculature variant known as "Arc of Buhler" (AOB) which is a persistent embryonic ventral anastomosis between the Celiac trunk and the Superior mesenteric artery. It is usually asymptomatic and found incidentally after evaluation for other pathologies. We herein report a pseudoaneurysm of Arc of Buhler being surgically managed after massive retroperitoneal hemorrhage. Unfortunately, the patient did not survive the procedure and passed away. AOB aneurysms present formidable risks to patients and diagnostic and therapeutic challenges to physicians. They are rare and require high index of suspicion on radiographic imaging. Present case reports underscore the importance of identifying it and treating it regardless of the size.

Endovascular Management of a Penetrating Zone III Retroperitoneal Gunshot Wound Injury; A Case Report.

Traumatic iliac vessels injuries secondary to gunshot wound can often be fatal at the scene. One of the intriguing complications of vascular injuries is arteriovenous fistula. If the patient survives, these lesions may often not be diagnosed on first evaluation and patients may present with clinical signs and symptoms years later. Open surgical repair can have prohibitive morbidity and mortality and endovascular techniques, an effective treatment alternative, can interrupt the abnormal vascular communication and preserve artery vein patency. We describe a unique case of iliac arteriovenous fistula (AVF), secondary to a bullet injury, identified by imaging studies and subsequently treated with endovascular surgery. In conclusion, traumatic AVF are rare. Traditional teaching mandates that zone III pelvic retroperitoneal hematomas secondary to penetrating trauma be explored.

A Fatal Case of Intra-Abdominal Hemorrhage Following Diagnostic Blind Percutaneous Liver Biopsy in a Patient With Peliosis Hepatis.

Peliosis hepatis (PH) is a rare vascular condition of the liver characterized by the presence of cystic blood filled cavities distributed randomly throughout the liver parenchyma. We describe a case of a 42-year-old previously healthy male patient, airlifted to us in a state of hemorrhagic shock after undergoing percutaneous diagnostic liver biopsy for lesions seen on CT scan. Repeat CT scan with IV contrast on presentation in our hospital showed intraperitoneal bleeding. Hepatic angiography failed to identify any specific bleeding source. A diagnostic laparoscopy was performed and approximate 9 L of hemoperitoneum was evacuated. The postoperative course was complicated with rapid hemodynamic deterioration, associated with acute hepatic failure progressively leading to multiorgan failure and death in spite of aggressive intensive care support. We suggest that PH should be considered as differential diagnosis of hypervascular hepatic lesions. It potentially can cause fatal acute non-traumatic liver hemorrhage.

Jejunal Diverticular Perforation Causing Small Bowel Obstruction in a Type 4 Hiatal Hernia: A Rare Case Report of a Nonagenarian Patient and Review of Relevant Literature.

Type IV paraesophageal hernia (PEH) is very rare and is characterized by the intrathoracic herniation of the abdominal viscera other than the stomach into the chest. We describe a case of a 90-year-old male patient who presented at our emergency department complaining of epigastric pain that he had experienced over the past few hours and getting progressively worse. On the day after admission, his pain became severe. Chest radiography revealed an intrathoracic intestinal gas bubble; emergency exploratory laparotomy identified a type IV PEH with herniation of only the jejunum with perforated diverticula on mesenteric side through a hiatal defect into mediastinum. There are a few published cases of small bowel herniation into the thoracic cavity in the literature. Our patient represents a rare case of an individual diagnosed with type IV PEH with herniation of jejunum with perforated diverticula.

Laminin-Dependent Interaction between Astrocytes and Microglia: A Role in Retinal Angiogenesis.

Retinal vascular diseases are among the leading causes of acquired blindness. In recent years, retinal microglia have been shown to influence vascular branching density and endothelial cell proliferation. However, how microglial recruitment and activation are regulated during development remains unclear. We hypothesized that microglial recruitment, activation, and down-stream signaling are modulated by components of the mural basement membrane. We used a reverse genetic approach to disrupt laminin expression in the vascular basement membrane and demonstrate that microglia respond to the mural basement membrane in an isoform-specific manner. Microglial density is significantly increased in the laminin γ3-null (Lamc3-/-) retinal superficial vascular plexus and consequently the vascular branching density is increased. Microglia also respond to astrocyte-derived matrices and become hyperactivated in the Lamc3-/- retina or when tested in vitro with cell-derived matrix. Pharmacological activation of microglia in the wild-type retina produced an Lamc3-/--like vascular phenotype, whereas pharmacological blocking of microglial activation in the Lamc3-/- retina rescued the wild-type vascular phenotype. On the molecular level, microglial transforming growth factor-ß1 expression is down-regulated in the Lamc3-/- retina, and SMAD signaling decreased in endothelial cells with a consequent increase in endothelial proliferation. The reverse effects were seen in the Lamb2-/- retina. Together, our results demonstrate a novel mechanism by which laminins modulate vascular branching and endothelial cell proliferation during retinal angiogenesis.

Myiasis on a Giant Squamous Cell Carcinoma of the Scalp: A Case Report and Review of Relevant Literature.

Non-melanoma skin cancer is the most common malignancy amongst Caucasians worldwide with basal cell and squamous cell cancer being the most common. Giant skin cancers are a relatively rare type of skin cancer that are, by definition, greater than 5 cm. This subtype by itself is associated with a significantly increased risk of complications and mortality. Myiasis is defined as infestation of body tissues of humans by dipterous larvae. Myiasis is often associated with malignant skin conditions. We describe a rare case of cutaneous myiasis located on a giant squamous cell carcinoma of the scalp in an elderly female. Myiasis coupled with malignant skin conditions provides a unique surgical challenge. This is especially true if the malignancy is invasive, as in our case, often requiring a multidisciplinary multimodality treatment plan.

A new family of trinuclear nickel(II) complexes as single-molecule magnets.

Three new trinuclear nickel (II) complexes with the general composition [Ni3 L3 (OH)(X)](ClO4 ) have been prepared in which X=Cl(-) (1), OCN(-) (2), or N3(-) (3) and HL is the tridentate N,N,O donor Schiff base ligand 2-[(3-dimethylaminopropylimino)methyl]phenol. Single-crystal structural analyses revealed that all three complexes have a similar Ni3 core motif with three different types of bridging, namely phenoxido (µ2 and µ3 ), hydroxido (µ3 ), and µ2 -Cl (1), µ1,1 -NCO (2), or µ1,1 -N3 (3). The nickel(II) ions adopt a compressed octahedron geometry. Single-crystal magnetization measurements on complex 1 revealed that the pseudo-three-fold axis of Ni3 corresponds to a magnetic easy axis, being consistent with the magnetic anisotropy expected from the coordination structure of each nickel ion. Temperature-dependent magnetic measurements indicated ferromagnetic coupling leading to an S=3 ground state with 2J/k=17, 17, and 28 K for 1, 2, and 3, respectively, with the nickel atoms in an approximate equilateral triangle. The high-frequency EPR spectra in combination with spin Hamiltonian simulations that include zero-field splitting parameters DNi /k=-5, -4, and -4 K for 1, 2, and 3, respectively, reproduced the EPR spectra well after a anisotropic exchange term was introduced. Anisotropic exchange was identified as Di,j /k=-0.9, -0.8, and -0.8 K for 1, 2, and 3, respectively, whereas no evidence of single-ion rhombic anisotropy was observed spectroscopically. Slow relaxation of the magnetization at low temperatures is evident from the frequency-dependence of the out-of-phase ac susceptibilities. Pulsed-field magnetization recorded at 0.5 K shows clear steps in the hysteresis loop at 0.5-1 T, which has been assigned to quantum tunneling, and is characteristic of single-molecule magnets.

Leiomyosarcoma of the Inferior Vena Cava - Radical Resection, Vascular Reconstruction and Challenges: A Case Report and Review of Relevant Literature.

Leiomyosarcomas of the inferior Vena Cava (IVC) are rare soft tissue sarcomas accounting for only 0.5% of all soft tissue sarcomas in adults with fewer than 300 cases reported. Extraluminal tumor growth along the adventitia of the IVC seems to be the common presentation. Intraluminal tumor growth is rare. The origin of the tumor is divided into three levels in relation to the hepatic and renal veins. The presentations and surgical modalities vary accordingly. Retroperitoneal tumors are often not diagnosed until the disease is at an advanced stage with large tumor growth and involvement of surrounding structures. This is partly because of the nonspecific clinical presentation as well as absence of early symptoms. Most patients present with abdominal or flank pain. Symptoms vary according to the dimensions of the tumor, growth pattern and localization of the tumor. Radical en bloc resection of the affected venous segment remains the only therapeutic option associated with prolonged survival. The goals of surgical management of these tumors include the achievement of local tumor control, maintenance of caval flow, and the prevention of recurrence. The involvement of renal or hepatic veins determines the strategy for vascular reconstruction. Reconstruction of the IVC is not always required, because gradual occlusion of the IVC allows the development of venous collaterals. However, when pararenal leiomyosarcoma of the IVC is present, reconstruction of the IVC and the renal vein is necessary to prevent transient or permanent renal dysfunction. Recent study has shown that radical surgery combined with adjuvant multimodal therapy has improved the cumulative survival rate. We report a case of IVC leiomyosarcoma in a young healthy woman along with details of its diagnostic workup and discussion of the surgical options and reconstruction of caval continuity.